Chronic Pain 101: The Importance of Multimodal Therapy

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NURA PAIN CLINIC MN

For more information about the author, click to view their website: www.nuraclinics.com

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Mar 28, 2023

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Minnesota - Twin Cities Metro Area

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Chronic pain is a major health issue affecting millions of people globally. It can have a debilitating impact on lives, preventing people from enjoying activities they love and limiting the quality of their day-today life. Recent surveys indicate that approximately 50 million adults in the U.S.—more than one in five—report experiencing pain every day or most days, most commonly in their back, hips, knees, or feet. People with chronic pain say it limits their functioning, including social activities and activities of daily living.   Chronic pain is generally defined as pain persisting for longer than 12 weeks despite medication or treatment.  Clinicians may use various determinations, but a general rule of thumb is that the pain has lasted beyond the expected duration after an acute injury or illness or is present without any history of an injury or insult. Taking a Multimodal Approach to Treatment Treating chronic pain is not a one-size-fits-all endeavor. To optimize outcomes, it is critical to form a multimodal treatment strategy. A multidisciplinary approach has been shown to be one of the most effective ways to manage chronic pain. A combination of medications, physical and behavioral therapies, injections, neuromodulation and in rare cases, implantable pain pumps should be considered in order to provide patients with the best possible results. Physicians who specialize in interventional pain management typically offer a full range of such options and work with their patients to develop a course of treatment aimed at helping them manage their chronic pain to the best extent possible.

Classifying Pain

For all physicians considering the challenge of chronic pain management, it may be helpful to review the different types of pain classification:

• Somatic pain is felt in the muscles, bones or soft tissues. It is typically localized and can be intermittent or constant. It is often described as an

aching, gnawing, throbbing, or cramping type of pain.

• Visceral pain comes from the internal organs and blood vessels and is typically more diffuse than localized. Visceral pain tends to be referred to other locations, and can be accompanied by symptoms such as nausea, vomiting, or tension in lower back muscles. It can be intermittent or constant, and is typically described as being dull, squeezing, or aching.

• Neuropathic pain occurs when the nervous system is damaged or not working properly. It can be experienced at the various levels of the nervous 


The Importance of Multimodal Therapy Tools for treating chronic pain system, from the peripheral nerves to the spinal cord and the brain. Nerve pain can be described as shooting, sharp, stabbing, lancinating, or burning.

Tools in the Pain Management Toolbox

A multimodal approach to managing chronic pain often involves “layering” options that range from conservative to highly interventional. Conservative management-The least invasive options for many patients include first-line therapies such as topical analgesics, physical therapy, acupuncture, chiropractic, transcutaneous electrical nerve stimulation (TENS) therapy and massage therapy. For some patients experiencing mild or temporary pain states, these interventions can be enough to manage the problem. For individuals who experience ongoing pain, these interventions can be helpful adjunctive therapies alongside other more intensive approaches.

Medication management- Depending on the type of pain and its severity, doctors may opt for either short- or long term use of over-the-counter medications like nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, anticonvulsants, neuropathic agents and in severe cases, opioids. While these medications can provide short-term relief, they may not be sufficient to manage chronic pain.  Regarding the use of narcotic pain relievers (such as fentanyl, buprenorphine, oxycodone, hydrocodone, hydromorphone, morphine and methadone), and practitioner education in the last few years has been extensive.  Education has reduced the number of opioid prescriptions and underscored their use as a tool for management of acute pain, which is their primary indication. There is considerable research showing that the use of opioids for chronic pain does not provide substantial benefit beyond the acute care period. Most providers are increasingly aware of this, and educating their patients about opioid risks and benefits is an ongoing responsibility of all physicians.  There are several non-narcotic prescriptions which can be used to manage chronic pain. The group of gabapentinoids (gabapentin and pregabalin) can be particularly effective, especially for neuropathic pain. Another commonly used medication is duloxetine, a serotonin and norepinephrine reuptake inhibitor, often used for neuropathic pain in combination with gabapentin. For myofascial pain, muscle relaxers such as tizanidine, baclofen, and cyclobenzaprine can be helpful for certain patients.  Medical cannabis is increasingly understood to be useful for select patients, with about a 50–60% reported success rate in reducing pain. Anecdotally, people who have previously used marijuana recreationally seem to respond well to it in a pain management context, because they understand what having cannabis in their system feels like. Other patients who have not used cannabis previously may not care for the side effects and therefore not report such positive results. In general, though, many physicians and patients agree that cannabis can be helpful to try in low doses and safely ingested in oral form. A comprehensive, multidisciplinary pain practice typically has physicians who can certify patients for medical cannabis.

Interventional Therapies

There are several interventional procedures that can be effective in addressing chronic pain, starting with local injections in the joint, spine or nerves. These can be trialed as part of a treatment plan for certain types of chronic pain, particularly in cases where the specific sources of pain have been identified. For example, injections can treat arthritis, nerve blocks can relieve neuropathic pain and epidural steroid injections can assuage radicular back and neck pain. When combined with physical therapy, these targeted treatments may help reduce inflammation and improve mobility. In cases where injection therapy does not prove adequate for ongoing pain relief, other advanced interventional  50 million adults in the U.S.— more than one in five— report experiencing pain every day or most days.  Therapies may be utilized. The technology and practice of implantable pain control devices is advancing rapidly, with life-changing outcomes for many more patients than ever before. These devices deliver very low doses of specifically targeted pain relief around the clock and present less risk of addiction and fewer side effects, removing concerns around either forgetting to take or taking too much medication. Peripheral nerve stimulation (PNS) therapy delivers an ongoing series of electrical pulses to a targeted area of a peripheral nerve, reducing the pain signals that are sent from the body to the brain.  For other cases, spinal cord stimulation (SCS) can be an effective solution. SCS therapy also uses electricity to modulate the way pain signals are sent from the body to the brain, with the modulation being done at the level of the spinal cord. One of the most common indications for SCS is “failed back syndrome”: people who have had surgery on their back but continue to have low back pain and possibly leg pain. SCS therapy can also be used for other indications, such as painful neuropathies including diabetic neuropathy and alcohol-induced neuropathy, as well as complex regional pain syndrome involving chronic arm or leg pain that develops after injury or illness. The data supporting use of spinal cord stimulation for chronic pain is favorable. The technology of today has greatly improved compared to even five or ten years ago, and results are getting better. Neuromodulation does not work for every patient, however, and we don’t ever promise or expect 100% pain relief; the goal is typically a 50–75% reduction in pain, enough to improve comfort, mobility and quality of life. In some cases where systemic medications, surgeries, interventional procedures and neuro-stimulation implants have failed, pain specialists may recommend an intrathecal drug delivery system, also known as a pain pump. The pain pump is surgically implanted in the abdomen or upper buttock and delivers a steady supply of medications directly into the intrathecal space where the spinal cord is located. The medications—typically a combination of an opioid and a local anesthetic—can be provided in very low doses, directly at the site of where those medications work on the spinal cord. Intrathecal drug delivery is sometimes referred to as a targeted drug delivery because it primarily targets spinal binding sites for pain relief, bypassing the blood brain barrier by infusing the therapeutic agents into the cerebrospinal fluid. Because of the targeted delivery, it reduces the mental side effects associated with systemic opioid management. Intrathecal drug delivery has flourished since its inception because it is uniquely effective. Many experienced pain physicians consider it to be “the best therapy for the worst pain.”

Physical and Behavioral Therapy

In conjunction with other interventions, it is paramount for pain management physicians to utilize physical and behavioral therapy as part of the treatment plan for chronic pain patients when indicated. Physical therapists can teach patients exercises that focus on posture, mobility, balance and strength-building that can provide long-term relief from chronic conditions like arthritis, fibromyalgia and low back pain. Behavioral therapy can also help patients address underlying mental health issues that commonly go hand in hand with chronic pain. When patients have depression or anxiety that is not well controlled, their chronic pain is often quite challenging to treat effectively.

Referring to a Pain Specialist

Gaining control over a patient’s chronic pain can present a real challenge to primary care physicians and other general practitioners. Faced with a patient that proves refractory to usual treatments, doctors may consider referring the patient to a specialist in pain management. Primary care clinicians should be aware of their options for referring a patient suffering from chronic pain in order to provide them with the best hope for achieving long-term relief. An experienced specialist may be able to tailor treatments specifically targeted for their patient’s condition, which can be invaluable when handling complex cases such as chronic pain conditions.  Chronic pain is challenging to treat.  As opposed to acute pain, wherein physicians often know the etiology of a patient’s pain, chronic pain often requires a more extensive workup to identify the source or sources of a patient’s painful condition. This can be especially true when it comes to spinally mediated pain, which is the most common complaint chronic pain physicians encounter.  The spine is a complex anatomic structure. The task a pain specialist undertakes is to find out what may be causing the pain, utilizing advanced imaging, tests and interventional therapies, which are often diagnostic as well as therapeutic.  When a patient is initially seen by a pain specialist, the physician takes a full history, reviews the referring provider’s notes and any diagnostic results to date. As previously mentioned, physical therapy is often a first line intervention for patients. If psycho-social stressors are present, behavioral health consultation is warranted. Additional workup such as diagnostic tests and imaging will then be considered if indicated. Once this workup has been initiated, the pain physician can hopefully find the source of the chronic pain and begin interventions and allied therapies in a more targeted approach. This all happens concurrently with the patient working with physical therapy, seeing a behavioral health therapist, and optimizing a medication regimen along the way as indicated. A comprehensive pain clinic often has physical therapy and behavioral health specialists on site as a part of their practice and can offer a multidisciplinary approach to chronic pain under one roof. 


A Focused, Intensive Approach

Many pain specialty practices offer a chronic pain program— an intensive, focused initiative designed for patients who may have exhausted their therapeutic options, are no longer seeking a specific diagnosis or additional interventions, and are simply living with chronic pain they are likely to have for the rest of their lives. Our program, and programs like it around the country, combine education with physical and behavioral therapy. Patients learn principles for self-management: quality nutrition, good sleep hygiene, smoking cessation, benefits of exercise in improving mental and physical health—basically how all the components of their own behaviors are going to help them manage their pain better and improve their quality of life. These programs are usually quite intensive, with patients coming every day or several days a week for the duration of the program, which may be four to eight weeks in length. Educating Patients and Setting Expectations When we think of patients achieving relief from their chronic pain, we typically mean their pain has become minimal enough that it doesn’t unduly affect their daily life. Chronic pain is challenging to treat; the longer the body experiences a hyper-excitable state while in pain, the more the brain remodels and adapts to the chronic pain state. This phenomenon is known as central sensitization and can present as a vicious cycle which can be hard to break. Breaking this cycle is what a pain specialist’s care team works toward. A key part of chronic pain management is educating patients about their health and their options, making sure they understand time to therapeutic effects, setting realistic expectations for each modality and helping them play a positive role in their pain relief journey.

Today more than ever before, there are options that can help nearly every patient. Taking a multimodal, multidisciplinary approach gives us the greatest chance of achieving significant pain management and improved quality of life.

Cody Foster, MD, practices at Nura Pain Management and is board certified in Anesthesiology and Pain Medicine

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From the moment you arrive, it's evident that this is not just a place of treatment but a haven for holistic healing.Expertise That Matters:At the core of Nura's ethos lies an unwavering commitment to excellence in care. Every member of the clinical team is not just highly skilled but deeply compassionate, embodying the belief that healing is as much about empathy as it is about expertise. Led by a cadre of distinguished physical therapists, each with a wealth of experience and a passion for innovation, Nura Pain Clinics sets the standard for quality care in the field of pain management.Tailored Solutions, Personalized Care:No two individuals are alike, and at Nura Pain Clinics, the approach to treatment reflects this fundamental truth. Here, there are no one-size-fits-all solutions; instead, every patient receives a bespoke treatment plan tailored to their unique needs, goals, and circumstances. Whether recovering from injury, managing a chronic condition, or seeking to optimize physical performance, clients can expect personalized care that honors their individual journey to wellness.Cutting-Edge Techniques, Timeless Wisdom:Innovation is the lifeblood of progress, and Nura Pain Clinics stands at the forefront of the latest advancements in physical therapy. From state-of-the-art equipment to cutting-edge techniques, the clinic embraces technology as a tool for empowerment, enhancing the efficacy of treatment while minimizing discomfort and downtime. Yet, amidst this commitment to innovation, Nura remains rooted in timeless principles of healing, drawing upon centuries-old practices and wisdom traditions to inform its approach.A Multidisciplinary Approach:True healing extends beyond the confines of a single discipline, recognizing the interconnectedness of body, mind, and spirit. At Nura Pain Clinics, this understanding is reflected in a multidisciplinary approach that integrates various modalities of care, from physical therapy and chiropractic care to acupuncture, massage therapy, and beyond. By harnessing the synergies between these diverse disciplines, Nura offers comprehensive solutions that address the root causes of pain and promote lasting vitality.Empowering Education:In the journey toward wellness, knowledge is power, and at Nura Pain Clinics, education is regarded as an essential component of healing. Patients are not mere recipients of care but active participants in their own health journey, empowered with the understanding and tools needed to make informed decisions and cultivate sustainable habits. Through workshops, seminars, and one-on-one consultations, Nura equips individuals with the insights and strategies they need to reclaim agency over their health and well-being.Community-Centric Care:Beyond the confines of its clinical walls, Nura Pain Clinics is deeply embedded in the fabric of its surrounding communities. Whether through outreach programs, partnerships with local organizations, or participation in community events, the clinic is committed to fostering wellness on a broader scale. By nurturing connections and building bridges within and beyond its geographical boundaries, Nura strives to create a ripple effect of health and healing that extends far beyond its immediate sphere of influence.A Legacy of Transformation:For those who have walked through its doors, Nura Pain Clinics is more than a healthcare provider; it's a catalyst for transformation. Here, lives are not just restored but revitalized, as individuals discover newfound strength, resilience, and joy in the journey toward wellness. With each success story and every milestone achieved, Nura reaffirms its mission to be a beacon of hope and healing in a world too often overshadowed by pain.In Conclusion:In a world where pain is all too prevalent, Nura Pain Clinics stands as a testament to the power of compassion, expertise, and innovation in the pursuit of healing. From its serene ambiance to its personalized approach, from its cutting-edge techniques to its timeless wisdom, every aspect of the clinic is crafted with one goal in mind: to empower individuals to live their lives to the fullest, free from the constraints of pain. As a pioneer in the field of physical therapy, Nura is not just transforming bodies; it's transforming lives, one step at a time.

Nura Pain Clinic

Pain Management 7400 France Avenue South, Edina, Minnesota, 55435

Nura Pain Clinics: Redefining Pain Management with Compassion and ExpertiseIn a world where the specter of pain looms large for so many, Nura Pain Clinics emerges as a beacon of hope and healing, dedicated to transforming the landscape of pain management. Founded on the principles of compassion, expertise, and innovation, Nura is more than just a clinic; it's a sanctuary where individuals find solace, support, and solutions on their journey toward relief and recovery.A Sanctuary of Healing:Step into the tranquil embrace of Nura Pain Clinics, and you're immediately enveloped in an atmosphere of warmth and reassurance. The clinic's ambiance is carefully curated to soothe the senses, with soft lighting, calming colors, and the gentle murmur of flowing water creating a haven of tranquility amidst the chaos of everyday life. Here, amidst the hustle and bustle of modernity, individuals find respite from the burdens of pain, welcomed with open arms into a space where healing is not just a goal but a guiding principle.Expertise That Inspires Confidence:At the heart of Nura Pain Clinics lies a team of dedicated professionals, each a beacon of expertise and compassion in their respective fields. Led by renowned pain management specialists, the clinical staff at Nura brings together a wealth of knowledge, experience, and skill to bear on the complex challenges of pain. From board-certified physicians to highly trained nurse practitioners, physical therapists, and holistic wellness practitioners, every member of the Nura team is united by a singular purpose: to provide the highest standard of care with unwavering compassion and integrity.Comprehensive Care, Tailored Solutions:Pain is as diverse and multifaceted as the individuals who experience it, and at Nura Pain Clinics, the approach to treatment reflects this fundamental truth. Here, there are no one-size-fits-all solutions; instead, every patient receives a comprehensive evaluation and a personalized treatment plan tailored to their unique needs, goals, and circumstances. Whether managing acute pain, chronic conditions, or the complex interplay of physical and emotional distress, clients can expect compassionate care that addresses the root causes of pain while promoting holistic well-being.Innovative Techniques, Evidence-Based Practice:In the pursuit of pain relief, innovation is key, and Nura Pain Clinics stands at the forefront of the latest advancements in pain management. From cutting-edge procedures and minimally invasive interventions to evidence-based pharmacotherapy and integrative therapies, the clinic offers a comprehensive array of treatment options designed to alleviate pain, restore function, and improve quality of life. Yet, amidst this commitment to innovation, Nura remains grounded in the principles of evidence-based practice, ensuring that every treatment modality is rigorously evaluated for safety, efficacy, and long-term outcomes.