Applied Evidence

Nonpharmacologic treatment of chronic pain: What works?

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Which therapies should you recommend for chronic low back pain, osteoarthritis, or fibromyalgia? This review—with 3 handy tables—summarizes the evidence.


› Recommend tai chi as an exercise modality for patients with osteoarthritis. A

› Recommend mindfulness training for patients with chronic low back pain (LBP). A

› Recommend a trial of either acupuncture or spinal manipulation for patients with chronic LBP. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


From The Journal of Family Practice | 2018;67(8):474-477,480-483.


In 2017, the American College of Physicians (ACP) published a clinical practice guideline on the management of low back pain (LBP) that states: “For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment…”1

This represents a significant shift in clinical practice, as treatment of pain syndromes often starts with analgesics and other medication therapy. This recommendation highlights the need for physicians to place nonpharmacologic therapies front and center in the management of chronic pain syndromes. But recommending nonpharmacologic therapies often represents a daunting task for physicians, as this category encompasses a broad range of treatments, some of which are considered “alternative” and others that are less familiar to physicians.

Nonpharmacologic treatment of chronic pain: What works?

This article discusses 3 categories of nonpharmacologic therapies in detail: exercise-based therapies, mind-body therapies, and complementary modalities, and answers the question: Which nonpharmacologic treatments should you recommend for specific pain conditions?

In answering the question, we will provide a brief synopsis of several treatments within these 3 broad categories to allow a framework to discuss them with your patients, and we will summarize the evidence for these therapies when used for 3 common pain conditions: chronic LBP, osteoarthritis (OA), and fibromyalgia. Finally, we will offer suggestions on how to utilize these therapies within the context of a patient’s treatment plan.

Just as it's uncommon to prescribe multiple medications from the same drug class, avoid recommending more than one nonpharmacologic treatment from each category.

This review is not without limitations. The quality of evidence is sometimes difficult to evaluate when considering nonpharmacologic therapies and can vary significantly among modalities. We sought to include the highest quality systematic reviews available to best reflect the current state of the evidence. We included Cochrane-based reviews when possible and provided evidence ratings using the Strength of Recommendation Taxonomy (SORT) system2 in the hope of helping you best counsel your patients on the appropriate use of available options.

Exercise-based therapies: Options to get patients moving

Therapeutic exercise is broadly defined as physical activity that contributes to enhanced aerobic capacity, strength, and/or flexibility, although health benefits are derived from lower-intensity physical activity even when these parameters do not change. Therapeutic exercise has well-documented salubrious effects including decreased all-cause mortality, improved physical fitness, and improvement in a variety of chronic pain conditions. In a 2017 Cochrane review of aerobic exercise for fibromyalgia, pain scores improved by 18%, compared with controls, although the quality of evidence was low (6 trials; n=351).3

Yoga is a system of physical postures and breathing and meditation practices based in Hindu philosophy. Most yoga classes and research protocols involve some combination of these elements.

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