BMJ  2003;326:1320-1321 (14 June), doi:10.1136/bmj.326.7402.1320-a

Dealing with pain

Integrative approaches to pain management: how to get the best of both worlds

¹ Center for Integrative Medicine, University of Maryland School of Medicine, James L Kernan Hospital, 2200 Kernan Drive, Baltimore, MD 21207, USA bberman{at}compmed.umm.edu

Despite the advances in conventional pain treatment, patients with chronic pain are often disappointed with Western medicine. Brian Berman considers how complementary medicine may be able to help

Introduction

Modern medicine has few good answers to the perplexing problem of chronic pain and, as a result, people with chronic pain often turn to complementary medicine. In most cases, people concurrently use complementary and conventional medicine, hoping perhaps to find the "magic bullet" cure but also realising they need to find other ways to cope and to improve their quality of life. A recent study published in JAMA has shown that people often turn to complementary therapies out of a desire to find approaches that are more congruent with a mind-body-spirit philosophy (not merely treating symptoms) and because they want to play an active part in their own healing.¹

Nevertheless, the medical profession is often ambivalent about the role of complementary approaches, partly from a lack of knowledge but also from a feeling that good practice should be based on solid scientific evidence of effectiveness and safety, which has been lacking in complementary medicine. As commendable as the scientific approach is, clinicians may be missing the boat by resting their case on the evidence argument and summarily dismissing complementary medicine. Patients are becoming increasingly well informed and want to be treated as partners in their health care but, finding or anticipating ambivalence among their primary care providers, they tend not to divulge their concurrent use of complementary medicine.² This has important implications for the legacy of the doctor-patient relationship, which should embody mutual trust and shared decision making, and holding back is obviously not in the best interest of either patient or doctor.

Safety is perhaps the most obvious concern about lack of disclosure (for instance, the potential for negative drug and herb interactions such as between warfarin and ginkgo biloba). However, we should also look at the potential of complementary therapies to give people more ways to help themselves—to reduce or cope with not only pain but also other aspects of chronic conditions such as anxiety and stress, or to change to more healthy lifestyles.

Mind-body therapies

The most obvious self help approaches are mind-body therapies. Many approaches, usually cognitive behavioural methods, are already incorporated into multidisciplinary pain programmes, but others—such as hypnosis, Qi Gong, and meditation—are less well accepted. In 1996 the US National Institutes of Health held a technology assessment conference on mind-body therapies for pain and insomnia, which found considerable evidence for their use, especially as adjunctive treatment.³ In many cases, a multidisciplinary approach that includes some form of stress management, coping skills training, cognitive restructuring, education, and possibly relaxation therapy is helpful for chronic conditions such as low back pain^{4 5} and rheumatoid arthritis and osteoarthritis.^{6 7} Relaxation and thermal biofeedback can be useful tools for recurrent migraines, while relaxation and electromyography muscle biofeedback, used alone or adjunctively, may help recurrent tension headaches.^8-10 Finally, therapies such as hypnosis, group therapy, relaxation, and imagery can significantly improve recovery time and alleviate pain when used in childbirth, before surgery, or during invasive medical procedures.^11-13

Acupuncture

In 1997 a National Institutes of Health consensus conference on acupuncture concluded that promising results have emerged for acupuncture, used alone or as a part of a comprehensive management programme, for several pain conditions.¹⁴ Although the quantity and quality of research are as yet insufficient for definitive judgments about the usefulness of acupuncture, its credibility as a pain treatment has been enhanced by basic science experiments showing that acupuncture needling releases endorphins and other neurotransmitters in the brain.¹⁵

Some of the strongest clinical evidence is in the treatment of dental and temporomandibular dysfunction pain, and research findings are promising for idiopathic headaches, fibromyalgia, and osteoarthritis. In the case of chronic pain and back pain the evidence is inconclusive, and the effectiveness of acupuncture for neck pain has not been supported.¹⁶ In general, acupuncture seems to be safe in the hands of experienced, licensed practitioners, though disposable needles should be used.

Chiropractic and massage

Many people turn to chiropractic and massage for relief of pain. Chiropractic generally involves manipulation of the spine, whereas massage applies pressure and traction to the soft tissues of the body.

Research on both is inconclusive, but a review by the US Agency for Health Care Policy and Research found that chiropractic is beneficial for acute back pain but that the evidence to support its use in chronic back pain is insufficient.¹⁷ Interestingly, patients often express greater satisfaction with chiropractic care than standard medical care even when the improvements in pain and disability are the same. A recent study attributes this greater satisfaction to communication of self care advice and explanation of treatment.¹⁸ Massage, on the other hand, may help low back pain and non-inflammatory rheumatic pain.¹⁹

Herbal medicine

Several herbs and neutraceuticals may help treat pain. Studies have found avocado and soybean unsaponifiables and devil's claw to be effective in treating pain due to osteoarthritis, while the evidence for the herbal preparation Phytodolor and topical capsaicin is promising.²⁰ The use of linolenic acid—found in borage seed oil, evening primrose oil, and blackcurrant seed oil—is supported by moderate evidence from trials in patients with rheumatoid arthritis.²¹ The evidence is strong for the use of chondroitin sulphate,²² glucosamine,²² and S-adenosylmethionine (SAMe),²³ particularly for pain related to osteoarthritis. All these treatments seem to be safe, and in many cases they have decreased the use of drugs such as non-steroidal anti-inflammatory drugs.

Homoeopathy

Research in homoeopathy, one of the more controversial complementary therapies, has shown some interesting results for both classical and complex homoeopathy in the treatment of rheumatic syndrome. The studies included in a recent review were small, but most were of high methodological quality, and all showed that homoeopathy was twice as effective as placebo.²⁴ As homoeopathic prescribing is highly individualised to a person's "constitutional picture" rather than to specific diseases, future research will need to meet this challenge as well as explore a plausible mechanism of action for homoeopathy.

The importance of good communication

When considering integrative care, which uses the best of both complementary and conventional approaches, lack of knowledge can cloud the waters, and lack of communication—between physician and patient but also between conventional and complementary practitioners—can make navigation difficult. Steering a clear course will require finding a complementary therapist who is well trained and preferably a member of a professional organisation (though some complementary therapies have yet to establish standard procedures for licensing, credentialing, and monitoring the behaviour of practitioners). Furthermore, doctor, patient, and complementary provider will need to communicate openly and monitor progress together, taking into account safety and efficacy (of both conventional and complementary approaches) as well as the preferences and expectations of the patient.

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Funding: National Center for Complementary and Alternative Medicine, National Institutes of Health (grant No 5-P50-AT00084-02), Laing Foundation, Kohlberg Foundation.

Competing interests: None declared.

Editor's note: We did try to commission a piece on conventional pain therapies in order to balance these articles, but we failed to get something we felt appropriate. If you want to read more about the advances in conventional pain treatments see "Management of pain" by Anita Holdcroft and Ian Powers, BMJ 22 March 2003, p 635.

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