Adv Ther (2021) 38:76–89

https://doi.org/10.1007/s12325-020-01554-0

REVIEW

A Comprehensive Review of Alternative Therapies

for the Management of Chronic Pain Patients:
Acupuncture, Tai Chi, Osteopathic Manipulative
Medicine, and Chiropractic Care
Ivan Urits . Ruben H. Schwartz . Vwaire Orhurhu . Nishita V. Maganty .
Brian T. Reilly . Parth M. Patel . Christopher Wie . Alan D. Kaye .
Ken F. Mancuso . Aaron J. Kaye . Omar Viswanath

Received: September 8, 2020 / Accepted: October 28, 2020 / Published online: November 12, 2020
Ó The Author(s) 2020

ABSTRACT patients utilizing alternative therapies for

chronic pain claimed they were helpful and can
Introduction: Non-pharmacologic alternative serve as an effective adjunctive for the treat-
therapies for pain have been around for a long ment of chronic pain. Some examples of alter-
time, some for hundreds of years. They have native therapies that will be discussed in this
been used throughout history to treat many review include acupuncture, tai chi, osteopathic
issues. manipulation, and chiropractic care. Acupunc-
Recent Findings: Currently, alternative medi- ture, traditionally a Chinese practice, is
cine is most frequently used to treat muscu- becoming more popular across the world to
loskeletal pain, and between 59 and 90% of attempt to relieve pain. It involves the place-
ment of thin needles at various points in the

I. Urits (&)
V. Orhurhu A. J. Kaye

Department of Anesthesiology, Critical Care and Department of Anesthesiology, Medical University
Pain Medicine, Beth Israel Deaconess Medical of South Carolina, Charleston, SC, USA
Center, Harvard Medical School, Boston, MA, USA
e-mail: [email protected] O. Viswanath
Department of Anesthesiology, University of Arizona
R. H. Schwartz College of Medicine-Phoenix, Phoenix, AZ, USA
Department of Anesthesiology, Mount Sinai
Medical Center, Miami Beach, FL, USA O. Viswanath
Department of Anesthesiology, Creighton University
N. V. Maganty
P. M. Patel School of Medicine, Omaha, NE, USA
University of Arizona College of Medicine-Phoenix,
Phoenix, AZ, USA O. Viswanath
Valley Anesthesiology and Pain Consultants,
B. T. Reilly Phoenix, AZ, USA
Creighton University School of Medicine, Phoenix
Regional Campus, Phoenix, AZ, USA

C. Wie
Department of Anesthesiology, Mayo Clinic
Arizona, Phoenix, AZ, USA

A. D. Kaye
K. F. Mancuso
Department of Anesthesiology, Louisiana State
University Health Sciences Center, New Orleans, LA,
USA
Adv Ther (2021) 38:76–89 77

body. The efficacy of acupuncture for pain is

heavily debated. More research and discussion
DIGITAL FEATURES
are necessary to determine the exact role it plays
This article is published with digital features,
in the treatment of chronic pain. Tai chi is also
including a summary slide, to facilitate under-
a traditional Chinese practice that is often used
standing of the article. To view digital features
as a form of meditation and for potential health
for this article go to https://doi.org/10.6084/
benefits. Tai chi involves a series of complex
m9.figshare.13142822.
movements such as squatting combined with
deep breathing to achieve relaxation and pain
reduction. Osteopathic manipulative treatment INTRODUCTION
(OMT) is a technique used by both osteopathic
physicians (DO) as well as other health profes- Pain occurs in 30.7% of adults [1]. Between 9
sionals to manage a wide range of conditions in and 12 million people in the US suffer from
any given patient. The technique involves uti- chronic pain [2]. Chronic pain is incredibly
lization and manipulation of the muscu- debilitating and comes in many different forms.
loskeletal system to achieve potential health Some different types of chronic pain include
benefits. OMT has been used as therapy for neuropathic, nociceptive, and nociplastic pain.
many issues but is commonly used for pain It is associated with decreased function both
conditions. physically and emotionally as well as a decrease
Summary: Alternative therapies may serve as in quality of life [3]. Additionally, the total cost
an effective adjunctive treatment modality for burden due to chronic pain in the US is esti-
the management of chronic pain conditions. mated to be between $560 and $635 billion
There has been a tremendous amount of dollars annually [3]. There are many ways to
research dictating the effectiveness of alterna- manage pain. Pharmaceutical therapy is usually
tive therapies for chronic pain management. the first choice with opioid therapy often being
The purpose of this review is to provide a considered for severe chronic pain. Patients that
comprehensive evidence-based update of alter- require opioids for pain relief usually have
native therapy used for the management of exhausted more conservative analgesics such as
chronic pain conditions. non-steroidal anti-inflammatories and acet-
aminophen. Opioids, despite being highly
Keywords: Acupuncture; Chiropractor; addictive, are still one of the most prescribed
Osteopathic manipulative treatment; Pain; Tai pharmaceuticals for this particular issue. There
chi are five opioid medications in the top 200 most
prescribed drugs in the US and one within the
Key Summary Points top 10 [4]. The increase in opioid use in the US
is multifactorial. However, many attribute the
increase over the years to both the introduction
Alternative therapies provide evidence-
of pain as the fifth vital sign in the 1990s and
based options for patients dealing with
the aggressive marketing of OxyContin by Pur-
chronic pain to avoid unwanted opioid
due Pharma [5, 6]. A 2019 literature review
use.
noted that around 6% of the US abused opioids
These techniques have been utilized for in some form [2]. Prescription opioids are often
centuries with proven results. described as a ‘‘gateway into the drug culture’’
[7]. The rise in prescription opioid abuse has
Tai chi, acupuncture, and osteopathic
been linked to increases in heroin and synthetic
manipulation therapy are all viable
opioid (fentanyl, etc.) related deaths with a 20%
options for improving mobility and
and 72% bump in overdose deaths as a result of
reducing pain symptomatology.
these substances, respectively [5]. Deaths from
opioid overdose have risen 156% from 2010 to
78 Adv Ther (2021) 38:76–89

2015 [8]. There are alternative medications physicians (DO) as well as other health profes-
available to treat daily pain. NSAIDs are one of sionals to manage a wide range of conditions in
the most common classes of non-opioid pain any given patient. The technique involves uti-
medication. These drugs may not adequately lization and manipulation of the muscu-
control pain and are associated with increased loskeletal system to achieve potential health
risk of gastrointestinal ulcers and bleeding benefits. OMT has been used as therapy for
[9, 10]. Several other classes of drugs such as many issues but is commonly used for pain
antidepressants and muscle relaxants are often conditions. A systematic review of OMT for low
prescribed for pain, but have weak evidence for back and pelvic pain after surgery showed evi-
efficacy against chronic pain [10]. Non-phar- dence suggesting moderate reduction in pain
macologic alternative therapies for pain have for these conditions following OMT [16]. Chi-
been around for a long time, some for hundreds ropractic care is a practice founded in the 1890s
of years. They have been used throughout his- that is a well-established form of alternative
tory to treat many issues. Currently, alternative medicine in the western world. Like OMT, it
medicine is most frequently used to treat mus- focuses on manual manipulation of the body to
culoskeletal pain and between 59 and 90% of treat issues with the musculoskeletal system.
patients utilizing alternative therapies for Chiropractic care is very controversial, espe-
chronic pain claimed them to be ‘‘helpful’’ [11]. cially in the discussion of chronic pain. There is
Based on these findings, it appears that alter- a clear need to step away from opioids in the
native therapies can serve as an effective management of chronic pain given the current
adjunctive for the treatment of chronic pain. epidemic. Alternative therapies are needed to
Some examples of alternative therapies that aid in management of chronic pain so there is a
will be discussed in this review include reduced focus on opioid pain management.
acupuncture, tai chi, osteopathic manipulation, Chronic pain, unlike acute pain, often does not
and chiropractic care. Acupuncture, tradition- have a discernable physiologic cause or pathol-
ally a Chinese practice, is becoming more pop- ogy [17]. Therefore, alternative therapies such as
ular across the world to attempt to relieve pain. those discussed above may serve to be a rea-
It involves the placement of thin needles at sonable alternative to opioids for management
various points in the body. A 2012 meta-anal- of chronic pain conditions. We focused our
ysis of nearly 18,000 patients found acupunc- review on the most prevalent form of pain in
ture to be better than sham and no acupuncture the patient population, low back pain. In this
therapy for chronic pain control [12]. However, review, we will be discussing the benefit of uti-
the efficacy of acupuncture for pain is heavily lizing alternative medicine approaches to the
debated. More research and discussion are nec- patient with chronic pain. This article is based
essary to determine the exact role it plays in the on previously conducted studies and does not
treatment of pain [13]. Tai chi is also a tradi- contain any studies with human participants or
tional Chinese practice that is often used as a animals performed by any of the authors.
form of meditation and for potential health
benefits. Tai chi involves a series of complex
movements such as squatting combined with ACUPUNCTURE
deep breathing to achieve relaxation and pain
reduction [14]. An overview of current Low Back Pain
Cochrane reviews regarding physical activities
and chronic pain suggests that interventions Acupuncture, a form of alternative medicine
such as tai chi are potentially beneficial in that originated in China over 3000 years ago,
reducing chronic pain and increasing quality of has been increasingly used for pain manage-
life; however, additional research is needed ment. There are a number of forms of
before specific recommendations can be made acupuncture including needling, moxibustion,
[15]. Osteopathic manipulative treatment and cupping [18]. Needling involves inserting
(OMT) is a technique used by both osteopathic needles, typically 32–36 gauge, into specific
Adv Ther (2021) 38:76–89 79

acupuncture points on the body. Needles can be electroacupuncture versus medium frequency
made of ceramic, bronze, iron, gold, silver, or electrotherapy, there was a significant
stainless steel. In electroacupuncture, a current improvement in pain based on ODI scores in
is applied through the needle. Laser acupunc- the electroacupuncture group [24]. In addition,
ture uses non-thermal laser irradiation on results of a randomized double-blind trial illus-
standard acupuncture points. Moxibustion uti- trated that laser acupuncture using cups with a
lizes burning moxa above the skin near pressure frequency of 200 Hz and output power of
points. Finally, cupping is a technique in which 50 mW resulted in similar pain reduction and
bamboo, glass, or ceramic cups are used to cre- quality of life scores as a sham laser cupping
ate a vacuum over the acupuncture points [19]. control. This demonstrates that cupping itself
Nearly 400 acupoints have been describes may provide a therapeutic effect for low back
worldwide, located on nearly 20 meridians, or pain. One limitation of the study was that laser
channels of energy. The goal of acupuncture is therapy was only studied for three treatments
to promote flow of Qi, the essence of life, [25].
through the meridians [20].
Although acupuncture has been used in a Pregnancy
variety of clinical disorders, it is most frequently
used for chronic pain management. Acupunc- Acupuncture may also be a useful treatment in
ture is beneficial for low back pain up to 2 years pregnancy-related low back pain. The preva-
after treatment. In a randomized controlled trial lence of low back pain during pregnancy is
(RCT) of 241 patients aged 18–64, acupuncture estimated to be between 30 and 70% [26]. Back
was found to have a significantly favorable pain in pregnancy is due to a combination of
effect on the SF-36. Patients who had received hormonal, mechanical, and motor changes. An
ten acupuncture sessions over 3 months had a enlarging uterus to carry a growing fetus causes
5.6-point increase on the SF-36 at 12 months increased strain on the lumbar spine, which
and an 8.0-point increase at 24 months com- results in low back pain. The enlarging uterus
pared to those receiving standard treatment. causes abdominal muscles to stretch signifi-
Furthermore, the patients that received cantly resulting in a decrease in strength and
acupuncture reported lower scores on the coordination of the lumbopelvic muscles, par-
Oswestry Disability Index (ODI) and McGill ticularly the gluteus medius. Finally, a hormone
pain measure, although this was not statistically released by the placenta called relaxin is
significant. There were no severe adverse effects thought to weaken joint strength, resulting in
of acupuncture reported in this study [21]. In low back pain [27]. Acupuncture is an emerging
another RCT, 130 adults with low back pain treatment for pregnancy-related low back pain.
were randomized to receive acupuncture or In the EASE back pilot trial, 125 pregnant
sham acupuncture twice weekly for 6 weeks. patients were randomized to receive standard
Patients who received true acupuncture repor- care for back pain, standard care plus sham
ted lower scores for pain compared to those that acupuncture, or standard care plus true
received sham acupuncture. Sham acupuncture acupuncture. After six treatments over 8 weeks,
in this study was defined by using blunt needles patients receiving sham acupuncture and true
without penetration on acupuncture points. acupuncture endorsed improvement in pain
This demonstrates that acupuncture has more and physical health. Patients reported no dif-
than a placebo psychologic effect and there is a ference in quality of life but stated that they had
physiologic mechanism underlying its success fewer nighttime awakenings and sleep distur-
[22]. In addition, standard acupuncture therapy bances due to back pain. Earlier studies sug-
is shown to be equally effective to individual- gested that acupuncture may lead to pre-term
ized therapy for patients [23]. Electroacupunc- labor in pregnant patients; however, recent lit-
ture has been shown to be effective in the erature, including the EASE back trial, reported
treatment of chronic sciatica. In a study of 100 no serious adverse events associated with
patients randomized to receive
80 Adv Ther (2021) 38:76–89

acupuncture in pregnancy. The most common expression of 5-HT7R, a serotonin pathway, and
side effects include lightheadedness and pain at subsequent alleviation of migraine symptoms
the acupuncture site [26]. A Cochrane review [34]. Magnetic resonance spectroscopy pre- and
published in 2015 reported that there was no post-acupuncture found a significant increase in
significant difference in sham acupuncture with N-acetylaspartate and creatine in the thalamus
prenatal care and true acupuncture with pre- [35]. Future studies are necessary to better
natal care in pregnant patients with pelvic pain. understand the mechanism behind acupunc-
However, compared to prenatal care alone, ture and duration of symptom relief.
acupuncture results in moderate improvement
in pelvic pain [28]. Acupuncture may also have Complex Regional Pain Syndrome (CRPS)
utility in improving labor pain. A Cochrane
review published in 2011 stated acupuncture Complex regional pain syndrome (CRPS) is a
used at variety of acupoints resulted in a chronic neuropathic pain syndrome believed to
reduction of labor pain. Patients were also more be caused by inflammation or damage to the
satisfied with acupuncture as a pain treatment nervous system after an injury. CRPS is com-
compared to standard treatment [29]. Two monly managed with NSAIDs, steroids, antide-
studies published in 2011 demonstrated that pressants, and regional pain blocks. It can often
patients who received electroacupuncture dur- be resistant to these forms of standard pain
ing labor had a significant reduction in pain treatment. Acupuncture may be an important
[30]. treatment option for CRPS. In a case report of a
29-year-old man with CRPS after polydactyly
Migraines resection, bee venom acupuncture resulted in
significant reduction in pain. After 14 over
Acupuncture is a useful treatment in the man- 3 months, the patient reported complete reso-
agement of migraines. A 2016 Cochrane review lution of pain symptoms and no longer needed
evaluated 22 RCTs with over 4000 participants analgesic medications [36]. In another case
and found that acupuncture resulted in a 50% report, ultrasound-guided dry needling resulted
reduction of migraines in 41% of the patients. in almost complete improvement of pain and
Acupuncture was superior to sham acupuncture motor dysfunction within 2 months of treat-
in reduction of migraines, and a small benefit ment. In animal studies, electroacupuncture is
was found even 12 months after treatment [31]. thought to work by inhibiting mechanical
In a study of 20 women suffering from chronic hyperalgesia and edema in chronic post-is-
migraines, ear acupuncture resulted in a reduc- chemia pain mouse models. This effect is
tion of migraine attacks per month in 37.5% of enhanced when electroacupucture is used in
women [32]. When combined with tuina ther- conjunction with endothelin receptor type B
apy, a form of therapeutic massage, acupunc- (ETB) antagonists [37].
ture may be more effective in treating The efficacy of acupuncture for chronic pain
migraines. In an RCT of 45 patients, those conditions is summarized in Table 1.
receiving tuina therapy combined with
acupuncture compared with those receiving
acupuncture alone or control therapy had a TAI CHI
significant reduction in attack frequency,
severity of pain, and duration of migraine. The Low Back Pain
combination of tuina with acupuncture resulted
in less analgesic use by patients in the trial [33]. Tai chi is a Chinese mind-body exercise that has
Although acupuncture appears to be effective in been used for health promotion and disease
relieving migraines, its mechanism of action is prevention in Asia for hundreds of years. In
not well understood. In an animal study, America, the prevalence of tai chi practice has
acupuncture resulted in a decrease in the grown steadily since 2002, with a 14.5%
Adv Ther (2021) 38:76–89 81

Table 1 Efficacy of acupuncture in the treatment of chronic pain conditions

Low back pain Acupuncture is superior to traditional pain management in patients with low back pain.
The number of sessions required for therapeutic effect is varied
Pregnancy Acupuncture and sham acupuncture are important treatment options in pregnancy-related
back pain and labor
Migraine Acupuncture may result in a reduction of the frequency and intensity of migraine
headaches. Larger cohort studies are needed to analyze this further
Complex regional pain Based on case reports, acupuncture may improve chronic pain in patients with CRPS
syndrome (CRPS)

prevalence in 2017. Tai chi practice has age 50 with chronic lower back pain, Chen-style
increased in each demographic across the US. tai chi led to a reduction in pain on the visual
Most people report using tai chi for overall analog scale compared to core stabilization
wellness; however, approximately 15% of peo- training. There was no difference in lower limb
ple use tai chi to help with specific medical proprioception in tai chi versus core stabiliza-
conditions. Tai chi practice is usually used for tion training. Chen-style tai chi places greater
pain, arthritis, and mental health [38]. In a emphasis on alternating between fast and slow
randomized controlled trial of 320 retired ath- movements, which is thought to increase lum-
letes with chronic lower back pain, tai chi bar spine stimulation and improve lower back
practice resulted in reduction of pain compared strength. Core stabilization training utilizes a
to no exercise and jogging, but had no signifi- Swiss ball to perform specific core-strengthen-
cant difference compared with swimming [39]. ing exercises [42]. In older individuals with
In another randomized controlled trial of 160 multiple comorbid conditions including HIV
people, tai chi was performed 18 times over and substance abuse, tai chi may improve
10 weeks and led to a reduction of pain and physical function and reduce substance use. In
bothersome back pain and improved self-re- one study, 55 adults with a mean age of 55 who
ported disability based on the Roland-Morris had HIV and substance abuse were randomized
Disability Questionnaire scale. This study to receive cognitive behavioral therapy (CBT)
focused on a 10-week trial of tai chi; however, with tai chi, support group therapy, or control.
future studies are needed to understand the Individuals in the CBT followed by tai chi group
long-term impact of tai chi on low back pain reported a reduction in pain intensity, decrease
[40]. In addition, the broader implications of tai in substance use, and improvement in physical
chi practice such as the effect on daily physical performance outcomes [43]. In the patients that
activity remain to be studied. A 12-week tai chi were required to attend CBT and tai chi, atten-
intervention for low back pain resulted in dance was less than compared to support group
increased knee extension and right plantar therapy alone, which suggests that individuals
flexion compared to core stability training. This may need to be motivated to attend both.
demonstrates that tai chi may have beneficial
neuromuscular effects in addition to pain Multiple Sclerosis
reduction [41].
Multiple sclerosis (MS) is an autoimmune neu-
Elderly Patients rodegenerative disease that affects the central
nervous system. Patients with MS can have a
Older individuals may also benefit from tai chi variety of neurologic symptoms including
practice. In a randomized trial of 43 adults over ataxia, impaired balance, and tremors. In
82 Adv Ther (2021) 38:76–89

addition, they also have higher reported rates of who have experienced or witnessed trauma. It is
pain, depression, and fatigue. Given that tai chi characterized back recurrent flashbacks, night-
is a mind-body exercise it can have valuable mares, and hypervigilance. Often patients with
effects on both physical and psychologic con- PTSD also suffer from chronic musculoskeletal
ditions. In a study of 32 MS patients, tai chi pain generally in the back and neck. PTSD is
practiced twice weekly for 6 months resulted in traditionally treated with CBT; however, this
significant improvement in balance and coor- may not address the chronic pain that these
dination. To assess balance and coordination, patients suffer. Tai chi may be a useful tool in
two well-established tests consisting of 14 tasks improving chronic pain in patients with PTSD.
and 10 tasks, respectively, were utilized. In In a study of 11 patients with PTSD, 90.0% of
addition to the physical improvements, patients individuals reported their health would
who were in the tai chi group had lower self- improve with tai chi. After completing 36 tai chi
reported scores for depression and fatigue. This sessions over 3 months, participants reported a
study shows that tai chi may be a promising reduction in current pain based on the PROMIS
intervention for MS patients improving both pain intensity score. There was a decrease in use
physical and psychologic parameters [44]. of pain medications before and after the inter-
However, this study had a small sample size and vention although this was not statistically sig-
relatively long intervention period; therefore, nificant. Some participants noted that tai chi
repeating the study in a larger cohort with a made them feel pain or discomfort while prac-
shorter duration may be helpful. Tai chi has also ticing; however, no other adverse events were
demonstrated significant benefits for depres- reported [47]. In a case report of 44-year-old
sion, quality of life, and motor control [45]. In Lebanese man with PTSD, tai chi resulted in
an 8-week, prospective, nonrandomized con- marked improvement in back and neck pain. In
trolled trial, 40 patients with MS or peripheral the future, larger studies are needed to evaluate
neuropathy participated in either a mediation the effect of tai chi in PTSD patients with
group or standard care. Patients who were in the chronic pain [48].
mediation group, which consisted of tai chi, The efficacy of tai chi for the treatment of
had significant improvement in pain following chronic pain conditions is summarized in
weekly 30-min meditation classes [46]. This Table 2.
study was limited by the small sample size and
lack of randomization.
OSTEOPATHIC MANIPULATIVE
Post-Traumatic Stress Disorder (PTSD) MEDICINE
Osteopathic manipulative medicine (OMT) is
Post-traumatic stress disorder (PTSD) is a psy-
the usage of physical techniques by trained
chiatric condition that occurs in individuals
physicians that are intended to help facilitate

Table 2 Efficacy of tai chi in the treatment of chronic pain conditions

Low back pain Short-term, tai chi reduces pain in chronic lower back pain
Older patients Tai chi improves back pain in patients[age 50 and those with comorbid conditions such as
HIV and substance abuse
Multiple sclerosis There is minimal evidence that tai chi improves pain in MS patients. Several studies
demonstrate improvement in balance, coordination, depression, and fatigue
Post-traumatic stress Tai chi may be beneficial in patients with PTSD and musculoskeletal pain
disorder (PTSD)
Adv Ther (2021) 38:76–89 83

the healing of patients. The Journal of Family was also a RCT, but contained only 145
Practice defines OMT as ‘‘the process by which patients. The 2016 study contained 345
DOs use their hands to diagnose illness and patients, thus increasing the power of the study.
injury and then mobilize a patient’s joints and In the 2016 study, patients with LBP were
soft tissues using techniques that include mus- randomly assigned using a computer-generated
cle activation, stretching, joint articulation, and algorithm to receive either OMT or sham OMT.
gentle pressure to encourage the body’s natural They then received treatment at weeks 0, 1, 2, 4,
tendency to heal itself’’ [49]. However, it is 6, and 8 followed by an outcome assessment at
important to note that OMT is not restricted to week 12. Outcomes were defined by a 100-mm
osteopathic physicians, as allopathic physicians visual analog scale (VAS) and the Roland-Morris
can undergo additional training if they wish to Disability Questionnaire (RMDQ). In total, 23
use it in their own practice. The American patients enrolled in the study experienced
Osteopathic Association (AOA) encourages the adverse events, but none were determined to
use of OMT by trained physicians [50]. With the have been caused by study interventions. The
growing number of osteopathic medical schools results of the study showed a statistically sig-
in the United States, the number of physicians nificant difference between the two groups. The
with the training to offer OMT is rising. Cur- number needed to treat (NNT) for patients who
rently, over 20% of medical students attend an underwent OMT was 9.9 (95% CI 5.8–36.2.)
osteopathic medical school [49]. However, this study was limited by its inclusion
Although the AOA’s recommendation is criteria, which required patients to meet mini-
based on evidence-based published literature, it mum thresholds of pain using the VAS or
is not without criticism. Critics of OMT point to RMDQ. As such, the usage of OMT for the
the subjectivity of the quality of treatment treatment of patients with minor LBP remains
offered by different physicians, as it can vary unclear [51]. Additionally, the study is limited
greatly depending on the physician’s training, by its limited follow-up of participants. While
experience, and frequency with which the per- the study demonstrates a statistically significant
form OMT. Additionally, people are critical of difference at 12 weeks, it fails to examine the
the lack of universality of the recommended long-term outcomes of the patients. Given the
techniques. Many osteopathic physicians have time-consuming nature of OMT, it may be dif-
become dissuaded from using OMT because of ficult for patients to continue to receive treat-
the poor financial reimbursement, its time-in- ment on a weekly or biweekly basis. Thus, the
tensive nature, and/or its lack of applicability in long-term efficacy of OMT in the treatment of
different fields of practice, such as radiology and LBP remains unclear and warrants further
pathology [50]. This section aims to examine research.
the efficacy of OMT in the treatment of lower
back pain and migraines. Migraine

Low Back Pain While OMT continues to be offered by osteo-

pathic physicians for the treatment of migraine
Given that low back pain is the most common headaches, its efficacy is more controversial
cause of disability worldwide, the effectiveness than in the treatment of LBP. A 2015 random-
of OMT in the treatment of LBP warrants ized controlled trial that included 105 patients
investigation. In 2016, Licciadarone, Gatchel, revealed a statistically significant improvement
and Aryal published the results of a randomized in functional improvement of patients who
controlled trial on the effectiveness of OMT in underwent OMT for the treatment of migraine
the treatment of LBP. The study was designed to headaches. Patients who underwent OMT
resemble a 2011 publication titled ‘‘Osteopathic experienced a reduction in HIT-6 score, drug
Health Outcomes in Chronic Low Back Pain consumption, number of days with migraine(s),
(OSTEOPATHIC) Trial.’’ The 2011 publication pain intensity, and functional disability [52].
84 Adv Ther (2021) 38:76–89

Table 3 Efficacy of osteopathic manipulation in the However, the two groups receiving chiropractic
treatment of chronic pain conditions manipulation experienced superior improve-
ments in perceived pain and were more satisfied
Low back Shown to be effective in the short term,
with their treatment compared to the group
pain although data regarding its long-term that received medical management alone [53].
efficacy are yet to be published This study is limited by its small sample size as
Migraines Low level of evidence to support its efficacy well as selection bias. With just 153 patients
involved, it is difficult to come to a consensus
on the effectiveness of chiropractic manipula-
With a patient sample size of just 105 patients, tion in the treatment of LBP. Additionally,
further studies are required to increase the because patients were recruited using mail and
power of this evidence. media, a selection bias was inherent in the
In 2017, Cerritelli et al. performed a thor- study. To determine the applicability of these
ough systematic review that aimed to further results to the general population, additional
assess the effectiveness of OMT in the treatment studies will need to be performed.
of patients with migraine headaches. Using five
of the six studies available at that time, the
Migraine
authors concluded that there is a ‘‘low level of
evidence that OMT is effective in the manage-
ment of headache.’’ However, they acknowl- Despite a lack of clinical evidence supporting its
edged that more thorough studies are required use, chiropractic manipulation continues to be
to be able to come to a more agreed-upon con- commonly used in the treatment of migraine
clusion [52]. headaches. A 2017 study by Moore et al. showed
The efficacy of osteopathic manipulation for that 53.0% of chiropractors use manipulation to
the treatment of chronic pain conditions is treat patients ‘‘often,’’ 40.9% use it ‘‘sometimes,’’
summarized in Table 3. 5.7% use it ‘‘rarely,’’ and only 0.4% use it
‘‘never.’’ Given the lack of evidence to support
its applicability in this population of patients,
CHIROPRACTIC these statistics are surprising. However, given
that migraine headaches are one of the leading
Low Back Pain causes of disability worldwide, there is no
shortage of patients to be seen with this con-
In 2017, Goertz et al. published the results of a dition. Many patients prefer a non-medicinal
randomized-controlled trial studying the effi- approach to treatment and thus view chiro-
cacy of chiropractic manipulation in the treat- practic manipulation as a viable approach.
ment of LBP. In this study, patients were Given the lack of evidence to support its use in
assigned to one of three cohorts: medical care this patient population, alternative approaches
only, medical and chiropractic care, or medical should be considered.
and chiropractic care with additional interpro- According to Moore et al., ‘‘The high use of
fessional collaboration. Potentially eligible chiropractors by those with migraine would
patients were contacted electronically or via suggest these providers are likely to be address-
mail. Patients were required to have experi- ing some of the healthcare needs of this popu-
enced at least 1 month of LBP and needed to lation’’ [54]. However, what this statement fails
rate the pain as at least a 4 on an 11-point scale. to acknowledge is that the demand for a specific
One hundred thirty-one subjects participated in therapy does not directly correlate to its effi-
the trial. The results of this study showed cacy. The placebo effect is a well-understood
improvements in pain and back-related dis- concept, and its existence is highly accepted by
ability in each of the three groups. None of the the medical community. As a result, one cannot
groups appeared to be statistically significant deduce that simply because patients are using
from the others in these measurements. chiropractors to treat their migraines their
Adv Ther (2021) 38:76–89 85

treatment must be effective. To address this Table 4 Efficacy of chiropractic manipulation in the
issue, a randomized placebo-controlled trial treatment of chronic pain conditions
must be performed.
In 2016, Chaibi et al. showed that such a Low back Low level of evidence to support its efficacy
study can be performed. Although their patient pain
sample size was just 104, the results of their Migraines Highly popular, although no evidence to
study showed no significant difference between
support its efficacy
patients who had received chiropractic manip-
ulation or sham therapy [55]. Without a ran- Neck pain Efficacy remains unclear for acute and
domized controlled trial that contraindicates chronic neck pain
these data, the use of chiropractic manipulation
in the treatment of patients with migraine
headaches is a poor use of resources. Addition- Regarding patients with chronic neck pain ([
ally, with the principle of beneficence in mind, 3 months), Bussieres et al. reached a similar
providers must question whether providing conclusion. This conclusion was the result of
services to patients that have been shown to be two previous publications comparing patients
effective solely because of the placebo effect is with grades I and II back pain who received one
ethical. manipulation session per week for 20 weeks and
those who did not. One of the two studies
showed a decrease in pain level at the 12-week
Neck Pain
mark. However, neither study showed a statis-
tically significant difference between the two
The use of chiropractic practices in the treat- groups at 52 weeks. From these studies, Bus-
ment of patients with acute neck pain remains sieres et al. recommended the use of manipu-
poorly studied. As a result, the recommenda- lation in the treatment of persistent neck pain.
tions remain unclear. In 2016, Bussieres et al. Once again, they acknowledged that this rec-
published guidelines based upon six previously ommendation is weak and supported by low-
published systematic reviews on the topic. quality evidence. Additionally, they acknowl-
Regarding patients with recent-onset (0–- edged that the potential benefits and conse-
3 months) neck trauma, they supported the quences of manipulative therapy were roughly
usage of manipulation if the patient desired equal. With this in mind, manipulative therapy
such treatment. However, they acknowledged in the treatment of persistent neck pain appears
that this recommendation was based upon low- to be a poor use of resources and other forms of
quality evidence. This was largely due to the therapy should be considered (56).
short follow-up time of the patients involved in The efficacy of chiropractic therapy for the
the main study they used to make this recom- treatment of chronic pain conditions is sum-
mendation. Patients in this study were treated marized in Table 4.
four times over the course of 2 weeks and
monitored using the Kaplan-Meier recovery
curve. Patients were randomly assigned to CONCLUSION
receive their treatment from physiotherapists,
chiropractors, or osteopaths and were required Chronic pain is an issue that affects millions of
to have grade I or II neck pain. Although they patients daily. Current treatments usually
found that there was no statistically significant include pharmacologic therapies, most notably
difference between the different groups, one opioid therapy. However, chronic opioid use
cannot deduce from this that chiropractic carries immense risk given the potential for
manipulation is an effective treatment for neck overdose and addiction with this class of med-
pain. Doing such assumes that manipulation in ications. With the current crisis surrounding
general aids in the recovery of neck pain, which opioid use and increases in opioid-related
is not necessarily true. deaths in the US, there is a clear need for
86 Adv Ther (2021) 38:76–89

alternative treatment of chronic pain. Many of the work as a whole, and have given their
the pharmacologic alternatives to opioids either approval for this version to be published.
are not as effective for chronic pain or carry
their own risks and adverse effects such as in Disclosures. Ivan Urits is a member of the
increased risk of gastrointestinal bleeding. journal’s Editorial Board. Ruben H. Schwartz,
Other modalities for treating chronic pain Vwaire Orhurhu, Nishita V Maganty, Brian T.
include therapies such as acupuncture, tai chi, Reilly, Parth M. Patel, Christopher Wie, Alan D.
OMT, and chiropractic care, which were all Kaye, Ken F. Mancuso, Aaron J. Kaye, and Omar
evaluated in this review as alternative and Viswanath have nothing to disclose.
holistic approaches to managing chronic pain.
Acupuncture was shown to be effective in Compliance with Ethics Guidelines. This
reducing chronic low back pain and pregnancy- article is based on previously conducted studies
related pain. However, they were ultimately and does not contain any studies with human
inconclusive in their use for migraines and participants or animals performed by any of the
CRPS. Tai chi, similarly, was shown to be useful authors.
in chronic low back pain, specifically in the
older population. However, it was ineffective for Open Access. This article is licensed under a
MS-related pain and PTSD. OMT was shown to Creative Commons Attribution-NonCommer-
be useful in management of low back pain but cial 4.0 International License, which permits
not for migraine. Chiropractic manipulation any non-commercial use, sharing, adaptation,
was not shown to be effective in management distribution and reproduction in any medium
of low back pain, migraine, or neck pain. or format, as long as you give appropriate credit
Overall, the evidence for these alternative to the original author(s) and the source, provide
therapies in the management of chronic pain is a link to the Creative Commons licence, and
mixed. While there is some evidence to claim indicate if changes were made. The images or
that specific therapies can be effective for other third party material in this article are
specific types of pain (for example, acupuncture included in the article’s Creative Commons
for low back pain), there was also evidence licence, unless indicated otherwise in a credit
available to refute that claim. At this point in line to the material. If material is not included
time we cannot conclude that alternative ther- in the article’s Creative Commons licence and
apies are a replacement for pharmaceutical your intended use is not permitted by statutory
management of chronic pain. However, they regulation or exceeds the permitted use, you
may play a role as adjuvant therapies that can will need to obtain permission directly from the
potentially reduce a patient’s overall opioid copyright holder. To view a copy of this licence,
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ded to evaluate the role of alternative therapies nc/4.0/.
in the context of chronic pain management.

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