Nonpharmacologic

Management of Pain
Scott F. Nadler, DO

Pain is a complex phenomenon with various causes and issues associated with
its occurrence. This complexity is especially true for those who have chronic pain.
In light of the multifactorial nature of this problem, the treatment plan has to
be individualized for each patient. The nonpharmacologic management of
pain is the focus of this review article with an attempt to substantiate the individual components through the peer-reviewed medical literature. Strategies that
have support in patients with chronic pain include the use of manipulation and
mobilization, exercise, and psychological intervention; bed rest, bracing, and
therapeutic modalities have not been validated in this patient population. The
active use of heat modalities through a wearable wrap that allows patients to
remain active during treatment has demonstrated efficacy in patients with
acute pain and may be beneficial in patients with chronic pain, as well. The
goal of treatment may not necessarily be to cure pain, but to manage it and
restore functionality.

cute pain is the normal physiologic

response to a noxious chemical,
thermal, or mechanical stimulus, and it
usually is time limited. Chronic pain,
however, is a state in which pain persists
beyond the usual course of the disease
and may cause intermittent or continuous pain for months or years. The limited objective findings encountered in
Correspondence to Scott F. Nadler, DO, Professor,
University of Medicine and Dentistry of New
JerseyNew Jersey Medical School, 90 Bergen St,
Suite 3100, Newark, NJ 07003-2425.
Dr Nadler is a consultant to Procter & Gamble.
E-mail: Sfnadler@cs.com

the patient with pain makes quantification of the pain response difficult. These
issues make it especially difficult to validate the level of pain between different
patients with the same disease process.
This article approaches the treatment
regimen for patients with pain from a
nonpharmacologic perspective, focusing
on the literature dealing with nonpharmacologic treatment modalities for neck
and low back pain (Figure). It is hoped
that readers will be able to use the evidence presented to enhance their ability
to treat these difficult patients.

Bed Rest
This continuing medical education
publication supported by an unrestricted
educational grant from Merck & Co

The use of prolonged bed rest in the treatment of patients with neck and low back
pain and associated disorders is without
any significant scientific merit. Bed rest

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supports immobilization with its deleterious effects on bone, connective tissue,

muscle, and psychosocial well-being. For
severe radicular symptoms, limited bed
rest of less than 48 hours may be beneficial to allow for reduction of significant
muscle spasm brought on with upright
activity. Patients should be instructed to
avoid resting with the head in a hyperflexed or extended position. The proactive approach emphasizes activity modification as opposed to bed rest and
immobilization.
Two days of bed rest is commonly
cited as the appropriate duration for the
individual with low back pain, and
though no literature exists to support the
use of bed rest in neck pain disorders,
48 hours would be considered the
window for bed rest in individuals with
these conditions, as well.1 Elimination of
bed rest has not been found to be detrimental to individuals with nonspecific
neck or low back pain, and avoidance of
such confinement may help to limit the
unwanted side effects of the immobilization syndrome. It is suggested to
avoid or limit bed rest with modification
of activity as the ideal approach.

Bracing
Immobilization has been used for thousands of years to treat injuries to the
human body. Unfortunately, immobilization may lead to deleterious effects
that may compromise treatment outcome, such as muscle fiber atrophy,
decreased proprioception, and loss of
cervical and lumbar range of motion
(ROM).2 This loss may be a clinically significant problem in an individual who
already has compromised muscle function. McPartland et al2 demonstrated
atrophy of the suboccipital muscles along
with fatty infiltration in patients with
chronic neck pain as compared with
healthy control subjects.
In acute neck pain secondary to
whiplash injury, Gennis et al3 demonstrated no advantage of a cervical collar
in the treatment of patients with soft
tissue injury with respect to the duration
or degree of persistent pain as compared
with matched control subjects treated
without use of a cervical collar.
In regard to the treatment of patients
with cervical radiculopathy, Persson et al4
Nadler Nonpharmacologic Management of Pain

demonstrated no significant advantage of

a cervical collar over surgery or physiotherapy in the treatment of patients with
chronic cervical radiculopathy. A cervical collar may be useful in the initial
48 to 72 hours after injury, especially in
the face of neurologic compromise.
Nothing exists to support continued use
of cervical immobilization after this
period of time.
Existing literature has failed to
demonstrate the efficacy of lumbar
bracing as a means to prevent low back
injury in the workplace.5 In addition,
lumbar bracing appears to not enhance
dynamic lifting capacity, nor improve
lumbosacral biomechanics.5 In fact,
lumbar supports have not afforded more
protection than a proper lift without
the support.6-8 There may be a role after
injury for the use of lumbar braces
to prevent re-injury. This role has not
clearly been established in the medical
literature and probably is helpful as
a proprioceptive reminder to use
proper spine mechanics with lifting and
bending activities.

Manipulation and Mobilization

Manipulative treatment is commonly
used in the treatment of patients with
neck pain and associated disorders.
Many different types of manual treatment exist, including soft tissue myofascial release, muscle energy/contractrelax, and high-velocity low-amplitude
manipulation. Soft tissue myofascial
release may include various techniques,
including effleurage, ptrissage, friction,
and tapotement. It has been shown to
improve flexibility, decrease the perception of pain, and decrease the levels
of stress hormones.9-11
Cherkin et al12 demonstrated massage to be as effective as patient selfdirected education and more effective
than acupuncture. Mealy et al13 demonstrated that patients receiving mobilizing
physical therapy showed significant
improvements in cervical movement and
pain 8 weeks after the accident compared
with a group receiving the standard treatment of rest and a cervical collar.
Soft tissue myofascial technique may
be useful in addressing myofascial restriction and should be considered an adjunct
to exercise and postural training. Muscle
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Checklist

Bed rest
Bracing
Manipulation and mobilization
Traction
Therapeutic modalities
Transcutaneous electrical
nerve stimulation
Electrical stimulation
Ultrasound
Superficial heat
Cryotherapy
Exercise
Education
Psychological intervention
Infectious arthritis

Figure. Nonpharmacologic modalities for

the management of pain.

energy techniques or patient-assisted

mobilization requires the patient to resist
movement taking into account the four
planes of cervical motion. The desired
response is improvement of motion
restriction. Although no controlled trials
have been done regarding patient-activated techniques, this low-risk, patientcontrolled technique has potential advantage over more passive manipulative
techniques.
High-velocity, low-amplitude
manipulative technique is a component
of both osteopathic and chiropractic
manipulative treatment. Only highly
trained practitioners should administer
this technique and only after conducting
a careful history and a thorough physical
examination. Severe complications have
been reported with these techniques,
including stroke and spinal cord injury
and have been mainly attributed to poor
patient selection, inadequate training,
and treatment with the patients neck
in the extended plane.14,15 Despite these
complications, the relative risk is low
when taking into consideration the
limited number of complications despite
the millions of treatment sessions
done yearly.
Qualified personnel have also supported a limited course of manipulative

treatment as part of the consensus-based

recommendation of the Quebec Task
Force on Whiplash-Associated Disorders.16 Jette and Jette17 demonstrated in
the treatment of 358 subjects with neck
disability that treatment with mobilization and manipulation was associated
with better outcome in health perceptions and decreased disability on the neck
disability index. Hurwitz et al,18 in a
meta-analysis of manipulation and mobilization for neck pain, demonstrated that
in two of three controlled trials that shortterm benefit was achieved using cervical
mobilization for acute neck pain. No
research into the number of sessions, frequency, and duration of manipulative
treatment esixts.
The initial manipulation prescription may be administered in conjunction
with an exercise program for the first
two weeks of treatment. Patient-activated
treatment, termed muscle energy, can be
incorporated at a frequency of up to two
to three times per week and should be in
conjunction with an active exercise program during the first month, as patient
activation may be considered part of a
strengthening program. Regularly scheduled follow-up visits are necessary to
monitor for change in symptoms or
physical examination findings (or both).
Clearcut goals of treatment should
be established at the onset of treatment.
A lack of improvement after three to four
treatment sessions should result in a discontinuation of manipulation and a
reassessment. Manual medicine treatment may thus be incorporated into the
initial treatment of patients with acute
neck pain to facilitate the patients active
exercise program and should not be considered a stand-alone treatment strategy.
Manipulation and mobilization have
gained support in the treatment of
patients with acute low back pain.19
Although several studies have demonstrated the efficacy of manipulation and
soft tissue mobilization in the treatment
of patients with acute low back pain,
some have not been found to be effective.20-23 The current literature is confounded by poor study design, execution, and poorly quantifiable objective
measures. The consensus of the Agency
for Health Care Policy and Research
(AHCPR) guidelines19 was that manual

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medicine techniques can relieve acute

pain and reduce symptoms in the initial
1 to 4 weeks of treatment. Manual
medicine treatment may be incorporated
into the initial treatment of patients with
acute low back pain to facilitate the
patients active exercise program.
Treating practitioners should be
aware of the contraindications for manipulation, especially manipulation provided with the patient under general
anesthesia, which has been demonstrated
to be a high-risk practice. Although superior patient satisfaction levels have been
demonstrated among those patients
receiving manipulation-based care, no
support exists for maintenance treatment
once the painful episode has resolved.

Traction
Cervical traction is a therapeutic modality
that can be administered with the patient
in the supine or seated position. Traction may reduce neck pain and works
through a number of mechanisms
including passive stretching of myofascial
elements, gapping of facet joints,
improving neural foraminal opening,
and reducing cervical disc herniation.24-27
It has been found to reduce radicular
symptoms in individuals with confirmed
radiculopathy and localized neck pain
in individuals with cervicogenic pain
and spondylosis.25-27 Cervical traction
may be initiated during physical therapy
with the patient properly instructed in
home use. It is not a stand-alone treatment modality and should be done in
conjunction with range-of-motion (ROM)
exercises, appropriate strengthening, and
correction of postural issues.
The use of lumbar traction has long
been a preferred method of treating
patients with lumbar disc problems. It
requires approximately 1.5 times body
weight to develop distraction of the vertebral bodies. This can be cumbersome
and time consuming as well as difficult
for most patients to tolerate. At the present time, no evidence exists in the peerreviewed literature to support this form
of treatment. No significant difference in
outcome has been demonstrated with
traction versus sham traction, with the
group treated with traction having
greater morbidity.28 Given the effectiveness of more active treatment, traction

is generally not recommended in

the treatment of patients with acute low
back pain.

Therapeutic Modalities
Therapeutic modalities should be considered an adjunct to an active treatment
program in the management of acute
low back pain. They should never be
used as the sole method of treatment.
The prescribing physician should first
be aware of all indications and contraindications for a prescribed modality
and have a clear understanding of each
modality and its level of tissue penetration.
The goals of treatment should be
clear to the patient and the treating therapist from the onset of treatment. Patients
are done an injustice when a therapeutic
physical therapy program is modality
intensive as opposed to exercise based.
Jette and Jette17 demonstrated a poor
functional outcome in patients treated
with a passive, modality-intensive program compared with patients in an exercise-based program.
If at all possible, patients should be
instructed in the use of simple modalities
at home before their physical therapy sessions and in conjunction with their home
exercise program. Overall, research to
support the sustained use of therapeutic
modalities in the treatment of neck pain is
limited. According to the Quebec Task
Force on Whiplash-Associated Disorders,16 modalities such as ice, moist heat,
ultrasound, and massage are supported as
optional adjuncts only in the first 3 weeks
of treatment. Continued use of therapeutic
modalities thereafter in isolation would
not be scientifically supported.

Transcutaneous Electrical
Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) has been used to treat
patients with various pain conditions,
including neck and low back pain. Success may be dictated by many factors,
including electrode placement, chronicity
of the problem, and previous modes of
treatment.29 TENS is generally used in
chronic pain conditions and not indicated in the initial management of acute
cervical or lumbar spine pain.30-32 Overall,
research is limited in regard to the iso-

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lated use of TENS in the treatment of

patients with acute cervical and lumbar
spine disorders, though it has been used
in combination with ROM exercises,
spray and stretch, and myofascial
release.33
TENS should not be initiated until
an adequate trial of pharmacologic intervention has been attempted to reduce
pain. TENS can be costly and compliance with treatment is questionable.34
When TENS is used, documentation of
greater than 50% reduction in pain with
a treatment trial may help substantiate its
true beneficial effects as opposed to a
placebo response.35

Electrical Stimulation
High-voltage pulsed galvanic stimulation has been used in acute neck pain to
reduce muscle spasm and soft tissue
edema. It is commonly used despite the
lack of hard scientific evidence for its efficacy. Its effect on muscle spasm and pain
is thought to occur by its counterirritant
effect on nerve conduction and a reduction in muscle contractility. Use of electrical stimulation should be limited to
the initial stages of treatment, such as
the first week after injury, so that patients
may quickly progress to more active
treatment that includes restoration of
ROM and strengthening.32 Electrical stimulation often may be combined with ice
or heat to enhance its analgesic effects.

Ultrasound
Ultrasound is a deep-heating modality
that is most effective in heating structures such as the hip joint, which superficial heat cannot reach. It has been found
to be helpful in improving the distensibility of connective tissue which facilitates stretching.36,37 It is not indicated in
acute inflammatory conditions where it
may serve to exacerbate the inflammatory response and typically provides only
short-term benefit when used in isolation. It is perhaps best used in the region
of the upper trapezius or lumbar
paraspinals to facilitate active stretching
and strengthening.
Ultrasound should not be used over
the anterolateral aspect of the neck where
the close proximity of the cervical or
brachial plexus may result in alterations
of membrane stability with potential
Nadler Nonpharmacologic Management of Pain

harm to the patient. In addition, ultrasound is contraindicated over a previous

laminectomy where similar effects may
occur. It should be discontinued as
motion is improved, with progression
into a more active stretching, strengthening, and home exercise program.37

Superficial Heat
Superficial heat can produce heating
effects at a depth limited to between 1
cm and 2 cm. Deeper tissues are generally not heated owing to the thermal
insulation of subcutaneous fat and the
increased cutaneous blood flow that dissipates heat. It has been found to be
helpful in diminishing pain and
decreasing local muscle spasm. Superficial heat, such as the hydrocollator pack,
should be used as an adjunct to facilitate
an active exercise program. It is most
often used during the acute phases of
treatment when the reduction of pain
and inflammation are the primary goals.
Jette and Jette17 demonstrated a significantly poorer outcome in subjects with
neck pain treated with heat and cold
modalities as compared with active exercise-based treatment. The reason for this
phenomenon may be linked to the need
for relative immobilization during therapeutic modality use without active exercise-based treatment.38,39
Continuous low-level heat therapy
is a new concept in superficial heat treatment that allows for active as compared
with passive use of therapeutic heat. It
has demonstrated effectiveness in
reducing pain, decreasing muscle stiffness, improving flexibility, and
decreasing disability.40 If this therapy is
beneficial, patients should be educated on
the use of the heatwrap and apply it on
a home basis before their therapy or
home exercise program.

Cryotherapy
Cryotherapy can be achieved through
the use of ice, ice packs, or continuously
via adjustable cuffs attached to cold water
dispensers. Intramuscular temperatures
can be reduced by between 3C and 7C,
which functions to reduce local
metabolism, inflammation, and pain.
Cryotherapy works by decreasing nerve
conduction velocity, termed cold-induced
neuropraxia, along pain fibers with a
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reduction of the muscle spindle activity

responsible for mediating local muscle
tone.41,42 It is usually most effective in
the acute phase of treatment, though it
can be used by patients after their physical therapy sessions or their home exercise program to reduce pain and the
inflammatory response.
Cryotherapy is applied over a region
for 15 to 20 minutes, three or four times
per day initially and then on an asneeded basis. Peripheral nerve injury
and local frostbite secondary to prolonged cryotherapy has been described;
therefore, cryotherapy should not be
directly applied over peripheral nerves or
the skin for sustained periods unmonitored.43-47

Exercise
Correction of posture may be the simplest technique to relieve symptoms in
patients with nonspecific neck or low
back pain, though it is extremely difficult to change habits. The physician
should instruct patients to assume their
worst postural slump position with
forward protrusion of the head, flexion of
the neck, rounding of the shoulders, and
increased thoracic kyphosis and reversed
lumbar lordosis while sitting. Next, the
physician should instruct patients to correct these postural abnormalities through
retraction and extension of the head,
retraction of the shoulders, extension of
the thoracic spine, and return of the
lumbar lordosis.
Pearson et al48 demonstrated in a
trial of repeated neck retractions that
ROM was not affected, but resting posture was significantly improved. Black
et al49 demonstrated the effects of sitting
posture on neck positioning with
increased lumbar kyphosis resulting in
neck extension, whereas sitting erect
resulted in relative neck flexion. Postural
exercises with neck retractions and correction of lumbar lordosis would therefore be considered an early strategy to
obtain functional recovery. Range of
motion exercises should be done in a
pain-free range in all four planes of
motion (flexion/extension, sidebending,
and rotation) on a daily basis.
In conjunction with ROM exercises,
flexibility exercises should be added to
address muscles restricted by the lack of

neck motion. Although flexibility exercises have not been specifically described,
clearly stretching of the upper trapezius,
levator scapula, and scalenes (anterior,
middle, posterior) would not be deleterious in most patients with nonspecific
neck pain while stretching the quadratus
lumborum along with the deeper lumbar
musculature and may serve to improve
overall ROM and function in the lumbar
spine. Hanten et al50 demonstrated sustained stretching to be superior to active
ROM when used as part of a home exercise program.
Caution should be observed in the
case of radiculopathy and cervical
spondylotic myelopathy where extension or rotatory movements (or both) of
the cervical spine may exacerbate symptoms. Isometric strengthening of the cervical spine musculature should be appropriately done, addressing frontal, sagittal,
and transverse plane motion. Highland
et al51 demonstrated significant reductions in pain and improved isometric
strength and ROM in patients with
degenerative disc disease, herniated
discs, and cervical strains who were
placed on an 8-week program of isometric strengthening and ROM exercises.
Caution must be observed in prescribing
isometric exercises to anyone with concomitant hypertension or cardiac issues.
In such individuals, isotonic strengthening may be preferred. Compared with
individuals treated with passive modalities, individuals with disability from
neck pain had superior physical functioning with the inclusion of flexibility
and strengthening exercises.17
Jordan et al52 demonstrated in a
group of individuals with chronic neck
pain, no significant difference in outcome
between groups treated with intensive
muscle strengthening, heat or cold modalities, or manipulation at 4- and 12-month
follow-up except for a significant increase
in endurance in the group treated with
intensive strength training.52 Overall, a
comprehensive program incorporating
flexibility, ROM, and postural correction
with strengthening is clinically supported
in the treatment of patients with neck
pain and associated disorders.
In the lumbar spine, studies have
demonstrated a reduction in aerobic fitness level in patients with low back

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pain.53-55 Some raise questions as to

which is the cause and which is the effect.
Cady and colleagues study on firefighters is often cited to support the
importance of aerobic fitness in the prevention and treatment of acute low back
pain.53 Unfortunately, this study did not
measure the incidence of low back pain
but instead, analyzed on-the-job low back
injury that required missed work. The
firefighters with a lower fitness profile
had a greater number of missed work
days from low back injury. Cady et al54
did find that the firefighters with
improved aerobic fitness did have fewer
missed days from work because of low
back injury independent of age.
Aerobic exercise may also decrease
the psychological impact of low back
pain by improving mood, decreasing
depression, and increasing pain tolerance.56 Theoretically, aerobic exercise
may help to improve the bodys ability to
break down scar tissue via tissue plasminogen activator.57 Improvement of aerobic fitness is a reasonable goal in conjunction with an active exercise program
that emphasizes restoration of normal
lumbosacral motion, trunk strengthening,
and instruction in proper body
mechanics. A program of aerobic exercise
alone would be overly simplistic, unlikely
to benefit most patients, and potentially
pain provoking. Deconditioning should
be avoided at the onset by limiting bed
rest and immobilization. Patients who
are significantly deconditioned should
be instructed in the basics of aerobic exercise, including a proper warmup, cooldown, and an assessment of target exercise intensity by heart rate or rating of
perceived exertion.
Conflicting literature exists on the
efficacy of strengthening exercises in the
treatment of patients with acute and
chronic low back pain.58-61 Some of this
conflicting literature is due to poor study
design, difficulty in randomization, and
the lack of specific diagnosis in most
studies.60,61 There has also been debate
over the merits of flexion versus extension exercises for the treatment of patients
with various low back conditions.62,63
Some studies have shown that flexion
exercises are helpful in patients with posterior element dysfunction, such as
spondylolysis and spondylolisthesis.62

Others have demonstrated the efficacy

of an extension-based program in
patients with discogenic low back
pain.63,64 Unidirectional exercises by
themselves are essentially too simplistic
to address the multitude of pathophysiologic changes that occur with acute and
recurrent low back pain episodes.
Movement of the upper and lower
extremities in various planes provides a
progressive challenge while patients are
in therapy and later during their performance of work and activities of daily
living. The overall goal of this comprehensive exercise program is to reduce
pain, develop the muscular support of
the trunk and spine, and to diminish
stress to the intervertebral discs and other
static stabilizers of the spine.
Therapy sessions should be actively
directed and limited to a number that
ensures that patients have a conceptual
understanding of the entire program,
demonstrate good technique in doing
the exercises, and can do them independently at home. In addition, activity-specific training should be incorporated so
that patients are instructed to maintain a
neutral spine and dynamic muscle support of their spine in all activities of daily
living, work, and recreation. These comprehensive programs have now been
well documented, and they are commonly used in the treatment of individuals with chronic pain.61-64

Patient Education
It is essential that patients have an understanding of the likely etiology of their
pain. The education of patients should
include a review of the basic anatomy
and biomechanics of the spine and the
etiology of patients complaints. The
treatment plan should be discussed and
should include a description of recommended imaging studies, medications,
injections, and therapeutic exercise.
Physicians should review proper posture, biomechanics of the spine in activities of daily living, and simple methods
to reduce symptoms. Proper education
ensures that patients will become active
participants in their treatment as they
progress to a more comprehensive home
exercise program. Patients must be made
to understand the necessary commitment
to their program, as poor compliance

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with treatment may be a risk factor for

poor patient outcome.
Patients must be made to understand that their neck pain may not be
cured but managed and that when they
hurt, it does not mean they are always
causing themselves harm. Physicians
therefore must consider patient education an ongoing process that must be
continually refined.

Psychological Intervention
Chronic neck and low back pain in our
society is a direct result of a complex
interaction between medical and psychosocial factors. Spengler et al65 demonstrated that while up to 50% of the workforce report limitations secondary to low
back pain, only between 3% and 5% file
a workers compensation claim. Troup
et al66 demonstrated that the patients
perceived physical capacities were more
predictive of future injury than measured
capacities. A psychological assessment
may be invaluable to determine the
extent of overlay that may be having an
impact on functional recovery from an
episode of neck or low back pain.
Mannion et al67 demonstrated that
the use of psychological questionaires
such as the Modified Somatic Perception
and Zung Questionnaires were predictive of patients in whom serious back
pain was likely to develop. Pain diagrams may also be clinically useful and,
in the hands of trained personnel, may
help predict patients with nonorganic
causes of back pain.68 Early identification of psychosocial problems may be
important in understanding and possibly
preventing chronicity.69
Although many studies have
reported psychological factors noted in
patients with acute pain to ultimately
lead to chronicity, others deem them
unrelated, with stronger correlations to
job satisfaction, marital status, education,
and pending litigation.70-77 Various batteries of tests exist in the psychological
milieu and should be administered by
an appropriately trained psychiatrist or
psychologist. Overall, psychosocial factors may play a role in those patients with
neck or low back pain by altering their
response to symptoms and treatment.19

Nadler Nonpharmacologic Management of Pain

Comment
Chronic pain can be a difficult problem
to properly diagnose and treat. Physicians managing individuals with pain
must understand the anatomy and
pathophysiology of the various conditions affecting the human body as well as
the mechanism and biomechanics to support the various treatment strategies.
Physicians must use all the available
modalities, both pharmacologic and nonpharmacologic, in managing chronic
pain. They must use the existing scientific
evidence to guide the treatment program
as using unproved methods may affect
outcome. At times, thoughtful review of
the available literature provides a basis
for the use of unproved treatment
methods in those patients who are failing
to respond to approved techniques.
Considering the cost of chronic pain,
it is imperative that patients affected by
chronic pain be treated aggressively and
preferably in the acute stage when it is
easier to obtain significant results. The
goal of this article is to provide the evidence behind the nonpharmacologic
strategies of pain management to ultimately improve the care of patients who
have chronic pain.

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Nadler Nonpharmacologic Management of Pain