Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain
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As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management” in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans’ access to non-pharmacological approaches.
KEY WORDSveterans chronic pain psychological therapies complementary and alternative medicine self-management
The SOTA was funded through the Veterans Health Administration Office of Health Services Research and Development. The authors would like to acknowledge the leadership of Dr. David Atkins, Ms. Geraldine McGlynn, and Ms. Karen Bossi in supporting the work of the conference, as well as that of the conference co-chairs Dr. Erin Krebs and Dr. Robert Kerns, whose intellectual effort in planning and chairing the conference is represented in the content of this manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
- 1.CDC Guideline for Prescribing Opioids for Chronic Pain. https://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed June 3, 2017
- 2.Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2017; 166(7):514–530.CrossRefPubMedGoogle Scholar
- 3.VA/DoD Clinical Practice Guideline Management of Opioid Therapy for Chronic Pain. https://www.healthquality.va.gov/guidelines/pain/cot/. Accessed June 3, 2017.
- 6.Chou R, Qaseem A, Snow V, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain. Ann Intern Med 2007;147(7):478–491.Google Scholar
- 8.Rosenberger PH, Kerns R. Implementation of the VA Stepped Care Model of Pain Management. Ann Behav Med. 2012;43:S265-S.Google Scholar
- 9.Kerns RD. Implementation of a stepped care approach to pain care in the VA. Ann Behav Med 2010;39:118.Google Scholar
- 11.Comprehensive Addiction and Recovery Act. https://www.congress.gov/bill/114th-congress/senate-bill/524/text. Accessed June 21, 2017
- 13.Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;(11):CD007407. https://doi.org/10.1002/14651858.CD007407.pub3
- 15.Richmond H, Hall AM, Copsey B, et al. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One Aug 5;10(8):e0134192. https://doi.org/10.1371/journal.pone.0134192. eCollection 2015
- 20.Hann KEJ, McCracken LM. A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. J Contextual Behav Sci 2014;3(4):217–227.Google Scholar
- 24.Cherkin DC Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA. 2016;315(12):1240–1249. https://doi.org/10.1001/jama.2016.2323 CrossRefPubMedPubMedCentralGoogle Scholar
- 25.Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015; (1):CD004376.Google Scholar
- 26.Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Re. 2014(4):CD007912.Google Scholar
- 28.Hochberg MC, Altman RD, April KT, Benkhalti M, et al. American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee Arthritis Care Res 64, 4, 2012, 465–474 DOI https://doi.org/10.1002/acr.21596
- 29.Hayden JA, Van Tulder MW, Tomlinson G. Systematic Review: Strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005; 42:7765–785Google Scholar
- 30.Choi BKL, Verbeek JH, Tam WWS, Jian JY. Exercise for the prevention of recurrence of low-back pain. Cochrane Database of Syst Rev. 2010; (1): CD006555.Google Scholar
- 33.Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Data Syst Rev. 2017; (1):CD011279.Google Scholar
- 34.Coeytaux RR, McDuffie J, Goode A, et al.. Evidence Map of Yoga for High-Impact Conditions Affecting Veterans. VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs; VA ESP Project #09-010; 2014.Google Scholar
- 37.Weiland LS, Skoetz N, Pilkington K, Vempati R, D’Adamo C, Berman B. Yoga treatment for chronic non-specific low back pain. Cochrane Database of Syst Rev. 2017; (1): CD010671.Google Scholar
- 38.Groessl EJ, Liu L, Chang DG et al. Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial. Am J Prev Med. 2017. https://doi.org/10.1016/j.amepre.2017.05.019.
- 41.Hempel S, Taylor S, Solloway M, et al.. Evidence Map of Tai Chi. VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs; ESP Project #ESP 05–226;2014.Google Scholar
- 45.Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016; (3):CD005523.Google Scholar
- 47.Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 2017;21(2):201–216. https://doi.org/10.1002/ejp.931.CrossRefPubMedGoogle Scholar
- 48.Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.Google Scholar
- 49.Côté, P., Wong, J.J., Sutton, D. et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016; 25: 2000. https://doi.org/10.1007/s00586-016-4467-7.
- 52.Southerst D, Yu H, Randhawa K, et al. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Chiropr Man Therap 2015; 23:30. https://doi.org/10.1186/s12998-015-0075-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.Deare JC, Zheng Z, Xue CCL, et al.. Acupuncture for treating fibromyalgia. Cochrane Database of Syst Rev. 2013; (5): CD007070. https://doi.org/10.1002/14651858.CD007070.pub2.
- 57.Hempel S, Taylor SL, Solloway MR, et al. Evidence Map of Acupuncture. VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs; 2014Google Scholar
- 58.Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015; (9): CD001929. https://doi.org/10.1002/14651858.CD001929.pub3.
- 59.Miake-Lye I, Lee J, Lugar T, et al. Massage for Pain: An Evidence Map VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs (US); 2016.Google Scholar
- 60.Patel KC, Gross A, Graham N, et al. Massage for mechanical neck disorders. Cochrane Database Syst Rev. 2012; (9): CD004871. https://doi.org/10.1002/14651858.CD004871.pub4.
- 61.Piper S, Shearer HM, Côté P, et al. The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Man Ther 2016;21:18–34. https://doi.org/10.1016/j.math.2015.08.011.CrossRefPubMedGoogle Scholar