Brief overview of non-drug therapies for pain

Psychological assessment and treatments are designed to manage pain, distress and disability. They can be provided by the primary physician or in collaboration with a clinical psychologist through a care plan.

Although psychological interventions are being used with increasing frequency, efficacy is variable and still emerging. For example, for chronic neuropathic pain there is currently insufficient evidence of the efficacy and safety to recommend psychological interventions.²²³

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps patients modify situational factors and cognitive processes that exacerbate pain and trains patients in behavioural techniques to manage pain. CBT has shown small positive effects on disability, mood and catastrophic thinking, with some benefits lasting more than six months post treatment.⁸⁷ There is a lack of evidence on the efficacy and safety of CBT for people with neuropathic pain.⁸⁸

Mindfulness in chronic pain

Mindfulness has become an increasingly popular self-management technique for many long-term conditions, including chronic pain.²²⁴ Mindfulness originates from a Buddhist contemplative tradition, and involves focusing attention on immediate experience (ie ‘on the moment’) and approaching it with curiosity, openness and acceptance.²²⁴

There is good evidence for effectiveness (for pain and/or depressive symptoms) of mindfulness-based interventions for patients with chronic pain with heterogeneous pathophysiology²²⁵ but limited evidence of benefit in chronic low back pain. Mindfulness-based interventions may have a positive impact on perceived pain control with a moderate effect size,²²⁶ but there was no evidence of a benefit in terms of clinical outcomes such as pain intensity.²²⁴ There may be benefit in fibromyalgia.²²³ More high-quality studies are needed.⁸⁶

Movement, exercise and exercise therapies, regardless of their form, are recommended in the management of patients with chronic pain.

Most patients with chronic pain are physically deconditioned from inactivity.⁸⁹ There is strong evidence that normalisation of activity, as far as possible, is associated with reduction in the level of pain and improvement in function and wellbeing of patients with CNCP,^22,89,227 including low back pain,^82,228 osteoarthritis of the knee⁸³ and hip,⁸⁴ and fibromyalgia.⁸⁵ With low back pain, staying active is associated with less pain intensity,²²⁹ improved function²³⁰ and reduced disability in the long term.⁸⁶ Pilates has low-quality and inconsistent evidence of effectiveness in improving chronic low back pain.^231,232

The Royal Australian College of Physicians (RACP),²³³ the RACGP and other bodies recommend that returning to work (where possible and appropriate) has substantial benefits in improving patient morbidity and wellbeing.^233,234

Australian physiotherapists play a critical role in assisting the management of chronic pain. They are familiar with the biopsychosocial approach to pain and work across all age groups in primary care settings. Physiotherapists provide a range of evidence-based care, designed with the aim of diminishing pain and improving quality of life, to rehabilitate and improve movement.

The effectiveness of physiotherapy will be dependent on the nature and range of physical intervention strategies used and what conditions are treated.^{50,230,231,235–241} For example, there is no high-quality evidence to support the use of ultrasound for improving pain or quality of life in patients with non-specific chronic low back pain.²⁴² There is low to moderate effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, and massage for chronic low back pain.^230,231,235

Providing education and training to patients about the nature of pain and its effects can help selfmanagement.^{21,230,243,244} When combined with other treatments that are also consistent with a biopsychosocial framework, education appears to offer clinically important improvements in pain and disability.^245–248

Neuroscience education or pain neurophysiology education (PNE) is a range of educational interventions that present biological information about pain. There is evidence that increasing knowledge of pain-related biology:

• helps patients understand a biopsychosocial approach to rehabilitation
• decreases catastrophising^227,249
• results in short-term reductions in pain and disability.^{228,229,243,245,246}

There is moderate-quality to high-quality evidence that patient education in primary care can provide longterm reassurance for patients with acute or sub-acute low back pain.²¹ It also shows promise for patients with fibromyalgia.²⁵⁰

Effective teaching strategies (ie those that increase patient knowledge, decrease anxiety and improve patient satisfaction) include those using computer technology, audio and videotapes, written materials and demonstrations.²⁵¹