Nondrug treatments assessed for chronic pain relief
Most effects were small and long-term evidence was sparse, and while there was no evidence suggesting serious harms from any of the interventions studied, data on harms were limited.
Exercise, multidisciplinary rehabilitation, acupuncture, cognitive behavioral therapy (CBT), and mind-body practices were most consistently associated with slight to moderate improvements in function and pain for five chronic pain conditions for at least one month, a recent evidence review concluded.
To assess which noninvasive, nonpharmacological treatments for common chronic pain conditions improve function and pain for at least one month after treatment, the authors reviewed 202 randomized controlled trials of treatments for chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache.
The studies reviewed efficacy or harms compared to usual care, no treatment, waitlist, placebo, or sham; to pharmacological therapy; or to exercise. Most trials enrolled patients with moderate baseline pain intensity and duration of symptoms ranging from three months to more than 15 years. The most common comparison was against usual care. Short term was defined as less than six months, intermediate term was defined as six months to less than 12 months, and long term was defined as 12 months or more.
The full report and evidence summary were published June 11 and are available free of charge from the Agency for Healthcare Research & Quality.
Most effects were small and long-term evidence was sparse, wrote the authors, who also noted that, while there was no evidence suggesting serious harms from any of the interventions studied, data on harms were limited.
Interventions that improved function and/or pain for at least one month included the following for each condition.
Chronic low back pain. In the short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care. Except for spinal manipulation, these interventions also improved pain.
Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). There were improvements in pain for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect; SOE: low); and spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects; SOE: moderate).
For acupuncture, there was no difference in pain intermediately, but there was a slight long-term improvement (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain during short-term, intermediate-term, and long-term follow-up (SOE: moderate). In the short and intermediate terms, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation of 20 or more hours per week or more than 80 hours total was not clearly better than non-high-intensity programs.
Chronic neck pain. Acupuncture and the Alexander Technique (an educational process to retrain patterns of movement and posture) were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low) at short and intermediate terms, but no improvement in pain was seen at any time (SOE: low). Short-term, low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any three among muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function over the short and long term (SOE: low).
Knee osteoarthritis. Exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low).
Hip and hand osteoarthritis. Evidence was sparse. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care over the short term (SOE: low). The effect on function was sustained in the intermediate term (SOE: low).
Fibromyalgia. In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. In the intermediate term, slight functional improvements persisted for exercise (SOE: moderate), acupuncture, and CBT (SOE: low) and were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low). Pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all). Massage (SOE: low) improved long-term pain slightly, but no clear impact on pain was found for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low). Short-term CBT was associated with a slight improvement in function but not pain compared with pharmacologic treatment.
Chronic tension headache. Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain in the short term versus usual care, and laser acupuncture was associated with slight pain improvement in the short term compared with sham (SOE: low).
There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited, the report stated.
“Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions,” the authors concluded. “Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.”