Integrative Medicine as an Adjunct to Orthopaedic Surgery

James R. Ficke, MD; Nathan M. Moroski, MD; Steven D. Ross, MD; Ranjan Gupta, MD


J Am Acad Orthop Surg. 2018;26(2):58-65. 

In This Article

Mind-and-body Practices

Chiropractic treatment is defined by the World Federation of Chiropractic as "a health profession concerned with the diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the function of the nervous system and general health."[31] One survey reported that 5.4% of the US population used chiropractors in 2008.[32] The researchers estimated that 19% of patients seeking care for low back pain used chiropractic treatment. In Australia, chiropractic ranks second behind medical practitioner for patients who seek care for low back pain.[31,32] A literature review that examined the efficacy of chiropractic interventions on low back pain found slightly improved pain and disability in both the short and medium term for acute and subacute low back pain.[15] However, no evidence supported or refuted that these interventions provided clinically meaningful differences for pain or disability in people with low back pain compared with other interventions. Only 2 of 12 studies reported adverse events; of these 2 studies with adverse events, 15.1% of patients reported minor or transient exacerbations of symptoms. No serious adverse effects were reported.[15] To date, 26 deaths have been reported following chiropractic treatment;[15] most of these are thought to occur as a result of a vascular accident due to vertebral artery dissection. A review of these cases concluded that the risks of chiropractic treatment outweigh its benefit.[33]

Osteopathic manipulation techniques are based on an ideology of the existence of a myofascial continuity, that is, a tissue layer that connects all parts of the body. Practitioners attempt to diagnose and manage somatic dysfunction by manipulation and thus address a variety of ailments. This technique is most commonly used for back pain but also is used for other musculoskeletal issues and other systemic diseases. Licciardone et al[16] conducted a randomized controlled trial on the efficacy of osteopathic manipulative treatment compared with both sham manipulative treatment and no treatment. Patients who received osteopathic manipulation reported greater improvements in back pain, greater satisfaction with care, better physical functioning and mental health, and fewer cotreatments. Patients who received sham treatment also reported greater improvements in back pain and physical functioning and greater satisfaction than the no intervention group. The authors concluded that no substantial benefit existed with osteopathic manipulation versus sham manipulation. In a meta-analysis, Franke et al[17] reviewed 15 studies on osteopathic manipulative treatment for nonspecific low back pain. This treatment has clinically relevant effects for reducing pain and improving functional status in patients with acute and chronic nonspecific low back pain and in pregnant and postpartum women ≥3 months after treatment. The authors of the study recommended larger, high-quality randomized controlled trials with robust comparison groups.

Cheng and Huang[18] performed a meta-analysis of 15 randomized controlled trials that examined the efficacy of massage therapy on pain and dysfunction in patients with neck pain. Patients who received massage therapy had better immediate effects on pain and relief compared with inactive therapies. No evidence was found that massage therapy improves dysfunction. The authors concluded that additional high-quality randomized controlled trials are needed, especially studies that compare massage with other active therapies.

Vickers et al[19] performed a meta-analysis of 29 randomized controlled trials that examined the efficacy of acupuncture for chronic pain. Acupuncture was found to be markedly superior to both sham and non–acupuncture-based treatment for back and neck pain, OA, and chronic headache. The authors concluded that acupuncture is effective for the treatment of chronic pain. Because of modest but important differences between sham and true acupuncture, the authors suggest that factors beyond the specific effects of needling are important to the results of treatment. In another meta-analysis, Collins et al[34] found that acupuncture was effective when used as a second-line treatment modality for anterior knee pain.

A survey reported that 20.4 million Americans practice yoga, which indicates a 29% increase in 4 years.[35] Yoga practitioners spend an estimated $10.3 billion per year on classes and products. Holtzman and Beggs[20] conducted a meta-analysis of eight randomized controlled trials examining the effect of yoga on chronic low back pain and found it may be an efficacious adjunctive treatment of low back pain. The strongest and most consistent evidence was found for short-term benefits on functional disability. Additional high-quality randomized controlled trials that include active control groups are needed.

Relaxation techniques, such as deep breathing exercises, meditation, biofeedback, and guided imagery, are other forms of integrative medicine used to manage a large variety of disorders, including fibromyalgia, pain, rheumatoid arthritis, asthma, anxiety, and other systemic conditions. Posadzki and Ernst[21] systematically reviewed nine randomized controlled trials examining the effect of guided imagery on musculoskeletal pain; the results of eight trials suggested that guided imagery results in a substantial reduction in pain.

Relaxation techniques are generally considered safe. However, anxiety, intrusive thoughts, or fear of losing control have been reported.[21] Reports of worsening of symptoms, especially in patients with epilepsy or certain psychiatric conditions, are rare.[21]