There has been a recent surge in interest among policymakers and physicians in the nonpharmacologic treatment of pain in general, and low back pain in particular. This is the result of growing awareness that pharmacologic treatments have not only caused significant harm, they have also failed to achieve a reduction in the number of people in chronic pain.
It is now widely acknowledged that prescription opioids, even used as directed, can cause addiction, even after short-term use. Millions of patients have become addicted and over 190,000 have died. Opioids are also implicated in 21% of fatal auto accidents, cause an increase in all-cause mortality1, can cause falls in the elderly, and can lower immunity.2 There is also no evidence that opioids are an effective treatment for chronic pain, with some studies finding that patients who use opioids do worse in the long term than similar patients who were never prescribed opioids.3,4,5
There is also growing evidence that NSAIDs, both prescription and over-the-counter, cause a significant increase in the risk of heart disease and stroke, even after short-term use. This led the FDA in 2015 to require a black box warning on all NSAIDs except aspirin. The increased risk of GI complications and related deaths from NSAIDs has long been known.
At the same time, pharmacologic treatment of pain has failed to stem the tide of Americans who suffer from chronic pain, with 100 million Americans estimated to suffer.6 This is more than cancer, heart disease, and diabetes combined. Chronic pain costs our economy over $600 billion annually, with about half due to medical expense and the rest attributable to lost productivity. Low back pain is the leading cause of disability in the U.S. and worldwide.
These dismal developments caused the CDC in 2016 to issue voluntary prescribing guidelines for opioids that recommended limiting the use of opioids and replacing them with less risky treatments, including nonpharmacologic treatments. These guidelines were quickly followed by the National Pain Strategy, which also recommended moving away from pharmacologic treatment for pain and using more nonpharmacologic treatments. Earlier this year, the American College of Physicians issued revised guidelines for the treatment of low back pain which recommended that nonpharmacologic treatments replace pharmaceuticals as first-line treatments for both acute and chronic low back pain. Even the traditionally very conservative American Medical Association has recently started including articles about the efficacy of alternative medicine approaches to low back pain in the Journal of the American Medical Association (JAMA).
This shift in medical opinion is not only a reaction to concerns about drug efficacy and safety, it is a response to the growing body of evidence, including both randomized, controlled trials and patient surveys, demonstrating the efficacy and safety of many nonpharmacologic treatments for low back pain. What follows is a brief review of selected nonpharmacologic treatments.
Acupuncture is a treatment system that involves inserting thin needles into specific points on the body in order to positively affect a patient’s health. The needles affect the flow of energy, known as qi. Acupuncture is a therapy that has been developed and refined over thousands of years and is part of traditional Chinese medicine (TCM).7
Acupuncture has been the subject of significant research, including research into its underlying mechanisms and its effect on clinical conditions, including pain. Studies have shown that acupuncture affects the supply of neurochemicals, including levels of endorphins, cortisol, serotonin, and dopamine.8 Other studies have shown changes in levels of brain activity with needling of acupuncture points.9
A 2007 study of 1,162 patients compared acupuncture, sham acupuncture (superficial needling at non-acupuncture points), and conventional therapy (a combination of drugs, physical therapy, and exercise) for effectiveness against low-back pain. The study concluded that both acupuncture and sham acupuncture were almost twice as effective as the conventional treatment for chronic back pain. The improvements lasted at least six months.10
In a 2012 study that included individual patient data from 29 controlled studies with a total of 17,922 patients, researchers concluded that acupuncture is an effective treatment for chronic back and neck pain, osteoarthritis, and chronic headaches.11
The World Health Organization states that acupuncture is safe if it is properly performed by a well-trained practitioner. WHO reported that acupuncture is nontoxic and that adverse reactions are minimal. Effects on pain were found to be comparable to morphine without the side effects and risks.12
Biofeedback uses sensitive electronic instruments to measure a person’s bodily processes and then feeds back that information to the person so that control of the physiology can be learned. Several types of biofeedback—including muscle tension (EMG), temperature (blood flow), heart rate variability (HRV), and brain wave (neurofeedback)—have been shown to be helpful for reducing chronic pain. Biofeedback is often paired with coaching in relaxation techniques.
Biofeedback can enhance the effectiveness of relaxation training by giving the patient information on the effectiveness of his efforts. Biofeedback takes measurements on the surface of the body, and this information is used as part of an educational process. It is completely safe and without negative side effects.
In a 1993 study comparing EMG biofeedback, cognitive behavioral therapy, and conservative medical management for back pain and temporomandibular joint (jaw) pain, the biofeedback group had the most positive changes posttreatment. At 6- and 24-month follow-ups, only the biofeedback group had maintained significant improvements in pain severity, interference with daily activities, emotional distress, and reductions in the use of the healthcare system for pain treatment.13 In another study, 50 chronic pain patients were randomly assigned to a biofeedback-plus-relaxation training group or a pain education group. The biofeedback/relaxation group reported significantly less pain and anxiety compared to the pain education group.14
The chiropractic profession was founded in the United States in 1895. Chiropractors diagnose, treat, and prevent disorders of the musculoskeletal system. More than 90% of patients who seek care from chiropractors are seeking relief from pain, including back and neck pain and headaches.15
Chiropractic treatment has been shown to be much safer than any conventional pain treatments. The estimated risk for serious complications for cervical (neck) manipulation is 6.39 per 10 million manipulations; for lumbar (low-back) manipulation, the estimate is 1 serious complication for every 100 million manipulations, according to a 1998 study sponsored by nonpartisan nonprofit research institute, the RAND Corporation. Compare this to the 156,000 serious complications per 10 million cervical spine surgeries and 32,000 serious complications per 10 million patients using nonsteroidal anti-inflammatory drugs (NSAIDs). The same literature review found that spinal manipulation was more effective for both acute and subacute low-back pain without sciatica than comparison treatments, and that cervical manipulation was effective for neck pain and muscle tension-type headaches.16
In 1997, the Agency for Health Care Policy and Research reported that chiropractic spinal manipulation was one of the few evidence-based treatments recommended for the treatment of low-back pain.17
A systematic review and meta-analysis published last month in JAMA of 26 randomized clinical trials of spinal manipulation for acute low back pain found statistically significant moderate improvements in both pain and function.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is based on the idea that thoughts affect behavior and emotions and that changing maladaptive thoughts can improve mood and functioning. Many chronic pain patients fear the consequences of their pain and worry about their ability to cope with it. They may have unrealistic fears that their resumption of normal activities at home and at work will result in further injury. These thoughts and fears may prolong or prevent recovery. CBT uses cognitive restructuring (replacing unhelpful beliefs with more positive ones) and behavioral experiments, such as gradual exposure to feared situations and activities, to improve emotional and physical well-being.
A 2012 meta-analysis of 46 randomized controlled studies of CBT for chronic low-back pain found that when compared with wait-list controls, CBT had the following effects: Reduced pain, anxiety, avoidance, back-related worry, catastrophizing, depression, disability, and stress and increased coping, health-related quality of life (females only), pain control, pain self-efficacy, perceived ability to function, general quality of life, and social support. CBT also offers economic benefits in terms of reduced healthcare visits, reduction in work days lost, and a higher likelihood of return of work.18
Many studies have shown that CBT and exercise in combination were as effective as back surgery over both the short and long term, with lower costs and fewer risks.19,20,21,22,23,24
A 2016 study published in JAMA found that both cognitive behavioral therapy and mindfulness-based stress reduction treatment of adults with chronic low back pain found significantly greater improvement in back pain and functional limitations than with usual care.
It makes intuitive sense, based on what is now known about the connection between chronic pain and stress, that learning to become more relaxed would result in reduced pain. There are two types of relaxation techniques: active and passive. Active, or progressive, relaxation, produces lower arousal as specific muscles are voluntarily tensed and relaxed, and as the individual learns to differentiate between relaxation and tension. Passive relaxation includes deep breathing or using words or imagery to induce lower arousal. Meditation, for instance, involves focusing on a calming or neutral word or phrase to the exclusion of everything else, including habitual worries or fears. When negative stimuli are removed, the body moves toward relaxation. Effective relaxation strategies involve practicing the techniques frequently until a relaxed state can be achieved quickly in any time of need. This level of training in relaxation is called training to mastery.
Results of studies on relaxation as a treatment for chronic pain have found that different behavioral interventions that have a relaxing effect tend to significantly reduce pain, though there is not enough evidence to determine which relaxation techniques are most effective for which disorders. No studies have reported any negative side effects of relaxation training.25
A multidisciplinary technology assessment panel convened by the National Institutes of Health in 1996 to evaluate the evidence base for behavioral and relaxation approaches in the treatment of chronic pain found that the evidence was strong for the use of relaxation techniques in alleviating chronic pain in many medical conditions.26
Low-level laser therapy
Low-level laser therapy (LLLT) has been in use in Europe as a medical treatment for more than 40 years. Only recently has it begun attracting significant interest in the United States.
Two types of lasers are used for medical purposes. High-power lasers are used to cut through tissue; low-level lasers have the opposite effect—they stimulate tissue repair. In LLLT, a light is applied to an area of the body to relieve pain, reduce inflammation, and promote tissue regeneration. The light is usually a laser or LED between 1 mW and 550 mW in the red or near-infrared spectrum. It’s typically applied to the injured area for a very short time, generally a minute or so, a few times a week for a few weeks. The effect has been compared to photosynthesis, in which the absorbed light causes a chemical change in the tissue.27
The process by which low-level lasers promote healing is called photomodulation. LLLT increases the production of adenosine triphosphate (ATP), the fuel our cells use for energy. The more ATP available to our cells, the faster we heal. LLLT also increases the permeability of cell membranes, which allows waste products to be removed and nutrition to be absorbed into the cells more efficiently. LLLT secondary effects include anti-inflammatory effects, decreases in nerve irritability, and an increase in circulation in the area of injury or chronic pain. Whole-body effects from the treatment include increased immune cell production, increased production of endorphins (the body’s own painkillers), and improved nerve function.
Over 400 LLLT randomized clinical trials and more than 4,000 laboratory studies have been published. A 2010 meta-analysis of 22 studies published in the Clinical Journal of Pain investigated the magnitude of relief experienced by patients receiving LLLT for a variety of chronic pain conditions. A statistically significant and large effect was found.28
A 2015 study reported on a five-year follow-up of 50 back pain patients who had discography (a procedure to confirm that an abnormal disc was generating the pain) and who then were treated with LLLT. The patients received three LLLT sessions per week for 12 weeks. Forty-nine patients had a significant improvement on a scale that measures disability at the end of the course of treatment. The improvements were found to be maintained at one-year and five-year follow-ups.29
Massage and bodywork
Therapeutic massage and bodywork include a wide variety of techniques that involve manipulation of soft tissue or subtle energy to alleviate pain or resolve structural imbalances so that health and well-being are improved.30 There are many different types of massage and bodywork. These can be classified into three types of approaches:
- Gentle bodywork includes a light application of touch, as in Swedish massage, craniosacral therapy, and lomilomi massage. These techniques help the body relax and return to its natural state of balance. For treatment of pain, gentle bodywork techniques are best suited to patients with significant pain, at least initially, as they are less likely to aggravate the condition than forms of massage that use more pressure.
- Structural bodywork includes Rolfing, Hellerwork, and other schools of structural integration. The goal of this bodywork is to change structure by creating a direct change in muscles, tendons, ligaments, and other soft tissues to restore structural balance and reduce strain. The pressure applied with these techniques can create short-term pain.
- Deep tissue bodywork, which focuses on the alleviation of pain and discomfort, includes, in addition to deep tissue massage, neuromuscular therapy, Trager psychophysical integration, and myofascial release.31
A 2001 study of patients with chronic low-back pain found that 10 massage sessions significantly reduced pain and disability, with benefits still evident 9 to 10 months after completions of treatment.32
A 2008 Cochrane Collaboration review of 13 randomized trials of massage for low-back pain, which included a total of 1,596 participants, concluded that massage was more likely to work when combined with exercises (usually stretching) and education, and that the benefits outweighed those achieved by relaxation, physical therapy, education in self-care, or acupuncture. Acupressure, or pressure point massage techniques, seemed to provide greater relief than Swedish massage did.33/sup>
A large 2011 randomized controlled study compared two types of massage—structural and relaxation—to usual care for people 20 to 65 years old with non-specific chronic low-back pain. The treatment groups received 10 massages over a 10-week period by experienced massage therapists. Both massage groups had similar functional outcomes and symptom bothersomeness scores that were significantly superior to usual care. Benefits persisted for at least six months.34
A 2014 study comparing the effects of deep tissue massage on low-back pain to deep tissue massage plus NSAIDs found that 10 deep tissue massages of 30 minutes each effectively reduced low-back pain and associated disability. No additional benefit was seen from adding NSAIDs to the treatment.35
Marijuana grows wild in all but the coldest climates all around the world. It has been used medicinally for thousands of years and was part of the U.S. Pharmacopeia until 1941 when anti-drug zealots had it banned. The marijuana plant contains more than 100 substances known as cannabinoids, which are unique to the plant. The most well-known are THC and CBD.36 The brains of mammals also produce substances known as endocannabinoids, which have been referred to as “the brain’s own marijuana.”37 Whether they are produced by the body (endogenous) or derived from plants or synthetic formulations (exogenous), cannabinoids bind to receptors on cells throughout the body to create their effects.38 These cannabinoid receptors are involved in metabolic regulation, craving, pain, anxiety, bone growth, and immune function.39
A survey of 100 consecutive medical marijuana patients who were returning for their annual recertification in Hawaii found that 97% used marijuana primarily for relief of chronic pain. They reported an average 64% decrease in pain—a decrease on a 10-point pain scale from 7.8 to 2.8. Half also reported relief from stress and anxiety; 45% reported insomnia relief; and 71% reported no negative side effects. No serious adverse effects were reported. Some of the patients reported they were able to reduce or eliminate their use of opioids.40
Medical marijuana users, some of whom were using it for chronic pain, answered a recent online survey that included the question, “How effective is medical cannabis in treating your symptoms or conditions?” The respondents were offered the option of choosing 0% “no relief” up to 100% “complete relief.” The average response was 74.6% ± 0.6.41
Some common nutritional deficiencies have been found to be associated with chronic pain, and supplementation with them has been found to provide relief. These include vitamin D42, magnesium43, and Omega-3 fatty acids.44
Physical therapists develop an individualized treatment plan to increase mobility, reduce pain, improve function, and prevent disability. Physical therapists use a variety of techniques, which include heat, cold, water, ultrasound, electrical stimulation, manual therapy, and exercise.
Manual therapy is treatment performed primarily with the hands. Manual therapy can include massage; mobilization (movement to loosen tight tissue around a joint to improve flexibility and alignment); and manipulation (pressure applied to a joint with hands or a special device). Exercise can include stretching, core-strengthening exercises, lifting weights, and walking. It may also include instructions in a home exercise program.
A review of randomized controlled trials from 1961 to 2009 found strong evidence for the use of manual therapies for the treatment of chronic low-back pain and knee pain for adults with musculoskeletal pain.45
Many nonpharmacologic therapies exist that can provide significant benefits for low back pain patients. The stumbling blocks to the utilization of these therapies are the lack of patient and provider awareness, lack of insurance coverage and limited availability in many communities.
1. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA, 2016, Jun 14.315(22) 2415-22.
2. Vellejo, R., de Leon-Casasola, O., & Benyamin, R. (2004). Opioid therapy and immunosuppression. American Journal of Therapeutics, 11, 354-365.
3. Vogt, M. T., Kwoh C. K., Cope, D. K., Osial, T. A., Culyba, M., & Starz, T. W. (2005). Analgesic usage for low-back pain: Impact on health care costs and service use. Spine, 30, 1075-81.
4. Webster, B. S., Verma, S. K., & Gatchel, R. J. (2007). Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery, and late opioid use. Spine, 32, 2127-2132.
5. Mahmud M. A., Webster, B. S., Courtney, T. K., Matz, S., Tacci, J. A., & Christiani D. C. (2000). Clinical management and the duration of disability for work-related low back pain. JOccup Environ Med, 42, 1178-1187
6. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education. (2011) Relieving Pain in America, a Blueprint for Transforming Prevention, Care, Education and Research. Washington, D.C.: The National Academies Press.
7. Wang, D. & Audette, J. (2008). Acupuncture in Pain Management in Contemporary Pain Medicine: Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management, Audette JF and Bailey A, eds. Totowa, NJ: Humana Press, 379.
8. Wang & Audette. (2008). Acupuncture in Pain Management, 385-388
9. Wang & Audette. (2008). Acupuncture in Pain Management, 389-391.
10. Haake, M., Muller, H., Schade-Brittinger, C., Basler, H., Schafer H, Maier C, Endres H, Trampisch H, Molsberger A. (2007). German acupuncture trials (GERAC) for chronic low-back pain. Archives of Internal Medicine, 167(17), 1892-1898.
11. Vickers, A., Cronin, A., Maschino, A., Lewith, G., MacPherson, H., Victor, N., Foster, N., Sherman, K., Witt, C., & Linde, K. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine, 172(9), 1444-1453.
12. World Health Organization. (2002). Acupuncture review and analysis of reports on controlled clinical trials, 5.
13. Flor, H. & Birbaumer, N. (1993). Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy and conservative medical interventions in the treatment of chronic musculoskeletal pain. Journal of Consulting and Clinical Psychology, 61(4), 653-658.
14. Corrado, P., Gottlieb, H., & Abdelhamid, M. H. (2003). The effect of biofeedback and relaxation training on anxiety and somatic complaints in chronic pain patients. American Journal of Pain Management, 13(4), 133-139.
15. Plamondon, R. (1995). Summary of 1994 ACA annual statistical study. Journal of the American Chiropractic Association, 32(1), 57-63.
16. Coulter, I., (1998). Efficacy and risks of chiropractic manipulation: What does the evidence suggest? Integrative Medicine, 1(2), 61-66.
17. Cherkin, D. C.., Mootz, R. D., (eds.) (1997). Chiropractic in the United States: training, practice and research. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. AHCPR Publication No. 98-N002.
18. Sveinsdotir, V., Eriksen, H.R., & Reme, S.E. (2012) Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. Journal of Pain Research, 5, 371-80.
19. Brox, J. I., Sorensen, R., Friis, A. et Al. (2003). Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low-back pain and disc degeneration. Spine, 28(17), 1913–1921.
20. Brox J. I., Reikeras, O., Nygaard, O., et al. (2006). Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain, 122(1–2), 145–155.
21. Brox, J. I., Nygaard, O. P., Holm, I., Keller, A., Ingebrigtsen, T., & Reikeras, O. (2010). Four-year follow-up of surgical versus non-surgical therapy for chronic low-back pain. Ann Rheum Dis, 69(9), 1643–1648.
22. Keller, A., Brox, J. I., Gunderson, R., Holm, I., Friis, A., & Reikeras, O. (2004). Trunk muscle strength, cross-sectional area, and density in patients with chronic low-back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine, 29(1):3–8.
23. Froholdt, A., Holm, I., Keller, A., Gunderson, R. B., Reikeraas, O., & Brox, J. I. (2011), No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low-back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. The Spine Journal, 11(8), 718–725.
24. Fairbank, J., Frost, H., Wilson-MacDonald, J., Yu, L. M., Barker, K., & Collins, R. (2005). Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low-back pain: the MRC spine stabilisation trial. BMJ, 330(7502), 1233.
25. Carroll, D. (1998). Relaxation for the relief of chronic pain: a systematic review. Journal of Advanced Nursing, 27, 476-487.
26. NIH Technology Assessment Panel of Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia, Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. (1996). JAMA, 276(4), 313-8.
27. Huang, Y. Y., Chen, A. C., Carroll, J. D., & Hamblin, M. R. (2009). Biphasic dose response in low-level light therapy. Dose Response, 7(4):358-83.
28. Fulop, A. M., Dhimmer, S., Deluca, J. R., Johanson, D. D., Lenz, R. V., Patel, K. B., et al. (2010). A meta-analysis of the efficacy of laser phototherapy on pain relief. Clinical Journal of Pain, 26, 729–736.
29. Ip D, Fu NY. (2015). Can intractable discogenic back pain be managed by low-level laser therapy without recourse to operative intervention? Journal of Pain Research, 8, 253-6.
30. Madore, A. & Kahn, J. R. (2008). Therapeutic Massage and Bodywork in Integrative Pain Management in Contemporary Pain Medicine: Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. Audette, J. F. & Bailey, A. (eds.). Totowa, NJ: Humana Press, 363.
31. Madore, A. & Kahn, J. R. (2008). Therapeutic Massage and Bodywork in Integrative Pain Management, 355.
32. Cherkin, D. C, Eisenberg, D., Sherman, K. J., Barlow, W., Kaptchuk, T. J., Street, J., & Deyo, R. A. (2001). Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low-back pain. Archives of Internal Medicine, 161(8), 1081-8.
33. Furlan, A. D., Imamura, M., Dryden, T., & Irvin, E. (2008). Massage for low-back pain. Cochrane Database of Systematic Reviews (4). Art. No.: CD001929.
34. Cherkin, D. C., Sherman, I., Kahn, K., Wellman, R., Cook, A., Johnson, E., Erro, J., Delaney, K., Deyo, R. (2011). A comparison of the effects of 2 types of massage and usual care on chronic low-back pain: a randomized controlled trial. Annals of Internal Medicine, 155(1), 1-9.
35. Majchrzycki, M., Kocur, P., & Kotwiki, T. (2014). Deep Tissue Massage and nonsteroidal anti-inflammatory drugs for low-back pain: a prospective randomized trial. The Scientific World Journal, 1-7.
36. Mehmedic, Z., Chandra, S., Slade, D., et al. (2010). Potency trends of 9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008. Journal of Forensic Science, 55, 1209-1217.
37. Nicoll & Alger. (2004). The brain’s own marijuana.
38. Mackie, K. (2006). Cannabinoid receptors as therapeutic targets. Annual Review of Pharmacology and Toxicology, 46, 101-22.
39. Webb, C. W. & Webb, S. M. (2014). Therapeutic benefits of cannabis: a patient survey. Hawai’i Journal of Medicine and Public Health, 73(4), 109-11.
40. Mackie. (2006). Cannabinoid receptors as therapeutic targets.
41. Piper BJ, Beals ML, Abess AT, Nichols SD, Martin MW, Cobb CM, DeKeuster RM. (2017). Chronic pain patients’ perspectives of medical cannabis. doi: 10.1097/j. pain.0000000000000899. [Epub ahead of print]
42. Schreuder, F., Bernsen, R. M., vn der Wouden, J. C. (2012). Vitamin D supplementation for nonspecific musculoskeletal pain in non-Western immigrants: a randomized controlled trial. Annals of Family Medicine, 10(6):547-55.
43. Yousef, A. & Al-deeb, E. (2013). A double-blinded randomised controlled study of the value of sequential intravenous and oral magnesium therapy in patients with chronic low-back pain with a neuropathic component. Anaesthesia, (68), 260-266.
44. Maroon, J. C. & Bost, J. W. (2006). Omega-3 fatty acids (fish oil)as an inti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4), 326-31.
45. Bokarius, A. & Bokarius, V. (2010). Evidence-based review of manual therapy efficacy in treatment of chronic musculoskeletal pain. Pain Practice, 10(5), 451-458.
Cindy Perlin, LCSW
Cindy Perlin is a Licensed Clinical Social Worker, certified biofeedback practitioner, chronic pain survivor and the author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain-Free. She has been in private practice in the Albany, NY area for 25 years, helping her clients to improve their emotional and physical wellbeing.