Cognitive Behavioral Therapy (CBT)

Teaches individuals with pain how to stop negative or distorted thoughts about pain. Negative thoughts are replaced with more positive, helpful thoughts.

Weekly sessions can be individualized or in group settings. Sessions are typically 8 weeks with possible booster sessions (sessions can range 2 – 24 weeks).

Individuals learn:

• Self-management skills (including relaxation)
• Cognitive restructuring
• Acceptance and Problem solving
• Wellness behaviors such as sleep hygiene 

CBT effectively reduces pain, disability, distress, and may help while individuals voluntarily taper off opioid medications. Benefits continue with skill mastery for months after completing treatment. Transportation and cost may be a barrier. Some programs are available through self-directed learning (self-help books, virtual reality, smartphone or internet-based platforms).

CBT has minimal risk. Rarely, individuals with underlying mental health conditions struggle, or are disruptive in group settings. Individual CBT is best in those circumstances.

Encourage individuals to:

• Keep an open mind
• Practice techniques
• Complete the program

Progressive Muscle Relaxation (PMR)

Elicits the relaxation response by sequentially tensing then relaxing muscle groups in an orderly (e.g., head to toe) fashion. PMR can be performed with or without biofeedback.

Biofeedback

Involves using sensors to measure and make the person aware of biological responses to aide in mastery of treatments like muscle relaxation or other mind-body therapies.  

PMR may be effective for pain-related symptoms such as mental and emotional stress and sleep disturbance.

PMR has minimal risk, but individuals may experience increased anxiety or intrusive thoughts during relaxation. If those arise, the method can be modified to lower these undesired effects.

Biofeedback has been most used for headaches, and with advances in sensor technology is available for an expanding array of pain types.

Encourage individuals to:

• Dedicate a safe, comforting space to practice
• Plan a regular time to do PMR or biofeedback and practice daily
• More frequent practice facilitates mastery in 1-3 months
• Combine with other therapies such as calm music or ambient noise
• Seek assistance if needed

Acceptance Commitment Therapy (ACT)

Helps individuals develop acceptance of their symptoms, including their thoughts about their pain.

ACT programs are led by a professional and require 8-10 sessions with between-session work. 

Individuals learn:

• Accept thoughts about pain
• Have a flexible outlook
• Appreciate and focus on the valued actions and relationships in their lives.

ACT may be effective for pain-related symptoms such as mental and emotional stress.

ACT has minimal risk, but therapy may increase an individual’s anxiety or uncomfortable thoughts/feelings arising from self-reflection. ACT is not recommended for those with cognitive or memory impairment.

Encourage individuals to:

• Be patient as it takes time, to develop the skills required for maximum benefit.
• Combine with other therapies

Concentration Based Therapies

Meditation is a process of awareness. Typically, a      word or phrase is repeated during the act of focusing.

Mindfulness Based Stress Reduction (MBSR) allows for the individual to focus on the awareness of (without emotionally responding to) thoughts, sensations, and surroundings as they occur.

Guided Imagery involves relaxation and deep breathing during the visualization of an image. Initially the focus is on a pleasant, safe image. With mastery of “safe place” imagery, the technique can be extended to focus on stressors and discomforts and imagine changing them.

More advanced sessions can be led by a hypnotherapist and can vary in length or purpose.

Concentration based therapies can take several sessions to help pain and programs can last 8-10 weeks.

Concentration based therapies may be effective for the reduction of the mental and emotional distress associated with pain.

Concentration based therapies have minimal risk, but individuals may experience increased anxiety or intrusive thoughts before mastering relaxation, guided imagery, or self-hypnosis skills.

Encourage individuals to:

• Be patient as mastery takes time to help with pain
• Dedicate a comforting space to practice
• Plan a regular time to practice concentration therapies
• Meditation can be done in a seated or lying position with eyes closed or gazing at a focal point.
• Combine with other therapies
• Seek assistance if needed.

Technology-Assisted Therapies

Internet-based systems and mobile health software applications delivered on devices such as phones, tablets, and computers.

Technology can offer:

• CBT interventions (e.g., guided acupressure and exercises)  
• Education on understanding pain and learning strategies to cope with pain
• Self-management to monitor and track pain-related information

Virtual Reality

Allows users to be immersed in a virtual experience through a head set device and software application. Specific evidence-based software applications are available for pain, some with biofeedback.

Technology may make pain interventions accessible and offer pain and distress reduction.  

There is minimal risk with using technology, but here is a possible loss of privacy with health information.

Virtual reality may cause motion sickness or dizziness depending on the experience type and duration.

Encourage individuals to:

• Learn how to use technology-based interventions
• Do not accept or approve apps that seem suspicious to protect privacy
• Ask your health care provider to recommend trusted health sites for education
• Review the ratings of software applications and the cost
• Use VR in a safe place
• Use VR while sitting and for no longer than 15 minutes
• Consider activity limitations when selecting a VR experience.

Therapeutic Exercise

Exercise helps by increasing the production of chemicals that help with healing and pain. Exercise program can be developed in conjunction with a Physical/Occupational Therapist &/or self-directed.

Exercise types include:

• Cardiovascular-Respiratory (endurance) building
• Strength training
• Education of proper form/positioning, repetitions, and stretching.

Exercise is effective for pain, muscle strength, joint range of motion, balance, and flexibility.

Risks of exercise may include fatigue, increased pain and/or swelling; especially during the first days or weeks of establishing a routine.

Fear-avoidance of exercise can be overcome by graded motor imagery techniques.

Encourage individuals to:

• Seek approval from a health provider prior to beginning an exercise regimen.
• Try water-based therapies if an individual has difficulty with load-bearing exercise.
• Prevent soreness with ice, heat, or a low-risk medication before or after activity.

Manual Therapy

Includes mobilization, instrument assisted manipulation, or spinal manipulative therapy. The therapies are delivered by a trained health professional (e.g., Chiropractor, Physical Therapist, or Osteopath)

Multiple sessions may be necessary, and payors vary in coverage.

Manual therapy may be best for back pain, headaches, or sciatica.

Risks of manual therapy may include increased pain, stiffness, or soreness. Serious injuries are rare, but more common with neck mobilization.

Encourage individuals to:

• Stretch and drink water after sessions
• Massage (simple) can also help after treatments.
• Can be combined with other low-risk therapies

Massage Therapy

Can be simple or specialized (myofascial release). Myofascial release involves applying tension on the hardened areas of muscles to increase blood flow.

Massage therapy may be effective for soothing musculoskeletal pain and stiffness.

Risks of massage therapy may include fatigue, increased pain and swelling.

Encourage individuals to:

• Consult their health care provider, especially if firm or strong pressure is going to be applied
• Stretch and drink plenty of water after massage
• Try combining with thermotherapy

Therapeutic Equipment

Includes the use of braces, orthotics, traction, and or compression sleeves. These items can help with positioning and stabilize and support the area of musculoskeletal pain.

Therapeutic equipment may be effective to relieve pressure and pain on the affected area.

Risks associated with the use of therapeutic equipment may include muscle soreness and skin irritation or breakdown from the device.

Encourage individuals to:

• Be patient because it may take time to find the best fitting device
• Compare the cost and quality of the equipment
• Seek an expert to help find the correct fit
• Take care of the skin and monitor for breakdown

Thermotherapy

Involves the application of heat or cold to increase or decrease temperature to the area impacted by pain.

Contrast therapy is the alternation of cold and heat which can be achieved with hot/cold packs or wraps.

Cryotherapy involves near-freezing temperatures that may have greater risks than benefits in older adults.

Thermotherapy may help with musculoskeletal pain, muscle spasm, and inflammation.

Contrast therapy can be effective for those with inflammation and pain due to Rheumatoid Arthritis.

Risks of thermotherapy may include nerve and tissue damage, frostbite (cryotherapy) or burns, inflammation or circulation-related problems.

Encourage individuals to:

• Use with caution if there are circulatory, cognitive, or sensory-motor deficits 
• Protect the skin
• Set a timer to monitor time of thermotherapy use
• Do not leave on skin for long period or use with a person unable to remove it if uncomfortable.
• Do not use plug-in devices with a damaged cord.

Transcutaneous Electric Nerve Stimulation (TENS)

TENS may promote the release of chemicals to decrease pain sensation and dilate blood vessels in the injured tissue. TENS involves the application of pads on the skin around the affected area to deliver pulses of electrical stimulation at different frequency and intensity.

TENS is effective for acute and chronic pain symptoms.

Risks of TENS may include skin irritation. problems with electrodes adhering to the skin.

Encourage individuals to:

• Have clean and dry skin to prevent problems with electrodes adhering to the skin
• Be careful when applying to fragile skin and do not apply over broken skin.
• Do not start with high frequency or intensity, always start low and go slow
• Document TENS use and results
• Be mindful of costs associated with additional supplies will be needed such as batteries, electrode patches, and other adhesive agents

Low Level Laser Therapy

Involves the use of wavelengths of light to accelerate the healing of tissues.

Therapy may take multiple sessions (8 to 30 sessions) that are dependent on the individual’s pain severity.

Low level laser therapy may be effective for inflammation, neck, back, joint pain, and neuropathy.

Low  level laser therapy has minimal risks.

Encourage individuals to:

• Be patient with multiple therapy sessions
• Wear eye protection during treatment
• Do not use if diagnosed with cancer
• Do not use if wearing a pacemaker or spinal stimulator

Pacing Activities

Includes gradually increasing activity periods while balancing with periods of rest or non-painful activities.

Activity pacing that help patients overcome fear-avoidance patterns may be better than formats that have patients listening to body signs to determine when to start or stop activities.

Individuals will:

• Write down symptoms and activities in predefined short increments daily and take rest breaks
• Align rest before symptoms have had a chance to limit activities

Pacing activities may be effective for preventing the exacerbation of pain.

Risks of pacing of activities may include fatigue or frustration if pain flares. 

Encourage individuals to:

• Be proactive and patient because planning may take time
• Break down tasks and create goals
• Use a logbook or try using technology such as an app to document activity, rest, and symptoms.

Prolotherapy

Involves the injection of small amounts of sugar and/or platelet-rich plasma into the painful area to increase the growth of healthy tissue.

Multiple prolotherapy sessions may be needed with a licensed health care provider.

Prolotherapy may be effective for arthritic and back pain, fibromyalgia, and tendinopathy.

Moderate risks of prolotherapy include more pain and inflammation after the procedure.

Encourage individuals to:

• Apply heat to the treated area
• Communicate with a health provider regarding pain symptoms after the injection

Acupuncture

Is a traditional Chinese treatment where thin needles are inserted into the skin to stimulate specific points on the body. https://www.nccih.nih.gov/health/acupuncture-in-depth

Acupuncture may work by triggering the immune system to release chemicals that help decrease pain.

Acupressure

Is less invasive than acupuncture and includes the manual rubbing of the soft tissues and joints of the body, at the sites of traditional acupuncture points.

These therapies may take 6-12 sessions.

Acupuncture is effective for a variety of pain types. Acupressure may decrease muscle tension and increase circulation.

Risks of acupuncture may include bleeding or bruising, soreness at the needle insertion site or temporary exacerbation.

Encourage individuals to:

• Be proactive and patient as it may take several sessions to get the full benefit.
• Check the acupuncturist’s credentials.
• Combine with other therapies
• Monitor the skin

Movement-based mind body interventions

Yoga, Tai chi, Qigong

Incorporate parts of slow, controlled  physical motion, stretching,  physical posture, breathing exercises, and meditation.

Movement-based mind body interventions may be effective for balance, reduction of arthritis back and neck pain, migraines, fibromyalgia pain, general pain intensity and improve physical and emotional function. 

Risks of movement-based mind body interventions may include injury from strains or sprains. Serious injuries are rare.

Encourage individuals to:

• Seek provider approval first
• Wear comfortable clothing and breathe
• When beginning, practice these therapies under the guidance of a qualified instructor
• Do not try advanced movements alone
• Seek modifications for movements based on physical ability

Diet, Nutrition, and Nutritional Supplements

• Protein rich foods or supplements include amino acids which help  decrease inflammation. Many chemicals that help control pain are created from amino acids.
• The intake of foods with Magnesium, Omega 3 Fatty acids may help reduce inflammation
• The intake of Vitamin D helps with cell growth, inflammation reduction, and maintains bones.
• Herbals such as Ginger and Curcumin

Several nutrients and help reduce inflammation which contributes to pain symptoms.

Herbals may help with pain due to a decrease in muscle mass. 

Risks of dietary and nutritional supplements may include interactions with medications.

Encourage individuals to:

• Try to incorporate nutrient dense foods into a well-balanced diet
• Be aware of costs because non-drug therapies can be expensive and not readily accessible
• Be aware of side effects
• Consult a pharmacist or registered dietitian to help evaluate the costs, benefits, and relative risks before using any supplementation
• Have a health provider check  blood Vitamin D level and recommend dosage 
• Read labels and be consistent with the supplement brand

Spirituality

An individual experience that can be connected to religious beliefs. Practices depend on culture and can include prayer or communion with a higher being, use of oil, songs, reciting spiritual readings, or meditations.  Spirituality can provide encouragement and distraction.

Spirituality may be effective for coping, provide strength, and comfort for individuals in pain and experiencing pain-related symptoms.

Spirituality has minimal risks, however if pain is viewed as a punishment from a higher power, a negative response could occur and cause fear , anger, or disconnection.

Encourage individuals to:

• Keep spiritual items nearby
• Have a list of individuals who can assist with spiritual practices if needed.

Topical local anesthetic

Work by blocking pain transduction in nerve endings.

Common names:

• Lidocaine, Lidoderm,  Xylocaine jelly

Available as a spray, cream, gel, or patch.

Topical local anesthetics may be effective for neuropathic/nerve pain and have lower rates of systemic side effects.

Risks of topical local anesthetics may include skin irritation.

Encourage individuals to:

• Use care while applying cream, gel, and patches
• Wash hands and do not touch eyes, nose, or mouth
• Do not put on irritated skin
•  Keep out of reach of children
• Use caution when disposing patches

Topical NSAID

Common names:

• Voltaren Gel, Flector Patch, and Actron

Topical NSAIDs may be effective for mild muscle and joint pain and have lower rates of systemic side effects.

Risks of topical NSAIDs may include kidney, liver, and GI problems.

Encourage individuals to:

• Try topical NSAIDs before trying oral NSAIDS.
• Use care while applying cream, gel, and patches
• Wash hands and do not touch eyes, nose, or mouth
• Do not put on irritated skin
•  Keep out of reach of children
• Use caution when disposing patches

Topical rubefacients

Works by increasing blood circulation to the painful area. Contain salicylate (a component of aspirin), menthol, and nicotinate.

Common names:

• Tiger balm, Blue Emu, Aspercream, Biofreeze, Bengay, Myoflex, Icy-Hot, Flexeril.

Available as medicinal or herbal creams or gels

Topical rubefacients may be effective for mild muscle and joint pain.

Risks of topical rubefacients may include salicylate toxicity with repeated applications over large areas. May cause burning, itching, stinging, and redness at the application site.

Encourage individuals to:

• Use care while applying cream, and gels
• Wash hands and do not touch eyes, nose, or mouth
• Do not put on irritated skin
•  Keep out of reach of children
• Use caution when disposing patches
• Apply to area after activity or shower.

Capsaicin

Capsaicin is derived from chili peppers.

Works by reducing a chemical that sends pain signals to the brain.

Common names:

• Capzasin or Salonpas

Available without a prescription (0.025-0.1% concentration) as a gel, cream, and patch

High potency Capsaicin (8%) is available only by prescription and applied in clinical settings.

Capsaicin may be effective for mild to moderate joint pain and peripheral nerve pain.

Risks of Capsaicin may include burning, itching, stinging, and redness at the application site. Creams or gels must be applied 3-4 times a day.

Encourage individuals to:

• Use care while applying cream
• Try applying thin layer with a cotton ball or use gloves
• Wash hands and do not touch eyes, nose, or mouth
• Do not put on irritated skin
• Do not cover or apply additional heat to the area
• Keep out of reach of children
• Use caution when disposing patches
• Apply to area after activity or shower
• Remember it may take a few weeks of use to help and for initial burning to stop
•  Document how long it takes to be effective.

Acetaminophen

May work by blocking neuro-inflammation and pain signals in the central nervous system.

Common names:

• Acetaminophen, Extra Strength Tylenol, Tylenol Arthritis

Do not take or use more than 3000mg – 4,000 per day as instructed, from all sources.

Acetaminophen may be effective for many types of mild to moderate pain. This medication can enhance the effects of many other analgesics.

Risks of acetaminophen may include liver damage with high doses, especially with liver comorbidity, fasting or dehydration, alcohol, or tobacco use

Encourage individuals to:

• Consider acetaminophen as the first choice for mild-moderate pain
• Start with a low dose and then increase
• Reduce dose if pain is not better at higher doses
• Consult health care provider and pharmacist about use for potential drug interactions and dosing guidance, especially with kidney or liver disease.
• Read labels of all medications to identify hidden sources of acetaminophen (e.g., cough, cold/flu, other pain medications)

Alcohol combined with acetaminophen can create or worsen liver damage

Cannabinoids

Cannabidiol is commonly known as CBD.

• CBD is a chemical found in cannabis (e.g., marijuana, hemp).
• Hemp derived CBD generally contains < 1% of the psychoactive tetrahydrocannabinol (THC) found in medical cannabis.
• CBD is not FDA approved for pain
• Products sold in states where it is legal have varying amounts of CBD and THC are available as topicals, sprays, oils, beverages, edibles etc. 
• CBD is available in prescription form (Epidolex^TM) for seizures but is sometimes prescribed “off-label” for pain.  

CBD may reduce inflammation, pain, cancer-related pain, and neuropathic pain associated with multiple sclerosis.

CBD may have moderate risks including sedation, sleep disturbance, infection, anemia, and the potential for drug-drug interactions.

The risk for adverse events is associated with the dose of CBD consumed and the presence of THC.

Encourage individuals to:

• Consult health provider before and during use
• Read labels and watch for inconsistencies
• Use with caution and according to instructions
• Do not take or use more than the dosage
• Do not take more if an effect is not felt
• Use caution if older than 50 and using products that contain THC

CBD and THC is not approved for pain by the FDA in the US.