3. Common Medical Treatments

Since pain is subjective and varies between individuals, it can be tough to pinpoint a perfect treatment. It’s realistic to expect some trial and error as there’s no “one-size-fits-all” solution to pain management. In this chapter, we’ll discuss common treatments.

Heat

Heating pads and cold packs are the most traditional forms of pain management. Confusion arises on which to use when. Generally, heat treatments work better for chronic conditions; ice is used more often for acute injuries. That said, the advice you’ll hear most often from your health-care provider is to use what makes you most comfortable. This may even include alternating heat and cold. (See “Heat or Ice?”)

Heat increases the flow of blood and thus the supply of nutrients and oxygen to affected areas. Applying heat can relieve pain by relaxing muscles, producing a sedative effect, and decreasing muscle tension. Heat is your best option for relieving stiffness.

Moist heat penetrates deeper than dry. A hydrocollator is a heating pad that applies moist heat to superficial and subcutaneous (just below the surface) tissues. Other methods of applying heat are baths, showers, hot tubs, and whirlpools using water between 92° and 100°F.

A Journal of Clinical Nursing study found that heat application every other day decreased pain and disability in people with knee osteoarthritis. It also improved quality of life scores of physical function, pain, and general health perception of people.

Heat, according to the journal Spine, is not an appropriate therapy for:

  • Dermatitis
  • Deep-vein thrombosis
  • Diabetes
  • Peripheral vascular disease
  • Open wounds
  • People with severe cognitive impairment

Cold

Applying an ice pack, chemical cold pack, or cooling-therapy system to a painful area can make things feel better until you find a more permanent remedy. Cold decreases temperature, inflammation, metabolic activity, circulation, muscle spasms, and pain. It shrinks blood vessels and, in doing so, minimizes bleeding and swelling. Cold therapy helps with pain by reducing nerve-end sensitivity.

Cold therapy tips. If you’ve aggravated an old injury, it may be best to use ice for the first 48 to 72 hours or until the swelling subsides. Ice is often recommended if the pain limits your motion. (If you’re just stiff, heat may be the better option.)

Apply ice for 10- to 30-minute periods, separated by at least an hour between applications. The duration of applications also should vary with the area of the body being iced. Tissues, muscles, and structures that lie close to the surface of the skin or have little surrounding body fat require less icing time than those that lie deeper in the body. Place a thin cloth between the ice pack and your skin to avoid a “burn.”

Medicine

Medications shouldn’t be your go-to method for treating chronic pain, says the American Chronic Pain Association (ACPA), but it’s what most of us reach for first. “The use of analgesics (pain relievers) and other medications is a common method of chronic-pain treatment,” says the ACPA. “Pain medications can be helpful for some people with chronic pain, but they are not universally effective. It is important to remember that each person may respond in a different manner to any medication. In fact, in some individuals, pain medications may actually worsen their symptoms over time or cause unwanted or dangerous side effects.”

The ACPA organizes drugs into four pain-medicine categories:

  • Non-opioids (acetaminophen, aspirin, NSAIDs)
  • Opioids (morphine, codeine, oxycodone, hydrocodone)
  • Adjuvant analgesics (medications originally used to treat something other than pain, such as anti-depressant or anti-seizure medications)
  • Other medications (those that have no pain-relieving properties but may be part of an overall pain-management plan).

Non-Opioids

Found in over 600 medications (including Tylenol, Datril, and several forms of Excedrin), acetaminophen is the most common drug ingredient in the United States, says the Consumer Healthcare Products Association. Generally safe and effective for relieving pain (although not inflammation), acetaminophen is especially helpful in treating pain related to osteoarthritis of the hip and knee.

Some studies show that it’s as effective as naproxen and ibuprofen (both NSAIDs) in relieving lower back pain, although a study in the European Journal of Pain found ibuprofen to be usually more effective in producing pain relief than acetaminophen. Those findings questioned using acetaminophen as a first-line analgesic for several pain-related conditions.

Although there is little risk to taking acetaminophen according to its directions, taking too much too often can cause liver damage and death. Men who regularly take acetaminophen and other common pain relievers also may have an increased risk of hypertension.

Overdoses of acetaminophen account for 40 to 50 percent of all annual acute liver failure cases each year in the United States. Before taking acetaminophen, tell your doctor if you have had liver disease or if you regularly drink alcohol. Also, check the labels of all your medications to find out if they contain acetaminophen.

The FDA warns not to exceed 2,000 mg/day of this drug. Manufacturers must limit the amount of acetaminophen to 325 milligrams (mg) per tablet or capsule and put a black box warning on labels of all acetaminophen products.

The guidelines recommend acetaminophen as the first-line treatment for mild-to-moderate pain for older adults, but that recommendation is being reconsidered. Consult your physician regarding how much of this and other over-the-counter medications you can take daily.

NSAIDs

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are available over the counter and in prescription strength. These popular medications (like aspirin, ibuprofen and naproxen) treat pain and inflammation and are used by over 30 million of us every day. According to a 2017 report in the journal Open Heart, NSAID use is most common in women, and people over 60, those with a high body mass index, increased waist circumference or with heart disease. Regular use in people over 65 is as high as 96 percent, according to the February 2018 edition of Aging and Disease.

The downside to NSAIDs includes stomach irritation, gastrointestinal bleeding, gastric ulceration, and diminished kidney (or kidney failure) with prolonged use. The American Geriatrics Society has established guidelines for pain management that encourage people to seek alternatives to aspirin, ibuprofen, and other NSAIDs. Taking more than one type of NSAID during the same period (one month, for example) has a negative effect on both physical and mental health.

Aspirin. Approximately half of American adults regularly use aspirin, according to a study in the American Journal of Preventive Medicine. Aspirin works by reducing substances that contribute to pain, inflammation, and fever.

It’s also used to treat or prevent a heart attack, stroke, or chest pain. Problem is, aspirin’s side effects can be severe (i.e. stomach-lining irritation, gastrointestinal bleeding, and blood thinning). See “Aspirin’s Risks,” on page 42.

If you do use aspirin, be sure that you:

  • Don’t take aspirin (unless directed by a doctor) if you take blood thinners, corticosteroids, medications for hypertension or diabetes, methotrexate, or probenecid.
  • Never consume alcohol when taking aspirin or other NSAIDs.
  • Avoid taking aspirin with ibuprofen. Using the two drugs together can increase the risk for heart attack and can negate the cardio-preventive benefits of daily aspirin therapy.

COX-2 Inhibitors

A new type of NSAID, Cyclooxygenase-2 (COX-2) inhibitors reduce inflammation with lower risks of stomach irritation and bleeding than those found with NSAIDs. COX-2 enzymes are prostaglandins that promote inflammation.

Unfortunately, there is a link between COX-2 inhibitors and heart problems. Celecoxib (Celebrex) is the only COX-2 inhibitor still available (albeit with a warning indicating its risks). COX-2 inhibitors are used for osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis, among other conditions.

Topical Pain Meds

Available in creams, sprays, and patches, topical pain medications are easier on the stomach. Some of them, such as capsaicin, lidocaine (a local anesthetic) and diclofenac (an NSAID), are applied to the skin directly or through pain patches. When the medication is absorbed into the skin, it blocks the pain signals locally. Side effects include rash or itching at the application site, stomach pain, constipation, diarrhea, and nausea.

EMLA cream contains lidocaine and prilocaine that can be applied before certain medical procedures. Its effects can last for up to three hours under a dressing, and for one to two hours after the cream is removed.

Derived from the seeds of chili peppers, capsaicin is used in cream, gel, or patches to treat pain associated with arthritis, shingles, and diabetes, among other conditions. It works by stimulating nerve-ending receptors to alter pain-related messages sent to the brain, reducing the perception of pain. It also allows calcium to enter the cells until the receptors shut down.

Capsaicin can provide temporary relief over long periods but may irritate the skin and produce a burning sensation in the first few weeks of use. It may take three to four weeks of use to determine whether it is effective.

Some topical medications contain trolamine salicylate, which is similar to aspirin. With trade names like Aspercreme and Sportscreme, these appear to be safe, but there’s little evidence that they’re effective for chronic pain. Others, like Bengay and Icy Hot, stimulate sensory receptors and may distract from mild muscle or joint soreness but also are unlikely to relieve chronic pain.

Opioids

A buzz word at every news outlet, you’ll be hard-pressed to find someone who hasn’t heard the term “opioid.” Derived from the poppy plant, opioid drugs contain opium, codeine, and morphine. As such, these narcotics can relieve discomfort by altering the way the brain perceives pain.

The United States continues to experience an epidemic of opioid misuse and overdose. Americans consume 99 percent of all hydrocodone, the most commonly prescribed opioid pain reliever worldwide.

For a select few, opioids act as a panacea, granting them relief from the relentless pain that rules their bodies. The vast majority, however, can likely manage their pain effectively without the use of an opiate. Instead, they could turn to non-opioid pain relievers, certain antidepressants and anticonvulsants, physical therapy, exercise, and behavioral therapy, all of which you’ll learn more about in this report.

Often prescribed to manage post-operative pain, opioids are most effective in the first few days following surgery. There’s no evidence that opioids are effective when taken long-term. After two to seven days, an opiate’s most concerning side-effect can come into play, and that’s addiction. Between 21 and 29 percent of people prescribed opioids for chronic pain end up misusing them.

Physicians are facing complicated and often confusing rules about prescribing opioids, all designed to prevent the drugs’ overuse and misuse. According to a 2018 study published in The New England Journal of Medicine, limits are placed on the dosage forms, quantities, or both, despite the lack of proof that these conditions will help avoid serious complications for people. Another study suggests limiting the amount of opioid prescribed to a person could help combat the current epidemic. See “States Limit Opioid Prescriptions.”

Examples of opioids are morphine, oxycodone, and hydrocodone. They can effectively relieve acute and cancer pain but can produce significant side effects, including drowsiness, dizziness, and constipation. Opioid treatment for chronic pain is more controversial.

Opioid Risks

  • Opioids raise the risk of bone fractures in older adults. One study showed that the annual fracture rate in the over-age-60 group increased from 4 to 10 percent among those taking opioids.
  • In another study, one-third of people with cancer using opioids scored higher on measures of confusion, disorientation, and forgetfulness.
  • A third study showed that older people who took drugs such as codeine and oxycodone after short hospital stays had an increased risk of becoming long-term narcotic users.
  • The results of a 2017 study showed that close to 70 percent of prescription opioid medications are kept in homes with children 17 and under where the drugs are not stored safely.

Prescribing Limits

In 2016, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain. Three principles directly relate to chronic pain sufferers:

  • Non-opioid therapy is preferred for chronic pain unless the discomfort is related to cancer, palliative care, or end-of-life care.
  • When opioids are used, the lowest possible effective dosage should be prescribed to reduce the risk of opioid-use disorder and overdose.
  • Providers should exercise caution when prescribing opioids and monitor all people closely.

Despite these recommendations, some doctors are hesitant to prescribe opioids, both for medical and legal reasons.

Antidepressants

Several painful conditions (including osteoarthritis) respond well to antidepressants. This group of drugs works by increasing the concentration of certain chemical messengers (neurotransmitters) in the brain, some of which directly relieve pain.

Their primary role is to treat depression, which is closely intertwined with pain. It’s like a never-ending cycle—chronic pain can lead to depression and depression can magnify the awareness of pain. See “Antidepressants May Relieve These Types of Pain.”

Low-dose tricyclic antidepressants (TCAs)—such as amitriptyline (Elavil, Endep, Vanatrip), imipramine (Tofranil), and desipramine (Norpramin)—have been used for the treatment of pain related to nerve damage. The relatively low doses of TCAs that are used to treat pain have fewer side effects (like sedation and dry mouth) than the high-dose TCAs used to treat depression.

Venlafaxine (Effexor) is an antidepressant (not a tricyclic) that can be effective in treating lower back pain, osteoarthritis, and rheumatoid arthritis.

Duloxetine HCL (Cymbalta) has shown promise in reducing chronic lower back pain, according to the American Academy of Pain Medicine. Also, the Journal of the American Medical Association reported that duloxetine can help relieve chronic pain caused by certain cancer drugs. The Cochrane Library published a study showing that duloxetine may be effective in treating diabetic neuropathy and fibromyalgia.

Some antidepressants may be as effective as most opioids for improving a person’s chronic pain and ability to function. In addition to antidepressants, anti-anxiety drugs also act as muscle relaxants and are occasionally used as pain relievers.

Antidepressants, though, can have unpleasant side effects. These include, sedation, nausea, weight gain, sexual problems, dry mouth, and blurred vision. Also, daily use of selective serotonin reuptake inhibitors (SSRIs) may significantly increase the risk of fractures.

Steroids/Corticosteroids

Some steroids and other anti-arthritis drugs are administered by epidural injections, but that practice has been called into question due to long-term side-effects such as tendon weakening and increased risk for arthritis and osteoporosis. However, most studies indicate they provide at least short-term relief for leg pain from herniated disc and spinal stenosis.

In general, steroids are effective in treating inflammation and pain, as well as the underlying causes of pain, such as lupus and rheumatoid arthritis. However, they suppress the immune system and often offer only a short period of relief. Side effects include depression, upset stomach, elevated blood pressure, cataracts, bone thinning, and osteoporosis.

Surgery Options

Nearly half of healthy, active older adults have back discomfort, found a 2018 study conducted by researchers at Johns Hopkins University. Better back pain management—some of it surgical—allows many sufferers to remain mobile enough to lead active, productive lives.

Only 1 percent of people with back pain require surgery and many of them undergo a minimally invasive spine surgery (MISS), which involves a shorter incision, causes less damage, results in less bleeding, and promotes a faster recovery. MISS is used for a variety of procedures including decompression, spinal fusion, micro-discectomy, micro-laminectomy, vertebroplasty, and kyphoplasty.

Spinal Fusion

During this procedure, two vertebrae are joined together by a bone (or synthetic bone) graft, screw, rod, plate, cage, or a combination of those components. It’s usually performed with other surgical procedures of the spine, such as a laminectomy.

Fusion can be appropriate for spondylolisthesis, stenosis, or other conditions that cause low back and leg pain. However, it immobilizes an area of the spine which can place additional stress on areas above and below the fused vertebrae. A study that included more than 3,000 subjects found that over 70 percent of people were satisfied with their lumbar fusion to treat low back pain.

Disc Replacement

Disc replacement has changed the way we treat chronic back pain. In certain situations, disc replacement produced better results in relieving back pain than fusion.

Here’s how it works: a plastic-and-steel device replaces a damaged disc in the spinal column. The disc is removed and replaced with an artificial core that floats between two metal plates.

Disc replacement offers an effective alternative for some of the 200,000 Americans who undergo spinal fusion surgery each year. People with the artificial disc were able to maintain better neck motion than those who had spinal fusion. The American Academy of Orthopaedic Surgeons has expressed concern about the technically demanding nature of the artificial disc procedure, but a significant number of people continue to choose this option.

Discectomy and Laminectomy

Back surgery usually has two goals: 1) Decompression for those with a disc or bone that’s pressing on a nerve. 2) Stabilization to stabilize and strengthen a weak area of the spine.

In an effort to reach these goals, two procedures remove all or part of a herniated disc: discectomy and laminectomy. A discectomy involves open surgery with a possible overnight stay in the hospital. A microdiscectomy is less invasive, causes less damage to surrounding tissue, and allows for a faster recovery.

Also known as decompression surgery, laminectomy (or microlaminectomy) is performed to relieve pressure on one or more spinal nerves by removing the back part (lamina) of a vertebra. This procedure is used only when conservative measures are ineffective.

MILD

Most often used in older adults with spinal stenosis, minimally invasive lumbar decompression (MILD) removes some of the tissue in and around the spinal cord. It’s usually performed below the level of the spinal cord.

Vertebral Augmentation

The two most common types of vertebral augmentation are vertebroplasty and kyphoplasty. Both involve injecting a material that hardens into a fractured vertebra to stabilize it. These are performed under moderate sedation or general anesthesia and take about 30 minutes. Pain may not be eliminated, but most people get noticeable relief within a day or two. The procedures carry risks, but they’re rare.

Vertebroplasty

This procedure involves injecting medical-grade bone cement into the spine to stabilize fractured bone in a person with osteoporosis. After the cement hardens, the crushed bone fragments fuse together, no longer rubbing against nerve endings. Its success rate is nearly 80 percent. One drawback: Vertebroplasty can increase the risk of additional fractures in adjacent vertebrae.

Kyphoplasty

Kyphoplasty is a minimally invasive technique for treating pain caused by compression fractures of the spine. First, a small tube is inserted into the vertebra. A balloon follows before it’s inflated to re-establish some of the lost vertebral height. Next, the balloon is removed, and the newly created cavity is filled with medical-grade, orthopedic cement.

Kyphoplasty is followed by a period of rehabilitation and physical therapy, with most people being encouraged to resume normal activities as soon as possible. Older adults with osteoporosis-related spinal fractures who have had kyphoplasty have reported improvements in pain, daily function, and quality of life.

Kiva VCF Treatment

Approved by the FDA in 2014, Kiva treats vertebral fractures by inserting a small coil implant inside the vertebral body and then filling the implant with medical cement. Kiva’s advantage is using less cement, which decreases pressure on the vertebral bodies. The incidence of fractures is less after Kiva implants than after kyphoplasty or vertebroplasty.

Transdiscal Biacuplasty

Transdiscal biacuplasty is used for people with disc pain and controlled herniated discs. Two probes are inserted directly into the disc. Radiofrequency energy passes between the two probes and heats tissue. A built-in water-cooling system allows radiofrequency energy to heat a larger volume of disc tissue than with other methods.

Neuromodulation

Neuromodulation (nerve stimulation) devices stimulate nerves with pharmaceutical agents, electrical signals, or other forms of energy. They work by modulating abnormal neural pathway behavior caused by the disease process.

Potential benefits of this technique include pain relief, restoration of function or normal bowel and bladder control, and Parkinson’s disease tremor control. Among the more than 20 forms of neuromodulation techniques are drug-infusion pumps, nerve blocks, deep-brain stimulation, occipital-nerve stimulation, peripheral-nerve stimulation, spinal cord stimulation, and percutaneous electrical nerve stimulation.

Nerve Blocks

A nerve block is the injection of a local anesthetic or other substance around or near a nerve, nerve network, or pain-sensitive trigger point. A nerve block can help those who suffer from many causes of chronic pain, including lower back and neck pain, sciatica and spinal stenosis, complex regional pain syndrome, peripheral vascular disease, shingles, myofascial pain syndrome, and cancer pain.

The nerve block works by interrupting pain pathways and preventing pain messages from reaching the brain. In addition to anesthetics, there are various nerve-block methods, such as corticosteroids to treat an area of inflammation like a herniated disc, nerve entrapment, or a pain trigger point.

The real value of nerve blocks is their ability to provide temporary pain relief—often long enough to aid in rehabilitation. However, they are of limited use for the short-term relief of lower back pain and provide no long-term relief. Even when recommended, nerve blocks should be considered as part, not all, of a total pain-management program.

People who are taking anti-blood-clotting therapy—such as heparin, warfarin (Coumadin), or clopidogrel bisulfate (Plavix)—should not have a nerve block. Those with an active infection around an area where the nerve block is to be applied also should avoid a nerve block.

Infusion Pumps

An infusion pump administers medication or other fluids directly into the spinal fluid or into the epidural space that surrounds the spinal cord. They’re widely used in hospitals, nursing homes, and in private homes. For example, morphine or other narcotics can be used in the pump as painkillers while muscle relaxers can be infused to control muscle spasms.

A drug pump can lessen chronic pain in failed back-surgery syndrome, cancer, chronic pancreatitis, and several conditions affecting the nervous system. Pumps also can treat muscle spasms and pain associated with multiple sclerosis, stroke, brain injury, spinal cord injury, and cerebral palsy.

Some are designed for stationary use at a person’s bedside. Ambulatory infusion pumps are designed to be portable or wearable. Some infusion pumps alert users when air or another blockage is detected in the tubing that delivers fluid. Newer versions alert users when there’s a risk of an adverse drug interaction or when they set the pump’s controls outside of safety limits.

Deep Brain Stimulation

An extremely aggressive method of pain control, deep brain stimulation (DBS) delivers electrical impulses to specific brain areas to restore disrupted circuits. It is used for a limited number of conditions, including severe pain, cancer pain, and neuropathic pain. DBS is not FDA approved to treat chronic pain, however, so insurance won’t cover it for that condition.

Here’s how it works: The scalp is numbed, so the person feels no pain. Electrodes are surgically implanted in the brain. The person determines the frequency and extent of stimulation, operating a transmitter that sends signals to a receiver connected to electrodes (which are located under the skin).

DBS is costly and risky. Nevertheless, people who’ve used it usually report a disappearance in pain. Other senses don’t seem to be affected, and there’s no mental confusion like that associated with opioid drug therapy. DBS might have the potential to reduce cluster headaches, but studies are ongoing.

Occipital Nerve Stimulation

In occipital nerve stimulation (ONS), a small electrical device that sends impulses to the occipital nerve via leads is implanted at the base of the skull. At the first signs of a headache, the person activates the device. The brain then responds to the electrical stimulation, blocking the pain signal.

One study found that people had a reduction in severity and frequency of headaches within the first month after implantation. Although several other small studies have shown favorable results in treating migraine and other types of headaches, the FDA still considers occipital-nerve stimulation devices experimental. Although ONS may relieve migraine pain, it doesn’t address the cause.

PNS

In peripheral nerve stimulation (PNS) a small electrical device is surgically implanted next to one of the peripheral nerves, which are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that feel like mild tingles. Electricity is delivered from the generator to the nerve (or nerves) using one or more electrodes. The person can control stimulation by turning the device on and off, and by adjusting stimulation parameters as needed.

Spinal Cord Stimulation

Spinal cord stimulation (SCS) accounts for approximately 70 percent of all neuromodulation treatments, according to the International Neuromodulation Society (INS). SCS involves applying mild electric currents to the spine through devices that interrupt pain signals and replace pain with a mild tingling sensation.

During this procedure, a series of electrical contacts are placed in the epidural space of the spine near the region supplying nerves to the painful area. SCS is minimally invasive and performed on an outpatient basis. Usually, a person will try a temporary external system before receiving an implanted system.

The most likely candidates for SCS have had failed spinal surgery, severe nerve-related pain or numbness caused by sciatica, or another chronic pain condition, such as complex regional pain syndrome, peripheral vascular disease, or angina pain.

The device is implanted and allows a person to resume more daily activities than other treatment methods. A trial is allowed before agreeing to have a system implanted. It can be turned off, and a physician can remove the device at a person’s request.

Now for the downsides: SCS comes with typical surgery risks (bleeding, infection, and allergic reactions). Further risks following implantation include mechanical malfunctions, stimulation of the wrong location, and infection. The device can set off metal detectors and those who have it are discouraged from driving. Finally, people with SCS could develop a tolerance to the electrical stimulation, making it less effective over time. In that case, the device will need to be reprogrammed.

Other versions of SCS can detect a person’s body position and adjust the patterns of stimulation. Targeted SCS involves stimulation of specific nerve cells within the spinal cord to produce pain relief in a specific area. Dorsal root ganglion (DRG) stimulation is an example. The DRG receives information from the extremities or the trunk and conveys it to the brain, acting as a gatekeeper. It magnifies or diminishes the pain signal depending on the information it receives. DRG stimulation targets specific neurons and has been effective for pain associated with failed back surgery, complex regional-pain syndrome, and other conditions.

High-Frequency SCS

High-frequency SCS may offer better pain relief than the traditional version. One study showed high-frequency therapy reduced pain by more than half in 85 percent of people with back pain and 83 percent of those with leg pain.

PENS

A thin needle is inserted into the skin during Percutaneous Electrical Nerve Stimulation (PENS). It sends electrical impulses to the affected nerves. At this point, PENS is considered experimental for chronic pain. Before undergoing this procedure, people must be evaluated by a pain-management team.

Radiofrequency Ablation

Radiofrequency ablation (RFA) reduces pain via a radio wave-generated, continuous electrical current that heats an area of nerve tissue and blocks pain signals originating from that spot.

Ablation has been successful in treating chronic low back pain, neck pain, and joint pain caused by arthritis. RFA is successful 70 percent of the time, and the effects can last from six months to several years. Although there’s a slight risk of infection and bleeding at the site of insertion, most people tolerate RFA well and aren’t likely to have complications.

Pulsed radiofrequency (PRF) is a variation of RFA using short bursts of electrical current instead of a continuous flow. PRF may be an option for people with intractable hip pain. PRF yields “significant improvements” for those with a herniated disc and spinal stenosis.

Cooled radiofrequency is a more recent advance in neuroablation technology. It provides adequate therapeutic effects. It’s been efficient at treating problems related to sacroiliac-joint arthritis. Two studies published in Pain Medicine showed positive outcomes using the procedure for low back pain.

TENS

Transcutaneous electrical nerve stimulation (TENS) lies somewhere between traditional and alternative medicine. Usually consisting of a portable, battery-powered unit with electrical leads that are attached to the skin over the painful area, TENS reduces the sensation of pain.

TENS units are used in clinical settings by physical therapists and are available to purchase either over the counter or with a prescription for home use. A TENS sends an electrical current through the skin that lasts a fraction of a second, followed by a pause, before sending the next wave of current. It can be adjusted to deliver intermittent waves.

Exactly how TENS therapy works is not fully understood. It may stimulate the production of substances in the body that diminish pain. Another possibility is simply that the electrical waves distract people from their pain.

The American Academy of Neurology doesn’t recommend using TENS to treat chronic lower back pain that’s persisted for three months or longer because research says it’s ineffective.

Cefaly, the first transcutaneous TENS-like device specifically authorized for use prior to the onset of pain, is a headband that transmits a stimulus that limits pain signals. This is a preventative treatment for migraine headaches.

Osteopathy

The National Center for Complementary and Integrative Health (NCCIH) places osteopathic medicine and its practitioners (doctors of osteopathy, or DOs) in the same category as medical doctors (MDs) who practice mainstream medicine.

Osteopathic medicine is based on the premise that the musculoskeletal system represents the body’s blueprint. Therefore, most diseases are related to the musculoskeletal system. How the body functions is associated with how well the body structure is aligned.

Doctors of osteopathy receive the same basic training as medical doctors. They also are trained in hands-on adjustments (called osteopathic manipulation techniques) of muscles, bones, tendons, and ligaments, which they combine with conventional medical treatments.

According to the University of Maryland Medical Center, the best scientific evidence shows that OMT may be effective for a variety of chronic pain conditions, including low back pain, fibromyalgia, neck pain, and irritable bowel syndrome.

Chiropractics

Chiropractors believe two main tenets:

  • The nervous system coordinates the body’s functions, and
  • Disease is a result of abnormal nerve function.

Chiropractors use manipulation and adjustment of the body’s structures (e.g. the spine) to address these abnormalities, including back pain.

The goal of most chiropractic care is to restore lost range of motion in a back joint. The idea is to make a “motion segment” (two vertebrae and the disc that separates them) more flexible, rather than trying to return the spine to an ideal position.

Research on chiropractic treatment for lower back pain suggests that chiropractic adjustments can relieve acute pain as effectively as over-the-counter pain relievers or physical therapy. People who are most likely to benefit from manipulation experience pain symptoms for approximately two weeks or less.

The NCCIH says, “Most research on chiropractic has focused on spinal manipulation. Spinal manipulation appears to benefit some people with low back pain and may be helpful for headaches, neck pain, upper- and lower-extremity joint conditions, and whiplash-associated disorders.”

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of mental-health counseling. During therapy, a counselor attempts to help a person identify and correct ingrained patterns of negative thoughts and behaviors. CBT is deemed effective once the person can quickly identify a specific concern (in this case, chronic pain) and learn to cope with it, even if the level of pain remains unchanged.

CBT is considered by some to be a traditional pain-management treatment. It’s been recommended by physicians and has been studied in the professional literature for more than a decade. Others see CBT as a complementary technique because it almost always is used in combination with one or more additional pain-management strategies.

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