In our next section, we will discuss the rehab modalities and other complementary alternative medicine approaches for patients with chronic pain. The biopsychosocial model approach describes pain and disability as a multidimensional dynamic interaction among physiological, psychological, and social factors that can influence one another, resulting in chronic and complex pain syndromes. For this, we like to treat it using multiple approaches. Before starting a multidisciplinary treatment approach, it is important for the patient and their primary or their pain physician to come up with a treatment plan for that specific patient. Is the patient's expectations realistic? Are they obtainable? It is very important to set their expectations before you start the treatment program to let them know that they may not be 100% pain relief at the end of the treatment program. It is important for you to develop short and long-term goals so that the patient has something to strive for while they're going through their treatment. For each individual patient, they have different anatomy, different psychosocial factors that go into their life, so it is important to individualize the treatment plan for that specific patient. You want them to feel empowered over their pain and over their treatment plan. It's very important to ask the patient if they agree with the treatment plan or ask what they're trying to get out of the treatment plan. We want them to be very involved and participate well in their therapies. We want to integrate the anticipated functional gains with the patient, and also, we need to address comorbidities and psychosocial barriers before we start the multidisciplinary treatment plan. The American Society of Anesthesiologists' Practice Guidelines for Chronic Pain Management indicated that the use of multidisciplinary treatment programs were more effective in reducing the intensity of pain reported by patients for periods of time ranging from four months to one year when you compare that with conventional treatment programs. When utilizing a multidisciplinary team approach for a patient that is having pain, they may start with the primary care physician and then be referred to the pain specialist, but there are many other players on the team that can help the patient's pain. They may see another subspecialist besides the pain physician. They may see a psychologist or a psychiatrist to help with some of their psychological aspects of their pain. They might meet with a PT, an OT, or a trainer. Looking at their diet or nutrition or pharmacist, that can also be very helpful in treating someone's pain. Looking at their social workers or spiritual leaders can help them with some of their social or psychological aspects of treating pain, and also, knowing that they have family and friends that are supporting them throughout this process will also be helpful. Everyone on the multidisciplinary team approaches pain from a different aspect, but overall, the goals are usually the same. One, we want to reduce the patient's pain. We can do this by non-pharmacological or pharmacological needs. There's other modalities and interventions such as nerve blocks, interventional modalities, or surgery. We try to incorporate rehabilitative and holistic measures to see if some of that can ease the patient's pain. And then at the end of the journey, and also throughout the journey, different coping mechanisms for the patient to use or utilize to try to let the patient know that if we can't get your pain to go to 0%, what are some other ways that we can help cope with the pain? There are some reasons for pain medications to be used. We know that analgesia preserves function, quality of life, and psychological well-being. There's also parallel interventions that require pain medications to succeed, such as surgeries. And then other types could be psychological counseling, bracing, or physical and occupational therapy. Here's a short list of some non-pharmacological and non-interventional options to help treat patients' pain. Some very important ones to start with are always education and support groups. This will help set the patient's mindset appropriately to know how they're going to try to treat their pain. Exercise, therapies are always great options to keep the body moving. Some common modalities that we try to use are heat, ice, the TENS unit, massage, acupuncture, and chiropractic care are all very helpful and viable options to treat patients with chronic pain. Some less commonly used ones but still are very important are things like cognitive behavioral therapy, their spirituality, some biofeedback, and other types of relaxation exercises. Some common modalities that we try to utilize in pain management include thermotherapy, which can be heat or cold, hydrotherapy, light therapy, electrotherapy, and manual therapy. To speak a little bit more about heat, heat can impact a lot of things throughout the body. It can increase all of these, viscosity, nerve conduction, blood flow, and elasticity of soft tissues. Therapists know how to use this well whenever they're trying to stretch out, say, your hamstrings. We can always try to apply a little bit of heat before stretching out the intended muscle that they're targeting. Another important concept to know about thermotherapy, heat and cold included, is conduction versus convection versus conversion. Conduction is a heat exchange through direct contact. Convection is a transfer of thermal energy through movement in a fluid medium. Conversion occurs when a different type of energy is converted to heat energy. Superficial versus deep heat, superficial heats to about 2 to 3 centimeters in depth, which includes hydrocollator packs, a variety of fluid baths, and an infrared lamp. Deep heat goes deeper than 3 centimeters, and examples of that include ultrasound waves, short waves, and microwaves. Ultrasound are most commonly used and can heat bone, muscle, interface, even in deep hip structures. Some ultrasound uses can be for contractures or tendinitis. And some ultrasound precautions include malignancy, open emphasis, pacemaker, and pregnancy. Some indications for heat can include muscle spasms, pain, contracture, increased collagen extensibility, and accelerate the metabolic process. Some contraindications for heat can include acute inflammation, bleeding disorders, decreased sensation, edema, ischemia, and scarred skin. Another important aspect of thermotherapy is cold. Cold can impact the body like heat did previously, but almost the opposite way. It decreases viscosity, nerve conduction velocity, blood flow, and elasticity of soft tissues. It can also lead to vasoconstriction, decreased local metabolic activity, decreased enzymatic activity, and decreased O2 demand. Cold can result in analgesia and relaxation. It's usually used in the first 48 hours after acute musculoskeletal injury to decrease inflammation, edema, and pain. After about 20 minutes, tissues 2 centimeters deep are cooled by about 5 degrees Celsius. Some indications for cold can be acute trauma, edema, pain, hemorrhage, reduction of metabolic activity, and muscle spasms or spasticity. Some contraindications for cold therapy can be ischemia, Raynaud's disease, or insensitivity. In regards to electrotherapy, there are a couple of common examples. One is ionophoresis. This is the process of various drugs being introduced into a joint or periligamentous region via electrical current, topically delivered so it minimalizes the systemic side effects and it bypasses the liver metabolism. Another commonly used electrotherapy can be the TENS unit or transcutaneous electrical nerve stimulation. This uses the modulation of the gait control mechanism of the dorsal horn of the spinal cord that helps relieve some of the pain. In regards to physical and occupational therapy, there are three main types of therapeutic exercises that they try to utilize. The first is flexibility. With that, connective tissue stretches with a small amount of force and returns to its original length when the force is removed. For best results, stretching should be maintained for 30 seconds and can go longer with more practice. With continued stretching and flexibility, you can see improvements within one to two months. The next is muscle strength. A practitioner needs complete understanding of an anatomy for proper agonist and antagonist training. Gains in the first two weeks are usually related to neuromuscular reeducation and more efficient recruitment of muscles. Later gains are due to hypertrophy of muscle fibers and increased cross-sectional areas. The last type of therapeutic exercise tries to incorporate aerobic exercises. This aim is to improve aerobic capacity. We try to aim for three to six times a week for at least 15 minutes of continuous exercise for the aerobic capacity to increase. A good therapy program will usually incorporate all three of these. The therapy team will try to incorporate some of these aspects with their patients when they meet them so that they can have good quality therapies for their patient. They always start with trying to set up a good goal. Most times that can be decreasing pain or increased function. They try to find things that they can monitor, such as range of motion exercises or strength exercises. They try to define short-term goals in their programs and set time frames on trying to accomplish those goals. They look at outcomes. They use measurable outcomes and see which ones have been able to be achieved. They always give the patient a good home exercise program. They write it down and make sure that the patient is fully aware and understands their goals for the home exercise. Some common complementary and alternative medicines, also known as CAM, for pain medicine can be acupuncture, homeotherapy, meditation, yoga, tai chi, herbal medicine, and also hypnosis. If you're ever in doubt or unsure if a specific therapy is worth it or if it works, the NIH has a very useful website at the National Center for Complementary and Alternative Medicine at the website you see here. This allows you to search a specific type of CAM, and it will give you up-to-date and accurate evidence-based answers for most of your questions. To wrap up, here's a list of just a few other modalities that we really didn't get to touch on. For the modalities, there's eSTEM, ultrasound we touched on briefly, laser, magSTEM, spray and stretch, and low-intensity laser. There's some physical modalities, such as RF and cryo. And finally, there's always the use of botulism toxin preparations that can help some therapists stretch the patient and achieve maximal relaxation goals of some of those muscles.

chronic pain

individualized treatment plans

multidisciplinary treatment programs

complementary medicine

pain reduction