INTEGRATIVE PAIN MANAGEMENT

Holistic Approaches to pain management

 

I.                   Pain- a holistic definition

International Association for the Study of Pain gives this definition:

PAIN is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (Merskey, 1986).

Don Ranney, MD, FRCS, Founder and formerly Head of the School of Anatomy, University of Waterloo; Consultant, Orthopaedic Medicine and President, Disability Assessment Services, Inc. has some interesting comments about pain:

 “Pain is a perception, not really a sensation, in the same way that vision and hearing are. It involves sensitivity to chemical changes in the tissues and then interpretation that such changes are harmful. This perception is real, whether or not harm has occurred or is occurring. Cognition is involved in the formulation of this perception. There are emotional consequences, and behavioral responses to the cognitive and emotional aspects of pain.”  These factors can make it difficult to study pain especially in patients that can not define their pain.

Another classification, that distinguishes between normally functioning nerves and nerves whose function has been altered by pathology is as follows:

The persistent pain often experienced in chronic work-related musculoskeletal injuries, as well as in those with long continued pain for other reasons, may persist because of a Central Nervous System dysfunction. But this is a CNS dysfunction secondary to long continued peripheral pain. This is a concept yet to be addressed by any official declaration of the International Association for the Study of Pain.

Information is transmitted centrally and is ultimately perceived as pain because it travels to the spinal cord or brainstem as a train of electrical impulses in C fibres or A delta fibres of spinal or certain cranial nerves. After crossing the synaptic junction through an extremely complex series of chemical interactions the, signal passes once more electrically to higher CNS levels in Nociceptive Specific, or less pain specific Wide Dynamic Range neurons.

Eckart Tolle author of The Power of Now describes the Pain Body-“as long as you are unable to access the power of the Now, every emotional pain that you experience leaves behind a residue of pain that lives on in you.  It merges with the pain from the past, which was already there and becomes lodged in your mind and body. The pain body goes from being dormant to active depending on your mind. This pain body has also been described as “The dark shadow cast by the ego”.

Dr. Scott Fishman, MD Chief, Division of Pain Medicine at University of California, Davis in his book The War on Pain discusses the dimensions of pain.

“Emotions like depression and anger can increase pain’s decibel level or lower it.   Extreme, persistent anxiety can set in motion a reverberating loop of anxiety and pain, which stirs up more anxiety, and more pain.  Depression often lowers a person’s pain threshold, making a person vulnerable to a wider range of uncomfortable feelings than he or she would normally be.”

What is the difference between pain threshold and pain tolerance?

Dr. Fishman has an dramatic experiment to learn the difference between pain threshold and tolerance.  Fill a bowl with water and ice, plunge your hand into the bowl, and count the number of seconds before you feel the cold as painful.  That is your pain threshold.  Next, wait and see how much time passes before the pain of the cold forces you to withdraw your hand from the bowl. That is your pain tolerance. 

Pain influences include culture, gender.  Women have stronger initial reaction to pain but handle it better than men. (Fishman)

In general, Dr. Fishman, being an expert on pain management states “pain is what the patient says it is”.

Pain is a multidimensional phenomenon that by definition includes the role of the mind and body.  Therefore, in order to address a patient’s pain a holistic approach involving psychological factors as well as physical factors must be included if we are to make a lasting impact on pain and suffering. 

II.                 Holistic Therapies for Pain Management

A.     Acupuncture.  Acupuncture due to its mechanism of action address the mental and physical aspects of pain.

Definition: 2000 year old therapy involving inserting small disposable stainless steel needles into specific points ( approx. 2000 acupoints) on the body to induce a therapeutic change that includes physical and mental balance.  There are 12 main acupuncture channels and 8 secondary pathways called meridians.  Acupuncture effects the “qi” or energy by unblocking disharmonies in the flow of energy in the body according to TCM. 

Acupuncture points are believed to stimulate the central nervous system (the brain and spinal cord) to release chemicals into the muscles, spinal cord, and brain. These chemicals either change the experience of pain or release other chemicals, such as hormones, that influence the body's self-regulating systems. The biochemical changes may stimulate the body's natural healing abilities and promote physical and emotional well-being(Raso). There are three main mechanisms:

  1. Conduction of electromagnetic signals: Western scientists have found evidence that acupuncture points are strategic conductors of electromagnetic signals. Stimulating points along these pathways through acupuncture enables electromagnetic signals to be relayed at a greater rate than under normal conditions. These signals may start the flow of pain-killing biochemicals, such as endorphins, and of immune system cells to specific sites in the body that are injured or vulnerable to disease (NIH, Dale).
  2. Activation of opioid systems: Research has found that several types of opioids may be released into the central nervous system during acupuncture treatment, thereby reducing pain. (Takeshige)
  1. Changes in brain chemistry, sensation, and involuntary body functions: Studies have shown that acupuncture may alter brain chemistry by changing the release of neurotransmitters and neurohormones. Acupuncture also has been documented to affect the parts of the central nervous system related to sensation and involuntary body functions, such as immune reactions and processes whereby a person's blood pressure, blood flow, and body temperature are regulated. (Culliton, Han, Wu 1994)

Pre clinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine. (Wu 1995, Eskinazi, Tang, Cheng, Chen, Lee)

According to the NIH Consensus Statement on Acupuncture:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful. (Raso)

Increasingly, acupuncture is complementing conventional therapies. For example, doctors may combine acupuncture and drugs to control surgery-related pain in their patients (Okada). By providing both acupuncture and certain conventional anesthetic drugs, some doctors have found it possible to achieve a state of complete pain relief for some patients (Takeshige).  They also have found that using acupuncture lowers the need for conventional pain-killing drugs and thus reduces the risk of side effects for patients who take the drugs (Lao, Lewith).

Currently, one of the main reasons Americans seek acupuncture treatment is to relieve chronic pain, especially from conditions such as arthritis or lower back disorders (Tsibuliak, Bullock).  Some clinical studies show that acupuncture is effective in relieving both chronic (long-lasting) and acute or sudden pain, but other research indicates that it provides no relief from chronic pain (Deihl).  Additional research is needed to provide definitive answers.

FDA's Role

The U.S. Food and Drug Administration (FDA) approved acupuncture needles for use by licensed practitioners in 1996. Relatively few complications from the use of acupuncture have been reported to the FDA when one considers the millions of people treated each year and the number of acupuncture needles used.

 

Research Sponsored by NCCAM and OAM

NCCAM and OAM have supported scientific research to find out more about acupuncture. Examples of recent NCCAM-supported projects include:

With regard to earlier findings, researchers at the University of Maryland in Baltimore, with the support of OAM, conducted a randomized controlled clinical trial and found that patients treated with acupuncture after dental surgery had less intense pain than patients who received a placebo (Okada). Scientists at the university also found that older people with osteoarthritis experienced significantly more pain relief after using conventional drugs and acupuncture together than those using conventional therapy alone (Lytle).  OAM also funded several preliminary studies on acupuncture.

Listed below are abstracts for some of the current research that supports the use of acupuncture for pain management:

1.) Anesth Analg. 2004 May; 98(5):1359-64

 

The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture.

Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker SA, Szeles JC, Finster G, Schiesser AW, Heinze G, Kress HG.

Department of Anesthesiology and Intensive Care Medicine (B), Outpatient Pain Center, University of Vienna, Vienna, Austria. sabine.sator@univie.ac.at

Acupuncture is an established adjuvant analgesic modality for the treatment of chronic pain. Electrical stimulation of acupuncture points is considered to increase acupuncture analgesia. In this prospective, randomized, double-blind, controlled study we tested the hypothesis that auricular electroacupuncture (EA) relieves pain more effectively than conventional manual auricular acupuncture (CO) in chronic low back pain patients with insufficient pain relief (visual analogue scale [VAS] > or = 5) treated with standardized analgesic therapy. Disposable acupuncture needles were inserted in the auricular acupuncture points 29, 40, and 55 of the dominant side and connected to a newly developed battery-powered miniaturized stimulator worn behind the ear. Patients were randomized into group EA (n = 31) with continuous low-frequency auricular EA (1 Hz biphasic constant current of 2 mA) and group CO (n = 30) without electrical stimulation (sham-electroacupuncture). Treatment was performed once weekly for 6 wk, and in each group needles were withdrawn 48 h after insertion. During the study period and a 3-mo follow-up, patients were asked to complete the McGill questionnaire. Psychological well being, activity level, quality of sleep, and pain intensity were assessed by means of VAS; moreover, analgesic drug consumption was documented. Pain relief was significantly better in group EA during the study and the follow-up period as compared with group CO. Similarly, psychological well-being, activity, and sleep were significantly improved in group EA versus group CO, the consumption of analgesic rescue medication was less, and more patients returned to full-time employment. Neuropathic pain in particular improved in patients treated with EA. There were no adverse side effects. These results are the first to demonstrate that continuous EA stimulation of auricular acupuncture points improves the treatment of chronic low back pain in an outpatient population. IMPLICATIONS: Continuous electrical stimulation of auricular acupuncture points using the new point stimulation device P-stim significantly decreases pain intensity and improves psychological well-being, activity, and sleep in chronic low back pain patients.

 

 

 

2.)  Acupunct Med. 2004 Mar;22(1):23-8.

 


Acupuncture and moxibustion as an adjunctive treatment for osteoarthritis of the knee--a large case series.

Vas J, Perea-Milla E, Mendez C.

Centro de Salud de Dos Hermanas, Sevilla, Spain. jvas@acmas.com

BACKGROUND: In 1997, the first Pain Management Unit, which was set up as part of primary health care within the Andalusian Public Health System, offered acupuncture among other therapies. This observational study was conducted in preparation for a randomised controlled trial. METHODS: We conducted a descriptive study of patients who had been diagnosed with osteoarthritis of the knee. The patients received weekly acupuncture treatment, and related techniques, from November 1997 to November 2000. We recorded: socio-demographic data; measures of effectiveness, including intensity and frequency of pain; the daily dose of analgesic and anti-inflammatory medication; the degree of incapacity; and sleep disorders caused by pain in the knee. RESULTS: The 563 patients who presented were mainly female (88%) with an average age of 65 years (+/- 10.7); the average age of the male patients was 67 years (+/- 11.8). The condition in most patients (95%) was chronic: 54% had the condition for 5-10 years and a further 23% for more than 10 years. Of the total, 85 (15%) abandoned treatment and were excluded from the evaluation, while 75% of the remainder achieved a reduction in pain of 45% or more. This study is intended to form the basis for a subsequent controlled clinical trial of the effectiveness of acupuncture as a treatment for osteoarthritis of the knee. CONCLUSION: The degree of pain relief experienced by patients from acupuncture justifies a more rigorous study.

 

3.)  Am J Chin Med. 2003;31(6):945-54.

 


The effect of acupuncture on proinflammatory cytokine production in patients with chronic headache: a preliminary report.

Jeong HJ, Hong SH, Nam YC, Yang HS, Lyu YS, Baek SH, Lee HJ, Kim HM.

Department of Pharmacology, College of Oriental Medicine, Kyung Hee University, Seoul 130-701, South Korea.

Acupuncture has been widely used as a treatment for various conditions like headache and stroke, especially in Asian countries such as Korea and China. But few scientific investigations have been carried out. The aim of the present study is to investigate the effect of acupuncture on the production of inflammatory cytokines in patients with chronic headache (CH). Patients with CH were treated with acupuncture during the acute stage. Clinical signs of CH disappeared markedly after three months of treatment with acupuncture. Peripheral blood mononuclear cells obtained from a normal group and those from the patients with CH, before and after treatment with acupuncture, were cultured for 24 hours in the presence or absence of lipopolysaccharide (LPS). The amount of interleukin (IL)-1beta, IL-6 and tumor necrosis factor-alpha (TNF-alpha) in LPS culture supernatant was significantly increased in the patients with CH compared to the healthy control group (p < 0.05). But those cytokines came down toward the levels of the healthy group (p < 0.05) after treatment with acupuncture, although the levels still remained elevated. Plasma cytokine levels were analyzed to evaluate any change due to acupuncture treatment. There was little difference in the levels of IL-1 or IL-6 due to the treatment with acupuncture in the patients with CH, but significantly reduced plasma levels of TNF-alpha were observed. These data suggest that acupuncture treatment has an inhibitory effect on pro-inflammatory cytokine production in patients with CH.

 

4.)  Acupunct Med. 2003 Sep;21(3):80-6.

 


Superficial dry needling and active stretching in the treatment of myofascial pain--a randomised controlled trial.

Edwards J, Knowles N.

janetedwards_physio@yahoo.co.uk

A pragmatic, single blind, randomised, controlled trial was conducted to test the hypothesis that superficial dry needling (SDN) together with active stretching is more effective than stretching alone, or no treatment, in deactivating trigger points (TrPs) and reducing myofascial pain. Forty patients with musculoskeletal pain, referred by GPs for physiotherapy, fulfilled inclusion/ exclusion criteria for active TrPs. Subjects were randomised into three groups: group 1(n = 14) received superficial dry needling (SDN) and active stretching exercises (G1); group 2 (n = 13) received stretching exercises alone (G2); and group 3 (n = 13) were no treatment controls (G3). During the three-week intervention period for G1 and G2, the number of treatments varied according to the severity of the condition and subject/clinician availability. Assessment was carried out pre-intervention (M1, post-intervention (M2), and at a three-week follow up (M3). Outcome measures were the Short Form McGill Pain Questionnaire (SFMPQ) and Pressure Pain Threshold (PPT) of the primary TrP, using a Fischer algometer. Ninety-one per cent of assessments were blind to grouping. At M2 there were no significant inter-group differences, but at M3, G1 demonstrated significantly improved SFMPQ versus G3 (p = 0 .043) and significantly improved PPT versus G2 (p = 0 .011). There were no differences between G2 and G3. The mean PPT and SFMPQ scores correlated significantly in G1 only, though no significant inter-group differences were demonstrated. Numbers of patients requiring further treatment following the trial were: 6 (G1); 12 (G2); 9 (G3). CONCLUSION: SDN followed by active stretching is more effective than stretching alone in deactivating TrPs (reducing their sensitivity to pressure), and more effective than no treatment in reducing subjective pain. Stretching without prior deactivation may increase TrP sensitivity.

5.)  Acupunct Electrother Res. 2003;28(1-2):11-8.

 


Treatment of rheumatoid arthritis with electromagnetic millimeter waves applied to acupuncture points--a randomized double blind clinical study.

Usichenko TI, Ivashkivsky OI, Gizhko VV.

Anesthesiology & Intensive Care Medicine Department, University of Greifswald, Germany. taras@uni-greifswald.de

The aim of the study was to evaluate the efficacy and safety of electromagnetic millimeter waves (MW) applied to acupuncture points in patients with rheumatoid arthritis (RA). Twelve patients with RA were exposed to MW with power 2.5 mW and band frequency 54-64 GHz. MW were applied to the acupuncture points of the affected joints in a double blind manner. At least 2 and maximum 4 points were consecutively exposed to MW during one session. Total exposure time consisted of 40 minutes. According to the study design, group I received only real millimeter wave therapy (MWT) sessions, group II only sham sessions. Group III was exposed to MW in a random cross-over manner. Pain intensity, joint stiffness and laboratory parameters were recorded before, during and immediately after the treatment. The study was discontinued because of beneficial therapeutic effects of MWT. Patients from group I (n=4) reported significant pain relief and reduced joint stiffness during and after the course of therapy. Patients from group II (n=4) revealed no improvement during the study. Patients from group III reported the changes of pain and joint stiffness only after real MW sessions. After further large-scale clinical investigations MWT may become a non-invasive adjunct in therapy of patients with RA.

 

6.)  Rheumatology (Oxford). 2003 Dec;42(12):1508-17. Epub 2003 Jul 30.

 


Acupuncture for chronic low back pain in older patients: a randomized, controlled trial.

Meng CF, Wang D, Ngeow J, Lao L, Peterson M, Paget S.

Department of Rheumatology, Hospital for Special Surgery, New York, NY 10021, USA. mengc@hss.edu

OBJECTIVE: To determine if acupuncture is an effective, safe adjunctive treatment to standard therapy for chronic low back pain (LBP) in older patients. METHODS: The inclusion criteria for subjects were: (i) LBP > or =12 weeks and (ii) age > or =60 yr; the exclusion criteria were (i) spinal tumour, infection or fracture and (ii) associated neurological symptoms. The subjects were randomized to two groups. The control group of subjects continued their usual care as directed by their physicians, i.e. NSAIDs, muscle relaxants, paracetamol and back exercises. Subjects in the acupuncture group in addition received biweekly acupuncture with electrical stimulation for 5 weeks. Outcome was measured by the modified Roland Disability Questionnaire (RDQ) at weeks 0, 2, 6 and 9. The primary outcome measure was change in RDQ score between weeks 0 and 6. RESULTS: Fifty-five patients were enrolled, with eight drop-outs. Twenty-four subjects were randomized to the acupuncture group and 23 were randomized to the control group. Acupuncture subjects had a significant decrease in RDQ score of 4.1 +/- 3.9 at week 6, compared with a mean decrease of 0.7 +/- 2.8 in the control group (P = 0.001). This effect was maintained for up to 4 weeks after treatment at week 9, with a decrease in RDQ of 3.5 +/- 4.4 from baseline, compared with 0.43 +/- 2.7 in the control group (P = 0.007). The mean global transition score was higher in the acupuncture group, 3.7 +/- 1.2, indicating greater improvement, compared with the score in the control group, 2.5 +/- 0.9 (P < 0.001). Fewer acupuncture subjects had medication-related side-effects compared with the control group. CONCLUSIONS: Acupuncture is an effective, safe adjunctive treatment for chronic LBP in older patients.



7.)    J Spinal Cord Med. 2003 Spring;26(1):21-6.

 


Comment in:


Acupuncture as a promising treatment for below-level central neuropathic pain: a retrospective study.

Rapson LM, Wells N, Pepper J, Majid N, Boon H.

Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, Ontario, Canada.

BACKGROUND/OBJECTIVE: Below-level central neuropathic pain, a diffuse pain characterized by generalized burning, is commonly experienced by individuals with spinal cord injury (SCI). The objective of this study was to investigate the effects of an electroacupuncture protocol for the treatment of below-level central neuropathic pain developed at the Toronto Rehabilitation Institute, Lyndhurst Center, Toronto, Ontario, Canada. METHOD: Retrospective chart review. RESULTS: Thirty-six individuals with traumatic and nontraumatic SCI met the inclusion criteria. Of these, 24 showed improvement after treatment with the electroacupuncture protocol. Type of injury, level of injury, and duration of below-level central neuropathic pain was not correlated with improvement. However, individuals whose pain was described as bilateral (vs unilateral; P = 0.014) or symmetric (vs nonsymmetric; P = 0.026) were more likely to improve after acupuncture treatment. Overall, patients whose burning pain was bilateral, symmetric, and constant (P = 0.005) were the most likely to improve. CONCLUSION: This retrospective study suggests that the Lyndhurst Center Central Neuropathic Pain Acupuncture Protocol may be an effective treatment option for patients with SCI who are experiencing below-level central neuropathic pain. Additional prospective clinical studies are needed to confirm these findings.

 

8.)  Anesthesiol Clin North America. 2003 Jun;21(2):329-46.

 


Effective analgesic modalities for ambulatory patients.

Redmond M, Florence B, Glass PS.

Department of Anesthesiology, SUNY Stony Brook Health Sciences Center, L4-060 Stony Brook, NY 11794-8480, USA.

The introduction of government-mandated standards for pain management has focused our attention on postoperative pain. With the recent JACHO standards' for ambulatory surgery, it is imperative that all health care workers who care for these patients are familiar with appropriate pain management. Developments in our understanding of the pathophysiology of acute pain have further enhanced our ability to improve pain management for postoperative ambulatory patients. This has led to the concept of preventive analgesia (inhibition of physiological and pathological secondary inflammatory pain). Extensive work has shown that this is best achieved using a multimodel approach usually consisting of an NSAID, opioid, and local anesthetic. NMDA antagonists (ketamine, dextromethorphan) and alpha-2 agnoists (clonodine) show potential supplements to further enhance pain management, especially if given preemptively. Nonpharmacological intervention such as cold therapy or acupuncture may also be considered. The armanentarium for effective pain management has improved substantially over the past few years. The challenge is for health care workers to implement these therapies to obtain optimum pain management in ambulatory surgical patients.

 

9.)  Drugs. 2003;63(9):855-67.

 


Optimising postoperative pain management in the ambulatory patient.

Shang AB, Gan TJ.

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation.Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner.While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the treatment of acute pain.  Non-pharmacological methods for the management of postoperative pain include acupuncture, electromagnetic millimetre waves, hypnosis and the use of music during surgery. However, further research of these techniques is warranted to elucidate their effectiveness in this indication.  Pain is a multifactorial experience, not just a sensation. Emotion, perception and past experience all affect an individual's response to noxious stimuli. Improved postoperative pain control through innovation and creativity may improve compliance, ease of delivery, reduce length of hospital stay and improve patient satisfaction. Patient education, early diagnosis of symptoms and aggressive treatment of pain using an integrative approach, combining pharmacotherapy as well as complementary technique, should serve us well in dealing with this complex problem.

B.     Naturopathic Approaches to Pain Management.  A holistic approach that seeks to treat the cause of disharmony, assess and integrate all the body systems, and provide a safe and natural treatment that involves the patient.  Principles of naturopathic medicine include:  The healing power of nature,  Identify and treat the cause, First, do no harm, doctor as teacher, treat the whole person (body, mind, and spirit), preventative medicine, and wellness.

Naturopathic treatments to pain management may include:  Nutrition- Rule out food allergies, assess any nutritional deficiencies, counseling on psychological factors contributing to pain, massage therapy and other physical medicine modalities ( massage, ultrasound, craniosacral), prescribing herbal and nutritional supplementation, and other approaches.  Each treatment plan is individualized depending on the patient’s need.  Typical follow-ups and treatments last one hour.

Some specific naturopathic treatments for pain that have been researched extensively include glucosamine sulfate, natural anti-inflammatories ( bromelain, curcumin, wobenzyme), and topical or homeopathic arnica.

1.      Glucosamine sulfate:  A combination molecule of glucose and an amine that is found in large amounts in cartilage that has been utilized for relieving arthritis since the 1960s.  Mechanism of action proposed is by stimulating the biosynthesis of proteoglycans, restoring chondrocytes, and working as an anti-inflammatory.  Glucosamine is usually produced from chitin or the skeleton of shellfish.  Therefore, the only contraindication to prescribing glucosamine sulfate is allergies to certain shellfish.  Proper dosage is 500 mg TID for 3-6 months.  (Sahelian)

 

Glucosamine was found to be safe and effective in long-term placebo-controlled osteoarthritis trial (Reginster).  212 patients with mild to moderate osteoarthritis of the knee were randomly assigned to receive, in double-blind fashion, 1,500 mg of glucosamine sulfate (GS) or placebo once daily for 3 years. Mean and minimum joint-space width of the medial compartment of the tibiofemonral joint were assessed radiographically, at baseline and after 1 and 3 years.  Symptoms were scored by the Western Ontario and McMaster Universityes (WOMAC) osteoarthritis index.  In the intent-to-treat analysis, patients receiving placebo showed a mean joint-space loss after 3 years of –0.31 mm, compared with –0.06 mm in the GS group (p=0.043 for the difference between groups).  For the change in minimum joint space width, the values at 3 years were –0.40 and –0.07 mm, respectively (p=0.003 for the difference between groups).  Symptom scores at the end of the study showed a slight worsening form baseline in the placebo group, and an improvement in the GS group (p=0.02 for the difference between group).  There were no serious side effects attributable to the GS.  Fasting plasma glucose concentrations decreased slightly in the GS group.

2.      Arnica is an herb that has been utilized extensively in the US and Europe as a homeopathic remedy for pain and bruising as well as topically for pain relief. 

A study double blind placebo controlled trial in Norway found homeopathic arnica to be effective in reducing muscle soreness immediately after a marathon run (p=0.04) (Tveiten)

III.              Summary of Integrative Pain Management

An integrative approach to pain management is necessary to address the multifactorial aspects that define pain.  Hospitals in China have been utilizing an integrative approach to pain management for many decades.  Many hospitals across the world are integrating acupuncture and complementary treatment modalities into their programs.

What is an integrative approach to pain management?  First involves a modern medical assessment of pain causes and measurement, then address all aspects (mind, body, spirit) of pain through the safest most effective measures. 

Safe and effective holistic pain management interventions may include:

Acupuncture and Traditional Chinese Medicine, Naturopathic assessment and treatment thorough natural products, counseling, and physical modalities (massage, physical therapy, stretching, etc.)

What type of patient may benefit from holistic therapies?

Any type of patient, but especially patients that want to be more involved in their healthcare and are capable of the lifestyle changes, dietary recommendations, and commitment to physical modalities (acupuncture, massage) that can help them better manage their pain and suffering.  As with most conditions, early intervention is best for addressing pain. 

 

I.                   Cost/benefits of using acupuncture for pain management

Benefits of using acupuncture for pain management

Costs of using acupuncture for pain management

-reduced pain

-reduced hospital stays

-minimal to no side effects

-possible decreased need for pain-reducing medications and their side effects

-medicare and Medicaid does not reimburse for services

 

Paracelcus,” all illnesses can be cured, without exception, but to effect these cures we must get to the essence of our pain not just the symptoms.”

 

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Reginster, JY, et. al.  Long-term effects of glucosamine sulfate on osteoarthritis progression: a randomized, placebo-controlled clinical trial.  Lancet 2001;357:251-256.

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