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December 2002


Ancient Healing

By Renee Diiulio



Jeffrey Y.F. Ngeow, MD, uses acupuncture for pain treatment.

It stings. It aches. It burns. It hurts. There are many different types of pain, but perhaps the worst is chronic pain—the kind that just does not go away, the kind that stays with the patient, restricting his or her freedom. Those suffering from chronic pain must learn to manage it, to live with it. According to the American Academy of Pain Management, pain management is:

  • the systematic study of clinical and basic science and its application for the reduction of pain and suffering;
  • the blending of tools, techniques, and principles taken from the discrete healing arts disciplines and reformulated as a holistic application for the reduction of pain and suffering; and
  • a newly emerging field emphasizing an interdisciplinary approach with a goal of reduction of pain and suffering.1


ALTERNATIVE TREATMENT METHODS

The fields contributing to the management of chronic pain are not solely the newer methods so popular in Western medicine, but rather reflect older, traditional approaches as well. Alternative pain management modalities include acupuncture, physical therapy, massage, chiropractic, meditation, yoga, pilates, tai chi, stress management techniques, and psychotherapy.

All can be incorporated into a chronic pain treatment program by rehab professionals, according to Liz Van Wilgen, MSPT, a senior PT at the Integrative Care Center (ICC) of the Hospital for Special Surgery (HSS), New York.

The center opened in October 2001 to provide complementary care as an extension of traditional physician treatment to patients with osteoarthritis, rheumatoid arthritis, osteoporosis, tendonitis, low back pain, fibromyalgia, and other musculoskeletal conditions. The ICC differentiates between alternative, complementary, and integrative medicine, defining “alternative” as medicine that is practiced instead of conventional medicine; “complementary care” as that used in conjunction with conventional medicine; and “integrative care” as a combination of conventional and unconventional therapies, based on efficacy and safety.

Traditional methods offered by the ICC cover a variety of orthopedic and rheumatologic services and a range of physical therapy programs, for both individuals and groups. According to the center, the alternative care techniques used there are effective, safe, and evidence-based, and encompass mind-body therapy, acupuncture, massage therapy, and rehabilitation services.

In addition to providing integrative care, the center also aims to conduct research on the efficacy of these modalities in conjunction with, or independent of, conventional medicine. As they become proven, they gain greater acceptance in Western medicine. These programs are increasingly appearing in insurance policies, and patients can receive reimbursement for care. Some coverage will even contribute to gym memberships or yoga classes.

According to a California-based Landmark Report issued in 1999, 67% of health maintenance organizations offer at least one form of complementary alternative care.2 Another study found that 56% of Americans surveyed believe their health plans should cover alternative therapies.2

DETAILS, DETAILS…

Patients should take their insurance programs’ reimbursement policies into consideration when developing a pain management program with their provider. No two programs are alike. “Each case is treated on an individual basis,” says Van Wilgen. “We are not a chronic pain center, but if we find that an alternative method is appropriate, we will refer the patient on an individual basis to a provider in that discipline.”

In some instances, however, the patient will not need to be referred out. Jeffrey Y.F. Ngeow, MD, is the associate attending anesthesiologist at the HSS, as well as a clinical associate professor of anesthesiology at the Weill Medical College of Cornell University. Ngeow’s specialty is anesthesiology and pain management, and he is particularly interested in interventional pain management related to the musculoskeletal system. Certified with the American Board of Pain Medicine and the American Board of Anesthesiology, through which he has also added qualifications in pain management, Ngeow has completed a certificate program in acupuncture at the American Academy of Acupuncture in New York.

Certification is not required for all alternative methods, and even acupuncture has different programs for MDs and practitioners with no medical degree: medical doctors are certified; others are licensed. However, medical schools are increasingly offering courses in complementary and alternative medicine or CAM. According to a study by Wetzel et al in the September 2, 1998, issue of JAMA, 64% of medical schools in the United States offer coursework in this field. The majority of the 123 reported courses were stand-alone electives, but 31% were part of required courses.2

Van Wilgen suggests that medical professionals serious about incorporating different forms of treatment, particularly exercise, will benefit from further training. Yoga, tai chi, and pilates utilize precise movements to work different muscles and require this knowledge to be used effectively.

Yoga relies on breathing and posture to stretch and strengthen muscles all over the body, particularly the back. Balance, focus, and endurance are built with practice, which can be tailored for an individual. Tai chi improves mobility and balance by combining meditation with slow, circular motions. The positioning and movements strengthen the muscles, which is beneficial for those with osteoporosis, and relieves stiffness, a benefit for arthritis patients. Pilates targets the core muscles of the body—the abdominals, lower back, thighs, and buttocks—with slow and precise movements. Posture is improved, creating a healthier back.

Patients practicing these forms of exercise will need to invest some time before seeing results. Ngeow says the same of acupuncture. “It is important to manage a patient’s expectations when turning to alternative therapies,” he says. “Patients will expect miracles and be disappointed when they do not occur.”

STICKING TO IT

Rooted in ancient China, acupuncture utilizes procedures that involve stimulation of anatomical locations on the skin by a variety of techniques, most frequently the insertion of very thin metal needles into the skin. Placed precisely on the body, these needles are then stimulated electrically or manually. According to the ICC, electroacupuncture appears to be superior to manual acupuncture, and its safety profile is considered better compared to that of many standard therapies. Whether through biological mechanisms, as Western doctors have theorized, or through the rebalancing of chi, as alternative practitioners believe, acupuncture has long been used to treat pain in addition to other ailments.

According to Ngeow, the modality works best when the symptoms requiring pain treatment are incidental or it is the natural progression of the condition to recover. He says acupuncture can help speed the recovery process for headaches, inflamed joints, acute infections, asthma attacks, and tendonitis. Conditions of a shorter nature, such as a migraine or flareup of tennis elbow, may require only one or two treatments before relief is felt, but longer-lasting afflictions may take six or seven visits before results are seen.

Patients with more chronic conditions, such as chronic rheumatoid arthritis, chronic asthma, dermatosis, and muscle atrophy due to damaged nerves or spinal cord paralysis, should not expect acupuncture to eliminate the pain, Ngeow says. For these patients, the method should be incorporated into their overall treatment plan to help them tolerate the pain.

“Patients have come to expect miracles of acupuncture because they have seen it touted as a surgical anesthetic in the media or in tourist visits to Chinese hospitals. These cases, however, are very specialized. Not only must the patient be able to tolerate the treatment, but two to four acupuncturists must be present during the entire surgery to twirl the needles. It’s very labor-intensive and not cost-effective,” says Ngeow. “Acupuncture can be powerful, but it must be given time to work.”

If, however, the patient has experienced no relief after six or seven visits and wishes to discontinue treatment, Ngeow will support that decision. “Acupuncture functions with a cumulative effect. It typically takes four or five treatments before results are seen, and if patients drop out too early, they may be disappointed. But after six or seven visits with no results, it is likely that the patient will never benefit from acupuncture for that ailment,” he says.

Ngeow often uses the method as an adjunct to treatment. “Some conventional methods work for only a short time. For instance, epidural injections wear off after 3 months. Certain patients, such as diabetics, need to keep to a regimented injection schedule, meaning if the pain returns too quickly, they must endure it until the next shot. Acupuncture can act as a bridge, reducing the pain the patient feels. As the pain eases, the muscles become less tense, causing fewer muscle spasms,” says Ngeow.

Many patients, however, do not know the treatment’s relevance to their conditions. They know it exists, but not how it works. Ngeow will recommend treatments to those who ask and those who don’t. “If it can help them, they should try it,” he says.

This attitude is becoming more prevalent in the treatment of chronic pain, and as long as patients act under the advice of a physician, the philosophy may provide them with some relief.

Renee Diiulio is a contributing writer for Rehab Management.

References
  1. American Academy of Pain Management. What Is Pain Management? Available at: www.aapainmanage.org/aapm/ whatis.html. Accessed October 22, 2002.
  2. Foundation for the Advancement of Innovative Medicine. CAM Facts. Available at: www.faim.org/facts.htm. Accessed October 22, 2002.

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