Holistic Management of Chronic Back Pain - Research Paper Example

Holistic Management of Chronic Back Pain Aims and Objectives The aim of this study is to ascertain strategies to manage chronic back pain in relation to holistic nursing practice. The objectives of this study are to determine exercise-oriented comprehensive holistic management of chronic back pain by nurses through literature review. Research question How can chronic back pain be managed through exercise-oriented holistic approach by nurses? Background and rationale Chronic pain is a major health challenge affecting many people in the world. It is one of the most common reasons people seek medical attention. It is caused by different etiologies and in many conditions there may be no definite treatment (Farkas, 2005). Even in cases where successful treatment modalities are available, the need for adjuvant therapies may arise. Chronic pain not only cripples the individuals physically but also has negative effects on the social, emotional, spiritual, psychological and financial well-being of the individuals. It can critically affect the quality of life. Hence, management of chronic pain involves addressing of the human being 'in-total' and not just the 'part of body' which is causing pain (Farkas, 2005). Such an integrated approach is possible through understanding of holistic nursing. Holistic nursing may be defined as “all nursing practice that has healing the whole person as its goal” (AHNA, 1998). This form of nursing is a speciality practice which employs nursing theories, knowledge, intuition and expertise to guide nurses for proper therapeutic care of people. Holistic nursing. A holistic nurse is one who can be an instrument in healing and who can be a facilitator in the process of healing (AHNA, 1998). For this purpose the nurse may have to integrate complementary or alternative modalities of treatment into current clinical practice to meet the spiritual, physiological and psychological needs of the patient (Frisch, 2001). Pain is a symptom of injury or illness in the part of the body from where the pain arises. Pain may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP, 1986; cited in NHS, 2006, p.3). When the onset of pain is sudden and lasts for a brief duration, it is called acute pain. When pain lasts more than 3 months, it is known as chronic pain (Farkas, 2005). Many authors prefer to use 6 months as the cut-off time for chronic pain (Farkas, 2005). Some suggest that any pain that is persisting longer than the expected healing time for the tissues involved should be considered as 'chronic' (Farkas, 2005). According to IASP (1986; cited in NHS, 2006, p.4), chronic pain is "pain without apparent biological value that has persisted beyond normal tissue healing time". As discussed before, for those with terminal illness, holistic approach of pain management is crucial. The most widely employed method of pain relief is pharmacotherapy. There are many categories of medicines available to bring about pain relief. WHO's Pain Relief Ladder (WHO, 2009) is a useful guide to prescribe pharmacotherapy for pain. There are 3 steps in this ladder and the lowest step is that of mild pain. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The uppermost step is that of severe pain. This pain interferes with most of the daily living activities. The individual may need treatment for many weeks, months or even years. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan, Librach & Beyene, 2004). These medications are of no treatment value in neuropathic pain (Regan, 2000). If treatment with above medications is not effective, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. Generally, pain is associated with anxiety and fears, adjuvants like anti-anxiety drugs may be given. Anticonvulsants like gabapentin, pregabalin, topiramate, lamotrigine, tiagabine, zonisamide and clonazepam are useful to control pain in some neuropathic conditions (Poole, 2008). Certain anti-depressants like amytriptyline, nortriptyline and fluoxetine are useful adjuncts in chronic pain management. Drugs given to relieve pain must be given every 3-6 hours, round the clock. According to the WHO, the 'ladder approach' treatment allows a patient to get the right drug with the right dose at the right time in the most effective manner and at the least possible cost (WHO, 2009). This ladder has been declared useful even by SIGN (SIGN, 2008). For those who have failed to respond to medical therapy, non-pharmacological modes of treatment may be tried. Radiation therapy is an excellent and durable method of treatment for resistant metastatic bone pain (Regan, 2008). Pain which is not responsive to medicines or radiation therapy (for bone cancer pain), must be treated with surgical methods. Bone pains of cancer, neuropathic pains and visceral organ pains in malignancy will need surgical intervention for relief of pain at some stage or the other (Regan, 2008). Surgical implantation is one such method. Intrathecal delivery involves creation of small pocket under the skin in which an infusion pump is placed that delivers pain-relieving drug into the intrathecal space by means of a catheter (Mitten, 2001). This mode of drug delivery involves lesser dosage of medication and thus there are fewer side effects. In spinal cord stimulant implantation, low-level electrical signals to block specific nerves in the spinal cord are sent by a surgically-implanted device in the body so that pain signals are not transmitted to the brain and is useful in neuropathic conditions (Brenman, 2007). Injection of local anesthetics into nerves or their plexus with or without steroids can decrease pain for some time. One good example of this technique of pain relief is regional blocks using epidural steroid injections for leg pain due to radicular referred pain (Callin and Bennett, 2008). Other than pharmacological, radiotherapy and surgical intervention, there are many other approaches to pain relief. Regular exercise improves muscle tone, flexibility and strength and thus can diminish pain in the long run. Exercise is said to act by causing release endorphins which are natural pain killers of the body. Some of the useful forms of exercises are yoga, walking and swimming (Brenman, 2007). Other than exercise, there are many alternative therapies that have come up for the treatment of chronic pain though there is not much evidence to support these forms of treatment; the therapies claim to alleviate pain. Mind-Body therapies are the most common non-pharmacological approaches to chronic pain. These therapies adopt the mind's ability to take over the symptoms of the body. Some of the therapies which fit into this category are meditation, relaxation techniques, biofeedback, guided imagery, visualization and hypnosis. In visualization, the patient is asked to close his/her eyes and makeup a visual image of pain by creating a shape and size and adding color and motion to it. Then, this image is gradually replaced with a much more pleasant image and of smaller size. In electromyographic feedback, there is information about muscle tension in the body, so that the patient learns to control the muscle tension, thus alleviating pain. Self hypnosis and hypnotherapy decrease pain by blocking pain by means of refocusing strategies. Meditation and yoga are relaxation techniques and they are more useful in stress-related pain. Yoga also gently strengthens the muscles of the body (Brenman, 2007). Nurses are essential in the diagnoses and treatment of pain in all types of settings of health care. Since they are closest to the patients, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of chronic pain. Nurses can be the first persons to evaluate pain and then can advise the treating physician whether the pain remedy advocated was appropriate. Nurses can also evaluate the effects of the medications prescribed after the patient uses the medicines. Nurses must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When a patient reports side effects, the nurse must record, manage and monitor the symptoms, guide physician about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as coordinators of different specialities by educate the patients about the dosage of the drugs and about the need for good pain control (Delphi Study, 2007). In this literature review, management of chronic back pain through exercise oriented therapy with reference to holistic nursing care will be discussed after review of suitable literature. Methodology and Search Strategy Articles were retrieved using electronic database PUBMED using the MESH terms "Chronic back pain" "treatment" and "exercise oriented". The search yielded 101 articles. Eight articles were selected from the search based on inclusion and exclusion criteria. the inclusion criteria were: 1. Only -English articles. 2. Articles beyond 2005. 3. Studies based on chronic back pain and exercise therapy. The exclusion criteria were: 1. Articles published in other languages. 2. Articles before 2005. 3. Articles dealing with pharmacotherapy only. The abstracts of the articles were reviewed and the following articles were selected for literature review. the framework used was synthesis matrix. Literature review In a study by Burnham et al (2010), the researchers conducted a prospective study to ascertain multidisciplinary methods of management of chronic back pain in a rural setting. The team consisted of "a family physician, psychiatrist, psychologist, physical therapist, kinesiologist, nurse and dietician" (Burnham et al, 2010). The outcomes of the study were reviewed after 18 months and the authors opined that multidisciplinary team approach is a very successful method of management of chronic pain even in rural settings. In a systematic review by Chou and Huffman (2007), the researchers reviewed systematic reviews and randomized controlled trials pertaining to therapies for acute and chronic back ache. Based on the "study designs, population characteristics, interventions, outcomes, and adverse events", data was synthesized using Oxman criteria. After data synthesis and analysis, the authors opined that "therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation." Thus both Burnham et al (2010) and Chou and Huffman (2007) opined that holistic comprehensive management of chronic back ache which is inclusive of exercise or physical therapy is beneficial in chronic back pain. In a study by Westrom et al (2010), the researchers conducted a randomized controlled trial in which 200 participants, all of who were adults were employed and subjected to 12 week intervention in the form of individualized chiropractic and integrated care for low back pain. The study is still going on, but as of now, it is evident that integrated approach is very useful for management of chronic back pain. In another study by Maiers et al (2007), the researchers conducted a couple of randomized controlled trials with primary aims to assess the relative clinical effectiveness of "1) manual treatment plus home exercise, 2) supervised rehabilitative exercise plus home exercise, and 3) home exercise alone, in terms of patient-rated pain" for elderly low back pain and neck pain patients. According to this study, comprehensive management is effective in the management of chronic back pain and neck pain. Ewert, Limm, Wessels, et al (2009) conducted a randomized controlled trial to compare general physical exercise program as against secondary prevention program for chronic low back pain. From the results of the study, it was evident that "multimodal program is not superior to a general exercise program in influencing the process leading to chronic LBP in a population of nurses with a history of pain." In another randomized controlled trial by Johnson et al (2007), the authors examined the effect of active exercise, education and cognitive behavioral therapy on patients with persisting low back pain. The results of the study revealed that such a combination program produces only modest effects and hence such interventions need to be instituted only after further investigation. Rasmussen-Barr et al (2009) conducted a randomized controlled trial to examine the "graded exercise intervention emphasizing stabilizing exercises in patients with nonspecific, recurrent low back pain." In their study, the researchers found that such an intervention was definitely more effective than the regular walks advised in terms of improvement in disability and decrease in pain. Similarly, Cairns et al (2006) conducted a randomized controlled trial to examine the effects of spinal stabilization exercises over conventional physiotherapy for patients with recurrent chronic back pain. The results of the study revealed that both forms of treatment were similar to each other with respect to improvement in disability and pain and hence it can be said that there is no additional benefit of advising spinal stabilization exercises to patients when conventional exercises are useful. Results While most of the studies advise on integrated approach of management of low back therapy with inclusion of exercise regimens or physical therapy, some researchers are of the opinion that simple conventional physiotherapy may be just as useful as comprehensive management of chronic back pain. On the whole, the studies ascertain the role of comprehensive exercise-based management of chronic back pain in the long run. The evidence from these studies can be used for practice because most of them are randomized controlled trials. Conclusion Chronic pain is a very common condition demanding medical attention. It affects all aspects of the human-being including physical, emotional, social, spiritual, financial, cultural and psychological domains. The etiology of chronic pain is diverse and proper assessment is crucial for appropriate management. Holistic approach is the most appropriate management for chronic pain, because this problem affects the whole body and concentrating on only the physical aspects of pain cannot provide wholesome treatment. Nurses play an important role in providing holistic care due to their proximity with patients. Nurses are in a position to evaluate response to treatment and thus can provide useful information for further improvements in treatment. While pharmacotherapy is the mainstay of treatment in most chronic pain conditions, certain non-pharmacological methods may be useful in a small portion of people either as main therapy or adjunct therapy. Nurses can identify such suitable candidates and help in proper management of the patient. 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