Best Practice & Research Clinical Rheumatology 25 (2011) 299309

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, Dominos 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

bromyalgia, 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.
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 xing 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.: 1 734 998 6873; fax: 1 734 998 6900.
E-mail address: afton@med.umich.edu (A.L. Hassett).
1521-6942/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.berh.2011.01.005

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Non-pharmacological interventions do not share the status ascribed to pharmacological

approaches. Limited details are provided in most medical school curricula, reimbursement is
typically challenging and multi-million-dollar marketing campaigns common to pharmacological agents are missing. The term non-pharmacological intervention itself denes this set of
interventions by what they are not rather than by their strengths. The limited prole of nonpharmacological treatment is unfortunate, given that these interventions often have favourable
costbenet ratios and effect sizes that rival pharmacological interventions in the management of
pain [2,3].
Non-pharmacological interventions, such as cognitive-behavioural therapy (CBT), education and
exercise, have substantial efcacy for the management of chronic pain conditions including low back
pain (LBP) [4], arthritis (e.g., osteoarthritis (OA) and rheumatoid arthritis (RA)), complex regional pain
syndrome (CRPS), [5] chronic pelvic pain (CPP) [6] and conditions such as bromyalgia (FM) and
chronic widespread pain (CWP) [79].
Under the rubric of non-pharmacological interventions lies much variability. For example, exercise
studies in CWP have addressed activities ranging from calisthenics to belly dancing. Similarly, CBT, has
included everything from traditional cognitive restructuring and behavioural change strategies to
medication scheduling. This article helps to clarify the types of non-pharmacological treatments that
have the best evidence for use in CWP.
Exercise
The publication of approximately 80 studies evaluating exercise interventions, multiple review
papers, meta-analyses and multiple sets of guidelines [79] leave little doubt that exercise is
broadly considered to be an effective treatment for patients with FM and CWP. Exercise may be
particularly important for improving the health and functioning of individuals with CWP, given
that deconditioning and obesity are commonly observed in these patients. In a recent study,
Okifuji and colleagues reported that 47% of their sample was obese, while another 30% was
overweight. In their study, obesity was related to greater pain sensitivity, less physical strength
and worse sleep [10]. The successful integration of exercise can take different forms. Evidencebased exercise can be aerobic or more focussed on increasing strength and exibility; it can be of
high intensity and frequency or involve only adding a few steps each day. Exercise can be land- or
water-based, can range from whole-body exercise to cycling and involve structured approaches
such as Pilates and Tai Chi. 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.
Strength training (anaerobic exercise)
Strength training seeks to improve overall muscle strength. It is usually an anaerobic activity
focussed on using resistance (e.g., weights, machines and resistance bands) to oppose muscle
contraction in order to build muscle mass. Anaerobic exercise tends to require high-intensity activity,
over a discrete period of time, which leads to improved performance in short-duration activities.
Weight lifting and resistance training, as well as isometric exercises such as yoga and various forms of
martial arts, are included in this category of exercise.
Flexibility training
Stiffness and reduced range of motion are common complaints in patients with CWP. Stretching and
bending target increasing in range of motion, decreasing stiffness and/or minimising risk of injury.
These programmes include a thorough warm-up period, to loosen muscles, followed by a systematic
series of stretching exercises. Participants are usually instructed to stretch each area to the point just
before discomfort is experienced and to hold the position for approximately 1030 s. Following the
stretch, the muscles can be shook out and the same stretch is usually repeated.

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Aerobic exercise
Cardiorespiratory or aerobic exercise consists of physical activity performed at a minimum level of
moderate intensity over an extended period of time. Aerobic types of activities vary widely and can
include walking, running/jogging, cycling, swimming and dancing, as well as exibility and strengthtraining activities (e.g., yoga and weight/circuit training) that are performed at a more intense pace for
a longer duration. Training machines, such as a stationary cycle, rowing machine or elliptical trainer,
are frequently used. Pool-based aerobic exercise programmes offer individuals with pain the added
benets of reduced impact, increased resistance and comfort from immersion in warm water.
Moderately intense exercise, 6070% of age-adjusted maximum heart rate or approximately 110 beats
per minute for a 40-year-old, is associated with tness and fat burning.
Other movement therapies and mixed modality
Not all types of exercise t neatly into the aforementioned categories. For example, yoga can t into
all three categories, contingent upon the type of yoga and intensity of its practice. Other forms of
exercise that fall under the category of movement therapies studied in CWP and/or FM include Tai Chi
and Qigong. Lastly, mixed-modality interventions include more than one form of exercise, such as the
combination of strength training and aerobic exercise. When mixed-modality interventions are evaluated in research, the intervention is typically considered aerobic if there is an aerobic component. This
review conforms to this convention.
Support for efcacy reducing pain
Early hypotheses regarding the aetiology of CWP conditions, such as FM, centred on muscle
pathology [11]; therefore, exercise interventions were directed at building muscle strength or countering deconditioning [12,13]. Over time, evidence supporting muscle pathology in CWP conditions has
been sparse and, instead, favours more central factors. Thus, while there is support for the efcacy of
muscle strength training in the reduction of pain, in general [1418], there is little evidence that these
forms of exercise are addressing the specic pathology of CWP. In the case of CWP, mild strength
training, as opposed to moderate- or heavy-intensity strength training, is considered best [1921].
Few studies specically address exibility (stretching) training for CWP, although a number of
effective aerobic exercise programmes include a exibility-training component (e.g., ref. [22]). An early
study of exercise in FM found aerobic training to be superior to exibility training for improving tness,
but not for pain or sleep [23]. In a more recent randomised control trial (RCT), aerobic exercise was
better than exibility training for decreasing the number of tender points [24]. Similarly, another RCT
reported that aerobic training was superior to exibility training for increasing tness and decreasing
pain [25]. If yoga is considered to be exibility training, the evidence of effectiveness increases to
a certain degree [26,27]. For example, 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]. Taken together,
there is not sufcient evidence, as yet, to conclude that exibility training by itself is helpful for CWP,
but some individuals will benet from the programme.
The evidence supporting the efcacy of aerobic exercise for improving pain is compelling. Despite
early negative trails [23,2831], more recent RCTs are reporting strong effects for decreasing pain
[3235]. In a recent meta-analysis evaluating 35 RCTs, Hauser and colleagues reported that aerobic
exercise signicantly reduced pain in participants with FM with land-based and pool-based interventions yielding similar positive results [36]. The meta-analysis included studies published up to April
2009. Subsequent to this report, additional studies have also been supportive of aerobic exercise
[37,38]. Another therapy related to aerobic exercise is movement therapy. In a recent, single-blind RCT,
Tai Chi was compared with a control condition consisting of education plus stretching [39]. The authors
reported signicant improvement for the Tai Chi group with regard to both clinicians and patients
assessments of pain severity. Although only a handful of studies have been conducted to date, there is
growing evidence that both Tai Chi [39,40] and Qigong movement therapies may be benecial for some
individuals with CWP [41].

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Support for efcacy increasing functioning

In view of the fact that only a few studies have evaluated either strength or exibility training as
individual modalities, it is difcult to determine the specic impact of these exercise modalities on
functional status; however, improvements have been associated with interventions involving both
strength training [14,16] and exibility training [16,42]. In contrast, numerous RCTs have been conducted in aerobic exercise and have shown signicant improvement in functioning [32,35,38,4345].
Taken together, there is strong evidence that aerobic exercise programmes, land-based and waterbased, improve functioning in patients with CWP.
Support for efcacy other symptoms and outcomes
Aerobic training for individuals with CWP was associated with increased tness [23] and aerobic
work capacity [46], signicant improvement in the 6-min walk test [44] and better general health
[24,47]. In addition, aerobic training was associated with decreased fatigue [48], improved sleep [49],
less depression [25,34,44,49,50], better cognitive performance [51], greater self-efcacy [44] and
increased feelings of well-being [52]. Furthermore, aerobic exercise conducted in low-cost,
community-based settings [22], as well as in the home [35], was found to be highly effective for
patients with FM.
Due to a paucity of studies, there is far less evidence for other modalities; however, some studies
have shown that strength training for CWP patients has been associated with less fatigue [53] and
depression [16], while non-aerobic warm water exercises and education resulted in an improved 6-min
walk test, better grip strength, less anxiety and better quality of life [45]. Therefore, more studies are
needed to afrm the effectiveness of strength and exibility training.
Intensity and frequency
Jones and colleagues have recommended that low-intensity, non-repetitive exercise be used for
the treatment of FM [54]. 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]. However, another evidence-based review of
the exercise literature was published recently and concluded that insufcient evidence existed to
draw a conclusion with regard to the benet of low-intensity exercise on pain reduction [36]. By
contrast, there was robust evidence in favour of light to moderate aerobic exercise for pain. Other
ndings from the same review suggested that aerobic exercise training should be increased slowly,
beginning at levels just below capacity and then increased in duration and intensity until individuals
are exercising at low to moderate intensity (i.e., 5070% of age-adjusted maximum heart rate) for
2030 min per session 23 times per week [36]. Training programmes should have a duration of at
least 4 weeks, and education during the early stages of a new exercise programme is crucial. Patients
should be cautioned that, if they experience increased symptoms, they should decrease exercise until
symptoms improve. Lastly, if there is concern with regard to adverse effects, patients should
promptly consult with their physicians [56]. These recommendations are consistent with published
guidelines [7,9,56].
Attrition, persistence and motivation
What is the best way to engage chronic pain patients in regular exercise when they are frequently
obese, sedentary, depressed, fatigued and experiencing pain? This problem is reected in the attrition
rates observed in RCTs that evaluate exercise in CWP that have been estimated to range from 27% to
90% [36]. Interestingly, in this patient population, tness gains are not always associated with symptomatic improvement [25,57]. Therefore, it is highly likely that tailoring the exercise-treatment programme to patients needs, preferences and interests is key to deriving benet [7] and enhancing
adherence. The combination of exercise with CBT, which focusses upon patients thoughts and beliefs,
constiutes an optimal non-pharmacological therapeutic approach to CWP.

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Cognitive-behavioural therapy
CBT possesses a strong evidence base that supports its efcacy in the management of chronic pain
[58,4]. The term CBT, refers to a class of interventions, each of which is grounded upon a common
theoretical framework. For example, CBT interventionists will utilise a wide variety of skill-sets or
modules to produce outcomes. Typically, the choice of modules depends upon the intended target of
treatment (pain reduction, functional improvement, mood, etc.). That CBT content can vary depending
upon the need of the individual patient is actually a strength of the approach and underscores the
exibility of this therapeutic modality; however, such exibility has also contributed to some confusion
when it is assumed that CBT is a uniform intervention. 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.
The theory behind CBT
CBT is actually a hybrid of two efcacious forms of therapy: behavioural therapy (BT) and cognitive
therapy (CT). BT for chronic pain is grounded in the work of Fordyces operant model [59], as well as in
classical conditioning and social learning theory. BT focusses upon aspects of patients environments
that can lead to the development or maintenance of pain through reinforcement (e.g., avoidance,
attention, or pain relief from inactivity).
CT has its roots in the psychological treatment for depression [60]. In its application to pain
management, CT focusses on thoughts, beliefs, expectations and attributions that can lead to overwhelming affect, suffering and additional pain intensity and/or diminished functional status. In CT,
patients are trained to gain insight with regard to into how their thoughts, beliefs or expectations
inuence emotions, pain and functioning. They are then taught how to alter these thoughts and beliefs
in a manner that is better aligned with the management of pain.
In the context of pain, BT and CT techniques are often combined to form CBT. For any patient,
however, behavioural or cognitive elements may be differentially emphasised. In practice, CBT typically
includes three phases: (1) an educational phase, 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; (2)
a skills training phase; and (3) an application phase, in which patients learn to apply their skills in
progressively more challenging real-life situations [61]. The next section describes some of the specic
skills that are provided in CBT for pain as well as representative studies supporting the use of these
skills for the management of pain.
CBT skill-sets
Education
Education is a vital component of CBT and is typically the rst phase of treatment. 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.
Education typically involves providing the patient with an updated summary of the latest facts that
concern the type of pain they are experiencing, the latest approaches to treatment and a theoretical
framework for understanding the role of the patient in pain management. Education, by itself, 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.
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.g., through reduced muscle tension, heart rate and
breathing) [62]. To learn the response, the individual needs to practise the prescribed techniques
repeatedly until his/her body acquires the desired response. There is no consensus as to the best
method of teaching the relaxation response, for example, progressive muscle relaxation, visual
imagery, hypnosis, biofeedback all of which are based upon behavioural principles of reinforcement

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and appear to be useful modalities for learning this response. While relaxation has been found to be
efcacious, on its own, for reducing pain in FM [63,64], it is also one of most commonly used skills in
a multi-component CBT approach to pain management [6571].
Graded activation
Performing tasks can enhance ones self-esteem. Thus, on good days, patients will unwittingly
engage in more activity than personal limitations allow and will then suffer several bad days of
symptom ares, lost productivity and decreased self-esteem. Graded activation or time-contingent
pacing is a method of pacing that can improve physical functioning while minimising the likelihood of
pain are-ups. This approach has been successfully applied with LBP populations [72], rheumatological
populations [73], in patients with FM [7476] and in patients having chronic fatigue syndrome [77].
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. 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.
The patient and therapist must work together to develop a plan for steadily increasing the amount of
time spent on specied targeted behaviours. Time-based pacing can be used as a complementary skill
to help ensure the long-term adoption of exercise regimens, work-related activities and pleasant
activities, such as social outings and sporting activities.
Pleasant activity scheduling
Many individuals with chronic pain exclude enjoyment from their lives and leave time for only
essential tasks. While this strategy is understandable, and may work well in the context of acute pain,
long-term denial of personal pleasures can have devastating effects on mood and motivation,
increasing pain and reducing function. Enjoyment of pleasant activities is a natural way to elevate
mood [78] and invites condence in ones body to function at a higher level. As considered in CBT, this
behavioural change encourages scheduling of pleasant activities into ones day with the same priority
as a meeting, a doctors appointment, or a deadline [76].
Behavioural methods for improving sleep
Individuals with chronic pain have a number of problems related to getting a good nights sleep and
they include difculty falling asleep, being awakened by pain or discomfort or, after sleeping, awakening with feelings of being unrefreshed and unrestored. Behavioural strategies for sleep, if used
regularly, can help individuals obtain the required restorative sleep with additional benets in
improved mood, better management of pain, less fatigue and improved mental clarity [79]. Some of
these skills focus on timing strategies (e.g., having regular sleep routines), sleep behaviours (e.g.,
attempting to sleep only when in need of sleep) and behavioural avoidance of stimulating activities
(e.g., watching action movies, consuming nicotine or caffeine). CBT, which targets sleep, appears to
have a direct impact on pain symptoms and on functional interference resulting from non-restorative
sleep [80,81].
Cognitive difculties
Individuals with chronic pain will often report difculties with memory, concentration and mental
clarity [82]. The cause of cognitive difculties 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]. Behavioural approaches to stress reduction, such as inducing the relaxation
response, and structured rehearsal methods for improving memory (e.g., repetition and developing
associations) can provide benet; but this remains an area where more study is needed.
Problem-solving strategies
Individuals with chronic pain face interpersonal and functional challenges that rarely affect healthy
individuals. Programmatic problem-solving strategies can be taught to patients by helping them to
break large problems down into solvable pieces [84,85]. What is taught in therapy is a strategy for
solving problems rather than specic solutions; thus, patients learn a strategy that can be carried into
the future as new problems arise. Support for the use of problem solving in the context of CWP is

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derived from several studies demonstrating that improvements in the ability to deal with lifes
problems are associated with reduced pain [46,57,86].
Cognitive restructuring and reframing
Behavioural solutions to problems reect the beliefs held with regard to the nature of the problem
and beliefs about ones personal ability to effectively execute solutions. Strong convictions in ones
helplessness, the futility of trying to control illness or the inability to contribute meaningfully in life
tasks are examples of learned, automatic, thinking patterns that can impede successful adaptation.
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. Cognitive restructuring invites individuals to explore the origin of learned
automatic thinking patterns that contribute to maladaptive behavioural responses. With practice, new
thinking patterns can replace old ones that are more consistent with well-being and pain control. This
form of CT has been associated with improvements in pain [74].
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.g., distraction, reinterpreting the sensation of pain and ignoring the pain) [87,88].
These skills have been studied as stand-alone interventions or as part of a multi-component approach.
The use of CST has been associated with improvements in pain [46,57,65,74,86,89], sleep [57,65,86],
improvements in functional status [57,65,74,86,89] and improved mental health [46,65,74,86].
Interpersonal skills
Individuals with CWP often experience challenges in their dealings with other people. For example,
spouses may become frustrated with the pain and the limited functionality of the patient. Employers
may become less sympathetic over time and busy physicians may not have sufcient time to hear the
many important details that a patient wishes to communicate. Assertiveness training or other forms of
more effectively engaging in interpersonal processes are often taught in the context of CBT to help
improve ones self-efcacy to garner the support of others as well as to improve symptoms of pain
directly [57,74,75,89].
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. The duration of therapy is typically brief and involves
between 6 and 12 sessions, with booster sessions being used to reinforce change over a longer term.
Given the potential difculties in accessing trained therapists or difculties in travelling long distances
to receive therapy, alternatives to traditional face-to-face delivery methods have been explored. For
example, the delivery of CST can be accomplished over the telephone [90], 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 signicant impact upon symptoms [2].
Combining CBT with exercise multi-component treatment
Growing consensus supports a multi-component treatment approach for CWP that combines CBT
and exercise [7,9,92]. A recent meta-analysis found strong evidence that such treatment signicantly
reduced pain, fatigue and depression, while increasing the health-related quality of life (functioning),
physical tness and self-efcacy for pain [92]. The effects were evident immediately after treatment;
however, they did not appear to persist over time, which suggests that, similarly as in any chronic
health condition, ongoing intervention (e.g., maintenance of exercise) is required.
In addition to developing programmes that can be adopted and maintained over time, tailoring the
approach to patient needs is important. In a study of high risk FM patients, 158 patients were assigned
to a waitlist or one of two 16-session intervention groups developed to specically target one of two
coping styles (pain-avoidance or pain-persistence). The study found signicant differences between

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the intervention groups and the control group on all primary outcome measures, including pain,
fatigue, functioning, negative mood and anxiety, in the short and long term. This study exemplies how
combining CBT and exercise and tailoring such a programme to patient needs contribute to generate
optimum outcomes for patients with CWP [93].
Conclusions
It is likely that clinicians will continue to use pharmacological agents as a frontline approach to the
management of CWP. However, clinicians should be aware of the benets of non-pharmacological
approaches that possess comparable effect sizes for several domains of relevance (e.g., pain reduction,
improved functional status, improved mood). It is important to consider the type of non-pharmacological intervention needed for any given patient because both the needs of the patient and the
availability of non-pharmacological approaches can vary widely. Whereas access to trained nonpharmacological therapists can be challenging, Internet versions of CBT and exercise instruction are
beginning to be available to clinicians who can utilise these resources to provide standardised
instruction to their patients, who may not otherwise be able to access such care (e.g., rural patients)
[2,94]. Clinicians should not have to feel reliant upon medications alone when managing these usually
difcult and persistent cases. Optimal pain management appears to be constituted by a combination of
pharmacological and non-pharmacological approaches to care.
Practice points
 Exercise and CBT have comparable effect sizes to pharmacological approaches in key domains
such as pain reduction, increased functioning and improved mood.
 Aerobic exercise at a moderate intensity for 20- to 30-min sessions, 23 times a week, is
generally recommended. Low-impact, diverse and fun exercise can enhance persistence.
 Treatment strategies that include a combination of exercise and CBT and take into consideration a patients unique needs will likely provide the best results.

Research agenda
 Aerobic exercise is well supported, whereas other forms of exercise such as strength training
and movement therapies (e.g., Tai Chi) are promising, but require additional research study.
 Access to qualied providers of non-pharmacological care remains a problem; therefore,
online forms of CBT and CBT plus exercise need to be developed and evaluated.

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