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These are some of the

treatment options our patients use, along with their pain medicine, to get better results.


Our experience has shown that all of our patients

won't need all of these therapies, but....


Most of our patients will

need most of these therapies.





Aerobic Exercise. Our standard is 150 minutes of moderate aerobic exercise (walking) or 75 minutes of vigorous (jogging), or the equivalent, each week. Low endorphin levels cause chronic pain and depression 

(3). Aerobic exercise increases endorphins, resulting in less pain and depression, even for people with chronic pain (4). A recent medical study of 866 seniors followed for 14 years found that the seniors who engaged in regular aerobic exercise had a substantial reduction in musculoskeletal pain (5).





Sleep Correction. The standard is eight hours of quality sleep per night, or to get adequate sleep, which means waking feeling rested and not being sleepy during the day. Sleep deprivation causes peoples pain to intensify and makes pain 

medications less effective (6). 

Tobacco Cessation. Our standard is to be nicotine-free. Smokers have more pain and medical studies prove that pain medications don't work as well for smokers as nonsmokers (7). Quitting smoking promotes improvements in the back and leg pain of spinal disorders. Those who quit smoking have more reduction of pain in comparison to those who continue to smoke (8).

Participation. This means participating in the activities that are normal for the patients age such as raising children or working at a job, or active participation in hobbies for people of retirement age. Even people on “disability” can find volunteer positions that are compatible with their “ability”. The goal for adults who are not raising children is to work or volunteer at least 20 hours per week. Many health care providers consider participation to be the outcome of a successful treatment program. We have reclassified participation as a necessary treatment in our pain management program.There is strong evidence that unemployment is harmful to health, leading to higher mortality, poorer general health, more aches and pains, poorer mental health and increased utilization of medical services (9,10). On the other hand, there is strong evidence that working, or returning to work, is good for physical and mental health, i.e. work is therapeutic (11). Large studies have shown that activity-based rehabilitation and early return to work (or remaining at work) are therapeutic and beneficial for health and well-being for most workers with musculoskeletal conditions (12).

Adjuvant Medications. This includes the use of any medication, other than opioids, that may benefit the patient’s pain, such as tricyclic antidepressants, 

serotonin noradrenergic receptor inhibitors (SNRI’s), antiepileptic drugs and muscle relaxants. If a patient is depressed, sleep-deprived, and has too much pain, we may consider bedtime doses of mirtazapine, amitriptyline or trazodone, any one of which might benefit the sleep, depression and pain. If muscular spasms and pain are interfering with their sleep, we might prescribe a bedtime dose of tizanidine. Patients with neuropathy and insomnia may receive gabapentin. Topiramate may benefit neuropathic pain and migraines (13).

Natural Medications. There is enough published research that many natural medicines can now be prescribed based on solid medical evidence. A review of 17 studies confirmed that omega-3 fatty acids (fish oil concentrates) decrease the joint pain and stiffness of arthritis, causing patients to use less drugs like aspirin and ibuprophen (14). A meta-analysis of the herb Harpagophytum procumbens showed that it reduced back pain and arthritic knee pain (15). A double-blind study of the active ingredient of Harpagophytum showed significant reduction of chronic back pain (16). After 90 days of a double-blind, placebo-controlled trial for arthritis of the knee, patients taking the active ingredient of the herb Curcuma were able to walk 209 minutes longer than those receiving only standard medical care, before knee pain made them stop (17). A combination of two herbs (Curcuma and Boswellia) in a 30-day comparison trial, was more effective for the pain of knee arthritis than 100 mg of celecoxib (Celebrex) twice a day (18).

Topical Therapy. This includes any treatment the patient can apply to their skin to benefit their pain, including transcutaneous electrical nerve stimulation (TENS) therapy. There are a number of prescription patches, gels, and lotions that the FDA has approved as being effective for pain. Compounding pharmacies can supply many custom formulas for chronic pain. Over-the-counter (OTC) salicylate products are often overlooked, yet controlled trials indicate they are effective for chronic pain conditions (19). TENS therapy increases endorphins with resulting pain reduction (20).

Manual Therapy. This includes any hands-on treatments, including massage, manipulation, chiropractic, physical therapy or acupuncture. When added to ‘best medical care’, spinal manipulation reduces chronic back pain and improves back function, and massage has been shown to reduce chronic neck and low back pain (21). Acupuncture increases endorphins and is effective for chronic low back pain and works even better when added to other therapies (22, 23).


: 3. Almay BG, Johansson F, Von Knorring L, Terenius L, Wahlström A. Endorphins in chronic pain: Differences in CSF endorphin levels between organic and psychogenic pain syndromes. Pain. 1978;5(2).

4. Allen M. Activity-generated endorphins: A review of their role in sports science. Can J Sport Sci. 1983;8(3).

5. CHRONIC PAIN MEDICAL TREATMENT GUIDELINES Chronic Pain Medical Treatment Guidelines 8 C.C.R. §§9792.20 – 9792.26 MTUS (Effective July 18, 2009) Page 47 of 127.

6. Kundermann B, Krieg JC, Schreiber W, Lautenbacher S. Pain Res Manag. 2004;9(1):25-32.

7. Ackerman WE. The effect of cigarette smoking on hydrocodone efficacy in chronic pain patients. J Ark Med Soc. 2012 Oct;109(5):90-3.

8. Spine patients who quit smoking report diminished pain. ScienceDaily, Presented 19 Mar. 2013 at the 1013 annual meeting of the American Academy of Orthopaedic Surgeons. Published on the web 30 Oct. 2013.​

9. Waddell G, Burton AK. Is work good for your health and well-being? Cardiff University, UK: Centre for Psychosocial and Disability Research. 2006 

12. Chang V, Gonzalez P, Akuthota V. Evidence-informed management of chronic low back pain with adjunctive analgesics. Spine J. 2008;8(1):21-27.

13. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain. 2007 May;129(1-2):210-23.

14. Di Lorenzo C, Dell'agli M, Badea M, et al. Plant food supplements with anti-inflammatory properties: A systematic review (II). Crit Rev Food Sci Nutr. 2013;53(5):507-516.

15. Di Lorenzo C, Dell'agli M, Badea M, et al. Plant food supplements with anti-inflammatory properties: A systematic review (II). Crit Rev Food Sci Nutr. 2013;53(5):507-516.

16. Chrubasik S, Zimpfer Ch, Schütt U, Ziegler R. Effectiveness of Harpagophytum procumbens in treatment of acute low back pain.Phytomedicine. 1996;3(1):1-10.

​17. Belcaro G, Cesarone MR, Dugall M, Pellegrini L, Ledda A, Grossi MG, Togni S, Appendino G. Product-evaluation registry of Meriva®, a curcumin-phosphatidylcholine complex, for the complementary management of osteoarthritis. Panminerva Med. 2010 Jun;52(2 Suppl 1):55-62.

18. Kizhakkedath R. Clinical evaluation of a formulation containing Curcumalonga and Boswellia serrata extracts in the management of knee osteoarthritis.Mol Med Rep. 2013 Nov;8(5):1542-8. doi: 10.3892/mmr.2013.1661. Epub 2013 Aug 29.

19. Moore RA, Edwards JE, McQuay HJ, et al. Systematic review of efficacy of topical rubefacients containing salicylates for the treatment of acute and chronicpain.Brit Med J. 2004; 328:995. doi.10.1136/bmj.38040.607141.EE.

20. Clement-Jones V, McLoughlin L, Tomlin S, Besser GM, Rees LH, Wen HL.Increased beta-endorphin but not met-enkephalin levels in human cerebrospinalfluid after acupuncture for recurrent pain. Lancet. 1980;2(8201):946-9.7

21. UK BEAM trial team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: Effectiveness of physical treatments for back pain in primary care. Brit Med J. 2004;doi:10.1136/bmj.38282.669225.AE (published 29 November 2004).

22. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18(3). doi: 10.1186/1746-1340-18-3.

23. Imamura M, Furlan AD, Dryden T, Irvin E. Evidence-informed management of chronic low back pain with massage. Spine J. 2008;8(1):121-133.

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