Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Abstract

ii Key Messages Purpose of ReviewTo assess which noninvasive nonpharmacological treatments for common chronic pain conditions improve function and pain for at least 1 month after treatment. Key Messages• Interventions that improved function and/or pain for at least 1 month when used foro Chronic low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy [CBT]), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR). o Chronic neck pain: Exercise, low-level laser, Alexander Technique, acupuncture. o Knee osteoarthritis: Exercise, ultrasound. o Hip osteoarthritis: Exercise, manual therapies. o Fibromyalgia: Exercise, CBT, myofascial release massage, tai chi, qigong, acupuncture, MDR. o Chronic tension headache: Spinal manipulation.• Most effects were small. Long-term evidence was sparse.• There was no evidence suggesting serious harms from any of the interventions studied; data on harms were limited.iii This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.The information in this report is intended to help health care decisionmakers-patients and clinicians, health system leaders, and policymakers, among others-make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.This report may periodically be assessed f...

A Systematic Review of Biological Mechanisms and Chronic Pain Outcomes During Stress Reduction Interventions

“…Although the nonpharmacologic stress reduction interventions we evaluated in the present review were generally associated with improvements in pain outcomes, there was no consistent evidence that the interventions directly targeted the biological mechanisms of pain perception, as the selected biomarkers did not demonstrate repeated associations with changes in pain severity. Previous reviews have also identified mixed results of nonpharmacological stress reduction interventions on CP outcomes (Majeed et al, 2018;Skelly et al, 2018). Methodological differences across the studies in this review (i.e., the variations in measurement of pain, stress, and biological mechanisms; intervention designs) present a considerable challenge for reaching definitive conclusions other than to highlight the pressing need for additional research.…”

“…Authors of a recent review article in which they extensively investigated the long-term effectiveness of nonpharmacologic interventions across multiple CP populations identified similar findings, noting that future research should focus on sustainability of intervention effects (Skelly et al, 2018). However, Skelly et al (2018) did not include the investigation of biological measures in their review. Therefore, this article adds to these findings by stressing the need for standard protocols to investigate long-term effects of nonpharmacologic interventions and long-term measurement of biomarkers to understand the underlying processes.…”

“…Investigators measured biological samples at a follow-up time point in only one study, although they did not find sustained reduction in inflammatory mediators (Zgierska et al, 2016). Authors of a recent review article in which they extensively investigated the long-term effectiveness of nonpharmacologic interventions across multiple CP populations identified similar findings, noting that future research should focus on sustainability of intervention effects (Skelly et al, 2018). However, Skelly et al (2018) did not include the investigation of biological measures in their review.…”

“…Multiple types of nonpharmacologic stress reduction techniques exist that generally fall within broader categories such as relaxation techniques, physical training programs, cognitive behavioral therapy, massage, and biofeedback. Although health care clinicians frequently encourage patients with CP to use these methods and the methods have good feasibility, the findings regarding their effectiveness in improving pain-related outcomes are conflicting (Eller-Smith et al, 2018;Fisher et al, 2018;Majeed et al, 2018;Petersen & la Cour, 2016;Skelly et al, 2018;Theadom et al, 2015). One reason for this lack of agreement may be a limited understanding of how these methods target the biological mechanisms within the stress-response system.…”

Laboratory biomarkers of systemic inflammation – what can they tell us about chronic pain?

“…In the broader context of pain behavior, pain expressed by patients verbally is also just pain behavior and this may or not change with IMMRP even if other pain behaviors do change in a positive way. In the literature looking at outcomes of IMMRP, pain reduction is not too significant although other pain behaviors are usually modified to a somewhat greater extent [11][12][13].…”