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From the Townsend Letter for Doctors & Patients
January 2005



reviewed by Jule Klotter

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Bowen Technique
The Bowen Technique, developed by Australian Tom Bowen in the 1950s, is a gentle, hands-on therapy that addresses all types of musculoskeletal pains, including fibromyalgia and TMJ. The technique uses precise, light-pressured, rolling moves on muscle and connective tissue. This gentle technique resets and balances the autonomic nervous system, improves lymphatic flow, softens scar tissue, loosens adhesions, encourages the correction of misalignments, and increases relaxation and a sense of well-being. It can also encourage psycho-emotional shifts. The Australian government released a report on Tom Bowen and his work in 1975. The report found that Bowen, who saw about 13,000 patients each year, had an 80 to 90% success rate, usually in one or two sessions.

Before his death in 1982, Tom Bowen passed his techniques on to Oswald and Elaine Rentsch during a two-and-a-half year apprenticeship and asked them to teach others. During the first Bowen treatment, the practitioner performs sets of core Bowen movements, designed to balance the body. After each set of moves, the client is left to rest for at least two minutes, giving the body time to respond. A second treatment, one week after the first, is usually recommended. Except for the coccal procedure, which may induce labor in pregnant women, Bowen has no contraindications. Joanne Whitaker, MD, however, has observed changes in some patients' blood chemistry using microscopic live cell analysis that correspond to flu-like, detox symptoms, lasting up to five days after a session.

The Bowen technique (aka Bowtech®) has been the subject of several studies. In one study, people with fibromyalgia experienced varying degrees of improvement, lasting a few days to several weeks. In another, the technique was used on people with a frozen shoulder. Seventy percent regained full range of motion that equalled the non-affected side, and others experienced increased mobility. The technique has also benefitted people with TMJ, back and hip pain, and anxiety.

Bowen, Carol. Animal Bowen® (July 2005: Dead link.)
Rousselot, Patrik. Bowen Therapy Technique.
Stiles, KG. The Bowen Technique. Massage Therapy Journal, Summer 2003

Cancer Pain Management
Cancer pain management requires a dual approach, according to an article by Pam Kedziera, RN, MSN, clinical manager of the pain management center at Philadelphia's Fox Chase Cancer Center. People with severe pain, including those with cancer, often experience two different kinds of pain. Persistent pain is the continuous, long-term discomfort that requires around-the-clock (ATC) medication. Frequently, however, a moderate-to-severe flare-up, known as breakthrough pain, also occurs. Breakthrough pain is episodic and usually lasts about 30 minutes.

Some doctors increase the dose of ATC medication in the hope of preventing these breakthrough flare-ups; but higher doses also increase the likelihood of adverse effects, such as sedation, nausea, and constipation. Instead, Kedziera suggests using a long-acting opioid (e.g., controlled-release oral morphine, fentanyl patch) at a regular, sufficient dose to manage the persistent pain and a second prescription for short-acting opioids like morphine or hydromorphone to take as-needed for the breakthrough pain. Without the short-acting opioids to use as a back-up, patients may limit their activity because they fear bringing on a flare-up of severe pain.

Kedziera, Pam, RN, MSN, AOCN. The two faces of pain. RN February 1998

Ergonomics and Pain
Many times, the structural aches and pains that people experience are caused by lifestyle habits and poor ergonomics. Inadequate arch supports or unevenly-worn shoes can lead to an aching back or painful knees. Sleeping on an old, flimsy mattress can make a person feel tired and sore. Low back pain can also be caused by sleeping on the stomach. Dr. Lynn Kelly ( recommends sleeping on one's side using a regular-size pillow made from fiberfill or buckwheat hulls to support the head and neck.

In addition to the pillow under the head and neck, using a long pillow to separate the knees and ankles is very important, especially to low back pain sufferers. Without this support for the upper leg and hip while lying on one's side, the weight of the upper leg can pull on upper hip and sacroiliac joint, causing imbalances in the low back, resulting in sciatica and other painful ailments.

To prevent sciatica (irritation of sciatic nerve which causes pain down the back of the leg), Dr. Kelly cautions people to avoid sitting unevenly. Sitting on a wallet held in a back pocket can cause a misalignment of the sacroiliac joint, resulting in sciatica. Driving for long periods with the right foot pointed outward on the gas pedal can also irritate the sciatic nerve.

In an article on ergonomics at, Nancy C. Selby, BS, and John J. Triano, DC, PhD, warn about more general situations that can lead to pain. The first is maintaining the same posture for over 20 minutes, which "slowly stretches the elasticity out of the tissues" and leads to discomfort. Moving heavy loads is another opportunity for strained muscles and trauma. Joints can also be stressed by awkward, angled positions and by "frequent or repetitive stretching to the end range of motion." Changing positions and doing gentle stretches can go a long way toward reducing daily muscle and joint strain. For those who must spend long periods standing, the authors suggest taking pressure off the back muscles by propping one foot on a rail or box and changing position every 20 minutes. Standing on a rubber mat and wearing shoes with cushioning and good support may also lessen the strain of standing on a concrete floor for hours.

Hours spent before a computer—whether for work, study, or fun—can break many of the basics for good ergonomics. A user-friendly workstation with a chair that lets the user sit 'elbow high' to the table surface is a necessity. In addition, knees should be level to the hips. (A footrest or telephone book can help.) A Gannett News Service article reports that "back and neck strain may actually be a result of eye problems, since people will often put themselves through weird contortions trying to see through the wrong kind of correction lenses for computers." The article recommends positioning the computer screen about 20 inches from the eyes at a height that is easy to read. Some experts advise placing the screen so that eye level hits about two inches from the top of the screen. Others say the gaze should fall on the screen's center. The aim is to be able to sit comfortably and read the screen, without slumping or cricking the neck. The American Optometric Association recommends taking frequent breaks—"about 15 minutes for every 45 minutes on a computer"—and blinking more often. Keeping the computer screen clean with a damp cloth, eliminating glare, and increasing the font size also reduce eyestrain and body tension.

Bruzzese, Anita. Beware of ailments linked to computers. The Greenville News 15 September 2004
Kelly, Dr. Lynn. Ergonomics & Pain Prevention.
Selby, Nancy C. BS & Triano, John J., DC, PhD. Basic ergonomics. 15 May 2001,

Ice Therapy
For people who do not have cold sensitivity, ice therapy is a simple at-home remedy for reducing pain caused by muscle strain. Whether in the form of an ice pack wrapped in a towel to prevent ice burn or in the form of an ice massage, ice therapy slows nerve impulses and the pain-spasm reaction. It also slows inflammation and swelling that often accompany muscle injury and decreases tissue damage. Ice therapy is most effective if applied shortly after the injury. People with rheumatoid arthritis, Raynaud's Syndrome, cold allergic conditions, impaired sensation, or paralysis should not use ice therapy.
Ice massage therapy, according to, involves the gentle, circular application of ice over a six-inch area. Because the ice doesn't stay in one spot for long (unlike an unwrapped ice pack), ice burn is less of a concern. Although a regular ice cube can be used for massage, a large piece is more effective. The web site suggests using water frozen in a paper cup that has been peeled back to expose the ice surface. Ice massage should not be performed on the spinal column itself, just on the muscle. The goal is to numb the injured area without burning the skin.

Ahh . . . Ice massage therapy for back pain relief.

Magnetic Pain Relief Device
Scientists at Lawson Health Research Institute (London, Ontario) have invented a small device that uses a specific, pulsed, extremely low frequency (ELF) magnetic field to reduce pain perception. They began their research in 1995, by placing snails on a hot surface (40 degrees C/ ˜100 degrees F). Snails prefer cool surfaces and consistently reacted about five seconds after contact with the heat. The researchers then gave the snails morphine before placing them on the hot surface. With the pain killer, it took the creatures about 15 seconds to react. Next the researchers exposed the snails to specific magnetic fields and found one that produced the same delayed reaction as the morphine.
Having identified a pain-reducing magnetic impulse, the scientists moved on to humans. The Lawson researchers developed a headset to deliver ELF impulses and began testing the device on patients with either fibromyalgia or with rheumatoid arthritis. Patients wore the headsets for 40 minutes, at least twice a day, for one week. The scientists found "a significant reduction of pain in fibromyalgia and a very significant reduction of pain in arthritis patients." Alex Thomas, a bioelectromagnetics scientist with Lawson, says that it may take ten years before the device reaches the marketplace because of scientific controls. The magnetic field produced by this device is weaker than the field produced by an electric hair dryer. The device has no known side effects.

Miner, John. Small device gets rid of pain. Sun Media 14 May 2004.
Shupak, N. et al. Effects of exposure to a specific pulsed magnetic field on pain ratings in fibromyalgia patients: A double-blinded, randomized control design.

Mind-Body Pain Management
Biofeedback teaches people to consciously alter bodily functions that are usually involuntarily controlled, such as blood pressure, heart rate, and brain activity. It can also help people reduce their perception of pain. An important part of biofeedback training involves teaching people to relax. Relaxation counteracts tension that feeds the pain cycle. The Chronic Pain Haven web site says, "Many clinicians believe that some of their patients and clients have forgotten how to relax. Feedback of physical responses such as skin temperature and muscle tension provides information to help patients recognize a relaxed state." Biofeedback is being used to ease the pain of many chronic or recurring conditions, such as migraine or tension headaches. It is also used to treat digestive disorders, high/low blood pressure, cardiac arrhythmias, Raynaud's disease, epilepsy, and movement disorders. Because biofeedback does not address the underlying causes of pain, responsible biofeedback therapists ask clients to have a thorough physical exam before teaching them to use the technique.

Biofeedback is not the only mind-body technique used to alleviate pain and stress. Woodson Merrell, MD, Executive Director of the Continuum Center for Health & Healing at Beth Israel Medical Center, says that other techniques such as imagery and hypnosis are also helpful. He believes that meditation, which disengages conscious thought and leads to deep relaxation, is "the most effective of all." Dr. Merrell also advocates the use of acupuncture, which he feels is underutilized. "Acupuncture forces the nervous system to relax," he said in an interview for the American Pain Foundation. "It raises endorphins and mitigates the pain." Nevertheless, Dr. Merrell believes that mind-body techniques "are the most powerful way to reduce stress in the long-term" because they can be used at any time or place for no cost.

The American Pain Foundation. Physician Looks to Safest, Gentlest, Most Effective Methods to Treat Pain and Stress: An Interview with Woodson Merrell, MD. April 2002.
The Chronic Pain Haven. Biofeedback for chronic pain control.

Pain Assessment
Frequent pain assessment is a necessary part of any pain management program. Because of the subjective nature of pain and the varied responses that sufferers have to it, pain assessment takes skill. Some patients respond to pain overtly with vocalization (moaning, crying, screaming, gasping, and grunting) or by grimacing, clenching their teeth, or tightly closing their eyes, and wrinkling their brow. Others look calm and may respond to pain merely by avoiding conversation and social contact and/or by immobilizing or being protective of hurting body parts. Restlessness and pacing, muscle tension, rhythmic or rubbing motions, reduced attention span, crabbiness or irritation, and elevated blood pressure or heart rate may also indicate pain. As Sonia R. Strevy, RN, MS, writes in her article "Myths and Facts about Pain" (RN, February 1998), "Since only the patient knows how much pain he's experiencing, you need to ask him about it—at regular intervals."

A complete pain assessment includes questions about factors that make pain worse or better, about pain quality (dull, sharp, stinging), about whether the pain is localized or radiates, about timing (constant or intermittent), and about pain intensity. Several pain intensity scales are available. These scales can be descriptive (no pain, mild pain, moderate pain, severe pain, very severe pain, worst possible pain) or be numeric (a 0–10 scale, with 0 meaning no pain and 10 equaling worst possible pain). For children or people with diminished mental capacity, a picture scale can be used. This scale consists of 6 faces that correspond to the descriptive pain scale with the 'no pain' face smiling broadly. The smile gradually turns into a frown as the series of pictures progress to the right, until the last frowning face weeps with "the worst possible pain."

A new pain scale for children was developed by two-and-a-half year old Amanda Woodward and her mother Beverly Hillstrom. In February 1998, Amanda was diagnosed with an inoperative brain tumor. Her mother told Amanda that a ball, which wasn't supposed to be there, was in her head. One day Amanda told her mom that the ball was green. This specific shade of green meant that "the pain was so bad that it made her cry very, very hard." According to Amanda, "orange meant it still hurt a lot but not as much as green; yellow was for less pain; purple meant it hurt just a little, and pink was for when there was no pain at all." Amanda's doctors found that she used the same five colors to describe her pain throughout her illness. Amanda's mother began questioning other seriously-ill children and found that each child had their own five-color scale that described how much they hurt. Children who have never felt severe pain do not identify with the color scale and begin guessing at colors.

Amanda's mother has published a book called Amanda's Rainbow in memory of her daughter who died in October 1998. The book shows the rainbows that Amanda and three other children used to describe their pain levels. It also includes a pullout chart so that a child can create her own pain intensity-rainbow that can be displayed for caregivers. Dr. Zenon Cieslak, one of Amanda's pediatricians, points out that colors are among the first words that a child learns. He says that the rainbow concept "is especially appealing for children who have lost the ability to speak, as Amanda had before she died."

Bains, Camille. Describing pain by colour could help kids. Canadian Press 30 October 2002.
Strevy, Sonia R., RN, MS. Myths & facts about pain. RN February 1998.

Pain Management
In its 2000–2001 standards manual for accredited healthcare facilities and agencies, the Joint Commission on Accreditation of Healthcare Organization (JCAHO) included pain control requirements. In order to receive accreditation, facilities must have policies and procedures that encourage "the appropriate use of analgesics and other pain control therapies." As part of an accredited pain care management program, health care providers must employ regular pain assessment and reassessment and patient education about the importance of effective pain management.

Fears about possible addiction to pain-relieving drugs and the difficulty of assessing pain severity has resulted in under-treatment. Professor Harald Breivik, president of the European Federation of IASP whose organization co-sponsored the 1st Global Day Against Pain, says that chronic pain is a highly underestimated healthcare problem, "causing major consequences for the quality of life of the sufferer and a major burden on the healthcare system in the Western world." Pain causes more than discomfort. "Acute pain may contribute to wound dehiscence [a splitting open]," Sonia Strevy, RN, MS explains in her article "Myths & facts about pain," or cause guarding and decreased mobility. "The latter may contribute to pneumonia and embolism. Chronic pain diminishes quality of life and may also bring on anxiety, depression, and a sense of helplessness."

The World Health Organization has outlined a three-step approach for controlling pain. For the least severe pain, WHO recommends oral analgesics such as acetaminophen and ibuprofen. The next step includes mild opioids like codeine that can be used in combination with the oral analgesics if necessary. When pain refuses to subside, WHO advises moving to the third category: strong opioids like morphine or fentanyl (Duragesic, Sublimaze). The goal of pain management is to keep the patients as comfortable as possible and improve the quality of their lives.

Many clinicians use too low a dose of these strong opioids or avoid prescribing them because they fear that patients will become addicted to the drugs. Strevy's article marks the difference between physical dependence and psychological dependence (aka addiction). Patients using opioids can become physically dependent on the drugs after two or three weeks of use, depending on the dose. Physical dependence means that patients will experience withdrawal symptoms, if the drug is abruptly discontinued. Patients who are physically dependent on drugs with a short half-life (e.g. codeine, morphine) experience anxiety, chills, irritability, hot flashes, joint pain, sweating, and/or vomiting six to twelve hours after the last dose. Discontinuing opioid drugs with a longer half-life (e.g. levorphanol and transdermal fentanyl) usually results in less severe effects. Psychological dependence is a different phenomenon. An article by R. C. Rinaldi, E.M. Steindler et al [JAMA, 259(4), 555] defines psychological dependence as the "compulsive use of a substance resulting in physical, psychological, or social harm to the user and continued use despite that harm." Studies with cancer patients who have taken strong opioids for long periods show that very few become psychologically dependent on the drugs.

Effective doses of pain medication given at regular intervals (which avoids a see-saw effect) is just one part of pain management. Strevy's article mentions several non-drug approaches that can reduce the need for medication: massage, transcutaneous electrical nerve stimulation (TENS), exercise, heat/cold applications, progressive muscle relaxation, guided imagery, and therapeutic touch. By including these therapies in a pain management treatment program, drug reactions and medical costs decrease.

Patient education is essential for good pain management. "Many patients in pain don't ask for medication," Sonia Strevy explains, "and many of those who do don't ask early enough to obtain adequate pain control." Patients have diverse reasons for not requesting pain medication. They may not want to 'bother' the nurse. They may fear side effects from the drugs. The use of pain medication may conflict with a cultural or religious belief, or they may believe that their pain is "inevitable and untreatable." Explaining the risks and benefits of pain medication will help. Patients need to understand that forestalling pain before it takes hold and becomes unmanageable (i.e., taking medication before a painful procedure or increased activity) is more effective than waiting until they are in agony before asking for help. Pain management begins by letting patients know that "most pain can be controlled."

Acello, Barbara, RN, MS. Meeting JCAHO Standards for Pain Control. Nursing 2000, Vol 30, No. 1.
Australian Broadcasting Corporation. Pain relief a human right: WHO. 11 October 2004.
Strevy, Sonia R., RN, MS. Myths & facts about pain. RN February 1998.

Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous Electrical Nerve Stimulation (TENS) originated under the guidance of Dr. Norm Shealy in 1967. It involves sending electrical impulses through electrodes placed on or near a painful area. Although it does not address the underlying cause of pain, these electrical impulses produce a tingling sensation that reduces the pain itself. A TENS unit is commonly used in conjunction with other pain management therapies and can only be obtained with a prescription from a MD, DO, or DC. TENS can ease chronic and acute pain. It is effective in the treatment of neck and back pain, headache, migraine, arthritis, post-herpetic neuralgia, sciatica, lumbago, fractures, tennis elbow, muscle strains, post-operative pain, and childbirth. People using pacemakers need approval from their cardiologist before using TENS as the electrical impulses may prevent the pacemaker from working correctly. Also, electrical stimulation on the front of the neck, especially over the carotid sinus, may be hazardous.

In January 2003, Norm Shealy's SheLi TENS™ became available. According to the Shealy Health Net web site, the SheLi TENS™ has been "extensively tested" and "offers a superior result." Its price of $695 includes shipping and 3 electrodes. The SheLi TENS™ is available from Self-Health Systems, 5607 South 222nd Road, Fair Grove, Missouri 65648; phone 888–242–6105 (8am-5pm CT); fax 417–267–3102.

Masters Medical. What is TENS? TENS—Transcutaneous Electrical Nerve Stimulation.
Shealy Health Net. The SheLi TENS™. 9 January 2003


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