Non-Pharmacological Benefits for Integrative Pain Management

Learn about integrative pain management combined with non-pharmacological options that empower you to manage pain without medication.

Abstract

This educational post offers an in-depth exploration of non-pharmacological pain management strategies from the perspective of an integrative care practitioner. Authored by me, Dr. Alex Jimenez, this guide presents the latest findings from leading researchers, translated into practical, evidence-based applications for patients suffering from chronic pain. We will embark on a comprehensive journey, beginning with a detailed case study to frame our discussion. The core of this post is dedicated to dissecting the biopsychosocial model of pain, emphasizing the interconnectedness of biological, psychological, and social factors in the pain experience. We will meticulously investigate a wide array of treatment options, including psychological therapies like Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), guided imagery, and mindfulness, movement, and manual therapies such as targeted exercise, chiropractic care, massage, and cupping, and interventional pain management techniques like nerve blocks and neuromodulation. A significant portion is devoted to explaining the crucial role of integrative and complementary therapies, such as chiropractic care and acupuncture, in a multimodal treatment plan. This post will also detail our unique collaborative care model at Injury Medical Clinic PA, where I (Chiropractor) work alongside Dr. Maria Guadalupe Cardenas (Internal Medicine) to provide a seamless fusion of chiropractic, medical, and functional medicine services, ensuring a truly holistic and individualized approach to patient care and recovery.

Introduction: A Vision for Integrated Pain Care

Hello, I’m Dr. Alex Jimenez. Throughout my career, which has been enriched by diverse qualifications in chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP), my mission has been singular: to provide comprehensive, patient-centered care that addresses the root cause of pain, not just its symptoms.

Today, I want to share insights into the world of non-pharmacological pain management. This is a field I am deeply passionate about because it empowers patients, respects the body’s innate healing capacity, and offers sustainable solutions beyond a prescription pad. This post is not a lecture; it is an educational journey designed to unpack the complexities of chronic pain and illuminate the vast landscape of effective, evidence-based treatments available. We will explore the latest research from leading experts and see how these findings translate into real-world clinical strategies.

A cornerstone of our practice, Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic), is our collaborative and multidisciplinary approach. I am privileged to work alongside Dr. Maria Guadalupe Cardenas, MD, who serves as our esteemed Medical Director and Collaborative Physician. Dr. Cardenas is a Board-Certified Internist with over 40 years of invaluable experience (NPI #1164426749, Texas MD License #J2933). This partnership between a Doctor of Chiropractic and a Medical Doctor is fundamental to our philosophy. It allows us to create a powerful synergy, integrating the biomechanical and neurological focus of chiropractic care with the deep medical and systemic understanding of internal medicine. Together, with our dedicated team, we provide a spectrum of services—from personal injury rehabilitation and functional medicine to nutritional counseling and advanced diagnostics—all under one roof. This integrated model ensures that every patient receives a treatment plan that is not only multimodal but also truly holistic, considering every facet of their health and well-being.

To begin our journey, let’s consider a patient scenario that highlights the challenges and opportunities in modern pain management. This case will serve as our reference point as we explore the various strategies and build a comprehensive, individualized treatment plan.

Case Study: The Complexity of Chronic Pain

To truly understand the application of a multimodal approach, let’s start by examining a complex patient profile. As we progress through this post, I encourage you to think about how the different non-pharmacological strategies we discuss could be woven together to create a personalized tapestry of care for this individual.

Patient Profile:

• Age and Gender: 36-year-old female.
• Past Medical History: A history of breast cancer and chronic migraines. She completed chemotherapy and surgery in 2012.
• Presenting Complaints:

• • Chemotherapy-Induced Peripheral Neuropathy (CIPN): She experiences persistent neuropathy—characterized by numbness, tingling, and pain—in both her hands and feet. This is a direct, long-term consequence of her life-saving cancer treatments.
  • Chronic Migraines: She suffers from debilitating migraines approximately four times per month. She has astutely observed that stress is a significant trigger and exacerbating factor.
  • Thoracic Back Spasms: She reports painful, involuntary muscle contractions in her mid-back region.
  • Medication Sensitivity: She has a notable sensitivity to various medications. Opioids, a common first-line treatment for severe pain, are not well-tolerated. She has also tried gabapentin, a medication often used for nerve pain, but experienced intolerable sedating side effects, even at the lowest doses.

• Ineffective Past Treatments: She has diligently tried several conventional and complementary approaches without success, including alpha-lipoic acid (a supplement sometimes used for neuropathy), over-the-counter Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), acetaminophen, and various topical analgesics.

This patient’s situation is a perfect illustration of why a one-size-fits-all, pharmacology-centric approach often fails. Her pain is multifactorial, stemming from neurological damage (neuropathy), neurovascular dysfunction (migraines), and musculoskeletal issues (back spasms). Furthermore, her treatment is constrained by medication sensitivities and a history that demands a careful, nuanced approach. The central question we must ask is: What would a truly effective, multimodal, and non-pharmacological treatment plan look like for her?

The Biopsychosocial Model of Pain: Treating the Whole Person

To truly master non-pharmacological pain management, we must move beyond a purely biomedical framework. The biopsychosocial model is the modern, evidence-based lens through which we must view pain. I often explain this to my patients using a “pie” analogy. The entire pie represents their total experience of suffering. If we focus only on the physical sensation of pain, we are addressing only a small slice of that pie. To provide truly comprehensive care, we must address the whole pie.

This model posits that pain is a dynamic experience influenced by the interplay of three core domains:

1. The Biological Domain: The Physical Foundation

This is the most familiar territory for many clinicians. It encompasses the physical and physiological aspects of the body.

• Genetics: Individual genetic variations can influence pain sensitivity, inflammation levels, and even how we metabolize pain medications.
• Comorbidities: Other health conditions, like diabetes, autoimmune disease, or heart disease, can significantly impact a patient’s pain experience and their ability to recover.
• Disease Severity & Injury: The nature and extent of the underlying pathology or injury (e.g., the degree of nerve damage in neuropathy or the severity of a disc herniation).
• Age: The aging process brings changes in tissue elasticity, healing capacity, and the prevalence of degenerative conditions like arthritis.
• Nutrition: This is a hugely influential factor. A diet high in processed foods, sugar, and unhealthy fats promotes a state of chronic, low-grade inflammation, which is like pouring gasoline on the fire of pain. Conversely, an anti-inflammatory diet—rich in fruits, vegetables, omega-3 fatty acids, and whole foods—can be profoundly healing. It provides the building blocks for tissue repair and helps to quiet the inflammatory messengers that drive pain.
• Sleep: Sleep is not a passive state; it is a critical period for tissue repair, hormone regulation, and memory consolidation. Poor sleep is a potent pain amplifier. When a patient is sleep-deprived, their pain threshold lowers, their mood worsens, and their ability to cope plummets. We know from countless studies that disrupted sleep significantly worsens pain perception the following day.
• Inflammation: This is a central biological process in many chronic pain states. Understanding and modulating inflammation through diet, lifestyle, and targeted therapies is a key goal.

2. The Psychological Domain: The Inner World

This domain relates to a person’s thoughts, emotions, and behaviors. It is often the most overlooked, yet most powerful, determinant of disability from pain.

• Coping Mechanisms & Stress: How does the patient cope with stress and pain? Do they have healthy outlets, or do they retreat and ruminate? High levels of stress hormones like cortisol can directly increase inflammation and pain sensitivity.
• Pain Catastrophizing: This is a specific negative thought pattern involving rumination (constantly thinking about the pain), magnification (exaggerating the threat of the pain), and helplessness (feeling powerless to control the pain). Catastrophizing is one of the strongest predictors of who will develop chronic pain and disability after an injury.
• Expectations & Beliefs: If a patient enters treatment believing “nothing will ever work” or expecting 100% pain relief, these beliefs can become self-fulfilling prophecies. A core part of our job is to help patients cultivate realistic expectations and shift their focus from complete pain eradication to improving function and quality of life.
• Mood & Affect: Is the patient showing signs of depression, anxiety, or anger? These emotional states are not just reactions to pain; they share overlapping neural circuits with pain in the brain. Treating depression can directly reduce pain perception, and vice versa.
• Cognition: Chronic pain can affect cognitive function, leading to what many patients describe as “brain fog.” This can impact memory, attention, and decision-making.
• Resilience: The ability to bounce back from adversity. Fostering psychological resilience is a key therapeutic goal.

3. The Social Domain: The External World

This domain encompasses the patient’s environment, relationships, and cultural context.

• Cultural & Spiritual Beliefs: A patient’s cultural background can shape how they express pain, what treatments they are willing to accept, and where they seek support. For many, a spiritual community can be a profound source of comfort, purpose, and social connection, acting as a powerful non-pharmacological intervention.
• Family & Relationships: How are the patient’s relationships with their family, partner, and friends? Is there support and understanding, or is there conflict and disbelief? Chronic pain can strain relationships, leading to social isolation. Intimacy can also be significantly affected.
• Work Environment: Is the patient able to work? Is their job physically demanding or highly stressful? Did a recent job loss coincide with the onset or worsening of their pain? The loss of work is not just an economic blow; it can be a profound loss of identity, routine, and social connection.
• Social Activities: Has pain forced the patient to give up hobbies and social engagements they once enjoyed? This withdrawal from life-affirming activities can create a vicious cycle of isolation, depression, and worsening pain.
• Daily Routine: I always ask patients, “Walk me through a typical day.” This simple question can reveal so much. What does their day look like from the moment they wake up until they go to bed? This helps us identify specific functional goals. Are they unable to cook a meal? Walk the dog? Play with their grandchildren? These become our targets for improvement.
• Economic Factors: Financial stress is a major contributor to the overall burden of chronic pain. The inability to work, combined with the high cost of healthcare, can create immense pressure that exacerbates the entire pain experience.

By consciously assessing all three domains, we can create a treatment plan that is truly holistic and has a much higher chance of success. A chiropractic adjustment (biological) combined with CBT (psychological) and support group resources (social) is infinitely more powerful than any one of these interventions in isolation.

Breaking the Vicious Cycle of Chronic Pain

Chronic pain perpetuates itself through a devastating feedback loop. Understanding this cycle is the first step toward breaking it. From a clinical perspective, I see this play out every single day.

Here is the anatomy of the chronic pain cycle:

1. The Initial Pain Event: This could be an injury, a surgery, or the onset of a disease.
2. Muscle Guarding & Tension: The body’s immediate, protective response is to tighten up. Muscles around the painful area contract in an attempt to splint and protect it. This is a helpful reflex in the short term, but disastrous in the long term.
3. Reduced Movement: Because movement hurts and the muscles are tight, the person naturally begins to move less. They avoid activities that they fear will provoke the pain.
4. Reduced Circulation: This decreased movement leads to poor blood flow in the affected tissues. Blood carries oxygen and nutrients necessary for healing and removes metabolic waste products. When circulation is compromised, healing stagnates.
5. Muscle Inflammation & Weakness: The combination of constant tension and poor circulation leads to local inflammation and the accumulation of waste products (like lactic acid) in the muscle tissue. The muscles, now underused, begin to weaken and decondition (atrophy).
6. Increased Pain: These weakened, inflamed, and stiff tissues become even more painful and sensitive. The brain receives a barrage of danger signals from the periphery.
7. Reinforcement of the Cycle: This increased pain reinforces the initial fear of movement, leading to even more muscle guarding, more tension, and more avoidance.

And so the cycle spins, gathering momentum. The patient becomes trapped. Our primary goal as clinicians is to identify where we can intervene to break this cycle. Integrative chiropractic care, for example, is exceptionally effective at intervening at multiple points. A spinal adjustment can directly reduce muscle guarding and improve joint mobility (breaking steps 2 & 3). Soft tissue techniques can improve circulation (breaking step 4). Prescribing specific therapeutic exercises helps to rebuild strength and break the pattern of reduced movement (addressing step 5). By doing so, we halt the perpetuation of pain signals, allowing the body to exit this destructive loop.

The Psychological Impact of Chronic Pain: Another Vicious Cycle

Just as there is a physical cycle of chronic pain, there is a parallel psychological cycle that is equally debilitating. These two cycles feed and amplify each other.

1. Pain Sensation: The physical experience of pain occurs.
2. Anxiety & Hypervigilance: The brain interprets the pain signal not just as a sensation but as a threat. This triggers anxiety and a state of hypervigilance, where the person becomes intensely focused on the pain and scans their body for any sign of it.
3. Altered Nervous System (Central Sensitization): This constant state of anxiety and focus “winds up” the central nervous system. A phenomenon known as central sensitization occurs, where the spinal cord and brain become hyperexcitable. Neurons that carry pain signals become more efficient at firing and require less input to do so. In essence, the “volume knob” for pain in the central nervous system gets turned up.
4. Increased Pain Perception: As a result of central sensitization, the patient experiences more pain from the same or even less peripheral stimulus. They may also experience allodynia (pain from a stimulus that is not normally painful, like the light touch of clothing) and hyperalgesia (an exaggerated pain response to a painful stimulus).
5. Reduced Movement & Behavioral Avoidance: This intensified pain experience reinforces the belief that movement is dangerous, leading to further withdrawal, social isolation, and depression.
6. Worsened Mood & Anxiety: The social isolation and loss of function fuel feelings of hopelessness, depression, and anxiety, which in turn feed back into the state of hypervigilance, completing the vicious loop.

This cycle explains why two people with the same MRI findings can have vastly different levels of pain and disability. The one who is trapped in this psychological cycle will suffer far more. This is precisely why behavioral management is not an optional add-on; it is a direct, neurobiological intervention designed to break this cycle.

Building the Care Team: The Power of Multidisciplinary Collaboration

A multimodal approach is most effective when delivered by a multidisciplinary team. No single practitioner can be an expert in everything. The true art of integrative care lies in knowing who to bring to the table and how to coordinate their efforts. At our clinic, this principle is the foundation of our practice.

Here are the key players in a comprehensive pain management team:

• The Patient: The most important member of the team. Patient engagement, education, and active participation are non-negotiable for success.
• Chiropractors (DC) & Physical Therapists (PT): As a chiropractor, my focus is on the biomechanical and neurological integrity of the body. We are experts in manual therapies, spinal health, and restoring functional movement. PTs design and implement rehabilitative exercise programs to build strength and resilience. Together, we form the cornerstone of physical rehabilitation.
• Medical Doctors (MD/DO): The collaboration with Dr. Cardenas, our Medical Director, is vital. Her expertise in internal medicine provides essential medical oversight, diagnostic acumen, and management of comorbidities that can influence pain. This partnership ensures that all aspects of a patient’s health are considered, allowing us to integrate different therapies and manage any necessary pharmacology safely.
• Nursing Professionals (RN/APRN): Nurses are often the navigators of the healthcare system. They are exceptional at patient education, triaging patient concerns, and identifying practical needs we might overlook, such as applying for a handicap placard or coordinating follow-up appointments. Their continuous communication is the glue that holds the team together.
• Pharmacists: Our pharmacy colleagues are invaluable resources. They can help us navigate complex medication regimens, identify potential drug interactions (especially with supplements), and suggest alternative dosing strategies to minimize side effects.
• Psychology & Psychiatry Professionals: These specialists are our go-to experts for the behavioral and psychological interventions mentioned earlier. A psychologist can provide CBT or ACT, while a psychiatrist can manage co-occurring mood disorders like depression or anxiety, which are deeply intertwined with chronic pain.
• Occupational Therapists (OT): While physical therapy focuses on restoring movement, occupational therapy focuses on restoring function in daily life. An OT can help a patient adapt their home or work environment, learn new ways to perform tasks (like cooking or dressing), and regain independence in meaningful activities.
• Integrative & Functional Medicine Practitioners: This is a role I am passionate about. We look at the body as an interconnected system, investigating root causes related to nutrition, gut health, hormonal balance, and environmental exposures. This “systems-based” approach can uncover and address underlying drivers of inflammation and pain.
• Addiction Medicine Specialists: For patients who have developed or are at high risk for substance use disorders, these specialists are essential for providing compassionate, evidence-based care to manage dependency while still addressing their legitimate pain needs.

By assembling this team, we move from treating a “symptom” to caring for a “whole person.” This collaborative ecosystem is the engine that drives effective, sustainable pain relief.

A Foundation of Care: Thorough Assessment and Risk Stratification

Before any treatment begins, a meticulous and comprehensive assessment is paramount. This is perhaps the most critical non-pharmacological intervention we perform. Rushing this step is like building a house on a shaky foundation.

The Art of the Comprehensive History

A detailed patient history is not a checklist to be completed; it is a conversation to be had. This is where we begin to uncover the nuances of the patient’s biopsychosocial story.

• Previous Treatments: I ask patients to create an exhaustive list.

• • Medications: “What have you tried? What was the exact dose? For how long did you take it? What was helpful? What caused side effects?” This is crucial for medications like antidepressants or anticonvulsants. A patient might say, “I tried gabapentin, and it didn’t work.” My follow-up questions are, “What was the highest dose you reached, and how long were you on it?” If they only took a low dose for a few days, that wasn’t a true therapeutic trial.
  • Procedures: For interventions like epidural steroid injections or nerve blocks, I ask two key questions: “What percentage of pain relief did you experience?” and “For how long did that relief last?” A patient who got 80% relief for three months from a specific injection provides a vital clue for future treatment planning. I keep a detailed log of this information in the patient’s chart.
  • Complementary & Alternative Treatments: It’s essential to ask specifically about supplements, herbs, acupuncture, massage, etc. This helps us understand what they’ve been drawn to and can reveal potential interactions with other planned treatments.

• Current Treatments: What are they doing right now to manage their pain? This gives us a baseline from which to work.
• Social & Psychological History: This is where we explore the other domains of the biopsychosocial model.

• • Social Relationships & Daily Activities: “Tell me about your support system. Are you employed? What do you enjoy doing for fun?”
  • Psychiatric History: “Have you ever been diagnosed with or treated for a mood disorder like depression or anxiety?”
  • Substance Use History: A non-judgmental inquiry into past and present use of alcohol, tobacco, and other substances. This includes asking about family history as well.
  • Adverse Childhood Experiences (ACEs): This is a sensitive but critically important area of inquiry.

Understanding Adverse Childhood Experiences (ACEs)

ACEs are potentially traumatic events that occur during childhood (ages 0-17). Research, particularly the landmark CDC-Kaiser Permanente ACE Study, has unequivocally shown that these experiences have a profound and lasting impact on adult health (Felitti et al., 1998).

What constitutes an ACE?

• Abuse: Experiencing physical, emotional, or sexual abuse.
• Neglect: Experiencing physical or emotional neglect.
• Household Dysfunction: Witnessing violence against a parent; growing up in a household with substance use problems, mental illness, parental separation or divorce, or an incarcerated household member.

The cumulative effect of these experiences can disrupt a child’s neurological development and stress-response systems, leaving them with a “sensitized” nervous system. As adults, individuals with a high ACE score are at a significantly increased risk for a host of chronic health problems, including:

• Chronic pain conditions like fibromyalgia and migraines
• Autoimmune diseases
• Mental illness (depression, anxiety, PTSD)
• Substance use disorders

Understanding a patient’s ACE score is not about blaming the past; it is about recognizing a key biological and psychological vulnerability. It helps explain why their nervous system might be more reactive to pain and why they may have a harder time coping. It signals that psychological and behavioral interventions are not just “adjunctive” but are, in fact, essential first-line treatments for this individual.

Characterizing the Pain: A Framework for Goal Setting

When discussing the pain itself, I use a simple framework to guide the conversation and ensure I gather all the necessary details. I steer the conversation away from a numerical pain score and toward functional goals.

1. Analgesia/Aggravating Factors: What makes the pain better (analgesia) and what makes it worse (aggravating)? This helps us identify triggers to avoid and palliative measures to encourage.
2. Activities of Daily Living (ADLs): How does the pain affect their physical, emotional, and psychosocial function? “What can you no longer do that you wish you could?”
3. Antecedents: When did it start? What was the onset like? What are the patterns or variations throughout the day?
4. Current Level & Goals: What is your pain level now, and more importantly, what is our goal? A goal is not “to have zero pain.” A goal is “to be able to walk my dog around the block,” or “to cook dinner for my family without having to sit down every five minutes,” or “to go to Disney World with my grandchildren.” These tangible, functional goals become our markers for success. They are specific, measurable, and meaningful to the patient.

The Multimodal Approach: Assembling Your Therapeutic Toolbox

When I consult with a patient like the one described, I visualize a comprehensive “toolbox” of therapeutic options. To make these treatments more approachable, I often organize them into clear “buckets” that align with clinical goals. The era of relying on a single tool—like a specific medication class—is behind us. Effective pain management is about multimodal care, which means strategically selecting and combining different treatments to address the various dimensions of a person’s pain experience.

Psychological Therapies for Pain, Stress, and Function

This category focuses on the mind-body connection. Patients often feel hesitant about starting formal behavioral therapy, but these psychological modalities offer accessible gateways that build confidence. The tools here are powerful because they can reframe a patient’s relationship with their pain and directly quiet the nervous system.

• Cognitive Behavioral Therapy (CBT): One of the most well-researched therapies for chronic pain (Williams et al., 2012), CBT helps patients identify and change negative thought patterns and behaviors related to pain.
• Acceptance and Commitment Therapy (ACT): Instead of changing thoughts, ACT teaches patients to accept them without judgment and commit to actions that align with their personal values, even in the presence of pain.
• Hypnosis: Clinical hypnosis utilizes a state of focused attention to increase relaxation and alter the perception of pain, for example, by using imagery of a “control dial” for pain that the patient can learn to turn down.
• Mindfulness Meditation: This practice trains the brain to observe pain without judgment, reducing the emotional suffering associated with it. By cultivating nonjudgmental awareness, it alters cortical networks involved in attention and emotion regulation.
• Guided Imagery: This technique uses structured, verbal scripts to engage the senses—sight, sound, touch, smell, and taste—to evoke calming experiences that reduce stress. It activates sensory and limbic brain regions, reshaping emotional responses to pain.
• Music Therapy: Listening to curated music can activate the brain’s reward circuits, modulate mood, and distract from pain. Its tempo and structure can even influence heart rate and autonomic balance.
• Aromatherapy: Using essential oils like lavender through diffusion can directly influence the brain’s mood and arousal centers via the olfactory system, promoting relaxation and improving sleep.
• Virtual Reality (VR): This emerging technology offers immersive distraction, using goggles or projectors to reduce the brain’s perception of acute pain, especially during medical procedures.

Physical, Manual, and Somatic Interventions

These therapies target the body directly, aiming to restore function, reduce inflammation, and improve physical resilience. This is where integrative chiropractic care shines.

• Exercise & Physical Therapy: Tailored physical activity is one of the most potent non-pharmacological tools. A structured physical therapy program is designed to improve strength, flexibility, and movement patterns.
• Nutrition: An anti-inflammatory diet can fundamentally alter the body’s internal environment, reducing the biochemical drivers of pain.
• Integrative Chiropractic Care: This includes a range of hands-on techniques like spinal adjustments, soft tissue mobilization, and neuromuscular re-education to restore proper biomechanics and nervous system function.
• Massage Therapy: Effective for reducing muscle tension, improving circulation, and decreasing stress hormones, promoting a sense of well-being.
• Cupping Therapy: This technique uses negative pressure to mobilize tissue and improve circulation, often used for myofascial syndromes and chronic back pain.
• Acupuncture: Involves inserting fine needles at specific points; acupuncture is believed to stimulate the release of natural pain-relieving chemicals and reduce inflammation.
• Yoga and Tai Chi: These mind-body practices combine physical postures, breathing, and meditation to improve flexibility, balance, and body awareness while calming the nervous system.

Interventional Pain Management

These are more specialized, procedure-based options, often performed by pain management specialists, which can provide targeted relief.

• Nerve Blocks: The injection of an anesthetic to “turn off” pain signals from a specific nerve or group of nerves, such as an occipital nerve block for migraines.
• Trigger Point Injections: Targeting hyperirritable knots of muscle (trigger points) with a local anesthetic or saline to release tension and pain.
• Neuromodulation: Advanced techniques that use electrical stimulation to modulate pain signals, such as Spinal Cord Stimulators (SCS) or Transcutaneous Electrical Nerve Stimulation (TENS).
• Dedicated Joint Injections: Corticosteroid or hyaluronic acid injections directly into inflamed joints like the knee or shoulder.
• Botox Injections: FDA-approved for the prevention of chronic migraines, Botox works by blocking the release of neurotransmitters involved in pain signaling.
• Intrathecal Pumps: A surgically implanted device that delivers micro-doses of medication directly to the spinal cord, often used for severe, refractory cancer pain.

Pharmacological Options (Used Judiciously)

While our focus is non-pharmacological, a truly integrative plan acknowledges the role of medication when appropriate. The key is to use them as part of a broader strategy, not as the sole solution.

• NSAIDs & Topicals: For acute inflammation or localized pain.
• Antidepressants & Anticonvulsants: Certain medications in these classes are effective for neuropathic pain by modulating neurotransmitters.
• Muscle Relaxers: For acute episodes of severe muscle spasm.
• Opioids: Reserved for severe, acute pain or specific end-of-life care scenarios, with rigorous monitoring and a clear exit strategy.

By visualizing these options, we can begin to see how a rich, layered treatment plan can be constructed, moving far beyond simply writing a prescription.

Behavioral and Psychological Interventions: Rewiring the Brain for Pain Relief

If a significant part of the chronic pain problem lies in the brain’s interpretation and response, then therapies that target the brain are essential. These are powerful, evidence-based, non-pharmacological treatments.

Building a Pathway to Behavioral Health

As clinicians, we must be adept at guiding patients toward these resources. Many patients may be resistant to the idea of “seeing a psychologist for their back pain,” fearing it implies the pain is “all in their head.” We must frame it skillfully.

• Referral to a Specialist: A direct referral to a psychologist, licensed clinical social worker (LCSW), or therapist who specializes in pain is the gold standard. I explain it this way: “Chronic pain changes how the brain processes signals. These therapies are like physical therapy for your brain. They help to retrain the brain to turn down the volume on pain and improve your ability to cope. It’s a critical part of a comprehensive treatment plan.”
• Self-Guided Courses & Apps: For patients who are hesitant or face barriers to access, starting with a self-guided resource can be a fantastic first step. There are numerous evidence-based apps and online programs for mindfulness, CBT, and pain management (e.g., Curable, Headspace, Calm). I might even suggest specific guided meditations on YouTube. These can serve as a “gateway,” allowing the patient to experience the benefits firsthand, making them more open to seeing a specialist later.
• Sleep Medicine & Sleep Hygiene Education: As discussed, sleep is paramount. If a patient reports poor sleep, my first intervention is education on sleep hygiene. This is a simple yet profoundly effective behavioral intervention that our nursing staff can expertly deliver.

• • The Routine: Go to bed and wake up at the same time every day, even on weekends. This sets the body’s internal clock (circadian rhythm).
  • The Environment: The bedroom should be a sleep sanctuary. This means it should be cool, dark, and quiet. I recommend a room temperature between 65-67°F (around 18-19°C). Blackout curtains, an eye mask, and earplugs or a white noise machine can be transformative.
  • The “No-Device” Rule: The blue light emitted from phones, tablets, and TVs suppresses the production of melatonin, the hormone that signals the brain it’s time to sleep. All devices should be turned off at least an hour before bed. The bedroom is for sleep and intimacy only—not for working, watching TV, or scrolling through social media. We need to reprogram the brain to associate the bed with sleep.
  • I have seen countless patients improve their pain and energy levels simply by implementing these behavioral changes, often without needing any sleep medication.

• Referral to Psychiatry: If there is a significant, co-occurring psychiatric disorder like major depression, bipolar disorder, or severe anxiety, a referral to a psychiatrist is necessary for diagnosis and potential medication management, which can work synergistically with our other pain therapies.

Deep Dive into Specific Behavioral Therapies

• Cognitive Behavioral Therapy (CBT): CBT is one of the most well-researched therapies for chronic pain (Williams et al., 2012). It is a structured, goal-oriented form of “talk therapy” that operates on a simple principle: our thoughts, feelings, and behaviors are interconnected. CBT helps patients:

1. 1. Identify automatic negative thoughts about their pain (e.g., “This pain will never end,” “I am useless because I can’t work”).
   2. Challenge the validity of these thoughts by examining the evidence for and against them.
   3. Replace these distorted, unhelpful thoughts with more balanced, realistic, and adaptive ones (e.g., “I have good days and bad days, and I can learn strategies to manage the bad days,” “My productivity does not define my worth”).
   4. It also involves behavioral components like activity pacing (learning to do activities in manageable chunks to avoid the “boom-bust” cycle) and relaxation training.

• Acceptance and Commitment Therapy (ACT): ACT takes a slightly different approach. Instead of trying to change or eliminate painful thoughts and feelings, ACT teaches patients to accept them as a part of the human experience without letting them rule their lives. It’s about creating psychological flexibility. The core components are:
  • Acceptance: Making room for uncomfortable sensations, feelings, and thoughts without struggling against them.
  • Cognitive Defusion: Learning to “unhook” from thoughts; seeing them as just thoughts, not objective reality.
  • Being Present: Cultivating a moment-to-moment awareness of experience (mindfulness).
  • Values Clarification: Identifying what is truly important and meaningful in life (e.g., family, creativity, compassion).
  • Committed Action: Taking concrete steps and setting goals that are in service of those values, even in the presence of pain. The goal of ACT is not to feel better, but to live better.

• Hypnosis: Clinical hypnosis is a state of focused attention and heightened suggestibility, guided by a trained therapist. It is not stage magic. During hypnosis, a patient can become deeply relaxed and more open to suggestions that alter their perception of pain. For example, a therapist might use imagery of a “control dial” for pain that the patient can learn to turn down, or suggest a feeling of numbness or coolness in the painful area. It can be a powerful tool for changing the brain’s interpretation of pain signals. Self-hypnosis apps and recordings can also be effective for at-home practice.

Physical Interventions: Restoring the Body

While we address the mind, we must simultaneously work to restore the physical body. This is where movement, nutrition, and hands-on therapies become central.

The Power of Movement: Physical Therapy and Exercise

The instinct for a person in pain is to stop moving. Our job is to gently and safely reverse that instinct. “Motion is lotion” is a common refrain in our clinic.

• Land vs. Water Therapy: For patients with severe pain or a high fear of movement (kinesiophobia), starting with aquatic therapy can be a game-changer. The buoyancy of the water supports the body, reduces the load on painful joints, and provides gentle resistance. I often tell patients, “You don’t have to be a competitive swimmer. Just get in the lap lane at your local gym and walk back and forth.” The hydrostatic pressure of the water can also help reduce swelling. This can build confidence and serve as a bridge to land-based therapy.
• Prescribed, Individualized Exercise: A referral to physical therapy is not just about having someone stretch you twice a week. A good PT will perform a thorough assessment and prescribe a specific, progressive home exercise program. This is the most important part of the therapy. The patient must be empowered and educated to perform these exercises consistently on their own. The goal is to build strength, improve flexibility, and restore healthy movement patterns.
• The Role of a TENS Unit: A Transcutaneous Electrical Nerve Stimulation (TENS) unit can be an excellent adjunct to facilitate physical therapy. This portable device uses electrodes placed on the skin to deliver a low-voltage electrical current. It is thought to work in two ways:

1. 1. Gate Control Theory: The gentle electrical sensation travels along large nerve fibers to the spinal cord, “closing the gate” on the pain signals that travel along smaller nerve fibers.
   2. Endorphin Release: The stimulation may trigger the body to release its own natural pain-relieving chemicals, called endorphins.

• I often prescribe a TENS unit for patients to use during their exercises or when they have a flare-up of muscle spasm. For many, it provides enough relief to move more freely and participate more fully in their rehabilitation.

Advanced Neuromodulation Techniques

Beyond a simple TENS unit, there are more advanced forms of neuromodulation that are showing promise:

• Transcranial Magnetic Stimulation (TMS): A non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain. It is FDA-approved for depression and is being studied for its potential to modulate the brain’s pain-processing centers (Lefaucheur et al., 2014).
• Vagus Nerve Stimulation (VNS): The vagus nerve is a major component of the parasympathetic (“rest and digest”) nervous system and has a powerful anti-inflammatory effect. VNS, which can be done via an implanted device or non-invasively through a device that clips to the ear, is being explored as a treatment for conditions with an inflammatory component, like rheumatoid arthritis and potentially some chronic pain states.

Unlocking Vitality: Chiropractic Wisdom and the Science of Functional Healing- Video

Procedural and Interventional Options: Targeted Relief

For some patients, more targeted, procedure-based interventions are a necessary part of the multimodal plan. An interventional pain management physician, an anesthesiologist, or a physiatrist typically performs these. It’s helpful to think of these options in terms of the body part they target.

• For the Spine:

• • Epidural Steroid Injections: Used for radicular pain (sciatica) caused by a herniated disc or spinal stenosis. A corticosteroid (a powerful anti-inflammatory) is injected into the epidural space to reduce inflammation around an irritated nerve root.
  • Sacroiliac (SI) Joint Injections: The SI joint is a common, but often overlooked, source of low back pain. Injecting a local anesthetic and steroid into the joint can be both diagnostic (if the pain goes away, the SI joint is the culprit) and therapeutic.
  • Medial Branch Blocks & Radiofrequency Ablation (RFA): For pain originating from the small facet joints of the spine. A block is first performed to see if numbing the medial branch nerves (which supply the facet joints) relieves the pain. If it does, a follow-up procedure called RFA can be performed, where a specialized needle uses heat to create a lesion on the nerve, providing longer-lasting relief (often 6-18 months).

• For Peripheral Nerves & Muscles:

• • Sympathetic Nerve Blocks: Used for complex regional pain syndrome (CRPS), a condition involving dysfunction of the sympathetic nervous system.
  • Peripheral Nerve Blocks: Targeting a specific peripheral nerve, like the median nerve for carpal tunnel syndrome.
  • Trigger Point Injections: As mentioned, this involves injecting a small amount of local anesthetic or even just saline (“dry needling”) directly into a taut band of muscle. In our practice, this is a technique we use frequently, especially for conditions like myofascial pain syndrome, tension headaches, and the thoracic spasms described in our case study. It can provide immediate release of muscle tension, breaking the pain-spasm cycle and creating a window of opportunity for manual therapy and stretching.

• For Joints & Headaches:

• • Dedicated Joint Injections: Corticosteroid injections into large joints like the shoulder, hip, or knee can provide significant relief for osteoarthritis or inflammatory arthritis.
  • Occipital Nerve Blocks: An excellent treatment for cervicogenic headaches (headaches originating from the neck) and some types of migraines. The greater and lesser occipital nerves at the base of the skull are blocked with a local anesthetic.
  • Botox (OnabotulinumtoxinA) Injections: FDA-approved for the prevention of chronic migraines. It involves a series of 31 small injections into specific muscles of the head and neck every 12 weeks. It works by blocking the release of neurotransmitters involved in pain signaling. For our case study patient with chronic, stress-related migraines, this would be a prime non-opioid consideration.
  • Trigeminal Nerve Blocks: For facial pain conditions like trigeminal neuralgia.

• Surgical & Advanced Options:

• • Intrathecal Pumps: As noted, these are typically reserved for severe cancer pain or spasticity, delivering medication directly into the cerebrospinal fluid.
  • Spinal Cord Stimulators (SCS) & Peripheral Nerve Stimulators (PNS): These are “pacemakers for pain.” An SCS involves implanting small electrodes near the spinal cord, which are connected to a small generator. The device delivers gentle electrical impulses that mask or interrupt pain signals on their way to the brain. They are highly effective for conditions like failed back surgery syndrome and CRPS. A PNS works on the same principle but targets a specific peripheral nerve. The evolution in this technology over the last decade has been astounding.

Complementary and Integrative Therapies: The Evidence-Based Frontier

This category of treatments is where our practice truly embraces a holistic philosophy. It’s vital to differentiate between evidence-based complementary therapies and unproven “alternative” treatments. It’s also important to use the correct terminology with patients to build trust and set clear expectations.

• Clarifying the Terms:

• • Complementary Medicine: A non-mainstream practice that is used together with conventional medicine. Example: Using acupuncture and physical therapy to treat chronic low back pain. This is the model we advocate for.
  • Alternative Medicine: A non-mainstream practice that is used in place of conventional medicine. Example: Using only special diets to treat cancer instead of chemotherapy. This can be dangerous and is not a model we support.
  • Integrative Medicine: This is the highest level of care. It refers to a coordinated approach that merges conventional and evidence-based complementary therapies in a holistic, patient-centered model. It’s about bringing the best of all worlds together. This is the philosophy that guides our collaborative practice with Dr. Cardenas.

Here are some of the most powerful evidence-based complementary therapies for pain:

Integrative Chiropractic Care

As a Doctor of Chiropractic, this is the heart of my practice. Modern, evidence-based chiropractic care is far more than just “cracking backs.” It is a sophisticated, hands-on approach to healthcare that focuses on the intricate relationship between the body’s structure (primarily the spine) and its function (as coordinated by the nervous system).

• Spinal Manipulative Therapy (SMT) / Adjustments: This is the hallmark of chiropractic care. It involves applying a specific, controlled, high-velocity, low-amplitude (HVLA) force to a joint that has become restricted in its movement. The goals are to:

• • Restore Mobility: Improve the range of motion of the joint.
  • Reduce Pain: Rapid stretching of the joint capsule and surrounding muscles triggers a cascade of neurological reflexes that can inhibit pain signals at the spinal cord level.
  • Decrease Muscle Hypertonicity: Release tension in the surrounding muscles.

For our case study patient with thoracic back spasms, chiropractic adjustments to the thoracic spine would be a primary intervention to restore normal movement and break the spasm cycle.

• Spinal Mobilization: For patients who are sensitive or wary of SMT, we use mobilization, which applies gentle, low-velocity manual forces within the joint’s passive range of motion. This technique promotes synovial fluid movement and provides graded sensory input to desensitize the area and restore movement confidence.
• Soft Tissue Mobilization: We use a variety of techniques to address muscles, ligaments, and fascia. This includes:

• • Myofascial Release: Applying sustained pressure to release restrictions in the fascial connective tissue that encases muscles.
  • Instrument-Assisted Soft Tissue Mobilization (IASTM): Using specially designed tools (like Graston or Gua Sha tools) to detect and break down scar tissue and fascial adhesions.
  • Trigger Point Therapy: Applying direct pressure to release trigger points.

• Therapeutic Exercise Prescription: We don’t just provide passive care. We empower patients by prescribing specific exercises for strengthening, stabilization, and flexibility to support the corrections we make and prevent recurrence.
• Neuromuscular Re-education: Training the patient to improve their posture, balance, and body mechanics during daily activities.

For a patient like the one in our case study, integrative chiropractic care could address her thoracic spasms directly. By improving spinal mechanics and reducing nerve irritation in the neck, it could also potentially help reduce the frequency and intensity of her cervicogenic headaches, which often co-exist with migraines.

Acupuncture

An ancient practice rooted in Traditional Chinese Medicine, acupuncture involves inserting very thin needles into specific points on the body. From a Western medical perspective, its effects are believed to be mediated by:

• Stimulating the release of endorphins and other neurochemicals.
• Modulating the autonomic nervous system.
• Reducing inflammation.

The evidence for acupuncture is particularly strong for chronic low back pain, knee osteoarthritis, and headaches/migraines (Vickers et al., 2018). For our case study patient, acupuncture could be a powerful tool for her migraines, her neuropathy, and her back spasms.

Massage Therapy

Therapeutic massage can be incredibly effective for reducing muscle tension, improving circulation, decreasing stress hormones like cortisol, and promoting a sense of well-being. Different styles can be used for different purposes, from relaxing Swedish massage to deep tissue massage for chronic muscle knots.

Yoga and Tai Chi

These ancient mind-body practices combine physical postures, breathing techniques, and meditation. They are excellent for improving flexibility, balance, strength, and body awareness. Crucially, they also have a powerful effect on the nervous system, promoting relaxation and reducing the “fight-or-flight” response that is so often overactive in chronic pain patients. The evidence supporting yoga for chronic low back pain is particularly robust.

Nutritional Supplements

While a food-first approach is always best, certain supplements have evidence for their role in pain management when used appropriately.

• Magnesium: Can help with muscle relaxation and may be beneficial for migraines and muscle cramps.
• Omega-3 Fatty Acids (Fish Oil): Powerful anti-inflammatory effects.
• Turmeric (Curcumin): Another potent natural anti-inflammatory.
• Vitamin D: Deficiency is common and has been linked to chronic musculoskeletal pain.
• B Vitamins: Particularly important for nerve health and may be helpful in some cases of neuropathy.

It is absolutely critical that supplement use is guided by a knowledgeable practitioner (like a functional medicine provider) and that the entire care team is aware of them to avoid potential interactions with prescription medications.

Safety Protocols and Medical Oversight: The Role of Internal Medicine

Safety is non-negotiable in our practice. Under Dr. Cardenas’s oversight, we maintain rigorous protocols to identify contraindications and protect patients, especially before performing manual therapies like chiropractic adjustments.

We rigorously screen patients before manipulating the spine. Dr. Cardenas’s medical oversight empowers us to investigate red flags and coordinate diagnostics.

• Absolute or major contraindications to spinal manipulation include:

• • Fever, unrelenting night pain, pain at rest
  • Below-knee numbness or weakness with a radiculopathy pattern
  • Progressive leg weakness, loss of bowel/bladder control (cauda equina syndrome)
  • Any progressive neurological deficit
  • Direct trauma, unexplained weight loss, history of cancer (requires careful evaluation)
  • Known fractures, severe osteoporosis, acute tissue disruption (e.g., ligament tear)

• Managing Adverse Events:

• • Temporary local soreness after an adjustment is common and typically resolves within 24-48 hours.
  • More serious but rare events, like disc herniation or symptom exacerbation, are mitigated by our thorough screening process, careful technique selection, and gentle mobilization for sensitive patients.

Integrating spinal manipulation and mobilization into a progressive, supervised exercise plan, with medical monitoring and imaging when indicated, yields superior outcomes and protects patients from unnecessary risk. This structure ensures that complementary therapies are applied responsibly within a robust medical framework.

Clinical Observations from My Practice in El Paso

Over the years, my clinical observations have consistently shown that integrative, coordinated care yields better outcomes for complex pain and injury cases. I invite readers to review our resources for deeper insight into our casework and clinical processes at personalinjurydoctorgroup.com and my professional profile on LinkedIn.

• Key Observations:

• • Patients who engage with psychological therapies early—like guided imagery, mindfulness, and relaxation—tend to navigate flare-ups more effectively and have fewer emergency visits.
  • Chiropractic manipulative therapy, when combined with mobilization, neuromuscular re-education, and functional movement, outperforms any single modality for mechanical pain syndromes.
  • The addition of acupuncture often accelerates recovery in neuropathic conditions and headaches, especially when paired with TENS and movement therapies.
  • Tai chi and yoga foster patient autonomy and confidence; they serve as excellent bridges to formal rehabilitation and strength training programs.
  • Aromatherapy and music therapy improve adherence to care plans by making daily self-care practices more enjoyable and calming.
  • VR is surprisingly effective for procedural anxiety and acute pain episodes. Patients appreciate its novelty and the sense of control it provides.
  • Crucially, the medical oversight from Dr. Cardenas ensures safe progression, early identification of red flags, and appropriate diagnostics—particularly in personal injury contexts where the mechanism of injury can be complex.

These observations align with the latest literature and reinforce our commitment to integrated, whole-person care.

Putting It All Together: An Individualized Treatment Plan for Our Case Study

Now, let’s return to our 36-year-old female patient and apply everything we’ve discussed to build her a truly comprehensive, non-pharmacological treatment plan.

Her Problems:

1. Chemotherapy-Induced Peripheral Neuropathy (Hands/Feet)
2. Chronic Migraines (~4x/month, stress-related)
3. Thoracic Back Spasms
4. Medication Sensitivities (Opioids, Gabapentin)

Our Integrated, Multimodal Plan:

• Foundation: Education & Goal Setting:

• • Our first session would be a deep dive into the biopsychosocial model. We would educate her on the vicious cycles of pain and how our plan will address her whole person, not just her symptoms.
  • We would collaboratively set functional goals. Perhaps her goals are to type on a keyboard for 30 minutes without severe hand pain, walk barefoot in her house without wincing, and reduce her migraine days by 50%.

• Medical Oversight (with Dr. Cardenas):

• • Cardenas would provide comprehensive medical oversight, reviewing her medical history, screening for any red flags, and ensuring there are no contraindications to our proposed treatments. She would manage her cancer survivor follow-up care and review all supplements to ensure safety and efficacy. Her role provides the medical authority and diagnostic rigor that cements the entire integrative plan.

• Behavioral & Psychological Interventions:

• • Given her stress-related migraines, a referral to a psychologist for CBT or ACT would be a top priority. This would equip her with tools to manage stress, challenge catastrophic thoughts about her pain, and commit to valued activities.
  • We would immediately implement sleep hygiene education to ensure she is getting restorative sleep, which is critical for both pain and migraine management.
  • We would introduce her to mindfulness meditation via a guided app to help her change her relationship with the constant neuropathic sensations.

• Physical & Somatic Interventions:
  • Integrative Chiropractic Care:

• • • We would perform gentle thoracic spinal adjustments and mobilization to address the mobility restrictions contributing to her back spasms.
    • We would use myofascial release and trigger point therapy on her thoracic paraspinal and upper trapezius muscles.
    • We would assess her cervical spine, as dysfunction here often contributes to migraines. Gentle cervical work would be beneficial.

• • Physical Therapy:

• • • A referral to a PT specializing in neurological conditions would be made. They would design a program focused on balance training and proprioceptive exercises to help her “retrain” the nerves in her feet.
    • They would prescribe gentle strengthening exercises for her core and thoracic extensors to provide long-term stability for her mid-back.

• • Nutrition:

• • • A consultation to transition her to a whole-foods, anti-inflammatory diet would be crucial. We would focus on increasing her intake of omega-3s, colorful vegetables, and antioxidant-rich foods while eliminating processed foods and sugar.

• Complementary & Interventional Therapies:

• • Acupuncture: We would strongly recommend a course of acupuncture, as it has evidence for all three of her primary complaints: neuropathy, migraines, and musculoskeletal pain.
  • Botox Injections: Given the frequency of her migraines and their significant impact, she is a perfect candidate for prophylactic Botox injections, a highly effective, non-opioid, evidence-based treatment. We would coordinate a referral to a neurologist or pain specialist who performs this procedure.
  • TENS Unit: We would prescribe a TENS unit for her to use at home on her mid-back during spasm flare-ups and potentially on her feet to modulate the neuropathic pain signals.

This layered, dynamic, and collaborative plan is a world away from simply trying another pill. It empowers the patient, respects her body’s limitations and strengths, and addresses every facet of her biopsychosocial experience. This is the future of pain management, and it is a future that we are proud to be building every day at Injury Medical Clinic.

Conclusion: A New Paradigm for Pain Care

The journey through non-pharmacological pain management is a journey toward empowerment, resilience, and a restoration of life. It requires a fundamental shift in perspective for both clinicians and patients—a move away from the passive search for a magic bullet and toward the active, collaborative process of building health from the ground up.

By embracing the biopsychosocial model, assembling a multidisciplinary team, and skillfully weaving together behavioral, physical, interventional, and complementary therapies, we can break the vicious cycles of chronic pain. We can offer our patients more than just temporary relief; we can offer them a roadmap back to a life defined not by their pain, but by their passions, their relationships, and their purpose.

At Injury Medical Clinic, our collaboration between chiropractic, internal medicine, and functional medicine is a living embodiment of this paradigm. We are committed to providing this level of deep, integrative, and personalized care because we have seen its power to transform lives. The tools are available, the evidence is growing, and the time for this new approach is now.

References

• Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.
• Lefaucheur, J. P., André-Obadia, N., Antal, A., Ayache, S. S., Baeken, C., Benninger, D. H., Cantello, R. M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di Lazzaro, V., Filipovi?, S. R., Hummel, F. C., Jääskeläinen, S. K., Kimiskidis, V. K., Koch, G., Langguth, B., Londero, A., … Garcia-Larrea, L. (2014). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clinical Neurophysiology, 125(11), 2150–2206.
• Vickers, A. J., Vertosick, E. A., Lewith, G., MacPherson, H., Foster, N. E., Sherman, K. J., Irnich, D., Witt, C. M., & Linde, K. (2018). Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The Journal of Pain, 19(5), 455–474.
• Williams, A. C. de C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, 11, CD007407.

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