Evidence-based Practice in Chronic Pain: A Multidimensional Biopsychosocial Paradigm is the "Need of the Hour" in Palliative Care.

Sir,

I read with interest and enthusiasm the article on evidence-based practice of chronic pain and I wish to congratulate Garg et al.[1] on their breakthrough initiative to enlighten the clinical and scientific palliative care settings with the re-emerging evidence-based practice paradigm, which is the need for the hour in developing countries.

I wish to add a few points on the article;

The paper was titled so, but I could find little or no information on non-pharmacological interventions for management of chronic pain in terms of established high-level evidence. Recently, published systematic reviews and meta-analyses unanimously recommend physical activity for prevention and/or management of both cancer[2] and non-cancer chronic pain for patients of all ages around the globe.[3]

Physical therapy treatment options for chronic pain included the use of physical modalities, transcutaneous electrical nerve stimulation, manual physical therapy and exercise therapy, which not only enable symptom control, but also enhance quality-of-life.[4] The updated evidence of efficacy currently exists for virtual reality,[5] graded motor imagery[6] and activity pacing prescriptions.[78]

Recent understanding of chronic pain had shifted from a biomedical dimension to a behavioral dimension[9] leading to a biopsychosocial approach[10] to evaluation and management of chronic pain.

Interdisciplinary programs involve the use of multiple disciplines such as physical and occupational therapy, pain psychology, medical pain management, vocational rehabilitation, relaxation training and nursing educations.[11] Such an interdisciplinary rehabilitation approach was shown to be effective in management of people with chronic pain.[12]

Physical activity as a part of an individualized exercise prescription provides a safe, cost-free, non-pharmacologic way of managing pain has been found to reduce anxiety and depression, improve physical capacity, increase functioning and independence and reduce morbidity and mortality.[13] Such a prescription when combined with the cognitive-behavioral therapy as a multi-component approach had garnered good evidence of effectiveness as stand-alone, adjunctive treatments for patients with chronic pain.[14]

The biopsychosocial disease consequence model describes the rehabilitation process of patients with chronic pain as a three-axial (biopsychosocial) and 3D (disease consequences) assessment and intervention grid for functioning,[15] which is yet to be explored in evidence-based practice for chronic pain.