Pain management a comprehensive review


Transcutaneous electrical nerve stimulation



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Transcutaneous electrical nerve stimulation

TENS is a type of stimulation that utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief [107]. Additionally, there is evidence that TENS may activate certain subsets of nerve fibers that may block the transmission of pain at the spinal level.

  1. Distraction

Distraction is a useful tool to help alleviate pain, particularly for children [55]. In children, using colourful objects, singing, telling stories, or reading books and viewing videos is particularly useful for distraction. Older individuals can engage in distraction techniques such as watching television or listening to music. Distraction in the form of video or board games can sometimes prove effective. Distraction eases pain by taking the individual’s attention away from the sensation of the pain.

Distraction need not be tangible. Mentally distracting oneself can work just as well as physically distracting oneself. Picturing a pleasant place or experience from the past can help the individual work through the pain sensation.



  1. Guided imagery

Guided imagery offers patients the opportunity to form images of their pain and in turn conduct a dialogue with the pain [55]. Guided imagery provides patients with an environment that is primarily established by a trained therapist asking questions, where the patient can create their own images that they will then use to understand their pain and communicate with it.

Pain is an excellent arena for the use of guided imagery, although the technique is used for a range of issues. Since many people who have pain worry about it and imagine that it may never end, they end up seeing themselves in a state of helplessness. The aim of guided imagery is to use images to change that perception of helplessness by allowing the patient to converse with the pain and therefore have some power to change the situation. In one study [97] of 177 individuals who had chronic back pain, 76% treated with guided imagery were living normal lives with little or no pain, 8% had experienced improvement in their pain, and 16% experienced no change. That the majority of people in this study experienced immense improvement indicates that guided imagery is a viable treatment option for pain.

Biofeedback is often used along with guided imagery to allow practitioners to observe how the individual is making changes to their bodily functions. Biofeedback is accomplished through hand held machinery that offers the practitioner an audio and visual look at how heart rate and muscle tension changes as the individual moves through guided imagery.



  1. Hypnosis

Hypnosis was first approved to be used in a medical environment by the AMA in 1958. Hypnosis is an increasingly popular treatment, particularly when used in conjunction with medication. In hypnosis, a mental health professional or physician guides the individual into a state of altered consciousness that permits the individual to focus their attention in such a way that pain is then reduced [55].

Hypnosis is generally utilized to control a physical response, such as the amount of pain a person can withstand. Hypnosis likely results in pain relief by acting on certain chemicals within the nervous system, in turn slowing impulses [108]. While in a hypnotic state, the individual temporarily tunes out the conscious aspect of the brain; this leads to a reduction in distracting thoughts. Other physical changes occur, such as the slowing of respiration and pulse rate. Additionally, individuals become more open to suggestion, which makes hypnosis perfect for making suggestions to reduce pain. Following hypnosis, the practitioner can then reinforce the suggestions made to help the individual continue with the new, healthier behaviour.

Hypnosis is generally conducted by an experienced practitioner in increments of half an hour to one hour to start, followed by 10 to 15 minute follow-up appointments. Some practitioners are able to give the individual post-hypnotic suggestions to allow the individual to induce hypnosis on themselves after the course of treatment is complete.


  1. Relaxation techniques

Relaxation techniques involve things such as deep breathing or stretching to reduce pain. Deep breathing allows for greater focus and mindfulness, which may lead to pain reduction by acting on chemicals in the nervous system [55]. Additionally, greater delivery of oxygen to the brain can help alleviate pain in certain pain conditions, such as in some types of headache.

Stretching is commonly recommended to help reduce pain, with one of the most recommended stretching activities being yoga. Not only does stretching help with flexibility, and therefore pain, but activities such as yoga refocus attention, which helps alleviate pain.

Another relaxation technique is performing muscle relaxation exercises. This involves the individual moving through a series of movements in which they at turns tense and relax certain groups of muscles in a certain order. Often this technique begins at the feet and moves upward to the head area.

Still another relaxation technique is meditation. Meditation involves clearning the mind by entering a state of mental and physical quiet to reduce anxiety. This practice leads to lowered blood pressure and slowed metabolism, as well as an increased threshold for pain. Even though the mind and body remain relaxed the individual is still awake and alert.

Relaxation training is often useful in those who suffer from migraine headache. Utilizing this kind of training allows the individual to control the development of their pain as well as monitor the body’s response to stressors.


  1. Neurologic and neurosurgical approaches to pain management

    1. Stimulation procedures

Electrical stimulation, which includes transcutaneous electrical stimulation (TENS), deep brain and spinal cord stimulation, or implanted electric nerve stimulation, is an extension of age old pain management practices where the nerves are subjected to a variety of stimuli. This includes cold or heat therapy, or massage. However, electrical stimulation requires a major surgical procedure and is not the right choice for everyone. Additionally, electrical stimulation is not 100% effective. The techniques utilized in electrical stimulation require special equipment as well as personnel that are trained in the exact procedure being used [107].

    • TENS utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief. Additionally, there is evidence that TENS may activate certain subsets of nerve fibers that may block the transmission of pain at the spinal level.

    • Deep brain and intracerebral stimulation is a more extreme treatment that requires that certain areas of the brain, particularly the thalamus, be surgically stimulated. This type of stimulation is generally only used for certain conditions, such as severe pain, cancer pain, central pain syndrome, and phantom limb pain.

    • Stimulation of the spinal cord utilizes electrodes that are surgically inserted into the epidural space in the spinal cord. Individuals are then able to deliver a small electrical charge to the spinal card by using a small transmitter.

    • Peripheral nerve stimulation utilizes electrodes that are placed on certain areas of the body. Individuals are then able to deliver a small electrical charge to the area that is affected by using a small transmitter.

    1. Administration of intraspinal opioid.

Pain is extremely common, and is especially so in the low back. This type of pain can be devastating and disabling. While it is true that analgesics can provide relief in a fair number of patients, intraspinal opioids are a good option for those who are unable to tolerate oral medication [109]. Intraspinal opioids are delivered via an implanted pump.

While intraspinal opioids can be advantageous, they come with similar side effects as do other opioid treatments. It is essential that practitioners work to identify those best suited for this type of therapy.



    1. Interruption of tract conducting the pain

Nerve blocks for management of pain are utilized both for diagnosis and for therapeutic purposes. Some common diagnostic and therapeutic blocks are;

  • Epidural steroid injections. These are used in particular if there is sharp, shooting pain in the spinal nerve and is performed if the pain is bilateral and includes multiple level nerve roots.

  • Selective nerve root blocks. This type of block is done if there are only one or two nerve roots involved in radicular pain. This block is sometimes utilized for diagnosis.

  • Peripheral nerve blocks. This type of block is done if the pain is in the distribution of peripheral nerves.

  • Autonomic ganglion blocks. These types of blocks are utilized both for diagnostic and therapeutic purposes. There are a number of pain conditions for which these are used.

XII. Alternative therapies

A variety of factors affect how pain is perceived and dealt with. One factor is the extent and type of injury. Another is emotion and state of mind. Altering an individual’s mood or state of mind can be very effective when treating pain conditions [4]. Regardless of the alternative therapy chosen, relief of pain is the number one reason why Americans consult alternative therapies [110]. In an effort to locate alternative therapies that are effective at relieving pain and with few side effects, American spend billion each year on alternative treatments [111]. The National Center for Complementary and Alternative Medicine studied 31,044 adults and discovered that of these adults 36% had utilized some form of alternative medicine therapy in the preceding 12 months [112]. The researchers suggested that alternative therapies may be seen as viable choices if other therapies proved to be ineffective or had too many side effects. It is therefore essential that practitioners be aware of the alternative therapies – and adequately educated in their usage – that may be utilized to treat pain and answer patient questions effectively to ensure that there are no interactions with drug therapies, if they are being used. One study conducted by Eisenberg et al. [113] indicated that many physicians do not adequately address the use of alternative therapies because they are not knowledgeable enough about them. Another study indicated that patients were likely to begin these therapies without speaking to a doctor because of a perceived disapproval of the therapy. Therefore, it is essential that practitioners gain the necessary knowledge and remain open-minded to the use of alternative therapies in order to ensure that patients have the proper care [114].



  1. Music therapy

Music therapy is a practice in which musical intervention is utilized to manage an individual’s pain. Music therapy is typically performed by a credentialed professional who has completed a course of education in a music therapy program. Music – along with the development of a therapeutic relationship – is utilized to address physical, cognitive, or psychological needs in individuals of all levels of functioning. Music therapy is a noninvasive therapy. Music therapy outcomes are mediated through the patient’s responsiveness to the music and the music therapy relationship. Emerging finds in the area of neuroscience indicate that some individuals respond better to music therapy than do others [115]. The reason for this is not yet known.

  1. Herbal therapy

Utilizing herbal therapies to treat pain is becoming increasingly popular [116]. Herbal therapies may be used alone or as a way to complement traditional approaches. However, it is important to note that research in this area that examines the efficacy of such therapy is quite limited. There are still a number of questions that remain about the underlying mechanisms in herbal therapy to provide analgesia [117]. In spite of the fact that they are utilized extensively, there is a lack of scrutiny or regulation on herbal supplements.

A great number of those who utilize herbal therapies have chronic conditions. One study by Boon et al. [118] indicated that some individuals who have breast cancer utilize alternative therapies – including herbal therapy – for a variety of reasons, including boosting the immune system, increasing the quality of life, providing a feeling of control in their lives, to aid other medical treatment or to treat the cancer itself. There are many problems that lead individuals to utilize herbal therapies, but the most common are anxiety, chronic pain, back problems, and urinary tract problems [119].According to several studies, [120] those most likely to seek alternative treatment are women and older adults.

Most individuals believe that herbal treatments have fewer side affects than do conventional medical treatments [113]. However, those who use herbal therapies do face the potential of adverse effects, including drug and herb interaction, as most alternative therapies are utilized in conjunction with conventional medical approaches [113]. In fact, one survey [113] indicated that 79% of survey respondents believe that the combination of alternative therapies and conventional therapies is more effective than is either approach on its own.

It is important to consider the possible risks associated with herbal therapies. For example, interactions between herbs or between herbs and standard medical treatment can produce undesirable side effects [117]. One such interaction is the interaction between St. Johns Wart and certain antidepressants such as sertraline; side effects of this combination include nausea or vomiting, or anxiety [121]. Additionally, herbal remedies remain unstandardized, a fact that can prove difficult for practitioners to determine exactly what is causing an interaction. A study conducted by Abbott et al. [122] indicated that 8% of those participants who tried herbal medicine had some sort of adverse reaction. Some researchers [123] indicate that herbal remedies are simply dilutions of naturally occurring drugs, which may contain many different chemicals that are not well regulated or well documented.

Further, labels on herbal therapies are not always a reliable source of information, not often listing details such as effectiveness or potential side effects [124]. The lack of information is opposed to what the general public believes must be included on labelling on herbal remedies. For example in one study [125] 68% of study participants indicated that they thought the government required makers of herbal remedies to provide labelling that detailed the remedy’s possible side effects and dangers.


  1. Reflexology

Reflexology involves applying appropriate pressure to certain areas of the feet, hands, or ears, which in turn alleviates pain or improves an individual’s general health. Reflexology is performed by qualified reflexology therapists. Reflexology should not be used to diagnose or cure medical problems; however, millions use it as a complement to other medical treatments. It is in particular used to address conditions such as anxiety, cancer, diabetes, asthma, cardiovascular problems, headaches, and PMS.

Reflexology is growing in popularity in particular in Europe and Asia and is used in these regions as a complement to other medical treatments as well as a preventative measure. The power of reflexology can be seen through the results obtained by corporations in Denmark who have employed reflexologists starting in the 1990s [126]. Studies indicate that utilizing reflexology has resulted in a lowered amount of sick leave or absenteeism for corporations that have employed reflexologists. Employees also have reported experiencing greater satisfaction with their jobs after having 6 reflexology sessions.

There are a number of reflexology points in several areas on the body. Reflexology theory indicates that there are reflexology points on the feet, hands, and ears. These correspond to certain organs, bones, or body systems. Applying pressure to certain organs can affect organs or body systems.

Most reflexologists use maps to see what areas correspond with different areas of the body:





Reflexology points on the feet and their corresponding systems. Obtained from: UMN Center for Spirituality & Healing [126]

Each foot on the map represents one half of the body, divided vertically. For example, the left foot corresponds to all organs and systems on the left side of the body; conversely the right food corresponds to all organs and systems on the right side of the body.

Reflexologists pay perform a general session in which multiple organ systems are addressed, or he or she may choose to focus on one specific problem area. For instance, if there is limited time and the person needs to relax quickly, the reflexologists may choose to work only on the ears. Regardless of the chosen approach, reflexology works to release stress in the nervous system and provide energy balance for the body.

Researchers from the University of Portsmouth [127] who have studied the effects of reflexology have discovered that people perceived around 40% less pain as well as were able to withstand pain sensations for approximately 45% longer when reflexology was utilized as a mode of pain relief. Participants in the study conducted at the university were told to submerge their hand in a bucket of ice water. All participants participated in both a session where they received reflexology prior to submersion as well as a session in which they believed they were receiving a TENS treatment, although the machine was not actually turned on. Researchers discovered that when participants received reflexology prior to submersion had the ability to keep their hand submerged longer as well as a greater ability to tolerate the pain from the ice for a longer time period.

Dr. Carol Samuel, who was a researcher on the study indicated that the study is one of the first to scientifically examine reflexology as a pain relief treatment. Samuel indicated that the results of the study suggest that reflexology may be effective when utilized as a complement to conventional drug therapy in certain conditions, such as cancer, osteoarthritis and backache. She went on to state, "As we predicted, reflexology decreased pain sensations. It is likely that reflexology works in a similar manner to acupuncture by causing the brain to release chemicals that lessen pain signals" [127].

Reflexology is commonly criticized for not being studied appropriately and under carefully controlled enough conditions. However, in this study the TENS ruse was utilized as the control against which reflexology was studied, and therefore has a greater scientific basis. Dr. Samuel has gone on to add, “This is an early study and more work will need to be done to find out about the way reflexology works…however, it looks like it may be used to complement conventional drug therapy treatment of conditions that are associated with pain…” [127].



  1. Magnetic therapy

Magnets have not been shown to work effectively for any purpose related to health; however, static magnets are widely marketed as a device to help alleviate pain [128]. Since scientific research does not support magnet usage as a viable technique to alleviate pain, it is not recommended that magnets be used in replacement for conventional treatments. Additionally, individuals should not utilize magnets in lieu of seeking help from a licensed health professional. It is important to note that magnets are not a safe treatment method for all individuals, particularly those who use insulin pumps or pacemakers, as magnets can interfere with these devices [129]. Generally, however, it is safe to use magnets; practitioners should simply be aware if an individual is trying magnet therapy and know the risks so he or she can pass these on to the patient. There have rarely been side effects or complications resulting from magnet therapy.

Magnets produce a force that is measurable; this is called a magnetic field. Magnets that are static – the kind of magnet used in magnet therapy – have fields that do not change in measureable force. Magnets are generally made from certain metals or alloys, such as iron or some other mix of metals. Magnets come in different strengths that are measured in gauss units. The type of magnet generally marketed for relief of pain have a strength of 300 – 5,000 gauss [130]. To put this into perspective, this strength is many times greater than the magnetic field of the earth, but much less strong than the magnets utilized in MRI machines, which are about 15,000 gauss or higher. Magnets are frequently marketed for a number of different kinds of pain, including pain in the back or pain that results from conditions such as fibromyalgia. Magnet therapy is also available in a number of different forms, including insoles for foot pain, bracelets or other types of jewelry, in mattress pads for back pain, and in bandages to prevent localized pain relief.

While there is no scientific evidence supporting utilizing magnet therapy for pain, a study sponsored by the National Institutes of Health [129] that examined back pain in a small pool of participants has indicated that participants generally benefited from utilizing magnets. However, this study is not conclusive, as it was small; most more rigorous trials have indicated that magnets do not have any affect on pain.


  1. Electrotherapy

Electrotherapy is a treatment that is commonly utilized to help reduce both acute and chronic pain [131]. It is considered most helpful to utilize this treatment immediately following the injury. Electrotherapy works by stimulating the nerve fibers with small currents of electricity. This stimulation then in turn promotes the release of endorphins which alleviates the pain. Electrotherapy treatment is conducted by a qualified health professional. Electrotherapy may be used in addition to other therapies such as heat and cold therapy or conventional medical treatments.

There are several types of this non-painful therapy, which differ in frequency, effect, and waveform. Some of the commonly utilized forms of electrotherapy are transcutaneous electrical stimulation (TENS) and percutaneous electrical stimulation (PENS), inferential current (IFC), and galvanic stimulation (GS):



    • TENS utilizes small electrical pulses that are delivered to nerve fibers through the skin. These pulses cause the muscles to change in certain ways, such as becoming numb or contracting, which results in temporary pain relief. TENS machines may be utilized in a clinical setting, or individuals will be instructed in how to utilize one of these units at home. TENS is a therapy that can be tolerated for hours, but pain relief lasts for a shorter period.

    • PENS is an electrotherapy treatment that is similar to TENS, only PENS utilizes thin, acupuncture-type needles. This electrotherapy treatment is generally tolerated for a shorter amount of time than is TENS, but pain relief also usually lasts longer.

    • IFC is a deep form of TENS and works by delivering a high-frequency waveform that penetrates skin very deeply. This is a good therapy to target those deeper causes of pain sensation.

    • GS is an electrotherapy that issues a direct current over the area treated. This current affects blood flow. This type of electrotherapy is most commonly utilized for acute injuries that result from major trauma and that are combined with bleeding or swelling. GS is also effective at treating lower back pain or muscle spasms.



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