Alternative Therapies and Modalities

As the saying goes, “a carpenter is only as good as his tools.” Years of education and clinical practice have given you the knowledge and insight to know how to treat your patients’ musculoskeletal pain. Now, you need to decide what tools you’ll keep in your toolbox that not only get the job done, but get you the most bang for your buck!

Aside from products like kinesiology tape, elastic resistance, topical analgesics and thermal therapy, there’s a wealth of alternative therapies and modalities you can use to compliment your care and set yourself apart from the competition. Learn about these recommended tools that you can easily integrate into your clinic, but keep in mind that some of these options have weak evidence to support their efficacy in pain relief. Identify the products you think would work best for your patients and test them out; you’ll never know until you try!

Soft Tissue Mobilization


Instrument assisted soft tissue mobilization (IASTM) has exploded in popularity over the last few years, but manual therapy has been around for ages. Multiple studies have shown that manual therapy can enhance traditional clinical care to deliver elevated pain relief,1,2,3,4 and IASTM makes it that much easier by enabling you to perform soft tissue interventions and avoid pain of your own. Think of the tools as an extension of your hands; you’re delivering an intense, targeted treatment to the tissue, yet your hands are experiencing significantly less stress and fatigue. This allows you to give more pain relief with less effort!

One of the strongest proposed mechanisms of IASTM for pain reduction is the Gate Control Theory5, as well as a “vascular/circulatory effect that improves blood flow and removal of metabolites6.” IASTM is used to treat patients with soft tissue dysfunction, including tendinopathy, fasciopathy, myofascial pain/trigger points, nerve entrapment, ligament injury, adhesions and scar tissue6.

Can Instrument Assisted Soft Tissue Mobilization (IASTM) Eliminate Pain?

Dry Needling


Dry needling has recently broken through in multiple clinical segments (albeit, controversially). Think of dry needling as the cousin of acupuncture. Instead of basing the practice off of eastern ideals like meridians and yin and yang, dry needling is practiced based on western medicine principles such as anatomy, physiology and neuropathology6. Physical therapists, chiropractors, athletic trainers and more are using dry needling as a method of pain management, and research is catching up to prove its adequacy.

Now onto the mechanisms of pain relief. When a needle is inserted into the skin, adenosine, hydrogen and nitric oxide is released into the interstitial fluid.

“This vasodilation is thought to bring an increase in blood volume to an area. It is believed that this increased blood flow essentially dilutes inflammatory markers in the area, and brings in fresh, oxygenated blood needed for healing. Calcium gene-release peptide (CGRP) is also released at the site of needle insertion. CGRP is a local anti-inflammatory and antinociceptive peptide. This local sensation is perceived in the peripheral nervous system, and signals the release of enkephlin in the dorsal horn of the spinal cord. Enkephlin is an anti-nociception pentapeptide. Finally, the spinal cord communicates with the brain to release the beta-endorphin, neuropeptide6.”

Research has also shown that dry needling can be effective in managing myofascial trigger point pain in the neck and shoulders7 myofascial pain in the upper quarter8 and for myofascial pain syndrome9. Sensing a pattern here? If practicing dry needling is legal in your state, try it out on patients with myofascial pain!

When to Use Dry Needling for Pain Relief



We’ve all seen elite athletes on television with those circular bruises. Cupping uses glass, plastic, bamboo or silicone cups to suction onto the skin, creating a vacuum. This negative pressure is thought to release deep tissues, relax stiff muscles and increase blood flow under the affected area, therefore creating the mechanism to relieve pain. Cupping is often used in conjunction with dry needling to deliver extended results.

While there is a mixture of research substantiating the use of cupping for pain relief, a systematic review concluded:

“Two randomized clinical trials suggested significant pain reduction for cupping in low back pain compared with usual care and analgesia. Another two randomized clinical trials also showed positive effects of cupping in cancer pain and trigeminal neuralgia compared with anticancer drugs and analgesics, respectively. Two randomized clinical trials reported favorable effects of cupping on pain in brachialgia compared with usual care or heat pad. The other randomized clinical trials failed to show superior effects of cupping on pain in herpes zoster compared with anti-viral medication. Currently there are few randomized clinical trials testing the effectiveness of cupping in the management of pain. Most of the existing trials are of poor quality. Therefore, more rigorous studies are required before the effectiveness of cupping for the treatment of pain can be determined10.”

For patients dealing with pain and dysfunctions in nerves or muscles, add cupping to your treatment plan for a potential boost in pain reduction.

How Cupping Differs from Other Soft Tissue Interventions

Foam Rolling


Most of your patients are probably familiar with myofascial rolling; they just might not know it. Foam rollers and roller massagers are commonly used in gyms and on fields around the world as a part of warm up and recovery, but these tools can also be a critical component of musculoskeletal pain management.

There are a few possible mechanisms behind rolling for pain relief. Initially thought to affect muscle and fascia, researchers are finding that neurological mechanisms may play a large role in the benefit of myofascial rolling. Pain pressure thresholds increase after myofascial rolling both in the affected area and the contralateral or distal area, suggesting centralized pain modulation during roller massage. Because of the pain associated with roller massage and subsequent reduction in pain, Aboodarda et al. suggested a “diffuse noxious inhibitory control” counter-irritant mechanism, whereby nociceptive sensations to the brain inhibit pain transmission both locally and distantly11.

Roller massage is a type of that massage targets the soft tissue and has been proven to reduce delayed onset muscle soreness (DOMS)12,13 and muscle soreness14. Best of all, foam rollers and roller massagers are portable, cost-effective tools your patients can use outside of your clinic. Have them use these tools to address muscle or fascia pain as needed.



Transcutaneous electrical nerve stimulation is a modality that uses the placement of electrodes onto the skin over an area of pain to deliver electrical currents and impulses along the nerve fibers. Some professionals suggest that the mechanism behind TENS and pain relief is “the electricity from the electrodes stimulating the nerves in an affected area and sending signals to the brain that block or ‘scramble’ normal pain signals. Another theory is that the electrical stimulation of the nerves may help the body to produce natural painkillers called endorphins, which may block the perception of pain15.”

There are limited studies supporting the use of TENS for musculoskeletal pain management, but many physical therapists and athletic trainers utilize TENS with great success. Try offering this treatment in your clinics, and if your patients are satisfied with the results, you can even suggest they purchase a unit of their own for home use.

Frickin' Lasers


Low level laser therapy is another modality used by many clinicians to deliver a variety of patient outcomes, such as pain reduction. Low level laser therapy works by using “low-intensity light energy as a treatment modality to induce a photochemical reaction in cells, a process is known as photobiomodulation. Through photobiomodulation, low level laser therapy is thought to promote tissue regeneration, decrease inflammation and reduce pain. Light (photonic) stimuli excite the body's cells infusing them with energy (through ATP production)6.” There are a variety of lasers on the market that offer diverse wavelengths and features.

Research has shown a high probability of patients with myofascial pain syndromes, shoulder pain, neck pain and DOMS to see significant reductions in pain from low level laser therapy16. Another study suggests that the use of lasers can produce an immediate effect on decreasing acute neck pain for up to 22 weeks after the completion of treatment17. Utilize laser therapies in patients in these populations as a part of your pain management program.

Therapeutic Ultrasound


To the patient, ultrasound is commonly known for use during pregnancy, cardiology exams and more. However, physical therapists, chiropractors, athletic trainers and other professionals are using therapeutic ultrasound to address their patients’ musculoskeletal pain. Professionals are using this modality to generate heat in the tissue to potentially increase blood flow, reduce swelling and relax tight tissues, muscles or joints18.

Therapeutic ultrasound studies are often of low to moderate quality, yielding little clinical evidence to support its use for pain relief. Try ultrasound with patients dealing with any musculoskeletal pain when appropriate.



Paraffin is a great modality used by many hands-on healthcare professionals to treat pain. Commonly used by patients with hand arthritis; this treatment utilizes paraffin wax to deliver heat that loosens achy muscles and joints. Clinicians believe that paraffin works the same way a heat pack might: delivering heat to the affected area increases blood flow and circulation, which relaxes muscles and tissue and oftentimes makes movement easier and less painful. On top of that, the oils used in paraffin treatments give the skin a surge of moisture.

When paired with joint mobilization, paraffin therapy has been shown to improve the symptoms and quality of life in patients with post-traumatic stiff ankle and post-traumatic stiff hand19,20. Use paraffin therapy with your patients dealing with hand, wrist, foot or ankle pain to reduce their symptoms and make them feel like they just came back from the spa!

1. Abbott JH et al. 2013. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial.1:clinical effectiveness. Osteoarthritis Cartilage 21(4):525-34.

2. Abbott JH et al. 2015. The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. J Orthop Sports Phys Ther 45(12):975-83.

3. Celenay ST et al. 2016. A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 46(2):44-55.

4. Deyle GD, et al. 2005. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program Phys Ther 85(12):1301-17.

5. Melzack R, Wall PD. 1965. Pain mechanisms: a new theory. Science. 150(699):971-979.

6. Page P, Bishop, Falsone S. 2016. Alternative therapies in sports physical therapy. (Manske R, Ed) APTA Sports Physical Therapy Section Musculoskeletal Home Study Course.

7. Liu L, Huang QM, Liu QG, et al. 2015. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 96(5): 944-955.

8. Kietrys DM et al. 2013. Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther 43(9):620-634. doi:10.2519/jospt.2013.4668

9. Dunning J et al. 2014. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev 19(4): 252–265.

10. Jong-In K et al. 2011. Cupping for Treating Pain: A Systematic Review. Evid Based Complement Alternat Med. 2011: 467014. doi: 10.1093/ecam/nep035.

11. Aboodarda SJ, Spence AJ, Button DC. 2015. Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Musculoskelet Disord. 16:265.

12. Jay K, et al. 2014. Specific and cross over effects of massage for muscle soreness: randomized controlled trial. Int J Sports Phys Ther. 9(1):82-91.

13. Pearcey GE et al. 2015. Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. J Athl Train. 50(1):5-13.

14. Macdonald GZ et al. 2014. Foam rolling as a recovery tool after an intense bout of physical activity. Med Sci Sports Exerc 46(1):131-42.

15. https://www.webmd.com/pain-management/tc/transcutaneous-electrical-nerve-stimulation-tens-topic-overview

16. Fulop AM, Dhimmer S, Deluca JR, et al. A metaanalysis of the efficacy of laser phototherapy on pain relief. Clin J Pain. 2010;26(8):729-736.

17. Chow RT, Johnson MI, Lopes-Martins RA, et al. 2009. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet. 374(9705):1897-1908.

18. http://abcnews.go.com/Health/TreatingPain/story?id=4047863

19. Rashid S et al. 2013. To evaluate the efficacy of Mobilization Techniques in Post-Traumatic stiff ankle with and without Paraffin Wax Bath. Pak J Med Sci. 29(6): 1406–1409.

20. Sibtain F et al. 2013. Efficacy of Paraffin Wax Bath with and without Joint Mobilization Techniques in Rehabilitation of post-Traumatic stiff hand. Pak J Med Sci. 29(2): 647–650.