Data from a review of U.S.-based clinical trials published in Mayo Clinic Proceedings suggest that some of the most popular complementary health approaches — such as yoga, tai chi, and acupuncture — appear to be effective tools for helping to manage common pain conditions. The review was conducted by a group of scientists from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health.
Millions of Americans suffer from persistent pain that may not be fully relieved by medications. They often turn to complementary health approaches to help, yet primary care providers have lacked a robust evidence base to guide recommendations on complementary approaches as practiced and available in the United States. The new review gives primary care providers — who frequently see patients with chronic pain — tools to inform decision-making on how to help manage that pain.
“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects. As a result, many people may turn to nondrug approaches to help manage their pain,” said Richard L. Nahin, Ph.D., NCCIH’s lead epidemiologist and lead author of the analysis. “Our goal for this study was to provide relevant, high-quality information for primary care providers and for patients who suffer from chronic pain.”
The researchers reviewed 105 U.S.-based randomized controlled trials, from the past 50 years, that were relevant to pain patients in the United States and met inclusion criteria. Although the reporting of safety information was low overall, none of the clinical trials reported significant side effects due to the interventions.
The review focused on U.S.-based trial results on seven approaches used for one or more of five painful conditions — back pain, osteoarthritis, neck pain, fibromyalgia, and severe headaches and migraine — and found promise in the following for safety and effectiveness in treating pain:
Acupuncture and yoga for back pain
Acupuncture and tai chi for osteoarthritis of the knee
Massage therapy for neck pain with adequate doses and for short-term benefit
Relaxation techniques for severe headaches and migraine.
Though the evidence was weaker, the researchers also found that massage therapy, spinal manipulation, and osteopathic manipulation may provide some help for back pain, and relaxation approaches and tai chi might help people with fibromyalgia.
“These data can equip providers and patients with the information they need to have informed conversations regarding non-drug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH. “It’s important that continued research explore how these approaches actually work and whether these findings apply broadly in diverse clinical settings and patient populations.”
Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings, 2016;91(9):1292-1306 DOI: 10.1016/j.mayocp.2016.06.007
Hip strengthening exercises performed by female runners not only significantly reduced patellofemoral pain — a common knee pain experienced by runners — but they also improved the runners’ gaits, according to Indiana University motion analysis expert Tracy Dierks.
“The results indicate that the strengthening intervention was successful in reducing pain, which corresponded to improved mechanics,” said Dierks, associate professor of physical therapy in the School of Health and Rehabilitation Sciences at Indiana University-Purdue University Indianapolis. “The leg was going through more motion, suggesting that the (pain) guarding mechanism was reduced, and coordination or control of many of these peak or maximum angles in the leg were improved in that they were getting closer to occurring at the same time.”
Only in recent years have researchers begun studying the hips as a possible contributor to patellofemoral pain (PFP). This study is the first to focus on hip strength and gait changes during prolonged running. Dierks, director of the Motion Analysis Research Laboratory at IUPUI, discussed his findings at the American College of Sports Medicine annual meeting in Denver.
The runners in Dierks’ study received no training or coaching on proper running form, which makes the improvements more notable. The improvements in mechanics resembled those of uninjured runners, when muscles, joints and limbs move economically and in synch with each other.
About the study
The study involved four runners and a control group comprising another four runners. Hip strength measurements and kinematic data — minute measurements of how the women’s hips, knees and shin bones moved and rotated while they ran — were taken before and after the runners in the control group maintained their normal running schedule for six weeks. The measurements were repeated for all of the runners before and after the next six-week period in which they all performed the hip-strengthening exercises.
The exercises, performed twice a week for around 30 to 45 minutes, involved single-leg squats and exercises with a resistance band, all exercises that can be performed at home. This study is part of an ongoing study involving hip exercises and PFP pain, with 10 runners successfully using the intervention.
After the six-week program, the movement of the hips and knees in relation to each other improved for both groups of runners, demonstrating increases in joint angles between the foot, shin and thigh.
The study used a pain scale of zero to 10, with 3 representing the onset of pain and 7 representing very strong pain — the point at which the runners normally stop running because the pain is too great. The injured runners began the six-week trial registering pain of 7 when they ran on a treadmill and finished the study period registering pain levels of 2 or lower; i.e. no onset of pain.
PFP, one of the most common running injuries, is caused when the thigh bone rubs against the back of the knee cap. Runners with PFP typically do not feel pain when they begin running, but once the pain begins, it gets increasingly worse. Once they stop running, the pain goes away almost immediately. Dierks said studies indicate PFP essentially wears away cartilage and can have the same effect as osteoarthritis. His study participants showed many of the classic signs of PFP, the most prominent being their knees collapsing inward when running or doing a squat exercise move.
Co-authors of “The Effect Of Hip Muscle Strengthening On Pain and Running Mechanics In Females With Patellofemoral Pain” are Rebecca L. Phipps, Ryan E. Cardinal, Peter A. Altenburger, IUPUI.
The above post is reprinted from materials provided by Indiana University.
To understand why back pain recurs, we need to first look at why pain occurs to begin with and then how back pain physiotherapy can help. Back pain generally stems from some form of trauma or loading placed on your back, which may occur as a one off incident or be repetitive loading over time. Normally your core muscles will control your spine and allow an even distribution of load in the appropriate tissues. However, in an acute incident or with poor biomechanical control these muscles will not be able to withstand the load placed on them and trauma will occur. This trauma may cause damage to the tissues within your spine including the disc, joints and muscles.
It is essential to determine how and why the injury occurred
Once your back has been subjected to trauma the damage sustained may alter thestructure of your spine, including arthritis within the joints, disc disruption or bone alignment. Whilst physiotherapy will aim to alleviate your pain, regain full spinal movement and prevent further spinal damage it is important to determine why the injury occurred to understand the underlying cause and surrounding factors so that the same incident is not replicated and your back can be appropriately managed in the long term. The most important aspects of this management include altering your biomechanics to optimise your back function, modifying any activities which may aggravate your back, having optimal sleep postures and implementing an exercise routine including stretches and strengthening to maintain appropriate muscular stability and flexibility.
Biomechanical corrections are vital
Biomechanical corrections are vital to allow appropriate load distribution throughout the spinal column. The spinal column is very long, thin and has attachments to the other major structural components within your body. There are many different muscles which attach to it which can pull each individual spinal segment in a different direction. Those with back pain will often be overactive in particular muscle groups and under active in others, particularly their ‘core’ muscles. Your physiotherapist is likely to discuss these with you and may make alterations depending on your particular posture. It is important that following your treatment you continue to maintain these alterations. This may mean the need to continue stretches and specific strengthening exercises longer term to prevent reverting back to previous postures.
Activity modification is often required
Activity modification is often required to prevent re-injuring your back after your injury. Most people will have specific movements or activities which will cause them pain during the recovery from a back injury. It is important to take note of these activities and understand why they are painful so that once your pain is gone you are still aware of activities which are most likely to cause you pain in the future. You may need to modify these activities to prevent ongoing loading of your spine in a particular way, such as changing your work setup so you don’t have to lift from the ground repetitively or altering your desk setup so you can sit or stand during the day to prevent stiffness and slumped spinal postures. And it is important to remember, that whilst you don’t have pain currently, factors that contributed to a back injury in the first place are likely to be the contributing factors in recurrence of an injury.
Sleep postures are vital in the care of your back as such a large proportion of your life is spent in bed. It is important to maintain a neutral spinal position, where your spinal is relatively flat and straight, to prevent unnecessary stress being placed on particular spinal segments. You should make sure that your back has appropriate support from your mattress and pillow and that these are replaced and turned regularly to maintain their optimal shape.
Exercise is a necessary long term part of treatment
Exercise is likely to be given to you as part of your treatment for your back injury and should become part of your long term management. This may include a combination of stretches and strengthening exercises which are required to maintain your spinal alignment and prevent you from reverting back to your previous posture and biomechanics. Clinical Pilates or specific gym exercises are a great medium for this, particularly in a supervised environment where your physiotherapist is able to monitor your posture and positioning at all times to gain the most benefit. Hydrotherapy is also a fantastic way to complete your rehabilitation due to the reduced weight bearing placing less impact on the affected areas and allowing greater flexibity in the warm water. By completing these structured programs the resistance, intensity and difficulty can be regularly monitored and adjusted for people at all stages of rehabilitation.
Seek early intervention if pain recurs
If you feel like your back pain is recurring it is important to seek early intervention. Your physiotherapist will be able to analyse your symptoms and resolve your pain much more quickly if you return earlier and have less associated tissue involvement.
Exercise therapy is as effective as surgery for middle aged patients with a common type of knee injury known as meniscal tear (damage to the rubbery discs that cushion the knee joint), finds a study in The BMJ this week.
The researchers suggest that supervised exercise therapy should be considered as a treatment option for middle aged patients with this type of knee damage.
Every year, an estimated two million people worldwide undergo knee arthroscopy (keyhole surgery to relieve pain and improve movement) at a cost of several billion US dollars. Yet current evidence suggests that arthroscopic knee surgery offers little benefit for most patients.
So researchers based in Denmark and Norway carried out a randomised controlled trial to compare exercise therapy alone with arthroscopic surgery alone in middle aged patients with degenerative meniscal tears.
A randomised controlled trial is one of the best ways for determining whether an intervention actually has the desired effect.
They identified 140 adults (average age 50 years) with degenerative meniscal tears, verified by MRI scan, at two public hospitals and two physiotherapy clinics in Norway. Almost all (96%) participants had no definitive x-ray evidence of osteoarthritis.
Half of the patients received a supervised exercise programme over 12 weeks (2-3 sessions each week) and half received arthroscopic surgery followed by simple daily exercises to perform at home.
Thigh muscle strength was assessed at three months and patient reported knee function was recorded at two years.
No clinically relevant difference was found between the two groups for outcomes such as pain, function in sport and recreation, and knee related quality of life. At three months, muscle strength had improved in the exercise group.
No serious adverse events occurred in either group during the two-year follow-up. Thirteen (19%) of participants in the exercise group crossed over to surgery during the follow-up period, with no additional benefit.
“Supervised exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term,” say the authors. “Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no radiographic evidence of osteoarthritis to consider supervised structured exercise therapy as a treatment option.”
How did this situation — widespread practice without supporting evidence of even moderate quality — come about, ask two experts in a linked editorial? “Essentially, good evidence has been widely ignored,” say Teppo Järvinen at the University of Helsinki and Gordon Guyatt at McMaster University in Canada.
“In a world of increasing awareness of constrained resources and epidemic medical waste, what we should not do is allow the orthopaedic community, hospital administrators, healthcare providers, and funders to ignore the results of rigorous trials and continue widespread use of procedures for which there has never been compelling evidence,” they conclude.
1.Nina Jullum Kise, May Arna Risberg, Silje Stensrud, Jonas Ranstam, Lars Engebretsen, Ewa M Roos. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ, 2016; i3740 DOI: 10.1136/bmj.i3740