Non-medication treatments for pain

Hot and cold treatments: Heat and cold are two of the oldest known pain treatments. Heat may be used before a sports activity to prevent injury. It is also useful for the treatment of chronic pain when no inflammation is present. After an injury has completely healed and the muscles, joints and tendons remain stiff, heat treatments can increase flexibility. It can also reduce stiffness associated with arthritis. Heat should not be used too soon after an injury.

Cold is the treatment of choice immediately after an injury and should continue to be used as long as inflammation and swelling are present. This is generally 3 to 4 days, but may last as long as 6 weeks depending on the seriousness of the injury.

Heat therapy causes blood vessels to dilate. The increased blood flow to the tissues increases the oxygen and nutrient supply. It also removes waste products that produce pain away from the site. Heat also alters the sensation of pain, reduces muscle spasms, relaxes tense muscles and increases range of motion.

Heat treatments are available in the form of hot showers, hot baths, hot tubs, hot-moist compresses, dry or moist heating pads, how water bottles, and commercial chemical/ gel packs. Punctured commercial hot packs should be immediately discarded, since the chemical agent/gel can burn the skin. Hot packs in any form should always be wrapped in toweling to prevent burns. Heat treatments are often applied for 20 minutes or longer two to three times daily.

Why should heat not be used after an injury?

After injury damaged blood vessels and cells begin to leak blood and fluid into the area resulting in swelling and pain. Heat dilates blood vessels, which increases the blood flow in the area and increases swelling and pain. Cold decreases the blood flow, reducing swelling and pain. After a few days the damaged blood vessels begin to repair and regrow but they continue to be very weak. If heat is applied too soon the increased blood flow to the area can damage the newly healed blood vessels. Cold should be used for 3 to 4 days minimum and for as long as any swelling is present.

Cold therapy (Cryotherapy) reduces the size of blood vessels, which decreases the blood flow to the area. This reduces inflammation, swelling, muscle spasm and pain. Ice also decreases firing of nerve endings which helps to numb deep pain.

Cold may be applied to the skin in the form of commercial cold packs, ice cubes wrapped in towels, a bag of frozen vegetables or hydrotherapy (ice water). Cold therapy is generally applied for about 15-20 minutes two to three times daily, which is generally shorter than that used for heat therapy. The benefits of cold treatments usually last longer than heat.

Cold or ice should never be applied directly to the skin. Cold packs, ice packs or ice cubes should always be wrapped in towels or something similar to prevent skin and nerve damage. Punctured commercial cold packs should be immediately discarded, as the chemical agent/gel will burn skin.

Occupational Therapy - Occupational therapists assess movement patterns used by patients in pain and teach them to move without provoking pain. They recommend appropriate exercises and equipment to help patients remain mobile, increase muscle tone, reduce stress on bones and continue to perform necessary tasks. They search for ways patients can safely and comfortably adapt to physical limitations and work closely with patients, their caregivers and family members in the treatment of acute or chronic pain, rehabilitation or palliative care.

Physiotherapy - Physical therapists are health professionals trained to use a variety of techniques to relieve pain. They frequently use a combination of treatments which may include exercise, electrical stimulation therapy, acupuncture, mobilization of joints, low power laser therapy, ultrasound, relaxation therapy, and a variety of hot and cold treatments.

Exercise - An appropriate exercise program designed by an experienced health care provider can help reduce acute and chronic pain and improve function. When possible, it is helpful to get the needed exercise in the form of pleasurable activities. Because some exercises can make some conditions worse, (i.e. herniated discs) it is important to work with an expert in health and exercise. Benefits of exercise have been seen in chronic back pain, osteoarthritis, intermittent claudication (blocked arteries in the veins), fibromyalgia, peripheral neuropathy, neck pain, shoulder pain and knee pain etc.

Exercise decreases pain through:

• Strengthening muscles (weak muscles can cause chronic pain)
• Relieving tension (tense muscles can cause chronic pain)
• Improving sleep (poor sleep increases pain perception)
• Improving blood flow (? oxygen and nutrients and ? pain causing waste products)
• Releasing endorphins (the body's natural pain reducing chemicals)

Electrical Stimulation Treatments (Nerve stimulation treatments) - Nerve stimulation treatments use small electrical currents to stimulate an area to relieve pain. Non - invasive electrical stimulation treatments involve placing electrodes coming from a small generator onto the skin and more invasive forms require surgical placement of electrodes into the body.

Theories of how electrical stimulation works include:

• Blocking the transmission of pain impulses
• Triggering the release of the body's natural pain relieving endorphins
• Decreasing the number of impulses running through excited nerves
• Activates pain inhibitory circuits

Electrical nerve stimulation treatments include:

• Transcutaneous electrical nerve stimulation TENS
• Peripheral nerve stimulation
• Spinal cord stimulation
• Deep brain or intra-cerebral stimulation

Transcutaneous electrical nerve stimulation, TENS - One or two pairs of electrodes, coming from a small generator (electrical box) are placed on the skin over the painful area and a small electric charge is used to stimulate nerve fibers to control pain. The patient is able to control the size of the electrical charge. TENS has been used for acute and chronic pain such as labor pain, back pain, shoulder pain, knee pain, arthritic pain, myofacial pain (muscles in the face), post operative pain, and visceral pain.

TENS should not be used:

• while sleeping or driving (may accidentally turn the machine on high)
• on the front of the neck or over the heart
• if you have a pacemaker
• on skin with severe nerve damage
• during pregnancy ? (may cause miscarriage during the first trimester and premature labor in the third trimester)

Peripheral nerve stimulation - Peripheral nerves are nerves that go from the outer parts of the body (skin, muscles, bones, organs etc) to the spinal cord. Electrodes are surgically placed directly on the nerve, close to the injured site. A small patient controlled generator (similar in size to a cardiac pacemaker) is placed under the skin (often in the abdomen or buttocks). The generator can be programmed through the skin to deliver an electrical current as needed to the affected area.

Spinal chord stimulation is a last resort treatment for pain. Small electrodes are surgically inserted into the epidural space of the spinal cord. A pulse of electricity is delivered to the spinal cord from a small generator (the size of a cardiac pacemaker) implanted under the skin, usually in the abdomen or buttocks. Pain is replaced with a tingling sensation. Once the electrodes have been surgically placed, patients can test the system at home for a few days or weeks, using a generator that can be taped onto the skin. If they find the system useful they can then choose a minor surgery to have a generator placed under the skin, usually in the abdomen or buttocks.

Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains. Electrodes are surgically implanted into a selected area of the brain. A small patient controlled generator, the size of a pacemaker is then implanted into the abdomen or buttocks if the treatment is found to be effective.

Low power laser treatment (laser phototherapy) - Low power laser lights use a light source that can generate pure light of a single wavelength to stimulate photochemical reactions in cells. A physical therapist or occupational therapist directs the light over the injured site. This results in increased blood flow to the area and increased cellular metabolism. Some studies report more rapid healing of soft tissue injuries (sprains, bursitis) and reduced pain. Although some studies appear hopeful, the treatment remains controversial. More studies are needed to determine the most effective wavelengths, sites of application (i.e. joint versus nerves), duration of treatment and for how long the treatment is effective.

Ultrasound - Ultrasound is another form of heat therapy used by physical therapists to reduce pain. High-energy sound waves, from the head of an ultrasound machine are guided over the painful area. It is particularly useful in soft tissue injuries, such as joint and muscle sprains, bursitis, and tendonitis. Results for relief from arthritis pain vary.

Psychological Treatments - Psychological factors can impact response to pain and perception of pain. Treatments that relieve stress, anxiety, depression, sleep problems and unhealthy responses to pain can improve pain perception and tolerance levels. Psychological treatments may be delivered by family physicians, psychologists, counselors, nurses or other health care providers.

Humor - Humor may sound like a strange treatment for pain but used along with other appropriate pain treatments it can be surprisingly effective. Laughter, not only distracts from pain but it releases endorphins, the body's natural pain killer. Endorphins lower pain levels by attaching to opiate receptors, elevates mood and enhances the body's immune response. Humor also increases blood flow and the rate and depth of breathing. This improves oxygen supply to the tissues and more efficient removal of waste products (toxins) from the area. Many cancer clinics now employ laughter therapists.