The term “pain control” for many people immediately brings to mind an image of pills that are taken to provide pain relief. Although medications can be effective in providing relief of pain, they should not be the first and only treatment used for pain control after orthopaedic surgery. Simple and in most cases low cost methods can be utilized to decrease pain associated with injury and surgery. Prior to beginning any treatment, discuss the risks and alternatives with your doctor.
Ice (Cold Therapy)
Cold therapy is one of the most simple and inexpensive forms of treatment for pain. Most importantly, it is highly effective. In addition to directly helping to reduce pain, it also helps to reduce swelling and inflammation. Cold therapy helps to numb the area where it is applied as well. Ice is especially helpful in the acute phase after orthopaedic injury or surgery, but can also be beneficial with chronic pain as well. Cold therapy can be accomplished in many ways from placing ice in a zip-top bag to machines that pump ice water through a device wrapped around the treatment area. It is important to take care not to place ice directly on skin and to monitor areas where cold therapy is being used, as skin sensation may be diminished after an injury/surgery, and ice left in place too long can cause irreversible damage. To avoid placing ice on the skin for too long, many people often recommend icing on a schedule of 20 minutes on, 20 minutes off, and repeating. There is no magic to the amount of time ice is in place. The bottom line is that ice helps, so you want to use it as much as you can without causing damage to the overlying skin. Ice can be used throughout the day while giving your skin frequent breaks. Ice can even help when a cast or splint are in place, but it is critical to keep the cast or splint dry when placing ice around one.
Heat
Heat, in contrast to cold therapy, does not provide as much benefit acutely after injury or surgery. Immediately after injury, heat can increase inflammation and swelling in the area of injury which could even contribute to greater pain. Heat can be very helpful, however, in dealing with chronic pain. Heat therapy can be used to relieve both pain and stiffness. Heat therapy can be achieved through heating pads, steamed towels, hot tubs, and heat pain-relieving creams. Heat therapy can be especially helpful for muscle soreness, neck and low back pain. As with cold therapy, when using heat therapy it is important to pay close attention to the condition of the skin to avoid burns, and those with diminished temperature sensation should consider not using heat therapy.
Elevation
After an injury or surgery, swelling will very often occur in the affected limb. Swelling can cause pain by increasing the pressure in the local tissues. In addition to swelling, bruising near or remote from the site of injury can occur. For example, with a fracture around the shoulder (proximal humerus), it is not uncommon to have bruising in the hand. This demonstrates that limb swelling is highly dependent on gravity. Therefore, the primary solution to swelling is to elevate the limb. In the case of the lower extremities, the toes should be higher than the knee and the knee should be higher than the heart. In the case of the upper extremities, the hand should be higher than the elbow, and the elbow higher than the heart. By elevating just higher than the heart, venous bloodflow is improved and fluid collects less in the extremity. Depending on the type of surgery or injury, swelling can persist for several months, during which time elevation when possible remains helpful.
Bracing/Immobilization
Depending on the source of pain, bracing may be an excellent option for providing pain relief. For many tendon injuries, bracing providing compression, heat, and/or immobilization can help to both reduce pain acutely and to allow the tendon to heal. In the case of pain related to arthritis, bracing may help to offload pressure in portions of a joint where cartilage has deteriorated, or bracing may serve to immobilize joints and prevent painful gliding of arthritic joint surfaces across each other. Finally, in nerve disorders bracing may help relieve pressure on a nerve that is exacerbated by certain positions and therefore improve pain.
Massage
Therapeutic massage may help provide relief of pain caused by muscle soreness. It has been shown to be especially helpful in cases of headache, back, neck, and shoulder pain. Massage may improve motion in some conditions and also provide relief from tendon overuse injuries. In some instances deep tissue massage may help reduce scar tissue as well. Although not quite synonymous with therapeutic massage, a technique known as desensitization therapy can be extremely helpful in relieving pain in areas that have become hypersensitive to touch. In such cases, pain may be caused by a stimulus as little as a bedsheet touching the area. With desensitization a stimulus is provided in an attempt to ultimately reduce the hypersensitivity by helping the body to adapt and ultimately decrease the overactivity of nerves in the area contributing to the hypersensitivity. The technique involves starting with a light stimulus to the affected area and increasing the duration and intensity of the stimulus gradually until the body and involved nerves have adapted to the stimulus and pain is diminished.
Meditation
Meditation can be described as any of several techniques whereby the practitioners state of consciousness elevates to one of increased focus and awareness. Meditation can have the result of achieving intense focus on a single subject while blocking out all other subjects from the mind. Meditation can also be used to reduce stress and to provide other wellness benefits such as pain reduction. Meditation has been shown to decrease pain severity and sensitivity in patients treated with opioids for chronic low back pain (1). Unfortunately, the suggestion that meditation can help in reducing pain causes some people to think that the suggestion itself implies the pain is not real, or exaggerated. Nothing could be further from the truth and this belief causes many people to never try a treatment that can be incredibly helpful in reducing pain in their lives. In fact, using meditation as a means to control pain is an area that has been extensively researched and its benefits are backed by good science. Much like there are different types of pain pills, there are different ways of meditating to provide pain relief. There is no right or wrong way to meditate, and it is key to personalize your meditation in a manner that works best for you.
One of the simplest and most basic techniques that can be used to help with pain is deep, steady breathing – deep inhale in through the nose and slow steady exhale out through the mouth. It is difficult to accurately convey the profound effect that conscious control over such an automatic bodily function can have at times of severe pain. I have had experiences with thousands of people (from small children to mature adults) where I have directly observed the pain from a broken bone be effectively managed with this technique alone. This is not to say that deep breathing completely resolves such pain, but it can certainly help to control it.
Intense focus on the area of the body involved with pain – and on the pain itself – is one form of meditation that can be very effective. This may seem counter-intuitive, and in fact most people look for something to distract them from their pain. An intense focus on the body area in pain, however, where all other distraction and thoughts disappear for the duration of the session can help to control pain. The pain can be thought of as a separate entity all of its own and separate from the individual. This can bring the minds interaction with the painful stimulus to a new level. One begins to take note of qualities of the pain, pinpoint locations, and fully experience the pain without trying to resist it. By doing this a better understanding can be obtained of the responses being caused by the pain, which can often help to better control these responses.
For more information on meditation and its benefits in pain control, see the following research papers:
1. Zgierska AE, et al. Mindfulness meditation and cognitive behavioral therapy intervention reduces pain severity and sensitivity in opiod-treated chronic low back pain: pilot findings from a randomized controlled trial. Pain Med. 2016 Oct; 17(10):1865-81. Full Text Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063022/
2. La Cour P, Petersen M. Effects of mindfulness meditation on chronic pain: a randomized controlled trial. Pain Med. 2015 Apr;16(4):641-52. Abstract Link: https://www.ncbi.nlm.nih.gov/pubmed/25376753
3. Gu Q, Hou JC, Fang XM. Mindfulness meditation for primary headache pain: a meta-analysis. Chin Med J (Engl). 2018 Apr 5;131(7):829-838. Full Text Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5887742/
4. Banth S, Ardebil MD. Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain. Int J Yoga. 2015 Jul-Dec;8(2):128-33. Full Text Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479890/
TENS (Transcutaneous Electrical Nerve Stimulation)
TENS is a treatment aimed at reducing pain by placing a low current through the skin. A TENS unit is a small hand-held device that can produce an electric current. Electrodes attached to the device are placed on the skin at the area of pain which then stimulates sensory nerves with a tingling sensation that is thought to “jam” the pain messages at the level of the spinal cord (known as Gate Control Theory, described by Melzack and Wall in the 1960’s). The actual mechanism that helps some people experience pain relief with use of TENS has not been definitively proven.
TENS has been reported to help in pain reduction when used appropriately for both acute and chronic pain. A randomized trial in the Journal of Shoulder and Elbow Surgery from 2017 showed lower pain scores in patients after rotator cuff repair surgery using TENS as well as decreased narcotic use when compared to placebo (1).
Reference:
1. Mahure SA, Rokito AS, Kwon YW. Transcutaneous electrical nerve stimulation for postoperative pain relief after arthroscopic rotator cuff repair: a prospective double-blinded randomized trial. J Shoulder Elbow Surg. 2017 Sep;26(9):1508-13. Abstract: https://www.ncbi.nlm.nih.gov/pubmed/28735847
Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) is a form of therapy that allows an individual with chronic pain to identify that pain in a thoughtful way, its sources, and its exacerbating factors as well as to develop skills to help manage it. CBT is meant to help in understanding challenging situations and to understand negative thoughts and reactions to those situations. It aims to give people control over their pain by teaching them ways to control these reactions through mastery of their own thoughts, emotions, and behaviors.
Much of the research into CBT and its efficacy is centered around its use for chronic pain conditions. In a two year follow-up study of a prospective randomized trial in patients with chronic low back pain the authors were able to demonstrate a sustained benefit at 2 years in functional improvement among patients undergoing CBT (1). Studies have also suggested that CBT is effective in improving pain postoperatively (2).
Further Reading on CBT:
1. Cherkin DC, et al. Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017 Feb;317(6):642-4.
2. Archer KR, et al. Cognitive-behavioral-based physical therapy for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial. J Pain 2016 Jan;17(1)76-89. Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709178/
3. Turner JA, et al. Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial. Pain 2016 Nov;157(11):2434-44. Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069124/
Guided imagery
Guided imagery is similar to meditation and CBT (both discussed above) in that it uses clinically proven methods relying on mental techniques to help treat pain. Like with other mental techniques for pain reduction, it is important to recognize that the ability to control pain through mental techniques in no way suggests that pain is not real. In fact, even pain in cancer patients receiving chemotherapy in a randomized controlled trial showed significant improvement with guided imagery (1). Guided imagery intervention turns a mental images into sensory qualities so the participant can smell, feel, taste, hear, or see what they are visualizing in order to improve overall well-being. Additionally, guided imagery has been shown to be beneficial in treating pain from arthritis (2), fibromyalgia (3), and postoperative pain (4).
References on Guided Imagery:
1. Charalambous A, et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: A randomized control trial. PLos One. 2016 Jun;11(6). Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920431/
2. Giacobbi PR Jr, et al. Guided imagery for arthritis and other rheumatic diseases: a systematic review of randomized controlled trials. Pain Manag Nurs. 2015 Oct;16(5):792-803. Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605831/
3. Zech N, et al. Efficacy, acceptability and safety of guided imagery/hypnosis in fibromyalgia – A systematic review and meta-analysis of randomized controlled trials. Eur J Pain. 2017 Feb;21(2):217-27. Abstract: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejp.933
4. Carpenter JJ, Hines SH, Lan VM. Guided imagery for pain management in postoperative orthopedic patients: an integrative literature review. J Holist Nurs. 2017 Dec;35(4):342-51. Abstract: https://www.ncbi.nlm.nih.gov/pubmed/30208778
Music therapy
Music can be used to provide pain relief and has been clinically proven to help in treating pain from many different sources. Music is found that is meaningful to the person experiencing pain and can be used to help alter the pain response. According to key findings from the American Music Therapy Association, “music therapy is a powerful and physically non-invasive medium, unique outcomes are possible when interventions are directed to reduce pain, anxiety, and depression. These outcomes appear to be mediated through the individual’s emotional, cognitive and interpersonal responsiveness to the music and/or the supportive music therapy relationship.”
Nerve block
Pain is mediated through signals sent from peripheral nerves to the spinal cord and ultimately to the brain. When that signal is altered, the sensation of pain can be diminished or removed all together. Nerve blocks serve to reduce/remove pain through the delivery of a numbing medication around a nerve or group of nerves that are involved in the pain signal. Nerve blocks are often used for perioperative pain control, and can be used for therapeutic, diagnostic, and prognostic purposes. Rebound pain can result when a nerve block wears off, especially after a surgical procedure, so additional pain control methods (such as elevation, medication, etc.) should be employed before the nerve block wears off.
It is important to note that a nerve block is an invasive procedure and can have complications. A discussion with the provider performing the nerve block should be undertaken regarding risks, benefits, and alternatives to nerve blocks.
Oral and IV pain medications
Pain medications are the first (and sometimes the only) thing many people think of when considering ways to control pain. Medications can be effective at controlling pain but can also have associated side effects. There are different types of pain medications with various mechanisms of action, and therefore some pain medications are more helpful and better suited for certain types of pain than others.
Acetaminophen is an over-the-counter (OTC) pain medication and is one of the most commonly used pain medications in the United States. As with all pain medications, Acetaminophen should never be taken in higher dosages or more frequently than directed by your physician. Acetaminophen is an excellent medication for the treatment of arthritis and is a much better option for chronic pain treatment than opiods, because unlike opiods your body does not build a tolerance to acetaminophen over time. Similarly to Acetaminophen, non-steroidal anti-inflammatory medications (NSAIDs) are also excellent treatment options for arthritis related pain, provided that medical conditions are not present that prohibit the use of these medications. NSAIDs are available with or without a prescription and work by inhibiting inflammation. NSAIDs can therefore be extremely helpful in treating conditions related to inflammation (such as tendinitis, bursitis, etc).
Tramadol is an opioid pain medication that works on receptors in the brain to block pain signals. Additional examples of opioids include oxycodone, morphine, percocet, and norco, among others. Use of opioids can lead to dependence, as well as tolerance (decreased effectiveness with chronic use). Opioids are commonly used to help control severe pain immediately following surgery, with a goal to discontinue use beyond 2 weeks after surgery in most cases.
Exercise
Although of limited benefit in the relief of acute pain, a personalized therapy program tailored to you and your specific problem can be extremely helpful in the case of chronic pain. Muscles that surround the painful body region can be trained to help relieve tension from a painful area. For example, muscles that cross a joint can provide stability and take pressure off of painful areas when trained appropriately. Additionally, muscle strengthening and training can be used to offload nearby injured or inflamed muscles. The key here is that the correct exercises (performed properly) to address specific problems must be implemented to see the benefits of exercise. The wrong types of exercise (such as running for arthritic knee pain), can be detrimental and contribute more to the underlying cause of pain, whereas the right exercises can help tremendously.
Flexibility is an important part of overall physical health as well. Pain can often be the result of muscle imbalance and tightness, causing malalignment and increased pressure in the wrong body areas. For example, hamstring tightness can be the root cause (or at least a major contributor) to some types of low back pain. A meaningful stretching program typically takes only approximately 10-15 minutes per day and is free, with no equipment necessary. Stretching can take weeks or months to see the beneficial effects, however, so unfortunately many people do not stick with it long enough to see the tremendous benefits that can be achieved.