Chronic pain: an integrative approach

Resources References Online activity

Chronic pain in Australia

About 20% of Australians experience chronic pain, and in up to 5% (approximately one million people) it significantly affects function and quality of life.^[63]

Often no persisting injury can be identified, but pain continues because of long-term changes within the neurological system. Sometimes pain develops without any readily identifiable pathology.^[63]

Chronic pain may lead to secondary physical consequences, such as:^[36]

• deconditioning
• postural changes
• psychological effects including changes in behaviours and thoughts
• change in sleep pattern
• change in appetite.

A person’s social and psychological environment contributes to pain perception.^[63]

Chronic pain: a challenge in general practice

* see: RACGP position statement on medical use of cannabis products

The pivotal role of general practice in chronic pain management

If your knowledge of chronic pain management is up to date, continue reading. If not, click here to read the refresher (2 minutes).

Chronic pain is defined as any non-cancer pain of >3 months duration which interferes with the person’s functioning or wellbeing.

For a patient with chronic pain, assessment involves a thorough history, clinical examination, and psychosocial evaluation.

Psychosocial assessment should include assessment of coping mechanisms, impact of pain on ability to perform activities of daily living, on relationships and sleep, and any symptoms of anxiety and depression.^[4]

Effective chronic pain management involves a long-term patient-centred multifaceted (and ideally multidisciplinary) management plan, aiming to optimise function and quality of life.

For many people with chronic pain, non-pharmacological interventions can reduce the pain to a level that is easier to control. For others, the pain may persist but they may experience an increased ability to cope with the pain and minimise its effect on their lives.^[63]

Principles of chronic pain management

• Effective therapeutic relationship with a bio-psychosocial approach to treatment, aiming for reduction of symptoms and/or improvements in function, mood and quality of life.
• Education about pain, including:
  • difference between acute and chronic pain
  • legitimising and de-stigmatising the individual’s pain. Key message that individuals can ‘learn to manage the pain so that it does not rule their life’.
  • emphasis on importance of active self-management rather than reliance on passive strategies
  • debunking false beliefs about pain – explaining that hurt does not mean harm in chronic pain
  • encouraging return to normal activities as soon as possible
  • psycho-education – identifying when a person’s pain seems to be affected by their beliefs, worries, responses, mood state or interactions with those around them, or when pain is affecting mood and behaviour. Highlighting that the use of a psychological management technique does not mean that their pain is not real or that the pain is not being taken seriously.
• Psychological interventions such as CBT, including developing skills in:
  • specific goal setting
  • identifying and managing triggers and unhelpful thoughts such as catastrophic thinking (eg ‘this pain is killing me’)
  • understanding limits, pacing of activities and problem solving
  • reducing sense of helplessness.
• Always consider the most cost-effective and evidence-based treatment modalities.
• Limit passive modalities such as reliance on pharmaceuticals and/or on intensive therapist involvement to short term only. It may be reasonable to initiate passive modalities to help with desensitisation, then progress to increasingly active approaches that aim to restore function.
• Ensure regular review of any prescribed pharmaceuticals, avoid unnecessary poly-pharmacy or excessive dosages by allowing an adequate trial and assessing each medication before adding another.

Definitions

Why an integrative approach to chronic pain management?

Rational integrative medicine in general practice

Integrative therapeutic options from a wide range of approaches have been evaluated for use in the management of chronic pain (see Table 2), and some have been found to be effective.

The quality and strength of evidence supporting the use of complementary therapies differs between conditions and between categories of therapies. For instance, patients with osteoarthritis might benefit from a trial of complementary medicines (eg chondroitin sulfate, topical capsaicin), orthotics and exercise therapies.^[63,56]

There is some evidence to support use of exercise therapies in a range of chronic pain conditions including osteoarthritis, chronic low-back pain, and fibromyalgia.^[63,22]

In contrast, a 2015 NHMRC review concluded that there are no health conditions for which there is reliable evidence that homeopathy is effective. Chronic pain conditions for which homeopathy was evaluated included migraine, fibromyalgia, rheumatoid arthritis, osteoarthritis, chronic polyarthritis and ankylosing spondylitis.^[41]

The quality and strength of evidence supporting the use of complementary therapies differs between conditions and between categories of therapies. For instance, patients with osteoarthritis might benefit from a trial of complementary medicines (eg chondroitin sulfate, topical capsaicin), orthotics and exercise therapies.

Article (7 minutes): Holliday S, Hayes C, Jones L, et al. 2018. Prescribing wellness: comprehensive pain management outside specialist services. Australian Prescriber 2018;41:86-91.

Chronic pain management is covered extensively in the gplearning Pain Management in general practice Active Learning Module

Table 2. Complementary therapies evaluated in chronic pain management

PDF print version

Chronic pain (general)

Therapy	Evidence	Prescribing notes
General strengthening and aerobic exercise	Systematic review evidence (overview of multiple systematic reviews of low- to medium-quality studies with inconsistent results) for benefits on range of chronic pain conditions, physical function and quality of life[22]	Particularly beneficial when combined with CBT or other mind-based therapy[63] [S!] Can increase pain if pain system sensitised[63]
CBT	Systematic review evidence for overall small–moderate improvement in pain, disability, mood and catastrophising, immediately post treatment, compared with treatment as usual[69] Strong evidence for the effectiveness of CBT in chronic pain in selected patients for changing perception of pain and reaction to pain and other stressors[63] Combination of CBT and other therapies may be more effective than CBT alone for managing chronic pain[63]	[C!] The quality of CBT programs varies[63]
Vitamin D	Systemic review evidence of benefit in range of painful conditions (pooled data) versus placebo, including conditions characterised by widespread non-specific pain (eg musculoskeletal pain, fibromyalgia) localised pain (eg low back pain, dysmenorrhea, arthritis, migraine)[71]
Community support groups	Qualitative and quantitative evidence for benefits on function and adapting to life with chronic pain, but not on pain[18,57]
Medicinal cannabis	Systematic review evidence (poor-quality studies) for possible modest, short-term effect with nabiximol[60]	[C!] Tolerance and risks inadequately studied[60]
Massage	Evidence for massage therapy is conflicting, but overall suggests short-term benefits in a range of chronic pain conditions[40]	Because effects are short-term, frequent repetition is necessary[39]
Hypnosis	Weak evidence for use in chronic pain[63]
Herbs/spices	Inadequate evidence to support the use of curcumin (turmeric) in chronic pain management[63]
Neurofacilitation (Bobath, proprioceptive neuromuscular facilitation)	Few studies in chronic pain[63] Insufficient evidence from RCTs with inactive controls or usual care to ascertain effects on pain
Feldenkrais	Few studies in chronic pain[63]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Fibromyalgia

Therapy	Evidence	Prescribing notes
General strengthening and aerobic exercise	Aerobic training improves function and might reduce pain and tender points[63] Strength training may improve function and reduce pain and depression[63]
Hydrotherapy	Moderate-to-strong evidence for short-term improvements in pain, health status and quality of life with exercise in water for fibromyalgia[63]
Acupuncture	Systematic review evidence (low-to-moderate quality RCTs) for benefit on pain compared with compared with no treatment or standard therapy, and (moderate-quality RCTs) for comparable pain reduction with medical acupuncture and sham acupuncture[16]	[C!] Long-term use should be avoided in favour of active approaches[63]
Tai Chi	Low-quality evidence for benefit in fibromyalgia pain, compared with usual care[58]
Qi-gong	Low-quality evidence for benefit in fibromyalgia pain, compared with usual care[58]
Yoga	Low-quality evidence for benefit in fibromyalgia pain[58]
Medicinal cannabis	Insufficient evidence to ascertain effects on fibromyalgia pain[60]
Electromyography biofeedback	RCT evidence showing no benefit on pain[58]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Low-back pain (chronic)

Therapy	Evidence	Prescribing notes
General strengthening and aerobic exercise	Small reduction in pain and small improvement in function[63]	Benefits in low-back pain increased when exercise combined with CBT or other reinforcement[63] Exercise programs more likely to be effective if supervised, individually designed and include strengthening and stretching components[36] Patient preference is important to encourage adherenc[36] [✔] Recommended as a first-line option by some clinical practice guidelines[50]
Pilates	Systematic review (low- to moderate-quality evidence) evidence for benefit[72]
Tai chi	Systematic review evidence for pain relief[31]	[✔] Recommended as a first-line option by some clinical practice guidelines[50] At least 6 weeks of tai chi may be needed for pain relief effects[31]
Yoga	Short- and long-term benefits reported[39] Systematic review evidence for slight, clinically non-significant improvement in pain and improvement in function after 3–6 months[68]	[✔] Recommended as a first-line option by some clinical practice guidelines[50]
CBT	Enhances benefits of exercise[63]	[✔] Recommended by some clinical practice guidelines as an option to consider as part of a multifaceted treatment plan[4,50,44] CBT could be considered for people who avoid normal activities due to false beliefs about back pain[44]
Occupational therapy	Systematic review evidence that multifaceted ‘back school’ interventions (workplace ergonomics, education) in occupational setting are more effective than exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls on pain, functional status and return to work during short and intermediate-term follow-up[28]
Manipulation	Systematic review of high-quality evidence found spinal manipulation can provide short-term relief of mild to moderate pain some patients with chronic nonspecific low-back pain, but is no more effective than other interventions[54,63]	[S!] May exacerbate low-back pain[63] [C!] Can lead to dependency on therapist for repeated short-term pain relief[63] Main role is as part of multimodal approach to restore activity; not an appropriate long-term solution[63] [✔] Recommended by some clinical practice guidelines as a component of multifaceted treatment plan that includes exercise, with or without psychological therapy[44]
Physiotherapy	Benefits for low-back pain reported in RCTs combining physiotherapy with other restorative modalities, eg fitness classes, and exercise therapy[4]	[✔] Recommended as part of a multimodal approach to pain management by mainstream clinical practice guidelines[4]
TENS	Benefits in back pain reported in meta-analysis of RCTs versus sham treatment[4]	[✔] Recommended as part of a multimodal approach to pain management by mainstream clinical practice guidelines[4] Other clinical practice guidelines recommend against TENS[44]
Topical herbal preparations	Systematic review evidence that topical Capsicum frutescens (Cayenne) reduces pain more than placebo[47] Evidence from low- to moderate-quality studies for benefits of topical Symphytum officinale L (comfrey root extract), topical Solidago chilensis (Brazilian arnica), and topical lavender essential oil versus placebo[47]
Herbs/spices	Systematic review evidence (low- to moderate-quality studies) for benefits of oral Harpagophytum procumbens (devil’s claw) and oral Salix alba (white willow bark)[47]	[C!] Willow bark contains salicylates
Operant conditioning therapy	Systematic review evidence (moderate-quality RCTs) for benefit versus wait-list and similar effects as cognitive therapy[27]
Hydrotherapy	Limited evidence for benefit of long-term use of hydrotherapy[63]
Acupuncture	Equivocal evidence for benefits in chronic low-back pain from meta-analysis of RCTs versus sham acupuncture and RCT versus conventional therapy, benefits reported in observational studies[4] Acupuncture alone is more effective in short-term improvement in pain and function, compared with no treatment, but no more effective than other conventional treatments[63] Combination of acupuncture and conventional therapies more effective than same therapies alone[63]	Acupuncture and dry needling appear to be useful adjunctive treatments for chronic low-back pain[63] Indirect factors (eg expectation and belief) may play contribute to benefits of acupuncture on pain.[39] [✔] Recommended as a first-line option or adjuvant by some clinical practice guidelines[4,50] Some clinical practice guidelines recommend against acupuncture[44] [C!] Long-term use should be avoided in favour of active approaches.[63]
Massage	Systematic review of RCTs found low-quality evidence of short-term benefit[21]	[C!] Can lead to dependency on therapist for repeated short-term pain relief[63] Main role is as part of multimodal approach to restore activity; not an appropriate long-term solution[63] [✔] Recommended by some clinical practice guidelines as a component of multifaceted treatment plan that includes exercise, with or without psychological therapy[44]
Thermotherapy	Limited evidence to support use of superficial heat; too few RCTs to ascertain effects in chronic low-back pain[20]
Feldenkrais	[Insufficient evidence from RCTs with inactive controls or usual care to ascertain effects on pain] Limited RCT evidence for similar effect on pain as ‘back school’ approach[48]
Therapeutic ultrasound	Benefit for pain or quality of life not supported by high-quality evidence[17]
Prolotherapy	Not effective for pain reduction[15]
Electromyography biofeedback	Effect on pain not demonstrated by robust RCT evidence but RCT evidence for reduction in paraspinal muscle tension[65]	[✔] Recommended by some clinical practice guidelines as an option to consider as part of a multifaceted treatment plan[4]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Migraine

Therapy	Evidence	Prescribing notes
Acupuncture	Systematic review of evidence from RCTs shows small benefit for acupuncture as adjunct to symptomatic treatment of episodes for reducing frequency of episodes[33]
CoEnzyme10 (ubidecarenone)	Weak evidence for benefit in preventing migraine[63]	If patient requests, good safety profile justifies a 3-month trial despite weak supporting evidence, eg 200 mg orally, twice daily for 3 months, then review[63]
B Group vitamins	Weak evidence for benefit of riboflavin (B2) in preventing migraine[44,63]	Good safety profile justifies a 3-month trial (eg 200 mg orally, twice daily for 3 months, then review), despite weak supporting evidence, if patient requests[63]
Magnesium	Weak evidence for benefit in preventing migraine[63]	If patient requests, good safety profile justifies a 3-month trial despite weak supporting evidence, eg 400 to 650 mg orally, once daily for 3 months, then review[63]
Nutritional medicine	Anecdotal evidence for benefit in migraine prevention:[63] strategies to stabilise blood glucose levels (eg regular meals, avoiding excess simple carbohydrates) limiting caffeine avoiding known triggers for individual (eg alcohol, monosodium glutamate, citrus fruit, chocolate, preserved meats) adequate hydration (eg 1.5– 2 litres water/day)
Occupational therapy	Anecdotal evidence for benefit of healthy work practice (good posture when using computer, regular short breaks to stretch and rest eyes) in migraine prevention[63]
Relaxation training	Anecdotal evidence for benefits of progressive muscular relaxation in preventing migraine, especially if stress is a trigger[63]
Meditation	Anecdotal evidence for benefits in preventing migraine, especially if stress is a trigger[63]
Environmental medicine	Anecdotal evidence for benefit of avoiding perfumes (if trigger for individual) in migraine prevention[63]
Regular physical activity	Anecdotal evidence for benefit of regular physical activity (eg walking 30–40 minutes, 3 to 4 times a week) in migraine prevention[63]
Regular sleep/wake cycle	Anecdotal evidence for benefit of regular sleep schedules in migraine prevention[63]
Homeopathy	Homeopathy is not more effective than placebo for the treatment of headache and migraine[41]
General strengthening and aerobic exercise	[Insufficient evidence from RCTs to ascertain effects on pain]	[S!] Running and jumping can trigger migraine (walking is suitable)[63]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Multiple sclerosis

Therapy	Evidence	Prescribing notes
Medicinal cannabis: THC	Systematic review evidence for pain reduction benefit[61]	Mild to moderately severe adverse events are common[5]
Medicinal cannabis: nabiximols and THC: cannabidiol extract combinations	Inconsistent evidence for pain reduction benefit[61]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Neck pain (chronic)

Therapy	Evidence	Prescribing notes
Acupuncture	Moderate evidence for short-term relief of chronic neck pain[63]
Manipulation	Systematic review reported moderate-quality evidence that thoracic manipulation may improve pain short term.[23] Meta-analysis of low-quality trials suggested cervical mobilisation alone may achieve pain improvement similar to that of ultrasound, TENS, acupuncture and massage.[23] Limited evidence from low-quality RCTs suggested mobilisation alone may be no more effective than inactive treatment,[23] but may be effective when part of multimodal approach[63]	[S!] Neck manipulation is associated with rare but serious adverse effects (eg dissection, stroke, death)[11]; Risk of serious adverse events (rare)[23] [S!] May exacerbate neck pain[63] [C!] Can lead to dependency on therapist for repeated short-term pain relief[63] Main role is as part of multimodal approach to restore activity; not an appropriate long-term solution[63]
Occupational therapy	Systematic review evidence for lack of effect of workplace interventions (including ergonomic strategies) on neck pain in workers[1]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Osteoarthritis

Therapy	Evidence	Prescribing notes
General strengthening and aerobic exercise	Can reduce pain, increase wellbeing, prevent deterioration of fitness[63]
Stretching	Stretching and strengthening exercises may be beneficial in OA of the hand[63]
Tai chi	Systematic review evidence for benefit in OA pain,[73] including knee OA[19]	[C!] Tai chi may be associated with minor musculoskeletal pain[67]
Hydrotherapy	Exercise in water for knee or hip OA can provide short-term improvement in pain, physical function, mental health and quality of life[63]
Chondroitin sulfate	Systematic review evidence for small benefit (alone or in combination with glucosamine) on OA pain versus placebo[56] Conflicting evidence for benefit in combination with glucosamine sulfate in painful knee OA[63] Inadequate evidence for disease-modifying effect in OA in combination with glucosamine sulfate[63]	Usual dose 800–1200 mg/day orally, eg treatment trial 3–6 months[63] [C!] Most products manufactured from animal cartilage (eg cow or shark)
Topical capsaicin	May be beneficial in OA of the hand[63]
Herbs/spices	Systematic review evidence (moderate-quality RCTs) that oral Boswellia serrata (Indian frankincense) may improve pain compared with placebo[13] RCT evidence of benefits on OA pain-related symptoms with curcumin (complex extract from turmeric rhizome with turmeric volatile oil) alone or in combination with boswellic acid (extract from Indian frankincense root)[26] Systematic review evidence for benefits with Arnica gel, comfrey extract gel[12]	Arnical gel adverse effect no better than that of topical NSAIDs[12] [C!] Willow bark contains salicylates
Aids/orthotics	The use of joint protection techniques and devices (eg splints, tap turners) may be beneficial for OA of the hand[63]
Healthy weight	Weight loss reduces pain in overweight people with knee OA[8]
Glucosamine sulfate	Evidence from large RCTs suggests benefit no greater than placebo[63] Conflicting evidence for benefit in combination with chondroitin sulfate in painful knee OA[63]	Inadequate evidence for disease-modifying effect in OA in combination with chondroitin sulfate[63] Meta-analyses limited by heterogeneity between products[63] Usual dose 1500–2000 mg/day orally, eg treatment trial 3–6 months[63] [C!] Most formulations prepared from shellfish [C!] Quality varies between brands
Fish oil	Benefit in OA pain not supported by systematic review of RCTs (low-quality evidence)[55] Low doses may have same effect as anti-inflammatory doses in OA of knee[29]
Medicinal cannabis	Insufficient evidence to ascertain effects on OA pain[63]	[C!] Tolerance and risks inadequately studied[60] Mild to moderately severe adverse events are common[5]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Rheumatoid arthritis

Therapy	Evidence	Prescribing notes
Fish oil	Systematic review evidence for benefit in RA pain[55] Mild anti-inflammatory effect in rheumatoid arthritis[63]	Low risk of harm[63] [✔] Recommended by RACGP guidelines for early RA as an adjunct for management of pain and stiffness in patients with RA[52] Recommended dose at least 2.7 g omega-3 fatty acid/day orally[63] May take up to 3 months for maximal effect[63]
Herbs/spices	Systematic review evidence that gamma linolenic acid (evening primrose oil, borage oil, or blackcurrant seed oil) benefits RA symptoms[14]	[✔] GLA suggested by RACGP guidelines for managing early RA as an option that might provide relief of pain, morning stiffness and joint tenderness in RA patients[52] Usual doses are 1400 mg/day of GLA or 3000 mg/day of evening primrose oil[52] Oral Tripterygium wilfordii (thunder god vine) used for RA but adverse effects reported[52] [C!] Willow bark contains salicylates
Smoking cessation	Smoking associated with poor prognosis and response to treatment[63]	All patients should be advised to quit[63]
Nutritional medicine	Clinical trial evidence for benefits of vegetarian diets and Mediterranean diets on RA pain, but findings uncertain due to few trials and generally poor quality[25]	No diet has shown consistent benefit in RA.[63] Restrictive diets can have unwanted effects on nutrition. [✔] Regardless of any possible effects on pain, Mediterranean diet can be recommended for general health benefits[42,63] [✔] A diet that includes plenty of foods rich in fish oil (omega 3 fatty acids) is recommended for people with early RA[52]
Aids/orthotics	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]
General strengthening and aerobic exercise	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]	[✔] In addition to any possible effects on pain, aerobic exercise is recommended for people with RA because it improves physical function, helps maintain healthy body weight, and has psychological and cardiovascular benefits. Strengthening exercise is recommended to prevent muscle wasting.[63] [C!] Exercise may cause short-term pain, but patients should be reassured that benefits outweigh risks.
TENS	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]
Thermotherapy	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]	[C!] Clinical practice guidelines discourage over-reliance on thermotherapy in favour of active approaches[63] [S!] Prolonged use can result in thermal injury[63]
CBT	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]	[C!] The quality of CBT programs varies[63] Combination of CBT and other therapies may be more effective than CBT alone for managing chronic pain[63]
Relaxation training	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]
Meditation	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]
Mindfulness	Limited evidence for benefit on residual non-inflammatory joint pain in RA[63]
Medicinal cannabis	Insufficient evidence information to ascertain effects on RA pain[60]	[C!] Tolerance and risks inadequately studied[60] Mild to moderately severe adverse events are common[5]
Tai chi	Systematic review evidence does not show benefit on pain[24]	Does not exacerbate RA pain[24]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

Tension-type headache (chronic)

Therapy	Evidence	Prescribing notes
Acupuncture	Systematic review of evidence from RCTs shows benefit in reducing frequency of chronic tension-type headaches, but not superior to physiotherapy, massage or exercise[34]	[✔] Course of acupuncture recommended by some clinical practice guidelines for prevention of chronic TTH[43]

LEGEND

Supported by some evidence for benefit

Limited or weak evidence of benefit

Insufficient evidence to assess presence or absence of benefit

Evidence of absence of benefit

[S!] Safety warning
[C!] Caution
[✔] Recommended by a systematically developed clinical practice guideline

CBT: Cognitive–behavioural therapy; GLA: gamma linolenic acid; OA: osteoarthritis; PENS: percutaneous electrical nerve stimulation; RA: rheumatoid arthritis; RCT: randomised controlled trial, TENS: transcutaneous electrical nerve stimulation; THC: delta-9 tetrahydrocannabinol; TTH: tension-type headache

If you would like to do a short case study on this topic, you can enrol in the Chronic pain: an integrative approach activity on gplearning. Completion of the online activity is worth 2 CPD Activity points.

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Additional resources

• Table 1. Examples of alternative medicine
• Table 2. Complementary therapies evaluated in chronic pain management

RACGP resources

• RACGP Communication Skills ALM
• RACGP Integrative medicine. Curriculum for Australian General Practice 2016
• RACGP Pain Management Contextual Unit
• RACGP Integrative Medicine Contextual Unit
• RACGP position statement on medical use of cannabis products

Links to external resources

• Australasian Integrative Medicine Association
• Complementary Medicines Australia
• Pain Management Network. NSW Government and NSW Agency for Clinical Innovation
• Faculty of Pain Medicine Australian and New Zealand College of Anaesthetists
• Medicines Line 1300 633 424
• MedlinePlus. Herbs and Supplements (evidence A–Z)
• Table of drug interactions with complementary medicines (In: Moses GM, McGuire T. Drug interactions with complementary medicines. Australian Prescriber 2010: 33: 181.
• National Institute of Complementary Medicine
• Therapeutic Goods Administration Codeine information hub: Education resources for health professionals
• Therapeutic Goods Administration clinical guidance documents for prescribers of medicinal cannabis products

Resources for patients

• Australian Pain Management Association resources
• Arthritis Australia fact sheets
• Arthritis Australia. Dealing with pain. Arthritis information sheet. 2007 (reviewed May 2015).
• National Institute of Complementary Medicine fact sheets
• Therapeutic Goods Administration. Buying medicines and devices online
• Therapeutic Goods Administration. Complementary medicines

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References

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