Despite their favorable benefit-to-risk profile, noninvasive nonpharmacologic therapies are not always covered or fully covered by insurance (43). Access and cost can be barriers for patients, particularly persons who have low incomes, do not have health insurance or have inadequate insurance, have transportation challenges, or live in rural areas where services might not be available (121). Health insurers and health systems can improve pain management and reduce medication use and associated risks by increasing reimbursement for and access to noninvasive nonpharmacologic therapies with evidence for effectiveness (9,43). In addition, for many patients, aspects of these approaches can be used even when access to specialty care is limited. For example, previous guidelines have strongly recommended aerobic, aquatic, or resistance exercises for patients with osteoarthritis of the knee or hip (166) and maintenance of physical activity, including normal daily activities, for patients with low back pain (158). A randomized trial found no difference in reduced chronic low back pain intensity, frequency, or disability between patients assigned to relatively low-cost group aerobics and those assigned to individual physiotherapy or muscle reconditioning sessions (175). Low-cost options to integrate exercise include walking in public spaces or use of public recreation facilities for group exercise. Physical therapy can be helpful, particularly for patients who have limited access to safe public spaces or public recreation facilities for exercise or whose pain has not improved with low-intensity physical exercise. A randomized trial found a stepped exercise program, in which patients were initially offered an Internet-based exercise program and progressively advanced to biweekly coaching calls and then to in-person physical therapy if not improved at previous steps, successfully improved symptomatic knee osteoarthritis, with 35% of patients ultimately requiring in-person physical therapy (176). In addition, primary care clinicians can integrate elements of psychosocial therapies such as cognitive behavioral therapy, which addresses psychosocial contributors to pain and improves function (177), by encouraging patients to take an active role in the care plan, supporting patients in engaging in activities such as exercise that are typically beneficial but that might initially be associated with fear of exacerbating pain (159), or providing education in relaxation techniques and coping strategies. In many locations, free or low-cost patient support, self-help, and educational community-based or employer-sponsored programs are available that can provide stress reduction and other mental health benefits. Clinicians should become familiar with such options within their communities so they can refer patients to low-cost services. Patients with higher levels of anxiety or fear related to pain or other clinically significant psychological distress can be referred for treatment with a mental health specialist (e.g., psychologist, psychiatrist, or clinical social worker).
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