Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain
Open accessAbstract
As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.
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Among EBPs, CBT, ACT, and MBSR are widely used and have the strongest evidence for treating chronic pain and mental health conditions prevalent in US veterans.
“three of the most widely used EBPs with the strongest evidence for effectiveness in chronic pain as well as for multiple mental health conditions common among U.S. military veterans.8,9”
From Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review (2023) · cites this paper as [9]
The Psychological/Behavioral Therapies section reviews evidence for CBT, ACT, and MBSR in chronic pain, including some improvements in mood or distress. It does not establish that all three are among the most widely used therapies or have the strongest evidence for multiple mental health conditions common among U.S. veterans. The veteran-specific evidence it discusses concerns CBT for chronic pain. (LLM, conf=0.87)
Experimental — accuracy not yet measuredCBT, ACT, and MBSR are effective treatments for chronic pain and for depression, anxiety, and other mental health conditions prevalent in US veterans.
“Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions.”
From Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review (2023) · cites this paper as [9]
The Psychological/Behavioral Therapies section supports CBT, ACT, and MBSR for chronic pain and reports improvements in mood, depression, distress, or pain-related anxiety among people treated for pain. It does not establish that all three are effective treatments for several mental health conditions as distinct diagnoses, or specifically establish that claim for US veterans. (LLM, conf=0.87)
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- Authors
- Kligler, B., Bair, M. J., Banerjea, R., DeBar, L., Ezeji-Okoye, S., Lisi, A., Murphy, J. L., Sandbrink, F., & Cherkin, D. C.
- Affiliations
- Veterans Health Administration (US)
- Oregon Health & Science University (US)
- Kaiser Permanente Washington Health Research Institute (US)
- Corresponding author
- Kligler, Benjamin
- ORCID
- Venue
- Journal of General Internal Medicine
- Published
- 2018-04-09
- Volume
- 33
- Issue
- S1
- Pages
- 16-23
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC5902342
- OpenAlex
- W2797750378
- Cited by
- 95
- References
- 64
- Citations by year
- 2026: 6 · 2025: 10 · 2024: 8 · 2023: 14 · 2022: 13 · 2021: 14 · 2020: 19 · 2019: 6 · 2018: 4
- FWCI
- 6.94
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Journal of General Internal Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Health Services Research and Development
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Keywords
- chronic musculoskeletal pain, non-pharmacological pain management, Veterans Health Administration, opioid use reduction, manual therapy, team-based care, stepped care, self-management, veterans, implementation barriers, research priorities
- MeSH terms
- Behavior Therapy, Exercise Therapy, Health Policy, Humans, United States, United States Department of Veterans Affairs, Physical Therapy Modalities, Consensus, Chronic Pain, Musculoskeletal Pain, Pain Management
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