Case-Based Review

Nonpharmacologic Treatment of Chronic Pain—A Critical Domains Approach

Journal of Clinical Outcomes Management. 2016 February;23(2)

References

1. Institute of Medicine. Relieving pain in America a blueprint for transforming prevention, care, education, and research. In. Washington, DC: National Academy of Sciences; 2011.

2. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain 2009;10:895–926.

3. Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311:1547–55.

4. National Pain Strategy. A Comprehensive Population Health-Level Strategy for Pain. 2015. Accessed at http://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf.

5. Brummett CM, Goesling J, Tsodikov A, et al. Prevalence of the fibromyalgia phenotype in spine pain patients presenting to a tertiary care pain clinic and the potential treatment implications. Arthritis Rheum 2013.

6. Williams DA, Clauw DJ. Understanding fibromyalgia: lessons from the broader pain research community. J Pain 2009;10:777-91.

7. Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311:1547–55.

8. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152:S2–15.

9. Goesling J, Clauw DJ, Hassett AL. Pain and depression: an integrative review of neurobiological and psychological factors. Curr Psychiatry Rep 2013;15:421.

10. Hassett AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin North Am 2009;35:393–407.

11. Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil 2015;29:1155–67.

12. O’Connor SR, Tully MA, Ryan B, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meta-analysis. Arch Phys Med Rehabil 2015;96:724-34 e3.

13. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil 2015;94:358–65.

14. Hauser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther 2010;12:R79.

15. Burckhardt CS, Goldenberg D, Crofford L, et al. Guideline for the management of fibromyalgia syndrome. Pain in adults and children. Glenview, IL: American Pain Society; 2005.

16. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis 2008;67:536–41.

17. Chou R, Huffman LH, American Pain Society, American College of Pain Medicine. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007;147:492–504.

18. Chou R, Qaseem A, Snow V, , Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Pain Medicine, American Pain Society low back pain guidelines P. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478–91.

19. Hauser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther;12:R79.

20. Okifuji A, Donaldson GW, Barck L, Fine PG. Relationship between fibromyalgia and obesity in pain, function, mood and sleep. J Pain 2010.

21. Gore M, Sadosky A, Stacey BR, et al. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine 2012;37:E668-77.

22. Von Korff M, Crane P, Lane M, et al. Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication. Pain 2005;113:331–9.

23. Reme SE, Tangen T, Moe T, Eriksen HR. Prevalence of psychiatric disorders in sick listed chronic low back pain patients. Eur J Pain 2011;15:1075–80.

24. Arnold LM, Hudson JI, Keck PE, et al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006;67:1219–25.

25. Hassett AL, Radvanski DC, Buyske S, et al. Psychiatric comorbidity and other psychological factors in patients with “chronic Lyme disease”. Am J Med 2009;122:843–50.

26. Epstein SA, Kay G, Clauw D, et al. Psychiatric disorders in patients with fibromyalgia. A multicenter investigation. Psychosomatics 1999;40:57–63.

27. Goesling J, Henry MJ, Moser SE, et al. Symptoms of depression are associated with opioid use regardless of pain severity and physical functioning among treatment-seeking patients with chronic pain. J Pain 2015;16:844–51.

28. Hassett AL, Cone JD, Patella SJ, Sigal LH. The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome. Arthritis Rheum 2000;43:2493–500.

29. Giesecke T, Williams DA, Harris RE, et al. Subgroupings of fibromyalgia patients on the basis of pressure pain thresholds and psychological factors. Arthritis Rheum 2003;48:2916–22.

30. Walen HR, Cronan PA, Bigatti SM. Factors associated with healthcare costs in women with fibromyalgia. Am J Manag Care 2001;7 Spec No:SP39-47.

31. Hassett AL, Aquino JK, Ilgen MA. The risk of suicide mortality in chronic pain patients. Curr Pain Headache Rep 2014;18:436.

32. Robinson RL, Birnbaum HG, Morley MA, et al. Depression and fibromyalgia: treatment and cost when diagnosed separately or concurrently. J Rheumatol 2004;31:1621–9.

33. Fitzcharles MA. In: Canadian Rheumatology Association’s 64th Annual Meeting; 2009.

34. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.

35. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092–7.

36. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80:1–13.

37. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1–9.

39. Bernardy K, Fuber N, Kollner V, Hauser W. Efficacy of cognitive-behavioral therapies in fibromyalgia syndrome - a systematic review and metaanalysis of randomized controlled trials. J Rheumatol 2010;37:1991–2005.

39. Beck JS. Cognitive therapy: basics and beyond. New York: Guilford Press; 1995.

40. Bernardy K, Füber N, Köllner V, Häuser W. Efficacy of cognitive-behavioral therapies in fibromyalgia syndrome - a systematic review and metaanalysis of randomized controlled trials. J Rheumatol 2010;37:1991–2005.

41. Bernardy K, Klose P, Busch AJ, et al. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev 2013;9:CD009796.

42. Nielson WR, Walker C, McCain GA. Cognitive behavioral treatment of fibromyalgia syndrome: preliminary findings. J Rheumatol 1992;19:98–103.

43. Nicassio PM, Radojevic V, Weisman MH, et al. A comparison of behavioral and educational interventions for fibromyalgia. J Rheumatol 1997;24:2000–7.

44. Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol 2002;29:1280–6.

45. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach. Spine 1992;17:641–52.

46. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther 1992;72:279-90; discussion 91–3.

47. McAllister SJ, Vincent A, Hassett AL, et al. Psychological resilience, affective mechanisms and symptom burden in a tertiary-care sample of patients with fibromyalgia. Stress Health 2015;31:299–305.

48. Toussaint LL, Vincent A, McAllister SJ, et al. A comparison of fibromyalgia symptoms in patients with healthy versus depressive, low and reactive affect balance styles. Scand J Pain 2014;5:161–6.

49. Hassett AL, Simonelli LE, Radvanski DC, et al. The relationship between affect balance style and clinical outcomes in fibromyalgia. Arthritis Rheum 2008;59:833–40.

50. Zamirinejad S, Hojjat SK, Golzari M, et al. Effectiveness of resilience training versus cognitive therapy on reduction of depression in female iranian college students. Issues Ment Health Nurs 2014;35:480–8.

51. Asgharipoor N, Asgharnejad Farid A, Arshadi H, Sahebi A. A comparative study on the effectiveness of positive psychotherapy and group cognitive-behavioral therapy for the patients suffering from major depressive disorder. Iran J Psychiatry Behav Sci 2012;6:33–41.

52. Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. J Clin Psychol 2009;65:467–87.

53. Bolier L, Haverman M, Westerhof GJ, et al. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 2013;13:119.

54. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol 2001;56:218–26.

55. Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. Am Psychol 2005;60:410–21.

56. Seligman ME, Rashid T, Parks AC. Positive psychotherapy. Am Psychol 2006;61:774–88.

57. White DK, Keysor JJ, Neogi T, et al. When it hurts, a positive attitude may help: association of positive affect with daily walking in knee osteoarthritis. Results from a multicenter longitudinal cohort study. Arthritis Care Res (Hoboken) 2012;64:1312–9.

58. Strine TW, Chapman DP, Balluz LS, et al. The associations between life satisfaction and health-related quality of life, chronic illness, and health behaviors among U.S. community-dwelling adults. J Community Health 2008;33:40–50.

59. Grant N, Wardle J, Steptoe A. The relationship between life satisfaction and health behavior: a cross-cultural analysis of young adults. Int J Behav Med 2009;16:259–68.

60. Baruth M, Lee DC, Sui X, et al. Emotional outlook on life predicts increases in physical activity among initially inactive men. Health Educ Behav 2011;38:150–8.

61. Kalmbach DA, Pillai V, Roth T, Drake CL. The interplay between daily affect and sleep: a 2-week study of young women. J Sleep Res 2014;23:636–45.

62. Simor P, Krietsch KN, Koteles F, McCrae CS. Day-to-day variation of subjective sleep quality and emotional states among healthy university students-a 1-week prospective study. Int J Behav Med 2015;22:625–34.

63. von Kanel R, Mausbach BT, Ancoli-Israel S, et al. Positive affect and sleep in spousal Alzheimer caregivers: a longitudinal study. Behav Sleep Med 2014;12:358–72.

64. Cohn MA, Fredrickson BL, Brown SL, et al. Happiness unpacked: positive emotions increase life satisfaction by building resilience. Emotion 2009;9:361–8.

65. Ostir GV, Berges IM, Markides KS, Ottenbacher KJ. Hypertension in older adults and the role of positive emotions. Psychosom Med 2006;68:727–33.

66. Stone AA, Cox DS, Valdimarsdottir H, et al. Evidence that secretory IgA antibody is associated with daily mood. J Pers Soc Psychol 1987;52:988–93.

67. Steptoe A, Wardle J, Marmot M. Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A 2005;102:6508–12.

68. Kok BE, Coffey KA, Cohn MA, et al. How positive emotions build physical health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychol Sci 2013;24:1123–32.

69. Bhattacharyya MR, Whitehead DL, Rakhit R, Steptoe A. Depressed mood, positive affect, and heart rate variability in patients with suspected coronary artery disease. Psychosom Med 2008;70:1020–7.

70. Hausmann LR, Parks A, Youk AO, Kwoh CK. Reduction of bodily pain in response to an online positive activities intervention. J Pain 2014;15:560–7.

71. Muller R, Gertz KJ, Molton IR, et al. Effects of a tailored positive psychology intervention on well-being and pain in individuals with chronic pain and a physical disability: a feasibility trial. Clin J Pain 2015.

72. Flink IK, Smeets E, Bergbom S, Peters ML. Happy despite pain: Pilot study of a positive pscyhology intervention for patients with chronic pain. Scandinavian Jounral of Pain 2015;7:71–9.

73. Hassett AL, Radvanski DC, Buyske S, et al. Role of psychiatric comorbidity in chronic Lyme disease. Arthritis Rheum 2008;59:1742–9.

74. Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol 2015;11:513–20.

75. Fishbain DA, Cole B, Lewis JE, Gao J. What is the evidence for chronic pain being etiologically associated with the DSM-IV category of sleep disorder due to a general medical condition? A structured evidence-based review. Pain Med 2010;11:158–79.

76. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy Am J Psychiatry 1994;151:1172–80.

77. Affleck G, Urrows S, Tennen H, et al. Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia. Pain 1996;68:363–8.

78. Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial. Arch Intern Med 2005;165:2527–35.

79. Jacobson E. Progressive relaxation. Chicago: University of Chicago Press; 1938.

80. van Tulder MW, Koes B, Malmivaara A. Outcome of non-invasive treatment modalities on back pain: an evidence-based review. Eur Spine J 2006;15 Suppl 1:S64–81.

81. Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998;14:232–8.

82. Rucco V, Feruglio C, Genco F, Mosanghini R. [Autogenic training versus Erickson’s analogical technique in treatment of fibromyalgia syndrome]. Riv Eur Sci Med Farmacol 1995;17:41–50.

83. Bawa FL, Mercer SW, Atherton RJ, et al. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis. Br J Gen Pract 2015;65:e387–400.

84. Ost LG. The efficacy of acceptance and commitment therapy: an updated systematic review and meta-analysis. Behav Res Ther 2014;61:105–21.

85. Crowe M, Jordan J, Burrell B, et al. Mindfulness-based stress reduction for long-term physical conditions: a systematic review. Aust N Z J Psychiatry 2015.

86. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain 2011;152:533–42.

How effective is exercise for treating chronic pain and how should it be integrated into treatment?

Exercise

Over the last 5 years, a number of meta-analyses have been conducted to evaluate a robust literature regarding exercise interventions for the treatment of chronic pain [11–14]. The evidence is strong that patients with chronic pain benefit from increased physical activity and in many cases the effect size is quite substantial [14]. Meta-analytic data suggest that aerobic exercise results in significantly less pain and disability [13], improved physical fitness [14], less fatigue and better mood [14]. Exercise can be land-based or water-based [14], be conducted at a slight to moderate intensity and/or even involve only a program of walking [12]. Most established guidelines highlight the benefits of including exercise as part of the nonpharmacologic management of patients with chronic pain [15–18].

Data suggest that chronic pain patients should begin exercise training slowly starting at levels below capacity and increase duration and intensity over time until patients are exercising at low to moderate intensity (ie, 50% to 70% of age-adjusted maximum heart rate) for 20 to 30 minutes per session 2 to 3 times per week [19].

Obesity and deconditioning are common and are thought to contribute to pain sensitivity, poor sleep, and depressed mood [20]. Lisa is overweight and inactive. She injured her back and reports generally avoiding any form of exercise. Getting her moving will be imperative as an increase in physical activity could not only help her to lose weight, but could have the added benefits of decreasing her pain and stiffness, helping her sleep better and improving her mood and self-esteem. Yet, she reports not having the time or motivation.

A reasonable approach would be to not prescribe formal exercise at first but rather encourage small and immediate changes in how she already goes about her day. One concrete step would be to encourage her to stand up and stretch every 20 minutes or so while working at her computer. This is something that she cites as directly contributing to her pain. Next, an increase in physical activity such as adding a few steps every day and doing regular activities with more vigor would be a great initial step.

One of the most formidable barriers to getting patients to exercise is the perception that they must go to the gym and begin a formal program in order to achieve any benefit. As an employed single mother with two children Lisa likely lacks the time and resources for a formal exercise program. She could instead, begin a walking program that starts with reasonable goals (eg, 6000 steps per day) and builds at a slow and steady pace (eg, add 100 steps per day). Activity trackers range in price, but a simple pedometer can be found for under $10. By initiating such a walking program, the things she does already such as chores around the house all count as physical activity. She could do these with more energy and mindfulness and incrementally add activity over time.