Nonpharmacologic, Complementary, and Alternative Interventions for Managing Chronic Pain in Older Adults

Key words: Musculoskeletal pain, complementary and alternative medicine, yoga, tai chi, acupuncture, biofeedback, anatomic point stimulation, music therapy.
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Chronic musculoskeletal pain is common in older adults. Currently available pharmacological interventions for chronic pain in elders may be limited by cost, adverse effects, and potential drug-drug interactions, all of which are leading patients and their healthcare providers to seek safer options, such as alternative or complementary pain management therapy. According to the World Health Organization, complementary and alternative medicine encompasses a broad set of healthcare practices that are not part of a country’s own tradition and are not integrated into the dominant healthcare system.¹

The intent of this article is to assess the literature with regard to nonpharmacologic therapeutic interventions that pertain to the care of older adults with chronic musculoskeletal pain. Some of the data were gathered through a PubMed/MEDLINE search using the following search terms: alternative therapy, complementary therapy, pain, musculoskeletal, osteoarthritis, fibromyalgia, elderly, aged, and geriatric. A separate search was done for popular alternative medicine strategies. Based on these searches, we identified which alternative therapies have been supported by randomized clinical trials in the management of chronic musculoskeletal pain in the elderly population. Anecdotal reports of other health and quality-of-life benefits of complementary and alternative medicine therapy are also discussed in this review. The use of systemic therapies (ie, oral, topical, or parenteral herbs and dietary supplements) is beyond the scope of this review. 

Prevalence and Cost of Alternative Medicine in the United States 

A national survey conducted by Eisenberg and colleagues²  brought attention to the cost of alternative and unconventional therapy in patients with advanced or chronic medical conditions and to the extent that these interventions were being used by this population. They interviewed 1539 individuals (response rate, 67%) in a national sample of adults aged 18 years or older in 1990. One in three respondents reported using at least one unconventional therapy in the past year, and, of these respondents, one-third said that they saw alternative therapy providers on average 19 times in 1 year. The highest rate of visits was in nonblack individuals, between the ages of 25 and 49 years, with relatively higher education levels and higher incomes compared with other sociodemographic groups. Approximately 72% of respondents had not informed their primary care physicians about using alternative therapy. Once these data were extrapolated to the general population, the number of visits to unconventional therapy providers was estimated to be 425 million in 1990. In comparison, the number of visits to all US-based primary care physicians in that year was 388 million. In addition, expenditures associated with using unconventional therapy amounted to $13.7 billion, three-quarters of which was paid out of pocket. To put this amount into context, $12.8 billion was spent out of pocket for all hospitalizations in the United States at that time.² 

A follow-up study in 1998 by Eisenberg and colleagues³ evaluated the trends in alternative medicine use in the United States between 1990 and 1997. They found that the percentage of participants using alternative therapies during the previous years had increased from 33.8% in 1990 to 42.1% in 1997. The therapies that increased most rapidly included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy.

In a survey of 117 US medical schools, 64% of respondents reported offering elective courses in complementary or alternative medicine or including coverage of the topic in required courses. Common topics include chiropractic, acupunctural, homeopathic, and herbal therapies, as well as mind-body techniques; however, there was significant diversity with regard to content, format, and requirements among these courses.⁴

Chronic Pain in Older Adults  

Chronic pain can either be categorized as nociceptive or neuropathic. Nociceptive pain is perceived after exposure to a noxious stimulus or to a stimulus that would become noxious if prolonged. Nociceptive pain is further subdivided into somatic pain (arising from skin, bones, tendons, nerves, and blood vessels) and visceral pain (arising from the abdominal cavity and thorax). Mediated by stimulation of thinly myelinated or unmyelinated afferent nerves, nociceptive pain is often characterized by a burning sensation. Neuropathic pain is sharp, shocking pain that follows the paths of nerves and is due to nerve irritation or damage. The most common cause of neuralgia is distal peripheral neuropathic pain that is most commonly seen with diabetes, alcohol abuse, and HIV infection. Other causes include nutritional deficiencies (ie, vitamin B₁₂, folate), uremia, monoclonal paraproteinemia, hypothyroidism, autoimmune diseases, infections, use of certain drugs, and exposure to toxins.⁵ There are numerous causes of chronic pain in older adults, but for the purpose of this review, we will concentrate on the nonpharmacologic management of somatic, nociceptive pain in this population, with emphasis on arthritic pain and myofascial pain—two of the most commonly reported chronic pain conditions in geriatric practice. 

A national survey conducted between 2007 and 2009 found that 50% of persons aged 65 years and older had physician-diagnosed arthritis.⁶ Osteoarthritis (OA), the most common joint disorder in the United States, is estimated to affect approximately 27 million Americans.⁷ A 2010 review reported knee OA in 10% of men and 13% of women aged 60 years and older, with an expectation that these percentages will rise in the future due to increasing longevity and obesity.⁸ The pathogenesis and progression of OA is associated with advanced age, female sex, history of trauma or repetitive use of joints, joint laxity, and muscle weakness.^8,9 After conducting a series of interviews with more than 2600 patients with knee OA, Lapane and colleagues¹⁰ found that complementary and alternative therapy was sought by 47% of participants, with nearly one-fourth of participants using alternative therapy in combination with conventional medication.

Myofascial pain syndrome refers to localized pain and inflammation in the body’s connective tissue that covers the muscles. Fibromyalgia is considered a subtype of myofascial pain syndrome.¹¹ The prevalence of fibromyalgia in the United States is about 2%, representing nearly 5 million people.⁷ The prevalence is higher among women (3.4%) than men (0.5%), rises in middle age, and peaks at 7.4% among those aged 70 to 79 years.⁷ 

Regardless of its etiology, chronic pain often causes patients to experience anxiety and depression, sleep deprivation, and functional impairment or disability.^12,13 Management of pain in older adults is further complicated by comorbidities; polypharmacy and the inherent risk of drug-drug interactions; and altered pharmacodynamics among older persons, resulting in more severe adverse reactions. The magnitude of the problem of chronic pain in elderly persons—in conjunction with the hope for enhanced safety of alternative therapies—likely explains why complementary interventions continue to be popular among older adults.

The popularity of nonstandard modalities to relieve chronic pain endures despite an overall lack of quality data to support their efficacy. For example, a 2012 review of randomized controlled trials that examined the effectiveness of complementary therapies for patients with rheumatoid arthritis (RA) could not establish evidence that alternative treatments, such as acupuncture, meditation, autogenic training, healing therapy, progressive muscle relaxation, static magnets, and tai chi, are effective in RA pain management.¹⁴

Role of Exercise in Managing Chronic Pain 

In a systematic review of 43 trials evaluating a total of 72 exercises, Hayden and colleagues¹⁵ found that stretching and strengthening were the two most effective exercises for improving pain and functioning, respectively, in patients with chronic low-back pain. In this section, we examine the popular mind-body exercises of tai chi and yoga.

Tai Chi  
Tai chi chuan, also called taijiquan, is an ancient martial art popularly known by the shortened term tai chi.¹⁶ There are numerous styles of tai chi, each employing varying techniques of controlled breathing, weight-shifting movement, meditation, and self-defense. Some styles have been modernized or adapted across cultures, but generally, all styles can be traced back to the five traditional schools of thought: Chen, Yang, Wu (Hao), Wu, and Sun.^17,18 Tai chi is practiced by more than 2.3 million American adults.¹⁶ In many studies, tai chi has been shown to enhance balance, strength, flexibility, and self-efficacy (ie, the confidence in one’s ability to complete tasks and reach goals) in addition to reducing pain, depression, and anxiety across diverse patient populations with chronic conditions.^19,20 

A prospective, randomized, controlled clinical trial by Hartman and colleagues²¹ reported clinical evidence for the use of tai chi in patients with arthritis. The trial involved 33 community-dwelling adults (mean age, 68 years) with a diagnosis of lower extremity OA who participated in either two 1-hour tai chi sessions weekly or their usual physical activities and routine care. The tai chi group experienced significant improvement in self-efficacy for arthritis symptoms, total arthritis self-efficacy, tension level, and general health satisfaction (P<.05).

A randomized clinical trial conducted by Fransen and colleagues²² included 152 older adult patients with chronic pain due to hip and knee OA. Patients were assigned to participate in hydrotherapy classes, tai chi classes, or a control group that was put on a waiting list. When compared with the control group at the 12- and 24-week follow-ups, participants in the tai chi classes demonstrated significant and sustained pain and function improvements according to scores on the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and other physical performance tests. 

Wang and colleagues²³ evaluated 40 obese older adults (mean age, 65 years; mean body mass index, 30 kg/m²) with knee OA who were randomly assigned to participate in either 1-hour tai chi classes or wellness educational sessions (control group) every week for 12 weeks. Compared with the control group, tai chi participants exhibited significantly reduced pain and function improvement on the WOMAC, Patient Global Visual Analog Scale (VAS), Physician Global VAS, timed chair stand test, Center for Epidemiologic Studies Depression Scale, self-efficacy score, and Short Form-36 Physical Component Summary. No severe adverse events of tai chi exercise were observed.

Using similar methods, Wang and colleagues²⁴ subsequently conducted a randomized trial evaluating the benefits of Yang-style tai chi for fibromyalgia. The study assigned 66 people to a tai chi group or to a control group, which consisted of wellness education and stretching. Participants in both groups attended twice weekly 1-hour sessions. At 12-week follow-up, the tai chi group had clinically significant improvements on the Fibromyalgia Impact Questionnaire. The results also demonstrated clinically important improvement in measures of pain, sleep quality, depression, and quality of life in the tai chi participants. Moreover, these benefits were maintained at 24 weeks with no reported side effects. Compared with the control group, more patients in the tai chi group were able to stop their fibromyalgia medication, but this finding did not reach statistical significance.

Falls are a leading cause of injury in older adults and pose significant threats to mobility, function, and quality of life. In a systematic review, Chan and colleagues²⁵ examined the effects of tai chi on balance improvement and fall reduction in older adults. Based on their review, the researchers concluded that tai chi was effective in improving balance among older adults, but that it may not necessarily be superior to other interventions. They also cautioned that tai chi may be contraindicated in some vulnerable older adults, necessitating appropriate prescreening for frailty in this population, and advised that it may take at least 3 months for the therapeutic effects of tai chi to become clinically evident.²⁵

Sleep is known to play an integral role in modifying pain perceptions, affecting how persons with chronic pain cope with and handle their pain; thus, sleep quality should also be considered when managing chronic pain in elders. Li and colleagues²⁶ sought to assess whether tai chi can affect sleep quality. The authors conducted a randomized controlled trial that involved 118 patients (age range, 60-92 years) who received either 1-hour tai chi sessions or low-impact exercise sessions three times weekly for 6 months. Compared with the control group, tai chi participants demonstrated significant improvements on the Epworth Sleepiness Scale, had a higher global score on the Pittsburgh Sleep Quality Index (PSQI), and showed improvements across the five PSQI subscales of sleep quality, onset latency, duration, efficiency, and disturbances. Based on these findings, the authors concluded that tai chi has clinical benefits with regard to self-reported sleep quality, daytime sleepiness, and other sleep problems. This study suggests that tai chi may be worth exploring for elders experiencing sleep disturbances, provided they are physically capable of performing such exercises. Further research in this area is warranted. 

Limitations of tai chi studies. Lack of standardization across study formats and methods make it difficult to draw conclusions about the long-term benefits of tai chi on musculoskeletal pain. There are few well-designed randomized controlled trials that assess tai chi effectiveness, and most of the aforementioned studies are limited by small sample sizes, thereby making generalization of results problematic. 

Additionally, some studies have contraindicated tai chi in some patients. For example, Simic and colleagues²⁷ reviewed 24 studies evaluating various gait modification strategies (including tai chi) that can unload the medial knee joint in OA patients. They noted that the tai chi gait might actually increase external knee adduction moment, which is a marker of medial knee joint load. More long-term, large-scale studies are needed before physicians can confidently recommend or advise against tai chi exercises for their patients, in particular, in the frail and vulnerable elderly population.

Yoga
Based in Hindi philosophy, yoga takes many forms, each involving different styles of controlled breathing and movement to achieve a state of relaxation similar to tai chi; but whereas tai chi uses fluid, interconnected movements, yoga emphasizes mindful pausing at different postures and poses.^28,29 Because of its more gentle approach, yoga has become an increasingly popular choice among older adults, noted by the National Center for Complementary and Alternative Medicine (NCCAM) as the sixth most commonly used complementary therapy in people of all ages.³⁰ In an Australian osteoporosis clinic, older adults identified yoga among the top four complementary and alternative therapies most often employed as adjunctive treatment for either holistic health reasons or pain management.³¹

Qualitative research methods are presenting fruitful avenues for understanding the self-reported benefits of yoga to patients with pain. Tul and colleagues³² conducted interviews with seven patients (average age, 46.6 years), the majority of whom had musculoskeletal pain. The participants completed an 8-week course of hatha yoga, a style generally considered the most “gentle” or adaptable yoga style. These interviews identified the following potential explanations for the benefits derived from yoga: (1) mindfulness of breathing redirects attention from pain; (2) the meditative nature of yoga practice reduces stress (and in turn may improve the pain threshold); (3) yoga aids in self-awareness of muscular tension, thereby expanding the patient’s repertoire of actions designed to reduce bodily tension and attendant pain; and (4) insight into the personal experience of pain enables opportunities to reduce anxiety associated with pain. 

The qualitative improvement in pain attributed to yoga has been well demonstrated in both degenerative and inflammatory disorders afflicting older adults. In a pilot study that included OA patients aged 50 years and older, knee pain and function improved with an 8-week course of Iyenger yoga (ie, a style of hatha yoga that uses props, such as wooden blocks and belts to achieve body alignment).³³ One NCCAM-funded study of 90 people with chronic low-back pain found that participants who practiced Iyengar yoga had significantly less disability, pain, and depression after 6 months.³⁴ In another study, postmenopausal women with RA who participated in 10 weeks of yoga class three times per week experienced a decreased perception of pain and depression and improved balance.³⁵ Pilkington and associates³⁶ also showed yoga to be a feasible intervention for patients with depression, but the study did not report sufficient details as to which styles, postures, or practice duration were associated with better outcomes.

Limitations of yoga studies. Implementation of yoga as a complementary treatment of chronic pain in elders is not well supported by research literature. This is in large part due to a relative lack of enrollment of ethnic minority elders, as well as nonethnic elders aged 80 years and older, in many such protocols.³⁷ As Morone and Greco³⁸ reported in a literature review, some mind-body interventions require modifications before they can be safely implemented in older adults; hence, future well-conducted studies on yoga for managing nonmalignant pain in elders may need to take into account not only drop-out rates, which can be as high as 22%, but may also require modification or omission of exercise postures that are potentially problematic for these patients, such as one-leg stand or inverted postures. The relatively short follow-up periods on outcome measures continue to plague the quality of studies of yoga interventions. Indeed, prospective data on yoga and other complementary and alternative interventions is not only weak in terms of durability of improvement but also lack adequate documentation as to whether such interventions can reduce opioid use in chronic pain patients.³⁹

Cognitive-Behavioral Approaches to Chronic Pain Management 

Clinical efficacy and cost-effectiveness of cognitive-behavioral therapy was well documented in a review by Cipher and associates.⁴⁰ What follows is a brief review of these approaches with a focus on mindful meditation, biofeedback, and music therapy.

Mindful Meditation
Mindfulness is a form of meditation that involves awareness of the present moment in a nonjudgmental manner. Historically a Buddhist practice, mindful meditation can be considered a universal human capacity proposed to foster clear thinking and open-heartedness, and at times, encourage empathy and alleviate anguish.⁴¹ Mindfulness requires no cultural or religious background to be useful, as the goal of the intervention is to maintain awareness moment by moment by disengaging oneself from strong attachments to beliefs, thoughts, or emotions, and thereby developing a greater sense of emotional balance and well-being.⁴¹ In the past few decades, the practice has attracted the attention of neuroscientists and psychotherapists, who have reported the benefits of mindful meditation in managing pain and stress and in improving quality of life. 

The work of Jon Kabat-Zinn, PhD, has been vitally important to understanding the role of mindfulness in pain therapy. In 1982, he published evidence to support meditation as effective behavioral therapy in self-regulation of chronic pain.⁴² His study involved 51 patients with chronic pain (predominantly low-back pain, neck and shoulder pain, and headache) who had not improved with traditional medical care. After 10 weeks of participation in a mindful-meditation program, 65% of the patients showed a reduction of 33% or greater in the mean total Pain Rating Index, and 50% of patients showed a reduction of 50% or more. There was also a significant reduction in mood disturbance and psychiatric symptoms, benefits that remained relatively stable on follow-up.⁴²

In 1985, Kabat-Zinn and colleagues⁴³ showed statistically significant reductions in measures of present-moment pain, inhibition of activity due to pain, negative body image, pain symptoms, mood disturbance, anxiety, and depression in 90 patients with chronic pain who were trained in mindfulness meditation compared with a group of patients who were treated with traditional protocols. The improvement appeared to be independent of sex, source of the referred pain, and type of pain. The majority of subjects reported continued high compliance with the meditation practice as part of their daily lives. The benefits noted during the meditation training were maintained up to 15 months for all measures, except for present-moment pain.⁴³

Another Kabat-Zinn⁴⁴ study involved 250 patients with chronic pain and showed an initial large and significant benefit of mindful meditation on physical and psychological status. These outcomes were maintained on follow-up; however, the pain status scores tended to revert to pre-intervention levels. More recent studies have corroborated the purported benefits of mindfulness not only in managing pain, but also in managing stress, eating disorders, diabetes, sleep disturbances, hypertension, and other conditions that can affect pain perception and impact quality of life.^45,46 

When practiced by healthcare providers, mindful meditation may also improve patient-provider relationships. Epstein⁴¹ explained that the focus and insight cultivated by mindful meditation may help healthcare providers make fewer errors, hone their clinical judgment skills, and exude humility and compassion, thereby improving their ability to communicate with patients and provide better care. Although Epstein did not examine how practitioner mindfulness might specifically benefit patients with chronic musculoskeletal pain, if such practitioners are better equipped to communicate with their patients, it can be surmised that they may also be better equipped to identify the potential causes of their patients’ pain and find solutions, including complementary and alternative treatments. 

Biofeedback 
First developed in the 1940s, biofeedback treatment consists of training patients how to control physiologic responses, such as brain activity, blood pressure, muscle tension, or heart rate, using a variety of techniques, such as hypnosis, guided imagery, and spouse-assisted cognitive-behavioral therapies. According to Kee and colleagues,⁴⁷ older adult pain patients who participate in behavioral and rehabilitation therapies can substantially reduce their use of pain medications and, at the same time, decrease pain and increase physical function.

In a retrospective analysis of self-reported clinical data from 5750 adults, 13% of patients used biofeedback or relaxation techniques for managing their chronic pain⁴⁸; however, multivariate analysis demonstrated that this particular modality was used more frequently in younger patients than in older patients. Quality studies on the efficacy of the intervention in elderly pain patients are lacking. Our literature search found one review demonstrating successful biofeedback therapy consisting of relaxation (diaphragmatic) breathing in managing fecal incontinence in older patients (mean age, 62 years),⁴⁹ suggesting that this therapy may be applicable to manage pain in older adults. 

A hypnotic procedure is used to encourage and evaluate responses to suggestions. During the process the subject is guided to respond to either direct suggestions (traditional hypnosis) or permissive suggestions (Ericksonian hypnosis).⁵⁰ Imagery is defined as a dynamic, psychophysiologic process in which a patient imagines and experiences an internal reality in the absence of external stimuli. These images can be initiated by the patient or guided by a therapist (guided imagery). Data on the effectiveness of hypnosis and guided imagery as potential interventions for chronic pain are flawed by methodological quality and treatment efficacy measures.⁵¹ 

Cognitive-behavioral therapy with the use of pain coping skills, as a separate modality or in conjunction with routine medical management, has also been suggested to decrease pain and psychological disability in older individuals with knee OA.⁵² A study by Keefe and colleagues⁵³ assessed the value of spouse-assisted pain coping skills in 88 OA patients. From baseline to the 12-month follow-up, significant improvements were noted in patients’ self-efficacy, which was associated with decreases in pain, psychological disability, and physical disability. Training in spouse-assisted coping skills consists of attending pain coping sessions as well as marital communication and support skills. Keefe and colleagues⁵⁴ described this training in a three-step process: (1) the therapist provides instruction on a coping skill (eg, relaxation); (2) the patient is asked to practice the skill in a physically demanding situation while the therapist models the use of prompting and reinforcement techniques; and (3) the patient practices the coping skill while his or her spouse prompts and reinforces him or her. Mutual goal-setting and opportunities to apply these strategies in real situations (eg, prolonged standing on shopping trips) are important to successful use of this therapy. 

Collectively, these studies show that cognitive-behavioral therapies may have long-term benefits. However, the psychological interventions in these studies place a strong emphasis on coping with pain psychologically, rather than on physical rehabilitation, and as a result, there is little improvement in measures of physical function. 

Music Therapy
Music therapy uses various music-based interventions to achieve a variety of therapeutic goals, and it has been promoted for relief of pain, stress, and anxiety. Controlled studies of noncancer pain management in older adults via music therapy are few and far between. In a randomized controlled trial involving 200 palliative care patients, music therapy that incorporated therapist-guided relaxation was shown to be effective in lowering pain as compared with standard care using scheduled analgesics.⁵⁵ Mean change in Functional Pain Scale scores was significantly greater in the music therapy group (differences in mean, -.05; P<.0001). Moreover, most small controlled trials document reduced anxiety, rather than reduced pain.^56-58 For example, a controlled trial that included individuals undergoing sigmoidoscopy could not demonstrate reduced pain even when individuals had the opportunity to dictate their favorite musical style of intervention.⁵⁹ Among the few studies specifically targeting older adults, a controlled trial of orthopedic surgery patients suggested that listening to music not only reduced pain, but also reduced episodes of acute confusion and improved ambulation after hip and knee surgery.⁶⁰

Stimulation of Anatomic Points for Pain Relief

Acupuncture, transcutaneous electrical nerve stimulation (TENS), spinal manipulation, massage therapy, and static magnet therapy have all been used to manipulate anatomic points on the body to relieve pain. What follows is a brief review of these modalities.

Acupuncture
Rooted in ancient Chinese culture, acupuncture refers to a family of procedures used to stimulate anatomical points.⁶¹ Although millions of Americans seek acupuncture therapy every year, often for pain relief, there is much debate about its value. Acupuncture is traditionally performed with the use of thin needles, but other acupunctural procedures may involve the use of electroanalgesia, heat, pressure, and laser-generated light.

One of the possible mechanisms of action attributable to acupuncture is activation of endogenous opioid mechanisms. Recent data, obtained by using functional magnetic resonance imaging, suggest that acupuncture has regionally specific, quantifiable effects on relevant brain structures.⁶² Furthermore, acupuncture may stimulate gene expression of neuropeptides. Acupuncture analgesia differs from placebo because it has a delayed onset of action and benefits are sustained for a prolonged duration of time.⁶²

A review by Staud⁶³ found several randomized trials have provided strong evidence for beneficial acupuncture effects on chronic lower back pain and pain from knee OA; however, these studies have been inconsistent and contradictory. If performed correctly, acupuncture has few adverse effects, but some reported adverse effects have included transmission of an infectious agent through needle insertion; broken, forgotten, or misapplied needles; pneumothorax; transient hypotension; minor bleeding; contact dermatitis; and pain.⁶⁴

The benefit of acupuncture in managing fibromyalgia is somewhat inconsistent and questionable. A 2010 systematic review with a meta-analysis of controlled clinical trials of the efficacy of acupuncture in the management of fibromyalgia concluded that there is a small analgesic effect of acupuncture in fibromyalgia pain, but that such benefit was not clearly distinguishable from bias.⁶⁴ The authors were unable to recommend acupuncture for fibromyalgia management, and there was no evidence for a reduction of fatigue and sleep disturbances, or improvement of physical function at post-treatment or at the 26-week follow-up.

Transcutaneous Electrical Nerve Stimulation
TENS uses a low-voltage electrical current produced by a battery-powered device and delivered via electrodes placed on the skin to stimulate the nerves for therapeutic purposes. This therapy has been shown to be a fairly effective method of alleviating localized pain in elders, particularly due to its ability to limit or eliminate the need for use of systemic analgesic medications. Since patients differ in their response to TENS, a trial period is usually recommended and even required by certain insurance carriers.⁶⁵ TENS was introduced more than 30 years ago as an adjunct to the pharmacological management of pain. However, despite its widespread use, TENS therapy has not been well tested, specifically in persons with chronic lower back pain.⁶⁵ A Cochran systematic review found only two randomized clinical trials involving a total of 175 patients evaluating the use of TENS in managing chronic lower back pain.⁶⁶ However, the two studies differed in several aspects, including the eligibility criteria, study design, methodological quality, inclusion and exclusion criteria, and type and method of TENS application. In one of these trials, TENS produced significantly greater pain relief than the placebo; however, in the other trial, no statistically significant differences between treatment and control groups were shown for multiple outcome measures. Therefore, there is inconsistent evidence to support the use of TENS as a single treatment in the management of chronic lower back pain. Larger, multicenter, randomized controlled trials are needed to better assess the true effectiveness of TENS.⁶⁶

Spinal Manipulation Techniques 
Spinal manipulation, commonly used by chiropractors, is a form of manual therapy that involves the movement of a joint to its paraphysiological zone, which requires moving the patient’s joints beyond their end range of motion but not past the anatomic range of motion for the joint being manipulated. There is application of loads and short-lever, high-velocity movement of the joint, at times causing cracking or popping sounds.⁶⁷

A systematic review by Standaert and associates⁶⁷ indicated that structured exercise and spinal manipulative therapy have fairly similar clinical benefits in terms of functional improvement and pain reduction in patients with chronic lower back pain. However, there is insufficient evidence to comment on the benefit of acupuncture compared with either structured exercise or spinal manipulation. There are also insufficient data to address the differential effects of structured exercise, spinal manipulative therapy, or acupuncture for specific subgroups of patients with chronic lower back pain. The evidence regarding the relative cost-effectiveness of structured exercise, spinal manipulative therapy, or acupuncture in the treatment of chronic lower back pain are also lacking.⁶⁷

In a systematic review of 26 randomized, controlled trials (total participants, 6070), nine of which had a low risk of bias, Rubenstein and colleagues⁶⁸ reported that there is some high-quality evidence that spinal manipulation technique has a small, but not clinically relevant, short-term effect on pain relief and function in comparison with other interventions. The quality of evidence is inconsistent as to whether spinal manipulation technique has a significant short-term effect on pain relief and functional status when used in combination with another intervention. The study reported insufficient data on the benefits of spinal manipulation technique for recovery time, return-to-work time, quality of life, and costs of care.⁶⁸

Performing spinal manipulation on elders carries an inherent risk of adverse effects, yet the available literature implies that serious adverse events following lumbar spinal manipulation, such as worsening lumbar disc herniation or cauda equina syndrome, are rare.⁶⁷ In 2002, Meeker and Haldeman⁶⁹ found no serious complications reported with spinal manipulation in more than 73 controlled clinical trials or in any prospectively evaluated case series. However, spinal manipulation technique is to be strictly avoided in patients with progressive or severe neurologic deficits due to increased risk of accidental additional nerve injury, especially is cases with structural instability.^68,69

Massage Therapy
Massage therapy uses a variety of techniques to press, rub, or manipulate the muscles and soft tissues of the body. Studies have indicated that massage therapy might help alleviate noncancer pain in a variety of populations. In a survey that asked 401 veterans with noncancer pain about their use of complementary and alternative medical therapy, massage was the most preferred of all modalities.⁷⁰ A small controlled study suggested that massage therapy may reduce self-reported pain in cardiac surgery patients,⁷¹ whereas another randomized trial of 600 patients, with a mean age of 64 years, showed a significant reduction in postoperative pain using massage as an adjuvant therapy.⁷²

A randomized controlled trial compared the long-term benefits of massage therapy, exercise prescription with nurse-delivered behavioral counseling, and lessons in the Alexander technique (ie, a mode of relaxation that teaches participants how to stop using unnecessary levels of muscular and mental tension in everyday life) in 579 patients with chronic or recurrent lower back pain. Of these patients, 144 received normal care (control group), 147 received massage therapy,
144 participated in six Alexander technique lessons, and 144 participated in 24 Alexander technique lessons; half of each of these groups were randomly assigned to exercise prescription with nurse-delivered behavioral counseling.⁷³ At the 1-year follow-up, exercise and lessons in the Alexander technique—but not massage therapy—remained effective for relieving back pain.

Static Magnet Therapy
Compared with electromagnetic therapy in which a magnetic field is produced by the flow of electricity, static magnet therapy is administered by placing magnets on the skin (eg, magnetic bracelets) or by adding them to mattress pads, shoe inserts, or on other items of clothing.¹⁴ Magnets have been popularly marketed for pain control, but in the absence of strong evidence, the National Institutes of Health does not advise using magnets as a replacement for conventional medical treatment and it notes that magnet therapy may not be safe in some patient populations, such as those with pacemakers or insulin pumps.⁷⁴ A January 2013 report by the Arthritis Research UK group has reviewed three trials which have examined the effectiveness of static magnet therapy for knee OA, two for fibromyalgia, two for lower back pain, and one for RA. Based on their review, the authors concluded that magnet therapy is considered safe (with the exception of high-strength magnet use, which may interfere with medical devices); however, there is little evidence that supports its effectiveness in OA pain but it can increase leg strength and result in decreased disease-related disability.⁷⁵

Considerations for Advising Complementary and Alternative Therapy in Geriatric Patients

Interest in complementary and alternative medicine is high, and several studies suggest that treatment strategies that use or incorporate this approach have been increasing in recent years. The prevalence of complementary and alternative medicine, with and without physician supervision, is also growing despite the lack of high-quality studies on its efficacy and safety in the geriatric population. Therefore, physicians should be well informed of the current available evidence regarding complementary and alternative therapies to appropriately advise patients who inquire about such treatments during clinical visits.

In this review, we found that most of the currently available studies include small numbers of participants, some lack an active control group, and the end points are usually subjective and difficult to interpret. The patient characteristics, medications, and comorbidities are not well defined in the majority of these studies. The details of the protocol and adherence to the protocol are not clearly defined in the majority of the studies. Therefore, the results cannot be reliably applied to different patient populations. Nevertheless, these concerns should not deter geriatricians from inquiring about and using some of these complementary and alternative medical interventions to manage chronic pain in their patients. The Table provides links to online resources that healthcare providers can share with patients who are seeking additional information of each of the therapies discussed in this review. What follows is our recommendations for giving individualized advice to patients considering starting or continuing with a complementary or alternative therapy.

Exercise Therapies
Although studies to date show various exercise regimens (ie, tai chi and yoga) to be a relatively safe complementary and alternative medicine strategy, with little to no risk of physical harm, these interventions, especially when used by older adults and frail patients, should be individualized according to each patient’s physical and cognitive abilities and cardiovascular condition. Optimizing the management of the patient’s comorbid medical conditions, as well as modifying the dosing and timing of the medications that may increase the risk of injuries and falls, is of utmost importance, particularly because exercise also increases these risks. Cardiopulmonary assessment for regimens involving exertion, as well as a baseline review and supervision of any prescribed exercise routine by a certified physical therapist, is prudent.

Cognitive-Behavioral Therapies 
The cognitive-behavioral therapies of meditation, biofeedback, and music therapy are generally considered safe and free of risk in healthy persons. In rare cases, however, meditation may cause or worsen symptoms in persons with psychiatric problems,⁷⁶ so a mental health assessment may be warranted before advising patients to start such therapies. Biofeedback methods have essentially no risks, but because state laws regulating biofeedback practitioners are varied,⁷⁷ healthcare providers should advise patients to seek certified practitioners with experience treating their specific condition. Music therapy has no risk, but its ability to reduce pain has a weak evidence base. There are a wide variety of music-based interventions, so interested patients should be encouraged to educate themselves on the options.

Anatomical Point Stimulation Therapies
Despite conflicting data about whether acupuncture and other modalities of stimulating anatomical points effectively manage pain, few serious adverse effects have been reported with these therapies. However, that does not mean that all patients are good candidates to receive such treatments. Patients should be advised to seek out an experienced and licensed acupuncturist to minimize the risk of infection from unsterilized tools. Additionally, patients on anticoagulant therapy should be advised of the increased risk of bleeding associated with acupuncture and vigorous massage.⁷⁸ Electroacupuncture, TENS therapy, and magnet therapy are ill advised in patients with an implanted medical device.

Conclusion

High-quality studies on efficacy and safety of complementary and alternative medicine in the geriatric population are lacking. The results of many available studies cannot be reliably applied to different patient populations. Nevertheless, these concerns should not deter geriatricians from inquiring about and using some of these complementary and alternative medicine interventions for managing chronic pain in their patients. When caring for older adults with chronic musculoskeletal pain, a multidisciplinary approach to pain management is best. In addition to conventional medical treatment, clinicians should not overlook the potential benefits of complementary and alternative medicines if there is a likelihood of pain improvement and reduced reliance on oral analgesics. Clinicians should be well informed of the evidence and carefully consider each patients’ individual circumstances, including psychological issues (eg, depression, dementia), sources of social support, body type and dietary considerations, and other potential medical and socioeconomic constraints. More long-term and large-scale trials of complementary and alternative medicine in managing chronic pain are needed, especially as the use of these therapies become increasingly ubiquitous in the older population.

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Disclosures: 

The authors and the series editor report no relevant financial relationships.

Address correspondence to:

Mandana Hashefi, MD

George Washington University

2150 Pennsylvania Ave NW

Suite G-400

Washington, DC 20037

mhashefi@mfa.gwu.edu