Publications
APS Bulletin • Volume 8, Number 1, 1998
Research Update
Robert J. Gatchel, PhD, Department Editor
Applying Alternative Medical Approaches to Managing Chronic Pain Syndromes: If Not Now, When?
Brian M. Berman, MD; James P. Swyers, MA
What is alternative medicine? Who uses it and why?
Alternative medicine (AM) encompasses a broad domain of healing resources. AM has been defined to include all health systems, modalities, and practices, with their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period (e.g., biomedicine) (Panel on Definition and Description, 1997). A widely divergent group of more than 150 different practices representing a "hodgepodge of beliefs and treatments" falls under this broad heading (Murray & Rubel, 1992, p. 61). Recent estimates indicate that more patient consultations take place in the United States with providers of AM therapies than with conventional primary care physicians (Eisenberg et al., 1993) and that Americans spend almost $14 billion every year on AM treatments. There is evidence that this trend will continue to grow, both in the United States and in other developed countries (British Medical Association, 1993; Fisher & Ward, 1994; MacLennan, Wilson, & Taylor, 1996; Northcott & Bachynsky, 1993).
A recent national survey found that users of AM tended to be mostly middle-aged and white (Paramore, 1997). Back, neck, and shoulder pain were the most common reasons for a visit to an AM practitioner; respondents also frequently reported headache, stress, and anxiety disorders. Chiropractic treatment, therapeutic massage, relaxation techniques, and acupuncture, in that order, were the four most frequently used AM therapies. Most users had chronic conditions rather than acute syndromes. Other surveys have found that individuals with chronic musculoskeletal and rheumatologic disorders are high users of AM treatments and approaches (Boisset & Fitzcharles, 1994; Cherkin, MacCornack, & Berg, 1989; Cronan, Kaplan, Posner, Blumberg, & Franklin, 1989; Kronenfeld & Wasner, 1982; Thomas, Carr, Westlake, & Williams, 1991).
Although some AM users express complete dissatisfaction with or rejection of conventional medicine (Eisenberg et al., 1993; Paramore, 1997; Vincent & Furnham, 1996), few completely reject or abandon it. Rather, most seek out conventional medical treatment first and if they are not completely satisfied, they migrate to AM practitioners or approaches as a way to supplement their conventional treatment (Paramore; Vincent & Furnham). Patients use AM treatments in part because they value the "whole person" treatment approach used by many AM practitioners and because they want a range of therapeutic options, both alternative and conventional. They will make use of these different forms of medicine on different occasions (Lerner & Kennedy, 1992; Paramore).
What is the evidence base for the efficacy of the major AM therapies for chronic pain?
A number of small, controlled clinical trials support the efficacy of AM therapies such as acupuncture (e.g., Christensen et al., 1992; DeLuze, Bosia, Zirbs, Chantraine, & Visher, 1992; Vincent, 1989), chiropractic (e.g., Cherkin & MacCornack, 1989; Meade, Dyer, Brown, Townsend, & Frank, 1990), and mind-body techniques (e.g., Caudill, Schnable, Zuttermeister, Benson, & Friedman, 1991; Kabat-Zinn, Lipworth, & Burney, 1985) for treating various chronic pain syndromes. However, several consensus development conferences and systematic reviews of the literature on the efficacy of these therapies for treating chronic pain have produced less optimistic conclusions.
For example, a recent National Institutes of Health (NIH) consensus development conference on acupuncture concluded that it is effective for acute pain such as postoperative dental pain, but that the evidence for its efficacy in treating chronic pain is still weak (NIH Consensus Development Conference on Acupuncture, 1997). Our own systematic review of the literature on acupuncture for chronic pain revealed that of 45 randomized controlled trials involving pain lasting for more than 3 months, only 8 were high-quality studies based on Jadad's (1996) validated criteria and other criteria known to reduce threats to internal validity (Berman, Ezzo, Singh, Lao, & Jadad, 1997). Only half of these eight studies had reported statistically significant positive results for acupuncture's effectiveness. All of the studies that significantly favored the efficacy of acupuncture focused on musculoskeletal conditions. Furthermore, Cherkin's (1997) study in a systematic review of the literature to determine whether acupuncture is more effective than placebo or standard treatment (e.g., medication or exercise) for nonspecific low-back pain found that most studies of acupuncture were of poor quality, with heterogeneous designs, patient populations, and methodologies. Moreover, most of the reports overstated conclusions based on data presented in the papers, and there was little evidence of effect. Cherkin noted, however, that this does not mean that acupuncture is not effective in the treatment of low-back pain--only that the literature has not proven its effectiveness.
The efficacy data for chiropractic and mind-body (e.g., hypnosis, meditation-relaxation) techniques for treating acute rather than chronic pain are equally inconsistent. An Agency for Health Care Policy and Research review of the literature on treatments for low-back pain (Bigos et al., 1994), which included both conventional and AM therapies, found that chiropractic was effective for the treatment of acute low-back pain, but the data were insufficient to judge its efficacy for treating chronic low-back pain. Similarly, an NIH technology assessment conference on the efficacy of mind-body approaches for the treatment of chronic pain and insomnia (NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia, 1996) found "strong evidence" to support the use of relaxation techniques and hypnosis in reducing chronic pain.
Thus, despite the extensive use of AM treatments by chronic pain sufferers, definitive evidence is still lacking that these treatments work for chronic pain syndromes. Indeed, the literature reviews collectively point to a need for more and better research on many of these therapies. However, until investigators design and initiate definitive studies, what attitude should pain treatment specialists adopt toward patients' use of such therapies? Should they remain neutral until more evidence becomes available? Should they advise their patients against using such treatments? Or should they take a more proactive approach by helping their patients explore and make decisions about using such treatments or even begin to integrate promising AM therapies and approaches into their practice?
Exploring the existing evidence for the "standard" therapies currently used to treat chronic pain syndromes may help us address these questions. Comparing the state of the evidence for standard therapies with that for AM treatments for chronic pain may help provide criteria for informed, objective decisions about AM treatments and approaches. Although the following discussion focuses on current conventional treatments for chronic low-back pain, we believe the issues are also germane to the treatment of other chronic pain syndromes.
How does the evidence for conventional therapies for chronic low-back pain compare with the evidence for AM therapies?
Although some of the conventional medical therapies currently used to treat chronic pain syndromes have proven effective in rigorously controlled clinical trials, many have not. For example, Deyo (1993) reviewed evidence for many of the standard therapies currently used to treat chronic low-back pain and found the database supporting such treatments to be inadequate and inconsistent. He noted, "Much of the current research on treatment for back pain is firmly rooted in the case-series tradition," and there "is a host of problems with this paradigm" (p. 2154). Other deficiencies in the research literature on treatments for low-back pain, according to Deyo, include a predominance of retrospective case series, inadequate baseline descriptions of the patients in most studies, inconsistent results, and poor outcome measures.
In analyzing the available literature supporting the use of a specific intervention (i.e., lumbar spine fusion) for chronic low-back pain, Turner and colleagues (1992) could not identify any randomized trials. They found that only 9% of the studies were clearly prospective in design. They also found that blinded evaluation outcomes were rated (i.e., rating of outcomes clearly performed by someone other than the operating surgeon) in only 17% of the studies and that fewer than two-thirds of the studies even reported what proportion of the patients was followed up.
On the basis of such negative assessments of evidence for the efficacy of many conventional treatments for low-back pain, particularly surgical treatments, should one conclude that such treatments do not work? Obviously, the many physicians who administer these therapies believe that they have benefit for their patients. Nevertheless, if these reviewers are to be believed, one might conclude that the evidence for the efficacy of many standard therapies is no better or worse than that for the major AM approaches for treating chronic low-back pain, or chronic pain in general.
What is the case for a more proactive attitude toward AM approaches?
Perhaps the most prudent attitude for pain management specialists to adopt toward AM therapies is to be supportive of their patient's preferences. If patients express a desire to try or explore the use of AM treatments, physicians should be willing to discuss all plausible treatment approaches, both conventional and alternative, that may have benefit for their patients' particular conditions. Indeed, although the evidence for the efficacy of AM therapies such as acupuncture, chiropractic, and mind-body approaches (e.g., hypnosis, meditation-relaxation) in the treatment of chronic pain is not yet definitive (as determined by large-scale, randomized, placebo-controlled clinical trials), sufficient evidence from small, controlled trials and case-series reports exists to warrant categorizing these particular treatments as plausible. Such an approach is particularly justified in light of the study of almost 2,000 pain clinic patients by Davies, Crombie, Brown, & Martin (1997) that demonstrated that for three treatments, antidepressant drugs, acupuncture, and sympathetic nerve blocks, there was little diminution in success rates regardless of how many other treatments previously had been applied. Davies and colleagues concluded: "Pain clinics which pursue a policy of trying all possible and plausible therapies may offer the best chance of providing at least some symptomatic relief to patients with chronic pain....Most patients will gain some relief when the full range of therapies is applied" (p. 207).
Furthermore, Flor, Fydrich, and Turk (1992), in a meta-analysis of 65 studies on the efficacy of multidisciplinary treatments for chronic back pain, found that such multidisciplinary treatments were superior to no treatment, waiting list controls, and single-discipline treatments (e.g., medical treatment or physical therapy). Moreover, the effects appeared to be stable over time. Perhaps more importantly, the beneficial effects of the multidisciplinary treatments extended beyond improvements in pain, mood, or interference to behavioral variables such as return-to-work and use of healthcare resources. Cutler and colleagues (1994) obtained similar results in a recent metaanalysis examining the efficacy of nonsurgical treatment approaches to the management of chronic pain as compared with surgical approaches. This study found that a nonsurgical multidisciplinary approach to treatment, as compared with surgical approaches, more than doubled the number of patients who returned to work.
Conclusions
Chronic pain sufferers, particularly those with musculoskeletal and rheumatologic disorders, are some of the greatest users of AM treatments and approaches. Acupuncture, chiropractic, and mind-body approaches (e.g., hypnosis, meditation-relaxation) are among the AM treatments most frequently used by such patients. Although there is fairly convincing evidence that these therapies are valuable for treating acute pain, little definitive evidence exists that they are effective for treating chronic pain. On the other hand, this situation is not unique to AM therapies. The review literature for the efficacy of many conventional medical therapies for treating chronic low-back pain, for example, also indicates that definitive evidence is lacking.This lack of definitive evidence from large-scale randomized control trials does not mean that none of these therapies work. Obviously, many do work for certain groups of patients. Pain treatment specialists may want others to maintain an open mind regarding the therapies they believe work; they also should maintain an open mind about AM therapies for which at least some evidence of efficacy in the treatment of chronic pain exists. Unless properly designed and controlled trials disprove the efficacy of a particular AM therapy, the pain specialist should consider it to be a plausible treatment for chronic pain. Therapies such as acupuncture, chiropractic, and mind-body approaches (e.g., hypnosis, meditation-relaxation) are generally safe when administered by a properly trained practitioner, so their use is warranted for those patients who have not responded adequately to standard care. Such patients may have little to lose and much to gain by trying these AM treatments.
Several recent literature reviews have demonstrated that a multidisciplinary approach to the treatment of chronic pain syndromes is likely to have benefit, not only in reducing pain but also in restoring function to the patient. Therefore, pain specialists who are willing to initiate a dialogue with their patients regarding AM or even to begin integrating promising AM treatments into their practices should not only enrich their relationship with patients but should also increase the likelihood of positive responses to therapy. In answer to the title of this article, we believe that pain treatment specialists should begin to consider the utility of applying promising AM treatments, particularly acupuncture and chiropractic approaches, to the treatment and management of chronic pain syndromes.
References
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Brian Berman is director and James Swyers is senior medical editor of the complementary medicine program at the University of Maryland School of Medicine in Baltimore.