Pain management techniques

There is currently no universally accepted classification of pain management techniques for back pain or neck pain. In general, pain management techniques can be grouped in terms of their invasiveness. Some, such as physical therapy, are not invasive at all and do not inherently involve the use of medications. Other pain management techniques, such as pain medications, are purely pharmacologic in nature, while still others involve invasive techniques such as injections. Some pain management techniques fall into two or more groups, such as injections, which invasively introduce medications into the body.

We can classify the most widely used techniques in terms of the degree of intervention they involve:

• Noninvasive non-drug pain management
• Non-invasive pharmacologic pain management
• Invasive pain management

Noninvasive non-drug pain management
There is an immense variety of noninvasive non-drug pain management techniques available for treating back pain and neck pain. A few of the most widely accepted in comprehensive pain management programs are the following:

• Exercise—physical exertion with the aim of training or improvement. Includes the McKenzie method, water therapy, flexion exercises, aerobic routines, and many others. May involve active, passive, and resistive elements. Exercise is necessary for proper cardiovascular health, disc nutrition, and musculoskeletal health.

• Manual techniques—manipulation of affected areas by means of chiropractic adjustments, osteopathy, massage therapy and other techniques. Some evidence for the effectiveness of certain techniques is available.

• Behavioral modification—use of behavioral methods to optimize patient responses to back pain and painful stimuli. Cognitive therapy involves teaching the patient to alleviate back pain by means of relaxation techniques, coping techniques, and other methods. Biofeedback involves the gradual alteration of neuromuscular signals for symptomatic improvement.

• Cutaneous stimulation —superficial heating or cooling of skin. These pain management methods include cold packs and hot packs, and should be used in conjunction with exercise.

• Electrotherapy —the most commonly known form of electrotherapy is transcutaneous electrical nerve stimulation (TENS). TENS therapy attempts to reduce back pain by means of a low-voltage electric stimulation that interacts with the sensory nervous system. Randomized controlled trials have yielded either positive or neutral results regarding the efficacy of TENS as a treatment for back pain.

Noninvasive pharmacologic pain management
Pain relievers and related drugs are used at every stage of the medical treatment of back pain, from the initial onset of acute pain to facilitation of rehabilitation, treatment of chronic back pain and alleviation of pain in cases of failed back surgery. The most common noninvasive pharmacologic treatments for chronic back pain are:

• Analgesics—includes acetaminophen. Long-term use involves risk of renal damage.

• Nonsteroidal anti-inflammatory agents (NSAIDs)—includes aspirin, ibuprofen, naproxen, and the new COX-2 inhibitors.

• Muscle relaxants—used to treat muscle spasms due to pain and protective mechanisms.

• Narcotic medications—most appropriate for acute or post-operative pain. Since use of narcotics entails risk of habituation or addiction if not properly supervised, they are not often used for chronic conditions.

• Antidepressants and anticonvulsants—used to treat neuropathic (“nerve”) pain.

Invasive pain management techniques
Invasive techniques in pain management involve invasion of instruments and devices into the body. However, pain management should be distinguished from surgery, which involves a greater degree of surgical insult and permanent alteration of tissue than other invasive pain management techniques.

A multitude of invasive pain management therapies have been used to treat neck and back pain. Some of the most popular include:

• Injections—direct delivery of steroids or anesthetic to nerve, joint or epidural space. Injections into the facet, peripheral nerve, “trigger point” and other locations are also known as “blocks”. These may provide relief of pain (often temporary) and can be used to confirm diagnosis. Epidural injections provide temporary relief for severe back pain.

• Prolotherapy—injection of solution to stimulate blood circulation and ligament repair at affected site. The effectiveness of this technique is not known.

• Surgically implanted electrotherapy devices—implantable spinal cord stimulators (SCS) and implantable peripheral nerve stimulators. Clinical data offers inconclusive findings on the effectiveness of SCS.

• Implantable opioid infusion pumps—surgically implanted pumps that deliver opioid agents directly to affected nerve. The appropriateness and effectiveness of these devices for treating chronic back pain is controversial.

• Radiofrequency radioablation—deadening of painful nerve via heat produced by a specialized device. The efficacy of this treatment is mixed.