CHRONIC PAIN MANAGEMENT :

(NON PHARMACOLOGICAL METHODS)

Dr. (Prof.) G. P. Dureja
Keywords : Chronic pain, Management, Non Pharmacological
methods.
Because chronic pain is so complex, there are often
multiple treatment goals. These goals may include more
comfort (being pain-free is often not possible when pain
has become chronic), better physical functioning, improved
coping and less distress, getting back to work, helping the
family cope, and other positive outcomes.
multimodality approach. A multimodality
approach to chronic pain includes a combination of therapies
selected from eight broad categories:

Drug therapies
Psychological therapies
Rehabilitative therapies
Anesthesiological therapies
Neurostimulatory therapies
Surgical therapies
Lifestyle changes
Complementary and Alternative medicine therapies

Pain management by rehabilitative approaches

Some types of pain therapies have been classified as
rehabilitative because they are performed or directed by
physiatrists (physicians who specialize in rehabilitation
medicine) or by physical or occupational therapists, or
because they have the specific goal of improving function
as well as relieving pain.

Physical therapy (PT)

PT can be an important part of the treatment strategy.
PT techniques are useful in teaching patients to control
pain, to move in safe and structurally correct ways, to
improve range of motion, and to increase flexibility, strength
and endurance. Active and Passive modalities can both
be used, but active modalities, such as therapeutic exercise,
are particularly important when the goal is to improve both
comfort and function.

Bed rest
The use of prolonged bed rest in the treatment
of patients with neck and low back pain and associated
disorders is without any significant scientific merit. Bed
rest supports immobilization with its deleterious effects
on bone, connective tissue, muscle, and psychosocial wellbeing.
For severe radicular symptoms, limited bed rest of
less than 48 hours may be beneficial to allow for reduction
of significant muscle spasm brought on with upright
activity. Patients should be instructed to avoid resting
with the head in a hyperflexed or extended position. Two
days of bed rest is commonly cited as the appropriate
duration for the individual with low back pain, and though
no literature exists to support the use of bed rest in neck
pain disorders, 48 hours would be considered the window for
bed rest in individuals with these conditions, as well. 3
Bracing
Immobilization has been used for thousands of years
to treat injuries to the human body. Unfortunately,
immobilization may lead to deleterious effects that may
compromise treatment outcome, such as muscle fiber atrophy,
decreased proprioception, and loss of cervical and lumbar
range of motion (ROM).4
Manipulation & mobilisation
with neck pain and associated disorders.
Many different types of manual treatment exist, including
soft tissue myofascial release, muscle energy/contract-relax,
and high-velocity low-amplitude manipulation. Soft tissue
myofascial release may include various techniques, including
effleurage, ptrissage, friction, and tapotement. It has been
shown to improve flexibility, decrease the perception of
pain, and decrease the levels of stress hormones. 9-12
Manipulation and mobilization have gained support
in the treatment of patients with acute low back pain.13
Traction
Cervical traction is a therapeutic modality that can
be administered with the patient in the supine or seated
position. Traction may reduce neck pain and works through
a number of mechanisms including passive stretching of
myofascial elements, gapping of facet joints, improving

neural foraminal opening, and reducing cervical disc

herniation.17-18 It has been found to reduce radicular
symptoms in individuals with confirmed radiculopathy and
localized neck pain in individuals with cervicogenic pain
and spondylosis.19-20 Cervical traction may be initiated during
physical therapy with the patient properly instructed in
home use.
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS)
has been used to treat patients with various pain conditions,
including neck and low back pain. Success may be dictated
by many factors, including electrode placement, chronicity
of the problem, and previous modes of treatment.21 TENS
is generally used in chronic pain conditions and not indicated
in the initial management of acute cervical or lumbar spine
pain.22-23 Overall, research is limited in regard to the isolated
use of TENS in the treatment of patients with acute cervical
and lumbar spine disorders, though it has been used in
combination with ROM exercises, spray and stretch, and
myofascial release.24,25
Thermal modalities
Thermal modalities include a variety of methods
that produce heating and cooling of the tissues to manage
acute and chronic musculoskeletal pain. Superficial heat,
such as moist hot packs, increases skin and joint temperature
and blood flow, and may decrease joint stiffness and muscle
spasms.
Diathermy
Diathermy involves the use of high-frequency
oscillating current and ultrasound (inaudible sound wave
vibrations) to create deep heating. The deep heating may
reduce the perception of pain. It is believed to promote
healing and decrease inflammation. While there has not
been a great deal of research on the effectiveness of
diathermy and ultrasound for pain relief, it appears that
there are short-term beneficial effects with the use of
diathermy and significant improvement in pain relief with
ultrasound, as with other heating modalities
Ultrasound
Ultrasound is a deep-heating modality that is most
effective in heating structures such as the hip joint, which
superficial heat cannot reach. It has been found to be

helpful in improving the distensibility of connective tissue

which facilitates stretching.26-29 It is not indicated in
acute inflammatory conditions where it may serve to
exacerbate the inflammatory response and typically
provides only short-term benefit when used in isolation
Cryotherapy
Cryotherapy can be achieved through the use of
ice, ice packs, or continuously via adjustable cuffs attached
to cold water dispensers. Intramuscular temperatures can
be reduced by between 3 C and 7 C, which functions to
reduce local metabolism, inflammation, and pain.
Cryotherapy works by decreasing nerve conduction
velocity, termed cold-induced neuropraxia, along pain
fibers with a reduction of the muscle spindle activity
responsible for mediating local muscle tone.30-31
Exercise
Correction of posture may be the simplest technique
to relieve symptoms in patients with nonspecific neck or
low back pain, though it is extremely difficult to change
habits.

Psychological/Mind-Body therapies for chronic pain

management
Psychological factors are important contributors to
the intensity of pain and to the disability associated with
chronic pain. Pain and stress are intimately related. There
may be a vicious cycle in which pain causes stress, and
stress, in turn, causes more pain. Mind/body approaches
address these issues and provide a variety of benefits,
including a greater sense of control, improved coping skills,
decreased pain intensity and distress, changes in the way
pain is perceived and understood, and increased sense of
well being and relaxation. These approaches may be very
valuable for adults and children with pain.
Cognitive-Behavioral therapy (CBT)
CBT has proven to be effective in reducing pain
and disability when it is used as part of a therapeutic
strategy for chronic pain. CBT addresses the psychological
component of pain, including attitudes and feelings, coping
skills, and a sense of control over ones condition. It can
provide educational information and diffuse feelings of fear
and helplessness. CBT may include training in various types
of relaxation approaches, which can help people in chronic

pain lower their overall level of arousal, decrease muscle

tension, control distress, and decrease pain, depression and
disability.43
CBT has been found to be effective as part of a
treatment regimen for a variety of pain conditions including
episodic migraine and chronic daily headache, chronic
musculoskeletal pain, pain in the well elderly, chronic
cancer pain, rheumatoid arthritis and osteoarthritis,
fibromyalgia, myofascial temporomandibular disorders,
chronic low back pain, carpal tunnel syndrome pain, and
chronic pelvic pain.44-51
Biofeedback
Biofeedback is the use of electronic monitoring
instruments to provide patients with immediate feedback on
heart rate, blood pressure, muscle tension, or brain wave
activity. This allows the patient to learn how to influence
these bodily responses through conscious control and
regulation. Electromyographic (EMG) biofeedback, for
example, can teach patients how to relax a particular
muscle or how to achieve more generalized relaxation
for stress reduction. Biofeedback has been shown to be
effective in the management of migraine headaches,
fibromyalgia, temporomandibular disorders, and rheumatoid
arthritis, Raynauds disease, tension headaches, headaches
in children and the pain associated with irritable bowel
syndrome.43,55-61

Advanced interventional pain management

Intradiscal electrothermal therapy (IDET) is a
new, minimally invasive approach for the treatmentof
discogenic Low back pain. Initial results with this treatment
are encouraging, but more clinical studies are needed to
prove its efficacy. It involves percutaneously threading
a flexible catheter (Spine Cath) into the disc tissue with
fluoroscopic guidance. The catheter is composed to
thermal resistive coil enabling heating its distal part to the
desired temperature.
Radio frequency lesioning in pain management
Over the years, many techniques have been used to
selectively destroy nervous tissue in the spinal axis, brain
and other locations in the body. Of the various techniques
that have been used, the radiofrequency (RF) technique
has proven itself to be the most effective and is certainly

the most widely used (table 1).62-63

Table - 1 : Advantages of radiofrequency ablation.

-

A new perspective in the management of Acute and Chronic Pain

Great advantage over conventional neurodestructive procedures
Provides prolonged and complete Pain relief
Significantly better Outcome as compared to Neurolysis with alcohol

Radiofrequency (RF) is an alternating electric

field with oscillating frequency of 500,000 Hz.
Heat is produced around the electrode leading to neuro
destruction.
greater density of treatment, as well as the hottest part
of the lesion, will be in the tissue directly adjacent to the tip of the
electrode.

temperature which can be totally controlled by the operator.

a well circumscribed lesion can be produced.64

Since myelinated fibres are more resistant to heat

than unmyelinated fibres, differential effects can be produced.
Indications of RF neuroablation
Radiofrequency neuroablation is frequently carried
out for following conditions :
- Lumbar RF sympathectomy for peripheral vascular
disorders and complex regional pain syndrome (CRPS)
of lower extremity
- RF ablation of Gasserian Ganglion or of individual
branches for
- trigeminal neuralgia
- Cervical, thoracic, lumbar facet joint RF denervation
- Stellate ganglion lesioning for CRPS of upper extremity
- Cervical thoracic lumbar, sacral rhizolysis
- Sacroiliac joint denervation
- Intervertebral disc annuloplasty in intervertebral disc
prolapse
Radiofrequency ablation vs. chemical neurolysis
The advantages of radiofrequency techniques versus
other neurodestructive methods are that:65
- The lesion size can be adequately controlled.
- Good monitoring of the lesion temperature can be
performed with a thermal coupled electrode.
- Good placement of electrode is facilitated with
electrical stimulation and impedance monitoring.

- Ability to utilize the same radiofrequency cannula for

different types of spinal axis lesions.
- Can be performed under local anaesthesia or sedation.
- Rapid recovery.
- Low morbidity and mortality.
- Ability to repeat radiofrequency lesions if the neural
pathway regenerates.
Spinal cord stimulation for management of chronic
intractable pain
Electrical stimulation for treatment of pain was first
documented in 600 B.C., utilizing electrical power from
the torpedo fish. In 1967 Spinal cord stimulation was
introduced by Shealy and associates.66 Their work was
based on the gate control theory of pain proposed by
Melzack and Wall. With recent advances in technology,
the SCS has become a part of minimally invasive treatment
for controlling intractable chronic pain syndromes. The
stimulating electrodes are placed in the epidural space
percutaneously in similar manner as an epidural catheter is
placed. Improvements in hardware design and selection
criteria have enhanced the efficacy of SCS, and success
rates of 50% to 70% have been reported in different series. 67
Mechanism of action
The Melzack and Wall gate control theory of pain
was the foundation for the first SCS trials. It was based on
the idea that stimulation of A-beta fibers closes the dorsal
horn gate and reduces the nociceptive input from the
periphery. However it seems that other mechanisms like
increased dorsal horn inhibitory action of neurotransmitters
such as alpha-aminobutyric acid (GABA) and adenosine
A-1, the potential activation of descending analgesia
pathways by serotonin and norepinephrine are another
explanations for SCS action.68-69
Patient selection, indications and contraindications
When patient symptoms and sequel of pain can not
be controlled satisfactorily with conventional modes of
treatment like non-steroidal anti-inflammatory drugs
(NSAID), weak and strong opioids, physical and occupational
therapies and cognitive and behavioral therapies or side
effects of high doses of opioid are intolerable, then he
should be given a trial of SCS. Before SCS implantation,
a psychological evaluation of the patient is recommended.

Indications of SCS
Failed Back Syndrome
Complex Regional Pain Syndrome of lower extremity
Nerve injuries causing causalgia
Peripheral vascular diseases
Phantom limb syndrome
Chronic intractable angina
1. Patients with complex regional pain syndrome (CRPS)
or with neuropathic pain symptoms of upper or lower
extremities are the best candidates for SCS trial.
Complex regional pain syndrome (CRPS) is a chronic progressive
disease characterized by severe pain, swelling and changes in the
skin. There is no cure. The International Association for the Study of
Pain has divided CRPS into two types based on the presence of
nerve lesion following the injury.
Type I, formerly known as reflex sympathetic dystrophy (RSD),
Sudeck's atrophy, reflex neurovascular dystrophy (RND) or
algoneurodystrophy, does not have demonstrable nerve lesions.
Type II, formerly known as causalgia, has evidence of obvious nerve
damage.
3. Diabetic neuropathy may respond well to SCS, but
the infection risks in these patients are higher than in
the nondiabetic population.
4. The use of SCS in postherpetic neuralgia is
controversial.
5. Phantom limb pain is another indication of SCS.
6. Severe peripheral vascular disease is also an indication
for SCS. Patients with advanced peripheral vascular
disease who are not fit for surgical management
respond well to SCS, with reported efficacy rates
ranging from 60% to 100%. Besides providing pain
relief, SCS promotes ulcer healing and potentially
contributes to limb salvage.
7. Ischemic heart disease refractory to pharmacologic
and surgical treatments may respond well to SCS,
with reported efficacy rates of 60% to 80% several
years after implantation. These patients have
demonstrated a reduction in anginal pain, decreased
use of short-acting nitrates, and increased exercise
capacity.72
Advantages of SCS
Effective alternative for chronic, intractable pain
Effective alternative to back re-operation

 Reversible alternative to neuroablation

Cost effective
Contraindications
Infection, drug abuse, and severe psychiatric disease
are major contraindications for SCS implantation.
Implantation technique
Strict aseptic conditions are paramount for
implantation procedure. For lumbar lead placement, the
patient is placed in the prone position, and for cervical
placement both prone and lateral decubitus positions are
used. Both trial and permanent implantations are performed
under local anesthesia with light intravenous (IV) sedation.
The most common entry sites are the T 12-L 1 and L1-L2
spinal inter- spaces for the lumbar area and C7-T1 for the
cervical area (fig. 2).
Complications
The most common encountered complications of
SCS are
hardware failure
lead migration
infection
skin irritation at the IPG site, and
failure to provide pain relief.
Continuous intrathecal drug delivery systems for
cancer and nonmalignant pain
Intrathecal drug delivery has gained its popularity
since the discovery of opioid receptors in the spinal cord.73
It provides targeted delivery of medications and avoids side
effects encountered by systemic administration of drugs.
Opioids are delivered to the intrathecal space via a surgically
implanted subcutaneous pump containing a reservoir for the
medication. The pump is easily refilled with medication
every 2 to 4 months depending on the infusion rate
Medications other than opioids
The epidural route is more costly because
of the maintenance needed for the external system, and it
is. frequently more inconvenient for the patient; therefore,
it should be reserved for short-term use only (less than 3
months). The completely implanted intrathecal delivery is
preferred when treatment is expected to last longer than
3 to 6 months.
Patient selection
1. Cancer pain patients responds well to intrathecal
therapy in carefully selected patients. The following

cancer patients might be considered for intrathecal

trial:
Patients who develop intolerable side effects to opioids
given by oral or parenteral route (nausea, vomiting,
sedation, constipation)
Patients who have a life expectancy of more than 3
months
Patients who have no obstruction in CSF flow
Patients who have neuropathic cancer pain that does
not respond to oral regimen and nerve blocks.
2. Nonmalignant pain may respond to intrathecal therapy
but it should be considered as a last resort. In general,
patients with cancer pain tend to respond better to
intrathecal therapy than patients with nonmalignant
pain. Therefore, the selection criteria for intrathecal
therapy for nonmalignant pain should be very strict.

Surgical approaches for chronic pain

management
Surgery is usually performed to treat the underlying
disorder. Rarely, a surgical procedure may be suggested as
a primary treatment to relieve pain. These procedures
involve specific lesions in the nervous system. They are
usually considered only for highly selected patients. For
example, a patient who has a painful neuroma developed
after a nerve injury might be cured if the neuroma is
removed. Patients with so-called sympathetically-maintained
pain are sometimes offered surgery that cuts sympathetic
nerves. Patients with cancer or other serious diseases are
occasionally offered a surgical technique in which a cut is
made in nerves or the spinal cord (Dorsal Rhizotomy) to
try to block activity in the nervous system that may be
sustaining the pain. Presacral Neurectomy is also performed
surgically and can relieve pain in patients with terminal
cancer of cervix etc. All of these surgical approaches
have some risks, and the availability of new therapies,
such as neuraxial infusion and spinal cord stimulation, has
steadily decreased their use.