6

Considering Best Practices on Chronic Pain Treatment and Management in Adults

The workshop’s fourth session discussed best practices and methods of categorizing chronic pain; advances in treating, managing, and measuring adults’ pain levels; and how much various types of chronic pain treatments alleviate functional limitations. The speakers were Kemly Philip, division chief of musculoskeletal and interventional pain and assistant professor, Department of Physical Medicine and Rehabilitation at the UTHealth McGovern Medical School; Carol Greco, associate professor of psychiatry and physical therapy at the University of Pittsburgh; and Julie Fritz, distinguished professor of physical therapy and athletic training at the University of Utah.

AN OVERVIEW OF CHRONIC PAIN IN ADULTS

After reviewing what previous speakers had discussed about the nature of chronic pain and its effects on decreasing function and increasing disability, Kemly Philip explained that acute and chronic pain management should be individualized, multimodal, and multidisciplinary (Pain Management Best Practices Inter-Agency Task Force, 2019). Management should include a combination of medication, restorative therapies, interventional procedures, behavioral health approaches, and complementary and integrative health approaches.

The most recent guidelines from the Centers for Disease Control and Prevention recommend starting with non-opioids such as nonsteroidal anti-inflammatories or anti-convulsants as first-line therapies for adults with chronic pain and to use the lowest effective dose of these analgesics

(McDonagh et al., 2020). If opioids are needed, it is imperative to ensure the benefits outweigh the risks, said Philip, by using risk assessment tools and an opioid pain medication agreement.

She noted there is a large variety of image-guided interventions that can be used to both identify and treat sources of pain. Such interventions include joint and peripheral nerve injections, epidural steroid injections, radio-frequency ablation, neuromodulation, and others. These interventions have fewer systemic side effects compared to pharmacologic interventions; they limit the need for pharmacologic interventions or surgery (U.S. Department of Health and Human Services, 2019); and when combined with therapy, they produce a synergistic benefit (Kraal et al., 2018). Philip said that between 2000 and 2013, use of interventional pain procedures increased by 236 percent among fee-for-service Medicare beneficiaries (Manchikanti et al., 2015).

CHRONIC PAIN MANAGEMENT FROM A PSYCHOLOGIST’S PERSPECTIVE

Carol Greco discussed the biopsychosocial model of pain and its importance for understanding an individual’s pain experience and needs. The biopsychosocial model of pain holds that pain is complex and that many biological, psychological, and social factors influence it. She explained that pain is experienced in a personal, psychological, and social context, and understanding an individual patient’s context can help better tailor a treatment plan and lead to better outcomes. The medical setting and system, the clinic personnel, and the clinical provider are all part of the social context of pain and its treatment.

Greco listed several approaches to assessing an individual’s beliefs about pain, including the Fear Avoidance Belief Questionnaire, the Pain Catastrophizing Scale to identify unhelpful beliefs about pain, the Chronic Pain Acceptance Questionnaire to assess resilience, and the STarT Back Screening Tool for low back pain.

There is a good evidence base, said Greco, to support the use of psychological approaches for treating chronic pain and illness symptoms. These include cognitive behavioral therapy (CBT; Gatchel and Rollings, 2008), acceptance and commitment therapy (ACT; McCracken and Vowles, 2014; Ma et al., 2023), and mindfulness-based stress reduction (MBSR; Qaseem et al., 2017; Skelly et al., 2020). CBT, said Greco, aligns with the biopsychosocial model, is patient-centered, and requires the patient to be an active participant in treatment. It addresses the cognitive, emotional, and behavioral dimensions of chronic pain by helping the patient reconceptualize the pain. CBT targets unhelpful thought patterns, such as “I will never get better,” through cognitive reframing and building new habits and brain

pathways. ACT, a variation of CBT, is driven more by the patient’s self-defined values and what is hindering moving toward those. ACT is based on acceptance and mindfulness and being willing to engage in activities even though pain is present.

MBSR, a favorite of Greco’s, is an eight-week, group-based psycho-education program that uses secular meditation methods to reduce reactivity to pain and stress and increase coping ability. MBSR also includes home practice, using mindfulness in one’s daily life, and stretching. The American College of Physicians and Agency for Healthcare Research and Quality both recommend MBSR for chronic low back pain. Greco cited several studies showing that adults participating in MBSR experienced more improvement in pain symptoms compared to control groups (Morone et al., 2009; Greco et al., 2021).

Greco has also been involved in research integrating psychosocial methods into physical therapy treatment and training physical therapists and chiropractors to add biopsychosocial self-management methods into their practices. These include patient-centered communication, shared decision making, and relaxation strategies (Farrokhi et al., 2020; Delitto et al., 2021; Main et al., 2023; Leininger et al., 2025).

Greco said that psychological treatments should not replace other treatments. It is important, she added, to understand the billing limits within the health care system for psychological treatments for chronic pain. One potential problem is that psychologists, social workers, and counselors use mental health diagnostic and billing codes, which could lead to the assumption that the patient has a mental health problem, not a physical health condition.

CLINICIAN PERSPECTIVES ON CHRONIC PAIN TREATMENT AND MANAGEMENT IN ADULTS

Julie Fritz identified the various ways adults manage chronic pain based on data from a national survey (Figure 6-1; Rikard et al., 2023). What stood out to her from these data was that a primary intervention involved unsupervised exercise. She noted that a recent systematic review of 301 studies on 56 treatments for low back pain found that only about 10 percent of the treatments had a measurable benefit on pain intensity, though exercise was effective.

Fritz said the finding that exercise had a positive benefit of modest magnitude is consistent across chronic pain conditions (Skelly et al., 2020; Hayden et al., 2021). The challenge is identifying the right type and amount of exercise for a specific type of chronic pain and determining how to combine that with a psychological intervention. What does matter for effectiveness is adherence to whatever exercise or behavioral regimen is prescribed (Jones et al., 2025).

There are other considerations regarding what makes exercise more effective (Alaiti et al., 2022; Wood et al., 2024). Despite purported differences in mechanisms, said Fritz, many exercise interventions across different pain conditions share mediators such as self-efficacy, fear of movement, and pain beliefs. Adherence and outcomes of exercise likely improve when the mechanisms of trust, motivation, and confidence are used to enhance therapeutic alliance. In addition, exercise prescribed in a way that is tailored to an individual’s goals, with personalized advice, education, and reassurance, can increase motivation and adherence.

Fritz said the specific exercise may not matter as much as developing a personalized plan to which the person can adhere. Supervised exercise programs, such as those with a physical therapist, can be particularly beneficial when provided as part of a tailored multimodal intervention in a manner that builds a therapeutic alliance and intrinsic motivation for behavior change. The optimal therapeutic alliance, she explained, is achieved when both the patient and provider agree on the goals of treatment and the methods to achieve positive health outcomes (Ardito and Rabellino, 2011).

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