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Noninvasive Nonpharmacological Treatments for Chronic Pain: A Systematic Review Update

Systematic Review Draft

Open for comment through Nov 12, 2019

This report is available in PDF only (Draft Report [8.63 MB]; Appendixes [5.66 MB]) People using assistive technology may not be able to fully access information in these files. For additional assistance, please contact us.

Key Messages

  • Interventions that improved function and/or pain for at least 1 month after treatment completion: 
    • Low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy [CBT]), spinal manipulation, low level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).
    • Neck pain: Exercise, low level laser, mind-body practices, massage, acupuncture.
    • Knee osteoarthritis: Exercise, CBT.
    • Hip osteoarthritis: Exercise, manual therapies.
    • Fibromyalgia: Exercise, CBT, myofascial release massage, tai chi, qigong, acupuncture, MDR.
    • Tension headache: Spinal manipulation.
  • Most effects were small; long-term evidence was sparse.
  • Function and/or pain did not improve with: ultrasound (low back pain, osteoarthritis), inferential therapy, traction (low back pain), relaxation training, body awareness therapy (neck pain), electromagnetic field therapy, pain coping therapy, acupuncture (knee osteoarthritis), low-level laser therapy, multidisciplinary rehabilitation (hand osteoarthritis), or magnetic pads (fibromyalgia).
  • Although evidence was limited, serious harms were not reported with the interventions.

Structured Abstract

Objectives. We updated the evidence from our 2018 report assessing persistent improvement in outcomes following completion of therapy for noninvasive nonpharmacological treatment for selected chronic pain conditions.

Data sources. Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews), through November 2017 (prior AHRQ report) and from September 2017 through December 2018 (for this update report), reference lists,, and our previous report.

Review methods. Using predefined criteria, we selected randomized controlled trials (RCTs) 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 reported results for a at least 1 month post-intervention. We analyzed effects and assessed strength of evidence at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).

Results. We included 228 RCTs (26 new to this update). Many were small (N<70) and evidence beyond 12 months after treatment completion was sparse. The most common comparison was with usual care. Evidence on harms was limited with no evidence suggesting increased risk for serious treatment-related harms for any intervention. Effect sizes were generally small for function and pain.

Chronic low back pain: Psychological therapies were associated with small improvements compared with usual care or an attention control for both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). Function improved over short and/or intermediate term for low-level laser therapy, spinal manipulation, massage, yoga, acupuncture and multidisciplinary rehabilitation (SOE moderate at short term for massage and yoga, low for all others). Improvements in pain at short term were seen for massage, mindfulness-based stress reduction, acupuncture and multidisciplinary rehabilitation (SOE: moderate), low-level laser therapy and yoga (SOE: low). At intermediate term, spinal manipulation, yoga, multidisciplinary rehabilitation (SOE: moderate) and mindfulness-based stress reduction (SOE: low) were associated with improved pain. Compared with exercise, multidisciplinary rehabilitation improved both function and pain at short and intermediate terms (small effects, SOE: moderate.)

Chronic neck pain: Short-term, low-level laser therapy (SOE: moderate), massage (SOE: low) improved function and pain; combination exercise improved both short and long term compared with usual care (SOE: low). Acupuncture improved function short and intermediate term, but there was no pain improvement compared with sham acupuncture (SOE: low). Compared with acetaminophen, Pilates improved both function and pain (SOE: low).

Osteoarthritis: Exercise resulted in small improvements in function and pain at short (SOE: moderate) and long term and moderate improvement at intermediate term (SOE: low) for knee osteoarthritis versus non-active comparators. Small improvements in function and pain with exercise were seen for hip osteoarthritis short-term (SOE: low). Functional improvement persisted into intermediate term, but pain improvement did not (SOE: low).

Fibromyalgia: Functional improvements were seen with exercise, mind-body practices, multidisciplinary rehabilitation (SOE: low) and acupuncture (SOE: moderate) short-term compared with usual care, attention control or sham treatment. At intermediate term, there was functional improvement with exercise and acupuncture (SOE: moderate), CBT, mindfulness-base stress reduction and multidisciplinary rehabilitation (SOE: low). Long-term, functional improvements persisted for multidisciplinary rehabilitation without improvement in pain (SOE: low). Compared with exercise, Tai Chi conferred improvement in function short and intermediate term (SOE: low.)

Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation resulted in moderate improvement in pain short-term.

Conclusions. Trials identified subsequent to the earlier report largely support previous findings, namely that exercise, multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices, massage and mind-body practices most consistently improve function and/or pain beyond the course of therapy for specific chronic pain conditions. Additional research, including comparisons with pharmacological and other active controls, on effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.