Complementary Therapies for Pain Management

Complementary Therapies published on May 11, 2012
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Gary Deng, MD, PhD
Integrative Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York

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Hi. My name is Gary Deng. I am physician at the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center. Today, we are going to talk about Complementary Therapies for Pain Management. Hopefully, by the end of the session, we will be able to learn how to define complementary therapies and to define integrative medicine and to recognize the current state of science in integrative medicine research and also to understand how to incorporate complementary therapies in pain management.

First, let us talk about the definitions. What exactly is complementary therapy? Over the years, there has been some of the modality that has not been part of the current Western medical practice setting that is being used by patients, especially patients with chronic conditions that have not responded adequately to conventional care. Because they come from a diverse source and there is a variable level of evidence supporting their use, they are not part of the standard of care. On the other hand, some of these therapies can be quite helpful in selected population of patients. So, complementary and alternative medicine has been defined by the National Center for Complementary and Alternative Medicine as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. So, as you can see, this is almost a definition by exclusion. By this very nature, the value of the evidence supporting them has been very variable. Some can be used together with conventional medicines to help patients such as using acupuncture in addition to the usual care to treat pain, that is why we call it complementary medicine. On the other hand, there are some therapies that are called “alternative medicines” especially in treating difficult-to-treat conditions, people want to use that instead of conventional care and those are so-called alternative medicines. We asked patients to stay away from them because they can be harmful in many cases to them.

So what exactly are these therapies? We can basically put them into one of the five groups; some are biologically based, such as the use of natural products that are available as dietary supplements or herbs and these can be biologically active so they have their effects and side effects. Some are called mind-body medicines. They try to harness the power the connection between mind and body and use that to reduce symptoms and to improve well-being. Others are body-based practices such as massage therapies or certain exercise regimens, and the fourth group are called energy medicine, that is based on the theoretical framework that there is energy involved in the biological process, although such energy has never been reproduced from the measures with modern scientific equipments. There are also whole medical systems that encompass everything among the above four groups. One example is traditional Chinese medicine, another one is aromatic medicine from India, also naturopathy and homeopathy from Europe, and some native folk medicine from Americans. So, they tend to incorporate a little bit of every one of the above four group of therapies. These therapies can be quite appealing to patients because sometimes you hear dramatic media reports that some patients have, it is hard to believe just thinking these therapies, because they are natural, they are less invasive, they are gentle, they have special appeal to them and many of these therapies focus on the spiritual and emotional well-being, which is also a draw to patients and a lot of them offer a sense of hope, especially for patients with intractable symptoms or medical problems. Lastly, but not the least, they empower patients because a lot of these therapies emphasize on self-care, on things patients can do to help themselves, which is very appealing to our patients.

In order to use these therapies appropriately, we have to know their safety and efficacy and that only comes from research. By doing research or literature reviews, we are able to assign a grade of recommendation for some of these therapies that we can use together with standard of care. When we combine the therapy that has been shown to have a good safety record, some evidence supporting their benefit for a particular patient population or a particular medical condition, when we incorporate them together with mainstream care, we call it integrative medicine. They are used to improve the quality of life and also to improve the well-being of our patients. We often incorporate those therapies in the mainstream setting. To do that, we have to be careful in maintaining a very open communication between the therapist who would deliver this treatment and other health care professionals involved in the care of the patients.

At Memorial Sloan-Kettering Cancer Center, we established such a clinic and later a center for integrative medicine. We established that about 10 years ago. In this service, we offer clinical consultations and we provide acupuncture, massage, mind-body therapies, and these are provided both as an outpatient setting or as an in-patient setting. Touch therapy or massage therapy is a major part of what we offer to patients with aches and pains and tension. They tend to reduce chronic wear and tears or muscle strains and they also reduce anxiety. There are several different techniques where we use touch therapy or massage therapy such as the Swedish massage techniques. Reflexology refers to massage therapy that is focused mainly on the feet. Shiatsu is another technique that emphasizes more on putting pressure on certain points derived from the Japanese medicine. Sometimes we also add a mind-body component to it such as Reiki therapy and aroma therapies using smell to create an environment that is more soothing and relaxing.

We all know there is a strong connection between our mind and body and sometimes when our body is hurt, we create emotional or psychological problems. On the other hand, if we have psychological or emotional problems, our perception of symptoms can change. By doing meditation, hypnotherapy, guided imageries, biofeedbacks, although we may not alter the pathological process that induces pain, we may be able to change patients’ perception of the pain. Therefore, lessen their impact on the suffering of patients. Movement therapy is usually used to help people resume their daily activity, to improve their flexibility and performance status. They are very helpful in patients with arthritic problems or recovering from surgery or other harsh treatment. Complementary therapies that target patients with movement problem includes the following: Tai-Chi, which is originally a form of martial arts that involves very fluid and gentle movement and later get converted into an exercise routine that is especially good for elderly patients. Studies have shown they help improve their flexibilities and also their balance. Yoga emphasize on the posture and also the breathing and the mind-body connection, some meditative components in there that also reduce tension in the body. Qi-Gong is another form of combination movement therapies and meditative practices and there are certain other exercise programs that has been developed specifically for a particular indication.

Music therapy is being used a lot in palliative care, especially patients who are suffering pain in palliative care because music touches a deep part of our soul and it elicits very strong feelings and by doing music, we are able to reduce the suffering and pain of patients with very advanced disease. In our institution, we use music therapy a lot in patients with advanced cancer, poor prognosis, end-of-life patients. Another complementary therapy that is being used quite commonly in pain management is acupuncture. Acupuncture involves the insertion of needles to certain body points and then followed by manipulation of the needles. We are going to talk a lot more about it in a short while.

The last group of complementary therapies that has been used and asked a lot about by patients are these natural products available as nutrition or dietary supplements. They could be herbs, vitamins, minerals, or other natural products. Some of them has been studied for pain control. For example, glucosamine chondroitin for arthritic pain and capsaicin from the hot chili pepper for topical use in pain control. In order to summarize data on these natural products, we made a website showing what study has been done, what are the active ingredients of these natural products as some of them can be quite complex, what are the contraindications and interaction with other drugs. We make this freely available to the general public and also to health care professionals. So here is the website. Especially for some of the more obscure natural products you may be able to find them here and learn more about, so it is a good resource.

Now, how do we apply these complementary therapies in clinical practice?  We have to rely on evidence, evidence from basic science research, but more importantly our clinical trials. Based on the data on their safety and efficacy, we are able to put them into one of these four groups. There are those that are safe and helpful, what I call them the A groups. There are those that are safe, but we are not sure whether they are helpful or not, those are the B group. Those that are useful but with risk such as natural products, biologically active natural products that can have effects and side effects, they belong to the C group. There are also those that are harmful with no benefit after research and those are the D group therapies. We are going to focus more on the A group therapies that has shown a good safety record and evidence of helpfulness and benefit to patients, although the evidence of pain control may be strong or weak, but at least they have some evidence.

When we talk about pain management, we have to be able to look at the data and have some practical guidelines so we can use in clinical practice. Not everyone can read every paper that has been published on a particular therapy for a particular indication. So, together with American College of Chest Physicians and Society for Integrative Oncology, we developed a set of evidence-based clinical practice guidelines for integrative medicine and because their use in cancer care focus a lot on pain control and relief of symptoms, a lot of these recommendations applies to the management of chronic pain and we use the same criteria as in any guideline development. We consider both the evidence and the strength of evidence, as well as the benefit versus risk burden. Sometimes, the evidence is not strong because for complementary therapies it is not that easy to always do multiple randomized controlled trials, so, in that case, we weigh the strength of evidence and look at the burden and risk for patients and derive a set of guidelines, then we grade them to either 1A, 1B, 1C or 2A, 2B, 2C, and these are all published. When we talk about pain management, especially management of chronic pain, here are the recommendations:

Regarding the use of mind-body medicine, there have been many randomized controlled trials studying a variety of mind-body techniques, hypnosis, meditation, and so on, trying to use and apply them to the pain management setting. The advantage of these therapies is they are safe and they are relatively good evidence supporting their benefit. So limitations are mainly logistics. They are time consuming and they also require active participation of patients. Some patients are not in tune to this kind of practice. So, based on the systematic reviews of mind-body medicine pain control and the separate meta-analysis, we recommend the use of mind-body modalities as part of a multidisciplinary approach to reduce chronic pain. In addition to that, there is also evidence suggesting they will help reduce anxiety and mood disturbance, which we often see in patients suffering from chronic pain conditions. Other therapies such as support group or cognitive behavior therapies and other similar interventions tapping to the power of the mind and how it controls how we feel with our body are also beneficial to these patients and the strength of evidence is also stronger and they got a 1A grade of recommendation.

The second group of complementary therapies that could be quite helpful are these massage or touch therapies. The advantage of these therapies is that they are also safe and the skills are readily available. There are many massage therapists that have been trained that are practicing in the community. The limitation is minimal. There may be some safety issues involved, especially if your patient is prone to bleeding or there are areas of anatomic changes, such as fractures or recent injury. We may not want to do massage therapy in those areas, but in general, if the practitioners are well-trained, it is a very safe modality and for us,  when we look at the data summarizing all the randomized controlled trials and systematic reviews and meta-analysis, we draw the conclusion that massage therapy can be quite helpful for patients with chronic pain, especially patients who are not responding to other therapies, including massage therapy, could be helpful. It is particularly helpful for patients with muscular skeletal pain or tension or pain evolved from muscle spasm and tension.

Another major complementary therapy that has been used a lot in pain control is acupuncture. When we look at the evidence of randomized controlled trials, meta-analysis, and the systematic reviews, we found that there is good evidence supporting acupuncture in controlling chronic pain. However, the limitations are that they are not always readily available. In some patients, if the practitioners are not well-trained, there could be harm. There is a rare adverse event reported in patients with immune suppression or bleeding tendencies that are harmed by acupuncture. So the choice of a good acupuncturist is very important.

When we do acupuncture, the practitioner inserts these needles into a certain part of the body and these needles are made of solid stainless steel, sterile, individually wrapped. They are thinner than regular IV needles so they tend to produce less tissue trauma and the acupuncturist usually locate the points that are called acupoint. This needle, when they come out of the wrap, there is a guide tip around them, so they tap the tail of the needles so the needle penetrates the skin and then they remove the guide tube and then twist and turn and advance or withdraw the needle to elicit certain stimulations. The acupuncturist can stimulate a needle by mechanical stimulation, by manipulating the needles manually, or they can apply heat or electric pulses to the needle. There are thousands of randomized controlled trials done studying acupuncture for pain controls. There are also several good systematic reviews summarizing the data of acupuncture in controlling of certain conditions. Here is the paper of systematic review on acupuncture for rheumatological problems and they draw the conclusion that many systematic reviews have recently been done only for osteoarthritis, low back pain, and lateral elbow pain, is the evidence sufficiently sound to warrant positive recommendations of this therapy in routine care of rheumatic patients. This is also where we can use complementary therapy because anti-inflammatories or other modalities we use do not always give us adequate pain control of patients suffering from these conditions. Another indication is postoperative pain. These are more acute pain and a systematic review of randomized controlled trials show that auricular acupuncture is helpful. But it is not compelling because the effects size is not that big, so their conclusion is it is promising but not compelling. A common chronic pain problem experienced by women is pelvic or back pain during pregnancy.  A systematic review has been done to look at how to use acupuncture for pelvic and back pain in pregnancy. The conclusion they drew was that limited evidence supports acupuncture use in treating pregnancy-related pelvic and back pain. However, additional high-quality trials are needed to test the existing promising evidence for this relatively safe and popular complementary therapy.

Fibromyalgia is what gives everybody a headache for patient for us to treat these patients. It appears to not respond to anything. So there have been many attempts to studying acupuncture for the treatment of fibromyalgia. A systematic review with a meta-analysis has been done of all the controlled clinical trials and the conclusion is that a very small analgesic effect of acupuncture was present. It is not clearly distinguishable for bias therefore, acupuncture cannot be recommended for the management of fibromyalgia.

So, how exactly does acupuncture work in controlling pain? Most of the mechanistic studies focus on neuroscience studies. It appears that a certain neurotransmitter has been involved in the processing of pain signals and acupuncture can modulate them. There are many papers published on opiates or opiate receptors interactions and acupuncture effects on them and a recent study that has been published on Nature Neuroscience in 2010 showed that adenosine is another neurotransmitter that appears to be involved. In this study they use knockout mice, which does not have adenosine receptor and they find analgesic effect of acupuncture is abolished when adenosine receptor is knocked out, which pinpoint in this particular animal model, adenosine acts as the transmitter that has been modulated by acupuncture in this analgesic effect. Further, there has been several functional imaging studies of the brain using either functional MRI or PET scan to see which parts of the brain are stimulated or suppressed by acupuncture. When we summarize all the data together, it appears that the limbic system is modulated by acupuncture and as we know, the limbic system is involved in mood, emotion, such as fear, anger, anxiety, and also the perception of pain. So when we look at all the data so far, we can conclude that acupuncture, massage therapy, and mind-body therapies can be used as complementary therapies as part of a multimodal pain management plan. We do not advocate using complementary therapies alone. They have to be part of a multidisciplinary treatment plan and the patient has to be carefully selected and more importantly, the therapy has to be carefully selected and qualified. When we apply them to clinical practice, we also have to consider patient’s preference because for example some patients will not be able to do meditation or be receptive to having a needle stick into them by an acupuncturist. We also have to consider the cost and feasibility.

From a standpoint of a practitioner, if you are doing data in clinical practice, what is more important for you is to develop your own resource of information and also a source of reliable well-qualified professional complementary therapy practitioners. Those are the people who can work together to help patients control their chronic and you only find these people by personal interaction or by first-hand knowledge of their effectiveness in treating patients because these therapies, although there are national accreditation bodies accrediting and licensing them, the level of skills can vary, so I suggest you to find in your local communities a group of therapists that you have trust in and you have good rapport and you got good patient feedback.

So, to summarize, complementary therapy can be a valuable addition to the chronic pain management plan, although they have their limitations. So how to apply them in clinical practice depends on your clinical judgment and awareness of the clinical evidence supporting their use and also showing their limitations.

Thank you for joining us today on this talk on complementary therapy and chronic pain management.

Last modified: July 13, 2012