Table Of ContentIntegrative 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
