Objective Pain Assessment: a Key for the Management of Chronic Pain – PubMed.gov – National Library of Medicine


The Pain Free Institute

2020 Jan 23;9:F1000 Faculty Rev-35. doi: 10.12688/f1000research.20441.1. eCollection 2020.

Objective Pain Assessment: a Key for the Management of Chronic Pain

Xiaohan Xu 1Yuguang Huang 1Affiliations expand

Free PMC article


The individual and social burdens associated with chronic pain have been escalating globally. Accurate pain measurement facilitates early diagnosis, disease progression monitoring and therapeutic efficacy evaluation, thus is a key for the management of chronic pain. Although the “golden standards” of pain measurement are self-reported scales in clinical practice, the reliability of these subjective methods could be easily affected by patients’ physiological and psychological status, as well as the assessors’ predispositions. Therefore, objective pain assessment has attracted substantial attention recently. Previous studies of functional magnetic resonance imaging (fMRI) revealed that certain cortices and subcortical areas are commonly activated in subjects suffering from pain. Dynamic pain connectome analysis also found various alterations of neural network connectivity that are correlated with the severity of clinical pain symptoms. Electroencephalograph (EEG) demonstrated suppressed spontaneous oscillations during pain experience. Spectral power and coherence analysis of EEG also identified signatures of different types of chronic pain. Furthermore, fMRI and EEG can visualize objective brain activities modulated by analgesics in a mechanism-based way, thus bridge the gaps between animal studies and clinical trials. Using fMRI and EEG, researchers are able to predict therapeutic efficacy and identify personalized optimal first-line regimens. In the future, the emergence of magnetic resonance spectroscopy and cell labelling in MRI would encourage the investigation on metabolic and cellular pain biomarkers. The incorporation of machine learning algorithms with neuroimaging or behavior analysis could further enhance the specificity and accuracy of objective pain assessments.

Keywords: chronic pain; electroencephalography; functional magnetic resonance imaging; objective assessment.

Conflict of interest statement

No competing interests were disclosed.No competing interests were disclosed.No competing interests were disclosed.

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  1. Mills SEE, Nicolson KP, Smith BH: Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019;123(2):e273–e283. 10.1016/j.bja.2019.03.023 – DOI – PMC – PubMed
  2. F1000 Recommendation

Coping with Chronic Pain – American Psychological Association

Coping with chronic pain

Chronic pain is physically and psychologically stressful and its constant discomfort can lead to anger and frustration with yourself and your loved ones.Date created: 20113 min read


Coping with chronic pain

Chronic pain is physically and psychologically stressful and its constant discomfort can lead to anger and frustration with yourself and your loved ones. By definition, chronic pain is pain that lasts longer than six months and affects how a person lives their daily life. While physicians can provide treatment for the physical dimensions of chronic pain, psychologists are uniquely trained to help you manage the mental and emotional aspects of this often debilitating condition.

Several medical treatments may be used to alleviate chronic pain, including over-the-counter or prescription medication, physical therapy, and less utilized treatments, such as surgery. However, these options are only a few of the pieces necessary to solve the puzzle of chronic pain. Mental and emotional wellness is equally important—psychological techniques and therapy help build resilience and teach the necessary skills for management of chronic pain.

Chronic pain is physically and psychologically stressful and its constant discomfort can lead to anger and frustration with yourself and your loved ones. By definition, chronic pain is pain that lasts longer than six months and affects how a person lives their daily life. While physicians can provide treatment for the physical dimensions of chronic pain, psychologists are uniquely trained to help you manage the mental and emotional aspects of this often debilitating condition.

Several medical treatments may be used to alleviate chronic pain, including over-the-counter or prescription medication, physical therapy, and less utilized treatments, such as surgery. However, these options are only a few of the pieces necessary to solve the puzzle of chronic pain. Mental and emotional wellness is equally important—psychological techniques and therapy help build resilience and teach the necessary skills for management of chronic pain.

Tips on coping with chronic pain

Manage your stress. Emotional and physical pain are closely related, and persistent pain can lead to increased levels of stress. Learning how to deal with your stress in healthy ways can position you to cope more effectively with your chronic pain. Eating well, getting plenty of sleep and engaging in approved physical activity are all positive ways for you to handle your stress and pain.

Talk to yourself constructively. Positive thinking is a powerful tool. By focusing on the improvements you are making (i.e., the pain is less today than yesterday or you feel better than you did a week ago) you can make a difference in your perceived comfort level. For example, instead of considering yourself powerless and thinking that you absolutely cannot deal with the pain, remind yourself that you are uncomfortable, but that you are working toward finding a healthy way to deal with it and living a productive and fulfilling life.

Become active and engaged. Distracting yourself from your pain by engaging in activities you enjoy will help you highlight the positive aspects of your life. Isolating yourself from others fosters a negative attitude and may increase your perception of your pain. Consider finding a hobby or a pastime that makes you feel good and helps you connect with family, friends, or other people via your local community groups or the internet.

Find support. Going through the daily struggle of your pain can be extremely trying, especially if you’re doing it alone. Reach out to other people who are in your same position and who can share and understand your highs and lows. Search the internet or your local community for support groups, which can reduce your burden by helping you understand that you’re not alone.

Consult a professional. If you continue to feel overwhelmed by chronic pain at a level that keeps you from performing your daily routine, you may want to talk with a mental health professional, such as a psychologist, who can help you handle the physical and psychological repercussions of your condition.

APA gratefully acknowledges the assistance of Nancy Molitor, PhD, Alan Keck, PsyD, and Katherine Nordal, PhD in developing this article.

Complex Regional Pain Syndrome Fact Sheet – National Institute of Neurological Disorders and Stroke


Understanding Complex Regional Pain Syndrome (CRPS) | Keck School of  Medicine of USC
USC Keck School of Medicine – University of Southern California

Complex Regional Pain Syndrome Fact Sheet

What is complex regional pain syndrome?
What are typical symptoms of CRPS?
What causes CRPS?
How is CRPS diagnosed?
How is CRPS treated?
What research is currently being done on CRPS?
Where can I get more information?

What is complex regional pain syndrome?

Complex regional pain syndrome (CRPS) is a broad term describing excess and prolonged pain and inflammation that follows an injury to an arm or leg. CRPS has acute (recent, short-term) and chronic (lasting greater than six months) forms. CRPS used to be known as reflex sympathetic dystrophy (RSD) and causalgia. People with CRPS have changing combinations of spontaneous pain or excess pain that is much greater than normal following something as mild as a touch. Other symptoms include changes in skin color, temperature, and/or swelling on the arm or leg below the site of injury. Although CRPS improves over time, eventually going away in most people, the rare severe or prolonged cases are profoundly disabling.

Most CRPS illnesses are caused by improper function of the peripheral C-fiber nerve fibers that carry pain messages to the brain. Their excess firing also triggers inflammation designed to promote healing and rest after injury. In some people the nerve injury is obvious but in others a specialist may be needed to locate and treat the injury.

  • Historically, people were classified as having CRPS-I (previously called RSD) when there was uncertainty about the exact nerve injured.
  • After a doctor identifies the specific nerve injured, people are diagnosed as having CRPS-II (previously known as causalgia). Many people labeled with CRPS-II have more extensive injuries that also damage nerves going to muscles (motor nerves) to cause weakness and muscle shrinkage in certain areas, making it easier to identify. Motor nerves control the movement of muscles under conscious control, such as those used for walking, grasping things, or talking.

Since both types of CRPS have identical symptoms, both may be caused by nerve injury, although nerve injuries in CPRS I are typically more subtle and go unnoticed.

CRPS is more common in women but can occur in anyone at any age, with a peak around age 40. It is rare in the elderly, who have less inflammation after injury, and in young children who heal so quickly and completely.

The outcome of CRPS is highly variable:

  • Most illnesses are mild and recover over months to a few years as the injured nerve regrows. If this doesn’t happen, symptoms can linger to cause long-term disability.
  • The outcome depends not only on the severity of the original injury, but also on the person’s underlying general and nerve health. Younger people, children, and teenagers almost always recover, as do older adults with good circulation and nutrition. Smoking is a major impediment to nerve regeneration as is diabetes and previous chemotherapy. Removing barriers to healing increases the chance and speed of recovery.
  • Rare individuals experience prolonged severe pain and disability despite treatment. This may indicate underlying separate problems interfering with healing requiring additional testing and treatment.

Because of the varied symptoms, the fact that symptoms may change over time, and the difficulty finding a positive cause in some cases, CRPS is hard to treat. There is no treatment that rapidly cures CRPS.


What are typical symptoms of CRPS?

Most individuals do not have all of these symptoms, and the number of symptoms typically reduces during recovery.

  • Unprovoked or spontaneous pain that can be constant or fluctuate with activity. Some say it feels like a “burning” or “pins and needles” sensation, or as if the affected limb was being squeezed. Over time, if nerves remain chronically inflamed, pain can spread to involve most or all of the arm or leg, even if the originally affected area was smaller. In rare cases, pain and other symptoms occur in a matching location on the opposite limb. This “mirror pain” is thought to reflect secondary involvement of spinal cord neurons (nerve cells). Mirror pain is less severe and resolves as the injured nerves recover.
  • Excess or prolonged pain after use or contact. There is often increased sensitivity in the affected area, known as allodynia, in which light touch, normal physical contact, and use is felt by the person to be very painful. Some notice severe or prolonged pain after a mildly painful stimulus such as a pin prick, known as hyperalgesia.
  • Changes in skin temperature, skin color, or swelling of the affected limb. The injured arm or leg may feel warmer or cooler than the opposite limb. Skin on the affected limb may change color, becoming blotchy, blue, purple, gray, pale, or red. These skin symptoms typically fluctuate as they indicate abnormal blood flow in the area. Opening and closing the small blood vessels under the skin is controlled by the C-nerve fibers that are injured in CRPS.
  • Changes in skin texture. Over time, insufficient delivery of oxygen and nutrients can cause skin in the affected limb to change texture. In some cases, it becomes shiny and thin, in others thick and scaly. Avoiding contact or washing painful skin contributes to this build-up.
  • Abnormal sweating and nail and hair growth. On the affected limb, hair and nails may grow abnormally rapidly, or not at all, and people may notice patches of profuse sweating or no sweating. All are under neural control and influenced by local blood circulation.
  • Stiffness in affected joints. This common problem is that reduced movement leads to reduced flexibility of tendons and ligaments. Tight ligaments or tendons sometimes rub or pinch nerves to provide an internal cause of CRPS in people who do not have external injuries.
  • Wasting away or excess bone growth. In CRPS-affected limbs, bones that receive signals from the damaged nerves rarely become affected. These abnormalities are often visible on X-rays or other imaging where they help specialists pinpoint the location of nerve damage and identify best treatments. Rough or enlarged areas of bone, such as after a poorly healed fracture or from a bone cyst, can irritate passing nerves and initiate or prolong CRPS.
  • Impaired muscle strength and movement. Most people with CRPS do not have direct injury to the nerve fibers that control the muscles coordinating muscle movement. However, most report reduced ability to move the affected body part. This is usually due to pain and abnormalities in the sensory input that helps coordinate movements. Also, the excess inflammation and poor circulation are not healthy for muscles. Rare patients report abnormal movement in the affected limbs, fixed abnormal posture called dystonia, and tremors in or jerking. These can reflect secondary spread of disturbed neural activity to the brain and spinal cord. Most resolve by themselves during CRPS healing, but some people require orthopedic surgery to lengthen contracted tendons and restore normal flexibility and position.


What causes CRPS?

Most CRPS is caused by damage to, or dysfunction of, injured peripheral sensory neurons, which then has secondary effects on the spinal cord and brain. The central nervous system is composed of the brain and spinal cord; the peripheral nervous system involves nerve signaling from the brain and spinal cord to all other parts of the body.

It is unclear why some people develop CRPS while others with similar trauma do not. In more than 90 percent of cases, CRPS is triggered by nerve trauma or injury to the affected limb that damages the thinnest sensory and autonomic nerve fibers. These “small fibers”—which lack insulating thick myelin sheaths (a protective coating, like insulation that surrounds a wire)—transmit pain, itch, and temperature sensations and control the small blood vessels and health of almost all surrounding cells.

The most common actions or activities that lead to CRPS are:

  • Fractures. This is the most common cause, particularly wrist fractures. Nerves can become injured from a displaced or splintered bone, or pressure from a tight cast. Very tight or painful casts must be immediately cut off and replaced to prevent this complication.
  • Surgery. A surgical incision, retractors, positioning, sutures, or post-operative scarring can cause nerve injury. Sometimes the cause can be identified and repaired, but CRPS can develop even after surgery goes well.
  • Sprains/strains. Connective tissues ruptures, or the causal trauma, can permit excess movement of a joint that stretches nearby nerves.
  • Lesser injuries such as burns or cuts. These are the visible signs of injuries that may also have damaged underlying nerves.
  • Limb immobilization (often from casting). In addition to rarely pressing on nerves and restricting blood flow to the hands and feet as above, casts force prolonged disuse of a limb and deprive it of sensory input. After a cast is removed neurons need time to readapt to normal signaling.
  • Very rare penetrations, such as from a cut or needle stick, can accidentally pierce a superficial sensory nerve. Nerve specialists help locate the injured nerve by mapping the sensory changes on the skin. Larger penetrating nerve injuries are ideally surgically repaired immediately to permit the cut nerve fibers to regrow into the farther nerve portion to reconnect with target tissues.
  • Less than 10% of individuals with CRPS report no causal injury of trauma. Here, the cause is often an undiagnosed internal nerve injury. These include nerve rubbing or tethering against hard internal structures or scars. Tiny clots sometimes block blood flow to a nerve and injure it. Very rarely, a new tumor, infection (such as leprosy), or abnormal blood vessels irritate a nerve. New CRPS without evident cause requires thorough evaluation to check for internal problems.

Poor circulation can impede nerve and tissue healing. Damage to the small fibers that control blood flow causes many symptoms of CRPS. Blood vessels in the affected limb can dilate (open wider) to leak fluid into the surrounding tissue, causing red, swollen skin. This can deprive underlying muscles and deeper tissues of oxygen and nutrients, which can cause muscle weakness and joint pain. When skin blood vessels over-constrict (clamp down), the skin becomes cold, white, gray, or bluish.

CRPS develops only in the limbs because circulation is constrained there. Arterial blood pumped down to the hands and feet must fight gravity to return upwards in the veins to the heart. C-fiber damage can impede this, permitting blood fluids to remain in the limb where the swelling then further blocks return blood flow. Slowed circulation impedes delivery of oxygen and nutrients needed for healing and sometimes causes spreading of cellular injury. Breaking the cycle by reducing limb swelling and restoring circulation is often the key that permits recovery to begin.

  • People should keep CRPS-affected arms and legs elevated when resting or sleeping to help excess fluid return to the heart.
  • Exercise every day–even if only for a few minutes–is critical to improve circulation and oxygenation. Physical therapists can help devise an exercise regimen.
  • For some individuals, compression stockings or sleeves can limit the swelling, particularly when standing.

Other influences on CRPS include:

Poor nerve health. Conditions such as diabetes or exposure to nerve toxins can leave the nerves less resilient. Individuals with generalized peripheral neuropathies may be unable or slow to regrow their nerve cells from an injury or stress that wouldn’t cause problems in healthy nerves. A key to CRPS recovery is improving general nerve health by removing or improving conditions that slow nerve regrowth.

Immune system involvement. The C-fiber nerve cells also communicate with immune cells to help us heal from injury. Excess or prolonged nerve signaling can dysregulate immune cells in the affected limb, as does CRPS-associated poor circulation. Some people with CRPS have elevated local levels of inflammatory chemicals called cytokines that contribute to the redness, swelling, and warmth in the CRPS-affected limb. CRPS is more common in individuals with other inflammatory and autoimmune conditions such as asthma. Some individuals with CRPS may have abnormal antibodies that promote an immune attack on small fibers.

Genetics. Genetics, along with environment, influence each person’s ability to recover from injury. Rare family clusters of CRPS have been reported. Familial CRPS may be more severe with earlier onset, greater dystonia, and the involvement of more than one limb.


How is CRPS diagnosed?

No specific test can confirm CRPS and identify the injured nerve. Diagnosis includes:

  • Detailed examination by a physician such as a neurologist, orthopedist, or plastic surgeon familiar with normal patterns of sensory nerve anatomy. Having patients draw the outline of their most abnormal skin often reveals the affected nerve.
  • Nerve conduction studies detect some but not all CRPS-associated nerve injuries (some injuries involve tiny nerve branches of that cannot be detected this way).
  • Imaging nerves by ultrasound or magnetic resonance imaging (MRI), also called magnetic resonance neurography (MRN), sometimes reveals underlying nerve damage. Characteristic bone and bone marrow abnormalities on MRI can help identify the injured nerve.
  • Triple-phase bone scans (using a dye) sometimes shows CRPS-associated excess bone resorption (the normal breakdown and absorption of bone tissue back into the body), which can help with diagnosis and localization.

Since CRPS generally improves over time, diagnosis is easiest early in the disorder and should not be delayed.


How is CRPS treated?

Most early or mild cases recover on their own. Treatment is most effective when started early.

Primary therapies that are widely used include:

Rehabilitation and physical therapy. This is the single most important treatment for CRPS. Keeping the painful limb or body part moving improves blood flow and lessens circulatory symptoms, as well as maintains flexibility, strength, and function. Rehabilitating the affected limb helps prevent or reverse secondary spinal cord and brain changes associated with disuse and chronic pain. Occupational therapy can help people learn new ways to become active and return to work and daily tasks.

Psychotherapy. People with severe CRPS often develop secondary psychological problems including depression, situational anxiety, and sometimes post-traumatic stress disorder. These heighten pain perception, further reduce activity and brain function, and make it hard for patients to seek medical care and engage in rehabilitation and recovery. Psychological treatment helps people with CRPS to feel better and better recover from CRPS.

Graded motor imagery. Individuals are taught mental exercises including how to identify left and right painful body parts while looking into a mirror and visualizing moving those painful body parts without actually moving them. This is thought to provide non-painful sensory signals to the brain that helps reverse brain changes that are prolonging CRPS.

Medications. Several classes of medication have been reported as effective for CRPS, particularly when given early in the disease. However, none are approved by the U.S. Food and Drug Administration (FDA) to be marketed specifically for CRPS, and no single drug or combination is guaranteed to be effective in everyone. Drugs often used to treat CRPS include:

  • Acetaminophen to reduce pain associated with inflammation and bone and joint involvement.
  • Non-steroidal anti-inflammatory drugs (NSAIDS) to treat moderate pain and inflammation, including over-the-counter aspirin, ibuprofen, and naproxen in sufficient doses.
  • Drugs proven effective for other neuropathic pain conditions, such as nortriptyline, gabapentin, pregabalin, and duloxetine. Amitriptyline, an older treatment, is effective but causes more side effects than nortriptyline, which is very similar chemically.
  • Topical local anesthetic ointments, sprays, or creams such as lidocaine and patches such as fentanyl. These can reduce allodynia, and skin coverage by patches can provide additional protection.
  • Bisphosphonates, such as high dose alendronate or intravenous pamidronate, that reduce bone changes.
  • Corticosteroids that treat inflammation/swelling and edema, such as prednisolone and methylprednisolone.
  • Botulinum toxin injections can help in severe cases, particularly for relaxing contracted muscles and restoring normal hand or foot positions.
  • Opioids such as oxycodone, morphine, hydrocodone, and fentanyl may be required for individuals with the most severe pain. However, opioids can convey heightened pain sensitivity and run the risk of dependence.
  • N-methyl-D-aspartate (NMDA) receptor antagonists such as dextromethorphan and ketamine are controversial unproven treatments.

Spinal cord stimulation. Stimulating electrodes are threaded through a needle into the spine outside the spinal cord. They create tingling sensations in the painful area that helps block pain sensations and normalize signaling into the spinal cord and brain. Electrodes can be placed temporarily for a few days to assess if stimulation is likely to be helpful. Minor surgery is required to implant the stimulator, battery, and electrodes under the skin on the torso. Once implanted, stimulators can be turned on and off and adjusted with an external controller.

Other types of neural stimulation. Implanted neurostimulation can be delivered at other locations including near injured nerves (peripheral nerve stimulators), under the skull (motor cortex stimulation with electrodes), and within brain pain centers (deep brain stimulation). Recent noninvasive commercially available treatments include nerve stimulation at the peroneal nerve at the knee. Another is repetitive Transcranial Magnetic Stimulation or rTMS, a noninvasive form of brain stimulation that uses a magnetic field to change electrical signaling in the brain. Similar at-home use of small transcranial direct electrical stimulators is also being investigated. These stimulation methods have the advantage of being non-invasive; however, repeated treatment sessions are needed to maintain benefit, so they require time.

Spinal-fluid drug pumps. These implanted devices deliver pain-relieving medications directly into the fluid that bathes the nerve roots and spinal cord. Typically, these are mixtures of opioids, local anesthetic agents, clonidine, and baclofen. The advantage is that very low doses can be used that do not spread beyond the spinal canal to affect other body system. This decreases side effects and increases drug effectiveness.

Alternative and holistic therapies. Based on studies from other painful conditions, some individuals are investigating accessible treatments such as medical marijuana, behavior modification, acupuncture, relaxation techniques (such as biofeedback, progressive muscle relaxation, and guided motion therapy), and chiropractic treatment. These do not benefit the primary cause of CRPS, but some people find them useful. They are generally accessible and not dangerous to try.

Limited use therapy for the most severe or non-resolving pain that has not responded to conventional treatment, such as ketamine. Some investigators report benefit from low doses of ketamine—a strong anesthetic—given intravenously for several days. In certain clinical settings, ketamine has been shown to be useful in treating pain that does not respond well to other treatments. However, it can cause delusions and other symptoms of psychosis with long-lasting impact.

Rarely used former treatments include:

Sympathetic nerve block. Previously, sympathetic blocks—in which an anesthetic is injected next to the spine to directly block the activity of sympathetic nerves and improve blood flow—were used. More recent studies demonstrate no long-lasting benefit after the injected anesthetic wears off and there is the risk of injury from needle injections, so this approach has fallen from favor.

Surgical sympathectomy. This destroys some of the nerves that carry pain signals. Use is controversial; some experts think it is unwarranted and makes CRPS worse, while others report occasional favorable outcome. Sympathectomy should be used only in individuals whose pain is temporarily dramatically relieved by sympathetic nerve blocks.

Cutting injured nerves or nerve roots. People with CRPS often ask if cutting the damaged nerve above the site of injury would end the pain. In fact, this causes a larger nerve lesion that will affect a larger area of the limb. Also, the spinal cord and brain react badly to being deprived of stimulation which can result in central pain syndromes. Other than in exceptional circumstances such as palliative care, this should not be performed.

Amputating the painful lower limb. This is an even more drastic and disabling form of nerve cutting, and the consequences are irreversible, whereas CRPS almost always improves over time, albeit sometimes slowly. Amputation is thus not appropriate for pain control alone, but it is rarely required to manage bone infection or to permit use of a prosthesis for long-affected non-recovering individuals. This last resort should not be performed without input from several specialists along with psychological counseling.


What research is being done on CRPS?

The mission of the National Institute of Neurological Disorders and Stroke (NINDS) is to seek fundamental knowledge about the brain and nervous system and to use it to reduce the burden of neurological disease. NINDS is part of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world, and leads NIH research on CRPS.

The NIH HEAL (Helping to End Addiction Long-termSM) Initiative is an ambitious trans-agency effort to speed scientific solutions to stem the national opioid public health crisis. Through the Initiative, NIH supports research to enhance pain management and improve treatment for opioid misuse and addiction. The NIH HEAL Initiative includes research focus areas led by 12 NIH Institutes and Centers supporting hundreds of projects that reflect the full spectrum of research from basic science to implementation research. In Fiscal Year 2019, NIH awarded $945 million in funding for grants, contracts, and cooperative agreements across 41 states through the HEAL Initiative. For more information, see the HEAL Initiative.

NINDS-supported scientists are studying new approaches to understand and treat CRPS, and to intervene to limit the symptoms and disability associated with the syndrome. Other NIH institutes also support research on CRPS and other painful conditions. Research efforts include:

  • understanding how CRPS develops by studying immune system activation and peripheral nerve signaling using model systems of the disease
  • genetic and other approaches to investigate the contribution of peripheral inflammatory cells and central nervous system non-neuronal cells peripherally and centrally to the acute phase of CRPS and its transition to the disorder’s chronic phase
  • examining serum and skin biopsies to better understand changes in immunity that are seen in post-traumatic CRPS. Such studies may provide support for future CRPS clinical trials using intravenous immunoglobulin (IVIG), rituximab B cell antibodies, and other FDA approved treatments for autoimmune disease
  • studying neuroplasticity in children and adolescents with CRPS—who generally have a better prognosis than adults—to gain insights into mechanisms that may prevent chronic pain and develop more effective therapies for the disease
  • experimentally evaluating the use of ketamine (which has been used in adults as an add-on therapy to treat adult chronic pain) and dexmedetomidine (which has sedative and analgesic properties) to treat pain in children; and
  • investigating the effectiveness of transcranial magnetic stimulation in reducing CRPS-related pain and associated cognitive, physical, and emotional symptoms.

More information about research on CRPS supported by NINDS and other NIH Institutes and Centers can be found using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies RePORTER also includes links to publications and resources from these projects. Enter “CRPS” to start your search.


Where can I get more information?

For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN) at:

P.O. Box 5801
Bethesda, MD 20824

Information also is available from the following organizations:

(information on peripheral nerves for patients, professionals, and researchers hosted by Harvard University)

Reflex Sympathetic Dystrophy Syndrome Association (RSDSA)
P.O. Box 502
99 Cherry Street
Milford, CT   06460

International Research Foundation for RSD/CRPS
1910 East Busch Boulevard
Tampa, FL   33612

“Complex Regional Pain Syndrome Fact Sheet”, NINDS, Publication date September 2020.

NIH Publication No. 20-NS-4173.

Complex Regional Pain Syndrome Brochure (pdf, 529 kb)

Back to Complex Regional Pain Syndrome Information Page

See a list of all NINDS disorders

Publicaciones en Español

Síndrome de Dolor Regional Complejo

Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient’s medical history.

All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.


Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments – PubMed.gov – National Library of Medicine


Review Am Fam Physician

. 2020 Oct 15;102(8):465-477.

Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments

Diane M Flynn 1Affiliations expand

  • PMID: 33064421


Chronic low back pain, neck pain, hip and knee osteoarthritis, and fibromyalgia are the most common types of chronic musculoskeletal pain. Because no individual therapy has consistent benefit, a multimodal treatment approach to chronic musculoskeletal pain is recommended. Many nonpharmacologic, noninvasive treatment approaches yield small to moderate improvement and can be used with pharmacologic or more invasive modalities. Systematic reviews and guidelines support the effectiveness of various forms of exercise in improving pain and function in patients with chronic pain. Cognitive behavior therapy and mindfulness techniques appear to be effective for small to moderate short- and long-term improvement of chronic low back pain. Cognitive behavior therapy may also be effective for small short- and intermediate-term improvement of fibromyalgia. Spinal manipulation leads to a small benefit for chronic neck and low back pain. Acupuncture has a small to moderate benefit for low back pain and small benefit for nonpain fibromyalgia symptoms. Massage or myofascial release yields a small improvement in low back pain, hip and knee osteoarthritis, and fibromyalgia. Low reactive level laser therapy may provide short-term relief of chronic neck and low back pain, and ultrasound may provide short-term pain relief for knee osteoarthritis. Multidisciplinary rehabilitation may be effective for short- and at least intermediate-term improvement in pain and function for chronic low back pain and fibromyalgia. Patients should be encouraged to engage in a variety of therapies aligned with their preferences and motivation.

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Cited by 2 articles

Publication types

  • Review

MeSH terms

  • Acupuncture Therapy
  • Chronic Pain / therapy*
  • Cognitive Behavioral Therapy
  • Exercise
  • Fibromyalgia / therapy
  • Humans
  • Low Back Pain / therapy
  • Low-Level Light Therapy
  • Manipulation, Spinal
  • Massage
  • Mindfulness
  • Muscle Relaxation
  • Musculoskeletal Pain / therapy*
  • Neck Pain / therapy
  • Osteoarthritis, Hip / therapy
  • Osteoarthritis, Knee / therapy
  • Pain Clinics
  • Patient Education as Topic
  • Ultrasonic Therapy

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NIH-funded Study Suggests Brain is Hard-wired for Chronic Pain – National Institutes of Health

NIH-funded study suggests brain is hard-wired for chronic pain


Brain’s white matter may determine susceptibility to chronic pain.Image of a brain scanScientists used the structure of the brain’s white matter (green lines) to predict whether a subject would recover from low back pain. Red dots represent differences in white matter structure between subjects who recovered and who suffered chronic pain. Apkarian lab, Northwestern University Feinberg School of Medicine.

The structure of the brain may predict whether a person will suffer chronic low back pain, according to researchers who used brain scans. The results, published in the journal Pain, support the growing idea that the brain plays a critical role in chronic pain, a concept that may lead to changes in the way doctors treat patients. The research was supported by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health.

“We may have found an anatomical marker for chronic pain in the brain,” said Vania Apkarian, Ph.D., a senior author of the study and professor of physiology at Northwestern University Feinberg School of Medicine in Chicago.

Chronic pain affects nearly 100 million Americans and costs the United States up to $635 billion per year to treat. According to the Institute of Medicine, an independent research organization, chronic pain affects a growing number of people.

“Pain is becoming an enormous burden on the public. The U.S. government recently outlined steps to reduce the future burden of pain through broad-ranging efforts, including enhanced research,” said Linda Porter, Ph.D, the pain policy advisor at NINDS and a leader of NIH’s Pain Consortium. “This study is a good example of the kind of innovative research we hope will reduce chronic pain which affects a huge portion of the population.”

Low back pain represents about 28 percent of all causes of pain in the United States; about 23 percent of these patients suffer chronic, or long-term, low back pain.

Scientists have thought the cause of low back pain could be found at the site of injury. However, recent studies suggest that the brain may be more involved with chronic pain.

“Currently we know very little about why some patients suffer chronic low back pain,” said Debra Babcock, M.D., Ph.D., a program director at NINDS. “The earlier we detect pain will become chronic, the better we may be able to treat patients.”

Dr. Apkarian and his colleagues addressed this by scanning the brains of 46 people who had low back pain for about three months before coming to the hospital but who had not had any pain for at least a year before.

The researchers scanned the subjects’ brains and evaluated their pain with doctor’s examinations and questionnaires four times over a period of one year. About half of the subjects recovered at some time during the year; the other half had pain throughout, which the researchers categorized as persistent.

Previously, the Apkarian laboratory showed that the volume of grey matter in the brains of the same subjects who had persistent pain decreased over the same year. Grey matter describes the area of the brain where the central bodies and branched antennae, or dendrites, of nerve cells reside. They also showed that brain activity could be used to predict whether a subject recovered or experienced persistent pain.

In this study, the researchers used a scanning technique called diffusion tensor imaging (DTI) which measures the structure of white matter, the nerve cell wires, or axons, which connect brain cells in different parts of the brain. They found a consistent difference in white matter between the subjects who recovered and the subjects who experienced pain throughout the year.

“Our results suggest that the structure of a person’s brain may predispose one to chronic pain,” said Dr. Apkarian.

In agreement with this idea, the researchers also found that the white matter of subjects who had persistent pain looked similar to a third group of subjects known to suffer from chronic pain. In contrast, the white matter of the subjects who recovered looked similar to that of healthy control subjects.

To test this idea further, the researchers asked whether the white matter differences they saw during the initial brain scans predicted whether the subjects would recover or continue to experience pain. They found white matter brain scans predicted at least 80 percent of the outcomes.

“We were surprised how robust the results were and amazed at how well the brain scans predicted persistence of low back pain,” said Dr. Apkarian. “Prediction is the name of the game for treating chronic pain.”

The nucleus accumbens and the medial prefrontal cortex are two brain regions thought to be involved with pain. Further examination of the brain scans suggests that the white matter structure connecting these brains regions is different between the subjects who recovered and those who had persistent pain.

“Our results support the notion that certain brain networks are involved with chronic pain,” said Dr. Apkarian. “Understanding these networks will help us diagnose chronic pain better and develop more precise treatments.”

This study was supported by a grant from NINDS (NS35115) and an anonymous foundation.

NINDS is the nation’s leading funder of research on the brain and nervous system. The NINDS mission is to reduce the burden of neurological disease – a burden borne by every age group, by every segment of society, by people all over the world.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH…Turning Discovery Into Health®


Mansour et al. “Brain white matter structural properties predict transition to chronic pain” Pain, 154, October 2013, DOI #: 10.1016/j.pain.2013.06.044

For more information about chronic pain, please visit:

For more information about NIH’s Pain Consortium, please visit:

Complementary Health Approaches for Chronic Pain: What the Science Says – National Center for Complementary and Integrative Health


NCCIH Clinical Digest

for health professionals

Complementary Health Approaches for Chronic Pain: What the Science Says

September 2016

Clinical Guidelines, Scientific Literature, Info for Patients: 
Complementary Health Approaches for Chronic Pain



In general, research on complementary health approaches for fibromyalgia must be regarded as preliminary. However, recent systematic reviews and randomized clinical trials provide encouraging evidence that practices such as tai chi, qi gong, yoga, massage therapy, acupuncture, and balneotherapy may help relieve some fibromyalgia symptoms.

The Evidence Base

The evidence base on efficacy of complementary health approaches for fibromyalgia consists of mostly preliminary research. More recent systematic reviews and randomized clinical trials provide encouraging evidence that practices such as tai chi, qi gong, yoga, acupuncture, mindfulness, and biofeedback may help relieve some fibromyalgia symptoms. There is insufficient evidence that any natural products can relieve fibromyalgia pain, with the possible exception of vitamin D supplementation, which may reduce pain in people with fibromyalgia who have vitamin D deficiencies. Current diagnostic criteriaare available from the American College of Rheumatology. Treatment often involves an individualized approach that may include both pharmacologic therapies (prescription drugs, analgesics, and NSAIDs) and nonpharmacologic interventions such as exercise, muscle strength training, cognitive-behavioral therapy, movement/body awareness practices, massage, acupuncture, and balneotherapy.


  • Natural products. Small studies have examined various natural products—such as topical creams containing capsaicin or dietary supplements like S-adenosyl-L-methionine (SAMe) or soy—for fibromyalgia. A 2010 systematic review concluded that there is not enough evidence to determine whether these products provide a health benefit.
  • Mind and body approaches. Findings from some studies of tai chi, yoga, mindfulness training, and biofeedback for fibromyalgia symptoms suggest beneficial effects, but the evidence is too limited to draw definitive conclusions about whether these approaches are helpful.
  • Acupuncture. A 2013 Cochrane review of 9 studies involving a total of 395 participants found low-to-moderate evidence that acupuncture improves pain and stiffness in people with fibromyalgia, compared with no treatment and standard therapy. The reviewers also found moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.


  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients should modify or avoid certain tai chi postures due to acute back pain, knee problems, bone fractures, sprains, and osteoporosis.


Several dietary supplements, including riboflavin, coenzyme Q10, and the herbs butterbur and feverfew, have been studied for migraine, with some promising results in preliminary studies. Results of research on mind and body practices such as relaxation training, biofeedback, acupuncture, and spinal manipulation for headaches suggest that these approaches may help relieve headaches and may be helpful for migraines.

The Evidence Base

  • The evidence base on efficacy of natural products for relieving headaches comes from small randomized controlled trials. A 2012 update to an evidence-based guideline from the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society provides recommendations on some dietary supplements for episodic migraine prevention in adults based on a review of 15 studies.
  • The evidence base on efficacy of mind and body practices such as relaxation training, acupuncture, and spinal manipulation for headaches consists of reviews of data from randomized controlled trials, and the evidence base for biofeedback, tai chi, and massage therapy for headaches consists of only a few small, randomized controlled trials.


  • Natural products. The Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society issued an update in 2012 to existing evidence-based guidelines on NSAIDs and other complementary health approaches for episodic migraine prevention in adults. The review supporting these recommendations found:
    • In two studies, butterbur (petasites) significantly reduced the frequency of migraines compared with placebo. In the first study, butterbur reduced the frequency of attacks by 3.3 ± 1.5 to 1.8 ± 0.8 attacks/month after 4 weeks, to 1.3 ± 0.9 attacks/month after 8 weeks, and to 1.7 ± 0.9 attacks/month after 12 weeks (p ≤ 0.05). In the second study, two separate dosages of butterbur (75 mg BID and 50 mg BID) reduced the frequency of migraines (48 percent and 36 percent, respectively) compared with placebo (26 percent). Based on these studies, the guidelines state that butterbur “should be offered to patients with migraine to reduce the frequency and severity of migraine attacks.”
    • Riboflavin, magnesium, and feverfew are probably effective for migraine prevention.
    • In one small study, coenzyme Q10 was more effective than placebo in reducing frequency of migraines from baseline to 4 months post-treatment. Based on this single study, the guidelines indicate that coenzyme Q10 is “possibly effective” for migraine prevention.
  • Biofeedback. The efficacy of biofeedback has been evaluated in numerous studies for tension headaches, with positive results. However, a 2009 systematic review of 11 randomized controlled trials concluded that there is conflicting evidence on the effectiveness of biofeedback compared with placebo to prophylactic drugs or any other treatment. Several studies have shown biofeedback decreased the frequency of migraines. A 2007 meta-analysis of 55 studies found a modest effect for biofeedback interventions and was seen lasting over an average followup phase of 17 months. However, a 2008 review concluded that biofeedback has beneficial clinical effects for migraine but whether those effects are specific or non-specific remains unclear.
  • Relaxation techniques. There is limited evidence to support the efficacy of relaxation techniques for tension-type headaches. A 2009 systematic review of eight studies comparing relaxation training to wait list conditions found inconsistent results. Authors of the review concluded that there is no indication, based on current evidence, that relaxation training is better than no treatment or a placebo. A 2008 meta-analysis of 53 studies suggests that relaxation training is less effective than biofeedback. The US Headache Consortium guidelines for management of migraines include behavioral and physical treatment recommendations based on evidence from 39 controlled trials. The guidelines indicate that relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine and combined with preventive drug therapy to achieve additional clinical improvement for migraine relief.
  • Tai chi. Data are too limited to draw meaningful conclusions about whether tai chi is effective for tension-type headaches. One small clinical trial (n=47) suggested that a 15-week program of tai chi was effective in reducing the impact of tension-type headaches when compared to a wait-list control group.
  • Acupuncture. The combined results from studies evaluating the efficacy of acupuncture for headaches indicate that acupuncture may provide beneficial clinical effects, but whether those effects of acupuncture treatment are specific or non-specific has not been determined, and is under active investigation. A 2012 individual patient data meta-analysis concluded that acupuncture can be a reasonable referral option for chronic pain conditions, including headache.
  • Massage therapy. Limited evidence from two small studies suggests massage therapy is possibly helpful for migraines, but clear conclusions cannot be drawn. A 2011 systematic review of these two studies concluded that massage therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
  • Spinal manipulation. Findings from numerous systematic reviews on spinal manipulation for headaches are contradictory. A 2011 review concluded that higher-quality systematic reviews are needed before the benefit of spinal manipulation for headaches can be defined.


  • Riboflavin and coenzyme Q10 are generally well tolerated, but magnesium supplements may cause diarrhea.
  • In clinical trials, use of feverfew was associated with mild adverse effects such as open sores in the mouth and upset stomach. Butterbur is generally well tolerated but may cause mild gastrointestinal upset. Some butterbur products contain the potentially harmful chemicals pyrrolizidine alkaloids (PAs). Butterbur products labeled or certified as PA-free are also available.
  • Riboflavin supplements, feverfew, and butterbur are not recommended for pregnant women.
  • Relaxation techniques are generally considered safe for healthy people; however, there have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain mental illnesses, or with a history of abuse or trauma.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients with acute back pain, knee problems, bone fractures, sprains, and osteoporosis may need to modify or avoid certain tai chi postures.
  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were addressed. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke. Safety remains an important part of ongoing research.

Irritable Bowel Syndrome (IBS)

Although no complementary health approach has definitively been shown to be helpful for irritable bowel syndrome (IBS), some studies on hypnotherapy and probiotics have been promising.

The Evidence Base

  • The evidence base on efficacy of complementary health approaches for IBS comes from a 2014 American College of Gastroenterology monograph; a few, large, well-designed studies; and other studies with methodological flaws.


  • Hypnotherapy. A 2014 American College of Gastroenterology monograph found evidence that a variety of psychological therapies, including hypnotherapy, may be effective in improving IBS symptoms; however, the quality of evidence is very low. Findings from a 2013 systematic review indicated that hypnotherapy may provide beneficial clinical effects for managing IBS symptoms; however, the studies were of poor quality. Another 2013 systematic review of three randomized controlled trials in children showed benefits of hypnotherapy over standard medical care.
  • Herbal medicine. Much of the research on herbal remedies for IBS has been done in China. A 2006 Cochrane review of 71 herbal remedies compared to placebo or conventional pharmacologic treatment found limited evidence suggesting that a few of these herbal remedies might help improve IBS symptoms including abdominal pain, constipation, and diarrhea. However, the review emphasizes that the studies were generally of poor quality.
  • Peppermint oil. Results from studies on peppermint oil for IBS are mixed, but there is some evidence that enteric-coated peppermint oil capsules may be modestly effective in reducing several common symptoms of IBS—especially abdominal pain, bloating, and gas. The 2014 American College of Gastroenterology monograph on the management of IBS and idiopathic constipation identified 5 randomized controlled trials involving a total of 482 participants and gave a “weak” recommendation, based on moderate quality of evidence, for the use of peppermint oil for IBS. A 2011 Cochrane review of 56 studies found statistically significant benefits of antispasmodics, including peppermint oil. The review concluded that there is evidence to support the use of antispasmodics, such as peppermint oil, for the treatment of IBS.
  • Probiotics. Probiotics have been associated with an improvement in IBS symptoms compared with placebo. A 2010 systematic review of 19 randomized controlled trials in 1,650 patients found that probiotics were statistically significantly better than placebo; however, the authors concluded that the magnitude of benefit and the most effective species and strain are uncertain. The 2014 American College of Gastroenterology monograph on the management of IBS and idiopathic constipation found that aggregated data do indicate that probiotics improve global symptoms, bloating, and flatulence in IBS; however, quality of evidence is low and recommendations regarding individual species, preparations, or strains cannot be made because of insufficient and conflicting data. Recommendations regarding individual species, preparations, or strains cannot be made at this time because of insufficient and conflicting data.
  • Acupuncture. A few small studies have indicated that acupuncture has some positive effect on quality of life in people with IBS, but in general, systematic reviews have concluded that there is no convincing evidence to support the use of acupuncture for the treatment of IBS symptoms. A 2012 Cochrane review of 17 randomized controlled trials found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life. However, in comparative effectiveness Chinese trials, patients reported greater benefits from acupuncture than from two antispasmodic drugs (pinaverium bromide and trimebutine maleate), both of which have been shown to provide a modest benefit for IBS.
  • Other approaches. Evidence for other complementary health approaches sometimes tried in treating IBS—including melatonin, meditation, reflexology, yoga, and herbal remedies such as artichoke—is too limited to draw any conclusions about effectiveness.


  • Non-enteric coated forms of peppermint oil may cause or worsen heartburn symptoms.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Most people do not experience side effects from probiotics or have only mild gastrointestinal side effects such as gas. But some case reports exist of serious adverse events, and research on safety is ongoing. A 2008 review of probiotics safety noted that Lactobacillus rhamnosus GG has been widely studied in clinical trials for a variety of conditions and generally found to be safe. However, a recent review of Lactobacillus and Bifidobacterium noted that the long-term, cumulative effects of probiotics use, especially in children, are unknown, and also pointed to evidence that probiotics should not be used in critically ill patients. A 2011 Agency for Healthcare Research and Quality assessment of the safety of probiotics, partly funded by NCCIH, concluded that the current evidence does not suggest a widespread risk of negative side effects associated with probiotics. However, the data on safety, particularly long-term safety, are limited, and the risk of serious side effects may be greater in people who have underlying health conditions.

Low-Back Pain

Evidence-based clinical practice guidelinesfrom the American College of Physicians and the American Pain Society (ACP/APS) provide a useful algorithm for diagnosis and treatment of patients with chronic low-back pain. In general, the guidelines recommend a conservative approach to diagnosis and treatment, except when patients have progressive neurologic deficits or cauda equina syndrome, or are suspected of having underlying conditions requiring urgent intervention (e.g., vertebral infection or cancer with impending spinal cord compression).

  • The systematic review supporting these recommendations (Chou and Huffman, Ann Intern Med. 2007;147(7):492–504) found:
    • Good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks’ duration) low-back pain.
    • Fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low-back pain.
  • The guidelines recommend that practitioners consider these non-pharmacologic interventions as appropriate options when treating patients whose low-back pain does not improve with more conservative self-care.
  • It is important to know that interpreting and summarizing current evidence about diagnosis and treatment of chronic low-back pain is particularly challenging because of major differences in patient populations, eligibility criteria, diagnostic studies, treatments, and outcome measures across different studies, and the variety of health care professions involved in care of patients.
  • Read more on the current evidence about spinal manipulation, acupuncture, massage, and yoga—the complementary approaches most often used by people for chronic low-back pain.

The Evidence Base

  • The evidence base on efficacy of several mind and body approaches such as spinal manipulation, acupuncture, massage, and yoga consists of several independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.


  • Spinal manipulation. The systematic review supporting the 2007 clinical practice guidelinesfrom the ACP/APS found good evidence that spinal manipulation (as well as cognitive-behavioral therapy, exercise, and interdisciplinary rehabilitation) are all moderately effective for chronic or subacute (>4 weeks’ duration) low-back pain. A 2010 Agency for Healthcare Research and Quality (AHRQ) systematic review concluded that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. The researchers did not find consistent differences when they compared spinal manipulation with massage or physical therapy. A 2011 Cochrane reviewof 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function.
  • Acupuncture. A rigorous 2012 patient data meta-analysis found clear evidence that acupuncture is useful in treating chronic back and neck pain, and the investigators concluded that it is therefore a reasonable referral option. While they found evidence of acupuncture-specific effects attributable to needling, suggesting that acupuncture is more than an elaborate placebo, they noted that these effects are relatively modest and that other non-acupuncture-specific factors are major contributors to the clinical benefit. Findings from a 2016 review of evidence suggest that acupuncture can help some patients manage low-back pain.
  • Massage. A 2015 Cochrane review found evidence that massage may provide short-term relief from low-back pain, but the evidence is not of high quality. The long-term effects of massage for low-back pain have not been established.
  • Yoga. In a 2011 study, researchers compared yoga (a protocol developed using the principles of viniyoga) with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. The investigators concluded that yoga classes were more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing symptoms due to chronic low-back pain, with benefits lasting at least several months. Conclusions from another 2011 study of 313 adults with chronic or recurring low-back pain suggested that 12 weekly yoga classes resulted in better function than usual medical care.
  • A systematic review supporting the 2007 ACP/APS clinical practice guidelinesfound fair evidence that acupuncture, as well as massage, yoga, and functional restoration are effective for chronic low back pain and included them as options physicians should consider when patients with chronic low-back pain do not respond to conventional treatment.
  • Natural products. A 2014 Cochrane review of 14 randomized controlled trials involving 2,050 participants found preliminary evidence that devil’s claw and white willow bark (taken orally) may be helpful for low-back pain over the short-term. Topical preparations of cayenne, comfrey, Brazilian arnica, and lavender essential oil may provide some pain relief, although evidence for these natural products was of moderate quality at best.


  • Many reviews have concluded that spinal manipulation for low-back pain is relatively safe when performed by a trained and licensed practitioner. The most common minor side effects include feeling tired and temporary soreness. There have been a few reports of cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, following spinal manipulation. However, the vast majority of cases of CES are not associated with previous spinal manipulation, and in the few cases that are, it is unclear whether this is a complication of manipulation or an underlying disease condition which is causing back pain.
  • In people whose pain is caused by a herniated disc, manipulation of the low back appears to have a very low chance of worsening the herniation. For risks associated with spinal manipulation affecting the upper (cervical) spine, see the NCCIH fact sheet Chiropractic: An Introduction.
  • Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Massage therapy appears to have few risks when performed by a trained practitioner. However, massage therapists should take some precautions with certain health conditions. In some cases, pregnant women should avoid massage therapy. People with conditions such as bleeding disorders, thrombocytopenia and those taking anticoagulant medications should avoid forceful and deep tissue massage. Massage should not be done in any potentially weak area of the skin, such as wounds.
  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. However, injuries from yoga, some of them serious, have been reported in the popular press. People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

Neck Pain

Available evidence indicates that acupuncture for neck pain may provide better pain relief compared to no treatment. There is some evidence that spinal manipulation may help relieve neck pain, but much of the research on has been of low quality.

The Evidence Base

  • The evidence base on efficacy of spinal manipulation and acupuncture for neck pain consists of several systematic reviews. The evidence base on efficacy of massage for neck pain is based on several small studies of poor quality and a 2013 systematic review.


  • Manual therapies. Reviews of research on manual therapies (primarily manipulation or mobilization) and acupuncture for chronic neck pain have found mixed evidence regarding potential benefits and have emphasized the need for additional research. A 2015 Cochrane review of 51 randomized controlled trials involving a total of 2,920 participants concluded that there is some evidence to support the use of thoracic manipulation versus control for neck pain, function, and quality of life; however, results for cervical manipulation and mobilization are few and diverse. The reviewers noted that these findings suggest that manipulation and mobilization present similar results for each outcome at immediate-, short-, and intermediate-term followup. Multiple cervical manipulation sessions may provide better relief of pain and improvement in function than certain medications at immediate-, intermediate-, and long-term followup. Because there is risk of rare but serious adverse events for manipulation, more rigorous research is needed on mobilization, and comparing mobilization and manipulation versus other treatment options. A 2007 review noted that clinical guidelines often endorse the use of manual therapies for neck pain, although there is no overall consensus on the status of these therapies.
  • Massage therapy. A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2013 Cochrane reviewof 15 trials on massage therapy for neck pain showed “very low level evidence” that certain massage techniques may have been effective in reducing pain and improving function. Authors of the review concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.


  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke, which involves the arteries that supply blood to the back of the brain. Safety remains an important part of ongoing research.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.


Clinical practice guidelines issued by the American College of Rheumatology recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and non-pharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines conditionally recommend tai chi, along with other non-drug approaches such as self-management programs and walking aids, for managing knee OA. Acupuncture is also conditionally recommended for those who have chronic moderate-to-severe knee pain and are candidates for total knee replacement but can’t or won’t undergo the procedure.

The Evidence Base

  • The evidence base on efficacy of various complementary health appraches for osteoarthritis consists of several independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.


  • Glucosamine and chondroitin. The preponderance of evidence on glucosamine and chondroitin sulfate—taken separately or together—indicates little or no meaningful effect on pain or function. Independent clinical practice guidelines published in 2012 by the American College of Rheumatology(ACR) (95KB PDF), and in 2010 by the American Academy of Orthopaedic Surgeons (AAOS) recommend not using glucosamine or chondroitin for OA. Recommendations from Osteoarthritis Research Society International(OARSI) published in 2014 conclude that current evidence does not support use of glucosamine or chondroitin in knee OA for disease-modifying effects, but leave unsettled the question of whether either may provide symptomatic relief.
  • DMSO and MSM. DMSO and MSM are two chemically-related dietary supplements that have been used for arthritic conditions. However, evidence does not suggest that DMSO and MSM are helpful for OA symptoms.
  • SAMe. SAMe is a molecule that is naturally produced in the body and is often taken as a dietary supplement. There is not enough evidence to support the use of SAMe for OA of the knee or hip.
  • Herbs. Although some results suggest that a few herbs such as ginger, avocado-soybean unsaponifiables (ASUs), and the Ayurvedic herb Boswellia serrata, taken orally, may be have modest benefits for OA symptoms, the overall evidence is weak. There is some evidence that topical arnica gel and comfrey gel may also be helpful. In addition, not all herbs have been studied or prepared in a consistent way, and conclusions among reviews of the literature provide conflicting interpretations. There is also a general lack of safety data available for many herbs.
  • Acupuncture. A 2012 meta-analysis concluded that acupuncture can be helpful and a reasonable referral option for OA pain. The authors of the meta-analysis also noted that significant differences between true (actual) and sham acupuncture indicate that acupuncture is more than a placebo; however, these differences are relatively modest. Findings suggest that factors other than the specific effects of needling contribute to the therapeutic effects of acupuncture. In a 2008 systematic review of 10 randomized controlled trials of acupuncture for OA of the knee in 1,456 patients, the authors concluded that these studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with OA of the knee. A 2010 systematic review of 16 trials of 3,498 patients examined the effects of acupuncture for OA in peripheral joints and found that although acupuncture, when compared to a sham treatment, showed statistically significant, short-term improvements in OA pain, the benefits were small and not clinically relevant. In contrast, acupuncture, when compared to a waiting list control, showed statistically significant and clinically relevant benefits in people with peripheral joint OA.
  • Massage therapy. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physicial functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function.
  • Tai chi. A 2013 meta-analysis of 7 randomized controlled trials involving 348 participants found that a 12-week course of tai chi provides benefits of improvement in arthritic symptoms and physical function in patients with OA; however, any long-term benefits of tai chi on OA symptoms has not yet been investigated. A 2013 systematic review and meta-analysis of 5 randomized controlled trials involving 252 participants found moderate evidence for short-term improvement of pain, physical function, and stiffness in patients with OA of the knee who practiced tai chi. A 2009 prospective, single-blind, randomized controlled trial of 40 participants found that tai chi demonstrated significantly greater improvement in pain and physical function, as well as improvement in depression, self-efficacy, and quality of life.


  • There are few complications associated with acupuncture, but adverse effects such as minor bruising or bleeding can occur; infections can result from the use of nonsterile needles or poor technique from an inexperienced practitioner.
  • Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.
  • Tai chi is considered to be a safe practice.

Rheumatoid Arthritis

While conventional medical therapies such as biologic agents or disease-modifying antirheumatic drugs (DMARDs) are able to modify the disease course of rheumatoid arthritis (RA) and prevent erosions, no natural product has been shown to alter the course of the disease. Omega-3 fatty acids found in fish oil may have modest benefits in relieving RA pain symptoms. No other dietary supplement has shown clear benefits for RA, but there is preliminary evidence for a few, particularly fish oil, gamma-linolenic acid, and the herb thunder god vine. However, serious safety concerns have been raised about thunder god vine. Results from clinical trials suggest that some mind and body practices—such as relaxation, mindfulness meditation, tai chi, and yoga—may be beneficial additions to conventional treatment plans, but some studies indicate that these practices may do more to improve other aspects of patients’ health than to relieve pain.

The Evidence Base

  • The evidence base on the efficacy of natural products such as fish oil and Gamma-Linolenic Acid (GLA ) for rheumatoid arthritis consists of several randomized controlled trials. The evidence base on efficacy of other natural products—thunder god vine, boswellia, ginger, green tea, and turmeric—are from laboratory studies.
  • The evidence base on efficacy of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training for rheumatoid arthritis symptoms consists of a 2010 systematic review. Only a few small randomized controlled trials have been conducted on acupuncture, tai chi, and yoga for RA.


  • Fish oil. Clinical trials on RA have found that fish oil supplements may help alleviate tender joints and morning stiffness. Other studies have found that fish oil may reduce the daily NSAID requirement of RA patients. Results of a 2008 randomized, controlled trial found that compared with placebo, participants who received a blend of cod liver oil and fish oil over a 9-month period reduced their NSAID intake by more than 30 percent.
  • GLA. There is some preliminary evidence that GLA (gamma linolenic acid) may be beneficial for RA; however, the quality of the studies on GLA has been inconsistent. The more rigorous studies suggest that GLA may relieve symptoms such as joint pain, stiffness, and tenderness; in some cases, GLA led to a decreased need for NSAID medication. A 2011 Cochrane reviewfound evidence from seven studies indicating potential benefits of GLA from evening primrose oil, borage seed oil, or blackcurrant seed oil, in terms of reduced pain intensity; improved disability; and an increase in adverse events that was not statistically different.
  • Thunder god vine. Findings from laboratory and animal studies suggest that Tripterygium wilfordii (thunder god vine) may fight inflammation and suppress the immune system. A 2011 Cochrane reviewexamined three human studies of oral thunder god vine and one study of topical thunder god vine for RA and concluded that Tripterygium wilfordii products may reduce some RA symptoms, however, oral use may be associated with several side effects.
  • Acupuncture. Acupuncture has been studied for a variety of pain conditions, but very little acupuncture research has focused on RA. A 2010 Cochrane reviewof two studies—one on acupuncture and the other on electroacupuncture for RA—concluded that acupuncture has no effect on ESR, CRP, pain, patient’s global assessment, number of swollen joints, number of tender joints, general health, disease activity, and reduction of analgesics. Although findings from the study on electroacupuncture showed that electro-acupuncture may reduce symptomatic knee pain, the review noted that the poor quality of the trial, including the small sample size, preclude its recommendation.
  • Mindfulness, biofeedback, and relaxation training. A 2010 systematic review of 31 studies in 2,021 patients looked at the benefits of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training on the physical and psychological symptoms associated with RA. There was some evidence that these techniques may be helpful, but overall, the research results have been mixed. A 2008 study of 144 patients compared cognitive-behavioral therapy emphasizing pain management with mindfulness meditation for RA. Findings from the study indicated that mindfulness meditation improved participants’ ability to cope with pain. Participants with a history of depression responded better than others to mindfulness meditation.
  • Tai chi. A few small studies have been conducted on tai chi for RA. A 2007 systematic review concluded that tai chi has not been shown to be effective for joint pain, swelling, and tenderness, although improvements in mood, quality of life, and overall physical function have been reported. A small 2010 study of 15 participants found that tai chi improved lower-limb muscle function post-treatment and at the 12-week followup; however, there was no evidence that it reduced disease activity or pain.
  • Yoga. Yoga incorporates several elements of exercise that may be beneficial for arthritis, including activities that may help improve strength and flexibility. A 2013 systematic review of 8 randomized controlled trials involving a total of 559 participants found very low evidence on the effects of yoga on pain associated with RA.


  • Omega-3 fatty acid supplements usually do not have serious adverse effects, but may extend bleeding time. People taking anticoagulants or NSAIDs should use caution. Products made from fish liver oils may contain vitamins A and D as well as omega-3 fatty acids, which can be toxic in large doses.
  • Side effects of GLA may include headache, soft stools, constipation, gas, and belching. Some borage oil preparations contain chemicals called pyrrolizidine alkaloids that may harm the liver.
  • A systematic review on thunder god vine for RA concluded that serious side effects occurred frequently enough that the risk of using it outweighs its benefits. Depending on the dose and type of extract, thunder god vine may cause serious side effects. Thunder god vine can affect the reproductive system, possibly causing menstrual changes in women and infertility in men. Long-term use may decrease bone mineral density in women, potentially increasing the risk of osteoporosis. Other side effects can include diarrhea, upset stomach, hair loss, headache, and skin rash.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Some people have reported soreness, but most studies have found that tai chi is relatively safe for people with RA.
  • People with RA who have limited mobility or spinal problems should perform yoga exercises with caution. People with RA may need assistance in modifying some yoga postures to minimize joint stress and may need to use props to help with balance.




Irritable Bowel Syndrome

Low-Back Pain

Neck Pain


Rheumatoid Arthritis

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH’s Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH website at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.


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Clinical Digest Archive

Infographic: The Path to Chronic Pain – Curable

Chronic pain looks different for everyone.

For some, the journey begins in childhood (Step #1). For others, it begins at the onset of symptoms (Step #6). Both paths are equally valid and real.

The path to chronic pain infographic - Curable

Tap here to download a printable version of this infographic.

Did anything you see here surprise you? Here are a few things to keep in mind as you allow this information to settle:

  • This is not a comprehensive list of all the factors that contribute to chronic pain. Anything that’s happened in your brain, body, or life could play a role.
  • You may find that ALL of these factors are relevant to you, or that only a few of them are. Either way, your pain is very real and your experience is valid.
  • Everything depicted in this infographic is a natural, human response. If any of these factors influence your pain, it does not mean that you have done anything wrong.
  • The development of chronic pain is not your fault AND there are things you can do to break the cycle. Both of these things can be true.

Pain – National Center for Complementary and Integrative Health



Pain is the most common reason for seeking medical care. It is also a common reason why people turn to complementary and integrative health approaches. If you are considering such an approach for pain, this information can help you talk with your health care provider.

NCCIH supports and conducts pain research at the NIH labs in Bethesda, Maryland and by funding research and grants around the country. We also provide information for both consumers and health professionals.

What’s New

Consumer Information on Pain

Pain Program at the NCCIH Labs

Grant Funding for Pain Initiatives

Health Professional Information

Friday Morning Inspiration – Marian Griffey, ACPA Facilitator

Good morning, everyone!

At this time yesterday (shortly before 5:00a.m.) the temperature was already 91 degrees. The barometric pressure was intense, and the humidity level so high the concrete was sweating. By 10:00a.m. the sun was too intense for anything but ants/mosquitoes. Our first small-group parking-lot Pain Management session proved to be a test of our willingness/need to seek one another’s company/support. Weather conditions might have taken our minds off of our physical pain, but gave us another kind of misery to contemplate. Were we increasing our risk of skin cancer in lieu of risking our lives to potential exposure to COVID?

This pandemic has occupied our thoughts/dictated our actions for these many long months. We waited like prisoners in our homes for the date of freedom to be announced. We were as giddy as five year old children two days before Christmas as we gathered at the Senior Center again, happy to be reunited and looking forward to the “normal” weekly gathering. Unfortunately, it took only one person one visit to put our entire Group into a state of uncertainty/fear. Coming from a COVID hotspot, she brought our indoor gathering to an abrupt halt.

I am reminded of a health lecture that was given many years ago, when AIDS had swept a broad stroke of panic/uncertainty across the world. The speaker cautioned her young-mind audience to be aware of the fact that the person you choose to have sex with is bringing with him/her all the other people they have had sex with, referring to the microscopic organisms transmitted person-to-person.

I am also remembering a graphic commercial showing the power/volume/ coverage of a single sneeze. … And the black-light revelation of how our hands transmit germs to everything we touch. …

Spray infection image (coronavirus) for synthesis on black background

Similarly, we transmit bits-n-pieces of self everywhere we go, to everyone we meet. We wash our hands with soap/water, sanitize them and the surfaces we touch. We wear a mask, take precautions, and exhaust ourselves with thinking/ planning/doing the best we can. Yet, there is no shield of protection, no guarantee that we are 100% safe 100% of the time. We simply do what we can, wherever we are, with what we have. We do our best to be our best for sake of self/others. It’s not a contract that promises a reward or a star-studded crown. It’s simply common sense.

Which is why Group members unanimously voted to stop meeting indoors. We care about one another enough to adjust our behavior for the greater good. And so, we met outdoors … in the heat/humidity … amongst the ants/mosquitoes … for as long as we could tolerate conditions. We laughed together. We shared joy at the sight of wood-stork, ibis, anhinga, hawks, dragonflies … . We filled out eyes with Nature, blue sky, a zillion shades of green, sunlight sparkling on the pond. We watched parents/children enjoying playtime in the Park, and marveled at the ability of people who could play tennis/pickle ball/disc golf despite the sun/heat/humidity. We waved to friends as they drove by or crossed the parking lot.

We found our personal point-of-balance in the process. Discovered how to adjust our thoughts/feelings from “loss” to “joy”. Quality versus quantity! Indoors, we would have been more physically comfortable. Out there, we found a greater sense of shared thoughts/feelings/experiences. We created happy brain-files that we now share in common, and that’s just about the best pain-management “tool” we could ever have!

CRAFTSMAN Portable 20.5-in Ball-bearing 3-Drawer Red Steel Lockable Tool Box  in the Portable Tool Boxes department at Lowes.com

LAST WEEK’S NEURON-STRETCHING CHALLENGE:Who wrote: “… at some point we have to make a plan. … There’s a time for propping things up, and then there is past time.”

ANSWER: Barbara Kingsolver, from her latest novel “Unsheltered”. 

THIS WEEK’S NEURON-STRETCHING CHALLENGE:(A) Who; and, (B) in what year — instituted a project to preserve all known literature and knowledge, resulting in a massive encyclopedia of 4,000 volumes, covering a period from the 11th to the 13th centuries?

I hope you are discovering that your toolbox of pain-management tools is a reliable resource, readily available, and with room for additional tools. Tell me, please-n-thanks, what tool(s) you’ve used lately that made you smile despite the pain, which one(s) assisted you in creating happy brain-files. Isn’t it remarkable — this magic thing of giving/sharing “tools” and yet never depleting our supply?

Tool Kit: Pain Self-Management Program PRE-ORDER NOW!

Stay kind. Stay sharing-n-caring. Stay aware of how many lives your life is influencing. Toss a wave/smile as you move through the world. Let that be the next pandemic to circle the globe! 

Gentle hugs/much love,Marian

Tips for Facilitating Online Peer Support Groups – WordPress

Tips for Facilitating Online Peer Support Groups


“In times of crisis people want to know that you care,
more than they care what you know.”
~~ Will Rogers

This resource is under development…
…for facilitators of online peer support groups by facilitators of online peer support groups.

Why create these tips?

There is a lot of information available about online technology and online “business meetings,” but not a lot about facilitating online peer support groups. So a group of us came together and said, “let’s write this together, as peers, based on our lived experience of facilitating/attending these kinds of groups.” We’ve been meeting weekly, having conversations about what we’re learning, and adding to this list of “tips” through a collaborative and mutual learning process.

We invite you to join us at one of our meetings. Send a request to join at the end of this page. We currently meet on Tuesdays at 5:15 pm (Eastern). Other facilitators are holding meetings throughout the state on different days of the week, times of day as seen in our Online Support Groups page. Whether you can join us online or just want to share your ideas and experiences — both from facilitating live support groups as well as attending online groups — we welcome your contributions.

Questions we asked:

(Click a question to jump to discussion about the question)

Guidelines and Resources we liked:

Acknowledgements and Contact Info

What makes an online group good?

The consensus was inclusiveness is important. People need to feel welcome, respected, and that they matter. This can be harder to achieve in an online environment.

An ideal group size is 10-12 people. People are able to participate without hiding out or tuning out. If  more than 12 show up, the facilitator may use breakout rooms (if available) to divide into smaller groups and ask a co-facilitator, or someone in the small group to lead the discussion. The  goal is to give everyone who came a chance to give and receive mutual support.

Having agreements (guidelines, principles of support) about how members will support themselves and each other is important. These might be read by the group and then posted in the chat. Examples of group agreements are provided below.

Consider Technology Inequality

Disparities exist related to access to technology and technical experience. Having everyone on video may not be possible for those without home computers or smartphones. Others may lack experience with the technology. Still others may feel uncomfortable with the way their background (home) environment might show up on video. Whatever the reason, don’t engage in video shaming. Meet people where they’re at and help them to feel as supported as possible.

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What role does an online facilitator play that is different?

As with in-person peer support groups, the facilitator is still an equal member of the group with an added task of opening up the group, orienting the group to the technology, striving for equal opportunities for sharing during the group, and closing the group.

A good facilitator is neither a teacher nor an expert. A guide on the side not a sage on the stage. To shift from “teacher” to “facilitator” ask yourself, W.A.I.T. (Why am I talking?)  Use the role to manage time and discussion so members feel like they contributed or got something of value from attending. The facilitator can chime in with personal examples from time to time, but at the end of the group, all members should feel ownership, like, “we did it for ourselves.”

In an online group, the facilitator may need to give newcomers an orientation to the audio and video controls of the technology, such as how to mute and unmute the audio, turn the camera on or off, use the chat,  and explain when to use these features in the group.


It is harder for a solo facilitator to manage the technology and the interpersonal aspects of a group. Having a co-facilitator can be helpful. One facilitator can manage the group process while the other can provide the technical support.

For example, the main facilitator can open the group on time, welcome everyone, give an orientation to the format and support agreement, and encourage participation in group discussion. The second facilitator can give the orientation to the technology and keep an eye on video and phone lines for background noise, which can be muted manually if the co-facilitator has host/co-host privileges. This can be very important as echoes sometimes happen when people join from multiple devices (phone and computer at the same time). The second facilitator can also manage the process of creating breakout rooms if the group size becomes too large and the group decides to split into smaller groups.

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What is the best format or structure for an online group?

There are a lot of different group types and formats.

    • Open (drop in) groups
    • Closed (groups that have bonded over a shared topic or task)
    • Support
    • Task-focused

The purpose of the group should be clear to all participants, including the time commitment and expectations of participation. As is true of in-person groups, online groups can be chaotic if you don’t have an agenda or plan. At a minimum, be sure you know how you will open the group, orient people to the technology, allow sharing during the group, and close the meeting.

Opening the group

Briefly introduce yourself, describe how to mute and unmute and use the Chat feature. Ask everyone to “check in” with something simple like, “tell us who you are, where you are, and what you do.” Adding a visual icebreaker, like “show us what you are wearing on your feet,” can be short, fun, and helpful to make people feel relaxed.

If you demo a brief and lighthearted introduction, others are likely to do the same.

While members are checking in, jot down a list of who joined to organize the conversation and keep track of who has spoken. This can help you to facilitate giving everyone an opportunity to share something.

Support or Comfort Agreement

Support or comfort agreements are based on mutual support and offer a common language and set of expectations for the way group members will treat themselves and each other with respect.

Some examples can be found below. Adapt them for your own group members. Use principles and a format that works best for the culture of your group.

Invite participants to read the agreements or principles and add items of their own. Ask: “what will help you stay present?” Members might add, “drink water,” or “get up and stretch,” or “tell a joke and laugh out loud.”

After everyone has had a chance to contribute, post the agreements in the chat where group members can see them throughout the rest of the group. The agreement can be revisited and used as a way of deepening the conversation around the values of mutual support.

Language matters. Encourage everyone to use human language and avoid jargon.

Group Discussion

A group may be based on a specific topic, or members may bring issues they want to get support on. In either case, give the format and how they know they can take a turn to speak.

You might go around in a circle, like a “virtual” talking stick, and call upon people one by one in the order they arrived contribute (this is where keeping a list as they enter the group or do the initial check-in can be handy). Or, ask people to raise their hand (you can see it if they are on video) and call upon them. If people are on the phone, be sure to invite them to unmute and say their name when they’re ready to speak like, “this is Albert, I have something to add…” Or you encourage a topic in the Chat and call on people from there.

Clearly describe how to join the discussion otherwise people may start talking over each other, which can be frustrating for everyone. Asking people to raise their hand so it is visible on video or saying their name and waiting to be called on if they’re on the phone is away for you (as the facilitator) to know when someone wants to speak. Once a discussion starts, remind everyone to stay on mute unless they are speaking. Say they may need to be manually muted if they are causing an echo or background noise.  

Using the Chat

The Chat can be a distraction for some or it can be a helpful way for those who are shy to speak up.  Check with the group about whether using the Chat adds to or takes away from the quality of the group.

One way to use the Chat constructively is to pose a question and ask everyone in the group to redirect their attention to the Chat answer the question or make a comment during the pause.

The Chat can’t be used by those who call in by phone, but the facilitator (or a technical support co-facilitator) can invite text a messages to the facilitator’s phone number (or a group member) where they can be added by the facilitator to the Chat.

Creative use of cell phones during the group could be a topic for discussion.

Wrapping up the group

Before the end of the group, ask if people came with something they hoped to get support for. If any urgent needs arise, save other topics for the future.

Also ask for those who have been quiet if they have any thoughts or observations to offer the group. Sometimes all it takes is an invitation to speak. But participation is voluntary and everyone can choose to just listen.

Closing the group

Before everyone leaves, offer a way to bring the group to closure. You might ask everyone to say a word or something they are feeling about attending the group. Be sure to invite people to come back and give the dates/times for next meeting.

Some technical tips…

    1. Password protect the group, share it with your co-facilitator(s) and if you are on Zoom keep the HOST code handy. It allows you to assign/re-assign a co-host, divide the meeting into breakout rooms, and manually mute people who have background noise while someone else is talking.
    2. Keep the phone number and access for the meeting handy, in case you need to call in because of poor audio quality or an unstable internet connection.  If you call in while staying on the computer video, turn your computer ‘speakers’ off. This is different choosing ‘mute’. If you’re on both the computer and the phone there will be a loud echo that will make it impossible for people to hear each other. Just remember to turn your computer speakers back on after the meeting is over.

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Other Considerations

“Being a peer supporter means you’re the expert
at not being the expert, and that takes expertise.”
~~ Chris Martin, Recovery Innovations

Avoid being “the expert”.

If you’re promoting a perspective other than your personal lived experience, creating “teachable moments,” or ending every group member’s contribution with a summary and your own conclusion about what was said, you’re putting yourself in a position of authority over the group. In peer support groups, the facilitator is an equal member of the group, so it is okay to occasionally share personal experiences, just like every other member, as long as it does not done in a way that takes power away from the group.


One way to avoid falling into the trap of becoming “the expert” is to frequently pause and consider the impact of what you are about to say. W.A.I.T. stands for, “Why am I talking?” If you are giving an instruction related to the group process or personal experience that is pertinent to the group discussion, that’s fine. But if you’re trying to teach something or say something just to “fill a gap of silence,” you may instead be taking away an opportunity from those who are shy or take longer to speak up. Allowing time for silence is an important part of good facilitation.

Remember, Language Matters

Language is important. It is also important for people to feel respected regardless of their position or opinion.

The facilitator is not the “language police.” Shaming someone is against the principles of support. If jargon comes up that feels uncomfortable or group members disagree with, ask the group questions like, “Help me to understand how it relates to peer support,” or “I’m curious about whether there might be a different way to say what you said in a more human way?”

As you explore the use of language with the group, ask people to not take it personally. It is an opportunity to learn with and from each other, and to gain a richer understanding from different perspectives.

When there are conflicting opinions, and someone seems upset or offended, respectfully ask if there is an “elephant in the room.” (For example, people may have hard feelings but are not comfortable expressing them.) If an “elephant” is identified, invite the group into a conversation to clear the air. Maybe say, “ouch,” or “I’m really sorry, I didn’t know,” in a genuine way.

Conflict is not always bad. It can raise unspoken issues for all members to discuss and share from their different perspectives, leading to greater awareness of each other’s views and the importance of valuing differences.

Use hope, humor, inspiration, positive affirmations, a sense of community and “carefronting” (as opposed to confronting) to address differences and keep redirecting questions back to the group to encourage collaborative learning that come from the wisdom of the members of the group, rather than trying to be the ‘expert’. This gives everyone the chance to contribute and to learn together.

“Elephant” discussions can also lead to new additions to the group agreements (or working agreements among facilitators and group members). Any discoveries about new ways for the group to grow together is good. Remember, we’re all in the market for growth!

Be Transparent

If you’re new to facilitating in an online environment, let people know! These days, people are in a “perpetually learning mode,” and most people are patient and forgiving as we are all learning new skills. Those with experience with online technology might step forward (is there a teenager in the room?) and be able to guide and provide extra help in unexpected ways!

We’re all peers. Especially when we’re in the role of the facilitator. Each of us have things going on too. If we feel overly responsible for making the group successful, we take away the group’s ownership of and responsibility for its own success. We can’t do it all. We can always do our best but we don’t need to be perfect. As peers, it is important for us to be and show that we are human.

If you have thoughts on the tips, warmline connections to share, or other ways for people to get connected during this time of social distancing, feel free to share them with us at  academy.virtual.community@gmail.com.

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Guidelines, Principles of Support, and Conversation Starters