A Complementary Approach to Pain Management

Meenakshi Khatta, MS, CRNP


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

In This Article

Spinal Manipulation

Spinal manipulation is a popular form of treatment used by chiropractors, osteopathic physicians, allopathic physicians, physiotherapists, and other healthcare professionals to treat a range of primarily musculoskeletal problems. The American Chiropractic Association defines spinal manipulation as a passive manual maneuver "during which the three joint complex may be carried beyond the normal voluntary physiological range of movement into the para-physiologic space without exceeding the boundaries of anatomic integrity."[63] The essential characteristic is a low- or high-velocity thrust -- brief, sudden, and carefully administered at the end of the normal passive range of movement -- in an attempt to increase the joint's range of movement. This distinguishes manipulation from other forms of manual therapy. The 1-year prevalence figures of spinal manipulation in representative samples of general populations are high[64]:

  • 15% (1996, Australia);

  • 10% (1988, Austria);

  • 33% (1996, United Kingdom); and

  • 7% (1997, United States) and 16% (1998, United States).

There are many reviews of spinal manipulation for persistent musculoskeletal pain. Most of them focus on low back pain, for which the volume of trial data is significantly more substantial than for any other condition. One systematic review located 26 RCTs comparing spinal manipulation against placebo (sham treatment) for acute and chronic back pain.[65,66] A meta-regression analysis of these 26 RCTs reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments (namely, physical therapy, massage, exercises, back schools [group education and, possibly, work simulation or occupational health at worksites], and drug treatments [analgesics, anti-inflammatories, etc.]).

Summary: CAM and Pain Management

The evidence as presented in this article indicates that some forms of CAM can be effective for relief of pain. They offer hope for patients who face adverse effects from the use of NSAIDs and opioids. However, the evidence for some of these studies is not compelling. This may be due to the unique challenge of conducting rigorous trials in CAM. For example, performing a sham acupuncture treatment could be logistically difficult.

Conducting rigorous clinical trials in CAM is also difficult due to the culture that prevails among people who choose such modalities, many of whom believe in these therapies and are unwilling to participate in being randomized. Product quality is also a challenge. Herbal preparations and nutritional supplements are regulated by the US Food and Drug Administration in a different manner from either over-the-counter or prescription drugs. Therefore, there is great variability in their quality, which may affect research.

Advanced practice nurses (APNs) face multiple challenges when patients ask for their input about CAM therapies. Patients seek advice from their providers regarding the validity of the CAM research and its application. APNs have to be cognizant of herb-drug and herb-food interaction. Since CAM is consumer driven, people believe in the modality they choose. While APNs need to be supportive of their patients' choices, they also may need to advise caution and provide education about the best ways to integrate therapies to achieve desired results.


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