A Complementary Approach to Pain Management

Pain and CAM

Complementary/alternative medicine (CAM) has been defined as, "diagnosis, treatment and/or prevention [that] complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine."^[1] The majority of patients suffering from pain due to musculoskeletal conditions will use some form of CAM.^[2]

Persistent pain may be associated with morbidity such as depression and anxiety,^[3,4,5,6,7] physical disability,^{[6,8,9,10,11,12,13]} and sleep disturbance.^[11,14,15] Despite the prevalence of pain in musculoskeletal disorders, effective treatments are not without severe side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause serious morbidity and mortality.^{[16,17,18,19]} Opioids, although effective, may cause constipation, altered mental status, and falls.^[20,21,22] When traditional treatments are ineffective or cause morbidity, patients either have to suffer in pain or seek alternative treatment.

Many different CAM modalities are used to treat pain; amongst the most popular are:

• Acupuncture;
  
  

• Mind-body therapy;
  
  

• Herbal preparations;
  
  

• Ayurvedic therapy;
  
  

• Nutritional supplements; and
  
  

• Spinal manipulation.

This article reviews the effectiveness of each of these modalities based on the best evidence available in the form of randomized clinical trials (RCTs) or systematic review of such studies.

Acupuncture

The first written account of acupuncture is believed to be the 2300-year-old Huang Di Nei Jing, or the Yellow Emperor's Classic of Internal Medicine.^[23,24] Since that time, acupuncture has undergone several evolutionary processes, both in theory and practice. Energy, or Qi (chi), flows up and down the meridians. Sometimes the energy is blocked, deficient, excessive, or unbalanced. This throws Yin (the feminine aspect of life) and Yang (the masculine counterpart) out of balance, which in turn causes illness. Acupuncture restores the balance, thereby encouraging healing.^[25]

Thus far, there is not a concrete method to prove whether or how acupuncture works. There are several theories, however, to explain the benefits of treatment, and researchers have been experimenting with nuclear medicine techniques to study acupoints and meridians.^[25] Acupuncture is believed to stimulate secretion of endorphins, serotonin, and noradrenaline in the central nervous system. Acupuncture could also work by constricting or dilating blood vessels due to release of vasodilators such as histamine. Acupuncture also may have a role in controlling pain by closing the gates of nerve fibers that result in pain perception.

Back pain and fibromyalgia.The data on effectiveness of acupuncture in the treatment of back pain are conflicting. A meta-analysis of 12 RCTs looking at acupuncture as a symptomatic treatment of back pain resulted in favorable outcomes with acupuncture.^[26] A systematic review of all RCTs of acupuncture for fibromyalgia revealed only 3 studies,^[27] each of which supported use of acupuncture for relief of fibromyalgia symptoms.

Neck pain.Even though clinical or anecdotal reports often show neck pain relief from acupuncture, a systematic review of RCTs provided mixed evidence regarding how this modality compares with placebo for neck pain^[28]:

• In 1 trial, acupuncture was superior to waiting-list controls;
  
  

• 3 trials showed acupuncture to be either equal or superior to physiotherapy; and
  
  

• Needle acupuncture was not superior to indistinguishable sham control in 4 out of 5 studies.

The bottom line was that for the 8 high-quality studies included in this review of acupuncture vs placebo for neck pain, 5 were negative.

Osteoarthritis. An RCT of 570 patients with osteoarthritis of the knee were randomized to true acupuncture or sham. At the end of 26 weeks, acupuncture seemed to provide improvements in function and pain relief as adjunctive therapy for osteoarthritis of the knee.^[29]

Because even the best-designed studies are methodologically limited, it is difficult to draw definitive conclusions that will generalize to clinical practice. Most studies are methodologically limited because of:

• Questionable intervention quality;
  
  

• Lack of an adequate control group; and/or
  
  

• Lack of adequate follow-up.

The use of a sham acupuncture group (that is, placement of needles superficially and/or in nonacupuncture points) as an experimental control is problematic. There is evidence that acupuncture needles placed in nonacupuncture points lead to pain reduction because of stimulation of endorphin release via a mechanism called diffuse noxious inhibitory control.^[30] Because of the difficulties in designing rigorous acupuncture studies, we continue to rely on our clinical experience as evidence of the effectiveness of acupuncture.

Topics in Advanced Practice Nursing eJournal. 2007;7(1) © 2007 Medscape

Cite this: A Complementary Approach to Pain Management - Medscape - May 31, 2007.