Research on Chronic Pain
Below are brief summaries of relevant research on Chronic Pain. To find more information about an article, click on the title of the article.
- Overview of the Integrative Approach
- Causes and Risk Factors
- Related Health Conditions
- Psychological and Social Factors
- Treatments
- Overview
- Acupuncture and East Asian Medicine
- Exercise/Movement Therapies: Yoga, Tai Chi, Physical Therapy
- Healing Arts/Creativity
- Manual Medicine: Massage, Chiropractic, Craniosacral therapy
- Mind-body: Biofeedback, Relaxation/Meditation, Hypnotherapy, Guided Imagery
- Nutrition, Herbs, Dietary Supplements
- Therapies for Psychological Health
- Age-specific: children, young adults, older adults
- Gender specific: Chronic pain in men and women
- Environmental influences
Overview of the Integrative Approach
Bergman S. Management of musculoskeletal pain. Best Practice & Research. Clinical Rheumatology. 2007; 21(1):153-66.
Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments for chronic low back pain and fibromyalgia. Pain medications offer limited help in chronic widespread pain like fibromyalgia. Antidepressants and anticonvulsants help some patients with chronic pain.
Stanos S, Houle TT. Multidisciplinary and interdisciplinary management of chronic pain. Physical Medicine & Rehabilitation Clinics of North America. 2006; 17(2):435-50, vii.Multidisciplinary pain management programs look at emotional, physical and social factors in treating pain. Treatment teams may include a physiatrist, physical or occupational therapist, pain psychologist, relaxation (biofeedback) therapist, vocational and recreational therapists, social workers, and nurses. The key is ongoing communication between the patient and all team members.
Quinn F, Hughes C, Baxter GD. Complementary and alternative medicine in the treatment of low back pain: a systematic review. Physical Therapy Reviews. 2006; 11(2): 107-16.
Recent reviews have found that chiropractic, osteopathy, acupuncture, and massage are useful therapies in the management of low back pain. This review showed encouraging results for yoga, homeopathy, herbal therapies, and hypnotherapy as well.
Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. American Journal of Physical Medicine & Rehabilitation. 2005; 84(3 Suppl):S64-76.
It is important to identify and treat pain early and to recognize contributing factors such as depression and poor pain control. Combining physical, psychological and medical approaches achieves better pain control and improved function than single approaches.
Mansky PJ, Wallerstedt DB. Complementary medicine in palliative care and cancer symptom management. Cancer Journal. 2006; 12(5):425-31.
Studies show that ear acupuncture, therapeutic touch, and hypnosis may help manage cancer pain. Music therapy, massage, and hypnosis may lessen anxiety, and acupuncture and massage may help relieve cancer fatigue. Acupuncture, selected herbs, hypnosis and guided imagery may help with nausea and vomiting. Meditation may help manage depression and anxiety. Cancer patients should only use herbal medicines under the guidance of an oncologist knowledgeable in their use because of possible interactions with prescription medications.
Causes and Risk Factors
Jung BF, Johnson RW, Griffin DR, Dworkin RH. Risk factors for postherpetic neuralgia in patients with herpes zoster. Neurology. 2004; 62(9):1545-51.
Risk factors for developing postherpetic neuralgia after shingles include being older, female, and having early symptoms, greater rash severity, and more severe pain.
Maizels M. The patient with daily headaches. American Family Physician. 2004; 70(12):2299-306.
Treatment of chronic daily headache focuses on reducing headache triggers and using medication to prevent headaches (commonly anti-depressants, antiepileptic drugs, and beta blockers). Anxiety and depression should also be treated to significantly improve quality-of-life.
Moalem G, Tracey DJ. Immune and inflammatory mechanisms in neuropathic pain. Brain Research - Brain Research Reviews. 2006; 51(2):240-64.
Inflammatory and immune factors in the nervous system play an important role in nerve pain. Damage to the nervous system leads to the release of inflammatory chemicals that contribute to: 1) increased sensitivity to pain, 2)the experience of non-painful stimuli as painful, and 3) spontaneous pain.
Ranjbaran Z, Keefer L, Stepanski E, Farhadi A, Keshavarzian A. The relevance of sleep abnormalities to chronic inflammatory conditions. Inflammation Research. 2007; 56(2):51-7.
Through its effect on the immune system, sleep disturbances can worsen chronic inflammatory conditions like rheumatoid arthritis, aggravate disease symptoms such as pain and fatigue, and lower quality of life.
Reijman M, Pols HA, Bergink AP, et al. Body mass index associated with onset and progression of osteoarthritis of the knee but not of the hip: the Rotterdam Study. Annals of the Rheumatic Diseases. 2007; 66(2):158-62.
In this study of 3,585 people aged 55 years or older, a high body mass index was associated with the development and progression of knee osteoarthritis, but not with hip osteoarthritis.
Tunks ER, Crook J, Weir R. Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis. Canadian Journal of Psychiatry. 2008 Apr; 53(4):224-34.
Chronic pain predicts the onset of new depression and depression predicts the onset of new chronic pain. Other factors that also play a role in the course of chronic pain include age, sex, severity of pain, psychosocial problems, and unemployment.
Walsh CA, Jamieson E, Macmillan H, Boyle M. Child abuse and chronic pain in a community survey of women. Journal of Interpersonal Violence. 2007; 22(12):1536-54.
Considerable evidence links abuse as a child to chronic pain in adulthood. In this study, chronic pain was significantly associated with physical abuse but not sexual abuse in women.
Related Health Conditions
Sleep Disorders
Garcia AD. The effect of chronic disorders on sleep in the elderly. Clinics in Geriatric Medicine. 2008; 24(1):27-38, vi.
Sleep patterns change as people age affecting their overall well being. Health conditions such as chronic pain can also significantly effect sleep and increase insomnia due to physical, psychological and social factors associated with the disease.
Tang NKY, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. Journal of Sleep Research. 2007; 16(1): 85-95.
In this study, clinical insomnia was noted in 53% of chronic pain patients and 3% of patients without pain. Insomnia was correlated with pain intensity, pain distress, general anxiety and depression, and health anxiety. Pain distress and health anxiety were the most significant predictors of insomnia.
Depression, anxiety and post-traumatic stress disorder
Buskila D, Cohen H. Comorbidity of fibromyalgia and psychiatric disorders. Current Pain & Headache Reports. 2007; 11(5):333-8.
Data supports a relationship between fibromyalgia and depression, panic disorders, anxiety, and post-traumatic stress disorder. Treatment of patients with fibromyalgia should focus both on physical and emotional dimensions.
Gastrointestinal complaints
Aamodt AH, Stovner LJ, Hagen K, Zwart JA. Comorbidity of headache and gastrointestinal complaints. The Head-HUNT Study. Cephalalgia. 2008; 28(2):144-51.
A higher prevalence of headache was found in people with reflux, diarrhea, constipation and nausea. The association between headache and GI complaints increased markedly with more frequent headaches.
Psychological and Social Factors
Backman CL. Arthritis and pain. Psychosocial aspects in the management of arthritis pain. Arthritis Research & Therapy. 2006; 8(6):221.
Psychosocial factors influence the experience of pain and pain influences feelings of well-being and the ability to participate in work, family life, and leisure. Psychosocial approaches to managing arthritis pain are summarized.
Brage S, Sandanger I, Nygard JF. Emotional distress as a predictor for low back disability: a prospective 12-year population-based study. Spine. 2007; 32(2):269-74.
In this study, people with both emotional distress and earlier back pain were most at risk for disability.
Jacobs JM, Hammerman-Rozenberg R, Cohen A, Stessman J. Chronic back pain among the elderly: prevalence, associations, and predictors. Spine. 2006; 31(7):E203-7.
In this study, chronic low back pain increased from 44% to 58% at ages 70 and 77 years, respectively, while the frequency of episodes and their severity decreased. Factors such as loneliness, depression, poor sleep, economic difficulties, unemployment, female gender, hypertension, and existing joint pain identify people most at risk.
Kaminsky L, Robertson M, Dewey D. Psychological correlates of depression in children with recurrent abdominal pain. Journal of Pediatric Psychology. 2006; 31(9):956-66.
Isolating oneself from others and catastrophizing were associated with increased depression in children with recurrent abdominal pain. Feeling more effective and having greater social support from teachers and classmates were associated with fewer depressive symptoms.
Kato K, Sullivan PF, Evengard B, Pedersen NL. Chronic widespread pain and its comorbidities: a population-based study. Archives of Internal Medicine. 2006; 166(15):1649-54.
Chronic widespread pain is common in many conditions such as fibromyalgia, chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders. These associations are influenced by factors including genes and the family environment.
Katona C, Peveler R, Dowrick C, et al. Pain symptoms in depression: definition and clinical significance. Clinical Medicine. 2005; 5(4):390-5.
About 50% of depressed patients report pain, and many types of pain occur more frequently in people with depression. Pain and depression may share common pathways and may both respond to treatment with certain antidepressants.
Koleck M, Mazaux JM, Rascle N, Bruchon-Schweitzer M. Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: a prospective study. European Journal of Pain. 2006; 10(1):1-11.
How people cope with low back pain influences the outcome. Coping includes the ability to adjust one's thinking, actions and feelings. Cognitive-behavior therapy may help patients with low back pain cope in a better way.
Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006; 332(7544):749-55.
Several gynecological and psychosocial factors, including drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic inflammatory disease, previous caesarean section, pelvic pathology, abuse, and related psychological conditions are strongly associated with chronic pelvic pain.
Munce SE, Weller I, Robertson Blackmore EK, et al. The role of work stress as a moderating variable in the chronic pain and depression association. Journal of Psychosomatic Research. 2006; 61(5):653-60.
In this study, both depression and chronic pain occurred twice as often in women as in men. Having a chronic pain condition and overall work stress were the strongest predictors of depression.
Naughton F, Ashworth P, Skevington SM. Does sleep quality predict pain-related disability in chronic pain patients? The mediating roles of depression and pain severity. Pain. 2007; 127(3):243-52.
Disrupted sleep and poor sleep quality were related to depression. These findings highlight the important role of sleep in chronic pain. It is possible that improving sleep may help reduce pain severity, depression and pain-related disability.
Osborne TL, Jensen MP, Ehde DM, et al. Psychosocial factors associated with pain intensity, pain-related interference, and psychological functioning in persons with multiple sclerosis and pain. Pain. 2007; 127(1-2):52-62.
The relationship between catastrophizing, social support, beliefs about pain, and the ability to cope was studied in people with multiple sclerosis (MS). The results suggest that specific psychosocial factors (such as catastrophizing) may play an important role in the ability to adjust to pain in people with MS.
Poundja J, Fikretoglu D, Brunet A. The co-occurrence of posttraumatic stress disorder symptoms and pain: is depression a mediator? Journal of Traumatic Stress. 2006; 19(5):747-51.
Results suggest that posttraumatic stress disorder (PTSD) and pain are related, and that the degree of depression will significantly impact the level of pain in PTSD. Treatment of PTSD and pain should include careful consideration of depression.
Samwel HJ, Evers AW, Crul BJ, Kraaimaat FW. The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients. Clinical Journal of Pain. 2006; 22(3):245-51.
In this study, helplessness significantly predicted level of pain and disability. Worrying significantly predicted depression.
Wiendels NJ, van Haestregt A, Knuistingh Neven A, et al. Chronic frequent headache in the general population: comorbidity and quality of life. Cephalalgia. 2006; 26(12):1443-50.
Patients with chronic headache had more musculoskeletal, gastrointestinal, psychiatric and endocrine/breast pathology and a lower quality of life. Many had a second chronic condition requiring daily medication.
Williams LS, Jones WJ, Shen J, et al. Outcomes of newly referred neurology outpatients with depression and pain. Neurology. 2004; 63(4):674-7.
Pain is more likely to last in patients with depression, and depression is more likely to last in people who also have pain.
TREATMENTS
Overview
Chen H, Lamer TJ, Rho RH, et al. Contemporary management of neuropathic pain for the primary care physician. Mayo Clinic Proceedings. 2004; 79(12):1533-45.
Neuropathic pain is associated with many diseases, including diabetes. It is very hard to treat with conventional pain medicines. A new treatment approach that combines physical rehabilitation, psychological techniques, and complementary medicine with prescription medications and interventional strategies is described.
Cassileth B, Trevisan C, Gubili J. Complementary therapies for cancer pain. Current Pain & Headache Reports. 2007; 11(4):265-9.
Complementary therapies, such as acupuncture, massage, mind-body therapies and music therapy, along with standard pain management can improve pain control and reduce the need for pain medication.
Soeken KL. Selected CAM therapies for arthritis-related pain: the evidence from systematic reviews. Clinical Journal of Pain. 2004; 20(1):13-8.
Evidence supports the use of acupuncture, the herb Devil's Claw, avocado/soybean unsaponifiables, capsaicin, and the supplements chondroitin, glucosamine, and SAMe to treat arthritis pain. Strong support exists for gamma linolenic acid (GLA) for rheumatoid arthritis pain.
Acupuncture and East Asian Medicine
Braun M, Schwickert M, Nielsen A, et al. Effectiveness of traditional Chinese "gua sha" therapy in patients with chronic neck pain: a randomized controlled trial. Pain Med. 12(3):362-9, 2011.
Gua sha is a traditional East Asian healing technique. Forty-eight patients with chronic neck pain were treated once with Gua sha and compared with patients treated with a thermal heat pad. After one week neck pain severity, pain at motion, and quality of life improved significantly better in the Gua sha group. The treatment was safe and well tolerated.
Asher GN, Jonas DE, Coeytaux RR, et al. Auriculotherapy for pain management: a systematic review and meta-analysis of randomized controlled trials. J Altern Complement Med. 2010;16(10):1097-108.
In this systematic review of 17 studies auriculotherapy (ear acupuncture) was effective in the treatment of a variety of types of acute and chronic pain.
Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010;10(2):94-102.
Acupuncture improved back pain, knee pain and headache in the short term. It improved knee pain and tension-type headache in the long term.
Molsberger AF, Schneider T, Gotthardt H, Drabik A. German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment. Pain. 2010;151(1):146-54.
Chinese acupuncture was found to be effective in a study of 424 patients with chronic should pain.
Trigkilidas D. Acupuncture therapy for chronic lower back pain: a systematic review. Ann R Coll Surg Engl. 2010;92(7):595-8.
Four studies in this review indicated that acupuncture can be better than usual care in treating chronic low back pain, especially when patients have positive expectations about acupuncture.
Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of Internal Medicine. 2004; 141(12):901-10.
At 8 weeks, patients getting acupuncture had greater improvement than those getting sham acupuncture in their ability to function but not in their level of pain. But at 26 weeks, patients getting acupuncture experienced significantly greater improvement than the sham group in both function and pain.
Coeytaux RR, Kaufman JS, Kaptchuk TJ, et al. A randomized, controlled trial of acupuncture for chronic daily headache. Headache. 2005; 45(9): 1113-23.
Patients who received acupuncture were 3.7 times more likely to report less suffering from headaches at 6 weeks. Medical management alone did not generally improve clinical outcomes.
Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. The Cochrane Library. 2006; (4): (CD001351).
Acupuncture, added to other conventional therapies, relieves back pain and improves function better than conventional therapies alone.
Haake M, Muller H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups. Archives of Internal Medicine. 2007; 167(17):1892-1898.
Low back pain improved after acupuncture treatment for at least 6 months. Acupuncture was almost twice as effective as conventional therapy (a combination of drugs, physical therapy, and exercise).
Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine. 2005; 142(8):651-63.
This review showed acupuncture provided effective short-term relief of chronic low back pain.
Martin DP, Sletten CD, Williams BA, Berger IH. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clinic Proceedings. 2006; 81(6):749-57.
Total fibromyalgia symptoms, especially fatigue and anxiety, were significantly improved in the acupuncture group during the study period.
Melchart D, Linde K, Berman B, et al. Acupuncture for idiopathic headache. The Cochrane Library. 2001; (4): (CD001218).
In this review, half the trials comparing true and sham (placebo) acupuncture for migraine and tension headaches reported true acupuncture was significantly superior. Evidence to date supports the value of acupuncture for the treatment of headache.
Meng CF, Wang D, Ngeow J, et al. Acupuncture for chronic low back pain in older patients: a randomized, controlled trial. Rheumatology. 2003; 42(12):1508-17.
Patients who received acupuncture had a significant decrease in disability at 6 weeks that lasted up to one month after treatment. Acupuncture was found to be an effective, safe additional treatment for chronic low back pain in older patients.
Osiri M, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis. The Cochrane Library. 2006; (4): (CD002823).
TENS uses low voltage electric current to stimulate the nerves in an area and is commonly used for pain management. In this review pain relief and knee stiffness improved significantly in patients receiving both TENS and acupuncture-like TENS (AL-TENS).
Thomas KJ, MacPherson H, Ratcliffe J, et al. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technology Assessment. 2005; 9(32): iii-iv, ix-x, 1-109.
At 24 months, patients receiving acupuncture were significantly more likely to report 12 months pain-free and less likely to report the use of medication for pain relief.
Trinh KV, Graham N, Gross AR, et al. Acupuncture for neck disorders. The Cochrane Library. 2006; (4): (CD004870).
This review showed moderate evidence that acupuncture is effective for acute and chronic neck pain.
Witt CM, Jena S, Brinkhaus B, et al. Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm. Arthritis & Rheumatism. 2006; 54(11):3485-93.
Patients with chronic pain from osteoarthritis of the knee or hip received either 15 acupuncture sessions in a 3-month period or usual medical care. Acupuncture plus routine care led to marked clinical improvement that lasted up to 6 months.
Exercise / Movement
Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011 Oct 24.
This trial compared 12 weekly classes of yoga to conventional stretching exercises or a self-care book for primary care patients with chronic low back pain in 228 adults with chronic low back pain. Twelve-week outcomes for the yoga group were superior to those for the self-care group. At 26 weeks, function for the yoga group remained superior. Yoga and conventional stretching were equally effective in improving function and reducing symptoms due to chronic low back pain, with benefits lasting at least several months.
Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Cephalalgia. 2011 Sep 2.
In 91 adults with migraine, exercising for 40 minutes three times a week was compared to a relaxation program or daily topiramate use (maximum 200 mg/day). Headache frequency was reduced in all 3 groups. Exercise may be another treatment option for the prevention of migraine.
Hall A, Maher C, Latimer J, Ferreira M. The effectiveness of Tai Chi for chronic musculoskeletal pain conditions: a systematic review and meta-analysis. Arthritis Rheum. 2009;61(6):717-24.
Tai Chi has a small positive effect on pain and disability in people with arthritis.
Williams K, Abildso C, Steinberg L, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine. 2009;34(19):2066-76.
Ninety people with chronic low back pain received either 24 weeks of yoga classes two times a week or standard medical care. Yoga improved disability, pain intensity, and depression in adults with chronic low back pain.
Wang C, Schmid CH, Hibberd PL, et al. Tai Chi is effective in treating knee osteoarthritis: a randomized controlled trial. Arthritis & Rheumatism. 61(11):1545-53, 2009.
Forty patients with knee osteoarthritis were randomly assigned to 60 minutes of Tai Chi or wellness education and stretching twice weekly for 12 weeks. Tai Chi was found to reduce pain and improve physical function, depression, and health-related quality of life for patients with knee osteoarthritis.
Abbott RB, Hui KK, Hays RD, et al. A randomized controlled trial of tai chi for tension headaches. Evidence Based Complementary and Alternative Medicine. 2007; 4(1):107-113.
In this study of patients with tension headaches, Tai Chi was effective in improving pain, energy, fatigue, social functioning, and emotional well-being.
Chatzitheodorou D, Kabitsis C, Malliou P, Mougios V. A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain. Physical Therapy. 2007; 87(3):304-12.
The effect of high-intensity aerobic exercise in people with chronic low back pain was studied. People in the exercise group had a 41% reduction in pain, 31% reduction in disability, and 35% reduction in psychological strain.
Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Physical Therapy. 2007; 87(1):32-43.
Six weeks of water physical therapy in a swimming pool resulted in less pain and joint stiffness and greater physical function, hip muscle strength and quality of life. Benefits remained 6 weeks after physical therapy was completed.
Hoffman MD, Hoffman DR. Does aerobic exercise improve pain perception and mood? A review of the evidence related to healthy and chronic pain subjects. Current Pain and Headache Reports. 2007; 11(20:93-7.
Aerobic exercise can produce an immediate improvement in mood and a reduction in the perception of pain. Regular exercise training is helpful in treating certain chronic pain and psychiatric conditions.
Hurwitz EL, Morgenstern H, Chiao C. Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA Low Back Pain Study. American Journal of Public Health. 2005; 95(10):1817-24.
Compared with back exercises, sport and recreational activities produced less low back pain, disability, and psychological distress. These results suggest that people with low back pain may get more physical and psychological benefit through nonspecific physical activities than through specific back exercises.
Klein PJ, Adams WD. Comprehensive therapeutic benefits of Taiji: a critical review. American Journal of Physical Medicine & Rehabilitation. 2004; 83(9):735-45.
This review of seventeen clinical trials confirmed that Tai Chi improved quality of life, level of activity, cardiovascular function, pain management, balance, and risk of falls. Tai Chi also enhanced immune response and improved flexibility and strength.
Mailloux J, Finno M, Rainville J. Long-term exercise adherence in the elderly with chronic low back pain. American Journal of Physical Medicine & Rehabilitation. 2006; 85(2):120-6.
Improvements in flexibility and strength were found in older adults who completed a 6-week physical therapy program of exercise and advice to remain active. Disability and pain scores improved and were maintained two years later.
Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial.Annals of Internal Medicine. 2005; 143(12):849-56.
Yoga was compared to conventional exercise in patients with chronic low back pain. Yoga improved function and reduced chronic low back pain, and the benefits lasted for at least several months.
Healing Arts/Creativity
Smyth JM, Stone AA, Hurewtiz A, et al. Effects of writing about stressful experiences on symptoms reduction in patients with asthma and rheumatoid arthritis. JAMA. 1999; 281: 1304-1309.
After 4 months, structured writing about stressful events improved symptoms in 112 patients with rheumatoid arthritis and asthma compared to patients who did not write. These gains were beyond those expected from standard medical care.
Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. Database of Systematic Reviews. 2006;(2):CD004843.
The thirty-one studies in this review evaluated the effect of music on pain. Listening to music was found to reduce pain intensity and lessen the need for pain medication.
Kemper KJ, Danhauer SC. Music as therapy. Southern Medical Journal. 2005; 98(3):282-8.
This review looks at the use of music to enhance well-being, reduce stress, and distract patients from unpleasant symptoms. Music often reduces pain associated with surgery, medical procedures and acute and chronic pain. It can enhance comfort and relaxation in patients receiving palliative care.
McCaffrey R, Freeman E. Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing. 2003; 44(5):517-24.
Previous studies show that music can improve motivation, mood, and feelings of control in older adults. In this study, music also helped to reduce pain.
Nainis N, Paice JA, Ratner J, et al. Relieving symptoms in cancer: innovative use of art therapy. Journal of Pain & Symptom Management. 2006; 31(2):162-9.
The effect of an art therapy session on pain and other symptoms common to adult cancer inpatients was studied. There were significant reductions in eight of nine symptoms measured, including distress and anxiety.
Pratt RR. Art, Dance, Music Therapy. Physical Medicine and Rehabilitation Clinics of North America. 2004;15(4):827-41, vi-vii.
Improvements in flexibility and strength were found in older adults who completed a 6-week physical therapy program of exercise and advice to remain active. Disability and pain scores improved and were maintained two years later.
Siedliecki SL, Good M. Effect of music on power, pain, depression and disability. Journal of Advanced Nursing. 2006;54(5):553-62.
Music was found to enhance the effects of pain medication and decrease pain, depression and disability.
Manual Medicine: Massage, Chiropractic, Osteopathy, Craniosacral therapy, Physical Therapy
Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 34(5):274-89, 2011.
Twenty-one studies were included. Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and headaches that originate in the neck.
Rubinstein SM, van Middelkoop M, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976). 36(13):E825-46, 2011.
There is high-quality evidence that spinal manipulation has a small, significant, short-term effect on pain relief and function in patients with chronic low back pain. No serious complications were seen.
Sherman KJ, Cherkin DC, Hawkes RJ, et al. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009;25(3):233-8.
Sixty-four patients with chronic neck pain received up to 10 massages over 10 weeks or a self-care book. Massage was effective in treating chronic neck pain in the short term.
Escortell-Mayor E, Riesgo-Fuertes R, Garrido-Elustondo S, et al. Primary care randomized clinical trial: manual therapy effectiveness in comparison with TENS in patients with neck pain. Man Ther. 2011;16(1):66-73.
Ninety patients with neck pain without nerve damage received either manual therapy or transcutaneous electrical nerve stimulation (TENS). Both therapies were effective for short-term pain reduction.
Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. The Cochrane Library. 2006; (4): (CD001878).
Evidence shows that spinal manipulation may prevent migraine headaches, with a short-term effect similar to that of a commonly used drug (amitriptyline). Amitriptyline was more effective than spinal manipulation in preventing chronic tension headaches. Both neck exercises and spinal manipulation are effective
in preventing headaches originating from neck disorders.
Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders. 2005, 6:43.
Six randomized controlled trials were included in this review. Osteopathic manipulation significantly reduced low back pain over short, intermediate, and long-term follow-up.
Tsao JCI. Effectiveness of massage therapy for chronic, non malignant pain: a review. Evidence-Based Alternative and Complementary Medicine. 2007; 4(2):165-179.
Research strongly supports massage for relief of pain in non-specific low back pain, and moderately supports its use for shoulder pain and headache pain. Preliminary evidence supports massage in the treatment of fibromyalgia, neck pain and carpal tunnel syndrome.
McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Physical Therapy. 2006; 86(5):710-25.
In this review, the following therapies were found to reduce pain and/or improve function: postural exercises, manual therapy with active exercise, acupuncture, relaxation therapy, biofeedback training, and low-level laser therapy treatment.
Quinn F, Hughes C, Baxter GD. Complementary and alternative medicine in the treatment of low back pain: a systematic review. Physical Therapy Reviews. 2006; 11(2): 107-16.
Recent systematic reviews have found that chiropractic, osteopathy, acupuncture, and massage are useful treatments for low back pain. In this review, encouraging results were also found for yoga, homeopathy, herbal therapies, and hypnotherapy.
Stanos SP, McLean J, Rader L. Physical medicine rehabilitation approach to pain. Medical Clinics of North America. 2007; 91(1):57-95.
Physical medicine rehabilitation for acute and chronic pain includes a variety of treatments such as active physical therapy, medication, cognitive behavioral therapy, and the use of passive modalities.
Mind-Body/Relaxation
Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: a systematic review of the evidence. Journal of Alternative & Complementary Medicine. 17(1): 83-93, 2011.
Ten studies were included in this review. Mindfulness-based interventions showed positive effects for reducing pain and improving depression and pain coping in patients with chronic pain.
Jensen MP, Ehde DM, Gertz KJ, et al. Effects of self-hypnosis training and cognitive restructuring on daily pain intensity and catastrophizing in individuals with multiple sclerosis and chronic pain. Int J Clin Exp Hypn. 2011;59(1):45-63.
In this study of 15 adults with multiple sclerosis (MS) self-hypnosis training and combined hypnosis-cognitive restructuring reduced average pain intensity.
Fox SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med. 2011;56(3-4):158-62.
An 8-week mindfulness program improved quality of life, daily pain scores, physical function, mental health, and social function in 12 women with chronic pelvic pain.
Merkes M. Mindfulness-based stress reduction for people with chronic diseases. Aust J Prim Health. 2010;16(3):200-10.
In a review of 15 studies, mindfulness-based stress reduction improved symptoms, overall well-being, quality of life, and health outcomes in patients with chronic diseases including fibromyalgia, chronic pain, and rheumatoid arthritis.
Chen YL, Francis AJ. Relaxation and imagery for chronic, nonmalignant pain: effects on pain symptoms, quality of life, and mental health. Pain Manag Nurs. 2010;11(3):159-68.
After 6-weeks of progressive relaxation and guided imagery, both approaches were effective additions to standard treatment of chronic pain.
Grant JA and Rainville P. Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study. Psychosomatic Medicine. 71(1):106-14, 2009.
This study compared pain perception in Zen meditators and a matched control group. Zen meditators had lower pain sensitivity and experienced pain relieving effects during mindful states which may be due to self-regulatory skills and/or altered breathing patterns.
Bagheri-Nesami M, Mohseni-Bandpei MA, Shayesteh-Azar M. The effect of Benson Relaxation Technique on rheumatoid arthritis patients: extended report. International Journal of Nursing Practice. 2006; 12(4): 214-9.
This study compared the effectiveness of the Benson Relaxation Technique plus medication to medication alone in patients with rheumatoid arthritis. There was a significant difference between the two groups in anxiety, depression and feeling of well-being.
Baird CL, Sands LP. Effect of guided imagery with relaxation on health-related quality of life in older women with osteoarthritis. Research in Nursing & Health. 2006; 29(5): 442-51.
Using guided imagery with relaxation for 12 weeks significantly increased quality of life in older women with osteoarthritis, and was not limited to improvements in pain and mobility alone.
Ball TM, Shapiro DE, Monheim CJ, Weydert JA. A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children. Clinical Pediatrics. 2003; 42(6):527-32.
Ten children with recurrent abdominal pain were trained in relaxation and guided imagery over 4 weeks. The children experienced a 67% decrease in pain during the therapy.
Elkins G, Jensen MP, Patterson DR. Hypnotherapy for the management of chronic pain. International Journal of Clinical & Experimental Hypnosis. 2007; 55(3):275-87.
This review found that hypnosis consistently produced significant decreases in pain in a variety of chronic pain problems.
Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut. 2003; 52(11):1623-9.
Of the 71% of patients who initially responded to hypnotherapy for irritable bowel syndrome, 81% maintained their improvement over time. The beneficial effects of hypnotherapy appear to last at least five years.
Kwekkeboom KL, Gretarsdottir E. Systematic review of relaxation interventions for pain. Journal of Nursing Scholarship. 2006; 38(3): 269-77.
Research supported relaxation interventions in 8 of the 15 studies reviewed. The most frequently supported technique was progressive muscle relaxation, particularly for arthritis pain.
Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain Management Nursing. 2005; 6(2):58-67.
Patients in one group listened to a guided imagery audiotape that helped them relax and change the sensory images related to their pain. After four days these patients described their pain as more tolerable and easier to control.
Mehling WE, Hamel KA, Acree M, et al. Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies in Health and Medicine. 2005; 11(4):44-52.
Breath therapy combines body awareness, breathing, meditation, and movement. In this study 36 patients with chronic low back pain received 12 sessions of breath therapy or physical therapy. Patients improved significantly with breath therapy, with changes in pain and disability comparable to those found after high-quality physical therapy.
Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Medicine. 2007;8(4):359-75.
Twenty studies on older adults with chronic pain were reviewed. There is some support for progressive muscle relaxation plus guided imagery for osteoarthritis pain. Tai chi, yoga, hypnosis, and progressive muscle relaxation were significantly associated with pain reduction.
Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain. 2007;134(3):310-9.
Patients in this study took an 8 week training in mindfulness meditation and meditated 4 times a week 30 minutes per day. The showed significant improvement in physical function, acceptance of chronic pain and their ability to engage in daily activities.
Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain. 2007; 128(1-2):111-27.
Fifty-five studies were analyzed to determine if biofeedback was effective in treating migraine. The frequency of migraines attacks and ability to influence migraines showed the strongest improvements.
Pradhan EK, Baumgarten M, Langenberg P, et al. Effect of Mindfulness-Based stress reduction in rheumatoid arthritis patients. Arthritis & Rheumatism. 2007; 28;57(7):1134-1142.
Participating in a meditation training program (Mindfulness-Based Stress Reduction) for 8-weeks followed by 4-months maintenance led to significant improvement in well-being and psychological distress (a 35% reduction) and some improvement in depressive symptoms at 6 months.
Nutrition, Herbs, Dietary Supplements
Berbert AA, Kondo CR, Almendra CL, et al. Supplementation of fish oil and olive oil in patients with rheumatoid arthritis. Nutrition. 2005; 21(2):131-6.
In this study there was significant improvement in rheumatoid arthritis in the group taking fish oil (3 grams a day) and in the group taking fish oil plus olive oil (9.6 mL) in joint pain intensity, handgrip strength after 12 and 24 weeks, morning stiffness, fatigue, and flexibility.
Gagnier JJ, vanTulder M, Berman B, Bombardier C. Herbal medicine for low back pain. The Cochrane Library. 2006; (4): (CD004504).
Studies on herbal medicine for low back pain show that standardized doses of Devil's Claw and White Willow bark are better than placebo for short-term improvements in pain and were equally as effective as 2.5 mg per day of Vioxx. Three trials on cayenne found moderate evidence of its effectiveness.
Heath KM, Elovic EP. Vitamin D deficiency: implications in the rehabilitation setting. American Journal of Physical Medicine & Rehabilitation. 2006; 85(11):916-23.
Vitamin D deficiency has been associated with musculoskeletal pain. At-risk populations are not getting enough vitamin D through sun exposure, and the current recommended daily allowances from diet and supplements appear to be too low. Treatment of vitamin D deficiency increased muscle strength and markedly decreased back and lower-limb pain within 6 months.
Maroon JC, Bost JW. Omega-3 fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology. 2006;65(4): 326-31.
250 patients with neck or back pain took omega-3 fatty acids in fish oil supplements: 78% took 1200 mg and 22% took 2400 mg. 59% were able to stop their prescription NSAID medications for pain. 60% said their overall pain was improved, and 60% said their joint pain had improved. Ibuprofen and omega-3 fatty acids showed equal effects in reducing arthritis pain.
Reginster JY, Bruyere O, Fraikin G, Henrotin Y. Current concepts in the therapeutic management of osteoarthritis with glucosamine. Bulletin (Hospital for Joint Diseases, New York). 2005; 63(1-2):31-6.
There is now a large body of evidence that glucosamine sulfate, given at a daily oral dose of 1,500 mg, is able to significantly reduce the symptoms of osteoarthritis in the lower limbs and spine in approximately two weeks.
Therapies for Psychological Health
Kroner-Herwig B. Chronic pain syndromes and their treatment by psychological interventions. Current Opinion in Psychiatry. 22(2):200-4, 2009.
Several reviews of research studies confirm that psychological interventions are moderately effective in the treatment of chronic musculoskeletal pain, especially back pain. In other pain syndromes, such as headache, fibromyalgia, and gastrointestinal pain in children, psychological interventions contributed to improvement.
Kerns RD, Thorn BE, Dixon KE. Psychological treatments for persistent pain: an introduction. Journal of Clinical Psychology. 2006; 62(11):1327-31.
Studies support the effectiveness of psychological treatments in reducing pain, depression, and disability in people with chronic pain.
Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychology. 2007; 26(1):1-9.
In this review, psychological therapies had a positive effect on pain intensity, physical functioning, depression and quality of life. Cognitive-behavioral therapy and mind-body therapies such as biofeedback, relaxation and hypnosis were specifically found to be effective.
Lin EH, Katon W, Von Korff M, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003; 290(18):2428-9. Antidepressant medications and psychotherapy reduced depressive symptoms and pain intensity and improved daily functioning and quality of life in older adults with arthritis and depression.
Okifuji A, Ackerlind S. Behavioral medicine approaches to pain. Medical Clinics of North America. 2007; 91(1):45-55.
Behavioral medicine addresses how people's thoughts and behavior affect their health. It focuses on the role motivation, commitment and active participation in the rehab process has in improving pain, daily functioning and quality of life.
Turner-Stokes L, Erkeller-Yuksel F, Miles A, et al. Outpatient cognitive behavioral pain management programs: a randomized comparison of a group-based multidisciplinary versus an individual therapy model. Archives of Physical Medicine & Rehabilitation. 2003; 84(6):781-8.
When group cognitive behavioral therapy was compared to individual therapy for chronic pain management, both treatments made significant and sustained improvements in control of pain and depression.
Age-specific
Child/Adolescent
Ball TM, Shapiro DE, Monheim CJ, Weydert JA. A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children. Clinical Pediatrics. 2003; 42(6):527-32.
Ten children with recurrent abdominal pain were trained in relaxation and guided imagery. The children experienced a 67% decrease in pain during the therapy. The use of relaxation along with guided imagery was safe and effective.
Compas BE, Boyer MC, Stanger C, et al. Latent variable analysis of coping, anxiety/depression, and somatic symptoms in adolescents with chronic pain. Journal of Consulting & Clinical Psychology. 2006; 74(6):1132-42.
Adolescents had a variety of coping strategies for recurrent pain. Those who used positive thinking, cognitive restructuring, acceptance and distraction had lower levels of anxiety, depression and physical complaints. Those who used denial, avoidance and wishful thinking had higher levels of anxiety, depression and physical complaints.
Diepenmaat AC, van der Wal MF, de Vet HC, Hirasing RA. Neck/shoulder, low back, and arm pain in relation to computer use, physical activity, stress, and depression among Dutch adolescents. Pediatrics. 2006; 117(2):412-6.
Musculoskeletal pain was found to be common in adolescents and is associated with depression and stress but not with computer use and physical activity.
Kemper KJ, Sarah R, Silver-Highfield E, et al. On pins and needles? Pediatric pain patients' experience with acupuncture. Pediatrics. 2000; 105(4): 941-47.
Most patients and their parents (70% children/59% parents) felt acupuncture had helped their pain symptoms and most rated the therapy as pleasant (67% children/60% parents).
Larsson B, Sund AM. Emotional/behavioural, social correlates and one-year predictors of frequent pains among early adolescents: influences of pain characteristics. European Journal of Pain. 2007;11(1):57-65.
In 2,360 adolescents aged 12- to 15-years, frequent back pain, depressive symptoms and recent parental divorce predicted multiple frequent pain.
Little CA, Williams SE, Puzanovova M, et al. Multiple somatic symptoms linked to positive screen for depression in pediatric patients with chronic abdominal pain. Journal of Pediatric Gastroenterology & Nutrition. 2007; 44(1):58-62.
This study tested whether multiple non-gastrointestinal (GI) symptoms in children with chronic abdominal pain is a marker for depression. With each addition of a non-GI symptom, the odds of a positive finding for depression doubled.
Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Psychosocial risks for disability in children with chronic back pain. Journal of Pain. 2006;7(4):244-51.
Two potential risk factors - use of catastrophizing as a coping technique and presence of a family history of pain - were associated with greater disability in children with back pain.
Tsao JCI, Meldrum M, Kim SC, et al. Treatment preferences for CAM in children with chronic pain. Evidence-based Complementary and Alternative Medicine. 2007; 4(3): 367-72.
In this study, over 60% of patients tried at least one complementary therapy for pain. The most popular therapies were biofeedback, yoga and hypnosis. Non-invasive approaches that enhanced relaxation and increased control were preferred.
Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent abdominal pain. Pediatrics. 2003; 111(1):e1-11.
This systematic review of treatments for recurrent abdominal pain in children found that the medications famotidine and pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules led to a decrease in pain levels. Studies on fiber had conflicting results and those on lactose avoidance showed no benefit.
Older Adults
Jacobs JM, Hammerman-Rozenberg R, Cohen A, Stessman J. Chronic back pain among the elderly: prevalence, associations, and predictors. Spine. 2006; 31(7):E203-7.
The prevalence of chronic back pain in older people increased from 44% at age 70 to 58% at age 77, although the pain was less severe. People who experience loneliness, depression, poor sleep, economic problems, unemployment, high blood pressure, and existing joint pain appear to be most at risk.
Karp JF, Reynolds CF 3rd, Butters MA, et al. The relationship between pain and mental flexibility in older adult pain clinic patients. Pain Medicine. 2006; 7(5):444-52.
The effects of persistent pain on mental flexibility, memory and information-processing speed in older adults was studied. Pain severity was associated with decreased mental flexibility.
Landi F, Onder G, Carpenter I, et al. Physical activity prevented functional decline among frail community-living elderly subjects in an international observational study. Journal of Clinical Epidemiology. 2007;60(5):518-24.
In this study of 2005 people 65 years or older, people who were active were significantly less likely to become disabled.
Landi F, Onder G, Cesari M, et al. Pain and its relation to depressive symptoms in frail older people living in the community: an observational study. Journal of Pain and Symptom Management. 2005; 29(3): 255-62.
In this study more than 40% of elderly patients experienced daily pain. The rate of depressive symptoms was significantly higher in patients with pain.
Ersek M, Turner JA, McCurry SM, et al. Efficacy of a self-management group intervention for elderly persons with chronic pain. Clinical Journal of Pain. 2003; 19(3):156-67.
Patients who participated in a 7-week pain self-management group showed significantly greater improvement in their ability to function and in their intensity of pain.
Gender Specific: Chronic Pain in Men and Women
Berkley KJ, Zalcman SS, Simon VR. Sex and gender differences in pain and inflammation: a rapidly maturing field. American Journal of Physiology - Regulatory Integrative & Comparative Physiology. 2006; 291(2):R241-4.
There are many differences between men and women in regards to pain due to genes, anatomy, nervous system, hormonal, psychological, lifestyle and social factors. Women have more painful diseases, some painful disorders act differently in women and men, and the effectiveness of some therapies is greater in one sex than the other.
Jablonska B, Soares JJ, Sundin O. Pain among women: associations with socio-economic and work conditions. European Journal of Pain. 2006; 10(5):435-47.
Sixty-three percent of women in this study reported pain during the last 3 months. Work strain and lack of social support were significantly related to more severe and disabling pain.
Wijnhoven HA, de Vet HC, Picavet HS. Prevalence of musculoskeletal disorders is systematically higher in women than in men. Clinical Journal of Pain. 2006; 22(8):717-24.
Studies show that musculoskeletal pain occurs more frequently in women than men 25 to 64 years old. In those with chronic pain, women's pain levels were more severe.
Environmental Influences
Strouse TB. The relationship between cytokines and pain/depression: a review and current status. Current Pain and Headache Reports. 2007;11(2):98-103.
Cytokines are molecules released when the immune system is stimulated, as in response to environmental stresses. This article reviews evidence on how symptoms, such as mood disorders and neuropathic pain, are related to pro-inflammatory cytokine activity.
Andersen JH, Haahr JP, Frost P. Risk factors for more severe regional musculoskeletal symptoms: a two-year prospective study of a general working population. Arthritis & Rheumatism. 2007; 56(4):1355-64.
Highly repetitive work predicted arm pain, heavy lifting and prolonged standing predicted low back pain, and heavy pushing or pulling predicted lower limb pain. Low job satisfaction predicted neck/shoulder pain and lower limb pain.
A high body mass index was highly associated with lower limb pain.