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Am Fam Physician. 2020;102(8):465-477

Related letter: Prolotherapy: An Evidence-Based Adjunctive Therapy for Knee Osteoarthritis

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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.

No one pain therapy alone consistently confers meaningful benefit for chronic musculoskeletal pain. On average, patients with chronic musculoskeletal pain experience small to moderate improvement in pain intensity and function from any single therapy; therefore, a multimodal treatment approach that maximizes likelihood of benefit and minimizes risk of harm is recommended.4

A multimodal pain treatment plan (Figure 1) should emphasize self-management and may include the physical and psychological approaches summarized in this evidence review, as well as medications and herbal therapies, therapeutic injections, and surgery, which are beyond the scope of this article. Patients should be encouraged to engage in a variety of therapies aligned with their preferences and motivation.

Patient Education

Patient education on neurophysiology, as part of a multicomponent self-management program, has demonstrated effectiveness for chronic low back pain.5 Patient education may also reduce pain and nonpain symptoms in fibromyalgia.6 Patient education on the diagnosis and on activity, lifestyle modification, and weight reduction, if indicated, is recommended but not empirically proven for osteoarthritis.7 No benefit has been established for chronic neck pain.8 The evidence for patient education is summarized in Table 1.537

Physical Activity

Physical activity that enhances or maintains muscle strength, physical fitness, flexibility, or overall health is recommended for most types of chronic pain.38

CHRONIC LOW BACK PAIN

Research on exercise in general shows that in patients who have low back pain with or without lumbar radiculopathy, exercise leads to a small to moderate improvement in pain and a small improvement in function in the short term1012 (one to less than six months), small improvement in pain in the intermediate term (six to less than 12 months), and moderate improvement in pain in the long term (12 months or more).10

Motor control exercise is initially guided by a therapist, then continued independently, and focuses on improving coordination and function of the deep muscles that support the spine. It provides a moderate pain benefit and small functional benefit for low back pain that is slightly better than with general exercise for low back pain.11,12,23

Several movement disciplines improve pain and function. Yoga is recommended for chronic low back pain and results in small to moderate pain and functional benefits in the short and intermediate term.5,1012,2528 Tai chi (a flowing series of movements that are coordinated with breathing) results in moderate pain benefit (equivalent to swimming) and small functional benefit for low back pain.1012

CHRONIC NECK PAIN

Although general exercise has no clear benefit for chronic neck pain, specific strengthening exercises of the neck, upper back, and shoulders reduce neck pain.10,14 Combinations of muscle performance, muscle reeducation, mobility, and aerobic exercises improve neck pain and function.10

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