NONPHARMACOLOGIC INTERVENTIONS FOR PAIN

Evidence-based nonpharmacologic therapies are safe when correctly administered and can be effective components of comprehensive pain management that can reduce the need for opioids. Nonpharmacologic therapies can be the sole intervention, or they can be combined with other treatments. Nonpharmacologic interventions include physical, psychological, and mind-body modalities.

Many disciplines are involved in managing a patient’s pain through the use of these nonpharmacologic approaches. The most important member of the interdisciplinary team is the person with pain—the patient. Other team members may include:

• Significant others (family, friends, etc.)
• Physicians, physician assistants, and nurse practitioners
• Nurses
• Psychologists
• Occupational therapists
• Physical therapists
• Recreational therapists
• Vocational counselors

Physical Modalities

Physical modalities for relief of pain refer to any therapeutic medium that uses the transmission to or through the patient of thermal, electrical, acoustic, radiant, or mechanical energy.

• Thermal modalities (heat and cold)
• Manual modalities (massage, manipulation therapy)
• Acupuncture
• Electrophysical agents (TENS, iontophoresis, percutaneous electric nerve stimulation)
• Acoustic modalities (ultrasound, phonophoresis, shortwave and microwave diathermy, vibroacoustic therapy)
• Light therapy (low-level laser, ultraviolet light)
• Interventional modalities (injection, radiofrequency ablation, intrathecal pump, spinal cord stimulator)
• Dry needling

Psychological Modalities

One of the most common types of psychotherapy used in pain management is cognitive-behavioral therapy (CBT). CBT can be described as the “gold standard” psychological treatment for persons with a wide range of pain issues. It can be used alone or in conjunction with medical or interdisciplinary rehabilitation treatments. Currently, CBT is the prevailing psychological treatment for individuals with chronic pain issues (Physiopedia, 2022a).

Acceptance and commitment therapy (ACT) helps patients to shift their primary focus from reducing or eliminating pain to fully engaging in their lives. The goal of the therapy is to help patients accept whatever discomfort exists, both physical and emotional, while continuing to live their lives according to their values (Glasofer, 2021).

Mind-Body Techniques

Biofeedback is the use of instrumentation to mirror psychophysiologic processes, such as blood pressure, heart rate, and skin temperature, of which an individual normally is unaware and which may be brought under voluntary control. Types of biofeedback devices include:

• Electromyogram (EMG)
• Thermal
• Neurofeedback or electroencephalography (EEG)
• Electrodermal activity (ADA)
• Heart rate variability (HRA)

Relaxation therapies have been found helpful in the management of chronic headaches and other types of chronic pain. Relaxation encourages reduction in muscle tension, resulting in a decrease in pain intensity (NCCIH, 2022).

Hypnosis can provide analgesia, reduce stress, relieve anxiety, improve sleep, improve mood, and reduce the need for opioids. It can also enhance the effectiveness of other forms of relaxation therapies and biofeedback for pain (Cosio & Lin, 2020).

Diverting attention (distraction) from feelings and thoughts of pain is a well-researched pain coping strategy. Mental distractions actually block pain signals from the body before they ever reach the brain (Stanford Health Care, 2021; Keane, 2021).

Mindfulness-based interventions (e.g., meditation) have been found to have significant effects on chronic pain, yet the mechanisms underlying these effects are not well understood. There are several types of mindfulness-based interventions, including:

• Mindfulness-based stress reduction (MBSR)
• Mindfulness-based cognitive therapy (MBCT) (see above)
• Primary care brief mindfulness training (PCBMT)
• Mindfulness-based exposure therapy (MBET)
• Mantra-based meditation training
  (Cosio & Demyan, 2021)

Virtual reality provides immersive experiences that absorb more of the brain’s attention. With fewer mental resources left to process pain signals, people perceive less pain. VR causes a reduction of the electrical signals through which neurons communicate. Further validation tests of EEG and investigation on VR effects are needed to better understand how our brain acts while immersed in a virtual world (VirtualTimes, 2021).

Mirror therapy is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of a moving, nonaffected limb gives the illusion of normal movement in the affected limb. Mirror therapy exploits the brain’s preference to prioritize visual feedback over somatosensory/proprioceptive feedback concerning limb position. The reflection “tricks” the brain into thinking there are two healthy limbs (Physiopedia, 2022b).

Yoga is a mind-body and exercise practice that helps relieve chronic pain. Yoga has many of the same benefits as mindfulness practice due to the common focus on breath, body, and present-moment awareness. There are different types of yoga, with the most evidence of benefit being shown through Iyengar yoga, hatha yoga, and Viniyoga (DHWA, 2021).

Tai chi and qigong are forms of traditional Chinese exercise that incorporate the concepts of two opposing forces—yin and yang. Both exercises are based on the idea and core principle that increasing energy in the body, known as chi, through gentle and repeated movements can enhance a person’s well-being (Marks, 2022; Winchester Hospital, 2022).

Occupational Therapy and Pain Management

The role of the occupational therapist within an integrative pain management program focuses on function in daily living and takes a holistic and comprehensive approach to evaluate structural, physiologic, psychological, environmental, and personal factors that influence the experience of pain. The information obtained by patient evaluation is then used in the application of self-management strategies, functional activities, hands-on techniques, and specific exercises to improve function and participation.

OCCUPATIONAL THERAPY INTERVENTIONS

Depending on the area impacted by chronic pain, the occupational therapist provides the following interventions:

Physical mobility:

• Adaptive equipment selection and training
• Positioning equipment and strategies
• Functional mobility training (e.g., static positioning, dynamic movement, transfers, lifting and bending techniques)

Activities of daily living/self-care:

• Neuromuscular re-education
• Nerve mobilization
• Functional range of motion and strengthening exercises
• Activity pacing and energy conservation strategies
• Ergonomic and body mechanics training
• Fall prevention and safety
• Home evaluation

Instrumental activities of daily living:

• Adaptive equipment selection and training
• Transportation training, including comprehensive driver evaluations and driver rehabilitation

Health management:

• Patient education and disease self-management training, including trigger identification, symptom tracking, and pain flare-up planning
• Pain coping strategies, including physical modalities, complementary and alternative pain coping strategies, sensory strategies, self-regulation, and mobilization
• Pain and assertive communication training
• Medication management
• Eating routine strategies to avoid dietary pain triggers and improve energy management
• Establishing sustainable physical activities
• Time management strategies

Rest and sleep:

• Sleep hygiene and positioning strategies
• Cognitive behavioral therapy for insomnia
• Energy conservation and fatigue management

Education and work:

• Academic and work accommodations
• Ergonomic and body mechanics training
• Sensory strategies to monitor environmental triggers or exacerbating factors
• Advocacy and self-advocacy training
• Assertive communication training
• Community reintegration, including gradual re-entry plans
• Activity pacing and energy
• Environmental modifications
• Community and online resources exploration
• Compensatory cognitive strategies

Play, leisure, and social participation:

• Strategies to prevent social isolation
• Assertive communication strategies
• Personal values and interests exploration

(Reeves et al., 2022)

PRINCIPLES FOR OCCUPATIONAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021a) identifies the following principles that should guide occupational therapists in the management of pain. These principles include:

1. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
2. Pain is a complex phenomenon and a multidimensional experience.
3. Pain is a public health problem with social, ethical, and economic considerations.
4. People can experience pain at any stage of life.
5. The impact of pain on daily life needs to be considered in terms not only of physical limitations but also emotional and social influences on health and patient-defined well-being.
6. Activity analysis to explore the impact of pain on occupational performance (engagement in activities) needs to be considered from different perspectives, including factors (biological/psychological/spiritual/sociopolitical/environmental) that contribute to acute (or potential) challenges in the individual’s everyday life.
7. Cultural aspects relevant to pain expression and the pain experience need to be considered with all patients.
8. Self-management strategies need to focus on scheduling and adapting activities so that the person’s energy is maintained and pain is minimized.
9. Assessment and intervention plans to manage pain need to be collaborative between patient and therapist to ensure that the patient’s goals for intervention are identified and the strengths of the patient are recognized.
10. Occupational therapy assessment and management must be based on best available research evidence.
11. Prevention and intervention need to be addressed at both micro (individual) and macro (sociopolitical) levels.

Physical Therapy and Pain Management

Physical therapy is one of the most important nonpharmacologic measures to be considered in the management of pain. The physical therapist evaluates the patient with pain in order to:

• Determine the identity of the pain mechanism(s) to guide treatment
• Identify physical and psychosocial factors impacting pain so they can be addressed
• Assess the impact of pain on physical and psychosocial function
• Select appropriate goals
• Determine whether the patient requires referral to other healthcare providers

The goals of physical therapy include the reduction of pain, restoration of function, improved mobility, prevention or limitation of permanent physical disabilities, and encouragement of self-management through the use of physical, cognitive, and behavioral approaches to help reduce the impact of pain and disability (O’Sullivan et al., 2019).

PHYSICAL THERAPY INTERVENTIONS

When physical therapists work with patients who are experiencing pain, tests and measures are utilized to determine the causes of pain and to assess its intensity, quality, physical characteristics, and progression. Patients are also evaluated for risk factors for pain in order to prevent future pain issues. These factors may include disease history, cognitive and psychological factors, negative beliefs, and sedentary lifestyle.

Once contributors to the pain are identified, the therapist works with the patient to design an evidence-based management program with goals that are specific, measurable, achievable, relevant, and time-framed.

The physical therapist then implements the management program, which includes active approaches and passive approaches as indicated. These approaches include:

• Education about pain and how to manage pain, working with the patient toward regaining the ability to perform normal activities of daily living.
• Strengthening and flexibility exercises to improve movement with less pain. A graded exercise program may be instituted that gradually increases according to abilities. Exercises help to improve movement and coordination, reduce stress and strain on the body, and decrease pain.
• Manual therapies using hands-on techniques to manipulate or mobilize tight joint structures and soft tissues. Manual therapy may help increase range of motion, improve tissue quality, and reduce pain. Such therapies may include peripheral joint mobilization, myofascial mobilization, spinal mobilization, soft tissue mobilization, and therapeutic massage.
• Instruction in proper postural awareness and body mechanics, in order to help patients use their body more efficiently.
• Physical agents, which may include electrotherapies.

The therapist educates and supports the patient to adopt active rather than solely passive pain-management strategies that are meaningful to the patient and achievable, using motivational strategies and adherence techniques to support compliance.

Physical therapists include cognitive and behavioral approaches that support improved functional movement and pain outcomes, along with self-management strategies, as a key component of the management plan (IASP, 2021b).

MODALITIES

Modalities physical therapists may employ in pain management include:

• Thermotherapy
• Dry heat
• Hot packs
• Paraffin baths
• Tecar therapy
• Cryotherapy
• Ice packs
• Ice spray
• Immersion
• Ice massage
• Cryokinetics
• Biofeedback
• Manual therapies
• Massage
  • Connective tissue massage
  • Therapeutic massage
• Manipulation/mobilization
  • Dry needling
  • Soft tissue mobilization
  • Spinal and peripheral joint mobilization
  • Neural tissue mobilization
• Passive range of motion
• Electric stimulation
• Electric stimulation for tissue repair (ESTR)
• Functional electrical stimulation (FES)
• High-voltage pulsed current (HVPC)
• Neuromuscular electrical stimulation (NMES)
• Transcutaneous electrical nerve stimulation (TENS)
• Electrotherapeutic delivery of medications
• Iontophoresis
• Hydrotherapy
• Contrast bath
• Pools
• Pulsatile lavage
• Whirlpool tanks
• Acoustic
• Ultrasound
• Phonophoresis
• Traction devices
• Intermittent
• Positional
• Sustained
• Light therapy
• Laser (low level and high power)
• Ultraviolet
• Infrared and near infrared
• Cold laser therapy
(Physiopedia, 2021)

PRINCIPLES FOR PHYSICAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021b) identifies the following principles to guide physical therapists in the management of pain. These principles include:

1. Pain is a dynamic and complex experience involving interaction of biological, physical, psychological, social, and environmental factors specific to each individual.
2. Pain may be acute, acute on chronic, recurrent, chronic/persistent, and occur at any stage across the lifespan.
3. Pain assessment, treatment, and management are influenced by cultural, institutional, social, and regulatory factors.
4. Pain must be assessed in a comprehensive, safe, ethical, and consistent manner using valid and reliable assessment tools and outcome measures that help inform prognosis-making with consideration of risks, benefits, costs, and limitations of interventions.
5. Physical therapists should demonstrate empathic and compassionate patient communication when establishing person-centered pain-related goals and supporting self-management strategies.
6. Comprehensive pain management should be supported by sound theoretical models and empirical evidence and facilitate active patient involvement in developing lifelong healthy pain behaviors.
7. The physical therapist is an essential member of the pain management team and advocates for an individualized pain management plan that integrates the perspectives of patients, social support systems, and team members.