By Stephani Sutherland January 2017
When it comes to chronic pain, Western medical treatments are not optimal. Invasive surgeries—such as removal of an injured spinal disc or spinal fusion—and nerve blocks bring some people relief, but many others are not helped or even get worse after the procedures, which carry considerable risks. Drug treatments are mostly limited to narcotics such as morphine that can cause serious side effects and carry the potential for abuse and addiction, or over-the-counter medications like non-steroidal anti-inflammatory drugs (NSAIDs), which are not without risks either.
“All of us who are thinking about the management of chronic pain are aware that, alongside the use of pharmaceuticals, we need other strategies.”
Josephine Briggs, NIH
Considering these options, many patients have turned to complementary therapies to find relief. “All of us who are thinking about the management of chronic pain are aware that, alongside the use of pharmaceuticals, we need other strategies,” said Josephine Briggs, who heads the National Center for Complementary and Integrative Health (NCCIH), a part of the National Institutes of Health (NIH) in Bethesda, Maryland, US.
“The main reason people turn to complementary practices is overwhelmingly for pain,” said Briggs. Although herbal and dietary supplements are the most common non-pharmaceutical treatments sought by Americans, people with chronic pain more often choose mind- and body-focused therapies. In recent years, scientific studies of these practices have hinted at their pain-fighting potential, but this area of research is still in its infancy. Still, current findings suggest that some of the practices that seem to offer the best results for people with chronic pain include manual treatments, yoga, mindfulness and meditation.
Hands-on approach
Manual therapies encompass any manipulation of the body using the hands, including spinal or joint manipulation, by a doctor of chiropractic (DC), a doctor of osteopathic medicine (DO), or a physical therapist (PT), as well as massage by a licensed massage therapist. These treatments have a common goal, said Geoffrey Bove, a pain researcher at the University of New England in Biddeford, Maine, US, who is also a licensed chiropractor. “The unifying concept or proposed mechanism of action is to reduce and/or prevent stiff or dense, less-flexible tissue within and around joint structures,” Bove said. “Tissues are normally supposed to slide and glide. If they don’t, one result can be compressed or inflamed nerves.” Treatment might take the form of a spinal adjustment that is thought to restore normal movements, leading to reduced inflammation of an inflamed nerve. Other treatments might involve massage of tight, “knotty” muscles with the intent of making them more pliable. “We think that manual therapies work to reduce pain by increasing motion between the tissues,” Bove said.
But treating pain and treating the underlying condition are two separate things, cautioned Bove, whatever the type of treatment. For example, opioid medication might relieve the pain of carpal tunnel syndrome, but the cause of pain is still there. On the other hand, “if we can identify and treat the condition itself, the underlying problem goes away, and the pain probably goes away too.” In some cases, manual manipulations can help alleviate the cause of pain.
How effective are manual therapies for pain? “We can’t answer that question for pain in general—we have to consider individual conditions,” said Bove. For instance, research suggests that spinal manipulation can relieve low back pain for some people. “But that does not mean it will help any given person,” Bove said. “People’s different responses probably depend on whether or not established disease processes exist,” he said. Studies also suggest that massage can help relieve pain conditions including chronic low back pain and osteoarthritis pain. Another consideration for patients seeking manual therapy is that therapists can vary in their approach. “Different practitioners might use the same terminology to describe what they do, but deliver wildly different treatments,” Bove said. On the other hand, the treatments carry very low risks—particularly compared to surgical treatments, said Bove—and are not very expensive. “For most patients, the only way to know if a treatment will work is to try it,” Bove added.
Ancient practices
Over the past century, yoga has become wildly popular in the Western world, and studios can be found around the globe. According to a 2007 study, over 13 million adults practice yoga in the US—approximately 6% of the population. For many people, the idea of yoga conjures images of a studio packed with lithe, super-flexible bodies contorted into pretzel-shaped poses. But that modern conception differs substantially from the way that yoga has been practiced in India for approximately 4,000 years. Traditionally, yoga was transmitted from teacher to individual student rather than in large groups, and practiced mostly by men. And practicing physical postures, or asana—the focus of most group classes—makes up only a small part of the tradition. Other practices include seated breathing postures, called pranayama, as well as meditation and chanting mantras.
For someone with pain, a more traditional approach—using these various practices and delivered one-on-one—may be more appropriate than a group class aimed at fitness, said Gary Kraftsow, a yoga therapist and founder and director of American Viniyoga Institute in Oakland, California, US. “Yoga therapy adapts and applies yoga practices to help individuals or groups suffering from a specific condition,” including chronic pain. Just as with any treatment for pain, Kraftsow said, a yoga practice should be designed for the particular type of pain a person has, and it should consider the needs of the individual practitioner.
If used appropriately, yoga can benefit people with chronic pain. Studies have shown that after practicing a specially designed yoga asana sequence for several months, people with chronic low back pain experienced less pain, less functional disability and less depression than people who received standard care. Another study showed that simple stretching exercises reduced pain as well as yoga, suggesting that yoga’s physical stretching and strengthening aspects might partly account for the improvements. But yoga also somehow influences the relationship between practitioners and their pain, which may confer additional benefits, particularly for people living with intractable chronic pain. “We work with people to eliminate pain where possible, to reduce it when we can, and to develop strategies for them to continue to function and to help them cope with and manage expectations about the pain they are left with,” said Kraftsow. “Yoga helps people to gain an understanding of themselves in relation to pain, and how to integrate that into their lives so they’re not overwhelmed by the pain and can be more in control of it.”
The change in the practitioner-pain relationship may arise from yoga’s effects on the brain (see a review article here). A study conducted at NCCIH and at McGill University in Montreal, Canada, examined the effects of long-term yoga practice on pain tolerance in healthy subjects. Subjects had practiced yoga for six to 14 years, incorporating breath work and meditation with physical asana practice. The researchers asked the yogis to place their hand in a bucket of ice water. Later, they asked subjects to describe how they dealt with the pain. Compared to control subjects who had never practiced yoga, the practitioners were able to keep their hand in the ice water twice as long. “Not only did they tolerate pain longer,” said study author Marta Ceko, now at University of Colorado Boulder, “but they seemed to engage different mechanisms of dealing with the pain.” The yoga practitioners used strategies like observing their pain, rather than avoiding it. “The yogis seemed to be more mindful about their pain,” said Ceko. The control subjects, in contrast, “didn’t use those techniques. They just tried to make the pain go away, or to ignore it, and that didn’t seem to work. They couldn’t take it for as long.”
“Yoga and other integrative therapies seem to alleviate pain not so much by changing the physical sensation of pain, but by altering people’s reactions to the sensation.”
Marta Ceko, UC Boulder
The subjects’ ability to detect physical pain was not significantly different between the two groups. “But pain tolerance, which depends more on the affective, or emotional, component of pain, is where we see the biggest differences. Yoga and other integrative therapies seem to alleviate pain not so much by changing the physical sensation of pain, but by altering people’s reactions to the sensation,” Ceko said.
To find the neural basis of the change in yoga practitioners’ reaction to pain, the researchers also used magnetic resonance imaging (MRI) to see inside subjects’ brains. They found that, compared to non-practicing subjects, those who practiced yoga had more grey matter—the part of the brain made up of cell bodies, which contain the cell nucleus, as opposed to white matter that is made up of the nerve fibers that connect cells. When they analyzed the images, the researchers found that yoga practice correlated with changes in a brain area called the insula, which is crucial to how people sense their internal environment and form a sense of “self.”
Mind over matter
Mindfulness is another modern complementary practice for pain that originated from an ancient Eastern philosophy. In 1979, Jon Kabat-Zinn at the University of Massachusetts in Worcester, Massachusetts, US, adapted Buddhist meditation practices into a secularized treatment plan specially designed for healthcare clinics in the Western world; he called it Mindfulness-Based Stress Reduction (MBSR). People may have misconceptions about mindfulness, envisioning bald monks clad in orange robes sitting still for hours. But mindfulness practices can take many forms. “Mindfulness meditation is a practice designed to cultivate the cognitive state of mindfulness, which is premised on nonjudgmental awareness of the present moment,” said Fadel Zeidan, a pain and mindfulness researcher at Wake Forest School of Medicine in Winston-Salem, North Carolina, US.
Over the past 35 years, thousands of studies have investigated the effects of mindfulness on physical and mental health. For pain, however, the results are mixed. A 1985 study by Kabat-Zinn showed that ten weeks of mindfulness training provided significant benefits to chronic pain patients, including lowering the dosage of medication they took. “The researchers not only found that training reduced pain symptoms, but it improved subjects’ quality of life too,” said Zeidan. But a recent analysis of eleven studies showed little evidence that mindfulness treatments improved pain in people with a variety of pain conditions, perhaps in part because of the quality of the studies. “A lot of the research is not extremely well done,” Zeidan said.
Insights about how mindfulness training affects the experience of pain come from studies of healthy people. For example, Zeidan tested subjects’ pain ratings in response to a hot plate placed on their leg before and after mindfulness training. “Our studies show that three to four days of meditation training can significantly reduce pain,” Zeidan said. Similar to the yoga study, Zeidan also performed brain imaging on the subjects and found that they engaged a unique subset of brain areas associated with meditation-related pain relief. People vary in how mindful they start out, but anyone can improve with training. “If you never played golf before, and you play for 20 minutes a day for a few days, you’ll be better than before,” Zeidan said. “So the increase in mindfulness we see over time is not unbelievable. But what is amazing is how strong the effect is and how repeatable it is.”
What’s in a name?
NCCIH is dedicated to the study of treatments that were once commonly called “alternative.” “But the term ‘alternative medicine’ came to be used for approaches with little basis in scientific evidence, and that were used instead of conventional care,” Briggs said. Today, approaches including manual therapies, yoga and mindfulness are more commonly called “complementary” because they are usually applied together with medical treatments. The term “integrative health” refers to a growing movement in healthcare to treat patients more holistically—as a person, rather than an illness—and to coordinate conventional and complementary treatments. That shift was reflected in the recent name change of NCCIH, which was formerly called the National Center for Complementary and Alternative Medicine (NCCAM). “By and large, we are most focused on treatments that are used as a complement to or are integrated with conventional care, so we found those words better described what we do,” she said.
At the NCCIH, researchers are also investigating another non-medical treatment for pain so mainstream that few people would consider it “alternative” in any sense: exercise. “I like to think of exercise as a good health habit for everyone, and it’s certainly integrative,” Briggs said. When people are in pain, exercise might seem like the wrong idea. After all, said Briggs, sometimes pain is a warning that something is wrong in the body, signaling to people to rest and recover. “But often it’s not. Many chronic pain states do not have a simple underlying medical cause.” Pain sometimes lingers long after tissues have healed, or in some cases, such as fibromyalgia, the source of pain remains altogether mysterious. But while it might seem counterintuitive, exercise provides a range of health benefits for people with chronic pain, provided that the regimen does not worsen the underlying cause of pain (see a review article here). Researchers are still working to understand how exercise improves both physical and mental health, but studies suggest that exercise relieves pain through its effects on the brain as much as on the body.
Much remains to be learned about whether—and how—complementary treatments can help people living with chronic pain. Studies of treatments tailored to specific pain conditions will surely help in the quest to find winning prescriptions for complementary and integrative care for pain. But in the meantime, one thing is clear about complementary therapies when appropriately applied: they have low risk. “Nothing bad will happen to you—there are no side effects as with pain drugs,” Ceko said. Our brains have their own pain-fighting mechanisms, she said. “Being able to engage those systems with something that doesn’t require pills would be amazing.”
Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance journalist in Southern California. Find her at StephaniSutherland.com or on Twitter @SutherlandPhD
Additional resources:
National Center for Complementary and Integrative Health (NCCIH)
NCCIH: Chronic Pain
NCCIH: Statistics on CAM Approaches
Mindful Awareness Research Center (MARC) at the University of California, Los Angeles, US
http://relief.news/complementary-therapies-for-pain-what-does-the-research-say/
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