Precise estimates of the prevalence of chronic pain syndromes are difficult to ascertain. In the US, for example, there may be >30 million people with chronic or recurrent painful conditions. To date, there is still no one treatment that consistently and permanently alleviates chronic pain for all people. Since pain is likely to persist for a significant number of people, a disease management approach is highly desirable. In order to be both clinically effective and cost effective, a disease management algorithm should be developed based on the best available evidence. This article presents evidence relevant to clinical and cost effectiveness for different non-pharmacological strategies in treating chronic pain, including education, exercise, surgery, spinal cord stimulation, and interdisciplinary rehabilitation. Illustrative studies and comparative analyses of several outcomes (i.e. pain reduction, reduction in healthcare utilization, improvement in physical functioning, and closure of disability claims) are discussed. In addition, the costs of complications related to the more invasive treatments are highlighted. Given the wide diversity of syndromes that fit within chronic pain, no single algorithm can be provided that will be appropriate for all chronic pain diseases. The general steps in an algorithm for any chronic pain syndrome should include a thorough evaluation, the provision of information and reassurance to the patient, and the prescription of appropriate treatment that may eliminate the cause of palliate symptoms. Also, patients should be recommended for interdisciplinary rehabilitation when there is no treatable cause and symptoms are likely to persist. Routine monitoring and careful documentation of symptoms and both physical and emotional functioning are essential. Even when conventional medical and surgical modalities are provided, residual symptoms are likely to persist. Thus, self-management and functional restoration should be considered as adjunctive treatments for all chronic pain patients. Excessive diagnostic testing and futile efforts to eliminate all pain are discouraged as they are both costly and repeated failures may lead to patient passivity, emotional distress, and greater disability. In the absence of a specific treatment that has the potential to eliminate the cause of the symptoms (e.g. surgery), the available clinical and cost outcomes data suggest that if pain persists following the natural course of the disease and after the patient has been provided with reassurance and information, an interdisciplinary treatment approach that focuses on self-management and functional restoration is most effective. There is minimal research on the integration of such rehabilitation programs with other commonly used approaches such as medication or surgery.
