|Year : 2015 | Volume
| Issue : 2 | Page : 73-81
Complementary and alternative medicine in chronic neurological pain
Shri Kant Mishra1, Bhavesh Trikamji2, Elizabeth Togneri3
1 Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California; Department of Neurology, Olive View UCLA Medical Center, Sylmar, California; Department of Neurology, VA Greater Los Angeles, Los Angeles, California, USA
2 Department of Neurology, Olive View UCLA Medical Center, Sylmar, California; Department of Neurology, VA Greater Los Angeles, Los Angeles, California, USA
3 Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
|Date of Web Publication||15-Apr-2015|
Dr. Shri Kant Mishra
16111 Plummer Street, North Hills, California 91343
Source of Support: None, Conflict of Interest: None
Background: There is a growing trend towards opting for complementary and alternative medicine (CAM) in the therapeutic management of various medical disorders. We try to evaluate the current recommendations for CAM therapies in key neurological disorders. Materials and Methods: Sources like PubMed, Embase, UCLA libraries, USC libraries, and National Center for Complementary and Alternative Medicine (NCCAM) books were searched to gather data for this review. Results: We discuss the current recommendations for CAM therapies in headaches, neck pains, lower back pains, neuropathic pains, and cancer-related pains. The CAM therapies discussed include natural therapies, mind and body therapies, and several other modalities. Conclusion: We conclude that in spite of vast literature available on the CAM therapies for neurological disorders; there is little evidence for the most beneficial CAM remedies that target common neurological disorders. Although new CAM modalities are brought to light in addition to those that have existed for centuries, further scientific data from evidence-based studies is needed to accurately compare the CAM therapies amongst each other and allopathic treatments.
Keywords: Back pain, cancer pain, chronic pain, complementary and alternative medicine, headache, neck pain, neuropathic pain
|How to cite this article:|
Mishra SK, Trikamji B, Togneri E. Complementary and alternative medicine in chronic neurological pain. Indian J Pain 2015;29:73-81
| Introduction|| |
A vital element of neurological practice consists of the diagnosis and eventual treatment of painful conditions that are associated with central and peripheral nervous system dysfunctions. Most often, acute and episodic pains are treated with conventional pharmacological medicine, also referred to as Western or allopathic medicine. Unfortunately, a vast majority of chronic pain conditions are difficult to treat through conventional medication because of financial strains and adverse side effects. However, the careful collaboration of Western medicine with complementary and alternative medicine (CAM) ultimately presents a valid and novel solution. Currently, we have a great repertoire of pain management techniques, including pharmacological and nonpharmacological remedies, to help assuage neurological pain. However, there is little in the form of a review that summarizes the effectiveness of CAM methods available for the most common types of chronic neurological pain conditions, such as headaches, back and neck pains, neuropathic pains, and cancer-related pains. This paper attempts to offer clarity as well as an effective assessment concerning this dilemma.
| Materials and Methods|| |
The contents of this paper were obtained by literature review of various sources that include PubMed, Embase, UCLA libraries, USC libraries, and National Center for Complementary and Alternative Medicine (NCCAM) books.
Definition and types of CAM
The NCCAM defines CAM as a "group of diverse medical and health care systems, practices and products that are generally not considered part of conventional medicine".  "Complementary" generally refers to using a non-mainstream approach together with conventional medicine; whereas, "alternative" refers to using a non-mainstream approach in place of conventional medicine. NCCAM prefers to use the term "complementary health approaches" when discussing these practices and products. It classifies CAM modalities into two broad categories: Natural products and mind and body medicine.
These include herbal medicines (botanicals), vitamins, minerals, and "natural products" such as probiotics. Many of these are ingested as dietary supplements. In the 2007 National Health Interview Survey (NHIS), it was found that 17% of US adults had used a nonvitamin/nonmineral natural product; with fish oil/omega 3s being the most frequently used ones (37%). 
Mind and body medicine
This specialty focuses on the interplay between brain and mind, as well as the body and behavior, with the idea that the mind has powerful influence over pain states. Many mind and body techniques are ranked among the top 10 CAM modalities utilized by adults: Deep-breathing exercises (12%), meditation (9%), yoga (6%), acupuncture (1%), and progressive relaxation and guided imagery. 
Other complementary health approaches
Some approaches may not entirely fit into either of the two groups. For example, the practices of traditional healers, Ayurvedic medicine from India, traditional Chinese medicine (TCM), homeopathy, and naturopathy.
Chronic pain has affected close to 70 million Americans, while consequently causing permanent disability to many. Strikingly, approximately 10% of US population has consistent pain for more than 100 days per year. In terms of its prevalence, chronic pain was reported by the National Center for Health Statistics in 2007 as the cause for 70 million physician visits over a 3-year period. The pain in patients resulted in a loss of 4 billion workdays.  Furthermore, there is also a corresponding psychological influence, depression in particular, leading to a rise in both economic and psychological burden. 
While chronic pain has been identified as one of the major health problems by the National Institutes of Health (NIH), many of the methods used to treat it have remained constant and unchanging over the years.  Most chronic pain patients referred to conventional medical practices are treated with pharmacological agents such as nonsteroidal anti-inflammatory drugs (NSAIDS), analgesics, antidepressants, and narcotics. Unfortunately, these are associated with a fair amount of clinical toxicities and drug dependence following prolonged usage. Additionally, a large number of patients undergo various diagnostic and surgical procedures that add to their suffering and prolong their expenditure. , Ultimately, the conventional therapies for chronic pain conditions are either temporary or fail altogether. In search of an alternative treatment to alleviate pain, patients often seek other forms of pain remedies,  often without consulting their physicians. In a study of 180 patients with peripheral neuropathy it was found that 43% resorted to CAM therapies citing inadequate pain control as the primary cause. Half of them admitted to not consulting their physician before commencing CAM, which can be detrimental and even fatal in some cases.  Hence, the widespread use of CAM by 35-65% of chronic pain patients warrants a discussion on the efficacy of the commonly used CAM modalities in relation to the chronic neurological pain conditions. ,
In the US, the National Health Statistics Reports 2007 reported that nearly 40% of adults and 12% of children used CAM in the past 12 months - the most common therapies being nonvitamin, nonmineral, and natural products. These 38 million adults made an estimated 354 million visits to CAM practitioners like the acupuncturists, chiropractors, and massage therapists. A total of $33.9 billion was spent out of pocket on CAM: One-third on practitioner visits ($11.9 billion) and two-thirds on self-care products, classes, and materials ($22 billion).  There was a 47.3% increase in total visits to alternative medicine practitioners from 427 million in 1990 to 629 million in 1997 and the estimated expenditures for alternative medicine professional services increased by 45.2% during this period.  Based on these financial figures, CAM has arisen as an intriguing and promising new field of therapy for those with pain-related conditions. While CAM is culturally ingrained in Eastern societies, it is gradually gaining recognition in the Western world as well. There are currently a number of case-based trials that are looking at a few CAM alternatives like whole shark cartilage extract, green tea, selenium, enzymes, nutritional supplements, herbals, etc. These alternatives along with well-established remedies like acupunctures, massages, and mind-body medicine are showing promise in chronic pain management.
| Use of CAM in Various Neurological Disorders|| |
According to the National Headache Foundation, an estimated 28 million Americans have migraine headaches with an estimated 14 million suffering from undiagnosed migraine headaches. , While it is imperative to have a complete neurological evaluation and confirmation of the diagnosis prior to using CAM therapies, research has shown that CAM is used widely and frequently amongst those who suffer from headaches in general. A survey of 448 patients classified as having primary headaches in Germany and Austria showed that up to 82% use CAM therapies, with the most frequently used therapies being acupuncture (71%), massages (56%), and thermotherapy (29%);  while another German prospective observational study found that 54% of patients noted that CAM improved their symptoms.  The primary goal of CAM treatment for chronic headaches is prevention. An integrative multidisciplinary approach is key to the treatment of headaches. A sample management plan could include stress reduction through lifestyle changes characterized by avoiding activities that trigger headaches, relaxation training, leisure time activities, guided imagery, yoga, and biofeedback. 
Various herbal medicines, such as feverfew, ginkgo biloba, and ginger are helpful in treating headaches.  A double-blind randomized placebo-controlled trial of 72 patients found that a capsule of dried feverfew leaves daily decreased the frequency and severity of migraine attacks within 2 month's period.  Moreover, there were no serious side-effect reported. Additionally, the benefits of Indian hemp or marijuana in relieving various forms of headaches have been recently reported. , However as with most medicinal interventions, the use of marijuana poses serious psychological risks and the potential for addiction, thus prompting careful and regimented use.
Mind and body medicine
Relaxation to relieve muscle tension and stress is a very important lifestyle modification. This involves educating patients on how to reduce tension, work-related stress, and excessive responsibility by using mind-body modalities.  Regular meditation, deep relaxation, and biofeedback have been reported to be very helpful. , Furthermore, yoga and other types of mind-body practices have been used for prophylactic as well as symptomatic treatment of various types of vascular and muscle contraction headaches. , Acupuncture has been successfully used as a preventative measure for migraine headaches. ,, It was found to not only reduce the frequency of migraine attacks  but also treat childhood migraines.  The physiological process includes a regional stimulus that induces opioid peptides, substance P, histamine-like substances, bradykinin, serotonin, and proteolytic enzyme release.  In spite of success with acupuncture, there are various side effects that require caution such as pneumothorax  and epidural hematoma.  Additionally, trigeminal neuralgias and atypical facial pain has been successfully treated with acupuncture, psychological counseling, and biofeedback.  Mixed tension vascular headaches and other types of chronic headaches are treated effectively with bodywork using Trager approach and acupuncture. Behavioral therapy is sometimes helpful in chronic vascular and tension headaches. 
Other CAM practices
Based on a recent report which focused on the studies published between 1999 and 2009, it was found that Petasites (butterbur) is effective for migraine prevention and should be offered to patients with migraine to reduce the frequency and severity of migraine attacks. MIG-99 (feverfew), magnesium, and riboflavin were considered probably effective while Co-Q10 and estrogen were possibly effective for migraine prevention. Data was conflicting or inadequate to support or refute the use of omega-3 and hyperbaric oxygen for migraine prevention. 
Back and neck pain
In the 2007 NHIS, back pain was the most common reason for using CAM, followed by neck pain, joint pain/ stiffness, and arthritis. An estimated 70-75% of all adults in Western industrialized countries report suffering from low back pain (LBP) at some point in their lives  and 7-10% suffer for at least 6 months or longer. , It is one of the most common reasons for physician visits in America.  The annual incidence of LBP in the adult US population is 5% and the National Institute of Neurological Disorders and Stroke (NINDS) estimates that Americans spend at least $50 billion each year on LBP. It is the most common cause of job-related disability and a leading contributor to missed work. Though an estimated 1.8 billion people per day of work are lost each year from back pain alone, it has been shown that this can be successfully treated through CAM. 
A Cochrane systematic review of three herbal medicines in randomized controlled trials found that 50 or 100mg of Harpagophytum procumbens (devil's claw) or Salix alba (white willow bark) in the form of 120 or 240mg salicin daily is superior to placebo in short-term pain relief for chronic LBP and equivalent to taking 12.5 mg of rofecoxib daily. Also, Capsicum frutescens (Cayenne) has shown moderately favorable results as a topical preparation against placebo; however, these trials were of low quality. 
Mind and body medicine
In a randomized trial comparing the effectiveness of yoga; stretching exercises; and a self-care book in the treatment of LBP, yoga, and conventional stretching exercises were comparable in improving function and reducing symptoms.  In another study, yoga was shown to be helpful as a preventive and therapeutic remedy for LBP.  All forms of acupuncture have been found to be effective in LBP. ,,, A number of randomized, sham-controlled clinical trials have shown that acupuncture is more effective in the treatment of chronic LBP when compared to no treatment or conventional treatment alone.  Two large German studies of 1,162 patients  and 3,093 patients  with chronic LBP found that real or sham acupuncture were both superior to conventional therapy. On the contrary, a meta-analysis of 6,539 patients who received real acupuncture, sham acupuncture, or no treatment revealed that real acupuncture is not superior to sham acupuncture in the treatment of chronic LBP.  Interestingly, back pain in individuals with psychological factors improved with acupuncture lending credibility to the motivating belief behind CAM that the mind does have considerable influence over our body's physiological condition.  A recent study found that 7 weeks of Hegu acupuncture was significantly more effective than standard acupuncture, especially in the long-term (48 weeks).  This evidence supports the use of acupuncture as an evidence-based, effective treatment option alongside conventional medical management. Physical, chiropractic, and osteopathic manipulation, which involve muscle stretching and traditional bone setting, have also been used in the treatment of chronic pain. ,, A randomized trial of 64 patients with chronic neck pain found a clinically significant functional improvement in those who received 10 massages over 10 weeks (39%) versus those who received a self-care book (14%).  The physiological process involves the activation of two to three dermatomes via reflex arcs, polysynaptic segmental reflexes, and gate control mechanisms.  The central mechanisms include various neurotransmitters and modulatory systems, relating the manipulation of certain microscopic elements of the anatomy to the overall patient improvement.  Fifty-five percent of the massage group patients also experienced improvement in the symptom bothersomeness scale versus 25% in the self-care book group. Follow-up after 26 weeks showed that massage group members still reported improved function over the self-care book group. This suggests that massage therapy is beneficial for the short-term alleviation of neck pain.
Other CAM practices
Electrical stimulation as in transcutaneous electric nerve stimulation (TENS) has been used in the treatment of chronic back pain and found to increase the production of endorphins. However, in a controlled trial of TENS and exercise for chronic LBP, TENS was not found to be more effective than placebo and provided no benefit when compared to exercise alone. 
Chronic neuropathic pain
Neurological pain experts have defined neuropathic pain as "pain arising as a direct consequence of a lesion or disease affecting the somatosensory system".  It is usually chronic and difficult to treat with conventional analgesics. Moreover, quality of life is significantly impaired and the burden on healthcare costs is higher in comparison to other chronic pain syndromes.  Various mind and body practices , have been used in the treatment of generalized neuropathy, reflex sympathetic dystrophy (RSD), toxic and nutritional neuropathies, multiple sclerosis, peripheral diabetic neuropathy, post herpetic neuralgia, other noncancer pain syndromes.
In a systematic review of six double-blinded placebo-controlled trials (n = 656), topical capsaicin was found to have a significant benefit in the treatment of chronic pain.  Moreover, with a number needed to treat of 5.7, it may be a useful adjunct or sole therapy for patients. Acetyl-L-carnitine was found to be effective in improving chronic pain symptoms of diabetic neuropathy in two randomized controlled trials.  Ware et al., reported that a single inhalation of 25 mg of 9.4% tetrahydrocannabinol herbal cannabis three times daily for 5 days reduced the intensity of pain. 
Mind and body medicine
Acupuncture has been found to be helpful in both acute and chronic painful conditions at regional and central levels. , The integration of behavioral and relaxation approaches including biofeedback were useful in reducing chronic pain (NIH Technology Assessment Panel). , Hypnotherapy on the other hand, has been successfully used in treating RSD  and neuralgic pain. 
The use of therapeutic massage has been proven to be helpful in treating pain due to osteoarthritis. 
Other CAM practices
Various forms of electrical stimulation have been used in chronic pain management, particularly in RSD.  Long-term use of TENS was found to be effective in chronic posttraumatic pain management. , Some studies to assess the efficacy of TENS demonstrated little evidence in chronic pain relief. , Pain related to diabetic neuropathy was shown to improve with TENS or percutaneous electric nerve stimulation (PENS) in three randomized controlled trials.  Biomagnetic therapy has also been used in treating chronic pain, particularly related to tissue ischemia and fibromyalgia with low frequency and low intensity magnetic energy. 
Pain is one of the biggest physiological and financial challenges in the care of cancer patients. With the overwhelming prevalence of Western medicine utilized to treat their primary pain, cancer patients may be led to treat the secondary adverse pain resulting from traditional treatment through CAM methods. It is possible that their lack of interaction with CAM therapies encourages the patient to try them, as they are dynamic in type as well as seemingly harmless in practice. The total cost of pain-related hospitalizations, emergency visits, and physician office visits was $12,000 per year per breakthrough pain (BTP) patient and $2,400 per year per non-BTP patient.  Most patients with cancer pain undergo conventional therapy and CAM therapies simultaneously. The National Cancer Institute (NCI) established an Office of Cancer Complementary and Alternative Medicine (OCCAM) in 1998 to coordinate and enhance the activities of NCI in the arena of CAM.
In a study of 2,466 cancer patients, a Taiwanese traditional herbal diet consisting of analgesic herbs like peony roots and licorice roots and a Taiwanese tonic vegetable soup made from Lilii bulbus, Nelumbo seeds, and Jujube fruits was found to alleviate cancer pain.  Additionally, herbal tea mixtures like Essiac and Flor-Essence were reported to improve quality of life, alleviate pain, and in some cases, impact cancer progression among cancer patients. However, there was no clinical evidence.  Cannabis and cannabinoids are the most commonly used products for cancer pain and palliative therapies.  Shen-Mai-San is a TCM composed of processed Ginseng radis, Liriope spicata, and Schizandrae fructus that is found to be effective for treating cancer-related fatigue. 
Mind and body medicine
Hypnosis has been found to be useful for cancer pain and nausea. In addition, relaxation therapy, music therapy, and massage for anxiety and acupuncture for nausea are beneficial.  In a randomized controlled trial, auricular acupuncture revealed a significant reduction in pain intensity when conventional therapy failed. Shiatsu represents a group of manual therapeutic techniques, including acupressure. It offers cancer patients a nonpharmacologic method to relieve symptoms and improve quality of life throughout the course of illness. It is relatively effective and safe for other associated symptoms such as fatigue, muscular pain, and body image dissatisfaction.  Syrjala et al., concluded that relaxation and imagery training reduces cancer-related pain. 
Other CAM practices
Patients suffering from cancer pain often resort to nonconventional CAM therapies in order to alleviate their suffering. Some prefer spiritual counseling and prayer, while others prefer music or pet therapies.
| Discussion|| |
The growing prevalence of CAM therapies in the treatment of pain disorders suggests an increasing effectiveness in both preventing and treating headaches, lumbago, cervical pain, chronic neuropathic pain, and cancer-related pain. Its healing influence extends into the future care of the patient, as carefully monitored CAM therapies have been bereft of any harmful adverse effects, such as physiological dependence or psychological disturbance. Unlike conventional therapies for chronic pain management, patients have an opportunity to discontinue therapy if they fail to see clinical improvement without any concerns for drug dependence. Ultimately, CAM therapies have the potential to work in collaboration with pharmacological approaches, as long as there is a careful watch over the interaction between therapies. Furlan et al., who studied the efficacy, side effects, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) in treating cervical pain and lumbago found that all of the CAM remedies were significantly and equally efficacious in reducing both immediate and short-term pain. 
In light of promising research pronouncing the efficacy of CAM, terminally-ill cancer patients most commonly utilize biologically based therapies (especially dietary supplements) followed by alternative medical systems and mind-body interventions.  Conversely, recent phase I studies with advanced cancer patients have also shown that biologically based CAM was associated with poorer overall quality of life.  Other research targeting various forms of CAM has presented acupuncture as a safe and effective treatment for controlling pain, nausea, vomiting, and vasomotor symptoms associated with cancer and chemotherapy. As another potential CAM treatment, the mind-body practice of yoga can also assist in enhancing emotional well-being and delay further deterioration.  Supporting the view that cooperation between both types of therapies is most effective, a unique combination of Pan-Asian medicine and vitamins in collaboration with conventional therapy has shown improved survival when compared to conventional therapy alone.
CAM therapies have already been integrated into Western culture as demonstrated in a number of studies. This overall trend favoring CAM over traditional treatment supports the notion that the increasing prevalence of CAM therapies may be due to their superior effectiveness to traditional therapies.
Interestingly, the level of pain is the only consistent predictor of both the likelihood of trying CAM and how many types of CAM are used. Based on the results reported by Ayers and Kronenfeld, it was found that the frequency of use of CAM therapies corresponds with the severity of pain felt by the individual. The probability of people using CAM and variance of CAM therapies utilized increased as the level of pain progressed to a higher intensity. Only spiritual healing in the form of prayer and the number of CAM types used for chronic illnesses were found to be statistically significant in the reduction of pain. 
However, despite these promising results and the fact that many CAM therapies are low risk, there exists a danger when combining CAM and conventional therapies. Specifically, there is a possible fatal ramification when allowing herbal supplements to be a part of normal clinical treatment, such as prescription drugs. A particular risk arises when, due to the wide conception that a natural supplement is harmless, patients do not discuss with their primary physician regarding their decision to use herbal supplements. Unaware of this fact, many prescription drugs can have deleterious effects when combined with certain herbs.  In a study of 318 cancer patients, 51.6% admitted to taking natural herbs and food supplements like Siberian ginseng, kava kava, and evening Primrose oil.  These supplements were associated with risks of changes in blood pressure, hepatotoxicity, and seizures, respectively, especially when doses were not properly monitored. The possibility of harm due to lack of regulation of the herbal supplement, compounded with a lack of dialogue with a physician, and the misconception that anything natural will be risk free, has led to the multitude of risks associated with CAM therapies. These contrasting studies have thus led to an overall preference for clinical treatments as the principal form of treatment, rather than CAM therapies, which would assist later on given that severity of pain has increased. Furthermore, many people may sway in their decision to use CAM due to the lack of evidence. While there may be studies in accordance with the benefits of CAM, the test subjects are often small in number, and thus not as objective as needed.
| Conclusion|| |
Chronic pain is a severe and continuously growing problem both domestically in the United States as well as globally. Given its varying degrees of intensity, pain has resulted in a wide spectrum of disabilities, significantly impacting the economy in terms of cost of medical care and loss of productivity. Unfortunately, many of these problems consisting of severe chronic pain are not adequately relieved through modern allopathic treatment. As a further burden, conventional medical treatment is also expensive and associated with adverse effects. Given these common frustrations, patients tend to seek other forms of alternative treatment without informing their primary care physicians or specialists. The NCCAM classifies the various CAM modalities and recognizes the significance and potential of these nonconventional therapies in providing efficacious and cost-effective management of various painful conditions, coinciding with the rise in popularity of this type of treatment.
Not surprisingly, the use of CAM therapies for pain management has become a rapidly growing trend. There were 630 million documented visits to CAM providers in 1997, compared with only 430 million visits to primary care physician. Furthermore, some visits to CAM practitioners remain undocumented. This rapid inflation in CAM treatment has had impacts in healthcare policy. For example, more than 65% of health maintenance organizations (HMOs) cover at least one form of CAM, with chiropractic care being the most frequently covered. However, due to the popularity of massage, yoga, acupuncture, homeopathy, biofeedback, diet, and herbal therapies; some insurers are beginning to cover these as well. In contrast to most conventional therapies which focus their efforts on relieving the physiological origin of pain, healing through CAM focuses on the physical, psychological, and spiritual needs of patients. In general, the users of CAM therapies do not reject conventional therapies; rather they add CAM therapies in addition to them, and the combination can often have damaging side effects. Even though preliminary studies have shown the utility of some CAM modalities, there is a lack of clear scientific evidence-based standardization in the practice of alternative medicine. Despite this, patients continue to seek pain relief by using herbal medicines, acupuncture and manipulative medicine, yoga, mind - body medicine, electromagnetic medicine, etc. There is a need for further studies to elucidate the mode of action and to scientifically validate the usefulness of CAM methodologies. Neuroscientists, clinical neurologists, neurosurgeons, and other clinicians interested in pain should be actively involved in these studies to further development and productive collaboration, ultimately increasing the sample size in studies and providing a greater awareness for potential side effects when using not only CAM but traditional therapies as well. Most importantly, well-designed clinical trials and health services research studies are required for further development to investigate this rapidly growing trend. While these therapies can be seen to be in conflict with Western medicine, CAM therapies ultimately reveal the true intention of medical care: Treat the person not the disease.
| References|| |
Jacobson L, Mariano A. General considerations of chronic pain. In: Loeser J, editor. Bonica′s Management of Pain. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 241-54.
Romano JM, Turner JA. Chronic pain and depression: Does the evidence support a relationship? Psychol Bull 1985;97:18-34.
Assefi N, Bogart A, Goldberg J, Buchwald D. Reiki for the treatment of fibromyalgia: A randomized controlled trial. J Altern Complement Med 2008;14:1115-22.
Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ 2009;339:b3002.
Asher GN, Jonas DE, Coeytaux RR, Reilly AC, Loh YL, Motsinger-Reif AA, et al
. Auriculotherapy for pain management: A systematic review and meta-analysis of randomized controlled trials. J Altern Complement Med 2010;16:1097-108.
Hemmilä HM, Keinänen-Kiukaanniemi SM, Levoska S, Puska P. Does folk medicine work? A randomized clinical trial on patients with prolonged back pain. Arch Phys Med Rehabil 1997;78:571-7.
Brunelli B, Gorson KC. The use of complementary and alternative medicines by patients with peripheral neuropathy. J Neurol Sci 2004;218:59-66.
Nahin RL, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Rep 2009:1-14.
Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al
. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-75.
Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis A randomized controlled trial. Neurology 1998;50:466-70.
Lawrence EC. Diagnosis and management of migraine headaches. South Med J 2004;97:1069-77.
Gaul C, Schmidt T, Czaja E, Eismann R, Zierz S. Attitudes towards complementary and alternative medicine in chronic pain syndromes: A questionnaire-based comparison between primary headache and low back pain. BMC Complement Altern Med 2011;11:89.
Ossendorf A, Schulte E, Hermann K, Hagmeister H, Schenk M, Kopf A, et al
. Use of complementary medicine in patients with chronic pain. Eur J Integr Med 2009;1:93-8.
Achterberg J, Dossey L, Gordon JS, et al
. Mind-Body Interventions. In: Alternative Medicine: Expanding Medical Horizons. A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States, prepared under the auspices of the Workshop on Alternative Medicine, Chantilly, Virginia, September 14-16, 1992. Chantilly, Virginia: NIH Publication # 94-066; 1992.
Johnson ES, Kadam NP, Hylands DM, Hylands PJ. Efficacy of feverfew as prophylactic treatment of migraine. Br Med J (Clin Red Ed) 1985;291:569-73.
Murphy JJ, Heptinstall S, Mitchell JR. Randomised double-blind placebo-controlled trial of feverfew in migraine prevention. Lancet 1988;332:189-92.
Mackenzie S. Indian Hemp in persistent headache. JAMA 1887;9:731-2.
Robbins MS, Tarshish S, Solomon S, Grosberg BM. Cluster attacks responsive to recreational cannabis and dronabinol. Headache 2009;49:914-6.
Blanchard EB. Biofeedback and its role in the treatment of pain. In Proceedings of NIH Technology Assessment Conference: Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia, NIH Washington, DC, 1995. p. 33-8.
Sun-Edelstein C, Mauskop A. Alternative headache treatments: Nutraceuticals, behavioral and physical treatments. Headache 2011;51:469-83.
Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med 1985;8:163-90.
Pintov S, Lahat E, Alstein M, Vogel Z, Barg J. Acupuncture and the opioid system: Implications in management of migraine. Pediatr Neurol 1997;17:129-33.
Wang LP, Zhang XZ, Guo J, Liu HL, Zhang Y, Liu CZ, et al
. Efficacy of acupuncture for migraine prophylaxis: A single-blinded, double-dummy, randomized controlled trial. Pain 2011;152:1864-71.
Baischer W. Acupuncture in migraine: Long-term outcome and predicting factors. Headache 1995;35:472-4.
Pomeranz B. Scientific research into acupuncture for the relief of pain. J Altern Complement Med 1996;2:53-60.
Olusanya O, Mansuri I. Pneumothorax following acupuncture. J Am Board Fam Pract 1997;10:296-7.
Chen CY, Liu GC, Sheu RS, Huang CL. Bacterial meningitis and lumbar epidural hematoma due to lumbar acupunctures: A case report. Kaohsiung J Med Sci 1997;13:328-31.
List T, Helkimo M. Acupuncture in the treatment of patients with chronic facial pain and mandibular dysfunction. Swed Dent J 1987;11:83-92.
Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1346-53.
Andersson GB. Epidemiological features of chronic low-back pain. Lancet 1999;354:581-5.
Speed C. Low back pain. BMJ 2004;328:1119-21.
Berman BM, Swyers JP. Establishing a research agenda for investigating alternative medical interventions for chronic pain. Prim Care 1997;24:743-58.
Gagnier JJ, van Tulder MW, Berman B, Bombardier C. Herbal medicine for low back pain: A cochrane review. Spine 2007;32:82-92.
Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, et al
. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med 2011;171:2019-26.
Birch S, Hammerschlag R, Berman BM. Acupuncture in the treatment of pain. J Altern Complement Med 1996;2:101-24.
Morris MM. Overview of acupuncture in chronic pain clinical research. J Altern Complement Med 1996;2:125-7.
Melzack R, Jeans ME, Stratford JG, Monks RC. Ice massage and transcutaneous electrical stimulation: Comparison of treatment for low-back pain. Pain 1980;9:209-17.
Diehl DL, Kaplan G, Coulter I, Glik D, Hurwitz EL. Use of acupuncture by American physicians. J Altern Complement Med 1997;3:119-26.
Berman BM, Langevin HM, Witt CM, Dubner R. Acupuncture for chronic low back pain. N Engl J Med 2010;363:454-61.
Haake M, Muller HH, Schade-Brittinger C, Basler HD, Schäfer H, Maier C, et al
. German Acupuncture Trials (GERAC) for chronic low back pain: Randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med 2007;167:1892-8.
Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, et al
. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487-96.
Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: A systematic review. Spine (Phila Pa 1976) 2008;33:E887-900.
Elkayam O, Ben Itzhak S, Avrahami E, Meidan Y, Doron N, Eldar I, et al
. Multidisciplinary approach to chronic back pain: Prognostic elements of the outcome. Clin Exp Rheumatol 1996;14:281-8.
Yun M, Shao Y, Zhang Y, He S, Xiong N, Zhang J, et al
. Hegu acupuncture for chronic low-back pain: A randomized controlled trial. J Altern Complement Med 2012;18:130-6.
Sherman RA, Arena JG. Biofeedback in the assessment and treatment of low back pain. In: Bazmajian J, Nyberg R, eds. Spinal manipulative therapies. Baltimore: Williams & Wilkins, 1992:177-97.
Laitinen J. Acupuncture and transcutaneous electric stimulation in the treatment of chronic sacrolumbalgia and ischialgia. Am J Chin Med 1976;4:169-75.
Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain 2009;25:233-8.
Melzack R, Wall PD. Pain mechanisms: A new theory. Science 1996;150:971-9.
Toomey TC, Ghia JN, Mao W, Gregg JM. Acupuncture and chronic pain mechanisms: The moderating effects of affect, personality, and stress on response to treatment. Pain 1977;3:137-45.
Pioro-Boisset M, Esdaile JM, Fitzcharles MA. Alternative medicine use in fibromyalgia syndrome. Arthritis Care Res 1996;9:13-7.
Clifford JC. Successful management of chronic pain syndrome. Can Fam Physician 1993;39:549-59.
Fusco BM, Giacovazzo M. Peppers. The promise of capsaicin. Drugs 1997;53:909-14.
Turner JA, Romano JM. Evaluating psychological interventions for chronic pain: issues and recent developments. In Advances in Pain Research and Therapy, Vol. 7 (ed. C. Benedetti, CR Chapman, G. Moricca) Raven Press, New York: 1984, p. 257-97.
Mason L, Moore RA, Derry S, Edwards JE, McQuay HJ. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ 2004;328:991.
Evans JD, Jacobs TF, Evans EW. Role of acetyl-L-carnitine in the treatment ofdiabetic peripheral neuropathy. Ann Pharmacother 2008;42:1686-91.
Ware MA, Wang T, Shapiro S, Robinson A, Ducruet T, Huynh T, et al
. Smoked cannabis for chronic neuropathic pain: A randomized controlled trial. CMAJ 2010;182:E694-701.
Wang E, Saxena M. Acupuncture for neuropathic pain in adults. Cochrane Database Syst Rev 2011;2011:CD008988.
Reports OoSaH. Chronic pain - hope through recovery. In: U.S. Department of Health and Human Services Public Health Service NIoH, editor. NIH Publications; 1989. p. 31-8.
Gainer MJ. Hypnotherapy for reflex sympathetic dystrophy. Am J Clin Hypn 1992;34:227-32.
Sacerdote P. Teaching self-hypnosis to patients with chronic pain. J Human 1978;4:18-21.
Eckes Peck SD. The effectiveness of therapeutic touch for decreasing pain in elders with degenerative arthritis. J Holistic Nurs 1997;15:176-98.
Mehta M. Alternative methods of treating pain. Anaesthesia 1978;33:258-63.
Kumar A, Tandon OP, Bhattacharya A, Gupta RK, Dhar D. Somatosensory evoked potential changes following electro-acupuncture therapy in chronic pain patients. Anaesthesia 1995;50:411-4.
Fried T, Johnson R, McCracken W. Transcutaneous electrical nerve stimulation: Its role in the control of chronic pain. Arch Phys Med Rehabil 1984;65:228-31.
Lehmann TR, Russell DW, Spratt KF, Colby H, Liu YK, Fairchild ML, et al
. Efficacy of electroacupuncture and tens in the rehabilitation of chronic low back pain patients. Pain 1986;26:277-90.
Macdonald AJ, Macrae KD, Master BR, Rubin AP. Superficial acupuncture in the relief of chronic low back pain. Ann R Coll Surg Engl 1983;65:44-6.
Pittler MH, Ernst E. Complementary therapies for neuropathic and neuralgic pain: Systematic review. Clin J Pain 2008;24:731-3.
Fitzcharles MA, Esdaile JM. Nonphysician practitioner treatments and fibromyalgia syndrome. J Rheumatol 1997;24:937-40.
Fortner BV, Okon TA, Portenoy RK. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain 2002;3:38-44.
Wu TH, Chiu TY, Tsai JS, Chen CY, Chen LC, Yang LL. Effectiveness of Taiwanese traditional herbal diet for pain management in terminal cancer patients. Asia Pac J Clin Nutr 2008;17:17-22.
Tamayo C, Richardson MA, Diamond S, Skoda I. The chemistry and biological activity of herbs used in Flor-Essence herbal tonic and Essiac. Phytother Res 2000;14:1-14.
Bowles DW, O′Bryant CL, Camidge DR, Jimeno A. The intersection between cannabis and cancer in the United States. Crit Rev Oncol Hematol 2012;83:1-10.
Lo LC, Chen CY, Chen ST, Chen HC, Lee TC, Chang CS. Therapeutic efficacy of traditional Chinese medicine, Shen-Mai San, in cancer patients undergoing chemotherapy or radiotherapy: Study protocol for a randomized, double-blind, placebo-controlled trial. Trials 2012;13:232.
Vickers AJ, Cassileth BR. Unconventional therapies for cancer and cancer-related symptoms. Lancet Oncol 2001;2:226-32.
Argash O, Caspi O. Touching cancer: Shiatsu as complementary treatment to support cancer patients. Harefuah 2008;147:707-11, 750, 749.
Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: A controlled clinical trial. Pain 1995;63:189-98.
Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, et al
. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139.
Yun YH, Lee MK, Park SM, Kim YA, Lee WJ, Lee KS, et al
. Effect of complementary and alternative medicine on the survival and health-related quality of life among terminally ill cancer patients: A prospective cohort study. Ann Oncol 2013;24:489-94.
Ayers SL, Kronenfeld JJ. Using zero-inflated models to explain chronic illness, pain, and complementary and alternative medicine use. Am J Health Behav 2011;35:447-57.
Skovgaard L, Pedersen IK, Verhoef M. Use of bodily sensations as a risk assessment tool: Exploring people with Multiple Sclerosis′ views on risks of negative interactions between herbal medicine and conventional drug therapies. BMC Complement Alternat Med 2014;14:59.
Werneke U, Earl J, Seydel C, Horn O, Crichton P, Fannon D. Potential health risks of complementary alternative medicines in cancer patients. Br J Cancer 2004;90:408-13.