How far should we go with providing pain relief?

So, patients want and expect pain relief. Should that be our end goal then? Do whatever we can to relieve pain? It might not necessarily be what brought them to us (perhaps it’s their disability levels), but when they do come to us, they want pain relief.

Pain relief at any cost?

The question that I struggle with still is whether or not I should be using modalities (e.g. TENS, IFC, ultrasound, acupuncture) if patients say they get short-term pain relief from them. The concern I have with using them is that patients may become reliant on them. I don’t want them to think that they need those modalities to get better the next time they have a flare-up (instead of other active strategies they can do on their own) or that they were “healed” by the modalities.

I don’t know if this is a legit concern though.

First, some of my personal experiences seem to disprove these assumptions. I’ve used TENS as part of my rehab plan with patients and have discharged them as they were happy with their progress. They were very willing to continue exercising on their own to keep improving and seemed to understand the importance of not just idling around if they had pain. They didn’t seem reliant on it.

On the other hand, I have had patients tell me that they went for therapy before, had exercises and modalities, and believed that it was the modalities that helped rather than the hard work they put into it. So now, after many years, the problem has returned and they want the modality again that they believe helped them so much before. I wonder if there is any qualitative research on patients’ experiences with modalities and what they think about them.

Second, this case study from Louis Gifford illustrates a brilliant way of using and explaining TENS. Maybe there’s an art to using them in a way that does not promote dependence on passive modalities over time.

Third, in this great post by Bronnie Lennox-Thompson, she suggests that defining active = good and passive = bad is too simple (I’m not even sure how “active” and “passive” are distinguished to be honest) since these strategies are always used with some goal in mind. For example, if someone uses TENS so that they can continue going to work, is that such a bad thing? On the other hand, if they use it in the hopes that it will cure them, might that be a problem? As well, Bronnie suggests that perhaps, “it’s not so much the skills used in the process of living everyday life that promotes self management and self efficacy – I think it may be an “attitude”.  In other words, it’s not what you do, but the way that you do it (or the spirit that you do it in).” So are there ways that, as clinicians, we can offer these pain-relieving modalities in a way that promotes an attitude of pain acceptance? (Going back to the art of therapy…)

Lastly, why is it important to me that patients don’t become “reliant” on me or some sort of modality? What’s wrong with that in the first place? Is there actually something wrong or is it just my own, possibly inaccurate, core beliefs influencing my clinical judgment? Let’s be honest, part of the reason I became a physiotherapist was so that I would know how to help myself!

What are your experiences with modalities? Do you use them? Why or why not?

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