Complementary and Alternative Pain Management, Part 2

Introduction

• Anesthesiologists have many nonpharmacologic tools to help their patients address both acute and chronic pain. Some of these tools include physical therapy/targeted exercise, mindfulness/meditation/guided imagery, aromatherapy, virtual and augmented reality, biofeedback, cognitive behavioral therapy, trigger-point therapies, massage therapy, and neurostimulation.
• Exploring multimodal pain management strategies that help patients tolerate pain and improve function are the primary goals of incorporating nonpharmacologic tools. Growing evidence supporting these modalities has led healthcare payors to reimburse for such services.
• Please see the summary on complementary and alternative pain management, part 1, for more details on acupuncture, meditation/mindfulness, aromatherapy, and hypnosis. Link
• This summary will focus on physical therapy, biofeedback, virtual and augmented reality, cognitive behavioral therapy, massage therapy, and neurostimulation.

Physical Therapy

• Physical therapy and other targeted exercises, including occupational therapy, can help to improve mobility and function, reduce pain, and prevent further injury. It may involve exercises, stretches, and other techniques to improve strength and range of motion.¹
• Specific exercises may be prescribed by a physical therapist to target specific muscle groups or to support desensitization (for example, in complex regional pain syndrome). For patients who may have restrictions or pain with full weight-bearing, aqua therapy (i.e., exercises performed while in a pool of water) is an alternative.

Biofeedback

• Biofeedback is a modality in which patients receive feedback (e.g., auditory, visual, or tactile) about their physiology (e.g., heart rate, muscle tension, skin conductance) and are trained or guided through strategies to change these states.²
• Patients learn to self-regulate these physiological processes with the help of feedback information and develop greater awareness or control of these processes, which in turn allows patients to consciously reduce states which may be associated with increased pain. For example, patients can be connected to an electromyographic interface and trained to reduce muscle tension based on a real-time readout of a specific muscle group.

Virtual and Augmented Reality

• Virtual reality (VR) is a technology that uses computer-generated simulations to create immersive and interactive experiences. By immersing individuals in a virtual environment, VR can help to distract them from their pain, reduce anxiety and stress, and provide a sense of control over their pain. In addition, VR can be used to teach individuals pain-coping strategies and relaxation techniques, such as deep breathing and progressive muscle relaxation, in a controlled and engaging manner.³
• By contrast, augmented reality (AR) similarly uses computer-generated imagery but superimposes this into a person’s view. Unlike VR, which creates an immersive virtual environment, AR enhances the real world with digital information, providing a more grounded and natural experience. Similar to VR, AR can be used to distract individuals from pain, provide education and support, and encourage active participation in pain management strategies. For example, AR can be used to provide real-time feedback on posture, movements, and exercises to help with pain conditions.³

Cognitive Behavioral Therapy

• Cognitive behavioral therapy (CBT) is a form of psychotherapy that focuses on how a person’s thoughts, beliefs, and attitudes can impact their physical and emotional experiences. CBT has been found to be effective in treating chronic pain by helping individuals manage the psychological and emotional aspects of their pain.⁴
• During CBT, patients learn to identify and challenge negative or unhelpful thought patterns and behaviors that can contribute to pain and replace them with more positive and adaptive ones. They also learn coping skills and stress management techniques, such as deep breathing and relaxation exercises, to help manage their pain more effectively.⁴

Massage Therapy and Trigger Point Therapies

• Massage therapy is a manual therapy that involves the manipulation of soft tissue to improve well-being. It can aid in treating pain by reducing muscle tension, increasing blood flow, and improving joint mobility. By reducing muscle tension and promoting relaxation, massage therapy may help to reduce pain sensitivity and improve the overall experience of pain.⁵
• There are many types of massage therapy styles/traditions. One in particular, trigger-point therapies, involves either manual massage or needling or injection of local anesthetics and/or steroids to induce myofascial release, which aims to relieve muscle tension. Evidence is mixed on the long-term efficacy of massage therapies, but patients do report improvement in short-term pain and functional outcomes.^5,6
• Please see the OA summary on myofascial pain syndrome and trigger point injections. Link

Neurostimulation

• Various modalities of neurostimulation can be used to change pain perception, which includes transcutaneous electrical nerve stimulation (TENS), peripheral nerve stimulation, and spinal cord stimulation. The latter two modalities are more invasive than TENS. The underlying theory behind these modalities is the gate theory of pain, in which nonpainful signals effectively block the afferent signaling of pain at the level of the spinal cord.
• TENS is a procedure in which electrodes, placed on a person’s back, give off an electric signal that stimulates nerve cells through the skin. The numb-like feeling that results can help some people overcome pain. Sometimes TENS is used in combination with acupressure/acupuncture to simulate specific acupoints, which may have benefits for pain. Pain may be temporarily relieved with the use of a small TENS device that directs mild, electrical pulses to nerve endings beneath the skin in the painful joint area. TENS blocks pain messages to the brain and modifies pain perception.⁷
• Please see the OA summary on TENS for more details. Link
• Peripheral nerve and spinal cord stimulators are devices that are implanted in the body to relieve pain by delivering a low-level electrical stimulation that interferes with the transmission of pain signals. Modern stimulator devices have been designed to provide high-frequency stimulation, which may be less perceptible than early generations of these devices in which stimulation was more noticeable but nonpainful.⁸