Complementary Therapies

When it comes to therapy, there is no one size fits all. Some things may work well for certain individuals while they may irritate another person’s symptoms. Complementary therapies are often passive- meaning that the provider is doing something to you. 

It takes many approaches to manage chronic pain- these therapies may be one tool in your tool kit for chronic pain management. 

In this module, you will learn about:

  1. Massage
  2. TENS
  3. Chiropractic
  4. Acupuncture

Massage

  • What is it?

    • Massage involves the repeated rubbing, kneading, and/or squeezing of tissue by hand or with a tool.
  • How does it work?

    • Massaging stimulates increased blood flow and muscle relaxation.
    • The exact physiological mechanism by which massage exerts its widespread influence on the human body is unknown. 
    • Massage may activate various physiological effects that in turn contribute to mood, tissue repair, pain modulation, and relaxation.
  • Who offers it?

    • RMT- Registered Massage Therapist
    • In order to practice massage therapy in Ontario, your therapist must be registered with the College of Massage Therapists of Ontario.
    • Registered massage therapists (RMT) attend college for 1-3 years before completing the College of Massage Therapists of Ontario Certification Examination.
  • The evidence

    • Despite the long-time popularity of massage for pain reduction, there is inconsistent evidence to support its effectiveness for these purposes. 
    • There is literature that supports some pain relief from massage therapy for chronic pain conditions. However, massage therapy is generally administered as complementary to therapy and not as a first line of treatment. 
    • You may find massage helpful as an extra tool to pair with your current pain management strategy.
    • Those experiencing increased sensitivity to touch or temperature change may find massage causes their symptoms to flare rather than alleviating them.

Key concepts:

  • Massage is the rubbing, kneading, and/or squeezing of tissue by hand or with an assistive tool.
  • The use of massage therapy treatment stimulates increased blood flow and muscle relaxation.
  • Although some research suggests that massage therapy provides some pain relief for chronic pain conditions, it is generally administered as complementary rather than as a first line of treatment.

TENS

  • What is it?

    • TENS is Transcutaneous Electrical Nerve Stimulation.
    •  It uses electrical stimulation to excite your sensory nerves.
    • TENS is typically applied via a small battery operated unit.
    • Electrodes are placed on the skin over the painful area and wires connect the electrode to the unit.
    • Once the unit is turned on, you will feel a tingling sensation under the electrodes.
  • How does it work?

    There are different theories as to how TENS affects your pain levels. These include:

    • Pain Gate Mechanism: the electric stimulation goes through the skin to affect the nerves underneath. It may cause those nerves to block the sensory input from the painful region from reaching the brain. In other words, it may turn off the pain message.
    • The Endogenous Opioid System: the electrical stimulation may increase the production of endorphins, which in turn dampen the pain signals.
    • The electrical stimulation can improve blood flow by causing small muscles to repeatedly contract and relax. Some people report feeling a relaxing effect on their muscles because of this.
  • Who offers it?

    TENS is often applied by health care providers including physicians, physiotherapists, and chiropractors. There are also at home devices. Always speak to a healthcare provider before using. 

  • The evidence

    There is limited evidence as to whether TENS has an impact on pain in fibromyalgia, chronic low back pain, or neuropathic pain. Further studies need to be completed on this modality.

Key concepts:

  • Transcutaneous Electrical Nerve Stimulation, or TENS, uses electrical stimulation from electrodes to excite the sensory nerves.
  • The Pain Gate Mechanism hypothesizes that electrical stimulation administered from TENS blocks the sensory input from the affected pain region from reaching the brain.
  • The Endogenous Opioid System stipulates that electrical stimulation increases production of endorphins, the body’s natural painkillers.
  • Current research supporting the effectiveness of TENS for pain reduction in fibromyalgia, chronic low back pain, or neuropathic pain is limited.

 

Manual therapy

 

 

  • What is it?

    • Medical professionals such as chiropractors can use manual (hands on) techniques to treat the neurological and musculoskeletal systems.
    • They should take a detailed history of your pain and then perform a physical examination in order to assess your alignment, posture, strength, and range of motion.
    • Their treatment approach can include spinal and soft tissue manipulation.
    • Some chiropractors incorporate other modalities such a shock wave therapy or electric muscle stimulation.
    • Your chiropractor may recommend certain exercises or an ergonomic assessment of your workspace.
  • Who offers it?

    • Chiropractors practicing in Ontario must be registered with the College of Chiropractors of Ontario.
    • Physiotherapists practicing in Ontario must be registered with the College of Physiotherapists of Ontario.
    • Your practitioner of choice should not be trying to enroll you in a long-term commitment to treatment.
    • You should not be asked to sign up for a payment plan involving a certain number of visits over a given period.
  • The evidence

    • There currently is a lack evidence on the effect of chiropractic treatment on chronic pain. 
    • If you have osteoporosis, active inflammatory arthritis, or cancer, you should speak with your primary care provider prior to meeting with a chiropractor. You may not be eligible for spinal manipulations.

     

Key concepts:

  • A chiropractor is a medical professional who uses manual techniques to treat the neurological and musculoskeletal systems.
  • Treatment by a chiropractor involves spinal and soft tissue manipulation, but may incorporate other modalities such a shock wave therapy or electric muscle stimulation.
  • Chiropractors practicing in Ontario must be registered with the College of Chiropractors of Ontario.
  • Current evidence on the effectiveness of chiropractic treatment on chronic pain is lacking.Continue: Acupuncture

Acupuncture

 

  • What is it?

    • Acupuncture has been used in China for millennia.
    • It involves the use of very thin solid needles, as opposed to hypodermic needles, which are hollow.
    • These pre-sterilized, single-use disposable needles are used to pierce the skin over specific “acupoints”.
    • During your first visit with an acupuncturist, they should take a detailed medical history and perform a physical exam. You will then be asked to either sit or lie down.
    • The needles are inserted 1-1.4” into your body.
    • Sometimes, acupuncturists will use heat or electricity to stimulate the needles.
    • Normally, acupuncture does not hurt.
    • Occasionally, people report feeling the needles as they penetrate the skin or a feeling of heat once they are inserted.
  • How does it work?

    • One theory held by traditional Chinese medicine practitioners, is that acupuncture works by affecting neurohormonal pathways.
      • This means that by affecting the nervous system, acupuncture may cause the brain to release endorphins, which dampen the pain signal.
      • The needles may cause this biochemical response in the body by stimulating the nerves. 
    • Recent neuroimaging studies have shown that acupuncture can activate our bodies pain inhibition system
  • Who offers it?

    • There are different avenues for accessing acupuncture.
    • You may be seeing a physiotherapist or a chiropractor who practices acupuncture.
      • They must register with their respective provincial regulating bodies.
    • Conversely, you may be seeing a Traditional Chinese Medicine Practitioner or Acupuncturist (TCMP).
      • If you are seeing a TCMP, they must be registered with the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario.
  • The evidence

     

    There is mixed evidence as to the effect of acupuncture on chronic pain. Some studies have shown little difference between the relief people experienced receiving acupuncture versus receiving sham acupuncture.

     

Key concepts:

  • This treatment involves the use of thin solid needles to pierce the skin over specific “acupoints”.
  • Current evidence on the effectiveness of acupuncture as a treatment for chronic pain is mixed.
  • For acupuncture, you may be seeing a physiotherapist, chiropractor, or a traditional Chinese Medicine practitioner or acupuncturist (TCMP).

Points to remember:

  • One size does not fit all! We are all different and what may work for someone else may not work for you.
  • Most complementary therapies can have a short-term relieving effect but a limited impact on long-term change in symptoms.
  • Research your provider’s qualifications and find someone who is the right fit for you. 
  • Before you consent to any treatment, make sure you understand the potential risks and benefits.
  • An active approach to therapy has a longer-lasting impact on pain reduction but complementary therapy may help with the symptom relief necessary to increasing your physical activity.

Bergeron-Vézina K.2017, Filion C., Couture C., Vallée É., Laroche S., Léonard G. (2017). Adjusting Pulse Amplitude During Transcutaneous Electrical Nerve Stimulation Does Not Provide Greater Hypoalgesia, retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29116826

Butler D & Moseley GL (2003). Explain pain. Noigroup Publications

Carroll, D., Moore, R.A., McQuay, H. J., Fairman, F., Tramèr, M., Leijon G. (2000). Transcutaneous electrical nerve stimulation (TENS) for chronic pain, retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003222/full

Cherkin, D. C., Sherman K. J., Avins, A. L., Erro, J. H. RN, MN, Ichikawa, MS, Barlow, W. E., Delaney, K., Hawkes, R., Hamilton, L., Pressman, A., Khalsa, P. S., Deyo, R. A. (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832641/

Ernst, E., Lee, M.S., Choi, T.Y. (2011). Acupuncture: does it alleviate pain and are there serious risks? A review of reviews, retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21440191

Franke, H., Franke, J-D., Fryer, G. (2014). Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis, retrieved from https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-15-286

Gibson, W., Wand, B. M., O'Connell, N. E. (2017). Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults, retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011976.pub2/full

Haas, M., Groupp, E., Kraemer, D. F. (2004). Dose-response for chiropractic care of chronic low back pain, retrieved from http://www.sciencedirect.com/science/article/pii/S1529943004001184

Hurwitz, E. L., Morgenstern, H., Harber, P., MPH, Kominski, G. F., Yu, Adams, A. H. (2002). A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study, retrieved from http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.92.10.1634

Johnson, M. I., Claydon, L. S., Herbison, G. P., Jones, G., Paley, C. A. (2017). Transcutaneous electrical nerve stimulation (TENS) for fibromyalgia in adults, retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012172.pub2/full

Khadilkar, A., Odebiyi, D. O., Brosseau, L., Well, G. A. (2008). Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain, retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003008.pub3/full

Licciardone, J.C., Kearns, C.M., Minotti, D.E. (2013). Outcomes of osteopathic manual treatment for chronic low back pain according to baseline pain severity: results from the OSTEOPATHIC Trial, retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23759340

Madsen M.V., Gotzsche P.C., Hrobjartsson A. (2009).  Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups, retrieved from https://www.painscience.com/biblio/acupuncture-treatment-for-pain-review.html

Moseley GL (2010). Painful yarns. Noigroup publications. Orrock, P.J., Myers, S. P. (2012). Osteopathic intervention in chronic non-specific low back pain: a systematic review, retrieved from https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-14-129

Palmgren, P. J., Sandström, P. J., Lundqvist F. J., Heikkilä, H. (2005). Improvement After Chiropractic Care in Cervicocephalic Kinesthetic Sensibility and Subjective Pain Intensity in Patients with Nontraumatic Chronic Neck Pain, retrieved from http://www.sciencedirect.com/science/article/pii/S0161475405003659

Sapolsky RM (2009). Why zebras don’t get ulcers 3rd ed. Henry Holt Publishing

Rubinstein, S.M., Van Middelkoop, M., Assendelft, W.J., De Boer, M.R., Van Tulder, M.W. (2011). Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review, retrieved from https://www.ncbi.nlm.nih.gov/pubmed?term=Rubinstein%20SM,%20van%20Middelkoop%20M,%20Assendelft%20WJ,%20de%20Boer%20MR,%20van%20Tulder%20MW.%20Spinal%20manipulative%20therapy%20for%20chronic%20low-back%20pain:%20an%20update%20of%20a%20Cochrane%20review.%20Spine%202011;36:E825%E2%80%9346

Tsao, J. C. I. (2007). Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876616/

Wall P (2000). Pain: the science of suffering. Columbia University Press.

76 Grenville St. Toronto, ON M5S 1B2 Canada

TAPMI Hub Clinic

Phone: 416-323-6269 Office Fax: 416-323-2666 Hours: 8:00 a.m. – 4:00 p.m. Monday – Friday

Administration

Dr. Tania Di Renna, Medical Director William Cachia, Administrative Director