An update on non-pharmacological interventions for pain relief

Abstract

Chronic pain affects a substantial portion of the population, yet current treatments often fail to provide adequate relief. Non-pharmacological interventions, which target behaviors and brain processes underlying the experience of pain, hold promises in offering relief for people with chronic pain. This review consolidates the current knowledge concerning the efficacy of non-pharmacological interventions for chronic pain. We focus on psychological interventions (e.g., cognitive behavioral therapy-based interventions and emotion-based therapies) that use mental techniques and physical practices (e.g., exercise, massage, acupuncture, and yoga) that use body techniques to reduce pain. The efficacy of neuromodulation is also discussed. Given that placebo and expectation effects may enhance benefits for non-pharmacological interventions, we also discuss placebo interventions and expectation management practices. Finally, we describe digital therapeutics as an emerging approach for managing chronic pain. We argue that non-pharmacological interventions are critical adjunctive or stand-alone interventions for chronic pain conditions.

Keywords: cognitive behavioral therapy; exercise; expectations; extended reality and therapeutic digital applications; neuromodulation; placebo effects.

Graphical abstract

Figure 1

Non-pharmacological interventions may trigger a series of changes in the peripheral and central nervous systems These changes include, but are not limited to, the release of endogenous neuropeptides (e.g., endorphins), changes in neural activities, reductions in inflammatory markers (e.g., cytokines interleukin-10 and tumor necrosis factor alpha), and muscle strengthening.

Figure 2

Adapted embodied view of pain framework This framework categorizes pain responses into three levels along a continuum, illustrating how non-pharmacological interventions can address various aspects of the pain experience. Level 1 responses: These involve physiological changes that occur independently of cognitive or emotional engagement. Interventions primarily targeting this level include physical therapy modalities such as exercise, massage, neuromodulation (e.g., repetitive transcranial magnetic stimulation [rTMS], transcranial direct current stimulation [tDCS]), acupuncture, open-label placebo (OLP) and dose-extending placebos, and mind-body practices. Some interventions may also incorporate psychological elements, reflecting their dual impact on pain management. Level 2 responses: This level encompasses psychological processes that influence cognitive and emotional states. Interventions at this level include cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), emotional awareness and expression therapy (EAET), pain reprocessing therapy (PRT), and mindfulness-based approaches. Certain interventions in this category may also address physiological responses, illustrating the interconnectedness of the pain experience. Level 3 responses: This level responses involve dissociations from bodily experience. Interventions targeting this level include augmented reality (AR) and virtual reality (VR) therapies, which create immersive experiences designed to reduce pain perception. This framework assists clinicians in understanding pain as a multifaceted and disruptive force, guiding them in selecting appropriate intervention strategies tailored to different pain response levels. It is important to note that, while interventions are categorized by their primary focus, many operate across multiple levels of response, reflecting the complexity of pain mechanisms and the synergistic effects of non-pharmacological approaches.