- 5 Things About Chronic Pain and Pain Management in the Age of Opioids
- Treatment Options for Chronic Pain
- Topical pain relief
- Possible side effects
- Surgical implant
- Trigger point injections
- Acupuncture and acupressure
- Treatment options for chronic pain
- 2. What are some of the typical medications used for the treatment of chronic pain? What are some of the common side effects associated with these medications?
- 3. If I am taking narcotic (opioid) medication for chronic pain, does that mean I am addicted?
- 4. What are some of the more common nerve block procedures for the treatment of chronic pain? What are some of the common side effects associated with these nerve blocks?
- 5. Will I receive a bill from the pain management specialist?
- Non-opioid options for managing chronic pain
- Chronic Pain Syndrome Treatment & Management: Approach Considerations, Physical Therapy, Occupational and Recreational Therapy
- Chronic Pain
- What is chronic pain?
- Who treats chronic pain?
- How is chronic pain diagnosed?
- What are the options for treating chronic pain?
- What are some of the special challenges of chronic pain?
5 Things About Chronic Pain and Pain Management in the Age of Opioids
Payers and providers are looking to keep vulnerable patients in pain from becoming addicted to painkillers, but those who live with pain on a daily basis are understandably upset at the thought of losing access to medications they say keep them functional. Here are 5 takeaways from recent coverage about this important issue.
On Monday, July 9, the FDA is hearing from patients with chronic pain at a day-long meeting in an effort to understand “their perspectives on the impacts of chronic pain, views on treatment approaches for chronic pain, and challenges or barriers to accessing treatments.” The FDA is also accepting comments electronically until September 10.
The number of Americans living with chronic noncancer pain is thought to be about 100 million, according to one estimate. However, efforts to manage chronic pain have come under scrutiny because of the rising toll of deaths from prescription opioids and illicit synthetic opioids.
Payers and providers are looking to keep vulnerable patients in pain from becoming addicted to painkillers, but those who live with pain on a daily basis are understandably upset at the thought of losing access to medications they say keep them functional.Here are 5 takeaways from recent coverage about this important issue.
1. More doctors are speaking out about leaving patients at risk of untreated pain.
Opioids should not be totally eliminated to treat chronic pain, providers say.
But CMS and other payers, responding to voluntary guidelines passed by the CDC in 2016, are recommending that the average daily morphine milligram equivalents (MME) be set at 90 mg per day and that the duration be limited.
As a result, providers writing prescriptions for more than that amount are frequently faced with “hard edits” triggering prior authorizations.
Although the guidelines were not intended to affect patients with cancer, they often do. A recent opinion column in JAMA Oncology said that inconsistencies and lack of evidence in opioid prescribing guidelines are confusing clinicians who care for patients with long-term cancer and survivors and have the potential to jeopardize patients’ pain management.
2. Payers and others need more information about the issue; prescription drug monitoring programs may vary.
One surprising finding of a recent study about payers is that some impose prescribing restrictions on non-opioids. Using the example of low back pain, a study in JAMA Open suggests that insurers could help to reduce opioid overuse by expanding access to non-opioid alternatives through improved coverage and reimbursement policies.
Another issue facing the entire healthcare system, including payers, pharmacy benefit managers, government officials, and others, are gaps in data, policy, and information that prevent improved prevention and treatment strategies to fight opioid use disorder (OUD) from taking hold in the first place.
One tool set up to fight OUD actually had the opposite effect, according to one study, which found limited evidence that prescription drug monitoring programs work as intended. Three of the studies reviewed actually found an increase in heroin overdose deaths after the programs began.
3. For acute pain, the recommendation is to try non-opioids first.
In an effort to improve the safety of opioid use while in the hospital and upon discharge, recommendations from the Society of Hospital Medicine suggests clinicians restrict the use of opioids to cases of severe pain or cases of moderate pain only in patients who do not respond to or cannot take non-opioid pain medications acetaminophen or ibuprofen.
4. An old drug, ketamine, is making a comeback.
Ketamine infusions have been used since the 1960s for chronic pain. It also been used for severe depression, in emergency departments, in the perioperative period for individuals with refractory pain, and in opioid-tolerant patients.
Recently, guidelines were released for the use of intravenous ketamine for chronic pain.
These guidelines recommend that doctors consider subanesthetic ketamine infusions for patients undergoing painful procedures, those already dependent on opioids, those using opioids for chronic pain but who have an acute exacerbation, and others.
5. Could marijuana could have a role to play?
Earlier this year, 2 studies involving Medicare and Medicaid found some interesting associations between marijuana and the possibility that it helped patients cut back on prescription opioids.
One study looked at prescribing patterns for opioids in Medicare Part D and the implementation of state medical marijuana laws. Medicare Part D prescriptions for opioids fell by 2.21 million daily doses filled per year (95% CI, −4.15 to −0.27) when laws went into effect in a given state. The type of law implemented proved key, with greater reductions in opioid prescriptions observed in states with more structured laws that increased access to medical cannabis.The other looked at Medicaid prescription data from 2011 to 2016 and found that both medical and recreational marijuana laws were associated with annual reductions in opioid prescribing rates of 5.88% and 6.38%, respectively.
Treatment Options for Chronic Pain
Recognizing that chronic pain is a problem is the first step in finding treatment. Start by talking to your doctor about chronic pain symptoms. Together you can identify the source of the pain and come up with a comprehensive treatment plan that takes into account your overall health and lifestyle.
Over-the-counter (OTC) and prescription medications are often used to manage pain. However, for many people, a combination of treatments is most effective.
Medications may be combined with:
- physical therapy
- relaxation techniques
- psychological counseling
Micke Brown, B.S.N., R.N., is the Director of Communications for the American Pain Foundation (APF). Brown believes that a “multi-modality” treatment is the best approach to managing chronic pain.
“Pain and its treatment are complex, and what works best for one may not work for another,” says Brown.
“The secret to creating an effective pain treatment plan is adding the right ingredients to find the recipe that works for the individual.”
Read more: Learn how to assess your pain »
The most common types of OTC pain relievers are acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs). Types of NSAIDs include:
Both acetaminophen and NSAIDs can be used successfully to relieve mild pain. NSAIDs also reduce inflammation and swelling.
Long-term use of either type of drug can have potentially severe side effects. Talk to your doctor before you use any OTC medicine for chronic pain.
Topical pain relief
Oral medications are not the only type of OTC pain relief. Topical creams are also available. These are often used to relieve pain associated with arthritis and muscle aches.
Some chronic pain can’t be controlled with OTC medication. In these cases, your doctor may want to prescribe something stronger. The American Chronic Pain Association (ACPA) identifies several major classes of medications used to treat chronic pain. These include:
- nonopioids, such as aspirin, NSAIDs, and acetaminophen
- opioids, such as morphine, codeine, hydrocodone, and oxycodone
- adjuvant analgesics, such as certain antidepressants and anticonvulsants
Antidepressants affect the way the brain processes pain. They can be very effective at treating certain types of pain. They can also improve depression and anxiety, which may indirectly improve chronic pain symptoms by helping with your coping skills.
Possible side effects
Medications can cause a variety of unpleasant side effects, ranging from mild to severe. Talk to your doctor if you experience any unusual symptoms. Some of these include:
- edema, or swelling
- nausea and vomiting
- diarrhea or constipation
- breathing difficulties
- abnormal heartbeat
If chronic pain is not alleviated by oral medications, there are other options. Your doctor may want to try a surgical implant.
There are several types of implants used for pain relief. Infusion pain pumps can deliver medication directly where needed, such as to the spinal cord. Spinal cord stimulation can use electricity to alter the pain signals sent to the brain.
Trigger point injections
Trigger points are a special type of tender area within the muscle. Injections of a local anesthetic, which may also include a steroid, can be used to relieve pain in these areas. Not all adults have trigger points.
They are most often found in people with specific conditions such as:
- chronic pelvic pain
- myofascial pain syndrome
The ACPA states that alternative therapies often lessen the need for medications and other more invasive procedures. Alternative therapies include:
- cognitive therapies
- behavioral therapies
- physical therapies
These forms of treatment also allow people to take a more active role in pain management.
“Pain is the oil light on your body's dashboard telling you that something desperately needs attention,” says Jacob Teitelbaum, M.D., the medical director of the Fibromyalgia and Fatigue Centers. “Just as the oil light will go out when you put oil in your car, pain will often go away when you give your body what it needs.”
Regular exercise and physical therapy are usually part of any pain management plan.
Dr. Teitelbaum believes exercise is critical in the relief of pain. A large percentage of pain comes from tight muscles. These may be triggered by overuse, inflammation, or other conditions.
Regular exercise is important for treating chronic pain because it helps:
- strengthen muscles
- increase joint mobility
- improve sleep
- release endorphins
- reduce overall pain
Relaxation techniques are often recommended as part of a treatment plan. They help to reduce stress and decrease muscle tension. Relaxation techniques include:
Yoga also has other benefits for chronic pain. It can help strengthen muscles and improve flexibility.
Acupuncture and acupressure
Acupuncture and acupressure are types of traditional Chinese medicine. They relieve pain by manipulating key points of the body. This prompts the body to release endorphins which can block messages of pain from being delivered to the brain.
Biofeedback is another technique for pain management. It works by measuring information about physical characteristics such as:
- muscle tension
- heart rate
- brain activity
- skin temperature
The feedback is used to enhance an individual’s awareness of physical changes associated with stress or pain. Awareness can help a person train themselves to manage physical and emotional pain.
Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to specific nerves. The current interrupts pain signals, and triggers the release of endorphins.
Several states have laws permitting the use of cannabis, also known as medical marijuana, for pain relief. It is also used to manage the symptoms of other serious illnesses cancer and multiple sclerosis.
According to the Mayo Clinic, cannabis has been used as a method of pain relief for centuries. There is a great deal of controversy and misinformation about cannabis use. However, recent research has made more people aware of the plant’s medicinal properties. It is now legal for medical use in several U.S. states.
Talk to your doctor before you use cannabis. It is not safe for use in all patients, nor legal for medicinal uses in all states.
There are many different treatment options for chronic pain. Talk to your doctor about your chronic pain symptoms. Your doctor can help you decide on a combination of alternative and medical treatments to manage your symptoms.
Treatment options for chronic pain
There are a variety of options for the treatment of chronic pain. Under the general category of medications, there are both oral and topical therapies for the treatment of chronic pain. Oral medications include those that can be taken by mouth, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and opioids.
Also available are medications that can be applied to the skin, whether as an ointment or cream or by a patch that is applied to the skin. Some of these patches work by being placed directly on top of the painful area where the active drug, such as lidocaine, is released. Others, such as fentanyl patches, may be placed at a location far from the painful area.
Some medications are available over the-counter (OTC) while others may require a prescription.
There are many things that may help with your pain which do not involve medications. These things may help relieve some pain and reduce the medications required to control your pain.
Examples include exercises, best performed under the direction of a physical therapist. There are also alternative modalities, such as acupuncture.
Transcutaneous Electro-Nerve Stimulator (TENS) units use pads that are placed on your skin to provide stimulation around the area of pain and may help to reduce some types of pain symptoms.
Finally, there are interventional techniques that involve injections into or around various levels of the spinal region. These can involve relatively superficial injections into the painful muscles, called trigger point injections, or may involve more invasive procedures.
There are multiple procedures that range from epidural injections for pain involving the neck and arm or the back and leg, facet injections into the joints that allow movement of the neck and back to injections for burning pain of the arms or legs due to a syndrome called Complex Regional Pain Syndrome or Reflex Sympathetic Dystrophy (CRPS).
2. What are some of the typical medications used for the treatment of chronic pain? What are some of the common side effects associated with these medications?
There are several categories of medications that are used for the treatment of chronic pain. In general, your primary physician, patient management specialist, or pharmacist may be to answer any questions about the dosage and side effects from these medications. The most commonly used medications can be divided into the following broad categories:
- Nonsteroidal Anti-inflammatory Drugs and Acetaminophen: There are many different types of nonsteroidal anti-inflammatory medications (NSAIDs), some of them (such as ibuprofen) may be obtained over-the-counter. NSAIDs can be very effective for acute muscular and bone pain as well as some types of chronic pain syndromes. When taken for an extended period of time or in large quantities, they may have negative effects on the kidneys, clotting of blood, and gastrointestinal system. Bleeding ulcers is a risk of these medications. Long-term use of cyclooxygenase II (COX II) inhibitors may be associated with an increase in cardiovascular (heart) risks. Acetaminophen is easily obtained over-the-counter, however, care should be taken not to take more than 4000 mg in 24 hours; otherwise, several liver failure may occur. There are some opioid medications that combine acetaminophen within the medication. You should be aware that many over-the-counter medications have acetaminophen as one of their ingredients and when taken in combination with prescribed medication, this may result in an overdose of acetaminophen.
- Antidepresssants: Some of the older categories of antidepressants may be very helpful in controlling pain; specifically the tricyclic antidepressants. The pain relieving properties of these medications are such that they can relieve pain in doses that are lower than the doses needed to treat depression. These medications are not meant to be taken on an “as needed” basis but must be taken every day whether or not you have pain. Your physician may attempt to lessen some of the side effects, particularly sedation, by having you take these medications at night. There are some other side effects dry mouth that can be treated with drinking water or fluids. These medications may not be given to patients with certain types of glaucoma. In addition, these medications should never be taken in larger doses than are prescribed.
- Anticonvulsants (Anti-seizure) Medications: These medications can be very helpful for some kinds of nerve type pain (such as burning, shooting pain). These medications also are not meant to be taken on an “as needed” basis. They should be taken every day whether or not you feel pain. Some of them may have the side effect of drowsiness which often improves with time. Some have the side effect of weight gain. If you have kidney stones or glaucoma, be sure to tell your doctor as there are some anticonvulsants that are not recommended to be given under those conditions. The newer anticonvulsants do not need liver monitoring but required caution if given to patients with kidney disease.
- Muscle Relaxants: These medications are most often used in the acute setting of muscle spasm. The most common side effect seen with these medications is drowsiness.
- Opioids: When used appropriately, opioids may be very effective in controlling certain types of chronic pain. They tend to be less effective or require higher doses in nerve type pain. For pain is present all day and night, a long acting opioid is usually recommended. One of the most frequent side effects is constipation, which if mild may be treated by drinking lots of liquids, but may need to be treated with medications. Drowsiness is another side effect which often gets better over time as you get used to the medication. Excessive drowsiness should be discussed with your physician. Nausea is another side effect which may be difficult to treat and may require changing to another opioid.
3. If I am taking narcotic (opioid) medication for chronic pain, does that mean I am addicted?
Taking opioids in the way that they have been prescribed by your doctor for the treatment of chronic pain is associated with a very low risk of becoming addicted to those opioids.
There are some predisposing factors to opioid addiction. These include having a history or a family history of substance abuse or of certain psychiatric illnesses.
The following are definitions for addiction, tolerance, and physical dependence according to the American Pain Society:
- Addiction has a genetic basis in addition to a psychological aspect to the behavior. Addiction is associated with a craving for the abused substance (such as an opioid), and continued, compulsive use of that substance despite harm to the person using the substance. In addition to having a genetic predisposition, there may be an environmental influence affecting both the development and manifestation of the additive behavior.
- Tolerance occurs after prolonged exposure to a drug. The effects of that drug results in progressive decrease in its effectiveness.
- Physical Dependence is usually seen in the form of drug withdrawal after the drug has been abruptly stopped or rapidly reduced. It can also be seen when an opioid antagonist is given to someone who is taking an opioid. It is a state of adaptation. Withdrawal symptoms last from approximately 6 to a peak of 24 to 72 hours after the drug has been withdrawn. Some of the symptoms include nausea, vomiting, sweating, abdominal pain or diarrhea and can occur after taking the opioid for as short a period as 2 weeks. It is not a sign of addiction.
If you are prescribed opioids by your doctor, you are to take the opioids as they have been prescribed. If your pain continues despite taking the opioid, it is inadvisable to take more opioid than prescribed without first seeking the advice of your doctor.
Taking a long-acting opioid a few times per day is less ly to give the sensation of euphoria that may be associated with some short acting opioids. Long-acting opioids are not meant to be taken on an “as needed” basis and should be taken whether or not you have pain and should not be taken more frequently than prescribed by your doctor.
Constipation is one of the more frequently seen side effects of chronic opioid use, remedies, such as stool softeners and stimulants, are available.
4. What are some of the more common nerve block procedures for the treatment of chronic pain? What are some of the common side effects associated with these nerve blocks?
The vast majority of injections done for the diagnosis or treatment of chronic pain are performed on an outpatient basis. Some are performed on inpatients, who may be already hospitalized for other reasons.
All of them may be performed under fluoroscopic (x-ray) guidance but are sometime performed in the office without x-ray. For any nerve block, you need to tell your doctor if you are allergic to contrast dye or if you think you may be pregnant.
Below is a brief description of some of the more commonly performed nerve blocks by pain management specialists.
- Epidural Steroid injection: Epidural steroid injection is an injection performed in the back or neck in an attempt to place some anti-inflammatory steroid with or without a local anesthetic into the epidural space close to the inflamed area that is causing the pain. These injections are generally done for pain involving the back and leg or the neck and arm/hand. They may be done under x-ray guidance. Common side effects include soreness of the back or neck at the point where the needle enters the skin, there may be some temporary numbness in the involved extremity but persistent numbness or weakness (lasting over 8 hours) should be reported to your doctor. Epidural steroid injections may be placed in the lumbar (low back), thoracic (mid back), or cervical (neck) regions.
- Facet Joint Injection: The facet joints assist with movement of the spine both in the neck and back. Injection into these joints can provide relief of neck and back pain; these injections are always performed under x-ray guidance. Common side effects include soreness in the neck or back when the needle was inserted. You will be on your stomach for this injection if it is done for back pain; however you may either be on your stomach or back if the injection is performed for neck pain, depending on the preference of the physician. A needle is placed in your neck or back and advanced to the level of the joint under x-ray visualization. Contrast dye is used if the needle is put within the joint, and sometimes used if the injection is designed to numb the nerves to the joint. This block is often a diagnostic block and a more long lasting injection may be indicated if you have significant pain relief from this injection.
- Lumbar Sympathetic Block: A lumbar sympathetic nerve block is performed for pain in the leg that is thought to be caused by complex regional pain syndrome type I (or CRPS I). These injections are often performed under fluoroscopic (x-ray) guidance. Local anesthetic is placed near to the lumbar sympathetic chain in order to relieve the pain. Your leg will ly become warm immediately following the injection: this is an expected effect and not a complication. Back soreness is one of the more common side effects. If you feel any sharp pains down your leg or to your groin during the injection, you should let the physician know immediately. There may be some temporary numbness following the injection but if there is persistent numbness or weakness (> 8 hours) the doctor should be notified. You will be lying on your stomach for this injection. The injection is done from the back, in the lower aspect of the back. A needle is placed, often under x-ray guidance, to a spot just to the side and approaching the front part of the spine where the ganglion is located. If it is done under x-ray, a small amount of dye is injected to make sure the needle is in the right spot. After the doctor is satisfied that the contrast dye is in the right place, they will inject numbing medicine then remove the needle.
- Celiac Plexus Block: A celiac plexus block is generally performed to relieve pain in patients with cancer of the pancreas or other chronic abdominal pains. A needle is placed via your back that deposits numbing medicine to the area of a group of nerves called the celiac plexus. This injection is often performed as a diagnostic injection to see whether a more permanent injection may help with the pain. If it provides significant pain relief then the more long lasting injection may be done. This injection is usually performed under x-ray guidance. You will be lying on your stomach for this injection. The needle is place via the mid back and placed just in front of the spine. Contrast dye is injected to confirm that the needle is in the right spot; followed by some numbing medicine.
- Stellate Ganglion Block: A stellate ganglion block is an injection that can be performed for the diagnosis of complex regional pain syndrome of the arm or hand or for treatment of pain to that area. It can also be used to help to improve blood flow to the hand or arm in certain conditions that result in poor circulation of the hand. Side effects may include soreness in the neck where the needle was placed. In some instances the side effects may include droopiness of your eyelid on the side that is injected, along with a temporarily stuffy nose and sometimes temporary difficulty in swallowing. This injection is performed with or without x-ray guidance. You will be lying on your back for this injection with your mouth slightly open. It is very helpful to the doctor if you try not to swallow during the injection. If this injection is performed under x-ray the doctor will first inject a small amount of contrast to confirm the placement of the needle then inject some numbing medicine.
5. Will I receive a bill from the pain management specialist?
Your pain management specialist is a physician specialist your surgeon or internist, and you probably will receive a bill for your pain management specialist's professional service as you would from your other physicians. If you have any financial concerns, your pain management specialist or an office staff member will answer your questions.
Non-opioid options for managing chronic pain
If you started taking prescription opioids to manage chronic pain, then you will need new pain relief options when you cut back or stop taking opioid drugs. Following are options that alone, or in combination, may help.
Cold and heat. Cold can be useful soon after an injury to relieve pain, decrease inflammation and muscle spasms, and help speed recovery. Heat raises your pain threshold and relaxes muscles.
Exercise. Staying physically active, despite some pain, can play a helpful role for people with some of the more common pain conditions, including low back pain, arthritis, and fibromyalgia.
Weight loss. Many painful health conditions are worsened by excess weight. It makes sense, then, that losing weight can help to relieve some kinds of pain.
Physical therapy (PT) and occupational therapy (OT). PT helps to restore or maintain your ability to move and walk. OT helps improve your ability to perform activities of daily living, such as dressing, bathing, and eating.
Transcutaneous electrical nerve stimulation (TENS). This technique employs a very mild electrical current to block pain signals going from the body to the brain.
Iontophoresis. This form of electrical stimulation is used to drive medications into areas of pain and reduce inflammation.
Ultrasound. This therapy directs sound waves into tissue. It is sometimes used to improve blood circulation, decrease inflammation, and promote healing.
Cold laser therapy. Cold laser therapy, also called low-level laser therapy, is FDA-approved to treat pain conditions. The cold laser emits pure light of a single wavelength that is absorbed into an injured area and may reduce inflammation and stimulate tissue repair.
Mind-body techniques. Mind-body relaxation techniques are commonly used at hospital-based pain clinics. They include:
- Progressive muscle relaxation
- Breathing exercises
- Hypnosis therapy
Yoga and tai chi. These mind-body and exercise practices incorporate breath control, meditation, and movements to stretch and strengthen muscles. They may help with chronic pain conditions such as fibromyalgia, low back pain, arthritis, or headaches.
Biofeedback. This machine-assisted technique helps people take control of their own body responses, including pain.
Therapeutic massage. Therapeutic massage may relieve pain by relaxing painful muscles, tendons, and joints; relieving stress and anxiety; and possibly impeding pain messages to and from the brain.
Chiropractic. Chiropractors try to correct the body's alignment to relieve pain and improve function and to help the body heal itself.
Acupuncture. Acupuncture involves inserting extremely fine needles into the skin at specific points on the body. This action may relieve pain by releasing endorphins, the body's natural painkilling chemicals. It may also influence levels of serotonin, the brain transmitter involved with mood.
Psychotherapy. These professionals can offer many avenues for pain relief and management. For example, they can help you reframe negative thinking patterns about your pain that may be interfering with your ability to function well in life, work, and relationships. Seeing a mental health professional does not mean the pain is “all in your head.”
Pain-relieving devices. A range of assistive devices can help support painful joints, relieve the pressure on irritated nerves, and soothe aches and pains. They include splints, braces, canes, crutches, walkers, and shoe orthotics.
Topical pain relievers. These medication-containing creams and ointments are applied to the skin. They may be used instead of or in addition to other treatments.
Over-the-counter medications. Pain relievers that you can buy without a prescription, such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn) can help to relieve mild to moderate pain.
Herbal or nutritional pain relievers. Scientific evidence supporting their effectiveness for pain relief is scant.
Non-opioid prescription drugs. Certain medications can be very effective for treating condition-specific pain. Examples include triptans for migraine headaches and gabapentin (Neurontin) or pregabalin (Lyrica) for nerve pain.
Corticosteroid injections. Used occasionally, corticosteroid injections can relieve pain and inflammation caused by arthritis, sciatica, and other conditions.
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
Chronic Pain Syndrome Treatment & Management: Approach Considerations, Physical Therapy, Occupational and Recreational Therapy
A self-directed or therapist-directed physical therapy (PT) program, individualized to the patient's needs and goals and provided in association with occupational therapy (OT), has an important role in functional restoration for patients with chronic pain syndrome (CPS). [7, 23, 24]
The goal of a PT program is to increase strength and flexibility gradually, beginning with gentle gliding exercises. Patients usually are reluctant to participate in PT because of intense pain.
PT techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasonographic therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations.
(According to a double-blind study, exercise groups have significant benefit over TENS.) Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain.
Other intervention should be offered to enable greater confidence and comfort when patients do not progress in a reasonable amount of time.
A prospective study by Masterson et al suggested that physical therapy using pelvic floor rehabilitation may offer an effective treatment for men with idiopathic chronic pelvic pain syndrome. Treatment response was considered robust in five 10 patients (50%), and moderate in two 10 (20%), with therapy involving the following  :
- Internal and external manual therapy of the pelvic floor and abdominal musculature to promote muscle relaxation
- Therapeutic exercises aimed at improving range of motion, mobility/flexibility, and muscle strength
- Biofeedback aimed at strengthening and relaxing the pelvic floor musculature
- Neuromodulation to relax the pelvic floor musculature and relieve pain
A literature review by Andrade et al did not find clear evidence regarding exercise’s impact on inflammatory markers in patients with fibromyalgia. However, none of the studies used in the report indicated that treatment-related exercises caused patients’ symptoms to worsen. 
A study by Grinberg et al of female patients with chronic pelvic pain syndrome indicated that myofascial physical therapy (MPT) is not only associated with long-lasting alleviation of pelvic pain, but also with anatomic, neurophysiologic, and psychological benefits.
The investigators state that MPT leads to hypertonicity relief, reduction in sensitivity to experimental pain, improvement in endogenous inhibitory system functionality, and lowering of psychological distress (with regard to anxiety, pain catastrophizing, somatization, and depressive symptoms). 
A literature review by Haller et al indicated that in patients with chronic pain, craniosacral therapy (CST), which employs fascial palpation, is superior to sham treatment with regard to improvement in pain intensity and disability at 6 months. The study included patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain. 
A randomized, controlled trial by Rodríguez Torres et al indicated that a neurodynamic mobilization program can reduce pain and fatigue and improve neurodynamics and function in patients with fibromyalgia.
The study included 48 patients with fibromyalgia who were randomized to a twice-a-week active neurodynamic mobilization program or to a control group, with results evaluated using the Brief Pain Questionnaire, the Pain Catastrophizing Scale, neurodynamic tests, the Health Assessment Questionnaire Disability Index, and the Fatigue Severity Scale. 
A phase II, randomized, sham-controlled clinical trial by Mendonca et al indicated that the use of a combination of transcranial direct current stimulation (tDCS) of the primary cortex and aerobic exercise is more effective in managing in fibromyalgia than is either of these modalities by itself, having significantly impacted pain, anxiety, and mood. However, motor cortex plasticity response did not differ between the three groups, with the investigators suggesting that perhaps the combination of tDCS and aerobic exercise influenced other neural circuits. 
A literature review by Knijnik et al indicated that repetitive transcranial magnetic stimulation (rTMS) has a better effect on quality of life than does sham stimulation in patients with fibromyalgia, with the superior impact seen after 1 month of treatment. However, although reductions in pain intensity were found, changes in depressive symptoms were not. 
This therapy has significant benefit in the treatment of rheumatoid arthritis and osteoarthritis. Electrodes should be applied over or near the area of pain with the dipole parallel to major nerve trunks. TENS application should be avoided near the carotid sinus, during pregnancy, and in patients with demand-type pacemakers. The most common adverse effect of TENS is skin hypersensitivity.
Use of these modalities is encouraged for the treatment of CPS, although the use of cold in neuropathic pain is controversial.
More than 100 million American adults suffer from chronic pain, according to the Institute of Medicine. Chronic pain — pain that doesn’t go away — can take over your life. It can make you miss work, keep you awake at night, hold you back from leisure activities and even keep you from eating properly. And, it can affect relationships with friends and family.
What is chronic pain?
Most pain goes away. You recover from surgery. Your toothache gets treated. Your sprained ankle heals. That occasional headache responds to aspirin. These are examples of acute, or temporary, pain.
Chronic pain is pain that won’t go away, lasting three months or longer.
Examples include arthritis in your knees, back or neck that hurts most days; frequent migraine headaches; surgical pain that isn’t treated properly and lingers; and pain from muscle injuries that don’t heal correctly.
Other common causes of chronic pain are:
- Back and neck injuries
- Fibromyalgia and musculoskeletal pain
- Phantom limb pain (experienced by those who have had a limb amputated)
Who treats chronic pain?
Pain treatment is complex and can cause more harm than good if it is not provided by a physician with specific training in pain management. Just as there are physicians who specialize in treating conditions such as cancer, heart disease or allergies, there are physicians who specialize in treating pain.
These physicians complete four years of medical school and further training in a specialty, such as anesthesiology, physical medicine and rehabilitation, psychiatry or neurology, followed by an additional year of training to become an expert in chronic pain. Be sure your specialist is certified in a pain medicine subspecialty by a member board of the American Board of Medical Specialties, such as the American Board of Anesthesiology.
Pain treatment is complex and can cause more harm than good if it is not provided by a physician with specific training in pain management.
While you may know that physician anesthesiologists manage pain before, during and after surgery, you may not realize that some specialize in managing chronic pain. In fact, decades of research by physician anesthesiologists have led to the development of more effective treatments for chronic pain.
This specialized training and expertise is essential: The spine and nerves that register pain are delicate, and everyone’s anatomy and pain tolerance are different. Pain medicine specialists are also experts in using a wide variety of medications, which can effectively alleviate pain for some patients.
Physician anesthesiologists are medical doctors who specialize in anesthesia, pain management and critical care medicine.
While all physician anesthesiologists know how to treat pain, some choose to specialize in pain medicine and are especially skilled and experienced in taking care of people with chronic pain.
If you suffer from chronic pain, consider seeing a physician anesthesiologist who specializes in pain medicine.
How is chronic pain diagnosed?
The pain medicine specialist will work with you and any other physicians, such as your primary care physician, surgeon or oncologist, depending on the source of your pain. While other physicians manage and treat your medical conditions such as arthritis or cancer, the pain medicine specialist is in charge of diagnosing and treating your pain.
Here are some things a pain medicine specialist may do:
- Review your medical records, X-rays and other images.
- Perform a complete physical examination.
- Ask you to describe your pain, explain where it hurts, how long it has hurt and what makes the pain feel better or worse.
- Request the completion of a detailed questionnaire about the impact your pain is having on your life, how it interferes with your daily activities and what your treatment goals are.
- Order tests for diagnosis and treatment.
What are the options for treating chronic pain?
If you’re one of the millions of people who suffer from chronic pain, talk to your pain medicine specialist about treatment options, including:
- Medication – Over-the-counter remedies, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), and more powerful drugs, such as opioids, may help ease your pain. Other medications can help too, including antidepressants, anti-seizure medications and steroids. Your physician may suggest a combination of medications to address different aspects of your pain. Because some of these medications, such as opioids, can be addictive, and other medications can cause side effects or interact with each other, it’s important that a qualified pain medicine specialist manages your medication plan.
- Physical therapy – Some types of pain respond well to physical therapy, specific exercises that help build up or stretch muscles and ease pain. Your pain medicine specialist can work with a physical therapist, orthopedic surgeon or physical medicine specialist to prescribe a physical therapy program.
- Medical procedures – A number of procedures can help with pain control, including nerve blocks, surgery and snipping overactive nerves. Extensive research is being done to develop high-tech techniques to block or minimize pain using radio waves, electrical currents or medication pumps.
- Complementary therapies – Some people find relief using biofeedback, relaxation, meditation, acupuncture, visualization or other alternative therapies.
- Lifestyle changes – You can help manage your pain by being as healthy as possible. If you smoke, get help so you can quit. Try to maintain a healthy weight to avoid the stress excess weight puts on painful hips and knees. Good nutrition is important, and exercising can often relieve or prevent pain.
What are some of the special challenges of chronic pain?
People who are in pain may not be able to fully engage in work or enjoy life. And some people with chronic pain develop another problem that can be even more serious than the pain itself — opioid addiction.
More than 300 million prescriptions are written every year for opioids, and 2 million Americans abuse these powerful painkillers. While opioids can be very effective at treating pain, they are extremely addictive, especially when used over a long period of time.
This is why opioids should be used only with the supervision of a physician who understands how they work and how they can be used safely.
Physician anesthesiologists can change lives. “If I didn’t have a physician anesthesiologist on my medical team, I predict that right now, I would still be overweight, inactive and clinically depressed.” – Kathleen Callahan, chronic pain patient