Overview
Integrative healthcare is defined by the United States National Institutes of Health as a comprehensive, often interdisciplinary approach to treatment, prevention, and health promotion that brings together complementary and conventional therapies. In the United States, the National Center for Complementary and Integrative Health (NCCIH) is responsible for research on promising integrative health approaches. The mission of NCCIH is to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health approaches and their roles in improving health and healthcare. Budget for NCCIH in the United States exceeded USD$146 million in 2019, testifying to interest by the public and governmental agencies in exploring efficacy and safety of many of these approaches. Complementary and integrative health approaches contrast with alternative medicine, which is defined as unproven practices used in place of conventional health approaches. Some examples of complementary and integrative health approaches commonly used in the United States and other parts of the world to treat acute and chronic pain are delineated as follows. In light of the recent opioid crisis in the United States, and in search of alternatives to long-term opioid therapy to treat chronic nonmalignant pain, interest in complementary and integrative approaches has grown and adapted by many patients and clinicians alike.
Acupuncture
Acupuncture is defined as insertion of thin needles on specific points in the skin for the purposes of restoring health and promoting wellness. First known written documentation of acupuncture, Huangdi Neijing (“Yellow Emperor’s Inner Classic”), dates back to 100 BCE. Acupuncture is typically associated with Traditional Chinese Medicine (TCM) and is the form most widely adopted in the United States, although variants with different philosophies and approaches have been developed in the treatment of pain. TCM approach involves belief in qi (life force) that courses within the body in specific channels called meridians. Disease state involves dysfunction of the qi , and acupuncture among other treatments is used to restore the proper flow of qi . TCM often uses herbs as part of its treatment, along with cupping and moxibustion, which involves burning dried mugwort plant ( Artemisia vulgaris ) on different points on the body.
A typical TCM acupuncture session involves placing the patient in a comfortable position (usually supine or prone) and inserting needles for a length of time, typically 20 to 30 minutes. Needles may be stimulated with heat, pressure, manual manipulations, or electricity. Needle insertion may be associated with de-qi, which refers to paresthesia or deep ache as the needle is being inserted. Acupuncture treatment is unique to each recipient and may be altered on subsequent treatments depending on response to prior treatments.
Practices related to acupuncture include acupressure, in which physical pressure is applied to specific points on the body for therapeutic purposes. Cupping refers to the practice of placing a suction cup on the skin for the purposes of mobilizing blood flow and promoting healing. Tui na is a method of stimulating the flow of qi by various techniques that do not involve needles. Electroacupuncture involves use of electrical stimulation to the acupuncture needles that are inserted in the body. Bee venom acupuncture involves injecting purified, diluted bee venom into acupuncture points.
The efficacy of acupuncture for pain has been extensively studied. A meta-analysis evaluating efficacy of acupuncture for chronic pain indicated that acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persisted over time and could not be explained solely in terms of placebo effects. Authors concluded that acupuncture is a reasonable option for a patient with chronic pain.
Cochrane review for acupuncture for neck disorders concluded that there is moderate-quality evidence that suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up. Those who received acupuncture report less pain and disability at short-term follow-up than those on a waitlist. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.
In a systematic review and meta-analysis, verum acupuncture was shown to be more effective than sham acupuncture for pain relief, improving sleep quality and reforming general status in fibromyalgia syndrome.
While acupuncture with roots in TCM is the most widely practiced and known form of acupuncture, acupuncture from other traditions also exist. Examples include Japanese acupuncture, Korean acupuncture, French Energetic Acupuncture (French Meridian Acupuncture), scalp acupuncture, and auricular acupuncture (which includes Battlefield Acupuncture). Nonthermal, low-intensity laser to stimulate acupuncture points has been incorporated in some acupuncture treatments.
Acupuncture is a relatively safe treatment, but as with any procedure involving needles, complications can be seen. In a prospective observational study of 229,230 patients who received an average of 10.2 acupuncture treatments, 8.6% reported at least one adverse effect and 2.2% reported one that required treatment, with most common adverse effects being bleeding or hematoma (6.1% of patients, 58% of all adverse effects) and pain (1.7%). Two patients were found to have pneumothorax, one requiring hospital treatment and the other requiring observation only. The longest duration of a side effect was 180 days (nerve lesion of the lower limb). While relatively safe, practitioners should consider providing patients with an informed consent that reviews risks, benefits, and alternatives prior to delivery of acupuncture treatments.
Tai Chi/Qigong
Tai Chi and Qigong are traditional Chinese exercises that integrate the body and mind. It includes breathing control, slow movements, mental relaxation, and meditation. Tai Chi and Qigong are widely practiced in China and have spread internationally for their purported health benefits. As of 2017, yoga, Tai Chi, and Qigong were practiced by 14.5% of US adults, with pain and arthritis as among the top medical conditions for which people used these modalities.
Zou and colleagues in a systematic review and meta-analysis of randomized controlled trials examining Tai Chi, Qigong, and yoga noted that these practices appear to reduce pain intensity and disability in patients with low back pain compared with control groups. Of the three, Tai Chi had a significantly superior effect on pain management irrespective of noncontrol comparison or active control comparison (conventional exercises, core training, and physical therapy programs). A systematic review by the United States Agency for Healthcare Research and Quality noted that Tai Chi and Qigong were associated with slight short-term (1–6 month) improvements in function and pain for fibromyalgia patients, although the strength of evidence was considered low.
Tai Chi was shown in a systematic review and meta-analysis of 18 randomized controlled trials to have positive evidence of immediate relief of chronic pain from osteoarthritis; there were some beneficial evidence regarding the effects of Tai Chi on immediate relief of chronic pain from low back pain and osteoporosis. Tai Chi has been reported to improve quality of life, functional balance, and pain in patients with multiple sclerosis. Another systematic review and meta-analysis of 15 randomized controlled trials of Tai Chi for patients with chronic musculoskeletal conditions found that there is moderate-quality evidence for effectiveness of Tai Chi compared with no treatment or usual care at short term for pain and disability. Additional high-quality trials with large samples sizes were recommended to assess short- and long-term benefit from Tai Chi for chronic musculoskeletal pain conditions.
Ayurvedic Medicine
Ayurveda is a system of medicine originating from India and South Asia that emphasizes holistic approaches to health and a balance in lifestyle. Ayurvedic medicine consists of individualized treatments consisting of multimodal components such as manual therapies, nutritional therapy, herbs, lifestyle counseling, and yoga-based exercises. The term “ayurveda” is Sanskrit derived from Ayu (life) and Veda (knowledge). Sushruta Samhita is one of the most widely accepted Ayurvedic texts and dates back over 2000 years, although the concepts leading to the formulation of Ayurveda dates back to well before that time.
Medicinal therapy is highly individualized in Ayurveda, and pharmacy is highly developed. The choice and dose of medicine are influenced not only by disease but by the individual’s constitution and the environmental conditions likely to affect the individual’s Doshas , or energy that defines every person’s makeup. Ayurvedic medicine subscribes to almost 70 books containing more than 8000 recipes for the preparation of different medicines, most of which are derived from minerals and plants.
One such Ayurvedic preparation, curcumin, a yellow pigment derived from the spice turmeric and an essential component of curry powder dried from C urcuma longa , has been found to exert a powerful anti-inflammatory effect by blocking numerous inflammatory pathways. A meta-analysis of randomized controlled trials has shown that curcumin can treat osteoarthritis patients effectively and improve Western Ontario and McMaster Universities Osteoarthritis Index Scale and Visual Analog Scale score. Side effects from the use of curcumin were not higher than that of ibuprofen.
Neuropathic pain may also respond to Ayurvedic preparations. Research and evaluation of effectiveness of Ayurvedic medicine are limited by wide variation and quantity of pharmacologically active substances in plants. In addition, some herbs that form ingredients for Ayurvedic medicine are endangered or vulnerable plants, and cultivation in other areas are impractical, raising concerns over potential adulteration of commercially prepared drugs. ,
Yoga
Yoga is a mind-body practice with origins in India. It has three main components: physical poses/posture, breathing control, and meditation/relaxation. A systematic review and meta-analysis by Lauche et al. found low-quality evidence for the effects of yoga on pain, physical function, and stiffness secondary to osteoarthritis. A systematic review and meta-analysis found preliminary evidence of short-term efficacy of yoga in improving headache frequency, headache duration, and pain intensity in patients suffering from tension-type headaches. Agency for Healthcare Research and Quality systematic review on noninvasive nonpharmacological treatment for chronic pain found that yoga was associated with slight improvements in function and pain for short- (1 to less than 6 months, strength of evidence moderate) and intermediate-term (greater than or equal to 6 months and less than 12 months, strength of evidence low).
Cochrane review on yoga for treatment of chronic nonspecific low back pain concluded that there is low-to-moderate certainty evidence that yoga compared with nonexercise controls results in small to moderate improvements in back-related function at 3 and 6 months. Yoga may also be slightly more effective for pain at 3 and 6 months. Yoga was associated with more adverse events than nonexercise controls but may have the same risk of adverse events as other back-focused exercise. Yoga was not associated with serious adverse events.
A randomized trial comparing yoga, physical therapy, and education for chronic low back pain concluded that a manualized yoga program (12 weekly 75-minute classes) was noninferior to physical therapy for function (as measured by Roland Morris Disability Questionnaire) and pain (as measured by an 11-point scale), and the improvements were maintained at 1 year with no differences between maintenance strategies.
In a randomized clinical trial involving military veterans with chronic low back pain, yoga improved health outcomes despite evidence that the participants had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously; the magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use.
Homeopathy
Homeopathy is a system of medical treatment developed by German physician Samuel Hahnemann at the end of the 18th century that utilizes highly diluted
Homeopathy has been suggested as a potential treatment option for fibromyalgia in a comprehensive literature review and meta-analysis based on 10 case reports, 3 observational studies, 1 non-randomized, and 4 randomized controlled trials, although authors acknowledged that any conclusions based on the results of the review have to be regarded as preliminary. In addition, homeopathy has been suggested as a potential treatment option to treat symptoms related to low back pain, including in a randomized controlled trial by Beer et al. involving 248 patients (of whom 137 completed the study) as measured by the Hannover Functional Ability Questionnaire (intent-to-treat analysis = 0.11, per-protocol analysis p = .029), although further studies are needed to clarify the role homeopathy may play in treatment of low back pain in the future.
Naturopathy
Naturopathy refers to approaches to healthcare that reprioritizes the order of therapeutics, first emphasizing lifestyle-oriented self-care, preventive behaviors, nutrition, physical activity, and stress-management counseling before proceeding with medications, herbs, homeopathy, and manual therapy. There is less emphasis on the use of over-the-counter medications, prescription drug therapies, or surgical interventions.
There are eight accredited schools of naturopathy in North America. In the United States, naturopathy is licensed in 22 states, the District of Columbia, and Puerto Rico and the US Virgin Islands. Third-party insurance coverage for naturopathy varies by state and range from minimal coverage (e.g., California) to legislatively mandated coverage (e.g., Washington State).
Integrating naturopathic medicine into acute inpatient care has shown the potential to improve patient satisfaction and form a stronger relationship between care staff and patients. Further research is needed to the determine effectiveness of naturopathy in the treatment of acute and chronic pain.
Chiropractic
Chiropractic approaches focus mainly but not exclusively on spinal manipulation to adjust subluxations. Chiropractic was founded in the 1890s by Daniel David Palmer, a Canadian-American who proposed that most diseases of the body could be attributed to misaligned vertebrae, or spinal subluxation. Existence of spinal subluxations, as defined by chiropractic practitioners, has been challenged in conventional medical literature. Spinal mobilization as a treatment can also be performed by other medical providers, such as osteopaths and physical therapists, although distinctions remain between chiropractic manipulations and those employed by nonchiropractors.
A Cochrane review concluded that there is slightly improved pain and disability in the short term, and pain in the medium term, for acute/subacute low back pain when combined chiropractic interventions are utilized for low back pain. In a systematic review of pragmatic studies, chiropractic care for low back pain appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared with exercise therapy and medical care, although whether chiropractic or medical care is more cost-effective could not be answered.
For the treatment of fibromyalgia, chiropractic care received a “strong against” recommendation by the European League Against Rheumatism based on studies of poor quality and lacking robust interpretable data.
Risks associated with chiropractic spinal manipulation are controversial but may be not inconsiderable. Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare; incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies.
Osteopathy
Osteopathic medicine was founded by American A. T. Still in 1874 as a medical study of the relationship that the osseous structure and its interrelationships have on health. A T. Still developed osteopathy after witnessing the death of his three children in 1864 during a meningitis outbreak and the powerlessness of the allopathic medicine of his time to treat them. He advocated abandoning all use of drugs in favor of dietary, spiritual, and mechanical functional treatment. A. T. Still found the American School of Osteopathy in Kirksville, Missouri, in 1892. American Association of College of Osteopathic Medicine was founded in 1898 to support and assist the osteopathic medical schools in the United States ( https://www.aacom.org accessed Nov 30, 2019). As of 2019, there are 36 accredited colleges of osteopathic medicine in the United States, accounting for 25% of all US medical students.
Osteopathic medicine’s guiding principles include the following: 1) the body is a unit; 2) structure and function are interrelated; 3) body has the innate ability to heal itself; and 4) rational practice of medicine must take these principles into account. Central to its tenet is that the body is considered as a unified whole as opposed to a summation of its parts. In addition, the individual is considered an extension of his or her entire environment: social, family, environmental, nutritional, and psychospiritual. Osteopathic manipulative medicine is aimed at restoration of function. Primary structural diagnosis in osteopathic manipulative medicine is “somatic dysfunction” which is defined by the American Osteopathic Association as “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements.”
Systemic reviews and meta-analysis suggest that clinically relevant effects of osteopathic manipulative treatment (OMT) were found for reducing pain and improving functional status in patients with acute and chronic nonspecific low back pain and for low back pain in pregnant and postpartum women at 3 months posttreatment. Larger randomized controlled trials with robust comparison groups were felt to be needed to further validate the effects of OMT on low back pain.
OMT has been proposed as a potentially effective treatment option for various types of headaches. A systematic review by Orrock and Myers, based on two studies, concluded that osteopathic intervention was similar in effect to a sham intervention for treatment of chronic nonspecific low back pain; and that there is similarity of effect between osteopathic intervention, exercise, and physical therapy. Further, visceral osteopathic manual therapy applications may improve results in treating patients with chronic nonspecific low back pain.
Massage
A Cochrane review evaluating massage therapy for nonspecific low back pain evaluated 25 trials and concluded that there was very little confidence that massage was an effective treatment for low back pain. Acute, subacute, and chronic low back pain had improvements in pain outcomes with massage, but only in the short-term follow-up. Functional improvement was observed in participants with subacute and chronic low back pain when compared with inactive controls, but again only for the short-term follow-up. Only minor adverse effects were noted with massage. A systematic review of randomized controlled trials by Nelson and Churilla concluded that there is low-to-moderate quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving certain functional outcomes, although it is unclear whether massage therapy is more effective than other forms of treatment.
Massage, along with warm pack and thermal manual methods, may have a role in reducing pain during labor in women in a Cochrane review. The quality of evidence for studies ranged from low to very low.
Aromatherapy
Aromatherapy involves the use of essential oils for clinical benefit. A systematic review of randomized placebo-controlled trials concluded that there is moderate level evidence for the superiority of aromatherapy (inhalation, massage or oral use) for pain reduction over placebo in primary dysmenorrhea.
Music Therapy
Music therapy has been shown in randomized controlled trials to provide statistically significant improvements in pain in critically ill patients. Music therapy has been suggested as a nonpharmacologic intervention to ameliorate pain in infants undergoing painful procedures involving skin puncture as part of routine medical care.
Low-Level Laser Therapy
In a systematic review, low-level laser therapy was associated with moderate improvement in function and pain in chronic low back pain patients, with moderate strength of evidence.
Mindfulness-Based Stress Reduction
In adults with chronic low back pain, treatment with mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT), compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR, as with CBT, may be an effective treatment option for patients with chronic low back pain.
MBSR was evaluated in a systematic review of 7 randomized controlled trials. The authors concluded that MBSR may be associated with short-term effects on pain intensity and physical functioning. Long-term randomized controlled trials that compare MBSR with active treatments were felt to be needed in order to better understand the role of MBSR in the management of low back pain.
Guided Imagery
Guided imagery may be a useful adjunct for pain management in patients undergoing orthopedic surgery, nonmusculoskeletal pain, arthritis, and other rheumatic diseases, although additional research in this area was needed.
Virtual Reality
Virtual reality is the use of technology, such as a head-mounted display, tracking system, and sound device, to create an interactive three-dimensional experience. Augmented reality superimposes a computer-generated image on a user’s visual field, thus enhancing the user’s real-world view. Use of virtual reality and augmented reality has been proposed as potential treatment options for treatment of phantom limb pain and pain and anxiety management in children. Low-cost virtual reality headsets were shown to reduce perceived pain in healthy adults in a multicenter randomized crossover trial. Virtual reality is an effective treatment for reducing acute pain and may reduce chronic pain according to a systematic review and meta-analysis by Mallari et al.
Reflexology
Reflexology proposes that the feet are representative of the body and that massaging specific points of the feet increases blood supply to mapped organs in the body. Treatment uses a homunculus-like model for different points of the body as projected onto the foot. Currently research is limited on effects of reflexology in treating chronic pain.
Energy Healing
Energy healing for the treatment of pain may include Reiki, therapeutic touch, and healing touch. There has been limited research evaluating these interventions and their effect on pain despite interest in these modalities. Evidence with a high risk of bias suggested that Reiki and prayer meditation might be associated with pain reduction.
Prayer
Active prayer, like other active coping strategies for pain, may facilitate self-management of pain and thus enhance pain outcomes.
Discussion
Use of integrative and complementary approaches is an evolving area with potential to improve delivery of care for patients suffering from acute and chronic pain. They are widely used in the United States and around the world, especially in areas where access to conventional Western medicine approaches may be limited. Research into effectiveness of these approaches for the treatment of pain is accelerating and suggests potential benefit for many of these approaches in the treatment of pain. A systematic review by the Agency for Healthcare Research and Quality noted that exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices are consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Further research is needed to clarify their efficacy and role in the treatment of pain patient, especially with regard to comparative research on sustainability of effects beyond the immediate posttreatment period. In balance, the risk-benefit ratio appears favorable in incorporation of most of the complementary and integrative approaches to manage chronic nonmalignant pain syndromes at this time.
References
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