Emerg Med Clin N Am 23 (2005) 529–549

Complementary and Alternative Pain Therapy

in the Emergency Department
a,b
James N. Dillard, MD, DC, CAc, FAAPM&R , Sharon
c,
Knapp, MS, FNP, NP-C *
a
Columbia University College of Physicians and Surgeons, 630 West 168th Street,
New York, NY 10032, USA
b
Rosenthal Center for Complementary and Alternative Medicine, 630 West 168th Street,
New York, NY 10032, USA
c
Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Road,
Mail Code CDW-EM, Portland, OR 97239-2984, USA

Comprehensive care of patients with pain and the complexities in treating it

requires understanding the physiologic dynamics of pain, pharmacologic
methods for treatment, as well as other measures available for treatment outside
of the emergency department that may be part of the patients self-care and belief
system. A brief review of the pathophysiology of pain pathways, a review of
pain management principles, and a review of complementary and alternative
medicine (CAM) therapies used will be discussed. Using CAM strategies with
conventional treatments is becoming increasingly popular among patients.
Understanding all treatment modal-ities will allow the practitioners to better
meet the needs of their patients and be aware of potential interactions, which
may complicate their medical management in the emergency department.

Management of pain in the emergency department is a seemingly simple

task, but one that reportedly has been done poorly [1–3]. Very few medical
schools have acute pain control as part of a core curriculum. With little formal
training it may be assumed that pain control is not a priority. Extensive teaching
is not necessarily the answer, but some focused teaching and increased
awareness may be what is needed to improve pain management [4]. Pain has a
predictable presence in patients, but the management of pain is often a single
modality of therapy. Traditionally, a one-shot [sic] approach to pain is the
approach in the emergency

* Corresponding author.
E-mail address: knappsh@ohsu.edu (S. Knapp).

0733-8627/05/$ - see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2004.12.015 emed.theclinics.com
530 DILLARD & KNAPP

department. This amounts to intravenous, intramuscular, or oral narcotics as the

method of choice for most pain and injection of anesthetic agents for local or
regional pain as prevention.
The Joint Commission on Accreditation of Hospitals Organizations mandates
evaluation, treatment, and assessment of effectiveness of pain treatment. As of
2001, pain assessment has become the fifth vital sign (http://www.jcaho.org/,
accessed 1/25/03). With this mandate, treating pain has become a priority of
health care providers. It is estimated that as many as 75 million Americans live
with chronic pain, and 22% of patients in primary care report poorly controlled
pain [5,6]. Pain is a costly national problem in lost workdays, hospitalization,
physical therapy, disability, and pharmaceutical cost, as well as litigation costs
surrounding pain. Chronic pain accounts for 21% of all emergency room visits,
and causes 25% of days lost in the workplace [6]. It is the third most common
health care problem, behind heart disease and cancer, but disables more
individuals than heart disease and cancer put together.

Studies indicate that, on average, only 57% of a patient’s pain is relieved

with the best prescribing practices (Steven Passik, PhD, presentation at APS
meeting, March 2002, Baltimore). This remaining 43% then is open to
improvement in prescribing or in the absence of a clear surgical or other
invasive option, and presents an opportunity for the application of
nonpharmacologic and complementary therapies to provide additional relief.

There are a number of key factors to be mindful of in pain management. Pain

intensity and quality are important to understanding underlying
pathophysiology. Pain syndromes are associated with distinct etiologies, and
have prognostic and therapeutic implications. Our understanding of pain has
recently moved forward with our increased knowledge of pain neuromodulators
and the discovery of neurobiologic processes of pain.

Pathophysiology of pain

Two major types of pain exist: nociceptive and neuropathic. Nociceptors are
free afferent nerve fibers that distinguish noxious from innocuous stimuli. These
are located in the skin, subcutaneous tissue, and visceral and somatic structures.

Somatic nociceptive pain arises from bone, joint, muscle, skin, or connective
tissue. Direct trauma to tissues is the typical cause of this type of pain. Visceral
pain arises form visceral organs like the gastrointestinal tract or pancreas.
Visceral nociceptive pain may arise from the organ or capsule or from
obstruction of a hollow viscus causing intermittent, poorly localized pain.
Somatic nociceptive pain is described as sharp, aching, throbbing, pressure, or
vise like. Visceral nociceptive pain is often described as gnawing or cramping, or
if due to obstruction of a hollow viscus, may be described as
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 531

aching, sharp, or throbbing. This is the pain often associated with appendicitis,
cholecystitis, or pleurisy.
There are a number of important neuromodulator substances that act on
peripheral and central receptors. Peripheral receptor activation begins with
injury and the release of inflammatory substances such as mast cells,
macrophages and lymphocytes, bradykinin, and histamine. There is also
neurogenic activation that occurs with the inflammatory response. These
substances sensitize the nociceptor, during early tissue injury. This response to
injury results in the release of pro-inflammatory mediators producing
vasodilation and extravasation of plasma proteins in the arachidonic acid
metabolic pathway, prostaglandin, leukotriene, and other inflammatory
substances such as potassium, serotonin, and substance P. These either serve to
sensitize or excite primary afferent nerves or trigger vasodilatation in response
to the injury. Such tissue damage also results in peripheral site release of local
endogenous opioids [7].
Moving from tissue injury toward the central nervous system additional
neuromodulators exist that play a role in pain. Those acting on receptors in the
dorsal horn include opioid (mu, kappa, and delta), alpha adrenergic, gamma-
aminobutryic acid (GABA), serotonin, and adenosine, neurokinin, N-methyl-D-
aspartate (NMDA), and non-NMDA receptors such as alpha-amino-3-hydroxy-
5-methyl-4-isoxazolepropioic acid (AMPA). The peria-quaductal gray of the
midbrain is involved in central mediation of pain. This area contains both opiate
or endorphin receptors and significant levels of endorphins. Receptors are
located at presynaptic and postsynaptic nociceptive afferent nerves. Afferent
stimulation results in the release of substance P, glutamate, and calcitonin gene-
related peptide. Glutamate acts on AMPA receptors, substance P on neurokinin
receptors. The activation of non-NMDA receptors appears to play a role in the
development of abnormal responses to chronic pain and the altered response to
stimuli. Because of these distinctions it is recommended that pain be describes
in terms of its physiologic as well as pathophysiologic responses [7].

Neuropathic pain can be centrally or peripherally generated. It is usually

defined as pain persisting at least 3 months. Centrally generated pain may be the
result of deafferentation or sympathetic stimulation, the kind of pain arising
from phantom limb pain, stroke, or spinal cord injuries. Peripheral pain may
occur along the distribution of many peripheral nerves or can be associated with
a known peripheral nerve injury from trauma or disease such as you would see
in herpetic neuralgia. Neuropathic pain is often described as burning, tingling,
or lancinating. Pain can also have associated symptoms related to the a ffected
nerves. Also, neuropathic pain may persist even though there is absence of
ongoing disease. It is important to understand these associations to not only aid
in diagnostic evaluation, but to effect treatment of the cause of the pain and the
pain itself.
The chronic nature of neuropathic pain is a pathophysiologic response to
disease or injury. Unlike nociceptive pain, neuropathic pain is not initiated
532 DILLARD & KNAPP

through activation of nociceptors, but is related to reduced inhibition, and thus is

not always responsive to narcotics. The development of neuropathic pain
continues to be an area of study. There is evidence to suggest that sensitization
and cellular hyperexcitability or ‘‘wind-up’’ of nociceptive stimuli contributes to
the development of neuropathic pain. This carries import to the practitioner.
Preemptive use of narcotics may help to prevent sensitization and development
of allodynia from a painful event or surgery. The use of local anesthetics,
narotics, and nonsteroidal anti-inflammatory drugs (NSAIDS) have reports of
decreasing the need for postprocedure pain medication, and may benefit patients
in preventing chronic pain [7].
Pharmaceutical preparations used to treat pain are many. There are three
groups of drugs commonly used to treat pain. (1) Nonopioids that includes
Acetaminophen and NSAIDS, (2) opioids that include those that are mu
agonists and the agonists-antagonists, and (3) adjuvant drugs that includes
antidepressants, anesthetics, anticonvulsants, muscle relaxants, alpha-adrenergic
agonists, NMDA blockers, neuroleptics, and corticosteroids. Some of these have
side effects, dose–tolerance effects, routes of administration considerations, and
onset of analgesia and analgesic ceilings to be aware of. These medications
offer relief for many, but not all. Those patients looking for additional relief
may turn to complementary and alternative medicine for relief.

Complementary alternative medicine

Complementary and alternative medicine is defined as ‘‘those medical

systems, professions, practices, interventions, modalities, therapies, appli-
cations, theories, or claims that are currently not a part of the dominant or
conventional medical system’’ [8]. Many of these therapies may indirectly target
neuromodulators and be beneficial as adjunctive treatments for pain.
CAM encompasses nonconventional approaches to healing, beyond
traditional medicine. The National Center for Complementary and Alternative
Medicine (NCCAM) is a component of the National Institute of Health, and is
the Federal government’s proponent agency for scientific research on
complementary and alternative health practices [9]. Many areas of research are
now underway to examine efficacy and therapeutic benefit of some these
nontraditional approaches to care. Understanding CAM and integrating its
effective therapies add a multidisciplinary approach to care that meet the
patients cultural and belief systems.
Patients turn to CAM for a many reasons. Many of the therapies are popular
because they place an emphasis on harmony and balance of the mind, body,
spirit, and external environment. Patients who choose alternative therapies are
not necessarily dissatisfied with conventional medicine; rather, they may want
more control and involvement in their care [10]. Many patients seen in the
emergency department may be using one or
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 533

more of these CAM therapies as part of their health practices. It is important to

have an understanding of these therapies, the potential benefits, limitations, and
potential side effects while caring for your patients.
Complementary and alternative medicine are two different approaches:
complementary medicine is any form of therapy used in combination with other
alternative treatments or standard/conventional medicine. Comple-mentary
therapy usually serves to relieve symptoms and improve quality of life. It is
often used to control side effects of conventional therapy.
The theoretical basis for many alternative therapies is derived from Eastern
culture, tradition, and philosophy. Some practices are accepted into traditional
care without much forethought or hesitation; others are scrutinized for lack of
evidenced-based studies proving efficacy. For some of these therapies the
benefit is derived from ‘‘hypothetical’’ modulation or reduction in afferent
nociceptive input to higher brain centers or a theoretical release of natural
endorphins [10].
Six general categories of alternative and complementary therapies have been
outlined by NCCAM. These are: mind–body interventions, diet lifestyle
modification, herbal remedies, manual healing, bioelectromagnetics (BEM), and
pharmacologic–biologic treatments [9]. Some of the therapies included are
familiar, and have gained mainstream acceptance. Diet and lifestyle
modification are considered important in Healthy People 2010 guidelines.
Transcutaneous electrical nerve stimulators (TENS) and acupuncture are well-
known therapies. Hypnosis, biofeedback, and re-laxation techniques are
considered mind–body interventions and have been incorporated in psychiatric
practice by many. Vitamin therapy has known preventive benefits for prevention
and treatment of illness since the discovery of scurvy by early mariners, in the
prevention of neural tube defects in prenatal care, and may play a role in heart
disease. There are other additional therapies that exist that are cultural practices
used by patients.

Traditional alternative medicine

Traditional alternative medicine has been practiced worldwide for cen-turies

and includes acupuncture, Ayurveda, and Naturopathy, Chinese/ Oriental
medicine. Understanding the uses and limitations will help navigate through the
waters of CAM.

Mind/body treatment approaches

Many types of mind/body treatment approaches are used to reduce pain.

Precise mechanisms for pain reduction using these practices are not completely
understood, but they may involve the activities of neuro-transmitters, serotonin,
and catecholamines that influence the mind’s perception of pain. Hypnosis,
biofeedback, and relaxation techniques,
534 DILLARD & KNAPP

such as meditation and autogenic training, are the primary forms. In some cases,
these methods have been found to be both beneficial and economical. Of all the
alternative therapies used for pain relief, three techniques are the most widely
accepted and are taught in medical schools, and these are available at many
hospitals and outpatient clinics.
Numerous research studies support the benefits of mind/body treatment
approaches. In 1995, a 35-member National Institute of Health panel was
convened to determine the value of specific mind/body techniques for treating
pain [11]. In particular, the panel found biofeedback to be effective in the
treatment of tension headaches and other types of chronic pain, and hypnosis to
be useful in adjunctive treatments for cancer pain, irritable bowel syndrome,
temporomandibular joint syndrome, tension headaches, and chronic
inflammatory disorders.
Systematic reviews of the literature indicate that mind/body interventions can
be effective for health conditions that are caused or made worse by stress [12].
Relaxation techniques can be helpful for pain control [13]; and relaxation and
visualization techniques may also be of benefit [14]. These simple techniques
can be easily taught in the office or at the bedside, or used during diagnostic
procedures in the emergency department, and may provide the pain relief, as
well as an enhanced sense of self-efficacy in the setting of chronic pain. Patients
using relaxation techniques for pain report improved sense of well-being and
score higher on quality-of-life scales after receiving instruction in meditation,
affirmation, imagery, and ritual [15].
A cost-effectiveness study in 1991 determined that cancer patients who
participated in psychotherapy and relaxation therapies cut their costs and
experienced pain reduction and decreased clinic visits by 36% when compared
with patients not using these combined techniques [16]. Pediatric patients, and
older patients, particularly with some cognitive impairment, may respond better
to passive distractions for pain relief than active mind/ body therapies, such as
an engaging movie or familiar music. But generally, all forms of mind/body do
have some benefit in attenuating pain [17].

Massage, body work, and postural therapies

Massage is found to be helpful both physically and emotionally. The rubbing

not only soothes sore muscles but the mind as well. A review of six studies in
2004, evaluating massage and chiropractic, failed to demonstrate convincing
evidence for prolonged pain relief [18]. Patients do report subjective benefit and
relief from massage. The reason for the discrepancy may be emotional benefit.
Massaging muscles and soft tissue stimulates nerves, increases blood flow, and
relieves stress in the muscles. A number of different types of massage exist
today:
Swedish Massage: this massage technique involves the use of long, smooth
strokes, strokes that knead and compress, deep circular movements,
vibration, and tapping.
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 535

Oriental Massage: this technique is very gentle and relaxes a person.

Shiatsu: this Japanese form of massaging is actually a form of acu-pressure,
exerting massaging pressure on certain key points of the body.
Thai Massage: this massage technique also involves the use of Yoga and
certain Chinese traditional medicine methods.
A small study done in 1989 by researchers in Norway measured
concentration of plasma beta-endorphins after massage and found that levels
increased 16% and remained elevated for approximately 1 hour [19]. This may
lend support for the theories that postulate that massage helps control pain by
increasing pain-reducing neurochemicals such as endorphins and serotonin in
the brain and spinal cord. Variations of Swedish, deep-tissue, sports, and
neuromuscular methods are frequently used.
Patients may also explore other types of massage or body work. Generally,
body work is nonaerobic movement with controlled breathing that can be
practiced to reduce stress and anxiety. Postural body work therapies teach
patients how to realign their bodies, improve posture and movement, and reduce
structural stress. Only a few controlled studies have been done on these
techniques, and most of the reported benefits are subjective. There is moderate
evidence of efficacy for mind–body therapies in the areas of hypertension and
arthritis; however, more research is needed to determine the benefits in treating
chronic back pain, sports injury-related pain, headaches, and joint pain [20].

Tai Chi, an ancient form of martial art based on Taoism, a Chinese belief
system, is one form of body work. The practice of Tai Chi includes slow,
graceful movements and rhythmic breathing. It is reported to have a beneficial
role in pain reduction in patients with arthritis [21]. It is also reported to:

decrease blood pressure,

increase stamina, muscle tone, and flexibility,
improve posture, balance, muscle mass, and strength in older people.
Yoga is an ancient posturing and breathing technique from India. Yoga means
‘‘union.’’ Yoga also uses slow movement, in addition to meditation and
breathing exercises to reach a state of relaxation. Two limited studies of yoga of
patients with osetoarthritis and carpal tunnel syndrome showed improvement in
pain relief with the use of yoga. Yoga uses stretching and improves strength, so
it theoretically should be beneficial for additional musculoskeletal problems
[22]. Yoga is also reported to help:

reduce stress
reduce pain associated with some chronic illnesses
eliminate headaches and insomnia.
improve stamina for some athletes
enhance quality of life for some cancer patients.
536 DILLARD & KNAPP

Chinese medicine

Traditional Chinese medicine is based upon descriptive metaphors for human

bioenergetic properties that do not translate well or directly into the English
terms used for them. Chinese medicine’s basic concept is that a vital force of life
surges through the body (also called Qi). Any imbalance to this life force can
cause disease and illness. According to traditional Chinese medicine, pain is due
to a conflict between blood and Qi, which in turn, results in stagnancy.
Relieving this stagnancy, balancing the energy, nourishing the blood, and
building up deficient blood are all ways that Chinese medicine treats pain.
Traditional Chinese doctors use acupuncture techniques to correct the flow of
Qi. They use herbal medicines to reestablish balanced Qi, blood, and moisture in
organ networks, to avert excess wind, heat, cold, dryness, and dampness.
Perhaps the most well-known Chinese therapy is acupuncture.

Acupuncture is the practice of puncturing the skin with needles at certain

anatomic points in the body to relieve specific symptoms associated with many
diseases. The anatomic points (acupuncture points) are thought to have certain
electrical properties, which affect chemical neurotransmitters in the body.

Acupuncture is one of the oldest, most commonly used medical practices in

the world. Originated in China more than 2500 years ago, acupuncture gained
attention in this country in the 1970s, when China and the United States opened
relations. The practice has been growing in popularity since. Studies support the
use of acupuncture for the treatment of acute and chronic types of pain,
including osteoarthritis, back pain, dysmenorrhea, and migraines [23]. In an
effort to determine precisely how acupuncture works, researchers have isolated
changes in the immune, neurochemical, and hormone functions, as well as in
pain pathways following acupuncture treatment, but the exact mechanisms of
action from a Western perspective remain elusive. Acupuncture may act as a
pain preventative, theoretically, by acting on the sympathetic nervous system.

Acupuncture theories today are based on extensive laboratory research, and

have become widely known and accepted. In addition, controlled studies have
shown evidence of the effectiveness of acupuncture for certain conditions.
Approximately 10,000 certified acupuncturists practice in the United States
today. Not all certified acupuncturists are physicians, but currently, increasing
numbers of certified acupuncturists are US physicians who have incorporated
acupuncture into their medical practices.
Acupuncture has been shown to benefit cancer patients who are receiving a
stable dose of analgesic. Patients reporting pain scores using a visual analog
pain scale had observed reduction in pain intensity from auricular acupuncture
[24]. Acupuncture has been shown to be effective in the treatment of facial,
dental, and labor pain, knee osteoarthritis, and fibromyalgia [25–28]. Just like
many therapies used, acupuncture has had
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 537

mixed reviews on the treatment of back pain, head ache, and neck pain [29–31].

Chinese herbs

Chinese herbs for pain treatment often have analgesic properties, some of
which are extremely potent. In China, as here, herbal medicines are typically
taken as teas, capsules, tablets, or extracts. But depending upon the type and
severity of the pain, some preparations in China are given in hospitals
intravenously or subcutaneously.
Corydalis yanhusuo, or corydalis tuber, is an example of a potent Chinese
herb used for neuralgia, painful menstruation, and gastrointestinal spasm.
Corydalis contains numerous potent alkaloids that inhibit activity in the brain
stem associated with pain perception, and it has sedating properties: the
powdered drug has a potency 1% that of opium. One of the predominant
alkaloids responsible for these effects is tetrahydropalma-tine, which has been
isolated and tested on mice to determine its tran-quilizing e ffects. It appears to
inhibit postsynaptic dopaminergic receptors and simultaneously to increase the
availability of zy-aminobutyricacid receptors. These actions both reduce pain
and relieve anxiety. Another corydalis alkaloid, dihydrocorydaline, was used in
a clinical study to determine its effects in the treatment of dysmenorrhea.
Dihydrocorydaline (50 mg) taken three times a day reduced menstrual pain in
32 of the 44 patients, to varying degrees. Exhaustion, headaches, and decreased
menstrual flow were typical side effects [32].

Ayurveda

Ayurveda is a natural system of medicine that originated in India more than

3000 years ago. Ayurveda translates to ‘‘knowledge of life.’’ Based on the idea
that disease is due to an imbalance or stress in the individual’s consciousness,
Ayurveda encourages certain lifestyle interventions and natural therapies to
regain a balance between the body, mind, and the environment.

Ayurveda treatment begins with an internal purification process, followed by

a special diet, herbal remedies, massage therapy, yoga, and meditation. Studies
have shown reductions in blood pressure, cholesterol, and reaction to stress in
people who practiced Ayurvedic methods.
In India, Ayurveda is considered a form of medical care, equal to
conventional Western and homeopathic medicine. Practitioners of Ayur-veda in
India undergo state-recognized, institutionalized training. However, Ayurvedic
practitioners are not licensed in the United States.
Ayurveda can have positive effects when used as an alternative therapy in
combination with standard/conventional medical care.
538 DILLARD & KNAPP

Ayurveda attributes pain syndromes to imbalances and stagnation in

constitutional types, known as doshas. The three doshas are vata, kapha, and
pitta. The location and type of pain are believed to be dependent on which of
three constitutional types is aggravated or stagnant, which in turn, determines
the treatment. Often, such treatment is herbal as well as dietary, and involves
giving patient’s botanical substances or foods that either stimulate or soothe the
constitutional imbalance. These preparations are characterized as sweet, sour,
salty, bitter, astringent, or pungent, and are often combinations of these types.

For example, vata, which is normally dry, cold, and light in quality, is
balanced with substances that are wet, warm, and dark. In Ayurvedic practice,
such substances are usually sweet. But in the case of obstructive vata, sweet
substances are thought likely to exacerbate blockage, so these patients are given
pungent herbs and foods to stimulate the movement of vata.

Triphala and trikatu are two Ayurvedic herbal standards that may be
recommended by a practitioner to relieve blockages that cause pain. Trikatu is a
blend of black pepper, ginger, and Indian pepper. The Indian pepper used in
trikatu (long pepper; pippali) contains elements similar to capsaicin in cayenne
pepper. It is used as a topical painkiller for arthritic conditions, and is thought to
stimulate and then inhibit pain by destroying substance P. Constituents in ginger
can block the cyclooxygenase pathway, preventing the formation of
inflammatory prostaglandins [33]. One study done at the Miami Veterans
Administration Medical Center and University of Miami found that highly
concentrated extract of two ginger species had a beneficial effect on
osteoarthritis of the knee [34].

Homeopathy

‘‘Like cures like. Any substance which can produce a totality of symptoms in a
healthy human being can cure that totality of symptoms in a sick human
being.’’ — Samuel Hahneman (father of Homeopathic medicine).

The idea behind homeopathy is that if a large dosage of a certain substance

produces certain symptoms, a small dosage of the same substance may cause the
opposite effect. In other words, if a person suffers from throbbing headaches,
he/she might be treated with a very diluted dosage of belladonna, a poisonous
herb that causes throbbing headaches in high doses.
Classic homeopathy depends on the assessment of a patient’s specific clinical
pattern, and relies on individualized treatment strategy. Evidence for
applications of homeopathic remedies exists for dental pain, sports injury, and
some types of arthritis. Homeopathic remedies for pain may be taken either
internally or externally. Homeopathic arnica ointment, for example, has long
been recommended for sports-related injuries, such as sprains, with subjective
benefit [35].
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 539

A double-blind, placebo-controlled crossover trial demonstrated that

homeopathic Rhus toxicodendron reduced tender points by 25% in patients with
fibromyalgia following 4 weeks of treatment [36]. However, another study of
homeopathy and rheumatoid arthritis was negative for effect [37]. Like many
treatments and therapies more study needs to be done to determine e fficacy in
measurable studies versus subjective reports.

Osteopathy and chiropractic

With use of manual manipulation of the spine, chiropractors believe they can
improve a person’s health without surgery or medication. They believe most
illnesses are due to blockages along the nerve bundles in the spinal cord. Spinal
manipulation as now performed has extraordinary heteroge-neity, making it
impossible to form sweeping conclusions about its efficacy [38]. A wide range
of techniques is used, varying from extremely gentle contacts or mobilizations
to very forceful manipulations. The most common and most studied form is
referred to as high-velocity low-amplitude mobilization, where the slack is taken
out of a spinal joint and a very rapid short thrust is applied to gap the joint. An
audible click is often heard. These manipulations, using either osteopathic or
chiropractic techniques, show considerable effectiveness for the treatment of
various types of back pain. Research found that chiropractic is beneficial for
acute back pain, but that the evidence to support its use in chronic back pain is
insufficient [39].
The Agency for Health Care Policy and Research, a federal research and
information agency organized in 1989, released its guidelines for the treatment
of acute low back pain. The guidelines recommend spinal manipulation, either
osteopathic or chiropractic, above more typical forms of physical therapy
(including traction, diathermy, TENS, and ultrasound). Osteopathic and
chiropractic treatments were found to have benefits that were equal to or
superior to placebo. Although the specific physiologic effects of spinal
manipulation are largely unknown, the The Agency for Health Care Policy and
Research guidelines acknowledge that the methods used often meet with
positive results [39].
Several positive meta-analyses and systematic reviews have been done on
chiropractic manipulative therapy, but the final evidence of its efficacy remains
dependent to some degree on the relative quality of the studies done [40–42].
Spinal manipulation remains immensely popular for back pain, and safety of the
procedure is quite good [43].
Osteopathic treatment of acute low back pain has been supported by some
positive findings in randomized controlled trials, although most recent studies
tend to show little effect [44]. Due to its universal popularity, chiropractic care
is sometimes considered the first line of alternative therapy for various types of
pain, including fibromyalgia and neck and back pain. Many medical
practitioners are now willing to send spinal pain patients for a trial of spinal
manipulative therapy, although most would
540 DILLARD & KNAPP

limit the trial to no more than six to eight treatments before wanting to reassess
the patient.

Nutritional and botanical dietary supplements

Calcium and magnesium are the two minerals most often recommended for
supplementation in the treatment of pain syndromes. Calcium is recommended
for conditions such as osteoarthritis, or more as a preventative or corrective
supplement in treatment of osteoporosis than as a painkiller. Usual daily dosage
is 1000 mg to 1500 mg [45].
Magnesium, a mineral required for musculoskeletal maintenance and health,
is used as a tocolytic, and has long been valued in treating migraines. Because it
relaxes skeletal and smooth muscles after they contract, magnesium is
considered a relaxation-promoting mineral. The recommen-ded daily allowance
for magnesium is 320 mg per day for nonpregnant and lactating women, 360 mg
per day for pregnant women, and 420 mg per day for men 31 years and older.
Dosages up to 1000 mg magnesium a day appear to be safe in healthy women
with no significant medical problems.
Current trends in supplemental treatment of pain conditions also include use
of essential fatty acids—particularly gamma-linolenic acid (omega-6) and fish-
derived eicosapentaenoic acid (omega-3)—and glucos-amine sulfate. Essential
fatty acids are the starting point from which the body makes both prostaglandins
and leukotrienes. Omega-6 fatty acids convert to one- or two-series
prostaglandins and to the substances similar to prostaglandin called
leukotrienes. The one-series prostaglandins are considered beneficial. They
appear to inhibit inflammation, lower choles-terol, and reduce blood pressure.
However, the two-series prostaglandins, along with the leukotrienes, are
associated with pain and inflammation. The reduction or alteration by essential
fatty acids intake may help with the inflammation and pain resulting from the
series-2 prostaglandin endpoints [46].

Omega-3 fatty acids, found in marine animal fats and some vegetable oils,
are converted to three-series prostaglandins (generally anti-inflamma-tory in
effect) and to a less noxious form of leukotriene. The combination of omega-3
and omega-6 oils may be especially beneficial, as the presence of omega-3 fatty
acids tends to prevent the omega-6 oils from being converted to less favorable
endpoints.
Fish oil and flax seed oil both provide omega-3 fatty acids. Fish oil is
beneficial in the treatment of arthritis [47–49]. The benefits of flax seed oil are
less clear because there are more interactions with other vegetable oils.
Glucosamine-sulfate has been shown to be more effective in reducing
osteoarthritic pain than NSAIDs, shark cartilage, chondroitin sulfate, or placebo;
some investigators feel glucosamine may have disease-modifying properties in
osteoarthritis and actually slow the deterioration of joints characteristic of this
condition [50,51]. Glucosamine typically takes 4 to
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 541

6 weeks to take effect [52]. At doses of 500 mg three times a day, glucosamine-
sulfate is considered safe, although mild stomach discomfort and elevation of
blood pressure due to salt content is sometimes reported.

Botanical medicine

Pain-reducing botanicals are typically spoken of in terms of their

mechanisms of action or in terms of the actions in the same manner as
pharmaceutical drugs. Phytochemists (plant chemists) are just beginning to
develop an understanding of the mechanisms of action of the many botanical
substances in use.
Long et al have reviewed herbal medicines for osteoarthritis, Ernst and
Chrubasik have reviewed anti-inflammatory herbs, and Almeid and colleagues
have summarized botanical products that have centrally acting analgesic
properties [53–55]. Literally hundreds of plants have been found to have
antinociceptive and anti-inflammatory properties, including those traditionally
thought of for other medicinal purposes [56]. It remains to be seen which plant
products will be born out for safety, efficacy, and tolerability in human clinical
trials.
Devil’s Claw has been studied, and is reported to benefit patients with knee,
hip, and back pain with few adverse reactions [57–59]. White willow bark has
been studied for pain relief with some success. This plant is a source of
salicylate, and as such has the potential to initiate an anaphylactic response in
patients with aspirin allergy [60]. Other painkilling herbs include cayenne,
which can be taken either internally or rubbed onto painful arthritic joints, the
active ingredient being capsaicin [61]. Ginko Biloba, an extract formula that is
also gaining popularity as a possible deterrent to Alzheimer’s disease and other
types of dementia, has also been used for pain relief. One recent trial showed
that a proprietary herbal formula, Reumalex, helped reduce chronic arthritis pain
[62]. Ginko Biloba extracts have been proven to reduce leg pain associated with
intermittent claudication [63]. The mechanism of action of Ginko Biloba is
through inhibition of glycine and antagonism of GABA in neurologic tissue. In
patients with seizures, this may lower their seizure threshold and precipitate
seizures in an otherwise well-controlled epileptic [64,65]. It is these kinds of
actions and interactions practitioners must be mindful in when having
discussions with patients.

In general, herbal treatments for pain are used topically or internally. One
useful topical agent, cajeput oil, is usually administered in combination with
other oils, such as peppermint, clove, menthol, eucalyptus, St. John’s wort,
cayenne, or arnica oil. Cajeput has been shown to relieve musculoskeletal pain,
headache, hemorrhoid pain, neuralgia, rheumatic pain, and pain resulting from
sports injuries.
With multiple drug prescriptions the provider is always mindful of
interactions. The same holds true for patients taking multiple herbal
542 DILLARD & KNAPP

treatments for their self-diagnosed or naturopathically managed conditions. St.

John’s wort is well known to induce Cytochrome P-450, and now evidence
exists that it induces both CYP3A4-catalyzed sulfoxidation and CYP2C19-
dependent hydroxylation. For patients treating their depression and pain with
these multiple herbal preparations that have gastroesophageal reflux disease and
take omeprazole, they may be making their gastroesoph-ageal reflux disease
worse. By inducing both CYP3A4 and CYP2C19, plasma concentrations of
omeprazole decrease placing them at risk of recurrence of their erosive
esophagitis. Clinically relevant interactions with other drugs may occur and
must be taken into account when St. John’s wort is being taken because
metabolism through the CYP3A4 substrates represent at least 50% of all
marketed medications [65].

Bioelectromagnetics and magnetic therapy

Electromagnetic (EM) therapy is based on the belief that an imbalance of the

EM frequencies or fields of energy can cause illness. By applying electrical
energy to the body, the imbalance can be corrected. Many electrical devices and
nonelectrical magnetic appliances are available, and are used to treat a variety of
symptoms. However, the US Food and Drug Administration do not approve
most.
The theory behind BEM is that nonionizing EM fields, in the extremely low-
frequency range, may benefit certain conditions, due to EM changes to ligand–
receptor interactions at the cell membrane [66,67]. The effects of BEM are
thought to result from a change in membrane transport and gene expression.
BEM may one day prove to be the effectual factor in therapies that use energetic
healing techniques, such as therapeutic touch.
Techniques of nonionizing BEM are either thermal (producing heat in
biologic tissue) or nonthermal. Thermal methods are used with laser and
radiofrequency (RF) surgery, RF diathermy, and RF hyperthermy. However, the
nonthermal applications are more prevalent in alternative medicine. Microwave
resonance therapy (MRT) is a method of nonthermal nonionizing BEM used
extensively in Russia. MRT incorporates low-intensity sinusoidal microwave
radiation, and has had favorable results in treating many conditions, including
arthritis, pain, and hypertension. Often, MRT is applied to acupuncture points.

Transcranial EM stimulation of the prefrontal cortex has been shown in

multiple studies to have an effect on pain, but this is probably not an alternative
or complementary technique [68].
Stationary magnets have been studied for pain of many different body areas,
with varying reports of benefit. A summary of success from a number of
different studies has been reported in the treatment of knee pain, chronic pelvic
pain, postpolio pain, and carpal tunnel pain [69–73]. Little to no benefit was
found in treating wrist pain, fibromyalgia, and low back pain, and no benefit in
treating heel pain associated with plantar fascitis [74–77].
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 543

EM stimulation has been shown to help with knee pain [78,79]. Small studies
have been done evaluating therapy on diabetic neuropathy with promising
results; however, additional testing and study are needed [80]. Trock and
Vallbona have reviewed literature that examined either magnet therapy or pulsed
EM fields (PEMF). Trock found that PEMF was a benefit to the growth of bone
and cartilage in vitro, and had potential application as an arthritis treatment.
PEMF stimulation is already a proven remedy for delayed fractures, with
potential clinical application for osteoarthritis, osteonecrosis of bone,
osteoporosis, and wound healing. Magnet therapy has had mixed reviews and
mostly anecdotal benefits [81,82]. Suffice it to say that the jury is still out on the
efficacy of magnetic fields for pain, although generally PEMF seem to be more
supported by the literature than are static magnetic fields.

Complementary therapies in palliative care

Attention to palliation in the setting of terminal illness has only recently

come to the conventional medical community from its origins in the mid-20th
century in England. Although hospice services are widely available, most US
hospitals still do not have a palliative care service, including many of the oldest
and most prestigious medical institutions. Efforts to remedy this are currently
underway in many medical centers.
Palliative care is, by definition, multidisciplinary. The emphasis in palliative
care on the social, spiritual, and psychologic needs of the patient is inherently a
‘‘holistic’’ approach. Integration of complementary therapies for pain and other
symptoms is a natural extension of this multidisciplinary foundation, both in the
hospice setting as well as the hospital units. Although it is clearly not possible to
do everything for every patient, select complementary therapies may be helpful
to patients approaching the end of life. Conventional nursing, pastoral care, and
psychologic services may be appropriately augmented by mind/body therapies,
massage, aromatherapy, acupuncture, yoga, or other techniques.

Shumay and colleagues [83] have studied the existing use of CAM
techniques in the cancer population, finding more use among women, better
educated, Caucasian, and having more severity of symptoms, particularly
nausea and vomiting. Pan and colleagues [84] have reviewed 21 studies of CAM
therapies, and concluded that although there is still a paucity of data, some
CAM therapies are probably useful for the terminally ill. DiGianni and
colleagues [85] have studied women with breast cancer and concluded that little
evidence exists to support CAM use beyond psychosocial interventions. Power
and colleagues [86] have studied the used of CAM therapies in the HIV
population.
Although the evidence base may not currently be strong to justify the use of
complementary therapies with the terminally ill, many patients do try to request
these approaches, and some seem to find benefit from them. The
544 DILLARD & KNAPP

concern exists that patients may delay seeking traditional treatment for cancer
and use experimental CAM as initial therapy [87]. From a research viewpoint,
that which is unproven is not disproved, but should be used as adjunct to known
therapies. One or more of the CAM therapies may be of benefit in the palliative
care setting, despite the lack of solid evidence at this time.

Cultural practices not abuse

A number of practices in Southeast Asia Folk medicine practices such as

cupping, coining, and moxibustion run counter to accepted norms and are often
misinterpreted as physical abuse. These practices may leave marks or
discoloration on the skin, and at first glance may appear to be bruises. Coining
(cao gio) and cupping (giac) are oriental folk medicine practices, which seem to
have surfaced in the country during the Viet Nam era. Coining involves rubbing
the skin with a coin producing a welt, while cupping uses a suction device or a
piece of cotton soaked in rubbing alcohol is ignited and placed in the cup which
is then held horizontally and placed over the skin, extinguishing the flame. This
creates heat within the cup. Often leaving a circular area of discoloration. Both
coining and cupping bring the ‘‘bad wind’’ to the surface where it can escape
and restore balance, and therefore health, to the body. It is generally used for the
treatment of minor illnesses, such as colds and fevers. Unfortunately, both
produce marks easily interpreted as physical abuse.

Summary

One primary reason patients go to emergency departments is for pain relief.

Understanding the physiologic dynamics of pain, pharmacologic methods for
treatment of pain, as well CAM therapies used in treatment of pain is important
to all providers in emergency care. Asking patients about self-care and
treatments used outside of the emergency department is an important part of the
patient history. Complementary and alternative therapies are very popular for
painful conditions despite the lack of strong research supporting some of their
use. Even though evidenced-based studies that are double blinded and show a
high degree of interrater observer reliability do not exist, patients will likely
continue to seek out CAM therapies as a means of self-treatment and a way to
maintain additional life control. Regardless of absolute validity of a therapy for
some patients, it is the bottom line: ‘‘it seems to help my pain.’’ Pain
management distills down to a very simple endpoint, patient relief, and
comfort. Sham or science, if the patient feels better, feels comforted, feels less
stressed, and more functional in life and their practices pose no health risk,
then supporting their CAM therapy creates a true wholistic partnership in their
health care.
 ALTERNATIVE PAIN THERAPY IN THE EMERGENCY DEPARTMENT 545

CAM should be relatively inexpensive and extremely safe. Such is not

always the case, as some patients have discovered with the use of botanicals. It
becomes an imperative that all providers be aware of CAM therapies and
informed about potential interactions and side effects when helping patients
manage pain and explore adding CAM strategies for pain relief. The use of
regulated breathing, meditation, guided imagery, or a massage for a pain
sufferer are simple but potentially beneficial inexpensive aids to care that can be
easily employed in the emergency department. Some CAM therapies covered
here, while not easily practiced in the emergency department, exist as
possibilities for exploration of patients after they leave, and may o ffer an
improved sense of well-being and empowerment in the face of suffering and
despair.
The foundations of good nutrition, exercise, stress reduction, and
reengagement in life can contribute much to restoring the quality of life to a
pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral
therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete
the conventional picture. Adding in simple mind/body therapies, touch
therapies, acupuncture, or others may be appropriate in select cases, and
depending on the circumstances, may effect and enhance a conventional pain
management program. Armed with an understanging of pain dynamics and
treatments, practitioners can better meet patient needs, avoid serious side
effects, and improve care when addressing pain management in the emergency
department.

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