As so many people in chronic pain know, medication alone often is not enough to relieve pain.  The tenacity of chronic pain often leads people to areas outside of conventional Western medicine.  More and more Americans are trying complementary and alternative treatments for their ailments, and this is especially true for those in chronic pain.  According to a study in the Journal of the American Medical Association, 40% of Americans and more than two-thirds of the world population use complementary or alternative therapies.¹  Since 1990, Americans have increased their use of such therapies by 30% and paid $27 billion in out-of-pocket expenses.²   The quality of research supporting complementary and alternative approaches varies from therapy to therapy.  As with any treatment approach, use of complementary therapies should be discussed with your doctor.

What is the Difference between Complementary and Alternative Medicine?
The terms "complementary medicine" and "alternative medicine" often are used interchangeably, but the two are different.  Complementary therapies are used together with traditional Western medicine.  For example, you may take opioids to manage your day-to-day pain and use guided imagery to help manage a breakthrough pain episode.  Alternative medicine is used in place of conventional medicine.  For example, using a special diet to treat your arthritis instead of using medications recommended by a physician is using alternative medicine.

Complementary techniques to manage pain include diet, exercise, biofeedback, massage, chiropractic care, acupuncture, and self-regulation techniques such as self-hypnosis, relaxation training, yoga, reiki (a natural healing process using the hands to tap a universal life energy) and Jin Shin Jyutsu (a process to balance the body's energies to bring optimal health and well-being).

Practitioners of complementary medicine, such as acupuncturists, chiropractors, and naturopaths, often view health as a balance of physical, emotional and spiritual factors. Complementary treatment often attempts to restore that balance.  The most widely used complementary medicine practices in the United States are acupuncture, chiropractic, homeopathy, naturopathy, and herbal medicine.³

Choosing Practitioners and Techniques
One of the most important decisions you can make when deciding to pursue complementary therapies is choosing a qualified and knowledgeable practitioner to ensure you receive the best care.  Another vitally important aspect of using complementary or alternative therapies is to tell your physician.  As much as 60% of complementary therapy use is not disclosed to physicians—it cannot be emphasized enough that your health care providers need to know what therapies, herbs, or other medications you may be using or are considering using.⁴  Many herbal remedies interact adversely with medications and some complementary therapies may not be appropriate for your condition (e.g., massage may not be comfortable for people with rheumatoid arthritis)

The National Center for Complementary and Alternative Medicine (NCCAM) recommends that you consider the following factors when choosing a complementary or alternative medicine (CAM) health care practitioner.⁵

• Speak with your primary health care provider regarding the therapy in which you are interested. Ask if he or she can recommend a CAM practitioner or if they are willing to make a referral.
• Ask basic questions about a CAM practitioner's credentials and practice (e.g., Where were they trained? How long have they been in practice? What licenses or certifications do they have? How much will the treatment cost?).
• Be sure to check with your insurer to see if the cost of therapy will be covered. For example, some insurers cover visits to a chiropractor. If your insurance includes any provisions for CAM, ask your insurer for a list of CAM practitioners who accept your insurance.
• Meet with the practitioner and determine if he or she is right for you (e.g., Did you feel comfortable with the practitioner? Did he or she answer your questions and respond to you in a way that satisfied you? Does the treatment plan seem reasonable and acceptable to you?).
• Contact a professional organization for the type of practitioner you are seeking. Often, professional organizations have standards of practice, provide referrals to practitioners, have publications explaining the therapy that their members provide, and may offer information on the type of training needed and whether practitioners of a therapy must be licensed or certified in your state.

Acupuncture
Originating in China more than 2,500 years ago, acupuncture involves inserting long, extremely thin needles into specific points along the body to prevent, diagnose, and treat disease.  Acupuncturists believe that energy—called qi—circulates through the body and that pain or illness results when this energy is blocked from moving along specific pathways, called meridians.⁶  According to principles of acupuncture, health can be restored by inserting needles along the meridians to remove energy blocks and achieve balance.  Acupuncture can be used to relieve pain and discomfort. It also can be combined with electrical stimulation (electro-acupuncture).

The American Academy of Medical Acupuncture states that acupuncture is useful as a primary therapy for both acute and chronic musculoskeletal pain problems, including muscle spasms, sprains, repetitive strain disorders (e.g., carpal tunnel syndrome), myofascial pain conditions (e.g., muscle tension headaches, soft tissue pain in the neck, regional shoulder pain), postherpetic neuralgia, peripheral neuropathic pain, and headaches.⁷  The World Health Organization recommends acupuncture for disorders such as tennis elbow, sciatica, low back pain, headache, migraine, trigeminal neuralgia, peripheral neuropathy and more.⁸

Biofeedback
Biofeedback is a technique that teaches people to use visual or sound cues to control their own biological responses to pain and stress.  To teach people to "listen" to their bodies, a biofeedback trainer may use a device that detects electrical signals from the muscles and translates those signals into a sound, like a beep, or a visual, like a light, that people can recognize.  For example, the machine flashes a light or sounds a beep every time a person's muscles become tense so that people learn to associate sensations occurring within the muscles with tension levels.⁹  They then can learn to relax muscles and induce a state of calmness that can help improve pain.  After going through a series of treatments, people learn how to respond without using the machine.  Some devices help people learn to control their physical functioning by measuring skin temperature, heart rate, sweat gland activity and brain wave activity.¹⁰

Chiropractic Manipulation
Chiropractors, osteopathic physicians and manual therapists most commonly practice this intervention, which involves moving tissue by the laying on of hands.  According to the International Chiropractic Association, the primary focus of chiropractic is the detection, reduction and correction of spinal misalignments and nervous system dysfunction.¹¹  Doctors of chiropractic attempt to get to the root cause of a health problem and seek to maximize the natural strengths of the body and its capacity to heal itself without the use of drugs or surgery.

When performed gently, manipulation is usually referred to as mobilization.  Doctors of chiropractic and osteopathy often perform manipulations that are called adjustments.  Patients may experience temporary pain relief from this therapy and many prefer these interventions because they avoid the potential side effects or complications of medications or surgery.  Patients often can learn manipulation techniques that are helpful in improving mobilization and can be performed at home in six to eight sessions. Long-term and ongoing dependence on these therapies to provide pain relief is discouraged.

Guided Imagery
Guided imagery is a relaxation technique that involves sitting or lying quietly and imagining yourself in a favorite peaceful setting (e.g., beach, forest). Guided imagery, also called visualization, is more than just picturing your favorite peaceful setting—it's truly imagining yourself in that setting. Be as specific as possible. Imagine what sounds you hear, what sensations you feel (e.g., cool or warm breeze), the textures you might feel, the sights you might see. The more specific your visualization, the higher level of relaxation you'll experience as your mind truly is "in" the relaxing place you're picturing.

Herbal Medicines and Supplements
Many people come across herbal remedies when they're looking for relief.  In the United States, herbal remedies do not have to meet quality control standards. The US Food and Drug Administration (FDA) does not regulate the manufacture of herbal remedies or dietary supplements.  Such remedies and supplements do not need FDA approval before they are marketed. 

The FDA defines a dietary supplement as a product taken by mouth that contains a "dietary ingredient" intended to supplement the diet, including vitamins, minerals, herbs or other botanicals, amino acids and substances such as enzymes, organ tissues, glandulars, and metabolites.¹² The Dietary Supplement Health and Education Act (DSHEA) of 1994 places dietary supplements in a special category of "foods," and requires that supplements be labeled as such.  Under the DSHEA, a manufacturer of a supplement must determine that the product is safe and that any claims made about the product must be substantiated by adequate evidence to show that such claims are not false or misleading.

Because such remedies are not regulated, it's important to protect yourself when choosing to take such remedies. 

·         Check with your doctor before taking any herbal remedy.  Herbal remedies can interact with prescription medications and have adverse outcomes for you.

·         Choose remedies that have a National Formulary seal.  This seal indicates that the herbs were prepared according to standards established by the United States Pharmacopoeia.

·         Read the label carefully, especially if you have allergies.  Check with your doctor about ingredients that are unfamiliar.

Homeopathic Medicine
Homeopathy is an alternative, non-toxic approach used to treat illness and relieve discomfort in a wide range of health conditions. Founded in Germany in the late-1860s, the practice of homeopathy is based on using the "law of similars" to stimulate a healing response — a principle that goes back to the days of Hippocrates. The law of similars states that a substance that will cause disease symptoms in a normal person can, when given in homeopathic dilutions to an ill individual, prompt the same set of symptoms to initiate a healing response. Homeopathic preparations, called remedies, must be prepared in a certain way, and the dilution used will depend on the symptoms being treated. As with any alternative or complementary therapy, make sure you consult with your physician before taking traditional and homeopathic remedies at the same time. Mixing medications can result in harmful medical interactions.

Hypnosis
Hypnosis involves entering an altered state of consciousness whereby suggestions made while an individual is in an altered state can lead to changes in behavior or, in the case of pain, altered physical sensations.  According to the American Society of Clinical Hypnotists, clinical hypnotists use mental imagery to help patients visualize their pain or disease and then encourage them to imagine these images changing to healthy ones (e.g., a patient with a headache may focus on visualizing constricted blood vessels in the brain and then imagine the blood vessels opening and relieving the pain).¹³  Self-hypnosis involves inducing an altered state of consciousness — and thus controlling pain sensation — by yourself.

Naturopathic Medicine
Naturopathic medicine was founded on the principles of the healing power of nature, focuses on optimizing wellness and preventing disease, and has been around for centuries.  Naturopathic physicians (NDs) are primary health care providers who use therapies that are generally natural and nontoxic, including clinical nutrition, homeopathy, botanical medicine, hydrotherapy, physical medicine, counseling, and sometimes acupuncture.¹⁴  Naturopathic physicians study at a four-year, graduate level naturopathic medical school that includes the basic sciences studied by medical doctors.  They must take and pass board examinations to be licensed as primary care physicians. Naturopathic medicine can be used to complement conventional medicine and NDs may refer patients to appropriate medical specialists for certain conditions (e.g., an oncologist or surgeon).¹⁵

Progressive Muscle Relaxation
Progressively relaxing your muscles is a technique that requires some practice but can help you achieve a state of complete relaxation. Begin by focusing on your toes and feet—deliberately tense the muscles in your toes and feet and then concentrate on letting the tension go in each muscle. Move your way up your body until you reach your head. Be careful about tensing areas in which you feel pain—if necessary, avoid those areas and focus on relaxing the rest of your body. When the rest of your body is relaxed, your pain areas won't feel as tense.

Relaxation Breathing
Using breathing techniques helps your body relax and takes your mind away from everyday worries. Practice relaxation breathing by taking a breath in through your nose as you count to four, hold it as you count to seven, and breathe out through your mouth while you count to eight. It may seem silly or uncomfortable at first, but relaxation breathing will feel more natural with practice. Slow, steady relaxation breathing can help you relax tense muscles and truly focusing on your breathing can help you break a cycle of negative thoughts.

Yoga
Yoga is a great way to improve flexibility and muscle tone, develop good deep breathing and relaxation techniques, and reduce stress. Yoga, developed 5,000 years ago, is an exercise that focuses on physical postures called "asanas" and breathing exercises called "pranayma." As with any exercise program, it's important to discuss yoga with your health care provider before beginning. It might help to begin your yoga practice in a class where an instructor can help you learn the postures and breathing.

Conclusion
Complementary and alternative medicine may offer you some different ways of dealing with your pain.  At the least, relaxation breathing, guided imagery, and self-hypnosis may help you take your mind off of your pain.  Be sure to check with your doctor before beginning any complementary treatments or medications to ensure you choose techniques and medications that will not interfere with or have adverse interactions with traditional medical techniques and medications.

References

1. D M Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," Journal of the American Medical Association 280 (Nov 11, 1998) 1569-1575.
2. Ibid.
3. "What is complementary medicine?" Available from http://www.health.com/health/wynks/_CompMeds5-WYNK2000-MAL/. Accessed 22 June 2003.
4. Eisenberg et al, JAMA, 1998
5. National Center for Complementary and Alternative Medicine, "Selecting a Complementary and Alternative Medicine Practitioner," Available from http://nccam.nih.gov/health/practitioner/index.htm. Accessed 23 June 2003.
6. Available from http://www.drweil.com/. Accessed 23 June 2003.
7. J M Helms, "An overview of medical acupuncture," Available from http://www.medicalacupuncture.org/acu_info/articles/helmsarticle.html. Accessed 22 June 2003.
8. American Academy of Medical Acupuncture, "Frequently asked questions about acupuncture," Available from http://www.medicalacupuncture.org/acu_info/faqs.html. Accessed 22 June 2003.

9.       Association for Applied Psychophysiology and Biofeedback, "What is biofeedback?" Available from http://www.aapb.org/public/articles/details.cfm?id=4. Accessed 23 June 2003.

10.   Ibid.

11. International Chiropractors Association. Available from http://www.chiropractic.org. Accessed 22 June 2003.
12. US Food and Drug Administration, "Dietary supplements," Available from http://www.cfsan.fda.gov/~lrd/advice.html#dietary. Accessed 24 June 2003.
13. American Society of Clinical Hypnotists, "Definition of hypnosis," Available from http://www.asch.net/. Accessed 24 June 2003.
14. American Association of Naturopathic Medical Colleges, "Frequently asked questions," Available from http://www.aanmc.org. Accessed 23 June 2003.
15. Ibid.

 Resources

General Information

The National Center for Complementary and Alternative Medicine
NCCAM Clearinghouse
P.O. Box 7923
Gaithersburg, MD 20898
E-mail: info@nccam.nih.gov
Toll Free: (888) 644-6226
International: (301) 519-3153
Fax: (866) 464-3616
http://nccam.nih.gov

Acupuncture

American Academy of Medical Acupuncture
4929 Wilshire Boulevard, Suite 428
Los Angeles, California 90010
(323) 937-5514
http://www.medicalacupuncture.org/

Chiropractic Care

International Chiropractors Association
1110 N. Glebe Road, Suite 1000
Arlington, VA 22201
(800) 423-4690
http://www.chiropractic.org

Dietary Supplements

Office of Dietary Supplements
National Institutes of Health
Web site: ods.od.nih.gov

Center for Food Safety and Nutrition
U.S. Food and Drug Administration
5100 Paint Branch Parkway
College Park, MD 20740-3835
Web site: vm.cfsan.fda.gov

Hypnosis

American Society of Clinical Hypnosis
140 N. Bloomingdale Rd.
Bloomingdale, IL 60108-1017
(630) 980-4740
Fax: (630) 351-8490
http://www.asch.net/

Naturopathic Medicine

American Association of Naturopathic Medical Colleges (AANMC)
3201 New Mexico Avenue NW, Suite 350
Washington, DC 20016
(866) 538-2267 (toll-free)
Fax: (202) 274-1992
E-mail: info@aanmc.org
http://www.aanmc.org

The American Association of Naturopathic Physicians
3201 New Mexico Avenue, NW Suite 350
Washington, DC 20016
(866) 538-2267
Fax: (202) 274-1992
http://www.naturopathic.org/