Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States

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Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States - Mayo Clinic Proceedings

 Cancer pain is certainly a major public health concern but is more likely to be addressed outside the primary care setting (eg, by oncologists, at cancer centers, as part of palliative care).

 Article Outline

1. Low Back Pain
   1. Acupuncture
   2. Massage Therapy
   3. Osteopathic Manipulative Therapy
   4. Spinal Manipulation
      1. Chronic LBP
      2. Acute, Subacute, or Mixed LBP
   5. Yoga
2. Fibromylgia
   1. Acupuncture
   2. Relaxation Techniques
   3. Massage
   4. Tai Chi
   5. Yoga
3. Neck Pain
   1. Massage
   2. Spinal Manipulation
4. OA of the Knee
   1. Acupuncture
   2. Glucosamine and Chondroitin
   3. Massage Therapy
   4. Methylsulfonylmethane
   5. S-Adenoyslmethionine
   6. Tai Chi
   7. Yoga
5. Severe Headache and Migraine
   1. Acupuncture
   2. Massage
   3. Omega-3 Fatty Acids
   4. Relaxation Techniques
   5. Spinal and Osteopathic Manipulation
6. Overall Summary of RCT Data
7. Safety
   1. Comparisons to Recent Systematic Reviews
   2. Caveats
8. Supplemental Online Material
9. Supplemental Online Material
10. References

 Overall Summary of RCT Data

Tables 3 and 4 provide concise summaries of the reviewed clinical trial data for each complementary approach stratified by painful health conditions and various control groups. In these tables, positive trials are those in which the complementary approach provided statistically significant improvements in pain severity or pain-related disability or function compared with the control group. Negative trials are those in which no difference was seen between groups. Based on a preponderance of positive trials vs negative trials, current evidence suggests that the following complementary approaches may help some patients manage their painful health conditions: acupuncture and yoga for back pain; acupuncture and tai chi for OA of the knee; massage therapy for neck pain with adequate doses and for short-term benefit; and relaxation techniques for severe headaches and migraine. Weaker evidence suggests that massage therapy, SM, and osteopathic manipulation might also be of some benefit to those with back pain, and relaxation approaches and tai chi might help those with fibromyalgia.

Caveats

A number of methodological issues temper our conclusions. The trial samples tend to be white, female, and older, with very few, if any, minority group participants; as such, the generalizability of the findings to the breadth of patients seen by primary care physicians in the United States is still unresolved. Often, the trials reviewed were small, with fewer than 100 total participants.

Small trials are prone to more variability and to false-negative results. In many of the trials in which the statistical superiority of a given complementary health approach was reported, it was not clear if the differences vs the control group were clinically relevant. For the given painful health condition, a wide number of outcome measures were often used to assess pain and function. This plethora of outcomes may partly explain the conflicting results seen across trials. For most complementary approaches, there are no standard treatment protocols or algorithms, and in the case of dietary supplements, no rigorously established dosages and products; as such, trials of a given complementary approach rarely compare the exact same intervention. Our findings that relatively few mild adverse events and no serious adverse events were associated with complementary approaches are consistent with the findings from a number of systematic reviews.^{125, 126, 127, 128, 129, 130, 131, 132, 133} However, even large clinical trials are not powered to identify infrequent adverse events, and therefore, it is likely that this review underestimates the entire range of events associated with the complementary approaches examined. Finally, our review was intended to be an overview of data from RCTs performed in the United States. The inclusion of RCTs performed outside the United States may have resulted in a different set of recommendations.