Nondrug pain management offers a variety of options to manage pain without medication (Tables 1, 2). Physical interventions like massage, heat/cold therapy, and acupuncture target the body to reduce pain sensations. Psychological approaches such as relaxation techniques and meditation address the emotional aspects of pain. Additionally, religious practices, music therapy, and even spiritual reflection can all contribute to pain management [38, 39]. These drug-free methods are cost-effective and have minimal side effects, but implementing them safely and effectively can be challenging in some healthcare settings [38]. Studies indicate that numerous nondrug alternatives can be cost-effective and successful. These options include physical therapy, yoga, educational initiatives, acupuncture, and spinal manipulation. Cognitive-behavioral therapy (CBT) can also be a beneficial approach for specific conditions [40]. The analysis of data from 14,767 patients across 12 European hospitals showed that 44.4% of patients used at least one non-pharmacological method for pain management, but these patients reported slightly lower pain relief (68.6% ± 25.7%) than those who did not use NPMs (71.2% ± 27.9%), a statistically significant difference (p < 0.001). The use of NPMs did not affect patients’ desire for more pain treatment, except for a positive effect observed in the subgroup of total knee replacement patients [41]. There is limited evidence supporting nondrug treatments like heat, spinal manipulation, massage, acupuncture, and exercise for certain acute pain conditions [24].

The findings from this research suggest that non-pharmacological methods such as physical therapy and mental health interventions can complement the use of opioid pain medication following surgery. A meta-analysis showed that psychological preparation was associated with a reduction in postoperative negative effects (standardized mean difference [SMD] of −0.35) and reduced time of hospitalization (mean difference of −0.52 days). However, due to high heterogeneity, confidence in these findings is limited [42]. Additionally, nondrug interventions help prevent and manage postoperative delirium, such as helping patients reorient themselves, encouraging early movement, promoting a regular sleep schedule, ensuring proper hydration, and providing visual and hearing assistance [43]. Research shows that transcutaneous electrical nerve stimulation (TENS) may enhance movement and respiratory function, and reduce postoperative symptoms such as nausea, vomiting, chest infections, hypoxia, cardiac issues, pressure ulcers, deep vein thrombosis, loss of appetite, and wound infections, as well as feelings of depression and anxiety [44]. Additionally, these approaches are cost-effective with fewer side effects, aiding post-discharge care as well [45]. These approaches may offer a safer option or supplement to medication. However, due to the limited number of direct comparisons between different techniques, it is difficult to determine which methods are most effective for individual patients. Nevertheless, combining nondrug options like physical therapy, mental health strategies, and education for both patients and caregivers can significantly improve pain relief. However, while some nondrug approaches work on their own, others tend to be more effective when used alongside medications [46]. Multimodal analgesia, which combines these nondrug therapies with medication, including CBT, aligns more closely with the biopsychosocial model of pain, acknowledging the diverse factors contributing to pain perception and management [45, 47] (Fig. 1).

The findings of the review on non-pharmacological methods for managing postoperative pain are promising. The studies discussed here indicate that using complementary approaches can reduce pain levels and the need for opioid medication. Techniques such as physical therapy and psychological interventions were effective in managing postoperative pain and reducing opioid reliance (Tables 1, 2). This highlights the potential for integrating complementary methods into standard pain management protocols. This holistic approach offers the potential to enhance patient outcomes and aid recovery, underscoring the significance of a comprehensive strategy to improve patient well-being and reduce opioid-related risks. A study assessed the use of complementary and alternative medicine for managing postoperative pain. The review analyzed eight studies—five randomized and three non-randomized. All the studies focused on postoperative pain, and five of them showed a significant reduction (p < 0.05). Additionally, five studies looked at opioid consumption, and two of these found significant differences (p < 0.05). Due to heterogeneity, a meta-analysis was not feasible, and potential bias was identified in all of the studies [48]. Non-pharmacological interventions like education, therapy, and distraction techniques can be used before, during, and after surgery [49]. These methods are often cost-effective and easy to implement, and can reduce pain and anxiety, especially for anxious patients. They can also empower patients to manage their pain [49]. Additionally, patients can actively manage pain through safe and cost-effective drug-free methods such as deep breathing, massage, and music [50]. Music therapy is a safe, affordable intervention that has been shown to reduce pain, anxiety, and the need for pain medication in various surgical settings, such as orthopedic, cardiac, and gynecologic surgery [51]. Furthermore, a meta-analysis by Fu et al. revealed that perioperative music significantly reduced postoperative opioid requirement by 31% (95% CI −45% to −16%) and intraoperative propofol and midazolam requirements by 72% (95% CI −101% to −43%) and 107% (95% CI −170% to −44%), respectively. However, it did not significantly impact the length of hospital stay [52]. The study analyzed data from 14,767 patients who underwent surgery. While 44.4% of patients used non-pharmacological methods (NPMs) such as distraction and cold packs, these methods were not associated with significant pain relief compared to those who did not use NPMs. Patients who did not use NPMs experienced slightly more pain relief (71.2% vs. 68.6%). Additionally, the use of NPMs also did not influence the need for additional pain medication. However, in the specific case of total knee replacement patients, NPMs were associated with some pain relief [53]. A review found that various psychological approaches (relaxation, education, therapy) may reduce postsurgical pain and opioid use, but results varied across studies [54]. Similarly, a review of 18 studies found that non-pharmacological interventions like CBT, relaxation, exercise, massage, and music improved sleep quality, reduced pain, and alleviated anxiety in post-cardiac surgery patients compared to usual care [55]. Further research is needed to assess the comparative effectiveness of treatments for different acute pain conditions, and their impact on non-pain outcomes including long-term effects, postoperative complications, length of hospital stays, co-effectiveness, and chronic pain prevention.

Postoperative discomfort can be minimized and managed with a variety of preoperative, intraoperative, and postoperative techniques [47]. Pre-surgery anxiety and fear can be alleviated through pre-anesthesia education, leading to higher patient confidence and satisfaction and faster recovery. The preoperative education provided to patients should set forth clear, evidence-based expectations regarding the anticipated dietary intake, pain relief measures, physical rehabilitation regimen, and mobility targets during the postoperative recovery period [56]. Patients should be informed about post-surgical pain options. This education can reduce opioid use, anxiety, sedation needs, and hospital stays, especially for high-risk patients. Even for others, knowing their options helps them participate in care decisions [47]. Preoperative anxiety is common, affecting up to 61–80% of patients. However, pre-surgery information provided in various formats, like videos or slide shows, can significantly reduce anxiety in patients opting for regional anesthesia. This approach is easy to implement and can benefit a large number of patients [57]. Preoperative education for cardiac surgery patients was found to significantly reduce preoperative anxiety (p = 0.02) and length of intensive care unit (ICU) stay (p = 0.02), and led to moderate improvement in postoperative anxiety, depression, and patient satisfaction (p = 0.04), according to a meta-analysis of 22 trials involving 3167 participants [58].

Physical modalities like TENS, acupuncture, massage, cold therapy, heat therapy, and others are utilized in perioperative pain control. While generally safe, evidence of their efficacy as supplementary treatments in a multimodal approach varies widely [47] (Fig. 1). Non-pharmacological approaches for postoperative pain control can be utilized from preoperative to postoperative stages. These cost-effective and straightforward interventions include patient education, CBT, and distraction techniques like music and aromatherapy. They enhance patient independence and autonomy and are increasingly explored due to concerns regarding traditional pharmacological side effects [49].

Humans have long used cold therapies, known as cryotherapy, for health and recovery. These treatments reduce pain, improve well-being, and aid post-exercise recovery [59]. Physiologically, the importance of cryotherapy lies in its effectiveness in providing pain relief by slowing the speed of sensory nerve conduction [59]. Ice therapy after shoulder surgery helps with pain, but how much and for how long depends on anesthesia. With a specific block used during surgery, 24 h of very cold ice (5 °C) works best. Without the block, shorter bursts of very cold ice at 5 °C (16 h) followed by less ice (24 h) provide better relief at 10 °C [60]. Cryotherapy is a cost-effective and convenient approach used to reduce pain, swelling, and stiffness after knee surgery. It accelerates rehabilitation and helps patients get back to normal life faster [61]. Newer technologies that combine cold therapy with compression are emerging and may offer even better pain management results [61]. However, there are some drawbacks to consider. While traditional cold therapy aids in acute injury analgesia, prolonged use may delay healing. Hyperbaric gaseous cryotherapy offers improved analgesia and anti-inflammatory effects, but conflicting study results persist [62]. Additionally, studies suggest it might not always benefit bone healing. Studies suggest it cools tissues up to 3 cm deep, potentially reaching bone in thin patients [63]. The long-term cooling on bone is not well understood. It is important to note that pain relief from cryotherapy likely comes from numbing the skin, not muscles or bones [63]. Cryotherapy has the potential to decrease inflammation but could also hinder the healing process. Although it can alleviate pain and swelling, it has the possibility of limiting blood flow and delaying the delivery of healing agents to the injured area. Consequently, this may result in tissue necrosis or nerve impairment [62]. Research suggests potential benefits for elderly patients after hip fracture surgery [64]. Applying ice after surgery may help alleviate swelling and discomfort, but the efficacy of this approach following oral surgery is still unclear [65]. Further high-quality research is required to fully understand the effects of both cold therapy and hyperbaric gaseous cryotherapy [59].

Fortunately, low-level heat therapy offers a safe, drug-free, and effective option for managing both acute postoperative pain and chronic lower back pain. Studies have shown its benefits in reducing pain scores, promoting muscle recovery, and helping patients return to normal function [66,67,68]. Heat therapy works by relaxing muscles, improving circulation, and flushing out pain-causing chemicals [67]. A study illustrated that individuals who underwent warming immediately after hernia surgery reported notably reduced pain scores (p = 0.014) compared to those who did not receive warming [68]. Hilotherapy significantly minimizes swelling and pain, accelerating the recovery of mandibular movement, enhancing patient comfort, and simplifying care for medical staff [69]. Thirty patients had third molar surgery and were treated with either Hilotherm or conventional cooling. Hilotherm resulted in less swelling, reduced pain, fewer neurological issues, and higher patient satisfaction compared to conventional cooling [70]. However, in a randomized trial, the Hilotherapy mask significantly cooled facial skin after facelift surgery but caused a notable increase in patient-reported postoperative swelling [71].

A study on electrical nerve stimulation and acupuncture-like TENS (ALTENS) for reducing postsurgical pain medication use found that their effectiveness depended on stimulation parameters. Across 21 trials with 1350 patients, both methods reduced analgesic consumption by 26.5% compared to placebo. However, trials confirming “strong, subnoxious” electrical stimulation at adequate frequencies showed a 35.5% reduction, while those lacking confirmation had only a 4.1% reduction. This variance showed statistical significance (p = 0.0002), highlighting the importance of appropriate stimulation parameters for optimal pain relief and reduced medication use [72]. Additionally, research shows that TENS may enhance movement and respiratory function, and reduce postoperative symptoms such as nausea, vomiting, chest infections, hypoxia, cardiac issues, pressure ulcers, deep vein thrombosis, loss of appetite, and wound infections, as well as feelings of depression and anxiety [44]. However, the evidence is not entirely consistent. For instance, a study investigating the use of TENS following inguinal hernia surgery in men revealed no substantial disparity in pain levels, respiratory function, or medication usage between the TENS and placebo groups, despite the patients’ perception of benefit [73]. Conversely, research involving the application of high-frequency TENS (100 Hz) for alleviating pain following inguinal hernia surgery showed a notable decrease in pain and medication usage compared to a placebo group during the initial 24 h after the surgery. Active TENS notably decreased postoperative pain intensity at 2, 4, 8, and 24 h post-inguinal herniorrhaphy versus placebo TENS (p < 0.05). Analgesic usage was significantly lower in the active TENS group (p = 0.001) [13]. Likewise, the application of TENS to acupuncture points for pain control following hip replacement surgery in elderly patients produced favorable outcomes, as individuals in the TENS group needed less pain medication during the initial two days after the surgery [74].

A randomized trial found no significant reduction in patient-controlled analgesia (PCA) use with TENS compared to sham TENS after total knee arthroplasty, concluding that TENS has no utility for postoperative pain management in this surgery [75]. Patients undergoing cardiac surgery who received a parasternal block had better pain control and required less opioid medication than those using TENS or receiving no treatment. Although TENS provided some pain relief compared to no treatment, it was not as effective as the block [76]. Transcutaneous electric acupoint stimulation (TEAS) appears to be effective in managing postsurgical pain. Research indicates that it reduces pain scores and opioid requirements significantly compared to acupuncture or no treatment, particularly for abdominal surgeries. TEAS may also enhance recovery and reduce nausea, vomiting, and hospital stay after laparoscopic procedures [77]. However, the review indicates that TENS could be used alongside medication in perioperative situations to help relieve acute pain and decrease the need for pain medication during and after surgery [44]. The efficacy of prolonged TENS application to manage postoperative pain has been debated due to differences in pain severity and surgical procedures [78]. A meta-analysis of 472 patients revealed that TENS was effective in reducing pain and opioid usage after total knee arthroplasty. Patients who received TENS reported lower pain scores and consumed fewer opioids at 12, 24, and 48 h post-surgery than those who did not receive TENS [79]. In contrast, a randomized controlled trial (RCT) found that TENS did not reduce postoperative pain after inguinal herniorrhaphy, despite patients’ belief in its effectiveness [73]. The clinical efficacy of TENS for various types of pain is unclear due to inconsistent use, lack of knowledge, and methodological issues in studies. However, TENS may be considered as an additional treatment option alongside analgesic medication for managing acute postsurgical pain [80]. Given the mixed results of current studies, future research should critically examine the potential of TENS as an adjunct therapy for postoperative pain management. Rigorous RCTs are planned to evaluate the parameters of TENS therapy and the variations in physiotherapy techniques.

Research in the 1970s and earlier studies from the 1800s suggested that acupuncture has the potential to elevate pain thresholds and trigger the release of internal mediators, indicating possible analgesic effects. A 1977 study found that acupuncture notably raised pain threshold by 27.1%, compared to just 6.9% in the control group, providing further evidence for its pain-relieving properties [77]. Research on the effectiveness of acupuncture for postsurgical pain is inconclusive, with some studies lacking strong evidence [47]. However, a review of over 39 studies suggests it can be beneficial, potentially decreasing pain and opioid use and improving patient satisfaction after surgery, making it a valuable addition to pain management strategies [81]. Studies on specific surgeries such as cesarean section indicate that acupuncture is effective and safe for pain relief, with reduced recovery time and no side effects [82]. Acupressure might be a leading non-pharmaceutical method for postsurgical pain, potentially reducing discomfort and improving mobility for up to a week [83].

Acupuncture techniques like electroacupuncture show promise for various surgeries, including abdominal, spine, and pelvic procedures, with the potential to decrease pain and nausea, leading to reduced reliance on opioids, although more research is needed to identify the most suitable technique for individual patients [77]. A review of 22 studies suggests that acupuncture tended to help with pain relief, with 15 studies showing less or later use of pain medications. However, five studies saw no pain difference between acupuncture and controls. Acupuncture might be safe for postsurgical pain, but larger studies are needed to confirm its overall effectiveness [84]. However, a review of 22 studies involving 1878 patients found some evidence that acupuncture sped up early recovery after colorectal surgery. Patients receiving acupuncture experienced faster passage of gas (MD −0.77 h, 95% CI −1.22 to −0.33 h), earlier bowel movements (mean deviation (MD): −1.41 h, 95% CI −2.20 to −0.63 h), and quicker defecation (MD −1.03 h, 95% CI −1.88 to −0.18 h). They also had less nausea/vomiting (RR 0.72, 95% CI 0.59–0.89), but acupuncture did not significantly reduce pain [85].

A systematic review including 33 RCTs found that massage therapy (MT) is effective in postoperative pain control, with a large effect size (SMD −1.32, 95% CI −2.01 to −0.63, p = 0.0002). The remarkable pain-relieving effect was observed in both immediate and 4–6-week follow-up assessments. Notably, the duration or dose of massage therapy (MT) did not impact its effectiveness, and MT appeared more beneficial for adults than other age groups. Additionally, MT had effective analgesic effects for cesarean section and cardiac surgeries compared to orthopedic procedures [86]. However, the review acknowledges some limitations, including potential publication bias, high heterogeneity among studies, and difficulty in implementing double-blinding. While supervised rehabilitation can reduce pain within a week, its impact on function is less clear. Similarly, the effectiveness of ultrasound and laser therapy in pain management remains inconclusive, although laser therapy might offer relief for other symptoms [83].

A review of seven cardiac surgery studies found significant heterogeneity in massage therapy protocols, limiting generalizability. While four out of five studies demonstrated that massage significantly reduced anxiety and pain, several failed to show decreased analgesic requirements, undermining the validity of these findings. The review does not support the use of massage therapy because there is a lack of current evidence to support its effectiveness in improving physiological outcomes like the onset of atrial fibrillation after cardiac surgery [87]. Research involving 60 children (aged 6–18) who had heart surgery revealed that there was no notable distinction in pain or anxiety levels between the massage therapy and reading groups during the initial 24 h (T1) and 48 h (T2) following the surgery. At the time of discharge (T3), children who received massage therapy showed a significant decrease in state-trait anxiety scores compared to the control group (p = 0.0075). Furthermore, the group receiving massage therapy showed a notable decrease in total benzodiazepine exposure during the initial 3 days following the surgery (median 0.002 mg/kg vs. 0.03 mg/kg, p = 0.0253) and required fewer benzodiazepine pro re nata (PRN) doses (median 0.5 vs. 2, p = 0.00346). There were no variances in the overall opioid intake between the groups [88]. In a single-blind study involving 31 post-cardiac surgery patients, with 16 participants in the experimental group and 15 in the placebo group, researchers discovered that administering a 10-min foot massage twice a day within 30 min of receiving opioid pain medication resulted