Chronic Pain Management: Nonpharmacologic Therapies
ABSTRACT: Nonpharmacologic therapies for managing chronic pain are often underutilized even though it is well accepted that they can both reduce pain and improve functioning. Treatments such as psychotherapy and physical and occupational therapies are especially useful for teaching patients skills that they can use to manage their pain. Finally, there is substantial evidence that acupuncture can also provide relief of pain with minimal risk of adverse events.
Key words: chronic pain, nonpharmacologic therapies, psychotherapies, physical therapy, occupational therapy, acupuncture
There are many therapies for treating chronic pain ranging from medications to invasive techniques, including injections and surgery. Often overlooked and underused are the various nonpharmacologic therapies, such as psychotherapy, physical therapy (PT), occupational therapy (OT), and acupuncture (Table). Because of the limited education most physicians receive on chronic pain in medical school and postgraduate training, they often have little knowledge about the potential role these therapies have in managing this problem, much less any experience in utilizing them.
With the exception of acupuncture, each of these therapies teach patients skills they can use to both manage their pain and, just as importantly, to maximize their levels of functioning. For many cases of chronic pain, there is no easy answer for relieving it, so it is often important to focus on managing the pain rather than seeking a frequently unobtainable cure. Pain can easily destroy patients’ lives by forcing them to be inactive. Therefore, it is vital to provide therapies that can at least enable them to cope as best as possible with the pain and go on with their lives.
Although these therapies, when performed correctly, have virtually no risk of adverse events, they are often not utilized until after patients with chronic pain have undergone more invasive treatments such as injections and surgery. As it is relatively rare that a delay in performing the more invasive therapies will have any detrimental effect on their potential for benefitting the patient, it certainly makes sense to try the more conservative therapies first.
Psychotherapies
Patients with chronic pain often fear that being referred for psychotherapy indicates that their pain is not “real” and is “all in their heads.” Therefore, it is important to educate them that such referrals in no way indicate this and that the psychotherapeutic modalities can be very beneficial regardless of the etiology of the pain.
Psychological problems are common among patients with chronic pain, with a high degree of comorbidity between depression and anxiety and chronic pain.1 Although it is commonly believed that the psychological problems are usually secondary to the pain, in fact pain is a frequent symptom of depressive and anxiety disorders. It has also been established that when both psychological problems and chronic pain are present, each tend to be more severe and difficult to treat. The presence of depression and anxiety can even interfere with the analgesic effects of medications as demonstrated by a study that showed they were associated with a reduction in efficacy of opioid therapy.2
However, even for patients without marked psychological issues, psychotherapeutic techniques can be beneficial for the management of pain alone. Many patients develop concerns and fears that engaging in activities will exacerbate their pain and therefore reduce their activity levels. This in turn can lead to increased pain resulting from a downward spiral of inactivity and deconditioning.
Cognitive-behavioral therapies. Cognitive behavioral therapies (CBTs) have generally been found to be the most efficacious for patients with chronic pain. The goal of CBT is to reorient the way patients think about their problems and develop alternative ways to cope with them.3
Very often patients with chronic pain have limited strategies for what to do when the pain worsens. All they may think of is taking medication or terminating their activities. Furthermore, they may focus on things they were able to do before the pain began and view the future negatively. CBT can enable them to focus on those things they still are able to do and aid them in seeing the future in a more positive light.
Hypnosis, biofeedback, and relaxation techniques. Therapies such hypnosis, relaxation therapy, and biofeedback can aid patients in gaining greater control over the pain and also offer them alternative coping methods.
There are many misconceptions about hypnosis. In contrast to the frequent fictional portrayals in which the person who is being hypnotized falls under control of the hypnotist, the reality is completely different. Hypnosis is simply a state of heightened concentration, suggestion, and relaxation. At no time does the person lose self-control and it is impossible to induce people to do anything they do not want to do. Unless a patient is psychotic and thus might suffer a further sense of loss of reality if hypnotized, it is virtually impossible for those who are hypnotized to suffer any harm from it.
Because patients may be very anxious about how hypnosis works, they may receive limited benefit from the initial session. Once they understand the falsity of fictional portrayals, they are usually much more amenable to hypnosis and can then benefit from it.
Another misconception about hypnosis is that if it is beneficial for pain it indicates that the pain has a psychological rather than a physical basis. In fact, the opposite is true; patients whose pain has a clear physical etiology have been shown to receive more benefit from hypnosis than those whose pain is secondary to psychological factors.4
Deciding what suggestions to use when the patient is being hypnotized should be individualized by interviewing patients before they undergo hypnosis to see what is likely to be most efficacious. Some of the more common techniques are teaching patients to focus attention away from the pain by redirecting their thoughts to some comforting, relaxing scene such as the beach or mountains; by having them imagine that they are being taken back to a time before the pain began; or by considering the site of the pain to be hot and then imagining it being cooled off.
Relaxation is a part of hypnosis but simple relaxation techniques can be taught relatively quickly. The more patients practice these techniques, the more useful they usually find them. The basic technique usually includes muscle relaxation in which patients are asked to tense and then relax different parts of their body. Another method is to focus on breathing.
Biofeedback involves learning how to control what are normally autonomic physiologic functions such as skin temperature, pulse, and muscle tension through the use of instruments that allow patients to be aware of these functions. Biofeedback has been found to be most beneficial for migraine headaches, but it can be utilized for numerous types of chronic pain.5 A criticism of biofeedback is that many patients with chronic pain already over-focus on their bodies and their pain and that a therapy which causes them to focus even more on these may be somewhat detrimental.
Despite the absence of adverse events, there are several drawbacks to biofeedback and hypnosis. Many people are unsuccessful in using hypnosis and biofeedback because they are unwilling to take the time to practice at home the techniques they learn in therapy sessions. Furthermore, it can be difficult for patients to find well-trained practitioners of these therapies because both require separate training to become proficient in using these techniques. Biofeedback also requires practitioners to purchase biofeedback equipment.
In contrast, simple relaxation techniques can be easily learned by clinicians and in turn taught to their patients. Relaxation techniques are also very useful in treating patients with acute pain. Furthermore, relaxation techniques may be beneficial in potentially stressful and painful situations such as when patients are about to undergo surgery.6
Family and group psychotherapies. Two other forms of psychotherapy that can be beneficial for patients with chronic pain, but are infrequently provided outside of formal pain programs, are family and group therapies.
Family members often are confused about the best way to help the pain sufferer. If they do too much for the patient, they may be seen as reinforcing the pain. If they do too little, the patient may accuse them of being unfeeling and unsympathetic. Patients and their families are often unaware of this paradox and, if they are, they may not know how to address it.
Patients with chronic pain are frequently isolated by it. The pain often results in loss of employment or reduction in other activities outside of the home, leaving the patients without the usual daily interactions and support systems. Even those who are able to maintain social interactions outside of the home may find it difficult to talk about the impact of the pain on their lives.
Group therapy provides an opportunity to talk with others who are undergoing similar experiences, diminishing the sense often experienced by patients with chronic pain that no one else really understands what they are going through. Also, group members can use their own experiences to help others to resolve many of the daily problems ranging from physical to psychological to financial that these patients commonly endure.
Physical Therapy
Many different therapies fit under the general heading of PT.7 Some, such as massage and electrical stimulation, are therapies that are performed on the patient; others, most notably exercise, focus on teaching patients skills that can enable them to maximize functioning.
There are some physical therapists who primarily dedicate their practices to treating patients with chronic pain. However, most treat a broad range of patients who require PT: for example, those injured in accidents or disabled by illnesses such as strokes or Parkinson’s disease. There are therapists who can and do provide excellent care for these patients and for those whose primary problem is chronic pain. However, even as a pain specialist my knowledge of
the various therapies is still limited. I have often referred patients whom I believe would benefit from PT for evaluation by physiatrists who can then prescribe more specific PT rather than just general recommendations.
For most patients with chronic pain, exercise-based PT appears to be the most efficacious. Deconditioning often results from pain-related inactivity. Therefore, patients often need instruction in how to exercise without exacerbating the pain. PT is usually optimized when patients develop relationships with their therapists enabling them to trust them, knowing that will they never ask patients to do anything that will worsen their problems. This can be difficult because patients often find when they initially enter PT they experience a temporary increase in pain as they begin to reverse the effects of deconditioning.
PT is commonly prescribed to patients who undergo surgery for pain such as spine surgery for low back pain and knee and hip replacement. However, it can also be very useful for patients who undergo less invasive procedures for pain including acupuncture, nerve blocks, and epidural corticosteroid injections. Patients may find that these therapies make it easier to perform the PT activities. Ideally, provision of these treatments should be coordinated with scheduling PT.
Transcutaneous electrical nerve stimulation. Electrical stimulation, usually involving the use of transcutaneous electrical nerve stimulation (TENS), is frequently employed as part of PT for patients with chronic pain.8 Unfortunately, patients may not be informed that TENS units can be prescribed for use outside of their PT sessions.
A TENS unit consists of a small, battery-operated unit that can be attached to a belt. Wires, usually four in number, which run under clothes, are attached to the unit and to electrodes similar to those used for ECGs; these electrodes are applied to the painful parts of the body. Controls on the unit allow it to be turned on and off and can adjust the intensity of the stimulation. When TENS is done during a PT session, the therapist typically controls the intensity but patients can easily learn to do this themselves. Thus, they can use it throughout the day without needing to stop their activities. Most patients experience the stimulation as a gentle vibration.
It is usually recommended that the TENS unit be left on for 30 to 45 minutes alternating with a similar period of time when it is left off. Continuous stimulation diminishes the effect of TENS.
TENS is not only beneficial for reducing pain once it occurs, but it can also have a prophylactic effect. Patients can turn on the unit before starting activities that may bring on or exacerbate the pain, such as riding in a car for those with low back pain.
The only risk associated with the use of TENS is in those patients with a cardiac pacemaker, and even then unless the TENS electrodes are placed near the pacemaker, there is very little risk of harm. However, if TENS is being considered for patients with pacemakers, it is best to check with their cardiologist first.
Medical supply companies usually carry TENS units. The only part of the apparatus that needs to be replaced are the batteries and the electrodes, which depending on how careful patients are with them and also on individual factors, most notably how much patients sweat, usually last anywhere from 1 to 2 weeks.
Many insurance carriers cover the cost of a TENS unit for home use. Typically, they will rent the unit for 1 to 2 months first to ensure that the patient will use it. After that period, if the patient finds it beneficial, the insurer will usually proceed to purchase the unit.
Unfortunately, in 2012 Medicare decided to stop paying for TENS therapy for chronic low back pain, although it will continue to cover it for other types of chronic pain. The stated reason for this was the limited research demonstrating the benefit of TENS for chronic low back pain.9 Interestingly, Medicare continues to pay for other far more invasive therapies, including epidural corticosteroid injections and surgery, for which there is limited research to support their efficacy in many cases of chronic low back pain.
Occupational Therapy
Of all the therapies discussed in this article, OT is probably the one with which most physicians are least acquainted.10,11 Although there is a certain degree of overlap between OT and PT, they are separate disciplines and their practitioners receive different training. Even its name is misleading as many people believe that it indicates that it is only useful for patients who work outside of the home. In fact, OT can be beneficial for all patients who find that chronic pain interferes with their ability to perform activities they are either required to do, such as a job or daily chores, or those they want to do.
Until some health problem develops, such as chronic pain, which impairs the ability to engage in daily activities, most people perform these activities the same way every day and give little thought to them. Once chronic pain occurs, patients may be unable to continue to do them. Instead of having to eliminate these activities from their lives, OT can teach them alternative methods for performing activities that not only may be less likely to exacerbate the pain but may actually reduce it.
Most people are at least aware of the importance of performing activities in an ergonomically correct way but often do not do so and may even be unaware of what is the best way. OT can provide specific, detailed instruction to patients to enable them to function with the least amount of impairment from the pain.
Acupuncture
Despite the widely held view that there is little to indicate that acupuncture actually works, there is in fact substantial evidence demonstrating the efficacy of acupuncture for the treatment of chronic pain. In a 2003 report the World Health Organization (WHO) found sufficient evidence to support the use of acupuncture for a number of different conditions including headache, arthritic joint pain, and fibromyalgia.12 In 2007, the American Pain Society/American College of Physicians reviewed the evidence for nonpharmacologic therapies for chronic low back pain. A fair level of evidence was found for the use of acupuncture for this problem.13 The same year an observational study of 2564 patients with chronic low back pain found that those who received acupuncture reported significant reductions in both pain and the number of days lost from work.14
A 2011 review of studies on acupuncture reported that it only appeared to be beneficial for neck pain,15 but a 2012 review found it to be effective for back and neck pain, osteoarthritis, and chronic headache.16
A number of factors probably enter into these last two conflicting reports, but a major factor appears to involve a significant deficiency in many of the studies on acupuncture: what is considered “active acupuncture” and what is considered “sham acupuncture,” which is used for comparison.
In many studies, active acupuncture is considered to be the technique in which the needles are inserted into the classic Chinese acupuncture points. This is usually compared with sham acupuncture, in which the needles are inserted elsewhere in the body. Because sham acupuncture has often proved to be as effective as active acupuncture, the interpretation is that this demonstrates that any benefit is primarily due to a placebo effect.
What is often overlooked is that there is little evidence indicating anything unique or different about the classic points. In fact, when treating pain, most physician acupuncturists—including myself—ignore the classic points and insert the needles at the site of the pain. Furthermore, the benefits of veterinary acupuncture have been well demonstrated, and there is no explanation for why an animal would assume that having needles stuck into it would provide pain relief. And, of course, how much of the benefits of any other treatments for chronic pain may be related to a placebo effect is also unknown.
Another factor in the varying results on acupuncture efficacy involves how it is performed. Many studies, including those in which multiple acupuncturists are involved, have used manual manipulation of the inserted needles. Even a single acupuncturist performing all the treatments would have difficulty providing anything close to the same treatment for each patient, much less any standardization being possible when many different practitioners are involved.
Electrical stimulation of the needles provides much more consistency than manual manipulation, increasing the likelihood the treatment will be beneficial and allowing greater standardization when acupuncture is being studied. The advantage of electrical stimulation is supported in a review of five studies on acupuncture as an adjunct to conventional treatments for pain related to fibromyalgia. The two studies that used manual manipulation of the needles found no benefit. However, the three that utilized electrical stimulation had positive results.17
Acupuncture can be performed by physician and non-physician acupuncturists. As with medical licensing, the requirements for acupuncture licensing vary according to state. In some states, anyone who is licensed to practice medicine can practice acupuncture whether that physician has ever had any training, while other states require a specified number of hours of training. Whether the required education can be fulfilled solely from course work or whether hands-on experience is required for licensure also varies.
As far as I am aware, in all the states non-physician acupuncturists must be specifically licensed to practice it. These practitioners often point out that that their education on acupuncture is more extensive than that of physician acupuncturists. However, what they fail to note is that one can attend many of the acupuncture schools without a college degree and that they have to teach basic anatomy and physiology, topics about which it can be safely assumed physicians already have expertise.
Although I may be biased as a physician acupuncturist myself, I do believe it is safer to have acupuncture performed by a physician. I know there are many competent acupuncturists who are not physicians. However, several important concerns about non-physician acupuncturists have been noted.
The first concern regards the major serious adverse event associated with acupuncture: infection. There are physicians who are careless regarding infection control measures; however, most are generally well aware of and enforce them. Furthermore, the procedures to ensure these measures are carried out are usually part of office and hospital protocols. In contrast, non-physician acupuncturists may be less knowledgeable about infection control or they may practice in environments less conducive to it.
The best way to avoid any risk of infection from acupuncture is for the practitioner to use disposable needles. Not only does this guarantee that the needles are sterile but also that the needles are sharp and nonbrittle, which means they are both easy to insert and will not break during the treatment.
Unfortunately, studies demonstrating acupuncture-related infections have failed to differentiate between treatment performed by physicians and non-physician acupuncturists.
There are two additional reasons why physician acupuncturists might be preferred to non-physicians. The first is alluded to in the WHO report on acupuncture, which noted that “acupuncture seldom makes the condition worse. In most instances, the main danger of its inappropriate application is neglecting the proper conventional treatment.”12
Physician acupuncturists are able to examine patients and review their medical histories to determine if there are underlying medical conditions that require treatment. Unfortunately, there are still non-physician acupuncturists who do not believe it is their responsibility to at least inform patients that such conditions need to be ruled out and simply proceed with acupuncture.
The other reason is that physicians are usually aware of other potential therapies for managing pain besides acupuncture, while non-physicians may lack this knowledge.
Although there is a widely held belief that the efficacy of acupuncture is based on some mystical and confusing system of energy channels flowing in the body, in fact, there is scientific evidence for how it works. It is clear that acupuncture results in the release of endogenous opioids, including enkephalin, beta-endorphin, and dynorphin.18
One of the questions that has perplexed researchers is how acupuncture can continue to provide benefits for long periods of time after the treatment is performed. At least one study has suggested a possible explanation for this phenomenon. Utilizing functional MRI, Dhond and colleagues19 compared the resting-state brain activity of 15 healthy subjects who received acupuncture and sham acupuncture consisting of simulated needling but no actual insertion. The acupuncture consisted of needling at a single traditional acupuncture point. They found that the acupuncture but not the sham treatment produced multiple changes in the brain including enhanced resting default network mode (DMN) connectivity with several areas of the brain including the anterior cingulate cortex, periaqueductal gray, amygdala, and hippocampus. The DMN is one of the resting state networks in the brain that is deactivated during the performance of a task.19 The authors theorized that these changes in areas of the brain involved in a variety of functions including the perception of pain and of memory may explain at least some of the lasting effects of acupuncture. This study also found evidence that acupuncture may induce changes in the sympathetic nervous system.19
Taken overall, these various studies indicate that acupuncture continues to be a useful treatment but that more and better studies on both its clinical efficacy and underlying mechanisms of action are needed.
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