Whole Health Library

Elena is a 55-year-old retired Army officer.  After retiring from active duty five years ago, she began working for a nearby Air Force base in a high level administrative position.  She began visiting a primary care clinician three years ago, but does not come in frequently because she has historically been in good health.  In the past year, however, she has developed ongoing neck pain and right knee pain.  An X-ray and MRI of her neck showed some degenerative changes but were otherwise normal.  An X-ray of her right knee showed some osteoarthritis.  Traditional over-the-counter analgesic medications provided minimal relief.  Six weeks of physical therapy was also not helpful.  Because of these treatment failures, she was seen in pain management and started on twice-daily oxycodone.  Although this does help her pain when she takes it, her function has not improved.  The medications cause some fatigue.  Despite these limitations, she is concerned about stopping the opioid medication because it is the only thing she has found to be even temporarily helpful.

Elena feels the pain is having a negative impact on her life, as the neck pain is making driving her car and riding her bike more difficult.  In addition, the mild depressive symptoms that she had dealt with intermittently in her life to this point have become more persistent over the past few months.  Her sleep quality is decreasing and she has gained 10 pounds in the past year.  She is frustrated with these negative changes and poor treatment options and is looking for a better approach to her health.

On her Personal Health Inventory (PHI), Elena rates herself as a 2 out of 5 for her overall physical well-being and a 1 for overall mental and emotional well-being. When asked what matters most to her and why she wants to be healthy, Elena responds:

“I want to feel I am making a positive impact in the world around me. My 2 children and 2 grandchildren are the most important people to me. I want to be around them as much as I can, as well as be able to be active in the outdoors.”

The Personal Health Inventory (PHI) has eight areas of self-care where Elena rates herself on where she is, and where she would like to be. Elena decides to first focus on the areas of Moving the Body and Power of the Mind by scheduling walks daily and consulting professionals to gain a better understanding on relaxation.

For more information, refer to Elena’s PHI.

Chronic pain is incredibly common, with worldwide estimates at 20% by the World Health Organization (WHO).[1]  In the United States, it is estimated that as many as 100 million people live with some degree of chronic pain.[2]  The consequences of pain are widespread and include negative effects on home activities, work productivity, relationships, and emotional states.[1]  It furthermore has repercussions for all of society, due to lost work productivity, increased health care costs, and elevated disability costs.  The estimated cost of chronic pain in the United States alone is $210-$635 billion annually.[1,2]

Despite its common occurrence, chronic pain remains a treatment challenge.  Pain is a subjective experience that has many influences.  Even for localized pain, there are often multiple physiologic sources of pain.  Low back pain and neck pain exemplify this, as potential pain generators include the fascia, muscles, ligaments, facet joints, discs, and sacroiliac joints.[3]  Chronic pain results in adaptive changes in the central nervous system, altering normal pain processing.  The pain experience is further influenced by a person’s psychological and emotional experience.[3] Social, structural and systemic drivers of health all have a significant impact on the experience of chronic pain. Quiton et al. (2020) examine the intersectional effects of sex, race, age, and poverty status on pain in an urban community sample. The study found that individuals belonging to multiple at-risk groups (e.g., women living in poverty) are at a higher risk of experiencing pain, independent of depressive symptoms.[59] Kapos et al. (2024) discusses how social factors at the interpersonal, community, and societal levels—such as social support, economic systems, and cultural practices—directly and indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations.[60] Due to these multiple influences, it is very difficult to be specific in the diagnosis and treatment of pain.  Treatment approaches that are too narrow, not taking into account the entire pain experience, are likely to fail.

Conventional medical treatments involve medications, interventional pain procedures (e.g., epidural injections, radiofrequency ablation), surgical interventions, and physical therapy.  Medication recommendations normally begin with acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).  These are generally regarded as the safest medications, but they are certainly not without risk.  Acetaminophen carries the risk of hepatotoxicity, and NSAIDs cause gastrointestinal bleeding, interfere with platelet aggregation, can worsen renal function, and may increase risk of cardiovascular events.[4]  Tricyclic antidepressant medications are recommended as adjunctive treatments for both nociceptive and neuropathic pain.[4]  These may cause sedation and are on the Beer’s list for cautious use in the elderly.[5]  Opioid medications are under increasing scrutiny due to their multiple adverse effects, potential for misuse (e.g., pseudoaddiction, when a person uses medications inappropriately but is not seeking a “high”), risk of addiction, and lack of functional improvement compared to non-opioid analgesics.[1]

Interventional and surgical treatments for pain will vary depending on the suspected source of pain.  Overall, however, in chronic pain conditions they are often of little benefit; they typically have only short term benefit and are not indicated for diffuse pain conditions. A systematic review by Jonas et al. in 2019 assessed the efficacy of invasive procedures for chronic pain compared to sham procedures. The review included 25 trials with 2,000 participants and found that there is little evidence for the specific efficacy of invasive procedures beyond sham for chronic pain. Specifically, the meta-analysis subsets for low back pain and knee pain showed no significant difference between invasive procedures and sham treatments in terms of pain reduction.[61]  There is room for improvement with current conventional approaches to both diagnosis and treatment of chronic pain.  Patients remain frustrated with treatment options and outcomes, and they turn to complementary treatments for pain more often than for any other diagnosis.[6]  Pain is an area where a Whole Health approach is clearly needed by clinicians and patients alike.  Broadening treatment goals and therapeutic options for patients like Elena has the potential to improve both patient and provider satisfaction with approaching this challenging problem.

Chronic pain can be incredibly challenging to treat.  The more a patient’s care can be individualized, and the more a clinician can draw from both conventional therapies and complementary approaches, the more successful treatment is likely to be.

Moving the body

Movement is often limited in patients with chronic pain, leading to a cycle of deconditioning, weakness, stiffness, hyperalgesia and, therefore, further reductions in movement.  Breaking this cycle with some form of exercise prescription is a vital part of a therapeutic plan in chronic pain. 

Exercise can affect pain on multiple physiologic levels, making it an ideal treatment modality.[7]  Exercise can improve aerobic capacity, strength, and flexibility.  This combination can lead to increased functional capacity over time.  Exercise itself can alter pain perception, inducing hypoalgesia to new pain stimuli; increased pain threshold can follow both aerobic and strength training.[5]  In individuals with chronic pain, this is best demonstrated at low to moderate intensity training.[5]  Exercise is also known to have effects centrally, improving sleep and depressive symptoms.[8,9]  These symptoms commonly coexist with chronic pain and affect pain perception, making them excellent targets for treatment.

Movement therapies represent a diverse group of interventions.  Traditional exercises include generalized aerobic training (walking, running, biking, swimming, etc.), strength training, and joint-specific flexibility programs.  Other disciplines such as yoga and tai chi incorporate multiple aspects of fitness and also include mind-body components. It can sometimes be helpful to consider the specific evidence for specific pain conditions. For example, for fibromyalgia, a combination of aerobic and resistance exercise was found to be the most effective in improving quality of life, pain alleviation, and physical function.[58]  In addition, it is important to remember that the type of exercise does not impact adherence to a program.[10]  Exercise prescriptions should take into account a person’s current functional status, treatment goals, and interests. 

The American College of Sports Medicine recommends addressing exercise frequency, intensity, time of the activity, and type of activity when making exercise recommendations.[11]  In addition, they recommend a minimum of 150 minutes of aerobic activity per week.[11]  Depending on a patient’s functional status, this may not be reasonable.  Starting slow with an exercise program is sound advice for anyone, but this is of increased importance in patients with chronic pain.  Exercising at too high of an intensity has the potential of worsening pain perception in patients with fibromyalgia pain.[5]  Just titrating up is important for many other activities, so too is it important with physical activity; the all-or-nothing behavioral pattern is not helpful where exercise is concerned. 

It is also important to keep accessibility in mind when recommending more physical activity.  For example, some Veterans do not feel safe walking in their neighborhoods and/or do not have money to join a gym.  Problem solving regarding barriers to increasing activity and providing consistent encouragement are an important part of recommending movement as well.  For more information on tailoring physical activity recommendations to individual patients, refer to the Prescribing Movement clinical tool for more information.

Yoga warrants mention when discussing specific exercise options with patients due to increasing literature supporting its use in pain.  There is research with positive outcomes in chronic low back pain, rheumatoid arthritis, and chronic headaches, to name a few.[12,13] This may be an attractive option for patients who have not been active due to their pain, as yoga styles can be gentle and highlight the mind-body aspects of the discipline.  Finding gentle ways to introduce movement is critically important, and patients with chronic pain can use yoga to move in ways that do not aggravate pain.  In addition, the mindful awareness aspects of yoga may help with concurrent depressive and anxiety symptoms.[12]  There are many ways to learn or incorporate yoga.  A helpful book on mindful movements is listed in the resources section.  More information on yoga is featured in the Yoga clinical tool.

Individualize physical activity for any given patient.  Keep individuals’ exercise preferences, the location of their pain, barriers that limit their exercise and comorbidities in mind as you develop an exercise prescription that suits their specific needs.

Nutritional choices can influence pain directly or indirectly.  Some foods have known anti-inflammatory properties, which may affect pain through altering cytokine and oxidant production.[14]  Indirectly, food can affect pain through improving mood, energy level,  and sleep.     .

Omega-3 fatty acid components of the diet have been found to decrease inflammatory mediators, whereas omega-6 fatty acids are generally pro-inflammatory.[15]  Sources of omega-3 in foods include salmon, sardines, flaxseeds, walnuts and pumpkin seeds.  Omega-6 fatty acids are found in meats and dairy products.  Supplementation with omega-3 fatty acids has been found in meta-analysis to improve joint tenderness and morning stiffness in patients with rheumatoid arthritis.[16]  Aside from fatty acids, natural anti-inflammatory agents can be found in some spices.  Turmeric and ginger also can alter inflammatory mediators, and because of this are available in concentrated versions as supplements. [15]  Research regarding outcomes in pain measures is mixed and is focused on amounts found in supplements.[15]  The amounts found in food are unlikely to have an effect on pain in isolation, but it is a safe way to add anti-inflammatory components to the diet.  Fruits and vegetables add numerous phytochemicals to the diet, which are naturally high in antioxidants. 

The Mediterranean diet offers many of the anti-inflammatory components offered above in addition to having research supporting cardiovascular health benefits, provided that individuals do not rely too heavily on processed foods when they follow it and provided that they have no symptoms that are triggered by eating certain grains.  The Mediterranean diet emphasizes fruits, vegetables, whole grains, olive oil, and nuts while limiting the intake of meat and dairy products.  A trial of a Mediterranean-style diet is reasonable and most patients would benefit from an individualized nutrition assessment.  When in doubt, emphasize a “whole foods nutrition” approach that minimizes packaged and process foods in general, recognizing that what people can eat is influenced by where they live, their cultural background, and what foods they know how to prepare.

Most recently, a systematic review and meta-analysis published in Pain Medicine found that whole-food dietary interventions, including elimination protocols, vegetarian/vegan diets, and Mediterranean diets, among others, had a positive effect on pain reduction in patients with chronic pain. This review highlighted that no single diet was superior, suggesting that common factors such as diet quality and nutrient density might play a role in modulating pain physiology.[59]

Addressing sleep habits is vital in patients with chronic pain.  There is a complex interplay between pain, sleep, and mood.  Sleep disorders are associated with chronic pain and depression, as well as other medical problems such as heart disease.[17]  Sleep disturbance and pain intensity are related, and this relationship seems bi-directional.[18]  It is well known that sleep disturbance can be a consequence of chronic pain.  In addition, it has been shown that sleep disturbance can reduce pain thresholds, and increase the chance of developing fibromyalgia.[19]  In addition, sleep problems interfere with the ability to cope with chronic pain.[20]

A 2018 systematic review and meta-analysis, revealed that improvements in sleep were associated with better physical functioning and reduced pain-related outcomes in the general population.[60]  In the Veteran population, Koffel et al. demonstrated that changes in sleep complaints significantly predicted changes in pain outcomes over a 12-month period in a randomized trial involving veterans with chronic musculoskeletal pain. Specifically, improvements in sleep at 3 months were associated with reductions in pain at 12 months.[61]

Helping a patient with chronic pain with sleep disorders can be challenging, but fortunately many recommendations overlap with others that will be helpful for pain.  In general, patients should view sleep and energy as something to address all day, not just at bedtime.  Nutrition and exercise recommendations discussed above may also help with sleep.  An attempt should be made to optimize evening sleep hygiene habits.  Supplements with beneficial effect on sleep may also be considered, such as melatonin and valerian.  For more information, refer to Recharge. Various Power of the Mind tools can also be helpful, as discussed below.

Spirituality and life’s purpose are not traditionally part of a clinical discussion regarding pain.  There are multiple reasons for this, including that it may be difficult as a physician to know what to do with that information.  For a patient-centered approach, having an understanding of what is most important to a particular patient is useful in determining overall treatment goals.  Hasenfratz et al. highlighted that more than 60% of chronic pain patients desired the integration of spiritual aspects into their treatment, particularly those with higher levels of education and more severe pain.[62]  Having the solitary goal of reducing pain does not relate to functional status or quality of life and is not helpful in guiding treatment choices.[21]  Having functional goals that are mutually agreed on between patient and clinician may improve satisfaction for both parties.  When those functional goals can be tied to something that is intimately important for a person, such as “enjoying more time with my grandchildren,” the goals have much more personal meaning.  Ferreira-Valente et al. reported that spirituality, particularly aspects related to hope and a positive perspective, was moderately associated with better psychological function and adaptive pain coping responses, such as ignoring pain sensations and task persistence.[63]  For an extensive discussion of spirituality and its relationship to health, please refer to Spirit and Soul.    

Never underestimate the importance of spirituality and mind-body approaches in the treatment of chronic pain.  Many clinicians with a successful track record in treating chronic pain note that these areas are fundamental.  What truly gives a person a sense of meaning and purpose and how can that individual seek this despite the pain?  And how does the person contextualize the pain?  The pain itself is a signal – the firing of nerve fibers.  Suffering is how we respond to that signal, and it can look different for each individual.  How can a person most effectively use mind-body tools to cope?

Mind-body interventions represent multiple psychological, social, and spiritual approaches to problems; these approaches include psychotherapy, meditation, relaxation, guided imagery, hypnosis, and biofeedback.  The CDC Clinical Practice Guideline for Prescribing Opioids for Pain, updated in 2022 by the American Academy of Family Physicians, also supports the use of mind-body practices, including cognitive behavioral therapy (CBT) and mindfulness practices, for improving function and reducing pain in chronic pain conditions.[64]

The link between mind-body interventions and chronic pain is important to consider, given that the central nervous system makes adaptive changes in chronic pain.  For example, when experiencing chronic pain, the volume of gray matter is decreased in the prefrontal and thalamic areas.[22]  Using mind-body interventions directly addresses this component of central-mediated pain.[23]  In addition, therapies targeted at a patient’s psychosocial experience have been shown to affect both pain perception and related psychological symptoms, such as depression or anxiety.  Overall, this is an important category of therapies to discuss with patients, as it may improve not only pain, but also mood-related symptoms, stress management, and illness-related coping skills.

Osteoarthritis, rheumatoid arthritis, chronic low back pain, chronic headache, fibromyalgia, and post-surgical pain are among the many conditions that have been studied with mind-body interventions.[24]  A Cochrane review on behavioral therapies in chronic low back pain concluded that strong evidence exists for a moderate effect on pain relief and mild improvement in functional status and behavioral outcomes with behavioral therapies.[25]  Similar findings were found in a meta-analysis for rheumatoid arthritis, with psychologic-behavioral interventions improving pain, disability, psychologic status, and coping.[24]  The current evidence in fibromyalgia is less robust, currently with limited evidence of benefit when behavioral treatments are used in isolation.[26]  However, there is moderate evidence of effectiveness when combined with aerobic exercise.[24]  More general chronic pain also seems to be effectively treated with mind-body therapies.  A meta-analysis found cognitive behavioral therapy in chronic pain effective with improved pain, coping skills, activity level and social function.[27]  Acceptance and commitment therapy (ACT) and a number of other psychotherapeutic approaches have also been found to have benefit.[28] In addition, a systematic review and meta-analysis published in 2022 evaluated the effects of mind-body exercises (MBE) such as Tai Chi, yoga, and qigong on chronic pain in middle-aged and elderly populations. The study found that MBEs had a moderate effect on reducing pain compared to nonactive and active control groups, with a standard mean difference (SMD) of -0.64 (95% CI: -0.86 to -0.42).[65]  For more detailed information on potential therapeutic options, refer to Power of the Mind.

Broadly, mind-body therapies have shown promise in decreasing pain and improving function with many diagnoses.[24]  The best choice for an individual patient will depend on what is available in the region and which therapies resonate most with the patient.

Mindfulness meditation is an excellent option for many patients with chronic pain.  There is evidence that mindfulness can decrease pain intensity and stress levels.[29,30]  Potential exists for mindfulness to impact PTSD, which is of particular relevance to Veterans with chronic pain.[31]  This form of meditation can be self-taught, is free, and can continue indefinitely as a self-care modality.  There are also many resources that can be offered to patients to assist in learning about the practice and in performing the meditation itself.

There are multiple supplements with proposed benefit in pain conditions.  While some of these products have research supporting their effectiveness, many do not.  When discussing supplements with patients, it is recommended to discuss them as part of a holistic approach as opposed to a solitary treatment solution.  Also, it is important to be critical of the supplement brand and source to improve the likelihood of getting the desired dose of a product.

Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual.  Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind.  Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer

Pain medications are not the only option.  Whether or not you choose to recommend them yourself, it is important to be familiar with various dietary supplements that patients often take for pain management.  From omega-3 and vitamin D to herbals such as devils’ claw and turmeric, these supplements are garnering increased attention from patients and researchers alike.

Omega-3 supplementation

As discussed above, supplementation with omega-3 fatty acids has been found in meta-analysis to improve joint tenderness and morning stiffness in patients with rheumatoid arthritis.[16]  Efficacy is more clearly established in inflammatory conditions such as osteoarthritis or rheumatoid arthritis. A systematic review and meta-analysis by Bahamondes et al. (2021) evaluated the effect of omega-3 on painful symptoms in patients with osteoarthritis (OA) of the synovial joints. The study included six randomized controlled trials with a total of 454 patients and found that omega-3 supplementation significantly reduced pain compared to control groups (mean difference = 22.89; 95% CI, 3.37-42.42). The studies included in this review used varying doses, but the effective doses were generally in the range of 2 to 4 grams per day of omega-3 fatty acids.[66]  Another systematic review by Raad et al. (2021) examined dietary interventions with or without omega-3 supplementation for the management of rheumatoid arthritis (RA). The review included 20 studies and found that omega-3 supplementation may contribute to pain reduction and improvement in other RA-related symptoms, although the evidence was of low quality due to high variability among studies.[67]  It is unknown what effect omega-3 supplementation has on pain with less of an inflammatory component.[15]  Doses should be standardized based on the amount of EPA and DHA present in the supplement, and should not exceed two gms per day of EPA + DHA to get the desired benefit.  Omega-3 supplements are quite safe and may improve other aspects of health, such as reducing triglycerides.

Vitamin D

The relationship between vitamin D deficiency and chronic pain is intriguing, but not yet clear.  Epidemiologic studies have correlated low vitamin D levels and chronic musculoskeletal pain, with prevalence in one study exceeding 90%.[32,33]  Vitamin D deficiency is known to cause osteomalacia and a resultant dull, achy pain which can be either localized or widespread.[34]  In addition, vitamin D deficiency is associated with muscle weakness and increased falls.[34]  A systematic review by Lombardo et al. (2022) evaluated the efficacy of Vitamin D supplementation in the treatment of fibromyalgia syndrome (FMS) and chronic musculoskeletal pain (CMP). The review included 14 randomized controlled trials and found that Vitamin D supplementation may have beneficial effects in reducing pain, particularly in individuals with established Vitamin D deficiency.[68]  Another systematic review by Venkatesan et al. (2022) focused on the efficacy of Vitamin D supplementation in improving clinical status and alleviating symptoms in patients with fibromyalgia. This review included 12 studies and concluded that Vitamin D supplementation was associated with significant improvement in clinical status and various outcome measures, including pain reduction.[69]  The most commonly effective doses were in the range of 2,000 to 4,000 IU per day.

Devil’s claw (Harpagophytum procumbens)

A 2007 study found five systematic reviews on devil’s claw and noted strong evidence of effectiveness for low back pain and osteoarthritis pain of the knee and hip.[35]  This effect was not inferior to NSAIDs.  The review concluded by stating, “Since there is strong evidence for devil’s claw…the possible place in the treatment schedule before NSAIDs should be considered.”[35] A 2022 review summarized studies from 2011 to 2022. This review highlights the potential of devil's claw in managing chronic inflammatory conditions and pain, although it emphasizes the need for more in vivo clinical studies to validate the findings from in vitro studies.[70]  Doses should contain at least 50 milligrams of the harpagoside constituents, which equates to 2.6 gms/day of the root.  Effects are dose-dependent.  Devil’s claw is generally well tolerated.

Willow bark (Salix alba)

Willow bark contains salicin, which is related to aspirin.  It has been used for centuries to relieve pain.[36]  The mechanism of action is thought to be COX-2 inhibition, similar to aspirin, but without the effects on prostaglandins or coagulation.[37]  There is evidence of efficacy in chronic low back pain similar to that seen in rofecoxib 12.5 mgs.[36] Evidence for use in osteoarthritis is mixed.[36]  The effect is dose-dependent, and the willow bark dosage used in studies was standardized to 240 mgs of salicin.

Other herbal anti-inflammatories

Other herbal medicines have known anti-inflammatory properties, most notably turmeric and ginger.  Both of these supplements have some preliminary evidence to support their use, but overall evidence is not strong at this point.  Ginger has shown some effectiveness for osteoarthritis of the knee and turmeric for rheumatoid arthritis.[35]  One relevant systematic review is by Doyle et al. (2023), which evaluated the safety and efficacy of turmeric (Curcuma longa) extract and curcumin supplements in musculoskeletal health, including chronic pain conditions such as osteoarthritis and rheumatoid arthritis. This review included 21 randomized clinical studies and found that turmeric extract and curcumin supplements can be effective adjuvants for managing musculoskeletal health with a low incidence of adverse events.[71]

Glucosamine and chondroitin

These are compounds found in the joint cartilage, synovial fluid, and connective tissue.  Both may prevent cartilage destruction, and as such, they have long been popular supplements for osteoarthritis (OA).  Evidence of effectiveness has been mixed and controversial.  A Cochrane review found efficacy for glucosamine sulfate, but this was specific to the Rotta brand and not noted when findings were pooled together with research on other brands.[38]  Improvement in knee OA was in both pain and function.  Glucosamine hydrochloride supplements have not shown efficacy in OA.  Glucosamine sulfate has also been tested specifically for chronic low back pain and showed no evidence of efficacy.[39]  A 2023 review included eight randomized controlled trials and found that the combination of glucosamine and chondroitin showed a statistically significant advantage in the total Western Ontario and McMaster Universities Arthritis Index (WOMAC) score compared to placebo, although the effect on the Visual Analog Scale (VAS) score was not significant.[72]  For patients with knee OA it may be worth a trial of therapy, keeping in mind the effects may not be seen for three months.  Dosing for both glucosamine and chondroitin is in the range of 500 milligrams three times daily.

Topical capsaicin

Capsaicin is widely available as a cream in various doses.  It is useful as a short-term analgesic, and a review has shown it to be superior to placebo for acute episodes of chronic low back pain.[40]  It is widely available in most drug stores.

Manual and manipulative therapies

Manual therapies encompass a diverse group of techniques and providers.  They share the common goal of attempting to normalize structure in order to improve function.  Manual therapy techniques are practiced by osteopathic physicians, chiropractors, physical therapists, and massage therapists.  High velocity, low amplitude (HVLA) thrusts, soft tissue mobilization, muscle energy, strain-counterstrain, myofascial release, and craniosacral therapy are all potential techniques employed by manual medicine clinicians.  The most common application of these techniques is to improve pain and function, so they are certainly applicable to the chronic pain population.

Osteopathic physicians and chiropractors practice spinal manipulative therapy.  This is most often associated with HVLA thrust techniques, although several techniques are typically used in conjunction with HVLA in an attempt to improve function.  Multiple mechanisms of action have been proposed, although it is not clear what most contributes to improved outcomes.  Gapping of facet joints, improved joint range of motion, and activation of spinal stretch reflexes are all thought to play a role.[41] 

Spinal manipulative therapy has been the subject of multiple reviews with some positive, although conflicting results.  A 2005 meta-analysis including six controlled trials and 525 patients concluded that osteopathic manipulative treatments significantly reduce low back pain.[42]  A 2011 Cochrane review concluded that spinal manipulative treatment “…was as effective but not more effective than standard medical treatment or physical therapy.”[43] However, when a 2012 review assessed spinal manipulation for multiple diagnoses, it found that the majority of systematic reviews have failed to show a benefit in terms of reducing pain.[44]  Taken together, the evidence favors spinal manipulation in the treatment of low back pain.  This view is supported by multiple national guidelines on the treatment of chronic low back pain, including the National Institute for Health and Care (NICE) guidelines.[45] It is difficult to generalize this conclusion to chronic pain of any source, however, as the evidence is not conclusive for other specific pain diagnoses.[46]

Massage therapy focuses on soft tissue techniques and may be used as a primary intervention or an adjunct treatment, preparing patients for exercise or other modalities.[47] A 2008 review concluded that strong evidence exists that massage is effective for nonspecific chronic low back pain.[47]  Interestingly, effects of massage can be long-lasting, with improvements shown at one year of follow-up.[47]  A systematic review by Mak et al., published in 2024 in JAMA Network Open, evaluated the use of massage therapy for various painful adult health conditions from 2018 to 2023. This review included 129 systematic reviews, of which 41 used formal methods to rate the certainty or quality of evidence. The findings indicated that while no conclusions were rated as high-certainty evidence, there were seven conclusions rated as moderate-certainty evidence, all suggesting beneficial associations of massage therapy with pain reduction.[73]  In addition, self-massage has been shown to improve chronic neck and back pain, stress, anxiety, fatigue, quality of sleep, and health-related quality of life.[74]  There is also evidence of benefit for massage therapy in patients with fibromyalgia.[48]  Massage therapy is safe, although care needs to be taken in patients with hypersensitivity to not cause a flare of pain with more aggressive soft tissue treatments.  For more information, refer to the Massage clinician tool.

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Acupuncture

Acupuncture is one of several elements of traditional Chinese medicine (TCM), and it has a history of more than 2,000 years of use.  Even though acupuncture represents one piece of TCM, it is often practiced as an independent therapy.  For additional information, refer to the Acupuncture clinician tool.

While the WHO lists over 40 disorders effectively treated with acupuncture, pain is the common reason acupuncture is used.[49]  There is a growing literature base and multiple reviews supportive of using acupuncture for these multiple indications.  From 1991 to 2009, nearly 4,000 acupuncture research studies were published, and pain was a focus of 41% of them.[49]  Cochrane reviews showing effectiveness of acupuncture have been published for neck pain, low back pain, headaches and osteoarthritis.[50]  Several other literature reviews support the use of acupuncture in the treatment of chronic low back pain.[51-53]  The NICE low back pain treatment guidelines list acupuncture as a primary therapeutic option.[47]  The Cochrane summary on the use of acupuncture in migraines concludes that “acupuncture is at least as effective, and possibly more effective than prophylactic drug treatment, and has fewer adverse effects.”[54] Li et al. (2020) conducted a systematic review and model-based longitudinal meta-analysis, which included 77 randomized clinical trials involving chronic shoulder, neck, knee, and low back pain. They found that acupuncture required a treatment duration of at least 5 weeks to achieve 80% of its maximum analgesic effect. The study highlighted that acupuncture provided a higher analgesic effect compared to sham acupuncture and conventional therapy, particularly for low back pain and other body locations.[75]  Xiong et al. (2024) conducted a systematic review and meta-analysis on acupuncture for myofascial pain syndrome. They found that acupuncture significantly reduced pain intensity compared to control groups, as evidenced by greater decreases in Visual Analog Scale (VAS) scores and improvements in pain-related indices.[76]

Back to Elena

Through the process of completing her Personal Health Inventory, Elena realized that her pain had a bigger influence on other areas of her life than she realized.  Her mood and sleep had worsened, physical activity decreased, and the quality of her relationships were suffering.  In addition, she realized that her sense of purpose and identity was lacking since her retirement from active duty.  She was able to understand how these areas were interconnected, and more significantly, she realized that she could control many aspects of her pain experience.  Her pain had made her feel helpless to this point, since none of the treatments seemed to have a big effect.  Knowing that she had control over many aspects of the quality of her life was empowering.

Elena began by walking daily, even though she could only go a much shorter distance than she was used to.  She started supplementation of omega-3 fatty acids.  She decided to include a series of acupuncture treatments as well.  She liked the idea that acupuncture had the potential to influence not only her pain but also to impact her mood and sleep.  Elena found over the next month that this combination of treatments greatly reduced her pain, and she was able to start weaning her opioid medications.  When the pain in her knees flared a little, she treated it by using ice or capsaicin cream instead of taking an opioid.  This normally controlled her symptoms enough to get her through the pain. 

In an effort to reconnect with her sense of meaning and purpose, Elena started volunteering at the local VA hospital, trying to redirect the passion that she felt from her years in service into serving her fellow Veterans.  She also signed up for an art class, something she always wanted to do but had put off.  Elena also wanted to explore meditation, but she decided to start with simple breathing exercises so as not to make too many changes at once.

Eventually, she was able to eliminate her daily pain and just had to deal with occasional neck and knee stiffness.  She was able to get back to hiking, even if it was not on trails quite as challenging as she had done previously.  She found that her time with her grandchildren was more enjoyable due to her improved pain, mood, and energy level.  She continued with exercise and omega-3 supplementation.  She had such good results from acupuncture that she continued to go two to three times per year in an effort to maintain her new level of improved function.

Online

• VA Clinical Practice Guideline for Lower Back Pain: http://www.healthquality.va.gov/guidelines/Pain/lbp/
• VA Clinical Practice Guideline for Opioid Therapy in Chronic Pain: http://www.healthquality.va.gov/guidelines/Pain/cot/
• American Chronic Pain Association: http://theacpa.org/
• American Academy of Pain Management: http://www.aapainmanage.org/
• University of Wisconsin Integrative Medicine Patient Handouts: http://www.fammed.wisc.edu/integrative/modules
• Patient-developed pain coping resource: http://www.paintoolkit.org/
• Tell Me About Your Pain podcast: https://podcasts.apple.com/us/podcast/tell-me-about-your-pain/id1503847664
• Power of the Mind overview: https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/power-of-the-mind.asp
• Recharge overview: https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/recharge.asp
• Spirit and Soul overview: https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/spirit-soul.asp
• Passport to Whole Health: https://www.va.gov/WHOLEHEALTHLIBRARY/passport/index.asp

Books

• Gordon, A, Ziv Alon. The Way Out: A Revolutionary, Scientifically-Proven Approach to Healing Chronic Pain. New York, NY. Avery, 2021.

“Chronic Pain” was written by Russell Lemmon, DO and updated by Vincent Minichiello, MD (2014, updated 2024).      

This Whole Health overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

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