The successful physical rehabilitation of older individuals requires that pain be eliminated or minimized to a level that allows the improvement of related impairments (e.g. weakness, low endurance, loss of joint range of motion [ROM], etc.), overcoming activity limitations (e.g. inability to ambulate independently, ability to sit for only brief periods, etc.) and the prevention of participation restrictions (e.g. inability to work at the community food bank or to travel to visit grandchildren, etc.). Analgesic medications are the most common treatment used for pain management in older adults. Fortunately, hazards associated with some popular medications used for pain control by the elderly are becoming increasingly well known. Factors related to proper pharmacological management of pain are discussed in Chapter 12.

Although Clinical Practice Guidelines established by the American Geriatrics Society have most recently emphasized pharmacologic interventions for persistent pain (American Geriatrics Society, 2009), non-pharmacologic (NP) approaches alone or in combination with medications have also been recognized as an integral part of care (American Geriatrics Society, 1998, 2002). Proper use of conservative interventions for pain control can lessen the need for medications and may allow postponement of elective surgery for some painful conditions that are common in older adults. Traditionally, conservative NP interventions have not been well utilized in the management of some diagnoses associated with pain in older individuals (e.g. osteoarthritis of the hip) (Shrier et al., 2006). Among the NP/non-surgical interventions rated at 89% or higher on strength of research in the Osteoarthritis Research Society International consensus guidelines for management of hip and knee osteoarthritis were: education, exercise, weight control, walking aides and referral to physical therapy for evaluation and instruction (Zhang et al., 2008). Interestingly, in a recent study of almost 600 community-dwelling older adults, NP approaches were used more frequently (68%) than pharmacological approaches (49%) to manage persistent pain (Stewart et al., 2013).

This chapter reviews evidence regarding the effectiveness of conservative interventions commonly used to control pain experienced by older people (i.e. individuals aged 55 years and more). Interventions discussed include assistive devices and orthotics, massage, electrical stimulation, thermal agents and exercise. Information from systematic reviews focused on diagnoses common for older people, and randomized control trials (RCTs) limited to older individuals are emphasized. Theoretical mechanisms of action for these interventions in controlling pain are outlined in Box 67.1 (Barr, 2000), which can be used to provide rationale for the selection and application of specific interventions.

Properly selected and fitted assistive or orthotic devices act to limit mechanical forces that would otherwise stimulate pain at a site of pathology, inflammation or trauma (see Box 67.1). Canes and walkers are among the most common assistive devices used by older individuals with pain. Hip joint contact forces can be reduced by more than 30% using a cane held in the hand opposite to the involved hip. Raised seats on toilets and chairs act to limit joint forces at the hips and knees during push-off from a seated position. However, assistive devices that are improperly fitted or used incorrectly can act to increase pain (Abdulla et al., 2013).

Impact-absorbing shoes may help to relieve foot, ankle, knee and hip pain from osteoarthritis (OA). Hodge et al. (1999) assessed foot orthotics (prefabricated, standard custom molded, custom with metatarsal bar, custom with metatarsal dome) for older patients with rheumatoid arthritis (RA). Pressure at the first and second metatarsal heads was significantly reduced by all orthoses tested. The standard custom molded and dome orthoses significantly decreased walking pain. However, only the dome orthosis significantly decreased pain during standing, and it was preferred by the majority of patients. A pilot study by Seligman and Dawson (2003) demonstrated that a combination of customized heel pads and soft orthotic inserts produced a significant decrease in heel pain from plantar fasciitis.

Knee pain from medial compartment OA may be decreased by the use of lateral heel wedges in shoes. These wedges shift more of the joint loading to the lateral side of the knee. With medial femorotibial osteoarthritis, Maillefert et al. (2001) found that, when compared with neutral insoles, laterally wedged insoles were associated with significantly decreased nonsteroidal anti-inflammatory drug (NSAID) consumption at 6 months. However, scores on Western Ontario & McMaster Universities Osteoarthritis (WOMAC) index subscales for pain, joint stiffness and physical function did not differ significantly for the two types of insoles. In a 2-year follow-up, Pham et al. (2004) found essentially the same outcomes, and no significant difference in the rates of joint space narrowing. Interestingly, using lateral wedges in combination with subtalar straps for 6 months, Toda and Tsukimura (2004) demonstrated significant decreases in both the femorotibial angle and pain but no significant changes with traditional insoles. Knee braces incorporating a varus unloader increase femorotibial separation during walking and can be used for unicompartmental knee pain, but these have not been found to be effective for obese patients with knee OA (Buckwalter et al., 2001). Systematically reviewing brace and orthotic effectiveness in the treatment of knee OA, Brouwer et al. (2009) concluded that a brace or laterally wedged insoles have a ‘silver’ level of evidence for a small beneficial effect on pain; however, long-term adherence for either was low. Most recently, Shamliyan et al. (2012), as part of an Agency for Healthcare Research and Quality supported analysis, found orthotics to improve knee pain associated with OA.

Spinal orthoses can provide varying degrees of immobilization, plus important tactile cues, for patients with neck and back pain. While a soft cervical collar does little to immobilize, tactile cueing can help a patient with mild spondylosis to limit motion or improve alignment of the cervical spine. For a patient with RA and atlantoaxial subluxation, a rigid Philadelphia collar or a sternal–occipitoandibular immobilizer (SOMI) may be required.

Kyphosis related to spinal osteoporosis often causes chronic upper and middle back pain in older women. A cruciform anterior spinal hyperextension (CASH) orthosis or Jewett hyperextension orthosis can be used to limit spinal flexion. In contrast, an orthosis that limits extension, such as a Williams flexion orthosis, can be used to control pain from spinal stenosis. Compression fractures from spinal osteoporosis may call for a thoracic lumbosacral orthosis (TLSO). Pfeifer et al. (2004) evaluated the ‘Spinomed’, a lightweight perispinal metal orthosis, with an abdominal pad and shoulder straps. It was worn only 2 hours per day by women with osteoporotic vertebral fractures. At the end of 6 months, orthosis wearers demonstrated: a 38% decrease in ‘average’ pain; a 27% decrease in limits of daily living; an 11% decrease in kyphotic angle; a 25% decrease in sway; and an increase of 73% in back extension and 58% in abdominal flexor strength.

Massage is defined as the intentional and systematic manipulation of soft body tissues to enhance health and healing (Benjamin & Tappan, 2005). There are many varieties of massage, ranging from the comfortable and gentle superficial stroking of effleurage, to the invigorating kneading of petrissage, to uncomfortable forms of deep friction massage. Potential mechanisms underlying pain relief with these various forms of massage are noted in Box 67.1.

A limited number of studies on massage have been conducted exclusively with older individuals. Sansone and Schmitt (2000) had trained certified nursing assistants (CNAs) to provide ‘tender touch’ massage to older nursing home residents suffering from chronic pain and dementia over a period of 12 weeks. Patients experienced decreased pain and anxiety scores, and the CNAs reported improved ability to communicate with the residents. Mok and Woo (2004) determined that 10 minutes of nightly slow stroke back massage given to hospitalized patients with shoulder pain after cerebrovascular accident was associated with significantly decreased pain and anxiety that lasted for up to 3 days when compared with a control group.

Clinical electrical stimulation as done by rehabilitation professionals uses electrodes placed on the surface of the skin to stimulate nerves transcutaneously. More specifically, transcutaneous electrical nerve stimulation (TENS) involves the stimulation of cutaneous and peripheral nerves to control pain. At least six types, or ‘modes’, of TENS have been described in the literature: conventional (or ‘high frequency’), strong low-rate (or ‘acupuncture-like’), brief intense, pulse-burst, modulated and hyperstimulation (see Table 67.1) The potential mechanisms of action for these TENS modes are noted in Box 67.1.

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Skeletal muscle function in older people Neurocognitive disorders Complementary therapies for the aging patient Rehabilitation after stroke Gait training Wound management

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