Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update (April 16, 2020). Andrea C. Skelly, Ph.D., M.P.H., Roger Chou, M.D., Joseph R. Dettori, Ph.D., M.P.H., M.P.T., Judith A. Turner, Ph.D., et al. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 (Apr)

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Summary of Changes Since the Previous Report

This systematic review is an update to an earlier report published in 2018 and is one of three concurrent systematic reviews on treatment of chronic pain. The other reviews are on opioid and nonopioid pharmacological treatments. The scope and Key Questions for this update were the same as for the original review with the following additions: (1) we sought trials including pregnant or breastfeeding women with a history of one of the five chronic pain conditions; (2) topical agents (lidocaine, diclofenac, capsaicin), medical cannabis, and muscle relaxants were considered for inclusion as active comparators; and (3) we sought to evaluate the degree of nociplasticity/central sensitization as a possible modifier of treatment effect.

Meta-analyses from the 2018 report were updated, and new analyses conducted to summarize data and obtain more precise estimates on the primary outcomes of function and pain. Summary strength of evidence (SOE) tables were updated based on the totality of underlying evidence (i.e., the 2018 review evidence in combination with that from newly identified studies). To the evidence base of 218 publications (202 trials) in the 2018 report, 34 publications (31 trials) were added for this update, with the following results.

• No trials in pregnant or breastfeeding women with pre-existing chronic pain or trials comparing interventions with topical agents, medical cannabis, or muscle relaxants were identified.

• No data were available to evaluate nociplasticity as a modifier to treatment effectiveness or safety.

• Few new trials compared interventions with active comparators.

• Only two new trials of exercise for knee osteoarthritis provided long-term information.

• No new trials of interventions for chronic tension headache were identified.

In the update report, the Key Points summarize the main findings across the evidence included in the prior report and new trials, and note where new trials were added. Footnotes to the summary SOE tables denote changes in effect size and/or SOE based on new trials. New trials with at least low evidence at timeframes where previously no evidence was identified included randomized controlled trials (RCTs) of massage (neck pain) and mindfulness practices (fibromyalgia). RCTs with at least low evidence of new interventions or comparators included interferential therapy (low back pain), exercise versus acetaminophen (neck pain) or versus analgesics and nonsteroidal anti-inflammatory drugs (NSAIDS) (knee OA), and tai chi versus exercise (fibromyalgia).

In many instances, neither effect size nor SOE changed with the addition of new trials, and evidence was insufficient for some new trials. Changes to SOE or effect size versus the prior report based on new RCTs included the following.

• For low back pain, SOE was upgraded from low to moderate for short-term functional improvement with exercise but downgraded to low for pain improvement (due to increased inconsistency across trials), and effect size for pain improvement increased to moderate. Effect size for yoga was upgraded to moderate for short-term function but downgraded to small for short-term pain.

• For neck pain, new evidence for massage led to an effect size upgrade for function from none to small short term, and added evidence for intermediate-term pain. A new RCT compared exercise with acetaminophen.

• For knee osteoarthritis, there were no changes in SOE, but effect estimates for exercise were upgraded for function (small to moderate) intermediate term and pain at long term (none to small). Effect size was upgraded for improved short-term pain from none to small with cognitive behavioral therapy. Effect sizes for function and pain for ultrasound were downgraded from small to none, and there was no effect of exercise compared with analgesics and NSAIDS.

• For fibromyalgia, there were no changes in SOE, but effect sizes for pain were upgraded (none to small) intermediate term for exercise; for function with cognitive behavioral therapy effect, sizes were downgraded (small to none) short term but upgraded one level at intermediate term (small to moderate), and one new RCT on mindfulness contributed data for the intermediate term.

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Table 1

Changes to effect size and/or SOE with the addition of new trials are summarized in Table 1.

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