Nonpharmacologic Approaches to Pain Management

1
Nonpharmacologic Approaches to Pain Management

• Basics for Healthcare Providers
• The Iowa Pain Management Initiative
• From Department of Pain Medicine and Palliative
  Care, Beth Israel Hospital

2
Psychologic Treatmentsfor Chronic Pain

• Behavioral treatment
• Biofeedback
• Cognitive-behavioral treatment

3
Behavioral (Operant) Treatment Model

• Operant focus on behavior
• Use of medication
• Pattern of daily activities (eg, rest)

4
Behavioral Treatment Intervention

• Change the consequences of (pain) behavior
• Medications administered on a schedule
  ratherthan PRN
• Social responses, particularly spouses and
  families, shift from pain-related to activity-
  and wellness-related communication training
  often integrated
• Pacing of daily activities diminishes both
  aversive consequences of being active and
  positive consequences of rest record keeping,
  daily logs often critical

5
Behavioral Treatment Outcomes

• Reduce pain
• Reduce anxiety
• Improve coping
• Increase activity level
• Reduce pain behavior

6
Biofeedback Model

• Psychophysiologic
• Physiologic responses that are not typically
  under voluntary control or have become
  dysregulated
• Stress responses to pain and emotional
  challenges of living with chronic pain

7
Biofeedback Intervention

• Learning to influence physiologic parameter
• Electromyography
• Galvanometry (electrodermal)
• Temperature
• Shaping of behavior
• Typically includes training in relaxation
  techniques

8
Biofeedback Outcomes

• NIH Technology Assessment Panel
• Evidence is moderate for the effectiveness of
  biofeedback in relieving many types of pain
• For example
• Reduction in tension and migraine headaches
• Reduction in episodes of Raynauds

9
Cognitive-Behavioral Treatment Model

• Affect and behavior are largely determined by
  cognitive processes
• Behavior results from a complex interaction
  between cognitive structures (eg, beliefs),
  cognitive processes (eg, automatic thoughts),
  overt responses, and the intrapersonal and
  interpersonal consequences of these multiple
  components

10
Cognitive-Behavioral Treatment Intervention

• Integrates behavioral and biofeedback
  interventions
• Adds focus on cognitive structures and cognitive
  processes

11
Cognitive-Behavioral TreatmentIntervention

• Sessions focus on identifying and challenging
  maladaptive cognitive structures and processes
• Homework focuses on personal experiments
  designed to test the validityof cognitive
  structures and processes

12
Cognitive-Behavioral Treatment Intervention

• Emphasis on self-management
• Share 4 common components
• Education
• Skills acquisition
• Cognitive and behavioral rehearsal
• Generalization and maintenance

13
Cognitive-Behavioral Treatment Outcomes

• NIH Technology Assessment Panel
• The evidence is strong for the effectiveness of
  (relaxation) in reducing chronic pain in a
  variety of medical conditions
• The evidence is moderate for the usefulness of
  cognitive-behavioral treatment in chronic pain

14
Rehabilitative Approaches

• Physical therapy and exercise
• Work hardening and functional restoration

15
Physical Therapy and Exercise

• Patient educationback school
• Best effects when integrated into a comprehensive
  rehabilitation program
• Electrotherapeutic and thermal interventions
• Exercise
• Recommended for chronic low back pain,
  osteoarthritis, fibromyalgia

16
Work Hardening and Functional Restoration

• Aggressive physical therapy
• Work conditioning
• Psychosocial support

17
Complementary/Alternative Approaches

• Spinal manipulation
• Acupuncture
• Massage
• Heat or cold therapy
• Hatha yoga
• Healing Touch
• Tai chi
• Meditation

18
Complementary/Alternative Approaches

• Spinal manipulation
• Study quality is generally poor and findings
  inconsistent across studies
• Overall, studies suggest efficacy forlow back
  pain
• Subgroups of individuals may benefit more

19
Complementary/Alternative Approaches

• Acupuncture
• Reviews of the available studies support the
  efficacy of acupuncture for musculoskeletal pain,
  recurrent headache, osteoarthritis knee pain, and
  possibly fibromyalgia

20
Complementary/Alternative Approaches

• Massage
• Manipulates muscles, tendons, ligaments
  by applying pressure to the body

21
Complementary/Alternative Approaches

• Heat or cold therapy
• Applies heat or cold directly to an area
• Increases or constricts blood flow, depending
• On type of pain being addressed

22
Complementary/Alternative Approaches

• Hatha Yoga
• Focuses on physical poses and controlled
• breathing
• Reduces stress
• Enhances peacefulness in body and mind

23
Complementary/Alternative Approaches

• Healing Touch
• Reorients energy in the body to allow and support
  healing

24
Complementary/Alternative Approaches

• Tai Chi
• Moving in a series of slow, relaxed continuous
  movements
• Focus on breathing and meditation

25
Complementary/Alternative Approaches

• Meditation
• Emptying the mind of thought
• Focus on breathing, a sound, or an object