Chronic pain literature review

There are many evidence-based ways to treat chronic pain. Multiple studies have shown that combining treatments to address the biological, psychological, and social nature of chronic pain works well.

​Resources below outline evidence behind various treatments for chronic pain. 

Acupuncture

German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups

Archives of Internal Medicine 

(Haake et al., 2007)

“Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.”

Acupuncture for chronic pain: individual patient data meta-analysis

Archives of Internal Medicine

(Vickers et al., 2012)

“Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo.”

Acupuncture for chronic pain

JAMA

(Vickers and Linde, 2014)

“Acupuncture is associated with improved pain outcomes compared with sham-acupuncture and no-acupuncture control, with response rates of approximately 30% for no acupuncture, 42.5% for sham acupuncture, and 50% for acupuncture.”

Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain 

American Journal of Epidemiology 

(Witt et al., 2006)

“Acupuncture plus routine care was associated with marked clinical improvements in these patients and was relatively cost-effective.”

 

Exercise therapy

Exercise for treating fibromyalgia syndrome

The Cochrane Library

(Busch et al., 2007)

For individuals with fibromyalgia, “there is moderate quality evidence that aerobic-only exercise training at recommended intensity levels has positive effects global well-being and physical function and possibly on pain and tender points.”

Exercise for osteoarthritis of the knee

Cochrane Database of Systematic Reviews

(Fransen et al., 2015)

“High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee osteoarthritis.”

Exercise for osteoarthritis of the hip

Cochrane Database of Systematic Reviews

(Fransen et al., 2014)

“Pooling the results of these 10 randomized controlled trials (RCTs) demonstrated that land-based therapeutic exercise programmes can reduce pain and improve physical function among people with symptomatic hip osteoarthritis.”

Exercise therapy for treatment of non-specific low back pain 

Cochrane Database of Systematic Reviews

(Hayden et al., 2005)

"Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider."

 

Group exercise models

GLA: D® Back group-based patient education integrated with exercises to support self-management of back pain-development, theories and scientific evidence

BMC Musculoskeletal Disorders

(Kjaer et al., 2018)

“The GLA:D Back program for people with persistent or recurrent non-specific back pain includes two lectures of patient education and 16 twice-weekly exercise sessions. The content is aligned with clinical guideline recommendations and elements compiled from the underlying scientific literature about patient education, exercises and prognostic factors.”

Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study

Family Practice

(Sowden et al., 2011)

“This paper describes in detail the IMPaCT Back study’s subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.”

 

Physical therapy

The effect of timing of physical therapy for acute low back pain on health services utilization: a systematic review

Archives of Physical Medicine and Rehabilitation

(Arnold et al., 2019)

Early physical therapy (PT) for acute low back pain (LBP) may reduce health services utilization (HSU), cost, and opioid use, and improve health care efficiency…Early PT for acute LBP has favorable effects on patient-reported outcomes, such as pain, disability, and quality of life, compared to delayed PT or usual care…There is evidence that supports direct access to PT in reducing HSU.”

The influence of patient choice of first provider on costs and outcomes: analysis from a physical therapy patient registry

Journal of Orthopaedic & Sports Physical Therapy

(Denniger et al., 2018)

“The initial patient choice to begin care with a physical therapist for back or neck pain resulted in lower cost of care over the next year, while resulting in similar improvements in patient outcomes at discharge from physical therapy.”

Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs

Health Services Research

(Frogner et al., 2018)

When patients with low back pain (LBP) "saw a physical therapist first, there was lower utilization of high-cost medical services as well as lower opioid use, and cost shifts reflecting the change in utilization.”

 

Psychological therapy

Acceptance and commitment therapy: a transdiagnostic behavioral intervention for mental health and medical conditions

Neurotherapeutics

(Dindo, Van Liew, and Arch, 2017)

Acceptance and Commitment Therapy (ACT), a psychotherapy used to treat a wide array of mental and physical conditions, has been shown to improve functioning and quality of life for patients with chronic pain.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis

Cochrane Database of Systematic Reviews

(Kamper et al., 2015)

“Patients with chronic low back pain (LBP) receiving multidisciplinary biopsychosocial rehabilitation (MBR) are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment.”

Psychological therapies for the management of chronic pain (excluding headache) in adults

Cochrane Database of Systematic Reveiw

(Williams, Eccleston, and Morley, 2012)

“Cognitive behavioral therapy (CBT) is a useful approach to the management of chronic pain.” CBT has weak effects in improving pain, has small effects on disability associated with chronic pain, and is effective in altering mood and catastrophising outcomes.

 

Occupational therapy

An interdisciplinary pain rehabilitation programme: description and evaluation of outcomes

Physiotherapy Canada

(Bosy et al., 2010)

This report describes an interdisciplinary pain rehabilitation program with a cognitive behavioral focus. Improvements in vocational status, pain levels, and levels of anxiety and depression were reported, as well as a reduction in pain medications.

Occupational therapy interventions in chronic pain: a systematic review

Occupational Therapy International

(Hesselstrand et al., 2018)

“Occupational therapy interventions should start from the identified needs of the person with chronic pain; no support exists for the effectiveness of electromyographic biofeedback training as a supplement, more studies are needed to confirm this result; the efficacy of instructions on body mechanics was significant during work‐hardening treatment; and occupational therapists need to perform and present more clinical studies of high quality and high‐evidence level to build up a trustworthy arsenal of evidence‐based interventions, for example, in persons with chronic pain.”

 

Spinal manipulation therapy

A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain

Journal of Manipulative and Physiological Therapeutics

(Hoiriis et al., 2004)

“Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale.”

Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis

JAMA

(Paige et al., 2004)

“Among patients with acute low back pain, spinal manipulative therapy (SMT) was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.”

Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

BMJ

(Rubinstein et al., 2019)

“SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.”

 

Stratified spine care

Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison

The Annals of Family Medicine 

(Foster et al., 2014)

“Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs."

Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial

The Lancet

(Hill et al., 2011)

“The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care. At 12 months, stratified care was associated with a mean increase in generic health benefit and cost savings compared with the control group.”

Is establishing a specialist back pain assessment and management service in primary care a safe and effective model? Twelve-month results from the Back pain Assessment Clinic (BAC) prospective cohort pilot study

BMJ Open 

(Moi et al., 2018)

“Evaluation of the BAC pilot suggests it is a potentially safe and cost-saving alternative model of care. Results of the BAC pilot merit further evaluation to determine the potential cost-effectiveness, longer term and broader societal impact of implementing BAC more widely.”

 

Trauma and emotional pain

Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits

Brain

(Hashmi et al., 2013)

There is distinct non-overlapping circuitry of brain activity for acute back pain and chronic back pain. Additionally, the location of chronic back pain brain activity overlaps with emotion-related circuitry.

Evaluating psychosocial contributions to chronic pain outcomes

Progress in Neuro-Psychopharmacology and Biological Psychiatry

(Meints and Edwards, 2018)

“Increasing evidence suggests an association between both psychological and physical trauma and chronic pain. There are strong prospective links between early-life traumatic experiences and the subsequent development of chronic pain (Afari et al., 2014; Brennstuhl et al., 2014; Burke et al., 2017; Jones et al., 2009; McBeth et al., 2001; Romans et al., 2002). In a recent meta-analysis, the authors reported that the presence of past traumas is associated with a 2- to 3-fold increase in the development of chronic widespread pain (Afari et al., 2014).”

Cumulative childhood adversity as a risk factor for common chronic pain conditions in young adults

Pain Medicine

(You et al., 2018)

“Cumulative childhood adverse events may be a more relevant risk factor for chronic pain conditions than the experience of a specific type of adverse event. Clinicians and researchers need to evaluate cumulative childhood adversity when assessing its link to chronic pain.”

 

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