Restorative therapies Physical and occupational therapy are recommended for acute and chronic pain and are best combined as part of a multidisciplinary treatment plan after a thorough assessment. 3 Traction is frequently used as part of physical therapy and, although evidence that it is clinically effective is lacking, the HHS Inter- Agency Task Force suggests it should be investigated separately and considered as a treatment modality for low-back or neck pain. 3 Unfortunately, despite evidence of improved outcomes, use of these physical and occupational therapies are frequently challenged by incomplete or inconsistent reimbursement policies, and policymakers have been asked to look more closely at improving payer polices. 3 There is high-quality evidence that therapeutic exercise improves outcomes over bed rest. 3 Principally investigated as a treatment for spinal pain, therapeutic exercise has been shown to help patients function better and to help them overcome the anxiety and fear of movement that worsen pain and disability. Transcutaneous electric nerve stimulation research is plagued by a lack of high-quality, unbiased studies, and overall evidence of efficacy is limited. 3 It has been investigated for treatment of acute low-back Interventional options Interventional pain management describes a variety of techniques that vary in terms of their invasiveness. Techniques may use image-guided technology to help diagnose and treat sources of acute and chronic pain. Such treatments may help minimize the use of oral pain medication, including opioids, but have risks as well as advantages that should be understood and discussed with patients. Low complexity interventions include: ● Trigger point injections, usually composed of an anesthetic like lidocaine, which disrupt the tense bands of skeletal muscle fibers that produce pain and can be used to treat headaches, myofascial pain syndrome, and low-back pain. 3 ● Joint injections, often of corticosteroid into various joints, which are useful for inflammatory arthritis and basal joint arthritis. 3 ● Peripheral nerve injections, which are injections of local anesthetic agents or other medications by single injection or continuously by catheter, frequently delivered perioperatively and also useful for treatment or prevention of peripheral neuropathies, nerve entrapments, CRPS, headaches, pelvic pain, and sciatica. 3 Medium complexity interventions include: ● Facet joint nerve blocks as common diagnostic and therapeutic treatments for facet-related spinal pain of the low back and neck. 3 ● Epidural steroid injections to deliver anti- inflammatory medicine to the epidural space, which are frequent treatments for back and radicular pain and have been shown to reduce need for healthcare visits and surgeries, although risks should be weighed and discussed with the patient. 3
pain, postpartum pain, phantom limb pain, and knee osteoarthritis, and, despite limited evidence, can be considered among the safer self-care options with appropriate patient education. 3 Massage therapy includes Swedish, shiatsu, and deep tissue or myofascial release types. A systematic review found massage can be effective in the general population for pain, anxiety, and to improve health-related quality of life compared to sham, no treatment, and active comparators. 34 The application of cold and heat is a standard approach in relieving the symptoms of acute pain. Evidence supports use of cold therapy to reduce pain after surgery and heat wraps to relieve pain symptoms and increase function in acute low-back pain. 3 The evidence has not been robust that therapeutic ultrasound is more effective than placebo for musculoskeletal pain conditions; however, recent findings show it can be effective in relieving knee osteoarthritis. 3 Nonrigid bracing may improve function and is unlikely to cause muscle atrophy when used for short periods. 3 ● Radio-frequency ablation, which uses needles to deliver high-voltage bursts of energy near nerves to block pain transmission and has shown promise for cervical radicular pain. 3 ● Regenerative/adult autologous stem cell therapy, which is a promising area of research for many painful conditions. 3 ● Cryoneuroablation, which uses a cryoprobe to freeze sensory nerves at the source of pain to provide long-term pain relief and may be considered for numerous intractable pain conditions that include paroxysmal trigeminal neuralgia, chest wall pain, phantom limb pain, neuroma, peripheral neuropathy, knee osteoarthritis, and neuropathic pain caused by herpes zoster. 3 ● Neuromodulation, which delivers stimulation to central or peripheral nervous system tissue and has shown efficacy in low-back and various headache disorders. 3 High complexity interventions include: ● Spinal cord stimulators, which are devices to deliver a form of neuromodulation that has demonstrated efficacy in low-back and lower extremity pain. 3 ● Intrathecal pain pumps, which can deliver opioids (and other medications) into the spinal fluid with fewer side effects and at lower doses than with oral opioids, although significant side effects such as delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism can occur. 3
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Book Code: MDCO1025
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