ATrain Education

 

Continuing Education for Health Professionals

Pain: Healthcare’s Persistent Challenge

Module 15

Non-Pharmacologic Approaches to Pain Management

Professionals approaching pain management from a non-pharmacologic perspective use diverse techniques to address the needs of their clients. Those trained within the traditional, Western medical model include physical and occupational therapists, doctors of osteopathy, chiropractors, psychologists, mental health practitioners, physiologists, and athletic trainers and kinesiologists, among others. Many Western-trained practitioners are adding alternative techniques to their practices.

Alternative practitioners make up an ever larger piece of the pain management universe. Most are trained in what would be considered complementary and alternative medicine and many are being included in Western medicine under the increasingly popular and effective approach called integrative medicine. Alternative practices include traditional Chinese medicine, acupuncture, cognitive-behavioral practices, meditation, hypnotherapy, massage therapy, and body-based practices such as yoga, Tai Chi, and Feldenkrais, among others.

Approaches overlap and professions argue about who does what and even who can do what. For example, physical and occupational therapists are using pain management techniques once exclusively in the domain of chiropractors, acupuncturists, and doctors of osteopathy. Nurses and doctors are encouraging patients to use mindfulness meditation, yoga, and other alternative practices to manage pain. In almost every profession, the amount and breadth of education and training has increased, and with it many innovative approaches and practices are competing with the traditional, pain-medicine model. The development of interdisciplinary, integrative pain management programs, which draw on the expertise of multiple disciplines, is perhaps one of the most encouraging developments in the field of pain management.

Interdisciplinary Pain Rehabilitation

Interdisciplinary pain rehabilitation programs are becoming more common, especially for the treatment of chronic pain. A growing body of literature supports the immediate and long-term benefits of the interdisciplinary rehabilitation approach. In this model, healthcare professionals work from the same facility, with daily meetings about the patients’ progress, sharing the same treatment vision and passing the same message to the patients (Kurklinsky et al., 2016).

In one such program at the Mayo Clinic Comprehensive Pain Rehabilitation Center in Jacksonville, Florida, the overall goal is to improve function in people with chronic pain. The physical therapy component focuses on general reconditioning with graded exposure to activity, gradual reduction of fear-avoidance behaviors, and incremental elimination of other pain behaviors. Daily exercise sessions include a morning stretch group, which incorporates 15–20 minutes of whole-body active range of motion, gentle dynamic stretching, moderate static stretching, balance, and coordination training. Cardio and strength groups are also performed. During cardio group, each patient’s goal is to complete 20–30 minutes of moderate conditioning activities within an age determined target heart rate zone followed by 5–10 minutes of static stretching. During strength group, each patient uses free weights, resistance bands, or body weight resistance to complete a whole-body strengthening and stability circuit (Kurklinsky et al., 2016).

The occupational therapy component focuses on the role of moderation and balance in daily activities. The overall goal is to increase functional independence and improve participation in life roles. Group lecture topics include home safety and modification, body mechanics and ergonomics, cleaning and yard work strategies, cognitive strategies, driving, fall prevention, self-care, shopping, time management, and vocational training. Each Friday, the occupational therapists lead a time management session for weekend planning to help patients appropriately moderate their schedule and balance activity during their time away from the structured program. Midway through the program, an OT meets with each patient to begin planning his or her days immediately after the program. There are also three individual biofeedback sessions during which patients learn diaphragmatic breathing and muscle relaxation and how to utilize these strategies during daily activity and functional mobility (Kurklinsky et al., 2016).

A pain psychologist leads up to three group therapy sessions each day. Discussion topics include anger, anxiety, fear, assertiveness, behavior change, central sensitization syndrome, cognitive behavioral therapy, identifying pain cycles, coping with pain and depression, difficult-day planning, distraction, drug interventions, forgiveness, goal setting, grief, maintaining lifestyle changes, pain behaviors, perfectionism, personal responsibility, problems solving, relationships, relaxation, self-esteem, sleep, stress, and withdrawal. There are also weekly question and answer sessions for the group members with no scheduled topic and weekly sessions for family and friends to learn about the pain rehabilitation program and ask questions. There are also work groups for distraction and difficult-day planning, nutrition, posture, and pain rehabilitation program tools (Kurklinsky et al., 2016).

Throughout the three-week program, nurses serve as patient care coordinators. They take the lead in medication management and tapering (under the direction of a physician). With patient authorization, nurses in the program also communicate with primary and specialty care providers outside of the pain rehabilitation team to assist with continuity of care into the future (Kurklinsky et al., 2016).

Physical and Occupational Therapy

Physical and occupational therapists (PTs and OTs) have long been involved in pain management. Starting in World War I, “reconstruction aides” began to develop their profession by tending to soldiers on the battlefield and those returning from war. Since that time, PTs and OTs have significantly expanded their scope of practice, education, and training. As movement specialists, they play a key role in the assessment and management of pain.

Physical and occupational therapists are particularly well-positioned to assume an educational role for patients related to healthy lifestyles and exercise. They encourage a model of care based on health, which includes initiating and supporting behavior change, optimal nutrition, weight reduction, reduced sedentary activity, and increased physical activity. As nonpharmacologic practitioners, therapists integrate health education into practice, including initiating and supporting smoking cessation, improved sleep hygiene, and stress management (Dean & Hansen, 2012).

Physical and occupational therapy generally involves one-on-one sessions, which can include manual therapy, movement analysis, or supportive technologies and equipment that assist the client in mobilizing and strengthening muscles, or improving motion in tendons, joints, and connective tissue. Patient education plays a key role in rehabilitation therapy with emphasis on body mechanics and changing habits and patterns of movement that lead to pain and dysfunction.

Physical and occupational therapists provide expertise in the use of assistive devices, orthotics, braces, as well as positioning devices, which designed to improve function, support areas of weakness, and reduce pain. Patients are referred to rehabilitation therapy following surgery, stroke, accidents, and illness and for education and training, with the goal of helping patients return to or even improve their prior level of function. In some states, a person can see a PT without a doctor’s referral, a practice referred to as direct access.

Clinical practice guidelines are becoming the standard of practice for physical and occupational therapists. In a review of guidelines for the treatment of low back pain, adherence to physical therapy clinical practice guidelines has been shown to play an important role in certain measures of healthcare utilization and costs. With a few exceptions, those patients with low back pain who were treated by therapists using accepted clinical practice guidelines had lower overall healthcare utilization including fewer PT visits, shorter duration of care, fewer prescription medications, fewer physician or emergency department visits and less use of advanced imaging and injection procedures. Also, decreased costs have been associated with prescription medications, surgical procedures, and total low back pain related costs for those patients with low back pain treated by guideline-adherent physical therapy interventions (Hanney et al., 2016).

Therapeutic Exercise

Both PTs and OTs make extensive use of therapeutic exercise in the treatment of pain. Therapeutic exercise is an active treatment designed to address pain, maintain or improve strength and range of motion, increase blood flow, improve proprioception, and prevent muscle guarding, spasms, and contractures. Exercise programs directed by a physical or occupational therapist are tailored to the individual patient, based on assessment of impairments, patient preference, and co-morbidities.

Low back pain, neck pain, migraine, and other musculoskeletal disorders are 4 of the top 10 causes of disability worldwide (Lancet, 2015). By far, the most common reason for a referral to physical therapy is for low back pain, and often the pain has no structurally identifiable cause. Exercise therapy has been shown to be particularly effective for patients with low back pain. Results indicate that exercise therapy decreases pain intensity, alleviates disability, and improves physical functions for a long period (eg, 12-month followup) (Ishak et al., 2016).

Meta-analyses have also been conducted on the effectiveness of exercise as low back pain treatment. In 2006 researchers systematically reviewed trunk strengthening exercise and revealed that this exercise can alleviate pain and improve functions more effectively than aerobics and other exercises. Others have reported that progressive resistance exercise is effective and safe for patients experiencing muscle force deficiency and pain-related problems and that exercise improves the ability of patients to perform daily life activities (Ishak et al., 2016).

Proprioceptive training, in which passive and active sensory feedback exercises are used to improve motor function, may be more effective than traditional exercise in the treatment of low back and neck pain. Proprioception relates to our conscious awareness of where our body and limbs are in space. Proprioception also has unconscious components, for example it is associated with the control of posture, balance, and muscle tone.

In a systemic review of proprioceptive training techniques, researchers identified five main categories of proprioceptive-based interventions:

  1. Active movement/balance training (single-joint active movements, single-joint passive and active movements, multi-joint passive and active movements, multi-joint active movements, and whole body balance training)
  2. Passive movement training (passive motion apparatus focused either on single-joint or multi-joint movement)
  3. Somatosensory stimulation training (muscle or vibro-tactile vibration ranging from whole-body vibration to local vibration of a single segment, thermal stimulation, multi-somatosensory stimulation, magnetic stimulation, electrical stimulation, and acupuncture)
  4. Somatosensory discrimination training (active exploration of objects with the hand, tactile discrimination of textures, wrist or ankle joint position discrimination, and wrist joint velocity discrimination tasks)
  5. Combined/multiple system training (multiple components of the three main categories mentioned above or multi-sensory approaches) (Aman et al., 2015)

For patients with musculoskeletal conditions such as chronic neck pain, knee ligament reconstruction, ankle injury, and osteoarthritis, training consisted of active multi-joint or whole body movement as well as whole body balance training. Among the musculoskeletal conditions, proprioceptive training proved most beneficial for improving function in knee osteoarthritis, leading to significant functional improvement (Aman et al., 2015).

Transcutaneous Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) is widely used all around the world for relieving a variety of painful conditions. Controlled clinical trials have clearly demonstrated that TENS has a specific antalgic effect (relieves pain), but the intrinsic mechanism remains largely unknown. For this reason, clinically TENS is largely used by trial and error, and the optimal setting of stimulation parameters is still a matter of debate (Buonocore et al., 2013).

TENS Apparatus

image: Transcutaneous Electrical Nerve Stimulator

Transcutaneous Electrical Nerve Stimulator. Source: Wikipedia.

The term TENS covers a variety of techniques that use electrical stimulation of the skin for pain control. HF-TPNS (high-frequency transcutaneous peripheral nerve stimulation) is a subtype of TENS, where the trunk of a peripheral nerve is electrically stimulated at high frequency using surface electrodes. Accurate placement of electrodes is commonly considered very important for pain relief (Buonocore et al., 2013).

TENS has been shown to relieve pain effectively in cases of musculoskeletal pain, arthritic pain, low back pain, neuropathic pain, and post operative pain. Some studies have reported that the application of TENS improves motor function (Suh et al., 2015).

Therapeutic Ultrasound

Therapeutic ultrasound is among the most commonly used physical modalities for treating soft tissue injuries and pain. It involves the use of ultrasonic sound waves applied directly to a patient’s skin, which causes the underlying tissue to vibrate and mildly heat, improving blood flow to the affected tissue. It is delivered using a hand-held, rounded wand in either of two modes: (1) continuous mode, in which the delivery of ultrasound is nonstop throughout the treatment period; and (2) pulsed mode, in which the delivery of ultrasound is intermittently interrupted (Ebadi et al., 2012).

The therapeutic effects of ultrasound are classified as thermal and nonthermal. Ultrasonic energy causes soft tissue molecules to vibrate from exposure to the acoustic wave. This increased molecular motion generates frictional heat and consequently increases tissue temperature. This thermal effect is thought to cause changes in nerve conduction velocity, increase in enzymatic activity, changes in contractile activity of skeletal muscles, increase in collagen tissue extensibility,* increase in local blood flow, increase in pain threshold, and reduction in muscle spasm (Ebadi et al., 2012).

* Extensibility means the ability of muscles to be stretched to their normal resting length and beyond, to a limited degree.

The nonthermal mechanical effects are proposed to be achieved through the application of pulsed, low-intensity therapeutic ultrasound. A number of studies using animal models of cartilage injury to evaluate the effect of therapeutic ultrasound on the rate of cartilage degeneration have shown benefits. In some of these in vitro studies, pulsed low-intensity therapeutic ultrasound—with temporal average intensities achievable using devices widely available in physical therapy practice—has been used with beneficial effects on cartilage repair (MacIntyre et al., 2013).

In other studies, very-low-intensity pulsed therapeutic ultrasound, such as that used in bone healing systems, has been used. Very-low-intensity pulsed ultrasound slowed progression of cartilage degeneration in the guinea pig model of idiopathic osteoarthritis—particularly in those guinea pigs with early rather than established degeneration. The studies in the animal models suggest that very-low-intensity pulsed ultrasound could stimulate the repair of injured cartilage and, if applied at early stages, may slow the progression of knee osteoarthritis (MacIntyre et al., 2013).

Heat/Cold Therapy

The application of heat and cold to reduce pain or promote comfort is a common intervention. However, there are few studies investigating the impact of heat or cold on pain or function. A meta-analysis of heat and cold for low back pain concluded that continued intermittent use of heat (over a 5-day period) reduced pain intensity and improved function.

Cold therapy includes cold packs, cold baths, vapocoolant sprays, cold compression, continuous-flow cold therapy, and ice massage. Cold alters the pain threshold, reduces local swelling, decreases tissue metabolism and bleeding, and decreases muscle spasm and spasticity. Cold may be contraindicated in patients who are hypersensitive to cold (as in Raynaud’s phenomenon), have marked hypertension, have arteriosclerosis, or have diminished circulation.

Heat can usually be initiated 48 hours following an operation or injury, and is commonly used in combination with other treatments. Thermal agents are used to apply heat superficially or as deep-heating applications. Superficial methods include hot packs, warm whirlpools, and paraffin. Deep heat, such as ultrasound, can increase the temperature of the tissues 3 to 5 centimeters in depth. Heat has the advantage of inducing relaxation and decreasing joint stiffness, muscle spasm, and guarding. It assists in increasing range of motion and increases superficial circulation.

Dry Needling

Dry needling is the penetration of a needle through the skin without introduction of any drug (Chou et al., 2012). Dry needling uses a thin, flexible needle to stimulate underlying myofascial trigger points,* and muscular and connective tissues for the management of neuro-musculoskeletal pain and movement impairments. Dry needling is used by physical therapists to treat pain and reduce or restore impairments of body structure and function (APTA, 2013).

*Trigger point: a hyperirritable nodule or knot in the fascia surrounding the muscle.

Although there is strong evidence to support the use of dry needling in the treatment of various neuromuscular pain syndromes, the American Physical Therapy Association and several state boards of physical therapy have narrowed their definition of dry needling to an “intramuscular” procedure. More specifically, these professional organizations have equated the procedure of dry needling with the terms intramuscular manual therapy (IMT) or trigger point dry needling (TDN) (Dunning et al., 2014).

In June 2016 the American Medical Association adopted a policy directing that physical therapists and other non-physicians practicing dry needling should—at a minimum—have standards that are similar to the ones for training, certification, and continuing education that exist for acupuncture. “Lax regulation and nonexistent standards surround this invasive practice. For patients’ safety, practitioners should meet standards required for licensed acupuncturists and physicians,” announced AMA board member Russell W.H. Kridel (AMA, 2016c).

Manual Therapy

Manual therapy is an important and specialized area within many professions, particularly physical therapy, osteopathy, and chiropractic. Manual therapists use a variety of nonsurgical techniques directed to the patient’s spine and extremities for the purpose of assessing, diagnosing, and treating various symptoms and conditions. Manual therapy techniques can be categorized into four major groups: (1) manipulation (thrust manipulation), (2) mobilization (non-thrust manipulation), (3) static stretching, and (4) muscle energy techniques. The definition and purpose of manual therapy varies across healthcare professionals (Clar et al., 2014).

Manual therapists mobilize areas of the spine or other painful joints using their hands, forearms, or elbows to apply a force with a therapeutic intent. Manual therapy approaches and techniques include massage, joint mobilization/manipulation, myofascial release, nerve manipulation, strain/counterstrain, and acupressure (Smith, 2007).

Spinal manipulation and mobilization are commonly used treatment modalities for back pain, particularly by physical therapists, osteopaths, and chiropractors. Their use has been steadily increasing in the West. For example, in the United States, 33% of people with low back pain are treated by a chiropractor. A United Kingdom-based study surveyed the use of chiropractic/osteopathy services for back pain in a randomly selected sample of adults aged 18 to 64 years living in four counties of England. Of the respondents with back pain, 13.4% had consulted with osteopaths or chiropractic practitioners (Clar et al., 2014).

A 2010 review of scientific evidence on manual therapies for a range of conditions concluded that spinal manipulation or mobilization may be helpful for several conditions in addition to back pain, including migraine and neck-related headaches, neck pain, upper- and lower-extremity joint conditions, and whiplash-associated disorders. The review also identified a number of conditions for which spinal manipulation or mobilization appears not to be helpful (eg, asthma, hypertension, menstrual pain) or the evidence is inconclusive (eg, fibromyalgia, mid-back pain, premenstrual syndrome, sciatica, temporomandibular joint disorders) (NCCIH, 2012).

Mobilization

Mobilization is a manual therapy technique applied to painful or restricted joints that uses low grade, low velocity, small or large amplitude passive movement and neuromuscular techniques within a patient’s range of motion. Mobilization is typically used by physical and occupational therapists and chiropractors, often in conjunction with patient education, heat/cold therapy, and therapeutic exercise.

One such mobilization technique was developed by Geoffrey Maitland, an Australian physiotherapist who developed a system of manual therapy for the treatment of joint and back pain. In this technique, joint mobilization is gently applied by hand following a thorough and detailed subjective and objective physical examination. Mobilization involves a nearly imperceptible (Grade I) or slightly more forceful (Grades II, III, and IV) oscillation of the affected joint.

The gentle oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brainstem levels. These non-stretch motions help move synovial fluid to improve nutrition to the cartilage (Kumar et al., 2012).

Gentle mechanical force during mobilization may include breaking up of adhesions, realigning collagen, or increasing fiber glide when specific movements stress specific parts of the capsule. Mobilization techniques may increase or maintain joint mobility by inducing biologic changes in synovial fluid (Kumar et al., 2012).

Mobilization has an effect on blood flow in the vessels supplying the nerve fibers and synovial fluid surrounding damaged, avascular articular cartilage. This facilitates an exchange of fluid, which increases venous drainage and disperses chemical irritants. Mobilization causes a reversal of the ischemia-edema-inflammation cycle and reduces joint effusion. It also relieves pain by reducing the pressure over the nerve endings (Kumar et al., 2012).

Manipulation

The velocity of the technique has been the subject of great debate. The merits of high-velocity techniques (thrust techniques) have been compared to low-velocity techniques (non-thrust techniques). Some have described high-velocity techniques as manipulation and low-velocity techniques as mobilization while others consider these terms synonymous (Smith, 2007).

It is thought that spinal manipulation affects muscles, tendons, ligaments, and fascia, altering orientation or position of anatomic structures, unbuckling some structures, releasing entrapped structures, or disrupting adhesions. In 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options for practitioners to consider when low back pain does not improve with self-care. A 2010 Agency for Healthcare Research and Quality (AHRQ) report noted that complementary health therapies, including spinal manipulation, offer additional options to conventional treatments, which often have limited benefit in managing back and neck pain. The AHRQ analysis also found that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity (NCCIH, 2013).

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