“And who, except the gods, can live time through forever without any pain?” – Aeschylus
Pain happens to everyone; in the body, heart, or mind; short or long term, gentle or aggressive. Pain is both friend and foe. It alerts and protects us from harm. It saddles us, it gives us strength; it teaches us to bond and care. Pain has a hard-wired, essential connection to our lives. When pain transcends the physical experience and reverberates in our minds, an open disposition to heal should be our best ally.
Healing Where it Hurts: Healing Body and Mind
Pain is a multidimensional phenomenon; it has biological, psychological, cultural, and societal components, and the same factors also determine how we perceive, process, and react to pain. Accordingly, pain perception and treatment responses have been shown to depend on peripheral and central sensitivity to both nociceptor stimulation (the molecular underpinnings of detection, transmission, and conscious perception), and psychosocial environment (patient agency, access to health care, family and professional support, etc).
Thus, it seems logical that pain management strategies, especially those formulated to treat persistent or chronic pain, should lead to better results when they are integrated holistically, taking into account all the above aspects. In recent years the concept of Integrative Pain Care, that is, the idea that proper treatment of pain requires the integration of many therapies, has taken root within the chronic pain community.
Pain happens to everyone; in the body, heart, or mind; short or long, gentle or aggressive. Share on XIntegrative Pain Care
Conventional + Complementary + Alternative
Mainly through the administration of drugs and surgery, Conventional Medicine has a primary role in relieving pain (especially acute pain). For chronic pain conditions, however, it has become clear that over-dependence on pain medicines — especially opioids, but also over-the-counter analgesics– can result in serious health problems. The main critique of modern conventional medicine is that it “engages the patient around a problem or a disease and spends more effort on disease management than on health promotion” (1). This means that quite often, conventional medical practice treats the symptoms of the disease, without effectively addressing the underlying causes.
In light of these caveats, and with increased awareness that psychosocial factors play a significant role in maintaining health and wellness, acceptance and validation of complementary approaches to pain treatment have steadily gained traction. Complementary and alternative medicine (CAM) practices are those that complement or replace standard medical care and include chiropractic, traditional Chinese medicine (TCM), massage, yoga, naturopathy, nutritional therapy, and meditation, amongst others (2). Rather than focusing on disease, these disciplines target a person’s overall health and are sometimes referred to as “mind-body” therapies.
Integrative Pain Care, a core component of Integrative Medicine, is the integration of all available, evidence-based healthcare strategies and disciplines in developing an effective pain management plan. It is a practical, patient-centered approach that emphasizes the natural ways one can treat pain, complementing or replacing pharmacological options that are often unsustainable, risky or both. Importantly, it seeks a “seamless engagement of the full range of established health factors—physical, psychological, social, preventive, and therapeutic” (3).
Pain is a multidimensional phenomenon; it has biological, psychological, cultural, and societal components, and the same factors determine also how we perceive, process, and react to pain. Share on XHere are five disciplines that are important components of Integrative Pain Care.
1- Physical Therapy
Physical therapists are increasingly becoming a point of entry into the health care system and deal with, on a daily basis, multiple conditions associated with pain. Through a patient-centered approach aimed at restoring functional mobility, they play an important role in managing and relieving chronic pain. Typical treatments include aerobic training, strengthening and flexibility exercises, manual therapy, posture awareness techniques, and instruction on body mechanics principles. Electrophysical modalities (heat, cold, ultrasound, electrical stimulation) are also sometimes used. Moreover, physical therapists also help patients understand what is causing their pain, and educate them on the contribution of peripheral and central hypersensitivity to chronic pain. Well-trained physical therapists can design a patient-centered pain management plan by promoting health and wellness habits and routines, and recommending additional physical, psychological, and spiritual activities to prevent and relieve pain. Cognitive-behavioral skills are also being integrated into physical therapy including MBSR, CBT, and ACT.
2- Nutrition
Nutrition and diet interventions are key players in the holistic approach to treat health deficits, supported on the belief that “the myriad health problems plaguing modern society result from weaknesses in the body’s physiological foundations brought on by poor nutrition” (6). Poor nutrition is indeed a critical contributor to most chronic diseases, such as obesity, diabetes, cardiac and respiratory insufficiencies, and even cancer. Many of these non-communicative diseases include pain as a hallmark symptom. Nutrition is also part of the scope of practice for physical therapists. A combination of physical therapy and nutrition is promising for conservatively treating non-communicable disease and chronic pain syndromes.
3- Psychology
Pain perception is shaped by both objective (somatosensory) and subjective (affective/motivational) experiences. Neurophysiology and neurocognitive research have shown that pain perception and tolerance are greatly influenced by mood and emotions, influencing what has been defined as the brain’s pain matrix or signature; simply put, anger, sadness, and anxiety exacerbate the pain experienced, while contentment and calm help reduce it. (7, 8) As explained in our previous blog, Psychology of Pain: What it Means and Why it Matters, enlisting the help of a pain psychologist could be catalyze a breakthrough for patients struggling with chronic pain.
4- Exercise therapy
A common misconception amongst people living with chronic pain is that exercising will only aggravate pain and that resting and inactivity are needed to alleviate it. Indeed, in most cases, the opposite is true, as extensive research has shown the many physical and psychological benefits of regular exercise, which include improved metabolism, immune function, sleep, and emotional regulation (9). While intense aerobic exercise has been shown to decrease pain (exercise-induced hypoalgesia or “runner’s high”) most chronic pain patients, especially the elderly, will benefit from low-impact aerobic exercise and activities such as yoga, tai-chi, and pilates.
5- Traditional Chinese Medicine (TCM)
TCM has its roots in ancient China, where is an integral part of the country’s health care system. It includes a range of traditional therapies such as acupuncture, herbal medicines, and exercise (tai chi and qigong) that seek to restore the body’s balance and harmony. In TCM, a disease is believed to arise from an imbalance between the natural opposing forces of yin and yang, which can block the flow of qi (vital energy). Reports of its benefits date from thousands of years ago, but are preponderantly based on empirical knowledge; however, scientific validation is ongoing through modern analytic methods that begin to identify and characterize the bioactive principles in TCM herbs and preparations, and its pharmacological actions (4). On the other hand, the physiological mechanisms underlying the analgesic effects of acupuncture have started to come to light (5). All of this contributes to TCM’s increased adherence to evidence-based medicine standards and a wider acceptance.
The ancient Greeks recognized that pain has roots in both physical and psychological grounds, and used medicines (herbs and narcotics), speech, and even group therapy to treat pain Share on X
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One Pain Too Many (Opportunities to Heal)
Pain is likely the oldest symptom experienced by man. The ancient Greeks recognized that pain occupies both the physical and psychological spaces, in turn using medicines (herbs and narcotics), speech, and even group therapy to treat pain (10). We have come a long way from ancient times and yet, the same basic principles remain true. Today, a modern biopsychosocial approach to pain management requires us to address the extent of actual tissue dysfunction or damage (biological aspect); how pain is perceived and tolerated (psychological aspect); and how the social context (social aspect) impacts the experience of pain. Knowledge of the potential benefits and risks of Integrative Pain Care will allow physical therapists to provide personalized advice for pain treatment, while empowering patients to make positive health choices that help to control and prevent pain-related conditions.
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REFERENCES:
1- Tick, H. Integrative Pain Medicine: A Holistic Model of Care. IASP. In Pain: Clinical Updates May 2014 (Volume 22, Issue 2) www.iasp-pain.org/PublicationsNews/NewsletterIssue.aspx?ItemNumber=3512
2- Houzé B, El-Khatib H, & Arbour C. (2018) Efficacy, tolerability, and safety of non-pharmacological therapies for chronic pain: An umbrella review on various CAM approaches. Prog Neuropsychopharmacol Biol Psychiatry. 87(Pt B):307-321
3- Institute of Medicine. Integrative medicine and the health of the public: a summary of the February 2009 summit. Washington, D.C.: National Academy of Sciences Press; 2009
4- Huang, L., Xie, D., Yu, Y., Liu, H., Shi, Y., Shi, T., & Wen, C. (2017). TCMID 2.0: a comprehensive resource for TCM. Nucleic acids research, 46(D1), D1117-D1120.
5- Lim, T. K., Ma, Y., Berger, F., & Litscher, G. (2018). Acupuncture and Neural Mechanism in the Management of Low Back Pain—An Update. Medicines, 5(3), 63.
6- Nutritional Therapy Association. https://nutritionaltherapy.com/
7- Tracey, I., & Mantyh, P. W. (2007). The cerebral signature for pain perception and its modulation. Neuron, 55(3), 377-391.
8- American Psychological Association. http://www.apa.org/helpcenter/pain-management.aspx
9- Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Practice & Research Clinical Rheumatology, 29(1), 120-130.
10- Fradelos, Ε., Fradelou, G., & Kasidi, E. (2014). Pain: Aspects and treatment in Greek antiquity. Journal of Medical Sciences and Public Health, 2(2), 29-36.
