An Historical Perspective: A Global View of Evolving Pain Treatment Modalities
Over a period of 13 years, as head of the pain clinic Ambulatorium Süd in Austria in the period 1976 to 1989, the author personally treated, on average, 3,800 new pain patients each year. Experience derived from the large volume of pain patients (comprised of 4% benign diseases-various, 7% cancer pain, 10% sympathetic dystrophies, 25% articular pain, and 54% neuralgias), the extended timeline, and numerous intervening research projects, has given the author a unique perspective and an extensive knowledge base. While the average pain reduction for all patients observed over the 13 years was 56%, evolving techniques over that time period resulted in the last 5,500 patients (including 3,000 private patients) experiencing an average pain reduction of 92%.
Treatments can be grouped into three basic strategies: procedures (to treat underlying causes of pain), conservative measures (that comprises a continuum from PM&R to drugs in the opiate- and morphine-derivative group), and operative measures. Ideally, a practitioner should be able to freely select the optimum treatment modality for a given diagnosis, yet due to resource limitations (especially in certain parts of the world), alternatives can be used. Table 1 summarizes the three basic strategies together with the resource requisites.
|Pain Relieving Strategy||Resource Requirement|
Treat underlying condition or disease
|medical specialists (internist, orthopedist, etc.)|
|Conservative methods Non-drug use
|PM&R facilities, specialists, equipment
medication to prevent gastric damage
medication for obstipation
|operative facilities & neurosurgeons
Table 1. Summary of pain reduction strategies with corresponding resource requirements.
Procedures for Underlying Conditions
Pain associated with a specific disease or condition is often reduced or eliminated by treating the underlying causes. Several examples illustrate pain-generating conditions that, when treated, often reduces or eliminates associated pain.
Thalamic pain, often reported in the aftermath of a stroke, is caused by diminished circulation through certain areas of the thalamus. A stellate block to increase the circulation in that region, while not considered a method for pain reduction, does eliminate the pain.1
A patient with osteoporosis is encouraged to increase physical activity in order to decrease the amount of calcium leaving the bone structures. The patient may be also be prescribed a drug which replaces the loss of calcium and strengthens the bony structure (e.g., fluorine and a biphosphonate) to reduce the possibility of fractures. The side benefit is a long-term reduction in pain without analgesics.
Pain occurring with breast cancer has been found to be exacerbated by hormones. For this condition, adjusting hormone levels will reduce the pain, again with no analgesics.
Similarly, gout is a disease that causes pain due elevated levels of uric acid. Medication to excrete the excess uric acid and maintain a normal level will, in most cases, cause the pain to disappear.
Methods for reducing pain without drugs are available mainly from the specialties of physical medicine and neuropsychology. These various principles may be separated into several special fields, which are listed in Table 2 and summarized in the following sections.
|Methods of physical medicine2|
|Methods of neuropsychology3|
Table 2. Summary of non-pharmacological modalities.
The determination of which type of physical therapy to be used for the optimum reduction in pain should be determined by a physician with special training in physical medicine. The particular method to be selected for the appropriate patient largely depends on the particular disease or cause of pain. The following is a brief description of the listed methods of physical medicine.
Mechanotherapy comprises passive and active exercises, various types of massage, extensions, suspensions, ultrasound — sometimes as phonophoresis; various techniques of relaxation and therapeutic dance methods — sometimes combined with music therapy. There are special types of manual therapy and exercise variations for different types and locations of pain. Of course, this approach may be contraindicated for certain causes of pain (e.g. a disc protrusion).
Electrotherapy may be used either as direct current (DC) in the form of galvanisations, iontophoresis, and pulsed currents. Transcutaneous Electrical Nerve Stimulation (TENS) in its DC form is optimally effective and suited for treating pain. Electrotherapy may also be used as alternating current (AC) in the form of low or middle frequency currents, interferential currents, and high frequency AC, (short waves, microwaves, decimeter waves). TENS in its AC form, however, is only minimally — if at all — useful for reducing pain; the main application for instruments delivering AC are muscular indications. Application of electricity also includes magnetic field therapy, as well as the various forms of laser. The latter is only used at a special frequency and solely for the treatment of joint pain — having little impact on neurogenic pain.
Thermotherapy may be applied either as heat (bath, hot air, red light therapy, sauna, hot packs, hot sand, hot water baths, mud bath, etc.) or cold applications (cold packs, cryotherapy, icing sprays, cold room, cryojet, etc.).
Hydrotherapy is very often quite effective especially for chronic pain, if used as a hot bath, water massage, balneotherapy with peloids, or climatic bath.
The optimum method of neuropsychology is typically determined by a neurologist, psychologist, or, more recently, a psychiatrist with fellowship training. Following is a brief description of the listed non-pharmacological methods of neuropsychology.