Integrative Pain Medicine Contemporary Pain Medicine Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management Series Editor Steven Richeimer, md Director, USC Pain Center, University of Southern California, Los Angeles, California, USA Integrative Pain Medicine The Science and Practice of Complementary and Alternative Medicine in Pain Management Edited by Joseph F. Audette, MA, MD Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Spaulding, Massachusetts, Harvard Medical School, Boston, Massachusetts Allison Bailey, MD Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Editors JosephF.Audette AllisonBailey HarvardMedicalSchool HarvardMedicalSchool Boston,MA,USA Boston,MA,USA SeriesEditor StevenRicheimer USCPainCenter UniversityofSouthernCalifornia LosAngeles,CA,USA ISBN:978-1-58829-786-0 e-ISBN:978-1-59745-344-8 LibraryofCongressControlNumber:2007943541 ©2008HumanaPress,apartofSpringerScience+BusinessMedia,LLC Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenpermissionof thepublisher(HumanaPress,999RiverviewDrive,Suite208,Totowa,NJ07512USA),exceptforbriefexcerptsin connectionwithreviewsorscholarlyanalysis.Useinconnectionwithanyformofinformationstorageandretrieval, electronicadaptation,computersoftware,orbysimilarordissimilarmethodologynowknownorhereafterdeveloped isforbidden. Theuseinthispublicationoftradenames,trademarks,servicemarks,andsimilarterms,eveniftheyarenotidentified assuch,isnottobetakenasanexpressionofopinionastowhetherornottheyaresubjecttoproprietaryrights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityforanyerrorsoromissionsthat maybemade.Thepublishermakesnowarranty,expressorimplied,withrespecttothematerialcontainedherein. Cover Illustration: The cover image is called a Sri Yantra or “great object” and belongs to a class of meditation devicesusedmainlybythosebelongingtotheHindutantrictradition.Thecentraldiagramconsistsofnineinterwoven isoscelestriangles,withfourpointingupwardstorepresentSakti,theprimordialfemaleessenceofdynamicenergy, andfivepointingdownwardstorepresentingSiva,theprimordialmaleessenceofstaticwisdom.Theimagerepresents thecontinuousprocessofCreativeGeneration,withindwellingMahavidyaDevatasinallthetrianglesandstupaand lingammotifscombiningBuddhistandHindusymbolism(Nepal,c.1700).Thepatternisalsoasymbolicmanifestation of the Fibonacci series or phi, the golden ratio, which is a mathematical representation of repeating patterns found throughoutnature.Inthisway,theSriYantracanbeviewedasagraphicrepresentationoftheintegrationofancient knowledge(CAM)andModernScience,whichistheaspirationofthisbookandIntegrativeMedicine. Printedonacid-freepaper 987654321 springer.com This book is dedicated in loving memory of Grace Peterson Audette and Mary Frances McConathy. Preface The field of Pain Medicine has evolved over the last 20 years to include an increasing array of sophisticated and technologically complex diagnostic and thera- peutic procedures. Concurrent to this advancement has been the development of a battery of pharmacological options to treat pain, from extended-release formulations of analgesics to antidepressants and anticonvulsants designed to treat specific types of pain syndromes. Despite (and perhaps because of) this phenomenal growth, it is not uncommon for patients with persistent pain to find themselves having gone through a number of procedures and taking a growing list of medications without ever experi- encing true resolution of the condition or a return to a normal lifestyle and function. Inherentinthisapproachistheviewpointthattheclinician’sroleistodosomethingto thepatientthatwillreducesymptomsratherthantoworkinconcertwith thepatientto either resolve the root causes or ameliorate the functional consequences of their pain condition. Although motivated by the desire to help, this model of pain management neglects individual choice and personal responsibility. This approach is of even greater concern in special populations such as the elderly. Bytheyear2030,peopleolderthan65yearswillcomprise20%ofthetotalpopulation in the United States. The most common explanation for disability reported by older persons is musculoskeletal pain. Whether due to arthritic or non-arthritic causes, pain is a major factor in disability in this age group even when other impairments and symptoms are taken into account. Although pain, in and of itself, is a primary concern of the elderly, it is the associated impairments that have the most devastating impact on quality of life, morbidity, and mortality. The elderly are also more likely to be on multiple medications for other chronic conditions. The addition of pain medications and invasive procedures to this growing list may have dangerous and possibly fatal outcomes. This problem in Pain Medicine has two sides, however. Many patients who come to pain management clinics are seeking quick fixes. They may lack the motivation or interest to devote time and effort toward lifestyle changes that could have a more profound impact on the root causes of their pain. Patients may feel that they do not have the time to care for themselves or to work with the clinician in a collaborative model of care. They may want to be at the end of treatment before it has started and without having to experience a process of healing. They may want the physician to prescribe a medication or perform a procedure that will reduce or eliminate pain quickly, even when there may be little chance of success. Unfortunately, physicians are all too often ready to make such heroic attempts, sometimes at the expense of patient wellness. Asnewtreatmentsareattemptedtorelievepainfulsymptomswithoutimprovement, patientsmaybecomeincreasinglypassiveandcandevelopasenseofhopelessnessand despair. This is the current culture of technological medicine in which we live. Our vii viii Preface society believes that everything can be fixed and that patients have a right to never experience pain. Advanced imaging, invasive procedures, and surgery are viewed as superiorformsofdiagnosisandtreatment,whileemphasisonself-careandoptimization of the body’s natural healing process is minimized. However, when technologically advanced treatments fail, clinicians may become dismissive, blaming the patient for lack of success. Given this kind of feedback, patients may find themselves without the ability to cope with the uncertainty of a journey through life with pain. Without the help of a guide, they may be unable to negotiate this difficult path that demands personal growth, lifestyle change, and acceptance. When this occurs, patients may begin to disregard the painful body part, seeing it as separate from themselves. The painful part may never be integrated back into the whole of consciousness and being, but is left to atrophy. In this pain management quagmire, Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management offers an alternative that can provide a perfect counterbalance to the paternalistic, technological medicine predominant today. Jon Kabat Zin speaks to this concept in his book, Full Catastrophe Living, when discussing the concept of rehabilitation. The word comes from the Latin root habilitare, which means “to enable,” but is also related to the Frenchverbhabiter,whichmeans“tolivein,toinhabit,todwell.”Thustorehabilitate someone means not only to re-enable them, but also to teach them how to re-inhabit, to live or dwell in, their body again. The goal is to help patients to accept their limitations and become an integrated whole again. The ideals of integrative medicine help reintroduce a model of care that is more process oriented and whole body in nature. This should not be taken to mean that science does not play an important role in developing novel treatments for pain. However, a scientific approach to pain management need not be based entirely on reductionism. The current trend of the science–medicineinterfacetrainsclinicianstoanalyzesomethingintosimplerelements or organized systems. Neck pain can be best assessed and evaluated by looking at the patient’s X-ray or MRI image, while factors such as the candy bars and coffee consumed all day long, the computer work station, the stress of work and home, or the grief over the loss of a family member are just noise to be filtered out of the assessment. Instead, an enhanced scientific view can be adopted. This view recog- nizes that there remains much that we have yet to learn about the complexity of the human experience of pain and its treatment. For example, structures such as fascia and muscle tissue appear capable of generating pain that can be at times severe and may become chronic. Yet, within conventional medicine, the muscle and fascia are essentially invisible to standard methods of imaging. Therefore, little emphasis has been placed on understanding how this type of pain arises and ways in which to treat it. Many integrative treatments discussed in this book have mechanisms of action that appear to work at the level of the muscle or the fascial tissue. Another important concept in this enhanced scientific view is that the body is an integratedwhole.Paininonepartofthebodymustbetheresultofacomplexseriesof whole body structural and psycho-biological changes that leads to the surfacing of this symptom in one region. To the pure reductionist this may appear unscientific. In our enhanced scientific model, however, a more thorough understanding of the intercon- Preface ix nectednessofthevariousstructuresandregulatorysystemsandthewaysthattheymay affect pain syndromes is integrated into our comprehension. Through basic science research and an appreciation of the complexity of pain and the inter-relationships between structure and function, we can develop a model of pain management that is both scientific and integrative in its approach. This is the model presented in Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. We begin with several chapters that discuss pain and its management from a mechanistic standpoint. Thesechapterspresentascientificbasisforpotentialmechanismsofactionthatcanbe appliedtoanarrayofintegrativetherapies.Inthefollowingsection,specifictherapeutic approaches are discussed in terms of their application to pain management. Whenever possible, authors have attempted to propose hypotheses regarding mechanisms of actionforthesetherapies,incorporatinginformationfromtheintroductorybasicscience chapters. Finally, two integrative models of care are put forward as examples of how these principles may be applied in a pain management clinic setting. Ultimately, our hopeisthatthisbookwillfulfillbothscientificandphilosophicpurposesintheongoing development of the field of Pain Medicine and serve as a guide to help both clinicians and patients reconnect with a model of care that takes as primary the concept of rehabilitation. Joseph F. Audette, MA,MD Allison Bailey, MD Contents Preface............................................................................. vii Contributors........................................................................ xiii Part I Introduction 1. Legal and Ethical Issues in Integrative Pain Management........................... 3 Michael H. Cohen Part II Future Trends in CAM Research 2. Basic Mechanisms of Pain....................................................... 19 Frank Willard 3. The Functional Neuroanatomy of Pain Perception.................................. 63 Norman W. Kettner 4. Neuroimaging for the Evaluation of CAM Mechanisms............................ 85 Vitaly Napadow, Rupali P. Dhond, and Norman W. Kettner 5. Integrating Dry Needling with New Concepts of Myofascial Pain, Muscle Physiology, and Sensitization.............................................107 Jay P. Shah 6. Potential Role of Fascia in Chronic Musculoskeletal Pain .......................... 123 Helene M. Langevin 7. Biochemical and Nutritional Influences on Pain ................................... 133 Steve Parcell 8. Exercise Testing and Training in Patients with (Chronic) Pain...................... 173 Harriët Wittink and Tim Takken Part III Therapeutic Techniques 9. Meditation and Chronic Pain.....................................................195 Joshua Wootton 10. Adjunctive Hypnotic Management of Acute Pain in Invasive Medical Interventions...................................................211 Gloria Maria Martinez Salazar, Salomao Faintuch, and Elvira V. Lang 11. Energy-Based Therapies for Chronic Pain.........................................225 Eric Leskowitz xi xii Contents 12. Tai Chi in Pain Medicine........................................................243 Joseph F. Audette 13. Yoga in Pain Management.......................................................259 Loren Fishman and Ellen Saltonstall 14. Contemporary Aquatic Therapy and Pain Management.............................285 Douglas W. Kinnaird and Bruce E. Becker 15. Osteopathic Medicine in Chronic Pain............................................307 James H. Gronemeyer and Alexios G. Carayannopoulos 16. Chiropractic Pain Management: An Integrative Approach...........................333 Norman W. Kettner 17. Therapeutic Massage and Bodywork in Integrative Pain Management............... 353 Arthur Madore and Janet R. Kahn 18. Acupuncture in Pain Management................................................379 David Wang and Joseph F. Audette 19. Nutrition and Supplements for Pain Management..................................417 Maria Sulindro-Ma, Charise L. Ivy, and Amber C. Isenhart 20. Botanicals in the Management of Pain............................................447 Tieraona Low Dog 21. Chinese Herbal Medicine for Pain................................................471 David Euler Part IV Integrative Models 22. Integrative Pain Medicine Models: Women’s Health Programs......................497 Allison Bailey and Meryl Stein 23. Integrative Medicine: History, Overview, and Applications to Pain Management............................................................ 547 Joseph Mosquera Index.............................................................................. 571