Non-medication treatments for chronic pain ineffective

Treatments other than medication for people with chronic pain after spinal cord injury | Cochrane

Cochrane reviews are respected medical studies. This proves what so many of us have discovered: almost all the non-medication treatments we are urged to use (and spend money on) are not able to reduce our pain.

It seems the only reason these ineffective treatments are recommended is to avoid giving us opioids, which ARE effective for most.

Many people living with spinal cord injury (SCI) have chronic pain. Besides pain medication, other treatment possibilities are commonly offered.

This systematic review aims to summarise available evidence on the effectiveness and possible side effects of other forms of treatment.  

For any given type of intervention, only a few studies were found, and they included only small numbers of participants. Often the reported detail was insufficient. The overall quality of the studies was low. For instance, several studies used inappropriate comparison groups such as waiting lists. Consequently, the effectiveness of the treatments is uncertain.

For one type of treatment—transcranial direct current stimulation (tDCS)—results from two studies could be combined. The pooled results suggest that tDCS reduced pain in the short term and in the mid term.

Also, exercise programmes for chronic shoulder pain provided pain relief.

We found no evidence to suggest that 

  • repetitive transcranial magnetic stimulation (rTMS),
  • cranial electrotherapy stimulation (CES),
  • acupuncture,
  • self-hypnosis or
  • TENS

is better than the respective control interventions for reducing chronic pain.

Regarding outcomes other than pain, such as anxiety, depression or quality of life, as well as long-lasting side effects, no overall conclusions were possible, given that data were sparse.

The included studies do not permit firm conclusions regarding whether treatments other than medication for chronic SCI pain are effective and safe. Trials with greater numbers of participants and improved study quality are needed to determine the effectiveness and safety of such treatments.

Background

Chronic pain is frequent in persons living with spinal cord injury (SCI). Conventionally, the pain is treated pharmacologically, yet long-term pain medication is often refractory and associated with side effects. Non-pharmacological interventions are frequently advocated, although the benefit and harm profiles of these treatments are not well established, in part because of methodological weaknesses of available studies.

Selection criteria:

Randomised controlled trials of any intervention not involving intake of medication or other active substances to treat chronic pain in people with SCI.

Main results:

We identified 16 trials involving a total of 616 participants. Eight different types of interventions were studied.

Eight trials investigated the effects of electrical brain stimulation (transcranial direct current stimulation (tDCS) and cranial electrotherapy stimulation (CES); five trials) or repetitive transcranial magnetic stimulation (rTMS; three trials).

Interventions in the remaining studies included exercise programmes (three trials); acupuncture (two trials); self-hypnosis (one trial); transcutaneous electrical nerve stimulation (TENS) (one trial); and a cognitive behavioural programme (one trial).

Twelve studies had high overall risk of bias, and in four studies risk of bias was unclear. The overall quality of the included studies was weak. Their validity was impaired by methodological weaknesses such as inappropriate choice of control groups.

These are the hallmarks of ineffective interventions.

For tDCS the pooled mean difference between intervention and control groups in pain scores on an 11-point visual analogue scale (VAS) (0-10) was a reduction of -1.90 units (95% confidence interval (CI) -3.48 to -0.33; P value 0.02) in the short term and of -1.87 (95% CI -3.30 to -0.45; P value 0.01) in the mid term.

Exercise programmes led to mean reductions in chronic shoulder pain of -1.9 score points for the Short Form (SF)-36 item for pain experience (95% CI -3.4 to -0.4; P value 0.01) and -2.8 pain VAS units (95% CI -3.77 to -1.83; P value < 0.00001); this represented the largest observed treatment effects in the included studies.

Trials using rTMS, CES, acupuncture, self-hypnosis, TENS or a cognitive behavioural programme provided no evidence that these interventions reduce chronic pain.

Ten trials examined study endpoints other than pain, including anxiety, depression and quality of life, but available data were too scarce for firm conclusions to be drawn. In four trials no side effects were reported with study interventions. Five trials reported transient mild side effects.   

Conclusion:

Evidence is insufficient to suggest that non-pharmacological treatments are effective in reducing chronic pain in people living with SCI.

The benefits and harms of commonly used non-pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology.

 

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