Chronic pain is one of the primary reasons that patients try CAM therapies. Patients look for ways to relieve not only the daily pain but the anxiety and uncertainty that the pain produces. Many of the techniques are minimally invasive, such as acupuncture, or noninvasive, such as the energy therapies of Reiki or therapeutic touch (TT). Because many patients are attracted to this type of therapy, incorporating it into the plan of care can help track outcomes and determine benefit. Because the use of these therapeutics is controversial and research is limited, it is helpful to monitor the benefit of these therapies when they are added to a plan of care.
Many terms are applied to CAM therapies. Terms have changed through the years and some common terms are listed below. Currently, integrative is the term most often used with this category of therapeutic options.
Complementary: Techniques or additional therapies that are used in conjunction with recognized mainstream medical practices; for example, when music or relaxation is used with medication for low back pain.
Alternative: This term means foregoing recognized medical therapy and using other treatments for a condition; for example, when vitamin supplements, magnets and/or imagery is used in place of traditional cancer treatments. Integrative: A term coined by CAM practitioners to indicate the combined use of pharmacotherapy and nonpharmacologic methods for medical treatment. This term was first used by Dr. Andrew Weil and is the most common term applied to CAM therapies at this time. (NCCAM, 2004)
There are many different types of CAM therapies that are available for treating pain. Some are very simple to use, such as hot or cold therapy. Others, such as biofeedback, require patients to be educated about using the technique. Still others, such as TT, require a trained practitioner to administer them.
The four main areas or types of CAM as defined by the NCCAM are:
■ Body-based therapies, such as hot and cold therapy, massage, yoga, exercise, and acupuncture
■ Cognitive behavioral approaches or mind—body work, such as relaxation, biofeedback, meditation, distraction, and imagery
■ Nutritional approaches that incorporate the use of diet, herbs and vitamin supplements
Hot and cold applications are common home remedies. Patients are comfortable with the idea of using a heating pad for back pain or applying a cold pack for a minor muscle injury. Every household has an assortment of heating pads, ice packs, and the newer versions of microwave heating pads and wraps. Most patients find more comfort in heat and prefer it over cold packs. As for research support, a Cochrane report with low back pain patients indicates the therapies have limited support (French, Cameron, Walker, Reggars, Esterman, 2006). However, additional information indicates that a heat wrap can increase functionality in patients with low back pain (French, 2006).
The benefit of using a heating pad or hot pack can increase circulation to the affected area, decrease stiffness, reduce pain, and relieve muscle spasms (American Society of Pain Management Nurses [ASPMN], 2010). When using heat, patients should be cautioned to:
■ Use it for short periods of time.
■ Monitor use carefully over areas of decreased circulation to avoid burns.
■ Avoid placing it over areas where mentholated creams have been used, which can increase the potential for skin damage.
■ Heat should never be placed over a patch delivering medications such as fentanyl, medications for hypertension, or smoking cessation patches. The heat over these patches will increase the delivery of the medication to the patients and put them at risk for overdose. (Taken from D'Arcy, 2010)
Ice baths, cold packs, or ice massage are helpful for decreasing the pain minor injuries, low back pain, and muscle spasms (ASPMN, 2010). Many older patients refuse to try cold applications although it can be helpful for pain relief. The cold applications work by:
■ Decreased nerve conduction
■ Cutaneous counterirritation
■ Muscle relaxation
■ Reduction of local and systemic metabolic activity (ASPMN, 2010)
To improve the use of hot and cold therapy and avoid tissue damage, they should be used for intermittent short periods of time only. Patients with cardiovascular disease and diabetes, should take care to monitor the application sites for skin damage.
A common approach used by health care providers for patients with a minor ache or sprain is RICE therapy:
■ Elevation (Berry, Covington, Dahl, Katz, Miaskowski, 2006)
For patients with chronic pain, this technique may be less useful; during exacerbation of musculoskeletal pain, however, it may provide some added relief.
Acupuncture is one of the oldest CAM therapies. It originated in China where it balanced the yin and yang or energy of life forces (ASPMN, 2010). The Chinese believe that balancing the life energies creates a flow of energy called Chi or QI life energy forces along meridians located in the body (Weintraub, Mamtani, & Micozzi, 2008). If the flow of energy is blocked, weak, or in a state of imbalance, an illness or pain will occur (Khatta, 2007). Acupuncture restores balance to the body and open up the blocked chakras or energy blockages.
Acupuncture has several different variations in practice, depending on the part of the world where the practice originates. The classic approach is Chinese, and there are medical artifacts from history that indicate that acupuncture was used as a regular part of Chinese medicine for many centuries.
When acupuncture is performed, thin needles are inserted through the skin into predetermined points designed to release the blocked energy (ASPMN, 2010; Dillard & Knapp, 2005; NCCAM, 2004). The needles are manipulated by hand or electrically stimulated releasing neurotrans-mitters that can decrease pain (Dillard & Knapp, 2005).
Conditions for which acupuncture has been used include:
■ Low back pain, nausea associated with chemotherapy and pregnancy (Weintraub, Mamatani, Micozzi, 2008)
■ Dental pain (APS, 2005; Dillard & Knapp, 2005)
In a study of 570 patients with osteoarthritis receiving acupuncture, the patients in the study had improvements in function and decreased pain levels (Khatta, 2007). In a review of acupunture used for relief of low back pain, the outcome proved the treatment to be better than sham or no treatment for pain relief and improved function, but there was a recommendation for more research on the technique (Furlan, Brosseau, Imamura, Irvin, 2002). For low back pain, acupuncture was found to be more effective than sham acupuncture.
NIH and NCCAM define massage as pressing, rubbing, and otherwise manipulating muscles and soft tissue in the body (NCCAM, 2004). Massage can take several different forms, with deep tissue massage or a lighter technique. Aromatherapy can be combined with massage to make the experience more relaxing. Massage increases oxygenation and blood flow to the area which lengthens and relaxes the muscles. (NCCAM, 2004). Compared with other noninvasive interventions, massage can produce effective pain relief. Conditions for which massage has been found to be helpful are:
■ Stress management and comfort
■ Pain management
■ Improving mobility and movement
■ Part of a physical therapy regimen (Weintraub et al., 2008)
■ The popularity of massage is increasing with many patients requesting massage therapy from their physicians and if not covered by insurance about 90% of the patients for the treatment out of pocket (Weintraub et al., 2008)
Chiropractic treatment or adjustments consist of spinal manipulation and other techniques to align the body to reduce pain. About 90% of all patients who are referred to chiropractic treatment are seen for musculoskeletal pain; back, neck and headache pain (Weintraub et al., 2008). The findings on using chiropractic for pain relief are mixed. For low back pain, however, there is good evidence that chiropractic therapy is effective for chronic or sub-acute low back pain.
Other Types of Body-Based Therapies
Other forms of body-based therapies are not a well supported by research. These therapies include:
■ Copper bracelets
However, those that do have support can be useful to help relieve pain. Physical therapy has benefit for those patients who are able to comply with the physical demands. The benefit of physical therapy is to recondition a weakened patient, improve mood, reduce pain and maintain mobility while increasing overall functionality (APS, 2002; Bruckenthal & D'Arcy, 2007). For low back pain, exercise has good evidence to support it for pain relief. Yoga, a form of gentle stretching, has also been found effective for pain relief. Viniyoga has been found to be superior to regular exercise for improving functional status and the use of pain medications. Pool therapy, in which the patients perform the physical therapy exercises in a swimming pool, can lessen the strain on sore muscles and help support the body while exercising.
Clinical The use of cognitive behavioral therapy, progressive relaxPearl ation, exercise, interdisciplinary rehabilitation, functional restoration, and spinal manipulation have produced differences of 10 to 20 points on a 100-point visual analog scale.
Many patients are interested in using the complementary methods of relaxation, biofeedback, self-hypnosis, and imagery to provide additional pain relief (APS, 2002; D'Arcy, 2007). Not all patients find these techniques to their liking. For those patients who are willing to invest the time and energy in learning how to use these methods, a good outcome can be expected. Music is an easy to use and greatly appreciated form of distraction and relaxation therapy. In early days music was incorporated into healing rituals. For pain relief music can be used in several different ways for example:
■ Using music as a part of physical therapy regimen can make the experience more pleasurable.
■ Music can be used to help structure breathing, provide a base for imagery, or provide another form of relaxation.
■ Playing or composing music can help express inner feelings and provide a creative outlet.
Even so simple an intervention as listening to pleasurable music can relax and help a patients feel pleasant memories. To achieve the best results with music therapy using music that the patient likes and prefers is best.
Thiere are several different types of relaxation techniques that can be used to help control pain:
■ Regulating breathing, leading to decreased respiratory efforts
■ Relaxation tapes for progressive relaxation
■ Relaxation exercises (D'Arcy, 2007, 2010)
Relaxation techniques have been effective for decreasing pain (Cole & Brunk, 1999). These techniques result in the reduction of physical tension, muscle relaxation, and the promotion of emotional well-being (ASPMN, 2010; NCCAM, 2004). Using relaxation can be beneficial for patients who have chronic pain, cancer pain, and acute surgical pain (Dillard & Knapp, 2005). For patients who opt to use relaxation techniques some of the benefits include a heightened sense of well-being and improved scores on quality-of-life tools (Dillard & Knapp, 2005).
When patients use relaxation, they are asked to either progressively relax their muscles. Starting from the top of the body and progressing to the lower extremities, or focus on one process, such as controlling breathing. There are prerecorded tapes with relaxation exercises on them that patients can use at certain times of the day, such as when they feel stress building or as a help for relaxing to fall asleep. The patient can keep track of progress with a pain diary or journal.
Imagery is a form of relaxation using a mental image. When a patient uses imagery, he or she is encouraged to create a peaceful or soothing image. The patient can enjoy the feeling of comfort that the scenario provides (ASPMN, 2010). Images can be created by the patient or provided by tapes if the patient has difficulty creating a useful mental image. As an example a patient could be asked to relax and picture a beautiful, ripe, tart lemon sitting on a counter in a sunny kitchen. The patient is asked to see the image, smell the fresh lemon scent, and taste the tartness of the fruit. This image is peaceful and pleasant. Patients should choose images that they can easily call up from memory so that they can use the technique very easily when it is needed for pain relief or stress reduction.
Using imagery for pain relief can also include the use of an image that locates the area of pain, such as with a headache. The patients can picture the headache as a red or dark color when pain is present. Working with the image, the patients can use relaxation and cognitive restructuring to see the headache lifting from the head, and getting smaller in size, or the color turning to a more peaceful and restful blue tone. This type of imagery is a little more complex, but patients can learn to use it effectively to help decrease pain.
The Arthritis Self-Management Program combines body-mind therapies, education and communication skills
■ Cognitive restructuring
■ Physical activity to reduce pain
■ Problem solving
■ Development of communication skills to help interact with health care professionals (APS, 2002; D'Arcy, 2010)
The benefits of this program have demonstrated improved physical condition, long term pain reduction in a 4 year time period with a large cost savings that exceeds the initial cost of the program by 4 to 5 times. (Khatta, 2007) reduced pain that lasted over a 4-year time period and a cost savings of four to five times the cost of the program (Khatta, 2007).
Biofeedback, hypnosis, and meditation are other forms of relaxation techniques. Meditation, or mindfulness, has been found to reduce pain and help patients with chronic pain learn to cope more effectively with the condition (Khatta, 2007). If the patient can learn to quiet or center themselves to go through a series of images, or relaxation techniques, or focus on an object, meditation can be a useful adjunct for pain control. All of the mind—body techniques discussed previously have research support for their use, and which technique works for a specific patient depends on the type of approach the patient prefers.
Oriental cultures have used energy healing for many centuries. The idea of channeling energy from the universe through the patient to open blocked chakras is derived from the concept of Qigong, an external and internal energy life force. To use these therapies with patients in modern days, several newer energy therapies were developed to include Reiki, TT, and healing touch (Pierce, 2009).
There are some differences in the practices, but the overall concepts have a similar intent:
■ The human body has an energy field that is generated from within the body to the outer world.
■ There is a universal energy that flows through all living things, and it is available to them.
■ Self-healing is promoted through the free flowing energy field.
■ Disease and illness may be felt in the energy field and can be felt and changed by the healing intent of the practitioner (Pierce, 2009).
These energy therapies are effective for pain relief and relaxation. These therapies combine the best of the mind body holistic concept of CAM. Two of the most commonly practiced are Reiki and TT.
The Reiki practitioner who is performing a therapeutic session on a patient uses the natural energy of the universe and channels through the patient's body to unblock chakras, or energy points. The techniques used by Reiki practitioners were developed and taught by the Buddhist monk Mikao Usui from Japan beginning in 1914 (Pierce, 2009). In basic Reiki, the Reiki practitioner places his or her hands in specific configurations on the patient's body to channel the universal energy through the chakras, opening up blocked points. In more advanced levels of practice, a Reiki practitioner transmits energy long distance to benefit a specific person (NCCAM, 2004).
Reiki has been used in Eastern cultures to ease both the mind and body. There are three levels of Reiki practice. Each level includes some additional form of energy transfer. Even with the basic level, the patient feels relaxed and experiences emotional and physical healing. The Reiki practitioner who channels the energy for the patient also receives some benefit: he or she may feel more relaxed and in tune with his or her own body energy after the session is completed.
Studies to determine the benefit of Reiki have focused on patients with cancer. In a study of 24 cancer patients using Reiki or rest periods, the Reiki patients had a significant decrease in pain (Pierce, 2009).
TT originated in the 1970s as a collaboration between two women: Dolores Krieger and Dora Kunz. The practice was based on concepts similar to Reiki. Although the two originators hoped that TT would become a part of standard patient care, it has proved more difficult to operationalize than anticipated (Pierce, 2009). At this time, the practice remains a nonstandard addition to patient care, though it is popular in some areas of the country.
TT is a form of energy medicine in which the practitioner does not touch the patient receiving the therapy, but rather focuses the energy on the patient's aura. Smoothing the aura by the energy transfer from the practitioner to the patient can help provide healing energy. It is often mistakenly referred to as "laying on of hands," which has a more religious connotation. The premise of TT is that the practitioner's healing force transfers or channels energy, thereby positively affecting the recovery of the patient (NCCAM, 2004). As the TT practitioner allows his or her hands to move over the patient, blocked energy is identified, and through the practitioner's hands, healing forces are directed to the area to promote healing and pain relief. There are five steps to TT:
■ The practitioner takes time to relax and center their thoughts and mind
■ Assessment, the next step is an overall assessment of the patient's external energy field
■ The practitioner uses slow strokes down the patients energy field trying to unruffle and clear any energy blockage
■ The fourth step concentrates energy into a specific area that is blocked
■ The last step is an evaluation of the entire treatment process (Wein-traub et al., 2008)
There are some studies that indicate greater pain relief with the use of TT in patients with chronic pain and fibromyalgia when compared with patient groups not receiving the energy treatment option (Pierce, 2009). It is difficult to conduct a study with TT because the recipient will know when they are not receiving the actual treatment but only a sham. Because randomized placebo-controlled studies are not possible with TT, it is difficult to measure the true effect of the practice. Currently more research is being done to help support the concept of energy therapy as a true source of relaxation, pain relief, and health promotion.
Folk medicine and natural healing have long been a part of most cultures. Herbal remedies are some of the most common forms of complementary therapeutics (Khatta, 2007). The advantage of these therapies is that they are simple and easy to use, are viewed as non-invasive, and are benign with few side effects; on the negative side, they have little or no quality control mechanism. Between the years of 1990 and 1997, herbal remedy use increased by 380% (Khatta, 2007). Costwise, the annual expenditure on herbal remedies in the United States exceeds 1.5 billion dollars (Khatta, 2007).
In early days the compounds were made by local entrepreneurs and sold door to door but today internet usage has made it easy to obtain just about any supplement or herbal remedy that a patient could want. The early compounds had no quality control. Many of these tonics and elixirs had cocaine or high alcohol contents, with flavorings to make them palatable. Laudanum was a popular elixir used for pain relief from childbirth to war injuries.
Today, all dietary supplements are categorized under the Dietary Supplement Health and Education Act of 1994, which requires quality, safety, and efficacy standards. However, there are still discrepancies in contents of some of the supplements and herbal remedies sold over the counter, so buyers should always be wary of what they are purchasing. This is especially true for pregnant and compromised patients. Common herbal remedies include:
■ Cayenne (Capsicum). Capsaicin is the active ingredient of cayenne peppers (Khatta, 2007). Capsaicin, a cream made of the pepper extract, is sold as an over-the-counter cream, as a generic brand or with the brand name Zostrix at concentrations of 0.025% and 0.075%. The cream produces a strong sensation of heat, and it can also burn and sting. Patients who are using capsaicin should apply the cream three to four times daily over at least 2 weeks to see any improvement. When applying capsaicin cream, wearing gloves is advised and care with touching other parts of the body, especially the eyes, is recommended. A new 8% patch (Quetensa) is being marketed for treating intractable pain from PHN (See chapter 5 for more information). Capsaicin cream is recommended for use with:
■ Cluster headacahe
■ Itching and pain associated with postmastectomy pain syndrome
■ Postamputation pain
■ Devil's claw (Harpagophytum procumbens). Pain levels were reduced and functionality was increased in patients using this herb
■ Corydalis. A frequently used herb, corydalis is an alkaloid with potent analgesic properties (Dillard & Knapp, 2005). It traditionally has been used for menstrual pain. Feverfew is being used for migraine prophyaxis. In a review of 5 placebo controlled studies feverfew was found to be superior to placebo (Weintraub et al., 2008).
■ One of the most popular and disputed supplements for arthritis pain is glucosamine and chondroitin. Studies have shown a slowing of disease progression over time and that combination medications can affect pain in osteoarthritis patients (Khatta, 2007).
■ Omega-3 fatty acids affect prostaglandin metabolism, thereby affecting the inflammatory process. Fish oil has been found to have anti-inflammatory effects in patients with rheumatoid arthritis, whereas flaxseed oil has not had similar effect (Khatta, 2007). Alpha-Lipoic acid was found to be useful and reduce symptom scores for patients with peripheral neuropathies and diabetic neuropathy (Weintraub et al., 2008)
■ The use of iron supplements has produced positive results in patients with restless leg syndrome because low ferritin levels were found to be correlated with higher symptom burden and decreased symptoms after iron repletion. Caution with iron supplements is advised to avoid iron overload as it has been associated with increased cancer and other debilitating chronic conditions (Weintraub et al., 2008).
Patients who are taking nutritional supplements and herbal remedies should tell their primary care provider that they are using the substances. Because there is the potential for drug-drug interactions with mainstream medications, every patient should be asked if they are taking a supplement or herbal remedy. Only those supplements and herbs that have shown efficacy in clinical trials and are recommended by the NCCAM should be used for complementary pain relief.
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