Complementary/alternative medicine (CAM) has been defined as, "diagnosis,
treatment and/or prevention [that] complements mainstream medicine by
contributing to a common whole, by satisfying a demand not met by orthodoxy or
by diversifying the conceptual frameworks of medicine."[1] The
majority of patients suffering from pain due to musculoskeletal conditions will
use some form of CAM.[2]
Persistent pain may be associated with morbidity such as depression and
anxiety,[3-7]
physical disability,[6,8-13] and
sleep disturbance.[11,14,15]
Despite the prevalence of pain in musculoskeletal disorders, effective
treatments are not without severe side effects. Nonsteroidal anti-inflammatory
drugs (NSAIDs) may cause serious morbidity and mortality.[16-19]
Opioids, although effective, may cause constipation, altered mental status, and
falls.[20-22] When
traditional treatments are ineffective or cause morbidity, patients either have
to suffer in pain or seek alternative treatment.
Many different CAM modalities
are used to treat pain; amongst the most popular are:
- Acupuncture;
- Mind-body therapy;
- Herbal preparations;
- Ayurvedic therapy;
- Nutritional supplements; and
- Spinal manipulation.
This article reviews the effectiveness of each of these modalities based on
the best evidence available in the form of randomized clinical trials (RCTs) or
systematic review of such studies.
Acupuncture
The first written account of acupuncture is believed to be the 2300-year-old Huang Di Nei Jing, or the Yellow Emperor's Classic of Internal
Medicine.[23,24] Since
that time, acupuncture has undergone several evolutionary processes, both in
theory and practice. Energy, or Qi (chi), flows up and down the meridians.
Sometimes the energy is blocked, deficient, excessive, or unbalanced. This
throws Yin (the feminine aspect of life) and Yang (the masculine counterpart)
out of balance, which in turn causes illness. Acupuncture restores the balance,
thereby encouraging healing.[25]
Thus far, there is not a concrete method to prove whether or how acupuncture
works. There are several theories, however, to explain the benefits of
treatment, and researchers have been experimenting with nuclear medicine
techniques to study acupoints and meridians.[25]Acupuncture is believed to stimulate secretion of endorphins, serotonin, and
noradrenaline in the central nervous system. Acupuncture could also work by
constricting or dilating blood vessels due to release of vasodilators such as
histamine. Acupuncture also may have a role in controlling pain by closing the
gates of nerve fibers that result in pain perception.
Evidence of Efficacy
Back pain and fibromyalgia.The data on effectiveness of acupuncture in
the treatment of back pain are conflicting. A meta-analysis of 12 RCTs looking
at acupuncture as a symptomatic treatment of back pain resulted in favorable
outcomes with acupuncture.[26] A
systematic review of all RCTs of acupuncture for fibromyalgia revealed only 3
studies,[27] each of
which supported use of acupuncture for relief of fibromyalgia symptoms.
Neck pain.Even though clinical or anecdotal reports often show neck
pain relief from acupuncture, a systematic review of RCTs provided mixed
evidence regarding how this modality compares with placebo for neck pain[28]:
- In 1 trial, acupuncture was superior to waiting-list controls;
- 3 trials showed acupuncture to be either equal or superior to physiotherapy;
and
- Needle acupuncture was not superior to indistinguishable sham control in 4
out of 5 studies.
The bottom line was that for the 8 high-quality studies included in this
review of acupuncture vs placebo for neck pain, 5 were negative.
Osteoarthritis. An RCT of 570 patients with osteoarthritis of the knee
were randomized to true acupuncture or sham. At the end of 26 weeks, acupuncture
seemed to provide improvements in function and pain relief as adjunctive therapy
for osteoarthritis of the knee.[29]
Acupuncture and Clinical Practice
Because even the best-designed studies are methodologically limited, it is
difficult to draw definitive conclusions that will generalize to clinical
practice. Most studies are methodologically limited because of:
- Questionable intervention quality;
- Lack of an adequate control group; and/or
- Lack of adequate follow-up.
The use of a sham acupuncture group (that is, placement of needles
superficially and/or in nonacupuncture points) as an experimental control is
problematic. There is evidence that acupuncture needles placed in nonacupuncture
points lead to pain reduction because of stimulation of endorphin release via a
mechanism called diffuse noxious inhibitory control.[30] Because
of the difficulties in designing rigorous acupuncture studies, we continue to
rely on our clinical experience as evidence of the effectiveness of acupuncture.
pain-1
