Over the past few decades, the popularity of complementary and integrative medical therapies has greatly increased. Approximately 33.2% of adults1 and 11.6% of children2 reportedly use complementary health approaches, often with pain as the primary concern. It is estimated that 55.7% adults report experiencing pain within any 3-month period, and 11.2% of adults suffer from chronic pain on a daily basis.3 In a survey of adults who experienced a chronic musculoskeletal pain disorder in 2012, 41.6% reportedly used complementary health approaches for pain management.4
The term “alternative medicine” refers to the use of nonmainstream medical therapies in the place of conventional medical therapies. Complementary medicine is the utilization of nonmainstream medical therapies in conjunction with conventional medical care. As defined by National Institutes of Health’s National Center for Complementary and Integrative Health, integrative medicine coordinately addresses the incorporation of complementary approaches into mainstream health care.5
The prescribing of opioid analgesics is a common treatment in the management of acute and chronic pain. However, there are adverse effects associated with opioid use and the potential for addiction with chronic usage. Continued use of opioids for the treatment of chronic noncancer pain potentially increases risks to patients and the society,6 and there is increased concern about whether the overprescribing of opioids for chronic pain is contributing to the current opioid crisis. Novel nonopioid alternative pain therapies such as brain stimulation or gene therapy are being investigated given the current opioid crisis; however, focus on exploration in complementary and alternative therapies is also of importance.7 Integrative medicine for pain can play a major role in reducing the frequency and amount of opioid usage. This article represents a critical review of common uses of integrative medical therapies, with the goal of increasing the understanding about how these interventions may be integrated more routinely into pain management.
CLASSIFICATION OF COMPLEMENTARY AND INTEGRATIVE MEDICAL THERAPIES
There are several categories of complementary and integrative medical therapies. These include Ayurveda (traditional healing modality from India), homeopathic medicine, Native American medicine, naturopathic medicine, Tibetan medicine, and traditional Chinese medicine, each of which relies on diverse medical systems. Biologically based therapies utilize substances found in nature, such as herbs, foods, or vitamins. Mind-body medicine uses a variety of methods of enhancing the mind’s capacity to affect the body’s functions. Some of these include biofeedback, cognitive behavioral therapy (CBT), guided imagery, hypnosis, relaxation therapy, meditation, prayer, mental healing, music therapy, and patient support groups. Manipulative methods are based on the movement of 1 or more parts of the body, including chiropractic, osteopathic manipulation, and massage therapies. Bioenergetic therapies involve the use of energy fields, including acupuncture, reiki, therapeutic touch, and therapies that use electromagnetic fields. This article will focus on commonly used complementary and integrative medical therapies from each of these disciplines, including glucosamine and chondroitin, relaxation therapy, yoga, tai chi, massage therapy, osteopathic manipulation, chiropractic, acupuncture, and traditional Chinese medicine. We will address the use of these complementary medical therapies for chronic pain, such as headache, neck pain, low back pain, knee pain, and neuropathic pain, and for opioid addiction (Table 1). Detailed explanations of the assumed mechanism of action of these interventions are beyond the scope of this review article.
We searched the electronic database of PubMed including Medline (1966–), The Cochrane Library, EMBASE (1974–), PsycINFO (EBSCOhost) (1872–), and Science Citation Index Expanded (ISI Web of Science) (1945-). We adopted a sensitive search strategy using the following combination of keywords: “yoga and chronic pain management,” “relaxation and chronic pain management,” “tai chi and chronic pain management,” “massage and chronic pain management,” “osteopathic manipulation and chronic pain management,” “spinal manipulation and chronic pain management,” “acupuncture and chronic pain management,” “glucosamine and chronic pain management,” and “chondroitin and chronic pain management.” In addition, to avoid missing relevant articles, the references of all selected articles were screened for additional potentially eligible publications. All searches were performed up to August 1, 2017.
The final selection of studies was based on specific inclusion and exclusion criteria. Studies were included for review if they were (1) prospective; (2) used a randomized study design; (3) the sample size exceeded 30 subjects; (4) there was access to the full report; (5) the study was related to pain; (6) valid and reliable measures were used; (7) subjects were followed over time; and (8) the article was published after 1980. Studies were excluded if: (1) the data were collected retrospectively; (2) the goal of the study was other than to determine the effect of the treatment; (3) only specific patient groups were targeted (eg, adolescents, patients >70 years old); (4) the studies were not in English; or (5) the reference was related to a letter or meeting abstract. Thus, we excluded nonrandomized comparative studies, uncontrolled before-after studies, and descriptive time series studies.8 Those references that were repeated or judged to be based on the same study were also excluded.
Each citation was reviewed to determine whether it might meet our criteria for inclusion in the review. If it was considered that a citation might meet the inclusion criteria, the corresponding article’s abstract was reviewed. If it was thought that, based on the abstract, an article might meet the basic inclusion criteria, the authors read the article to make a final inclusion decision. Discrepancies in the decisions were resolved by discussion. Thirty-two publications were selected. From the 32 studies selected for review, predictor variables were reported only when the methods and statistical results of significance (P value, correlations) were sufficiently described in the text. For each selected article, information was obtained on number of subjects, types of treatment, length of follow-up, study design, summary of the results, and strength of the findings.
Due to the relatively small number of selected studies for each treatment category, lack of widely accepted rating systems for prospective studies,9 and the wide variation between studies regarding predictor variable, study design, statistical analyses, and outcome measures, the methodologic quality of the studies was not rated. Because the studies reviewed were clinically heterogeneous in terms of treatment types and outcome measures, pooling of the results was not possible. As a result, our analysis was generally qualitative rather than quantitative. Instead, to ensure the basic methodologic quality of the studies, we classified the methodologic strength of each study using a scheme previously used by other reviewers.8 These criteria emphasized whether a significant association between the integrative medicine treatment and the outcome was established. To compare the results of studies by intervention, we used the categorization scheme of (1) strong positive evidence; (2) weak positive evidence; and (3) no (negative) evidence to analyze all the studies. Studies with strong positive evidence had to have significant findings based on a randomization comparison group, include over 100 subjects, and have a follow-up time of longer than 3 months. We accepted the following final summary categories for establishment of the level of evidence:
The number of studies that found a significant association between the complementary treatment and outcome exceeds the number of studies with no significant association by 3 or more.
Preliminary Positive Evidence
The number of studies with a significant association between the complementary treatment and outcome exceeds the number of studies with no significant association by 2.
The number of studies with a significant association exceeds the number of studies with no significant association by 1 or less.
Preliminary Negative Evidence
The number of studies with no significant association between the complementary treatment and outcome exceeds the number of studies with a significant association by 2.
The number of studies with no significant association exceeds the number of studies with a significant association by 3 or more.
Altogether, 1686 articles were identified. Seven hundred fifty were omitted because the integrative alternative treatment was not the primary treatment or intervention used to treat the participants in the study or the focus of the study was not on the treatment of chronic pain, and 894 were omitted because they were not randomized prospective trials, they had <30 subjects, they were published before 1980, they were replications or abstracts, or they were not in English. Only 32 met the inclusion criteria for further review. The studies were grouped according to treatment intervention. We found a few articles that used integrative medicine approaches to treat chronic pain among subjects prescribed opioid therapy and investigated whether the treatment reduced use of prescription pain medication.
The following integrative medicine interventions for pain were evaluated: (1) glucosamine and chondroitin; (2) yoga; (3) relaxation techniques; (4) tai chi; (5) massage; (6) osteopathic and spinal manipulation; and (7) acupuncture.
Glucosamine and Chondroitin
Glucosamine and chondroitin are natural structural components of joint cartilage, which are commonly used as nutritional supplements for knee pain. One study involving 34 males utilizing placebo, double-blinded, 16-week randomized controlled trial (RCT) of a combination of glucosamine hydrochloride (1500 mg/d), chondroitin sulfate (1200 mg/d), and manganese ascorbate (228 mg/d) relieved symptoms of degenerative joint disease of the knee and low back. The visual analog scale for pain recorded at clinic visits decreased by 26.6%.10 Similarly, a systemic meta-analysis of glucosamine and chondroitin for treatment of osteoarthritis (OA) indicated some degree of efficacy in OA.11 Another study to evaluate the efficacy of a polymer of N-acetyl-d-glucosamine in a double-blind, placebo-controlled study in 60 patients with OA indicates that polymer of N-acetyl-d-glucosamine may be useful in treating patients with OA.12 An RCT of 205 subjects with knee OA randomly assigned to glucosamine (1.5 g/d) versus placebo in a 12-week, double-blind trial indicated that glucosamine was no more effective than placebo.13 A multicenter, double-blind, placebo- and celecoxib-controlled (200 mg/d) glucosamine (1500 mg/d) and chondroitin (1200 mg/d) trial evaluated 1583 randomly assigned patients with symptomatic knee OA. Neither glucosamine nor chondroitin sulfate reduced pain effectively in the overall group of patients with OA of the knee.14 A multicenter, double-blind, placebo-controlled trial randomly assigned 605 patients with chronic knee pain into 4 arms consisting of 1500-mg glucosamine sulfate and/or 800-mg chondroitin sulfate. Participants were randomly assigned to 4 groups taking glucosamine sulfate (1500 mg/d), chondroitin sulfate (800 mg/d), both glucosamine sulfate and chondroitin sulfate, or placebo. All 4 groups demonstrated a reduction in knee pain. The glucosamine and chondroitin combination group demonstrated significant reduction in joint space narrowing at the 2-year follow-up visit.15 Variation exists among different trial protocols in the definition of OA, formula of mediation, and outcome measurements. Table 2 displays a summary of information about the 4 studies included in the review, including number of subjects, primary subject diagnosis, follow-up period, outcome measures, study design, summary results, and categorization of the results. One study10 included 34 subjects, while the others had >200 patients. Follow-up time ranged from 12 weeks to 2 years. Only 1 study showed a weak positive finding and the rest of the studies had no result findings. There is limited evidence in support of the analgesic benefits from glucosamine 1500 mg/d and chondroitin 800–1200 mg/d in patients with OA of the knee. Overall, we summarized this treatment category as having conflicting evidence.
Yoga is the practice of gentle muscle stretching incorporated with breathing exercises to promote health. It has also been studied for adjunctive pain treatment for various conditions. A systematic review of 9 RCTs investigating yoga for low back pain, OA, headaches, or other type of pain for pain management indicated that yoga can lead to a significant reduction in pain when compared to various other control interventions.16 The exact mechanism is not clear; however, a magnetic resonance spectroscopic imaging study indicates that in experienced yoga practitioners, brain gamma-Aminobutyric acid levels increase after a session of yoga.17 An RCT of 228 adults with chronic low back pain indicated that the viniyoga (yoga style that allows teachers to create individualized practices of different orientation, length, and intensity) group had superior outcomes to the self-care group, though not to the exercise stretching group.18 A 12-week RCT of 95 low-income minority adults with moderate to severe chronic low back pain found no differences between once-weekly and twice-weekly Hatha yoga (a type of yoga emphasizing physical exercise and breathing control) groups in reducing pain and improving back-related function.19 Because of differences in the way yoga can be presented (eg, positions, frequency, length of classes), controlled comparisons in assessing yoga as a therapy for patients with chronic pain can be problematic. Cochrane reviewed 12 RCTs, which included a total of 1080 men and women with chronic low back pain, and found that yoga compared to nonexercise controls at 3–4 months produced small to moderate improvements in back-related function.20 Yoga also has potential benefits for women with endometriosis-related pelvic pain21 and fibromyalgia-associated pain. In a study of 53 female patients with fibromyalgia who were randomly assigned to an 8-week yoga awareness program or wait listed and received standard care, those assigned to the yoga group showed significant improvements in function and pain reduction.22Table 3 gives an overview of 3 studies included in the review that examined the effects of yoga. One study22 included 53 subjects and had a follow-up of only 8 weeks. All 3 studies were classified as having weak positive evidence. Overall, this treatment was categorized as having summary preliminary positive evidence for pain management.
Relaxation techniques are components of mind-body medicine that have gained wide acceptance within conventional medicine. Relaxation techniques include diaphragmatic breathing, guided imagery, mindfulness meditation, and progressive muscle relaxation, and have long played an important role in managing chronic pain. Biofeedback is the use of sensitive equipment to track physiologic changes in the body and can augment relaxation training. An RCT involving 141 college students demonstrated that relaxation training can significantly reduce tension headache frequency and reduce headache disability.23 Adults with musculoskeletal low back pain have also been shown to benefit from relaxation techniques. In 1 study, 90 patients with chronic pain were trained in a 10-week stress reduction and relaxation program consisting of mindfulness meditation. By the end of the program, ratings of pain intensity, activity interference, physical symptoms, and anxiety and depression were significantly reduced. Pain-related medication utilization was also decreased.24 In a Cochrane review of 30 RCTs, behavioral treatment, including relaxation, was shown to be effective in reducing low back pain in the short term.25 Another study randomly assigned 40 subjects to either brief mindfulness meditation training or a control group without mindfulness meditation. The meditation group demonstrated an increased heat pain threshold and more tolerance to a tonic pain stimuli compared to the control group.26 An RCT evaluated the effectiveness of mindfulness-based stress reduction (MBSR) in 342 patients with chronic low back pain compared with a control group. MBSR is a program combining mindfulness meditation and yoga into 8-week intensive group sessions and homework tasks. At 26 weeks, the percentage of participants with clinically meaningful improvement on the Roland Disability Questionnaire was higher among those who received MBSR and CBT than for usual care. MBSR may also be an effective treatment option for patients with chronic low back pain.27 A 26-week RCT of 35 patients with chronic low back pain also on opioid therapy showed positive benefit from mindfulness meditation with increased acceptability and feasibility compared with CBT.28 Functional magnetic resonance imaging has been used to assess the impact of mindfulness meditation and neural mechanisms in healthy human subjects. Four days of mindfulness meditation training significantly reduced pain intensity ratings and decreased activity of the primary somatosensory cortex when healthy subjects were presented with a noxious stimulus.29Table 4 presents an overview of 4 studies included in the review for relaxation. One study28 included 35 subjects and another study26 had 40 subjects. The study by Kabat-Zinn et al24 had a follow-up of 10 weeks. Three studies had >1 follow-up assessment.27,28,30 Two of the 4 studies were classified as having strong positive evidence and the other 2 had weak positive evidence for the effect of using relaxation for pain management. Overall, this treatment was categorized as having preliminary positive evidence.
Tai chi consists of slow low-impact systemic motion and gentle breathing exercises. It is rooted in ancient Chinese Taoist philosophy, which can enhance mental and physical well-being. One RCT assigned 114 participants to 12 weeks of group tai chi or to either conventional neck exercises or wait-listed control for chronic nonspecific neck pain. Participants in the wait-listed control group were asked to maintain their usual activities and therapeutic regimen, and at the end of the trial, they were offered the option to participate in either a tai chi or neck exercise group. Tai chi exercises and conventional neck exercises were found to be equally effective in pain reduction.31 Another RCT enrolled 55 seniors with cognitive impairment and OA of the knees to 3 weekly sessions of Sun style tai chi for 20 weeks. The 2 primary types of tai chi, Yang and Sun, differ in their movements. Yang style has big and open movements with less strenuous postures, whereas Sun style has a higher stance, less kicking, and uses a faster pace of movement. Participants’ Western Ontario and McMaster Universities Osteoarthritis Index pain and stiffness score improved significantly in the tai chi group.32 A systemic review of the tai chi impact on health also indicates that tai chi can alleviate pain in patients with arthritis.33 Sixty-six patients with fibromyalgia were enrolled in a randomized trial of Yang style tai chi twice a week for 12 weeks or to a control group with no tai chi. The subjects in this study who participated in tai chi demonstrated improvement in their Fibromyalgia Impact Questionnaire score and quality of life at 12 and at 24 weeks.34 Another study enrolled 101 patients with fibromyalgia in an RCT of Yang style tai chi versus controls. The results indicate that 90 minutes of tai chi twice weekly for 12 weeks can improve Fibromyalgia Impact Questionnaire scores and reduce pain.35 These studies suggest that either Yang style or Sun style tai chi may be useful for easing pain in OA and improving fibromyalgia symptoms. Peng36 performed an extensive review of literature and indicated that tai chi appeared to be an effective intervention in OA, low back pain, and fibromyalgia. Table 5 presents the findings of 4 outcome studies with tai chi for persons with neck pain, knee OA, and fibromyalgia. Two studies had over 100 subjects, and all 4 trials followed the subjects for at least 3 months. One of the 4 studies was classified as having strong positive evidence and the other 3 were classified as having weak positive evidence. Overall, this treatment was categorized as having preliminary positive evidence.
Massage therapy applies various manual techniques, including pressing, rubbing, and kneading of muscle groups and other soft tissue to promote well-being. Massage is one of the oldest forms of therapy in China, India, and Egypt. An RCT of 64 patients with neck pain was conducted in which subjects were randomly assigned to either receive up to 10 massages in 10 weeks versus a self-care book. Mean differences in neck pain symptom improvement between groups were strongest at 4 weeks and not evident by 26 weeks.37 Another study involving 228 individuals with chronic nonspecific neck pain enrolled participants to a 4-week course of 30-minute massages 2 or 3 times weekly versus 60-minute massages 1, 2, or 3 times weekly or wait-list control. The massage group that received 30-minute treatments did not significantly improve compared to the wait-list control group, while the patients receiving 60-minute massage treatments 2 and 3 times a week experienced better function and neck pain control.38 Another study enrolled 48 subjects with neck pain due to arthritis to either weekly massage or a wait-list control group. Between the first and the last massages, the massage group demonstrated a significant short-term reduction in self-reported and movement-associated pain, as well as an increase in range of motion.39 A study randomly assigned 179 patients with neck pain into 1 of 5 groups receiving 4 weeks of massage in different schedules. After 4 weeks of 60-minute sessions, treatment patients who received an additional six 60-minute massages per week improved in both function and pain control.40 Another RCT, investigating the effectiveness of massage for chronic low back pain, assigned 401 patients with nonspecific chronic low back pain to 1 of 3 groups: structured massage, relaxation massage, or usual care. The massage treatments both showed beneficial effects and improved functional at 10 weeks.41 Massage therapy has also been investigated in the treatment of knee OA. Sixty-eight patients were randomly assigned to either 8 sessions of standard Swedish massage over 4 weeks plus 4 sessions in the following 4 weeks or a control group that received a delayed intervention. The group receiving massage therapy demonstrated significant improvements based on Western Ontario and McMaster Universities Osteoarthritis Index global scores of pain, stiffness, visual analog scale, and physical function.42 A recent study of 125 patients with OA of the knee randomly assigned participants to one of four 8-week regimens of a standardized Swedish massage versus a usual care control. They concluded that the optimal regimen was 60-minute massage therapy, once weekly.43 Controlled trials have also shown that massage therapy can reduce pain and anxiety in children with juvenile rheumatoid arthritis.44 A meta-analysis of massage therapy in cancer pain indicated that massage therapy also reduces cancer pain compared to conventional standard care.45 Unfortunately, in the studies where the subjects were assigned to wait-list control conditions, it is difficult to tease out the efficacy of the treatment itself and the nonspecific benefits of touch, attention, and belief that the treatment will be beneficial indirectly transmitted by a caring therapist. Some of this effect is evident by the short-term benefit of the treatments found in some of the studies. Also, due to the nature of the intervention, it is difficult for the patients and providers to be blinded to the treatment. Table 6 shows an overview of 7 studies included in this review that explored the effects of massage for chronic pain. Four studies had over 100 subjects, and 5 trials included multiple follow-up periods. Only 1 of the 7 studies was classified as having strong positive evidence and the other 6 were classified as having weak positive evidence. Overall, this treatment was categorized as having preliminary positive evidence for efficacy in pain management.
Osteopathic and Spinal Manipulation
Osteopathic manipulation involves a combination of massage, mobilization, and spinal manipulation. Sixty-three male and female active duty soldiers with acute low back pain were randomly assigned to a group receiving osteopathic manipulation in addition to usual care versus a group receiving usual care only. Assessment measurements were performed before each of 4 treatment sessions and at 4-week posttrial. The osteopathic manipulative treatment subjects demonstrated a more rapid improvement in pain compared with the controls.46 Another RCT enrolled 455 patients with chronic low back pain and assigned them to either osteopathic manipulation or sham osteopathic manipulation, as well as to ultrasound therapy or sham ultrasound therapy. All subjects received 6 treatment sessions over 8 weeks. Results demonstrated that the patients receiving osteopathic manipulation therapy utilized prescription drugs for low back pain less frequently during the 12-week trial than the control group.47
In the United States, most spinal manipulation is performed by chiropractors. Chiropractic therapy is based on the understanding that impairment caused by spinal subluxations can be restored through spinal manipulation. Spinal subluxation is considered as 1 component of a complex syndrome of intervertebral dysfunction. A RCT enrolled 110 patients with low back pain to receive spinal manipulative therapy versus minimal manipulation. The results of the study showed that spinal manipulation produced greater attenuation of overthreshold heat response from quantitative sensory testing, thus demonstrating a reduction in pain sensitivity. Improvements were also observed in the control minimal manipulation group, which suggests that benefits may be related to the nonspecific effects of treatment, especially since the control group demonstrated the highest satisfaction rates.48 The results of another study of 400 patients with chronic low back pain indicated that the number of manipulations may affect outcome. Twelve sessions in a 6-week period yielded the best results at 24-week follow-up compared with 6 or 18 sessions of treatment.49 Again, the nonspecific effects of treatment may have contributed to this outcome. Another study investigated the short- and long-term effects of spinal manipulation. It compared spinal manipulative therapy plus home exercise and advice versus home exercise and advice alone among 192 patients with back-related leg pain. Spinal manipulative therapy plus home exercise and advice showed better results at 12 weeks, but not at 52-week follow-up.50 Another study reviewed 15 RCTs involving 1711 patients with acute low back pain who received spinal manipulation performed by physical therapists, chiropractors, and physicians. It concluded that spinal manipulation was associated with modest improvement in pain intensity and suggested that spinal manipulation is a reasonable approach for acute low back pain.51 Complementary medical therapies are generally known for having few long-term adverse effects; however, even in a recognized clinical setting, cervical manipulation can carry some risk.52 Published fatality cases have implicated vascular incidents that were related to the dissection of a vertebral artery.53Table 7 shows an overview of 4 studies that explored the benefit of osteopathic and spinal manipulation for the treatment of chronic pain. Three studies had over 100 subjects, and 2 of the 4 trials included multiple follow-up periods. Two of the 4 studies were classified as having strong positive evidence and the other 2 were classified as having weak positive evidence. Overall, osteopathic and spinal manipulation was categorized as having preliminary positive evidence in the management of chronic back pain.
Acupuncture is a technique of traditional Chinese medicine that has been practiced for over 3000 years. It involves the insertion and manipulation of hair-thin needles into distinct points on the body to balance a patient’s Qi—the body’s energy force. Electroacupuncture, the electrical stimulation of the needles, can also be utilized. In 1997, the National Institutes of Health issued a Consensus Statement of Acupuncture, declaring there was promising evidence to support the efficacy of acupuncture in reducing postoperative surgery and dental pain, as well as chemotherapy-related nausea and vomiting.54
Acupuncture has also been shown to reduce postoperative opioid dose requirements. Sun et al55 conducted a systematic review of 15 RCTs designed to examine the benefits of acupuncture for acute postoperative pain. Acupuncture was associated with a lower incidence of opioid-related side effects, including nausea, sedation, dizziness, pruritus, and urinary retention, as well as a lower dose of opioids.55 A more recent systematic review and meta-analysis of the efficacy of acupuncture for postoperative pain management showed that patients who received acupuncture or related techniques, for example, electroacupuncture or transcutaneous electric acupuncture point stimulation, had less pain and used less opioid analgesics on the first day after the surgery.56 Another study of opioid consumption compared acupuncture versus morphine usage among 300 patients with acute-onset moderate to severe pain in an emergency department. The investigators found a 92% success rate with pain reduction >50% in the acupuncture group compared to 78% in the morphine group.57
Several clinical reports have suggested that acupuncture can be useful for the treatment of patients with neck pain. In a pilot RCT involving 178 patients with chronic neck pain, the acupuncture group had better long-term outcomes based on a number of outcome measures compared with a control condition.58 In a recent systematic review addressing acupuncture for peripheral neuropathic pain, most of the RCTs reviewed showed acupuncture to be beneficial for the treatment of neuropathy related to diabetes mellitus, Bell palsy, and carpal tunnel syndrome.59 Another study of 517 patients with chronic neck pain found that acupuncture and related lifestyle advice, including diet, rest, and work, had better outcomes (eg, reduction in pain and disability) at 12 months, although it is difficult to determine the benefits of lifestyle advice alone.60
Acupuncture has also been used to treat low back and knee pain. An acupuncture RCT was conducted in which 1162 patients with low back pain were recruited and randomly assigned to 3 treatment conditions: true acupuncture, sham acupuncture, and conventional therapy.61 After 6 months, improvements were noted in both the true and the sham acupuncture groups. In another study, 638 patients with chronic low back pain were randomly assigned to receive 10 treatments over 7 weeks or usual care. The acupuncture group showed improvement compared to usual care without acupuncture.62 A systematic review of acupuncture for chronic low back pain indicated that acupuncture can provide short-term pain reduction and improved function.63 In another RCT involving 570 patients with OA of the knee, subjects who received 23 acupuncture sessions over 26 weeks showed greater improvement in function and pain relief over subjects in the control groups.64 Another meta-analysis of 10 RCTs of acupuncture for chronic knee OA concluded that acupuncture can provide short-term pain relief and improvement in short- and long-term physical function.65 A study addressing the duration of acupuncture effects in chronic pain patients analyzed the available data involving 29 trials and 17,922 patients and determined that the effects of a course of acupuncture treatment for chronic pain can persist over a year.66 Nahin et al67 reviewed 150 RCTs conducted in the United States over the past 50 years. They concluded that the strongest evidence was in support of acupuncture and yoga for back pain, acupuncture and tai chi for OA of the knee, massage therapy for neck pain, and relaxation techniques for severe headaches and migraine.
Table 8 shows an overview of 6 studies that met inclusion criteria for this review and that explored the benefit of acupuncture for chronic pain. All the studies had over 100 subjects, and all 6 trials included multiple follow-up periods, although the study by Wang et al68 followed the subjects for only 2 weeks. Four of the 6 studies were classified as having strong positive evidence and the other 2 were classified as having weak positive evidence. Overall, this treatment was categorized as having strong positive evidence.
In this brief review, we attempted to include articles that represented rigorously designed RCTs of alternative integrated medical therapies. We found weak evidence for yoga, relaxation, tai chi, massage, and manipulation and stronger evidence for acupuncture as complementary treatments for chronic pain. We did not find evidence in support of using glucosamine and chondroitin for arthritis pain. Only a few of the studies that we reviewed addressed the use of prescription medication, in general, and opioid medication, in particular, and the potential benefit of complementary treatment approaches in reducing use of pain medication. Studies by Licciardone et al47 and Kabat-Zinn et al24 reported decreased use of prescription pain medication with osteopathic manipulation and mindfulness meditation, and Zgierska et al28 reported that mindfulness meditation was beneficial in patients with chronic low back pain who are prescribed opioids for pain. Additional longitudinal controlled trials are needed to determine the effects of complementary and alternative treatments in reducing opioid use when managing chronic pain.
Many of the studies we reviewed demonstrate some treatment efficacy and benefit for persons with chronic pain. We recognize that in controlled trials of alternative treatments for pain, it can be difficult to control for the nonspecific effects of treatment. There is much evidence that attention, beliefs, expectancy, and the placebo effect of any intervention can improve outcome. Because the treatment intervention targeted in a clinical trial often needs to be administered by a knowledgeable provider (eg, acupuncture), it is challenging to design studies in which both the patients and the clinicians are blinded. We found that some studies were statistically underpowered and included a mix of patient populations. Many of the studies also did not follow patients for an extended period, and some studies were limited due to self-selection, drop out, and a restricted number of study participants. Attention to individual differences in response to treatment was also sometimes absent. Even though the initial evidence is promising for the long-term benefit of integrative medicine for chronic pain, we recognize that additional controlled trials are needed and conclusive objective evidence for the efficacy of any medical intervention without bias can be lacking. Future studies would be strengthened with the use of objective measures of function (eg, activity monitors), and biological outcome markers (eg, cortisol), that would allow for more objective outcome measures other than self-report alone. More attention to other outcomes such as reduced health care utilization and return-to-work can be stronger indicators of positive treatment.
Integrative medical therapies include a broad spectrum of practices and beliefs. Although these practices are not widely accepted, and are considered by some to be incompatible with the beliefs or standards of mainstream medicine, there is an increasing demand for complementary medicine therapies, and practitioners are beginning to realize the importance of understanding their use and benefits. In fact, more than half of medical schools in the United States now offer at least 1 course or clerkship in complementary medicine.69
In the current opioid crisis era, many integrative medical therapies can be used as complements to mainstream medicine to address pain and reduce opioid abuse and addiction-related disease. The Centers for Disease Control and Prevention guidelines indicate that nonopioid therapy is the currently preferred method for managing chronic pain.70 The consensus and results of this review suggest that complementary health approaches can help to improve pain and reduce opioid use, although additional studies are needed. With the public demand for integrative medical therapies increasing, additional RCTs are needed to evaluate the effectiveness of using integrative medical therapies to support current pain management techniques and to decrease reliance on opioid use.
We are grateful for the assistance of Meaghan Muir, MLIS, Manager, Library Services at Boston Children’s Hospital, who provided help with the literature search.
Name: Yuan-Chi Lin, MD, MPH.
Contribution: This author helped write and edit the manuscript.
Name: Limeng Wan, BS.
Contribution: This author helped write and edit the manuscript.
Name: Robert N. Jamison, PhD.
Contribution: This author helped write and edit the manuscript.
This manuscript was handled by: Honorio T. Benzon, MD.
1. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RLTrends in the use of complementary health approaches among adults: United States, 2002–2012. Natl Health Stat Report. 2015:1–16.
2. Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RLUse of complementary health approaches among children aged 4–17 years in the United States: National Health Interview Survey, 2007–2012. Natl Health Stat Report. 2015:1–19.
3. Nahin RLEstimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16:769–780.
4. Clarke TC, Nahin RL, Barnes PM, Stussman BJUse of complementary health approaches for musculoskeletal pain disorders among adults: United States, 2012. Natl Health Stat Report. 2016:1–12.
6. Crofford LJAdverse effects of chronic opioid therapy for chronic musculoskeletal pain. Nat Rev Rheumatol. 2010;6:191–197.
7. Volkow ND, Collins FSThe role of science in addressing the opioid crisis. N Engl J Med. 2017;377:391–394.
8. Turner JA, Loeser JD, Deyo RA, Sanders SBSpinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications. Pain. 2004;108:137–147.
9. Linton SJA review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 2000;25:1148–1156.
10. Leffler CT, Philippi AF, Leffler SG, Mosure JC, Kim PDGlucosamine, chondroitin, and manganese ascorbate for degenerative joint disease of the knee or low back: a randomized, double-blind, placebo-controlled pilot study. Mil Med. 1999;164:85–91.
11. McAlindon TE, LaValley MP, Gulin JP, Felson DTGlucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA. 2000;283:1469–1475.
12. Rubin BR, Talent JM, Kongtawelert P, Pertusi RM, Forman MD, Gracy RWOral polymeric N-acetyl-D-glucosamine and osteoarthritis. J Am Osteopath Assoc. 2001;101:339–344.
13. McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara KEffectiveness of glucosamine for symptoms of knee osteoarthritis: results from an internet-based randomized double-blind controlled trial. Am J Med. 2004;117:643–649.
14. Clegg DO, Reda DJ, Harris CL, et al.Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795–808.
15. Fransen M, Agaliotis M, Nairn L, et alLEGS Study Collaborative Group. Glucosamine and chondroitin for knee osteoarthritis: a double-blind randomised placebo-controlled clinical trial evaluating single and combination regimens. Ann Rheum Dis. 2015;74:851–858.
16. Posadzki P, Ernst E, Terry R, Lee MSIs yoga effective for pain? A systematic review of randomized clinical trials. Complement Ther Med. 2011;19:281–287.
17. Streeter CC, Jensen JE, Perlmutter RM, et al.Yoga Asana sessions increase brain GABA levels: a pilot study. J Altern Complement Med. 2007;13:419–426.
18. Sherman KJ, Cherkin DC, Wellman RD, et al.A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171:2019–2026.
19. Saper RB, Boah AR, Keosaian J, Cerrada C, Weinberg J, Sherman KJComparing once- versus twice-weekly yoga classes for chronic low back pain in predominantly low income minorities: a randomized dosing trial. Evid Based Complement Alternat Med. 2013;2013:658030.
20. Wieland LS, Skoetz N, Pilkington K, Vempati R, D’Adamo CR, Berman BMYoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;1:CD010671.
21. Gonçalves AV, Makuch MY, Setubal MS, Barros NF, Bahamondes LA qualitative study on the practice of yoga for women with pain-associated endometriosis. J Altern Complement Med. 2016;22:977–982.
22. Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist SDA pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010;151:530–539.
23. D’Souza PJ, Lumley MA, Kraft CA, Dooley JARelaxation training and written emotional disclosure for tension or migraine headaches: a randomized, controlled trial. Ann Behav Med. 2008;36:21–32.
24. Kabat-Zinn J, Lipworth L, Burney RThe clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8:163–190.
25. Henschke N, Ostelo RW, van Tulder MW, et al.Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010:CD002014.
26. Reiner K, Granot M, Soffer E, Lipsitz JDA brief mindfulness meditation training increases pain threshold and accelerates modulation of response to tonic pain in an experimental study. Pain Med. 2016;17:628–635.
27. Cherkin DC, Sherman KJ, Balderson BH, et al.Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315:1240–1249.
28. Zgierska AE, Burzinski CA, Cox J, et al.Mindfulness meditation-based intervention is feasible, acceptable, and safe for chronic low back pain requiring long-term daily opioid therapy. J Altern Complement Med. 2016;22:610–620.
29. Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RCBrain mechanisms supporting the modulation of pain by mindfulness meditation. J Neurosci. 2011;31:5540–5548.
30. D’Souza P, Pandhi RK, Khanna N, Rattan A, Misra RSA comparative study of therapeutic response of patients with clinical chancroid to ciprofloxacin, erythromycin, and cotrimoxazole. Sex Transm Dis. 1998;25:293–295.
31. Lauche R, Stumpe C, Fehr J, et al.The effects of tai chi and neck exercises in the treatment of chronic nonspecific neck pain: a randomized controlled trial. J Pain. 2016;17:1013–1027.
32. Tsai PF, Chang JY, Beck C, Kuo YF, Keefe FJA pilot cluster-randomized trial of a 20-week tai chi program in elders with cognitive impairment and osteoarthritic knee: effects on pain and other health outcomes. J Pain Symptom Manage. 2013;45:660–669.
33. Solloway MR, Taylor SL, Shekelle PG, et al.An evidence map of the effect of tai chi on health outcomes. Syst Rev. 2016;5:126.
34. Wang C, Schmid CH, Rones R, et al.A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363:743–754.
35. Jones KD, Sherman CA, Mist SD, Carson JW, Bennett RM, Li FA randomized controlled trial of 8-form tai chi improves symptoms and functional mobility in fibromyalgia patients. Clin Rheumatol. 2012;31:1205–1214.
36. Peng PWTai chi and chronic pain. Reg Anesth Pain Med. 2012;37:372–382.
37. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RARandomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009;25:233–238.
38. Sherman KJ, Cook AJ, Wellman RD, et al.Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. Ann Fam Med. 2014;12:112–120.
39. Field T, Diego M, Gonzalez G, Funk CGNeck arthritis pain is reduced and range of motion is increased by massage therapy. Complement Ther Clin Pract. 2014;20:219–223.
40. Cook AJ, Wellman RD, Cherkin DC, Kahn JR, Sherman KJRandomized clinical trial assessing whether additional massage treatments for chronic neck pain improve 12- and 26-week outcomes. Spine J. 2015;15:2206–2215.
41. Cherkin DC, Sherman KJ, Kahn J, et al.A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011;155:1–9.
42. Perlman AI, Sabina A, Williams AL, Njike VY, Katz DLMassage therapy for osteoarthritis of the knee: a randomized controlled trial. Arch Intern Med. 2006;166:2533–2538.
43. Perlman AI, Ali A, Njike VY, et al.Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One. 2012;7:e30248.
44. Field T, Hernandez-Reif M, Seligman S, et al.Juvenile rheumatoid arthritis: benefits from massage therapy. J Pediatr Psychol. 1997;22:607–617.
45. Lee SH, Kim JY, Yeo S, Kim SH, Lim SMeta-analysis of massage therapy on cancer pain. Integr Cancer Ther. 2015;14:297–304.
46. Cruser dA, Maurer D, Hensel K, Brown SK, White K, Stoll STA randomized, controlled trial of osteopathic manipulative treatment for acute low back pain in active duty military personnel. J Man Manip Ther. 2012;20:5–15.
47. Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KPOsteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Ann Fam Med. 2013;11:122–129.
48. Bialosky JE, George SZ, Horn ME, Price DD, Staud R, Robinson MESpinal manipulative therapy-specific changes in pain sensitivity in individuals with low back pain (NCT01168999). J Pain. 2014;15:136–148.
49. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MBDose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. Spine J. 2014;14:1106–1116.
50. Bronfort G, Hondras MA, Schulz CA, Evans RL, Long CR, Grimm RSpinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Ann Intern Med. 2014;161:381–391.
51. Paige NM, Miake-Lye IM, Booth MS, et al.Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis. JAMA. 2017;317:1451–1460.
52. Puentedura EJ, March J, Anders J, et al.Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012;20:66–74.
53. Ernst EDeaths after chiropractic: a review of published cases. Int J Clin Pract. 2010;64:1162–1165.
54. NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518–1524.
55. Sun Y, Gan TJ, Dubose JW, Habib ASAcupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008;101:151–160.
56. Wu MS, Chen KH, Chen IF, et al.The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11:e0150367.
57. Grissa MH, Baccouche H, Boubaker H, et al.Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med. 2016;34:2112–2116.
58. Liang Z, Zhu X, Yang X, Fu W, Lu AAssessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomised controlled study. Complement Ther Med. 2011;19suppl 1S26–S32.
59. Dimitrova A, Murchison C, Oken BAcupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis. J Altern Complement Med. 2017;23:164–179.
60. MacPherson H, Elliot B, Hopton A, Lansdown H, Birch S, Hewitt CLifestyle advice and self-care integral to acupuncture treatment for patients with chronic neck pain: secondary analysis of outcomes within a randomized controlled trial. J Altern Complement Med. 2017;23:180–187.
61. Haake M, Müller HH, Schade-Brittinger C, et al.German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167:1892–1898.
62. Cherkin DC, Sherman KJ, Avins AL, et al.A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009;169:858–866.
63. Liu L, Skinner M, McDonough S, Mabire L, Baxter GDAcupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196.
64. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MCEffectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004;141:901–910.
65. Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan SThe effects of acupuncture on chronic knee pain due to osteoarthritis: a meta-analysis. J Bone Joint Surg Am. 2016;98:1578–1585.
66. MacPherson H, Vertosick EA, Foster NE, et al.The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017;158:784–793.
67. Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJEvidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc. 2016;91:1292–1306.
68. Wang SM, Dezinno P, Lin EC, et al.Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. Am J Obstet Gynecol. 2009;201:271.e1–271.e9.
69. Cowen VS, Cyr VComplementary and alternative medicine in US medical schools. Adv Med Educ Pract. 2015;6:113–117.
70. Dowell D, Haegerich TM, Chou RCDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624–1645.