Dr. Johnson is a primary care provider in the spinal cord injury clinic and Ms. Cosgrove works in quality management, both at the Orlando VAMC in Florida.
Mind and body practices or provider-based CAM therapies such as chiropractic care, acupuncture, and massage increased significantly between 2002 and 2007, and many more patients may be willing to try these therapies for chronic low back pain if they do not have to pay out of pocket. 27,28 Multiple studies have also found that these treatments in addition to herbal medicine are the most commonly reported CAM treatments used for pain relief in adults. 3,17,22,23
Other commonly reported CAM therapies are garlic preparations, exercise, and yoga and meditation. 22,23 A large number of veterans have reported previous use or willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture for chronic noncancer pain. 17 In addition to acute care with conventional treatment, the VHA has now expanded services to allow for CAM as available treatment options for chronic musculoskeletal pain. 29 The majority of VHA facilities also provide and refer patients to CAM service providers. 30
This review article explores the evidence supporting the use of the most commonly reported CAM therapies; specifically acupuncture, massage therapy, and spinal manipulation for musculoskeletal pain relief. Because of the plethora of herbs and dietary supplements in the literature, these were not included in this review, although they are also reported among the most commonly used CAM therapies. 1,23,31 The investigators sought to examine the effectiveness of acupuncture, spinal manipulation, or massage compared with no treatment, sham therapy, or current noninvasive first-line treatment for chronic musculoskeletal pain.
Study Selection
To find research addressing this question, the authors searched the PubMed, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and the Cochrane Library for all relevant studies published between October 31, 2003, and October 31, 2013. The combined search from all sources for randomized controlled trials (RCTs) resulted in 1,157 studies with acupuncture and chronic pain, 343 studies with spinal manipulation and chronic pain, and 416 studies with massage and chronic pain. Acupuncture and chronic musculoskeletal pain yielded 94 studies, spinal manipulation and chronic musculoskeletal pain yielded 29 studies, and massage and chronic musculoskeletal pain yielded 55 RCTs.
Targeted searches were then conducted within the results for systematic reviews and meta-analysis of relevant studies of RCTs, focus on adults with any type of musculoskeletal pain, written in English, and had pain level or level of pain-related improvement as its primary outcome. The results were assessed for relevance to the review based on the information provided in the title, abstract, and the National Library of Medicine Medical Subject Headings. References of the search results were also searched manually for additional studies relevant to the review. Duplicated studies and those that looked at only acute or cancer pain were excluded. Thirteen systematic reviews and meta-analyses met the inclusion criteria (Table). The investigators reviewed the full reports and agreed to use the data that were abstracted from the studies.
Study Parameters
Four different categories of outcome measuring points for posttreatment follow-up are reported in the CAM studies: immediate, short-term, intermediate, and long-term. There are inconsistencies across studies for the timing of these 4 categories. Immediate posttreatment is defined as up to 1 day. 8,32-34 The duration for the short-term follow-up period is defined as between 1 day and 3 months 8,32,33; ≤ 3 months 35,36; closest to 3 weeks 37; closest to 4 weeks 34; 1 month 38; closest to 8 weeks, but < 3 months after randomization 39; or up to 25 weeks, but nearest to 12 weeks. 40Intermediate follow-up is between 3 months and 1 year 8,33,35; between 3 and 6 months 38; ≥ 3 months, but < 1 year 36; or closest to 6 months. 34Long term is defined as >12 months 8,35; closest to 6 months 37; 12 months 38; 1 year or more 36; closest to 6 months, but >3 months after randomization 34,39; or between 26 weeks and 56 weeks. 40
