How can nonpharmacologic interventions help my pain?

Pharmaceuticals, although convenient, timely, and affective- are not always the best option. The practitioner must use clinical reasoning and critical thinking skills in the administration of pain medications in a critically ill patient to prevent serious side effects and adverse reactions. Likewise, they have both the ethical and legal responsibility to provide safe, quality, and accountable pain management. The use of nonpharmacologic interventions in pain management is vital in the long-term prevention and/ or mitigation of pain.

Spinal cord stimulation has been used to effectively treat chronic pain of varied origins. Spinal cord stimulation is commonly used for control of pain secondary to failed back surgery syndrome and complex regional pain syndrome, as well as pain from angina pectoris, peripheral vascular disease, and other causes. By stimulating one or more electrodes implanted in the posterior epidural space, the patient feels paresthesia (numbness) in their areas of pain, which reduces the level of pain. Pain is reduced without the side effects associated with analgesic (pain) medications. Patients have improved quality of life and improved function, with many returning to work. Spinal cord stimulation has been shown to be cost effective as compared with conservative management alone. Additionally, transcutaneous electrical nerve stimulation (TENS) and other electrical agents have been used in the treatment of musculoskeletal pain conditions by reducing pain, due to muscle fiber stimulation, vasodilatation, increased blood flow, and hyperemia. TENS as an analgesic current is commonly used in pain clinics or at home by patients themselves and commonly is correlated with improved physical functionality within one month after the completion of the therapy program.  Similar effects have been shown using laser therapy and ultrasound. A study by Kim et al. in the journal of therapeutic science demonstrated that patients with shoulder impingement syndrome and knee osteoarthritis and showed a significant reduction in pain after 4 weeks of laser light therapy.

Chiropractic and physical therapy treatment methods such as chiropractic osteo-manipulation, soft tissue mobilization, as well as fascial release through cupping and other methods show promising effects in the reduction of pain by restoring proper kinematics and movement patterns, joint interdependence, and capsular freedom. In one study on chiropractic intervention by Peterson et al. patients reported feeling “much better” or “better” on the Patient Global Impression of Change scale at 1 week after the first chiropractic visit with continual improvements with further treatment. Patients with acute pain reported more severe pain and disability initially but recovered faster upon continued intervention. This may be due to the initial aggravation of the tissues, but with the proper input and force to the cells they will begin to adapt and realign with the intended methods. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy (pinched nerves) also improved. Furthermore, movement-based therapies and hands on manipulations, when aimed to target the lymphatic system can have profound effects on pain. Proper Lymph drainage is essential for the body to clear away toxins and cellular debris. When this system becomes inflamed or becomes placid, it can affect the surround neurovascular tissues resulting in hypoxia (low oxygen), neuralgia, and pain. In a study by Gody et al. it was demonstrated that manual lymph drainage is shown to be effective to reduce edema (swelling) and pain in resulting from a traumatic injury and musculoskeletal disorders. Likewise, acupuncture treatment most often takes place outside conventional health care settings in many countries, although this does not discredit their potential use for pain relief and treatment for several varying cases of muscular rheumatism, chronic pains, and neuralgia. Some of these pain management methods can be covered by insurance such as physical therapy, while others such as acupuncture tend to not be covered. Because various alternative treatments have not been recognized by insurance providers to be a significant and effective fact-based method of pain management they are not selected as a therapy approved to be paid for by their agency. This makes the financial cost, often expensive, of seeing these practitioners a burden. Additionally, the treatment time-frame typically is at least a month long and often requires office visits which demands the patients time which is commonly not a commodity for most individuals, especially those with families.

Nonpharmacologic pain management doesn’t have to be expensive though. Distracting the mind as a nonpharmacologic intervention has been shown to be a cost-effective method of addressing pain management and encouraging cooperation in children. Behavioral (eg, rehearsal, coaching), cognitive (eg, distraction, preparation), complementary (eg, medical and therapeutic art and playing), and physical (eg, positioning for comfort, heat/cold therapy, exercise) are all cheap and effective ways to manage pain. Determining which are best depends on the individual’s developmental level as well as how the person has coped with prior painful experiences. Catastrophizing, when individuals magnify the experience of pain, is associated with increased pain reports in children and adults alike. However, when taught coping promoting behaviors one is able to lower distress. Video games, tablets, books, and music are modalities to help distract oneself from pain.

Mindfulness-meditation, is a mind-body intervention combining focused attention on the breath with a reduction in the awareness of external sensations and consequent thoughts which has been shown by many studies as an effective approach for pain relief.  Brain imaging studies have also shown that similar brain areas are activated during both mindfulness meditation and pain-modulation techniques mediated by opioid receptors. Through this practice there is a great reduction in nociceptive processing in the thalamus (area of the brain) and noxious stimulation correlating with reductions in pain. Additionally, mindfulness meditation has been found to improve a wide spectrum of cognitive and health outcomes. Training in mindfulness meditation improves anxiety, depression, stress, and cognition. Mindfulness meditation attenuates the experience of pain by modulating expectations, the nature and orientation of attention toward the experience, and the corresponding emotional response. Likewise, various breathing techniques have shown to be effective at reducing pain by systemically relaxing the body, reducing muscle tone, and reducing oxidative and acidic stress. These methods are so far reaching that school-aged patients and geriatrics alike can be coached in deep breathing, and members of the medical team can use counting to encourage longer, deeper breaths that help to lessen pain. A classic method is box-breathing where the individual is instructed to breath in for 3 seconds, hold for 3, out for 3, and hold for 3. This can be increased or decreased upon the individual’s capacity or readiness.

The benefit from having heat or cold applied to areas of pain are well documented. Additionally, this has the psychological advantage of being a visible method of aid in which the patient can actively participate. Ice with compression provides relief from pain and is a readily available, simple, safe and inexpensive approach to pain management, by increasing the pain threshold, decreasing the use of analgesics and anti-inflammatory agents, relaxing spasms, increases mobility, and decreases the duration of hospital stay if needed.

Oxidative stress results from an imbalance between reactive oxygen species (ROS) production and antioxidant defense systems. ROS have been implicated in many degenerative neurologic conditions, such as Alzheimer’s disease and Parkinson’s disease, and oxidative stress may also contribute to pain in various diseases, including fibromyalgiadiabetes. Data suggest that oxidative stress may contribute to the nociceptive (pain) features. Clinical evidence suggests that vitamin C may protect against the development of complex regional pain syndrome (CRPS) and nociceptive and vascular changes. Administration of these agents significantly reduced fracture/cast- muscle pain. Clinical studies suggest that the oral administration of the antioxidant vitamin C reduces the incidence of CRPS after trauma and surgery. 

Likewise, recent interventional studies have shown promising effects of vitamin D supplementation on cancer pain and muscular pain—but only in patients with insufficient levels of vitamin D when starting intervention. Mechanisms for vitamin D in pain management are the anti-inflammatory effects mediated by reduced cytokine and prostaglandin release and effects on suppressing T-cell (immune cell) responses. Vitamin D may constitute a safe, simple and potentially beneficial way to reduce pain among patients with vitamin D deficiency. Vitamin D might influence nociceptive and inflammatory pain whereas low vitamin D levels have been associated with increased pain and higher opioid doses. Vitamin D is a hormone mainly synthesized in the skin in the presence of sunlight, thus increasing morning an evening sunlight exposure can further help alleviate pain. Sufficient vitamin D levels are important not only for a healthy skeleton but also for a healthy immune system. Additionally, dietary interventions, such herbs, supplementation, and eating an anti-inflammatory diet all seems to play a role in the reduction of pain.

Currently there is no road map for a comprehensive approach to pain management that included both pharmacologic and nonpharmacologic strategies. Pain as a 5th vital sign has made providers take their eye off the more complex goals of quality of life and overall functional ability, the system inadvertently contributed to reduced functioning and increased suffering of pain. The pressure to manage pain scores rate than to treat patients themselves has contributed to overprescribing opioids, widespread drug diversion, the resurgence of heroin addiction, increased disability from pain and deaths from overdose. Pain scores do not deliver accurate information about the status of a patient and pain scores do not always capture the level of function or quality of life. Poorly controlled and persistent pain leads to adverse outcomes including functional impairment, cognitive failure, depression, falls, sleep and appetite disturbances, and unnecessary health care use and expenses.

There are many different avenues and treatment protocols to reduce and manage both acute and chronic pain. It is essential that individuals become familiar with not only the pharmacologic but also the many varying nonpharmacologic interventions. It is further important that the people understand the side-effects of certain treatments, communicate effectively with their practitioners to establish the best line of treatment. No one person should be treated the same and no one person should receive a standardized treatment based solely upon literature. Although, clinical based evidence is important, it is crucial that a patient-centered approach be put into effect- selecting treatment protocols that will be most effective, with the least financial, social, and physiologic burden.

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