ATrain Education

 

Continuing Education for Health Professionals

OR: Pain, Healthcare's Persistent Challenge, 6 units

Module 17

Complementary, Alternative, and Integrative Therapies

Alternative practitioners make up an ever larger piece of the pain management universe. Most are trained in what would be considered complementary and alternative techniques, increasingly referred to as integrative medicine.

Complementary, alternative, and integrative health approaches are used to treat or manage disorders or symptoms associated with acute and chronic pain. Common complementary health approaches include mind and body interventions such as meditation, spinal manipulation, yoga, massage, tai chi, and acupuncture. A variety of natural products, including herbs, dietary supplements, and prebiotic or probiotic products are also commonly used (NCCIM, 2016a).

 

10 Most Common Complementary Health Approaches Among Adults—2012

image: graph of common complementary health approaches

*Dietary supplements other than vitamins and minerals.
Source: Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002–2012. National health statistics reports; no 79. Hyattsville, MD: National Center for Health Statistics, 2015.

 

Integrative Pain Management

“Integrative” healthcare brings conventional and complementary approaches together in a coordinated way. Researchers are exploring the benefits of integrative health in a variety of situations, including pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors (NCCIH, 2016a).

Complementary and integrative medicine provides patient-centered care, addressing physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health. It uses the most appropriate interventions from an array of disciplines to heal illness and help people regain and maintain optimum health (Abrams et al., 2013).

Integrative medicine is a popular approach to pain management, although for a large, structured healthcare organization, integrating diverse practices can be challenging. Healthcare organizations must balance supply and demand for services as well as combine the integrative medicine program into the established culture of a large hospital (Nate et al., 2015).

In an effort to capture data on patient-reported outcomes in integrative medicine, a number of leading clinics have collaborated to form the first practice-based research network in the field: the Bravewell Integrative Medicine Research Network (BraveNet). BraveNet’s initial project involved 4182 patients seeking care at nine clinical sites. The data confirmed the high utilization of integrative medicine by chronic pain patients and led to a Study on Integrative Medicine Treatment Approaches for Pain (SIMTAP). In this study, researchers reported the impact of a six-month integrative approach on chronic pain and a number of other related patient-reported outcome measures (Abrams et al., 2013).

In the SIMTAP study, practitioners at each of the sites devised treatment plans for participating chronic pain patients. All BraveNet sites include integrative physicians, acupuncturists, mindfulness instructors, and yoga instructors; some also incorporate massage therapists, manual medicine therapists, fitness and movement specialists, dieticians and nutritionists, psychologists, healing touch therapists, and other energy practitioners. The results of this study suggest that the tailored, multimodal approach to treating chronic pain combining conventional and complementary therapies improves quality of life and reduces pain, stress, and depressive symptoms (Abrams et al., 2013).

The National Center on Complementary and Integrative Health (NCCIH) and the U.S. Department of Veterans Affairs are sponsoring research to see whether integrative approaches can help active-duty military personnel and veterans experiencing chronic pain. NCCIH-funded studies are testing the effects of adding mindfulness meditation, self-hypnosis, or other complementary approaches to pain management programs for veterans. The goal is to help patients feel and function better and reduce their need for pain medicines that can have serious side effects (NCCIH, 2016a).

Some cancer treatment centers are using integrative healthcare programs such as acupuncture and meditation to help manage symptoms and side effects for patients who are receiving conventional cancer treatment. Although research on the potential value of these integrative programs is in its early stages, some NCCIH-funded studies have had promising results:

  • Cancer patients who receive integrative therapies while in the hospital have less pain and anxiety.
  • Massage therapy may lead to short-term improvements in pain and mood in patients with advanced cancer.
  • Yoga may relieve the persistent fatigue that some women experience after breast cancer treatment. (NCCIH, 2016a)

A growing body of evidence supports the efficacy and safety of non-drug and complementary health approaches to reduce pain and increase patients’ coping ability and general well-being. Many of these techniques have the potential to reduce the need for costly pain medications with harmful side effects. At a minimum, providers should have a basic understanding of the scientific evidence on complementary health approaches so that patients will not be reluctant to disclose their use.

Mind and Body Practices

Mind and body practices include a diverse group of procedures and techniques administered or taught by a trained practitioner. A 2012 National Health Interview Survey showed that yoga, chiropractic and osteopathic manipulation, meditation, and massage therapy are among the most popular mind and body practices used by adults. The popularity of yoga has grown dramatically in recent years, with almost twice as many U.S. adults practicing yoga in 2012 as in 2002 (NCCIH, 2016a).

Yoga

The various styles of yoga typically combine physical postures, breathing techniques, and meditation or relaxation. Hatha yoga, the most commonly practiced in the United States and Europe, emphasizes postures (asanas) and breathing exercises (pranayama) (NCCIH, 2016b).

Yoga typically combines a series of stretching exercises, breathing techniques, and progressive, deep relaxation.

image: yoga

Source: Photograph by Kennguru. Own work, CC BY 3.0.

A study involving ninety-five people aged 18 to 64 from six health centers in a low-income, predominantly minority area of Boston found that once- or twice-weekly yoga classes relieved pain, improved function, and reduced the need for pain medication in participants with chronic low back pain. The participants had moderate to severe chronic low back pain and significant related impairment. Most were unemployed or disabled, with annual household incomes of $40,000 or less. The program included home practice, keeping a log, meditation, and information on yoga philosophy (Saper et al., 2013).

Researchers found statistically significant and clinically meaningful improvements in pain and back-related function in both the once per week and twice per week groups. The most benefit was experienced within the first 6 weeks. Adverse events, mostly musculoskeletal pain, were common; they generally resolved on their own and were not serious (Saper et al., 2013).

In another study, regular and long-term practice of yoga was shown to improve pain tolerance. Findings showed that yoga practitioners have more gray matter in multiple brain regions compared with individually matched people who did not practice yoga. The study involved 14 experienced yoga practitioners, as well as 14 people who did not practice any mind-body techniques. Participants underwent a cold pain tolerance test by immersing a hand in cold water until they could no longer tolerate the pain. Researchers then asked participants about strategies they used to tolerate the pain. The researchers also conducted brain imaging scans to examine the structural differences in gray matter and white matter between the yoga practitioner group and the control group (Villemure et al., 2013).

Researchers found that yoga practitioners tolerated cold pain more than twice as long as the controls. They found no significant difference in total gray matter volume between groups, but yoga practitioners had greater gray matter volume in brain regions related to pain processing, pain regulation, and attention (Villemure et al., 2013).

The volume of insular gray matter in yoga practitioners positively correlated with the duration of yoga practice, suggesting that yoga experience contributed to these structural differences in the brain. In addition, yoga practitioners had increased white matter integrity within the left insula. Researchers observed that, to tolerate pain, yoga practitioners used cognitive strategies that are integral parts of yoga practice, such as observing the sensation without reacting, accepting the sensation, using the breath, and relaxation (Villemure et al., 2013).

Other studies suggest that a carefully adapted set of yoga poses may reduce low-back pain and improve function. One NCCIH-funded study of 90 people with chronic low-back pain found that participants who practiced Iyengar yoga had significantly less disability, pain, and depression after 6 months (NCCIH, 2016b).

Chiropractic Medicine

Chiropractic Manipulation

photo: chiropractor

A chiropractor demonstrating an adjustment on the patient’s thoracic spine. Source: Michael Dorausch, Creative Commons Attribution-Share Alike 2.0 Generic.

Chiropractic is a healthcare profession that focuses on the relationship between the body’s structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body’s natural ability to heal itself (NCCIH, 2012).

In the United States, chiropractic is often considered a complementary health approach. According to the 2007 National Health Interview Survey (NHIS), which included a comprehensive survey of the use of complementary health approaches by Americans, about 8% of adults and nearly 3% of children had received chiropractic or osteopathic manipulation in the past 12 months (NCCIH, 2012).

Massage Therapy

Massage therapy, as one of the complementary and alternative treatments, is defined as a therapeutic manipulation using the hands or a mechanical device that includes numerous specific and general techniques often used in sequence, such as effleurage (stroking), petrissage (kneading), and percussion. It may be the earliest and most primitive tool used to improve pain. The most ancient references to the use of massage come from China (around 2700 B.C.). Common types of massage therapy include Swedish massage, Shiatsu, Rolfing, reflexology, myofascial release, and craniosacral therapy (Kong et al., 2013).

Massage Therapy

photo: massaging a foot

Photograph of a man massaging a woman’s foot using baby oil as a lubricant. Attribution: Lubyanka, Creative Commons Attribution Share-Alike Unported 3.0 license.

Massage mechanically assists in venous and lymphatic flow, improves skin integrity and mobility, desensitizes tissue, and provides comfort and psychological support. Massage may be used to stretch muscles and is usually used in combination with other treatments.

Massage has proved effective in reducing pain, anxiety, and tension after cardiovascular surgery. In a study at Mayo Clinic, patients were randomized either to receive a massage or to have quiet relaxation time following surgery. Those who received massage therapy had significantly less pain, anxiety, and tension than the control group (Braun et al., 2012).

Burn victims suffer some of the most severe physical and psychological pain imaginable. Turkish researchers found that massage therapy reduced pain, itching, and anxiety levels in adolescents in the burn unit of a large university hospital. Massage therapy reduced all three symptoms from the first day of the study until the last (Parlak et al., 2010).

Researchers in Spain studied the effects of massage combined with myofascial release therapy* on patients diagnosed with fibromyalgia. Patients were randomized to receive either the combination therapy or a sham treatment during 20 weekly sessions. Immediately after treatment and 1 month later, the researchers found that anxiety levels, quality of sleep, pain, and quality of life were improved in the experimental group (Castro-Sánchez et al., 2011).

*Myofascial release therapy is a type of physiotherapy requiring special training that aims to release myofascial restrictions at the sites of certain painful points called trigger points.

A 2010 AHRQ evidence report, which summarized, critically appraised, and compared the evidence on clinical benefits, costs, and harms associated with use of complementary and integrative medicine and other therapies for the treatment of adults with low back, neck, and thoracic pain, found that massage was superior to placebo or no treatment in reducing pain and disability immediately post treatment only in subjects with acute/subacute but not in subjects with chronic low back pain (AHRQ, 2014).

Meditation

Monk in Meditation

photo: meditation

Phra Ajan Jerapunyo, Abbot of Watkungtaphao meditating in Sirikit Dam, Thailand. Creative Commons Attribution 3.0 Unported.

Meditation refers to a group of techniques rooted in ancient religious and spiritual traditions. It is used to increase calm, promote relaxation, improve psychological balance, cope with illness, or enhance overall health and well-being. People also use meditation for various health problems, including anxiety, pain, depression, stress, insomnia, physical or emotional symptoms associated with chronic illness and their treatment.

Mindfulness meditation is one of the most studied and practiced forms of meditation in America. In a study conducted by researchers at Wake Forest School of Medicine and Cincinnati Children’s Hospital Medical Center, researchers recorded pain reports in 78 healthy adults during meditation with a non-meditation control in response to painful heat stimuli and intravenous administration of the opioid antagonist naloxone (a drug that blocks the transmission of opioid activity) or placebo saline. Participants were randomized to 1 of 4 treatment groups: (1) meditation plus naloxone, (2) control plus naloxone, (3) meditation plus saline, or (4) control plus saline. People in the control groups were instructed to “close your eyes and relax until the end of the experiment” (NCCIH, 2016c).

Researchers found that participants who meditated during saline administration had significantly lower pain intensity and unpleasantness ratings compared to those who did not meditate while receiving saline. Importantly, data from the meditation plus naloxone group showed that naloxone did not block meditation’s pain-relieving effects. No significant differences in reductions of pain intensity or pain unpleasantness were seen between the meditation plus naloxone and the meditation plus saline groups. Participants who meditated during naloxone administration also had significantly greater reductions in pain intensity and unpleasantness than the control groups (NCCIH, 2016c).

These findings demonstrate that mindfulness meditation reduces pain independent of opioid neurotransmitter mechanisms. The researchers noted that because opioid and non-opioid mechanisms of pain relief interact synergistically, the results of this study suggest that combining mindfulness-based and drug/nondrug pain-relieving approaches that rely on opioid signaling may be particularly effective in treating pain (NCCIH, 2016c).

Traditional Chinese Medicine

Traditional Chinese medicine views the body as a system of channels through which energy flows. The Chinese call this energy qi or chi. Disease or illness is caused when the energy gets blocked or stagnates and doesn’t flow freely through the body. Herbs, acupuncture, qi gong, tai chi, and Chinese massage are mind-body techniques to help unblock the flow of chi through normal channels and thereby restore health. Practitioners of traditional Chinese medicine devise individualized treatment plans based on each patient’s unique diagnosis rather than following a standard intervention based on the complaint (Abrams et al., 2013).

In China, traditional medicine is one of the conservative treatments for lumbar disc herniation, and several studies have confirmed that it has certain effects on low back pain caused by lumbar disc herniation. Treatments include acupuncture, oral administration of Chinese medicine, external application of Chinese medicine, Chinese tuina (massage), and TCM-characteristic functional exercise. Clinically, these therapeutic methods are not used alone but in combination (Yuan et al., 2013).

In the treatment of pain due to lumbar disc herniation, different traditional Chinese medicine therapies have different advantages. Pain is the main symptom in the acute stage and acupuncture has good analgesic effect. Lumbar dysfunction is the main symptom in the remission stage and Chinese massage has good effect on improving dysfunction. Oral Chinese herbal formulae, external use of Chinese medicine, and Chinese herbal injection also showed good effect in relieving pain and improving dysfunction caused by lumbar disc herniation (Yuan et al., 2013).

Acupuncture

The term acupuncture describes a family of procedures involving the stimulation of anatomic points on the body using a variety of techniques. The acupuncture technique most often studied scientifically involves penetrating the skin with hair-thin metallic needles that are inserted a few millimeters into the skin.

Acupuncture Points

image: acupuncture points

Acupuncture sites. Source: NCCIH.

Researchers from the Acupuncture Trialists’ Collaboration analyzed data from randomized trials using acupuncture for chronic pain. These trials investigated the use of acupuncture for back and neck pain, osteoarthritis, shoulder pain, or chronic headache. For all pain types studied, the researchers found modest but statistically significant differences between acupuncture and simulated acupuncture approaches, and larger differences between acupuncture and non-acupuncture controls. The sizes of the effects were generally similar across all pain conditions studied (Vickers, 2012).

Acupuncture Treatment

image: acupuncture treatment

Basic acupuncture. Photo by Kyle Hunter, public domain.

These findings suggest that the total effects of acupuncture, as experienced by patients in clinical practice, are clinically relevant. They also noted that their study provides the most robust evidence to date that acupuncture is more than just placebo and a reasonable referral option for patients with chronic pain (Vickers, 2012).

How acupuncture works to relieve pain and other symptoms is still incompletely understood, although functional MRI (fMRI) studies are beginning to provide some answers. Acupuncture seems to change the way the brain perceives and processes pain. Using fMRI in 18 volunteers, German researchers viewed pain centers in the brain while applying an electrical pain stimulus to subjects’ ankles before and after acupuncture treatment. They reported that “activation of brain areas involved in pain perception was significantly reduced or modulated under acupuncture” (Theysohn et al., 2010).

Chinese Tuina (Massage)

Tuina is a form of bodywork or massage therapy that is usually used in conjunction with other types of traditional Chinese medicine. Among non-drug therapies, Chinese tuina is widely used in China for pain management. Tuina is thought to relieve pain by harmonizing the yin and yang of the organs. Tuina is considered gentle on the body and as such, patients often prefer tuina over pharmaceutical drugs (Zhang et al., 2015).

Tuina involves a wide range of technical manipulations conducted by a practitioner’s finger, hand, elbow, knee, or foot applied to muscle or soft tissue at specific body locations. It incorporates many of the principles of acupuncture, including the use of acupoints. For instance, tuina often uses manual techniques such as pushing, rubbing, kneading, or high-intensity, high-frequency patting to clear energy blocks along specific meridians associated with particular conditions (Yang et al., 2014).

According to traditional Chinese medicine, pain is usually caused by obstruction of qi, and consequently of blood circulation in the affected body region. Pathogenic factors such as blood stasis, qi stagnation, phlegm, dampness, and others can be identified as causative factors in the blockage. The central therapeutic goal of tuina is to remove energetic blocks which lead to qi stagnation. This leads to increased circulation and reduction of localized edema, which helps to reduce associated pain (Yang et al., 2014).

The A-Shi point in acupuncture theory is the tender, local dermal or muscular area or site on the body surface which reproduces the specific pain being treated when it is gently pressed. Its location indicates the precise place where qi and blood are blocked. Manipulation at the A-Shi point is done with the intention of removing the energetic block there to promote the free movement of qi and improve blood circulation in the region. Studies have demonstrated that one mechanism by which this type of massage therapy appears to be clinically beneficial is by reducing inflammation and promoting mitochondrial biogenesis for repair of damaged skeletal muscle (Yang et al., 2014).

Cupping

Cupping therapy (CT) is a traditional Chinese medical treatment which has been practiced for thousands of years. The World Health Organization’s defines cupping as a therapeutic method involving the application of suction by creating a vacuum. This is typically done using fire in a cup or jar on the dermis of the affected part of the body (Chi et al., 2016).

Cupping in Practice

image: woman receiving fire cupping

A woman receiving fire cupping in Haikou, Hainan, China. Source: Anna Frodesiak. Public domain.

Cupping is used by acupuncturists or other therapists, utilizing a glass or bamboo cup to create suction on the skin over a painful area or acupuncture point. It is mostly used in Asian and Middle Eastern countries and has been claimed to reduce pain as well as a host of other symptoms. There are two types of cupping. Dry cupping pulls the skin into the cup without drawing blood. In wet cupping the skin is lacerated so that blood is drawn into the cup (Kim et al., 2011).

Dry cupping creates a vacuum on the skin, with the ensuing negative pressure resulting in capillary rupture. The skin of the localized area becomes flushed and may show petechiae and ecchymosis or bruising, in which the duration is therapeutically beneficial. Cupping has multiple therapeutic functions which include (1) warming the channels to remove cold, (2) promoting qi and blood circulation, (3) relieving swelling, (4) accelerating healing, (5) adjusting body temperature, (6) treating fibromyalgia, (7) for stroke rehabilitation, hypertension, musculoskeletal pain, herpes zoster, (8) for the treatment of facial paralysis, acne, and cervical spondylosis, and (9) alleviating pain, including chronic neck, shoulder pain, and low back pain (Chi et al., 2016).

Movement-Based Therapies

Qi Gong and Tai Chi

Tai chi and qi gong are centuries old, related mind and body practices. They involve certain postures and gentle movements with mental focus, breathing, and relaxation. The movements can be adapted or practiced while walking, standing, or sitting. In contrast to qi gong, tai chi movements, if practiced quickly, can be a form of combat or self-defense (NCCIH, 2015).

Practitioners of Tai Chi

image: tai chi

Tai chi. Source: NCCIH, public domain.

Qi gong practice includes movement, body posture, mind exercises, concentration, relaxation, and breathing exercises. Tai chi involves slow movements emphasizing balanced postures, regular breathing, and concentration, integrating mind and body. Tai chi is used to help manage stress and anger; to improve strength, flexibility, and coordination; to improve lung function; to improve balance; and to reduce pain (Selfe & Innes, 2009).

In a study partly funded by the National Center for Complementary and Integrative Health involving patients with painful knee osteoarthritis, tai chi was as helpful as physical therapy in reducing pain and improving physical functioning. In this study, 204 patients age 40 or older, who had knee pain and proven osteoarthritis of the knee, were randomly assigned to standardized group tai chi training or standard one-on-one physical therapy. Both groups were then encouraged to continue their tai chi practice or home exercises for a total of 52 weeks. Patients in the two groups had similar decreases in pain and improvements in physical functioning after 12 weeks, and the benefits of treatment were maintained for the full 52 weeks of the study. Patients in the tai chi group had more improvement in depression symptoms and quality of life than those in the physical therapy group (NCCIH, 2016d).

Feldenkrais Method

The Feldenkrais Method (FM) is a type of exercise therapy that was developed over a period of decades in the last century by Moshe Feldenkrais. Feldenkrais put into practice an experiential process or set of processes, whereby an individual or a group could be guided through a series of movement- and sensation-based explorations (Hillier & Worley, 2015).

The purpose of the explorations is to learn to sense the difference between two or more movement options and discern which feels easier and is performed with less effort. This is compared with experiencing less favorable feedback such as pain, strain, or discomfort. Participants are encouraged to try many alternative movements to increase their awareness of distinctions and improvements (Hillier & Worley, 2015).

Because it promotes gentle movement within a comfortable range of motion, the Feldenkrais Method is particularly effective for older adults experiencing pain and stiffness from arthritis. It is taught in two parallel forms, Awareness Through Movement (conducted as a group exercise) and Functional Integration (one-on one approach) (Webb et al., 2013).

 

Feldenkrais for Everyday Life (3:33)

https://www.youtube.com/watch?v=uCM_C0Ly0Dc&index=4&list=PLx83c-HVFBfA5quYOUCc3F0z4ox3K054-

 

Single, randomized controlled studies of Feldenkrais exercises have reported statistically significant positive benefits compared to control interventions and include the following improvements:

  • Improved neck flexion and less perceived effort after a single Feldenkrais lesson for neck comfort
  • Reduced prevalence of neck pain and disability in symptomatic women after Feldenkrais, and
  • Reduced perceived effort in Feldenkrais group for people with upper torso/limb discomfort (Hillier & Worley, 2015)

In a small Australian study seeking to understand if participation in a Feldenkrais program improved mobility and decreased pain in participants with osteoarthritis, feedback was positive. Participants were asked to comment on their experience of pain and, in particular, the pain associated with their osteoarthritis after participating in the program. Ten of the fifteen participants said their pain level had improved, three were unsure, and two said they had not noticed any difference. Comments included “The pain is continual, but I manage it better,” “At the end of the session I was free from pain and felt energized,” “I can experience less pain in the knees, which is where the osteoarthritis appears for my body,” “The lessons…eased the pain in my lower back,” “No pain in the knees when going up stairs,” and “It is not a cure, however it is the best ‘exercise’ I have experienced for managing my osteoarthritis” (Webb et al., 2013).

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