Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments

 

Chronic low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia are the most common types of chronic musculoskeletal pain. Because no individual therapy has consistent benefit, a multimodal treatment approach to chronic musculoskeletal pain is recommended. Many nonpharmacologic, noninvasive treatment approaches yield small to moderate improvement and can be used with pharmacologic or more invasive modalities. Systematic reviews and guidelines support the effectiveness of various forms of exercise in improving pain and function in patients with chronic pain. Cognitive behavior therapy and mindfulness techniques appear to be effective for small to moderate short- and long-term improvement of chronic low back pain. Cognitive behavior therapy may also be effective for small short- and intermediate-term improvement of fibromyalgia. Spinal manipulation leads to a small benefit for chronic neck and low back pain. Acupuncture has a small to moderate benefit for low back pain and small benefit for nonpain fibromyalgia symptoms. Massage or myofascial release yields a small improvement in low back pain, hip and knee osteoarthritis, and fibromyalgia. Low reactive level laser therapy may provide short-term relief of chronic neck and low back pain, and ultrasound may provide short-term pain relief for knee osteoarthritis. Multidisciplinary rehabilitation may be effective for short- and at least intermediate-term improvement in pain and function for chronic low back pain and fibromyalgia. Patients should be encouraged to engage in a variety of therapies aligned with their preferences and motivation.

A chronic musculoskeletal pain disorder is the underlying diagnosis for 70% to 80% of those living with chronic pain.1 Among the top 12 causes of disability in the United States, musculoskeletal disorders cause more than one-third of years lived with disability and are among the leading causes of disability worldwide.2,3 Chronic low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia are the most common types of chronic musculoskeletal pain.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence rating*

Regular exercise is recommended for patients with chronic musculoskeletal pain.1012,1823 Because no specific type of exercise is clearly superior, patients should be encouraged to engage in the type of low-impact exercise they prefer.

B

Encourage yoga for patients with chronic low back pain, lumbar radiculopathy, knee osteoarthritis, or fibromyalgia.10,11,25,27,2830,3132

B

Encourage cognitive behavior therapy for patients with chronic low back pain or fibromyalgia.1012,25,41,42

B

Encourage mindfulness-based stress reduction for patients with chronic low back pain or fibromyalgia.1012,25

B

Consider spinal manipulation for patients with chronic low back pain or neck pain.10,48,49

B

Consider acupuncture for patients with chronic low back pain, neck pain, or fibromyalgia.1012,52,54

B

Consider massage or myofascial release for low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia.10,58,59,60,61

B

Consider multi- or interdisciplinary rehabilitation for patients with chronic low back pain or fibromyalgia that does not respond to initial therapies, or who have a significant psychological component.1012,71

B


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

*—All are based on multiple consistent systematic reviews, including Cochrane reviews, of low- to moderate-quality studies and evidence-based guidelines.

The Author

DIANE M. FLYNN, MD, MPH, is the primary care pain management advisor in the Department of Rehabilitative Medicine at the Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, Wash., and an adjunct assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to Diane M. Flynn, MD, MPH, Madigan Army Medical Center, 9040 Jackson Ave., Tacoma, WA 98431 (email: diane.m.flynn4.civ@mail.mil). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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