Pain Management Guide

USES & OTHER INFO
- Manual therapy is the skilled application of passive movement to a joint either within (‘mobilisation’) or beyond ('manipulation') its active range of movement
- Effects can be physiological, biomechanical/physical and psychological
- Techniques include oscillatory techniques, high velocity low amplitude thrust techniques, sustained stretching and muscle energy techniques.
- Can be applied to joints, muscles or nerves
- Aims of treatment are pain reduction, increasing range and quality of joint movement, improving nerve mobility, increasing muscle length and restoring normal function.
- 4 Categories: MTI (high-velocity low-amplitude manipulation), MT2 (mobilization and/or soft-tissue-techniques), MT3 (combination of MT1 & MT2), and MT4 (mobilization with movement).
- Performed by a range of medical professionals, including certified athletic trainers, physical therapists, chiropractors, massage therapists, and osteopathic doctors.

POSSIBLE SIDE EFFECTS
- Mild discomfort during treatment
- Bruising post-treatment

BEST USED WITH
- Skilled physical therapy
- Therapeutic exercise

USES & OTHER INFO

- Safe and effective; can be used for pain modulation and soft tissue manipulation.
- Utilizing an instrument, the clinician will apply the recommended pressure to the area and begin scraping across the surface of the skin.
- Frequencies and pressure depend on the goals of the clinician as part of a skilled rehabilitation program.

POSSIBLE SIDE EFFECTS
- Mild discomfort during treatment
- Bruising post-treatment

BEST USED WITH
- Skilled physical therapy
- Therapeutic exercise

USES & OTHER INFO

- The cup is applied to the skin and with a manual vacuum, air is removed from inside the cup creating the suction to the skin. This vacuum seal then promotes blood flow to the area.
- Application can vary as some clinicians will leave the cup on the affected area for a short amount of time, manually moving the cup across the surface of your skin, creating manipulation of the connective tissue.
- Many therapeutic interventions are compressive in nature, but cupping is one of the only true decompressive interventions.
- Utilized for many conditions, most commonly used for tight/sore musculature alongside a skilled rehabilitation program.

POSSIBLE SIDE EFFECTS
- Mild discomfort during treatment and bruising post treatment.

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO

- Blood Flow Restriction or “BFR” is when external pressure is placed on a proximal limb to promote blood pooling in capillary beds distal to the tourniquet.
- Studies have shown that muscle hypertrophic adaptations, (release of growth hormones, insulin growth factors) can be induced with much lower intensities (20-30% of 1RM).

POSSIBLE SIDE EFFECTS
- Biggest risk factors are associated with improper tourniquet use. Improper use, too much pressure, improper placement, time, etc., can result in severe damage to the tissue.

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Requires an external unit alongside sleeves that cover the affected limb(s).
- Once the sleeves are in place, they are connected to the unit that will sequentially provide compression starting distally and proximally through the sleeve by pumping air into each pocket or segment along the sleeve.
- As the air pressure increases to its max, the system will move up the chain creating a “milking” effect of the limb.

POSSIBLE SIDE EFFECTS
- Improper equipment creating a tourniquet on limb

BEST USED WITH
- Recovery, electrical stimulation, edema control, and DVT decrease risk

USES & OTHER INFO
- There is clear evidence that vibration therapy stimulates the central nervous system to assist with decreasing pain and improving the perception of improved range of motion.
- Full body vibration therapy has been proven to have a hormonal response, but both full body and local vibration therapies still need further research to fully understand the mechanisms behind the results.

POSSIBLE SIDE EFFECTS
- Patients should consult a MD if they are pregnant, have heart disease or advanced diabetes, or take blood thinning medications. Do not use directly over bone.

BEST USED WITH
- Recovery, skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- The biggest benefit and use for an unweighted treadmill is the ability to remove the amount of body weight from weight bearing activities.
- This allows athletes recovering from post-surgical or lower body injuries to start rehabilitation from non-weight bearing to weight bearing activities.

POSSIBLE SIDE EFFECTS
- Risk of drowning. Fear of water may affect ability to use.

BEST USED WITH
- Recovery, skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Electrodes are placed on the patient's skin and connected to the unit that delivers a specific current to the pads.
- The two common uses for electrical stimulation are for pain modulation or for muscle re-education, depending on the frequency used.

POSSIBLE SIDE EFFECTS
- Improper equipment can lead to electrical burns

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Two modes of delivery: a single-person cylindrical tube in which you lay or a small room that can hold 3-4 clients.
- The tube or room is securely pressurized, increasing the atmospheric pressure, allowing your lungs to capture more oxygen.
- Once the oxygen is in your system, it is carried through your body via blood, allowing your body to release certain growth factors and stem cells to help fight infections and promote healing.

POSSIBLE SIDE EFFECTS
- When improperly used: Lung and sinus damage, fluid buildup/rupture of middle ear, oxygen poisoning, seizures, changes in vision

BEST USED WITH
- Recovery, increase blood oxygen, release certain growth factors

USES & OTHER INFO
- Two forms of treatment:
- Standing solo in a cylinder chamber with your head exposed
- In a small room that holds up to 4 adults
- In treatment, your body is exposed to extreme low (-100℃ to -300℃) temperatures.
- Treatment time lasts 2-4 minutes and has been proven through recent research to reduce pain in injured individuals as well as reduce inflammation and markers that indicated cell damage.

POSSIBLE SIDE EFFECTS
- Hypothermia and frostbite have occured when used incorrectly

BEST USED WITH
- Recovery

USES & OTHER INFO
- Invasive therapy that utilizes high energy pulses or “shock waves” to the targeted area of the body.
- These pulses can vary in intensity based on several unique factors of the patient’s presentation.
- The pulses create a “popping”, “clicking”, and/or “tapping” sensation on the surface of the skin, but the energy of the pulse can travel deep into the body.

POSSIBLE SIDE EFFECTS

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Low Level Laser Therapy (LLLT) is a modality using low level laser or light emitting diodes across the surface of the skin.
- This near infrared light is used to reduce inflammation and pain, both acute and chronic in nature, as well as promote soft tissue healing and wound care.

POSSIBLE SIDE EFFECTS
- Damage to eyes if looking into lasers

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- High Power Laser Therapy that emanates triple wavelength radiations at the same time, working 8/10 cm deep, improving efficacy.
- These devices are referred to as “class IV” reaching 7.500 mW power following previous “class III” or low-level laser that had a limited power up to 500 mW.

POSSIBLE SIDE EFFECTS
- Treatment should follow strict protocols as additional trauma to the treatment area can occur if not followed.

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Sensory Deprivation Tanks or Flotation-REST (restricted environmental stimulation techniques) tanks are tanks filled with about 1 foot of water that has a high concentration of salt.
- This high concentration makes it very buoyant in which the patient can float easily in the tank.
- These tanks are found in soundproof and light proof rooms to restrict all external sensations once fully relaxed.
- Treatment starts lying on your back floating in a quiet dark room, allowing the body and mind to simply reset from all the external stress on the body.

POSSIBLE SIDE EFFECTS
- Do not recommend if patient is claustrophobic or has a fear of water

BEST USED WITH
- Recovery

USES & OTHER INFO
- Hivamat deep oscillation therapy is an approved modality by the FDA for use with muscle relaxation, increasing circulation and pain relief.
- This modality has two methods of delivery, either by wand or the clinician/therapist’s hands.
- An electrode is placed on clean, dry skin on both the clinician and the athlete and the clinician wears gloves with the use of baby powder to massage the treatment area.

POSSIBLE SIDE EFFECTS

BEST USED WITH
- Skilled physical therapy, therapeutic exercise, stem cell and PRP injections

USES & OTHER INFO
- The ARP Wave (Accelerated Recovery Performance) is a system that uses bio-electrical current, simultaneously with active range of motion/exercises to speed up the body’s natural healing ability.
- ARP Wave is said to have positive cellular effects of direct current electrical fields on bone and tissue healing.

POSSIBLE SIDE EFFECTS
- Thermal burns

BEST USED WITH
- Skilled physical therapy, therapeutic exercise

USES & OTHER INFO
- Mask covers the nose and mouth with different sized openings and flux valves.
- The openings and flux valves can be adjusted to increase the resistance of respiration, making it more difficult to breathe while wearing the mask.
- The goal of these masks is to mimic high elevation training which is proven to boost the production of red blood cells.

POSSIBLE SIDE EFFECTS
- Hypoxia - the absence of enough oxygen in the tissues to sustain bodily functions

BEST USED WITH
- Typically used during training, limited research has been found to show statistical benefits of hypoxia mask training. More research is needed.

USES & OTHER INFO
- Often described as acupuncture without the needles
- Used for various reasons: pain relief, improving fatigue and sleep disturbances.
- Acupressure can be applied by a trained practitioner or self-administered.

POSSIBLE SIDE EFFECTS
- Considered a low risk treatment with minimal side effects.
- If pressure is applied improperly, bruising can occur at the points on the body where acupressure is done.

BEST USED WITH
- Can be used alone or in combination with other treatments.

USES & OTHER INFO
- There are 117 conditions for which there is some evidence of efficacy for the use of acupuncture including various types of pain.
- A typical treatment involves the placement of needles in specific acupoints.
- There are various combinations of needles used specific to the diagnosis being treated and the school of acupuncture followed by the therapist.
- The needles may be stimulated manually, herbally, thermally, or electrically.
- A typical treatment may last from 20 - 60 minutes
- Acupuncture as practiced in traditional Chinese medication is a holistic, multi-disciplinary approach which involves the combined, systematic use of needles, herbs/medications, mind-body therapies, and restorative, physical exercise.

USES & OTHER INFO
- Used as a treatment for injuries to promote healing in damaged tissues and for chronic pain reduction.
- Used to reduce stress, improve mood and increase overall well-being.

POSSIBLE SIDE EFFECTS
- Muscle soreness can sometimes occur
- Some risks include having a previous deep vein thrombosis, open wound, recent fracture, or vulnerable skin tissue.
- People who are taking blood thinning medication should consult a doctor before participating in massage

BEST USED WITH
- Generally safe with pain-relieving medications

USES & OTHER INFO
- A solid filiform needle is inserted into the skin, typicalling into trigger points, to treat musculoskeletal and myofascial dysfunctions as well as pain modulation.
- Two commonly used techniques are inserting the needle and leaving it for a set period of time, or inserting and removing the needle in a continuous fast motion called pistoning.

POSSIBLE SIDE EFFECTS
- Some bleeding may occur alongside the onset of soreness and bruising.
- If the patient has an aversion to needles, this may not be the best modality to use.
- Fainting has occurred in some populations.

BEST USED WITH
- Skilled physical therapy and therapeutic exercise

USES & OTHER INFO

- Over-the-counter analgesic
- First line, primary analgesic for mild to moderate pain
- Frequently used as an adjunct with opioids for moderate to severe pain
- Can be used safely and synergistically with Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) with the combination providing greater analgesia than either alone
- Present in combination with opioids in medications such as Percocet and Vicodin

POSSIBLE SIDE EFFECTS

- Primary benefit is its relatively safe profile
- Primary side effect is liver toxicity, which is rare
- Should be avoided in individuals with liver disease

BEST USED WITH
- Opioids
- Physical therapy

USES & OTHER INFO
- Most commonly administered medications for pain and inflammation.
- Include non-prescription and prescription medications
- Drug of choice for short term management of acute nociceptive and/or inflammatory pain
- The evidence for their use in chronic and/or neuropathic pain is limited

POSSIBLE SIDE EFFECTS
- Gastro-intestinal hemorrhage (which can be potentially fatal)
- Bleeding problems
- Cardiovascular effects such as stroke and heart attack
- Impaired renal function including renal failure
- Liver damage
- While these risks are relatively rare for short term use (7 – 14 days), the likelihood increases with long term use

BEST USED WITH
- Physical Therapy
- Acetaminophen – combination has been shown to have a stronger effect than either alone

USES & OTHER INFO

- Effect is to decrease the inflammatory response to injury or other inflammatory process
- When injected, they also decrease the sensitivity of the pain nerves (c-fibers)
- Not performance enhancing steroids
- Takes several days for them to have an effect
- Not analgesic by themselves
- Rarely used for more than three weeks at a time

POSSIBLE SIDE EFFECTS
- Destructive effects on skin, bone, muscle, and soft tissue with long-term use
- Hunger, weight gain, and anxiety, and they may also impair sleep with short-term use
- Fluid retention
- Can aggravate diabetes or hypertension but will not cause them in the short-term, only when taken for months to years

BEST USED WITH
- Physical Therapy
- Acetaminophen
- Opioids

USES & OTHER INFO
- Pain relief
- Should only be used as part of a comprehensive, integrative, physician-supervised pain management program
- At the very least, should be combined with a physical modality (heat/cold/e-stim/other) and a restorative modality (stretching, strengthening, proprioceptive training)
- Because of risk of addiction, a family member should be included in the treatment team.

POSSIBLE SIDE EFFECTS
- Respiratory suppression
- Drowsiness
- Impaired coordination
- Dependence
- Death

BEST USED WITH
- Psychotherapy
- Physical therapy

USES & OTHER INFO
- Pain relief, depression and anxiety
- Should only be used as part of a comprehensive, integrative, physician-supervised pain management program
- At the very least, should be combined with a physical modality (heat/cold/e-stim/other) and a restorative modality (stretching, strengthening, proprioceptive training)
- Long term use is generally considered safe and non-habit forming

POSSIBLE SIDE EFFECTS
- Weight gain
- Blurred vision
- Drowsiness
- Impaired coordination
- May be lethal in overdose and when combined with alcohol

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Psychotherapy

USES & OTHER INFO
- Neuropathic pain, depression, anxiety
- Onset of action, once adequately dosed, is 1-4 weeks, with peak efficacy being achieved after 6-8 weeks
- Best suited for the management of chronic pain
- Long term use is generally considered safe and non-habit forming

POSSIBLE SIDE EFFECTS
- Increased blood pressure
- Urinary retention
- Sexual dysfunction
- Insomnia and increased sweating when taken in the evening

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Psychotherapy

USES & OTHER INFO
- Neuropathic pain, migraines, restless leg syndrome, seizures, depression, bipolar disorder, anger/impulse control issues
- Peak efficacy achieved after 6-8 weeks of adequate dosing
- Best suited for the management of chronic pain
- Long term use is generally considered safe and non-habit forming

POSSIBLE SIDE EFFECTS
- Weight gain
- Drowsiness
- Impaired motor coordination
- Lethal in overdose
- Can cause significant damage to the liver when combined with alcohol

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Psychotherapy

USES & OTHER INFO
- Pain treatment
- Derivative of chili peppers
- Onset of action is immediate, making this a good option for the treatment of acute muscular and neuropathic pain.
- Can have long lasting effects, less risks for drug interactions, and lower risk for systemic side effects.

POSSIBLE SIDE EFFECTS
- Increased sensitivity, burning and redness at the site of application
- In rare cases, it can cause severe burns and neurotoxicity

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Acetaminophen, NSAIDS and Opioids

USES & OTHER INFO
- Pain
- Derivative of the Camphor Laurel, a large evergreen tree
- Onset of action is immediate, and it has antibacterial, anti-fungal, and anti-inflammatory properties making this a good option for the treatment of acute topical pain

POSSIBLE SIDE EFFECTS
- Local irritation, and less commonly, severe burns and allergic reactions.
- If taken orally it can be lethal

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Acetaminophen, NSAIDS and Opioids

USES & OTHER INFO
- Pain
- Does not cause respiratory depression or cognitive side effects as opioids may
- Should only be used for severe, acute pain- Should never be used to prevent pain (prophylactically).

POSSIBLE SIDE EFFECTS
- Bleeding complications, particularly gastro-intestinal
- Should never be used with other NSAIDs, oral corticosteroids, or other blood thinners
- Should be never used in a player with a history of GI bleeding or kidney disease
- The risk is sufficient that the drug carries a black box warning

BEST USED WITH
-Physical Modalities
-Restorative Modalities
-Acetaminophen

USES & OTHER INFO
- TPI is used to treat myofascial pain, which is characterized by a tender tight band in a muscle. These may be due to primary injury in a muscle or secondary activation by a structural (bone, joint, ligament, internal organ) injury.
- A fine gauge needle is inserted into the trigger point and a small amount of local anesthetic or saline is inserted. Rarely, cortisone may be injected.

POSSIBLE SIDE EFFECTS
- Increased pain for a few days is common.
- Infection is rare.
- Inadvertent internal organ puncture (lung) is also rare.

BEST USED WITH
- TPI should never be as first line treatment. It should always be preceded by a trial of a physical (heat, cold, e-stim, massage), medication, and/or restorative exercise (stretching, strengthening).
- If these modalities fail to work, TPI can be done. It should always be accompanied by a physical and a restorative modality.

USES & OTHER INFO
- Used for a variety of medical conditions, primarily in pain management for specific types of back pain.
- More recently, uses have been expanded to other structures such as the knee.
- RFA involves the deliberate destruction of the sensory nerve to the painful structure using the heat generated from medium frequency alternating current.
- While it is a popular procedure in pain management clinics, the evidence remains contradictory.

POSSIBLE SIDE EFFECTS
- Increased pain during and after the procedure (usually temporary, but can be permanent).
- Infection is also a risk.
- The procedure should only be performed on small, sensory nerves. Damage to neighboring, larger nerves with motor nerve injury and associated weakness is a risk in spine procedures. This risk is thought to be low.
- What is an unknown risk is the development of a de-afferentive pain syndrome, similar to phantom pain. This is probably very common and explains the reason why the treatment is less effective when repeated.

BEST USED WITH
- RFA should never be a first line procedure and should never be performed to treat acute pain.
- Medication, local injection, physical modalities, and restorative modalities should be performed first and RFA should only be considered if there is failure to respond to these modalities.
- This is a procedure that should only be considered in a retired player. It is also important to note that there is no clear agreement on the success of this procedure.
- A substantial percentage of patients get no relief. Those who do obtain relief usually only experience relief for 3-6 months.
- While the procedure can be repeated, it is usually less successful in subsequent attempts.

USES & OTHER INFO
- The procedure is used to treat refractory joint, ligament, and tendon injury.
- It is thought that by injecting an irritant, the body's inflammatory system can be better mobilized to heal the injured tissue.
- All uses of the procedure are considered off-label.

POSSIBLE SIDE EFFECTS
- Increased pain during the procedure is expected and may last several days.
- Permanent increase in pain happens, but is rare.
- Infection is rare.
- Inadvertent puncture of internal organs (lung) is possible when treating rib related structures.

BEST USED WITH
- This modality should only be considered when a comprehensive pain management program consisting of medication, physical modality (heat, cold, e-stim), restorative exercise (stretching, strengthening, proprioception), and/or alternative modality (manual adjustment, acupuncture, massage) has failed.
- While the risk and cost are low, the potential benefit of this modality remains unclear.

USES & OTHER INFO
- Venous blood is obtained via routine blood draw and spun down in a centrifuge to concentrate and isolate platelets.
- The concentrated platelet product is then injected into the affected area (joint, tendon, ligament, muscle) to promote healing and decrease inflammation and pain.

POSSIBLE SIDE EFFECTS
- Since PRP utilizes our own body's natural healing mechanisms, side effects are rare.
- Pain and/or inflammation at blood draw site and/or injection site.

BEST USED WITH
- For optimal results, PRP should be used along with other treatment modalities such as physical therapy.

USES & OTHER INFO
- BMC is obtained by collecting bone marrow from the bone marrow cavity most commonly in the lower back at the posterior pelvis.
- The bone marrow is then spun down in a centrifuge to concentrate stem cells and progenitor cells.
- The concentrated product is referred to as BMC which is then injected into the area of interest (joint, tendon, ligament, muscle) to promote healing and decrease inflammation and pain.

POSSIBLE SIDE EFFECTS
- Since BMC utilizes our own body's natural healing mechanisms, side effects are rare.
- Pain, inflammation, and/or bruising at bone marrow harvest site and/or injection site.

BEST USED WITH
- For optimal results, BMC should be used along with other treatment modalities such as physical therapy.

USES & OTHER INFO
- Cognitive Behavioral Therapy for Insomnia (CBT-I)
Studies have shown that CBT-I can lead to long-term resolution of a variety of sleep issues
- Over the counter medications (Melatonin)
- Sedative Hypnotics
- Antidepressants
- Medication interventions are intended for short term use and should only be used under the supervision of a physician

POSSIBLE SIDE EFFECTS
- Variable based on the modality (see guide)

BEST USED WITH
- A comprehensive, integrative, supervised pain management program
- Medication interventions should be combined with CBT-I for the safest approach to long term relief

USES & OTHER INFO
- Treatment of acute and chronic pain
- Primarily based on a pharmaceutical plant-derived oral preparation with an equal amount of CBD and THC
- Not approved by the FDA, with the exception of four products: Marinol, Syndros, Cesamet and Epidiolex.

POSSIBLE SIDE EFFECTS
- Potential risks of very high doses of CBD (e.g., > 1200 mg) may include elevated liver function tests and drug interactions possibly related to the effects of CBD in drug metabolic pathways.
- With respect to cannabis products with THC, it is important to know that they can lead to a positive toxicology screen that is a violation of league rules and subject to disciplinary actions including suspensions and fines. Full spectrum hemp-derived CBD products may contain enough THC to produce a positive toxicology result.
- THC products may cause acute impairment of cognition, particularly verbal learning (which can last up to 72 hours depending on the frequency and quantity of use), acute impairment of ability to drive or operate machinery, and increased risk for the development of a Cannabis Use Disorder, which is greatest among young males (e.g., teens and early twenties) who are using for recreational reasons and are using inhalable forms.
- There is an association between THC use and the development of psychosis in adolescents and young adults.
- Pre-packaged vaporizer oils that contain THC, CBD, or nicotine have recently been identified as a source of severe lung disease and such products should be avoided.

USES & OTHER INFO
- Chronic Pain – has been shown to reduce subjective pain by as much as 25%
- Chronic migraines, complex regional pain syndromes, arthritis, sleep disorders, and spinal cord injury
- Other uses include stuttering, coping with stressful life situations/grief or loss/medical illnesses and injuries, pathological gambling, and smoking cessation
- Time-limited (e.g. 12-16 weeks)

POSSIBLE SIDE EFFECTS
- None

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Mindfulness Based Stress Reduction (MBSR)

USES & OTHER INFO
- Chronic pain, headaches, lower back pain, arthritis and insomnia
- Reduces the physiological effects of stress, pain or illness
- Improve mind and body awareness
- Gains have been shown to last up to 4 years after the intervention

POSSIBLE SIDE EFFECTS
- None

BEST USED WITH
- Massage
- CBT and CBT-I
- Physical Modalities
- Restorative Modalities

USES & OTHER INFO
- Musculoskeletal pain
- Two main objectives: 1) training acceptance of problematic, unhelpful thoughts and feelings that cannot and perhaps need not be controlled, and 2) commitment and action toward living a life due to chosen values

POSSIBLE SIDE EFFECTS
- None

BEST USED WITH
- Physical Modalities
- Restorative Modalities
- Mindfulness Based Stress Reduction (MBSR)

USES & OTHER INFO
- Chronic pain, gambling, complex regional pain syndromes, lower back pain
- Goal is to correct maladaptive behavioral responses to pain that develop through contingent relief from pain or pain-related fear
- Positive side effects on pain experience, mood, negative cognitive appraisals and functioning

POSSIBLE SIDE EFFECTS
- None

BEST USED WITH
- Mindfulness Based Stress Reduction (MBSR)
- Acetaminophen, NSAIDs, Opioids