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.^5–37

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 term^10–12 (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.^{5,10–12,25–28} 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.^10–12

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