In addition to ensuring that primary treatments for the underlying cause of the pain are used to the extent that they are appropriate, clinicians should consider the utility of non-pharmacological treatments for the management of BTP. These therapies cover a wide variety of techniques, many of which are time-honored but have not been subject to specific randomized trials. In fact, patients often use many of these treatments (e.g., limitation of activities, ice, heat, corsets, counter-irritant creams, or bandage wraps) before consulting a clinician. In addition, physical medicine techniques, such as correcting poor posture or harmful lifting techniques; de-conditioning; massage therapy; transcutaneous electrical nerve stimulation (TENS); and nerve blocks, should be integrated with the pharmacological treatments as indicated.
Patient education is a well-accepted strategy for alleviating acute and chronic pain. Acute flares of pain can originate from many sources—for instance, medications that lose their effectiveness at the end of their half-life, diseases that are associated with periodic pain flares, and disease progression. Patients may worsen their pain by engaging in activities for an inappropriate length of time. A gardener who can tolerate only 30 minutes in the yard may find himself planting for three hours when the spring flowers arrive. People who have difficulty getting out of a chair because of pain may spend all day at the mall shopping for a granddaughter’s homecoming dress. A patient who cannot tolerate an untidy house may spend a whole day cleaning.
Even though an increase in the dose of pain medication might be considered as an option to allow the patient to engage in an inappropriate level of activity, a better intervention would be to educate patients about the need to pace their activities and to pay attention to fatigue and physical limitations. This pacing of activities is really the art of pain medicine, which consists of encouraging patients to increase their overall level of activity without performing any one activity to the point of overexertion.
Pacing allows patients to return to activities in a sensible manner, which is preferable to engaging in the “all-or-nothing” behavior exhibited by some patients with chronic pain. Pacing breaks down a desirable activity into small, manageable segments. Patients can undertake a segment at a time, with rest stops and periods of relaxation in between. Instead of planting all of the spring flowers during one three-hour period, the gardener could choose to perform the task over several days. Using a timer as a reminder of when to stop can be helpful because the enjoyment derived from this activity can mask the actual amount of time spent in the garden. For the patient who enjoys shopping at the mall, pacing might mean spending two hours there instead of eight hours; instead of walking, she could ask her granddaughter to push her in a wheelchair.
These strategies, which are cost-effective, simple, and devoid of side effects or drug-drug interactions, are underused. Clinicians would be well advised to actively promote these commonsense approaches, which help patients to recognize their limitations and adapt their behaviors accordingly.