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Evidence Grows for Use of Complementary Treatments for Pain Patients

November 29, 2016
New evaluation of the literature finds complementary therapies, such as acupuncture, yoga, tai chi, and massage therapy, can be beneficial to patients suffering from pain conditions.

Interview with Richard L. Nahin, PhD, MPH

Many physicians and healthcare professional are sometimes skeptical about the benefits of complementary therapies—often citing a lack of high-quality published evidence. Well the wait may be over. 

The Symposium on Pain Medicine recently published a detailed evaluation of current literature assessing complementary therapies for the treatment of pain in adults.1 Such therapies, including acupuncture, massage therapy, yoga, and tai chi, showed evidence of being possibly beneficial to patients in pain.

“Medications may not completely relieve chronic pain or can produce unwanted side effects, including the potential for addiction. Thus, many people may turn to complementary health approaches to help manage their pain,” said Richard L. Nahin, PhD, MPH, lead epidemiologist at the National Center for Complementary and Integrative Health. “Our goal was to summarize the evidence-base on what is safe and effective when it comes to complementary approaches for pain.”

The review, which has been published in the Mayo Clinic Proceedings, exclusively focused on randomized controlled trials conducted in the US. Consensus determinations from the analysis include:

  • Acupuncture and yoga may be beneficial for patients with back pain
  • Acupuncture and tai chi may be beneficial for patients with knee osteoarthritis
  • Massage therapy may be beneficial for neck pain when given in strong doses for a short-term benefit
  • Relaxation techniques (expression training, relaxation training, biofeedback, and stress management) may be beneficial for patients with severe headaches and migraine

Complementary Health Practices in the US

With an estimated 126 million Americans suffering from pain,2 the growing need for safe, effective treatments has led many patients to incorporate complementary therapies into their treatment regimen.

Typically, patients turn to these therapies for chronic pain issues, paying out of pocket for these services. For instance, national survey data has reported $8.5 billion in out-of-pocket expenses for complementary health approaches related to back pain, alone.3

However, while there is a growing inventory of phase 3 research into the clinical efficacy and safety of complementary treatments for pain conditions, the lack of a prevailing professional consensus determining their clinical value has been a long-standing issue.

To remedy this, the Mayo Clinic Proceedings performed a systematic review of randomized controlled trials related to complementary health approaches. The review made sure to exclude any trials not conducted in the US, since “training and licensure of acupuncturists, chiropractors, and naturopathic doctors vary substantially among countries,” which could have an effect on the efficacy and safety of the treatments analyzed, the authors explained.

“One major goal for this study was to be as relevant as possible to primary care providers in the United States, who frequently see and care for patients with painful conditions. Providers need more high quality information on the evidence base for pain management tools,” Dr. Nahin told Practical Pain Management.

Approaches for Back Pain

Four randomized controlled trials were assessed which looked at the efficacy of acupuncture treatments for low back pain in patients aged 28 to 60 years (1092 total participants).4-7 Self-reports of pain intensity consistently showed acupuncture provided a modest benefit to pain intensity and function. In particular, one trial found pregnant women noticeably improved in pain intensity and functional status compared to no treatment.6

When specifically geared to people with back pain, yoga exercises can help relive low back pain.

Patients also appeared to gain benefits from weekly yoga sessions.8-9 However, the improvements in pain and function were mixed when results were compared against exercise/stretching regimens. Compared to no treatment at all, though, patients practicing yoga reported “significant modest reductions” in pain intensity and functional disability.10-11

Approaches for Knee Osteoarthritis

Similar to low back pain, patients suffering from knee osteoarthritis appeared to enjoy some relief of symptoms from the use of acupuncture treatments. Verum acupuncture, in particular, appeared to provide significantly better primary and secondary outcomes compared to controls.12-13

Researchers also found 4 randomized controlled trials found positive evidence of the effectiveness of tai chi (either Yang or Sun style) for the improvement of symptoms related to knee osteoarthritis.14-17 Specifically, Hartman et al,15 reported patients receiving Yang-style tai chi instruction experienced a significant improvement according to the Arthritis Self-Efficacy Scale compared to the routine care group.

The Benefits of Massage Therapy for Neck Pain

A typical problem increasingly reported in industrialized nations, neck pain has become a common source of complaint for Americans, especially as more people spend their work days in front of computer workstations.

The need for effective nonpharmacological options to treat neck pain is significant, and indeed, complementary health approaches are being thoroughly evaluated. Just recently, a study determined Yang-style tai chi courses could provide equitable benefits as exercise therapy for patients with neck pain.

However, the Mayo review placed specific endorsement of massage therapy for neck pain, citing 4 randomized controlled trials18-21 that found positive evidence of massage therapy sessions improving patients’ symptoms. For instance, Sherman et al found massage therapy over 10 weeks significantly improved patients Neck Disability Scores (NDS),20 while other studies reported patient improvements in related outcomes, such as range of motion and pain intensity.21

This response also appears to be dose dependent; patients given 60 minutes of massage therapy 2 to 3 times per week had significantly better improvements than patients receiving massage therapy for 30 to 60 minutes just once a week.21 And a follow-up study by Cook et al18 confirmed this notion, reporting patients who received one additional massage session per week for 6 additional weeks still received “significantly improved pain and function” compared to patients who did not receive the extra massage session.

The Benefits of Complementary Medicine for Chronic Pain Conditions

“These data give providers and patients additional information they need to have informed discussions about nondrug approaches for chronic pain.  Overall, the data suggest that some complementary approaches may help some patients manage, though not cure, painful health conditions,” Dr. Nahin said.

The Mayo review also made some weaker determinations, noting there is some evidence for massage therapy, spinal manipulation, and osteopathic manipulation as other possible options for patients with back pain. Also, patients suffering from fibromyalgia may see benefits from relaxation approaches and practicing tai chi. “While this condition is not as common as the other conditions in the review, individuals with fibromyalgia frequently use a variety of complementary approaches,” said Dr. Nahin.

In addition to the effectiveness of many complementary therapies for various pain conditions, the lack of safety concerns associated with complementary therapies make them ideal nonpharmacological options for patients seeking symptom relief sans the side effects and risks associated with drug-based therapies.

The most common adverse events noted in the Mayo review included some cases of gastrointestinal stress reported in trials assessing the efficacy of various dietary supplements, such as glucosamine and chondroitin. Some patients taking tai chi and yoga did report minor muscle or joint soreness. Acupuncture is known to cause some minor pain and/or bruising at the needling site, the authors noted.

According to Dr. Nahin, the lauded safety profile of many complementary therapies make them an ideal avenue of treatment for patients who want to avoid the dangerous side effects of pharmacological medications.

“Our findings indicate some of these approaches may hold promise in treating painful conditions so patients don’t solely rely on medical therapies which may not be effective on their own or may have harmful side effects.  This is particularly important in light recent guidelines on opiate use issued by the CDC,” Dr. Nahin said.

Unfortunately, like similar reviews of research into complementary medicines,22 the Mayo review could have been hampered by the nature of current research into these therapies. For instance, randomized clinical trials into complementary therapies typically feature small sample sizes with a high rate of variability and false-negative results. This often makes it difficult for researchers to determine if any differences observed between study groups are clinically relevant, the authors explained.

“For most complementary approaches, there are no standard treatment protocols or algorithms, and in the case of dietary supplements, no rigorously established dosages and products; as such, trials of a given complementary approach rarely compare the exact same intervention,” the authors wrote.

There is also the possibility the inclusion of data featured outside the U.S. could have influenced the recommendations featured in the Mayo Clinic Proceedings.

The Mayo Clinic Proceedings is targeted for internal medicine physicians and other practitioners interested in advancing their knowledge clinical medicine and the latest determinations from clinical research. The authors who contributed editorial and administrative roles in the production of the review have no relevant relationships with industry and reported no relevant conflicts of interest.

Last updated on: November 30, 2016
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Acupuncture: New Approach for Temporomandibular Disorders

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