Abstract: We identified 16 trials involving a total of 616 participants. Eight different types of interventions were studied. Eight trials investigated the effects of electrical brain stimulation (transcranial direct current stimulation (tDCS) and cranial electrotherapy stimulation (CES); five trials) or repetitive transcranial magnetic stimulation (rTMS; three trials). Interventions in the remaining studies included exercise programmes (three trials); acupuncture (two trials); self-hypnosis (one trial); transcutaneous electrical nerve stimulation (TENS) (one trial); and a cognitive behavioural programme (one trial). None of the included trials were considered to have low overall risk of bias. Twelve studies had high overall risk of bias, and in four studies risk of bias was unclear. The overall quality of the included studies was weak. Their validity was impaired by methodological weaknesses such as inappropriate choice of control groups. An additional search in November 2014 identified more recent studies that will be included in an update of this review. For tDCS the pooled mean difference between intervention and control groups in pain scores on an 11-point visual analogue scale (VAS) (0-10) was a reduction of -1.90 units (95% confidence interval (CI) -3.48 to -0.33; P value 0.02) in the short term and of -1.87 (95% CI -3.30 to -0.45; P value 0.01) in the mid term. Exercise programmes led to mean reductions in chronic shoulder pain of -1.9 score points for the Short Form (SF)-36 item for pain experience (95% CI -3.4 to -0.4; P value 0.01) and -2.8 pain VAS units (95% CI -3.77 to -1.83; P value < 0.00001); this represented the largest observed treatment effects in the included studies. Trials using rTMS, CES, acupuncture, self-hypnosis, TENS or a cognitive behavioural programme provided no evidence that these interventions reduce chronic pain. Ten trials examined study endpoints other than pain, including anxiety, depression and quality of life, but available data were too scarce for firm conclusions to be drawn. In four trials no side effects were reported with study interventions. Five trials reported transient mild side effects. Overall, a paucity of evidence was found on any serious or long-lasting side effects of the interventions. Evidence is insufficient to suggest that non-pharmacological treatments are effective in reducing chronic pain in people living with SCI. The benefits and harms of commonly used non-pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology.

Plain-language summary: We searched electronic databases until March 2011 and found 16 randomised controlled trials with a total of 616 participants. We grouped these studies by type of treatment into eight groups: Eight studies were on brain stimulation, of which five used electronic and three magnetic stimulation. Three studies were on exercise programmes, two on acupuncture and one each on self-hypnosis, transcutaneous electrical nerve stimulation (TENS) and a cognitive behavioural programme. The included studies used a range of different methods to measure pain and other outcomes. Comparison groups also varied and included sham interventions, waiting lists and other pain treatments. For any given type of intervention, only a few studies were found, and they included only small numbers of participants. Often the reported detail was insufficient. The overall quality of the studies was low. For instance, several studies used inappropriate comparison groups such as waiting lists. Consequently, the effectiveness of the treatments is uncertain. An additional search in November 2014 identified more recent studies that will be included in an update of this review. For one type of treatment—transcranial direct current stimulation (tDCS)—results from two studies could be combined. The pooled results suggest that tDCS reduced pain in the short term and in the mid term. Also, exercise programmes for chronic shoulder pain provided pain relief. We found no evidence to suggest that repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), acupuncture, self-hypnosis or TENS is better than the respective control interventions for reducing chronic pain. Regarding outcomes other than pain, such as anxiety, depression or quality of life, as well as long-lasting side effects, no overall conclusions were possible, given that data were sparse. The included studies do not permit firm conclusions regarding whether treatments other than medication for chronic SCI pain are effective and safe. Trials with greater numbers of participants and improved study quality are needed to determine the effectiveness and safety of such treatments.