2.

2 Non pharmacological intervention:

Nonpharmacological interventions play a crucial role in the management of

pathological pain, offering a diverse range of approaches to alleviate pain.
Studies have highlighted the effectiveness of interventions such as exercise,
cognitive behavioral therapy (CBT), yoga, acupuncture, massage, mindfulness,
and relaxation techniques in improving pain intensity, functional disability, and
psychological well-being in patients with chronic pain (1). These interventions are
particularly valuable for individuals with opioid tolerance or abuse, providing
drug-free pain management options (2). Additionally, non-pharmacologic
therapies are recommended as first-line treatments for chronic pain in
populations like people with disabilities and older adults, emphasizing the
importance of understanding and utilizing these interventions for effective pain
management (3).

2.2.1 Physical Therapy And Rehabilitation:

Physical therapy modalities include pain modulators like hot and cold packs,
ultrasound, short wave diathermy, Transcutaneous electrial nerve stimulation
(TENS), and laser. Hot and cold applications can be used together as in contrast
baths. In all these superficial heat agents should not be applied in high degrees,
due to possible risk of increase in pain (4).

In general, deep heating agents like ultrasound and short wave diathermy are not
recommended in the treatment of neuropathic pain. They are helpful especially in
joint contractures, and adhesions. It increases flexibility of collagen fibers and
circulation of connective tissues which help functional restoration (4).

TENS is one of the best modalities that has been shown to be effective in the
treatment of neuropathic pain. It is suggested that TENS activates central
mechanisms to provide analgesia. Low frequency TENS activates μ-opioid
receptors in spinal cord and brain stem while high frequency TENS produces its
effect via δ-opioid receptors (5).
Laser is another physical therapy agent that can be used in the treatment of
neuropathic pain. Very low level of laser has been shown effective in patients
with neuropathic pain. When very low laser therapy is applied, it decreases pain
and inflammation, in addition to improving functional ability (6).

Rehabilitation is also an essential part of treatment in neuropathic pain. The main

aims of rehabilitation are to decrease pain and amount of medication, improve
dysfunction, increase quality of life and physical activity and bring the patient’s
self-esteem back. Although one of the major parts of rehabilitation methods are
therapeutic exercise, there are no sufficient evidence supporting this idea in the
treatment of neuralgia. Many kinds of therapeutic exercises have already been
used in the rehabilitation program such as conditioning, strenghtening and
stretching exercises. Kuphal et al. developed a neuropathic pain model in
rodents by making a peripheral nerve injury in their sciatic nerve and showed that
25 days of exercises in water and swimming decreased pain. In this study,
extended exercises in water and swimming have been shown reducing edema,
inflammation and peripheral neuropathic pain in this animal model (7).

2.2.2 Psychological Intervention:

Psychological intervention incorporated alongside medical treatments play a

crucial role in helping patients adjust to pain, They are also effective in reducing
fear and distress during painful medical procedures such as needle-related
intervention (8).

The most commonly used psychological intervention include behavioural

treatments and activation, CBT, hypnosis, relaxation and distraction. Behavioural
intervention attempt to reward healthy behaviours and punish or ignore unhealthy
ones. positive reinforcement of healthy behaviours such as making an extra effort
increasing physical activity and withdrawal of attention to reduce sick leave
behaviuor (8).

2.2.3 Complementary And Alternative Medicine.

Complementary and alternative medicine comprises several approaches, but not
limited to natural products (e.g., herbs, probiotics, dietary supplements) and mind
and body practices (e.g., acupuncture, yoga, meditation, hypnosis) (9) .

Ginger has beautiful flowers but has been used as medicine by herbalists mostly
in India and China. It has uses for muscle pain and swelling, arthritis, headaches,
digestive and appetite problems, prevention of motion sickness, postoperative
nausea and vomiting, hyperemesis gravidarum, and also cold and bacterial
infections due to its anti-oxidant mechanism (10).

Curcuma longa contains an active compound called curcumin. It has traditionally

been used as an antiseptic, anti-inflammatory agent for wound healing as well as
an antioxidant and analgesic agent. Curcumin can regulate inflammatory
cytokines , With its anti-inflammatory effects, it has been used in autoimmune
diseases such as rheumatoid arthritis, inflammatory bowel disease, and multiple
sclerosis (10).

A dietary intake of omega-3 was demonstrated to help treat pain in conditions

such as rheumatoid arthritis, neuropathy, dysmenorrhea, and inflammatory bowel
disease. In patients with chronic pain, the levels of polyunsaturated fatty acids
are high, indicating a possible role in pain regulation . the combination of O3FA
and morphine in animal studies showed an additive anti-nociceptive effect, even
showing analgesic activity at a sub-therapeutic dose of morphine. Moreover,
chronic co-administration attenuated the development of tolerance to morphine
(10).

2.2.4 Neuromodulation Technique:

Spinal cord stimulation (SCS) of the dorsal columns located within the epidural
space has conventionally been believed to attenuate pain transmission by
inhibiting small nociceptive projections in the dorsal horn. In cases of traumatic
neuropathy and brachial plexopathy, the use of SCS carries a recommendation
with moderate certainty. Targeted drug therapy entails the direct delivery of
pharmacological agents to the dorsal horn of the spinal cord, thereby reducing
first-pass metabolism and enhancing potency. The current guidelines from the
American Pain Society (APS) suggest that there is insufficient evidence
supporting the use of intrathecal therapy for opioids or other alternative drugs in
non-radicular pain conditions. Recent studies suggest that targeted therapy may
be a viable option for patients requiring >50 morphine equivalent dose (MED) of
opioids, with a strong recommendation for its utilization if the requirements
exceed 90 MED (11)

Management of neuropathic pain is the most common reason for using

neuromodulation. As a therapy, this can be further broken down into SCS, DRG
stimulation and peripheral nerve stimulation (PNS).

Indications for neuromodulation have expanded to include axial back pain,

diabetic neuropathy, abdominal/pelvic pain, post-amputation pain, and
postsurgical pain syndromes including post-thoracotomy, post-inguinal hernia
repair, and post knee surgery pain (12).

The mechanism for neuromodulation’s therapeutic response is not fully

understood but Research has shown that neuromodulation results in local
changes of wide dynamic neuron excitability, facilitation of physiologic inhibition
mechanisms, and changes in activation of neurotransmitters including gamma
aminobutyric acid (GABA) (12).

Neuromodulation is now on the cutting edge of treatment as pharmacological

interventions have repeatedly failed with significant side effects and risks of
addiction (11).