CNI Health

Chronic Musculoskeletal Pain
Suggested Management
• Multimodal therapy (multidisciplinary rehabilitation) is effective and
recommended for chronic pain, for both subjective outcomes as well as
objective function outcomes (e.g. Return to work). In more difficult cases,
more intensive rehabilitation programs hold an advantage over less intensive
programs. Rehabilitation programs based in or co-ordinated with the
workplace offer advantages with respect to the outcome of return to work.
• Cognitive behavioural and behavioural therapies are effective and are
recommended for chronic pain, for the subjective outcomes of psychological
distress and suffering pain. There may be benefit in biofeedback and
relaxation, but the evidence is less strong for these modalities.
• Education is recommended as a component of a comprehensive rehabilitation
program. Although patient education plays an essential role in therapistpatient
interaction, and often results in subjective improvement, and is a
standard part of most multimodal therapies, by itself education has not been
demonstrated to be an effective treatment for chronic neck and back pain.
• There is contradictory evidence for efficacy of TENS or acupuncture. It
might worthwhile in an individual case if consistent benefits are clearly and
repeatedly documented.
• There is some evidence for the efficacy of manual therapy or manipulation,
particularly for chronic low back pain. Efficacy for neck pain can be
demonstrated when manual therapy is used in the context of a more
comprehensive treatment. Manual therapy or manipulation may be
worthwhile in an individual case consistent benefits are clearly and repeatedly
documented, and if there are no contraindications.
• Passive physical therapy modalities are not recommended in chronic pain.
Active exercise is recommended as part of a comprehensive rehabilitation
program.
• There is evidence for efficacy of NSAID in acute musculoskeletal pain. There
is equivocal evidence that NSAID may be beneficial in chronic
musculoskeletal pain. NSAID may be worthwhile in an individual case if
consistent benefits are clearly and repeatedly documented, and if there are no
contraindications.
• There is evidence for efficacy of tricyclic antidepressants in depression, in
chronic headache, or chronic neuralgia, but evidence for efficacy in chronic
soft tissue pain is contradictory, and there is equivocal evidence for efficacy in
chronic low back or neck pain.
• There is Level II evidence for a modes level of short term efficacy of
cortisone injection for lateral epicondylitis and there is Level II evidence for
lack of efficacy for chronic shoulder disorders.

Cortisone injection may be worthwhile in an individual case if consistent
benefits are clearly documented.
• The evidence for injection therapy into painful soft tissues (such as trigger
points) for chronic neck and back pain or myofascial pain, is contradictory. It
may be worthwhile in some cases if benefits are clearly and repeatedly
documented.
When musculoskeletal pain persists for three months or more, especially in the
case of psychological distress and functional impairment, and when persistent pain
is unresponsive to apparently appropriate therapy, a co-ordinated and more
intensive multidisciplinary approach is needed, which should include the
following:
• the patient's active participation
• practical goals for change and focus on the problem areas
• patient education including review of goals and progress
• promotion of function and return to work
• psychosocial intervention where appropriate
• closely co-ordinated approach by the treating physician or clinicians.
Even when pain relief as a goal eludes the patient and the physician, patients are
usually comforted by an empathic attitude, time to listen, and the offer of
emotional support. Function can usually be improved through modification of
methods or use of the following:
• aids
• modification of tasks
• changes of pace and rest periods
• active exercise for strengthening and increasing range.
Occasionally referral may be necessary to a specialized multimodal rehabilitation
program. In this case, the involvement of, and the continued supportive stance of
the primary physician is an important ingredient in the patient's progress.

Evidence
A unified system was used to represent the levels of evidence for each conclusion. The source for this rating system was McQuay, H. And Moore, A. An Evidence-based Resource for Pain Relief, Oxford U. Press 1998.
Level of Evidence Description
I Strong evidence from at least one systematic review of multiple well-designed randomized controlled trials.
II Strong evidence from at least one properly designed randomized controlled trial of appropriate size.
III Evidence from well-designed trials without randomization, single group pre-post, cohort, time series, or matched case-controlled studies
IV Evidence from well-designed non-experimental studies from more than one center or research group.
V Opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees.
Reference Guidefor Clinicians for the Treatment ofChronic Non-Malignant Pain 5