27 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

Complimentary Care: Opportunity to Explore Non-Drug Pain 

Management 
 

AK Mohiuddin 
Assistant Professor, Department of Pharmacy, World University of Bangladesh,  

Dhaka, Bangladesh 

Email: trymohi@gmail.com 

DOI: http://doi.org/10.5281/zenodo.2605756 

 

Abstract 

Aristotle (4th century B.C.) defined pain as emotion, being the opposite of pleasure. Whereas, 

Buddha stated “Pain is the outcome of sin”, as evidence that an individual was possessed by 

demons. In some religions it is the cost of attachment. Spiritual counseling thus may be more 

of a preference than medical management. Many non-physiologic factors (psychological, 

familial and societal attitudes, life stressors, and cultural or spiritual) contributing to the 

experience of and response to pain. Emotional stress, for example, anxiety and depression 

assume a key job in understanding of agony. Endless agony is related with expanded 

dimensions of burdensome side effects, anxiety, and insomnia paying little heed to disability 

status. it has both modifiable factors (mental health, co-morbidities, smoking, alcohol, 

obesity, physical activity/exercise, sleep, nutrition, economic status and occupational) and 

non-modifiable factors (age, sex, cultural and socioeconomic background, history of trauma/ 

injury/ interpersonal violence, heritage). The relationship between increased BMI and 

chronic pain in adults seems intuitive and may be related, in part, to increased weight-

bearing on joints, reduced physical activity and deconditioning. Patient with physical 

disabilities may have co-occurring chronic pain, but the prevalence and specific associated 

factors are unknown. Neuropathic pain (NeP) can be the result of a variety of conditions, 

including metabolic disease, infection, malignancy, trauma, medications, and toxins; 

estimates of 60% among those with chronic pain. Chronic pain affects 20% of the European 

population and is commoner in women, older people, and with relative deprivation. Its 

administration in the network remains commonly unacceptable, somewhat as a result of 

absence of proof for successful intercessions. Additionally, family and guardians' convictions 

and demeanors towards torment, either decidedly and contrarily to endure and express 

torment are imperative. Hazard factors incorporate socio-demographic, clinical, 

psychological, and biological factors.  Pain increases depression risk 3-5-fold. Pain, rather 

than chronic disease, is associated with the recurrence of depressive and anxiety disorders; 

50–80% of chronic pain patients report insomnia of a severity that warrants clinical 

attention. It is estimated that approximately one in five of the adult population in Europe 

suffers chronic pain, which is therefore more prevalent than asthma or diabetes. Chronic 

pain has long-term biological, psychological and social causes and consequences that are 

important in prevention and management. 

 

Keywords: Pain, Patient, Cancer, Fibromyalgia, Osteoarthritis, Surgical Pain 

 

INTRODUCTION 

Pain is an important determinant of 

HRQoL. Unfortunately, the experience of 

pain is frequently characterized by undue 

physical, psychological, social, and 

financial suffering. Adults who reported 

experiencing a pain condition in the prior 

month were found to have greater work 

productivity loss and HRU, including HCP 

and ER visits, and hospitalizations, than 

controls. Indirect costs due to work 

impairment, early retirement, and 



 

 

 

28 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

disability appear to account for much of 

the financial burden and hospitalizations 

being the greatest factor affecting direct 

costs. Inadequately controlled intense 

postoperative torment is related with 

expanded dismalness, utilitarian and 

personal satisfaction impedance, deferred 

recuperation time, delayed span of narcotic 

use, and higher medicinal services costs. 

Traditional opioids remain the standard of 

consideration for the administration of 

intense postoperative torment; nonetheless, 

the danger of narcotic related unfavorable 

occasions can restrict ideal dosing for 

absence of pain, prompting inadequately 

controlled intense postoperative torment. 

Danger of conventional agony regulation 

with torment executioners are all around 

announced and lethal impacts and potential 

reliance of manufactured opioids are not 

totally seen yet. Deaths from overdoses of 

opioids and sedatives had extremely 

substantial increments in the United States 

somewhere in the range of 2000 and 2014, 

an example not seen before ever. 

Acclaimed big names like Bruce Lee, 

Chris Penn, Elvis Presley, Heath Ledger, 

Anna Nicole Smith passed on from 

narcotic overdose. The monetary weight of 

medicine narcotic overdose, misuse and 

reliance is assessed to be $78.5 billion 

every year in the United States. Keeping 

up spotlight on biomedical medicines, 

including drugs, has constrained 

achievement in interminable agony. In 

addition, a substantial US outpatient 

consider found that just 0.12% of 

interminable agony meetings included 

torment pros. Dynamic self-administration 

and solid way of life decisions are crucial 

to tending to multisystem unpredictability 

and bridling neuroplasticity in unending 

torment. Pain relieving pharmaceutical 

medications are generally connected with 

an assortment of unfriendly reactions, for 

example, constipation, urinary retention, 

nausea, sedation, respiratory depression, 

myoclonus, delirium, sexual dysfunction, 

and hyperalgesia. Using UROPP to 

manage postsurgical pain after discharge 

did not result in any negative health 

consequences. These instances clearly 

reveal importance of understanding current 

evidence on noninvasive no 

pharmacological treatment of chronic pain. 

Consensus guidelines recommend multi-

modal chronic pain treatment with 

increased uptake of NPMs. The challenge 

of achieving adequate pain control without 

adverse side effects further compounds the 

problem and provides rationale for seeking 

complementary medicine alternatives. 

 

 
Figure 1: Graphical Abstract 



 

 

 

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Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

Over 76 million people in the US (that is 

one in every four Americans) have 

experienced pain that lasts longer than one 

day. Millions more suffer from acute pain 

every day. According to recent statistics 

put forth by the National Institutes of 

Health, “pain affects more Americans than 

diabetes, heart disease, and cancer 

combined.” (Source: Dr. Veronique 

Desaulniers. In Pain? 7 Natural Pain 

Management Techniques to Consider. 

Web The Truth About Cancer October 5, 

2016) 

 

Highlights 

1. The costs associated with chronic pain 
incurs an annual cost of $874 billion 

by the US population. 

2. Approximately 70 to 85% of the 
western population will develop low 

back pain at least once during their 

lifetime. 

3. In France, work productivity loss 
contributed almost 90% of the total 

costs incurred by patients with 

fibromyalgia 

4. Pain killers are usually associated with 
a variety of adverse side effects, such 

as constipation, urinary retention, 

nausea, sedation, respiratory 

depression, myoclonus, delirium, 

sexual dysfunction, and hyperalgesia. 

5. The economic burden of prescription 
opioid overdose, abuse and 

dependency is estimated to be $78.5 

billion each year in the United States.   

6. Chronic pain affects 20% of the 
European population and is commoner 

in women, older people, and with 

relative deprivation. 

7. Neuropathic pain (NeP) estimates of 
60% among those with chronic pain. 

8. Asia, Africa, and Latin America are 
collectively home to more than 50% of 

cancer patients; with more than half of 

global cancer-related mortalities 

occurring in Asia alone. 

9. Cancer pain is prevalent in almost 50% 
of all cancer patients and more than 

70% of patients with advanced cancer. 

10. Postoperative pain is not adequately 
managed in greater than 80% of 

patients in the US. 

11. The economic burden of migraine in 
the United States was $36 billion in 

2016. 

12. Mild -to-moderate pain may be 
relieved by non-drug techniques alone. 

Moderate- to-severe pain may require 

medication in addition to nondrug 

techniques 

13. Non-drug techniques can decrease pain 
intensity and can decrease awareness 

of pain to enable better coping some 

have been proven to work 

14. Public and private insurers have not 
yet widely adopted payor policies that 

are consistent with the ACP guideline, 

National Pain Strategy, and reported 

patient preference 

15. It has been estimated that 12.5% of 
men and 5.2% of women who aged 

74–84 years had Abdominal Aortic 

Aneurysm (AAA).  Furthermore, 

evidence has revealed that 

approximately 11,000 deaths were 

attributed to AAA each year in the 

United States. 

16. Chronic Postsurgical Pain (CPSP) 
reported 50%–85% following limb 

amputation, 11%–57% following 

mastectomy, 30%–55% after cardiac 

surgery, 5%–65% after thoracotomy, 

and 5%–63% following hernia repair. 

17. Companion of choice at birth increases 
the likelihood of vaginal births, 

reduces the need for caesarean 

sections, the use of forceps or vacuum 

during vaginal births, need to use pain 

medications during labor, shortens the 

duration of labor, improves women’s 

satisfaction with care and improves 

Apgar scores. 

18. An 8-week moderate intensity aerobic 
exercise at 40%–60% of heart rate 

reserve combined with conventional 

physiotherapy, significantly reduced 

nearly 50% Non-Specific Chronic Low 

Back Pain (NSCLBP). 



 

 

 

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Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

19.  Of those who suffer from Hemiplegic 
Shoulder Pain (HSP), up to 75% report 

moderate to severe pain with a third 

refractory to available treatments. 

20. TENS as an adjunct is effective in 
reducing lower limb spasticity when 

applied for more than 30 minutes over 

nerve or muscle belly in chronic stroke 

survivors. 

21. Although acupuncture is widely used 
to manage chronic pain, it remains 

highly controversial, largely due to the 

lack of a clear mechanism. 

22. Physical therapy should strongly be 
considered for the management of 

chronic pain to gradually increase 

flexibility and strength. 

23. Despite a number of reports and 
reviews supporting efficacy of yoga in 

health care, the awareness and 

integration of yoga in conventional 

healthcare remain limited. 

24. An 8-week yoga intervention resulted 
in improvement in pain and quality of 

life scores compared to the control 

group that was treated with NSAIDs. 

25. Modern medical system suggests 
Complementary and Alternative 

Medicine (CAM) and 

pharmacotherapy together, instead of 

long-term use of pain killers alone.

 

 
Figure 2: Pain Cycle 

 

When a person gets injured, the common 

response to pain is to guard their muscles. 

Over time, however, that guarding pattern, 

combined with fear, interferes with 

mobility—and when the patient reduces 

mobility, that in turn can cause more pain 

leading to increased lack of mobility, often 

including anger, frustration, and a sense of 

helplessness—truly a vicious cycle. Early 

intervention is really the key to prevent the 

onset of the cycle of chronic pain. If an 

injury is sustained—perhaps from a fall—

and it still hurts a week after the event, 

certainly it should be assessed. It may, as 

the result of this assessment, 

recommended a course of treatment, or 

refer the patient to a massage therapist, a 

physical therapist, or an orthopedic 

surgeon or neurosurgeon, depending on 

the type and severity of the injury (Source: 

Duncan CA. The Goal: Break the Chronic 

Pain Cycle. Web Health & Healing 

Online) 

 

Prevalence and Economic Burden of 

Chronic Pain 
Over 100 million Americans are living 
with chronic pain, and pain is the most 
common reason that patients seek medical 
attention [279]. In France, work 
productivity loss contributed almost 90% 



 

 

 

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Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

of the total costs incurred by patients with 
fibromyalgia [187]. Chronic 
uncomplicated neck pain, back pain, and 
lower back pain, with incidences of 18%, 
17.7% and 36%, respectively [268]. In a 
Canadian study of patients waiting for 
multidisciplinary pain treatment, direct and 
indirect costs were CAN$1,462 with time 
costs accounting for 84% of overall total 
costs [188]. The US spent 17.8% of it ' s 
GDP on healthcare in 2015, expected to 
increase to 20% or higher by 2025 
[189,190]. The direct and indirect costs 
associated with chronic pain from any 
cause in the USA are estimated to range 
from US$560 to US$635 billion yearly, 
which is almost twice as much as for 
cardiovascular diseases or cancer [188]. 
However, it affects nearly 1 of 2 adults and 
incurs an annual cost of $874 billion, 
found in another study [273]. These cost 
estimates are proportionally similar to 
those of European countries such as 
Ireland (€5.34 billion per year) and 
Sweden (€32 billion per year). 
Approximately 70 to 85% of the western 
population will develop LBP at least once 
during their lifetime. Of the people that 
consult their general practitioner for low 
back pain, one year later about 60% still 
report pain [191]. More than 50% pregnant 
women suffer from LBP during their 
pregnancy and such incidence has been 
reported as nearly 80%. Such painful 
condition can result in a long-term pain 
and disability after the delivery [192-194]. 
Pain is a common complication after SCI 
with prevalence of 18 to 96%, and almost 
30% of this pain are diagnosed as 
neuropathic pain. The intensity of the pain 
varies amongst these patients and it has 
been reported that 77.7% of patients with 
spinal cord injuries have moderate to 
severe pain [214]. Asia, Africa, and Latin 
America are collectively home to more 
than 50% of cancer patients; with more 
than half of global cancer-related 
mortalities occurring in Asia alone [195]. 
Studies have shown that at least 20–40% 
of cancer pain was not adequately relieved 
by application of the analgesic ladder 

[258]. Endometriosis-associated pain 
(EAP) has been reported that about 6% to 
10% women (Manifested as 
dysmenorrhea, non-menstrual pelvic pain, 
and dyspareunia) [186]. Cancer pain is 
prevalent in almost 50% of all cancer 
patients and more than 70% of patients 
with advanced cancer. About half of 
patients suffer with advanced cancer 
experience moderate-to-severe pain, while 
almost a quarter of patients suffer with 
more severe pain [195]. Pain is also 
associated with cancer treatment with 
more than 25% of patients enduring 
moderate-to-severe pain during treatment 
[196]. Postoperative pain is not adequately 
managed in greater than 80% of patients in 
the US, although rates vary depending on 
such factors as type of surgery performed, 
analgesic/anesthetic intervention used, and 
time elapsed after surgery [197]. Chronic 
orchialgia is defined as testicular pain, 
which may be either unilateral or bilateral, 
lasting for more than 3 months It is 
estimated that 25% of chronic orchialgia 
cases are idiopathic [218]. Migraine is now 
ranked as the second most disabling 
disorder worldwide reported by the Global 
Burden of Disease Study 2016 [227]. The 
prevalence and burden of self-reported 
migraine and severe headache in the US 
adult population is high, affecting roughly 
1 out of every 6 American and 20% 
women over a 3-month period. Headache 
is consistently the fourth or fifth most 
common reason for visits to the emergency 
department, accounting for roughly 3% of 
all ED visits annually. In reproductive 
aged women, headache is the third leading 
cause of emergency department visits 
[228]. The economic burden of migraine in 
the United States is substantial. In 2016, 
these direct and indirect costs amounted to 
an estimated total annual cost of $36 
billion [229]. The incidence rate of MM is 
three times higher in more developed 
countries compared to less-developed 
countries. The bone tissue destruction in 
MM results in bone pain, pathological 
fractures, and less frequently spinal cord 
compression [283]. 

 



 

 

 

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Journal of Pharmacological Research and Developments 

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Exhibit 1: Pathophysiologic Consequences of Unrelieved Pain [137-142] 
Immune system Decreased natural killer cell number, function and activity. Can lead to death. 

Pulmonary system Reflex muscle spasm leads to splinting which decreases pulmonary vital capacity, 

functional residual capacity, alveolar ventilation.  Leads to atelectasis, which often is 

followed by pneumonia and hypoxemia. 

GI system Increased sympathetic activity, which increases GI secretions and smooth muscle 

sphincter tone decreases intestinal motility. Leads to gastric stasis and paralytic ileus. 

CVS Sympathetic over activity which increases heart rate (decreased O2 to heart), peripheral 

resistance, BP, cardiac output, and O2 use.  Leads to hypoxemia and ischemia, especially 

of the heart and peripheral tissues.    

Musculoskeletal 

system 

Segmental and supra segmental reflexes with increased muscle spasm leads to impaired 
muscle metabolism and to muscle atrophy.     

Psychologic 

consequences 

Anxiety, fear, depression, distress, and suffering, hopelessness, helplessness and a 

decreased will to live (wish for assisted suicide or euthanasia). 

Neuronal 

plasticity 

Primary and secondary hyperalgesia with enabled NMDA receptors and aberrant 

communication of neurons in the peripheral and central nervous system. 

 

 
Figure 3: Pain and disability driver management model 

 

(A) refers to more common and/or 

modifiable elements; (B) refers to 

elements that are more complex and less 

modifiable, and that will prompt more 

aggressive or require interdisciplinary care 

to effectively address the problematic 

domain. Abbreviations: RTW, return to 

work; MSK, musculoskeletal. Patients 

present with certain physical and/or mental 

health comorbidities that can influence 

other domains driving symptom severity 

and disability. Musculoskeletal conditions 

such as low back pain, joint pain, arthritis, 

and rheumatism are the leading causes of 

disability in people during their working 

years. Notwithstanding its importance as a 

personal and clinical issue, chronic pain 

has turned into a sociopolitical and 

financial issue for open and private 

disability safety net providers. In spite of 

the fact that the expenses to debilitated 

people of their decreased prosperity can't 

be precisely estimated, disability program 

consumptions can be evaluated. There are 

numerous projects and arrangements to 

serve handicapped specialists. They 

contrast as far as their qualification 

criteria, the degree to which the receipt of 



 

 

 

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Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

advantages is liable to a methods test, the 

cutoff points on the dimension of market 

earnings allowed for continuation of 

benefits, and the degree to which these 

benefits are taxable (Source: Institute of 

Medicine (US) Committee on Pain, 

Disability, and Chronic Illness Behavior; 

Osterweis M, Kleinman A, Mechanic D, 

editors. Pain and Disability: Clinical, 

Behavioral, and Public Policy 

Perspectives. Washington (DC): National 

Academies Press (US); 1987. 5, Economic 

Issues and the Cost of Disability. 

Available from: 

 

https://www.ncbi.nlm.nih.gov/books/NBK

219239/?report=classic). 

 

Potential merits and misunderstandings 

of non-drug techniques 
Mild -to-moderate pain may be relieved by 

non-drug techniques alone. Moderate- to-

severe pain may require medication in 

addition to nondrug techniques [4], [11]. 

Advantages to nondrug interventions are:  

 Low cost and low risk of side effects,  
 Decrease in a patient’s unhelpful 

emotional reactions (such as anxiety, 

depression, aggressive behavior)  

 Increase in a patient’s sense of 
personal control and hope,  

 Better sleep and improved 
interpersonal relationships. 

 Increase the individual control feeling 
and decrease the feeling of weakness.   

 Improves the activity level and 
functional capacity.    

 Reduces the pain behavior and focused 
pain level.    

 Reduces the needed dosage of analgesic 
drug s thus decreasing the side effects of 

the   treatment [4], [13], [15]. 

 

 
Figure 4: Pathways and brain regions involved in the transmission and modulation of pain 

signals 
Essential afferent neurons, with their cell 
bodies in the dorsal root ganglia, or 
trigeminal ganglion (mouth and face), 
couple over to auxiliary neurons in the 
dorsal horn of the spinal line, or the spinal 

core of the trigeminal complex. The axons 
of the second request neurons cross the 
midline and task to the thalamus and an 
assortment of different focuses in the 
medulla oblongata, pons and mid mind, 



 

 

 

34 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

including the rostral ventral medulla 
(RVM) and the periaqueductal grey 
(PAG). Third request neurons, with their 
cell bodies in the thalamus, undertaking to 
the somatosensory cortex, in charge of the 
tactile discriminative viewpoints 
(intensity, location and quality) of pain, 
and to limbic cortical regions, for example, 
the front cingulate, isolated, and the 
prefrontal cortex engaged with the 
intercession of the full of 
feeling/emotional segments (aversiveness) 
of pain. Thalamic neurons additionally 
venture to the amygdala, which thus 
interfaces with the core component, a 
locale associated with both pain preparing 
and the intercession of remuneration 
inspirational conduct. These various brain 
regions also give input to the PAG, which 
via the raphe nuclei in the RVM, and to 
the locus coeruleus, send descending pain 
modulatory projections back to the first 
synapses in the afferent pathways (Source: 
Brodin E, Ernberg M, Olgart L. 
Neurobiology: General considerations - 

from acute to chronic pain. Nor 
Tannlegeforening Tid. 2016; 126: 28-33) 
While, potential demerits include not as 
well researched (a technique that works 
well for one person may not work well for 
another) [12]. Misunderstandings may 
keep patients and staff from trying the 
techniques but truth is: some patients may 
find the techniques burdensome or 
stressful, advanced techniques require 
special training (music and art therapy, 
therapeutic massage) [14]; non-drug 
techniques can decrease pain intensity and 
can decrease awareness of pain to enable 
better coping some have been proven to 
work; others are less well studied [15]. 
moderate- to-severe pain typically requires a 
combination of medication and nondrug 
therapy; hot and cold can work when applied 
to the opposite side of the body, or at a 
different site [16], enabling these techniques 
to be used when radiation therapy or open 
wounds prohibit use at the site of pain 
distraction can decrease pain and increase 
ability to cope; successful distraction does not 
mean pain is not real [17]. 

 

 
Figure 5: The fear-avoidance model 

 
Psychological variables assume a 
noteworthy job in both intense and chronic 
back pain, and in the change from intense 
to chronic pain. Psychosocial factors have 
in reality been found to have a more 
noteworthy effect than biomedical or 
biomechanical factors on back pain 
disability. Patients with a dread of the 
long-term outcomes of medical procedure 
are likewise at expanded danger of long 
haul pain and poor recuperation. 

Instructing patients and their carers about 
pain empowers an increasingly 
inspirational demeanor to pain relief5 and 
where conceivable we should endeavor to 
include patients in their pain the board 
technique. Data can give consolation that 
the sensations experienced after a system 
are typical and non-undermining. For 
instance, following an absolute knee 
substitution, patients are urged to prepare 
inside long stretches of medical procedure. 



 

 

 

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This might be awkward; however, it is 
imperative that patients are consoled that 
pain does not equivalent harm, that it is 
ordinary to encounter some uneasiness and 
it doesn't imply that they are endangering 
their task or that something isn't right. 
Through dynamic inclusion patients build 
up a more prominent feeling of self-
adequacy in regards to treatment and 
ailment related practices and might be 
bound to finish on the practitioner’s 
choices came to. Patients who react 
inactively to pain show more noteworthy 
distress and disability contrasted with the 
individuals who endeavor with tackle the 
issue. Assuming some responsibility for 
the reason for pain or the technique for 
absence of pain has a valuable impact. 
Social connections can likewise impact 
pain announcing and disability. The 
outflows of pain are fortified by the 
accomplice who acts to ease the patient's 
conduct action, and this is reflected in the 
expanded dimension of pain (Source: 
Reddi D, Curran N Chronic pain after 
surgery: pathophysiology, risk factors and 
prevention Postgraduate Medical Journal 
2014;90:222-227). 
 
 
 
Non-Drug Options of Pain management 

Unfortunately, non-pharmacological 
therapy is seldom used for acute 
postoperative pain relief, although it is 
beneficial and devoid of any significant 
adverse effects. No pharmacologic 
therapies have demonstrated benefit for 
acute pain with opioid sparing in hospital 
settings for inpatient post-operative pain 
and for acute pain not related to surgery 
[1,2]. Non-pharmacological pain 
management is the management of pain 
without medications [3]. Non-
pharmacological methods used in pain 
management can be classified in different 
ways.   In general; they are stated as 
physical, cognitive, behavioral and other 
complementary   methods   or   as   
invasive   or   -non-invasive   methods. 
This method utilizes ways to alter thoughts 
and focus concentration to better manage 
and reduce pain. Methods of non-
pharmacological pain include: 
 Education and psychological 

conditioning 
 Hypnosis 
 Comfort therapy 
 Physical and occupational therapy 
 Psychosocial therapy/counseling 
 Neurostimulation 
 Biofeedback techniques 
 Electrical stimulation 
 Meditation [1-10], [13] 

 

Exhibit 2: Selected Pain Terminology [47], [49] 
 Pain--An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or 

described in terms of such damage. 

 Pain from pathogenic/biological origin-- osteoarthritis (OA), rheumatoid arthritis (RA), systemic 
inflammatory rheumatic diseases, connective tissue diseases, post-herpetic neuralgia, and peripheral 

neuropathy, which are typically diagnosed via objective biologic or inflammatory markers, radiologic 

evidence or other identifiable tissue damage. 

 Pain from idiopathic origin, which often rely on subjective patient report, include complex regional pain 
syndrome (CRPS), fibromyalgia (FM), chronic widespread pain (CWP), subsets of chronic low back pain 

(LBP), and chronic pelvic pain (CPP). 

 Nociceptive pain—pain that arises from actual or threatened damage to nonneural tissue and is due to the 
activation of nociceptors (high threshold sensory receptors of the peripheral somatosensory nervous system 

that can transduce and encode noxious stimuli). This term, designed to contrast with neuropathic pain, is used 

to describe pain occurring with a normally functioning somatosensory nervous system as opposed to the 

abnormal function seen in neuropathic pain. 

 Inflammatory pain—pain in the presence of inflammation that is increased by pressure. 
 Dysfunctional pain—maladaptive pain, typically triggered without an external stimulus, which does not 

serve a known protective function (e.g., pain associated with fibromyalgia, irritable bowel syndrome, and 

some types of headache). 

 Neuropathic pain—pain caused by a lesion or disease of the somatosensory nervous system. Neuropathic 
pain is a clinical description (and not a diagnosis) that requires a demonstrable lesion or a disease that 

satisfies established neurological diagnostic criteria. 



 

 

 

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Clearly, public and private insurers have 

not yet widely adopted payor policies that 

are consistent with the ACP guideline, 

National Pain Strategy, and reported 

patient preference. Specifically, most 

health plans surveyed did not have policies 

in place that (1) emphasize the use of no 

pharmacological treatments at the 

forefront of the patient experience; (2) 

provide meaningful levels of coverage for 

care professionals who focus on guideline-

adherent nondrug therapies such as spinal 

manipulation, exercise, massage, 

acupuncture, and cognitive behavioral 

therapy; or (3) use financial incentives that 

favor the use of no pharmacologic options 

over commonly prescribed 

pharmaceuticals, including opioids [275].

 

 
Figure 6: Enhanced recovery for the chronic pain patients 

 

Strategies implemented preoperatively 

optimize the patient for surgery. 

Intraoperative and postoperative 

intercessions proceed a multimodal way to 

deal with pain the board. Preoperative 

advising for elective systems for the most 

part happens in the outpatient setting. 

Despite the fact that talk customarily has 

secured the sort of system and its related 

dangers, advantages, and options, new 

rules propose an increasingly careful and 

extensive methodology is justified. 

Individualized patient-focused training 

programs positively affect the perioperative 



 

 

 

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Journal of Pharmacological Research and Developments 

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course, affecting decreases in preoperative 

anxiety, narcotic prerequisites, and medical 

clinic length of remain. Prehabilitation is the 

way toward expanding practical limit before 

medical procedure so as to moderate the 

stress of the medical procedure. 

Prehabilitation may include oxygen 

consuming activity, quality preparing, or 

useful assignment preparing [Source: 

Moulder JK, Johnson KP. Enhanced recovery 

after surgery for the patient with chronic pain. 

OBG Manag. 2018 March; 30(3)] 

Exhibit 3: Cognitive–emotional drivers [278] 

Categories Operational definition and elements 

Maladaptive 

cognition 

Cognitive–emotional drivers include maladaptive cognitive strategies toward pain (ie, pain 
coping, pain catastrophizing), pain-related fears (ie, pain-related anxiety and fear, fear of 

movement), negative perception of pain/disability and expectations toward pain (ie, illness 

perception, pain self-efficacy), as well as negative mood (which is distinct from clinical 

depression). According to the fear-avoidance model, when maladaptive cognitive drivers are not 

addressed and if pain/disability persists, factors such catastrophizing, illness perceptions, 

negative emotions, and pain-related fears may lead to the development of maladaptive behaviors 

(eg, activity avoidance), which, in turn, may contribute to the maintenance of pain-related 

disability.  

Maladaptive 

behaviors 

Maladaptive behaviors can be manifested in various ways. For example, they may include 

“communicative” pain behaviors such as facial expressions (eg, grimacing or wincing) or 

verbal/paraverbal pain expressions (eg, pain words, grunts, sighs, and moans). They may also 

include “protective” or “safety” behaviors such as guarding of the back straight while lifting or 

bending/rubbing the back after performing an activity, strongly bracing before doing a 
functional task, or even completely avoiding performing a task.  

In addition to avoidance, displays of “protective/safety” behaviors (eg, guarding, holding, or 

rubbing the back) or communicative pain behaviors (eg, grimaces) have also been associated 

with heightened levels of perceived functional disability. Maladaptive behaviors are known to 

be strongly influenced by cognitive–emotional factors; their presence suggests that cognitive–

emotional drivers of pain must be assessed and addressed through behavioral or cognitive-

behavioral treatment interventions.  

They are clearly linked to enhanced pain perception, are predictors of long-term disability, and can explain the 

presence of persistent painful symptoms. As personal factors of an individual, the fourth domain relates to 

cognitive–emotional drivers, as “maladaptive cognition” (category A) and “maladaptive behaviors” (category B) 

will undeniably influence the treatment approach. 

 

Education and psychological 

conditioning 

High levels of pain, significant anxiety, or 

depressive symptoms before surgery put 

patients at elevated risk for chronic pain 

and prolonged opioid use following 

surgery [37]. Preoperative depression has 

been connected to an assortment of 

unfavorable results following lumbar 

combination, including expanded pain, 

disability, and 30-day readmission rates. 

The relationship among depression and 

narcotic utilize following lumbar 

combination is progressively applicable 

given the plague of narcotic maltreatment 

clearing the nation as of late [38]. It has 

been evaluated that 12.5% of men and 

5.2% of ladies who matured 74– 84 years 

had AAA. Moreover, proof has uncovered 

that around 11,000 deaths were ascribed to 

AAA every year in the United States. 

More than one-fourth of patients planned 

for AAA fix may have preoperative 

anxiety or depression [39]. Current 

psychological ways to deal with the 

administration of chronic pain incorporate 

intercessions that expect to accomplish 

expanded self-administration, social change, 

and intellectual change instead of 

straightforwardly wipe out the locus of pain. 

As such, they target the frequently 

overlooked behavioral, emotional, and 

cognitive components of chronic pain and 

factors contributing to its maintenance [18].

 

 



 

 

 

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Figure 7: Pre- and Post-Operative Education and Psychological Conditioning 

 

Individualized education is important for 

preparing patients for the operation both 

physically and psychologically. surgeries 

cause emotional, cognitive and 

physiological reactions in patients. 

Patients undergoing surgical intervention 

usually experience worries over 

outcomes such as becoming permanently 

disabled, loss of control over their body, 

loss of working ability, pain, loss of 

sexual ability, inability to wake up from 

anesthesia, and fear of death. Due to fear 

and anxiety, majority of patients have 

difficulty in coping with the operation 

process. Not having information about 

the diagnosis and treatment methods, 

patients may experience anxiety, 

including depression, in the pre-

operation period. Studies report that with 

individualized care and education, 

patients’ anxiety decreases and their 

satisfaction increases. The individualized 

education is given to patients before 

surgery was found to have potential 

effects on their post-operative pain levels 

(Source: Ertürk EB, Ünlü H. Effects of 

pre-operative individualized education 

on anxiety and pain severity in patients 

following open-heart surgery. Int J 

Health Sci (Qassim). 2018;12(4):26-34.).

  

Table 1: Psychological interventions in the management of patients with chronic pain 
Approaches Description 

Psychophysiological 

techniques 

Biofeedback is a learning technique through which patients learn to interpret 

feedback (in the form of physiological data) regarding certain physiological 

functions. For example, a biofeedback device may show measurements of muscle 

tension. Biofeedback may help to control pain, including chronic headaches and 

back pain [18,19]. 

Behavioral approaches 
(Relaxation Training) 

It can help reduce muscle 

tension and stress, lower 

blood pressure, and 

control pain [19].  

Diaphragmatic breathing is a basic relaxation technique lowering the harmful 

effects of the stress hormone cortisol, HR, BP and chances of injuring or wearing 

out muscles. It helps to cope with the symptoms of PTSD. It improves core muscle 

stability, body’s ability to tolerate intense exercise [20]. PMR is a systematic 

technique used to achieve a deep state of relaxation and has been shown to improve 

health-related QOL in a variety of medical and psychiatric illnesses. It is an 

effective and widely used strategy for stress relief that creates a state of deep 
relaxation by involving alternate tensing and relaxing of muscles [21,22]. 

Autogenic training (AT) combines passive concentration, visualization and deep 

breathing techniques, likely to produce specific cognitive effects such as reducing 

anxiety and enhancing positive mood. The emphasis is to not to control these 

natural healing systems, but rather to use their intrinsic potentials more fully. 

Autogenic training is the preferred mode of arousal regulation in many European 

countries [23-25]. 

Visualization/Guided imagery is one component of CBT that frequently is used 

and found effective in fibromyalgia. Imagery has been defined as a dynamic, 

psycho-physiological process in which a person imagines, and experiences, an 

internal reality in the absence of external stimuli. The guided imagery audio is 



 

 

 

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accompanied by soft background music and directs the visualization and 

imagination to a pleasant and peaceful place that has meaning for the participant to 

replace negative or stressful feelings [26, 27]. 

FAM of chronic pain is a heuristic most frequently applied in the context of non-

operative populations like chronic LBP. The FAM is a psychosocial model that 

seeks to understand the role of cognitive, behavioral, physical, and emotional 

factors in persistence of pain and disability. FAM measures have moderate 

relationships with preoperative pain and disability. Preoperative depression and 

work-related fear-avoidance beliefs were able to significantly explain the 10-week 

clinical outcome variances (leg pain, back pain, and disability) [28, 29]. 

Cognitive-behavioral 

approaches  
 

CBT interventions are delivered within a supportive and empathetic environment 

that strives to understand the patient’s pain from a bio psychosocial perspective and 
in an integrated manner, most common psychologic intervention for individuals 

with chronic pain. CBT is generally based on the “ABC” model and aims at 

changing dysfunctional thoughts, emotions, and behaviors. Additionally, CBT has 

been reported to improve quality of life and activities of daily living, chronic 

headache, facial pain, arthralgia, and fibromyalgia. Behavior modification strategies 

to effectively reduce pain and fatigue, and improve sleep, overall physical function 

and coping CBT focuses on reducing pain and distress by modifying physical 

sensations, catastrophic thinking, and maladaptive behaviors. Combining CBT 

approaches for pain and for sleep may produce greater improvements in pain and 

sleep outcomes compared to either approach in isolation.  Women benefit more 

from multimodal pain therapy including CBT-oriented group program than men. 

CBT had similar effects with fusion spine fusion surgery, but at 12 months the CBT 
group showed less fear avoidance [18], [30-35].  

Acceptance-based 

approaches 

Acceptance and commitment therapy (ACT) are the most common of the 

acceptance-based psychotherapies. ACT is a relatively newer psychological 

intervention being implemented in the chronic pain health care setting. ACT is 

based on behavioral principles and the psychological flexibility model, and unlike 

CBT, it does not emphasize the restructuring of distorted or catastrophic cognitions. 

The goal within ACT is to reduce the dominance of pain in person’s life through 

increased psychological flexibility. Unlike other approaches, ACT does not focus 

on symptom reduction – even though this can happen in ACT – but on making 

patients’ responses toward symptoms more successful in relation to their own goals. 

When used as an adjunctive therapy in pain management, ACT fosters the 

possibility of improved pain acceptance, which can have important implications for 
adaptive recovery in postsurgical patients [18], [33], [36]. 

 

Pain lasting longer than the normal healing 

process after surgery is an unwanted 

adverse event in any operation. CPSP can 

represent a severe nuisance to patients, 

leading to functional limitation and 

psychological trauma, as well as a problem 

for the operative team in the form of 

feelings of frustration and disappointment. 

Studies have reported incidences ranging 

from 50%–85% following limb 

amputation, 11%–57% following 

mastectomy, 30%–55% after cardiac 

surgery, 5%–65% after thoracotomy, and 

5%–63% following hernia repair. One 

reason for this variability is the difference 

in the time reference considered by each 

researcher for labeling pain as CPSP 

(varying from 2 months to 1 year 

postoperatively). More than a half of CPSP 

patients have neuropathic pain, the 

remainder having nociceptive (somatic or 

visceral) pain. A patient may have 

different components of pain, and these 

must be identified for effective 

management. During the preoperative and 

early postoperative period, it is very 

important to provide patient education and 

counselling about the chances of 

developing CPSP [40]. Multidisciplinary 

pain-management programs with 

psychological approaches, including CBT 

and mindfulness-based psychotherapy, 

have shown efficacy as treatments for 

chronic pain, and show promise as timely 

interventions in the pre/perioperative 

periods for the management of PSP [33]. 



 

 

 

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Exhibit 4: Evolution of behavioral psychotherapeutic approaches [31] 
 Behavioral psychotherapy 

type 

Theoretical background 

First 

wave 

Behavioral therapy Behavior analysis takes into consideration every behavior, 

including overt and covert 

The therapist focuses on specific learned behaviors and how the 

environment influences such behaviors 

Second 

wave 

Cognitive behavioral therapy CBT focuses on the development of individual strategies aimed to 

solve current problems and to change unhelpful patterns in 
cognitions (i.e., thoughts and beliefs), behaviors, and emotional 

regulation 

Third 

wave 

Acceptance and commitment 

therapy 

Dialectical behavioral 

therapy 

Integrative behavioral 

couples’ therapy 

Behavioral activation 

Cognitive behavioral analysis 

Third wave therapies prioritize the holistic promotion of health 

and well-being and are less focused on reducing psychological 

and emotional symptoms. These therapies abandon key 

assumptions associated with traditional cognitive therapy and is 

informed by emerging research in cognitive psychology and 

neuroscience. Concepts such as metacognition, acceptance, 

mindfulness, personal values, and spirituality are frequently 

incorporated into what might otherwise be considered traditional 

behavioral interventions 

 

Comfort Therapy 

Complementary therapies can increase 

comfort, decrease pain, promote relaxation 

and increase the quality of life for hospice 

patients and their families.  Therapies can 

be used individually or in combination. All 

therapies are individually tailored for each 

patient to offer unique benefits [41]. 

Comfort therapy can help improve the 

quality of life by alleviating symptoms of 

pain and providing relaxation and comfort. 

Response to treatment or therapy is 

individual and that what works for some 

might not be as effective for others [42]. 

Studies suggest that CAT enhance quality 

of care for patients nearing the end of life. 

Some types of CAT are associated with a 

lessening of symptoms, including anxiety 

and pain, and improvements in mood and 

sense of control [43]. Comfort therapy 

may involve the following: 

 

Companionship Patients with chronic 

pain from a non-supportive family tended 

to show more pain behaviors and more 

emotional distress compared with pain 

patients coming from supportive families 

[44]. Due to inadequate knowledge and 

skill, family caregivers may be unfamiliar 

with the type of care they must provide or 

the amount of care needed [45]. According 

to the Operant Conditioning Model of 

Chronic Pain, both verbal and non-verbal 

forms of communication are used to 

convey patients’ desire for support, 

attention and intimacy, and to elicit 

empathic responses from others. In turn, 

affected patients’ communication may be 

maintained by social reinforcement (e.g. 

the sympathetic response of significant 

others) [46]. WHO recommend 

intervention to improve labor outcomes 

and satisfaction. Companion of choice at 

birth increases the likelihood of vaginal 

births, therefore reduces the need for 

caesarean sections and the use of forceps 

or vacuum during vaginal births. In 

addition, it reduces the need to use pain 

medications during labor, it shortens the 

duration of labor and improves women’s 

satisfaction with care. It also improves 

Apgar scores (a measure of the physical 

condition of a newborn infant) of the 

newborns [49]. 

 

Moderate Exercise (Walk and Stretch) 
Physical activity is a well-documented, 

viable therapeutic modality for chronic 

pain conditions with beneficial effects on 

pain, sleep, cognitive function and 

physical function. Alternatively, self-

directed physical activity can be 

inexpensive, requiring minimal resources 

such as walking around one's 



 

 

 

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neighborhood and home-based programs. 

Quite uniformly, low to moderate intensity 

exercise defined as 50-60% of maximum 

heart rate (maxHR) tends to improve 

chronic pain symptoms [31], [52]. 

Exercise is effective for the management 

of chronic low back pain for up to 1 year 

after treatment and for fibromyalgia 

syndrome for up to 6 months [50]. An 8-

week moderate intensity aerobic exercise 

intervention at 40%–60% of heart rate 

reserve combined with conventional 

physiotherapy, significantly reduced 

NSCLBP by 47% [54]. Muscle soreness 

that sometimes occurs with starting a new 

exercise subsided as the participants 

adapted to the new activities [51]. 

Combined training, which included 

aerobic and resistance exercises for eight 

months, succeeded in decreasing pain from 

breast cancer [53]. Numerous helpful 

projects proposed for painful conditions 

comprise of non-intrusive treatment 

programs with preparation, and about 70% 

of outpatients and inpatients are alluded to 

active recuperation programs for painful 

conditions (primarily neck and low-back 

pain, lower-appendage osteoarthritis, 

sports wounds, all out joint substitution, 

upper-appendage musculoskeletal clutters, 

fiery joint inflammation). The exercise and 

mobilization techniques of physical 

therapy include aerobic training, specific 

muscular strength exercises, active and 

passive mobilization, and proprioceptive 

techniques [54]. Prevalence of knee OA 

increases with age, ranging from 3% 

among those aged 45–54 years old to 44% 

in those at least 80 years old. These 

prevalence estimates are expected to 

increase as the US population continues to 

age and obesity rates rise. Therapeutic 

exercise is often recommended as a first-

line conservative treatment for knee OA 

[55]. 

 

Heat/cold application: Superficial heating 

and cooling of tissues to provide pain 

relief in low to moderate levels of acute 

and chronic pain in adults [56]. 

Naturopathic non-intrusive treatment 

altogether improves foot usefulness and 

pain scores in impact point pain. Also, 

rotating packs improve foot usefulness 

scores [57]. RCTs have demonstrated that 

heat-wrap treatment gives transient 

decreases in pain and disability in patients 

with intense low back pain and gives 

fundamentally more prominent pain 

alleviation of DOMS than does cold 

treatment [58]. Cryotherapy (the utilization 

of extraordinary cold in medical procedure 

or other restorative treatment) and 

thermotherapy as remedial strategies in the 

patients with intense and chronic low back 

pain equally affected assuaging the pain 

dependent on evaluative and distinct 

measures [59]. Utilization of virus 

advances alleviation of pricking pain 

sensation and concealment of autonomic 

reactions, and that use of warmth has no 

such impact [50]. In the United States, 75 

% of patients with low back pain are 

treated with warming treatment and 7 % 

with cooling treatment. cooling treatment 

diminishes tissue blood stream because of 

vasoconstriction, and that it additionally 

lessens tissue digestion, oxygen usage, and 

irritation. Cooling treatment diminishes the 

speed of nerve conduction in shallow 

tissues by moderating the terminating of 

muscle axle afferents and reflex reactions, 

accordingly diminishing muscle fits and 

pain. Use of cooling therapy for 

musculoskeletal problems can also reduce 

intake of painkillers because it reduces 

pain and body fluid penetration [60]. Pain 

after thoracotomy is probably the most 

severe pain experienced after surgeries and 

patients who underwent cardiac surgeries 

report having most severe pain while 

coughing and deep breathing. Pain was 

significantly decreased with the use of 

cold gel packs [119]. Usually the chest 

tube removal (CTR) has been described as 

one of the worst experiences by patients in 

the intensive care unit. Regarding the 

relaxation and cold application methods 

showed relatively equal effects on 

reducing the pain owing to CTR [120]. 



 

 

 

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Figure 8: Essential oils for aromatherapy 

 

Elective treatments are habitually used to 

alleviate different indications of patients. 

They are utilized rather than standard 

therapeutic medications and elective 

treatments are particular from correlative 

drug which is intended to go with, not to 

supplant, standard restorative practices. 

Aromatherapy is usually used in 

combination with massage, can 

successfully treat pain when combined 

with conventional treatments. 

Additionally, the cost associated with 

aromatherapy is far less than the cost 

associated with standard pain management 

treatment (Source: Lakhan SE, Sheafer H, 

Tepper D. The Effectiveness of 

Aromatherapy in Reducing Pain: A 

Systematic Review and Meta-Analysis. 

Pain Res Treat. 2016; 2016:8158693). 

 

Lotions/massage therapy: Therapeutic 

massage is a CIM therapy which involved 

manipulation of the soft tissue of whole-

body areas to bring about generalized 

improvements in health [61, 62]. 

Reflexology treatment consists of massage 

of the disordered reflex zones. Massage is 

mainly used to promote relaxation, treat 

painful muscular conditions; it can also 

foster communication, including decreased 

stress (and decreased cortisol), improved 

sleep patterns, and enhanced immune 

function, [62-64]. The massage group had 

lower pain and anxiety levels and shorter 

duration of labor; lower pain than the 

ultrasound participants and reported 

greater functional status as measured on 

the foot and ankle pain assessment; 

significant improvement was noted for 

knee arthritis and pelvic (after 8 weeks 

therapy) pain; immediate reductions in 

neck pain [65]. Aromatherapy refers to the 

medicinal or therapeutic use of essential 

oils absorbed through the skin or olfactory 

system (although rare phototoxicity and 

carcinogenicity reported), is used as a part 

of nursing in many countries including 

Switzerland, Germany, England, Canada, 

and America [66-69]. Aromatherapy with 

orange oil can relieve pain in patients with 

fractured limbs. A study has shown that 

edible oil of orange can reduce breast pain 

caused by premenstrual syndrome [69]. 

The essential oils rosemary, geranium, 

lavender, eucalyptus, and chamomile can 

be safely used by nurses in the clinical 

setting, if applicable [70]. 



 

 

 

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Figure 9: Ayurveda Massage. (Source: Healing with Ayurvedic Herbs | Panchakarma 

Treatment Centre in Croydon London) 

 

Exhibit 5. Massage Techniques [61] 
 Effleurage—Gentle stroking along the length of a muscle 
 Petrissage—Pressure applied across the width of a muscle 
 Friction—Deep massage applied by circular motions of the thumbs or fingertips 
 Kneading—Squeezing across the width of a muscle 
 Tapotement—Light slaps or karate chops 

 

Meditation: Mindfulness meditation was 

introduced as a clinical intervention for 

conditions such as chronic pain and 

anxiety in 1979 [71]. Chronic pain patients 

increasingly seek treatment through 

mindfulness meditation, thought to work 

by refocusing the mind on the present and 

increasing awareness of one’s external 

surroundings and inner sensations, 

allowing the individual to step back and 

reframe experiences [72]. Meditation–

based interventions improve pain 

symptomology across a wide spectrum of 

pain-related disorders, including 

fibromyalgia, migraine, chronic pelvic 

pain [73]. Meditation, after the four-

session intervention, during noxious heat 

produced a mean 40% reduction in pain 

intensity and 57% reduction in pain 

unpleasantness ratings [74]. A variety of 

factors are now known to either increase or 

decrease pain-related brain activation, 

including: predictive cues, distraction, 

attention, expectation, beliefs, placebo, 

hypnosis, stress, anxiety, mood and 

emotional state [75]. Focused attention 

(FA), also known Shamatha (from 

Sanskrit), is associated with maintaining 

focus on a specific object, often the 

changing sensation or flow of the breath 

or an external object [76]. By contrast, 

open monitoring (OM), or Vipassana 

(Sanskrit translation), is associated with 

a non-directed acknowledgement of any 

sensory, emotional or cognitive event 

that arises in the mind. Zen meditation 

is considered to be one form of OM 

practice [77]. 

 



 

 

 

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Figure 10: Anatomy of Mind: Meditation gives access to most powerful layers of mind 

 

(Results may vary from person to person). 

Hypnosis has been pragmatically used for 

limited therapeutic targets, while Eastern 

meditation has much wider philosophical 

and existential implications, aiming for a 

radical liberation from all illusions, 

attachments, suffering and pain. The 

accessible information on the history, 

phenomenology, and neuropsychology of 

spellbinding and reflection demonstrate a 

few basic highlights, for example, the 

accompanying: (an) acceptance dependent 

on centered consideration; (b) ability to 

achieve a purposeful control of both 

biologic-substantial exercises and 

cognizant oblivious procedures. The 

Hypnotic Brain can fill in as an approach 

to tap neurocognitive inquiries and our 

intellectual tests can thus reveal new 

insight into the neural bases of 

mesmerizing. Discrete reflective styles are 

probably going to target distinctive 

neurodynamic designs. Late discoveries 

accentuate expanded attentional assets 

enacting the attentional and striking nature 

systems with rational observation. 

Cognitive and emotional equanimity gives 

rise to a eudemonic state, made of calm, 

resilience and stability, readiness to 

express compassion and empathy, a main 

goal of Buddhist practices. Structural 

changes in gray matter of key areas of the 

brain involved in learning processes 

suggest that these skills can be learned 

through practice. Hypnosis and Meditation 

represent two important, historical and 

influential landmarks of Western and 

Eastern civilization and culture 

respectively (Source: De Benedittis G. 

Neural mechanisms of hypnosis and 

meditation. J Physiol Paris. 2015 Dec; 

109(4-6):152-164. doi: 

10.1016/j.jphysparis.2015.11.001. Epub 

2015 Nov 10. Review. PubMed PMID: 

26554845). 

 

Music, art, or drama therapy: Music is 

one of a number of non-pharmacological 

methods of relieving chronic pain, along 

with exercise and cognitive behavioral 

therapy, that have been found to be 

effective in RCTs [78]. VMT may be 

effective in building essential stepping 

stones for chronic pain management, 

namely developing: 1) a positive 

relationship with one’s self; 2) enhanced 



 

 

 

45 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

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self-efficacy; 3) motivation and 

empowerment to take charge of one’s pain 

management; and 4) renewed social 

engagement [79]. The U sequence is a 

music therapy technique specifically 

developed for pain management [80, 81]. 

A single session of music therapy is 

effective in significantly reducing cancer 

pain when used along with standard 

palliative care in cancer patients with 

moderate to severe pain, chronic pain and 

anxiety/depression, by altering affective, 

cognitive, and sensory processes, music 

may decrease pain perception by 

distraction, change in mood, increased 

control, use of prior skills, and relaxation, 

reduces opioid requirements, improve QoL 

[82-89], [91]. Cepeda et al., shows that 

music therapy was best for short term pain 

after surgery [86]. Music is expressive; 

individuals may trigger a variety of 

emotions through creating music in groups 

or individually. Via its ability to modify 

the affective or cognitive state of the 

listener, music can be adapted to function 

as a behavioral intervention for pain [88]. 

Tolstoy said that music is the shorthand of 

emotion, and Congreve explained that 

music has charms to soothe a savage breast 

[90]. As a treatment adjuvant to reduce 

chronic pain in FM, and FM-associated 

sleep disturbances and increase functional 

mobility thereby reducing the risk of 

disability. However, effectiveness is 

higher when combined with aerobic 

exercise, which brings about further 

improvements in quality of life and 

balance [91-93]. Drama therapy made an 

important contribution to the healthy 

adjustment of some patients both to 

hospital life and to acquired disability [94-

96]. 

 

 
Figure 11: Music Therapy: Pain Management Part 2 | Michael Tyrrell 



 

 

 

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In the UK, music specialists are prepared 

to ace's dimension and are enlisted with 

Health and Care Professions Council as 

unified wellbeing experts. Aristotle 

perceived the natural capacity of tunes to 

outperform "emotions, for example, pity 

and dread, or excitement," and in this way 

"mend and sanitize the spirit." The Greeks 

distinguished Apollo as the dad of both 

recuperating and music, nearby his 

numerous different honors (as God of 

light, sun, truth, prediction, plague and 

verse). Two doctors acclaimed for utilizing 

their melodic capacities to actualize 

medicinal accomplishments portrayed 

chest percussion. Working room is a 

peaceful spot and genuine that there will 

be any additional clamor to the diversion 

and meddle with verbal correspondence 

between individuals. Music is a free 

method to improve patients stress and pain 

previously and amid medical procedure. 

Although there isn't enough evidence in 

order to draw a net conclusion about the 

effect of music in operating rooms (Vahed 

N, Kabiri N, Oskouei MM, Gavgani VZ, 

Khatooni AA, Sadooghi N. 130: THE 

EFFECT OF MUSIC IN OPERATING 

ROOM: A SYSTEMATIC REVIEW. 

BMJ Open. 2017; 7(Suppl 1): bmjopen-

2016-015415.130. Published 2017 Feb 8. 

doi:10.1136/bmjopen-2016-015415.130). 

 

Expressive Writing Intervention (EWI) 

Composing expands wellbeing and health 

in changed ways. people who have 

expounded on their own horrible 

encounters show factually noteworthy 

enhancements in different proportions of 

physical wellbeing, decreases in visits to 

doctors, and better safe framework 

working [96]. Written emotional 

disclosure in adolescents with recurrent 

abdominal pain, and anger letter writing in 

adults with heterogeneous pain may be 

beneficial.  Most disclosures of patients 

with RA were about the daily stress of the 

disease or other publicly known stressors 

(e.g., divorce, death of loved ones) rather 

than private or stigmatized stressors, 

which might have been more powerful to 

address [97]. Improved physical symptoms 

and reduced healthcare utilization in 

people with colorectal, breast, or prostate 

cancer and reduction in depressive 

symptoms, trauma-related cognitions and 

general behavioral problems in children 

with post-traumatic stress disorder also 

reported [98]. EWI may have a 

significantly positive impact on the 

physical health but not the psychological 

health in BC patients, but this benefit may 

not last long [99]. Patients with IBS 

treated with psychological therapy had not 

only reduced pain and anxiety but also 

reduced activity of the cingulate cortex 

and Para hippocampal gyrus [100]. 

Positive expressive writing may also be 

beneficial to those with musculoskeletal 

pain. Positive writing may be useful to the 

extent that it increases self-compassion 

and self-efficacy [146]. EWI is shown to 

be an effective intervention to improve 

QoL for Chinese-American breast cancer 

survivors [147]. A positive effect of 

expressive disclosure specifically on 

anxiety and specifically for young adults 

who were highly emotionally expressive 

[148]. EWI had a significant impact on 

reducing risk of eating pathology in female 

students and distress/depression during 

ART therapy of infertile women 

[149,150]. EWI with clinical samples 

shows potential benefit of written time 

management for stressed caregivers [151]. 

 

PASTOR: The Pain Assessment 

Screening Tool and Outcomes Registry 

(PASTOR) is a 20-30-minute survey that 

produces a comprehensive 3-page clinician 

report of a patient's chronic pain. PASTOR 

was developed as a direct result of the 

PMTF recommendations; it is designed to 

provide an outcomes registry to improve 



 

 

 

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evidence-based decision making by health 

care providers and to facilitate pain 

research [106]. PASTOR incorporates the 

DVPRS, pain interference assessment, 

neuropathic pain scale, headache 

assessment, and patient-defined activity 

goals. In addition, PASTOR includes 

screens for the following conditions: 

PTSD, anxiety, depression, and alcohol 

misuse. Additional pain correlates 

including global health, fatigue, 

satisfaction with social roles, anger, sleep-

related impairment, and physical function 

are also assessed [101,102,105]. It uses the 

computerized adaptive learning system of 

the NIH PROMIS which contains a large, 

validated databank of patient-reported 

outcome surveys. PASTOR serves two 

major purposes: first, it collects actionable 

information that can be used by clinicians 

to assess response to treatment and to 

guide pain management; and second, when 

aggregated from large numbers of 

respondents, it can identify best clinical 

practices [104,105,108]. PROMIS Pain 

Interference (PI) scores was a superior tool 

to gauge a patient's preoperative level of 

pain and functional ability compared to 

NPRS in foot and ankle patients [106].  

 

Pet Therapy: Pets provide 

companionship, unconditional love, and 

joy. For those with chronic pain, pets can 

give their owners even more [109]. 

According to the Delta Society (Non-

profit), pets decrease feelings of 

depression, loneliness, and isolation. Pets 

may also be able to do your heart some 

good — they are credited with lowering 

blood pressure and cholesterol [110]. The 

American Veterinary Medical Association 

classifies therapeutic animal assisted 

interventions (AAI) into three categories: 

animal assisted activities (AAA) that 

utilize companion animals; animal assisted 

therapy (AAT) that utilizes therapy 

animals and service animal programs 

(SAP) that utilize service animals [115]. 

Therapy dog visits in an outpatient setting 

can provide significant reduction in pain 

and emotional distress for chronic pain 

patients [111]. Reductions in measures of 

cardiovascular stress, improvements in 

neurophysiological stress markers (e.g., 

cortisol), increases in endorphins, and 

enhancement of immune factors is also 

reported. An average 12 minutes exposure 

to a therapy dog reduces anxiety in 34% of 

fibromyalgia patients, together with 

reductions in pain and improvements in 

mood [112]. Patients with major joint 

replacement exposed to dog therapy 

required less pain medication than controls 

[113]. The ED simultaneously represents 

an environment that has great need for the 

potential benefits of animal assisted 

therapy, but also presents unique 

challenges to its implementation.  In one 

ED, 93% of all patients indicated desire to 

see a therapy dog [114]. Therapy dogs 

offer a novel and useful complementary 

therapy for children undergoing surgical 

procedures [115]. AAA has the potential to 

benefit children with cancer because 

pediatric oncology patients often suffer 

from distress due to physical 

examinations, venipuncture, chemotherapy 

infusions, spinal taps, surgery, 

hospitalization, pain, fear of medical 

procedures, unpleasant physical 

symptoms, uncertainty, and worry about 

death [116]. Patients with brain tumors 

face serious and unique challenges with 

neurologic and neuropsychological 

problems that are specific to the location 

of the tumor and just not the systemic 

symptoms of the cancer [116,117]. Pet 

therapy significantly increases patients’ 

overall feeling of wellbeing and reduces 

anxiety about future uncertainty [118].

 

 



 

 

 

48 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Figure 12: Hospitalized kid on animal visit 

 

Understanding whether AAA is safe and 

effective for pediatric cancer patients is 

critical, especially because of concern 

about infection in immunosuppressed 

persons. Conducting AAA research in 

pediatric oncology requires understanding 

current regulations and variations in 

practice. Knowledge of regulations helps 

us understand elements required for 

intervention protocols (e.g., hand-

cleaning), whereas knowledge of practice 

variation can help us identify research 

opportunities (Source: Chubak J. Therapy-

dog visits for kids with cancer: A safe way 

to induce smiles? Web Kaiser Permanente 

Washington Health Research Institute July 

6, 2017. 

 

Positioning: Simply assisting a patient to 

change position in the bed or chair or 

while ambulating can improve comfort. 

Also, fitting body arrangement and 

backing of limits can improve quiet solace 

and viewpoint. Keeping things inside 

reach additionally makes a patient 

increasingly agreeable. Back pain is 

soothed by a few positions. The first is to 

put the head and trunk at 20° to 30° point. 

Wedge cushions are utilized to achieve 

this. At that point place a couple of pads 

under the knees, in the event that it is an 

emergency clinic bed, this is done 

effectively without pads. Moving the arms 

and legs while keeping the storage 

compartment still can exacerbate side 

effects. For instance, lifting a leg up while 

lying on the back would in general reason 

protests of back and leg pain. A few 

patients additionally had expanded back 

pain when lying face down and twisting 

the knee or handing the hip over or out. 

The patient can more often than not do it 

without anyone else's help utilizing the bed 

controls. Weight decrease happened in the 

sacral area with the pad and wedge 

frameworks brought about expanded 

weights in the back sidelong areas of the 

hindquarters and thighs. When utilizing 

off-stacking gadgets, thought ought to be 

given to all components, including tissue 

interface weights on the sacrum, expanded 

weights on other body areas, and the 

probability that these expanded weights 

will result in tissue harm. The pain is more 

terrible while changing positions or when 

hacking or wheezing in low back pain. 

Guaranteeing that the over-bed table, the 

phone, the attendant call catch, and the 

PCA control catch are all inside a patient's 

achieve diminishes rehash requests from 

the patient, yet in addition diminishes 

tolerant anxiety. Coming up next are 

purposes behind changing a patient's 

position: 

 To promote comfort and relaxation. 
 To promote good circulation. 
 To improve lung function. 
 To relieve pressure on skin and prevent 

skin breakdown (pressure sores) 

 To prevent loss of muscle tone 
 To prevent atrophy and contractures 
 To prevent edema (swelling) [121-127]



 

 

 

49 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Exhibit 6: Differential Diagnosis of Low Back Pain [127] 
Mechanical Low Back Pain Nonmechanical Spine Disease Visceral Disease 

Lumbar strain or sprain
†
 

  Degenerative disease 
  Disks (spondylosis) 
  Facet joints

‡
 

  Diffuse idiopathic skeletal 
hyperostosis

‡
 

Neoplasia 

  Metastatic carcinoma 
  Multiple myeloma 
  Lymphoma and leukemia 
  Spinal cord tumors 
  Retroperitoneal tumors 

Pelvic organs 

  Prostatitis 
  Endometriosis 
  Chronic pelvic inflammatory 

disease 

Renal disease 

  Nephrolithiasis 
  Pyelonephritis 
  Perinephric abscess 

Spondylolysis
‡ §

 

Spondylolisthesis
¶
 Infection 

  Osteomyelitis 
  Septic discitis 
  Paraspinal or epidural abscess 
  Endocarditis 

Herniated disk 

Spinal stenosis Vascular disease 
  Abdominal aortic aneurysm 
  Aortoiliac disease 

Osteoporosis with compression 

fracture 

Fractures 

Congenital disease 

  Severe kyphosis 
  Severe scoliosis 

Inflammatory arthritis 

  Ankylosing spondylitis 
  Reiter's syndrome 
  Psoriatic spondylitis 
  Inflammatory bowel disease 
  Polymyalgia rheumatica 

Gastrointestinal disease 

  Pancreatitis 
  Cholecystitis 
  Perforated bowel 

Paget's disease 

†A variety of terms are used to refer to muscle or ligament strains or sprains of the low back including lumbago, 

facet joint syndrome, sacroiliac syndromes, segmental or somatic dysfunction, fibromyalgia, and myofascial 

syndrome. 
‡The relationship between symptoms and objective findings for these conditions is not clearly established. 

§Spondylolysis is a defect in the pars interarticularis without vertebral slippage. 

¶Spondylolisthesis is anterior displacement of one vertebra, typically L5, over the one beneath it. 

 

Hypnosis 

The vast majority of the trance 

intercessions for chronic pain 

incorporate guidelines in self-

spellbinding. Spellbinding intercessions 

reliably produce noteworthy reductions 

in pain related with an assortment of 

chronic-pain issues. Likewise, 

entrancing was commonly observed to 

be more viable than no hypnotic 

mediations, for example, consideration, 

active recuperation, and training [129]. 

Therapeutic emplo yments of entrancing 

in dermatology incorporates diminishing 

distress from tingling or skin pain, 

adjusting instilled dysfunctional 

propensities, for example, scratching 

and so on [130]. 

  

 
Figure 13: Use of Hypnosis in the Treatment of Pain 



 

 

 

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There are three components in entrancing; 
retention, separation, and suggestibility. 
Retention is submerging profoundly into 
observation, creative ability, or a dynamic 
ordeal. The individuals who tend to 
effortlessly encounter assimilation are 
more hypnotizable than individuals with 
no experience. Separation is the isolating 
of the components of the psyche and 
conduct, for instance while reviewing a 
self-portraying memory, it is like the 
condition of imagining where the subject 
is both the onlooker, just as the principle 
character, at the same time. There could be 
a conduct in the condition of obviousness, 
or an affair of impression of the other body 
parts isolated to different pieces of the 
body. Suggestibility is that the subject 
effectively complies with the advisor's 
bearings amid mesmerizing. Be that as it 
may, this does not imply that the subject 
has totally lost his or her volition. Rather, 
as the subject is immersed in a state of 
hypnosis, the subject's judgment is 
reserved for a short time (Source: Lee JS, 
Pyun YD. Use of hypnosis in the treatment 
of pain. Korean J Pain. 2012; 25(2):75-80). 
 
The cerebrum regions that are initiated 
when pain is experienced are the thalamus, 
essential somatosensory cortex (SI), 
auxiliary somatosensory cortex (SII), 
insula, forebrain (eg. prefrontal cortex), 
amygdale, and front cingulated cortex 
(ACC) [131-133]. These cerebrum zones 
are known as the neuromatrix. ACC is in 

charge of the feelings (initiated amid 
adoration, love and eminently feeling) 
[131, 134]. Amid mesmerizing, when a 
disagreeableness because of pain is 
recommended to increment or reduction, 
the obnoxiousness changed in agreement 
to the recommendations, and the ACC 
action likewise changed as needs be 
[131,134-136]. Be that as it may, there 
were no adjustments in pain force and 
cerebrum movement including SI and SII 
[131]. The potential advantages of joining 
pain training (PE) with clinical 
spellbinding (CH) in the main preliminary 
appearing extra utilization of trance with 
PE results in improved results over PE 
alone in patients with chronic nonspecific 
low back pain [143]. Trance has been 
utilized in ophthalmic medical procedure 
for a long time, and a few instances of 
fruitful mesmerizing application have been 
accounted for. Easing of pain, particularly 
for patients who experienced clear pain 
amid the main eye medical procedure 
additionally detailed [144]. Patients with 
serious chronic ailments and propelled 
malignant growth accepting palliative 
consideration, have a mind boggling 
scope of pain and anxiety that can 
emerge right off the bat over the span of 
disease. Clinical entrancing can be 
viewed as a compelling adjuvant 
treatment for pain and anxiety control in 
malignancy just as in serious chronic 
ailments for patients accepting palliative 
consideration [145]. 

 

 
Figure 14: Changes in Different Areas in Brain after Hypnosis 



 

 

 

51 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Volume 1 Issue 1 

Three general conclusions can be drawn 
from this body of work. First, hypnosis 
and hypnotic analgesia suggestions have 
been shown to affect virtually all of the 
neurophysiological processes that underlie 
the experience of pain, from those in the 
periphery to those in the spinothalamic 
tract and numerous cortical areas. Second, 
the specific effects of hypnosis on brain 
activity depend on the wording of the 
hypnotic suggestions. Last, although 
people can respond to suggestions for pain 
relief without a hypnotic induction, the 
efficacy of analgesia suggestions is 

enhanced when they are preceded by this 
step. This latter finding might be related to 
neurophysiological changes that occur 
with a hypnotic induction, which are 
thought to reduce overall monitoring 
and executive functioning activities 
(Source: 136. Jensen MP, Day MA, 
Miró J. Neuromodulatory treatments for 
chronic pain: efficacy and mechanisms. 
Nat Rev Neurol. 2014 Mar; 10(3):167-
78. doi: 10.1038/nrneurol.2014.12. 
Epub 2014 Feb 18. Review. PubMed 
PMID: 24535464; PubMed Central 
PMCID: PMC5652321).

 

Exhibit 7: Counseling Points for the Patient with Neuropathic Pain [152] 
 A combination of treatment strategies is essential to achieve some degree of relief from chronic pain because the 

pain is the result of multiple causes. 

 Understanding medications, dosing schedules, side effects. Track of multiple medications may be required. 
 Realizing that medications may not be FDA-approved for treatment of neuropathic pain, and reference 

information may not be readily available. 

 Cautions about using alternative or natural medicines to provide relief. These usually are not effective and can 
be expensive. 

 Physical therapy, exercise, and psychological treatments are important to the treatment plan. Keeping 
appointments and being patient with expectations. 

 Setting reasonable goals for pain relief. Pain most likely will not be able to be completely cured. 
 Understanding neuropathic pain. Being knowledgeable about condition gives an opportunity to have input into 

the treatment plan. 

 Becoming proactive about health, and to achieve successes. 

 
Electrical Stimulation  
Electrical stimulation can relieve some 
severe and otherwise persisting pains. At 
its best it can be associated with either a 
gradual reduction in the pain or an 
increased ability by the patient to control 
his suffering. It seems particularly 
appropriate for use in the field of benign 
persistent pain [153]. It involves using a 
device to send a gentle electric current to 
nerves or muscles. This can help treat pain 
by interrupting or blocking the pain signals 
[19]. These devices are generally safe. 
However, they involve sending electrical 
impulses though body. So, it’s important 
to talk with physicians if patient has a 
pacemaker, another implanted device, is 
pregnant, with epilepsy, or having a heart 
problem [155]. It might have been prudent 
to separate these currents according to 
their primary uses in physiotherapy 
practice, rather than combining them 
together. TENS and IFC are used primarily 
for pain relief; HVPC is used for wound 
care and sometimes for pain relief; and 

NMES is used for muscle-fiber 
recruitment. NMES can be used safely and 
effectively in patients with cancer, chronic 
obstructive pulmonary disease, and heart 
disease [155,156]. Electrical stimulation 
often is used to augment physical therapy 
program after an injury or illness; it should 
not be the only treatment received when 
attending physical therapy [163]. There are 
different ES forms, including 
transcutaneous electrical nerve stimulation 
(TENS), neuromuscular electrical stimulation 
(NMES), interferential current (IFC), pulsed 
electrical stimulation (PES), noninvasive 
interactive neurostimulation (NIN), 
Iontophoresis [163,164]. Broader types 
include: Transcutaneous electrical stimulation 
(TENS); Implanted electric nerve stimulation 
(eg. PNS); Deep brain or spinal cord 
stimulation [19]. The recent advancements 
include improvement in ultrasound 
technologies, integration of ultrasound into 
clinical practice, percutaneous implantation 
techniques, smaller devices, and rechargeable 
and larger-capacity batteries [169]. 



 

 

 

52 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Figure 15: Electric Stimulation Therapy 

 

Electrical incitement treatment includes 

setting glue cushions with terminals on the 

patient's skin so as to coordinate a 

controlled electrical flow through the 

body. The anodes are set with the end goal 

that the electrical flow achieves the 

influenced territory of the body and causes 

a withdrawal of a focused on single muscle 

or gathering of muscles. While it might 

appear to be unnerving to send power 

through the body, it is really reproducing 

the electrical motivations that happen in 

the body amid typical development and 

exercise. Most patients don't feel any pain 

while accepting the treatment. The created 

withdrawal makes an expansion in blood 

supply the focused on zone, which can 

result in improved muscle quality and 

expanded recuperating. Contingent upon 

the seriousness of the condition, the 

electrical incitement can be expanded for 

an increasingly commanding constriction 

or diminished for a gentler withdrawal. An 

extra advantage of this treatment is that the 

nerves in the influenced territory are 

animated, which can square pain signals 

from the nerves to the cerebrum. This is 

why electric stimulation therapy is often 

used to help treat chronic conditions, but 

many acute conditions can be effectively 

treated as well. It is also thought that the 

electrical stimulation causes the body to 

produce endorphins, which naturally 

provide pain relief (Source: Web Back & 

Body Medical. Electric Stimulation 

Therapy) 

Implantable Peripheral Nerve 

Stimulation (PNS) 

The peripheral nervous system includes 

pathways outside of the spinal cord, 

specifically various plexuses and 

peripheral nerves.   Peripherally implanted 

nerve stimulation entails the placement of 

electrodes on a selected peripheral nerve.  

The stimulating electrode array is 

connected to an implanted pulse generator 

[165]. PNS has been shown to be 

efficacious in several chronic pain 

conditions including trigeminal 

neuropathic pain, episodic cluster 

headache (supraorbital nerve stimulation), 

chronic migraine/headache disorders 

(occipital nerve stimulation), fibromyalgia 

(C2 area stimulation), postherpetic 

neuralgia, complex regional pain 

syndrome type I and type II, isolated 

peripheral neuropathy, ilioinguinal, 

iliohypogastric, and lateral femoral 

cutaneous neuralgia, back pain, foot pain 

(tibial nerve stimulation), and coccydynia 

[169]. Post-stroke HSP is highly prevalent. 

Of those who suffer from HSP, up to 75% 

report moderate to severe pain with a third 

refractory to available treatments 

[166,168]. Data suggest that surface 

electrical stimulation (ES) is efficacious 

for treating HSP. However, it is not well-

tolerated and requires skilled personnel to 

maintain [166]. The mechanism of PNS-

mediated pain relief may include 

improvement in biomechanics of the 

glenohumeral joint and reversal of central 



 

 

 

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sensitization. Reduction in pain, reduction 

in pain interference, and improved pain-

free external rotation ROM without serious 

adverse events reported [166,167]. The use 

of ultrasound technology during 

implantation allows for percutaneous 

placement of the PNS electrode [25] and 

almost eliminates the need for skin 

incision and tissue dissection [171]. 

Currently, extra-neural electrodes have 

proven safe for chronic applications while 

invasiveness and long-term stability of 

intraneural electrode remain challenging 

for permanent implantation. Safety limits 

of stimulation parameters are still 

predominantly described in terms of 

electric charge [172]. Compared to the 

conventional battery-powered system, 

WINeRS (under research) can be used in 

closed-loop recording and stimulation 

experiments over extended periods without 

adding the burden of carrying batteries 

[173]. However, the criteria for patient 

selection for conventional PNS are:  

 Clear-cut etiology and corrected 
pathology (eg. Nerve entrapment 

syndrome) 

 Only patients with intolerable pain 
despite exercise, medication and TENS 

 Pain consistent with the sensory 
distribution of a single peripheral nerve 

 A positive diagnostic peripheral nerve 
block 

 Exclusion of nerve entrapment 
neuropathies 

 The patient is free of major 
psychological or psychiatric disease 

[169,170] 

Contraindications for the use of PNS 

mainly relate to surgical risk and 

include: 

 Coagulopathy, 
 Infection in the surgical site,  
 Psychiatric illness,  
 A failed diagnostic trial,  
 Requirement of periodic MRIs, such as 

for cancer patients, and  

 Complete sensory loss [169].
 

 
Figure 16: Peripheral Nerve Stimulation (PNS) 

 

Following a fruitful preliminary, a 

perpetual gadget, comprising of slender 

wires with electrical leads on their tips, is 

put through a needle under the skin. 

Furthermore, a battery is put under the 

skin through a little entry point. 

Everything is little enough to stay covered 

up under the skin. The framework can be 

turned on or off by the patient utilizing a 

remote control. Notwithstanding nerve 

wounds, a fringe nerve trigger embed is 

frequently used to treat conditions, for 

example, CRPS (complex provincial pain 

disorder) and lower back pain. (Source:  

Web National Spine & Pain Centers. 

Peripheral Nerve Stimulation (PNS) 



 

 

 

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Interrupts Pain Signals of Damaged 

Nerves). 

 

Neuromuscular Electrical Stimulation 

(NMES) 

In sports, NMES has been utilized for 

muscle fortifying, support of bulk and 

quality amid delayed times of 

immobilization, specific muscle retraining, 

and the control of edema. A wide 

assortment of triggers, including the burst-

adjusted substituting current ('Russian 

trigger'), twin-spiked monophasic beat 

current and biphasic beat current triggers, 

have been utilized to deliver these impacts 

[174]. It is often used to “re-train” or “re-

educate” a muscle to function and to build 

strength after a surgery or period of disuse 

[178]. During short-term disuse, NMES 

represents an effective interventional 

strategy to prevent the loss of muscle mass 

by increasing muscle protein synthesis 

rates [175].  Programs of NMES appear to 

be acceptable to patients and have led to 

improvements in muscle function, exercise 

capacity, and quality of life after 

Cardiovascular surgery [176, 179]. NMES 

can be safely implemented even in patients 

immediately after cardiovascular surgery 

and it helps to regain muscle strength only 

when applied for a sufficient number of 

days [177, 180]. It is safe for critically ill 

patients; however, it should be applied by 

duly trained professionals and with proper 

evidence-based parameters. Recent studies 

with variable methodological designs have 

shown that NMES is safe, feasible and 

beneficial for patients admitted to the ICU 

but available data are still inconclusive due 

to the heterogeneity of protocols and the 

small sample sizes [181]. A packaged 

intervention of TMT plus NMES may be a 

means of addressing not only LBP, but 

also impaired physical function and 

resultant disability, but studies among 

older adults have been limited [182]. 

Prevalence of postpartum LBP (PPLBP) 

has been reported to be 35% in the first 

month after the delivery, it is still the most 

prevalent painful condition, and is 

considered as a serious problem by one-

third of pregnant women. Limited data of 

using NMES for treating patients with 

PPLBP are available and it is ineffective to 

patients with PPLBP [183]. It might not 

benefit for patients with wrist dysfunction 

after AIS after 4-week treatment [184]. 

Although clinical meaning reported 

improvement is difficult to interpret, a 

20% improvement in swallowing 

performance following treatment reported 

in an older study in use of NMES in the 

rehabilitation of swallowing disorders 

[185]. It is effective in female Chinese 

patients with EAP after 10-week 

treatment. Further studies are still needed 

to warrant this result [186]. CUR is a very 

tricky disorder, involving inability to 

voluntarily urinate for patients with TBI. 

NMES could not relieve symptoms of 

Chinese patients with CUR after TBI, as 

well as improve their quality of life after 8 

weeks of treatment [198]. NMES is a 

valuable adjunct in patients with dysphagia 

and in patients with vocal fold paresis 

[199]. Combined NMES/TENS may be a 

valuable adjunct in the management of 

chronic back pain. Further research 

investigating the effectiveness of both 

NMES and combined NMES/TENS seems 

warranted [200]. No study found using 

NMES for the management in patients 

with NPP after SCI [201]. The efficacy of 

NMES being distinctly superior to that of 

TENS in maintaining long-term analgesia 

in HSP. However, NMES was not more 

efficacious than the TENS in improving 

the shoulder joint mobility, upper limb 

function, spasticity, the ability of daily life 

activity, and stroke-specific quality of life in 

HSP patients [202]. A recent trial found 

insufficient and inconclusive evidence from 

RCTs to inform on the role of NMES for 

treating people with PFP in current clinical 

practice [203]. NMES training appears to 

offset the changes in quadriceps structure and 

function, as well as improve the health status 

in patients with knee OA [204, 205]. NMES 

was not found effective for patients with 

CLBP after 4-week treatment [206]. 



 

 

 

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Figure 17: Repeated Muscle Contraction by NMES 

 

Suggested advantageous effects of 

neuromuscular electrical stimulation 

(NMES) with regard to muscle 

hypertrophy, atrophy, aerobic capacity, 

membrane excitability, and membrane 

translocation of GLUT4. NMES may 

preserve membrane excitability. 

Membrane translocation of GLUT4 is 

regulated by IGF‐1, AMPK, PGC‐1α, and 
its downstream targets, which may all be 

affected by NMES. Atrophy gene 

expression (MuRF‐1, atrogin‐1) increases 
upon dephosphorylating of FOXO3 

transcription factors, which is inhibited by 

downstream insulin signaling (Source: 

Yuki Iida and Kunihiro Sakuma. Chapter 

16. Skeletal Muscle Dysfunction in 

Critical Illness. In: Physical Disabilities - 

Therapeutic Implications 

http://dx.doi.org/10.5772/intechopen.6905

1) 

 

Transcutaneous Electrical Nerve 

Stimulation (TENS) 

TENS, is a methodology that utilizes 

electric flow to enact nerves for remedial 

reasons. The TENS unit is a little gadget, 

frequently battery-worked, which can here 

and there even fit into a pocket. It uses 

cathodes set on the skin and which 

associate with the unit by means of wires 

to address a focused on remedial objective. 

The units are said to be titratable, allowing 

for a high level of client resistance with 

few symptoms. Contrasted with numerous 

prescriptions, the gadget is free from the 

danger of overdose. TENS units are 

frequently very customizable, enabling the 

client to control beat width, force, and 

recurrence. Low recurrence of < 10Hz 

related to high force is utilized to create 

muscle withdrawals. High frequencies of > 

50 Hz are used with low intensity to 

produce paresthesia without muscle 

contractions [158], [207-212]. IASP works 

on two types of TENS: high frequency 

TENS [50-100 Hz, pulse per second 

(pps)], with low intensity (paresthesia, 

non-painful), pulse duration (50-200 μs); 

and low frequency TENS (<10 pps), with 

high intensity (to tolerance threshold), 

pulse duration (100-400 μs). What makes 

TENS worthwhile is that this technique, 

while substantially relieving acute and 

chronic pain, is noninvasive, inexpensive, 

safe and easy to use [220]. 



 

 

 

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 Exhibit 8: Exclusion criteria/contraindications for the use of a TENS unit [213] 
 TENS unit cannot be placed over the eyes. 
 TENS unit electrodes cannot be placed on opposite sides of the head that would result in a trans-cerebral 

current. 

 TENS unit electrodes cannot be placed on the chest and back that would result in a transthoracic current. 
 TENS units cannot be placed on the anterior neck due to the possibility of a vasovagal event or laryngospasm. 
 TENS units cannot be placed internally. 
 TENS unit electrodes cannot be placed directly over the spinal column. 
 TENS unit electrodes should not be placed near any sort of implantable device (spinal stimulator, pacemaker, 

etc.) where current from the TENS would interfere with the device. 

 For pacemakers or pacemaker/defibrillators, a TENS unit must be placed at least six inches away from the 
pacemaker AND during initial TENS unit placement, the patient should be on a cardiac monitor to watch for 

any interference. 

 TENS units should not be used over the uterus in pregnant women. 

 

TENS units appeared to be effective in ED 

for reducing pain [213]. TENS is useful 

and safe adjuvant in spinal cord injury 

patients for the management of 

neuropathic pain [214]. There is strong 

evidence that TENS as an adjunct is 

effective in reducing lower limb spasticity 

when applied for more than 30 minutes 

over nerve or muscle belly in chronic 

stroke survivors [215]. Repeated 

applications of TENS as an adjunct 

therapy for improving walking capacity 

and reducing spasticity in the same 

population [234]. After 6-week treatment, 

patients with AS did not show more 

promising outcomes in pain reduction 

[216]. TENS and IFC have similar global 

effects on acute/chronic pain and positive 

effects on function in both WOMAC and 

RMDQ questionnaires [217]. TENS is 

effective in reducing pain and improving 

patients’ QoL in cases of ICO. TENS is an 

easy-to-use, effective, noninvasive, and 

simple method for ICO-associated pain 

control and QoL improvement [218]. It has 

the potential to be a valuable therapeutic 

tool for women FSD in women without 

bladder problems [219]. It has been used 

for more than 45 years. However, despite 

all these advantages, there has been very 

little research into the therapeutic effects 

of TENS on brain activity [220]. Gamma 

band is a kind of brain wave which 

consists of very rapid oscillations (>30Hz) 

[221]. Moreover, it has been found that 

gamma band has an important role in pain 

perception as well as pain processing [222-

224]. High frequency TENS could reduce 

the enhanced gamma band activity after 

inducing tonic pain in healthy volunteers 

[220]. The effect of local and spinal TENS 

combined with the SWC for PI produced a 

significant improvement in size, healing, 

skin temperature, and pain levels in older 

adults with chronic PIs and cognitive 

impairment [225]. Treatment with TENS 

is effective for reducing pain in people 

with fibromyalgia. In addition, the 

inclusion of TENS in therapeutic exercise 

programs seems to have a greater effect 

than practicing therapeutic exercise in 

isolation [226]. TENS may serve as an 

effective and well-tolerated alternative for 

migraineurs. However, low quality of 

evidence demands further research [230]. 

TENS was not superior to fentanyl for pain 

relief in laparoscopic surgery with patients 

who underwent gynecologic laparoscopy 

under spinal anesthesia [231]. It can 

provide additional reduction in chronic 

post-stroke spasticity, mainly as additional 

therapy to physical interventions. Studies 

with better methodological quality and 

larger sample are needed to increase 

evidence power [232]. TENS was effective 

in reducing pain intensity during 

carboxytherapy in patients with cellulite in 

the gluteal region [233]. FS-TENS is an 

effective option for treating multisite 

chronic pain in a real-world setting. The 

most significant impact was a clinically 

meaningful reduction in pain interference 



 

 

 

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with activity and mood. There were also 

statistically significant reductions in 

pain intensit y and pain interference with 

sleep. Pain intensity and pain 

interference with activity and mood 

exhibited a dose–response association 

[235]. TENS may be effective for long-

distance walking in patients with pre-

radiographic knee osteoarthritis [236].  

 

 
Figure 18: Postulated mechanisms of action for TENS-induced analgesia 

 

TENS activates a complex neuronal 

network to result in a reduction in pain. 

TENS reduces hyperalgesia through both 

peripheral and central mechanisms which 

may involve: (1) Neurotransmitters & 

receptors that mediate TENS analgesia: 

HF TENS produces analgesia by activating 

endogenous inhibitory mechanisms in the 

central nervous system involving opioid 

GABA, and muscarinic receptors. (2) 

Reduction in central excitability: HF 

TENS also reduces central neuron 

sensitization and release of the excitatory 

neurotransmitters glutamate and substance P 

in the spinal cord dorsal horn in animals 

with inflammation. (3) Peripheral 

mechanisms: Some of the analgesic effects 

of TENS are mediated through peripheral 

adrenergic receptors (Source: Vance CG, 

Dailey DL, Rakel BA, Sluka KA. Using 

TENS for pain control: the state of the 

evidence. Pain Manag. 2014;4(3):197-209).

 

Exhibit 9 General Features of TENS [157-162] 
 It is a non-invasive, inexpensive, self-administered technique to relieve pain. 
 There are few side effects and no potential for overdose so patients can titrate the treatment as required. 
 TENS techniques include conventional TENS, acupuncture-like TENS and intense TENS. In general, 

conventional TENS is used in the first instance. 

 The purpose of conventional TENS is to selectively activate large diameter non-noxious afferents (A-beta) to 
reduce nociceptor cell activity and sensitization at a segmental level in the central nervous system. 

 Pain relief with conventional TENS is rapid in onset and offset and is maximal when the patient experiences a 
strong but non-painful paraesthesia beneath the electrodes. Therefore, patients may need to administer TENS 

throughout the day. 

 Clinical experience suggests that TENS may be beneficial as an adjunct to pharmacotherapy for acute pain 
although systematic reviews are conflicting. Clinical experience and systematic reviews suggest that TENS is 

beneficial for chronic pain. 



 

 

 

58 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

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Spinal Manipulation Primary Therapy 

(Chiropractic Care) 

Chiropractors use hands-on spinal control 

and other elective medicines, the 

hypothesis being that legitimate 

arrangement of the body's musculoskeletal 

structure, especially the spine, will 

empower the body to mend itself without 

medical procedure or drug [237-239]. 

While the pillar of chiropractic is spinal 

control, chiropractic care may likewise 

incorporate different medicines, including 

manual or manipulative treatments, 

postural and practice instruction, and 

ergonomic preparing (how to walk, sit, and 

remain to confine back strain). 

Chiropractors today often work in 

conjunction with primary care doctors, 

pain experts, and surgeons to treat patients 

with pain [240-242]. Chiropractors use 4 

broad categories of therapeutic 

interventions: (a) joint manipulation and 

mobilization, (b) soft tissue manipulation 

and massage, (c) exercise and physical 

rehabilitation prescription, and (d) home 

care and activity modification advice. In 

addition, nutritional and dietary 

counseling, physical therapy modalities 

(eg, heat, ice, ultrasound, electro-

modalities), and taping/bracing are also 

used as adjunct procedures [251]. Survey 

by Swedish Agency for Health 

Technology Assessment and Assessment 

of Social Services, SBU shows 69% of the 

physiotherapists stated that they frequently 

used ‘circulation training’ as compared to 

36% of chiropractors and 13% of the 

physiotherapists regularly used spinal 

manipulation whereas the corresponding 

figure for chiropractors was 96% [243]. 

Chiropractors are frequent providers of 

care for patients with lower back pain. 

Practitioner attitudes and beliefs have been 

shown to be associated with clinical 

outcomes for patients with low back pain 

[244]. Numerous people with LBP have 

never been to a chiropractor and may not 

be available to attempting it out of the blue 

for an assortment of reasons, including 

adverse open observations about 

chiropractic. Many have likely found out 

about the likelihood that chiropractic care 

may cause genuine damages, including 

vertebral course analyzation (VAD) 

prompting stroke, loss of motion, or 

demise. Notwithstanding, few are likely 

mindful that VAD itself may result in neck 

pain, provoking people to look for 

consideration, regardless of whether from 

chiropractors, PCPs, or different suppliers 

[249]. Spinal Manipulation confers some 

advantage in back pain with no 

unfavorable occasions [245]. For young 

people with chronic LBP, spinal control 

joined with exercise was more powerful 

than exercise alone over a 1-year time 

frame, with the biggest contrasts 

happening at a half year. These findings 

warrant replication and evaluation of cost 

effectiveness [246]. Chiropractic was 

superior to sham chiropractic and 

physiotherapy treatments, but it was less 

effective than pharmaceutical treatment 

and other therapies [254]. SMT could not 

lead to significantly different outcomes 

(clinical and biomechanical) in 

participants with CTP than a control 

condition only including the evaluation of 

spinal stiffness [247]. Chiropractic was 

one of the leading alternatives to standard 

medical treatment in cancer pain 

management [248, 250]. The 

effectiveness of chiropractic was 

equivalent to these conventional 

treatments in the management of neck 

pain [252]. Chiropractic demonstrated 

no significant difference with any other 

treatment mode in fibromyalgia [253]. 

CTTH is common, contributing to 

significant loss of work and high 

socioeconomic costs. Chiropractors 

have capacit y to offer an additive 

approach to patient care in FHT setting 

within collaborative care models [255].



 

 

 

59 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

 
Figure 19: Communication flow among patients, PCPs, CAM providers 

 

This outlines the unpredictable stream of 

correspondences among patients with 

chronic musculoskeletal pain, essential 

consideration suppliers (PCPs), and 

integral and elective prescription (CAM) 

suppliers inside and outside of an oversaw 

consideration framework. The CAM 

suppliers are acupuncturists and 

chiropractors. In spite of the fact that 

advancement is being made, poor joining 

of consideration remains a test over the US 

social insurance framework. As more 

safety net providers offer elective 

treatment benefits and as more doctors 

bolster the utilization of CAM medicines 

for pain the board, extra potential 

coordination challenges emerge. Patients, 

PCPs, and A/C suppliers want more 

correspondence; in this way frameworks 

should be made to encourage progressively 

open correspondence which could 

emphatically profit persistent results. 

Collaborative care provides patients with 

therapeutic options within an environment 

where health care providers and patients 

are informed (Penney LS, Ritenbaugh C, 

Elder C, Schneider J, Deyo RA, DeBar 

LL. Primary care physicians, acupuncture 

and chiropractic clinicians, and chronic 

pain patients: a qualitative analysis of 

communication and care coordination 

patterns. BMC Complement Altern Med. 

2016; 16:30. Published 2016 Jan 25. doi: 

10.1186/s12906-016-1005-4). 

 

Acupuncture 

Acupuncture is a customary Chinese 

routine with regards to medication that has 

picked up prevalence in Western culture 

and around the globe. It includes the 

inclusion of slender needles into the skin 

to animate nerves, muscles, and connective 

tissues all through the body with the 

objective of mitigating pain, strain, and 

stress. All the more extensively, needle 

therapy is really a group of various 

methodology. There are related dangers; 

be that as it may, genuine reactions are 

uncommon [256]. The Standard 

Acupuncture Nomenclature distributed by 

the WHO recorded around 400 needle 

therapy focuses and 20 meridians 

associating a large portion of the focuses 

[266]. Needle therapy treatment and 



 

 

 

60 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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control aggregate mediations in parallel-

bunch randomized preliminaries of needle 

therapy are not in every case definitely 

announced. While trying to improve 

guidelines, a global gathering of 

experienced acupuncturists and scientists 

conceived a lot of suggestions, assigning 

them STRICTA. The planned result is that 

mediations in controlled preliminaries of 

needle therapy will be all the more enough 

detailed, consequently encouraging an 

improvement in basic examination, 

investigation and replication of 

preliminaries [260]. Although acupuncture 

is widely used to manage chronic pain, it 

remains highly controversial, largely due 

to the lack of a clear mechanism [261]. 

American College of Physicians’ 

guidelines recommend acupuncture as one 

of several options, such as manual therapy 

or exercise, for patients with back pain 

[262]. UK NICE guidelines recommend 

acupuncture for chronic headache or 

migraine [263]. The adverse effects of 

acupuncture are short-lasting and mild, 

such as tiredness and drowsiness, making 

acupuncture potentially a safer choice of 

treatment for improving QoL of chronic 

PAWS patients [257]. There have been 

recommendations against using 

acupuncture for osteoarthritis in several 

guidelines including those from NICE 

[264] and the American Academy of 

Orthopedic Surgeons (AAOS) [265]. 

Compared with conventional drug therapy 

acupuncture alone did not show superior 

effects on pain relief. But along with drug 

therapy, resulted in increased remission 

rate of pain, shorter onset time of pain 

relief, longer duration of analgesia time, 

and better quality of life without serious 

adverse effects, as compared with drug 

therapy alone [258]. Acupuncture is 

effective for the treatment of chronic pain 

and is therefore a reasonable referral 

option [259]. Differences between true and 

sham acupuncture are smaller than those 

between true acupuncture and no 

acupuncture control [259,261]. No current 

guidelines recommend acupuncture for 

neck or shoulder pain [261]. Acupuncture 

is effective for the treatment of chronic 

musculoskeletal, headache, and 

osteoarthritis pain [267]. No systematic 

review has evaluated the effectiveness of 

acupuncture for combined neck pain, back 

pain, and lower back pain [268]. It is a safe 

and well-tolerated treatment option, 

improving a broader proportion of patients 

than current pharmaceutical options for 

women with fibromyalgia [269], however, 

for pain relief and reducing the number of 

tender points, acupuncture proved superior 

to drugs [270]. Acupuncture may depress 

pain by activating a number of 

neurotransmitters or modulators such as 

opioid peptides, norephinephrine, 

serotonin, and adenosine. Acupuncture 

may also activate the endogenous pain 

inhibitory pathway. Certain modes of 

acupuncture improved postoperative pain 

on the first day after surgery and reduced 

opioid use [271, 272]. 

 

Exhibit 10:  Conditions that may be amenable to acupuncture identified by the WHO [266] 
Upper respiratory tract 

disorders 

Acute sinusitis; Acute rhinitis; Acute tonsillitis 

Gastrointestinal 

disorders 

Acute/chronic gastritis; Chronic duodenal ulcer (pain); Chronic colitis; Pelvic pain 

Neurological disorders Headache; Migraine; Trigeminal neuralgia; Post-herpetic neuralgia; Peripheral 

neuropathies; Intercostal neuralgia 

Musculo-skeletal 
disorders 

Tennis elbow; Frozen shoulder; Cervico-brachial syndrome; Sciatica; Low back pain; 
Osteoarthritis; Phantom limb pain; Fibromyalgia 

Other Dysmenorrhea; Atypical chest pain; Labor pain/stimulation of labor; Dental pain 

 

 



 

 

 

61 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Figure 20: A mechanism of action of acupuncture in treating chronic pain 

 

The accurate instrument of how needle 

therapy diminishes HR in the meridian 

directs requires further examination so as 

to be replied. Two components are 

engaged with the change. One is the 

pathway identified with the vein 

framework. At the point when a needle is 

embedded into an acupoint, the nerve 

terminal which typically comprises of Aδ 

or C filaments is energized and sends a 

neural heartbeat flag to the focal nerve 

framework. At that point, an axon reflex 

creates which prompts the arrival of 

substance P (SP) and different synthetic 

concoctions into the interstitial liquid 

around the needle. SP and different signs 

diffuse and relocate to pole cells adjacent 

through interstitial stream along meridian 

channels. Pole cells then degranulate and 

discharge histamine which will keep on 

moving along meridian channels. SP and 

histamine can make encompassing veins 

grow and turn out to be increasingly 

penetrable enabling progressively 

interstitial liquid to stream outside the 

vessel. This quickens the stream along 

meridian channels and decreases the 

pressure driven obstruction along the 

channels. The lower resistance further 

facilitates the interstitial flow which can 

eliminate algogenic substances to relieve 

pain (Source: Zhang WB, Xu YH, Tian 

YY, et al. Induction of Hyperalgesia in 

Pigs through Blocking Low Hydraulic 

Resistance Channels and Reduction of the 

Resistance through Acupuncture: A 

Mechanism of Action of Acupuncture. 

Evid Based Complement Alternat Med. 

2013; 2013:654645).  

 

Physiotherapy 

Early physical therapy appears to be 

associated with subsequent reductions in 

longer-term opioid use and lower-intensity 



 

 

 

62 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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opioid use for all of the musculoskeletal 

pain regions examined [273]. Physical 

therapy or physiotherapy is a branch of 

rehabilitative medicine aimed at helping 

patients maintain, recover or improve their 

physical abilities. PTs practice in many 

settings, such as private-owned physical 

therapy clinics, outpatient clinics or 

offices, health and wellness clinics, 

rehabilitation hospitals facilities, skilled 

nursing facilities, extended care facilities, 

private homes, education and research 

centers, schools, hospices, industrial and 

this workplaces or other occupational 

environments, fitness centers and sports 

training facilities [274]. Both OT) and PT 

services are provided to clients/patients of 

all age groups, infants through older 

adults, from a variety of socioeconomic, 

cultural, and ethnic backgrounds, who 

possess or who are at risk for impairments, 

activity limitations, or participation 

restrictions. Both professions recognize 

that health and well-being are supported 

when individuals are able to engage in 

activities that promote quality of life 

through a healthy lifestyle [287]. The 

focus of physical therapist is differential 

evaluation and the treatment of 

dysfunction rather than differential 

diagnosis and treatment of disease as in the 

case of physician [288]. Globally, physical 

therapy professional organizations have 

called for physical therapists to perform 

lifestyle behavior management during 

customary care, or health-focused care, 

due to increasing morbidity and mortality 

related to no communicable diseases. 

Given the potential for health-focused care 

to improve health outcomes, physical 

therapists should integrate health 

promotion into their daily clinical practice 

[289]. Physical therapists follow the Guide 

to Physical Therapist Practice, APTA, and 

state-directed practice laws in their quest 

to provide best care for patients. Physical 

therapists are also team members in a 

delivery model for patients with rheumatic 

diseases and musculoskeletal conditions. 

Other team members may include 

rheumatologists, orthopedic surgeons, 

nurses, occupational therapists, social 

workers, pharmacists, and psychologists 

just to name a few [290]. 

 

 
Figure 21:  A comprehensive approach to manual physical therapy effectiveness accounting 

for interactions between patient, therapist, and intervention factors. 



 

 

 

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Examples of factors include preferences, 

expectations, outcome assessment, and 

shared decision-making (SDM). 

Additionally, this view acknowledges the 

interaction between patient and manual 

physical therapist, which may yield 

important outcome contributions, either 

directly (i.e. intervention selection) or 

indirectly (i.e. modified expectations or 

mood). Finally, this approach 

acknowledges the integration of targeted 

adjunct interventions such as psychosocial 

strategies and exercise that may (1) 

enhance the effectiveness of manual 

therapy for reducing the impact of pain, 

and/or (2) promote and maintain positive 

behavioral change (Source: Coronado RA, 

Bialosky JE. Manual physical therapy for 

chronic pain: the complex whole is greater 

than the sum of its parts. J Man Manip 

Ther. 2017; 25(3):115-117). 

 

Intervention such as mirror visual 

feedback with a 3D augmented reality 

system may augment manual therapy 

approaches by desensitizing the person and 

allowing a window for inclusion of 

complimentary treatment strategies [276]. 

PT intervention appears to be an effective, 

cost-effective, non-pharmacological 

method to decrease chronic pain in PLHIV 

[277]. PT should strongly be considered 

for the management of chronic pain to 

gradually increase flexibility and strength, 

for example in knee osteoarthritis where 

there is demonstrated benefit [280]. Risks 

of PT include myocardial infarction 

leading to sudden death, as well as 

worsening pain (especially at beginning of 

treatment) [279]. Patients with poor 

experience from physical therapy ignored 

the prescription since they could not see 

the difference between PAP and 

physiotherapy [281]. Survivors of major 

burn injury are subjected to painful 

physical therapy and occupational therapy 

that are essential for successful treatment 

and rehabilitation of their burns. The 

magnitude of the analgesic effect is 

clinically meaningful and is maintained 

with repeated use [282]. PT for primary 

idiopathic frozen shoulder can be useful 

for prescribing home exercises to increase 

shoulder mobility. Many physical 

therapies and home exercises can be used 

as a first-line treatment for adhesive 

capsulitis. PT has been shown to bring 

about pain relief and return of functional 

motion in patients with frozen shoulder 

[284]. An interdisciplinary management 

involving human embryonic stem cell 

(hESC) therapy along with physiotherapy 

as a supportive therapy offers regenerative 

treatment of the patients with SCI [285]. 

Poor adherence to physiotherapy can 

negatively affect outcomes and healthcare 

cost [286]. Taylor et al. showed the ability 

of the physical therapist to manage 

effectively and safely simple peripheral 

musculoskeletal injuries in the emergency 

department significantly reducing the 

length of stay, waiting and treatment time 

of patients [291]. An individual PT and 

rehabilitation program may augment 

improvements in patient-reported 

outcomes following arthroscopy for FAI 

syndrome, reported by FAIR trial [292]. 

Patients with moderate knee OA with 

different grades of pain can benefit from a 

physiotherapy rehabilitation program, 

which was shown to be highly effective in 

patients with moderate pain, although this 

effect might be reduced in patients with 

severe pain [293]. Upper limb 

rehabilitation technology (Armeo Spring 

as training tool) could hold promise for 

complementing traditional MS therapy. 

Significant gains were found in functional 

capacity tests. After training completion, 

TEMPA scores improved [294]. 

 

 



 

 

 

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Figure 22: The Armeo system is for arm and hand therapy (Physiotherapy) 

 

An exoskeleton supports the movements, 

while for motivation different videogames 

can be played. The modular "Armeo" 

system was specifically designed for 

patients, whose hand and arm function has 

been affected due to a neurological 

disorder. The robotic system includes an 

arm exoskeleton and software that not only 

provides treatment plans and 

documentation options but also a variety 

of different games. For example, patients 

are asked to collect coins in an underwater 

setting or grab specific products in a 

supermarket. Depending on the exercise, 

this trains range of motion and 

coordination, strength or stamina. Patients 

continuously and immediately receive 

performance feedback. Treatment progress 

is being recorded and measured at the 

same time, allowing for better assessment 

of the course of treatment thanks to this 

data. In doing so, patients always perform 

the appropriate and individually adapted 

training. (Source: Wart O. Exoskeletons, 

Serious Games and Co.: New 

Technologies in Rehabilitation. Medica 

Magazine 06/01/2017) 

Yoga 

The word “yoga” literally means “yoking”, 

or “joining together” for a harmonious 

relationship between body, mind and 

emotions to unite individual human spirit 

with divine spirit or the True Self [301]. 

Yoga is a vast system of practices and 

philosophy that originate in India. Yoga 

can be helpful in pain management with 

both physical and mental benefits, but 

yoga is not a quick fix solution. Yoga has 

many of the same benefits as mindfulness 

practice, due to the common focus on 

breath, body and present moment 

awareness [295]. Yoga is very helpful in 

treating some of the mechanical aspects of 

pain, for example when there are tight 

muscles which contribute to pain. 

However, practiced incorrectly or without 

proper supervision yoga can also 

exacerbate your pain in the short term, 

despite the fact that research shows yoga is 

as safe as usual care and exercise 

[296,297]. Despite a number of reports and 

reviews supporting efficacy of yoga in 

health care, the awareness and integration 

of yoga in conventional healthcare remain 

limited [318]. 



 

 

 

65 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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Volume 1 Issue 1 

 
Figure 23: Yoga for pain relief 

 

Yoga can help people with arthritis, 

fibromyalgia, migraine, low back pain, and 

many other types of chronic pain 

conditions. A study published in Annals of 

Internal Medicine found that among 313 

people with chronic low back pain, a 

weekly yoga class increased mobility more 

than standard medical care for the 

condition. Another study published at 

nearly the same time found that yoga was 

comparable to standard exercise therapy in 

relieving chronic low back pain. A meta-

analysis of 17 studies that included more 

than 1,600 participants concluded that 

yoga can improve daily function among 

people with fibromyalgia osteoporosis-

related curvature of the spine. Practicing 

yoga also improved mood and 

psychosocial well-being (Yoga for pain 

relief. Web Harvard Health Publishing, 

April, 2015) 

 

Recent controlled studies of yoga for 

managing pain have been based on Hatha 

or Iyengar yoga. Studies that have used 

Hatha yoga have concentrated on 

relaxation techniques and gentle postures 

tailored to specific patient populations 

[306].  Integrating ancient wisdom of yoga 

and spirituality in the conventional 

palliative care setting appears to be a 

promising, cost-effective, and time-

honored holistic approach offering a 

comprehensive wellness plan for patients 

[298]. Meditation and pranayama, along 

with relaxing asanas, can help individuals 

deal with the emotional aspects of chronic 

pain, reduce anxiety and depression 

effectively and improve the quality of life 

perceived [299]. There is a need for 

additional high-quality research to 

improve confidence in estimates of effect, 

to evaluate long-term outcomes, and to 

provide additional information on 

comparisons between yoga and other 

exercise for chronic non-specific low back 

pain [300]. Both yoga therapy and 

conventional exercise therapy, with 6 

months follow up resulted in significant 

benefits in CLBP, with the yoga 

intervention having the greater impact 

[301]. Beneficial effects of yoga could be 

associated with elevated serum BDNF 

levels and maintained serotonin levels. Lee 

et al. investigated the effect of yoga on 

pain, BDNF, and serotonin in 

premenopausal women with chronic low 

back pain. The yoga group had decreased 

pain, increased BDNF and unchanged 

serotonin [302]. Yoga is an acceptable and 

safe intervention, which may result in 

clinically relevant improvements in pain 

and functional outcomes associated with a 

range of MSCs [303]. Yoga intervention 

may reduce pain and catastrophizing, 

increase acceptance and mindfulness, and 

alter total cortisol levels in women with 

FM [304]. An 8-week Yoga of Awareness 

intervention may be effective for 

improving symptoms, functional deficits, 

and coping abilities in FM [305]. Yoga of 

Awareness” (YoA) is a mind/body 

program that, along with physical 

exercises, includes mindful meditation and 



 

 

 

66 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

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other coping tools drawn from the yoga 

tradition. Thus, it provides FM patients 

with both exercise and coping skills 

components of no pharmacological 

therapy [306]. Headache frequency and 

intensity were reduced more in Yoga with 

conventional care than the conventional 

care group alone. Furthermore, Yoga 

therapy enhanced the vagal tone and 

decreased the sympathetic drive, hence 

improving the cardiac autonomic balance 

[307]. In a randomized controlled trial 72 

migraine without aura patients were 

randomly assigned yoga therapy or self-

care. A significant reduction in migraine 

frequency was reported in the yoga versus 

self-care group [308]. 8 weeks of Hata 

yoga exercises on women with knee 

osteoarthritis found to be effective and it 

could be used as a conservative treatment 

besides usual treatments and medications 

to improve the condition of people with 

osteoarthritis [309]. Approximately 41.1% 

of males and 56.5% of females suffer from 

OA. Over 40% of adults between 50 and 

75 years are affected with knee OA 

worldwide. handgrip strength is positively 

related to normal bone mineral density in 

postmenopausal women, and can be used 

as a screening tool for women at risk of 

osteoporosis [310]. In a yoga group 

received IAYT intervention for 1 week at 

yoga center, right and left handgrip 

strength showed improvement after 1 week 

IAYT intervention [311]. The practice of 

yoga effects on knee OA reported positive 

outcomes on symptoms including pain, 

flexibility, functional disability, anxiety, 

and quality of life [312]. IAYT practice 

showed an improvement in TUG, STS, 

HGS, and Goniometer test, which suggest 

improved muscular strength, flexibility, 

and functional mobility [311]. Regular 

yoga training is helpful in reducing knee 

arthritic symptoms, promoting physical 

function, and general wellbeing in arthritic 

patients [313]. Yoga has been used 

clinically as a therapeutic intervention for 

improving strength, posture, balance, and 

flexibility in older adults [314]. 

Neuroinflammation is a complex process 

involving both the peripheral circulation 

and the CNS and is considered to underlie 

many CNS disorders including depression, 

anxiety, schizophrenia, and pain. Regular 

practice of yoga reduces inflammatory 

cytokines in general and might protect the 

individual from inflammatory diseases 

(significantly reduce levels of TNF-α and 

IL-6). This study is particularly important 

because it examined how yoga influences 

the body’s response to a stressor, in this 

case exercise, and found that it effectively 

dampened the pro-inflammatory response 

[315]. Raj-yoga meditation and pranayama 

in combination with conventional, 

noninvasive, treatment modalities showed 

promising results in MPDS patients as 

compared to either modalities alone [316]. 

In a cohort of women with chronic pelvic 

pain, an 8-week yoga intervention resulted 

in improvement in pain and quality of life 

scores compared to the control group that 

was treated with non-steroidal anti-

inflammatory drugs [317]. Despite a wide 

range of methodological gaps and 

limitations, yoga interventions were shown 

to be beneficial and yielded positive 

results without any adverse outcomes. It is 

also recommended that cancer caregivers 

are trained and certified as the “yoga 

therapists” who have knowledge of the 

particular disease and understand the needs 

of the patients [319]. The assortment of 

advantages inferred, the nonappearance of 

reactions, and the money saving advantage 

proportion of restorative yoga make it an 

intriguing option for family doctors to 

recommend to their patients with 

malignancy [320]. Malignancy patients in 

customary treatment more often than not 

get at least one of radiotherapy, 

chemotherapy, careful intercession and 

hormone treatment. The patients utilizing 

yoga as a correlative treatment in grown-

up malignant growth announced positive 

advantages regarding physical, 

psychological and social prosperity. The 

most ordinarily revealed direct advantage 

of yoga was its breath-related attention to 



 

 

 

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mind and body. Patients detailed partiality 

for yoga as a corresponding treatment, 

however felt at least one worries of 

transportation, planning, absence of time 

and cost were noteworthy obstructions to 

yoga adherence [321]. Yoga uses the 

model of five-dimensional perceptions. 

The human being is considered to 

experience every interaction through the 

physical, vital, emotional, intellectual and 

spiritual perceptions simultaneously, with 

the physical sheath being the grossest and 

others progressively subtler; and the 

intellectual and spiritual perceptions being 

the subtlest. It also states that the ripples in 

the emotional sheath affect the grosser 

dimensions of vital energy flow and 

physical body [299]. 

 

 
Figure 24: Systems network model of yoga for optimizing self-regulation 

 

The real appendages of yoga are spoken to 

in blue boxes as a range of abilities of four 

procedure instruments: morals, reflection, 

breath guideline, and stances. Utilization 

of these abilities (appendages of yoga) 

crosswise over intellectual, emotional, 

social, and autonomic spaces with regards 

to physical and emotional stress is 

proposed to sum up to comparative 

difficulties off the yoga tangle and in 

regular daily existence. Together, these 

apparatuses of yoga improve the 

productivity, bidirectional criticism, and 

reconciliation (+ dark lines) among high-

and low-level mind systems, and afferent 

and re-afferent contribution from 

interoceptive procedures (e.g., multi-

tactile, proprioceptive, vestibular, 

cardiovascular, pneumonic, 

musculoskeletal) with regards to stress. 

Through an accentuation on interoception 

and base up info, reconciliation 

encourages hindrance (red lines) of 

maladaptive types of subjective, 

emotional, and conduct yield just as 

autonomic yield related with stress. 

Proficiency improves the correspondence 

and adaptability among cerebrum and real 

frameworks to advise social yield. Yoga's 

four apparatuses are depicted to include 



 

 

 

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Journal of Pharmacological Research and Developments 

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specific administrative procedures related 

with each arrangement of mind systems 

(demonstrated in yellow boxes). With 

dominance of training, administrative 

procedures turn out to be more 

automatized, requiring less exertion to 

start when important and end all the more 

quickly when never again required. A 

focal official system underpins top-down 

instruments of attentional control and 

working memory permitting observing for 

appropriate objective coordinated conduct 

pursued without anyone else's input 

remedy if necessary. A FPCN bolsters 

official observing, meta-mindfulness, 

reappraisal, and reaction hindrance 

instruments. An ethical comprehension 

organize underpins inspiration and goal 

setting related with self-care and prosocial 

conduct. The dorsal consideration arrange 

bolsters attentional situating, and 

commitment. Hypothlamic– pituitary– 

adrenal (HPA) pivot correspondence with 

brainstem vagal efferents bolster 

parasympathetic control and homeostasis 

crosswise over frameworks. A 

striatopallidal– thalamocortical system is 

in charge of encouraging termination 

learning and reconsolidation of 

maladaptive propensities into conduct that 

is lined up with aims and results into 

versatile propensities. Specked lines speak 

to new, versatile pathways for reacting to 

stress. A concentration toward base up 

procedures encourages a move toward 

perceptual deduction instead of dynamic 

induction, and improves forecast and 

blunder revision forms, in this manner 

supporting ideal self-guideline (Source: 

Gard T, Noggle JJ, Park CL, Vago DR, 

Wilson A. Potential self-regulatory 

mechanisms of yoga for psychological 

health. Front Hum Neurosci. 2014; 8:770. 

Published 2014 Sep 30. 

doi:10.3389/fnhum.2014.00770). 

 

CONCLUSION 

Pain is intricate, so is their measures. 

There are numerous treatment alternatives 

- meds, treatments, and mind-body 

systems. Intense pain can last a minute; 

once in a while does it wind up chronic 

pain. Chronic pain perseveres for 

extensive stretches. Usually impervious to 

most therapeutic medicines and cause 

extreme issues. Once more, present day 

restorative framework recommends CAM 

and pharmacotherapy together, rather than 

long haul utilization of pain executioners 

alone. Way of life adjustment is another 

imperative thing to improve circumstance 

and continue the advantages of treatment. 

Pain might be situated in one piece of the 

body or it might be across the board. 

Studies propose that an individual's 

viewpoint and the manner in which they 

adapt emotionally to long haul (chronic) 

pain can impact their personal satisfaction. 

The event of pain ascends as individuals 

get more established, and ladies are bound 

to encounter pain than men. The helpless 

populace ought to be stayed in contact 

with doctors for pain the board and know 

about go betweens that may grant a further 

intensifying circumstance. Active 

recuperation centers around activities and 

stretches that assistance make the body 

more grounded and progressively ready to 

capacity and move. When the issue has 

been recognized, an active recuperation 

session could incorporate fortifying 

activities, low effect vigorous exercise, 

and pain alleviation extends. Our brains 

can influence how we see and experience 

pain. Stress and anxiety can even 

exacerbate chronic pain. Along these lines, 

body-mind treatments are valuable for 

helping patients better adapt to the pain 

and stress. Body-mind treatment works by 

showing patients how to deal with their 

feelings, musings, stress, and the body's 

physical reactions. There is abundant proof 

that stress and anxiety push the dimension 

of chronic pain. Serotonin and dopamine 

are two key synapses that influence our 

state of mind. Lopsided dimensions of 

these two synapses are connected to 

anxiety and depression issue. Stimulating 

living, grinning, watching motion pictures, 

delight trips, tattling, playing VDO 



 

 

 

69 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

diversions keeps us occupied and diminish 

stress related rot. With regards to 

overseeing pain, Buddha's outstanding 

words composed numerous hundreds of 

years back as yet seem to be valid: How 

you consider your pain can change how 

you feel it, regardless. Neuroscientific 

thinks about have demonstrated that our 

minds physically change when we 

experience positive or negative feelings. 

This assumes a critical job in how well we 

oversee pain, particularly on an everyday 

premise. The brain and body are in 

consistent correspondence, so the manner 

in which we see our pain can change the 

manner in which we feel it. This is the 

reason moving our points of view about 

our pain is so critical—it's a viable method 

to control our manifestations, no 

medications required. 

 

ACKNOWLEDGEMENT 

It’s a great gratitude and honor to be a part 

of healthcare research and education. I am 

thankful to Prof. Arinze Nkemdirim 

Okere, Associate Professor of Pharmacy, 

Florida A&M University, for his precious 

time to review my submission and 

providing his inputs to expand the thought. 

I am also grateful to seminar library of 

Faculty of Pharmacy, University of Dhaka 

for providing books, newsletters and 

journals. The greatest help was from my 

students who paid interest in my topic as 

class lecture and encouraged to write it. 

Despite a great scarcity of funding this 

purpose from any authority, the experience 

was good enough to carry on research. 

 

Summary 

The vast majority are eager to do pretty 

much anything to get away from the 

grasps of interminable agony. One of the 

primary cures offered to endless torment 

sufferers is prescription medications. 

Prescription painkillers are compelling 

much of the time. Be that as it may, the 

relief from discomfort they offer includes 

some major disadvantages for some. 

Painkillers risk getting to be addictive. 

What's more, as endless news reports have 

appeared, the consequences of dependence 

on painkillers can be wrecking. Non-

tranquilize therapies decline torment and 

can be utilized notwithstanding 

pharmaceuticals or in lieu of 

pharmaceuticals. They offer the likelihood 

to enhance your personal satisfaction. 

Similarly, as with some other treatment, 

every individual will react distinctively to 

various therapies, and there is no 

certification that any treatment will give 

total help with discomfort. Though many 

evidences were weaker, the researchers 

also found that massage therapy, spinal 

manipulation, and osteopathic 

manipulation may provide some help for 

back pain, fibromyalgia, osteoarthritis, 

cancer pain, knee replacement, migraine, 

frozen shoulder and chronic non-migraine 

headache. These data can equip providers 

and patients with the information they 

need to have informed conversations 

regarding non-drug approaches for 

treatment of specific pain conditions. It's 

important that continued research explore 

how these approaches actually work and 

whether these findings apply broadly in 

diverse clinical settings and patient 

populations. 

 

Compliance with the Ethical Issues 

 Ethics approval and consent to 
participate 

Animal and Human experiment: N/A 

Human Data Submission Approval: 

N/A 

 Consent for publication 
Consent to publish Individual Person’s 

data: N/A 

 Availability of data and materials 
Data sharing: Data will be provided 

upon request. 

 Competing interests 
The author declares that he has no 

competing interest 

 Funding 
Funding from individual/Organization: 

None 



 

 

 

70 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

 Authors’ contributions 
The individual contributions of 

authors: N/A 

 

Abbreviations: Neuropathic Pain (NeP); 

Health-Related Quality Of Life (HRQoL); 

Health Care Resource Use (HRU); Health 

Care Provider (HCP); Emergency Room 

(ER); Non-pharmacological Pain treatment 

Modalities (NPMs); Post-Traumatic Stress 

Disorder (PTSD); Progressive muscle 

relaxation (PMR); Low Back Pain (LBP); 

Fear Avoidance Model (FAM); Cognitive-

Behavioral Therapy (CBT); Antecedent-

Belief-Consequence (ABC); Abdominal 

Aortic Aneurysm (AAA); Chronic 

Postsurgical Pain (CPSP); Postsurgical 

Pain (PSP); Complementary And 

Alternative Therapies (CAT); maximum 

heart rate (maxHR); Non-Specific Chronic 

Low Back Pain (NSCLBP); Osteoarthritis 

(OA); Randomized Clinical Trials (RCTs); 

Delayed-Onset Muscle Soreness (DOMS); 

Complementary And Integrative Medicine 

(CIM); Vocal Music Therapy (VMT); 

Focused Attention (FA), Open Monitoring 

(OM); Fibromyalgia (FM); Rheumatoid 

Arthritis (RA); Expressive Writing (EW); 

Breast Cancer (BC); Irritable Bowel 

Syndrome (IBS); Pain Assessment 

Screening Tool and Outcomes Registry 

(PASTOR); Patient-Reported Outcomes 

Measurement Information System 

(PROMIS); Completed Integrative 

Modalities Pain Care Team (IMPACT); 

Functional Restoration Program (FRP); 

Validation Of The Defense And Veterans 

Pain Rating Scale (DVPRS); Post-

Traumatic Stress Disorder (PTSD); 

Department of Defense (DoD); Pain 

Interference (PI); Pain Management Task 

Force (PMTF); Emergency Department 

(ED); Animal Assisted Interventions 

(AAI); Animal Assisted Activities (AAA), 

Animal Assisted Therapy (AAT), Service 

Animal Programs (SAP); Chest Tube 

Removal (CTR); Somatosensory Cortex 

(SI); Anterior Cingulated Cortex (ACC); 

Primary Somatosensory Cortex (SI); 

Secondary Somatosensory Cortex (SII); 

pain education (PE); Clinical Hypnosis 

(CH); Assisted Reproductive Technology 

(ART); Expressive Writing Intervention 

(EWI); Transcutaneous Electrical 

Stimulation (TENS); Transcutaneous 

Electrical Acupoint Stimulation (TEAS); 

Percutaneous Electrical Nerve Stimulation 

(PENS); Repetitive Transcranial Magnetic 

Stimulation (rTMS); High-Voltage Pulsed 

Current (HVPC); Interferential Current 

(IFC); Neuromuscular Electrical 

Stimulation (NMES); Pulsed Electrical 

Stimulation (PES); Noninvasive 

Interactive Neurostimulation (NIN); 

Implanted Peripheral Nerve Stimulator 

(PNS); Range Of Motion ROM); 

Hemiplegic Shoulder Pain (HSP); 

Complex Regional Pain Syndrome 

(CRPS); Wireless Implantable Neural 

Recording and Stimulation (WINeRS); 

Trunk Muscle Training (TMT); 

Postpartum LBP (PPLBP); Endometriosis-

Associated Pain (EAP); Urinary Retention 

(UR);  Traumatic Brain Injury (TBI); 

Neuropathic Pain (NPP); Spinal Cord 

Injury (SCI); Patellofemoral Pain (PFP); 

Spinal Cord Injury (SCI); Ankylosing 

Spondylitis (AS); Rolland Morris 

Disability Questionnaire (RMDQ); 

Western Ontario Macmaster (WOMAC); 

International Association for the Study of 

Pain (IASP); Electroencephalographic 

(EEG); Spinal Manipulative Therapy 

(SMT); Chronic Thoracic Pain (CTP); 

Vertebral Artery Dissection (VAD); 

Chronic Musculoskeletal Pain (CMP); 

Chronic Tension-Type Headache (CTTH); 

Family Health Team (FHT); Pain 

Associated With The Spine (PAWS); 

Standards for Reporting Interventions in 

Controlled Trials of Acupuncture 

(STRICTA); Chronic Uncomplicated 

Musculoskeletal Pain Associated With The 

Spine (CMPS); American Academy of 

Orthopedic Surgeons (AAOS) ; National 

Institute for Health and Care Excellence 

(NICE); Total knee arthroplasty (TKA); 

Ultra-restrictive Opioid Prescription 

Protocol for Pain (UROPP); People Living 

with HIV (PLHIV); Physical Therapy 



 

 

 

71 Page 27-95 © MAT Journals 2019. All Rights Reserved 
 

Journal of Pharmacological Research and Developments 

Volume 1 Issue 1 

(PT); Multiple Myeloma (MM); human 

Embryonic Stem Cell (hESC); Shared 

Decision-Making (SDM); Occupational 

Therapy (OT); American Physical Therapy 

Association (APTA); Flexion, Adduction, 

And Internal Rotation (FAIR); 

Femoroacetabular Impingement (FAI); 

Test d'Évaluation des Membres Supérieurs 

de Personnes Âgées (TEMPA); Multiple 

Sclerosis (MS); Brain Derived 

Neurotrophic Factor (BDNF); Yoga of 

Awareness (YoA); Integrated Approach 

Of Yoga Therapy (IAYT); Timed Up and 

Go Test (TUG); Sit-to-Stand (STS); 

Handgrip Strength (HGS); Myofascial 

Pain Dysfunction Syndrome (MPDS) 

 

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