PAIN MANAGEMENT OVERVIEW
Many pharmacologic and non-pharmacologic approaches to treating pain are available to primary care providers. These options should be employed using the following general principles: Identify and treat the source of the pain, if possible, although pain treatment can begin before the source of the pain is determined. Non-drug approaches Many nonpharmacologic and self-management treatment options have been found to be effective alone or as part of a comprehensive pain management plan, particularly for musculoskeletal pain and chronic pain. 37 Examples include, but are not limited to, psychological, physical rehabilitative and surgical approaches, procedural therapies (e.g., injections, nerve blocks), complementary therapies, and use of approved/cleared medical devices for pain management. Primary care clinicians should know about the range of treatment options available, the types of pain that may be responsive to those options, and when they should be used as part of a multidisciplinary approach to pain management. 37 Clinicians should also be aware that not all nonpharmacologic options have the same strength of evidence to support their utility in the management of pain, and some may be more applicable for some conditions than others. Movement-based options Movement therapies that may be helpful in patients with chronic pain include muscle-strengthening, stretching, and aerobic exercise (e.g., walking, aquatics). Recommended exercise programs typically occur one to three times a week for a total of 60- 180 minutes per week, but any regimen must be carefully tailored to a patient’s existing level of physical conditioning, comorbidities, and cognitive status. 38-40 Additional movement-based options include: ● Physical therapy supervised by a licensed physical therapist, which can include resistance, aerobic, balance, and flexibility exercises as well as elements of massage, manipulation, or transcutaneous electrical nerve stimulation. ● Tai chi, a mind-body practice that combines controlled movements, meditation, and deep breathing. “Chair tai chi” can be an option for patients with limited mobility. ● Yoga , exercises or a series of postures designed to align muscle and bones and increase strength and flexibility. It can also relax mind and body through breathing exercises and meditation. Gentler forms of yoga that may be more appropriate for older patients include Iyengar, Hatha, or Viniyoga. Although these interventions may cause muscle soreness, increased back pain, or falls, movement- based options are generally considered safe. 40
Select the simplest approach to pain management first. This generally means using non-pharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects, and at the lowest effective doses. Establish a function-based, individualized treatment plan if therapy is expected to be long-term. Weight loss Some pain syndromes, such as knee osteoarthritis, are worsened by obesity. For some patients, pain due to this condition is improved by reducing body weight because of reduced loads and physical stresses on the affected joints. The goal of body weight reduction is a baseline weight loss of 7%-10% by calorie reduction and increased activity using a balanced diet with less than 30% of calories from fat, 15%-20% from protein, and 45%-60% from carbohydrates. 41 Passive options Acupuncture involves the stimulation of specific points on the body, most often involving skin penetration with fine metallic needles manipulated by hand but sometimes also including electrical stimulation or low intensity laser therapy. Potential adverse events include minor bruising and bleeding at needle insertion sites. 42 Massage is the manual manipulation of the body to promote relaxation, reduce stress and improve well- being. Handheld devices may also provide relief for some patients. Some patients may report muscle soreness. 43 Transcutaneous electrical nerve stimulation (TENS) is a machine that generates mild electrical pulses which are applied cutaneously. The electrical stimulation from TENS may block or disrupt pain signals to the brain, reducing pain perception. TENS machines can be used at home or in conjunction with other interventions like physical therapy. Cognitive and behavioral options Cognitive behavioral therapy (CBT) is a structured, time-limited (typically 3-10 weeks) intervention focused on how thoughts, beliefs, attitudes, and emotions influence pain and can help patients use their minds to control and adapt to pain. This therapy includes setting goals, often with recommendations to increase activity to reduce feelings of helplessness. 44 Meditation Mindfulness meditation programs typically include a time-limited (8 weeks; range 3-12 weeks) trainings with group classes and home meditation. The objective is to inculcate a long-term practice that helps patients refocus their minds on the present, increase awareness of self and surroundings, and reframe experiences. 45,46
Page 8
Book Code: MDAZ1124
Powered by FlippingBook