• 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 • 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 • Vertebral augmentation, which uses various techniques, including injecting cement into vertebral compression fractures that are painful and refractory to treatment 3 • Interspinous process spacer devices, which can provide relief for patients with lumbar spinal stenosis with neuroclaudication. 3 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. 35-37 The higher the impact of pain, the worse the disruption to the person’s relationships, work, physical activity, sleep, self-care, and self-esteem. 3 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. 3 Furthermore, high levels of depression and anxiety worsen pain and pain-related disability. 38 Patients with chronic pain have more disability than patients with other chronic health conditions. 3 In addition, patients with chronic pain are at increased risk for psychological distress, maladaptive coping, and physical inactivity related to fear of reinjury. 35 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. 3 • 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. 3,33,39 • 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. 3,40,41 • 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. 3,39,42-46 • 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. 3 Research indicates a positive impact on pain intensity, pain interference, and depressive symptoms. 47 psychophysiological approaches, which include biofeedback, relaxation training, and hypnotherapy, help patients develop control over their physiologic and psychological responses to pain. 3 ° or
• Self-regulatory
Biofeedback, which provides real-time feedback about physiologic functions such as heart rate, muscle tension, and skin conductance and has evidence of effectiveness for chronic headache in adults and children. 3,48 Relaxation training and hypnotherapy, which alter attentional processes and heighten physical and psychological relaxation, have empirical support in pain management. 3
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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. 3 The following treatments may be considered for acute and chronic pain, according to patient status: 3 • 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. 49 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. 3 Risks are minimal when performed by a licensed, experienced, well- trained practitioner using sterile needles. 3 • 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. 3 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. 3,50-53 • 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. 39,54
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