Keywords

Complementary and Integrative Health

What Is Complementary and Integrative Health?

Complementary and integrative health encompasses diverse medical and health-care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of MD (medical doctor) and DO (doctor of osteopathy) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between complementary health approaches and conventional medicine are not absolute, and specific complementary health approach practices may, over time, become widely accepted. “Complementary medicine” refers to use of complementary health approaches together with conventional medicine, such as using acupuncture in addition to usual care to help lessen pain. “Alternative medicine” refers to use of complementary health approaches instead of conventional medicine, which is uncommon. The characterization of specific health systems, practices, and products as within the purview of complementary health approaches changes continually as new complementary health approaches are introduced and therapies with scientifically demonstrated safety and efficacy are integrated into conventional medical care. “Integrative” health involves bringing conventional and complementary approaches together in a coordinated way (https://nccih.nih.gov/health/integrative-health).

The National Center for Complementary and Integrative Health (NCCIH) groups complementary health approaches into two subgroups: (1) natural products, which include the use of a variety of herbal medicines (also known as botanicals), vitamins, minerals, and other “natural products” as well as probiotics, and (2) mind–body practices, which include a large and diverse group of procedures or techniques administered or taught by a trained practitioner or teacher. Mind–body practices focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health. Many complementary health approaches embody this concept, including meditation, yoga, acupuncture, deep-breathing exercises, guided imagery, qi gong, tai chi, spinal manipulation (chiropractic), and massage therapy (MT). Other complementary health approach practices include (1) manipulation of energy fields to influence health (e.g., biofield therapies including healing touch (HT), Reiki, therapeutic touch (TT), and magnet therapy), (2) movement therapy, (3) traditional healers (e.g., Native American healers), and (4) whole medical systems, which are complete systems of theory and practice that have evolved over time in different cultures and apart from conventional medicine (e.g., traditional Chinese medicine, Ayurvedic medicine) (https://nccih.nih.gov/health/integrative-health).

How Prevalent Is Use of Complementary Health Approaches?

Despite the fact that rigorous, well-designed clinical trials for many complementary health approaches are often lacking and, therefore, the safety and effectiveness of many complementary health approaches are uncertain, complementary health approach use is common, particularly among individuals with chronic pain and advanced illness. Use of complementary health approaches is gaining acceptance in mainstream venues. In 2002, the White House Commission on Complementary and Alternative Medicine recommended integration of CAM therapies that are considered safe and effective into health care throughout the nation (White House Commission on Complementary and Alternative Medicine 2010).

The 2012 National Health Interview Survey (NHIS) found that complementary health approach use is prevalent. Thirty-three percent of US adults and 11.6% of children reported complementary health approach use in 2012, which is similar to 35.5% of adults surveyed in the 2007 NHIS (https://nccih.nih.gov/research/statistics/NHIS/2012/key-findings). In 1996, there were an estimated 630 million visits to complementary health approach providers, exceeding the number of visits to primary care physicians (Eisenberg 2005). A survey of patients hospitalized on surgical services in Adelaide, South Australia, revealed that 90% acknowledged using some complementary health approach modality, with the most commonly used modalities being biologically based therapies, including herbal and nonherbal preparations (69%) and mind–body interventions (65%), followed by manipulative and body-based methods (63%) (Shoroni and Abron 2010).

Use of complementary health approaches is more prevalent among those with advanced or chronic illnesses than is seen in the general public. One review found that complementary health approach use in cancer patients has been reported to be between 7% and 64% with an average of 31% (Eliott et al. 2008; Thompson et al., Chap. 31, this volume). Sixty-nine percent of oncology patients at one cancer center reported having used complementary health approaches (excluding use of spiritual practices and psychotherapy) in a study published in 2000 (Richardson et al. 2000). The most commonly used complementary health approach modalities among cancer patients are massage, nutrition, aromatherapy, relaxation, and reflexology (Lewith et al. 2002). In a study of patients undergoing radiation therapy for various cancers at rural cancer centers in Minnesota, complementary health approach use was reported by 95% of respondents when including prayer and exercise and 92% when these modalities were excluded. The five most commonly used complementary health approaches were spiritual healing/prayer (62%), exercise (20%), music (18%), chiropractics (16%), and meditation (13%) (Rausch et al. 2011). Similar prevalence of complementary health approach use has been found in other studies (Lim et al. 2010; Naing et al. 2011; Ndao-Brumblay and Green 2010). Patients with cancer report using complementary health approaches for boosting the immune system, relieving pain, and controlling side effects related to the cancer itself or its treatment (Mansky and Wallerstedt 2006; Thompson et al., Chap. 31, this volume).

Despite evidence of common use of complementary health approaches by cancer patients, oncologists refer patients for complementary health approach therapy less often than physicians from other specialties, and patients report that they do not disclose the use of complementary health approaches to their health-care providers (Rausch et al. 2011; Lee et al. 2008). This disconnect raises the concern that the use of complementary health approaches by patients with cancer is likely occurring outside the setting of oncology care centers and without the knowledge of or approval by oncologists. There are multiple barriers to integrating complementary health approaches with conventional medical care (Ben-Arye et al. 2008). Patients themselves may hinder this integration, including the views that complementary health “efficacy intrinsically requires faith” and that complementary health “is solely for cure, that it is for specific types of people, or that it implies a lack of faith in the medical profession” (Eliott et al. 2008, p. 65).

Health-care providers’ attitudes may impede integration of complementary health approaches into conventional medical care. Fadlon et al. found physicians had respect for what complementary health approaches could provide but were often concerned about hazards of complementary health approaches as well as ulterior motives of complementary health approach practitioners (Fadlon et al. 2008). Indeed, some complementary health approaches may interact with other more conventional therapies. For example, St John’s wort, Ginkgo biloba, and ginseng have been shown to have potentially adverse interactions with chemotherapeutic agents as well as other pharmaceuticals commonly used for patients with cancer, such as warfarin, cyclosporin, and anxiolytics (Lee et al. 2008). Health-care providers also report concern about potential liability they may face as a consequence of providing or referring complementary health approach therapies for patients (Hirschkorn and Bourgeault 2008). Evidence-based guidelines recommend that patients be asked about use of complementary health approaches and that evidence-based advice be given about the advantages and disadvantages of complementary health approach therapies (Cassileth et al. 2007). Proposed recommendations for effectively discussing complementary health approaches with patients include ten steps: (1) understand, (2) respect, (3) ask, (4) explore, (5) respond, (6) discuss, (7) advise, (8) summarize, (9) document, and (10) monitor. A critical feature of this recommended strategy is that the health-care provider does not have to be an expert in complementary health approaches in order to have an effective discussion about complementary health approaches with patients (Schofield et al. 2010).

Insurance coverage may influence whether or not patients pursue complementary health approach therapies. The NHIS 2007 survey found that for adults younger than age 65 years, those with private health insurance were more likely than those with public health insurance or those without health insurance to use biologically based, body-based, and mind–body therapies (Barnes et al. 2007). In addition, organizational factors, such as lack of space or resources, as well as organizational policies which preclude incorporation of complementary health approaches have been cited as barriers to integration of complementary health approaches into hospice (Hirschkorn and Bourgeault 2008).

Despite these barriers, Lewis et al. found that a wide variety of complementary health approach therapies can be successfully integrated into hospice settings, with preliminary data suggesting positive outcomes for patients and family members (Lewis et al. 2003). More than 80% of respondents to a national survey of hospices reported that they would support integration of complementary health approaches into their organization if not already present (Corbin et al. 2010).

Evidence for Use of Complementary Health Approaches in Chronic Pain and Palliative Care

This section presents evidence regarding selected complementary health approach modalities in the settings of chronic pain, cancer pain (where applicable) and palliative care. The modalities discussed were selected so as to not substantially overlap with other chapters in this edited volume. The presentation of the evidence is organized according to the following specified categories: (1) mind–body practices, (2) manipulative and body-based practices, (3) manipulation of energy fields, and (4) biologically based therapies. Where sufficient data are available, the evidence is presented in table format. For some modalities, little evidence is available. For these modalities, the existing evidence is described in the text only.

Despite many years of complementary health approach practice and common usage, rigorous scientific research on complementary health approach therapies has occurred only relatively recently. Complementary health approach research is also limited by methodologic and ethical issues. Gaps in research are thus the norm, and the current evidence base is insufficient.

Mind–Body Practices

A number of practices may be considered under the umbrella of “mind–body” practice, including biofeedback, progressive muscle relaxation, meditation, guided imagery, and hypnosis, as well as yoga and acupuncture. A structured review of mind–body interventions for older adults with chronic nonmalignant pain found that there were few randomized clinical trials with small numbers of participants. This review notes that while these interventions are feasible in this population and likely safe, with modifications tailored for older adults, there is not yet sufficient evidence to conclude that such interventions reduce chronic nonmalignant pain in older adults (Morone and Greco 2007). A summary of 28 systematic reviews found strong evidence for the use of mind–body therapies as adjunctive therapy for cancer patients given demonstrated efficacy in improving mood, quality of life, and coping with both the disease and treatment-related side effects. The same summary found strong evidence for use of mind–body therapies as adjunctive or stand-alone therapies for recurrent migraine and tension headaches and as adjunctive therapies in medical management of chronic low back pain (Astin et al. 2003).

Meditation

Meditation describes a group of techniques intended to enhance mental calmness and clarity, physical relaxation, and equanimity. While the practice of meditation takes a variety of forms, the common element is systematic focused attention on the present moment (mindfulness meditation), breath, a sound, word or phrase (transcendental meditation), prayer, part(s) of the body (body scanning), mental imagery (guided meditation), compassion or gratitude (loving–kindness meditation), or a pattern of movement (tai chi, qigong, or walking meditation). While some meditation techniques are rooted in ancient spiritual and cultural traditions, meditation is not a religious practice in and of itself.

Cultivating a meditation practice can enhance health and diminish suffering by changing the practitioner’s experience of thoughts and sensations leading to decreased pain, nausea, fatigue, anxiety, depression, and insomnia, for example. Additionally, meditation can improve physiologic parameters like blood pressure, for example, activate the immune system and reduce systemic inflammation and stress hormone production (Carlson et al. 2017).

Overall, the quality of clinical meditation research is limited but improving. Many studies utilize small sample sizes and lack uniform treatment protocols. Study results are more powerful when standard features of a treatment, such as dose, intensity, duration, and delivery, are measurable inputs. Mindfulness meditation, specifically mindfulness-based stress reduction (MBSR), a program of mindfulness meditation developed by Jon Kabat-Zinn, is the most commonly employed method used for studying the health benefits of meditation (Rogozinski et al., Chap. 30, this volume). The basic MBSR training is a well-defined program consisting of weekly sessions administered over 8–10 weeks.

Other studies examine a variety of mind–body techniques of which meditation is only one (Bauer et al. 2016; Carlson et al. 2017; Deng et al. 2013; Elkins et al. 2010; Greenlee et al. 2014; Millstine et al. 2017; Morgan et al. 2014; Running and Seright 2012; Satija and Bhatnagar 2017; Rogozinski et al., Chap. 30, this volume). For example, some examine a variety of complementary therapies to treat cancer-related pain (Running and Seright 2012), fatigue (Johns et al. 2016), anxiety/depression (Satija and Bhatnagar 2017), and sense of well-being (Castellar et al. 2014). In addition to clinical symptomatology, some studies examine the influence of mind–body techniques on biomarkers related to immune function and stress (Morgan et al. 2014).

Despite the limitations of the current body of literature on the use of meditation (few randomized clinical trials, small sample sizes, and variable control groups), it appears that meditation is a safe, inexpensive, and well-accepted intervention in the setting of chronic pain and palliative care. Additionally, given the potential complications of opiate use and abuse, it is in the patient’s best interest to fully explore the benefits of meditation and other complementary therapies that may be used to counteract pain.

The power of future research designs may be enhanced by studying a single standardized mind–body intervention in a large and diverse population. For example, the experience of pain, insomnia, or anxiety are not necessarily different for breast versus lung cancer patients, and a study design that allows for a larger sample size may produce more relevant data. Future studies should investigate diverse cancer populations using standardized treatment protocols that directly compare specific MBTs to one another (Carlson et al. 2017). The same may be said for patients with a variety of diagnoses but who are coping with similar symptoms. Similarly, a single intervention like meditation can influence multiple symptoms. For example, if general well-being is improved, the experience of pain may be influenced in a positive way.

Meditation has been studied recently in the context of many different clinical scenarios as follows:

  • Anxiety/depression (Baer et al. 2012; Botha et al. 2015; Chen et al. 2012; de Jong et al. 2016; Rod 2015; Serpa et al. 2014; Strauss et al. 2014)

  • Cancer-related symptoms (Carlson et al. 2017; Castellar et al. 2014; Greenlee et al. 2014, 2017; Kvillemo and Branstrom 2011; Overcash et al. 2013; Phianmongkhol et al. 2015; Satija and Bhatnagar 2017; Zernicke et al. 2013)

  • Illness in children and young adults (Jastrowski Mano et al. 2013; Malboeuf-Hurtubise et al. 2013; Sibinga and Kemper 2010; Simkin and Black 2014; Waelde et al. 2017)

  • Chronic pain syndromes (Andersen and Vaegter 2016; Ball et al. 2017; Brown and Jones 2010; Chapin et al. 2014; Hilton et al. 2017; Jeitler et al. 2015; Jensen et al. 2014; Khusid and Vythilingam 2016; la Cour and Petersen 2015; Lee et al. 2014; Panta 2017; Petersen and la Cour 2016; Reiner et al. 2013, 2016; Rod 2016; Selfe and Innes 2013; Teixeira 2010; Wong et al. 2011)

  • Diminished cognitive function (Gard et al. 2014; Luders 2014)

  • Immune system function (Morgan et al. 2014)

  • Headache (Andrasik et al. 2016; Bakhshani et al. 2015; Day et al. 2014; Millstine et al. 2017; Tonelli and Wachholtz 2014)

  • Hypertension (Goldstein 2012)

  • Irritable bowel disease (Gaylord et al. 2011)

  • Low back pain (Ardito et al. 2017; Banth and Ardebil 2015; Blodt et al. 2014; Cherkin et al. 2016; Cramer et al. 2012; Luiggi-Hernandez et al. 2017; Michalsen et al. 2016; Morone et al. 2009, 2016; Schutze et al. 2014; Zgierska et al. 2016a, b, 2017)

  • Sleep disorders (Nakamura et al. 2013) (Ong et al. 2014) and fatigue (Johns et al. 2016)

  • Smoking cessation (Brewer et al. 2011; de Souza et al. 2015; Tang et al. 2013)

  • Stress reduction in health-care workers (Dharmawardene et al. 2016; Orellana-Rios et al. 2017)

  • Well-being (Edwards and Loprinzi 2017; Fang et al. 2010; Goyal et al. 2014; Greeson et al. 2011)

A summary of results from a selection of studies (Table 33.1).

Table 33.1 Meditation evidence
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Yoga

Yoga combines physical movement, breath control, and meditation with the goal of uniting the mind, body, and spirit for health and self-awareness. Having originated in India and considered a sister science of Ayurveda, there are now many styles of yoga practiced around the world (Rakel 2018). This collection of practices includes postures, breathing techniques, nutrition, and meditation. Therapeutic yoga is considered a specific form of practice with its own professional organization. This distinguishes it from recreational yoga and helps patients, especially those with serious illnesses, feel more comfortable with the idea of yoga if they have not been exposed previously.

Cancer patients commonly have multiple symptoms that negatively influence their quality of life. These patients frequently seek out complementary therapies of which yoga is one. “Motives for participation in yoga were relaxation, the will to be physically active, the wish to pay more attention to one’s body, coping with psychosocial symptoms, contributing to their cancer rehabilitation process, and combing physical and mental processes” (van Uden-Kraan et al. 2013). Yoga has short-term beneficial effects for anxiety, depression, fatigue, perceived stress, QOL, and well-being (Satija and Bhatnagar 2017). The value of exercise is well established in our society. Exercise, generally, and yoga, specifically, has been studied for a variety of populations including those with advanced stage cancer who benefit by using exercise to decrease anxiety, stress, and depression while diminishing pain, fatigue, shortness of breath, constipation, and insomnia (Albrecht and Taylor 2012; Carson et al. 2017; McDonald et al. 2006). While yoga generally requires formal instruction, there are home-based programs that allow for the patient to practice on a regular basis (Carr et al. 2016; Selman et al. 2015). In one study of women with breast cancer, Tibetan yoga therapy was found to improve sleep and reduce fatigue in the short term, but if practiced twice weekly, there were long-term positive effects (Chaoul et al. 2018). Studies that include patients with any cancer type reveal similar benefit (Danhauer et al. 2017).

A systematic review of literature examining the impact of yoga on psychological adjustment of cancer patients identified ten studies, six of which were RCTs. Overall study quality was high; limiting factors included lack of long-term data and small sample size. Studies demonstrated improvements in sleep, stress levels, and mood. While a number of positive results were found, the authors concluded that the variability across studies and methodologic drawbacks limit the extent to which yoga can be considered effective for managing psychological symptoms associated with cancer (Smith and Pukall 2009). Yoga thus appears to be a promising intervention for improving psychological symptoms among cancer patients and for improving function among persons with chronic pain. It may also be a tool for palliative care clinicians to use during the workday to help mitigate stress and burnout (Perez et al. 2015).

Studies of yoga for chronic low back pain and knee osteoarthritis suggest that it may be effective for decreasing pain and fatigue and improving function. A clinical practice guideline on the diagnosis and treatment of low back pain issued by the American College of Physicians (ACP) and the American Pain society strongly recommends, based on low-quality evidence, yoga for patients with chronic or subacute low back pain (Qaseem et al. 2017) (Table 33.2).

Table 33.2 Yoga evidence
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Acupuncture

Acupuncture, a complementary modality that is one of the best known tools of traditional Chinese medicine (TCM), is based on the theory that one can regulate the flow of “Qi” (vital energy) by stimulation of certain points on the body with needles, heat, or pressure. Stimulation of specific points along the 12 primary and 8 secondary meridians is believed to restore the proper flow of Qi. It appears that the effects of acupuncture are mediated by the nervous system. Evidence includes observations that administration of local anesthesia at acupuncture needle insertion sites completely blocks the immediate analgesic effects of acupuncture and documented neurotransmitter release and changes in brain functional MRI signals during acupuncture (Berman et al. 2010; Han 2003; Wu et al. 1999).

Results of a systematic review that combined data from 11 clinical trials and 1200 participants suggests that acupuncture (and acupressure) may help with certain symptoms associated with cancer treatments, (Acupuncture, NCCIH-NIH, 2019). In the parlance of the A-, B-, and C-graded evidence vs. harm ratings, acupuncture receives an A rating (consistent or good-quality, patient-oriented evidence), for treatment of postmenopausal hot flashes, nausea and vomiting related to chemotherapy, pain, and peripheral neuropathy. Grade B ratings (inconsistent or limited-quality, patient-oriented evidence) are given for acupuncture for treatment of fatigue, anxiety, stress and depression, and lymphedema (Deng et al. 2004; Rakel 2018).

Patients in the palliative care setting tend to have multiple symptoms that diminish their quality of life, especially cancer patients, and acupuncture studies assess a myriad of symptoms (Ernst and Lee 2010; Lau et al. 2016; Lim et al. 2011; Marchand 2014; Romeo et al. 2015; Satija and Bhatnagar 2017; Towler et al. 2013), including chemotherapy- or radiation therapy-induced side effects, cancer pain, postoperative urinary retention, quality of life, vasomotor syndrome, postoperative gastrointestinal dysfunction, arthralgia, and immunomodulation (Lian et al. 2014). Given the development of increasingly effective antiemetics, acupuncture may not be as compelling a primary treatment for nausea and vomiting but is still important as a complementary therapy for some patients (Ezzo et al. 2006). Evidence is lacking, however, as to whether acupuncture is superior to other interventions available for treatment of chemotherapy-induced nausea and vomiting (Ernst and Lee 2010). Acupressure wristbands used at the P6 point have been used for nausea/vomiting related to chemotherapy. In one recent study, 500 patients with cancer and receiving chemotherapy were randomized to receive standardized antiemetics and acupressure wristbands, sham acupressure wristbands, or antiemetics alone. While the three groups did not have statistically different outcomes with respect to nausea and vomiting, the authors felt there was enough positive evidence to continue studying the use of acupressure wristbands in this setting (Molassiotis et al. 2014)

The ACCP recommends acupuncture as a complementary therapy for patients with lung cancer when pain is poorly controlled or when side effects such as neuropathy or xerostomia from other modalities are clinically significant as well as for poorly controlled nausea and vomiting associated with chemotherapy. A trial of acupuncture is recommended by the ACCP for patients with lung cancer who have symptoms such as fatigue, dyspnea, chemotherapy-induced neuropathy, or post-thoracotomy pain (Cassileth et al. 2007).

Low-quality evidence shows that acupuncture is associated with moderate improvement in pain relief immediately and up to 12 weeks following treatment compared with sham acupuncture, but there was no improvement in function (Qaseem et al. 2017). A clinical practice guideline on the diagnosis and treatment of low back pain issued by the ACP recommends, based on low-quality evidence, that acupuncture for patients with acute or subacute low back pain should select non-pharmacologic treatment, of which acupuncture is one modality. For chronic low back pain, there is moderate-quality evidence that acupuncture, as one of several non-pharmacologic therapies, is recommended with moderate-quality evidence. Acupuncture provides better short-term pain relief and functional improvement than no treatment and that the addition of acupuncture to other treatments provides a greater benefit than other treatments alone (Furlan et al. 2012).

Dyspnea is a common symptom in the palliative care population. It may or may not be directly related to a pulmonary disorder or have a single cause, making the management of this symptom challenging. While opioids, anxiolytics, and diuretics are used as first-line intervention, non-pharmacologic approaches like acupuncture may also be helpful. Further research is needed, and using a simple fan may provide the greatest potential benefit for the least possible cost and potential for complication (Kamal et al. 2012)

While acupuncture is generally safe and with few complications, practitioners treating oncology patients may benefit from additional training and access to laboratory values like neutrophils and platelets. For example, a large population-based study of acupuncture practice (n = 97,733 patients) revealed the most common toxicities resulting from needling to be local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%). Rare side effects have also been reported and include infection as well as pneumothorax associated with needling in the chest region (Zia et al. 2017) (Table 33.3).

Table 33.3 Acupuncture evidence
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Manipulative and Body-Based Practices

Manipulative and body-based practices focus on moving the bones, joints, and soft tissues of the body and, in doing so, affect the circulatory, lymphatic, neuroendocrine, and musculoskeletal systems. Manipulative/body-based practices are relatively familiar to and commonly accessed by the American public. In the National Health Interview Survey (2007), 8.6% of adults and 2.8% of children indicated that they used some form of osteopathic manipulation or chiropractic care, while 8.3% of adults and 1% of children used some form of MT for health or healing (National Health Interview Survey 2010). Massage is defined as “pressing, rubbing and moving muscles and other soft tissues of the body, primarily by using the hands and finge” (Integrative Health, NCCIH, NIH 2019). In this section, manipulation and massage will be discussed separately, including the proposed mechanisms of action, summary of evidence, and recommendations for use for management of chronic pain and other symptoms in chronic, life-limiting illnesses. NCCAM defines spinal manipulation as “the application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage and naturopathy” (Integrative Health, NCCIH, NIH 2019). Practitioners such as chiropractors, osteopathic physicians, and physical therapists perform manipulative procedures on the body. Insufficient data regarding craniosacral therapies were identified to warrant a separate discussion.

Massage

Massage is a manual therapy that has been a documented part of every known healing system as long ago as ninth century BCE. There are more than 80 different types of massage including Swedish, sports, deep tissue, myofascial trigger point, Shiatsu, reflexology, Thai, hand, aromatherapy, and manual lymph drainage. Massage can be full body or provided locally to specific areas of the body including the neck, shoulders, hands, and feet. It is primarily sought out as a treatment for pain. All massage therapy is based on the use of touch to release and lengthen areas of soft tissue, mobilize fluids, and improve the flow of Qi or life force energy.

There are multiple hypotheses related to the mechanisms of action of massage therapy for relief of chronic pain and other symptoms. The palliative effects of massage are proposed to be related to an increase in blood flow and lymph drainage reducing the accumulation of metabolites in the tissues, muscle relaxation through the manual release of muscle tension, the generalized relaxation response, release of increased serotonin that decreases noxious pain impulses to the brain, increased release of somatostatin promoting restorative sleep and decreased release of substance P secreted in deep sleep deprivation (Field 1998), endorphin release from the pleasant sensation of touch, overriding pain signals (gate control theory), and energy transfer and energy field repatterning. However, the actual mechanisms of action have not been established.

Massage in the palliative care setting has the potential to diminish pain, anxiety, fatigue, and depression, increase mobility, decrease use of opioid pain relievers, and enhance overall sense of well-being (Coelho et al. 2017). Integrating massage therapy into palliative care can affect statistically significant changes in pain, anxiety, relaxation, and inner peace of patients, decreasing pain intensity, depression, and anxiety while increasing the patients’ sense of relaxation and inner peace (Hou et al. 2010; Marchand 2014; Mitchinson et al. 2014).

Massage in its various forms may not be available to palliative care patients as in one recent study revealed that only about 51% of the centers in a major metropolitan area offered massage, usually in the form of Reiki or healing touch (Cowen et al. 2017). Additionally, we know that the majority of the US population uses some form of complementary therapies, and, specifically, 82% of an older adult population on an inpatient palliative care unit was in favor of trying these therapies, particularly music therapy, pet therapy, and massage (Grief et al. 2013; Van Hyfte et al. 2014).

Research on the effects of massage related to pain and palliative care is abundant (Collinge et al. 2012; Falkensteiner et al. 2011; Keir and Saling 2012; Lin et al. 2017; Mitchinson et al. 2014). Two meta-analyses of massage research have been published (Fellowes et al. 2004; Moyer et al. 2004). Fellowes et al. reported on eight RCTs of MT in patients with cancer published before 2002. A 19–32% reduction in anxiety was reported in four studies. Pain was an outcome in three studies and a decrease in pain occurred in one. Two studies showed a reduction in nausea and another revealed an effect on sleep (Fellowes et al. 2004). Moyer et al. (2004) included 37 trials with statistically significant overall effect sizes in categories of state anxiety, immediate assessment of pain, and delayed assessment of pain among others; the findings support the conclusion that MT is effective.

Several reviews focus specifically on massage for cancer, cancer pain, and palliative care at end of life. These reviews conclude that there is support for the use of massage for relief from cancer pain in those at end of life (Lafferty et al. 2006; Lopez et al. 2017) and improved diminished distress (Keir and Saling 2012). In his review of 14 trials of massage for cancer palliation and supportive care, (Ernst 2009a) reported “encouraging evidence.” He stated that the effect sizes for massage were small to moderate but added that these effects can be beneficial for this population. Finally, he noted the methodological flaws and pitfalls of the studies and pointed to the Kutner et al. (2008) study as a model for future research. While it is difficult to compare across studies because of variation related to type of massage, dosage, control conditions, and outcomes, there is a trend that massage has more positive effects than controls for decreasing pain intensity, nausea, fatigue, distressing symptoms, anxiety, and enhancing relaxation. MT can be safely integrated into the care of children with cancer and that it can be beneficial for managing side effects and the emotional turbulence of the experience (Hughes et al. 2008).

It can also be used to relieve the suffering of the patient’s loved ones and improve sleep for the health-care professionals (Chang et al. 2017; Cronfalk et al. 2010).

Massage has also been used to relieve symptoms in specific conditions like constipation (Andrews and Morgan 2013), osteoarthritis (Ali et al. 2017; Perlman et al. 2012), amyotrophic lateral sclerosis (ALS) (Blatzheim 2009), edema (Cobbe et al. 2017), HIV/AIDS (Hillier et al. 2010), spinal cord compression (Paniagua-Collado and Cauli 2017), rheumatoid arthritis (Field et al. 2013; Gok Metin and Ozdemir 2016; Nelson and Churilla 2017), low back pain (Qaseem et al. 2017), chronic pain (Nahin et al. 2016), chronic wounds (Rosenbaum 2012), and generalized anxiety disorder (Sherman et al. 2010).

A number of reviews have found that massage has demonstrated benefits for improving symptoms and functions for those with subacute and chronic nonspecific low back pain (Cherkin et al. 2011; Furlan et al. 2015; Imamura et al. 2008). For those with chronic low back pain, the effects were long lasting (at least a year after the end of sessions). The greatest benefit seemed to come from massage delivered by professional massage therapists with many years of experience and when massage was combined with stretching exercises and education. These reviews conclude that massage is effective for persistent low back pain (Qaseem et al. 2017).

Massage delivered by trained professionals is a safe therapy. There are a few reports of adverse reactions; however, for the most part, these are related to more exotic types of manual therapies delivered by the lay public (Ernst 2003a). Massage is contraindicated in persons with clotting disorders, taking anticoagulant medications, with potential or known venous blood clot, and at risk for fracture and over any lesions. Additionally, the National Cancer Institute urges precautions with cancer patients and to avoid massaging open wounds, bruises, or areas with skin breakdown, sensitivity due to radiation therapy, or directly over a tumor site (https://nccih.nih.gov/health/massage/massageintroduction.htm).

Many of the studies listed have methodological weaknesses, and a quality analysis was not conducted for this review. For example, small sample sizes are the norm. The intensity and duration of the intervention varies widely, so it is challenging to compare results. Some studies examine the effects of a few treatments, while others use ten or more treatments over weeks or months. The control conditions vary from usual care, exercise, relaxation, or other therapies. Many reports lack adequate descriptions of outcome variables although the quality of studies over time is improving.

Based on these data, MT provides some degree of efficacy, if only short term, for a variety of chronic pain syndromes. This conclusion is consistent with other reviews of MT for back pain.

Studies of MT for palliative care are given in Table 33.4. A variety of outcomes were measured including pain; distress from symptoms such as nausea, fatigue, and dyspnea; quality of life; anxiety; mood; sleep; and physiological measures of arousal. The most consistent improvement was in anxiety or enhanced indicators of relaxation. Immediate effects were more frequent than any sustained effects. Based on these data, MT can provide comfort and relief for those experiencing pain and distress related to symptoms from cancer and side effects related to treatment. The effects of massage may be temporary; however, even this temporary relief is significant. The consistency of the findings supports the use of MT for palliative and end-of-life care.

Table 33.4 Massage evidence table
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A clinical practice guideline on the diagnosis and treatment of low back pain issued by the ACP and the American Pain society weakly recommends, based on moderate-quality evidence, massage for patients with chronic or subacute low back pain (Qaseem et al. 2017). The ACCP recommends MT delivered by a massage therapist trained in oncology as part of a multimodality treatment approach for lung cancer patients experiencing anxiety or pain. The ACCP cautions that the application of deep or intense pressure is not recommended near cancer lesions or anatomic distortions and in patients with bleeding tendencies (Cassileth et al. 2007).

In summary, there has been profound increase in research related to outcomes of MT for chronic pain and palliative care over the past 25 years. While the methodological quality of the studies is variable, with small sample sizes and inadequate control groups, the overall consistency of effects is compelling. There is sufficient evidence to support the use of MT for chronic low back pain, and there is potential for its use for other chronic pain syndromes. In addition, there is evidence to support the use of massage for supportive, palliative care for those with cancer. Reviews have supported the efficacy of MT for chronic low back pain especially when combined with stretching and education and when provided by experienced therapists, and it may be cost-effective. Future RCTs should follow the CONSORT guidelines for reporting. A focus on the theoretical foundations to determine mechanisms of action should be a focus of future studies. The question of the length of time that effects deserves attention in future studies.

Chiropractic

Chiropractic practice is based on creating optimum structure for the support of the nervous system. D. D. Palmer originated the practice in Davenport, Iowa, in 1895. The most common use of chiropractic treatment is for back and neck pain; however, many chiropractors extol the virtues of the practice for maintaining a healthy nervous system and healing other organs. The foundation of chiropractic care is spinal manipulation; however, many practitioners add other forms of physical therapy/massage such as application of heat and ultrasound as well as counseling regarding nutrition, exercise, and lifestyle change.

While spinal manipulation is used safely by osteopathic physicians and chiropractors for the treatment of low back pain, there are questions about the safety of cervical adjustments, and spinal manipulation is not safe for persons with metastatic cancer to the spine or osteoporosis of the spine. In addition, chiropractic should be used cautiously for people with arthritis or osteoporosis, migraines, and blood clotting disorders or with those on anticoagulant therapy, vertebrobasilar vascular insufficiency, or arteritis (Natural Standard 2010). Informed consent of the risks is important as benign adverse events are common and serious events are rare (Swait and Finch 2017).

The theory underpinning chiropractic care is that vertebral subluxation (misalignment) interrupts the flow of impulses (Palmer called it “innate intelligence”) through the nervous system. These blockages create disturbances that result in disease. Another theory is that spinal adjustments break down adhesions that develop in the hypomobile or fixed Z joints, and the adjustments create space and promote physiological range of motion.

A considerable amount of research on chiropractic has been conducted for tension and migraine headaches, low back pain, carpal tunnel syndrome, dysmenorrhea, fibromyalgia, hip pain, infantile colic, temporomandibular joint disorder, neck pain, pelvic pain, and shoulder pain. The quality of studies varies; methodological problems include the lack of an appropriate control group, lack of blinding, small sample sizes, and variable dosages and types of manipulation, making comparisons across trials difficult.

Systematic reviews have been completed for chiropractic treatment for headache pain, low back pain, neck pain, dysmenorrhea, and infantile colic (Bronfort 1999). For this section, only the evidence related to chronic pain syndromes for headache, low back pain, and neck pain will be addressed because these are the three areas for which there is credible and consistent evidence of efficacy. There have been no studies focusing on spinal manipulation or chiropractic treatment for palliative care, that is, symptoms produced by life-limiting illnesses. Moreover, given the volume of clinical trials and the number of systematic reviews, only a selected number of relevant RCTs for the chronic pain syndromes are included in Table 33.5.

Table 33.5 Manipulation/chiropractic evidence
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Two reviews specifically addressed chronic headache pain (Bronfort et al. 2001a, 2004). In the first Cochrane Review, 22 studies were analyzed. The authors concluded that spinal manipulation was an effective prophylactic treatment for chronic migraine headaches, but the effect was not long lasting and was similar to the preferred pharmacotherapy for migraines. In the second review of nine RCTs, the authors reported that spinal manipulation was better than massage for chronic cervical headache.

Four RCTs of chiropractic spinal manipulation for chronic headache pain are summarized in Table 33.5 (Boline et al. 1995; Haas et al. 2010; Nelson et al. 1998; Nilsson et al. 1997). These were selected for their quality; all four examined chiropractic spinal manipulation for the treatment of chronic headache pain (migraine, cervicogenic and chronic tension type). SMT was compared to amitriptyline, the medication of choice for headache pain, light massage, deep friction massage with laser, and a combination of amitriptyline and SMT. Across these four studies, there was a small effect in favor of chiropractic spinal manipulation. There was not a significant clinical effect when compared to medication. Based on these reviews, there is evidence that chiropractic spinal manipulation has some benefit for a variety of chronic headache syndromes. The benefit may not be dramatic, is similar to medication, and may not be as cost-effective or convenient as amitriptyline. Even so, SMT can be a choice for those suffering from chronic headaches.

Four meta-analyses and 13 reviews were published for chiropractic treatment of low back pain. Some reviews did not specify the focus on acute, subacute, or chronic low back pain, although the differences in outcomes by type were reported in some (Bronfort et al. 1996; Shekelle et al. 1992). One meta-analysis based on 23 RCTs of variable quality concluded that spinal manipulation therapy (SMT) was better than the comparison treatments for low back pain based on calculated effect sizes (Anderson et al. 1992). Bronfort et al.’s (2004) systematic review concluded that there is moderate evidence that SMT provides a similar effect to NSAIDS and is better than physical therapy and exercises. In a review of nine trials on chronic low back pain, van Tulder concluded that there was strong evidence in favor of SMT over placebo and moderate evidence that SMT was better than usual care, bed rest, analgesics, and massage (van Tulder et al. 2003). Walker et al. (2010) conducted a review of 12 studies of combined chiropractic interventions (other than spinal manipulation) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with low back pain, finding that there was no difference between chiropractic and the comparison group treatments and there was no difference for combined chiropractic treatments for chronic low back pain. In a review of 64 RCTs, 12 guidelines, 13 systematic reviews/meta-analyses, and 11 cohort studies, Lawrence et al. (2008) concluded that the evidence for the use of spinal manipulation is as strong for chronic low back pain as it is for acute and subacute LBP. These researchers state that exercise with manipulation may improve outcomes and minimize recurrence. There was less evidence for LBP with leg pain and sciatica. A review of 265 RCTs and 5 non-RCTs, Furlan et al. (2010) found for both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Very few studies reported long-term outcomes. Based on these reviews, there is good evidence for the use of chiropractic spinal manipulation for the treatment of chronic low back pain.

Six RCTs of chiropractic therapy for low back pain are included in Table 33.5 (Bronfort et al. 1996; Cambron et al. 2006; Giles et al. 2003; Gudavalli et al. 2006; Palmieri and Smoyak 2002; Wilkey et al. 2008). The chiropractic therapies tested in these studies were either SMT, flexion-distraction, or manipulation under anesthesia. The results were mixed. In three of the six studies, there were no significant differences in pain between the treatment and control groups. In one study, manipulation under anesthesia was superior to routine chiropractic care, and in the other two, there were significant benefits to chiropractic care when compared to physical therapy exercise and acupuncture and medication. The results of these selected studies are overshadowed by the strength of the reviews; there is good evidence to support the use of chiropractic care for the treatment of chronic low back pain.

One meta-analysis and six reviews were conducted on chiropractic treatment for neck pain. The meta-analysis (Aker et al.) of nine studies showed some small effect (Aker et al. 1996). Vernon et al. (2007) reviewed 19 clinical trials and reported that there is “moderate to high quality evidence” that those with chronic neck pain that is not from whiplash benefit from a course of spinal manipulation or mobilization at 6, 12, and up to 201 weeks after treatment. Bronfort et al. (2004) concluded that for chronic neck pain, there is moderate evidence that spinal manipulation and mobilization were more effective than general practitioner management but that the effect was short term and no better than rehabilitative approaches. Other reviewers drew similar conclusions that spinal manipulation and mobilization when combined with exercise were beneficial but without exercise were not (Gross et al. 2004). Other reviewers reported that there was no evidence that spinal manipulation was effective for the relief of chronic neck pain (Ernst 2003b; Hurwitz et al. 1996; Shekelle and Coulter 1997).

Five RCTs testing the effects of chiropractic spinal manipulation and/or mobilization on chronic neck pain are included in Table 33.5. The frequency and duration of treatments varied. The evidence from the aforementioned reviews and these selected RCTs are inconclusive for the use of chiropractic treatment for chronic neck pain.

One Cochrane Review of three studies on manipulation for dysmenorrhea was published (Proctor et al. 2006). Spinal manipulation was no more effective than the sham; it was more effective than no treatment at all. A review of chiropractic manipulation in the treatment of colic in infants revealed no benefit over placebo to support its use (Hughes and Bolton 2002). There is no evidence to support the use of chiropractic treatment for these or any other chronic pain syndromes.

Based on this analysis chiropractic care can be beneficial for the treatment of chronic headache pain (tension-type, migraine, or cervicogenic) and for chronic low back pain. The evidence is contradictory and inconclusive for the use of chiropractic treatment for chronic neck pain. There is no evidence to support the use of chiropractic spinal manipulation for any other chronic pain syndromes. Even for headache and low back pain, the effects may be small and comparable to medication. Cost-effectiveness of chiropractic care for headache and low back pain is important to consider given the small differences in clinical significance.

Reflexology

Reflexology is defined by the Reflexology Association of America as “a protocol of manual techniques, such as thumb and finger-walking, hook and backup and rotating-on-a-point, applied to specific reflex areas predominantly on the feet and hands. These techniques stimulate the complex neural pathways linking body systems, supporting the body’s efforts to function optimally” (Reflexology Association USA, 2019). Few studies of the efficacy or effectiveness of reflexology for chronic pain or palliative care have been published (Table 33.6). Those that have been published tend to be small and demonstrate mixed results. Methodological quality of these studies is often poor; and most high-quality trials did not generate positive findings. Further complicating interpretation of the evidence is that published studies used different intensity and duration of treatment. The studies that did find positive effects demonstrated beneficial effects on pain and on mood (primarily anxiety) immediately following the reflexology session. Longer-term effects are less certain. Patients seem to demonstrate satisfaction with reflexology treatments. While reflexology would appear to have minimal risks, in one study, patients described the reflexology treatment as painful, at least initially. Three systematic reviews of reflexology concluded that the evidence to date does not demonstrate convincingly that reflexology is an effective treatment (Ernst 2009b; Wang et al. 2008; Wilkinson et al. 2008).

Table 33.6 Reflexology evidence
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Manipulation of Energy Fields

Perhaps the most controversial category of therapies is energy medicine or biofield therapies. Anderson and Taylor (2011) reference in their systematic literature review of biofield therapies historical accounts these energy-based interventions found in cultures globally. Jain et al. (2015) describe biofield therapies as “noninvasive therapies in which the practitioner explicitly works with a client’s biofield (interacting fields of energy and information that surround living systems) to stimulate healing response in patients” (p. 58). These therapies continue to be used by health-care professionals and the public for the alleviation of chronic pain and for palliation of symptoms related to chronic illnesses. The term “biofield therapies” replaced “energy medicine” by the US National Institutes of Health Conference in 1992 (Rubik et al. 2015). The National Center for Complementary and Integrative Health (NCCIH) states biofield therapies, such as Reiki and healing touch, as “mind–body practices.” Energy fields are characterized as veritable (measurable) or putative (yet to be measured). Those therapies involving electromagnetic fields such as magnets and light therapies are considered veritable. Practices based on putative energy fields include biofield therapies such as qi gong, Reiki, therapeutic touch, and healing touch (Integrative Health, NCCIH, NIH 2019). In this section each of the relevant therapies in this category will be described, along with the purported mechanism of action, a synthesis of evidence, and recommendations for use for chronic pain and palliative care.

Table 33.7 summarizes research in biofield and energy therapies for chronic pain and palliative care. The table includes randomized controlled trials (RCTs) and some trials without randomization. Only studies of chronic pain, including those conditions that are persistent, recurring, and not self-limiting, were included. For this reason, studies of episodic pain syndromes such as acute pain, migraines, and tension headaches were not included. Fifty studies of therapeutic touch, magnets, healing touch, Reiki, qigong, and spiritual healing are included. The decision was made to exclude other studies related to pulsed electromagnetic fields (PEMF), cranial electrotherapy stimulation (CES), and transcutaneous electrical nerve stimulation (TENS) in this review because these are less consistent with the definition of biofield therapies and may be classified as conventional therapies using electrical stimulation. Spiritual healing was included because the mechanism of action is consistent with the definition of biofield therapies.

Table 33.7 Manipulation of energy fields evidence
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In 2008 a systematic review of touch therapy studies for pain relief was conducted by the Cochrane Collaboration. Twenty-four studies with 1153 participants were included in this review. Of these studies, 5 focused on healing touch, 16 on TT, and 3 on Reiki. On average, participants experiencing the touch therapies had a 0.83 unit (on a 0–10 point scale) lower pain intensity than those not exposed to these therapies (95% confidence interval: −1.16 to −0.50) (So et al. 2008). The ACCP does not recommend therapies based on manipulation of energy fields for patients with lung cancer (Cassileth et al. 2007).

Magnetic Therapy

Magnets have been marketed and used by the public for the relief of chronic pain. They have been applied as insoles to relieve foot pain, attached to localized areas like lower back and joints, worn as wrist bracelets, or used in mattress pads for more generalized pain. The purported mechanism of action is that the magnetic field increases blood flow to the area/s causing pain, thereby enhancing the body’s ability to heal. Others suggest that the magnetic field increases the release of endorphins, altering pain perception and tolerance. Another hypothesis is that the electromagnetic field of the magnet may change the biofield in some way that promotes healing.

Ten studies listed in Table 33.7 focus on the use of magnets for chronic back pain; pelvic pain; hip, knee, or joint pain from osteoarthritis or rheumatoid arthritis; foot pain from diabetic neuropathy; and pain from post-polio syndrome. All those included in this review were double-blind RCTs with a placebo magnet used as the control. There is doubt about the ability of participants to remain blinded since it would be easy to test whether the device used had magnetic properties. The magnets were used for several days up to 6 months. In four of the ten studies, there were significant differences in pain reduction between those in the magnet therapy group and those in the placebo group; in the other six, there were not. Therefore, there is insufficient evidence to support the use of magnets for relief of chronic pain, especially insoles for foot pain or localized magnets to relieve back or joint pain (Pittler et al. 2007). In two studies persons with fibromyalgia had significantly greater pain reduction after sleeping on a magnetic mattress pad for 4 months and 6 months, respectively (Colbert et al. 1999; Harlow et al. 2004). Since there are no adverse effects associated with the use of magnets, this particular use is promising. There is beginning evidence to support the prolonged use of a magnetic mattress pad to relieve pain for persons with fibromyalgia. More research is needed; studies with larger sample sizes and prolonged magnet use are desirable to continue the research in targeted areas with potential.

Therapeutic Touch

Therapeutic touch (TT) is a biofield therapy that has been used since the early 1970s by nurses and other health professionals to promote generalized health and healing. The therapy was developed by a healer named Dora Kunz and investigated and explicated by Dolores Krieger, RN, PhD, a professor at New York University. Because of this, the particular practice is often referred to as the Kunz–Krieger method to differentiate it from similar touch therapies. Because of its roots in a university, there have been more studies of TT than others testing putative biofield interactions. TT is defined as an intentionally directed process during which the practitioner uses hands to facilitate the healing process (Krieger 1975a, b). The practice was associated with Ayurvedic cultural beliefs about healing but was formally linked to the tenets of Rogers’ (1970) Science of Unitary Human Beings, a nursing conceptual model. The conceptual system purports that both giver and receiver of TT are energy fields that are integral with each other and the environment, that patterns of imbalance in the field can lead to symptoms and disease, that this imbalance can be sensed in part with the hands, and that the field can be balanced through intention and modulation of this energy leading to objective and subjective changes.

The practice involves five steps: centering (calming, focusing, and setting an intention to help or heal), assessing the field (using the hands to sense any disturbances in the recipient’s energy field by scanning the body with the hands about 4 in. above the skin), unruffling the field (moving stagnant energy by sweeping the hands over the recipient’s body), repatterning the field (using the hands, usually 4 in. away from the skin, to balance the recipient’s energy field through channeling energy to areas of imbalance), and recognizing completion (ending the process when balance is sensed). An average treatment is 20–30 min.

TT is an innate human potential; the process can be learned through a training workshop at: http://therapeutictouch.org/. There are TT practitioners throughout the world; many are health professionals who integrate TT as part of their practice in acute, long-term, or community-based settings.

The practice of TT became controversial after a research study conducted by a 14-year-old for her science project was published in JAMA (Rosa et al. 1998) and was widely publicized by the media as scientific refutation of TT. Several credible critiques (Achterberg 1998a, b; Leskowitz 1998; Smith 1998; Cox 2003) have challenged the results of this study by pointing out fatal conceptual and methodological flaws.

Approximately 100 studies of TT have been published using a variety of designs and methods, with diverse populations and investigating a range of outcomes from anxiety, pain, depression, and general well-being to hemoglobin, wound healing, immunological markers, stress hormones, and engraftment following bone marrow transplant. While methodological quality varies, strength in design and methods has been encouraged by published Standards for Conducting Clinical Biofield Energy Healing Research (Warber et al. 2003). An analysis of a sample of 47 of the studies revealed that researchers reported changes in at least one of the outcome variables in 35 of the studies; some research focused on several outcomes with mixed results (Smith 2005).

Twelve of the studies in Table 33.7 focus on TT for chronic pain or palliative care. Populations include those with fibromyalgia, back pain, chronic musculoskeletal pain, amputees with limb/stump pain, or cancer pain. All but the two related to palliative care are RCTs. Control conditions are either a sham TT treatment (a treatment that appears authentic to the recipient) or standard care except for one study that used a comparison group of progressive muscle relaxation. Sample sizes are generally small.

In nine studies there was a significantly greater reduction in pain in the TT group as compared to the control. In the palliative care study, there was a greater increase in well-being in the group receiving TT as compared to the control. The only study without significant results was the phantom limb pain study in which the sample size was too small for any meaningful conclusions to be drawn. The number of sessions and the length of each session varied, but for the most part, there were multiple sessions over a period of weeks with each session lasting about 20 min.

There are no adverse effects of TT reported in the literature, and there is evidence for the use of TT as a complementary therapy for management of chronic pain. The reviewers for the Natural Medicines Comprehensive Database (2015) (https://naturalmedicines.therapeuticresearch.com/) concluded that the use of TT for pain is “possibly effective.” Studies suggest that TT may reduce pain in patients with osteoarthritis and may improve chronic muscle and joint pain in elderly patients. There is limited evidence for its use in other forms of symptom management in palliative care, although there is evidence that TT increases relaxation and decreases anxiety in other populations. Research related to the most efficacious dosage for relief of various chronic pain syndromes and relief of other symptoms associated with palliative care must continue. Studies with larger sample sizes, using sham controls and following the standards for biofield research, are important for the future. This means that funding of TT studies by NIH will continue to be essential.

Healing Touch

Healing touch (HT) has similarities to TT, but specific techniques vary. The premise for healing touch is that the “body is a complex energy system that can be affected by another to promote well-being” (Wardell and Weymouth 2004). Healing touch was originated in the 1980s by a nurse, Janet Mentgen. She formalized education and practice in the modality. Practitioners are trained formally in a certificate program offered through Healing Beyond Borders, Certifying Healing Touch™ (https://www.healingbeyondborders.org) or Healing Touch Program™ (https://www.healingtouchprogram.com/) which are endorsed by the American Holistic Nurses Association (AHNA). These organizations educate and certify healing touch practitioners and instructors, coordinate healing touch research, and assist integration of healing touch into a variety of health-care settings such as pain clinics, hospices, private practices, and nursing homes.

Eight studies in Table 33.7 focus on healing touch. Chronic pain reduction was the focus of six of the studies. Three studies were RCTs comparing HT to a no-treatment control, and three were quasi-experimental designs comparing HT to chiropractic, or HT provided by an experienced vs. a novice practitioner, or relaxation therapy. One RCT revealed no differences in cancer pain in terminally ill adults, and the other reported significant differences in chronic pain in nursing home residents who received HT compared to the controls; however, only percent changes were reported. In the three quasi-experimental studies, one had no differences in pain reduction between the treatment and control groups. Three studies focused on palliative care, HT was not significantly better than the controls in two studies. In one study HT was compared to MT, and the findings revealed decreased pain and fatigue and improved mood for both groups. In the other study, there were no differences in quality of life between those receiving HT and a no-treatment control. Based on these results, there is no evidence that HT is an efficacious treatment for chronic pain or palliative care. Strong research designs with randomization, sham controls, and sample sizes to produce adequate statistical power need to be employed in future research studies.

Reiki

Reiki is a biofield therapy that balances life force energy through aligning it with universal energy. In this way, Reiki is considered to be a spiritual practice. In a Reiki treatment, there is a purported transfer of energy between the practitioner and the recipient through laying on of hands. A particular series of hand placements are taught as the therapist channels Reiki energy to the recipient through direct touch or with the hand/s above the skin. An assessment energy using the hands is conducted prior to the treatment to identify areas on which the practitioner focuses treatment. Reiki can be directed to persons, animals, or things at a distance as well.

The practice of Reiki was developed in 1922 by a Japanese Buddhist monk, Mikao Usui, from ancient Tibetan Buddhist healing practices (Koopsen and Young 2009). Reiki principles and practices vary depending on the lineage of the teacher. The practice is passed down from master to disciples who receive attunements for channeling Reiki energy. There are three levels of training, with Reiki master as the highest level. Practitioners place their hands on the recipient on specific body parts in a specific sequence. There are no known adverse reactions to any of the biofield therapies. Reiki is used for self-care, health promotion, and healing.

Eleven studies in Table 33.7 focus on Reiki for chronic pain; eight studies were related to chronic pain and palliative care. The populations of the other three studies were adults with fibromyalgia, chronic pain for more than a year, and diabetics with neuropathic pain. RCTs and a randomized crossover were designs used. The number of sessions varied from 1 to 24 over several days to 6 months. Sham controls were used in four studies. There was a significantly greater pain reduction in Reiki treatment groups in three studies. In two of those, the difference was between the Reiki group and a no-treatment control group. In one study there were no within or between group differences in chronic pain for adults with fibromyalgia. In another study, there were significant within-group differences in neuropathic pain over a 12-week period but no differences between the Reiki and sham control.

There are no known adverse effects of Reiki. While there have been only a few studies, several studies produced promising results, and the study of Reiki for chronic pain and palliative care deserves continued attention. Evidence that Reiki is an effective therapy for chronic pain is inconclusive. Future research should focus on the minimum efficacious dose for pain relief (number of treatments, length of treatments, and spacing of treatments) and should incorporate sham control groups and sufficient sample sizes.

Qi Therapy

Qigong is a component of traditional Chinese medicine (TCM). The movements associated with qigong are practiced by many to strengthen internal Qi, the dynamic life force, and to create balance within the life force. Medical qigong has internal and external components. Internal Qi is developed by qigong; when practitioners develop their internal Qi through this process, they are able to share it with others, externally, in the healing process (Lee et al. 2001). The practice of internal Qi therapy or qigong involves a series of prescribed movements. Qi therapy using external Qi is shared through a transfer of life force energy.

According to TCM, disease and symptoms such as pain are manifestations of disturbances in the flow and balance of Qi. Qi therapy (both internal and external) can restore the flow of Qi and enhance balance and harmony, thus relieving the symptoms associated with these disturbances (Lee et al. 2001).

Four studies in Table 33.7 are RCTs of Qi therapy for chronic pain. One study employed a sham control, while the other three used a no-treatment control. Samples range from 40 to 123 and the therapy ranged from 1 to 18 sessions. In all three studies, those in the treatment group had a significantly greater reduction in pain as measured by a visual analog scale than the control group.

With only three small studies, it is not possible to draw conclusions. However, Qi therapy is safe and may be comforting and meaningful to those who ascribe to the cultural beliefs about health and illness that are part of TCM.

The use of the therapy can be supported in this context. There is some evidence to support its use for chronic pain; however, with three studies, the evidence is tentative. There needs to be additional well-designed studies to further explore Qi therapy for chronic pain and palliative care in more diverse populations.

Spiritual Healing

Spiritual healing has been included in this category of biofield therapies because it involves treating locally or at a distance through prayer or intentions. There can be multiple forms of spiritual healing and competing hypotheses related to the mechanism of action from divine intervention to the creation of changes in the biofield through the intentionality of consciousness.

In Table 33.7, there are two studies of spiritual healing for chronic pain. Abbot et al. (2001) examined both local and nonlocal forms of spiritual healing with adults with chronic pain. Both local and nonlocal sham treatments were used as controls. There was a decrease in pain in all study arms with no differences between the treatment and control groups. The second study of a prominent spiritual healer using chronic pain showed no differences in pain between the treatment and control groups Sundblom et al. (1994). Based on these two studies, there is no evidence to support the use of spiritual healing for chronic pain. Additional research must be conducted before any definitive conclusions can be drawn.

In summary, there has been significant research on the efficacy of biofield therapies for chronic pain and very little research that has specifically focused on palliative care. There is evidence that TT is an effective treatment for chronic pain. Results of research in the other biofield therapies are less conclusive although there are some promising results for Reiki and Qi therapy for treatment of chronic pain. There is no evidence that the biofield therapies of magnetic therapy, healing touch, or spiritual healing are effective except for possible use of magnetic mattress pads for pain associated with fibromyalgia. Future research should focus on well-designed RCTs that might use multiple outcome variables from biomarkers of inflammation or stress to qualitative descriptions of pain and comfort. New measures that are sensitive to energy such as nitric oxide might be considered as an outcome. Additional studies that examine the mechanism of action and dosage of biofield therapies are needed.

Biologically Based Therapies

Biologically based therapies include a variety of herbal medicines or “botanicals,” vitamins, minerals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites (Deng et al. 2013). There are no provisions in the law for the FDA to approve dietary supplements for safety or effectiveness; therefore, it is difficult for consumers and health-care providers to be assured of the quality and safety of a specific biologic supplement. Due to the potential of biologically based therapies to interact with other drugs, Asher et al. (2017) recommends clinicians consult reliable dietary supplement resources such as: NIH’s National Center for Complementary and Integrative Health (Herb-Drug Interactions, NCCIH-NIH, 2019), Memorial Sloan Kettering Cancer Center “About Herbs, Botanicals & Other Products” database (Herbs, Botanicals and Other Products database, MSKCC, 2019), the NIH’s Office of Dietary Supplements (NIH Office of Dietary Supplements, 2019), or Natural Medicines (Natural Medicines, 2019). A clinical recommendation by Asher et al. (2017) is that “clinicians should ask patients who take over-the-counter or prescriptions medications about their use of dietary supplements” (p. 106).

There is emerging research on the use of biologics for common chronic pain conditions; the most commonly used include chondroitin, glucosamine, Boswellia serrata, curcumin, and omega-3 fatty acids for osteoarthritis. Liu et al. (2018) completed a meta-analysis of 69 records of RCTs of 20 dietary supplements for osteoarthritis; the majority evaluated glucosamine and chondroitin. The review revealed that “chondroitin demonstrated small but statistically significant effects when compared with placebo” however “do not provide clinically meaningful benefit on osteoarthritis” (Liu et al. 2018, p. 8). The findings for Boswellia serrata extract and curcumin appear to have benefit (Cameron and Chrubasik 2014; Haroyan et al. 2018; Liu et al. 2018). Peddada et al. (2015) found promising results for the use of curcumin in musculoskeletal disorders including osteoarthritis. Kuptniratsaikul et al. (2014) concluded that Curcuma domestica extracts compared with ibuprofen in patients with osteoarthritis showed efficacy and safety compared to ibuprofen with fewer gastrointestinal side effects reported. Hill et al. (2016) evaluated low-dose versus high-dose omega-3 fatty acids in knee osteoarthritis and found no additional benefit of a high-dose fish oil and promising results in reducing pain long term.

Given the lack of evidence and potential to interact with prescription medications, botanicals should be used with caution and only under the guidance of a health-care provider knowledgeable in their use (Mansky and Wallerstedt 2006; Deng et al. 2004).

Summary

Complementary and Integrative therapies are used by a significant and growing number of people seeking relief from chronic pain, cancer pain and other symptoms of life-limiting illnesses and have the potential to decrease suffering and maximize quality of life for these individuals. Some of these therapies have promising and even compelling results supporting their efficacy, and health-care providers should refer their patients to these therapies if they are acceptable, accessible, and affordable. Health-care providers should encourage open communication with their patients regarding complementary and integrative therapy use, both to facilitate referrals where appropriate and to protect patients from ineffective, or even potentially harmful, therapies. Rigorous clinical trials are needed to determine the efficacy of many complementary and integrative therapies, particularly in the setting of life-limiting illness.