Back
Back
About

Movement & Body Strategies

  • Physical Therapy

    Physical Therapy

    • What is it
      • Physical therapy provides guidance for strengthening, stretching, and aerobic exercises to improve body movement, and boost physical capabilities, for patients with physical impairments due to pain and other musculoskeletal disorders.
    • How it works
      • Can produce positive changes in bone, cartilage, tendons, and muscle.
      • Primarily prescribed for musculoskeletal disorders including low back pain and joint osteoarthritis.
      • Many different physical therapy approaches exist.
        • Directional-preference therapy.
        • Core conditioning.
        • Cognitive functional therapy.
        • Movement control impairment therapy.
      • Evidence for effectiveness varies depending on the condition.
    • Pros and Cons

      Pros

      • Proven helpful for tempomandibular joint pain, low back pain.

      Cons

      • Methods may vary significantly from one provider to another.
      • Often requires multiple visits and copays.
      • Certain providers do not accept health insurance.

      Side effects

      • Possible side effects include increased pain, muscle soreness, and trauma.
  • Occupational Therapy

    Occupational Therapy

    • What it is
      • Occupational therapy provides treatments and instructions for patients to improve performance in daily tasks or occupational skills.
    • How it works
      • Patient receives an evaluation to determine therapeutic needs.
      • May include evaluation of home setting or workplace.
      • Occupational therapists makes suggestions for specific adaptations to improve independence with performing tasks.
    • Pros and Cons

      Pros

      • Proven beneficial for some conditions including low back pain, limb disorders, and headaches.

      Cons

      • Lack of evidence to support use for most painful conditions.
      • Often requires multiple visits and copays.

      Side effects

      • Possible side effects include increased pain and muscle soreness.
  • Regular physical activities

    Regular physical activities

    Group of seniors walking together outside.
    • What is it
      • Types of exercise: aerobic, strength training, and motor control.
      • Studies have found exercise leads to increased production of natural pain-relieving chemicals.
    • How it works
      • Exercise works to improve pain by stimulating the nervous system to release natural pain killers. Additionally, exercise helps to improve blood circulation and reduces joint stiffness.
      • Exercise is associated with improved pain control for numerous painful conditions (Rheumatoid arthritis, osteoarthritis, fibromyalgia, and dysmenorrhea).
      • Most guidelines recommend starting exercise at a low intensity and gradually progressing to a stronger intensity.
    • Pros and Cons

      Pros

      • Evidence suggests exercise is a safe pathway to reduce pain.
      • Low-to moderate-intensity exercise is adequate to improve chronic pain symptoms.
      • Inexpensive.

      Cons

      • It not clear how often, how intense, or how long a patient must work out to gain beneficial effect.
      • Frail patients will often require assistance to exercise safely.

      Side effects

      • Possible side effects included increased pain, muscle soreness, and trauma,
  • Yoga

    Yoga

    • What is it
      • Series of exercises that place focus on body awareness, attention, meditation, and relaxation.
    • How it works
      • Positively affects brain function to reduce stress and pain.
      • Helps to stretch muscles and improve range of motion.
    • Pros and Cons

      Pros

      • Effective to improve pain and physical disabilities associated with certain conditions (back pain, rheumatoid arthritis, and headache).
      • May also be effective to improve occupational performance and decrease depression.

      Cons

      • Not covered by insurance in most cases.
      • May be difficulty to find a provider.
      • Different varieties and levels of intensity that may not be suitable for all patients.

      Side effects

      • Rare side effects include increased pain, reduced range of motion, and disc herniations.
  • Tai Chi

    Tai Chi

    • What it is
      • Light-to-moderate intensity physical activities performed slowly with a focus on movement sense, abdominal breathing, and meditation
    • How it works
      • Designed to strengthen and stretch the body, improve the flow of blood, improve balance, position sense, and awareness of how the body moves
      • Commonly prescribed for low back pain, headaches, and osteoarthritis
    • Pros and Cons

      Pros

      • Evidence demonstrates Tai Chi can be helpful for osteoarthritis and chronic low back pain
      • No major adverse side effects have been reported

      Cons

      • Not covered by insurance in most cases
      • May be difficulty to find a provider

      Side effects

      • Possible muscle soreness
  • Other mind-body practices Alexander Technique

    Other mind-body practices Alexander Technique

    • What is it
      • Alexander Technique (AT) is an educational process to retrain habitual patterns of movement and posture.
    • How it works
      • AT providers believe that by identifying and retraining poor habits in posture and movement that a person can move more naturally and over time create less strain and pain.
    • Pros and Cons

      Pros

      • Preliminary evidence shows it may help with long-term back and neck pain in some people. It may improve general long-term pain and balance in some people, particularly general musculoskeletal pain and the elderly.

      Cons

      • Limited evidence. Multiple reviews and guidelines have concluded there is insufficient data to recommend AT.
      • Usually not covered by most insurances and often requires multiple visits.
      • Difficult to maintain benefit. Continual use of corrected posture and movement may be difficult to maintain without a lot of practice.

      Side effects

      • Possible side effects may include increased pain and muscle soreness.
    • Resources

      Citations

  • Other mind-body practices Feldenkrais

    Other mind-body practices Feldenkrais

    • What is it
      • Involves physical training that provides patients with improved body awareness and optimization of movement patterns. Better self-awareness is theorized to result in less joint strain and movement errors.
    • How it works
      • Two types of lesson plans: Awareness Through Movement (ATM), and Functional Integration (FI).
      • ATM: Often performed on a group of students who receive instructions on energy efficient and well-tolerated movement patterns to generate better self-awareness of body mechanics.
      • FI is one-on-one training involving touch, verbal coaching, and monitored movements. The goal is to make the patient sensitive to tension and faulty movements that contribute to pain. The patient learns to move in pain-free ways with more self-awareness.
    • Pros and cons

      Pros

      • Studies suggest Feldenkrais is beneficial for low back and neck pain.

      Cons

      • Not covered by most insurance companies.
      • Limited or lack of evidence to support effectiveness for most chronic pain.

      Side effects

      • Some exercise may lead to muscle soreness
    • Resources

      Citations

      • Hillier, Susan, and Anthea Worley. “The Effectiveness of the Feldenkrais Method: A Systematic Review of the Evidence.” Evidence-Based Complementary and Alternative Medicine, vol. 2015, 2015, pp. 1–12., doi:10.1155/2015/752160.
      • Plastaras, C. T., Schran, S., Kim, N., Sorosky, S., Darr, D., Chen, M. S., & Lansky, R. (2011). Complementary and Alternative Treatment for Neck Pain: Chiropractic, Acupuncture, TENS, Massage, Yoga, Tai Chi, and Feldenkrais. Physical Medicine and Rehabilitation Clinics of North America, 22(3), 521–537. .
      • Paolucci, T., Attanasi, C., Cecchini, W., Marazzi, A., Capobianco, S., & Santilli, V. (2018). Chronic low back pain and postural rehabilitation exercise: a literature review. Journal of Pain Research, Volume 12, 95–107. https://doi.org/10.2147/jpr.s171729
  • Ergonomics

    Ergonomics

    • What it is
      • Practices that enhance human function and health in the work environment.
    • How it works
      • Serves to make work settings suitable for employees by supporting the body with ideal posture, limiting excessive forces, and providing safe environments.
      • Examples include: adjustable desks, lifting precautions, work station designs, or custom chairs with back support.
    • Pros and Cons

      Pros

      • Proven beneficial for different musculoskeletal conditions, including back and arm problems.

      Cons

      • Not available from all employers.
      • Not covered by insurance.

      Side effects

      • Some adjustment may lead to muscle soreness.
  • Assistive devices

    Assistive devices

    • What is it
      • Appliances designed to stabilize or support a region of body for purpose of making a patient more able to function.
      • Common examples include: spinal and joint braces, walking canes, walkers, walking sticks, and wheelchairs.
    • How it works
      • Braces support joints to minimize pressure and swelling.
      • Walking aids support the body by reducing mechanical pressure along joint lines.
    • Pros and cons

      Pros

      • Studies suggest bracing is beneficial for many musculoskeletal problems including: tendinitis, spinal fractures, knee arthritis, and carpal tunnel syndrome.
      • Walking aids helpful for hip and knee osteoarthritis.

      Cons

      • Many devices require formal fitting and time to fabricate.
      • Cost may not be covered/fully covered by insurance companies.
      • Limited or lack of evidence to support effectiveness for many chronic pain conditions.

      Side Effects

      • Braces may lead to muscle weakness, muscle shortening, stiffness, increased pain, and muscle soreness.
    • Resources

      Citations

      Sprouse. RL et al. (2018). Braces and Splints for Common Musculoskeletal Conditions. Am Fam Physician. Nov 15;98(10):570-576

      Chang, V., & Holly, L. T. (2014). Bracing for thoracolumbar fractures. Neurosurgical Focus, 37(1). doi: 10.3171/2014.4.focus1477

      Fernandes L, Hagen KB, Bijlsma JWJ, et al (2013). EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the Rheumatic Diseases;72:1125-1135

Pain Management Skills

  • Understanding Pain

    Understanding Pain

    • What is it

      Information that helps you better understand chronic pain, how it differs from acute pain, how chronic pain develops and its impact on physical and mental health. The Beyond Pain App briefly provided some brief education on chronic pain and treatments, but there is a lot more to learn.

      Examples: Understanding pain better can be done in a variety of ways such as taking a chronic pain class, talking with your provider, books, and websites.

    • How it works

      A better understanding of pain provides you with a foundation to understand your pain and what treatments may be best. You may think about pain more appropriately, apply better treatment techniques, and reduce dysfunctional behaviors and thoughts that lead to more suffering.

    • Pros and cons

      Pros

      • Increased knowledge may help communication with providers and more appropriate selection of treatments.
      • Correct misunderstandings regarding chronic pain.

      Cons

      • There is limited evidence that education alone decreases pain or increases physical functioning. It should be used in conjunction with other pain management approaches.
      • There are many sources of inaccurate information which can lead to misinformation and confusion. Use only reliable sources of information. Check with your provider if you have questions about where best to look for information about your type of chronic pain.

      Side effects

      • None.
    • Resources

      Classes

      • Living Well with Chronic Pain. This is a standardized chronic pain class that may be available in your health care system or hospital. There may be other classes. Ask your doctor for available chronic pain classes.

      Books

      • Managing Pain Before It Manages You, 4th Edition, by Margaret A. Caudill. The Guildford Press, 2016
      • Managing Chronic Pain. A Cognitive-Behavioral Therapy Approach Workbook by John D. Otis. Oxford University Press, 2007

      Citations

      • Geneen LJ, Martin DJ, Adams N, Clarke C, Dunbar M, Jones D, McNamee P, Schofield P, & Smith BH. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis.
  • Relaxation Techniques

    Relaxation Techniques

    • What is it
      • Relaxation skills are techniques designed to reduce muscle tension and stress experienced with chronic pain.
      • Examples: Diaphragmatic breathing, progressive muscle relaxation, meditation, guided imagery, hypnosis, biofeedback.
    • How it works

      There are a variety of relaxation skills which work in different ways. Generally, they are designed to activate the parasympathetic nervous system and thereby reduce muscle tension and other physiological changes that often accompany chronic pain such as breath, heart rate, blood pressure and hormones. Reversing your body’s response to pain may improve pain, stress, and physical functioning. These techniques can be taught by various providers (psychotherapist, psychologist, health coach, or yoga instructor) or through self-help means such as apps, audio recordings, and books.

    • Pros and cons

      Pros

      • Reduced pain, decreased stress, increased ability to do physical and social activities.
      • Most techniques can be self-guided and easily used at any time.
      • Can be used for a many types of chronic pain not only musculoskeletal pain.

      Cons

      • Moderate effectiveness.
      • Often requires ongoing practice.
      • It may take time and practice to find the technique that works best for you.

      Side effects

      None

    • Resources

      Citations

      • American Psychological Association “Pain, Pain, Go Away–Psychological Approaches Help People Cope With Chronic Pain” 2006
      • Caudill, MA. Managing Pain Before It Manages You, Fourth Edition. Guildford. 2016
      • Turk, DC and Wintner, F. The Pain Survival Guide How To Reclaim Your Life, American Psychological Association, 2006
  • Pain Psychotherapies

    Pain Psychotherapies

    • What is it
      • Psychotherapies specific to pain. These are designed to help a person cope and manage chronic pain and improve behavioral, emotional, and cognitive changes that occur with chronic pain.
      • Examples: Cognitive Behavioral Therapy for Pain (CBT-P), Mindfulness Based Stress Reduction (MBSR), Acceptance and Commitment Therapy for Pain (ACT-P), Operant-Behavioral Therapy.
    • How it works

      There are distinct therapies that target different mechanism but generally address the behaviors, thoughts, and emotions that may change due to pain and make pain worse. It may include relaxation skills, activity rest cycling, behavior change, reducing stress reactions, and addressing thoughts about pain and movement.

    • Pros and cons

      Pros

      • Reduced pain, decreased stress, increased ability to do physical and social activities.
      • Address emotional reactions to chronic pain. Reduce anxiety and depression.
      • Can be used for a variety of chronic pains not only muscluskelatal pain.

      Cons

      • Often requires ongoing practice.
      • Difficulties in finding a treatment provider offering these services.

      Side effects

      • Increased awareness of emotions may temporarily increase psychological distress.
    • Resources

      Resources

      • Managing Pain Before It Manages You, 4th Edition, by Margaret A. Caudill. The Guildford Press, 2016
      • Managing Chronic Pain. A Cognitive-Behavioral Therapy Approach Workbook by John D. Otis. Oxford University Press, 2007
      • Cognitive Therapy for Chronic Pain. A Step-by-Step Guide by Beverly E. Thorn. The Guildford Press, 2017
      • Full Catastrophe Living by Jon Kabat-Zinn. Bantam Books, 2013

      Citations

      • Psychological Approaches to Pain Management, 3rd Ed – Turk, DC, Gatchel RJ. Guildford Press 2018, American Psychological Association
      • “Pain, Pain, Go Away–Psychological Approaches Help People Cope with Chronic Pain” 2006
  • General Psychotherapies

    General Psychotherapies

    Mid age man talks with a female counselor at home. One on one meeting
    • What is it

      Psychotherapy, or talk therapy, not specific to chronic pain can address other difficulties that may accompany chronic pain such as stress, anxiety, depression, insomnia and substance use/addiction.

    • How it works

      There are a wide variety of psychotherapies that can help people better manage emotional difficulties. Psychotherapy can help a person better manage troubling symptoms and therapy may improve overall psychological coping.

    • Pros and cons

      Pros

      • Improved psychological, mental, and emotional health such as improving anxiety, depression, insomnia and substance abuse/addiction.
      • May improve pain and functioning via improving emotions, coping and behaviors.

      Cons

      • Often requires ongoing practice.
      • May not directly address chronic pain.

      Side effects

      • Increased awareness of emotions may temporarily increase psychological distress.
    • Resources

      Citations

Complementary & Integrative Health

  • Massage

    Massage

    • What is it
      • Massage therapy is generally defined as treatment using touch to manipulate the muscles and other soft tissues of the body.
    • How it works
      • May work by changing the sensitivity of the nervous system, increasing clearance of inflammation, and improving the immune system.
      • Massage therapy represents many different techniques, which may vary from one provider to another.
      • Common types include: deep tissue, Swedish massage, sports massage, and chair massage.
    • Pros and cons

      Pros

      • Massage may be helpful for headaches, shoulder, neck, back, arthritis, postoperative, and temporomandibular pain.

      Cons

      • May not be covered by insurance.
      • Results may be temporary.

      Side effects

      • Rare side effects include nerve injury, organ injury, and paralysis.
      • The incidence of adverse events is unknown, but likely very low.
    • Resources

      Citations

      • Giannitrapani et al. (2019). Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain. Pain Medicine, 00(0), 2019, 1–10
      • Miake-Lye, I. M., Mak, S., Lee, J., Luger, T., Taylor, S. L., Shanman, R., . . . Shekelle, P. G. (2019). Massage for Pain: An Evidence Map. The Journal of Alternative and Complementary Medicine,25(5), 475-502. doi:10.1089/acm.2018.0282
      • Bervoets, D. C., Luijsterburg, P. A., Alessie, J. J., Buijs, M. J., & Verhagen, A. P. (2015). Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: A systematic review. Journal of Physiotherapy,61(3), 106-116. doi:10.1016/j.jphys.2015.05.018. Ernst, E. (2003). The safety of massage therapy. Rheumatology,42(9), 1101-1106. doi:10.1093/rheumatology/keg306
  • Acupuncture

    Acupuncture

    • What is it
      • Treatment option for managing different chronic pain conditions.
    • How it works
      • Acupuncture is a process where needles are inserted in specific areas of the body.
      • Different theories exist for why acupuncture works to provide pain relief.
      • Acupuncture may help to release natural pain killers from the brain, which leads to lower levels of pain.
    • Pros and cons

      Pros

      • Low risk of side effects.
      • Effective for different pain conditions.

      Cons

      • May not be covered by insurances.
      • Not available everywhere.
      • Benefits may be small or of a short duration.

      Side effects

      • Rare adverse events include infection, pneumothorax (air trapped in the space between the lungs and ribcage), nerve injury, spinal cord injury, bleeding, muscle soreness, bruising, and organ injury.
    • Resources

      Citations

      • Vickers et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The Journal of Pain, Vol 19, No 5 (May), 2018: pp 455-474
      • Kenji et al. Acupuncture therapy: mechanism of action, efficacy, and safety: a potential intervention for psychogenic disorders? Biopsychosoc Med. 2014; 8: 4
      • Acupuncture for chronic pain: an update and critical overview. Curr Opin Anesthesiol 2017, 30:583–592
      • Xu, S., Wang, L., Cooper, E., Zhang, M., Manheimer, E., Berman, B., . . . Lao, L. (2013). Adverse Events of Acupuncture: A Systematic Review of Case Reports. Evidence-Based Complementary and Alternative Medicine,2013, 1-15. doi:10.1155/2013/581203
  • Chiropractic care

    Chiropractic care

    • What is it
      • Chiropractic treatment is focused on the connection between the spinal column and the nervous system.
      • Often involves a mixture of manual methods, the most common being specific bodily adjustments, to correct the vertebral misalignment.
    • How it works
      • Two models have been proposed for how chiropractic adjustments reduce pain.
      • Biomechanical theory suggests that spinal manipulation reduces internal mechanical pressure in muscles and joints.
      • Neurological model proposes that spinal manipulation influences nerves in the spinal column, which alters pain processing in the brain.
    • Pros and cons

      Pros

      • Many scientific studies have demonstrated that chiropractic care can reduce pain.
      • Mainly used for back pain, neck pain, headaches, but also limb and joint pain.
      • Chiropractic interventions have been found to improve pain in the short term and in the medium term for acute and subacute low back pain.

      Cons

      • May not be covered by insurance.
      • Some serious side effects have occurred.
      • Not helpful for many conditions.
      • Benefits are often of short duration.

      Side effects

      • Serious complications are rare but adverse injuries from neck rotation include strokes, spinal cord compression, vertebral fracture, tracheal rupture, diaphragm paralysis, and internal bleeding.
    • Resources

      Citations

      • Navid, M. S., Lelic, D., Niazi, I. K., Holt, K., Mark, E. B., Drewes, A. M., & Haavik, H. (2019). The effects of chiropractic spinal manipulation on central processing of tonic pain -a pilot study using standardized low-resolution brain electromagnetic tomography (sLORETA).Scientific Reports,9(1). doi:10.1038/s41598-019-42984-3
      • Rubinstein, S. M., Zoete, A. D., Middelkoop, M. V., Assendelft, W. J., Boer, M. R., & Tulder, M. W. (2019). Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: Systematic review and meta-analysis of randomisedcontrolled trials.Bmj,L689.doi:10.1136/bmj.l689
      • Kaptchuk, T. J., & Eisenberg, D. M. (1998). Chiropractic.Archives of Internal Medicine,158(20), 2215. doi:10.1001/archinte.158.20.2215
      • Walker, B. F., French, S. D., Grant, W., & Green, S. (2011). A Cochrane Review of Combined Chiropractic Interventions for Low-Back Pain.Spine,36(3), 230-242. doi:10.1097/brs.0b013e318202ac73
  • Cannabinoids

    Cannabinoids

    • What is it
      • Medicinal compounds obtained from the Cannabis plant.
      • Compounds are called cannabinoids.
      • Two most popular compounds are tetrahydrocannabinol (THC) and cannabidiol (CBD).
    • How it works
      • Act upon receptors in the brain and immune system.
    • Pros and cons

      Pros

      • THC interacts with specific receptors to reduce pain, muscle tone, alertness, appetite, and mood.
      • CBD can produce a wide range of pharmacological activity including anticonvulsive, anti-inflammatory, antioxidant, and antipsychotic effects.
      • CBD is not associated with euphoria and mind-altering effects.
      • Some evidence to support the use of cannabis‐based medicines for the treatment of chronic pain.

      Cons

      • Acute and chronic cannabis can be harmful to several aspects of mental and physical well-being.

      Side effects

      • Can affect mood, reaction time, and general health
      • Possible addiction and associated with withdrawal effects
      • Studies have not identified specific a dose, duration, or frequency for long term use
      • Additional studies are needed before cannabis can be fully approved as a medication for pain relief
    • Resources

      Citation

      • Romero-Sandoval et al. (2018). Cannabis for Chronic Pain: Challenges and Considerations. (Pharmacotherapy 2018;38(6):651–662) doi: 10.1002/phar.2115
      • Häuser, W., Petzke, F., & Fitzcharles, M. (2017). Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management – An overview of systematic reviews.European Journal of Pain,22(3), 455-470. doi:10.1002/ejp.1118

Conventional Medicine

  • Acetaminophen

    Acetaminophen

    • What is it
      • Medication used to control pain.
      • Example: Tylenol.
    • How it works
      • Believed to work on parts of the nervous system to reduce pain but the exact mechanism is poorly understood.
    • Pros and cons

      Pros

      • Helpful to control acute pain for different conditions, including surgical pain, dental pain, and headaches.
      • Available without a prescription.
      • Does not cause drowsiness or addiction.

      Cons

      • Not proven effective for long term control of pain.
      • Long term use increases risk of potential side effects.

      Side effects

      • Use is limited by side effects, including potential for liver toxicity, high blood pressure, and gastrointestinal problems
    • Resources

      Citations

      • Anderson, B. J. (2008). Paracetamol (Acetaminophen): mechanisms of action. Pediatric Anesthesia, 18(10), 915–921
      • Ennis, Z. N., Dideriksen, D., Vaegter, H. B., Handberg, G., & Pottegård, A. (2015). Acetaminophen for Chronic Pain: A Systematic Review on Efficacy. Basic & Clinical Pharmacology & Toxicology, 118(3)
      • Roberts, E., Nunes, V. D., Buckner, S., Latchem, S., Constanti, M., Miller, P., … Conaghan, P. G. (2015). Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Annals of the Rheumatic Diseases, 75(3), 552–559
  • Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

    Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

    • What is it
      • Medication used to control pain and inflammation.
      • Examples include: ibuprofen, naproxen (Aleve), and diclofenac.
    • How it works
      • Decreases inflammation and nerve sensitivity.
    • Pros and cons

      Pros

      • Helpful to control acute pain for different skeletal conditions, including low back pain, muscle strain, and headaches.
      • Available without a prescription.
      • Does not cause drowsiness or addiction.

      Cons

      • Not proven effective for long term control of pain.
      • Long term use increases risk of serious side effects.

      Side effects

      • Use is limited by side effects, including stomach, kidney, and heart problems
    • Resources

      Citations

      • Enthoven et al. JAMA.NSAIDs for Chronic Low Back Pain. Jun 13;317(22):2327-2328
      • Ho, K. Y., Gwee, K. A., Cheng, Y. K., Yoon, K. H., Hee, H. T., & Omar, A. R. (2018). Nonsteroidal anti-inflammatory drugs in chronic pain: Implications of new data for clinical practice. Journal of Pain Research, Volume 11, 1937-1948
      • Enthoven WT1, Roelofs PD, Deyo RA, van Tulder MW, Koes BW. Cochrane Database Syst Rev. 2016 Feb 10;2:CD012087. Non-steroidal anti-inflammatory drugs for chronic low back pain
  • Opioids

    Opioids

    • What is it
      • Class of medication originally isolated from opium poppy plants.
      • Found to be helpful for pain and mood.
      • Synthetic opioids are now commonly used to control pain.
    • How it works
      • Influences how pain is processed in the brain and spinal cord.
      • Opioids are usually reserved for use over short periods of time, or for long-term use in rare situations where safer alternatives are not effective.
    • Pros and cons

      Pros

      • Studies have found opioids use can reduce discomfort and improve physical functioning for patients with chronic pain conditions.

      Cons

      • Can be expensive.
      • Must make regular visits to a physician to ensure compliance with federal regulations.
      • Long term use associated with serious side effects.

      Side effects

      Sedation, constipation, nausea, difficulty breathing at night, immune problems, hormonal changes, dependency, and death.

    • Resources

      Citations

  • Antidepressants

    Antidepressants

    • What is it
      • Medications originally designed to treat depression but found to be helpful for painful conditions.
      • Examples: duloxetine, nortriptyline.
    • How it works
      • Thought to reduce pain by influencing how different natural chemicals (neurotransmitters) work within the brain and nervous system.
    • Pros and cons

      Pros

      • Helpful for the treatment of low back pain, fibromyalgia, nerve pain, and myofascial (muscle and connective tissue).

      Cons

      • Requires a prescription.
      • Can be expensive.
      • Serious side effects can occur.
      • Amount of relief is generally small to moderate.

      Side effects

      • Side effects can include dry mouth, constipation, liver toxicity, low or high blood pressure, and heart rhythm abnormalities
    • Resources

      Citations

      • Nicol, A. L., Hurley, R. W., & Benzon, H. T. (2017). Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes. Anesthesia & Analgesia,125(5), 1682-1703
      • Beal et al. An Overview of Pharmacologic Management of Chronic Pain. Med Clin North Am.2016 Jan;100(1):65-79. doi: 10.1016/j.mcna.2015.08.006. Epub 2015 Oct 27.  “Antidepressants: Another Weapon against Chronic Pain.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 13 Sept. 2016, mayoclinic.org/pain-medications/art-20045647
  • Anticonvulsants

    Anticonvulsants

    • What is it
      • Medications originally designed to treat seizures but found to be helpful for painful conditions.
      • Examples: Gabapentin and Pregabalin.
    • How it works
      • Work in the brain and spinal cord to reduce pain signals.
    • Pros and cons

      Pros

      • Some evidence of benefit in treating nerve disorders and nerve pain associated with diabetes and abnormal metabolic conditions.

      Cons

      • Requires a prescription.
      • Can be expensive.
      • Amount of relief is generally small.

      Side effects

      • Dizziness, impaired balance, and swelling in the lower limbs.

      Citations

    • Resources

      Citations

  • Topical Pain Medications

    Topical Pain Medications

    • What is it
      • Medications rubbed onto the skin are called topical (local) pain relievers.
      • Examples: Lidocaine or diclofenac ointments, creams, or patches.
    • How it works
      • Targets local sensory nerve endings.
      • Only a small amount is absorbed into the blood circulatory system.
    • Pros and cons

      Pros

      • Topical NSAIDs are helpful for strains, sprains, joint, and hand osteoarthritis.
      • Topical high-concentration capsaicin (derived from chili peppers) was found to reduce pain for postherpetic neuralgia (pain related to shingles).
      • Produce local drug effects without the side effects associated with oral medication.
      • Can combined numerous drug categories into one compound (antidepressants, anticonvulsants, NSAIDS, numbing medication).

      Cons

      • Some forms require a prescription.
      • Can be expensive and/or not covered by insurance.
      • Amount of relief is generally limited to the area of applied and may not be helpful for individuals with widespread pain.

      Side effects

      • Skin irritation, allergic reaction, and discomfort.
    • Resources

      Citations

      • Moore, R. A. et al. (2019). Topical analgesics for acute and chronic pain in adults. Cochrane Database of Systematic Reviews
      • Coderre, Terence J. “Topical Drug Therapeutics for Neuropathic Pain.” Expert Opinion on Pharmacotherapy, vol. 19, no. 11, 2018, pp. 1211–1220., doi:10.1080/14656566.2018.1501026
  • Injections

    Injections

    • What is it
      • Injections can be used to numb nerves or to treat inflamed regions of the body.
    • How it works
      • Anti-inflammatory (corticosteroid) or proliferative (growth factors) medications are the most commonly used medications for treatment of inflamed nerves or damaged tendons.
      • Numbing medications can be injected into different areas of the body to identify pain generators.
    • Pros and cons

      Pros

      • Evidence supports injection therapy for some conditions, such as lumbar radiculitis (sciatica), low back pain, and regional nerve injuries.

      Cons

      • Results are typically short term (weeks to months of relief).
      • Invasive process often associated with some pain from needle insertion.

      Side effects

      • Risks include bleeding, infection, nerve damage, and allergic reaction.
    • Resources

      Citations

      • Smith, H., Youn, Y., Guay, R. C., Laufer, A., & Pilitsis, J. G. (2016). The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain. Medical Clinics of North America, 100(1), 103-115. doi:10.1016/j.mcna.2015.08.011
      • Xing, Dan, et al. “Intra-Articular Platelet-Rich Plasma Injections for Knee Osteoarthritis: An Overview of Systematic Reviews and Risk of Bias Considerations.” International Journal of Rheumatic Diseases, vol. 20, no. 11, 2017, pp. 1612–1630., doi:10.1111/1756-185x.13233
      • Rabago, David, and Bobby Nourani. “Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review.” Current Rheumatology Reports, vol. 19, no. 6, 2017, doi:10.1007/s11926-017-0659-3
  • Heat Therapy

    Heat Therapy

    • What is it
      • Heat therapy involves the use of heat applied to the body to increase tissue temperature.
      • Common methods include: electric heating pads, hot water bottles, hot wraps, hot baths, and ultrasound.
    • How it works
      • Bodily reactions to heat include: relief of pain, increase in blood flow, and improved elasticity of connective tissue.
    • Pros and cons

      Pros

      • Found to be better than placebo for acute low back pain, and muscle soreness.

      Cons

      • Benefits are often temporary (minutes to hours).
      • May require electric source limiting portability.

      Side effects

      • Possible side effects include skin discoloration. Patient with certain conditions, including poor circulation and diabetes mellitus, are at risk for worsening skin ulceration and burns.
    • Resources

      Citations

      • Malanga, G. A., Yan, N., & Stark, J. (2014). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine,127(1), 57-65. doi:10.1080/00325481.2015.992719
  • Ice / Cryotherapy

    Ice / Cryotherapy

    • What is it
      • Cryotherapy is defined as body cooling for therapeutic purposes.
      • Common methods: ice packs, gel pads.
    • How it works
      • Decreasing temperatures of skin and muscle.
      • Reduces blood flow to the cooled tissues by a nervous system reflex.
      • Reduces both swelling and inflammatory chemicals.
      • Creates a local numbing effect and reduces the energy needs of damaged tissues.
    • Pros and cons

      Pros

      • Helpful for acute muscle soreness and strain.

      Cons

      • Results are typically short term (minutes to hours of relief).

      Side effects

      • Frostbite, nerve injury.
    • Resources

      Citations

      • Bleakley, C., Bieuzen, F., Davison, G., & Costello, J. (2014). Whole-body cryotherapy: Empirical evidence and theoretical perspectives. Open Access Journal of Sports Medicine,25. doi:10.2147/oajsm.s41655 2
      • Malanga, Gerard A., et al. “Mechanisms and Efficacy of Heat and Cold Therapies for Musculoskeletal Injury.” Postgraduate Medicine, vol. 127, no. 1, 2014, pp. 57–65., doi:10.1080/00325481.2015.992719
      • Thomas, D., Maslin, B., Legler, A., Springer, E., Asgerally, A., & Vadivelu, N. (2016). Role of Alternative Therapies for Chronic Pain Syndromes. Current Pain and Headache Reports,20(5). doi:10.1007/s11916-016-0562-z
  • Transcutaneous Electrical Nerves Stimulator (TENS)

    Transcutaneous Electrical Nerves Stimulator (TENS)

    TENS treatment in physical therapy – therapist placing electrodes onto patient’s lower back
    • What is it
      • TENS unit can increase natural pain killers in the central nervous system and also reduce painful sensation originating from the brain.
    • How it works
      • TENS unit can increase natural pain killers in the central nervous system and also reduce painful sensation originating from the brain.
    • Pros and cons

      Pros

      • Safe, non-invasive form of pain relief.
      • Some evidence suggests stimulation can temporarily reduce different forms of pain.

      Cons

      • Units can be expensive and often are not covered by insurance.
      • Results from multiple studies have failed to reveal consistent findings.
      • Lack of evidence to support the use of TENS for long term relief of chronic pain.

      Side effects

      • Significant adverse events from TENS are rare
      • Skin irritation
      • Nausea and feeling faint
    • Resources

      Citations

      • Claydon et al. (2017). Transcutaneous electrical nerve stimulation (TENS) for fibromyalgia in adults. Cochrane Database Syst Rev. Oct; 2017(10)
      • Vance, C. G., Dailey, D. L., Rakel, B. A., & Sluka, K. A. (2014). Using TENS for pain control: The state of the evidence. Pain Management,4(3), 197-209. doi:10.2217/pmt.14.13
      • Johnson, M. (2007). Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Reviews in Pain,1(1), 7-11. doi:10.1177/204946370700100103
      • Gibson, W., Wand, B. M., Meads, C., Catley, M. J., & Oconnell, N. E.
  • Surgery

    Surgery

    View of multi-ethnic diverse operating room staff doctors surgeons nurses assisting performing doing surgery surgical procedure in operating room theater sterile clean professional hospital environment as a group team together careful healthcare dressed in scrubs uniforms gowns precaution protection making incision cut blade knife surgical tools on patient
    • What is it
      • Surgery can be performed for many forms of chronic pain, such as joint osteoarthritis and spinal nerve impingement.
    • How it works
      • Spinal cord stimulators emit an electrical impulse, which reduce painful sensation by distracting the brain and central nervous system.
      • General surgery can replace arthritic joints or decompress “pinched” nerves.
    • Pros and cons

      Pros

      • There is moderate evidence that surgery can help certain conditions (lumbar radiculopathy, joint arthritis, and nerve disease pain).

      Cons

      • Invasive, expensive, risks of significant adverse complications (paralysis, death).

      Side effects

      • Possible complications from surgery include infection, bleeding, blood clots, and nerve damage.
    • Resources

      Citations

      • Meier, K. (2014). Spinal cord stimulation: Background and clinical application. Scandinavian Journal of Pain,5(3), 175-181. doi:10.1016/j.sjpain.2014.03.001
      • Gademan, M. G., Hofstede, S. N., Vlieland, T. P., Nelissen, R. G., & Mheen, P. J. (2016). Indication criteria for total hip or knee arthroplasty in osteoarthritis: A state-of-the-science overview. BMC Musculoskeletal Disorders,17(1). doi:10.1186/s12891-016-1325-z
      • Bostelmann, R., & Steiger, H. J. (2014). Comment on “An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy”. The Spine Journal,14(9), 2273. doi:10.1016/j.spinee.2014.04.021
      • Furlan, A., Sandoval, J., & Mailis, A. (2002). Spinal cord stimulation for chronic pain. The Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd003783
      • Sinclair, C., Verrills, P., & Barnard, A. (2016). A review of spinal cord stimulation systems for chronic pain. Journal of Pain Research,Volume 9, 481-492. doi:10.2147/jpr.s108884