Non-pharmacologic Strategies for Pain Management

A pain management plan for acute pain often includes medications but non-medicine strategies should always be considered as an integral part of the plan. Often overlooked due to their simplicity, these strategies encourage the return to normal functioning that is so important when recovering from a surgical procedure, a physical trauma, or a medical condition. They are often easy to implement and can allow the patient to be an active participant in the pain management process. The PreEmpt Pain app has content dedicated to the various non-pharmacologic therapies. These strategies can be just as important as medications so make sure you choose a few of these listed below when developing a pain management plan.

To be effective, providers should communicate that these strategies listed below are indeed pain management strategies. This demonstrates to the patient and other providers that pain management is a multi-faceted endeavor and that even simple activities can have a positive impact on pain. Have a look at this article for more information on the benefit of these strategies for not only chronic pain but acute pain as well.

The better-known elements such as application of ice and heat can be helpful to reduce pain; ice helps to reduce inflammation and sharp pain, heat can be soothing to sore joints and muscles, improving blood flow.

Distraction techniques can be in the form of formal relaxation strategies such as progressive muscle relaxation and meditation which encourage mindfulness and directing one's attention to a specific activity. These may have an impact on the endogenous cannabinoid system. Have a look at this article for more information.

Transcutaneous electrical nerve stimulation (TENS) can be an important adjunct in pain management by increasing endogenous endorphin release and affecting the descending inhibitory pathways of the nervous system. Check out this article.

Diaphragmatic breathing / biofeedback can be a very powerful tool for pain, nausea, anxiety, overall stress reduction. Don't underestimate the power of using the breath in this therapeutic manner. Diaphragmatic breathing is not 'just breathing', it must be practiced in a specific way in order to reap the benefits. Don't just use this tool when the pain has increased, practice for one or two minutes a few times during the day to really get the full benefits. There are a number of smartphone apps to practice your diaphragmatic breathing so the tool is right in your hands.

The benefits of creativity include distraction and mindfulness and these affect the neurotransmitters associated with pain relief. Children and adults of all ages can benefit from creating art including drawing, painting, coloring, etc. Individuals should be encouraged to bring small items with them from home to distract them while in the hospital and recovering. Even if used for a short period, this can have a positive impact on mood and pain and are likely associated with decreased use of pain medications.

Meditation and yoga can encourage mindfulness and be a sources of distraction while in the hospital or home recovering from a surgical procedure or when you have a medical condition.

Meditation can balance the sympathetic and parasympathetic systems and reduce the

stress response. Ideally one can prepare for a surgical procedure or hospitalization by starting a daily meditation practice days before the procedure. One does not need to devote a great amount of time to sitting in reflection. In the beginning, even spending 5 minutes twice a day during a time where you will not be disturbed can get you started. Here is a list of the emotional benefits of meditation, courtesy of the Mayo Clinic.

- gain a new perspective on stressful situations

- building skills to manage your stress

- increase self-awareness

- reduce negative emotions

- increase imagination and creativity

- increase patience and tolerance Yoga can be meditative in its own way and can be both a relaxing or invigorating activity. As yoga's principles invite individuals to approach yoga based on their current capabilities, yoga can be modified for individuals including those individuals who are confined to bed or who prefer chair yoga. You'll find this article very informative.

Pet therapy

Numerous studies have demonstrated that interactions with domestic animals can have a positive effect on our mood and well-being. The simple act of interacting with animals can release neurotransmitters associated with happiness and well-being. Pet-assisted therapy can also improve self-esteem and motivation and have a positive effect on healing after surgery. Check out this article for more specific information.

Reading is often a favorite pastime that has many benefits especially when you need something to distract you from physical discomfort.

Reading keeps the mind active and can stoke our imagination and creativity. Individuals who read for just 3.5 hours a week enjoy a number of benefits including stress reduction, improvement of sleep, slowing of cognitive decline, enhancement of social skills, etc. For more information, check out this article. Journaling is an activity that many individuals enjoy. Along with the benefits of reducing stress and strengthening your emotional connections, journaling can also have a positive effect on immune function. Journaling may also have a positive impact on stressful experiences, such as having surgery and managing pain. Check out an article here for more information.

Chewing gum may not seem to be a therapeutic option but this article shows that it may be an effective treatment for the prevention or treatment of postoperative nausea and vomiting. Nausea can be a problematic symptom that certainly contributes negatively to the pain experience. Often the simple treatments can be the most powerful when used to improve the well-being of our patients. I have always believed that chewing gum can improve gastric emptying so if one struggles with appetite after a surgical procedure, one could consider chewing gum. Although not always proven in clinical studies, this could be a simple strategy to try. Gum-chewing can have other benefits as well. Be sure to check with your physician if you have questions about this for yourself as a patient.

Aromatherapy can have a multitude of benefits particularly in the postoperative period to address the numerous challenges of difficulty sleeping, increased pain, stress, nausea and more. Have a look at this article for more information on specific essential oils you can recommend for your patients. Some hospitals have recognized the power of aromatherapy and may offer these services as part of integrative medicine. Massage therapy is another integrative therapy well-known for its benefits in stress reduction, treatment of muscle tension and has numerous other benefits. You can read of the mechanisms for improved well-being in the article here.

Cognitive behavioral therapy is well known for its benefit in the treatment of chronic pain. But the way we think about pain after a surgical procedure can have a significant impact on our earlier return to functioning and could help our bodies recover faster. Having appropriate expectations of the surgical procedure and recovery is an important aspect of this therapy. This article provides a nice summary of the various techniques that can be used in the management of acute pain. These strategies can be part of a healthy approach to the normal challenges in life and should be encouraged for all individuals.

Physical therapy is important in the postoperative period to transition back to normal functioning. But physical therapy can also be important in the preoperative period to ensure individuals are in the best physical condition to withstand the stresses of surgery. Although it might be challenging, one should attempt to at least continue to perform activities of daily living independently and get some physical exercise if able. Being sedentary before and after a surgical procedure or with a medical condition may be associated with worse outcomes. In the postoperative setting, your doctor should set expectations for physical functioning based on the intensity of the surgical procedure. Some days, the expectations might be to sit out of bed to a chair three or four times per day. As healing progresses, one would be expected to ambulate a short distance and gradually increase mobility towards more independence. Participating in physical therapy despite the presence of some pain is important; basing willingness to participate in PT on the presence of pain contributes to deconditioning and complications such as pneumonia, deep vein thrombosis, and falls.

Acupressure / acupuncture This link contains beautiful images and some basic facts

about this integrative therapy now in use for over 5,000 years. Many institutions have recognized the benefit of acupuncture / acupressure and now have integrative medicine offerings available to patients. For those individuals who are needle-phobic or are at risk for infections from needle placement, acupressure is an effective alternative. Devices such as vaccaria seeds, gold beads, indwelling needles (ISP needles) can be used for acupressure. Patients can be taught to stimulate certain pressure points to decrease nausea, decrease anxiety, treat pain. An exciting aspect includes auricular acupuncture / acupressure which takes advantage of the characteristics of the ear which makes it amenable to treatment with beads or seeds for all sorts of ailments. Image courtesy of Advanced Therapy Institute of Touch.

Child Life therapy is offered in most children's hospitals, on the hospital wards and in emergency rooms, to prepare children for surgery and their hospital stay. Child life therapists are involved with fostering therapeutic relationships with medical providers. They help children (and their parents) manage their distress during medical evaluation, intervention, and hospitalization. This article provides a very thorough summary of the roles child life providers play as an active member of health care teams.

Speaking of play, board games / playing cards / jigsaw puzzles are some enjoyable activities that can be undertaken in the hospital setting and encourage us to direct our attention away from our pain and symptoms. One should not underestimate the power of distraction so whether you are a healthcare provider or a patient yourself, consider how having one of these activities available could provide a few minutes of respite from a challenging day.

Talking with friends / family can provide distraction and the social connection we crave. Any activity that requires attention away from pain can be a pain management strategy. Whether it is having family and friends visit in the room, meet in a common area, or connect via audio or video, maintaining these connections can have a number of benefits.

Spiritual advisors / Chaplain / Rabbi / Imam Many individuals seek comfort from a chosen spiritual advisor especially in times of physical challenge. Seeking a higher power to help guide one through trying times can provide great comfort. To this end, many hospitals have individuals available 24 hours a day to meet the needs of patients and family members. In addition, smartphone apps abound for various teachings that can bring solace to those in need.

While many people may not think of these strategies above as 'pain management strategies', your attention to these therapies will set you apart from others and allow a more comprehensive understanding of the pain management experience.

Does your hospital make it easy (or difficult) for you to recommend these strategies? What barriers do you encounter when considering non-pharmacologic strategies? Do you have personal experience with any of these therapies or have others that you would recommend? Feel free to share your thoughts and comments about this article.