• 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. 1 • Neuromodulation, which delivers stimulation to central or peripheral nervous system tissue and has shown efficacy in low-back and various headache disorders. 1 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 1 • 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. 1 • Vertebral augmentation, which uses various techniques, including injecting cement into vertebral compression fractures that are painful and refractory to treatment. 1 • Interspinous process spacer devices, which can provide relief for patients with lumbar spinal stenosis with neuroclaudication. 1 Behavioral Health Options There is ample evidence that chronic pain is both associated with and complicated by psychiatric, psychological, and social factors that exert tremendous influence over the pain experience and the success of treatment. 32-34 The higher the impact of pain, the worse the disruption to the person’s relationships, work, physical activity, sleep, self- care, and self-esteem. 1 Those with comorbidities that include depressive and anxiety disorders face additional challenges that complicate treatment by worsening pain and quality of life and rendering the activities of daily living more difficult. An estimated 30% of patients with chronic pain also have an anxiety disorder, such as generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), and agoraphobia. 1 Furthermore, high levels of depression and anxiety worsen pain and pain-related disability. 35 Patients with chronic pain have more disability than patients with other chronic health conditions. 1 In addition, patients with chronic pain are at increased risk for psychological distress, maladaptive coping, and physical inactivity related to fear of reinjury. 32 Behavioral therapies are valuable for helping patients cope with the psychological, cognitive, emotional, behavioral, and social aspects of pain.
Common behavioral health approaches include: • Behavioral therapy for pain, which seeks to reduce maladaptive pain behaviors, such as fear avoidance, and increase adaptive behaviors with the goal of increasing function; it has demonstrated effectiveness (and cost- effectiveness) for reducing pain behaviors and distress and improving overall function. 1 • CBT, which focuses on shifting cognitions and improving pain coping skills in addition to altering behavioral responses to pain; CBT is effective for a variety of pain problems (including low-back pain and fibromyalgia), helps improve self-efficacy, reduces pain catastrophizing, and improves overall functioning. 1,30,36 • Acceptance and Commitment Therapy, which emphasizes observing and accepting thoughts and feelings, living in the present moment, and behaving according to one’s values; it differs from conventional CBT in that psychological flexibility is created through accepting rather than challenging psychological and physical experiences. 1,37,38 • Mindfulness-based stress reduction (MBSR), which stresses body awareness and training in mindfulness meditation (i.e., nonjudgmental awareness of present-moment sensations, emotions, and thoughts), typically delivered in group format; research suggests effectiveness for coping with a variety of pain conditions (including rheumatoid arthritis, low-back pain, and MS) as well as improvements in pain intensity, sleep quality, fatigue, and overall physical functioning and well-being. 1,36,39-43 • Emotional awareness and expression therapy, which is an emotion-focused therapy for patients with a history of trauma or psychosocial adversity who suffer from centralized pain conditions; patients are taught the effect of unresolved emotional experiences on neural pathways involved in pain and how to adaptively express those emotions. 1 Research indicates a positive impact on pain intensity, pain interference, and depressive symptoms. 44 psychophysiological approaches, which include biofeedback, relaxation training, and hypnotherapy, help patients develop control over their physiologic and psychological responses to pain. 1 ° • Self-regulatory or
Complementary and Integrative Health Approaches These therapies can be overseen by licensed practitioners and trained instructors and are used as standalone treatments or in combination with a multidisciplinary plan. 1 The following treatments may be considered for acute and chronic pain, according to patient status: 1 • Acupuncture, which involves manipulating a system of meridians where “life energy” flows by inserting needles into identified acupuncture points; with its origins in Chinese medicine, acupuncture is received by an estimated 3 million Americans each year. 46 There is growing evidence of the therapeutic value of acupuncture in pain conditions that include osteoarthritis, migraine, and low- back, neck, and knee pain; however, existing clinical practice guidelines differ in their evidence analysis and recommendations for acupuncture use. 1 Risks are minimal when performed by a licensed, experienced, well- trained practitioner using sterile needles. 1 • Massage and manipulative therapies, including osteopathic and chiropractic treatments, which may be clinically effective for short-term relief and are recommended in consultation with primary care and pain management teams. 1 Despite the paucity of rigorous studies, the lack of detail on massage types, and the smallness of sample sizes, positive effects of massage are recognized for various pain conditions that include postoperative pain, headaches, and neck, back, and joint pain. 1,47-50 • MBSR, which is also discussed under behavioral health approaches, and which has evidence of statistically-significant beneficial effects for low-back pain, and is shown in a meta-analysis to significantly reduce the intensity and frequency of primary headache pain. 36,51 • Yoga, which uses stretching, breathing, and meditation and has been shown to be therapeutic in the treatment of various chronic pain conditions, particularly low-back pain. 52-55 Risks are minimal, and yoga can generally be practiced safely, especially when delivered in group settings. 1,56 • Tai chi, which originated as a Chinese martial art and uses slow movements and meditation, and which has demonstrated long-term benefit for osteoarthritis and other musculoskeletal pain conditions. 57,58 Like yoga, it is generally safe and has the benefits of a group setting and/or availability via telehealth. 1 • Spirituality, which encompasses a broad range of resources and practices, such as prayer and meditation, has growing evidence of benefit for people with pain. 59 It has long been integral to palliative and supportive care, and is gaining support as a means to help patients cope with and manage ongoing pain. 1
Biofeedback, which provides real-time feedback about physiologic functions such as heart rate, muscle tension, skin conductance, and has evidence of effectiveness for chronic headache in adults and children. 1,45 Relaxation training and hypnotherapy, which alter attentional processes and heighten physical and psychological relaxation, and have empirical support in pain management. 1
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