The Integrative Approach to Pain Management

Acupuncture and Traditional Chinese Medicine (TCM)

TCM is an inclusive medical system based on 3000-year-old ancient texts. It incorporates varied treatment modalities, including acupuncture, acupressure, Chinese herbal medicine, meditative movements such as tai chi and qi gong, moxibustion, cupping, and specialized massage techniques referred to as tui na.

Acupuncture and TCM are based on the theory that health is determined by the balance of vital energy flow, called qi (pronounced “chi”), which is thought to be present in all living creatures. TCM utilizes concepts, such as yin/yang, dampness, and wind, which have no equivalents in conventional medicine and are therefore difficult to explain in standard medical terms. “Yin” represents the concept of cold, slow, and passive, while “yang” represents energy that is hot, fast, and active. Health is believed to be based on a balance of these and other opposing forces such as dampness and dryness and require the free flow of qi. Disease is felt to arise from an imbalance in these forces. Imbalance leads to blockage of qi (vital energy) along specified pathways, called meridians. In all organisms, qi is believed to flow through particular channels, called meridians, and TCM therapies are utilized to unblock the flow of qi. Unlike in conventional medicine, treatment plans are highly individualized and are based on an individual’s constitution, as assessed by the TCM provider, as well as on their symptoms. Thus two patients with identical complaints might receive entirely unique treatment plans based on their baseline characteristics.

The acceptance of acupuncture in the United States continues to rise, with a 50% increase in use between 2002 and 2012. In that same time period, the number of United States licensed acupuncturists increased 100%. Acceptance is also growing among medical educators. A survey of Pain Fellowship Directors revealed positive impressions of acupuncture in the treatment of common pain conditions. Acupuncture is often included in their treatment planning, is frequently available through the institution, and is integrated into the Fellowship curriculum. Dry needling is also increasing in popularity. It is a treatment modality that has similarities to acupuncture (thin needles inserted into trigger points) but is performed by non-acupuncturists, such as physical therapists, and does not adhere to the principles of TCM. This has caused consternation for some in the acupuncture community, while others have advocated for a collaborative approach. Acupuncture points (acupoints) are located along the recognized meridians, and the process of acupuncture involves the insertion of thin needles into these points. Although meridians cannot be visualized anatomically, acupuncture points often correspond to depressions in muscles, bones, or neural foramina and may have their neurovascular bundle, which distinguishes the acupoint from surrounding tissue. They are often palpable and may be tender to palpation.

From a conventional medicine point of view, the mechanism of action of acupuncture has not been unequivocally determined. Theories for acupuncture efficacy include the release of endorphins and neurotransmitters, enhanced local immune response, enhanced circulation and smooth muscle relaxation, stimulation of tissue growth and repair, and spinal and peripheral nerve stimulation. Substantial evidence supports the theory that acupuncture creates physiologic change at the site of needle insertion, in the cerebral cortex, and hormone and endorphin release. It may also stimulate neurogenesis. It has been shown to reduce lameness in horses as well as pain and locomotion in dogs with musculoskeletal disorders, suggesting effectiveness that does not rely on the placebo response.

There is abundant evidence to support the use of acupuncture in varied medical conditions, yet there are particular challenges to acupuncture research that may affect results. Acupuncture has no true placebo control, and sham acupuncture has sometimes been shown to be as effective as true acupuncture. Inserting needles in “sham” acupuncture points might elicit physiologic change, and even sham acupuncture needles that press but do not puncture the skin may approximate acupressure effects if they are used at specified acupoints. In addition, standardized acupuncture treatments are often used in research to provide a consistent and replicable approach. That is, all patients with back pain would receive acupuncture at the same acupoints. However, this does not replicate the individualized treatment approach of acupuncture used in practice, thus creating a research environment that does not reflect real life conditions.

Acupuncture is used in various health conditions and is also used by those without specific symptoms to maintain optimal health. It is most commonly used for musculoskeletal pain relief. A 2001 review on acupuncture safety found that minor adverse events were common, but serious adverse events were rare. The most commonly reported adverse events were needle pain (1%–45%), tiredness (2%–41%), nausea or vomiting (0.01%–0.2%), and slight bleeding/bruising (0.03%–38%; Box 61.1 ). Feeling faint was very rare (0%–0.3%), and pneumothorax was extremely rare­—only occurring twice in nearly a quarter of a million treatments. A more recent overview of systematic reviews of acupuncture safety confirmed relatively frequent minor adverse events but rare serious ones. Acupuncture is safe even in people receiving anticoagulation.

Laws concerning the practice of acupuncture are defined by each state. Practitioners may include licensed acupuncturists who have completed over 1,000 hours of training at a college of Oriental Medicine or Masters level program, chiropractors who may receive some training within their professional course of study and may choose to pursue additional post-graduate training, and physicians and dentists who pursue acupuncture training after completing their professional programs. Most programs targeted to physicians, chiropractors, and dentists include approximately 200–400 hours of training. Board certification is available through the NCCAOM National Certification Commission for Acupuncture and Oriental Medicine ( https://www.nccaom.org ). For physicians, Board certification is available through the American Board of Medical Acupuncture ( http://www.dabma.org/requirements.asp ). Acupuncture styles differ and can include traditional Chinese acupuncture, five-element acupuncture, Korean or Japanese acupuncture, and auricular acupuncture. Evidence of superiority of one form over the others is not available.

A review of Cochrane reviews of acupuncture for pain found that acupuncture was effective for migraines, neck disorders, tension-type headaches, and peripheral joint osteoarthritis. One well-designed randomized controlled trial of acupuncture in the treatment of knee osteoarthritis involved 507 patients recruited from two University outpatient clinics ( Box 61.2 ). The patients were randomized into one of three groups: true acupuncture, sham acupuncture, or education control. The primary measured outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at eight and 26 weeks. Secondary outcomes were patient global assessment, 6 minute walk distance, and physical health scores of the 36-Item Short-Form Health Survey (SF-36). Participants in the true acupuncture group experienced significantly greater improvement in WOMAC function scores than both the sham acupuncture and education groups at eight weeks but not in WOMAC pain score or the patient global assessment. At 26 weeks, the true acupuncture group experienced significantly greater improvement than the sham and education groups in the WOMAC function score, WOMAC pain score, and patient global assessment. The authors concluded that acupuncture could be used as adjunctive therapy in the treatment of knee osteoarthritis.

A Cochrane review of acupuncture revealed that sham-controlled trials show statistically significant benefits; however, these benefits are small and may be due partly to placebo effects from incomplete blinding. Acupuncture has been shown to be helpful in the perioperative period to decrease anxiety, and postoperative analgesic requirements, and has been shown to improve chronic low back pain symptoms in some studies, but not others. It shows benefit in some musculoskeletal conditions, such as carpal tunnel syndrome, but no benefit in others, such as patellofemoral pain. A Cochrane review of acupuncture for the treatment of chronic tension-type headaches suggested that acupuncture could be a valuable non-pharmacologic tool in patients with frequent episodic or chronic tension-type headaches. It has also shown benefit in varied neuropathic conditions. A recent meta-analysis evaluated the efficacy of acupuncture for non-specific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain ( Box 61.2 ). The primary outcome measures were pain and function. Data from 39 studies, which included more than 20,000 patients, showed that acupuncture was superior to sham as well as no acupuncture control for each pain condition. Thus although the evidence suggests that acupuncture is beneficial for treating varied pain syndromes, the picture is unclear. Expectation of benefit, possible physiologic action of supposed sham controls, differing styles of acupuncture, and acupuncture research protocols that may not match the “real life” practice of acupuncture all create some uncertainty regarding the effectiveness of acupuncture for the treatment of pain. However, a mounting body of evidence suggests the benefits of acupuncture when added to conventional care and clear evidence of safety.

Mind-Body Medicine

The term mind-body medicine does not refer to a specific treatment modality; instead, it refers to a group of modalities unified by the underlying concept of an intricate connection between the mind and the body. The physical, emotional, spiritual, and social aspects of our lives impact health and wellbeing, and dysfunction in one domain can lead to dysfunction in another. Mind-body medicine asserts that the mind can positively affect the body in the pursuit of health and wellness.

Our daily experience makes it clear that the mind can affect physiology. Blushing from social embarrassment results from increased blood flow to the face, frightening movies can increase cardiovascular vital signs, and sexually stimulating visual material can increase blood flow to the penis. Similarly, psychological stress can lead to clear physiologic changes, most of which are potentially harmful. Chronically elevated blood pressure and heightened muscular tension leading to headaches or neck pain and increased incidence of chronic pain syndrome may be associated with stress. Pain and stress are interconnected, often generating a vicious cycle in which pain causes stress and subsequently stress causes more pain. Mind-body techniques can provide improved ability to cope with pain, decreased perception of pain, and an increased sense of wellbeing and relaxation. The psychological tendency to catastrophize has been associated with increased pain perception, and mind-body techniques can help temper this anxious state.

The relaxation response is a physical state or reaction that counteracts the physiologic and emotional responses to stress and is essentially the opposite of the fight or flight response. It was first described by Herbert Benson and colleagues at Harvard Medical School in the 1970s. Just as eliciting the stress response can generate unhelpful physiologic changes, eliciting the relaxation response can result in health inducing physiologic effects. The relaxation response is different than simply relaxing with a book or in front of the television. Although these activities may be considered “relaxing,” they do not generate the physiologic changes associated with the relaxation response. The relaxation response is elicited by focusing the mind on a particular word, phrase, breath, image, or action and adopting a passive attitude toward one’s thoughts. Modulation of cardiovascular parameters, muscular relaxation, and normalization of stress hormones such as cortisol, epinephrine, and norepinephrine are all associated with the relaxation response.

Mind-body techniques are varied and become easier to do with practice. Techniques include abdominal breathing, meditation, guided imagery, biofeedback, yoga, tai chi, qi gong, therapeutic arts, and even prayer. No mind-body technique is intrinsically more effective than another, and all can be used to decrease stress and elicit the relaxation response. Some involve movement and stretching, while others are practiced in seated or recumbent positions. They can be performed in groups, with an individual instructor, or alone. Patients may choose to try different mind-body techniques to find one, or several, that they prefer. Varied mind-body techniques have shown improvement in pain intensity and a suggestion of decreased need for opioids, with meditation and hypnosis showing more benefit than other mind-body techniques. One challenge in the field of mind-body medicine is the lack of clarity regarding the needed “dose” of mind-body practice required for benefit. One study of a very brief (10 min) relaxation training experience did not show increased experimental pain tolerance compared to control. Mindfulness Based Stress Reduction (MBSR) is a structured and standardized mind-body program that provides a large “dose” of mind-body practice. It is an eight-week training program with expectations for daily home practice. It usually requires a fee for participation. However, an online version is available at no cost ( https://palousemindfulness.com ). A randomized controlled trial of 342 adults aged 20–70 years with chronic low back pain found significant improvement in pain and functional limitation in those who participated in an MBSR program compared to usual care. CBT was also assessed; MBSR and CBT were equally effective, and improvements persisted at 26 weeks. Similar improvements in pain, as well as the quality of life, were found for patients with chronic headaches. Specific mind-body techniques are described in the ensuing paragraphs.