Pain – non-drug therapies

Psychological Interventions

Psychological assessment and treatments aim to manage pain, distress, and disability. These can be provided by primary physicians or in collaboration with clinical psychologists. The efficacy of these interventions varies, and for chronic neuropathic pain, there is insufficient evidence to support their effectiveness.

• Cognitive Behavioral Therapy (CBT): CBT helps modify situational factors and cognitive processes that exacerbate pain, showing small positive effects on disability, mood, and catastrophic thinking. However, its efficacy for neuropathic pain is not well established.
  • Identifying Avoided Activities: Recognize activities you have stopped or reduced due to back pain, such as lifting or carrying objects.
  • Recognizing Unhelpful Thoughts and Feelings: Identify fears or worries that prevent you from engaging in these activities.
  • Changing Unhelpful Thoughts and Behaviors: Learn to modify these thoughts and feelings to resume important activities.
• Mindfulness: Mindfulness-based interventions are effective for chronic pain and depressive symptoms, though evidence for chronic low back pain is limited. They may improve perceived pain control but not necessarily clinical outcomes like pain intensity.

Activity and Exercise Interventions

Exercise and movement are recommended for managing chronic pain. Patients often experience deconditioning due to inactivity, and normalizing activity can reduce pain and improve function and wellbeing.

• Types of Exercise: Includes general activity, specific therapies like Pilates, and returning to work, which all contribute to pain reduction and improved function.
• Common elements in exercise interventions:
  • Core or trunk strengthening
  • Flexibility and stretching
  • Aerobic exercises and functional restoration activities
  • Education and psychological principles (pacing, goal setting)
• as per HANDI
  • Motor Control Exercise (Stabilisation Exercises):
    • Focuses on retraining control and coordination of deep trunk muscles.
    • Involves one-on-one physiotherapy sessions with progressive functional tasks.
    • Effective for reducing pain and improving function, comparable to other exercises.
  • Yoga:
    • Combines postures, movements, breathing techniques, relaxation, and meditation.
    • Suitable for all ages and fitness levels, usually performed in supervised group sessions.
    • Effective for reducing pain and disability in LBP patients.
  • Pilates:
    • Similar to core strengthening exercises, focusing on deep muscle contractions.
    • Involves stabilising core muscles before complex movements.
    • More effective than minimal intervention, but not superior to other exercises.
  • Graded Activity Exercise:
    • Integrates physical and psychological components to reduce pain and disability.
    • Typically supervised by a physiotherapist in individual sessions.
    • Effective for improving pain and disability.
  • Tai Chi:
    • Low-impact activity with slow movements, breathing exercises, and meditation.
    • Suitable for all ages and fitness levels, usually performed in group sessions.
    • Safe and effective for treating LBP, improving pain intensity and disability.
  • Alexander Technique:
    • Focuses on improving posture, balance, coordination, and recognizing harmful habits.
    • Involves individual lessons with a qualified teacher.
    • Limited evidence but shows promise in combination with exercise for LBP.
  • Home-based Programs:
    • Include simple strengthening, stretching, and walking exercises.
    • Effective for reducing pain and disability, but adherence can be challenging.
    • Should be appealing and supported by health professionals to ensure compliance.
• Role of Physiotherapists: Physiotherapists provide evidence-based care to reduce pain and improve quality of life. The effectiveness varies with the type of intervention and condition treated. For example, ultrasound has no high-quality evidence for improving pain in chronic low back pain.

Neuroscience Education in Chronic Pain

Education about the nature of pain and its effects can help in self-management and, when combined with other treatments, can lead to significant improvements in pain and disability.

• Pain Neurophysiology Education (PNE): Educating patients about pain biology helps understand the biopsychosocial approach to rehabilitation, decreases catastrophizing, and results in short-term reductions in pain and disability. Effective educational strategies include using various media to increase patient knowledge and satisfaction.