Clinical Review State of the Art Review

Management of chronic pain using complementary and integrative medicine

BMJ 2017; 357 doi: (Published 24 April 2017) Cite this as: BMJ 2017;357:j1284

Re: Management of chronic pain using complementary and integrative medicine

The first rule of practising evidence-based Medicine is: read the evidence. The respondent below seems to have read a different article in declaiming all these treatments to be useless and dangerous, while under the impression that harms from western Medicine are axiomatically fewer. The lack of discrimination in criticism between any of the different modalities of treatments while branding them all a dangerous threat is also not very convincing.

The article describes a significant body of clinically meaningful RCT evidence - including inflammatory markers - finding that acupuncture may be as effective as DMARDS and may add benefit to DMARD treatment in patients with Rheumatoid Arthritis.
The article also describes a body of relevant evidence of benefit of acupuncture for chronic low back pain. As a USA Orthopaedic surgeon, Steven Zeitzew would know that; "The clinical practice guideline provided by the American College of Physicians and the American Pain Society recommends acupuncture as a non-drug therapy for CLBP patients.".

The harms of acupuncture suggested by the evidence are of the order 0.13%-0.14% for minor adverse events, with no serious adverse events in trials of 31,000 and 35,000 patients. Rather safer than NSAIDs, then.

As a family doctor who practises osteopathy free of charge in the NHS, I was disappointed not to see any mention in the article of the high quality RCTs showing significant clinical benefits of osteopathy, over and above exercise/physio. I have the advantage of continuity of care to know that these patients really do benefit substantially directly from osteopathic treatment, in all of the measures - pain, function, use of analgesics, employment/disability, referrals and reduction in surgery - which one would consider as important outcomes. The positive cost-effectiveness analysis of the UK BEAM trial has been published, so it is a shame to see that the recommendations for manual therapy have been weakened in the revised NICE guideline for back pain. Osteopathy is also safer than NSAIDs.

Where evidence is weak or conflicted, it is sensible to adopt equipoise and learn to tolerate uncertainty while further, better-targeted research evidence is allowed to emerge. Thanks to BMJ for publishing this interesting evidence review, I would recommend contributors read it.

Competing interests: As a medical practitioner of structural osteopathy, I use mechanical, predictable techniques to treat patients' musculoskeletal pain and dysfunction. I believe the evidence base is sufficient for osteopathy to be considered as a first-line treatment alongside or in place of conventional treatments such as physiotherapy.

17 June 2017
Nick Mann
GP & NHS Osteopath
Well St Surgery
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