OBJECTIVES: Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment.
DATA SOURCES: Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov.
REVIEW METHODS: Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).
RESULTS: Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain: At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (SOE: low). Osteoarthritis: For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis . Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). The effect on function was sustained intermediate term (SOE: low). Fibromyalgia: In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited.
CONCLUSIONS: Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
BACKGROUND CONTEXT: In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises.
PURPOSE: To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III.
STUDY DESIGN/SETTING: Systematic review and best evidence synthesis.
SAMPLE: Studies comparing the effectiveness of exercise to other conservative interventions or no intervention.
OUTCOME MEASURES: Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events.
METHODS: We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles.
RESULTS: We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice.
CONCLUSIONS: We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.
BACKGROUND: Neck pain is common, disabling and costly. Exercise is one treatment approach.
OBJECTIVES: To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.
SEARCH METHODS: We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).
SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.
DATA COLLECTION AND ANALYSIS: Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.
MAIN RESULTS: Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.
AUTHORS' CONCLUSIONS: No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.
Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment.
DATA SOURCES:
Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov.
REVIEW METHODS:
Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).
RESULTS:
Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (
SOE:
low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (
SOE:
low), and psychological therapies (
SOE:
moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect
low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects
, SOE:
moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (
SOE:
low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (
SOE:
moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (
SOE:
moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain: At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (
SOE:
low), but no improvement in pain was seen at any time (
SOE:
llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (
SOE:
moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (
SOE:
low). Osteoarthritis: For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (
SOE:
moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (
SOE:
low). Exercise was also associated with moderate improvement in pain (
SOE:
low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (
SOE:
low). Evidence was sparse on interventions for hip and hand osteoarthritis . Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (
SOE:
low). The effect on function was sustained intermediate term (
SOE:
low). Fibromyalgia: In the short term, acupuncture (
SOE:
moderate), CBT, tai chi, qigong, and exercise (
SOE:
low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (
SOE:
moderate) and CBT improved pain slightly, and tai chi and qigong (
SOE:
low) improved pain moderately in the short term. At intermediate term for exercise (
SOE:
moderate), acupuncture, and CBT (
SOE:
low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (
SOE:
low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (
SOE:
low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (
SOE:
low for all); massage (
SOE:
low) improved long-term pain slightly, but no clear impact on pain for exercise (
SOE:
moderate) or multidisciplinary rehabilitation (
SOE:
low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (
SOE:
low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited.
CONCLUSIONS:
Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
