Abstract
Chronic pain is becoming more prevalent in our aging population. It can be difficult to treat, and often the goal is to manage pain to allow function. Conventional therapies continue to be the mainstay of treatment, but there is a growing interest in novel or alternative/complementary treatments. These types of treatments are being employed when mainstream therapies have either failed or are added as an adjunct. These treatments will vary in the level of evidence as well as the effectiveness, and these issues need to be discussed with any patients that are considering these options. Risks versus benefits will also need to be discussed with patients before undertaking any treatments. Locating qualified individuals and insurance coverage will also need to be considered before the patient undertakes these treatments. This chapter will discuss some of the more popular novel treatments and describe basic treatments, indications, and evidence.
Key Concepts
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Chronic pain is defined as pain present longer than 3 months. A direct correlation between tissue pathology and the degree and duration of pain does not always exist.
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Rather than thinking in terms of a “cure,” the goal is to maximize function while avoiding morbidity from medications or procedures. A holistic, multimodal approach is advocated.
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This chapter will focus on an integrative approach that combines conventional with nonmainstream and novel practices.
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Many integrative treatments lack rigorous evidence; however, if the patient is following prescribed therapies, the integrative treatment is not harmful, and the patient is perceiving a benefit, they should be allowed to continue.
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Patients must understand that health insurance may not cover some of these treatments, although a flexible spending account can offset some costs if available.
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The patient as well as his or her support system should be involved in the care plan, and the patient should be empowered to set goals to achieve self-actualization.
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Patients should have regularly scheduled follow-up appointments to discuss the effectiveness of treatments as well as discussions of further management options if treatments are not having the desired effect.
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Restoration of normal sleep patterns is paramount in the treatment plan.
History
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Location and type of pain will depend on medical condition and will vary significantly.
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Performing a thorough history and physical exam is essential to making the correct diagnosis and treatment plan. It is also important to consider contributing factors such as socioeconomic class, previous treatments, comorbidities including psychological/mental illness, as well as social and occupational status.
Additional Tests
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Will vary widely based on type of pain, and could be used to verify diagnosis or rule out other conditions.
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Electrodiagnostic studies may be helpful for certain types of nerve conditions.
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Vascular studies can be done if there is a concern for vascular diseases.
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If history and physical exam are concerning for systematic disease, laboratory studies should be performed.
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A sleep study may be needed to diagnose an organic sleep disorder.
Treatments
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Acupuncture
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There are multiple theories of its mechanism of action, but none to date have been proven. In its most simplistic terms, it interrupts the pain signal to the central nervous system (CNS).
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In general it is very safe, although there are case reports of perforated organs, chiefly pneumothorax.
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There are a multitude of acupuncture techniques related to the combination of points chosen, length of treatment, manipulation/stimulation of the needle, and frequency of treatment.
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Although there are protocols, each patient responds differently and the acupuncturist should be flexible in their interventions.
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Patients can continue all other therapies while receiving acupuncture, but the goal would be to minimize or eliminate medications and/or procedures.
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Referrals for acupuncture treatment should include the diagnosis, previous treatments attempted, as well as ongoing treatments.
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The physician’s and patient’s goals should be communicated to the consultant.
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The proper expectation must be set, which is that acupuncture is an adjunct to the treatment plan.
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There is controversy whether dry needling can be considered a form of acupuncture and, as such, whether practitioners require the same rigor of training as acupuncturists. The same needle is used in both, but in dry needling the needle is passed multiple times into a symptomatic area, not necessarily an acupuncture point, and no external stimulation is provided. The procedure can be painful, often producing an ecchymosis. Benefit is felt to arise from stimulating beneficial local effects in the tissues.
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Injections
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Targeted injections can be a useful adjunct when accessible pain generators have been clearly localized.
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Multiple studies have shown placement failure rate as high as 70% for palpation guided only injections depending on location. Therefore it is recommended that ultrasound guided injections be performed when injecting the specific agents described below. Refer to Box 24.1 for locations and indications of injections.
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Dextrose prolotherapy : Mechanism of action is not completely understood, with several theories being proposed. It appears to cause an inflammatory response or destroys neo-neurovascular structures leading to pain improvement. 12.5-25% concentrations are injected either peri- or intratendonous or intra-articularly. Ligamentous injections are advocated by some as well.
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Botulinum toxin (BTX): A newer adjunct treatment that has shown promise for certain conditions. BTX is theorized to effect peripheral sensitization and possibly have an effect on central sensitization through pain transmission and modulation. BTX does not cross the blood-brain barrier and has no direct effect on CNS. Caution is advised when injected around the muscle tendon junction and judicious doses are recommended. Intra-articular injection for osteoarthritis has shown much promise, and the dose is adjusted for the size of joint ranging from 50 to 200 units.
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Platelet-rich plasma (PRP) has been a recent topic of much research and discussion. There are multiple variables to consider in regard to PRP use that impact on efficacy, including platelet concentration, leukocyte-rich versus leukocyte-poor, and viability of the platelets. To date it is unclear which preparation has the most efficacy. PRP can be effective in chronic tendinopathy treatment and possibly osteoarthritis, but has still not been proven to be effective for other conditions.
Box 24.1Related posts:
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