Integrative Medicine: Overview
Integrative medicine is a philosophy of care that integrates conventional allopathic medical therapies with modalities not typically included in conventional care and addresses the physical, emotional, and spiritual needs of the patient. This field of medicine is sometimes referred to as complementary medicine or complementary and alternative medicine (CAM). However, these terms refer more precisely to modalities such as acupuncture, meditation, nutritional supplements, and massage, all of which may be included in the integrative medicine “tool box.” In 2005 the Consortium of Academic Health Centers for Integrative Medicine defined integrative medicine as follows:
The practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health-care professionals and disciplines to achieve optimal health and healing.
The use of complementary medicine modalities in the United States is increasing. One study found that 62% of adults had used some form of complementary therapy in the previous 12 months. The most commonly used CAM therapies were prayer for the improvement of health, natural products, deep-breathing exercises, meditation, chiropractic care, yoga, massage, and diet-based therapies. It is estimated that in 1997, between $36 and $47 billion was spent on CAM therapies in the United States.
Pain syndromes, such as chronic back pain, appear to be increasing and are associated with significant health care costs. Unresolved pain has a wide-reaching impact in that it affects physical, emotional, and spiritual wellness and has a negative impact on social and occupational functioning. Integrative medicine, which adopts a mind-body approach to the treatment of pain and uses multiple effective CAM modalities, is well suited to address chronic pain syndromes. In 2002, 6% of the U.S. population used complementary medicine modalities for the treatment of back pain and 60% of respondents who used CAM for back pain perceived a “great deal” of benefit.
Multidimensional Perception of Pain
Perception of pain is multifactorial and involves a complex interplay between the peripheral and central nervous systems. As pain signals reach the brain from the periphery, the brain can modify these signals by activating inhibitory pathways and releasing substances such as endorphins and neurotransmitters. Alternatively, the brain can magnify nociceptive signals if they are perceived to be threatening, thus increasing the perception of pain. Connections between the cerebral cortex and the limbic system allow the brain to give meaning to the pain experience. It is this connection between emotions and pain perception that forms the basis of the mind-body approach to pain. Psychological factors such as the tendency to catastrophize have been associated with chronic pain, and the literature suggests a clear link between psychological variables and neck and back pain. Life stress in childhood or adulthood can be associated with adult pain syndromes, and anxiety and chronic pain often coexist. Depression and pain are related, with each negatively affecting the other, and negative emotional states of any kind can increase the severity of pain. Even brief interventions designed to address the emotional components of pain have been effective in decreasing its severity.
Using real-time functional magnetic resonance imaging (fMRI) to guide training, subjects were able to learn to control regions of the brain involved in pain perception and regulation, specifically, the rostral anterior cingulate cortex (rACC). When activation of the rACC was intentionally increased or decreased, there was a simultaneous change in the perception of pain from an experimentally induced pain. Subjects who trained with sham real-time fMRI did not show a similar change in pain perception. In addition, chronic pain patients who were trained to control activation of the rACC reported decreased levels of chronic pain after training. This experiment illustrates that patients can learn to control specific regions of the brain that are involved in pain perception, thus learning to exert control over their own pain. This is a form of biofeedback and contributes to scientific understanding of the mind-body connection.
Neuroimaging studies have shown that social pain and physical pain are reflected similarly in the brain. In one study, subjects played a virtual game that elicited feelings of being excluded. The rACC showed an increase in activity during exclusion—physiologic changes that are similar to those seen with physical pain. In addition, hypnotic suggestion of pain has been shown to create changes on fMRI in the rACC, thalamus, insula, prefrontal cortex, and parietal cortex, which are also influenced by pain originating in peripheral tissues. This suggests that pain initiated by the brain has significant similarity to pain originating in the periphery. This concept highlights the mind-body connection and is important for understanding and treating patients with acute and chronic pain.
Multidimensional Perception of Pain
Perception of pain is multifactorial and involves a complex interplay between the peripheral and central nervous systems. As pain signals reach the brain from the periphery, the brain can modify these signals by activating inhibitory pathways and releasing substances such as endorphins and neurotransmitters. Alternatively, the brain can magnify nociceptive signals if they are perceived to be threatening, thus increasing the perception of pain. Connections between the cerebral cortex and the limbic system allow the brain to give meaning to the pain experience. It is this connection between emotions and pain perception that forms the basis of the mind-body approach to pain. Psychological factors such as the tendency to catastrophize have been associated with chronic pain, and the literature suggests a clear link between psychological variables and neck and back pain. Life stress in childhood or adulthood can be associated with adult pain syndromes, and anxiety and chronic pain often coexist. Depression and pain are related, with each negatively affecting the other, and negative emotional states of any kind can increase the severity of pain. Even brief interventions designed to address the emotional components of pain have been effective in decreasing its severity.
Using real-time functional magnetic resonance imaging (fMRI) to guide training, subjects were able to learn to control regions of the brain involved in pain perception and regulation, specifically, the rostral anterior cingulate cortex (rACC). When activation of the rACC was intentionally increased or decreased, there was a simultaneous change in the perception of pain from an experimentally induced pain. Subjects who trained with sham real-time fMRI did not show a similar change in pain perception. In addition, chronic pain patients who were trained to control activation of the rACC reported decreased levels of chronic pain after training. This experiment illustrates that patients can learn to control specific regions of the brain that are involved in pain perception, thus learning to exert control over their own pain. This is a form of biofeedback and contributes to scientific understanding of the mind-body connection.
Neuroimaging studies have shown that social pain and physical pain are reflected similarly in the brain. In one study, subjects played a virtual game that elicited feelings of being excluded. The rACC showed an increase in activity during exclusion—physiologic changes that are similar to those seen with physical pain. In addition, hypnotic suggestion of pain has been shown to create changes on fMRI in the rACC, thalamus, insula, prefrontal cortex, and parietal cortex, which are also influenced by pain originating in peripheral tissues. This suggests that pain initiated by the brain has significant similarity to pain originating in the periphery. This concept highlights the mind-body connection and is important for understanding and treating patients with acute and chronic pain.
Integrative Medicine Modalities and Pain
Varied complementary medicine techniques have shown benefit in the treatment of pain. Domains such as traditional Chinese medicine (TCM), mind-body medicine, manual medicine, and others have an increasing body of evidence supporting their use for management of pain. The most commonly used and well-supported modalities are discussed in the following sections.
Acupuncture and Traditional Chinese Medicine
TCM is an inclusive medical system based on 3000-year-old ancient texts. It incorporates varied treatment modalities, including acupuncture, acupressure, Chinese herbal medicine, meditative movement such as tai chi and qi gong, moxibustion, cupping, and specialized massage techniques referred to as tui na.
Acupuncture and TCM are based on the theory that health is determined by the balance of vital energy flow, called qi (pronounced “chi”), which is thought to be present in all living creatures. TCM uses concepts such as yin and yang and dampness and wind, which have no equivalents in conventional medicine and are therefore difficult to explain in standard medical terms. “Yin” represents the concept of cold, slow, and passive, whereas “yang” represents energy that is hot, fast, and active. Health is believed to be based on a balance of these and other opposing forces, such as dampness and dryness, and to require free flow of qi. Disease is thought to arise from an imbalance in these forces. Imbalance leads to blockage of qi (vital energy) along specified pathways. In all organisms, qi is believed to flow through particular channels called meridians, and TCM therapies are used to unblock the flow of qi. Unlike conventional medicine, treatment plans are highly individualized and based on an individual’s constitution, as assessed by the TCM provider, as well as on the individual’s symptoms. Thus, two patients with identical complaints might receive entirely unique treatment plans based on their baseline characteristics.
Acupuncture points are located along the recognized meridians, and the process of acupuncture involves the insertion of thin needles into these points. Although meridians cannot be visualized anatomically, acupuncture points often correspond to depressions in muscles, bones, or neural foramina and may have their own neurovascular bundle that distinguishes the acupuncture point from surrounding tissue. They are often palpable and may be tender to palpation.
The mechanism of action of acupuncture, from a conventional medicine point of view, has not been unequivocally determined. Theories on the efficacy of acupuncture include release of endorphins and neurotransmitters, enhanced local immune response, enhanced circulation and smooth muscle relaxation, stimulation of tissue growth and repair, and spinal and peripheral nerve stimulation. Substantial evidence supports the theory that acupuncture creates physiologic change at the site of needle insertion, in the cerebral cortex, and in the release of hormones and endorphins. Endorphin levels in cerebrospinal fluid have been shown to rise after acupuncture treatment.
Despite abundant evidence supporting the use of acupuncture for varied medical conditions, there are particular challenges in conducting research on acupuncture that may affect the results. Acupuncture has no true placebo control, and sham acupuncture has sometimes been shown to be as effective as true acupuncture. Inserting needles in “sham” acupuncture points might elicit physiologic changes, and even sham acupuncture needles that press but do not puncture the skin may approximate the effects of acupressure if they are used at specified acupuncture points. In addition, standardized acupuncture treatments are often used in research in an effort to provide a standardized and replicable approach. That is, all patients with back pain would receive acupuncture at the same acupuncture points. However, this does not replicate the individualized treatment approach to acupuncture used in practice, thus creating a research environment that does not reflect real-life conditions.
Acupuncture is used for a wide variety of health conditions and is also used by those without specific symptoms to maintain optimal health. It is most commonly used for relief of musculoskeletal pain. A 2001 review on acupuncture safety found that minor adverse events were common but serious adverse events were rare. The most commonly reported adverse events were needle pain (1% to 45%), tiredness (2% to 41%), nausea or vomiting (0.01% to 0.2%), and slight bleeding or bruising (0.03% to 38%). Feeling faint was very rare (0% to 0.3%), and pneumothorax was extremely rare—occurring only twice in nearly a quarter of a million treatments.
Laws concerning the practice of acupuncture are defined by each state. Practitioners may include licensed acupuncturists who have completed more than 1000 hours of training at a college of Oriental medicine or masters-level program, chiropractors who may receive some training within their professional course of study and may choose to pursue additional postgraduate training, and physicians and dentists who pursue acupuncture training after completing their professional programs. Most programs targeted to physicians, chiropractors, and dentists include approximately 200 to 400 hours of training. Board certification is available to physicians through the American Board of Medical Acupuncture. Acupuncture styles differ and can include traditional Chinese acupuncture, five-element acupuncture, Korean or Japanese acupuncture, and auricular acupuncture. Evidence of superiority of one form over the others is not available.
A Cochrane review on acupuncture for pain found that it was effective for migraines, neck disorders, tension-type headaches, and peripheral joint osteoarthritis. One well-designed randomized controlled trial of acupuncture for the treatment of knee osteoarthritis involved 507 patients recruited from two university outpatient clinics. The patients were randomized into one of three groups: true acupuncture, sham acupuncture, or education control. The primary outcomes measured were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at 8 and 26 weeks. Secondary outcomes were patient global assessment, 6-minute walk distance, and physical health scores on the 36-Item Short-Form Health Survey (SF-36). Participants in the true acupuncture group experienced significantly greater improvement in the WOMAC function score than did both the sham acupuncture and education groups at 8 weeks, but not in the WOMAC pain score or patient global assessment. At 26 weeks, the true acupuncture group experienced significantly greater improvement than did the sham and education groups in the WOMAC function score, WOMAC pain score, and patient global assessment. The authors concluded that acupuncture can be used as adjunctive therapy for the treatment of knee osteoarthritis. Another randomized controlled trial in which acupuncture was added to advice and exercise in patients with osteoarthritis showed only small improvements in pain and no superiority of true acupuncture over sham acupuncture.
A recent Cochrane review of acupuncture revealed that sham-controlled trials show statistically significant benefits; however, these benefits are small and may be due partly to placebo effects from incomplete blinding. Acupuncture has been shown to improve chronic low back pain symptoms in some studies, but not in others. However, another Cochrane review of acupuncture for the treatment of chronic tension-type headache suggested that acupuncture could be a valuable nonpharmacologic tool for patients with frequent episodic or chronic tension-type headache. A recent meta-analysis using individual patient data evaluated the efficacy of acupuncture for the treatment of chronic pain. Data from 29 studies of back and neck pain, osteoarthritis, chronic headache, and shoulder pain were evaluated, and true acupuncture was found to be more effective than either sham acupuncture or nonacupuncture control in decreasing pain.
Thus, although the evidence is suggestive that acupuncture is beneficial for the treatment of varied pain syndromes, the picture is not entirely clear. Expectation of benefit, possible physiologic action of supposed sham controls, different styles of acupuncture, and acupuncture research protocols that may not match the “real-life” practice of acupuncture all create some uncertainty regarding the effectiveness of acupuncture for the treatment of pain. On the other hand, a mounting body of evidence suggests acupuncture to be beneficial when added to conventional care, with clear evidence of safety.
Mind-Body Medicine
The term mind-body medicine does not refer to a specific treatment modality; rather, it refers to a group of modalities that are unified by the underlying concept of an intricate connection between the mind and the body. The physical, emotional, spiritual, and social aspects of our lives have an impact on health and well-being, and dysfunction in one domain can lead to dysfunction in another. Mind-body medicine asserts that the mind can positively affect the body in the pursuit of health and wellness. Our daily experience makes it clear that the mind can affect physiology. Blushing from social embarrassment results from increased blood flow to the face, frightening movies can increase cardiovascular vital signs, and sexually stimulating visual material can increase blood flow to the penis. Similarly, psychological stress can lead to clear physiologic changes, most of which are potentially harmful. Chronically elevated blood pressure, muscular tension leading to headaches or neck pain, and the increased incidence of chronic pain syndromes may all be associated with stress. Pain and stress are interconnected, and a vicious cycle is often generated in which pain causes stress and subsequently stress causes more pain. Mind-body techniques can provide an improved ability to cope with pain, decreased perception of pain, and an increased sense of well-being and relaxation. The psychological tendency to catastrophize has been associated with increased pain perception, and mind-body techniques can help temper this anxious state.
The relaxation response is a physical state or reaction that counteracts the physiologic and emotional responses to stress and is essentially the opposite of the fight-or-flight response. It was first described by Herbert Benson and colleagues at Harvard Medical School in the 1970s. Just as eliciting the stress response can generate unhelpful physiologic changes, eliciting the relaxation response can result in health-inducing physiologic effects. The relaxation response is different from simply relaxing with a book or in front of the television. Although these activities may be considered “relaxing,” they do not generate the physiologic changes associated with the relaxation response. The relaxation response is elicited by focusing the mind on a particular word, phrase, breath, image, or action and adopting a passive attitude toward one’s thoughts. Modulation of cardiovascular parameters, muscular relaxation, and normalization of stress hormones such as cortisol, epinephrine, and norepinephrine are all associated with the relaxation response.
Mind-body techniques are varied and become easier to do with practice. Techniques include abdominal breathing, meditation, guided imagery, biofeedback, yoga, tai chi, qi gong, therapeutic arts, and even prayer. No mind-body technique is intrinsically more effective than another, and all can be used to decrease stress and elicit the relaxation response. Some involve movement and stretching, whereas others are practiced in seated or recumbent positions. They can be performed in groups, with an individual instructor, or alone. Patients may choose to try different mind-body techniques to find one, or several, that they prefer. Mind-body techniques have been shown to be helpful for varied conditions such as osteoarthritis, rheumatoid arthritis, headaches, procedural pain, and stress management. Specific mind-body techniques are described in the ensuing paragraphs.
Progressive Muscle Relaxation
Progressive muscle relaxation is a technique commonly used for eliciting the relaxation response and relieving muscular tension. It is easy to learn and is accessible even to people who may not be familiar with or interested in meditation. It involves sequentially relaxing various muscle groups, often starting at the head and moving down the body to the feet. Participants may tense a muscle before relaxing it (for example, clenching the jaw and then releasing it) or simply bring their attention to a muscle group and intentionally relax it. A sample progressive muscle relaxation script is provided in Appendix A.
Meditation
The term meditation refers to a broad variety of practices that are similar in form but may be quite distinct in intention. Depending on the culture and tradition of the meditator, meditation may be used to induce relaxation, increase vital energy (“qi” or “prana”), attain closeness to God, or induce a state of contemplation or ultimate consciousness. Many religious faiths, both Western and Eastern, include meditative practices within their traditions, and in the past 40+ years, more secular versions of meditation have gained popularity. These forms of meditation are generally considered relaxation techniques, and they involve an intentional focus on the act of breathing, a sound, an object, a phrase, or a movement. The goal of these forms of meditation is generally to increase awareness of the present moment, elicit the relaxation response, reduce stress, and enhance personal growth.
Two common forms of meditation used in the West are mindfulness meditation and concentrative meditation. In mindfulness meditation, participants direct their full attention to their breathing by focusing on each inhalation and exhalation. When thoughts, feelings, or sensations arise, the meditator simply notices and accepts them nonjudgmentally and brings attention back to the breath. In concentrative meditation, attention is focused intently on one thing such as an object (a candle) or a sound or on a word or phrase, which is repeated silently with each breath cycle. Common words and phrases might include “peace” with inhalation and “love” with exhalation or “all will/be well.”
Practicing focused attention in the present moment and nonjudgmental acceptance of experiences or thoughts decreases the mind’s tendency to worry about the future or ruminate about the past. It has also been found to be useful in pain conditions. In one interesting study of experimental pain, subjects were taught mindfulness meditation, which they practiced 20 minutes daily for 3 days. The investigators measured pain sensitivity before and after meditation training and found decreased sensitivity after 3 days of meditation. The authors believed that the increased ability to tolerate pain was related to decreased anxiety and an increased ability to focus on the present moment.
Mindfulness meditation has also been used successfully in older adults with chronic low back pain. Patients were randomized to an 8-week mindfulness meditation group or a wait-list control. The meditators had statistically significant improvements in pain acceptance, activity engagement, and physical functioning. Qualitative assessment of the same subjects revealed that meditation was beneficial for pain, sleep, attention, and well-being. It has also been shown to decrease the severity of bowel symptoms in women with irritable bowel syndrome, with benefits lasting for at least 3 months after mindfulness training.
Guided Imagery
Guided imagery is the generation of specific mental images to evoke a state of relaxation or physiologic change. It takes advantage of the communication links between the mind and the body and uses the imagination to generate intentional physiologic states, such as relaxation or relief of pain. It can be performed with a therapist and patient in person or by a patient alone listening to a recording.
One study of fibromyalgia patients randomized subjects to either 6 weeks of daily guided imagery audiotapes or usual care. People in the guided imagery group had statistically significant improvements in their ability to cope with fibromyalgia, with a decrease in the Fibromyalgia Impact Questionnaire (FIQ) score and increased self-efficacy in managing pain. Interestingly, the imagery dose was not significantly associated with outcome. This lack of dose-response relationship suggests that even using guided imagery infrequently might be beneficial. Guided imagery has also been shown to be beneficial for tension-type headache, recurrent abdominal pain in children, and musculoskeletal pain, although large, higher-quality studies are needed to confirm these results.
There is suggestive evidence that guided imagery is helpful in the perioperative period. It has been shown to reduce length of hospital stay and pharmacy costs and to decrease postoperative pain. A study of patients undergoing colorectal surgery showed that guided imagery significantly reduced postoperative pain, anxiety, and narcotic requirements while increasing patient satisfaction.
Hypnosis
Hypnosis involves leading the patient into a focused, trance-like state. By concentrating attention intensely on one specific thought, memory, feeling, or sensation and blocking out all distractions, patients become calm, relaxed, and open to hypnotic suggestion. Health-inducing suggestions can be offered, including a decrease in anxiety or pain. Patients’ free will remains intact during hypnosis, and they cannot be led against their will to actions that are dangerous to themselves or others.
There is evidence supporting the use of hypnosis for various pain syndromes such as chronic pain, cancer, osteoarthritis, sickle cell disease, temporomandibular disorder, fibromyalgia, non–cardiac-related chest pain, and disability-related chronic pain. In a review of hypnosis for procedure-related pain in children, hypnosis was consistently found to be more effective than control conditions in alleviating the discomfort of bone marrow aspiration, lumbar puncture, voiding cystourethrography, the Nuss procedure, and postsurgical pain. Hypnosis decreased anxiety and depressed mood in patients about to undergo excisional breast biopsy.
Yoga
Yoga originated in India but is now widely practiced throughout the world and is generally used to improve relaxation, strength, and flexibility. Yoga’s combined focus on mindfulness, breathing, and physical movements is health inducing for the mind and the body. Several styles of yoga are commonly practiced in the United States, including Hatha, Vinyasa, Ashtanga, Iyengar, Anusara, and Bikram, and each has unique intentions and techniques. Hatha yoga may be more appropriate for beginners, whereas Ashtanga yoga tends to be more physically demanding. “Power yoga” classes are appropriate for people seeking aerobic exercise, and they are often modifications of the Ashtanga style. Bikram yoga, often referred to as “hot yoga,” is practiced in a room heated to between 95° F and 100° F, and Iyengar yoga is particularly concerned with bodily alignment.
Yoga is often used as a relaxation practice, but it has also been shown to be helpful for pain conditions. In one study, yoga was found to be more effective than a self-care book but equal to a stretching regimen in relieving chronic low back pain. The benefits lasted for several months. Iyengar yoga was also found to reduce pain intensity, functional disability, and depression, and patients with chronic low back pain showed a trend toward decreased use of pain medication when compared with controls. Six months after the intervention, the yoga group still showed decreased functional disability, pain intensity, and depression when compared with the control group.
In a systematic review of yoga interventions, 9 of 10 randomized controlled trials suggested that yoga leads to a significantly greater reduction in pain than do the various control interventions, such as standard care, self-care, therapeutic exercises, touch and manipulation, or no intervention. The authors noted, however, that study quality was less than ideal and definitive judgment was not possible.
Tai Chi and Qi Gong
Tai chi and qi gong are ancient meditative movement techniques that combine standardized physical movements with meditation and relaxation breathing techniques. They have been used for thousands of years in China and as part of TCM theory and are thought to unblock and balance vital energy (“qi”). In the United States, tai chi and qi gong are often used to relieve stress, improve balance, and reduce pain. These techniques use conscious, often slow movements and focus on goals different from those of conventional Western exercise, such as developing consciousness within the body and enhancing the smooth flow of energy.
One study found that tai chi improves immunity and resistance to the virus that causes shingles in older adults, and several have shown benefits in alleviating osteoarthritis symptoms. A Cochrane review of the medical literature showed that tai chi may be helpful in rheumatoid arthritis patients by increasing range of motion of the ankle, hip, and knee. Patients enjoyed the exercise and reported subjective improvement.
Practice of qi gong has been shown to decrease weight, waist circumference, and insulin resistance and to increase leg strength. It might therefore be useful for patients with weight- and deconditioning-related painful conditions such as knee osteoarthritis, although in a meta-analysis of internal qi gong it was not shown to improve chronic pain syndromes. Very few high-quality studies of qi gong for pain have been published, and thus more evidence is needed to evaluate the utility of qi gong for pain conditions.
A recent review of the medical literature found significant beneficial health effects of tai chi and qi gong. The authors reviewed 77 articles reporting the results of 66 randomized controlled trials of the health effects of tai chi or qi gong in more than 6000 patients. Control groups included nonexercise controls, exercise controls, or both. The most convincing evidence of health benefits in this review was for bone density, cardiopulmonary fitness, prevention of falls, balance, quality of life, and self-efficacy.
Tai chi has also been shown to benefit patients with fibromyalgia. A single-blind, randomized trial of tai chi versus an attention control was recently published in the New England Journal of Medicine . The intervention group received tai chi instruction and practiced twice per week for 12 weeks, whereas the control group received an equivalent amount of wellness education and stretching. Subjects who practiced tai chi had highly statistically significant decreases in FIQ scores, and the benefit was maintained at 24 weeks. No adverse events were noted.
Therapeutic Art and Music
Creative arts can be used in the therapeutic environment to relieve stress, anxiety, and pain in patients and caregivers. Art therapy has been used to stimulate relaxation in the palliative care setting, as distraction from the negative side effects of bone marrow transplantation and to increase patient empowerment.
Music therapy was more effective in decreasing anxiety in ventilated patients in the intensive care unit than was an uninterrupted period of rest, and it was more effective than treatment as usual or scheduled rest in decreasing anxiety, pain, and pain-related distress in patients after open heart surgery. Patients randomly assigned to music during colposcopy had decreased pain and lower anxiety than did a non–music therapy group.
A Cochrane review of music therapy in people with cancer assessed 30 trials with a total of 1891 participants. They used music from multiple sources, including recorded music and music provided by trained music therapists, and found that music interventions may have beneficial effects on pain, anxiety, mood, and quality of life in people with cancer.
Energy Medicine
Energy medicine modalities, sometimes called biofield therapies, are based on the idea that all living creatures have energy that can be manipulated in the pursuit of health by a trained practitioner.
A recent 3-year study of 118 chemotherapy patients investigated the role of Reiki in the management of anxiety, pain, and global wellness in cancer patients. Pain and anxiety were evaluated with a visual analog scale (VAS). In patients who received the full treatment course (four Reiki sessions), mean VAS anxiety scores decreased from 6.77 to 2.28, which was a highly significant result. Mean VAS pain scores also decreased from 4.4 to 2.32, but this did not reach statistical significance. Another small study of the use of Reiki in community-dwelling older adults found significant improvements in pain, depression, and anxiety in patients who received Reiki, whereas another found a highly significant reduction in pain of varied causes after Reiki treatment.
A Cochrane review of touch therapies for pain evaluated the evidence for the efficacy of therapeutic touch, healing touch, and Reiki. Randomized controlled trials or controlled clinical trials evaluating the effect of touch on any type of pain were included. Twenty-four studies involving 1153 participants met the inclusion criteria, and only studies using a sham placebo or a “no treatment” control were included. Small, but statistically significant effects were found in patients receiving touch therapy. Interestingly, experienced practitioners of Reiki appeared to be slightly more effective. Two of the five studies evaluating analgesic use suggested that touch therapies minimized analgesic use.
Despite the presence of evidence suggesting that Reiki and related therapies are effective in controlling pain, the evidence is contradictory. Distant Reiki was not found to be effective in controlling pain in women after cesarean section. A review of the Reiki literature found that most trials suffered from methodologic flaws such as small sample size, inadequate study design, and poor reporting. The authors concluded that the evidence is insufficient to suggest that Reiki is an effective treatment of any condition. In another systematic review, 9 of the 12 trials detected a significant therapeutic effect of the Reiki intervention. However, using the Jadad quality score, 11 of the 12 studies were ranked “poor.” Thus, although Reiki is probably safe and may be effective in relieving pain and anxiety, higher-quality studies are needed to clarify its clinical indications.
Manual Therapies
The term manual therapy is nonspecific and refers to techniques that use the hands to diagnose and treat disorders of the musculoskeletal system. It is often used to treat a variety of painful musculoskeletal conditions, and several studies have demonstrated its effectiveness. Many studies show a significant effect on pain and improvement in outcome measures, although in some cases the effect size is small. Manual therapy may be performed by physical therapists, chiropractors, massage therapists, osteopathic physicians, and others and may include techniques such as craniosacral therapy and osteopathic manipulative techniques (OMTs).
Practitioners of manual therapy generally believe that musculoskeletal problems arise from abnormal movement patterns or postures, which lead to asymmetrical musculoskeletal forces and subsequent pain. Examples of musculoskeletal asymmetry that can lead to painful conditions include chronic elevation of one shoulder when carrying a heavy purse, abnormalities in tissue texture after prolonged immobilization, and forward head carriage associated with desk work, computer use, and prolonged sitting causing intervertebral disk deformation.
Several models attempt to explain the mechanisms by which manipulation or manual therapy modulates pain. There are three primary models:
Structural model : Misaligned structures impinge on nerves and stress soft tissues, thereby stimulating nociceptors. Common terminology includes “subluxation,” “pelvic obliquity,” “leg length inequality,” and “torsion.” It is believed that correction of these misalignments via manual methods eliminates pain.
Functional model : Muscular imbalance leads to abnormal joint loading, which in turn causes loss of joint function at the level of accessory motion. Terminology includes “somatic dysfunction,” “biomechanical lesion,” “blockage,” “muscular inhibition/facilitation,” and “instability/stabilization.” Syndromes include upper and lower crossed syndromes, each characterized by specific patterns of muscular facilitation (tightness) and inhibition (weakness). For example, upper crossed syndrome is characterized by facilitation or “tightness” of the upper trapezius, levator, sternocleidomastoid, and pectoralis muscles, whereas the deep cervical flexors, lower trapezius, and serratus anterior muscles are inhibited and weak. Practitioners use rehabilitative exercise and manipulation with the intention of correcting the imbalance and reducing nociceptive input. This is the current model presented in most chiropractic, physical therapy, and osteopathic programs.
Neurophysiologic model : This model is consistent with the emerging concept that the pain experience is a central nervous system output that is modulated by multiple factors such as stress, anxiety, fear avoidance, experience, and context in the brain’s “neuromatrix.” Wellens proposed that manual therapy introduces a novel stimulation into the central nervous system that may help the brain downregulate the perceived threat of nociceptive stimuli, thereby decreasing the pain by descending inhibition and other peripheral and central mechanisms. This in turn may stimulate a change in the maladaptive motor responses produced by the brain in response to pain. Other reflexive reactions at the spinal cord level may affect temporal summation and downregulate the value (threat) of the nociceptive input even more. Even though this model is hypothetical, there is an impressive emerging body of supportive literature.
It is likely that manual therapy provides pain relief through an interplay of all three models. Future research may help determine each model’s relative contribution.
Myofascial pain syndrome is a chronic musculoskeletal pain condition with a poorly defined and somewhat controversial pathophysiology. It may emerge after tissue injury, chronic stress-related muscular contraction, or excessive strain on a muscle, tendon, or ligament. Tender regions of hyperirritable, contracted muscle fibers, called trigger points, may form in the affected muscle group and cause local and referred pain. Myofascial trigger points are palpable, tender nodules within skeletal muscle that have characteristic referred pain patterns and physiologic activity that are different from those in normal muscle tissue. Trigger points may be treated with physical therapy, massage, transcutaneous electrical stimulation, selective voluntary contraction of antagonist muscles or muscle groups, injection of saline or local anesthetic medications, dry needling, or application of coolant spray combined with focused muscular stretching. Botulinum toxin has also been used.
Massage
Massage refers to the application of varied techniques to the muscles, ligaments, tendons, and related structures in the pursuit of health and wellness. Massage may be performed with the hands, elbows, forearms, or feet, as well as with appliances such as warmed stones. There are many types of massage, each with unique techniques and goals, such as Swedish massage, trigger point massage, reflexology, and lymphatic drainage.
Massage is often used to address pain syndromes such as back pain, neck pain, and sports injuries, as well as to aid in stress reduction and generation of the relaxation response. It has been found to improve symptoms of osteoarthritis of the knee and chronic low back pain, decrease medication use and medical costs, and decrease perception of cancer pain.
It is not clear whether some forms of massage are superior to others or whether all are equally effective. One recent study randomized 401 patients with nonspecific low back pain to relaxation massage, structural massage, or usual care and assessed their symptoms with the Roland Disability Score and the Symptom Bothersome Score. Participants were blinded to the type of massage but not to massage versus usual care. At 10 weeks, both massage groups had statistically significant improvements in both outcome measures when compared with those receiving usual care.
Although massage is generally safe for healthy populations, it can be dangerous in certain circumstances. Contraindications include, but are not limited to metastatic lesions, severe osteoporosis, thrombosis, infections or wounds, active inflammatory conditions, and bleeding disorders.
Chiropractic
Doctors of chiropractic focus primarily on the interaction between the structure and the function of the body, with particular attention paid to the spine. Historically, the primary goal was to correct musculoskeletal misalignments (subluxations) to relieve nerve pressure and thus alleviate pain and improve the body’s innate self-healing capability. The primary modality of chiropractic manipulative therapy is high-velocity, low-amplitude (HVLA) thrust manipulation (spinal adjustment). Adjustments generally involve use of the hands or a device to apply an intentional, controlled, rapid force to a joint or body segment thought to have impaired alignment or restricted motion. Restored intersegmental motion or joint position is believed to improve both function and general health. There are multiple chiropractic techniques, each with its own unique set of diagnostic and treatment protocols. Some use very little force, whereas others can be quite aggressive. The most common technique encountered is termed “diversified” and encompasses HVLA maneuvers for all joints of the spine and extremities. In addition to manual therapies, chiropractors may incorporate relaxation techniques, dietary guidance, nutritional supplements, physical therapy modalities, and rehabilitative exercise into their treatment plans. The combination of HVLA manipulation and rehabilitative exercise appears to provide the best outcomes.
Most patients who choose chiropractic care do so because of back and neck problems. Patients are generally satisfied with their chiropractic care. Although some have expressed concern that chiropractic treatment of the neck increases the risk for stroke, a large study that included more than 100 million person-years showed that these concerns are unfounded. Debate on this topic persists.
A systematic review of randomized clinical trials of manual therapies evaluated the evidence for spinal manipulation or mobilization in treating several different conditions, including 13 musculoskeletal conditions and headaches. The authors reviewed 49 systematic reviews, 16 evidence-based clinical guidelines, and an additional 46 randomized clinical trials not yet included in systematic reviews and guidelines. They found spinal manipulation to be effective in adults for acute, subacute, and chronic back pain, migraine and cervicogenic headache, and cervicogenic dizziness, and thoracic manipulation or mobilization was determined to be effective for acute and subacute neck pain.
Research is inconsistent regarding the efficacy of spinal manipulation or mobilization for the treatment of neck pain. One study found spinal manipulation or mobilization to be effective in improving neck pain symptoms when combined with exercise but not when used alone, but a literature review found chiropractic spinal manipulation to be ineffective for neck pain. A more recent Cochrane review detected a suggested benefit but also noted the need for higher-quality studies to confirm the result. A 2011 study provided evidence suggesting that HVLA manipulation of the cervicothoracic and upper cervical segments is superior to mobilization techniques for the relief of neck pain.
Osteopathic Manipulation
Doctors of osteopathy earn their DO degree from 1 of 26 osteopathic medical schools in the United States and are approved for the unlimited practice of medicine in all 50 states, the District of Columbia, and U.S. territories. Their scope of practice includes the ability to prescribe medications and perform surgery. Osteopathic medical education is similar to that found in allopathic medical schools, with the added focus on a holistic and preventive approach to medicine. In addition, osteopathic physicians learn OMT, which is not included in the allopathic medical school curriculum. OMT is a hands-on practice that attempts to restore normal movement and function and decrease pain.
Osteopathic physicians may choose any specialty and can earn board certification from both osteopathic and allopathic medical boards. Some osteopathic physicians complete allopathic residencies and practice indistinguishably from allopathic physicians, whereas others remain committed to osteopathic principles and practices.
Osteopathic principles include working in partnership with patients to facilitate wellness and prevent disease and the concept that structure influences function. That is, a structural problem in one part of the body may affect function in that region and possibly others. Osteopaths generally believe that the body has an innate ability for self-healing, and OMT techniques are thought to support this process.
OMT procedures are directed at increasing mobility in restricted areas of musculoskeletal function and reducing pain. Some practitioners focus on pain relief, whereas others are more interested in the influence of increased mobility within the system. The stated goal of OMT is to restore maximal, pain-free movement of the musculoskeletal system in postural balance. Techniques include a muscle energy technique, mobilization with and without impulses, indirect technique, myofascial release, and integrated neuromusculoskeletal technique.
OMT has been demonstrated to be effective for neck pain and migraine headache symptoms, with pain intensity, functional disturbance, and days of disability all showing improvement when compared with control. A systematic review and meta-analysis of OMT for low back pain concluded that OMT significantly reduces low back pain symptoms, with the effect lasting at least 3 months.
Orthopedic manual therapy is the name given to manual therapy as practiced by physical therapists. Manual therapy has only recently been introduced as part of the core physical therapy curriculum, with most practitioners gaining knowledge and skills through continuing education or fellowships. Physical therapists trained in manual therapy use techniques such as stretching, mobilization, manipulation, and muscle energy–related techniques to increase range of motion, improve function, modulate pain, decrease tissue inflammation, and facilitate tissue repair.
Practitioners of manual medicine may be trained as physical therapists, osteopathic physicians, chiropractors, and to some extent, massage therapists, and strict distinction between practice styles and techniques is lacking. A standardized knowledge base with certification available to all relevant practitioners would be valuable. It is not clear whether one profession will eventually “own” manual medicine or whether a new specialty will emerge. One suggested model is to offer fellowships in manual medicine with board certification that would be available to physical therapists, chiropractors, osteopathic physicians, allopathic physicians, and massage therapists.
Homeopathy
The field of homeopathy was developed by the German physician Samuel Hahnemann at the end of the 18th century in an effort to find a way to trigger the body’s natural ability to heal disease. Homeopathic medicines, called “remedies,” are made at homeopathic pharmacies by using a specialized process of dilution and shaking, called succussion. Remedies, which are often in tablet form, are individualized, and patients with the same symptom may be given very different remedies. Homeopathy is based on two principles that may be challenging for conventional health practitioners to accept: the “law of similars” and the “law of minimum dose.” The “law of similars” suggests that the substance that is most helpful for a disease or symptom is one that causes these same symptoms in a healthy person. For example, if a substance causes sleeplessness when taken at full strength, it might be used to treat insomnia homeopathically.
The “law of minimum dose” is based on the principle that the efficacy of a remedy increases as the dose is decreased. Homeopathic remedies are serially diluted, often until the remedy no longer contains any molecules of the original medication. The diluent, frequently water, is thought by homeopaths to be “imprinted” by the original substance, thus imparting therapeutic efficacy.
Most rigorous clinical trials and systematic analyses of the research on homeopathy have concluded that there is little evidence to support homeopathy as effective treatment of any specific condition. However, some reviews have found suggestions of positive results, and a randomized, controlled study of homeopathic treatment of fibromyalgia showed significant decreases in tender points in the treatment group. One randomized, double-blind controlled trial of homeopathy for rheumatoid arthritis showed that it was the homeopathic consultation rather than the remedy itself that led to positive outcomes. Anecdotal claims of the efficacy of homeopathic treatments are common from both practitioners and users of homeopathy, and the remedies tend to be safe. Large, well-designed studies are needed to clarify the effectiveness of homeopathy for varied health conditions.
Biologically Based Products: Herbs, Nutraceuticals, and Nutritional Supplements
A large body of clinical evidence supports the use of biologically based natural products for the alleviation of pain. This supportive evidence for pain reduction spans a wide variety of herbs, nutraceuticals, nutritional supplements, and food-derived topical products. Although the majority of the evidence assessed the effects of these products on osteoarthritis pain, there is also evidence from well-designed clinical trials supporting the use of natural products for rheumatoid arthritis, neuropathy, persistent neck and back pain, dysmenorrhea, and inflammatory bowel disease. The following products have the strongest evidence supporting their use for the reduction of pain.
Capsaicin
Capsaicin is derived from chili peppers of the genus Capsicum , which includes the cayenne pepper commonly used in cooking. Topical application of gel ranging from a 2.5% to 8% concentration of capsaicin is used to provide pain relief. The primary mechanism through which capsaicin is believed to reduce pain is depletion of substance P, a neuropeptide involved in the transmission of pain signals from nerve endings to the brain, as well as the activation of inflammatory cytokines in joints.
Many high-quality, randomized, double-blind placebo-controlled trials have found that topical application of capsaicin is an effective treatment of osteoarthritis pain. A meta-analysis found that topical capsaicin in concentrations between 2.5% and 7.5% was four times as effective as placebo in reducing osteoarthritis pain. No serious side effects were noted in these trials, although a burning sensation following topical application of capsaicin at these concentrations is common. Motivated by the relatively common sensation of burning experienced at these concentrations, a recent trial assessed topical application of capsaicin at a concentration of 1.25% in 100 patients with osteoarthritis of the knee. Capsaicin at this lower concentration was effective in improving pain. Even though a mild burning sensation was common, no participants dropped out of the study for this reason. Consequently, lower concentrations of topically applied capsaicin appear to be an effective treatment option for mild to moderate osteoarthritis pain.
Although most capsaicin research to date has focused on osteoarthritis pain, several recent studies have assessed its efficacy for neuropathic pain. Transient application of a dermal patch containing 8% capsaicin has been shown to be an effective option for reducing neuropathic pain. The patch was applied for between 30 and 90 minutes in these studies and repeated, as required, every 90 days. The capsaicin patch was generally well tolerated in these studies. However, as has been the case in studies using capsaicin gel, irritation localized to the site of application was the most common adverse event.
Boswellia Serrata
Extracts of the B. serrata plant have been used as an important component of Ayurvedic medicine for thousands of years. Western science has validated the traditional use of B. serrata for pain inasmuch as its extracts elicit powerful anti-inflammatory activity through its inhibition of the 5-lipoxygenase (5-LOX) enzyme. Several forms of B. serrata have been studied and used clinically, including traditional 60% to 70% extracts of B. serrata gum resin, as well as the commercial preparations Aflapin and 5-Loxin.
Five randomized controlled trials have been conducted to assess the effects of B. serrata on the pain associated with osteoarthritis of the knee. All these trials found statistically and clinically significant reductions in pain. Symptoms improved as early as 5 days after treatment commenced. In one trial, the reduction in pain persisted 1 month after the conclusion of treatment. The lasting reduction in pain is a unique benefit of B. serrata when compared with traditional pharmacologic therapies for pain. Daily dosages used in these studies were 333 mg of 65% standardized B. serrata extract, 100 mg of Aflapin, and 250 mg of 5-Loxin. B. serrata was well tolerated in all trials, and very few side effects were noted aside from minor gastrointestinal distress in some participants.
Glucosamine and Chondroitin
Numerous meta-analyses have determined that glucosamine, either combined with chondroitin or alone, is an effective treatment of osteoarthritis pain. A meta-analysis of 16 randomized, double-blind studies found glucosamine to be significantly more effective than placebo and more effective than or equal to nonsteroidal anti-inflammatory drugs (NSAIDs) with minimal adverse effects. Another review of randomized trials of both glucosamine and chondroitin found moderate to large effect sizes (0.44 and 0.78, respectively). A large randomized controlled trial ( N = 212) published since the aforementioned reviews found that patients taking 1500 mg of oral glucosamine sulfate daily for 3 years experienced no significant joint space loss and minimum joint space narrowing when compared with patients taking placebo.
Despite the abundance of positive evidence for glucosamine and chondroitin, the large Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) found mixed results, which are often misinterpreted. This five-arm trial compared glucosamine alone, chondroitin sulfate alone, glucosamine/chondroitin sulfate, and celecoxib with placebo. Participants in the glucosamine/chondroitin group did not demonstrate a statistically significant improvement over placebo in the primary outcome (20% improvement in the WOMAC pain score) of the overall study sample of patients with osteoarthritis of the knee (mild [ n = 1229] vs. moderate to severe [ n = 354]). However, 67% of the overall study sample in the glucosamine/chondroitin group experienced at least a 20% improvement in pain with a trend toward statistical significance ( P = 0.09). The lack of statistical significance at the P = 0.05 level was thought to be due to the unexpectedly high improvement in the placebo group (60.1%). Furthermore, among the 354 participants with moderate to severe osteoarthritis of the knee, 79% of those in the glucosamine/chondroitin combination group experienced at least a 20% improvement in the WOMAC pain score, which was statistically significant when compared with placebo ( P = 0.002). Interestingly, participants with moderate to severe arthritis pain in the celecoxib group did not demonstrate statistically significant improvement when compared with placebo, a finding that is rarely reported. Although a statistical comparison between the glucosamine/chondroitin and celecoxib groups was not reported in the paper, glucosamine/chondroitin was shown to be more effective than celecoxib in patients with moderate to severe osteoarthritis.
Even though the findings from the more than 50 randomized controlled trials of glucosamine/chondroitin for osteoarthritis pain have not been universally positive, consideration of the body of evidence suggests that glucosamine/chondroitin is a safe and at least moderately effective treatment of osteoarthritis pain. A daily dose of 1500 mg glucosamine and 1200 mg chondroitin has been studied most frequently and is the typical recommended dosage.
S -Adenosylmethionine
The reduction in joint pain provided by S -adenosylmethionine (SAM-e) was first observed as side effects in clinical trials for depression. Produced from l -methionine and adenosine triphosphate, SAM-e is a methyl donor involved in a wide variety of metabolic processes. Although its mechanism of action is not completely understood, SAM-e has been shown to possess anti-inflammatory and analgesic effects without causing gastrointestinal damage in animal models. SAM-e has also demonstrated chondroprotective effects through stimulation of chondrocytes and a subsequent increase in cartilage production.
A meta-analysis of 13 clinical trials revealed that SAM-e is comparable to ibuprofen and superior to placebo in reducing osteoarthritis pain. A large randomized controlled trial published subsequent to this review compared the efficacy of SAM-e with that of celecoxib in patients with osteoarthritis pain. This study found that SAM-e was as effective as celecoxib in relieving pain after 16 weeks of treatment. The onset of pain relief is slower than with some pharmacologic pain relievers, but SAM-e has no known side effects. Most clinical trials to date have used a daily dosage of between 400 and 1600 mg.
ω-3 Fatty Acids
Dietary ω-3 fatty acids, including α-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), can interrupt the production of inflammatory compounds such as prostaglandin E 2 , leukotriene B 4 , interleukin-1β, and tumor necrosis factor-α. ω-3 Fatty acids also inhibit the platelet-activating factor synthesis pathway, the cyclooxygenase pathway, and the 5-lipoxygenase pathway. Accordingly, ω-3 fatty acids are known to play an important role in modulating the inflammatory cascade and the pathophysiology of autoimmune conditions. Chief among the conditions affected by ω-3 fatty acids is rheumatoid arthritis.
ω-3 Fatty acids have been shown in numerous systematic reviews to reduce the pain and joint tenderness of rheumatoid arthritis. Multiple studies have also found that ω-3 supplementation can reduce dependence on NSAIDs and antirheumatic drugs. In addition to reduction of the pain associated with rheumatoid arthritis, ω-3 fatty acids have also been determined to be effective in reducing neck and back pain, neuropathic pain, and the pain from inflammatory bowel disease and dysmenorrhea. No significant toxicities have been associated with the use of ω-3 fatty acids, although patients taking anticoagulant medications should be mindful of the potential for interaction.
The ω-3 fatty acids EPH, DHA, and ALA are not produced endogenously in human beings and must be obtained through the diet. Dietary sources of ω-3 fatty acids include salmon, sardines, and other cold-water fish, fish and krill oil, and plant oil from flaxseed or walnuts. Although all forms of ω-3 fatty acids are important, EPA and DHA have direct anti-inflammatory effects and are more easily used by the body. Conversion from ALA to EPA and DHA is poor, particularly in men. Consequently, the optimal forms of ω-3 fatty acids taken for therapeutic purposes to relieve painful conditions are EPA and DHA. Therefore, most studies to date have investigated the effects of fish oil because of its high concentration of EPA and DHA. These studies show that a minimum daily dosage of 3 g of EPA and DHA is required for clinical efficacy in pain conditions. Benefits in alleviating pain generally become apparent after a period of at least several weeks.
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