CHAPTER 96: Physical Medicine and Rehabilitation

INTRODUCTION

The objectives of this chapter are to review the literature for articles about skilled therapy services applied to treat painful conditions; report primary outcomes of therapy participation (improved flexibility, strength, and endurance); and report secondary outcomes of therapy participation, including improved pain, disability, and quality of life. When the literature is informative, patient and provider attributes that guide patient selection for therapy are discussed. The terms “physical therapy for chronic pain” and “human,” were used to search the literature from January 1999 to January 2013. The search yielded 4940 articles, of which 200 were selected because they describe the application of licensed physical therapy¹ or the use of multidisciplinary programs² or functional restoration^3,4 as treatment for a painful disorder. That Cochrane reviews, systematic reviews, meta-analyses, randomized controlled trials (RCTs), and small series are included. Licensed physical therapy, as defined by the Centers for Medicare and Medicaid Services (CMS), is under the scope of PM&R and is a therapeutic activity funded by CMS and other payers in the United States. For articles not written in the United States, articles were selected that implied that a medical professional with an equivalent educational and licensing level of “licensed physical therapist” provided therapy services. Excluded were articles pertaining to exercise done at home or in a commercial gym, club, or spa, biofeedback, complementary and alternative medicine ([CAM]: homeopathy, acupuncture, hydrotherapy, massage), chiropractic manipulation, Tai Chi, Qi Gong, yoga, Pilates exercises, spas, balneotherapy (warm springs), mindfulness therapy, and cognitive-behavioral therapy (CBT) independent of a multidisciplinary program. Also excluded were articles that described exercise administered in nonmedical settings (commercial gyms or spas or home) and by trainers, instructors, certified trainers, “qualified lab personnel,” and kinesiologists. These exclusions were made because these activities, settings, or personnel do not fall under the scope of PM&R (e.g., CBT alone) or are activities that neither require medical prescription nor are reimbursed by medical insurance.⁵ (Fig. 96-1).

Discussions of rehabilitation applications for pain in the low back, knee, neck and pain caused by fibromyalgia and chronic regional pain syndrome, which were covered in the second edition chapter, are updated here. The current literature review permits a discussion of PM&R treatments for pain in the head and pelvic regions and for pain due to Achilles tendinopathy. The constructs of “back schools,” multidisciplinary programs, and functional restoration are also discussed.

BACKGROUND

The PM&R chapter in the second edition⁶ described the scope and philosophy of PM&R, explained the components of a detailed therapy script, and outlined basic prescriptions for various painful diagnoses. Simply put, PM&R focuses on ...