Integrative Medicine for Pain management!

Original: Nov. 1, 2019; Update: Nov. 6, 2019.

October is the National Breast Cancer Awareness month! According to breastcancer.org, over 12 percent of women in the U.S. will develop "invasive breast cancer" over their lifetime. In 2019 alone, over 280,000 such cases will be diagnosed. Expectedly, cancer diagnosis does take its toll on the patients' mental and physical well-being. Aside from its emotional impact, the disease commands the coordinated allocation and scheduling of multiple resources from scheduling/attending doctor appointments to maintaining a tight regimen of scheduled chemo treatments - all while working with a team of healthcare providers. Altogether, these significantly affect a patient well-being from a less than optimal quality of life to increased stress, anxiety, and pain (Editorial Staff, 2019).

Women & Pain Reporting Struggles: Regardless of advances in science and medicine, one common thread among all the serious illnesses, however, has been the way patients experience pain during their pre-, intra-, and post-care. Within the context of the month of October being the National Breast Cancer Awareness Month, the experience and management of pain becomes more poignant for women (Ruggeri, 2018).

Social determinants like race, class, and wealth have long been considered to impact someone's quality of care. Regretfully, another but less obvious one which often impacts people's health is gender. Studies have shown that women are less likely to be treated for their pain with their symptoms being taken less seriously. The net outcome is that women are left with inappropriate diagnoses, and hence, improper prognoses and treatments (Ruggeri, 2018).

Studies have shown that doctors often dismissed women "reports of pain as less serious." Society, regardless of whether there is an implicit bias, has often disparaged women for how they presented their pain for different clinical conditions. And, if there are “sex differences in the way women experience pain,” it is imperative that women receive a more personalized and tailored approach to their care. Such care should be based on given diagnostic tests "to rule out" any underlying organic issues, says Christin Veasley, co-founder and director at the Chronic Pain Research Alliance (Billock, 2018).

Change in Pain Management Perspectives: The aforementioned discussion highlights the role of social norms in reporting pain behaviors. And, given the slew of social and technical changes onto the US healthcare system, there has been a significant shift in patients' perspectives regarding health. Though no two treatment journeys are alike, patients are embracing now other modes of treatments like integrative, complementary, and alternative medicine. As novelty, these are used before, during, and after cancer care treatments, after a long standing Western medical approach to care (Pool et al, 2007).

For cancer, more and more patients are surviving cancer, given the advances in medical technology for early detection and treatments. In turn, those patients are encouraged to become more savvy about their illness, treatment, medications, and side effects. Most, if not all, of them are searching for a sense of 'normalcy.' And, to unravel the underlying emotional and physical pain associated with their diagnoses, prognoses, and treatments, those patients are inquiring more about the causes and treatments of their illnesses. They are exploring complementary modalities and ideas that could integrate into their daily lives, in whatever stage of their disease - whether newly diagnosed, currently in treatment, or several years post treatment (Sarvello, 2019).

Integrative Holistic Medicine: Within the scope of integrative medicine, for example, healthcare professionals are not only laser focused on the disease, but also on its pre-treatment symptoms and signs as well as the post-treatment side effects. Such regimen is a systematic plan that includes the integration of complementary/alternative medicines or CAM into the patient's treatment plan. Such systematic approach encompass a variety of non-standard medical care practices like massage, acupuncture, tai chi, and drinking green tea (Complementary and Alternative Medicine, 2019).

• Standard medical care includes best practices or standards of care (e.g., therapy, diagnoses, prognoses, treatments, procedures & surgeries) that are provided by M.D., D.O., physical therapists, physician assistants, psychologists, and registered nurses. Other terms are also used like biomedicine or allopathic, Western, mainstream, orthodox, or regular medicine.
• Complementary medicine includes practices used along with standard medical treatments. Not necessarily part of the standard treatment plan, these practices can include acupuncture & massage to lessen the side effects of cancer treatment.
• Alternative medicine includes practices used to supplant standard medical treatments, e.g., pain management or diet protocols to treat the side effects of cancer rather than maintenance protocols prescribed by oncologists.

Role of Integrative Approach: Integrative medicine is a total, holistic approach to medical care. This includes combining both the standard medical care and the CAM practices for a more effective and safer care. Such structured, integrated treatment regimen would benefit those patients with debilitating illnesses in myriad ways, e.g., pain, fatigue/nausea, and stress reliefs. This is especially effective for treating/managing cancer - a disease eloquently characterized itself into diverse diagnoses of extremely varied treatments/outcomes (Editorial Staff, 2019a). The net outcome is better integration of both practices onto the patient's well-being, i.e., patient's mind, body, and spirit. 

Integrative Structured Treatment Plans: For Patty Phillips, being diagnosed with stage II breast cancer had a profound impact on herself - a humbling life-changing experience. "After her initial shock," her experience was similar to others. Between chemo and radiation treatments, along with multiple visits to intensive care, she was at her lowest point when reached her nadir (Hattenstone, 2019).

Approach to her care required a holistic approach with "increased awareness and insight" into her life. Her integrative treatment included not only pharmaceutical care, but also CAM practices - a novel approach to use before, during, and after cancer care treatments. Pathways to her care were supported/enhanced with prayers, well-wishing cards, scarves, and more supporting healing touches, in addition to massage/physical therapy, acupuncture, & hypnotherapy (Editorial Staff, 2019a)

Pain Management for Chronic Pain: Often, patients succumb to unrelenting pain following severe illnesses or injuries. As a result of the debilitating effects of the numerous treatments and invasive procedures that follow, those patients often abdicate their freedom to "limited mobility & dependency on high doses of pain medication" for years. Henceforth, those patients are left to manage their chronic pain on the peripheral of our culture. It is a culture that equates "poor health with poor choices." Worse, those patients are widely stigmatized - often written off as lazy or overdramatic (Editorial Staff, 2019c).

Typically, the underpinnings of our US healthcare system are for the "wounds to heal and sickness to lessen" over time. Realistically, however, Homo Sapiens, ever mindful of their health shortcomings, have no luxury in selecting their mental or physical conditions. Rather, anyone & everyone could succumb to diseases and suffer from chronic pain. A case in point is those patients who are suffering from Neurological & Chronic Pain disorder (CRPS). They are at their worst, even when confined to a bed or wheelchair (Editorial Staff, 2019c).

CAM Practices - Historical Background: How did we get to the current US healthcare paradigm - one that is based on the traditional pharmaceutical-based treatment? How did this medical-based paradigm of access, delivery, and quality of care originate?

It all goes back 300 years ago to the medicine doctors, Rene Descartes and Sir Isaac Newton, who were contemplating the use of cadavers to study the human anatomy. Back then, the church blocked such effort, pushing instead the resolution to fragment the human being into four independent structures. At the end, 1) the church acquired the spirit; 2) the doctors controlled the biochemistry; 3) the therapists managed the flesh; and 4) the humans self-conducted their emotions (Barnes, 2019).

Since then, the separation of the human body into these four structures led to the concept of Dualism over Monism. The Dualism is the belief that the soul/mind can exist separately from the body. In contrast, the Monism is the belief that the two parts must coexist (Chadaga, 2019). Over time, Dualism drove the traditional therapy to prevail, with the Newtonian (classical physics) being the medical underpinnings of the US healthcare model. To uncover the root cause of illnesses, the reductionist point of view of separating both systems in life. Eventually, Max Plank, the father of quantum physics in 1923, was proven to be the best approach - the Myofascial Release Approach - a powerful combination of Newtonian Physics and Quantum Physics (Barnes, 2019).

Pain Management Paradigm Shift: Over time, humans were thrusted into believing or accepting as truths things that started a long time ago as myths. Things what sounded logical don't provide any basis in reality. Experts so called experts disseminated misinformation - exclaimed as logical but with no basis in reality - until we become to believe these myths as truths. The paradigm of reality was presented into elements of chemicals and machines, based on a series of beliefs of reality based on erroneous and incomplete information (Barnes, 2019).

Now, we know that the body is no more a two-dimension but rather a three-dimension platform. We also learned that the body is linear - therefore, all of the medical techniques we learned were also linear. However, our body is a proven to be a non-linear system made up of interconnected fractals. Our fascial, circulatory, and neurological systems all are of fractal nature, so are our trillions of cells in our body (Barnes, 2019).

CAM Practices - Acceptable Clinical Guidelines: For a holistic approach to care, new and unique principles of clinical guidelines should be explored, formulated, and recommended. These clinical guidelines are based primarily on published research evidence - assessed by grading systems for quality research. Fortunately, the shifts in pain management ideology have been significant enough to advocate non-invasive, non-pharmacological CAM tools. Expectedly, these practices are not commonly endorsed by many health organizations due to lack of high-quality research evidence. Studies without control group do not meet criteria for high-quality research (Massage Therapy Foundation, 2019).

The nature of anatomy presents a challenge. For high-quality research standards, randomized double-blinded studies must be conducted. These are controlled trials, in which the experiment and the control treatments are randomized across participants. Another challenge to consistency in research is that MT is defined differently between research studies and systematic reviews. To lend credence to MT validity, the quality of its research must meet the research review guidelines to become a standard of practice in health care and insurance coverage (Massage Therapy Foundation, 2019).

Therefore the CAM practices to gain acceptance will need rigor, larger sample sizes, and effective use of established research guidelines about their underlying etiology, risk factors, incidence, pathogenesis, clinical manifestations, prognosis, medical treatment and the implications for MT therapy of patients with disorders and conditions - w/ pain as key symptom of interest (Massage Therapy Foundation, 2019).

CAM Practices - Pain Management: Given these conflicting conditions, it is essential that our society yields a more empathetic healthcare system that could navigate the challenges of chronic illness. Medications aside, our providers should collectively incorporate other non-pharmaceutical treatments to treat their patients with chronic pain. Complementary and alternative treatments could contribute to pain management, via protocols that best fit their lifestyle and body.

Shermer, 2019, reported that the literature (research) on the efficacy of most CAM practices and modalities is thin and incomplete.". The topic of interest is not deeply researched in terms of evidence-based protocols to relieve pain (Shermer, 2019). The message here is that CAM are as important as any aspect of treatment. Yet, the research in many areas of CAM science is at best mixed (massage, nutrition) and at worst pseudoscientific or fraudulent (hydrogen water and oxygen inhalers) with uncertainty abound and many fads driving our behavior.

Patients might ask if "Does this work for pain and recovery? like massage, ice or hear or donning compression boots and electrically-stimulated? These practices might work in the sense that the patients feel better and therefore functions better. What we cannot say is that CAM works in the scientific sense like drugs are considered to "work" when effective on x% of patients, Y% of the time? Some might consider CAM as different recovery modalities just represent variations on the same few approaches to recovery.(Shermer, 2019)

For placebo effect, CAM modalities might just "soothing your muscles and body resulting in feeling better, though no measured physiological changes). These CAM practices provide a "ritual' giving us a sense of self-efficacy - as a formalized way to focus on resting. May be we could see CAM practices as existing on an "evidence continuum," from most effective (sleep, rest), to uncertain (icing, heat, compression, ibuprofen) to least effective (concoctions such as hydrogen effervescent magnesium pills and gluten-free recovery drinks).(Shermer, 2019)

Some are proven remedy for pain, others strategies aren't so effective, with no shred of evidence to prove their utility. By being proactive - it is a sense that can be seen and felt. Stretching is another placebo-like recovery method. Sometimes, there are "all but useless for recovery." Are these practices produce clinically important reductions in delayed-onset of discomfort.(Shermer, 2019)

That said, it is important not to discount the placebo effect or the "anticipatory response." Some CAM practices may work if you think they do for the simple reason that "the body's natural powers can be amazingly potent. "Expectations can create real biological effects." As it increases the natural circulatory healing process that comes with CAM practices.For example, one study showed that those patients with oral-surgery who were given placebo experienced a 39% reduction in pain - a benefit that disappearing when the placebo is replaced by a drug that blocks opioid receptor - the placebo effects exploits the body's natural opioid system." At the end, the process is necessarily personal - so it is important to monitor our body for a sense of when to rest and when to push on, and to listen to your body's feedback system(Shermer, 2019)

Many questions are still unanswered:(Shermer, 2019)

Should I get use CAM to get the circulation going, or just rest my achy body?

Should I apply ice or heat, as CAM?

Is there something special I should do during pre-, intra-, and post- CAM therapy?

When should I use CAM?

When should I just take it easy, rest, and eat healthy rather than CAM?

What vitamins and supplements should I take, instead of CAM?

The list goes on with a range of answers dizzying. If we get these questions wrong, risk debilitating setbacks, possibly even worse ones

CAM Practices - U.S. Pain Foundation: The US Pain Foundation is a non-profit organization with the purpose to promote evidence-based pain management practices. In turn, its overarching goals are to decrease pain and suffering, improve physical and mental functioning, and, to ensure improved quality of life. Considering pain management as a pertinent issue of quality of life, the foundation strives to enhance the quality of life and to improve the patient outcomes for more than 50 million Americans living with chronic pain. its free programs and services include educational events, a network of support groups, print magazine featuring patient stories, retreats for suffering kids (along with their families), robust federal and state advocacy programs, as well as the advocate for better access to safer, more effective and affordable treatment options (Editorial Staff, 2019c).

CAM Practices - Massage Therapy (MT). Did you know that over 140 hospitals and cancer centers in the US offer MT therapy services? (Sarvello, 2019). And, published research by the Massage Therapy Foundation concluded that MT is an effective therapeutic option for treating symptoms of many painful conditions - pain being the key symptom of interest (Massage Therapy Foundation, 2019). MT has also been helpful in managing an array of cancer-related symptoms as well as the side effects of many related treatments (Editorial Staff, 2019a).

Studies showed that MT (therapeutic option) has helped those cancer patients in managing their pain. In addition, it promoted a reduction in post-surgery anxiety and stress. The studies cited also an overall reduction of stress, yielding an increased comfort for all participants. In meta analyses of the MT effects on pain relief, the cohort group of health-related quality of life (HQoL) metrics were compared to the control group of the usual standard-of-care metrics. The cohort group exhibited statistically significant increases in quality of life, after controlling for both stress and anxiety. The HQoL scales are five functional scales (physical, role, cognitive, emotional, and social); two symptoms scales (fatigue and nausea); and the global QoL scale (Editorial Staff, 2019b).

Other studies also pointed to the benefits of MT for cancer-related sleep disorders and fatigue. In the randomized controlled trial of 60 patients with acute leukemia undergoing chemotherapy, the cohort group were observed for the effects of MT (slow-stroke back massage three times a week over the course of four weeks). That group experienced significantly reduced progressive sleep disorder, pain, and fatigue, as well as improved sleep quality over time (Editorial Staff, 2019b).

Anecdotally, MT can be extremely helpful tool for those with pain. Properly deployed, MT results in improved circulation, relaxed tight muscles, and lessened headaches - hence - decreased pain. One case in point is Nicole Hemmenway who lived in pain since 1994, when she was diagnosed with a neurological and chronic pain disorder called Complex Regional Pain Syndrome (CRPS). Over the course of several years, she lost mobility in her right hand with minimal use of her arm; became depended heavily on high doses of pain medication for years; and underwent numerous invasive procedures. Often, she was confined to a bed or wheelchair. Over time, she explored various non pharmaceutical treatments. As alternatives to the traditional pharmaceutical-based pain management paradigm, therapies like MT did much more to ameliorate living with pain. Not only did MT led to decreased pain, MT also can aid in sleeping better and reducing anxiety and stress (Editorial Staff, 2019c).

CAM Practices - Workforce Skills. To ensure ongoing safe & effective healing, the CAM Therapists must critically engage themselves into the pertinent investigative, critical thinking, and communication skills requisites. In managing the full-range of cancer-related issues, those therapists must communicate the intra- and post- care outcomes like contraindications, pain, constipation, hope, fear, and death (Sarvello, 2019). Their training extends beyond the traditional MT components of 1) the clinical and knowledge-based foundational information, and the hands-on skill instructions. Their specialization into cancer therapy should extend into the didactic elements of the latest cancer-related concepts and practices, like the short- and long-term side effects of chemotherapy, radiation, & surgery. To enhance their how-to skills in oncology massage, they must enroll into supervised clinical apprentices with cancer survivors or intra- & post-care cancer (undergoing oncology treatments) patients. undergoing cancer treatment, in addition to continued education on a regular basis to ensure ongoing safe and effective treatment for patients (Sarvello, 2019).

As more and more patients are seeking MT services at various integrated healthcare environments, the demand for skilled therapists is expectedly increasing. As a result, MT providers are more focused on enhancing their skills by attending clinical, knowledge-based, and latest research on MT based on disease and conditions. Therefore, questions to consider when identifying MT programs may include (Sarvello, 2019):

• What programs or courses are being taught near me?
• What are the objectives of the programs or courses?
• Who are the instructor(s)? What are their qualifications?
• Are the programs/courses research-informed with demonstrable clinical integrity?
• What are others' feedback about the programs or courses?
• Are the programs or courses board-certified or board-approved?

CAM Practices - Myofascial Release: Such therapy recognizes the fractal nature of human beings as the underpinning to the treatment of chronic pain. This is based on the "Fractal theory" of the Fractal Geometry by the French Mathematician Benoit Mandelbrot. The resultant healthcare delivery paradigm never took hold, due to the traditional science of medicine being long enshrined onto the Euclidean Geometry.

The Fractal Theory implies no straight lines to interconnected structures. In the realm of our fascial system of fractal nature, restrictions abound. Therefore, the fluidity of our soft tissue is inhibited upon illness or trauma. As it turns more viscous, it solidifies into a mass of crushing pressure on our trigger points. As expected, there are no standard medical diagnosis or testing for fascial restrictions. Thereto, all related ailments were either missed or misdiagnosed. In addition, most common types of therapy may yield marginal effects onto most of our interconnected (solidified) fascial system.

Lo and behold, the doctors of medicine fixation on the traditional paradigm has all but forbidden new methods of accessing and delivering medical care. In the 1940s, Nobel Laureate Albert Szent-Gyorgyi reported that our fascial system is not an insulator. Instead, it readily allows the flow of energy (consciousness) throughout our structure. In such case, our fascial system of interconnected fractals parlayed itself into a network of fiber optic that relays information (in the form of energy) into our mind/body structure. Properly deployed, the Myofascial Release therapy enables the flow of energy back into these solidified soft tissues, with resultant relieving of pain, headaches, fibromyalgia, and other ailments (Barnes, 2019).

CAM Practices - Low Back Pain Management: Did You Know … According to the National Institute of Neurological Disorders and Stroke (NINDS):

• "Eighty percent of adults suffer from low-back pain;
• L1 - L5 vertebrae are the most common areas of pain;
• Acute pain usually happens due to sprain or strain."

According to the National Health Review 2012 Survey, back (musculoskeletal) pain is one of the most common reasons for seeking complementary medicine. For such prevalent pain condition, CAM practices have been explored for validity and efficacy. For gaining credibility among healthcare providers, these CAM clinical guidelines were vetted over time based solely on research evidence.

In their reported clinical guidelines, both the American College of Physicians (ACP) and the Centers for Disease Control (CDC) have recommended other non-pharmacological treatments to improve the quality of care for patients with musculoskeletal pain. In 2017, the ACP (the second-largest physician group in the US) recommended non-invasive, non-pharmacological treatments for back (musculoskeletal) pain. Such clinical guidelines were based on extensive systematic reviews of both pharmacological (anti-inflammatories, opioids, etc.) and non-pharmacological therapies for low-back pain.

It is worth noting that a systematic review is a rigorous and structured way of compiling and evaluating research evidence. The ACP has strongly recommended "MT … as one of several non-pharmacological treatments for acute or subacute low back pain," as part of the multidisciplinary patient-centered holistic approach. Other non-pharmacological alternative therapies for chronic low back pain included other types of manual therapy, acupuncture, education, exercise, and ultrasound.

The CDC also noted the value of MT in its March 2016 recommendations for chronic back pain. It validated the value of more time-intensive, non-pharmacologic management approaches over opioid therapy, e.g., acetaminophen, NSAIDs, tricyclic antidepressants and MT. Other organizations like The Federation of State Medical Boards, The Joint Commission, and the Department of Health and Human Services have also recommended multidisciplinary approaches for treating chronic pain. This included non-pharmacological approaches to chronic musculoskeletal pain management (Massage Therapy Foundation, 2019).

CAM Practices - In sum: Long considered more conducive to relaying energy, our mind/matter complex structure becomes less restrictive with the appropriate CAM practices. As a result, our fascial system of interconnected fractals turns less resistive to the mass hypnosis of the traditional Western medicine-based healthcare access & delivery paradigm. In doing so, we are considering the 4th dimension of our mind/matter complex structure - the "Feeling" IQ - the intuitive, instinctive creative factor - as the deep, healing dimension (Barnes, 2019).

In bridging the four dimensions (the spirit, the biochemistry, the flesh, and the emotion) of the mind/body structure, the CAM practices will enable patients to become "mentally clear, emotionally and physically stronger, and physiologically healthy." The resultant Integrative medicine - the underpinning of these practices - is nothing short of opening the dialogue between providers and their patients. Such interaction will provide, above all else, the introductory conversation to better understand the needs/limitations of patients, and to identify/explain the providers approach to their treatment (Sarvello, 2019). This would allow for a "steady, caring connection" with the patient during which the provider-patient relationship flourishes.

All in all, the integrative medicine will help in managing the expectations of the provider/patient relationship, the current/future treatment plans, as well as any future outcomes (Sarvello, 2019). A key point is that different forms of CAM may be more beneficial at different times. Therefore, finding the right therapist and right technique is crucial to living with less pain (Editorial Staff, 2019c).

Side Note: "The words diagnosis and prognosis are commonly (though not exclusively) used in the medical field. Both terms contain the root word gnosis, which means "knowledge." But diagnosis and prognosis refer to different kinds of knowledge or information. The noun diagnosis refers to the process of analyzing information to understand or explain something - its adjective form is diagnostic. The noun prognosis is to forecast or prediction - a judgment about what is likely to occur in the future. In the medical field, diagnosis relates to identifying and understanding the nature of a disease or disorder, while a prognosis is a prediction of the probable outcome of a disease or disorder (Nordquist, 2019)."

A suspected diagnosis means patients with symptoms consistent with cancer, but no diagnostic investigations or formal diagnoses, yet.

Acute back pain is defined as lasting less than four weeks; Subacute back pain lasts four to 12 weeks; Chronic back pain lasting more than 12 weeks.

References:

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Nicole's Personal Journey with Pain - https://www.massagetoday.com/hemmenway

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Shermer, Michael. (2019, Feb. 8). Bookshelf: The Best Way to Get Better - Good to Go by Christie Aschwanden. [Opinion]. WSJ, p. A13