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Though the therapeutic use of water is an ancient practice, American interest waned after the end of the polio epidemic in the 1950s. NASA studies and research into the physiological effects of immersion, however, revived interest in the 1990s. Meanwhile, physicians and therapists in other countries continued to research and to develop techniques that now compose the primary approaches to aquatic therapy and rehabilitation in the United States. Aquatic therapy and rehabilitation is considered a multi-disciplinary specialty with some technique certifications and overall certification offered by the National Commission for the Credentialing of Aquatic Rehabilitation Disciplines (NCCARD). The essential properties of water—density, buoyancy, viscosity and specific heat—act on essentially every homeostatic system of the body, reducing edema, enhancing circulation, measurably reducing weight-bearing stress, and relieving pain. Turbulence, caused by moving water around the body, or by moving the body through water, provides further therapeutic benefits: thermal conductivity is enhanced; drag forces challenge movement and balance to strengthen muscles and improve proprioception; viscosity helps prevent the risk of falling; resistance to movement can be balanced between agonists and antagonists; painful movements can be stopped instantly to prevent damage; and combined with hydrostatic pressure, turbulence acts to further reduce pain. The multiple effects of immersion and movement in water provide a rich field for research. While research is not lacking internationally, much that has been done with aquatic therapy and rehabilitation is based on anecdotal or experiential evidence. With modern tools for measurement and quantification, scientific evidence for the value of the therapeutic use of water could lead to its greater acceptance and utilization, reducing healthcare costs and improving outcomes for millions of Americans. [ABSTRACT FROM AUTHOR]

Yoga is a practice that has evolved and survived over thousands of years, its teachings adapting to many cultures and eras of history. Until recently, yoga was known in the West mostly for the extraordinary feats of its adepts: voluntarily stopping and then restarting of the heart, holding the breath for extended periods, or contortionist positions of the body. Now, with more cross-fertilization in all aspects of physical fitness, yoga has become mainstream. What may be lost in this process is the greater picture of where yoga came from, what it is, and its many uses, including medical pain relief. This chapter is meant to acquaint the reader more fully with the practice of yoga and its potential roles within an integrative pain medicine practice. [ABSTRACT FROM AUTHOR]

Tai Chi Chuan (TCC) was developed many centuries ago as one of many different styles of Chinese martial arts and continues to be enjoyed in a form true to its beginnings throughout the world. The name is derived from the Chinese characters that mean "The Great Ultimate," indicating the high historic regard that exists for this physical art. On a philosophical level, the principles of TCC are founded on the teachings of Taoism and the writings of Lao Tzu (770-221 B.C.E.). The central method of achieving tranquility was to align oneself with the Tao, a term which has been translated as "the way" or "the path." These philosophical roots point to the fact that Tai Chi practice places great emphasis on training both the mind and the body to reach spiritual unity. In this chapter, TCC will be introduced as a therapeutic exercise rather than a martial art. Information about the history and philosophy of TCC will also be provided with a detailed review of the scientific literature, particularly for pain management. Finally, two case examples of the practical application of TCC for painful conditions will be given. [ABSTRACT FROM AUTHOR]

Presently the expansive growth of Integrative medicine has been fueled in part by a public discontent with conventional medicine and increasing consumer demand for medical advice on the subjects of lifestyle, nutrition, exercise, and natural therapies. Patients want more emphasis on health, healing and prevention of chronic illness rather than just diagnosis and treatment. Numerous peer-reviewed, published studies in the literature reflect the increasing popularity and use of integrative therapies in the populations of the United States and developed countries. The appearance of many Integrative and Complementary and Alternative Medicine (CAM) departments in major medical centers and schools (such as Harvard, Memorial Sloan-Kettering Cancer Center, Stanford, Duke, University of Maryland, Scripps, MD Anderson and many others), speaks to the wide acceptance and increasing public demand for these services. The increasing prominence of Integrative Medicine has led to the establishment and growth of the Consortium of Academic Health Centers for Integrative medicine (CAHCIM), which now includes over 30 medical schools. Appreciation of the self-healing nature of the human body and the interactions between the mind and the body are two fundamental principles of integrative medicine. The defining principles of Integrative Medicine are provided, training resources discussed and then examples of an integrative approach to the treatment of pain conditions are given. [ABSTRACT FROM AUTHOR]

Recognition of the important biological differences between men and women when it comes to pain processing is key to providing optimum care to women with both subacute and chronic musculoskeletal and pain conditions. Pregnancy, labor, and delivery, hormonal fluctuations of the menstrual cycle and the decrease in gonadal hormones that accompany menopause may all affect the musculoskeletal and neurological systems in varied and complex ways that may result in painful conditions. The precise mechanisms by which these changes occur remain under investigation. Nevertheless, pain programs in Women's Health should be designed to address the needs of women with a variety of health issues including, but not limited to, pregnancy and postpartum-related musculoskeletal problems, pelvic pain and pelvic floor muscle dysfunction, fibromyalgia and myofascial pain, osteoporosis and its complications, and general musculoskeletal health and fitness. In addition, Women's Health programs should recognize the effects of the sex hormones on pain processing and attempt to address underlying issues of hormone imbalance. An integrative model of care that combines high-quality complementary and alternative medicine (CAM) services with those of conventional medicine when appropriate may be the optimal setting in which to treat women with such pain disorders. [ABSTRACT FROM AUTHOR]

The rising cost of treating chronic pain is a significant public health problem, and given the aging of our population, one that will continue to grow. Unfortunately, many of the conventional medical interventions that we have to treat pain are better designed to deal with acute pain conditions. As a result, there is an expanding interest by patients in the use of complementary and alternative medicine (CAM) treatments for pain. Recent national surveys indicate that more and more patients are paying out of pocket for CAM treatments and the most common reason for seeking these treatments is persistent pain. Unfortunately, little is known about the appropriate care for patients with chronic pain using any type of treatment, whether with CAM or conventional options. As a result, patients are frequently treated symptomatically with medications that can be addictive in nature and procedures that often are not proven to be effective, all of which can cause a barrage of unwanted side effects. It is in this pain management setting that the growing research that is developing in Chinese herbal treatments among other CAM therapies can provide a perfect counterbalance to conventional approaches to help reintroduce a model of care that is more process oriented and helps move the patient from passive therapies to a more active role in their self-care. [ABSTRACT FROM AUTHOR]

Interest in botanical medicine is steadily growing in the United States. When compared to all other complementary and alternative medicine (CAM) practices, the greatest relative increase in the United States between 1997 and 2002 was for botanical medicine. Many of the top-selling herbs in the Uniteds States have been subjected to clinical trials in Europe and are recognized for numerous health conditions by authoritative groups such as the World Health Organization, The European Scientific Cooperative on Phytomedicine and the German Commission E. Their growing popularity has spurred research inquiries into their potential benefits, as well as concerns over product quality, long-term safety, herb-drug interactions, and use in specific populations (e.g., pediatrics, pregnancy). The National Center for Complementary and Alternative Medicine and the Office of Dietary Supplements are focusing considerable time and money on botanical research. Surveys indicate that CAM use is high in patients with chronic pain conditions, and back pain, in particular, is the single most common condition for which Americans use CAM. There is a great deal of historical evidence that reveals the extensive use of botanicals for the relief of pain. Plants with analgesic, anti-inflammatory and/or anti-spasmodic activities were widely employed and continue to be used. This chapter reviews the current data on botanical medicines that may be useful in the management of various painful conditions [ABSTRACT FROM AUTHOR]

This chapter discusses dietary guidelines and nutritional supplements that have been proven to be beneficial in the treatment of pain. First, a strong foundational diet is presented, including anti-inflammatory ingredients. Next, several key supplements that are helpful for pain conditions are discussed. The chapter is completed with a discussion of some of the most common chronic pain conditions, with specific dietary guidelines and nutritional supplement selections for each condition. [ABSTRACT FROM AUTHOR]

Acupuncture is a system of treatment which involves the insertion of thin, solid needles into specific areas of the body known as acupuncture points, or acupoints, with the intention of positively affecting a patient's clinical condition or health status. In recent decades, the integration of the Western scientific model has provided novel means of furthering our understanding of acupuncture and its effects. Of all the complementary and alternative therapies, acupuncture is one of the best researched. Since the National Institute of Health Consensus Statement on Acupuncture, published in 1997, there has been a flood of high-quality randomized controlled clinical trials as well as a much broader investigation into the basic mechanisms of acupuncture. This chapter will define the various mechanisms by which acupuncture is believed to operate, both from traditional naturalistic and modern scientific contexts. A brief historical narrative will bridge the two approaches as they have flourished over different periods of time. An evidence-based review of the potential uses of acupuncture for various pain conditions will follow, along with discussions regarding acupuncture safety and its incorporation into a integrative pain management practice. [ABSTRACT FROM AUTHOR]

The role of massage in pain management undoubtedly predates recorded history. Today, while there is broad public acceptance and usage of therapeutic massage and a growing body of literature exploring its safety and efficacy, theory and research regarding possible mechanisms of action lag far behind. This chapter explores the potential role of therapeutic massage and bodywork in contemporary integrative pain management. The range of methods that can collectively be called therapeutic massage and bodywork are described, the literature regarding their effect on pain is reviewed, and the little that is known about their mechanisms of action in relation to current theories of pain management is examined. Finally, case descriptions and suggestions about the beneficial use of therapeutic massage and bodywork in contemporary integrative pain management are offered. [ABSTRACT FROM AUTHOR]

Chiropractic management of spinal pain is increasingly utilized as an alternative or complement to pharmaceutical treatment. This chapter presents the role of chiropractic management, particularly spinal manipulative therapy in the treatment of spinal pain. The chapter presents an overview of the the historical roots of chiropractic education and practice, and contrasts them with contemporary education, practice, and the evolution of modern chiropractic research. The role of joint dysfunction as a pain generator is reviewed. The mechanisms underlying spinal manipulative therapy (SMT) are presented in the context of biomechanical and neurophysiological models as well as mind-body integration. The clinical setting for the delivery of chiropractic care in pain management is outlined. Clinical indications and contraindications for SMT are presented. The effectiveness and safety of SMT are reviewed. Research horizons are suggested which target questions ranging from the basic sciences, such as the biological mechanisms underlying joint dysfunction and SMT, to clinical sciences and the possible role of SMT in rehabilitation and post-operative care. [ABSTRACT FROM AUTHOR]

Osteopathic medicine traditionally emphasizes the unison of all body systems including the musculoskeletal system. This recognition includes a reciprocal relationship between structure and organic function. The musculoskeletal system, including the bones, muscles, soft tissues, nerves, and spinal column can exhibit primary disorders, usually secondary to injury and degenerative changes, but it can also reflect many internal illnesses and may influence the process of disease through the circulatory, lymphatic, nervous, or other body systems. In this review, the authors make no attempt to include all aspects of the Osteopathic philosophy and how it may influence medical care. However, in the treatment of chronic pain, as well as other fields of medicine, osteopathic approaches have long included the assessment of nociceptive and proprioceptive mechanisms in diagnosis and treatment. In this review, key anatomic, physiologic and homeostatic mechanisms, their scientific basis, and the influence they have on pain under pathological conditions are highlighted. A review of Osteopathic treatment techniques and examples of how they may enhance treatment strategies will follow. [ABSTRACT FROM AUTHOR]

A multidimensional model of chronic pain includes not only physiologic and psychological/emotional factors, but also the dimension of subtle energy. In this chapter, the subtle energy dynamics of chronic pain are explored by first outlining the subtle anatomy and energy physiology described in many healing traditions around the world. Then, specific pain conditions (myofascial pain, fibromyalgia, phantom pain, and complex regional pain syndrome) are reconceptualized as energy imbalances, and suggested interventions and clinical vignettes are described. A range of energy therapies is also described, including acupuncture, Reiki, Therapeutic Touch, and meridian-based psychotherapy. [ABSTRACT FROM AUTHOR]

Acute pain management remains a challenge to clinicians. Despite the advances in procedural techniques and pharmacologic treatment for patients, the use of narcotics and sedatives for clinical pain has considerable health system implications. An approach that safely provides comfort to patients while remaining cost-effective is highly desirable. Hypnosis as an alternative or adjunct to pharmacological management of acute pain has the potential to fulfill these requirements. This chapter presents the evidence for, and explores mechanisms of the benefits of, clinical hypnosis in acute pain management and presents a model of implementation in the modern medical environment. [ABSTRACT FROM AUTHOR]

For many of us, the word meditation evokes a matrix of mental images associated with its spiritual heritage, whether our own or that of others—a solitary yogi in loincloth, Buddhist monks seated in the semi-lotus position, or even Roman Catholic priests praying in long robes and sandals. Although we in the West, until comparatively recently, have been largely dissociated from our meditative roots, meditation has found expression in every major religious tradition, including Christianity, Judaism, and Islam. Only in the last 30 years has it been pared from its spiritual underpinnings and applied to more generalized and secular considerations of physical and emotional well-being. Now it is commonplace to see meditation taught on college campuses, in church and synagogue basements, and in hospitals and clinics—for the medically ill and the robust—as a means of improving and maintaining health. According to two recent national surveys, meditation was being sampled or practiced by seven to eight percent of the population in the United States during the one-year period studied. Despite this resurgence of interest, however, there remains considerable cultural mystery and even disagreement and misapprehension within the scientific community about the phenomenon. In this chapter, we will consider what meditation is and does, as well as why and how it can be an effective intervention in the reduction of medical symptoms, particularly in the management of chronic pain. [ABSTRACT FROM AUTHOR]

A vast body of literature supports the idea that exercise training is an important modality in the treatment and rehabilitation of the chronic pain patient. Exercise testing and prescription should therefore be incorporated in the therapeutic armamentarium of health care professionals working with chronic pain patients. In this chapter we present the scientific basis of the positive effects regular exercise can have on pain, mood, sleep, function, and fitness. Moreover, specific guidelines for exercise testing and prescription for the chronic patient are provided. [ABSTRACT FROM AUTHOR]

This chapter is meant to be an introduction to how plant extracts, vitamins, functional foods, minerals, nutraceuticals, and therapeutic diets might be utilized to improve symptoms in chronic pain. Emphasis will be placed on physiological processes and conditions where some form of nutritional intervention will have a high probability of being efficacious. An in-depth treatise on all pain mechanisms will not occur, as this will be covered elsewhere. Also, an exhaustive review of the clinical studies for or against specific treatments will not be undertaken. Inflammation, cytokines, neurohormones, and oxidative stress all play important roles in persistent pain conditions. Many aspects of immune and neuroendocrine function may be modified by dietary factors such as phenols, saponins, sterols, and antioxidants. Inflammation may be controlled at different levels. Omega-3 fatty acid supplementation can modify the eicosanoid cascade, tipping the balancevadjusts toward an anti-inflammatory profile. Lowering insulin and neurotoxin levels may also help to reduce inflammation by modulation of PLA2 activity. Flavanoids, such as rutin and quercetin, and retinoids, such as vitamin A, additionally help to inhibit PLA2 activity. Some examples of chronic pain conditions that may be amenable to dietary interventions include osteoarthritis, rheumatoid arthritis, fibromyalgia, autoimmune diseases, migraine headache, chronic abdominal pain, Crohn's disease, and arthralgia. Dietary interventions for pain include increasing fruit and vegetable intake, consumption of grass-fed beef and DHA eggs, lowering lectin consumption, adding functional foods such as soy and green tea, and elimination of food allergens. Lowering inflammatory cytokines and modifying the eicosanoid cascade with n-3 fats may attenuate systemic inflammation. Neuroendocrine perturbations, notably of cortisol and growth hormone, exist in many chronic pain states. Vital neurohormones such as melatonin and serotonin may be lower in chronic pain patients in connection with plasma amino acid imbalances. Metabolic deficits in mitochondrial function and glycemic control should also be addressed in order to reduce systemic inflammation and oxidative stress. Acid-base disturbances, primarily of dietary origin, may contribute to the progression of osteoporosis, which can lead to painful fractures and disability. The cartilage destruction seen in osteoarthritis is the result of an imbalance between catabolic and anabolic activity and may be modified by various antioxidants, as well as glucosamine, Chondroitin, and SAMe. Evidence indicates that obesity and insulin resistance contribute to chronic inflammation, providing good rationale for aggressive lifestyle and diet intervention in obese patients with chronic pain conditions. Targeted clinical nutritional interventions may effectively inhibit synthesis of inflammatory prostaglandins and cytokines. Though the subject of treating pain with nutritional factors is rarely discussed in medical textbooks, published data on the use of nutritional interventions in the treatment of various chronic inflammatory conditions does exist. Many opportunities to improve our treatment of chronic pain conditions through dietary changes exist and will be further elaborated on in the chapter "Nutrition and Supplements" that follows. [ABSTRACT FROM AUTHOR]

Many empirically developed physical therapy techniques as well as alternative manual therapies (e.g., Rolfing, myofascial release) are aimed at treating fascia and other "unspecialized" connective tissues; however, compared with muscles, joints, and the nervous system, very little research has been devoted to the role of fascia in chronic musculoskeletal pain. One possible reason for this discrepancy is the lack of an integrative pathophysiological model linking connective tissue to known musculoskeletal pain mechanisms . This chapter examines the potential role of fascia in musculoskeletal pain, especially regarding how connective tissue remodeling may interact with other factors such as fear of movement, muscle activity patterns and central nervous system plasticity. [ABSTRACT FROM AUTHOR]

Myofascial trigger points are a commonly overlooked cause of chronic neuromusculoskeletal pain and dysfunction. Examination for trigger points requires good palpation skills and understanding of the common referral patterns of myofascial pain. The unique neurobiology of muscle pain and the concepts of peripheral and central sensitization provide new insights into the pathophysiology of myofascial pain. Acupuncture dry needling is an effective technique for treating myofascial pain particularly when local twitch responses are elicited. Uncovering the biochemical profile of active myofascial trigger points and determining the local biochemical effects of needle insertion may help elucidate mechanisms behind the initiation and amplification of myofascial pain and how dry needling works. [ABSTRACT FROM AUTHOR]

Complementary and alternative medicine (CAM) research is entering a new era where state-of-the-art neuroimaging modalities are able noninvasively to measure brain response in humans to both simple and complex CAM stimuli. While the neurophysiological mechanisms of action for many CAM treatments and pain are not well understood and controversy regarding their clinical efficacy remains, neuroimaging research can begin to decode any specific treatment-related mechanisms, if indeed they exist. This chapter will briefly outline the pain neuromatrix and modern neuroimaging techniques such as functional magnetic resonance imaging (fMRI), positron emission tomography (PET), electroencephalography (EEG), and magnetoencephalography (MEG). We will also summarize neuroimaging results for several CAM treatments, though the focus will be on acupuncture, which has been most extensively researched with neuroimaging. Acupuncture is an ancient healing modality that originated in China and has been in use for over 2000 years. Importantly, acupuncture needling often evokes complex somatosensory sensations and may modulate the cognitive/affective perception of pain, suggesting that many effects are mediated by the brain and extending central nervous system (CNS) networks. Other CAM modalities evaluated with neuroimaging include meditation and biofeedback. We will also discuss future directions for CAM neuroimaging research, as this is a very dynamic and evolving field which may ultimately shed light on the mechanisms of action for several CAM treatments. [ABSTRACT FROM AUTHOR]

Pain is usually a source of warning and protection; this is not the case for chronic pain. The experience of pain is a form of consciousness consisting of integrated physical and psychological neural inputs. It typically originates with the spinal transmission of noxious sensory stimuli arising from damaged tissues; this level of processing is termed nociception. Signals are conveyed from the spinal cord to supraspinal networks that include the brainstem, subcortical, and cortical regions. This processing network is termed the pain neuromatrix. It is the supraspinal network that transforms the sensation of nociception into the complex and uniquely individual experience that is pain. Pain modulation (inhibitory or facilitatory) is emerging as an important clinical target for pharmacologic and non-pharmacologic interventions. This chapter outlines the neuroanatomical and physiological mechanisms underlying the experience of acute (physiological) and chronic (pathological) pain. It also highlights the theoretical role of CAM techniques in pain modulation. Finally, in order to provide an integrative view of pain perception, the dimensions of the pain experience are presented and contrasted, including the discriminative, cognitive, and affective elements. [ABSTRACT FROM AUTHOR]

Pain itself occurs in the central nervous system (CNS), while the peripheral nervous system reports on tissue damage via a mechanical event, termed nociception, characterized by the discharge of high-threshold primary afferent fibers. Neuronal responses in these peripheral fibers drive spinal cord activity and result in signals ascending to the brainstem and thalamus through spinal cord tracts. It is from the patterned activity of these ascending signals, distributed throughout a cerebral neuromatrix, that the brain assembles a feeling of pain. This may or may not be directly associated with nociceptive events occurring in peripheral tissue. Nociception can occur in peripheral tissue and not be detected as pain by the central nervous system; this typically is due to the activation of powerful inhibitory systems in the spinal cord and brainstem. Conversely, pain can be perceived in the brain in the absence of any peripheral nociception; a situation that can be fostered by a powerful facilitating system in the brainstem. The mechanisms by which these processes occur are outlined in this chapter. [ABSTRACT FROM AUTHOR]