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Best Practice & Research Clinical Rheumatology 25 (2011) 299–309

Contents lists available at ScienceDirect

Best Practice & Research Clinical
Rheumatology
journal homepage: www.elsevierhealth.com/berh

14

Non-pharmacological treatment of chronic widespread
musculoskeletal pain
Afton L. Hassett, Psy.D., Associate Research Scientist *,
David A. Williams, Ph.D., Professor
Department of Anesthesiology, University of Michigan Medical School, Chronic Pain & Fatigue Research Center, Domino’s Farms,
Lobby M, PO Box 385, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, USA

Keywords:
Chronic widespread pain
Fibromyalgia
Non-pharmacological treatment
Chronic pain
Exercise
Cognitive-behavioural therapy

Individuals with chronic widespread pain, including those with
fibromyalgia, pose a particular challenge to treatment, given the
modest effectiveness of pharmacological agents for this condition. The growing consensus indicates that the best approach to
treatment involves the combination of pharmacological and nonpharmacological interventions. Several non-pharmacological
interventions, particularly exercise and cognitive-behavioural
therapy (CBT), have garnered good evidence of effectiveness as
stand-alone, adjunctive treatments for patients with chronic pain.
In this article, evidenced-based, non-pharmacological management techniques for chronic widespread pain are described by
using two broad categories, exercise and CBT. The evidence for
decreasing pain, improving functioning and changing secondary
symptoms is highlighted. Lastly, the methods by which exercise
and CBT can be combined for a multi-component approach,
which is consistent with the current evidence-based guidelines of
several American and European medical societies, are addressed.
Ó 2011 Elsevier Ltd. All rights reserved.

Many clinicians (and patients) continue to consider chronic pain as an extended version of acute
pain. As a consequence, treatments frequently focus on ‘fixing’ the chronic pain rather than upon its
management. Reluctance to abandon the allure of a cure [1] has delayed the broad adoption of
combined pharmacological and non-pharmacological management of pain – the standard of care for
several other chronic illnesses such as diabetes, cardiovascular disease, hypertension and asthma.

* Corresponding author. Tel.: þ1 734 998 6873; fax: þ1 734 998 6900.
E-mail address: afton@med.umich.edu (A.L. Hassett).
1521-6942/$ – see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.berh.2011.01.005

Participants are usually instructed to stretch each area to the point just before discomfort is experienced and to hold the position for approximately 10–30 s. The successful integration of exercise can take different forms. D. which leads to improved performance in short-duration activities. Strength training (anaerobic exercise) Strength training seeks to improve overall muscle strength.. reimbursement is typically challenging and multi-million-dollar marketing campaigns – common to pharmacological agents – are missing.. are included in this category of exercise. given that these interventions often have favourable cost–benefit ratios and effect sizes that rival pharmacological interventions in the management of pain [2. Okifuji and colleagues reported that 47% of their sample was obese. exercise studies in CWP have addressed activities ranging from calisthenics to belly dancing. Limited details are provided in most medical school curricula. Anaerobic exercise tends to require high-intensity activity. complex regional pain syndrome (CRPS). has included everything from traditional cognitive restructuring and behavioural change strategies to medication scheduling. The term ‘non-pharmacological intervention’ itself defines this set of interventions by what they are ‘not’ rather than by their strengths. it can be of high intensity and frequency or involve only adding a few steps each day. Stretching and bending target increasing in range of motion. decreasing stiffness and/or minimising risk of injury. arthritis (e. machines and resistance bands) to oppose muscle contraction in order to build muscle mass. can range from whole-body exercise to cycling and involve structured approaches such as Pilates and Tai Chi. The limited profile of nonpharmacological treatment is unfortunate. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 Non-pharmacological interventions do not share the status ascribed to pharmacological approaches. less physical strength and worse sleep [10]. given that deconditioning and obesity are commonly observed in these patients. In a recent study. ‘CBT’. as well as isometric exercises such as yoga and various forms of martial arts. Non-pharmacological interventions.or water-based. osteoarthritis (OA) and rheumatoid arthritis (RA)). These programmes include a thorough warm-up period. Following the stretch.g. meta-analyses and multiple sets of guidelines [7–9] leave little doubt that exercise is broadly considered to be an effective treatment for patients with FM and CWP.A. Evidencebased ‘exercise’ can be aerobic or more focussed on increasing strength and flexibility. the muscles can be ‘shook out’ and the same stretch is usually repeated. have substantial efficacy for the management of chronic pain conditions including low back pain (LBP) [4].3]. obesity was related to greater pain sensitivity. followed by a systematic series of stretching exercises. It is usually an anaerobic activity focussed on using resistance (e. In their study. Under the rubric of non-pharmacological interventions lies much variability. Flexibility training Stiffness and reduced range of motion are common complaints in patients with CWP. to loosen muscles. while another 30% was overweight.L.300 A. such as cognitive-behavioural therapy (CBT). Exercise The publication of approximately 80 studies evaluating exercise interventions. Hassett. For example. weights. . Similarly. [5] chronic pelvic pain (CPP) [6] and conditions such as fibromyalgia (FM) and chronic widespread pain (CWP) [7–9]. multiple review papers. This article offers an overview of evidence-based exercise options for the treatment of CWP with practical suggestions to promote successful implementation of an exercise programme. over a discrete period of time. Exercise can be land. Exercise may be particularly important for improving the health and functioning of individuals with CWP. education and exercise.g. This article helps to clarify the types of non-pharmacological treatments that have the best evidence for use in CWP. Weight lifting and resistance training.

An early study of exercise in FM found aerobic training to be superior to flexibility training for improving fitness. .38]. increased resistance and comfort from immersion in warm water. Despite early negative trails [23.g. In a recent meta-analysis evaluating 35 RCTs. instead. yoga and weight/circuit training) that are performed at a more intense pace for a longer duration. Subsequent to this report. Hauser and colleagues reported that aerobic exercise significantly reduced pain in participants with FM with ‘land-based’ and ‘pool-based’ interventions yielding similar positive results [36].or heavy-intensity strength training. contingent upon the type of yoga and intensity of its practice. swimming and dancing. Pool-based aerobic exercise programmes offer individuals with pain the added benefits of reduced impact. exercise interventions were directed at building muscle strength or countering deconditioning [12. mixed-modality interventions include more than one form of exercise. yoga can fit into all three categories. Support for efficacy – reducing pain Early hypotheses regarding the aetiology of CWP conditions. as yet. is considered best [19–21]. centred on muscle pathology [11]. Although only a handful of studies have been conducted to date. are frequently used. there is not sufficient evidence. such as FM. The meta-analysis included studies published up to April 2009. a study comparing yoga to a waitlist control reported that their 8-week yoga intervention resulted in less pain and pain catastrophising in FM [27]. the evidence of effectiveness increases to a certain degree [26. another RCT reported that aerobic training was superior to flexibility training for increasing fitness and decreasing pain [25]. Thus. This review conforms to this convention. cycling. single-blind RCT. there is growing evidence that both Tai Chi [39. but some individuals will benefit from the programme. In a more recent randomised control trial (RCT). while there is support for the efficacy of muscle strength training in the reduction of pain. Taken together.40] and Qigong movement therapies may be beneficial for some individuals with CWP [41]. If yoga is considered to be flexibility training.L. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 301 Aerobic exercise Cardiorespiratory or ‘aerobic’ exercise consists of physical activity performed at a minimum level of moderate intensity over an extended period of time. Tai Chi was compared with a control condition consisting of education plus stretching [39]. such as the combination of strength training and aerobic exercise. rowing machine or elliptical trainer.g. as opposed to moderate. Aerobic types of activities vary widely and can include walking. there is little evidence that these forms of exercise are addressing the specific pathology of CWP. evidence supporting muscle pathology in CWP conditions has been sparse and. aerobic exercise was better than flexibility training for decreasing the number of tender points [24]. Similarly. as well as flexibility and strengthtraining activities (e. more recent RCTs are reporting strong effects for decreasing pain [32–35]. Lastly. Hassett. although a number of effective aerobic exercise programmes include a flexibility-training component (e. therefore. favours more central factors. Moderately intense exercise. When mixed-modality interventions are evaluated in research.13]. For example. such as a stationary cycle. Other movement therapies and mixed modality Not all types of exercise fit neatly into the aforementioned categories. additional studies have also been supportive of aerobic exercise [37. Over time. ref.28–31]. mild strength training. In the case of CWP.A. in general [14–18]. Another therapy related to aerobic exercise is movement therapy. Other forms of exercise that fall under the category of movement therapies studied in CWP and/or FM include Tai Chi and Qigong.27]. the intervention is typically considered aerobic if there is an aerobic component. is associated with fitness and fat burning.A.. to conclude that flexibility training by itself is helpful for CWP.. D. 60–70% of age-adjusted maximum heart rate or approximately 110 beats per minute for a 40-year-old. Few studies specifically address flexibility (stretching) training for CWP. The authors reported significant improvement for the Tai Chi group with regard to both clinicians’ and patients’ assessments of pain severity. but not for pain or sleep [23]. The evidence supporting the efficacy of aerobic exercise for improving pain is compelling. [22]). Training machines. In a recent. For example. running/jogging.

it is difficult to determine the specific impact of these exercise modalities on functional status. sedentary. community-based settings [22]. In contrast. fitness gains are not always associated with symptomatic improvement [25. aerobic training was associated with decreased fatigue [48]. Patients should be cautioned that. however. 50–70% of age-adjusted maximum heart rate) for 20–30 min per session 2–3 times per week [36]. persistence and motivation What is the best way to engage chronic pain patients in regular exercise when they are frequently obese.9.A. depressed. there is far less evidence for other modalities. improved sleep [49]. Lastly. constiutes an optimal non-pharmacological therapeutic approach to CWP. beginning at levels just below capacity and then increased in duration and intensity until individuals are exercising at low to moderate intensity (i.43–45].302 A. However. less depression [25. some studies have shown that strength training for CWP patients has been associated with less fatigue [53] and depression [16]. less anxiety and better quality of life [45]. Interestingly. land-based and waterbased. preferences and interests is key to deriving benefit [7] and enhancing adherence. fatigued and experiencing pain? This problem is reflected in the attrition rates observed in RCTs that evaluate exercise in CWP that have been estimated to range from 27% to 90% [36]. In addition. there was robust evidence in favour of light to moderate aerobic exercise for pain. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 Support for efficacy – increasing functioning In view of the fact that only a few studies have evaluated either strength or flexibility training as individual modalities. improve functioning in patients with CWP. Training programmes should have a duration of at least 4 weeks. better cognitive performance [51]. another evidence-based review of the exercise literature was published recently and concluded that insufficient evidence existed to draw a conclusion with regard to the benefit of low-intensity exercise on pain reduction [36].. The combination of exercise with CBT.42]. patients should promptly consult with their physicians [56]. as well as in the home [35]. This recommendation was based on a review of 46 trials conducted from 1988 to 2005 which demonstrated that the best results were associated with low-intensity programmes that were individualised to patient needs [55]. aerobic exercise conducted in low-cost. and education during the early stages of a new exercise programme is crucial. Other findings from the same review suggested that aerobic exercise training should be increased slowly. Hassett. These recommendations are consistent with published guidelines [7.47].38. significant improvement in the 6-min walk test [44] and better general health [24.57]. Attrition. if there is concern with regard to adverse effects.50].44. if they experience increased symptoms.e. D. there is strong evidence that aerobic exercise programmes.35. Furthermore. however. better grip strength. By contrast.L. Taken together.34. numerous RCTs have been conducted in aerobic exercise and have shown significant improvement in functioning [32. in this patient population.49. was found to be highly effective for patients with FM. Support for efficacy – other symptoms and outcomes Aerobic training for individuals with CWP was associated with increased fitness [23] and aerobic work capacity [46]. they should decrease exercise until symptoms improve. greater self-efficacy [44] and increased feelings of well-being [52].16] and flexibility training [16. . which focusses upon patients’ thoughts and beliefs. while non-aerobic warm water exercises and education resulted in an improved 6-min walk test. Therefore. improvements have been associated with interventions involving both strength training [14. Due to a paucity of studies. Therefore.56]. it is highly likely that tailoring the exercise-treatment programme to patients’ needs. more studies are needed to affirm the effectiveness of strength and flexibility training. Intensity and frequency Jones and colleagues have recommended that low-intensity. non-repetitive exercise be used for the treatment of FM [54].

CBT typically includes three phases: (1) an educational phase. CT focusses on thoughts. the latest approaches to treatment and a theoretical framework for understanding the role of the patient in pain management. progressive muscle relaxation. They are then taught how to alter these thoughts and beliefs in a manner that is better aligned with the management of pain.4].g. in which patients are introduced to a model for understanding their pain and the role that individuals can play in the management of the condition. expectations and attributions that can lead to overwhelming affect. avoidance. or pain relief from inactivity).A. CBT skill-sets Education Education is a vital component of CBT and is typically the first phase of treatment.). mood. For example. in which patients learn to apply their skills in progressively more challenging real-life situations [61]. CT has its roots in the psychological treatment for depression [60]. In CT.A. for example. visual imagery. The purpose of education is to establish rapport with the patient and to help ensure that the patient and the clinician are thinking about pain and their respective roles in pain management from a common perspective. such flexibility has also contributed to some confusion when it is assumed that CBT is a uniform intervention. The next section describes some of the specific skills that are provided in CBT for pain as well as representative studies supporting the use of these skills for the management of pain. That CBT content can vary depending upon the need of the individual patient is actually a strength of the approach and underscores the flexibility of this therapeutic modality.. is not considered to be an especially robust approach to treatment because simply learning what needs to change does not ensure that any behavioural action will occur.L. Education typically involves providing the patient with an updated summary of the latest facts that concern the type of pain they are experiencing. The term CBT. hypnosis. by itself. BT focusses upon aspects of patients’ environments that can lead to the development or maintenance of pain through reinforcement (e. beliefs. To learn the response. CBT interventionists will utilise a wide variety of skill-sets or modules to produce outcomes. In the context of pain. and (3) an application phase. as well as in classical conditioning and social learning theory. attention. D. In its application to pain management.g. each of which is grounded upon a common theoretical framework. Education. BT for chronic pain is grounded in the work of Fordyce’s operant model [59]. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 303 Cognitive-behavioural therapy CBT possesses a strong evidence base that supports its efficacy in the management of chronic pain [58. functional improvement. however. The theory behind CBT CBT is actually a hybrid of two efficacious forms of therapy: behavioural therapy (BT) and cognitive therapy (CT). the choice of modules depends upon the intended target of treatment (pain reduction. For any patient. etc.. patients are trained to gain insight with regard to into how their thoughts. suffering and additional pain intensity and/or diminished functional status. In practice. Typically. There is no consensus as to the best method of teaching the relaxation response. heart rate and breathing) [62]. through reduced muscle tension. refers to a class of interventions. the individual needs to practise the prescribed techniques repeatedly until his/her body acquires the desired response. The next section reviews theoretical underpinnings of CBT with some of the more common skill-sets that are used in the management of chronic pain. (2) a skills training phase. beliefs or expectations influence emotions. The relaxation response The most commonly used behavioural skill in CBT for pain management is a form of the relaxation response used to diminish autonomic arousal (e. Hassett. biofeedback – all of which are based upon behavioural principles of reinforcement . behavioural or cognitive elements may be differentially emphasised. however. BT and CT techniques are often combined to form CBT. pain and functioning.

g. on ‘good days’. Support for the use of problem solving in the context of CWP is . Pleasant activity scheduling Many individuals with chronic pain exclude enjoyment from their lives and leave time for only essential tasks.g. thus. lost productivity and decreased self-esteem. The cause of cognitive difficulties in chronic pain is not well understood but is likely to be associated with the lack of restorative sleep and the distracting nature of persistent pain on information processing [83]. D. Enjoyment of pleasant activities is a natural way to elevate mood [78] and invites confidence in ones’ body to function at a higher level. increasing pain and reducing function. The key to success of this strategy is to pace activities based upon time rather than upon subjective experiences of pain or upon the completion of tasks. Time-based pacing can be used as a complementary skill to help ensure the long-term adoption of exercise regimens. having regular sleep routines). Cognitive difficulties Individuals with chronic pain will often report difficulties with memory.L. What is taught in therapy is a strategy for solving problems rather than specific solutions. concentration and mental clarity [82]. sleep behaviours (e. rheumatological populations [73]. Programmatic problem-solving strategies can be taught to patients by helping them to break large problems down into solvable pieces [84. better management of pain. Graded activation or ‘time-contingent pacing’ is a method of pacing that can improve physical functioning while minimising the likelihood of pain flare-ups. As considered in CBT.. such as social outings and sporting activities. The patient and therapist must work together to develop a plan for steadily increasing the amount of time spent on specified targeted behaviours. While this strategy is understandable.. Active time can be as short as several minutes or as long as several hours depending upon what the patient can initially tolerate without exacerbation. and structured rehearsal methods for improving memory (e. awakening with feelings of being unrefreshed and unrestored. Behavioural approaches to stress reduction. patients learn a strategy that can be carried into the future as new problems arise. for reducing pain in FM [63. patients will unwittingly engage in more activity than personal limitations allow and will then suffer several ‘bad days’ of symptom flares. Behavioural strategies for sleep. if used regularly.81]. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 and appear to be useful modalities for learning this response. after sleeping. Thus.g.. Behavioural methods for improving sleep Individuals with chronic pain have a number of problems related to getting a good night’s sleep and they include difficulty falling asleep. a doctor’s appointment. Hassett. watching action movies. repetition and developing associations) can provide benefit.g. While relaxation has been found to be efficacious. but this remains an area where more study is needed. long-term denial of personal pleasures can have devastating effects on mood and motivation.304 A.64]. consuming nicotine or caffeine). Some of these skills focus on timing strategies (e.. Problem-solving strategies Individuals with chronic pain face interpersonal and functional challenges that rarely affect healthy individuals. attempting to sleep only when in need of sleep) and behavioural avoidance of stimulating activities (e. on its own. can help individuals obtain the required restorative sleep with additional benefits in improved mood. appears to have a direct impact on pain symptoms and on functional interference resulting from non-restorative sleep [80. Graded activation Performing tasks can enhance ones’ self-esteem. in patients with FM [74–76] and in patients having chronic fatigue syndrome [77]. less fatigue and improved mental clarity [79]. and may work well in the context of acute pain. or a deadline [76]. such as inducing the relaxation response. CBT. work-related activities and pleasant activities. it is also one of most commonly used skills in a multi-component CBT approach to pain management [65–71]. which targets sleep. being awakened by pain or discomfort or. this behavioural change encourages scheduling of pleasant activities into ones’ day with the same priority as a meeting.A. This approach has been successfully applied with LBP populations [72].85].

automatic. improvements in functional status [57.L. This form of CT has been associated with improvements in pain [74].89] and improved mental health [46.86].92]. however. with booster sessions being used to reinforce change over a longer term. new thinking patterns can replace old ones that are more consistent with well-being and pain control.86]. In a study of ‘high risk’ FM patients. Assertiveness training or other forms of more effectively engaging in interpersonal processes are often taught in the context of CBT to help improve one’s self-efficacy to garner the support of others as well as to improve symptoms of pain directly [57.9. Cognitive restructuring [60] is a cognitive skill that is used to challenge the rationality of negative automatic thoughts and seeks to instill alternative thinking that is capable of promoting greater functioning and well-being. Coping skills training Coping skills training (CST) refers to a set of CBT skills that are aimed directly at reducing the experience of pain (e. For example. A recent meta-analysis found strong evidence that such treatment significantly reduced pain.65. Cognitive restructuring and reframing Behavioural solutions to problems reflect the beliefs held with regard to the nature of the problem and beliefs about one’s personal ability to effectively execute solutions.86. maintenance of exercise) is required.74. sleep [57. Williams / Best Practice & Research Clinical Rheumatology 25 (2011) 299–309 305 derived from several studies demonstrating that improvements in the ability to deal with life’s problems are associated with reduced pain [46. Strong convictions in one’s helplessness. similarly as in any chronic health condition. ongoing intervention (e. the delivery of CST can be accomplished over the telephone [90]. The duration of therapy is typically brief and involves between 6 and 12 sessions. D. Cognitive restructuring invites individuals to explore the origin of learned automatic thinking patterns that contribute to maladaptive behavioural responses.g. 158 patients were assigned to a waitlist or one of two 16-session intervention groups developed to specifically target one of two coping styles (pain-avoidance or pain-persistence). With practice.65.65. fatigue and depression.86].A..65. thinking patterns that can impede successful adaptation. Methods of CBT service delivery CBT is commonly delivered either in a one-to-one format between a trained therapist and a single patient or with a therapist in a group setting. These skills have been studied as stand-alone interventions or as part of a multi-component approach. Combining CBT with exercise – multi-component treatment Growing consensus supports a multi-component treatment approach for CWP that combines CBT and exercise [7.57.88].A. which suggests that. Interpersonal skills Individuals with CWP often experience challenges in their dealings with other people. Employers may become less sympathetic over time and busy physicians may not have sufficient time to hear the many important details that a patient wishes to communicate.74.57. distraction. tailoring the approach to patient needs is important.74. the futility of trying to control illness or the inability to contribute meaningfully in life tasks are examples of learned. physical fitness and self-efficacy for pain [92]. The effects were evident immediately after treatment. spouses may become frustrated with the pain and the limited functionality of the patient. they did not appear to persist over time. In addition to developing programmes that can be adopted and maintained over time. For example.75. alternatives to traditional face-to-face delivery methods have been explored. while increasing the health-related quality of life (functioning). Given the potential difficulties in accessing trained therapists or difficulties in travelling long distances to receive therapy. Hassett. The use of CST has been associated with improvements in pain [46. CBT skills can be taught and supported by lay coaches [91] and therapist-less websites can provide patients with the content of cognitive and behavioural approaches with significant impact upon symptoms [2].86.89]. reinterpreting the sensation of pain and ignoring the pain) [87.g.. The study found significant differences between .74.89].

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