Nonpharmacological Pain Management

Treating Pain with Heat and Cold

  • Application of superficial heat or cold treatments may reduce or relieve pain by decreasing sensitivity to pain, producing vasodilation (heat) or vasoconstriction (cold) and by altering blood flow. 
  • Heat therapy increases blood flow, metabolism, and the elasticity of connective tissue. Increased tissue temperature stimulates vasodilation promoting blood flow (nutrients and oxygen).  
  • Cold therapy down-regulates production of inflammatory and pain-inducing prostaglandins and diminishes the activation threshold of tissue nociceptors.


  • Aromatherapy is part of a complementary or integrative approach used to promote comfort or enhance well-being
  • Essential oils used for aromatherapy are made from the distillate from an aromatic plant or oil expressed from the peel of a citrus fruit
  • UCSF encourages use of hospital-endorsed aromatherapy products only 


Biofeedback is less a “treatment” than a training technique. It involves creating an information loop between a physiological variable and the person’s awareness. This facilitates learned control of some physiological function. 

Pain itself cannot be easily detected or fed back by instruments, but body conditions associated with the pain can be.  For instance, muscle tension can be monitored by surface EMG, with visual and/or auditory feedback displaying the tension in a particular muscle area. Bruxism, neck pain, and back pain are common applications. 

Pain reduction includes “suffering reduction” because emotional calm activates descending inhibitory tracts (anterior cingulate cortex, periaqueductal gray, ventromedial medulla, and dorsal horn of spinal cord). Suffering inhibits this pain suppression system. The suffering component is integral to pain intensity. 

NOTE:  if a patient has experience with meditation, breathing, or other relaxation techniques, they will often see the potential of biofeedback for measuring and sharpening their skills. However, if a patient is passively waiting for something to take the pain away, they may not value a “do-it-yourself” approach. 

Common Outcomes after some sessions of biofeedback focused on pain:

  • Better control over both pain intensity and response to pain (anxiety, depression, panic, anger)  
  • Reduced dependence on opioids and analgesics
  • Having something to practice and improve upon (body control of some type)
  • Improved quality of control over attention to pain, diminish anxiety and suffering


  • Mechanism of action: 
    • Acupuncture is a non-pharmacologic modality that can reduce pain, nausea, anxiety, improve sleep, reduce perioperative opiate use and enhance wellbeing.  It is an excellent modality to use in addition to standard of care for patient-centered symptom management.  
    • The practice of acupuncture involves the insertion of ultra-thin needles through the skin at specific points throughout the body.  
    • Acupuncture is often dismissed by clinicians because we are still elucidating its mechanism of action and multiple studies show comparability of verum to sham acupuncture (while many show superiority of verum).  In contrast, oral acetaminophen or paracetamol, outside of rare indications (migraines), is consistently shown to be similar to placebo in reviews for pain, has an unknown mechanism of action for pain relief, and leads to more presentations for acute liver failure than alcohol yet is first line for pain treatment.  It is difficult not to see the cultural bias.   
    • Acupuncture is thought to exert its health effects by multiple pathways: 
    1. By stimulating the central nervous system to release neurotransmitters and hormones.
    2. Through connective tissue mechanoreceptors via matrix deformation leading to neuromodulation.
    3. In the tradition it comes from, acupuncture is used to balance the flow of qi or chi (often translated as ‘vital energy’ or ‘life energy’) resulting in healing.

Vibration: Transcutaneous Electrical Nerve Stimulation (TENS)

  • Transcutaneous Electrical Nerve Stimulation (TENS) transmits low-voltage electric current of different frequencies through the skin to affect peripheral nerves for therapeutic purposes, such as relieving pain.
  • A TENS unit consists of a battery-powered device that delivers electrical impulses through electrodes placed on the surface of the skin at or near nerves where the pain is located or at trigger points.

Mechanism of Action:

  • TENS may modulate or suppress pain signals in the brain.  Pain reduction or pain relief is achieved by:  
    • High frequency pulses: Suppressing the transmission of pain in nerves (the electrical pulses prevent communication between peripheral nerves and the brain)
    • Low frequency pulses: Stimulate the release of beta endorphins