Management

Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain,^[2] whether acute pain or chronic pain. Relieving pain (analgesia) is typically an acute process, while managing chronic pain involves additional complexities and ideally a multidisciplinary approach.

A typical multidisciplinary pain management team may include: medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists.^[3] The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics.

Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team.^[4] Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it. Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain and discomfort to reduce any suffering during treatment, healing, and dying.

The task of medicine is to relieve suffering under three circumstances. The first is when a painful injury or pathology is resistant to treatment and persists. The second is when pain persists after the injury or pathology has healed. Finally, the third circumstance is when medical science cannot identify the cause of pain. Treatment approaches to chronic pain include pharmacological measures, such as analgesics (pain killer drugs), antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy. ^{[citation needed]}

In the nursing profession, one common definition of pain is any problem that is “whatever the experiencing person says it is, existing whenever the experiencing person says it does”.^[5]

Pain management includes patient and communication about the pain problem.^[6] To define the pain problem, a health care provider will likely ask questions such as:^[6]

• How intense is the pain?
• How does the pain feel?
• Where is the pain?
• What, if anything, makes the pain lessen?
• What, if anything, makes the pain increase?
• When did the pain start?

After asking such questions, the health care provider will have a description of the pain.^[6] Pain is often rated on a scale from 1 to 10, known as the Numeric Rating Scale (NRS);^[7]

Rating Pain Level

• 0 No Pain
• 1 – 3 Mild Pain (nagging, annoying, interfering little with ADLs)
• 4 – 6 Moderate Pain (interferes significantly with ADLs)
• 7 – 10 Severe Pain (disabling; unable to perform ADLs)

This pain scale is based on a person reporting their pain intensity, with 0 representing no pain experienced and 10 indicating the worst possible pain.^[8] The NRS is a common tool used by clinicians and in research to understand personal pain levels and monitor changes over time.^[8] In the clinical context, pain management will then be used to address that pain.^[6]

There are many types of pain management. Each have their own benefits, drawbacks, and limits.^[6]

A common challenge in pain management is communication between the health care provider and the person experiencing pain.^[6] People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is.^[6] Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments.^[6] There is a risk in many types of pain management for the patient to take treatment that is less effective than needed or which causes other difficulties and side effects.^[6] Some treatments for pain can be harmful if overused.^[6] A goal of pain management for the patient and their health care provider is to identify the amount of treatment needed to address the pain without going beyond that limit.^[6]

Another problem with pain management is that pain is the body’s natural way of communicating a problem.^[6] Pain is supposed to resolve as the body heals itself with time and pain management.^[6] Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem.^[6]

Physical medicine and rehabilitation (PM&R), a medical specialty, uses a range of physical techniques, such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy in the management of pain.^{[citation needed]} PM&R techniques are usually part of an interdisciplinary or multidisciplinary program that might also include pharmaceuticals.^[9] Spa therapy has shown positive effects in reducing pain among patients with chronic low back pain, but its evidence base is limited.^[10] Studies have shown that kinesiotape can be used to reduce chronic low back pain.^[11] The US Centers for Disease Control recommended that physical therapy and exercise be prescribed as first-line treatments (rather than opioids) for multiple causes of chronic pain in 2016 guidelines.^[12] Applicable disorders include chronic low back pain, osteoarthritis of the hip and knee, and fibromyalgia.^[12] Exercise alone or with other rehabilitation disciplines (including psychotherapeutic approaches) can have a positive effects on pain.^[12] Besides improving the experience of pain itself, exercise can also improve individuals’ well-being and general health.^[12]

Manipulative and mobilization therapies are considered safe interventions for low back pain, with manipulation potentially offering a larger therapeutic effect.^[13]

Specifically in chronic low back pain, education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short-term relief of disability and pain.^[14]

Physical activity interventions, such as tai chi, yoga, and Pilates, promote harmony of the mind and body through total body awareness. These practices incorporate breathing techniques, meditation, and a wide variety of movements while training the body to perform functionally by increasing strength, flexibility, and range of motion.^[15] Physical activity can also benefit chronic sufferers by reducing inflammation and sensitivity and boosting overall energy.^[16] Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks),^[17] and overall quality of life, while minimizing the need for pain medications.^[15] More specifically, walking has been effective in improving pain management in chronic low back pain.^[18]

Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and control chronic pain via electrical impulses.^[19] Limited research has explored the effectiveness of TENS in relation to pain management of multiple sclerosis (MS). MS is a chronic autoimmune neurological disorder, which consists of the demyelination of the nerve axons and the disruption of nerve conduction velocity and efficiency.^[19] In one study, electrodes were placed over the lumbar spine, and participants received treatment twice a day and at any time when they experienced a painful episode.^[19] This study found that TENS would benefit MS patients with localized or limited symptoms in one limb.^[19] The research is mixed with whether or not TENS helps manage pain in MS patients.^{[citation needed]}

Transcutaneous electrical nerve stimulation is ineffective for lower back pain. However, it might help with diabetic neuropathy^[20] as well as other illnesses. ^{[citation needed]}

Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions, and it involves the application of low-intensity (up to 2 mA) constant direct current to the scalp through electrodes in order to modulate the excitability of large cortical areas.^[21] tDCS may have a role in pain assessment by contributing to efforts in distinguishing between somatic and affective aspects of pain experience.^[21] Zaghi and colleagues (2011) found that the motor cortex, when stimulated with tDCS, increases the threshold for both the perception of non-painful and painful stimuli.^[21] Although there is a greater need for research examining the mechanism of electrical stimulation in pain treatment, one theory suggests that the changes in thalamic activity may be due to the influence of motor cortex stimulation on the decrease in pain sensations.^[21]

Concerning MS, a study found that daily tDCS sessions resulted in an individual’s subjective report of pain decreased when compared to a sham condition.^[19] In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session.^[19]

Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas.^[22] Research examining tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases.^[22] Specifically, the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group (e.g., sham stimulation, stimulation of the DLPFC).^[22] However, this effect decreased after treatment ended, but remained significant for three weeks following the extinction of treatment.^[22]

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, was unable to quantify the difference in the effect on pain of real, sham and no acupuncture.^[23] A systematic review in 2019 reported that acupuncture injection therapy was an effective treatment for patients with nonspecific chronic low back pain, and is widely used in Southeast Asian countries.^[24]

Research has found evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain.^[25][26] Instead of thermal therapy, where reactant energy is originated through heat, Low-Level Light Therapy (LLLT) utilizes photochemical reactions requiring light to function.^{[citation needed]} Photochemical reactions need light in order to function. Photons, the energy created from light, from these photochemical reactions provide the reactants with energy to embed in muscles, thus managing pain.^[27] One study conducted by Stausholm et al. showed that at certain wavelengths, LLLT reduced pain in participants with knee osteoarthritis.^[28] LLLT stimulates a variety of cell types, which in turn can help treat tendonitis, arthritis, and pain relating to muscles.^{[citation needed]}

Audioanalgesia and music therapy are both examples of using auditory stimuli to manage pain or other distress. They are generally viewed as insufficient when used alone but also as helpful adjuncts to other forms of therapy.^{[citation needed]}

Interventional radiology procedures for pain control, typically used for chronic back pain, include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants.

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.^{[29][30][31][32][33]} Radiofrequency treatment has been seen to improve pain in patients with facet joint low back pain. However, continuous radiofrequency is more effective in managing pain than pulsed radiofrequency.^[34]

An intrathecal pump is sometimes used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. ^{[medical citation needed]}

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord, providing a paresthesia (“tingling”) sensation that alters the perception of pain by the patient.^{[medical citation needed]}

Intra-articular ozone therapy has been seen to alleviate chronic pain in patients with knee osteoarthritis efficiently.^[35]

Acceptance and commitment therapy (ACT) is a type of cognitive behavioral therapy that emphasizes behavior modification over symptom reduction, focusing on changing the context of psychological experiences and employing experiential behavior change methods.^[36] The central process in ACT revolves around psychological flexibility, which in turn includes processes of acceptance; awareness; present-oriented mindfulness in interacting with experiences; an ability to persist or change behavior; and an ability to be guided by one’s values.^[36] ACT has robust evidence in the scientific literature for a range of health and behavior problems, including chronic pain.^[36] ACT facilitates the dual processes of acceptance and behavioral change, enabling patients to cultivate psychological flexibility. This approach allows for a more dynamic and adaptable focus in therapeutic interventions, enhancing overall treatment effectiveness.^[36]

Recent research has applied ACT successfully to chronic pain in older adults due in part to its direction from individual values and being highly customizable to any stage of life.^[36] In line with the therapeutic model of ACT, significant increases in process variables, pain acceptance, and mindfulness were also observed in a study applying ACT to chronic pain in older adults.^[36] In addition, these primary results suggested that an ACT-based treatment may significantly improve levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain.^[36]

Cognitive behavioral therapy (CBT) in the setting of pain management aims to aid individuals in understanding the relationship between their pain, thoughts, emotions, and behaviors. A main goal in treatment is cognitive—thinking, reasoning, and remembering—restructuring to encourage helpful thought patterns.^[37] This will target healthy activities such as regular exercise and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques (e.g., relaxation, diaphragmatic breathing, and even biofeedback).^{[citation needed]}

Studies have demonstrated the usefulness of cognitive behavioral therapy in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability.^[38] CBT is significantly more effective than standard care in treatment of people with body-wide pain, like fibromyalgia. Evidence for the usefulness of CBT in the management of adult chronic pain is generally poorly understood, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials.^{[citation needed]} The crucial content of individual interventions has not been isolated, and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult.^[39]

In 2020, a systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain (excluding headaches). There is no evidence that behaviour therapy (BT) is effective for reducing this type of pain; however, BT may be useful for improving a person’s mood immediately after treatment. This improvement appears to be small and is short-term in duration.^[40] CBT may have a small positive short-term effect on pain immediately following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy.^[40] CBT may contribute towards improving the mood of an adult who experiences chronic pain, which could possibility be maintained for more extended periods of time.^[40]

For children and adolescents, a review of RCTs evaluating the effectiveness of psychological therapy for the management of chronic and recurrent pain found that psychological treatments are effective in reducing pain when people under 18 years old have headaches.^[41] This beneficial effect may be maintained for at least three months following the therapy.^[42] Psychological treatments may also improve pain control for children or adolescents who experience pain unrelated to headaches. It is not known if psychological therapy improves a child’s or an adolescent’s mood and the potential for disability related to their chronic pain.^[42]

A 2007 review of 13 studies found evidence for the efficacy of hypnosis in reducing pain in some conditions. However, the studies had limitations like small study sizes, raising issues of power to detect group differences, and lacking credible controls for placebo or expectation. The authors concluded that “although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions.”^[43]: 283

Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents.^[44] In clinical trials addressing other patient groups, it has significantly reduced pain compared to no treatment or some other non-hypnotic interventions.^[45] The effects of self-hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.^[46]

A 2019 systematic review of 85 studies showed it to be significantly effective at reducing pain for people with high and medium suggestibility, but minimal effectiveness for people with low suggestibility. However, high-quality clinical data is needed to generalize to the whole chronic pain population.^[47]

A 2013 meta-analysis of studies that used techniques centered around the concept of mindfulness concluded, “that MBIs [mindfulness-based interventions] decrease the intensity of pain for chronic pain patients.”^[48] A 2019 review of studies of brief mindfulness-based interventions (BMBI) concluded that BMBI are not recommended as a first-line treatment and could not confirm their efficacy in managing chronic or acute pain.^[49]

Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness.^[50][51] Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of ‘loving-kindness‘, and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism.^[50][52] It was developed by Vidyamala Burch and is delivered through the programs of Breathworks.^[50][51]

The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain.^[53][54] In the treatment of chronic pain, the three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine. The exact medications recommended will vary by country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.^{[citation needed]}

, particularly in the lower back and pelvis (PGP