Integrative Medicine Epidemiologist, Cary, NC
Dr. Fahey reports no financial relationships relevant to this field of study.
- Integrative therapeutics may play a role in treating chronic pain, as well as an adjuvant role with pharmaceutical and other allopathic treatments.
- Clinical trials support the use of acupuncture for a variety of pain conditions, including surgical pain, osteoarthritis, back and neck pain, and fibromyalgia.
- Massage therapy has been shown to benefit cancer pain, chronic pain, and headaches.
SYNOPSIS: There may be a role for acupuncture and massage in treating chronic pain.
Millions of people in the United States suffer from chronic pain, and a large percentage suffer disability due to that pain.1,2 Acute pain can become unmanageable, and, through a series of neurological and biological changes in the homeostatic systems of the body, can morph into chronic pain.3 Chronic pain encompasses a group of interconnected sufferings, including fatigue, sleep disturbances, impaired physical and mental function, and depression.4 Individuals with chronic pain experience disturbances in the central and autonomic nervous systems, endocrine system, and immunologic system.3
The National Center for Complementary and Integrative Health (NCCIH) indicated there is a need for more comprehensive treatment strategies to deal with chronic pain.5 Mounting evidence has proven the effectiveness of some integrative therapies for treating and managing chronic pain.3,5
Chronic pain is a public health issue in the United States, and emotional, psychological, and physical needs for patients with chronic pain need to be addressed.6,7 Chapman et al outlined a systems-based treatment for chronic pain. The mechanism of chronic pain begins with a complex stress response that activates multiple systems within the body.4 When addressing pain alone, only one piece of the puzzle is treated. Patients with chronic pain experience neurological, immunological, and emotional symptoms, which also must be examined. Chapman et al described this disruption within the systems of the body as supersystem dysregulation.4 This supersystem encompasses the nervous, endocrine, and immune systems. Chronic pain causes deregulation of this supersystem and is much more than just a neural issue. The interconnectivity and interdependence of these systems and all systems within the body working together is important for understanding how to treat chronic pain.
What Does This Mean for Treatment?
Managing symptoms in chronic pain is a challenge. According to the NCCIH, symptoms can change over time, and patients may experience multiple symptoms at once.5 The neural model of treating chronic pain has some limitations, as most patients continue to suffer and experience a reduced quality of life.5,8 Prescription opioid abuse, now a nationwide public health crisis, and the resultant socioeconomic damage lends to the limitations of the neural model. Researchers have discovered that certain interventions, including meditation and acupuncture, may affect central mechanisms of pain perception and processing, regulation of emotion and attention, and placebo responses.5 Although there is more to learn about these therapies, there is an opportunity to advance the science and understanding of how to treat chronic pain and its symptoms. The NCCIH suggests focusing on a patient’s health-related behavior vs. a disease treatment model.5 Health-related behaviors include exercise, healthy diet, adequate sleep, relaxation, and resilience and coping techniques. This review focuses on acupuncture and massage for treating chronic pain.
Acupuncture involves inserting thin needles through a person’s skin at strategic points.9 In a 1997 National Institutes of Health (NIH) Consensus Conference on Acupuncture, a panel determined there was sufficient evidence to support the use of acupuncture for several pain syndromes.10 The panel members noted that acupuncture showed promising results for treating chemotherapy-induced nausea and vomiting and postoperative dental pain. Ten years later, data from the 2007 NIH
Consensus Conference of Acupuncture showed clear evidence of acupuncture’s efficacy for adult postoperative and chemotherapy-related nausea and vomiting, as well as postoperative dental pain.10
Acupuncture has been used to treat several chronic pain conditions ranging from surgical pain to osteoarthritis. In a double-blind, controlled study, Kotani et al tested whether preoperative intradermal acupuncture along the bladder meridian provided reasonable postoperative analgesia.11 They found an increased fraction of patients with good pain relief in the recovery room compared to control (P < 0.05).11 Patients who had upper or lower abdominal surgery showed a 50% decrease in intravenous morphine use and 20-30% decrease postoperative nausea (P < 0.01). During recovery and on the first postoperative day, plasma cortisol and epinephrine concentrations decreased by 30-50% in the acupuncture group (P < 0.01).11
Acupuncture for Osteoarthritis
Manheimer et al reviewed 16 randomized, controlled trials comparing needle acupuncture with a sham or other control.12 They found 16 trials involving 3,498 people, including mostly older participants, with a mean ≥ 60 years of age and a mean duration of osteoarthritis knee pain of five years or more. Compared to a sham control at the short-term follow-up, patients receiving acupuncture showed improvements in osteoarthritis pain (standardized mean difference [SMD], -0.28; 95% confidence interval [CI], -0.45 to -0.11; nine trials; 1,835 participants; I2 = 64%), function (SMD, -0.28; 95% CI, -0.46 to -0.09; nine trials; 1,829 participants; I2 = 69%), and symptom severity (SMD, -0.29; 95% CI, -0.50 to -0.09; nine trials; 1,767 participants; I2 = 74%), but the results were heterogeneous.
Acupuncture combined with nonnarcotic analgesics may remove the need for opioid therapy and reduce side effects associated with higher dosages of medication.10 The most recent evidence-based treatment guidelines from the UK National Institute of Clinical Excellence (NICE Guideline 2008) and the Osteoarthritis Research Society International suggest that nonpharmacologic approaches should play a significant role. In a recent systematic review of osteoarthritis guidelines, five of the eight guidelines recommended acupuncture as an osteoarthritis treatment modality.8 An analysis of the Cochrane reviews found that the pain from migraines, neck disorders, tension-type headaches, and peripheral joint osteoarthritis benefitted most from acupuncture.13
Manyanga et al found that the practice of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility, and improved quality of life.14 In a systematic review and meta-analysis of 12 trials (n = 1,763), true acupuncture was compared to sham, no treatment, or usual care. Acupuncture use was associated with significant reductions in pain intensity (SMD, -0.29; 95% CI, -0.55 to -0.02; I2 = 0%; 10 trials; n = 1,699), functional mobility (SMD -0.34; 95% CI -0.55 to -0.14; I2 = 70%; nine trials; n = 1,543), and health-related quality of life (SMD -0.36; 95% CI, -0.58 to -0.14; I2 = 50%; three trials; n = 958). A subgroup analysis of pain intensity by intervention duration suggested pain intensity was reduced when intervention periods were more than four weeks (SMD -0.38; 95% CI, -0.69 to -0.06; I2 = 0%; six trials; n = 1,239).1
Acupuncture for Fibromyalgia
Researchers also have studied acupuncture for fibromyalgia pain. In 2006, Martin et al conducted a prospective, partially blinded, controlled, randomized trial in which patients received true or simulated acupuncture (control).15 Fifty patients (25 acupuncture, 25 control) participated in the study. Total fibromyalgia symptoms, as measured by the Fibromyalgia Impact Questionnaire (FIQ), improved significantly in the acupuncture group compared to the control group (P = 0.01). The largest difference in mean FIQ total scores was observed at one month (42.2 vs. 34.8 in the control and acupuncture groups, respectively; P = 0.007).15 During the follow-up period, fatigue and anxiety improved most significantly. In addition, acupuncture was well-tolerated and adverse effects were minimal.
Harris et al studied short- and long-term effects of traditional vs. sham acupuncture in patients with chronic pain and diagnosed with fibromyalgia. Patients were randomized to receive either traditional or sham acupuncture treatment over the course of four weeks; however, there were no statistically significant differences in pain reduction between the groups (P > 0.50).16 Yang et al evaluated the efficiency of acupuncture as a treatment for fibromyalgia syndrome, but did not find enough evidence to prove the efficacy of acupuncture.3
Acupuncture for Back Pain
Kliger et al published a review and found that acupuncture, compared with sham acupuncture and no treatment, was effective for treating chronic low back pain, with a moderate effect size of 0.55.17 They determined acupuncture to be safe, with the most common risk as transient mild discomfort. The Joint Commission recently added acupuncture as a treatment option for pain management at its accredited hospitals.18 Liu et al appraised 16 systematic reviews for chronic low back pain. Effect sizes were small to moderate; weighted mean difference ranged from -5.88 (95% CI, -11.20 to -0.55) at one month to -17.79 (95% CI, -25.50 to -10.07) at three months.19 For measures of pain, two of the three systematic reviews demonstrated the differences in effect were medium to large, and the remaining review reported statistically but not clinically significant effects (15/100 for visual analog scale [VAS] as minimal important change for pain; MD, -13.99; 95% CI, -20.48 to -7.50; P < 0.000; I2 = 34%).19
In a review by MacPherson et al, 29 trials met inclusion criteria, 20 involving sham controls (n = 5,230) and 18 non-sham controls (n = 14,597 involved patients with headache and migraine, osteoarthritis, and back, neck, and shoulder pain).20 In trials that used penetrating needles for sham control, acupuncture had smaller effect sizes than in trials using non-penetrating needles or sham control without needles. The difference in effect size was 20.45 (95% CI, 20.78-20.12; P = 0.007) or 20.19 (95% CI, 20.39-20.01; P = 0.058) after excluding studies showing large effects of acupuncture.19 In trials with non-sham controls, larger effect sizes were associated with acupuncture vs. non-specified routine care than vs. protocol-guided care. Although the difference in effect size was large (0.26), it was not significant (95% CI, 20.05-0.57; P = 0.1).20
Vickers et al determined the effect size of acupuncture vs. sham acupuncture and the effect size of acupuncture vs. non-acupuncture controls for back and neck pain, osteoarthritis, and chronic headache. Acupuncture was superior to sham acupuncture (P < 0.001) and there was less pain with acupuncture (back and neck, osteoarthritis, and chronic headache).21 Larger effect sizes were found when comparing acupuncture to non-acupuncture controls (P < 0.001). Acupuncture was found to be more valuable among patients with worse baseline pain scores and worse baseline mental status (P < 0.005).21
Yuan et al reviewed 75 randomized, controlled trials (n = 11,077) to determine if true acupuncture was superior to sham in the treatment of chronic neck pain or chronic low back pain.22 There was moderate-quality evidence that acupuncture was more effective than sham acupuncture in reducing pain immediately post-treatment for chronic neck pain (VAS, 10 cm; mean difference, -0.58; 95% CI, -0.94 to -0.22; P = 0.01), chronic low back pain (SMD, -0.47; 95% CI, -0.77 to -0.17; P = 0.003), and acute low back pain (VAS, 10 cm; MD, -0.99; 95% CI, -1.24 to -0.73; P < 0.001).22
Massage is defined as pressing, rubbing, and manipulating the skin, muscles, tendons, and ligaments, with pressure ranging from light stroking to deep pressure.9 Massage can be used to treat muscle tension, pain, and stress and may also be helpful for anxiety, digestive disorders, fibromyalgia, and headaches.9 According to Woodbury et al, massage generally produces a sense of happiness, calm, and improved circulation to affected areas.7 Massage is a helpful adjunct to the overall treatment algorithm for chronic pain.10 Lee et al conducted a meta-analysis of massage therapy for cancer pain.2 The meta-analysis included 12 studies (n = 559), including nine that were designated high-quality by Physiotherapy Evidence Database criteria. Based on the PEDro scale (SMD, -1.24; 95% CI, -1.72 to -0.75), researchers observed a reduction in cancer pain after massage. Cancer pain was reduced significantly with massage compared to no massage or conventional care (SMD, -1.25; 95% CI, -1.63 to -0.87).2 The results suggested that massage is effective for relieving cancer pain, especially for surgery-related pain.
In systematic review, Hassed evaluated the effect of massage on cancer-related pain and reached a similar conclusion. Twenty patients received therapeutic massages for 15-30 minutes and 21 patients received control therapy, which included nurse interaction. Prior to massage, the massage group patients’ mean pain scores were 9.5 ± 4.9 and the control group patients’ mean pain scores were 9.3 ± 6.9. After massage, massage group patients’ pain scores decreased to 7.3 ± 5, but the control group patients’ mean pain scores increased to 10.2 ± 6.7.23 Paired t test showed patients who received massage therapy had a nonsignificant decrease in pain (P < 0.10).23
Another review on chronic pain that focused on traditional Thai massage found pain reductions fluctuating from 25% to 80%, as well as improvements reported in disability, muscle tension, flexibility, and anxiety.24 In a review on massage for chronic headaches (six randomized, controlled trials), methodological limitations and lack of a control group limited the effectiveness of massage on chronic headaches.25
The future of pain management is changing to be more of an integrative practice, weaving in a variety of modalities to achieve optimal patient outcomes. An empathetic relationship between provider and patient based on shared decision-making and soothing communication can lead to beneficial results. Often, primary care providers are involved in directing care to integrative medicine providers and therapies, and also may have to advocate for insurance coverage of these approaches. Some insurance agencies will pay for a series of massages if there is a prescription and some will offer a few payments for these methods to cover a portion of the cost. Overall, the consideration of acupuncture and massage have the potential to address many aspects of chronic pain, may improve a patient’s quality of life, and may decrease pain severity and the need for prescription pharmaceuticals.
- Morone N, et al. A mind-body program for older adults with chronic low back pain. A randomized clinical trial. JAMA Intern Med 2016;175:329-337.
- Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, D.C.: The National Academies Press; 2011:1-382.
- Lee C, et al. Mind-body therapies for the self-management of chronic pain. Pain Med 2014;15:S21-S39.
- Chapman C, et al. Pain and stress in a systems perspective: Reciprocal neural, endocrine, and immune interactions. J Pain 2008;9:122-145.
- National Center for Complementary and Integrative Health. Mind-body therapies. Available at: https://nccih.nih.gov/health/mindbody. Accessed Dec. 10, 2017.
- Vowles K, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015;156:569-576.
- Woodbury A, et al. Complementary and alternative medicine therapies for the anesthesiologist and pain practitioner: A narrative review. Can J Anesth 2016;63:69-85.
- Zhang R, et al. Mechanisms of acupuncture electro-acupuncture on persistent pain. Anesthesiology 2014;120:482-503.
- Mayo Clinic. Massage get in touch with its many benefits. Available at: https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/massage/art-20045743. Accessed Dec. 10, 2017.
- Bauer B, et al. Complementary and alternative medicine therapies for chronic pain. Chin J Integr Med 2016;22:403-411.
- Kotani N, et al. Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology 2001;95:349-356.
- Manheimer E, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev 2010 Jan 20;(1):CD001977.
- Lee MS, Ernst E. Acupuncture for pain: An overview of Cochrane reviews. Chin J Integr Med 2011;17:187-189.
- Manyanga T, et al. Pain management with acupuncture in osteoarthritis: A systematic review and meta-analysis. BMC Complement Altern Mec 2014;14:312.
- Martin D, et al. Improvement in fibromyalgia symptoms with acupuncture: Results of a randomized controlled trial. Mayo Clin Proc 2006;81:749-757.
- Harris R, et al. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opid receptors (MORs). Neuroimage 2009;47:1077-1085.
- Kliger B, Teets R. Complementary/integrative therapies that work: A review of the evidence. AAFP 2016;94:369-374.
- Joint Commission Perspective. Available at: https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF. Accessed Dec. 18, 2017.
- Liu L, et al. Acupuncture for back pain: An overview of systematic reviews. Evid Based Complement Altern Med 2015;1-18.
- Macpherson H, et al. Influence of control group on effect size in trials of acupuncture for chronic pain: A secondary analysis of an individual patient data meta-analysis. PLoS One 2014;9:1-9.
- Vickers A, et al. OA03.01 Acupuncture for chronic pain: An individual patient data meta-analysis of randomized trials. BMC Complement Altern Med 2012;12:9.
- Yuan Q, et al. Traditional Chinese medicine for neck pain and low back pain: A systematic review and meta-analysis. PLoS One 2014;10: 1-37.
- Hassed C. Mind-body therapies — use in chronic pain management. Aust Fam Physician 2013;42:112-117.
- Keeratitanont K, et al. The efficacy of traditional Thai massage for the treatment of chronic pain: A systematic review. Complement Ther Clin Pract 2015;21:26-32.
- Chaibi A, Russell MB. Manual therapies for primary chronicheadaches: A systematic review of randomized controlled trials. J Headache Pain 2014;15:67.