Non-Pharmacological Pain Management

Non-Pharmacological Pain Management

• Refers to pain management interventions that do not involve medications
• Non-pharmacological interventions can be as effective, or more effective, than medication
• Utilising both pharmacological and non-pharmacological methods shows the most benefit for pain control
• Goals include decreasing fear, distress, and anxiety
• Aims to reduce pain and provide patients with a sense of control

Non-Pharmacological Therapy Categories

• Physical (sensory) interventions
• Psychological interventions

Physical (Sensory) Interventions

• Patient-specific
• Inhibit nociceptive input and pain perception
• Measures that can reduce pain intensity and improve patient's quality of life:
  • Massage
  • Positioning
  • Hot and cold treatment
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture
  • Progressive muscle relaxation

Psychological Interventions

• Continuous pain leads to maladaptive status and behaviours
• These behaviours worsens function, increases distress, and enhances the experience of pain day to day
• Patients suffering pain tend to show increased vulnerability to psychiatric illnesses like depression, anxiety disorders, and posttraumatic stress disorder
• The relationship between depression and pain is bidirectional
• Presence of a depressive disorder is a key risk factor in the transition from acute to chronic pain
• Most commonly used interventions include:
  • Cognitive behavioural therapy
  • Mindfulness-based stress reduction
  • Acceptance and commitment therapy (ACT)
  • Guided imagery and biofeedback

Other Interventions

• Spirituality and religion
• Music therapy

Cutaneous Stimulation and Massage

• Gate control proposes that stimulation of fibers that transmit nonpainful sensations can block or decrease pain impulses

Massage

• Involves rubbing/kneading joints, muscles with hands to relieve pain and decrease tension
• Interrupts the patient's cycle of distress
• Increases blood and lymphatic circulation
• Initiates an analgesic effect to the area being rubbed
• Decreases inflammation and edema
• Releases muscle spasms manually
• Increases endogenous endorphin release
• Conflicting sensory stimuli override pain signals
• Benefits can include stress reduction, muscle relaxation, lower blood pressure, and improved circulation
• Can help improve posture
• Strengthens the body's immune system
• Massages decrease pain and anxiety in many of the surgical and nonsurgical patients
• Can be beneficial in cancer patients, improving mood and quality of life
• Depression and anxiety have shown significantly improved with massage

Positioning

• A physical intervention that includes maintaining a proper body alignment to reduce stress and anxiety, especially in children
• Helps to prevent further complications
• Reduces the risk of developing injuries
• Prevents bed ulcers
• Alleviates pain
• Relieves muscle pain, tension, and discomfort
• Improves blood circulation preventing ulcers from developing
• Elevating extremeties can decrease pain and also prevent edema

Thermal Therapies

• Proponents believe that ice and heat stimulate the non-pain receptors in the same receptor field as the injury
• Both ice and heat therapy must be applied carefully and monitored closely to avoid injuring the skin
• Therapy should not be applied to areas with impaired circulation
• Therapy should not be used with clients with impaired sensation

Cold Treatment

• Ice should be placed on the injury site immediately after injury or surgery
• Ice therapy after joint surgery can reduce analgesic medication required
• Assess skin first before applying ice
• Apply to an area for no longer than 15 to 20 minutes at a time
• Should be avoided in clients with compromised circulation
• Can increase pain threshold
• Can decrease edema
• Suppresses the inflammatory process

Heat Treatment

• Stimulates the thermo receptors in the skin and deeper tissues
• Can help to reduce pain by closing the gating system in the spinal cord
• Application of heat increases circulation to an area and contributes to pain reduction by speeding healing
• Reduces striated muscle spasm by minimizing muscle spindle excitability and reducing tension in muscle trigger points
• Warming joints reduces viscosity of synovial fluid which alleviates painful stiffness during movement and increases joint range
• Superficial heat can produce heating effects at a depth limited to between 1cm and 2cm
• Helpful in diminishing pain
• Helpful in decreasing local muscle spasm

Therapeutic Ultrasound

• The application involves using a round-headed wand or probe in direct contact to the patients skin
• Gel is used on all surfaces of the probe head to assist in the transmission of waves and reduce friction
• Ultrasound is a high-frequency sound waves above the range of human hearing
• Links to increased blood flow, reduction in muscle spasm, and increased extensibility of collagen fibers
• Theoretical benefits include the stimulation of physiological processes such as tissue repair
• A deep-heating modality most effective in heating structures such as the hip joint, which superficial heat cannot reach
• Helpful in improving the distensibility of connective tissue which facilitates stretching
• Is not indicated in acute inflammatory conditions where it may exacerbate the inflammatory response
• Only provides short-term benefit when used in isolation

Transcutaneouselectrical Nerve Stimulation (TENS)

• Electrical device used to treat pain
• Consists of a battery-powered unit and has 2-4 leads connected to sticky pads
• Pads are positioned over the skin to cover or surround the painful area
• Decreases pain by stimulating the nonpain receptors in the same area as the fibers that transmit pain
• The TENS unit delivers a low-voltage electrical impulse to the padded surface electrodes in a series of alternating electrical current impulses
• Larger impulses activate large myelinated fibers
• Large nerve fiber stimulation is thought to block small pain-transmitting fibers
• Experts believe that TENS unit activates the release of natural endorphins at the pituitary level by using alternating low frequency pulses
• TENS produce analgesia by stimulating large afferent fibers
• It can help patients with chronic back pain, arthritis, neuropathic pain and mild-moderate acute pain
• When the TENS unit is turned on, patient feels a light tingling sensation over the area where the pads are placed
• The signal intensity, or pulse width, produced from the TENS device can be adjusted
• Goal is to produce paresthesia without muscle contraction
• At initial use, the patient adjusts the settings to find the most comfortable effective sensation
• TENS is virtually side effect free
• The mechanism includes activation of descending modulation systems and blocking of sympathetic outflow
• TENS should not be used in patients with cardiac pacemakers or a history of cardiac dysrhythmia

Exercise

• Posture correction exercise relieves symptoms in patients with nonspecific neck or low back pain but is extremely difficult to change habits

Acupuncture and Traditional Chinese Medicine

• Acupuncture has been used in China for over 3,000 years
• Needles were made from stones before the discovery of metals
• Today, most needles are made from stainless steel
• Single-use disposable needles are most popular Sterilisation can be a major concern with re-used needles
• The WHO recognises the diseases that can be treated with Acupuncture

Effects of Acupuncture

• Acupuncture needles stimulate A delta fibres entering the dorsal horn of the spinal cord
• These in turn mediate segmental inhibition of pain impulses carried in unmyelinated C fibres
• Connections in the midbrain enhance descending inhibition of C fibre pain impulses at other levels of the spinal cord
• Needling stimulates release of endogenous opioids and other neurotransmitters such as serotonin
• According to TCM theory, it explains the analgesic effect in terms of relieving the blocked "qi" along the meridians
• Qi normally flows freely in a defined direction along the 12 regular and other extra meridians
• Qi blockage can cause pain and other disease conditions
• Regulating the flow with needling and manipulation restores the flow and removes pain
• In order to achieve the maximum effect, treatment twice a week is recommended
• Daily treatment may bring about quick relief initially, but is not necessary
• A treatment usually takes 20 to 30 minutes
• A course of treatment consists of about 10 treatments
• A full course of acupuncture can be repeated, but a few weeks should be allowed between
• The rest in between courses of treatment allows restoration of endorphin level
• Acupuncture points that lie on the meridians use two alphabet letters to indicate the meridians
• A number is then added after the letters to locate the site exactly
• Standardised nomenclature helps communicate the exact acupoints being used
• It also facilitates training of acupuncturists whose first language is not Chinese
• Chinese names are still still frequently used in Chinese speaking countries

Acupuncture Technique

• Locate acupoints by recognising certain surface landmarks
• Locate acupoints by proportion
• Used to find acupoints located between two landmarks
• Some acupoints are at a short distance from a surface landmark
• Measure the distance of "cun"
  • One Cun equals the width of the distal phalangeal joint of the patient's thumb
  • The width of the patient's palm is around three cun
• Acupoint locators that use reduction in resistance or capacitance sometimes used
• Acupoints near the area of disease (ex; head region for headache/back pain) are local points
• Points at a distance from the disease area are known as distance points
• Distal acupoints are used to regulate qi
• Some distance acupoints well known for their effect
• ST 36 (Zusanli) acupoint is a well-known example for constipation, diarrhoea or stomach discomfort
• PC 6 (Neiguan) is an acupoint frequently used to treat nausea and vomiting
• Unilateral local acupoints on the same side as the diseased area are used
• Bilateral/Distance acupoints on the opposite side of the diseased area have a general effect
• Treatment bases decisions on the five-element and the theory of yin-yang
• Needles used are filiform needles comprising a handle and a body
• Needles are classified by length and diameter
• Solid single-use needles commonly 2-4cm long with diamaters of 0.25-0.3mm
• Very long needles penetrating two acupoints are used by traditional acupuncturists for point to point acupuncture
• Laser and short waves are employed in some centres to replace traditional needles
• The efficacy of these devices is still under investigation
• Disposable sterile acupuncture needles are commonly used in modern practice
• Aseptic technique is mandatory for needle insertion
• Needles inserted perpendicularly downward, or at a slanting angle
• To obtain a good effect, needles can be stimulated
• Acupuncturists can manipulate a needle by turning it clockwise or anticlockwise at very high frequency
• The frequency, direction of turning and the force of moving the needle in/out are important as they determine whether qi along the meridian is enhanced/reduced
• Electrical stimulation is delivered by a battery-powered multi-channel nerve stimulator is employed
• Continuous stimulation at a frequency of 2 Hz is the frequently used

Other Forms of Acupuncture

• Ear acupuncture is a micro-acupuncture technique
• First described in French and Chinese medicine in 1950
• Stimulation of a reflex point can relieve symptoms of distant pathology
• Ear acupuncture is a safe form of acupuncture
• Complications; infection, bleeding and haematoma
• Scalp acupuncture used for a number of years
• Different acupoints on the scalp represent different parts of the body
• Helps relief of certain disease conditions
• The most common condition in children treated by scalp acupuncture is cerebral palsy
• Other forms being developed each with varying degrees of success
• Tongue acupuncture's one method

Psychological Interventions

• Increase hospitalization and costs
• Medication worries
• Impaired ambulation
• Sleep disturbances
• Family worries
• Can cause Anxiety
• Depresion
• Pain

Cognitive Behavioural Therapy

• Pain is a complex experience that is influenced not only by its underlying pathophysiology, but also by an individual's cognition, affect, and behavior
• CBT attempts to alter the psychological principles governing pain
• Attitudes, beliefs, and expectations determine emotional and behavioral reactions to painful situations
• Irrational beliefs and distorted attitudes toward oneself, one's environment, and the future perpetuate depression and pain
• The first component is helping the patient understand that cognition and behavior can affect the perception of pain
• The second component is training by taught the pain control techniques of relaxation, imagery, and self-coping. )
• The third component involves what is learned in training is applied to daily situations, including pain flares and other challenges

Relaxation Techniques

• Believed to reduce pain by relaxing tense muscles that contribute to the pain
• Consists of abdominal breathing at a slow, rhythmic rate
• The client may close both eyes and breathe slowly and comfortably
• Techniques have shown positive results for patients with chronic neck pain, tension headache, low back pain and chronic pain related to rheumatologic and non-rheumatologic chronic inflammatory disorders

Guided Imagery

• Imagine in a special way achieve a specific positive effect
• May consist of combining slow, rhythmic breathing with a mental image of relaxation and comfort
• The client is asked to practice guided imagery for about 5 minutes, three times a day

Self-Coping

• How the patient interprets information is modified
• Self-defeating thoughts are transferred into the healing thoughts
• Patients learn to gain a feeling of control over their pain

Distraction

• Involves focusing the client's attention on something other than the pain
• Thought to reduce the perception of pain by stimulating the descending control system
• Effectiveness depends on the client's ability to receive and create sensory input other than pain
• Examples are watching TV, listening to music, complex physical and mental exercises
• Stimulation of sight, sound, and touch is likely to be more effective than the stimulation of a single sense

Biofeedback

• The practice of providing information to the patient about unconscious physiologic processes such as heart rate and muscle tension
• This form of therapy involves instrumentation that tracks specific physiologic indicators of tension in the body
• The most common form of biofeedback involves using electromyographic (EMG) feedback from the affected region
• The patient is able to see the electrical activity in muscle tissue
• Patients are able to monitor muscle spasm and overactivity
• The patient learns to control voluntarily a normally nonvoluntary aspect of physiology that may be linked to the pathogenesis of a given disease
• Biofeedback is thought to be most helpful in low back pain and headache related to myofascial spasm

Hypnosis

• Causes a relaxed state of mind and open to suggestion
• The goal is provide positive behavior changes to treat painful conditions
• Proposes the hypnotic state may increase patients' control over autonomic nervous system functions beyond conscious control
• An induction can take several seconds or up to 10 minutes or longer
• Contraindications include psychiatric illnesses such as schizophrenia and manic depression
• Has been effective in relieving or decreasing the amount of analgesic agents required in clients with acute and chronic pain
• Mechanism is unclear
• Induced by skilled people

Music Therapy

• Inexpensive and effective therapy for reducing pain and anxiety

Chiropractic Treatment

• Form of integrative medical treatment concerned with mechanical disorders of the musculoskeletal system
• D.D. Palmer founded chiropractic treatment in Davenport, Iowa in 1890
• His son B.J. brought it to prominence in the early part of the 20th century
• The World Health Organization defines chiropractic as a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and study of the effects of these disorders on general health
• The basis of chiropractic discipline is the philosophy that spinal joint dysfunction interferes with the body's overall function
• Should have spine health that promotes good general health
• Health is mediated through the nervous system
• Vertebral misalignment (subluxation) causes altered spinal nerve vibration
• Spinal nerve vibration can be too tense or too slack
• Will effect the body
• Vertebral subluxation can interfere with the "innate intelligence" exerted via the human nervous system
• Can be a primary underlying risk factor for many diseases such as diabetes, coronary artery disease, and hypertension
• Chiropractic treatment sessions involve manual therapy of the spine, joints, and soft tissue
• Emphasizes a variety of lifestyle modifications
• Includes diet and nutritional programs
• Self-care and coping strategies

Manipulation and Mobilization

• Most treatment involves manipulation of the spine, joints, and soft tissue
• Spinal manipulation is a manual maneuver of a joint complex past the normal range of motion but not dislocation to increase range of motion
• High-velocity passive motion to cause movement and stretching of joints and muscles to increase the range of motion
• Mobilization is used
• Measurable improvement in the patient's pain and function should occur during treatment
• Treatment should consist of 6 to 12 sessions
• Stop treatment if there is no lasting improvement
• Vertebral subluxation remains unsubstantiated
• May be helpful as an integrative option for musculoskeletal pain In general, chiropractic manipulation is safe when performed by a professional in an appropriate manner

Contraindications and Complications

• Absolute contraindications to spinal manipulation therapy include rheumatoid arthritis and unstable joints
• Spinal manipulation poses a risk complications that can result in disability
• Manual manipulation is associated associated with vertebrobasilar dissection, leading to a neurologic deficit