But Does it Work? Complementary and Alternative Medicine for Pain

March 22, 2011

Why do so many reviews of the evidence for the effectiveness of CAM therapies in pain management turn up the same unimpressive results?

Why do so many reviews of the evidence for the effectiveness of CAM therapies in pain management turn up the same unimpressive results?

Poorly controlled trials; poorly designed trials with small cohorts; ignoring the placebo effect; reliance on anecdotal data; why is it so often the case that when researchers attempt to study the alleged benefits of complementary and alternative interventions for pain they end up doing such a poor job? A quick search of PubMed for recently published reviews of studies evaluating the effectiveness of CAM in pain management confirms this.

When Put to the Test, CAM Comes up Short

“Complementary and Alternative Medicine in Chronic Pain,” published in the January 2011 issue of PAIN, provided “a brief overview of several popular CAM therapies involving various chronic pain states with an emphasis on neuropathic pain.” The authors concluded that despite the popularity of many CAM approaches to pain management, only very few CAM therapies “have shown high quality of scientific evidence, Level A recommendation, for their use. Widespread use of such therapies with little evidence of efficacy like magnets and dietary changes, epitomizes the vulnerable disposition of patients who at times seek out CAM because of inadequate pain control achieved with conventional treatments and a misconception that the CAM therapies lack adverse effects.”

Spinal Manipulative Therapy a Sham?

“A Systematic Review on the Effectiveness of Complementary and Alternative Medicine for Chronic Non-specific Low Back Pain,” published in the August 2010 issue of the European Spine Journal, assessed “the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP.” The study encompassed “35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients.” Only half of the studies (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias based on criteria recommended by Cochrane Back Review Group (CBRG). The authors concluded that “In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain.”

Acupuncture for Low Back Pain: Where’s the Evidence?

This review of the evidence for the efficacy of the use of acupuncture for treating acute or chronic low back pain in adults, published by the New Zealand Ministry of Health and updated in 2009, examined three systematic reviews and five additional randomized controlled trials of acupuncture for low back pain. It concluded that there is level two evidence (“evidence with reliability, but open to debate”) from the studies included in this review that “acupuncture is effective at reducing chronic low back pain in the short term (up to 3 months after treatment) although the benefit may be small.” There is level-three evidence (“Some evidence without a high degree of reliability”) that this benefit is “maintained up to 2 years after treatment (although further research is required to confirm this).” There is level-three evidence that acupuncture “is more effective than usual care (which includes a mixture of physiotherapy, medication and back exercises).” There is level-three evidence that spinal manipulation “is more effective than acupuncture for chronic low back pain.” There is “insufficient evidence to determine the relative benefits of acupuncture when compared with any other treatments for low back pain.” There is level-four evidence (“Some evidence, but based on studies without comparable groups”) that acupuncture “may reduce pain in people with acute low back pain.”

HCPLive wants to know:

Do you incorporate specific complementary and alternative therapies into your treatment plans for patients with chronic pain or other painful conditions?

If so, on what basis do you select these medicines and therapies?

Do you consult published clinical trials for evidence of efficacy of a given therapy before incorporating it into treatment?

How significant is the placebo effect in integrative medicine/CAM for pain management?

Are there specific CAM treatments that you will not use?

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