Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments

Chronic low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia are the most common types of chronic musculoskeletal pain. Because no individual therapy has consistent benefit, a multimodal treatment approach to chronic musculoskeletal pain is recommended. Many nonpharmacologic, noninvasive treatment approaches yield small to moderate improvement and can be used with pharmacologic or more invasive modalities. Systematic reviews and guidelines support the effectiveness of various forms of exercise in improving pain and function in patients with chronic pain. Cognitive behavior therapy and mindfulness techniques appear to be effective for small to moderate short- and long-term improvement of chronic low back pain. Cognitive behavior therapy may also be effective for small short- and intermediate-term improvement of fibromyalgia. Spinal manipulation leads to a small benefit for chronic neck and low back pain. Acupuncture has a small to moderate benefit for low back pain and small benefit for nonpain fibromyalgia symptoms. Massage or myofascial release yields a small improvement in low back pain, hip and knee osteoarthritis, and fibromyalgia. Low reactive level laser therapy may provide short-term relief of chronic neck and low back pain, and ultrasound may provide short-term pain relief for knee osteoarthritis. Multidisciplinary rehabilitation may be effective for short- and at least intermediate-term improvement in pain and function for chronic low back pain and fibromyalgia. Patients should be encouraged to engage in a variety of therapies aligned with their preferences and motivation.