GP Dr John Lloyd outlines the evidence base for the use of complementary and alternative medicines in pain management
Complementary approaches to pain control are numerous and popular. Between 20 and 75% of all adults in developed countries have used at least one type of complementary medicine within the past year. But almost all patients suffering from chronic pain will try some form of complementary medicine.
Although there is very limited evidence from clinical trials for the effectiveness of complementary therapies in the relief of chronic pain, we do know that some are effective and some almost certainly do not work. But for many there isn’t enough evidence to draw any conclusion.
Acupuncture has the best evidence base for the management of lower back, neck, knee, hip and shoulder pain. Although the evidence suggests its effects do not seem to be long lasting, it has been recommended by NICE in its guidance on the management of non-specific low back pain.1 But patients seem to like acupuncture and often want to continue after the end of a course of treatment. Courses are usually weekly for six to eight weeks.
In a 2009 study of 638 adults with chronic low back pain, patients undergoing 10 acupuncture sessions over seven weeks had greater improvement in symptoms than those who received standard care. One year after treatment, study members in the acupuncture group were also more likely to show significant functional improvements.2
A meta-analysis of 33 clinical trials concluded that acupuncture effectively relieved chronic low back pain. But the authors noted there was no evidence it was more effective than other active therapies.3
A 2009 Cochrane review suggested that acupuncture was at least as effective as medication at migraine prophylaxis4 while another review from the same year showed that it could have some benefit for people with frequent episodic or chronic tension headaches.5
There is some evidence that acupuncture may be useful for people with osteoarthritis – especially of the knee. A review and meta-analysis in 2007 concluded that acupuncture administered in an intensive two- to four-week treatment regimen might offer significant short-term relief of osteoarthritis-related knee pain.6
There is emerging but very tentative evidence that acupuncture may also be useful for carpal-tunnel syndrome, menstrual cramps, temporomandibular joint dysfunction and tennis elbow.
Alexander technique is a training process of ideal body posture and movement. Evidence that it was useful in low back pain was scant until a randomised controlled trial published in the BMJ found it provided long-term benefits for patients with chronic back pain.7 A subsequent review concluded that a series of six lessons in Alexander technique combined with an exercise prescription seemed the most effective and cost-effective option for the treatment of back pain in primary care.8
The application of essential oils, usually through gentle massage techniques, has been said to help chronic pain, but one systematic review was inconclusive.9
Chiropractic is a popular manual therapy based on an assumption that most health problems are due to misalignments of the spine and treatable through spinal manipulation.
There is continuing conflict of opinion on the efficacy of spinal manipulation for non-specific low back pain. A review in 2008 found strong evidence that it is similar in effect to medical care with exercise.10
A review in 2007 found good evidence that spinal manipulation is moderately effective for low back pain lasting more than four weeks,11 while a Cochrane review12 in 2004 found that spinal manipulation or mobilisation is no more or less effective than other standard interventions for back pain.
Some herbs have been shown to be effective. In a double-blind randomised controlled trial, devil’s claw (Harpagophytum procumbens) taken for three weeks was compared with placebo in 50 subjects with osteoarthritis. The herbal preparation was reported as significantly better than placebo for pain reduction. In another study, 89 patients with osteoarthritis were treated for two months with devil’s claw or placebo. Again, the herb produced reduction in pain and increase in mobility.13
Phytodolor – a proprietary preparation that contains Populus tremula, Fraxinus excelsior and Solidago virgaurea – has been shown to provide some relief in arthritis but no better than that associated with low doses of diclofenac or indomethacin.14
Claims have been made for homeopathy in benign, chronic conditions associated with pain, such as headache – but there is no sound evidence to back its use.
Some studies show that spinal manipulation and mobilisation techniques provide short-term relief for lower back pain.15 The Department of Health’s report, The Musculoskeletal Services Framework for England refers to osteopathy as a treatment option for musculoskeletal conditions.16
This technique is based on the idea that internal organs can be influenced through massaging areas on the soles of the feet. Claims have been made for effectiveness in chronic pain but published evidence is inconclusive.
Dr John Lloyd is a GP and sports medicine practitioner in Manchester
Competing interests None declared
Acupuncture has been recommended in NICE lower back pain guidance Acupuncture