title: Non-pharmacological interventions for chronic pain in people with spinal cord injury.
abstract: 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.
  
  
  OBJECTIVE
  To critically appraise and synthesise available research evidence on the effects of non-pharmacological interventions for the treatment of chronic neuropathic and nociceptive pain in people living with SCI.
  
  
  METHODS
  The search was run on the 1st March 2011. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), four other databases and clinical trials registers. In addition, we manually searched the proceedings of three major scientific conferences on SCI. We updated this search in November 2014 but these results have not yet been incorporated.
  
  
  METHODS
  Randomised controlled trials of any intervention not involving intake of medication or other active substances to treat chronic pain in people with SCI.
  
  
  METHODS
  Two review authors independently extracted data and assessed risk of bias in the included studies. The primary outcome was any measure of pain intensity or pain relief. Secondary outcomes included adverse events, anxiety, depression and quality of life. When possible, meta-analyses were performed to calculate standardised mean differences for each type of intervention.
  
  
  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). None of the included trials were considered to have low overall risk of bias. 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. An additional search in November 2014 identified more recent studies that will be included in an update of this review.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. Overall, a paucity of evidence was found on any serious or long-lasting side effects of the interventions.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Swiss Paraplegic Research, Nottwil, Switzerland.
authors.forename: Inga
authors.initials: I
authors.lastname: Boldt
authors.forename: Inge
authors.initials: I
authors.lastname: Eriks-Hoogland
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: Rob
authors.initials: R
authors.lastname: de Bie
authors.forename: Daniel
authors.initials: D
authors.lastname: Joggi
authors.forename: Erik
authors.initials: E
authors.lastname: von Elm
mesh_terms: D015670:Acupuncture Therapy / Q000379:methods; D001007:Anxiety / Q000628:therapy; D059350:Chronic Pain / Q000523:psychology / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods; D003863:Depression / Q000628:therapy; D004599:Electric Stimulation Therapy / Q000379:methods; D005081:Exercise Therapy / Q000379:methods; D006801:Humans; D006990:Hypnosis / Q000379:methods; D009437:Neuralgia / Q000523:psychology / Q000628:therapy*; D059226:Nociceptive Pain / Q000523:psychology / Q000628:therapy*; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement / Q000379:methods; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D015203:Reproducibility of Results; D020069:Shoulder Pain / Q000628:therapy; D013119:Spinal Cord Injuries / Q000150:complications*; D050781:Transcranial Magnetic Stimulation / Q000379:methods; D004561:Transcutaneous Electric Nerve Stimulation / Q000379:methods