A debate on integrative vs. interventional approaches to chronic pain: does telemedicine play a role?

Introduction

The biopsychosocial model of pain emphasizes that pain experiences and perceptions are influenced by a complex interplay of biological, psychological, and socio-environmental factors. Conventional pain management approaches often prioritize pharmacological treatments and invasive interventions to target pain anatomically and neurochemically. These methods typically focus on symptom management rather than addressing the underlying causes of pain. Integrative medicine, on the other hand, proposes a holistic approach that combines conventional medical treatments with lifestyle interventions and non-conventional therapies. This approach aims to treat the “whole person”, addressing physical, emotional, and social aspects of health, rather than solely focusing on symptoms. Given the expanding understanding of the multidimensional nature of pain, there is a growing belief among pain physicians about the incorporation of lifestyle medicine into pain management practices. Lifestyle medicine emphasizes factors such as nutrition, exercise, stress management, sleep hygiene, and social connectivity, which have been shown to play significant roles in pain modulation and overall well-being. For instance, specific dietary patterns can reduce inflammation, physical activity can alleviate chronic pain symptoms, and stress reduction techniques can improve pain tolerance and mental health. Should pain physicians expand their repertoire of medical intervention by integrating lifestyle medicine during consultations for pain management? In this article, the authors debate whether pain physicians should develop an integrative approach incorporating lifestyle medicine in pain treatment or focus on conventional interventions. The role of telemedicine will also be investigated.

Discussion

Integrative management of chronic pain

Lifestyle medicine is an evidence-based approach to healthcare that aims to improve patient outcomes by implementing lifestyle changes. Cultural factors have influenced various definitions of lifestyle medicine around the world, but six pillars remain central to the concept (Figure 1). Adopted by the American College of Lifestyle Medicine (ACLM), the only medical association that represents the field of lifestyle medicine, these pillars are nutrition, physical activity, stress management, avoidance of toxic substances, sleep, and social connections (1). Each of these may play a critical role in the biopsychosocial experience of pain. Treatment plans based on a holistic understanding of a patient including their lifestyle place patients at the center of their healthcare making them the drivers of their own health rather than being passive recipients of healthcare. The goal is to empower patients to adopt prescriptive lifestyle changes that will mitigate disease and symptoms with minimal reliance on medications and invasive interventions.

Figure 1 Pillars of lifestyle medicine.

Chronic pain rarely occurs in isolation. In most patients, pain occurs in the presence of other illnesses that also increase morbidity or mortality (1). These conditions have markers that stem from common metabolic or genetic etiologies and even from the commonalities of health inequities (2). Several chronic pain conditions including spinal pain, osteoarthritis, and fibromyalgia are experienced more frequently in patients with obesity (2). It is becoming clear that even with a normal body mass index (BMI), the distribution of visceral and abdominal fat may serve as a marker for pain and metabolic disease (2). While a BMI just short of 30 kg/m² is associated with a 20% higher incidence of pain a BMI >40 kg/m² skyrockets that risk to 254%. This is seen across ages and in animal models (2). Obesity in humans and in animals has been linked to a notable loss of axonal regenerative capacity with small fiber loss (3). In the laboratory setting, obese rats demonstrated more inflammation and hyperalgesia compared to lean rats (3). Excess white adipose tissue is an active endocrine organ that produces leptin, tumor necrosis factor (TNF), and adipokines that induce cytokine release from T cells and recruit M1 macrophages to signal an inflammatory cascade. It also increases inducible nitric oxide synthase (iNOS) expression to release proinflammatory inducible nitric oxide (iNO) in glia, neurons, and endothelium, which are implicated in migraines and neurodegenerative disease (3). Metabolic health and pain are closely interlinked. There is evidence that nutrition plays a role in mediating chronic inflammation and exacerbates pain through the activation of immune mediators which activate nociceptive nerve fibers implicated in pain sensations (1). It stands to reason then that a comprehensive approach to pain management should emphasize nutrition that may reduce inflammation and oxidative stress on the body. Thus, the focus of nutritional recommendations is to decrease proinflammatory eicosanoids, increase serotonin synthesis, decrease mitochondrial damage, modulate toll like receptors and manipulate nutrigenomics with the goal of reducing inflammation that accentuates pain responses (4).

Physical activity has a beneficial impact on patients with chronic pain as well. Multimodal exercise regimens have been shown to be effective at significantly reducing pain in patients with common chronic pain pathologies such as osteoarthritis, rheumatoid arthritis, chronic lower back pain, and fibromyalgia (5). One study found that individuals with fibromyalgia who underwent aerobic exercise were found to have significantly reduced nonsteroidal anti-inflammatory drug (NSAID) use (6).

Additionally, physical activity and prescriptive exercise modalities may serve to improve tissue pliability, mobility, balance, strength, and range of motion in patients with pain (7). These benefits of physical exercise may be modulated by increased endogenous serotonin, serotonin receptors, and opioids which help inhibit pain pathways in the brain (7).

Sleep is an important pillar of lifestyle medicine with a profound impact on chronic pain. Disordered sleep is present in 67–88% of chronic pain disorders and at least 50% of patients with chronic insomnia suffer from chronic pain (8). From a physiologic perspective, impaired sleep dampens pathways that primarily have analgesic effects such as the opioid, melatonin, and dopamine systems while accentuating pathways that increase pain sensitivity such as the inflammatory immune system pathways (9). The relationship between sleep and pain is bidirectional. Experimental sleep fragmentation which disrupts rapid eye movement (REM) sleep has been shown to increase spontaneous pain experience as well as heightened pain perception (8). Similarly, experimentally induced sleep deficit has been associated with the development of spontaneous pain and hyperalgesia (8). Consequently, it stands to reason that prescriptive lifestyle measures that improve sleep may meaningfully decrease pain perception.

In recent years, chronic stress has been implicated in disease progression in a multitude of pathologies as well as increased mortality (1). It induces inflammatory macrophages, increases cytokine release, decreases adiponectin, and through these mechanisms induces metabolic maladaptation, neurotransmitter imbalances, and sets the inflammatory stage for neurodegeneration, cardiovascular disease, metabolic syndrome, and sleep issues. Several studies have implicated stress in the genesis of overall ill-health. Perceived stress can lead to stronger responses to pain due to the interconnectedness of pain pathways, emotional processing areas, and cognitive processing pathways in the brain (10). An integrative, lifestyle modification-based approach prescribes mind-body stress reduction practices ranging from movement-based stress reduction techniques, such as massage therapy, relaxation techniques, and mindfulness meditation, to help dampen stress effects. Stress management methods may yield significant reductions in pain and pain-related drug use. Additionally, these modalities may also decrease concomitant anxiety, and fatigue, and thereby improve a person’s overall sense of well-being (11).

It has long been established that tobacco, alcohol, and illicit drug use have injurious effects on health (1). Lifestyle medicine encourages the avoidance of tobacco products, limited alcohol use, the prevention of substance abuse, and reduction in exposure to environmental chemicals. Tobacco is notable for increasing pain sensitivity after long-term use due to tolerance and acute withdrawal (12). Additionally, substance use disorder patients have been found to have more oxidant and less antioxidant biomarkers. These levels lead to greater oxidative stress on the body resulting in greater inflammation and greater nociceptive fiber activation leading to increased pain perception (13).

Social connections play an essential role in overall well-being. Lifestyle medicine emphasizes the importance of building and maintaining strong social bonds and connectedness to the community. The literature supports its importance in the management of chronic pain as well (1). One study showed that individuals with greater social disconnection had more trouble gaining pain relief as compared to individuals with greater social connectedness (14). Additionally, having strong social support networks could help individuals reduce their stress levels and reduce pain perception in a nonpharmacological way (10).

There are limitations to the use of medications and injections for chronic pain conditions that clearly need a holistic approach to treatment. A comprehensive pain treatment program should be able to integrate multidisciplinary management of chronic pain through a focused incorporation of lifestyle medicine that incorporates aspects from each pillar. Ideally, this would improve patient outcomes and reduce adverse effects from interventional approaches.

Interventional management of chronic pain

Patients presenting in pain are often in distress and do not want to suffer. Rapid diagnosis and treatment are vital. There is no arguing the implication of lifestyle factors on the propagation of chronic disease and perhaps even the patient’s pain perception. Yet there are several limitations that preclude the application of lifestyle medicine by pain physicians during consultation. As pain physicians in the current healthcare model, consultative time is best spent in initiating treatments with meaningful perceivable benefits of analgesia. The practice of interventional pain medicine is based on the understanding of anatomical and neurochemical pathways that mediate and maintain pain. There is no dearth of publications establishing the utility and efficacy of interventional procedures and pharmacological management of pain. It is a laudable goal to integrate lifestyle medicine in the management of pain. However, it is outside the scope of most pain management practices to integrate lifestyle medicine in pain management. Within the current health care paradigm, most practicing physicians have not studied lifestyle medicine and had limited exposure to it in their medical undergraduate curriculum (1). Moreover, within the usual practice models there is limited time for each patient consultation, which hinders the physician’s ability to adequately address lifestyle factors (15).

Insufficient resources including efficient training programs, support systems, and reimbursement models challenge the effective integration of lifestyle medicine during routine pain consultation (16). Even though the greatest barriers are the current healthcare systems and culture, a subset of barriers stem from patients’ expectations at their consultative visit (17). Patients in chronic pain usually have emotional and physical barriers that challenge the adoption of significant lifestyle changes (17). They often have complex medical conditions that create stress and limit mobility, sleep, and diet (18). These patients are seeking respite from pain and suffering so that they can re-engage with their lives. Most patients in pain desire analgesics or invasive interventions that will allow rapid recovery from pain, restore functionality, and improve quality of life. In appropriately selected patients, interventions can dramatically decrease pain and the emotional and physical stressors associated with pain (18). Injections are an efficient part of the treatment algorithm that allows for its quick and effective implementation (18). Interventional therapies are often experienced as being satisfactory as they generate a dramatic and noticeable difference. This is also true with relatively recent advancements such as the integration of spinal cord stimulators in the use of chronic pain management. Studies show that these stimulators may lead to a 50% reduction in pain symptoms compared to traditional medical therapy (18). Additionally, other nonpharmacological interventions such as radiofrequency ablation, intrathecal pumps, and steroid injections have provided similar significant reductions in pain symptoms in patients. This garners further compliance and engagement in usual life (18). Lifestyle modifications, take more buy-in from the patient and often take time to impact overall health and analgesia. Appropriately completed injections and interventions in well-selected patients allow for timely interventions increasing functionality and quality of life in patients that would otherwise be in pain waiting for lifestyle modifications to take effect.

Conclusions

With its focus on education and behavioral change integrating lifestyle medicine is time-intensive for both patients and clinicians. Even in highly motivated patients with high levels of health literacy, the time investment in lifestyle medicine may be a barrier. A large deterrent to lifestyle medicine is the inherent difficulty of adopting new habits and changing behaviors. Additionally, health disparities and inequities may lie at the root of limited access to resources and lack of social support (19). In the context of challenging social determinants some people have less capacity or health literacy to engage in their health care and may have limited access to lifestyle medicine-based prescriptions (19). Counseling about nutrition and exercise may help patients in the short term but this is questionable in the long term especially if there are geographic and economic constraints on lack of access to healthy foods or safe exercise environments. Additionally, patients from non-privileged socioeconomic backgrounds may not have the time, access, or resources for social support to implement certain lifestyle modifications (19).

Financial considerations challenge the implementation of lifestyle medicine during pain management consultations. In the popular practice of Western medicine, evidence-based care through injections and medications receives a degree of coverage by insurance companies, allowing patients increased access to these modalities. Commonly, the absence of insurance coverage for integrative therapies such as meditation, massage, exercise, acupuncture, and yoga limits the implementation of such treatments even in the motivated, economically sound patients desirous of such treatments. From a physician’s standpoint, since lifestyle medicine is founded on health behavior education several important medical services associated with lifestyle medicine are not acknowledged as reimbursable treatments for health behavior education (20). Additionally, ongoing intensive support for patient lifestyle changes is limited and 57% of ACLM members do receive compensation for the time spent in lifestyle medicine services they provide (20).

Thus, this is a systemic issue and needs to be addressed as such. Healthcare policy changes and increased insurance coverage favoring lifestyle medicine are key to lifestyle medicine integration into pain management. A good start is that many physicians are open to delivering lifestyle medicine education to patients, provided that they themselves are given the proper education and appropriate reimbursement (21). This can help pave the way for more widespread implementation as there is already interest in promoting lifestyle medicine among physicians. Another way this systemic issue can be tackled is through the dissemination of payment-specific resources that would allow physicians to learn lifestyle medicine billable codes. Lastly, new healthcare policies should emphasize a universal mechanism for reimbursements and encourage insurance companies to cover their associated costs based on evidence-based outcomes (20).

Coaching, counseling, or group education for lifestyle interventions can be administered by trained professionals, not necessarily physicians, because of the cost of service (20). Patient adherence without an adequate supportive healthcare team, thorough education, sufficient time with educators and practitioners, and referrals to group programs, lifestyle interventions will remain limited and thus unlikely to work meaningfully in most patients (22).

Intensive therapeutic lifestyle change cannot be effectively delivered during a 15-to-60-minute appointment. Investment in staff resources, time with patients to support their health journey, and nurturing long-term relationships are essential for success. There is a shortage of measures that reward the time-intensive interventions necessary for successful lifestyle medicine approaches that can help mitigate chronic degenerative and inflammatory diseases and continue the intensive therapeutic prescriptive lifestyle change programs to support patients so they can sustain their improvements (Figure 2).

Figure 2 Integrative vs. interventional approaches to chronic pain.

However, one modality that can make the integration of lifestyle medicine more feasible and accessible is telemedicine. It has the potential to mitigate some of the drawbacks of lifestyle medicine. For example, virtual visits often take less time than traditional visits which are affected by factors such as patient transportation and office check-in times (23). This can save on costs by limiting delays (23). Saving time in this area could potentially allow physicians to follow up more regularly with patients on lifestyle changes and monitor progress more closely. This would allow physicians to address one of the biggest shortcomings of lifestyle medicine which is adherence. For example, a study found that “between 1988 and 2006, the percentage of US adults adhering to 5 key health behaviors (not smoking, avoiding excessive alcohol consumption, eating five or more fruits/vegetables per day, exercising more than 12 times per month, and maintaining a healthy body weight) decreased from 15% to 8%” (24). Telemedicine may hold the key to allow healthcare providers to provide continuous patient support so that nonadherence and relapses are addressed with the goal of long-term behavior maintenance (24). Another benefit added by the addition of telemedicine is improved access to chronic pain management in rural areas (23). Having patients regularly come in for injections or procedures may not be possible given certain geographic limitations and in such cases promoting lifestyle medicine with regular telemedicine follow-ups may be superior (23). Additionally, research has shown that telemedicine aids in greater physician-patient connectivity which is associated with better patient adherence to care plans (23).

Despite these advantages, telemedicine has its own drawbacks and limitations. These include the inability to perform physical exams, potential difficulty accessing telemedicine tools, technical difficulties, and security concerns (25). Fortunately, lifestyle medicine recommendations are not completely dependent on the physical exam and follow-up on the pillars of lifestyle medicine can be communicated through verbal history taking. However, the other downsides are limited by advancements in technology and the prevalence of telehealth opportunities for patients. The hope is that these barriers will be minimized as society advances and telemedicine can become more available ideally as an adjunct to traditional in-person visits (25). Thus, telemedicine shows great promise in helping lifestyle medicine become more commonplace; spreading its benefits and attenuating its limitations associated with cost, adherence, and time (Figure 3).

Figure 3 Benefits of telemedicine.

Further research in the areas of lifestyle medicine with the integration of telemedicine and interventional approaches to chronic pain is necessary—ideally, a randomized controlled trial to investigate overall cost-effectiveness and long-term outcomes. Outcome measures should evaluate pain relief, functional improvement, and quality of life over a span of several years. Stratification of participants by pain type to determine if specific pain conditions respond differently to lifestyle changes compared to direct interventions may provide answers on the best approach for specific patient presentations. Investigating patient satisfaction, adherence rates, and telemedicine ease could further shed light on the practicality and sustainability of each approach.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-53/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-53/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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