Complementary and Alternative Medicine for Chronic Musculoskeletal Pain
Spinal Manipultaion
Spinal manipulation is high-velocity and low-amplitude localized force directed at specific spinal segments.34 It is performed by using the hands or a device to apply a controlled force to a joint of the spine and is practiced by osteopathic physicians, naturopathic physicians, chiropractors, physical therapists, and some medical doctors.19
In a study to assess its effectiveness, Rubinstein and colleagues found low-quality evidence to very-low-quality evidence to suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities, or other interventions for the relief of chronic low back pain.38 Comparative interventions included usual medical care, physical therapy, exercise, physiotherapy, and multimodal treatments. Standaert and colleagues also found no difference between motor control exercise and SMT in pain relief.42 They concluded that although the evidence is low, there is an indication that structured exercise and SMT seem to offer equivalent benefits in terms of pain for those with chronic lower back pain with clinical benefits evident within 8 weeks of care.42
Gross and colleagues found that when cervical manipulation was compared with control for chronic mechanical neck pain, there was moderate-quality evidence for similar effects at short-term and intermediate follow-up.34 They also reported low-quality evidence in support of thoracic manipulation alone or in combination with electrothermal or individualized physiotherapy and suggested cervical manipulation may provide short-term but not long-term pain relief.34 Furlan and colleagues reported moderate-quality evidence that spinal manipulation provided significantly better posttreatment neck pain relief compared with placebo.35 They also found low evidence that it was significantly better than placebo, acupuncture, and pain medication at immediate follow-up.35
Conclusion
Considerable effort was made to retrieve all studies; however, the authors cannot be certain that the review was exhaustive. They also relied on other analyses of primary studies for the conclusion.
The 3 types of musculoskeletal pain in the review were low back, neck, and knee pain related to osteoarthritis. The authors found that the most common CAM modality studied for chronic musculoskeletal pain was acupuncture. Studies on massage therapy and SMT that were relevant to the review were limited.
Two studies reported strong level of evidence for acupuncture.36,40 One study reported that acupuncture was superior to no treatment or to sham acupuncture for relief of chronic knee pain.40 The other study reported that acupuncture was more effective than conventional therapy alone when it was combined with conventional therapy for chronic low back pain, but there was no difference when compared with sham acupuncture for short-term pain relief.36 The strength of the evidence for acupuncture combined with conventional treatment for low back pain was conflicting. One other review found low evidence for its benefit. Similar to Hopton and MacPherson, this review found that acupuncture treatment seemed to provide effective short-term relief of chronic low back pain.14 Evidence would also seem to support acupuncture for the short-term relief of chronic neck pain and knee pain associated with osteoarthritis.
This review also found immediate and short-term benefits, although mostly with weak evidence, for the use of SMT in the treatment of chronic neck and low back pain. There was conflicting evidence for the support of massage therapy. Furlan and colleagues, however, found that acupuncture, SMT, and massage treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment.35 Inconsistencies may be related to the methodologic and clinical diversity of RCTs, which limit the extent of quantitative synthesis and complicates result interpretation.35 Also, better conclusions could be drawn if future studies use head-to-head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes.35
Although the relationship between conventional treatment and the world of CAM remains equivocal, review of the evidence suggests acupuncture and SMT may be effective treatment for various chronic painful musculoskeletal conditions.35,44,50,51 These CAM modalities are reasonable referral options to supplement conventional therapy for the treatment of chronic musculoskeletal pain when conventional therapy has not yielded satisfactory results.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
