Passive therapies

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girl prepping for ultrasound

​​​Passive therapies are treatments that do not require any effort from you. If you decide to use passive therapies, always ask your healthcare practitioner how many sessions you can expect to have and what kinds of improvements you should expect to see within a given timeframe.

What is the evidence for passive physical therapies?

It may seem easier to receive passive physical therapies than to take an active part in your treatment, but there is no clear evidence that passive therapies provide any long-term benefit for persistent pain relief. They may provide some limited short-term pain relief, however.

Are passive therapies right for me?

Your healthcare team may recommend passive physical therapies as a way to get your body ready for more active therapies. But remember that there is very little evidence that they will reduce pain on their own, without an active component. If you are considering a passive therapy, always ask your healthcare team if it would be a safe and worthwhile option for you to try.

Types of passive therapies for chronic pain

Below, we outline the following types of passive therapy, including the evidence for each one.

Transcutaneous electrical nerve stimulation (TENS)

TENS on the arm

TENS uses electrodes that are attached to a small battery-powered device and are placed on your skin, usually on either side of the location of the pain. Through the electrodes, electrical signals are transmitted into specific nerves. It is believed that this process may help by activating pain-reducing receptors. TENS is sometimes used to treat acute and persistent pain, for example lower back pain. It may be used with pain-relieving medications.

A physiotherapist will help you set up the TENS to find the most effective placement and level of electric current. The treatment time depends on the type of pain and your tolerance to the electrical stimulation. Any pain relief is short-term, however, lasting only while the TENS is applied, or up to an hour after it has been removed.

TENS is most likely to be useful by helping you feel well enough to exercise. Like other passive therapies, it should not be used as a standalone treatment. If TENS does work for you, it is something that you are able to do at home. Though TENS machines can be expensive, with a doctor’s referral, they may be covered by your extended health insurance. TENS machines can also be rented.

What is the evidence?

There is limited evidence for the effectiveness of TENS for treating chronic pain.

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Ultrasound

teen having ultrasound

Ultrasound therapy uses high-frequency sound waves (they cannot be heard by the human ear). These sound waves are applied to a painful area of the body using a small metal ultrasound treatment head. A gel is also applied to the skin to help with the treatment.

A physiotherapist applies the ultrasound therapy for short periods of time, usually between 10 and 20 minutes, depending on the size of area being treated. During this treatment you would feel the movement of the ultrasound head on your skin on the ultrasound gel but will not otherwise feel the ultrasound waves.

What is the evidence?

Although ultrasound therapy is used to treat acute pain in adults, there currently is no evidence that it benefits youth and young adults with persistent pain. Ultrasound is also not recommended for young teens if their bones are still growing, since ultrasound can cause problems when used over open growth plates in bones. Pregnant women cannot receive ultrasound over the abdomen, pelvis or back. In addition, ultrasound cannot be used over an area that has an infection.

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Acupuncture

acupuncture on hand

Acupuncture is an ancient Chinese treatment now performed throughout many other parts of the world. It involves inserting very tiny needles into the body at specific points and has been used to treat many medical conditions, including pain.

Traditional acupuncture is based on the theory that energy flows through invisible channels within the body. Regulating the flow of this energy by inserting and manipulating tiny needles at over 400 specific acupuncture points is believed to restore the balance and flow of this energy, relieving pain. Modern acupuncture is based on direct needling of trigger points along with traditional acupuncture points.

Acupuncture may work by stimulating the release of endorphins. It should only be provided by a practitioner with specialized training and certification.

What is the evidence?

Acupuncture has been shown to be effective in treating fibromyalgia, musculoskeletal pain, post-operative pain and nausea. There are early reports that acupuncture can be effective in treating other painful conditions, but more studies are needed to confirm this. Some people feel some immediate pain relief, but most people, especially those with persistent pain, need multiple sessions to get some relief. For others, acupuncture may not work at all.

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Laser therapy

teen boy getting laser therapy

Laser therapy involves applying focused light over a painful body part to treat musculoskeletal injuries or problems. A physiotherapist or occupational therapist applies the laser through the skin in a grid pattern using a small hand-held application wand. The therapist might, for example, hold the wand over an area of skin for 10 seconds at a time before moving to the next spot on the grid until the entire area is covered.

The length of treatment depends on the size of the area being treated. During the treatment you feel the gentle touch of the application wand but otherwise would not feel the laser. You and the physiotherapist applying the laser must wear sunglasses during the treatment.

What is the evidence?

Although laser therapy has been shown to some benefit in localized pain conditions in adults (such as elbow pain, neck pain, osteoarthritis), there is currently not enough evidence to show that it works for persistent pain in young people.

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Thermal (hot or cold) modalities

teen with ice pack

Thermal modalities are treatments that use heat or cold. Applying superficial heat to the skin can increase blood flow, while applying superficial cold can decrease blood flow. Heat can be helpful for decreasing local muscle spasms. Cold can slow down the transmission of pain messages through your nerves.

Thermal modalities can be helpful for reducing pain and inflammation. They can be used to prepare your body for more active therapies, such as exercise, and also help your body to recover after exercise.

Cold packs

Crushed ice, ice cubes or a bag of frozen peas can be used at home to make up a cold pack. Put the ice in a plastic bag and wrap it in a damp, thin towel. If you feel that the cold is too much, you can try wrapping the ice in a dry towel instead. Applying cold decreases blood flow and can help to relieve aches and stiffness.

How should I use a cold pack?

Never apply a cold pack directly to the skin. Neither should you put the weight of your limb on a cold pack. Both of these actions may burn the skin. Ice packs should not be used over a part of the body that is numb or has reduced sensation.

On areas of the body with thick muscle and tissues, the ice pack should be applied for 10 to 20 minutes at a time and then removed. For bony areas such as the hands or ankles, ice packs can be applied for short periods such as three to five minutes.

Check your skin under the ice pack every five minutes. If it is bright red, remove the pack and place another thin towel between the pack and your skin. Wait one to two hours, and then re-apply if necessary. Ice packs should not be applied to large areas of your body at one time because this may lower your core temperature. Ensure that the rest of your body is kept comfortably warm so you do not shiver while using an ice pack.

Hot packs

Applying heat increases blood flow and can help to relieve aches and stiffness. Moist heat is the best because it allows for a more even distribution of heat over your body and reduces the risk of burns. A hot water bottle wrapped in a damp towel is a great way to use moist heat, as it moulds well to the affected area.

How should I use a hot pack?

As with cold packs, never apply hot packs directly to the skin without a towel around the source of heat. Do not use heat on:

  • soft tissue injuries that are still acutely painful (in the first three weeks after an injury)
  • open wounds
  • areas of the body with reduced sensation or feeling, areas of bleeding or new swelling.

Always take care when using hot packs: make sure the heat feels comfortably warm, and not hot, to minimize the risk of developing blisters or burns. Remove the hot pack after 20 minutes, wait an hour, and then reapply if helpful.

What is the evidence for thermal modalities?

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There is some evidence that applying heat or cold packs can provide some pain relief for a short time. Depending on your preference, you may find one type of pack – cold or hot – more soothing than another. You can perform these treatments at home and use them before or after exercise.

Manual therapy (hands-on therapy)

foot massage

Manual therapy is a treatment given by a healthcare provider with their hands.

Massage

Massage therapy is a hands-on treatment that involves rubbing and kneading muscles and joints to relieve tension or pain. Massages for people with persistent pain should always be done by a registered massage therapist (RMT). Your RMT may also be able to teach you some self-massage techniques that you can use at home. For example, they may show you how to safely use a massage roller device to knead your muscles. It is also important to remember that, similar to other passive therapies, massage is most useful for helping people to relax their muscles so they can engage in gentle exercises and movement activities.

What is the evidence?

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There is some research evidence to support the use of massage in young people with headaches, juvenile idiopathic arthritis and persistent pain. There is no evidence to show that massage provided by anyone other than a registered massage therapist can help with pain.

Joint mobilization or manipulation

Joint mobilizations are passive stretches to your joints that your healthcare provider may do for you. This is a hands-on treatment where the healthcare provider will move your joints in patterns to increase your mobility. Joint manipulation is a similar technique, where your healthcare provider uses small manual thrusts on your joints to help increase your flexibility and reduce pain.

What is the evidence?

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There is some evidence that joint mobilization or manipulation may help adults with persistent neck pain, low back pain, migraines, headaches and pain in their extremities (fingers and toes). Right now, there is not enough evidence to know whether these therapies are safe or effective in treating persistent pain in young people. In particular, manipulation of the neck (called “cervical manipulation”) can be very dangerous and has been associated with risk of stroke and even death in adults. There have not been any safety studies in adolescents and only limited studies in young adults. Given these risks, the decision to use cervical manipulations should be very carefully considered if you are a young adult (aged 18 and older). You should avoid cervical manipulation completely if you are an adolescent (17 and younger).

Sources

DeSantana, J. M., Walsh, D. M., Vance, C., Rakel, B. A., & Sluka, K. A. (2008). Effectiveness of Transcutaneous Electrical Nerve Stimulation for Treatment of Hyperalgesia and Pain. Current Rheumatology Reports (6), 492–499. [Accessed April 15, 2016]

Gross, A., Miller, J., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., ... & Hoving, J. L. (2010). Manipulation or mobilisation for neck pain: a Cochrane Review​. Manual Therapy 15(4), 315-333.

Last updated: May 2nd 2016