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5 Articles in Volume 2, Issue #3
Acupuncture for Pain Relief
Intractable Pain
Menstrually-Related Migraine Treatments
Post-trauma Pain Management: A “Back to Basics” Approach
Spinal Cord Stimulation

Post-trauma Pain Management: A “Back to Basics” Approach

Part two of “Terrorism's Effect on Chronic Pain Perception” discusses the importance of a natural, simple, and integrative approach to chronic pain treatment. In the aftermath of the devastating events of September 11, the authors offer their unique insights about treating mind, body, and spirit in addition to the physical elements of pain. Sample exercises, including yoga and meditation, are adapted from “Women and Pain: Why It Hurts and What You Can Do” by Dr. Mark A. Young (Hyperion 2002).

The finding that terrorism and other forms of mass aggression can exert a potent and enduring impact on physical pain perception has only recently been confirmed.1 Acts of brutal terror such as the cataclysmic events of Sept. 11 have been reported to induce a potent exacerbation in pain intensity among people with chronic pre-existing painful ailments including arthritis and migraine.2

The tragedy that befell the world on September 11, 2001 serves as a cogent example of the devastating impact that reckless acts of terror, such as the World Trade Center and Pentagon attacks can have on physical pain perception. A retrospective multi-center study of 129 chronic pain patients reported in the March/April 2002 issue of Practical Pain Management demonstrated that average pain scores, as measured on the Visual Analog Scale (VAS) for all participants increased 27% after the Sept. 11 tragedy. Women experienced an almost two-fold increase in pain scores immediately following the event compared with men. Neither age, race or clinic location was found to be positively correlated with pain intensity.1

Chronic pain diagnoses represented in the multi-center cohort were varied and included patients with rheumatoid arthritis, degenerative arthritis, fibromyalgia as well as several other painful etiologies. Medical co-morbidities included heart disease and neurological illness. Patients with active psychological illness and cancer were excluded from the study.

A recent Robert Wood Johnson Foundation sponsored study,3 found that post-Sept. 11, Americans have become increasingly pre-occupied with chronic health concerns including arthritis, cancer, heart disease and HIV/AIDS. Since pain is a hallmark feature of many chronic illnesses, it is important to assess the impact of Sept. 11 on pain perception so that appropriate therapeutic interventions can be utilized.

Pain, Chronic Disease and Psychological Implications

Violence, mass acts of aggression and terrorism can provoke a “physiological alarm” among bystanders and those who are not directly victimized. An array of physical responses that can heighten pain can be unleashed. This can lead to a variety of somatic responses including muscle spasms, dysfunctional sleep patterns and significant pain exacerbation.

On a psychological front, it is important to recognize that chronic pain patients, who have experienced forms of trauma, may confront some very powerful emotional reactions that may cause the pain to flare and amplify. Immediately after a traumatic event, people may experience shock and denial, both of which are protective responses. As a result of Sept. 11, many people felt stunned and dazed during the immediate period after the attacks. This slowly gave way to a state of numbness and denial in which victims and bystanders failed to grasp and acknowledge the full intensity of the event. In the case of Sept. 11, many people, who were initially in utter disbelief, suddenly came to the stark realization that something awful and cataclysmic had taken place. In many cases, people suffering with chronic pain reported dramatic worsening in symptoms.

Natural, Integrative and Complementary Treatment Strategies

This article will focus on natural therapeutic and treatment modalities that can be applied to chronic pain patients who have experienced an exacerbation of their pain in the aftermath of tragedy or trauma. The reader is reminded that trauma can take many forms and is not necessarily limited to acts of terrorism and war crimes. Studies have documented that victims and observers of earthquakes, lightening storms, hurricanes and violent crimes have experienced a heightening of anxiety as well as an accompanying pain exacerbation.

Since stress and anxiety appears to have a major impact on pain intensity among victims of traumatic events, it is quite reasonable that holistic complementary medicine strategies, which place emphasis on the “mind-body connection,” be preferentially deployed. There is an abundance of recent literature profiling the gamut of integrative strategies.4-6 In the catastrophic aftermath of Sept. 11, many Americans are now emphasizing the importance of a “back to basics” approach. While most of the specific treatments offered in this overview are not necessarily specific to terror-induced pain, many can be generically applied to patients with fluctuations in their chronic pain due to various forms of trauma.

Case Reports

Two representative case reports will serve to highlight the importance of a multi-disciplinary program incorporating complementary strategies to help conquer the pain compounded by the Sept. 11 tragedy and other calamitous occurrences.

A 45-year-old secretary with a diagnosis of fibromyalgia sustained a significant worsening in her shoulder and neck pain following Sept. 11. Although neither she nor any of her family members were directly affected, she reported that the tension and the stress of the day contributed significantly to a pain worsening. Per the recommendation of her physician, she was started on an aerobic exercise program emphasizing swimming and brisk walking three times weekly. In addition, she was started on a yoga program and was referred for acupuncture treatment to help her deal with her anxiety and pain. After several weeks of this structured program, she reported an improvement.

A 72-year-old senior citizen with chronic pain associated with a history of Degenerative Joint Disease (DJD) — affecting her knees and hips — noted a significant worsening in her pain intensity following Sept. 11. Since one of her children was in the army, she became very anxious about his welfare and safety should he get “called up”. She also spent several sleepless nights reflecting on the tragic and unpredicted events of Sept. 11. Due to a significant pain exacerbation of her knees, the patient was started on a physical therapy regimen that consisted of quadriceps strengthening exercises, thermal modalities, ambulation exercises and a stretching program. To lessen her lingering symptoms of anxiety, she was taught a series of deep breathing exercises. In addition she received three sessions of hypnosis. The patient noted a significant improvement in her pain following a two-week period. Although the trauma of Sept. 11 would always persist, her physical pain complaints progressively improved.

A “Mind-Body” Overview

Pain management is enhanced by methods that increase the pain sufferer’s sense of mastery over his or her symptoms. It is probable that a perception of loss of control is one element in the intensification of pain symptoms experienced by chronic pain sufferers. Breathing exercises, guided imagery and yoga are practices that are likely to help individuals feel greater control of their symptomatology. Other self-empowerment activities include: attending pain support groups, participation in religious activities appropriate to the individual’s belief system and engaging in productive behaviors including working, family duties and volunteerism. Finally, it is critical to rule out major psychiatric conditions such as mood disorders, anxiety disorders, somatization disorders and psychotic disorders which must be treated to optimize pain control and remove potential confounders.

Pain management is enhanced by methods that increase the pain sufferer’s sense of mastery over his or her symptoms.

Exercise as a Treatment Modality

The power of exercise can never be understated. Exercise helps to promote release of endorphins, the body’s natural painkillers. Accumulating scientific research supports the role of exercise in battling chronic pain conditions exacerbated by stress including low back pain, tension headache, Temporomandibular Joint disease (TMJ) and complex regional pain syndromes. Aerobic exercise can relieve symptoms associated with osteoarthritis, rheumatoid arthritis, as well as fibromyalgia. Exercise also helps to fight depression. Anxiety and stress associated with national catastrophes and cataclysms, the likes of which were experienced on Sept. 11, can be “worked off” with exercise.

Exercise should include varied elements including aerobic exercise, stretching, flexibility and strength or resistance training. Aerobic exercise is helpful because it enhances overall fitness by optimizing the body’s use of oxygen. Aerobic exercises include swimming, brisk walking, bicycling and dancing.

Stretching exercises help to improve physical performance by increasing blood and nutrients to the joints. In so doing, stretching may reduce soreness and enhance posture and balance, as well as enhance range of motion.

Strength training is also an important facet of exercise since it helps to prevent injuries by making muscles, tendons and ligaments less vulnerable.

Yoga: Finding the Balance Between Mind and Body

Yoga is thought to prevent illness by maintaining balance between the mind and body. For people who have experienced pain exacerbations magnified by trauma, tragedy and terrorism, yoga may be an ideal modality because it helps to stabilize the physical as well as the mental elements. Many trauma survivors have anecdotally reported a significant reduction in anxiety and chronic pain after initiating a yoga program.

While there are many different yoga poses that the chronic pain sufferer can easily utilize to decrease his or her symptoms, the authors include a selection here. Yoga is an art and frequently requires years of study and practice and therefore it is important to seek out the help of a yoga instructor. Please note that these exercises should be carefully prescribed based on a patient’s physical limitations and capabilities. Table 1 presents two recommended yoga poses that may be helpful.

Yoga Poses Adapted for Chronic Pain Patients
Virsana (Hero's Posture)
1) Encourage the patient to kneel on the floor with knees together and feet spread approximately 18 inches apart
2) Instruct the patient to rest his/her buttocks on the floor or on a small pillow or rolled up towel.
3) No weight should be put on the feet but on to the sides of the thighs with the inner side of each calf touching the outer side of the thigh
4) Keep the toes pointing back and again touching the floor
5) Instruct patient to put hands on knees with palms facing up. Tell the patient to use each hand and form a circle with the thumb and index finger while keeping the other fingers extended.
6) Have the patient hold the position and breathe deeply for as long as possible.
Tree Pose
1) Encourage the patient to stand with his/her feet together and arms at the side
2) Tell the patient to shift weight to right foot.
3) Using his/her hands, place left foot on right ankle, calf or thigh.
4) Identify a point of focus on the floor or on the wall.
5) Have the patient place their palms together in front of the heart and raise them overhead, maintaining elbows straight.
6) Have the patient balance evenly on the inner and outer edges of the right foot
7) Tell the patient to slowly push raised leg to the side and to the rear.

Table 1. Examples of yoga poses that can be adapted to chronic pain patients.6

Role of the Support Group

People who experience chronic pain often report that stressful events cause an exacerbation of their pain symptoms. The anxiety associated with this often has a negative impact. Free and open communication with others in a similar situation can help to lessen the impact of a stressful event.

Research conducted on people who experienced a traumatic event has shown that candid dialogue can help reduce symptoms. A research investigation of Hawaiians who had survived a hurricane showed that those who received counseling were better able to cope years later then those who received no intervention.7


The use of acupuncture is beneficial not only in terms of pain control but also in terms of stress and anxiety reduction. Acupuncture involves the insertion of fine sterile needles into specific anatomic locations at specific angles and depths in order to influence the flow of what is referred to as ‘Qi’, and described as a vital force in the body. This enhances the body’s ability to self regulate and thereby promotes the body to heal and reduce pain. The pathophysiologic mechanism lies in the activation of the endogenous opioid peptide system.8

Acupuncture may be an ideal modality for chronic pain sufferers whose pain has been made worse by traumatic events like Sept. 11 since it exerts a calming, soothing effect (anxiety reduction) and helps to decrease pain associated with traumatic events.


The use of biofeedback provides the patient with a sense of control in reducing both pain and anxiety. Biofeedback therapy refers to the use of biofeedback instrumentation for the clinical goals of symptom and medication reduction, prevention and enhanced quality of life. The clinical goals are achieved through psycho-physiological self-regulation, a term describing the process in which mental, emotional, and physiological strategies and skills are learned and used by the patient.9 This provides a sense of empowerment as the patient has the ability to influence and control his/her own body.

In 1989, a group of biofeedback clinicians and researchers from several institutions assessed the clinical efficacy of biofeedback and found that biofeedback is effective for anxiety disorders and certain types of pain such as myofascial pain and rheumatoid arthritic pain.

Biofeedback therapy for muscle relaxation can involve the use of placing Electromyographic (EMG) electrodes on a muscle and teaching the patient to increase and decrease the level of firing created by the tension or tone in the muscle. When the patient has thoroughly understood the relationship between muscle contraction and relaxation with the corresponding visual and auditory display changes, the electrodes may be placed on the affected muscle. The concomitant use of deep breathing exercises, music, relaxation tapes and progressive relaxation techniques are very helpful in decreasing muscle tension.

Controlling an individual’s response to stress through a relaxation training response has been a useful adjunct. EMG, temperature and electroencephalographic sensors allow the subject to modify their efforts to elicit a relaxation response. Other methods include imagery techniques, breathing techniques, and cognitive-behavioral counseling. The challenge to these interventions is training the patient to generalize the relaxation response during stressful periods outside of the therapeutic environment. They can be used to lessen the impact of pain.

Relaxation Strategies

Stress and anxiety can cause muscles to become tense and result in an exacerbation of anxiety. Relaxation techniques, meditation and imaging techniques may help to reduce pain by reducing tension and enhancing ones mental state.

A technique known as ‘Progressive Muscle Relaxation’ can help to focus attention on reducing muscle tension in major muscle groups by systematically tensing and then relaxing individual muscle groups.

Instruct patients to:

  1. Create an inviting, relaxing milieu by turning down the lights, playing soft background music, lighting a candle.
  2. Suggest that patients wear comfort- able clothing and remove shoes.
  3. Suggest they lie down on a firm, flat surface such as a couch, bed or floor.
  4. Beginning with the feet and working up, slowly tighten and relax all mus- cles in the body.

Meditation Techniques

Although there are numerous forms of meditation including stationary forms and dynamic forms (tai chi, yoga), this age-old modality, regardless of format, can beneficially affect mind and body. The major goal of meditation is to achieve a state of relaxation and tranquility while preserving awareness. For the chronic pain patient who has experienced the psychological and physical consequences of trauma, meditation can bring about a pleasant set of psychological and physical benefits. There have been many studies demonstrating the physical and psychological benefits of relaxation and meditation. These include reduced pain, anxiety reduction, and depression reduction and stress relief. The authors of this article have been successfully using this modality in clinical practice and have found it to be especially suited to the “post-Sept. 11” pain population. See Table 2 for a simple meditation example.

Simple Meditation Example
  1. Instruct the patient to wear comfortable non-restrictive clothing and to sit in a quiet, warm, well-ventilated place.
  2. Have the patient sit up in an erect, relaxed fashion. Keep back straight and shoulders relaxed. Use a pillow for support. Hands can be kept on the lap or on the knees to maximize comfort.
  3. Patient should keep eyes closed.
  4. Patient should breathe deeply in and out through the nostrils.
  5. Slowly have patient relax body (shoulders, hands, fingers, toes, feet, legs, neck and face).
  6. Have patient focus on one word or phrase.
  7. Meditate for 15 minutes to 30 minutes.
  8. When patient is ready to stop, have him/her take a deep breath, exhale and gingerly stretch limbs and open eyes.

Table 2. Simple meditation example.6

Music Therapy

Music therapy includes listening to music, making music or creating music and may have healing powers. Music has been described by master clinicians as “a joyful expression of life... which can lift our fallen spirits, enrich our busy minds and heal our battered bodies.”8 Music has been anecdotally reported to reduce anxiety, decrease fear and serve as a “mood modulator.” Music may facilitate exercise by enabling patients to exercise more optimally and more regularly to the “sound of music.” During the throes of Sept. 11 painful aftermath, a significant number of patients in this cohort helped to beat the pain and anguish of the national crisis by playing common patriotic pop songs.


Although there are a multitude of analgesic medications available to the clinician, there is much to be said for maintaining a simplistic, “back to basics” approach to medication management. For those with simple musculo-skeletal pain and no contraindications, use of over-the-counter NSAIDs are a reasonable option because they possess not only analgesic qualities but also anti-inflammatory properties. Long recognized as the “grandfather of anti-inflammatories,” aspirin traces its history to the days of Hippocrates when the 5th century physician is said to have ground willow bark containing salicin (an aspirin derivative) to battle aches and pains. In more recent years, aspirin has been extolled because of its protective cardiac and neurological effects. Because of its anti-inflammatory, antipyretic and analgesic properties, enteric coated aspirin represents an ideal option for people who do not have any gastro-intestinal, hematological or systemic contraindications.


This article has provided an overview of select complementary medicine strategies that may help to alleviate the pain and anxiety associated with terrorism. With the continuing worlwide threat of post-Sept. 11 terrorism including suicide bombings, bioterrorism (i.e. anthrax), airline sabotage and, most recently, mailbox pipe-bombs, it is important for clinicians to be mindful of the nefarious impact of this form of “physio-psychological trauma” on chronic pain sufferers. Contemporary medicine's understanding of the association between terrorism, pain exacerbation and rational therapeutics is a “work in progress,” however the powerful link between the tragic events of Sept. 11 and VAS score pain intensification (see Practical Pain Management, March/April issue) underscores the importance of designing holistic, fundamental treatment strategies that benefit the mind as well as the body.

Last updated on: June 16, 2015
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