Alternatives and Controversies for Pain Management in the Elderly

Introduction

In addition to medications for relieving pain, elderly patients are increasingly turning to complementary and alternative therapies. A myriad of different options exists with varying claims of effectiveness in the management of pain, but most have had scant evidence to support their use. Since the establishment of the National Center for Complementary and Alternative Medicine (NCCAM) in 1998, however, a steadily growing body of literature has emerged, bringing larger-scale clinical trials that finally meet the scientific rigor necessary to make evidence-based recommendations for the treatment of pain. The two standout modalities for discussion in this article are spinal manipulation (a general term encompassing osteopathic manipulative treatment, chiropractic treatment, and physical therapy treatments) and acupuncture. Both of these therapies have been the subject of increased scrutiny due to their popularity with the public. This article will explain the mechanisms behind spinal manipulation and acupuncture, the current evidence available to support their use, and the role they should play in the overall pain management of an elderly patient. An overview of other selected alternative modalities will then be discussed.

Spinal Manipulation

Various versions of spinal manipulation have been in practice for thousands of years. The Edwin Smith surgical papyrus, which contains Egyptian hieroglyphics from the 17th century B.C.E., describes spinal injuries and sprains, as well as rudimentary traction techniques to treat them.¹ More recently, there has been a resurgence of spinal manipulation techniques in the United States since the late 19th century due to the work of osteopathic and chiropractic physicians. Both groups hold to the belief that structure and function are reciprocally interrelated, meaning that breakdown in the musculoskeletal system will lead to diminished function of the overall organism. Chiropractic theory focuses more specifically on the spinal column, although both chiropractors and osteopathic physicians are able to treat musculoskeletal complaints involving the entire body.

The techniques utilized by osteopathic and chiropractic physicians are generally divided into different treatment models, such as thrusting techniques or myofascial techniques. Thrusting techniques are the main treatments utilized by chiropractic physicians and involve gapping synovial joints that have been determined to be dysfunctional, such as the zygapophyseal joints of the spine. The rationale behind thrusting techniques is that improving alignment of the joints will reset all nervous system investments of that joint, as well as normalize muscle tone around the joint.² Thrusting techniques are generally considered safe, although complications have been reported in the literature, especially for cervical spine manipulation, such as acute stroke or vertebral artery dissections. Meta-analysis for establishing a complication rate has proven difficult, given the large variability between operators and likely underreporting, although estimates have ranged between one in 20,000 and one in one million individuals.³ Myofascial techniques are a collection of procedures that are intended to address muscle tone directly, as well as the fascial attachments between structures. These techniques are widely utilized by osteopathic physicians and chiropractors, as well as physical therapists, massage therapists, and other manual therapists.

A growing body of evidence is beginning to mount regarding the importance of fascia in maintaining various physiological processes, such as the circulation of lymphatic fluid, transmission of neurovascular signals, and dispersal of mechanical forces.⁴ The myofascial techniques are gentle and well-tolerated by most patients, and serious adverse effects are essentially nonexistent. Spinal manipulation, despite its widespread use and relatively mainstream acceptance, has few large-scale clinical trials to validate its efficacy. Most studies focus on neck or low-back pain, as these are common musculoskeletal complaints. The Cochrane database concluded that manipulation is likely helpful for mechanical low-back pain but not superior to other interventions such as physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), patient education programs such as back schools, or exercise.⁵ Smaller-scale studies have looked at manipulation for other disorders such as dysmenorrhea,⁶ asthma,⁷ otitis media,⁸ and headaches.⁹ Most of these studies have shown benefits, although methodological problems or small study sizes have prevented their incorporation into standard care. Spinal manipulation has a role to play in the overall management of pain. The main benefit to the geriatric population is that treatment can provide symptomatic relief through nonpharmacologic means, with relatively few complications.

Acupuncture

Similarly to spinal manipulation, acupuncture has been in practice for several thousand years, although its exact origins are unclear. The procedure involves insertion of fine metallic needles through the skin into specific points along the body in an effort to promote wellness and treat disease. In the classical sense, the philosophy behind acupuncture focuses on a life-giving energy called qi (pronounced “chee”), which circulates through the body along defined channels called meridians. There are several meridians that traverse the body, each responsible for its respective role in the physical, mental, and spiritual makeup of the body.¹⁰ Disease states are believed to derive from alterations in the flow of qi through the meridians. These alterations can be caused by blockages to proper flow or by problems arising in the production and absorption of qi. The end result is that meridians can be overexpressed or underexpressed, tipping the body out of its natural balance. As an example, depression is usually defined as an underexpression of qi, whereas anxiety is typically considered an overexpression or stagnation of qi flow.¹⁰

The acupuncture practitioner is trained to diagnose which meridians are involved with patient complaints, and to choose the appropriate acupuncture points along those meridians to help return the body back into balance. Frequently, external stimulation of acupuncture needles is also accomplished by various means such as heat, electrical stimulation, manual stimulation, or laser stimulation.¹⁰ Within the past 30 years, there has been an explosion in acupuncture research worldwide, and basic science has taken several steps toward understanding the physiology of how acupuncture works. The placement of acupuncture needles into the body causes a series of local biochemical changes, including vasodilatation and the stimulated production of endogenous opioids.¹¹ These changes also trigger a down-regulation of nociceptive firing activity peripherally, as well as a decreased central processing of spinothalamic efferent signals through a phenomenon known as gate control theory. The heavily myelinated Ia and Ib fibers that process pressure and vibration sense share the same interneuron with weakly myelinated and unmyelinated a-delta and c-fibers, which process pain.

According to gate control theory, by flooding the interneuron with pressure and vibration information from a body region in pain, the nociceptive signals are not able to be transmitted to the brain to be processed, and, therefore, the subjective awareness of pain is diminished.¹² Along with our basic understanding of acupuncture, the clinical applications of acupuncture are also under significant scrutiny. Based on current evidence, acupuncture has gained several widely accepted indications for pain conditions including low-back pain, neck pain, migraine headache, knee pain due to osteoarthritis, and myofascial pain. Acupuncture also has strong evidence to support its use in nausea associated with chemotherapy, pregnancy, and in postoperative management.¹³ Additionally, acupuncture has smaller-scale trials that suggest benefits in other disorders such as irritable bowel syndrome, depression, anxiety, smoking cessation, and acid reflux disease. The strength of these studies is not sufficient to warrant incorporation into standard care, but future studies are already under way to further expand the clinical utility of acupuncture.¹³

Overview of Other Selected Modalities

While spinal manipulation and acupuncture have found their way into evidence-based guidelines for various conditions, they represent a small minority of the numerous complementary and alternative modalities currently being used both in the United States and worldwide. Although the following therapies do not yet pass muster for evidence-based recommendations, they are often utilized by patients in search of nonpharmacologic treatment for pain. Therefore, background knowledge about the theories and practices of these modalities is essential for the geriatric provider.

Massage
Massage therapy is one of the most commonly used modalities in the United States and has been in practice for millennia. Massage therapy generally covers manual manipulation of the soft-tissue structures of the body. Although the exact mechanism of action is not clearly understood, massage likely shares the gate control theory mentioned above as a possible explanation for its benefits. Massage is also considered helpful in promoting a sense of well-being and reducing stress.¹⁴

Massage therapy has many variations in its practice, and several terms fall under the subheading of massage. Swedish massage refers to the practice of rubbing the soft tissue with kneading, stroking, or gliding movements, and represents the most basic form of massage. Other types of massage therapy incorporate the acupuncture meridians in treatment, such as acupressure (massage selectively applied to acupuncture points), reflexology (massage focusing on acupuncture points in the feet), or shiatsu (circular motions applied along the meridian lines). Some forms of massage therapy also include external elements to aid in stress relief, such as aromatherapy massage (using essential oils) or hot stone massage. Finally, massage therapy may seek to aggressively mobilize soft tissue to break up adhesions, fibrosis, or maintain flexibility, as seen in styles such as deep-tissue massage, rolfing, or sports massage.¹⁵ Results from the most recent Cochrane review on massage therapy for low-back pain suggest that it may be helpful for subacute or chronic low-back pain, especially when combined with exercise and education.¹⁶

A similar review for massage therapy in neck pain could not produce any recommendations due to poor quality of the literature.¹⁷

Mind-Body Medicine
Many complementary and alternative therapies focus on the connection between emotional stress, mental state, behavior, and body performance. The NCCAM designates mind-body medicine as a blanket term to describe modalities that seek to promote health by using mental processes to alter physical functioning. Mind-body therapies have a wide range in scope and size. Meditation or prayer are very commonly used and, along with other focused-attention therapies (eg, hypnosis, yoga), have been established to alter brain functioning on functional magnetic resonance imaging, and immunological function.^18,19 Another subsection of mind-body medicine includes biofeedback, progressive relaxation, and guided imagery, which strive to give the patient insight into his/her stressful state, and provide coping mechanisms via breathing, muscle contraction, and visualization exercises. Together, focused attention and coping mechanisms are sometimes referred to as “mindfulness,” and training in these techniques has been gaining some popularity despite relatively scant evidence.^20,21 Some mind-body therapies have become so widely accepted that they are now fully incorporated with mainstream medicine and are no longer considered complementary or alternative. Examples would include support groups and 12-step programs such as Alcoholics Anonymous or cognitive-behavioral therapy.²² Acupuncture, as discussed above, can be classified as mind-body medicine for two reasons: (1) the emotional and mental state of the individual is taken into account when making a diagnosis; and (2) one of the main functions and benefits of acupuncture is stress relief, which serves a mind-body purpose.

Energy Medicine
Energy medicine is founded on the principle that the human body is electrically active, and, therefore, generates an electromagnetic field that surrounds and penetrates the body. Incarnations of energy medicine stretch back to early Sanskrit practices from over 3000 years ago, which focused on seven midline energetic centers of the body called chakras. The energy that flows through the chakras is called prana. Acupuncture can also be considered a form of energy medicine because it relies on the flow of qi through the meridians, which is an energetic concept. The chakras are rough analogs of the meridians, as are qi and prana.²³ Several modalities borrow these energetic models to effect treatment.

Reiki is a popular system of healing whereby practitioners are trained to sense the electromagnetic field, also known as an aura, of a patient by sweeping the hands above the patient’s body. Any deficiencies in the aura or impedences to energy flow can then be corrected by using the practitioner’s own energy to clear the blockages. Traditional Japanese Reiki strictly follows the acupuncture meridians, while westernized Reiki combines the meridians and chakras into a unified system. Unlike acupuncture, Reiki has no large-scale clinical trials to support its use.²⁴ Another example of an energy medicine modality is qigong (prounouced “chee-gong”). This practice stems from the acupuncture meridians and involves rhythmic movements and specific exercises that are designed to magnify and redirect the flow of qi through the body. The patient typically learns the movements from a qigong master, and then implements them independently. Some smaller studies have been done suggesting possible benefits in reducing falls in the elderly, lowering blood pressure, and helping with depression and anxiety.²⁵ Again, these findings have not been verified through large-scale clinical trials.

Summary of Alternative Therapies

Increasingly, geriatric patients are turning to complementary and alternative therapies in an attempt to alleviate their painful conditions and promote wellness. Although once relegated to the fringe of medical practice, new and more sophisticated research is starting to shed light on these ancient modalities. Over the past few decades, spinal manipulation and acupuncture have made steady progress toward acceptance and may eventually be incorporated into standard medical care for many diseases. Healthcare providers have a responsibility to educate themselves regarding complementary and alternative therapies so that they can accurately field patients’ questions and make referrals when clinically appropriate.

Controversies Regarding Pain in Older Adults

When caring for the geriatric population, pain complaints are commonplace. As already discussed in other articles in this issue of Clinical Geriatrics, the pathophysiology of pain is complicated, and the pharmacokinetics of opiate medications pose unique challenges in the elderly. There are a number of controversies associated with pain management in the elderly, such as the exact role of opiates, opiate use in the postoperative population, pain management in the setting of cognitive dysfunction, polypharmacy, and driving recommendations in the elderly population. This article discusses each of the above listed controversies in detail in hopes of promoting understanding of the relevant pain guideline recommendations and evidence-based approaches to dealing with these important issues.

Does Getting Older Have to Hurt?
While aging in itself is not inherently painful, many conditions that occur as we age may have a component of pain. If we consider our bodies to be a complex collaboration of biochemical, electrical, and mechanical actions that occur billions of times over our lifespan, it then becomes easier to understand how these processes may not continue to be optimal as we reach our “golden years.” It is likely a combination of genetics, environment, and some luck that determines which of us will have our lives affected to a greater extent by pain. Genetically-linked disorders of the neuromusculoskeletal system, such as inflammatory arthritides, or disorders of metabolism such as diabetes, can lead to painful syndromes. Ongoing research suggests that how we live our lives, in terms of nutrition, exercise, and avoidance of toxins such as those found in nicotine products or ethanol, can contribute significantly to maintenance of good health and avoidance of pain-producing disease. Then, of course, some of us are simply in the wrong place at the wrong time. As such, we may be victims of accidents or other unplanned pain-producing trauma, such as a fall or motor vehicle collision.

So should we expect to have pain as we age? The answer for most of us is that we are likely to experience pain at some point in our lives, but for the majority it should not become a chronic or incapacitating experience. Alerting our patients to this can help ensure that they report any new or persistent pain that they are experiencing. Our job is then to properly assess, diagnose, and treat that pain to promote optimum function and to help maintain activities of daily living. Treatment plans need to be customized to the individual patient’s circumstances. For example, an acute injury is likely to recover as compared to an ongoing persistent pain problem. Due to physiological changes associated with aging that are well documented, the adage of “start low and go slow” is a good one to follow for pain management as well. However, it is important to remember the effective half-life of short-acting pain medications in comparison to the expectations that the pain will still be present when the medication effect wears off. Finding the appropriate medication, the effective dose for that patient, and the correct timing are all essential in providing the best pain relief possible.

Since older patients have been noted to be more stoic and report less pain, ordering a pain medication that is “as needed” may not be effective. This can be seen by evaluation of the Medication Administration Records of inpatients or by having the patients record a pain diary that includes medication doses. Older patients may be fearful of the potential adverse effects of pain medications, and thus avoid taking them despite significant pain. Educating patients on how to manage expected side effects from pain medication will help ease concerns, thus improving compliance.

Opiates in the Postoperative Setting
Surgical procedures pose unique challenges in the elderly population. Numerous studies have indicated that pain is frequently undertreated in the post-op setting. Approximately 70% of patients report moderate-to-extreme pain in the first 48 hours after surgical intervention.²⁶ Treatment often requires opiate analgesics, and many practitioners are concerned about potential complications such as altered cognition, respiratory depression, or impaired hepatic or renal function. To be sure, any of these complications can create barriers to healing and create stress for patients, staff, and families. Two evidence-based resources have emerged to help guide practitioners through the postoperative phase. The United States Veterans Health Administration/Department of Defense has published clinical guidelines for pain management in the postoperative setting.²⁷ Additionally, an online program called PROSPECT (www.postoppain.org) provides instant evidence-based recommendations available to everyone. Both resources are broken out by each specific procedure, as exact recommendations depend on where the surgery is being performed and what is being done.

As a general rule, use of opiates is deemed safe for short-term use in the postoperative setting, and the risks of respiratory depression or long-term addiction are negligible when properly monitored. Opiates should be titrated either to patient comfort or until side effects prohibit further escalation. With careful monitoring, opiates do not have a ceiling dose. Care should be taken to manage opiate side effects, particularly constipation, nausea, and insomnia. In terms of monitoring pain from a facility standpoint, hospitals that have a dedicated pain service and/or standardized postoperative order sets tend to have better outcomes and higher patient satisfaction scores. Newer delivery systems such as patient-controlled analgesia pumps are considered preferable, as they provide inherent dose regulation. In addition, interventional procedures such as regional nerve blocks or epidural anesthesia/analgesia have supportive evidence in surgeries on limbs or limited areas. The concurrent usage of COX-2 inhibitors or general NSAIDs has been shown to reduce opiate requirement for many procedures.

Nonpharmacologic measures are especially useful in geriatrics, as they reduce the need for opiates and are generally safe. Use of transcutaneous electrical nerve stimulation has moderate evidence of efficacy in many abdominal and orthopedic procedures. Biofeedback and other relaxation techniques can also improve patient comfort. In orthopedics, early mobilization and exercise ultimately improve outcomes. Other therapeutic modalities to consider include heat, cold, and massage. Postoperative delirium is a common complication in the elderly population. Unfortunately, no specific interventions have strong evidence for their benefit. For the geriatric patient in particular, nonpharmacologic supportive care is always the preferred first-line management. Simple measures such as having a clock and calendar clearly visible, keeping interruptions and distractions to a minimum, or having a family member bedside are often all that is required. Additionally, workup for secondary causes of delirum, such as metabolic disorders, infection, anemia, or medication adverse reactions, must be done. If a patient becomes agitated, one-to-one supervision and passive restraints (eg, bed alarms, mittens) are preferred over chemical sedation or more restrictive restraints such as wristbands or chair vests. In the event that chemical sedation is absolutely required, studies show that for the geriatric population, antipsychotics with low anticholinergic properties (eg, haloperidol) have fewer complications than benzodiazepines.²⁸

Pain Management in Cognitively-Impaired Persons
Since pain is considered a subjective experience, the gold standard for assessment is self-reporting.²⁹ For most adults, even those with cognitive impairment, the initial question can be posed as a numerical rating scale from 0-10, with 0 representing having no pain at all and 10 representing the worst pain imaginable. Some research suggests that for older adults with a more significant cognitive impairment, providing a more limited verbal descriptor scale (ie, from 0-5) is more effective.³⁰ For patients with more significant cognitive limitations, or as a secondary confirmation, other scales have been recommended by both the American Geriatrics Society in 2009³¹ and the British Geriatrics Society in 2007.³² A pain thermometer with descriptive adjectives provided can be very effective. Facial pain scales can be used to overcome language barriers.

Accommodations should be made not only for language barriers but also for decreased vision or hearing. Cultural differences may also impact patients’ reporting of pain. In addition to self-reporting, objective evidence of pain is helpful in the elderly population with cognitive impairment. However, the physiologic changes usually acknowledged to occur with an acute painful state, including tachycardia, hypertension, tachypnea, and sweating, may be absent with chronic pain states. Careful observation of the patient, especially during performance of some movement or task, can provide useful information as to the extent and location of the pain. Facial grimacing and guarding of the affected body part or region are commonly reported on pain assessments. Both positive signs (eg, groaning) and negative signs (eg, resisting care, withdrawing from activities) are seen with pain in the older population.³² Families and caregivers should be involved in the assessment of pain. As a part of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT),³³ a multidisciplinary panel developed a consensus regarding chronic pain clinical trials. The recommendations included assessing outcomes representing six core domains: (1) pain; (2) physical functioning; (3) emotional functioning; (4) participant ratings of improvement and satisfaction with treatment; (5) symptoms and adverse events; and (6) participant disposition (eg, adherence to the treatment regimen, reasons for premature withdrawal from the trial). A 12-question self-report has been shown to be effective in this regard.³⁴

Following initial assessment, reassessment for effectiveness of treatment interventions is critical. A continuous Quality Improvement plan with emphasis on a scientific, team approach to direct change efforts is recommended for screening and comprehensive assessment for pain in patients with cancer and preventive treatment of opioid-induced constipation.³⁵ The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) is in the process of field testing measures applicable to the inpatient setting for pain management. These may be added to the existing ORYX® core measure sets. It is likely, then, that the Physician Consortium for Performance Improvement convened by the American Medical Association will review the core set of pain management measures to identify a subset suitable for implementation at the physician level.

Polypharmacy and Elderly Persons
In general, the goal in treating medical illness in the elderly is to limit polypharmacy and reduce drug–drug interactions, toxic side effects, and medication-dosing mistakes. As multiple drugs are utilized, compliance with drug regimen usually decreases, and mistakes are magnified. Pain management is guided by the World Health Organization (WHO) “analgesic ladder.” This is a three-tiered approach to managing both malignant and nonmalignant pain: Tier 1 instructs providers to use adjunctive analgesics to treat mild pain, and tiers 2 and 3 instruct us to use adjunctive analgesics plus opiate therapy to treat moderate-to-severe pain.³⁶ In treating moderate-to-severe pain, polypharmacy is utilized to provide optimal pain relief. In the case of a patient with neuropathic pain (eg, trigeminal neuralgia), an anticonvulsant drug may be prescribed as an initial medication. If the pain remains severe, an opiate medication is commonly added. Finally, if the patient cannot sleep, a tricyclic antidepressant medication may be prescribed for both analgesia and sleep. It is easy to see how such a combination of medications can be effective for pain management, but be fraught with problems in the elderly patient. The rule of thumb in managing elderly patients is to start with easy regimens that have the least potential for side effects and toxicity. Analgesia can be achieved by prescribing lower doses than would be used to treat younger patients.³⁷

Since most medications are sedating in nature, clinicians should recommend that family members be available to monitor the patient. When adding a medication, the physician should be available to problem-solve as issues arise and to monitor for adverse events.³ When multiple medications are used, patients should walk away with an easy-to-understand handout on how to take the medications. Pill boxes should be encouraged to help limit dosing errors. In patients who have cognitive impairment, family members and caregivers need to be alerted to any pharmacologic changes or additions. Family members and caregivers also should help oversee medication dosing and monitor for any significant adverse events.

Driving While Taking Opiates in Elderly Persons 
Assessing the ability of the elderly patient to drive is always difficult for both the patient and the physician. Elderly individuals driving while using opiate therapy becomes even more sensitive. Intuitively, patients are asked to refrain from driving while using opiate therapy because of the inherent sedating quality. Whenever opiate therapy is initiated, the patients should be advised on the risks of driving. Restricting driving in the elderly individual can be devastating to him/her by limiting his/her ability to be independent and function in society. The real dilemma exists with the patient requiring chronic opiate therapy to improve his/her ability to function. It should be noted that there is a shocking lack of studies evaluating driving in this patient population. Some published data do exist which demonstrate that opiate users do not experience more accidents and moving violations than nonusers.^39,40

A small but interesting study was performed looking at patients using chronic opiate therapy, in three different modalities: pre-driver evaluation; a simulator evaluation in comparison to patients; and behavior evaluation. These patients were compared to cerebrally-compromised patients who underwent the same tests and passed. The results demonstrated that the chronic opiate user outperformed the cerebrally-compromised patient in most measures.⁴¹ When discussing driving and chronic opiate use with the elderly patient, the risks need to be clearly assessed and articulated. When able, referring a patient to a simulated driving test may provide some objective data for a very difficult decision-making process.

Summary of Controversies

The management of pain in the elderly is filled with controversies (so-called “gray areas”). Fortunately, in many cases, guidelines have been created to help practitioners in their clinical decision-making. Regardless of what recommendations may exist, though, ultimately the effective management of pain and its associated complications in the geriatric population is reliant on the judgment of the attending physician.

The authors report no relevant financial relationships.

Dr. Surve is Assistant Professor, Dr. Janora is Associate Professor, and Dr. Jermyn is Associate Professor and Chair Designate, Division of Rehabilitation Medicine, NeuroMusculoskeletal Institute, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford. Dr. Surve is also from the Department of Osteopathic Manipulative Medicine.

References

1. Sanan A, Rengachary SS. The history of spinal biomechanics. Neurosurgery 1996;39(4):657-669.

2. Herzog W. The biomechanics of spinal manipulation. J Bodyw Mov Ther 2010;14(3):280-286.

3. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: A comprehensive review of the literature. J Fam Pract 1996;42(5):475-480.

4. Findley T. Fascia Research II: Second International Fascia Research Congress. International Journal of Therapeutic Massage and Bodywork 2009;3(2):4-9.

5. Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low-back pain. Cochrane Database Syst Rev 2004;(1):CD000447.

6. Kokjohn K, Schmid D, Traino JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. J Manipulative Physiol Ther 1992;15(5):279-285.

7. Bockenhauer SE, Julliard KN, Lo KS, et al. Quantifiable effects of osteopathic manipulative techniques on patients with chronic asthma. J Am Osteopath Assoc 2002;102(7):371-375.

8. Mills MV, Henley CE, Barnes LL, et al. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861-866.

9. Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: A systematic review of randomized clinical trials. Cephalalgia 2002;22:617-623.

10. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. 1st ed. Berkley, CA: Medical Acupuncture Publishers; 1995.

11. Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: Endorphin implicated. Life Sci 1976;19(11):1757-1762.

12. Melzack R, Wall PD. Pain mechanisms: A new theory. Science 1965;150:971-979.

13. World Health Organization. Acupuncture: Review and analysis of reports on controlled clinical trials. http://apps.who.int/medicinedocs/en/d/Js4926e/s4926e.pdf. Accessed August 26, 2010.

14. Ernst E. Massage therapy for low back pain: A systematic review. J Pain Symptom Management 1999;17:65-69.

15. Yates J. A Physician’s Guide to Therapeutic Massage. 3rd ed. Ontario, Canada: Curtis-Overzet Publications; 2004.

16. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev 2008;(4):CD001929.

17. Haraldsson BG, Gross AR, Myers CD, et al; Cervical Overview Group. Massage for mechanical neck disorders. Cochrane Database Sys Rev 2006;(3):CD004871.

18. Lazar SW, Bush G, Gollub RL, et al. Functional brain mapping of the relaxation response and meditation. Neuroreport 2000;11(7):1581-1585.

19. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003;65(4):564-570.

20. Greeson JM. Mindfulness research update: 2008. Complement Health Pract Rev 2009;14(1):10-18.

21. 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(2):163-190.

22. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. National Health Stat Report 2008;(12):1-23.

23. Oschman JL. Energy Medicine: The Scientific Basis. 1st ed. London, UK: Churchill Livingstone; 2000.

24. Lee MS, Pittler MH, Ernst E. Effects of reiki in clinical practice: A systematic review of randomised clinical trials. Int J Clin Prac 2008;62(6):947-954. Published Online: April 10, 2008.

25. Rogers CE, Larkey LK, Keller C. A review of clinical trials of tai chi and qigong in older adults. West J Nurs Res 2009;31(2):245-279.

26. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534-540, table of contents.

27. Veterans Health Administration/Department of Defense Clinical Practice Guidelines: Management of postoperative pain (POP). Updated May 2002. http://www.healthquality.va.gov/pop/pop_fulltext.pdf. Accessed August 26, 2010.

28. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340(9):669-676.

29. Assessment scales. In: Weiner DK, Herr K. Rudy T, eds. Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment. New York, NY: Springer Publishing Company, Inc.; 2002:21.

30. Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain 2007;23(1 suppl):S1-S43.

31. American Geriatrics Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331-1346.

32. British Pain Society and British Geriatrics Society. Guidance on: The assessment of pain in older people 2007. http://www.bgs.org.uk/Publications/Publication%20Downloads/Sep2007PainAssessment.pdf. Accessed August 26, 2010.

33. Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain 2003;106 (3):337-345.

34. Blozik E, Stuck AE, Niemann S, et al. Geriatric Pain Measure short form: Development and initial Evaluation. J Am Geriatr Soc 2007;55:2045-2050. Published Online: November 20, 2007.

35. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, IL: American Pain Society; 2003.

36. World Health Organization. Cancer pain relief and palliative care. Technical Reports Series 804. World Health Organization. http://whqlibdoc.who.int/trs/WHO_TRS_804.pdf. Accessed August 26, 2010.

37. Bellville JW, Forrest WH Jr, Miller E, Brown BW Jr. Influence of age on pain relief from analgesics. A study of postoperative patients. JAMA1971;217:1835-1841.

38. Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc 2002;102:481-485.

39. Zacny JP. A review of the effects of opioids on psychomotor and cognitive functioning in humans. Exp Clin Psychopharm 1995;3:432-466.

40. Moskowitz H, Robinson CD. Methadone maintenance and tracking performance. In: Kaye S, Meier GW, eds. 9th International Conference on Alcohol, Drugs and Traffic Safety. San Juan, Puerto Rico; National Highway Traffic Safety Administration; 1983;995-1004.

41. Galski T, Williams JB, Ehle HT. Effects of opioids on driving ability. J Pain Symptom Manage 2000;19(23):200-208.