Clinical Review

Complementary and Alternative Medicine for Chronic Musculoskeletal Pain

A review of randomized clinical trial studies suggests that acupuncture and spinal manipulation may be effective for the treatment of chronic musculoskeletal pain.

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Musculoskeletal pain affects one-quarter of the adult population and is the most common reason for self-medication and for seeking health care. 1-3 It is also cited as the most common reason for the use of complementary and alternative medicine (CAM), and the lower back, head, neck, and knee are the most commonly reported areas of pain. 4-8 In 2007, the estimated annual cost of managing chronic pain, adjusted for inflation, ranged from $560 to $635 billion; whereas the direct out-of-pocket cost for patients with back pain was $34 billion. 9 Chronic pain persists beyond the usual course of disease or healing; generally about 3 months or longer. 10-12 The most common forms of pain include those associated with musculoskeletal disorders, such as degenerative arthritis, rheumatoid arthritis, osteoarthritis, myofascial pain, chronic headache, low back pain, and bone pain. 11,13-15

A large number of returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans have reported chronic pain symptoms, with back and head being the most common pain locations. 7 They experienced pain related to wearing heavy gear every day, being transported in armored vehicles over crater-ridden roads, and enduring less than optimal sleeping conditions. 16 Studies have found a significant number of subjects in this population who reported using CAM therapy. The OIF/OEF veterans were likely to have outpatient visits for musculoskeletal system disorders and to use CAM as an additional tool in pain management—not as a reaction to perceived inadequacies of conventional care. 17,18

Complementary and alternative medicine is often used to describe various substances, procedures, and approaches outside of mainstream, Western, or conventional medicine for health promotion, treating injuries, symptoms, and illnesses. 18,19 Although complementary and alternative are often used interchangeably, the 2 terms refer to different concepts. Complementary refers to the use of a nonmainstream approach with conventional medicine, whereas alternative refers to the use of a nonmainstream approach instead of conventional medicine. 19 About 40% of Americans use CAM for various reasons. 19

The services and self-care forms of CAM account for a large portion of out-of-pocket costs; patients are willing to pay for it themselves. In 2007, the U.S. spent $33.9 billion on out-of-pocket expenses for CAM classes, products, materials, and visits to CAM providers. 20 The costs are comparable with those of conventional health care services and prescription drug use. 20 One national study concluded that many patients use CAM in accordance with their beliefs, values, and philosophy concerning health and life. 21 Other studies found that many patients use CAM not only because of functional status, pain severity, or self-efficacy, but also because they perceive significant benefits in pain relief. 6,17,22-25 Some authors reported that CAM is used to augment and not replace conventional medicine and that it has now become part of the accepted armamentarium for managing chronic musculoskeletal pain. 6,17,25

The National Center for Complementary and Alternative Medicine at the National Institutes of Health (NIH) classifies CAM in 2 ways: (1) Mind and body practices, such as acupuncture, massage therapy, meditation, movement therapies, relaxation techniques, spinal manipulation, tai chi and qi gong, yoga, healing touch, and hypnotherapy; and (2) natural products, including probiotics, herbs, and vitamins and minerals usually sold as dietary supplements. 19 These products are regulated by the FDA but not as drugs. They have a different set of regulations under the Dietary Supplement Health and Education Act of 1994. 26


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