complementary and integrative approaches for pain

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Complementary and Integrative Approaches for Pain

Management

1. Complementary and Integrative Approaches for Pain

Management

1.1 Opening

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1.2 Introduction

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When traditional and conventional chronic pain management strategies are ineffective, patients will often search for other options. Over the last twenty years complementary and integrative approaches for pain management have grown substantially. One of the major challenges associated with the acceptance of complementary and integrative approaches for pain management is the generation of strong clinical evidence to assist health care providers in making informed clinical decisions for their patients. The National Center for Complementary and Alternative Medicine was established in 1998 and was recently renamed the National Center for Complimentary and Integrative Health (NCCIH). The National Center for Complementary and Integrative Health (NCCIH) is the Federal Government's lead agency for scientific research on complementary and integrative health approaches. NCCIH is 1 of the 27 institutes and centers that make up the National Institutes of health (NIH) within the United States Health and Human Services. Their mission is to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health and health care. The NCCIH website can be found here and is extremely beneficial in providing the most current information regarding complementary and integrative


approaches for improving health.

1.3 Understanding Terms and Definitions

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As with any emerging field definitions and terms evolve and change over time. This has led to some confusion in publications and text books. The abbreviation CAM for complementary and alternative medicine has been used for many years as an umbrella term for a plethora of treatments and techniques that have little in common other than they are not considered mainstream medicine.


1.4 Definitions

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Complementary, Alternative, and Integrative approaches are all very different. According to the National Center for Complementary and Integrative Health, (NCCIH) when describing these approaches, people often use the terms “alternative” and “complementary” interchangeably. The two terms actually refer to two different concepts. If a nontraditional approach is used together with a conventional medicine approach it is generally considered complementary. If a non-traditional approach is used instead of a conventional medicine approach it is considered alternative.

True alternative approaches are very uncommon. There are many definitions of “integrative” health care, but all definitions involve bringing conventional and complementary approaches together in a coordinated way. NCCIH generally uses the term “complementary health approaches” when they discuss practices and products of non-mainstream origin. They use “integrative health” when they talk about incorporating complementary approaches into mainstream health care. In order to avoid confusion as one reads through these definitions the differences between complementary and Integrative appear to be related to the key terms coordinated and incorporating. Integrative approaches are incorporated in a coordinated and deliberate manner as opposed to a complementary approach which may be


delivered in a more casual manner.

The boundaries between what is considered conventional medicine approaches and what is considered complementary approaches overlap and change with time. As an example, Guided Imagery a therapy used to help a person focus on calming images with the goal of achieving relaxation was once considered complementary or alternative, but is now used regularly in some hospitals to help with pain management.

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1.5 National Center for Complementary and Integrative Health (NCCIH)

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The NCCIH has three long range research goals or objectives for the advancement of science related to complementary and integrative medicine. Advance the science and practice of symptom management. Develop effective, practical, personalized strategies for promoting health and well-being. Enable better evidence-based decision making regarding use of complementary and integrative therapies and their inclusion in health care and health promotion.

There are five major objectives which serve these goals and include:

1. Advancing research on mind and body interventions, practices, and disciplines.

2. Advancing research on natural products. Increasing an understanding of "real world" patterns and outcomes regarding the use of complementary and integrative interventions and their inclusion in health care and health promotion.

3. Improving the capacity of the field to carry out rigorous research and.

4. Developing and disseminating objective, evidence-based information.


It is important for health care providers to develop an appreciation of the goals and objectives of an organization like NCCIH as they are establishing evidence to support complementary and integrative approaches that you may or may not want to recommend to your patients.

1.6 Complementary Approaches

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Complementary health approaches are generally classified into two groups and include natural products or mind and body practices. Natural products can include a variety of items such as herbs, vitamins, and minerals. The evidence regarding the health benefits achieved by the consumption of natural products has been inconclusive. It appears as though more rigorous research is required before any conclusions can be reached regarding the effects of these products in the human body and their safety.

Mind and body practices include a large and diverse group of procedures or techniques. According to the NCCIH website, a 2012 National Health Interview Study revealed that yoga, chiropractic manipulation, meditation, and massage therapy are among the most popular mind and body practices used by adults. The popularity of yoga has grown substantially in recent years, with almost twice as many U.S. adults practicing yoga in 2012 as in


2002. Additional mind and body practices can include acupuncture, relaxation techniques, tai chi, healing touch, hypnotherapy, and movement therapies. The amount of research on mind and body practices varies widely depending on the practice. Acupuncture, yoga, spinal manipulation, and meditation appear to be the most widely investigated approaches.

1.7 Acupuncture Treatment

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According to Practical Management of Pain 5th edition, Acupuncture is an ancient medical modality of traditional Chinese medicine. Acupuncture normally involves the insertion of needles into the skin for therapeutic purposes. The proposed mechanisms of acupuncture analgesia has been elucidated as being a consequence of peripheral acupuncture point stimulation, mobilization of central neural peptides, and triggering of the central inhibitory pathway for modulation of pain sensation. The concept of Yin and Yang is one of the essential theories of traditional Chinese medicine. Optimal physical condition requires a balance of Yin and Yang within the body. Disease is associated with an imbalance between Yin and Yang.

Acupuncture can be used to promote balance between Yin and Yang energy within the body. There are more than 365 identifiable acupuncture points in


the human body. The pathways which connect these acupuncture points are referred to as meridians. Qi (Pronounced Chee) is the energy flow through these meridians. When there is stagnation or inadequate flow of chee through the meridians pain or illness may occur. The flow of chee may be restored by the insertion of very fine needles into a combination of appropriate acupuncture points along the meridians.

According to Wall and Melzack’s textbook of pain sixth edition systematic reviews which critically evaluated the data regarding the effectiveness of acupuncture have arrived at cautious or negative conclusions. According to the data reviewed, acupuncture may be better than placebo for the alleviation of tension type headache, musculoskeletal pain, postsurgical pain, and osteoarthritis. These conclusions are tentative and will require more evidence to make strong clinical recommendations.

1.8 Chiropractic Treatment

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According to Practical Management of pain 5th edition, Doctors of Chiropractic focus primarily on the interaction between the structure and function of the body with particular attention paid to the spine. Historically the primary goal was to correct musculoskeletal misalignments also known


as 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 thrust manipulation also known as spinal adjustment. These adjustment generally involve the 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. 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. Spinal manipulation was found to be effective in adults for acute, subacute, and chronic back pain, migraine, cervicogenic dizziness and headache. Mobilization was determined to be effective for acute and subacute neck pain. As with many complementary and integrative approaches the research findings were inconsistent and higher quality investigations are required to confirm these results.

1.9 Massage Therapy

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According to Wall and Melzack’s textbook of pain 6th edition massage therapy involves various techniques of manipulating soft tissue through the use of


pressure, traction, vibration, and other means. Massage is frequently recommended and utilized for a variety of musculoskeletal problems such as back pain and fibromyalgia. Despite being one of the more popular mind and body practices the effectiveness of massage therapy has not been evaluated extensively. There are several systematic reviews of randomized controlled trials all of which stress the paucity and poor methodological rigor of the primary investigations. Adverse effects reported from massage therapy are often related to incompetent therapists.

1.10 Mind and Body Practices

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The term mind-body medicine 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 wellbeing. Mind-body medicine asserts that the mind can positively affect the body in the pursuit of health and wellness.

Mind and body practices are critically important for diagnosis and treatment of pain in the 21st century. The concept of chronic pain should expand beyond the traditional views of interpretation and modulation of nociceptive impulses. Chronic pain should be viewed as a complex phenomenon which


is mediated through mechanisms that involve more than the traditional view of tissue damage. The predisposition to align pain only with tissue damaging stimuli may be limiting. Pain evolves not only from tissue damaging stimuli, but may also serve as a consequence of the way stress, sleep, psychological parameters, and central autonomic nervous system affect brain function. Mind and Body Practices can modify physiologic responses and brain function which ultimately promote health and the ability of individuals to respond to stress. However, these modalities require practice and commitment from the patient.

1.11 Natural Products

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According to Practical Management of Pain 5th edition, A large body of clinical evidence supports the use of biologically based natural products for the alleviation of pain. This supportive evidence spans a wide variety of herbs, nutraceuticals, nutritional supplements, and food derived topical products. It appears as though 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, neuropathies, persistent back and neck pain, dysmenorrhea and inflammatory bowel disease. Products like Capsaicin, Boswellia Serrata, Glucosamine, and Chondroitin appear to have the strongest evidence for


their use in the reduction of pain. Since hundreds of herbal medicines are claimed to have analgesic effects it is not possible to provide a comprehensive review.

However, if you go to the NCCIH website and click on health information and then click on Herbs at a glance you will be provided with a series of brief fact sheets that provides basic information about specific herbs or botanicals common names, what the science says, potential side effects and cautions, with resources for more information.

The widespread notion that natural equals safe is clearly misguided as many herbal medicines can cause adverse effects through a range of phenomena to include: Toxicity of one or more ingredients in the plant extract, Interactions with other medications taken concomitantly, adulteration of the preparation with prescription drugs, contamination with toxic substances such as heavy metals. Health care providers must be aware if their patients are consuming herbal medicines. Understanding the dosing and potential interactions of herbal medicines with prescribed medications is important as problems will and do occur.

1.12 Case Study

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There are several options here. According to Practical Management of Pain 5th edition. A meta-analysis of 33 randomized controlled trials of acupuncture for low back pain indicated that acupuncture effectively relieves chronic low back pain. Another randomized controlled trial of 241 patients with low back pain revealed that a short course of treatment by a qualified traditional acupuncturist is a safe and effective method of pain management. However, according to Wall and Melzack’s Textbook of Pain Chapter 43 low back pain was not included as one of the situations in which acupuncture was reported to be better than a placebo. In addition, in table 43-3 the study by Furlan in 2005 reports that the data did not allow firm conclusions when describing the benefit of acupuncture for low back pain. Perhaps the best explanation to provide this gentleman with is, many complementary and integrative approaches require more research before any strong conclusions can be made and recommended for clinical practice. However, in terms of a risk benefit ratio seeking acupuncture treatment from a qualified individual is a reasonable choice if that is what you are seeking. You will ultimately be the judge of what is beneficial and what is not. I look forward to hearing what your experience is with this choice.

1.13 Knowledge Check

(Multiple Choice, 0 points, unlimited attempts permitted)


Correct Choice

Complementary Health Approach

Alternative Health Approach

X Integrative Health Approach

Holistic Health Approach

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1.14 End of Presentation

complementary and integrative approaches for pain

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