Traditional methods in chronic pain treatment: evidence-based medicine?

4 Aug 2015  |  Print

Traditional methods in chronic pain treatment: evidence-based medicine?

“Traditional and complementary medicine is an important and often underestimated part of healthcare.”

These are not the words of a backstreet ‘snake oil salesman’ or even of a traditional healer; they actually come from the World Health Organization (WHO).[1] As long as it is practised appropriately, traditional and complementary medicine (T&CM) should be taken seriously – not least in pain management.

What counts as T&CM?

The WHO divides T&CM into two different types:[2]

  1. Traditional medicine:Knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.
  2. Complementary (or alternative) medicine: A broad set of healthcare practices that are not part of that country’s own tradition and are not integrated into the dominant healthcare system.

Some of the most commonly practised forms of traditional medicine – such as Ayurveda, traditional Chinese medicine and acupuncture – originated in our region and remain popular today. Alternative approaches such as chiropractic and homeopathy are also widely used in many countries.[1]

T&CM approaches – assessing evidence quality

The principle of ‘evidence-based medicine’ is central to modern clinical practice. Hence, T&CM methods should be evaluated according to the same rigorous standards that are applied to conventional approaches.

These efforts are ongoing.

Indeed, there are now medical journals focused exclusively on the assessment of T&CM, such as the Journal of Evidence-Based Complementary and Alternative Medicine. Meanwhile, the American College of Physicians’ Evidence-Based Guide to Complementary and Alternative Medicine provides more than 400 pages of evidence-based analysis of T&CM approaches.[3]

Hence, there is a wealth of data on these approaches. But what do these data show? And are the data of sufficiently high quality to recommend T&CM methods? Perhaps unsurprisingly, results are mixed.[4,5]

Two common chronic pain conditions, low back pain and osteoarthritis, provide instructive examples.

For low back pain, a recent publication identified 22 systematic reviews and meta-analyses (SR-MAs) that assessed traditional Chinese medicine approaches to treatment: 16 for acupuncture, five for manual therapy, and one for cupping.[4] No SR-MAs were available for herbal medicines.

Based on the available data, the authors concluded that acupuncture can be moderately recommended for chronic low back pain, and that cupping and manual therapy can be weakly recommended for both (sub)acute and chronic low back pain.[4]

However, this evidence is not reflected in current Clinical Practice Guidelines (CPGs). Across 13 CPGs reviewed – including those from the USA, UK and Japan – none recommended acupuncture.[4] Greater consideration should be given to these methods when guidelines are updated in future.[4]

In osteoarthritis, a recent SR-MA examining the effectiveness of tai chi for osteoarthritis of the knee found five randomized controlled trials.[5] These studies provided moderate evidence for short-term improvement of pain, physical function and stiffness, but no evidence of long-term effects.

Hence, the use of tai chi might be tentatively recommended as an adjuvant treatment for patients with osteoarthritis of the knee.[5] However, there is a need for further high-quality trials, for example to assess long-term benefits.

Which T&CM approaches are most worth considering?

A recent review provides some helpful answers to this question. Based on Cochrane reviews and clinical studies, it assessed the quality of evidence supporting T&CM approaches in various fields, including pain medicine. Both efficacy and safety were addressed.[6]

With regard to chronic pain treatment, the key findings were:[6]

  • Acupuncture for various pain conditions: There is evidence – albeit of inconsistent or limited quality – in favor of the use of acupuncture for back, neck and shoulder pain, and also for osteoarthritis and headache. Benefits should be weighed up against potential adverse events, such as infection, skin irritation, hematoma, pneumothorax and spontaneous needle migration.
  • Yoga for low back pain: There is strong evidence for the short-term effectiveness and moderate evidence for the long-term effectiveness of yoga in the treatment of low back pain. This technique is not associated with significant adverse events.
  • Glucosamine supplements for osteoarthritis: There is evidence from a Cochrane review of 25 studies that oral glucosamine sulfate can reduce osteoarthritis pain and improve functionality.[7] Adverse events are typically not serious and may include mild gastrointestinal effects, drowsiness, skin reactions and headache. However, these supplements should be used with caution in patients with shellfish allergy, and may also increase the anticoagulant effects of warfarin.

Conclusions

There is a growing body of evidence to show that various forms of T&CM can be beneficial in patients with chronic pain syndromes. However, these therapies are not without their risks: it is a common but incorrect assumption among many patients (and some physicians) that T&CM approaches are ‘natural’ and hence harmless.[8]

Pain physicians should become familiar with these modalities in order to effectively discuss their potential benefits and harms with patients.[6]

References:

  1. 1. The WHO Traditional Medicines Strategy 2014-2023. Available at: apps.who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf. Accessed June 2015.
  2. 2. World Health Organization. Traditional Medicine: Definitions. Available at: www.who.int/medicines/areas/traditional/definitions/en/. Accessed June 2015.
  3. 3. Jacobs BP, Gundling K, eds. The ACP Evidence-Based Guide to Complementary and Alternative Medicine. 1st edition. Philadelphia, USA: American College of Physicians; 2009.
  4. 4. Cho HW, Hwang EH, Lim B, et al. How current Clinical Practice Guidelines for low back pain reflect Traditional Medicine in East Asian Countries: a systematic review of Clinical Practice Guidelines and systematic reviews. PLoS One 2014;9:e88027.
  5. 5. Lauche R, Langhorst J, Dobos G, Cramer H. A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee. Complement Ther Med 2013;21:396-406.
  6. 6. Zoorob R, Chakrabarty S, O’Hara H, Kihlberg C. Which CAM modalities are worth considering? J Fam Pract 2014;63:585-590.
  7. 7. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev 2005;18:CD002946.
  8. 8. Ernst E. Complementary medicine: common misconceptions. J R Soc Med 1995;88:244-247.

 

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