ChronicPainTreatments:WhatistheEvidence?

WorkSafeBCEvidenceBasedPracticeGroup April2010

ChronicPainTreatments:WhatistheEvidence?

TreatmentModality

TheBottomLine

PharmacologicalManagement
Topicaltreatments Topicalcapsaicin Conflictingevidenceonitseffectivenessfromtwohighqualitysystematicreviews (SR) examiningpartlydifferentprimaryrandomized/controlledtrials(R/CT).Onesystematic reviewconcludedthatinneuropathicpain,evidencefromsixR/CTsshowedthattopical capsaicin(0.075%)wasbetterthanplacebowithanumberneededtotreat(NNT)of5.7.In musculoskeletalconditionsinthreetrials,topicalcapsaicin(0.025%orplaster)wasbetter thanplacebowithanNNTof8.1.Anothersystematicreview,basedonfourR/CTs,concluded thatthenumberofpatientsreportingeitheratleast40%painreductionoratleast50%pain reductionandglobalimprovementwerenotdifferentfromplacebo.Bothsystematicreviews reportedthatpatientsweresignificantlymorelikelytowithdrawfromtreatment(e.g.dueto burningsensations)thanplacebo. Thereareconflictingconclusions fromtwohighqualitysystematicreviews.ACochrane basedSR,morerecentandincludingmoreprimarystudies,concludedthateventhoughitis welltolerated,thereisnoevidenceontheeffectivenessofsalicylatebasedtopical rubefacientsforacuteinjuries.Inchronicconditionstheirefficacyislessthantopicalnon steroidalantiinflammatorydrugs(NSAIDs).Thereisnoevidenceatallfortopical rubefacientswithothercomponents.AnotherolderSR,includingfewerprimarystudies, concludedthatinacuteconditions,topicalsalicylatewassignificantlybetterthanplacebo withanNNTof2.1.Therewasconflictingevidenceinchronicconditions. Forpostherpeticneuralgia,thereisinsufficientevidencetorecommendtopicallidocaineas afirstlineagent.Thereisalsonoevidenceonitseffectivenessinreducingpainintensityand painreliefscoresinpatientswithotherneuropathicconditions. Advicetouseeitheroralortopicalpreparationshasanequivalenteffectonkneepain,but oralNSAIDsappeartoproducemoreminoradverseeffectsthantopicalNSAIDs.Generally, theseresultssupportadvisingolderpeoplewithkneepaintousetopicalratherthanoral NSAIDs. Strongevidenceitiseffectiveforthetreatmentoftrigeminalneuralgia.Someevidenceitis effectivefordiabeticneuropathyandmaybeeffectiveforpainrelatedtoGuillainBarr syndrome.Patientsoncarbamazepineweresignificantlymorelikelytoreportadverse effects. Limitedevidenceitiseffectiveforpainreductionintemporomandibularjointdysfunction andinstomatodynia.

SourceofEvidence WorkSafeBC Coverage

(Literaturesearchdate)

1 (2004), 2(2009)

Notrecommended

Topicalrubefacients (c.q.salycilatebased)

3 (Dec2008), 4(2003)

Notrecommended

Topicallidocaine

5 (July2008)

Notrecommended

Topicalororalibuprofen forchronickneepainin olderpeople

6 (2006)

Not recommended

Anticonvulsantsforneuropathicpain 1.Carbamazepine 2 (2009), 7(Aug2007) Notrecommended

2.Clonazepam

7 (Aug2007)

Notrecommended

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

3.Lamotrigine

4.Lorazepam 5.Oxcarbazepine 6.Phenytoin 7.Sodiumvalproate 8.Topiramate

Someevidenceforpainreductioninpainfuldiabeticneuropathybutunlikelytobeofbenefit forthetreatmentofneuropathicpaininHIVrelatedneuropathy,intractableneuropathic pain,spinalcordinjuryrelatedpain,ortrigeminalneuralgia.Patientsonlamotriginewere significantlymorelikelytowithdrawfromtreatmentbecauseofadverseeffects. Nomoreefficaciousthanplacebo inpainfulpostherpeticneuralgia. Maynotbeeffectiveinpainfuldiabeticneuropathy.Patientsonoxcarbazepineweremore likelytoleavetreatmentbecauseofadverseeffectsincludingdizzinessandsomnolence. LimitedevidenceIVphenytoinmayreducepaininacuteflareupsofneuropathicpain. Someevidenceitmaybeeffectivetotreatdiabeticneuropathyandpostherpeticneuralgia. Noteffectiveintreatingspinalcordinjuryrelatedpain. Noevidencefortrigeminalneuralgia.Inconclusiveevidenceintreatingdiabeticneuropathy. Patientsreceivingtopiramateweresignificantlymorelikelytoreportsomnolence,fatigue andsedation. Nobenefitforgabapentincomparedtoplaceboforacutepostoperativepainatrest.In chronicpain,includingpostherpeticneuralgia,diabeticneuropathy,cancerrelated neuropathicpain,phantomlimbpain,GuillainBarrsyndrome,andspinalcordinjury,the NNTforimprovementwas4.3.However,gabapentinonlyreducedneuropathicpainbyless than1pointona010pointpainscale.Patientsweresignificantlymorelikelytowithdraw fromtreatmentbecauseofadverseeffectsincludingdizziness,somnolence,confusion, ataxia,edema,andfatigue.Thenumberneededtoharm(NNH)forminorharmwas3.7.The NNTforeffectivepainreliefindiabeticneuropathywas2.9andforpostherpeticneuralgia was3.9. Nobeneficialevidenceinestablishedacutepostoperativepain.Nostudiesinchronic nociceptivepain,likearthritis.Pregabalinatdosesof300mg,450mg,and600mgdailywas effectiveinpatientswithpostherpeticneuralgia,painfuldiabeticneuropathy,central neuropathicpain,andfibromyalgia.However,Pregabalinat150mgdailywasineffective.The bestNNTforeachconditionforatleast50%painreliefoverbaselinefor600mgpregabalin dailycomparedwithplacebowas3.9forpostherpeticneuralgia,5.0forpainfuldiabetic neuropathy,5.6forcentralneuropathicpain,and11forfibromyalgia.With600mg pregabalindaily,somnolencetypicallyoccurredin15to25%anddizzinessoccurredin27to 46%.Treatmentwasdiscontinuedduetoadverseeventsin18to28%.Higherratesof substantialbenefitwerefoundinpostherpeticneuralgiaandpainfuldiabeticneuropathy thanincentralneuropathicpainandfibromyalgia.

2 (2009), 7(Aug2007), 8(Aug2006) 7 (Aug2007) 2 (2009), 7(Aug2007) 7 (Aug2007) 7 (Aug2007) 2 (2009), 7(Aug2007) 2(2009), 7(Aug2007), 9(2007), 10(Jan2004), 11(2009)

Notrecommended

Notrecommended Notrecommended Notrecommended Notrecommended Notrecommended

9.Gabapentin

Notrecommended

10.Pregabalin

2 (2009), 7(Aug2007), 9(2007), 12May2009)

Notrecommended

Antidepressantsforneuropathicpain 1.TCA (includingamitriptyline, nortriptyline,desipramine, imipramineand clomipramine) ExceptforHIVrelatedneuropathies,tricyclicantidepressants(TCAs)areeffectiveandhave anNNTof3.6foratleastmoderatepainrelief.PatientsreceivingTCAsweresignificantly morelikelytowithdrawfromtreatmentbecauseofadverseeffectsincludingdrymouthand sedation.Atpresent,noappropriateevidencethatlofepramine,tripramine,dosulepin (dothiepin)ordoxepinisclinicallyeffectiveintreatingneuropathicpain.

2 (2009), 9(2007), 14(Oct2005) Notrecommendedasa standalonetherapy

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

2.SelectiveSerotonin ReuptakeInhibitor(SSRI) 3.Serotonin NorepinephrineReuptake Inhibitor(SNRI) a.Venlafaxine

Atpresent,noappropriateevidencethatSSRIsareclinicallyeffectiveintreatingneuropathic pain.

2 (2009)

Notrecommended Notapprovedasa standalonetherapy

Overall,VenlafaxinehasanNNTof3.1.FordiabeticneuropathytheNNTforeffectiveness was1.3;forpostherpeticneuralgiaitwas2.7.TheNNH(c.q.withdrawal)was16.2for venlafaxine.TheNNHforminoradverseeffectswas9.6forvenlafaxine. Duloxetine,60mgor120mgdaily,iseffectivefortreatingpainindiabeticperipheral neuropathyandfibromyalgia.Minorsideeffectsarecommonattherapeuticdoses.Itisas effectiveasothersimilardrugsalreadyonthemarket. Nodifferenceinpainrelief(standardizedmeandifference0.04)andconflictingevidenceon theireffectonpainintensity.Also,noclearevidenceinreducingdepressioninchroniclow backpainpatients.Overall,thereisnoclearevidencethatantidepressantsaremore effectivethanplaceboinpatientswithchroniclowbackpain. Antipsychotics,suchashaloperidol,flupentixol,fluphenazine,thioridazine, levomepromazine,prochlorperazine,sulpiride,tiaprideandpimozide,mightbeusedasan addontherapyintreatingchronicpainandasapossibilityfortreatingresistantpain. However,usageofantipsychoticsisassociatedwithextrapyramidalandsedatingside effects. Whilethecurrentliteratureprovidesevidenceforacutereliefofchronicnoncancerpain, informationsupportingtheefficacyandtolerabilityofketamineinthelongtermtreatment ofchronicpainisextremelylimited.Whetherketamineisanappropriatetreatmentforany specificchronicpaincondition,includingmigraineprophylaxisandfibromyalgia,needs furtherstudy. Thereisstrongevidencethatmusclerelaxantsaremoreeffectivethanplacebofor short termpainreliefforpatientswithacuteLBP.Thepooledrelativerisk(RR)fornon benzodiazepinesversusplaceboaftertwotofourdayswas0.80[95%CI;0.71to0.89]for painreliefand0.49[95%CI;0.25to0.95]forglobalefficacy.Adverseevents,however,with anRRof1.50[95%CI;1.14to1.98]weresignificantlymoreprevalent,especiallycentral nervoussystemadverseeffects(RR2.04[95%CI;1.23to3.37]).Variousmusclerelaxants werefoundtobesimilarinperformance. Thereisinsufficientevidencetoshowsignificantbenefitfromnonantiepilepticdrugs, includingbaclofen,tizanidine,tocainide,pimozide,proparacainehydrochloride, clomipramine,andamitriptyline,intrigeminalneuralgia.Sideeffectswererelatively commonandseriousonesrestrictedtheirclinicaluse.

2 (2009), 14(Oct2005) 2 (2009), 9(2007), 15(March2009) 13 (Nov2008) Notapprovedasa standalonetherapy

b.Duloxetine

Antidepressantsfornon specificlowbackpain

Antipsychoticsforacute andchronicpaininadults

16 (Oct2007)

Notapprovedasa standalonetherapy

Ketamineforchronicnon cancerpain

17 (2008)

Notapproved

Musclerelaxantsfornon specificlowbackpain

18 (Oct2002)

Notapproved

Nonantiepilepticdrugsfor trigeminalneuralgia

19 (Aug2005)

Notrecommended

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

Opioids Opioidsforneuropathic pain

Shorttermstudiesprovideonlyequivocalevidenceregardingtheefficacyofopioidsin reducingtheintensityofneuropathicpain.Intermediatetermtrialsdemonstratedthat opioidsareeffectiveforsomesubtypesofneuropathicpainandfortherelativelyshort durationofthepublishedstudies.Sideeffectssuchasnausea,dizziness,anddrowsiness werecommon. 20 (June2005), 2(2009) AsperPracticeDirective C101,theBoard providesopioidsfor8 weeks,withprogress reportsonpainand functionrequired. Approvalforextension canbesoughtafter consultationwiththe Board'smedical advisors.Should approvalbegiven,the injuredworkerandtheir physicianarerequiredto signatreatment agreement. Notrecommended

ThebenefitsofopioidsinclinicalpracticeforthelongtermmanagementofchronicLBP 21 (May2007) remainquestionable. Longtermopioidadministration,eitherorally,transdermally,orintrathecally,totreat 22 (May2009) chronicnoncancerpainreducedpainsignificantly.However,manyparticipantsdiscontinued duetoadverseeffects(oral:22.9%,transdermal:12.1%,intrathecal:8.9%)orinsufficient painrelief(oral:10.3%,intrathecal:7.6%,transdermal:5.8%).Signsofopioidaddictionwere reportedinabout0.27%ofpatients.Findingsregardingqualityoflifeandfunctionalstatus wereinconclusive.

Opioidswitchingto improvepainreliefand drugtolerability Hydromorphoneforacute andchronicpain

Noclearevidenceontheeffectivenessofswitchingopioidsforpatientswithinadequatepain 23 (Jan2003) reliefandintolerableopioidrelatedtoxicity/adverseeffects. Hydromorphone,apotentdrug,isnotsuperiorto morphineforthemanagementof moderatetoseverepain.Morphineisthegoldstandardforthemanagementofmoderateto severecancerrelatedpain.Hydromorphonebehaveslikeotherstrongopioidsintermsofits analgesicefficacyandtolerabilityanditisnotclinicallysignificantlydifferentfromother strongopioids,suchasmorphine. Moderatequalityevidencethatpatientsreceivingtramadolweresignificantlymorelikelyto reportatleast50%painreductioncomparedwithpatientsreceivingplacebo.Significantly morelikelytowithdrawfromtreatment;significantlymorelikelytoreportconstipation, nauseaanddizziness. Amongpatientswithosteoarthritis,tramadolortramadol/paracetamoldecreasespain intensity(8.5unitson100unitscale),producessymptomrelief,andimprovesfunction,but thesebenefitsaresmall.Adverseevents,althoughreversibleandnotlifethreatening,often causeparticipantstostoptakingthemedication. Maynotbebetterthanlessexpensiveanalgesics. 24 (Nov2006)

Notrecommended

Tramadolforneuropathic pain

2 (2009)

Notrecommended

25 (Aug2005)

2628(March2008)

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

PainManagementPrograms
Painmanagementprograms (PMPs) PMPs,alsoknownasMultimodalRehabilitationPainPrograms,consistofeducationon painphysiology,painpsychology,healthyfunction,andselfmanagementofpain problems;guidedpracticeonsettinggoalsandworkingtowardsthem;identifyingand changingunhelpfulbeliefsandwaysofthinking;relaxation;andchanginghabitswhich contributetodisability.ThereishighqualityevidenceontheeffectivenessofPMPsin reducingpain,returningpeopletowork,andreducingsickleavescomparedtopassive controlsorseparateinterventions.However,theireffectivenessforneckandshoulder painamongworkingageadultsisquestionable.Further,forchroniclowbackpain patients,itisimportanttoinvestigatethecomponentsofaprogrambeforecommittingto one.

29 (2007), 30(2006), 31(Nov2002), 32(2003)

WorkSafeBCprovides: Comprehensive MultidisciplinaryPain Assessmentinorderto assistcasemanagersin adjudicatingdecisionsin chronicpain; PainManagement Program,a multidisciplinary treatmentprogram consistingofa physiotherapist, occupationaltherapist, psychologist,pharmacist andphysicianwho assistworkerswho requireassessment and/ormanagementof theircomplexpainissue; Sympathetically mediatedPain RehabilitationServices,a multidisciplinaryteam treatinginjuredworkers diagnosedwithComplex RegionalPainSyndrome. Theseservicescanbe accessedthroughreferral bytheBoard'sMedical Advisors.

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

PsychosocialManagement
Psychologicaltherapiesfor themanagementofchronic pain(excludingheadache)in adults Cognitivebehavioural therapy Behaviouraltreatmentfor chroniclowbackpain CognitiveBehaviouralTherapy(CBT)andBehaviourTherapy(BT)haveweakeffectsin improvingpain.CBTandBThaveminimaleffectsondisabilityassociatedwithchronic pain.CBTandBTareeffectiveinalteringmoodoutcomes,andthereissomeevidence thatthesechangesaremaintainedatsixmonths.Guidanceisstillrequiredonthebest content,duration,intensity,andformatoftreatment. CBTyieldsbettersocialandphysicalfunction,aswellas25%greaterabilitytocope,in chronicpainpatientscomparedwithotherbehaviouraltherapies. Combinedcognitivetherapyandprogressiverelaxationtherapyis moreeffectivethan WLC(waitinglistcontrol)onshorttermpainrelief.Longtermeffectsareunknown.No differencebetweenbehaviouraltreatmentandexercisetherapy.

33 (Aug2008)

Partofmultidisciplinary PainManagement Program

30 (2006)

34 (Oct2003)

Partofmultidisciplinary PainManagement Program Partofmultidisciplinary PainManagement Program

Invasive/SurgicalManagement
Systematicadministrationof localanestheticagentsto relieveneuropathicpain Shockwavetherapyfor lateralelbowpain Spinalcordstimulation(SCS) forchronicpain Lidocaineandoralanalogsweresafedrugsincontrolledclinicaltrialsforneuropathic pain,werebetterthanplacebo,andwereaseffectiveasotheranalgesics.However,the effectivenessoflidocaineisveryshort,relativelyverysmallinsize,andassociatedwith potentiallyharmfulsideeffects. Extracorporealshockwavetherapy(ESWT)provideslittleornobenefitintermsofpain andfunctioninlateralelbowpain.SteroidinjectionsmaybemoreeffectivethanESWT. Shockwavetherapymaycausepain,nausea,andreddeningoftheskin.

35 (2004)

Notrecommended

36 (Feb2005)

Lowenergy shockwave therapyisnotapproved Notapproved

37 (Sept2003), TheremaybeevidenceontheefficacyofSCSinreducingpainamongComplexRegional 38(Mar2009) PainSyndromepatientsbutnotonfunctionandtheefficacystartedtoloseits effectivenessafter6months. WithregardtotheapplicationofSCStotreatlimbischemia,thereissomeevidenceonits effectivenessinsalvaginglimbs. WithregardtotheapplicationofSCStotreatfailedbacksurgerysyndrome,theevidence isinconclusiveinreductionofpainor,atbest,theremaybeshorttermeffectiveness(36 months)inpainreduction.Amonginjuredworkers,SCSisnotmoreeffectivethanpain clinicsorusualcareafter6months. Evidencefortheeffectivenessofsympathectomyforneuropathicpainisveryweak. Furthermore,complicationsoftheproceduremaybesignificant. 39 (Feb2003)

Sympathectomyfor neuropathicpain

Notapproved

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

Triggerpointinjectionsfor chronicnonmalignant musculoskeletalpain

Theevidenceforitseffectivenesswhenusedasthesoletreatmentforpatientswith chronichead,neck,andshoulderpainorwhiplashsyndromeisinconclusive.The combineduseofdryneedlingandtriggerpointinjectionswithprocaineoffersnoobvious clinicalbenefitinthetreatmentofchroniccraniofacialpain,whiletheeffectivenessof triggerpointinjectionsforthetreatmentofcervicogenicheadacheisunknown.Thereis noproofthattriggerpointinjectionsaremoreeffectivethanotherlessinvasive treatments,suchasphysicaltherapyandultrasound,inachievingpainrelief.Themost commoncomplicationoftriggerpointinjectionsisavasovagalsyncopalepisode.Other complicationscanincludebleeding,transversecutsortearsinthemuscles,injuryto nervefibres,damagetobloodvessels(ecchymosis,hematoma),infection,anaphylactic reaction,allergicreactiontotheinjectedfluid,andcompartmentsyndrome.

40 (Sept2004), 41(2003)

Notrecommended

PhysicalTherapy
Tractionforlowbackpain withorwithoutsciatica Spinalmanipulativetherapy foracuteandchroniclow backpain

Consistentresultsindicate thatcontinuousorintermittenttractionasasingletreatment 43 (Oct2006) forLBPisnotlikelyeffectivetotreatpatientswithacute,subacuteorchronicLBPwithor withoutsciatica. Forpatientswithacutelowbackpain,spinalmanipulativetherapywassuperioronlyto 42 (Jan2000) shamtherapy(10mmdifference[95%CI,2to17mm]ona100mmvisualanaloguescale) ortherapiesjudgedtobeineffectiveorevenharmful.Spinalmanipulativetherapyhadno statisticallyorclinicallysignificantadvantageovergeneralpractitionercare,analgesics, physicaltherapy,exercise,orbackschool.Resultsforpatientswithchroniclowbackpain weresimilar.

Notapprovedasa standalonetherapy TheBoardinitially approvestreatmentfor4 consecutiveweeks.If furthertreatmentis required,chiropractors needtosubmitareport delineatingtreatmentand returntoworkpriorto4 moreweeksoftreatment. Shouldtreatmentbe requiredbeyond8 consecutiveweeks, approvalfirstrequires reviewfromtheBoard's MedicalAdvisors. Notapproved

Photonicstimulationforthe treatmentofchronicpain

Interferentialstimulation (IFT)forthetreatmentof musculoskeletalpain

Photonicstimulatorsaredevicesthatproduceinfraredlight.Thislightisdirectedat specificpartsofthebodytoincreasebloodflowand,allegedly,relievepain.Thereisno reliableevidenceontheeffectivenessofphotonicstimulationforthetreatmentof chronicpain. NoevidencethatIFTissuperiortoplaceboforthetreatmentofmusculoskeletalpain.

44 (Nov2002)

45 (Aug2005)

Notapproved

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

Superficialheatorcoldfor lowbackpain

Thereismoderateshorttermevidencethatheatwraptherapyhasa smalleffectin reducingpainanddisabilityforpatientswithacuteLBP.Theadditionofexercisetoheat wrapsprovidesfurtherbenefit.Thereisstillnotenoughevidenceabouttheeffectofthe applicationofcoldforlowbackpainofanyduration,orforheatforchronicLBP.Heat treatmentsincludehotwaterbottles,softheatedpacksfilledwithgrain,poultices,hot towels,hotbaths,saunas,steam,heatwraps,heatpads,electricheatpads,andinfrared heatlamps.Coldtreatmentsincludeice,coldtowels,coldgelpacks,icepacks,andice massage. Currentevidencesuggeststhatelectricalstimulationtherapy,includingpulsed electromagneticfieldtherapy,mayprovideimprovementsforkneeOA.However,the clinicalsignificancefromapatient'sperspectivewasquestionable. Verylowqualityevidencethatpulsedelectromagneticfieldtherapy(PEMF),repetitive transcranialmagneticstimulation(rTMS)andtranscutaneouselectricalnervestimulation (TENS)aremoreeffectivethanplacebo.Lowqualityevidencethatpermanentmagnets (necklace)arenomoreeffectivethanplacebo.Verylowqualityevidencethatmodulated galvaniccurrent,iontophoresisandelectricmusclestimulation(EMS)arenomore effectivethanplacebo.

46 (Oct2005)

Notapprovedasa standalonetherapy

Electromagneticfieldsfor thetreatmentof osteoarthritis Electrotherapyforneckpain

47 (2001)

Notapproved

48 (Dec2008)

Notapproved

Conservativetreatmentsfor whiplashassociated disorders(WAD) Transcutaneouselectrical nervestimulation(TENS): a.forchronicpain

Unclearevidenceontheeffectivenessofeitherpassiveoractivetreatmentstorelievethe 49 (Nov2006) symptomsofWADgrades1or2. TheanalgesiceffectivenessofTENSstillremainsuncertain,includingfortreatmentof osteoarthritisofthekneeandchronicLBP.However,itmaybeeffectiveintreating diabeticneuropathy. 50 (Apr2008), 51(Aug2008), 52(July2007), 53(Apr2009) 54 (Oct2002)

Notapproved

b.rheumatoidarthritisin thehand

ThereareconflictingeffectsofTENSonpainoutcomesinpatientswithRA.Acupuncture likeTENS(ALTENS)wasbeneficialforreducingpainintensityandimprovingmuscle powerscoresoverplacebowhile,conversely,conventionalTENS(CTENS)resultedinno clinicalbenefitinpainintensitycomparedwithplacebo.However,CTENSresultedina clinicalbenefitinpatientassessmentofchangeindiseaseoverALTENS. Insufficientevidenceonitseffectivenessintreatingnonspecificlowbackpainorneck pain.Theoptimaldose,applicationtechnique,orlengthoftreatment,ifany,remainsto bedetermined.

TheBoardprovidesTENS aspartofaphysical therapyprogramfor musculoskeletalinjury relatedtreatment. Notapplicable

Lowlevellasertherapyfor nonspecificlowbackpainor neckpain

55 (Nov2007) 56(July2008)

Notapproved

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

ComplementaryandAlternativeMedicine
Touchtherapiesforpain reliefinadults Neuroreflexotherapy(NRT) fornonspecificlowback pain Massageformechanicalneck disorders Touchtherapies,includingHealingTouch(HT),TherapeuticTouch(TT)andReiki,showed verysmalleffects(0.83unitsona0to10unitscale)inloweringpainintensitycompared tounexposedparticipants.

57 (June2008)

Notapproved

Massageforlowbackpain

AlesswidelyusedtechniquefromSpain,NRTshowedshortterm(15to60days) 58 (July2009) statisticallysignificantlybetteroutcomesinpain,mobility,disability,medicationuse, consumptionofresources,andcosts,butnotqualityoflife. Neithermassagealonenormassagecombinedwithothertreatmentsshoweda 59 (Sept2004) significantadvantageoverothercomparisongroupsincludingnotreatment,hotpacks, activerangeofmovementexercises,interferentialcurrent,acupuncture,exercises,sham laser,TENS,manualtraction,mobilization,education,andpainmedication. Massagemightbebeneficialforpatientswithsubacuteandchronicnonspecificlowback 60 (May2008) pain,especiallywhencombinedwithexercisesandeducation.Thereisatrendtowards acupressureorpressurepointmassagetechniquesprovidingmorereliefthanclassic (Swedish)massage.

Notapproved

TheBoardprovides massage,deliveredbya RegisteredMassage Therapist,aspartof rehabilitativetherapyfor injuredworkerswith musculoskeletalrelated injuries.Massageis providedfor5 consecutiveweekswitha maximumof3treatments perweekuntilreturnto work.Treatmentis limitedtoone rehabilitationmassage perday.Shouldthe injuredworkernotreturn toworkafter5weeks, approvaltocontinue massagecanbeobtained afterconsultationwith theBoard'sMedical Advisorsforuptoa maximumof3additional weeksoftreatment.

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

10

Acupuncturefortension typeheadache

Thereareclinicallyrelevantshortterm(upto3 months)benefitsofacupunctureover routinecareforresponse,numberofheadachedays,andpainintensityamongpatients withacuteheadaches.Noevidenceonlongtermeffects(>3months).

61 (Jan2008)

Acupunctureanddry needlingforlowbackpain

Acupunctureforshoulder pain

Forchroniclowbackpain,acupunctureismoreeffectiveforpainreliefandfunctional 62 (Feb2003) improvementthannotreatmentorshamtreatmentimmediatelyaftertreatmentandin theshorttermonly.Acupunctureisnotmoreeffectivethanotherconventionaland "alternative"treatments.Acupunctureanddryneedlingmaybeusefuladjunctstoother therapiesforchroniclowbackpain. Thereisnotenoughevidencetosaywhetheracupunctureworkstotreatshoulderpainor 63 (Dec2003) whetheritisharmful.

WorkSafeBCdoesnot generallyaccept responsibilityforthecost ofacupuncture.Any exceptionmustbe previouslyauthorized, andwhenauthorized, treatmentisforashort periodoftimeandonlyin conjunctionwitha comprehensivetreatment planthatincludes activationandother painmanagement strategies.Upon approval,injuredworkers canreceiveuptofive acupuncturetreatments overtwoweeks. Notapplicable

Herbaltherapyfortreating rheumatoidarthritis

Theremaybesomepotentialbenefitfortheuseofgammalinolenicacid(GLA)in rheumatoidarthritisforreliefofpain,morningstiffness,andjointtenderness.GLAmay providesupplementaryoralternativetreatmenttoNSAIDsforsomepatients.

64 (2000)

Herbalmedicineforlowback Althoughtherehavebeen goodresultswiththreeherbalmedicines(Devil'sClaw pain (HarpagophytumProcumbens),WillowBark(SalixAlba),andCayenne(Capsicum Frutescens)inshorttermtrials,thereisnoevidenceyetthatanyofthesesubstancesare safeandusefulforlongtermuse. VitaminDforthetreatment ofchronicpainfulconditions inadults ThereisinsufficientevidenceforaneffectofvitaminDinchronicpainconditions.

65 (July2005)

Notapproved

66 (Sept2009)

Notapproved

WorkSafeBCEvidenceBasedPracticeGroup www.worksafebc.com/evidence

April2010

ChronicPainTreatments:WhatistheEvidence?

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References

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