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A Literature Review of the Effectiveness of Stimulatory and Physical Non-pharmacological Interventions in Managing Chronic Musculoskeletal Pain for Middle Aged and Older Adults

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Title:
A Literature Review of the Effectiveness of Stimulatory and Physical Non-pharmacological Interventions in Managing Chronic Musculoskeletal Pain for Middle Aged and Older Adults
Creator:
Crisanto, Linda
Publication Date:
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English

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Subjects / Keywords:
Acupuncture ( jstor )
Exercise ( jstor )
Low back pain ( jstor )
Massage ( jstor )
Musculoskeletal pain ( jstor )
Neck pain ( jstor )
Older adults ( jstor )
Pain ( jstor )
Psychoeducational intervention ( jstor )
Randomized controlled trials ( jstor )
Alternative medicine
Chronic pain
Musculoskeletal system
Older people
Genre:
Undergraduate Honors Thesis

Notes

Abstract:
Chronic musculoskeletal pain is a multi-dimensional experience that can severely impact a person’s quality of life. Therefore, the use of non-pharmacological interventions in managing chronic musculoskeletal pain for middle aged and older adults is of substantial public health importance. An extensive search of pertinent databases was performed to collect randomized controlled trials of non-pharmacological (stimulatory and physical) chronic pain interventions. The objective of this literature review is to provide insight into the efficacy of non-pharmacological interventions in hopes to improve care and restore functionality to those who experience chronic musculoskeletal pain. The results showed that both stimulatory and physical non-pharmacological interventions are effective in managing chronic musculoskeletal pain, with spinal cord stimulation showing the most effective results and exercise showing the least. Therefore, it is logical that pharmacological treatments be adapted in conjunction with non-pharmacological methods at clinical sites. Still, further research on the efficacy of these combinations is warranted so that better clinical decision-making can be made on a patient-to-patient basis. Keywords: Nonpharmacological, chronic, musculoskeletal pain, middle aged, older adults ( en )
General Note:
Awarded Bachelor of Science in Nursing; Graduated May 6, 2014 cum laude. Major: Nursing
General Note:
College/School: College of Nursing
General Note:
Advisor: Hyochol Ahn

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University of Florida
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University of Florida
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Copyright Linda Crisanto. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Running head: NON PHARMACOLOGICAL PAIN INTERVENTIONS 1 A Literature Review of the Effectiveness of Stimulatory and Physical Non pharmacological Interventions in Managing Chronic Musculoskeletal Pain for Middle Aged and Older Adults Linda Crisanto UF College of Nursing

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 2 Abstract Chronic musculoskeletal pain is a multi dimensional experience that can severely imp act a The refore, the use of non pharmacological interventions in managing chronic musculoskeletal pain for middle aged and older adults is of substantia l public health importance An extensive search of pertinent databases was performed to collect randomized controlled trials of non pharmacological (stimulatory and physical) chronic pain interventions. The objective of this literature review is to p rovide insight into the efficacy of no n pharmacological interventions in hopes to improve care and restore functionality to those who experience chronic musculoskeletal pain. The results showed that both stimulatory and physical non pharmacological interventions are effective in managing chronic musculoskeletal pain, with spinal cord stimulation showing the most effective results and exercise showing the least Therefore, it is logical that pharmacologica l treatments be adapted in conjunction with non pharmacolo gical methods at clinical sites. Still, f urther research on the efficacy of these combinations is warranted so that better clinical decision making can be made on a patient to patient basis Keywor ds : N onpharmacological chronic musculoskeletal pain, middle aged, older adults

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 3 Introduction Chronic musculoskeletal pain is a multi quality of life through diminished functional abilities, but impairs cognition a nd affect ( Bennell et al. 2005 ). Unresolved pain can lead to depression, anxiety, sleep disturbance s high health care costs and even permanent disability (Bennell et al., 2005 ). Current management of chronic musculoskeletal pain is largely ineffective Physicians are fearful about prescribing analgesic medica tions due to risk for addiction, adverse effects w ith long term use, and patients are reluctant to seek help ( Ebnezar, Nagarathna, Yogitha & Nagendra, 2012). The use of non pharmacological interventions in managing chronic musculoskeletal pain for middle aged and older adults is of substa ntial public hea lth importance. Although treating pain is individualized, t he purpose of this paper is to provide the evidence of stimulatory and physical non pharmacological approaches in chronic musculoskeletal pain management to ultimately help improve care and restore functionality of those who experience chronic pain. Hypothesis If a middle aged or older adult is e xperiencing chronic musculoskeletal pain and engages in stimulatory or physical non pharmacological approaches, then his or her pain may be reduced. Methodology and Sample Data Sources and Searches An extensive search of pertinent databases (PubMed, Medline, Goggle Scholar, Cumulative Index to Nursing and Al lied Health Literature (CINAHL), Academic Search Premier and PsychInfo ) was independently conducted to find studies of stimulatory and physical non pharmacological chronic musculoskeletal pain interventions. The following keywords were used : (n onpharmacological ) and ( chronic) and (musculoskeletal pain) and ( middle aged) and

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 4 (older adults). Articles that focused on chronic pain associated with acute major trauma, medical condition s can cer or infection s were excluded. Study Selection Criteria for inclusion in the review was that the article s were published in English in a peer reviewed journal within the last 10 years, the intervention study was a randomized controlled trial (RCT), the participants were aged 45 and older and have chronic musculoskeletal pain. Data Extraction Initial searches usin g the abo ve keywords yielded 8,561 items. After reviewing the title lists, examining the abstracts and studies, excluding duplicates from multiple databases, non intervention studies, pharmacological pain interventions, studies focusing on younger adults, the search yielded to 156 potentially eligible studies Of these, th e articles that completely met the inclusio n criteria were eight for stimulatory interventions and 13 for physical interventions ( See Appendix A ). Appendix B shows the characteristics of trials included in the analysis. Appendix C describes the characteristics of the participants en rolled in the selected studies. Appendix D is a summarization of the o utcomes Appendix E compares the pain level before and after the intervention. Appendix F shows the average amount of pain reduced from each non pharmacological intervention. Clinical Outcomes of Stim ulatory Interventions Acupuncture Acupuncture is a Chinese healing therapy involving the use of thin needles at specific points on the body. It has been used to help reduce musculoskeletal pain, particularly chronic shoulder, neck, back and knee pain in middle aged and older adults Acupuncture can even help symptoms of nausea and issue s with sleeping (Demir, 2012) Acupuncture helps by releasing

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 5 chemicals such as endorphins and serotonin that naturally block the sensation of pain (Demir, 2012). There are many different types of acupuncture treatments: acupoints, non trigger points and sham treatment ( Itoh, Katsumi, Hirota, & Kitakoji, 2007 ). For the standard acupuncture treatment involving only traditional acupoints for chronic neck pain, a blind ed randomized controlled trial evaluated the effectiveness of 30 minute treatme nts every week for 13 weeks ( Itoh et al ., 2007). decreased from 6.95 to 5.16 (Itoh et al., 2007). Therefore, th ere is some evidence for the efficacy of acupuncture in treating chronic neck pain. However, the success of response to acupuncture treatments depends on the choice and number of acu points treated. Electro acupuncture Electro acupuncture is a form of acupuncture in which electrical stimulation is added to the needles inserted in the body ( Ng, Leung, & Poon, 2003). This electric current stimulates cell activity and allows the body to release endorphins resulting in analgesia (Demir, 2012). A r andomize d controlled trial demonstrated the effectiveness of electro acupuncture in relieving chronic knee pain with the use of just two acupu ncture points for eight sessions each 20 minutes long and within a duration of two weeks (Ng, et al., 2003) scores using the Numerical Rating Scale (NRS) decreased from 4.69 to 3.33 (Ng, et al., 2003). Another randomized controlled trial demonstrated the effectiveness of 10 sessions of electro acupuncture coupled with conventional treatments in relieving chronic heel pain within duration of five weeks twice weekly ( Kumnerddee 2012 ). Rating Scale (NRS) decreased from 6 to 1.89 ( Kumnerddee 2012 ). Electro acupuncture also proved successful in inc reasing the functional ability and enhancing the quality of life in these older adults suffering from chronic knee pain induced from osteoarthritis (Ng et al., 2003).

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 6 Spinal Cord Stimulation (SCS) A spinal cord stimulato r is a device that helps manage chr onic intractable pain. A series of electrodes are surgically placed along the spinal cord creating an electrical field that will block the pain received by the brain (Taylor, Van Buyten & Buchser 2004). The device will change a painful abnormal sensation to a non painful tingling sensation. Patients can fully control the device by turning the device on or off and making the sensation stronger (Taylor et al., 2004) Electrical spinal cord stimulation is for patients who previously had surgeries most commonly seen are back surgeries, but still experience chronic pain and are not candidates for any other surgery ( North, Kidd, Farrokhi, & Piantadosi, 2005 ) A randomized controlled study of spinal cord stimulation was trialed for an average of 4.7 days in 70 patients who experienced chronic musculoskeletal abdominal pain (Kapural et al., 2010) Using the VAS 66 of the se 70 patients reported pain relief exceeding 50% as their pain decreas ed from 7.9 before trial to 2.45 after the SCS trial (Kapural et al., 2010) Improvement in pain scores even after 84 weeks follow up from permanent implantation in these patients showed a decreased in mean pain scores of 8 before implantation to 2.49 (Ka pural et al., 2010) In another randomized controlled trial also involving SCS treatment that lasted a least three days, involved 50 patients who experienced chronic back pain after having tried previous ineffective back surgeries (North et al., 2005) U sing the VAS their pain score decreased from 7.00 to 4.60 (North et al., 2005) Although the improvement in pain scores in both these studies were very significant, it is important to note that only physician can determine if this intervention is right for a person and that the cost for initial implantation varies from approximately $20,000 to $50,000 (Kapural et al., 2010) Transcutaneous Electrical Nerve Stimulation (TENS) TENS is a non invasive therapy in which electrode patches are applied to the skin around the areas of pain (Demir, 2012 ). Pain is reduced through the conduction of nerve stimulation and

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 7 ock pain reception (Demir, 2012 ). A randomized controlled trial demonstrated the effectiveness of TENS in relieving chronic knee pain involving eight sessions of low frequency TENS of 2 Hz and a pulse width of 200 s on two acupuncture points each 20 minute s long, and within a duration o f two weeks. using the NRS decreased from 4.19 to 3.00 (Ng, et al., 2003). In another randomized controlled trial, patients with low back pain completed a four week treatment of TENS with a daily average of 150 minutes per session ( Deyo, Walsh, Martin, Schoenfeld, & Ramamurthy 2009) mean pain scores using the VAS decreased significantly from 6.87 to 2.17 ( Deyo et al 2009). If used appropriately by an experienced therapist, TENS can also be effective towards other pathologies such as muscle spasm s and function al loss es that accompany chronic mu sculoskeletal pain (Demir, 2012 ). Clinical Outcomes of Physical Interventions Exercise Therapy Exercise therapy can be used to treat chronic pain, mo st commonly chronic bac k and neck pain. This type of intervention combines methods such as stretching, isometric and dynamic muscle strengthening, mobilizing exercises and endurance training ( Trott et al., 2009). A randomized controlled study of 38 patients with chronic neck pain were involved in 24 exercise the rapy se ssions over a period of three months ( Trott et al., 2009) Using the VAS after a three month follow up, these patients reported a decreased mean pain score from 4.71 to 4.45 ( Trott et al., 2009) In another randomized controlled trial, patients with chronic back pain participated in exercise therapy (Yeung, Leung, & Chow, 2003) This exercise therapy consisted of an hourly session each week for four consecutive weeks and was comprised of back strengthening and stretching exercises (Yeung et al., 2003) After this intervention using the NRS their mean pain scores decreased from 5.88 to 5.12 (Yeung et al., 2003)

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 8 Although exercise alone can help reduce chronic pain, it has been shown that exercise in co njunction with electro acupuncture can reduce pain more effectively, as well as decrease disability and improve functional capacity of patients with chronic low back pain (Yeung et al., 2003) In the same randomized controlled study as previously mentioned, another 26 participants were randomized to an exercise plus electro acupuncture group (Yeung et al., 2003) This group received the same exercise therapy and in addition underwent electro acu puncture three times per week for four weeks using standard acupoints (Yeung et al., 2003). These mean pain score using the VAS decreased from 6.38 to 3.81 (Yeung et al., 2003 ) Massage Massage can consist of different techniques in which one manipulates with their hands. In a randomized controlled study to determine the effectiveness of massage in chronic musculoskeletal pain, patients completed one hour massage sessions once a week for eight weeks by three licensed massage therapists ( Plew s Ogan, Owens, Goodman, Wolfe, & Schorling, 2005) The massage techniques used included Swedish, neuromuscular, and deep tissue ( Plew s Ogan et al. 2005) NRS decreased from 7.10 to 5.20 after 12 weeks ( Plew s Ogan et al. 2005) In another randomized controlled study, p atients were randomized into a massage group and a standard medical care group ( Walach, Guthlin, & Konig 2003) The massage group received 10 sessions of massage therapy, each 20 minutes lo ng, twice a week for five weeks (Walach et al., 2003). Using a n ine point Likert scale to 4.70 after a three month follow up (Walach et al., 2003) Although m assage therapy showed to have a positive impact on pain, including depression and anxiety, it is important to note that this impact attenuates over time.

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 9 Physical Therapy Physical therapy includes a variety of interventions each specific to individual ne eds that can help increase joint lubrication and mobility (Bennell et al., 2005) In a randomized controlled study, older adults experiencing chronic musculoskeletal pain participated in physical therapy for an hour per week for eight weeks ( Tse, Wan, & Ho, 2011). This physical therapy consisted of the following interventions: shoulder, neck, back, knee, hip and balancing exercises ( Tse et 2011). decreased from 4.89 to 2.89 ( Tse et al ., 2011) Another randomized controlled trial of older people who have knee osteoarthritis undergone physical therapy 30 45 minutes per week for 12 weeks (Bennell et al., 2005). This intervention involved knee taping, exercises to retrain the qu adriceps, hip and back muscles as well as balance exercises (Bennell et al., 2005) After a 24 week follow (Bennell et al., 2005) The use of physical therapy also increased patients blood flow reduced muscle tension, spasms, pain and depression, as well as enhanced functional mobility in middle aged and older adults (Bennell et al., 2005). Qigong Qigong is a traditional Chinese practice involving meditation, controlled breathing, and movement exercises (Trott et al., 2009). A randomized controlled study of Q igong was trialed for three months consisting of two sessions per week, each 45 minutes long, in 38 patients who experienced chronic neck pain ( Trott et al., 2009 ) Using the VAS decreased from 5.64 before trial to 4.74 after a six month follow up ( Trott et al., 2009 ) In another randomized controlled trial, elderly patients with chronic musculoskeletal pain undergone 20 minutes of Qigong, twice a w eek for four weeks (Yang & Kim, 2005) Compared to the control group who received standard care, there was a significant decrease in pain (Yang

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 10 & Kim, 2005) mean pain scores decreased from 7.30 to 4.60 after a six week follow up (Yang & Kim, 2005). t also showed improved symptoms psychologically such as their mood state (Yang & Kim, 2005). Tai Chi Tai Chi is a Chinese healing therapy that incorporates low impact exercises, breathing and meditation (Brisme et al., 2007). A randomized controlled study of Tai C hi sessions was trialed for twelve weeks, each 40 minutes long, three times a week, in middle aged and older adults who experienced knee osteoarthritis (Brisme et al., 2007). U sing the VAS mean pain scores decreased from 4.30 before trial to 3.05 after a six month follow up ( Trott et al., 2009 ) Another randomized controlled study evaluated the effectiveness of elderly persons with symptomatic osteoarthritis of the hips or knees in attending Tai Chi classes for one hour, twice a week for 12 weeks ( Fransen et al., 2007). These classes were conducted by four different trained Tai Chi instructors and patients reported a decrease i n their mean pain scores from 40.30 to 30.70 using t he Western Ontario and McMaster Universities Arthritis Index (WOMAC), in which scores were standardized to a 0 100 range ( Fransen et al., 2007). The use of these low impact movements and posture s can also reduc e chance s for injury ( Fransen et al., 2007). Yoga Yoga is a practice that harmonizes both the body and mind through v arious exercises. A randomized controlled study showed yoga reduced the amount of pain and functional disability in middle aged and older adults with chronic low back pain (Groessl, Weingartm, Johnson, & Baxi, 2010). After 10 weeks of yoga that consisted of a series of 32 yoga poses, using the NRS, 5 (Groessl et al., 2010) In another randomized controlled study, 250 participants who have osteoarthritic knees were randomized to

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 11 received yoga therapy 40 minutes per day for three months ( Ebnezar, Nagarathna, Yogitha, & Nagendra, 2012). after the intervention from 9.54 to 3.35 ( Ebnezar et al. 2012). Not only did yoga help reduce pain in patients in osteoarthritic knees, but also improved range of knee flexion joint tenderness, crepitus and walking time ( Ebnezar et al. 2012). Analysis After collecting all published material of stimulatory and physical non pharmacological approaches in chronic musculoskeletal pain management that met the inclusion criteria an analysis of the data was performed. Using Microsoft Excel spreadsheet software, one table was created to show the characteristics of all the trials included in this literature review such as the author and year the article was published the number of randomized patients in the trial, the type and whether the non pharmacological approach was either stimula tory or physical (see Appendix B ) Another table was created to show the characteristics of the patients in the trials collected, including the author and year the article was published, the mean age of the patients, the number and percentage of patients that were male or female, and the type of chronic musculoskeletal pain the patients had (see Appendix C). Appendix D is a summarization of the outcomes of the randomized controlled trials. A graph was composed showing the efficacy of stimulatory and physical non pharmacological interventions in managing chronic musculoskeletal pain by comparing the pre and post mean pain level for each intervention. Since more than one article was found for almost each type of intervention, the gra ph shows t he pre and post mean pain level of each article averaged together for each interv ention (see Appendix E ). The last graph demonstrates the success of stimulatory and physical non pharmacological interventions in managing chronic musculoskeletal p ain by computing the amount of pain that was reduced in

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 12 each intervention. To calculate the amount of pain that was reduced in each intervention, the pre and post mean pain level was averaged for each article per intervention and then their differences we re compared This graph provides the findings that show which intervention reduced the chronic musculoskeletal pain the most to th e least effective intervention (see Appendix F ). Findings Although each intervention proved to reduce chronic musculoskeletal pain in middle aged and older adults, the amount of pain reduced varied for each intervention. The findings of the intervention that was most effective in reducing chronic musculoskeletal pain in middle aged to older adults from the articles collected was spinal cord stimulation, which is a stimulatory non pharmacological approach. The least effective intervention in reducing chronic musculoskeletal pain in middle aged and older adults wa s exercise, which is a physical non pharmaco logical approach (see Appendix F ). Functions of the Study This literature review is a critical evaluation of material that has already been published. The function of this study was to organize, integrate and evaluate previously published material of stimulatory and physical non pharmacological approaches in chronic musculoskeletal pain management by doing a comprehensive search of pertinent databases: PubMed, Medline, Goggle Scholar Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier and PsychInfo In order to present an up to date, interpretive synthesis of the data collected of chronic musculoskeletal pain management in middle aged and older adult s it was necessary to learn how to read the primary literature, engage in scientific inquiry and be able to exclude any duplicates Duplicates s uch as multiple databases, non intervention studies, pharmacological pain interventions, and studies focusing on younger adults that may have occurred in the initial search were excluded (see Appendix A). This literature review began with

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 13 a research question and then annotated bibliographi es for each source was collected in order to organize the information from the articles Prior to the collection of articles and sources, the inclusion criteria had to be narrowed to include the following: published in English in peer reviewed journal within last 10 years, randomized controlled trial (RCT), part icipants aged 45 and older and have chronic musculoskeletal pain (see Appendix A) Once the articles were found that ap p lied to the inclusion criteria, it was important to categorize these interventions by type of non pharmacological approach: stimulatory or physical Problems with the Study The most challenging issue encountered with the study was with the data analysis. The actual process of analyzing the data was both challenging and very time consuming. There are thousands of articles pertaining to in terventions in managing chronic musculoskeletal pain. However, the solution to this problem was to narrow the inclusion criteria Expertise was gained in computing the data because one must learn how to inp ut all of the data from the articles into Microsoft E xcel spreadsheet software be able to convert the dat a into tables and graphs, compute the data by averaging the pre and post mean pain level for each article per intervention and subtract their differen ce in order to get the amount of pain that was reduced for each intervention. All in all, this study can empower one to gain scientific knowledge in the different types of research articles that exist, learn how to do APA formatting, how to read the research literature and how to compute data and operate Microsoft Excel spreadsheet software. Recommendation For Students For future students who are inter ested in following this project, it is recommended to follow the review process conducted because it is a very organized step by step approach that will help narrow and refine database searches (see Appendix A). It would also be beneficial for

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 14 students to print out all of the articles that meet the inclusion criteria in order to be able to read the arti cles completely and carefully, have the articles in order, highlight, and take notes. Another recommendation for future students who wish to follow this project is to be realistic about the amount of time they have availa ble to contribute to the study. Researching to conduct a literature review is a very time consuming process that requires dedication and discipline in order to produce meaningful results as one had to search all of the published writings that pertain to the research question. In addition, the process of analyzing all the data collected can be very demanding, time consuming, and may require learning how to operate certain foreign software. Lastly, s tudents who follow this project should genuine ly be interest ed and have a passio n for the topic and population researched This project appreciation for the research that has been done on the efficacy of different non pharmacological pain interventions and its purpose in evidence based practice. Conclusion The results of the various randomized controlled trials provide sufficient evidence that some stimulatory and physical non pharmacological treatments are effective in chronic musculoskeletal pain management for middle aged and older adults. Specific stimu latory and physical non pharmacological interventions reduced pain levels, increased functional mobility and improved quality of life through enhancing self efficacy and happiness. Spinal cord stimulation showed the most effective results while exercise s howed the least amount of pain reduction. Therefore, it is logical that pharmacological treatments be adapted in conjunction with non pharmacological methods at clinical sites in reference to chronic musculoskeletal pain in middle aged and older adults.

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 15 S till, further research on the efficacy of these combinations is warranted so that better clinical decision making can be made on a patient to patient basis. Clinicians should be aware of the benefits of adding non pharmacological interventions for chronic pain management in preferences, capabilities and willingness to do interventions

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 16 References Bennell K L Hinman R S Metcalf B R Buchbinder R McConnell J McColl G Green S & Crossley M. (20 05). Efficacy of physiotherapy management of knee joint osteoarthritis: A randomised, do uble blind, placebo controlled trial. Ann Rheum Dis., 64 (6), 906 12. Brisme J M Paige R .L., & Chyu M C (2007). Group and home based tai chi in elderly subje cts with knee osteoarthritis: A randomized controlled trial. Clin Rehabil. 21 (2), 99 111. Deyo, R. A., Walsh, N. E., Martin, D. C., Schoenfeld, L. S., & Ramamurthy, S. (2009). A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med ., 322 (23), 1627 34. Demir, Yurdanur. (2012). Non pharmacological therapies in pain management. InTech., 23 (1), 485 503. Retrieved from http://www.intechopen.com Ebnezar J Nagarathna R Yogitha B & Nagendra H R. (2012). Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in ost eoarthritis of the knee joint: A randomized controll ed study. J Altern Complement Med ., 18 (5), 463 72. Fransen, M., Nairn, L., Winstanley, J., Lam, P., & Edmonds J (2007). P hysical activity for osteoarthritis management: A randomized controlled clinical trial evaluating hydrotherapy or tai chi classes Arthritis Rheum., 57 (3), 407 14. Groessl, E.J., Weingartm, K.R., Johnson, N., & Baxi, S. (2010). The benefits of yoga for women veteran with chronic low back pain. J Altern Complement Med ., 18 (9), 832 38. Itoh, K., Katsumi, Y., Hirota, S., & Kitakoji, H. (2007). Randomised trial of trigger point acupuncture compared with other acupuncture for treatment of chronic neck pain.

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 17 Complement Ther Med., 15 (3), 172 179. Kapural, L., Deer, T., Yakovlev, A., Bensitel, T., Hayek, S., Pyles, S., Khan, Y., Kapural A., Cooper, D., Stearns, L., & Zovkic, P (2010). Technical aspects of spinal cord stimulation for managing chronic visceral abdominal pain: The results from the national survey. Pain Medicine 11 (5), 685 691. Kumnerddee W. (2012). Efficacy of electr oacupuncture in chronic plantar fasciitis: A randomized controlled trial. Am. J. Chin. Med. 40 (6), 1167 76. Ng M M Leung M C & Poon D M. (2003). The effects of electro acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow up evaluation. J Altern Complement Med ., 9 (5), 641 9. North, R. B., Kidd, D. H., Farrokhi, F., & Piantadosi, S. A. (2005). Spinal cord stimulation versus repeated lumbosacral spine su rgery for chronic pain: A randomized controlled trial. Neurosurgery, 56 (1) 98 107. Plew Ogan, M., Owens, J.E., Goodman, M., Wolfe, P., & Schorling, J. (2005). A pilot study evaluating mindfulness based stress reduction and massage for the management of chronic pain. J Gen Intern Med., 20 (1), 1136 38. Taylor, R.S., Van Buyten, J., & Buchser, E. (2004). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine 30 (1), 152 60. Trott, P. V., Wiedemann, A. M., Ludtke, R., Reisshauer, A., Willich, S. N., & Witt, C. M. (2009). Qigong and exercise therapy for elderly patients with chronic neck pain (QIBANE): A randomized controlled study. The Journal of Pain 10 (5), 50 1 508. Tse M M Wan V T & Ho S S. (2011). Physical exercise: does it help in relieving pain and

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 18 increasing mobility among older adults with chronic pain?. J Clin Nurs ., 20 ( 6), 635 44. Walach, H., Guthlin, C., & Konig M. (2003). Efficacy of massage therapy in chronic pain: A pragmatic Randomized Trial. J Altern Complement Med ., 9 (6), 837 46. Yang, K. H., & Kim, Y.H. (2005). Efficacy of qi therapy (external qigong) for elderly people with chronic pain. Intern. J. Neuroscience 115 (1), 1543 1245. Yeung, C. K., Leung, M. C., & Chow, D. H. (2003). The use of electro acupuncture in conjunction with exercise for the treatment of chronic low back pain. J Altern Complement Med ., 9 (4), 479 490.

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Running head: NON PHARMACOLOGICAL PAIN INTERVENTIONS 19 Appendix A Schematic representation of the review process for study inclusion Extensive search of pertinent databases: PubMed, Medline, Goggle Scholar, Cumulative Index to Nurs ing and Allied Health Literature (CINAHL), Academic Search Premier and PsychInfo Initial search using keywords ( n = 8, 561 ) Excluded duplicates from multiple databases, non intervention studies, pharmacological pain intervent ions, studies focusing on younger adults (8, 405 articles were excluded) Included only articles that met inclusion criteria: a) Published in English in peer reviewed journal within last 10 years b) Randomized controlled trial (RCT) c) Age 45 d) Undergoing chronic musculoskeletal pain Stimulatory Interventions ( n =8) Physical Interventions ( n =13) Potentially eligible studies ( n = 156)

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 20 Appendix B Characteristics of Trials Included in the Literature Review Mean Pain Level Trial (Yr) No. of Patients Randomized Pain S cale Pre I ntervention Post I ntervention Type of Intervention Treatment Regimen Bennell, et al (2005) 119 VAS (0 10) 5. 30 3. 10 Physical Therapy Physical Brisme, et al (2007) 41 WOMAC (0 10 0 ) 40. 30 3 0 05 Tai Chi Physical Deyo, et al (2009) 12 5 VAS (0 10) 6.8 7 2.1 7 TENS Stimulatory Ebnezar, et al (2012) 250 VAS (0 10) 9.54 3.35 Yoga Physical Fransen, et al (2007) 152 WOMAC (0 100) 40.30 30.70 Tai Chi Physical Groessl, et al (2010) 53 NRS (0 10) 5.50 4.50 Yoga Physical Itoh, et al (2007) 40 VAS (0 10) 6.95 5.16 Acupuncture Stimulatory Kapural, et al (2010) 70 VAS (0 10) 7.90 2.45 Spinal Cord Stimulation Stimulatory Kumnerddee, W. (2012) 30 NRS (0 10) 6.00 1.89 Electro a cupuncture Stimulatory Ng, et al (2003) 24 NRS (0 10) 4.69 3.33 Electro a cupuncture Stimulatory Ng, et al (2003) 24 NRS (0 10) 4.19 3.00 TENS Stimulatory North, et al (2005) 50 VAS (0 10) 7.00 4.60 Spinal Cord Stimulation Stimulatory Plews Ogan, et al (2005) 30 NRS (0 10) 7.10 5.20 Massage Physical Trott, et al (2008) 38 VAS (0 10) 5.64 4.74 Qigong Physical Trott, et al (2008) 38 VAS (0 10) 5.64 4.45 Exercise Physical Tse, et al (2011) 75 VAS (0 10) 4.89 2.89 Physical Therapy Physical Walach, et al (2003) 29 Likert scale (1 9) 5.90 4.70 Massage Physical Yang & Kim (2005) 43 VAS (0 10) 7.30 4.60 Qigong Physical Yeung, et al (2003) 26 NRS (0 10) 5.88 5.12 Exercise Physical Yeung, et al (2003) 26 NRS (0 10) 6.38 3.81 Exercise and Electro a cupuncture Physical and Stimulatory Total 1238 VAS, visual analog ue scale; WOMAC, The Western Ontario and McMaster Universities Arthritis Index; NRS, numerical rating scale; TENS, transcutaneous electrical nerve stimulation

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 21 Appendix C Characteristics of Patients Included in the Selected Trials Gender ( n %) Trial (Yr) Mean A ge (Yrs) Male Female Type of Chronic Pain Bennell, et al (2005) 67. 4 38 ( 32 ) 81 ( 68 ) Knee Osteoarthritis Brisme, et al (2007) 69. 8 7 (17. 1 ) 34 (82.9) Knee Osteoarthritis Deyo, et al (2009) 53.7 52 (4 1.6 ) 73 (58.4) Low Back Pain Ebnezar, et al (2012) 59.5 76 ( 30.4 ) 1 74 ( 69.6 ) Knee Osteoarthritis Fransen, et al (2007) 70.8 40 (26.3 ) 112 (73.7 ) Hip Osteoarthritis / Knee Osteoarthritis Groessl, et al (2010) 53 40 (75.5) 13 (24.5) Low Back Pain Itoh, et al (2007) 62.3 11 (27.5) 29 (72.5) Neck Pain Kapural, et al (2010) 63.7 27 (38.6) 43 (61.4) Musculoskeletal Abdominal Pain Kumnerddee, W. (2012) 53.8 15 (50) 15 (50) Heel Pain Ng, et al (2003) 84.38 1 (4.1) 23 (95.9) Knee Osteoarthritis Ng, et al (2003) 85.55 1 (4.1) 23 (95.9) Knee Osteoarthritis North, et al (2005) 52 24 (48) 26 (52) Back Pain Plews Ogan, et al (2005) 46.5 7 (23.3) 23 (76.7) Musculoskeletal Pain Trott, et al (2008) 75.9 2 (5) 36 (95) Neck Pain Trott, et al (2008) 76 2 (5) 36 (95) Neck Pain Tse, et al (2011) 81.9 18 (24) 57 (76) Knee Pain / Back Pain / Shoulder Pain / Multiple Joint Pain Walach, et al (2003) 64.2 3 (10.3) 26 (89.7) Musculoskeletal Pain Yang & Kim (2005) 72.58 8 (20) 32 (80) Musculoskeletal Pain Yeung, et al (2003) 55,60 5 (19.2) 21 (80.8) Low Back Pain Yeung, et al (2003) 50.4 4 (15.4) 22 (84.6) Low Back Pain

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 22 Appendix D Summarization of Outcomes Reference (Author Name, Year) Setting Sample Size/ Characteristics Study Design /Study Period Intervention Outcome variables Findings/Conclusion Bennell et al., 2005 Melbourne, Australia 119 community volunteers with knee osteoarthritis RCT Physiotherapy VAS, Global improvement, WOMAC Physiotherapy was no more effective than regular contact with a therapist. Brisme et al., 2007 Lubbock, Texas 41 adults with knee osteoarthritis RCT Tai Chi Mean overall pain, WOMAC Tai Chi group reported lower overall pain and better WOMAC physical function than the attention control group. Deyo et al., 2009 San Antonio, Texas 125 adults with low back pain RCT TENS VAS, Self rated pain scores Treatment with TENS is no more effective than treatment with placebo Ebnezar et al., 2012 Bengaluru, Karnataka 250 participants with knee osteoarthritis RCT Yoga VAS, Walking pain, Range of knee flexion, Walking time, Tenderness, Swelling, Crepitus, Knee disability Yoga therapy is better than therapeutic exercises in improving walking pain, range of knee flexion, walking time, tenderness, swelling, crepitus, and knee disability in patients with OA knees. Fransen et al., 2007 Sydney, Australia 152 older persons with chronic symptomatic hip or knee OA RCT Tai Chi WOMAC, SF 12 ph ysical component improvements in the SF 12 physical component summary score. Groessl et al., 2010 San Diego, California 53 adults with chronic back pain RCT Yoga NRS, CESD 10, SF 12 Mental Health Preliminary data suggest that a yoga intervention for VA patients with chronic back pain may improve the health of veterans. Itoh et al., 2007 Hiyoshi, Kyoto, Japan 40 elderly participants with chronic neck pain RCT Acupuncture VAS, Neck disability index Trigger point acupunctu re therapy may be more effective on chronic neck pain in aged patients than the standard acupuncture therapy. Kapural et al., 2010 Cleveland, Ohio 70 participants with chronic musculoskeletal abdominal pain RCT Spinal Cord Stimulation VAS, Opioid use SCS for the treatment of the musculoskeletal abdominal pain may provide a positive patient long term experience, significant improvements in pain scores and a decrease in opioid use. Kumnerdd ee, 2012 Bangkok, Thailand 30 patients with chronic plantar fasc iitis RCT Electro acupuncture VAS, FFI Electro acupuncture coupled with conventional treatments provided a success rate of 80% in chronic plan t ar fasciitis which was more effective than conventional treatments alone.

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 23 Ng et al., 2003 Hong Kong, China 24 subjects recruited from eight subsidized care & attention homes for the elderly RCT Electro Acupuncture NRS, TUGT EA treatment was effective in reducing OA induced knee pain and had additional advantage of enhancing the TUGT results as opposed to the control group. Ng et al., 2003 Hong Kong, China 24 subjects recruited from eight subsidized care & attention homes for the elderly RCT Transcutaneou s Electrical Nerve Stimulation (TENS) NRS, TUGT TENS treatment was effective in reducing OA induced knee pain but did not enhance the TUGT results. North et al., 2005 Baltimore, Maryland 50 patients selected for reoperation by standard criteria RCT Spinal Cord Stimulation VAS SCS is more effective than reoperation as a treatment for persistent chronic back p ain. Plews Ogan et al., 2005 Charlottes ville, Virginia 30 adults with musculoskeletal pain for greater than 3 months RCT Chronic Musculoskelet al Pain NRS, SF 12 physical and mental health status Massage may be more effective than Mindfulness Based Stress Reduction for reducing pain. Trott et al., 2009 Berlin, Germany 38 adults with chronic neck pain RCT Exercise VAS, NPAD, SF 36 No significant differences for pain, neck pain, disability and quality of life compared to no treatment or Qigong group. Trott et al., 2009 Berlin, Germany 38 adults with chronic neck pain RCT Qigong VAS, NPAD, SF 36 No significant differences for pain, neck pain, disability and quality of life compared to no treatment or exercise therapy group. Tse et al., 2011 Hong Kong, China 75 older adults with chronic musculoskeletal pain living in nursing homes. RCT Physical Therapy VAS, Mobility level There was significant effectiveness of physical therapy in relieving pain and enhancing functional mobility for older persons. Walach et al., 2003 Freiburg, Germany 29 patients in chronic back, neck shoulder, head and limbs pain RCT Massage 9 point Likert Scale Massage can be at least as effective as standard medical care in chronic pain syndromes. Relative changes are equal, but tend to last longer and to generalize more into psychological domains. Yang & Kim, 2005 Iksan, Korea 43 independent living residents with chronic musculoskeletal pain RCT Qigong VAS, Psychological assessment Findings suggest that Qi therapy may help eld erly cope with pain and associated mood disturbances. Yeung et al., 2003 Hong Kong, China 26 patients with chronic low back pain (LBP) RCT Exercise NRS, Aberdeen LBP scale, Lumbar spinal AROM, Isokinetic strength The combination of EA and back exercise was more effective than exercise alone. Yeung et al., 2003 Hong Kong, China 26 patients with chronic low back pain (LBP) RCT Exercise and Electro acupuncture NRS, Aberdeen LBP scale, Lumbar spinal AROM, Isokinetic strength The combination of EA and back exercise might be an effective option in the treatment of pain and disability associated with chronic LBP. AROM: Active Range of Movement FFI: Foot Function Index NPAD: Neck Pain And Disability Scale NRS: Numerical Rating Scale RCT: Randomized Control led Trial SF 12: Short Form health survey with 12 questions SF 36: Short Form health survey with 36 questions TUGT: Timed Up and Go Test VAS: Visual Analogue Scale WOMAC: The Western Ontario and McMaster Universities Arthritis Index

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 24 Appendix E Efficacy of Stimulatory and Physical Non pharmacological Interventions in Managing Chronic Musculoskeletal Pain 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 Mean Pain Level (0 10) Type of Intervention Pain Level PreIntervention Pain Level PostIntervention

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NON PHARMACOLOGICAL PAIN INTERVENTIONS 25 Appendix F Success of Stimulatory and Physical Non pharmacological Interventions in Managing Chronic Musculoskeletal Pain 0.51 0.87 1.11 1.55 1.80 2.10 2.57 2.74 2.95 3.60 3.93 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Exercise Acupuncture Tai Chi Massage Qigong Physical Therapy Exercise and Electro-Acupuncture Electro-Acupuncture TENS Yoga Spinal Cord Stimulation Amount of Pain Reduced (0 10) Type of Intervention


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