Health Articles

Psychologic modalities include formal psychotherapy, cognitive techniques (eg,relaxation training, distraction, biofeedback, and hypnosis), and behavioral therapy to reverse dysfunctional behaviors such as physical inactivity and social withdrawal. Many of these techniques can be applied by nonphysicians. However, the elderly do not easily engage in these activities and are often not given the opportunity to do so. There may be clinician bias against such techniques, and elderly patients may have subtle cognitive deficits or be disinclined to trust psychologic procedures. For older patients who are willing to participate and appear capable of benefiting, a psychologic approach should be offered.

Many rehabilitative modalities may directly ameliorate pain as well as increase the level of activity and reduce secondary myofascial complications that often contribute to chronic pain. Orthoses may be useful in splinting the painful region, reducing so-called incident pain that occurs with movement or the assumption of certain positions. Participation in physical therapy and exercise programs often improves psychologic outlook and social interaction, if not always the pain.

Joint replacement may cure intractable arthritic pain. Surgical lesions to manage cancer pain have been placed at every level of the nervous system, from peripheral nerve to cortex. The most common approach is cordotomy. Both chemical and surgical transsphenoidal pituitary ablation have been used to relieve cancer pain. These procedures should be considered only after analgesic drugs have failed and should be performed only by clinicians with expertise in cancer pain management.
Neuroablative surgery for providing analgesia is rarely appropriate in patients with nonmalignant pain syndromes. Occasionally, patients with reflex sympathetic dystrophy who obtain short-term relief from repeated temporary nerve blocks may be candidates for surgical sympathectomy. A new procedure, the dorsal root entry zone lesion, has been developed for the treatment of selected deafferentation pain syndromes. Data suggest this procedure should be considered particularly in patients with pain from nerve root avulsion.

Anesthetic approaches include trigger point injection, nitrous oxide inhalation in patients with advanced cancer, and a variety of somatic and sympathetic nerve blocks. Trigger point injection with saline or a local anesthetic is useful for myofascial pain. If palpation of a painful region reveals focal tenderness, injection may provide transitory relief, leading to improved physical activity, and occasionally, long-term analgesia. Nerve blocks (temporary or permanent, depending upon the solution injected) are most useful in managing sympathetically maintained pain and cancer pain and should be performed only by experienced personnel.

Neurostimulatory techniques enhance afferent stimulation to provide segmental analgesia. They are useful for localized pain, particularly that of neuropathic origin. Counterirritation, or brisk rubbing of the painful part, often preceded by application of a vapocoolant spray (Fluori-Methane or Fluro-Ethyl) and transcutaneous electrical nerve stimulation (TENS), now widely available, can be applied by the non-specialist. Although the analgesia provided is usually short-lived, and cognitive deficits and lack of manual dexterity may preclude their use in many older patients, the inherent safety of these techniques recommends their use. Other neurostimulatory techniques, including acupuncture, percutaneous electric nerve stimulation, dorsal column stimulation, and deep brain stimulation, require special expertise.