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Introduction

Pain is a significant health burden in the United States. According to 2018 data from the National Center for Health Statistics, a large proportion of US adults self-report having pain symptoms or medical conditions that may cause pain: 29.9% (low back pain), 23.7% (arthritis), 16.1% (neck pain), 15.5% (migraine or severe headaches), 9.4% (any cancer), and 5.2% (face or jaw pain).¹ An estimated 50 million adults experience chronic pain on a daily basis.²

Pain is a dynamic and complex physiologic process that involves physical, psychological, and social factors.^2-4 Pain transmission occurs through neurotransmitter activity in the peripheral and central nervous systems, which can be affected by physical abnormalities or hormone fluctuations.⁴ Pain perception occurs in the context of cognitive and behavioral functions of the brain and can be influenced by various cognitive states such as stress, relaxation, anxiety, or depression. The role of inflammatory responses and the immune system in pain transmission and perception are areas of ongoing study, especially for pain syndromes without a readily identifiable cause (eg, fibromyalgia) or symptoms that are inconsistent with the stimulus (eg, hyperalgesia due to central or peripheral sensitization).⁵ Overall, the numerous etiologies and complexity of chronic pain transmission and perception presents both barriers to and opportunities for its management. Nonpharmacologic treatments can effectively address multiple aspects of pain physiology and their use can be considered throughout the treatment course.

Comprehensive Approach to Pain Management

Effective management of both acute and chronic pain follows widely accepted general principles of pain management including multimodal and multidisciplinary approaches.^2,5 Multimodal pain control often involves combinations of strategies from several domains including medications, restorative therapies, interventional procedures, behavioral health, and complementary/alternative/integrative approaches.² Care should be individualized to the patient and reflect their preferences, beliefs, lifestyle, and practical issues such as physical mobility and financial burden. Rather than focusing on numeric assessments of pain severity (ie, treating a number), many experts recommend focusing on patient-defined measures of treatment success such as quality of life and function.⁵ For many patients and providers, nonpharmacologic therapies may be preferred to pharmacologic therapies due to their familiarity, ease of use, accessibility, and safety. Nonpharmacologic therapies may also maximize patient engagement, participation, and commitment compared to the passivity that can characterize treatment approaches that are more provider-centered.^5,6

Safety is another important factor that may cause patients and providers to rely on nonpharmacologic treatments in practice. Pharmacologic analgesics are effective but carry safety risks, particularly opioids. Opioid therapy is associated with hyperalgesia, respiratory depression, sedation, dependence, and risk of overdose.² Current and historic trends in widespread opioid use have led to increases in life-threatening complications such as overdose, abuse, and addiction, along with increased mortality. In response, regulatory and public health organizations are heavily promoting nonopioid analgesic strategies including nonpharmacologic therapies.⁵ For example, the Joint Commission now requires that accredited facilities provide evidence-based nonpharmacologic pain treatments, such as physical therapy, acupuncture, chiropractic therapy, massage, relaxation therapy, and cognitive behavioral therapy (CBT).^5,7

The focus of this article will be on the efficacy and safety of noninvasive, nonpharmacologic treatment options for chronic pain caused by various etiologies, although many of these treatment modalities are also used in the setting of acute pain (eg, injuries, procedure-related pain).

Nonpharmacologic Pain Treatment Options

Nonpharmacologic options for treating pain fall under several global categories: lifestyle, physical rehabilitative, mind-body, complementary and alternative medicine, device/procedure-based, and invasive/surgical strategies. A summary of nonsurgical approaches is available in Table 1.^2,5,8 The table provides common examples for each category but is not intended to be a comprehensive list of all possible treatment modalities.

Although some of these treatment modalities are well studied, there are limitations to the clinical evidence for the efficacy and safety of most nonpharmacologic treatments. These limitations include heterogeneous patient populations, subjective efficacy endpoints, observational nature of the data, small sample sizes, and lack of standardized interventions between studies. High-quality studies comparing nonpharmacologic interventions to each other and to pharmacologic and/or interventional therapies are also lacking.

Lifestyle-based treatments

A widely accepted underlying principle in contemporary pain management is that exercise is needed to maximize bodily function.² Unlike historical approaches to pain that emphasized rest, including bed rest, maintaining activity is currently a cornerstone of managing pain. Patient education can overcome fears or anxieties related to physical activity (eg, “if I am active, the pain will worsen”) and give the patient confidence in pursuing exercises that are safe for their underlying condition. If needed, low impact or no impact exercises can be implemented, including aquatic exercise.^9,10 Exercise may be more effective when undertaken in a class setting with an instructor rather than individually or at home. Post-exercise stretching can also decrease pain by relieving muscle tension.² According to a recent Cochrane review, data regarding the efficacy of exercise in managing chronic pain are conflicting but benefits on pain, physical function, and quality of life are likely, with few adverse events.¹¹

Specific diets that have been associated with decreased pain include anti-inflammatory diets (high in vegetables, fruits, legumes, and whole grains; low in animal protein), diets that minimize processed foods in general, and diets high in vitamin D.⁵ Some patients may self-identify certain foods that worsen their pain and choose to avoid those foods.

Sleep problems are common among individuals with pain. These concerns are interrelated, since difficulty sleeping can be caused by pain and pain can worsen with lack of sleep.^2,5 Inadequate or unrefreshing sleep can have other adverse health consequences as well (eg, compromised mental health, increased cardiovascular risk, decreased cognitive function). Nonpharmacologic sleep hygiene interventions are readily available, easily implemented, have negligible adverse consequences, and may have a substantial effect on pain symptoms as well as sleep duration and quality.⁵

Nicotine is a vasoconstrictor and has proinflammatory effects; therefore, decreased exposure to the pharmacologic effects of nicotine can increase blood flow and healing and decrease inflammation throughout the body.¹² Pain related to degenerative causes or inflammation may improve with smoking cessation.

Physical rehabilitative treatments

Treatment approaches that fall under the physical rehabilitative domain are also called ‘restorative’ therapies because they seek to decrease pain by restoring bodily function and activities of daily living.² Typically these therapies are administered by physical or occupational therapists.

Cold and heat have long been used to manage pain.² During the acute recovery period after an injury, many health care providers recommend RICE (rest, ice, compression, elevation) therapy to minimize swelling and inflammation and promote healing.^2,13,14 Ice can lead to local tissue damage and nerve palsies if used for long periods of time or if applied directly to the skin; therefore, patients should receive education on how to use this intervention safely (ie, keep a barrier between ice and skin, apply for only 15 to 20 minutes at a time).^13,15 Similarly, heat should only be applied for a limited duration of time (15 to 20 minutes) unless otherwise specified by the manufacturer of a commercial heat-producing product and should not be applied over topical medications or to areas of broken skin. Appropriate heat sources include warm compresses, hot water bottles, or heating pads.¹³ Topical heat carries an increased risk of skin flushing.¹⁶ Both ice and heat may have a role in managing chronic pain as well, especially during flare-ups.

Paraffin wax is another heat-based treatment that can be administered by the patient or by a professional.¹² Paraffin wax treatments are generally applied to the hands, elbows, and feet. As the warm, liquid wax cools and hardens, the heat penetrates into deep tissues to increase blood flow and muscle and joint flexibility.

The practices of physical and occupational therapy offer a wide range of benefits to patients with pain, including assessment of muscle and joint function, identification of exacerbating movements, and prescription of exercises to strengthen and maximize function.^6,18,19 Patient education and psychological support/reassurance are important activities performed by physical and occupational therapists. The goal of both physical and occupational therapy is for the patient to maintain (or regain) a desired level of function in their daily life by implementing changes in the patient’s environment and how they move in their environment.

Spinal traction or decompression is a specific nonpharmacologic treatment that can be administered by physical therapists, either manually or with a machine.^2,12 Applying gentle force to stretch the spine (traction) or increasing pressure/force to specific spinal areas (decompression) can decrease or redirect the pressure on a disc, which may lead to decreased pain, although efficacy data are limited.

Massage is described as physical manipulation of soft tissues with a goal of relieving pain and tension.⁵ Therapeutic massage often involves manual work to break up adhesions between muscles, ligaments, and fascia, including scar tissue, thereby releasing muscle tension and mobilizing fluid within the lymphatic system.¹² This therapy is well-studied in surgical populations, with evidence of efficacy and only minor safety concerns (eg, muscle soreness).⁵ Massage is also effective in patients with chronic pain, including neck pain and osteoarthritis, according to systematic reviews, although the overall quality of evidence is low.^2,20 When performed by a well-trained practitioner, massage has not been associated with any major adverse events.⁵

Spinal manipulation and manipulation therapy of other joints are usually performed by chiropractors and osteopathic physicians (often called ‘adjustment’) or physical therapists (often called ‘mobilization’).⁵ This technique involves applying targeted forces to the affected joint or vertebrae, which can be high or low forces depending on the desired degree of joint movement.¹² According to systematic reviews, spinal manipulation is an effective treatment for low back pain, neck pain, and migraine prevention and joint manipulation is beneficial for knee osteoarthritis and painful foot, ankle, wrist, and shoulder conditions.⁵ Safety concerns associated with manipulation therapies are generally minor but serious events have rarely occurred, including cervical artery dissection, stroke, and neck injury.^12,16

Kinesiotape is a special kind of tape that provides physical support when wrapped around a muscle group but does not restrict muscle movement because it has elastic properties.¹² Potential benefits of this muscle support include muscle activation, joint protection, and improved flow of blood and lymphatic fluids. Nonelastic tape or physical bracing can also be used to hold bodily structures in place with more rigidity, but this should be undertaken only on a short-term basis to prevent muscle atrophy and decreased function.^2,12

Specific exercise techniques that have been studied for relief of pain include yoga, Tai Chi, and pilates.⁵ Of these, yoga is the most extensively studied. Yoga is a combination of physical postures, breathing, and attention/meditation. Systematic reviews support the efficacy of yoga for low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, and neck pain. The only notable safety concerns with yoga are mild joint and back discomfort, similar to most forms of exercise. However, certain individuals may need to use modified positions due to concurrent medical conditions (eg, decreased bone health, glaucoma). Similarly, the use of Tai Chi (slow choreographed movements and attention to breathing) for low back pain and osteoarthritis is supported by systematic reviews. Tai Chi appears generally safe. Pilates is another exercise modality that combines strengthening with postural and muscle awareness. In systematic reviews, pilates has improved low back pain and function with only minor safety concerns (eg, muscle soreness).

Mind-body treatments

Mind-body approaches to pain management recognize the relationship between cognitive function and pain perception.²¹ CBT is the most widely studied mind-body pain treatment strategy. This technique empowers the patient to identify opportunities to improve their cognitive and behavioral reactions to pain, leading to reduced psychological distress and improved physical and social function.⁶ Changed thought patterns can alleviate emotional distress and downregulate the sympathetic nervous system, which may decrease an individual’s experience of pain and facilitate behaviors that promote well-being.¹² A similar strategy to CBT is operant behavior therapy, which uses positive and negative reinforcement to minimize behaviors that are detrimental to health and increase health-promoting behaviors.^2,6 Cognitive behavioral approaches can allow patients with pain to manage stress, pain-related fears, lack of motivation, social support disruption, and negative thinking, all of which can minimize the development or worsening of depression or anxiety symptoms.¹² Other behavioral strategies include acceptance and commitment therapy and emotional awareness and expression therapy.² When administered by individuals with adequate training, behavioral therapies are not associated with any major safety concerns, but caution may be warranted in patients with a history of psychosis.^2,17

Mindfulness involves focusing the mind by awareness of breathing and other mental and physiologic processes.⁵ MBSR has had positive effects on low back pain, headache, fibromyalgia, and irritable bowel syndrome. Systematic reviews report that mindfulness meditation improved depression symptoms and quality of life in patients with chronic pain.^22,23 The benefit of mindfulness-based techniques may include decreased attention to pain and a greater awareness of how negative thoughts about pain and pain-related distress can actually worsen pain.¹²

Relaxation-based techniques aim to balance the sympathetic and parasympathetic nervous systems through a process of directed physiologic changes that oppose physiologic symptoms associated with stress and pain such as muscle tension and shallow breathing.^5,21 According to systematic reviews, progressive relaxation is effective for low back pain and hypnosis/guided imagery is effective for rheumatic conditions including fibromyalgia.⁵ Aromatherapy with essential oils (either topical or inhaled) can be combined with relaxation or other mind-body techniques.⁸ Emotional and physical responses to the pleasant smells generated by aromatherapy have effectively treated postoperative pain and gynecologic pain.²⁴

Clinical evidence with music therapy is limited, but music is known to affect the brain and specific body processes related to pain such as stress/relaxation, emotions, and cognitive processing.^5,25 Systematic reviews support the benefit of music therapy on pain intensity, emotional distress, and analgesic consumption, including in patients with cancer, chronic pain, and in the palliative care setting.

In most individuals, mind-body therapies have not been associated with major safety concerns.⁵ However, relaxation may produce unexpected responses in certain individuals, including those with epilepsy or psychiatric conditions. Despite the likelihood of safety for most people, there is limited high-quality evidence to support the efficacy of mind-body therapies.^21,26

Complementary and alternative medicine treatments

The complementary and alternative medicine approach seeks to overcome the limitations of traditional medicine through nontraditional bodily manipulation.² For example, acupuncture involves stimulating specific body points with needles, heat, or pressure to affect pain transmission channels.^5,12 Several systematic reviews have shown that acupuncture decreases pain, opioid use, and opioid-related adverse effects, especially in the settings of postoperative pain, chronic shoulder pain, osteoarthritis, low back pain, and migraine.⁵ As long as the provider is well-trained and sterile needles are used, acupuncture appears to have few safety concerns, although minor bruising/bleeding at the needle insertion site can occur.^2,5,26

Device/procedure-based treatments

Electroanalgesia is defined as the use of electrical stimulation to the skin around the painful area.¹³ A common example of this technique is TENS. Electrical nerve stimulation can also be delivered in a more invasive percutaneous manner (PENS). Efficacy of these techniques is thought to be due to disruption of nerve pain signal propagation in both the peripheral and central nervous systems and increased production of endorphins.^13,27 Nonprescription electrical nerve stimulators for consumer application of TENS are approved by the Food and Drug Administration (FDA) for muscle and joint pain relief.¹³ Electrode pads are applied at sites throughout the body (as specified by each device manufacturer) and worn for 15 to 30 minutes up to 3 times daily. Safety risks of TENS devices include placing electrodes near the throat, chest, head, over the carotid arteries, or on broken or inflamed skin. These devices should be avoided by patients with implanted devices such as pacemakers, pregnant patients, children, and individuals with substantial lymphedema.^13,15,17 Many systematic reviews have evaluated the efficacy of TENS in various settings such as postoperative pain, low back pain, osteoarthritis, and diabetic peripheral neuropathy; results are conflicting overall.^2,27 A 2019 Cochrane review of TENS for chronic pain was unable to make any definitive conclusions about the efficacy of TENS in this setting due to the low quality of the available data.²⁸ However, TENS has been recommended in guidelines for the acute treatment of injury- or surgery-related pain.^15,17

Other electrical treatment modalities include interferential current stimulation of deeper tissues, pulsed electromagnetic field therapy, and the use of high frequency electric currents to generate heat in deep tissues (eg, diathermy).^2,12 These modalities are thought to decrease pain by improving circulation, tissue regeneration, and tissue repair, and by decreasing inflammation. Studies suggest that electrical treatment modalities may be useful for maintaining physical function of patients with osteoarthritis, but data are conflicting regarding effects on pain.^29-31 Ultrasound therapy uses a similar approach, but without generating heat.¹² A probe is used to transfer ultrasound waves through the skin into deeper tissues. The ultrasound waves cause tissue vibrations that can lead to increased blood flow and breakdown of scar tissue. Systematic reviews suggest efficacy of ultrasound for joint (knee, hip, shoulder) pain and function.^32,33

Laser therapy has been studied largely in patients with osteoarthritis, neuropathic pain, and low back pain, either alone or in combination with acupuncture.^8,34-38 With this modality, laser light is absorbed through the skin and causes cellular changes that lead to pain relief.⁸ Laser therapy has not been associated with any major safety concerns.

Biofeedback is a hybrid mind-body technique that uses a device-generated signal to train patients to manipulate and control their specific stress-related body processes, such as muscle tension.^2,5,12 According to meta-analyses, biofeedback may improve low back pain, headache, and fibromyalgia.⁵ This technique appears to be generally safe, but headache, fatigue, and sleep problems are rare potential adverse effects.

Virtual reality has been studied in adult and pediatric burn patients and patients with cancer, back pain, neuropathic pain, and procedure-related pain.^5,39 Overall, evidence supporting the efficacy of virtual reality is conflicting. Some evidence suggests that adjunctive use of virtual reality may decrease opioid requirements, while other studies found reductions in pain only while the technology was being actively used. Adverse effects of virtual reality include nausea and the potential to knock into objects in the real world while using a virtual reality device.⁵ The latter can be minimized by limiting use of virtual reality technology to a safe space in which another individual is present to prevent physical collisions.

Guideline-Supported Nonpharmacologic Treatments

Most clinical practice guidelines for painful medical conditions are heavily focused on pharmacologic therapy, but some practice guidelines provide comments and recommendations on the use of specific nonpharmacologic treatments for pain.

A 2010 guideline on chronic pain from the American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine endorses multimodal multidisciplinary approaches to pain treatment.⁴⁰ As part of multimodal therapy, 2 nonpharmacologic treatments are generally recommended for most patients with chronic pain: physical/restorative therapy and psychological treatments (including CBT, biofeedback, relaxation training, supportive therapy, group therapy, and counseling). Patients with back pain, neck pain, or phantom limb pain are appropriate candidates for TENS. Adjunctive acupuncture is recommended specifically for nonspecific, noninflammatory low back pain.

The Centers for Disease Control and Prevention (CDC) guideline on prescribing opioids for chronic pain comments on the efficacy of nonpharmacologic treatments for chronic pain, including CBT, physical therapy, weight loss, and exercise.⁴¹ This guideline also specifies that multimodal treatment approaches may be more effective than individual approaches (for example, psychological plus exercise therapies). Nonpharmacologic and nonopioid therapies are recommended first-line for chronic pain management in patients not in active cancer treatment, palliative care, or end-of-life care and should be continued in patients who later initiate opioid therapy. Nonpharmacologic therapies may also have a prominent role in patients who are tapering or discontinuing opioids.

For acute musculoskeletal injury, a 2019 guideline from the Orthopaedic Trauma Association recommends the use of immobilization, ice, and elevation as part of a multimodal approach to analgesia.¹⁵ Both TENS and cryotherapy can be considered. Mind-body and complementary strategies such as CBT, music therapy, and aromatherapy can be considered, with greater consideration for behavioral therapies for patients with exaggerated pain responses, symptoms of depression/anxiety/trauma, or less effective coping strategies (eg, catastrophic thoughts). Similarly, a 2016 guideline on management of acute postoperative pain recommends multimodal analgesia to minimize opioid use, which may include nonpharmacologic strategies.¹⁷ Specific nonpharmacologic strategies recommended in this guideline include TENS and mind-body behavioral therapies, both weak recommendations based on moderate quality evidence.

Targeted, evidence-based recommendations for nonpharmacologic management of some individual disease states are available.^{9,10,16,42,43} These recommendations are summarized in Table 2. The 2018 comprehensive systematic review findings from the Agency for Healthcare Research and Quality (AHRQ) are included in the table, which represent comparisons between interventions and no intervention/sham intervention/control groups; direct comparisons between interventions were too few to make any meaningful conclusions about the relative efficacy between interventions.⁴³ Overall benefits for all interventions were modest, with only slight/moderate effect sizes (no interventions resulted in large improvement) and only low/moderate strength of evidence (no interventions had a high strength of evidence). The AHRQ review found limited evidence of harm and no evidence of serious harm for any intervention.

Place in Therapy for Nonpharmacologic Treatment Options

In 2018, a pain task force from the Academic Consortium for Integrative Medicine and Health published a white paper on the role of nonpharmacologic treatments in pain care.⁵ The task force advocates for widespread use of nonpharmacologic therapies among all patients with pain, and states that nonpharmacologic options should be part of routine patient education. Ideally, nonpharmacologic care should be coordinated among professional disciplines and health care payers should provide insurance coverage for evidence-based treatments. In reality, barriers to using nonpharmacologic treatments have led to underutilization. Beyond financial concerns, other barriers to nonpharmacologic care include access disparities (eg, racial/ethnic, geographic), relative disempowerment of patients with pain, stigma, and a lack of awareness/education.^2,5

Ready access to nonpharmacologic pain therapies, especially those provided by health care professionals, is lacking for many patients.^2,5,44 Recent studies suggest that physical and occupational therapy and chiropractic care are frequently covered, but payers are less likely to cover TENS, acupuncture, and behavioral therapies.⁴⁵ An evaluation of state insurance coverage for nonpharmacologic treatments recommended in the American College of Physicians guideline for low back pain identified that only spinal manipulation was routinely covered (by 46 states).⁴⁶ The remaining guideline-recommended treatments (including CBT) were covered by few or no states for the indication of low back pain. Evidence regarding the cost-benefits of these therapies is mounting, with some studies reporting lower overall health care expenditures among patients with pain who use nonpharmacologic providers.⁵ Overall, evidence suggests that the cost of nonpharmacologic treatments is negligible compared to total medical costs typically associated with traditional pain treatment. Many mind-body treatments can be delivered in low cost ways via the internet, mobile apps, or telehealth.^2,15 In addition to direct costs, the financial impact of the non-pain health benefits of nonpharmacologic therapies should also be considered (see Table 3).⁵

Conclusion

Nonpharmacologic treatments should be a fundamental part of multimodal analgesic strategies and some patients experience adequate pain relief with nonpharmacologic strategies alone. Efficacy data for these strategies is largely limited and of low quality, but the relative safety and ease of use of nonpharmacologic approaches make them an attractive option for many patients. Nonpharmacologic treatments are recommended in clinical practice guidelines for some disease states (eg, low back pain, osteoarthritis, psoriatic arthritis). In the absence of practice guideline recommendations or definitive safety concerns that would support use or avoidance, respectively, of specific treatment modalities, decisions in clinical practice about whether to use nonpharmacologic treatments are largely made on a patient-specific basis.

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