The best treatment(s) for chronic primary musculoskeletal pain

The best treatment option(s) for adult and elderly patients with chronic primary musculoskeletal pain: a protocol for a systematic review and network meta-analysis –  free full-text /PMC6842192/ – Nov 2019

When researchers try to design studies about pain without differentiating between different kinds of pain, which I think invalidates those studies right away.

For myself, I’ve noticed several types of pain and each requires a different treatment:

  • For the pain from subluxations in joints, opioids work.
  • For my cervicogenic headaches, neck exercises work (and opioids initially).
  • For muscle spasms along the spine, muscle-relaxants are effective.
  • For the burn in muscles being used, nothing has worked.

Different pain requires different treatment, and I haven’t seen any studies about “pain” that rigorously control what kind of pain subjects have. 

Chronic primary musculoskeletal pain (CPMP) is one subcategory of the new classification of chronic primary pain for the upcoming ICD-11, defined as

  • chronic pain in the muscles, bones, joints, or tendons
  • that persists or recurs for more than 3 months and
  • is associated with significant emotional distress or functional disability.”

An array of pharmacological, psychological, physical, complementary, and rehabilitative interventions is available for CPMP, for which previous research has demonstrated varying effect sizes with regard to effectiveness in pain reduction and other main outcomes.

This highlights the need for the synthesis of all available evidence.

The proposed network meta-analysis will compare all available interventions for CPMP to determine the best treatment option(s) with a focus on efficacy and safety of interventions.


CPMP is a disabling condition for which several interventions exist.

This is exactly the kind of pain caused by EDS due to all the “micro-injuries” that arise from our defective connective tissue, so easily stretched and torn. It’s not “centralized pain” as is assumed with chronic pain that isn’t tethered to physical damage.

Our tiny, ever-accumulating injuries aren’t visible or measurable, so our pain is just written off as “central sensitization”.

To our knowledge, this is the first network meta-analysis to systematically compare all available evidence. This is required by national health institutions to inform their decisions about the best available treatment option(s) with regard to efficacy and safety outcomes.

In 2015, an International Association for the Study of Pain (IASP) Task Force, comprised of pain experts from across the globe, suggested a new and pragmatic classification of chronic pain for the upcoming ICD-11.

This classification includes seven categories, among them chronic primary pain (CPP). This new definition was created because the etiology for most pain conditions is unknown; CPP describes a condition where pain itself is the disease.

CPP is defined as pain in one or more bodily regions that persists or recurs for more than 3 months, is associated with significant emotional distress or functional disability, and is not better explained by another chronic pain condition.

CPP consists of the following subcategories:

  • chronic widespread pain,
  • complex regional pain syndrome,
  • chronic primary headache and orofacial pain, and
  • chronic primary visceral pain, as well as
  • chronic primary musculoskeletal pain.

These different categories share the following multiple similarities that allow to summarize them under the umbrella term CPP:

  • (1) high comorbidity rates between chronic pain conditions,
  • (2) similar interventions across syndromes,
  • (3) similar psychiatric comorbidities (i.e., mainly anxiety and depression),
  • (4) similar societal challenges (e.g., sick days and use of health care services), and
  • (5) the syndromes share genetic factors

Interventions for CPMP include

  • pharmacotherapy,
  • psychotherapeutic interventions,
  • physiological therapies,
  • rehabilitative interventions, and
  • complementary medicine.

Pharmacotherapy plays an important role in alleviating pain for these patients. Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and opioid analgesics are some of the most common classes of drugs provided.

With regard to effectiveness, pharmacological interventions show small to moderate effect sizes in recent meta-analyses compared to placebo.

“Small to moderate effect sizes” for opioid pharmaceuticals?

I’ve had my pain relieved by at least 75% by opioids for 25 years, which makes such statements hard for me to believe.

We have to remember that pain is as individual as people. There are many different origins and types of pain and even the same kind of pain can elicit very different reactions from different people.

We are doomed to failure if we keep trying to “standardize” pain treatment with “guidelines” that assume all pain is a single monolithic entity with equivalent effects on everyone.

Aging and disability are both related to an increased occurrence of chronic pain.

The anti-opioid zealots are trying to bring prescribing down to numbers not seen since 2000, but this doesn’t take into account how much the population has grown and, more specifically, how many more elderly people we have now.

Logically, the number of prescriptions should be much higher than in the past for those reasons alone.

Despite increasing awareness of the prevalence of pain among older adults, under-treatment remains an issue, not only because of polypharmacy and comorbid diseases, but also because of commonly held pain myths which are assumed to complicate care in the elderly.

1 thought on “The best treatment(s) for chronic primary musculoskeletal pain

  1. Charles Bruscino

    As per criminology, medical, social work and victimology literature, most patients with all types of chronic pain are vulnerable to abuse, neglect & exploitation (ANE), generally illegal in all states. Medical studies, “guidelines” & references specific to pain usually omit ANE as co-morbidities, to the detriment of patients. Why? Unscientific biases.

    Three populations are codified as being “vulnerable” to ANE: children, the elderly and adults with disabilities. The 2016 CDC Prescribing Guideline infamously omitted ANE as dominant factors in acute and chronic pain.

    The biases against prescribing opioid dosages specific to each patient, regardless of MME guidelines, is also unscientific, and is partly based in a virtual hatred of people with disabilities throughout the country.

    Here’s how this hatred has formed: “Disabled people game various disability systems to get a government check every month when in fact these lazy misbegotten people are not disabled, but undesirables making my taxes go up by gaming the system and draining the U.S. and states’ treasuries and business’ bottom lines; profits are sacrosanct, screw human beings that don’t toady up.”

    If even one innocent injured or disabled person is harmed as a result of such inhuman ideology then this is one too many.

    Such hatred of the disabled is an ugly cousin of racism, the ultimate ideology that puts profit above human beings and caused mass murder in the first half of the last century.

    Every person has unique DNA and different life experiences, thus each pain patient should be treated as an individual with concomitant pain treatment needs specific to the individual. Treatment “guidelines” are generalized suggestions that can never take the place of individualized care.

    Millions of Americans have safely used prescription opioids for years or decades. The CDC and others have failed to determine who exactly overdoses on prescription opioids that have been specifically prescribed for the overdose victim. They have failed to survey “responsible pain patients” (CDC, 2018) to see how we never overdose.

    Further, we can teach prescription opioid patients how to reduce their risks of overdosing, similar to other risk reduction methodologies, like motorcycle safety taught in all 50 states and the military. We have risk reduction procedures for virtually any human activity imaginable. Taking prescription opioids only as prescribed is a simplistic and irrational risk reduction methodology as there are so many factors that can make pain zoom out of control, even instantaneously like being victimized by ANE, that this simplistic notion of taking only has prescribed cannot provide adequate and meaningful pain relief for all patients.

    Individualized pain treatment is the way to go. Ask “responsible pain patients” how we safely use these medications.

    Liked by 1 person


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