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What Podiatrists Should Know About Non-Pharmacologic Options for Pain Control
Podiatric physicians and other clinicians continue to learn that pain is an internal, private experience, and patient self-reporting remains a cornerstone for its measurement, with sensory intensity being most typically assessed.1
The experience of pain is individualized, and the International Association for the Study of Pain (IASP) provides an updated definition; “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”2 Chronic pain can and does pose a significant public health concern, especially in populations already vulnerable to disparities in the availability of treatment resources; including the elderly, children and ethnic/racial minorities.3 Although the etiology and course of chronic pain can vary, patients with chronic pain may receive treatment using pharmacologic and/or non-pharmacologic approaches.3 This article will focus on non-pharmacologic approaches, including discussing its relationship to the opioid crisis, examples of such treatment options, and evidence related to their use.
The medical profession is well aware of the potential for misuse, abuse, and/or diversion of opioid medications. As the national crisis of opioid-related morbidity and mortality persists, it behooves clinicians to utilize opioid-sparing best practices.4 Pharmacologic alternatives to opioids may not show adequate efficacy, and carry their own risks and adverse effects. One such example is the increased risk of gastrointestinal bleeding with nonsteroidal anti-inflammatory drugs (NSAIDs).4
Non-pharmacologic techniques to address pain may include, but are not limited to: psychological interventions, attention strategies, cognitive-behavioral interventions, and physical modalities.5-8 Clinicians may choose to employ these strategies in addition to pharmacological interventions in a variety of scenarios, including acute pain and postoperative pain, with the potential for a reduction in opioid consumption, stress and anxiety among patients.5-8
Understanding Various Adjunctive Therapy Options
Podiatric physicians already often employ various non-pharmacologic therapeutic modalities to combat pain. For instance, ice can contribute to pain relief and may reduce inflammation and swelling. Heat may reduce muscle pain and stiffness. Each has potential, when appropriately applied, to provide some level of short- and long-term relief from pain.
Secondly, exercise and movement may play a vital role in pain control. Simply walking has potential benefits. Mind-body practices like yoga and tai chi (discussed more in-depth later in this article) incorporate breath control, meditation, and movements to stretch and strengthen muscles. Maintaining daily exercise and overcoming barriers to exercise can be a challenge for some, however, so clinicians should be aware of such challenges and help patients identify available resources in their communities.
The podiatric physician can also help patients suffering from pain explore elements of comfort therapy that may involve companionship, massage therapy, meditation, music, art, or drama therapy, pastoral counseling, and positioning.
What Role Could Acupuncture Play in Pain Management?
Acupuncture is a millennia-old form of alternative medicine that blends traditional Chinese medical concepts and modern medical techniques to provide pain relief while minimizing side effects by stimulating the body’s pain-relieving endorphins. Forms of acupuncture include needling, moxibustion, and cupping.9 Needling involves inserting needles (typically 32–36 gauge and made of ceramic, bronze, gold, iron, silver, or stainless steel) into specific acupuncture points on the body.10 In electroacupuncture, the provider applies a current is applied through the needle. Moxibustion utilizes burning moxa (sticks or cones similar to incense) above the skin near pressure points. Finally, cupping uses bamboo, glass, or ceramic cups to create a vacuum over the acupuncture points.10
Reports cite acupuncture’s use in a variety of clinical disorders, most frequently used chronic pain management.4 One such account is that of a 29-year-old male with a 7-year history of complex regional pain syndrome (CRPS) after digital surgery, whereby bee venom acupuncture resulted in significant reduction in pain. The patient reported complete pain resolution and no further need for analgesic medications after 14 treatments over 3 months.4,11 Modern practitioners may also employ acupuncture as surgical analgesia.12
Might Tai Chi Contribute to Pain Management?
For centuries, the Chinese mind-body exercise of tai chi has been a tool in health promotion and disease prevention.4 While most practitioners use tai chi for overall wellness, approximately 15% use it to help with specific medical conditions; usually pain, arthritis, or mental health.4,13 Research asserts that, in older individuals with multiple comorbid conditions, tai chi may improve physical function and reduce substance use.4,14
Insights on Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) consists of battery-powered unit and 2 to 4 leads connected to sticky pads, which one positions over the skin to cover or surround the painful area. The unit then delivers a low-voltage electrical impulse in a series of alternating electrical currents. The larger impulses are postulated to activate large, afferent, myelinated fibers, which in turn can block small pain-transmitting fibers. Additionally, reports contend that TENS units activate the release of natural endorphins by using alternating low-540 frequency pulses.15–17 Potential applications include patients with chronic back pain, arthritis, neuropathic pain, and mild-to-moderate acute pain. When turning the unit on, the patient may feel a light tingling sensation over the pad placement area.15–17
One can also adjust the signal intensity, also known as pulse width (duration of the pulse) produced from the TENS device, with a goal of producing paresthesia and analgesia without muscle contraction.15-17 At initial use, the patient adjusts the settings to find the most comfortable effective sensation.15-17 TENS does not have side effects, and the mechanism includes the activation of descending modulation systems and blocking of sympathetic outflow. TENS should not be used in patients with cardiac pacemakers or a history of cardiac dysrhythmia.18
Other Collaborative Team Members to Consider
Other health professionals may possess unique skills and methods to help patients relieve pain non-pharmacologically under the right circumstances. Chiropractic physicians practice a hands-on approach to treat pain including manual, mechanical, electrical and natural methods, along with nutrition guidance.8 Osteopathic physicians perform a hands-on manipulation technique applied to muscles, joints and other tissues to treat pain.8
Occupational therapists treat pain through the therapeutic use of everyday activities and may relieve pain associated with dressing, bathing, eating, and working.8 Therapy includes activities that increase coordination, balance, flexibility, and range of motion.8 Physical therapists treat pain by restoring, enhancing, and maintaining physical and functional abilities.8 Aoyagi and team found that patients who received physical therapy before and after total knee replacement during a prescribed timeframe had lower odds of long-term opioid use.19
Behavioral and mental health professionals, including psychiatrists, clinical social workers, marriage and family therapists, and counselors, provide therapies that identify and treat mental disorders or substance abuse problems that are roadblocks to pain management.8,20-23
Biofeedback and Other Mind-Body Interventions
Another non-pharmacologic pathway includes biofeedback techniques that use electronic devices to measure metrics such as breathing and heart rate.20-23 By watching how these measurements change, this data may assist patients in raising awareness of when their muscles are tense and thus, help them learn to relax them. As a result, biofeedback may help control pain.
Meditation may be another tool to empower patients suffering from chronic pain.20-23 Meditation is a mind-body practice in which patients focus their attention on something, such as an object, word, phrase, or their breath. This technique may help minimize discomfort by distracting from stressful thoughts or feelings.20,21-23 Distraction is another technique usually used to help children, especially babies. Using colorful, moving objects, or singing songs, telling stories, or looking at books or videos can distract preschoolers. Older children and adults find watching TV or listening to music helpful.23
Relaxation therapy may help reduce muscle tension and stress, lower blood pressure, and control pain, and involves strategically tensing and relaxing muscles throughout the body.20-23 One may use relaxation therapy with guided imagery (focusing the mind on positive images) and meditation. Relaxation or guided imagery employs exercises such as deep breathing and stretching can often reduce discomfort.20-23
What Are the Current Trends For These Treatments?
Stussman and colleagues investigated the number of office-based physicians recommending complementary pain therapies.20 Overall, more than half recommended at least one complementary health approach (CHA) in the last 12 months.20 The investigators determined that female physicians recommended each CHA at a higher rate than male physicians except for chiropractic and osteopathic manipulation.20 Among all office-based physicians, massage therapy was most commonly recommended (30.4%), followed by chiropractic/osteopathic manipulation (27.1%), herbs/nonvitamin supplements (26.5%), yoga (25.6%), and acupuncture (22.4%).20 General/family practice physicians most commonly recommendedchiropractic/osteopathic manipulation (54.0%) and massage therapy (52.6%).20
A different study by Ellis and team looked at non-pharmacological approaches to pain in residential care settings, concluding they are effective, especially when combining two or more.24 They recommend that staff working in residential care settings should receive training on best practices to recognize, assess, and manage pain, particularly in residents with dementia.24
Policy-Related Challenges and Pitfalls
The last decade held many new developments in non-pharmacologic pain treatment options, but unfortunately federal and insurance regulations may place restrictions on coverage for these treatments. As such, providers and patients may experience limits on usage of non-pharmacologic pain management options due to how insurance payments are administered under current Medicaid or Medicare reimbursement rules.25,26
Pollock and colleagues reported on the evolving policies regarding insurance payment for non-opioid pain management.8 In a 2016 survey of states, only 12 states out of 41 surveyed reported the start of programs or policies encouraging non-opioid pain management services by their Medicaid agencies.25-26 A 2018 cross-sectional study of 45 Medicaid, Medicare, and commercial plans for low back pain management options found that most covered physical and occupational therapy and chiropractic care services for chronic pain, but two-thirds of all plans did not cover acupuncture.25,26 Lastly, they identified the challenge facing some professionals who provide such services, such as athletic trainers, who may not be recognized as providers of those services under the Centers for Medicare and Medicaid Services (CMS).26-27
In Conclusion
Podiatric physicians can actively contribute to a comprehensive pain management team for patients with lower extremity pain. Educating oneself on non-pharmacologic pain treatment options available in the community, and the providers who render them, is one step towards addressing patients’ pain needs while minimizing or avoiding use of opioid medications. It is the author’s hope that this introduction to such non-pharmacologic options.
Dr. Smith is in private practice in Ormond Beach, FL. He consults for multiple government agencies and often lectures and writes about topics such as pharmacology and opioid mitigation.
References
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