Non-Pharmacological Approaches to Deprescription - A Resource for Group 6 PM081 Physiopedia

Non-Pharmacological Approaches

The following is a non-exhaustive list of non-pharmacological options both in and outside the scope of physiotherapy practice. The aim of this resource is to provide physiotherapists and other relevant health professionals with a baseline resource for complementary or alternative treatment options to consider when desiring to remedy clinical scenarios where overprescription is suspected. Clinical professional readers are advised to continually consider relevant and most recent available evidence in relation to their patients’ clinical situation and flagged medication. Additionally, non-prescribing clinical readers are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment.

Physiotherapy interventions

Patient education

The importance of increasing a patient’s understanding of their condition and treatment plan is not only of benefit for improving a patient’s adherence to treatment, but can also improve health outcomes [1]. Self-management of chronic conditions as well as preventative health intents rely heavily on provision of contemporary information and communication practice [2]. Primary focus for long term conditions commonly involves promotion of informed lifestyle choices, risk-factor modification, and active patient self-management [2]. Education can be provided through a variety of health care professionals, preferably done by providers who have undertaken adequate training for education, and patient communication. Recognized physiotherapy programmes typically include a component of patient education within their training, however, training interventions for physiotherapy students has shown to improve their self-efficacy and performance in the delivery of patient education [3]. Core competencies for health professional educators according to [4] include the following:

·      Feature a personal ethic, for social responsibilities and services towards others

·      Deliver accurate, proficient and evidence based care

·      Exercise preventative health care

·      Emphasize relationship-centred care with patients and their families

·      Consider the multiple determinants of health during provision of care

·      Remain culturally sensitive and open to diverse society

·      Utilize technology competently and effectively

·      Remain current in your field and continue professional development to advance education

In the United States, opportunity for health professionals to become certified health educators is provided by the National Commission for Health Education Credentialing. Information on credentialing can be found below:

Evidence for patient education’s effect on health outcomes vary across populations and pathologies, but has shown improvement in many. For patients with inflammatory arthritis, a 2015 systematic literature review investigated patient education delivered through face to face meetings with allied health professionals (including physiotherapists), patient groups, and online support programmes [5]. The best evidence emerging from the review resulted from face to face meetings as an interactive learning process. Beneficial effects were found in terms of adherence to treatment regimens, behavioural change, use of self-management strategies and well-being [5]. In rheumatoid arthritic patients, another systematic review reports patient education is either strongly recommended or recommended as an effective non-pharmacological option by 10 of the 13 selected clinical practice guidelines [6]. In the amputee population, patient education is recommended as a MDT approach aimed at changing the patient’s lifestyle in regards to physical activity and pain management, as long as it maintains a patient-cantered approach [7]. Improvements can be seen in depression, mood, self-management, and functional status, as well as pain and quality of life in certain populations [7]. In palliative care settings, patient education regarding cancer pain management has been systematically reviewed as well [8]. Authors reported modest but clinically significant reduction in cancer pain after patient-based educational interventions, and although these interventions are underutilized, they are recommended to be routinely used in practice. Additionally, for patients using opioids, an educational session may be more effective than the addition of co-analgesics [8]. Unfortunately, in regards to reducing falls in the elderly, patient knowledge and educational interventions were found to be ineffective [9].

Electrotherapy modalities

Electrotherapy modalities, also referred to as electrophysical agents, are terms to describe electrical devices that are safely applied by trained professionals to an injury site in effort to enhance, expedite, or improve the treatment plan and recovery process. There are a wide range of electrotherapy modalities used in physical therapy. Conventionally, they are used for pain management, reducing swelling, increasing local blood flow, and breaking down scar tissue and can be applied across various stages of injury recovery [10]. Common electrotherapy modalities used in pain management include transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), ultrasound, and laser therapy. More information on a wider variety of electrotherapy modalities and their multitude of uses can be found here.

TENS and IFC are similar modalities as they use electrodes around the desired site to apply electrical impulses in effort to provide symptomatic pain relief through the excitement of local sensory nerves, thereby stimulating the pain gate mechanism and/or opioid system to mask pain symptoms [10].

Evidence for IFC has been published through meta-analysis in knee osteoarthritic patients to reduce pain and likewise decreasing analgesic medication such as paracetamol intake [11]. Another meta-analysis for IFC states its potential use in musculoskeletal pain management when used as a supplement to other interventions [12]. The authors caution that no conclusive statements can be made due to heterogeneity and methodological limitations in this case. However, there appears to be a consensus that IFC should be used with exercise or as supplement to other interventions, and less effective for use on its own [11][12].

Evidence for use of TENS in pain management was demonstrated in a 2014 critical review, in which both high frequency and low frequency TENS can provide an analgesic effect when applied at a strong, non-noxious intensity [13]. High frequency TENS may be more appropriate for patients on opioid medication, as high frequency and low frequency parameters target different opioid receptors [13]. Varying these parameters has been a suggested strategy to avoid a development of tolerance in chronic pain conditions and prolong the analgesic effect if used daily. Populations which may benefit most from TENS include patients with post-operative pain, osteoarthritis, painful diabetic neuropathy, fibromyalgia, spinal cord injuries, and some acute pain conditions [13].

Ultrasound is one of the most widely used electrotherapy modality [10]. Although it is commonly referred to as an electrotherapy modality, it uses mechanical energy as opposed to electrical energy. Mechanical energy is created through the vibration of emitting sound waves from the head of the ultrasound and transmits through to the targeted tissues, providing thermal or non-thermal effects dependent on the parameters [10]. Clinical application includes use for tissue repair, fracture healing, and wound healing among others which can result in a secondary effect of pain relief [10]. A 2010 meta-analysis suggests that ultrasound may be effective for improving physical function and reducing pain in osteoarthritic knee joints, however, the evidence is low quality and there is demand for more definitive clinical trials [14]. Low quality evidence has also been reported for ultrasound by a Cochrane review in its use for short-term benefits (6-weeks) in pain and function in individuals with calcific tendinitis [15]. Further low quality evidence for ultrasound use has been shown in patients with non-specific chronic low back pain, for short-term improvement in function, although authors suggest this may not be clinically significant [16]. Unfortunately, no high-quality evidence exists for ultrasound’s reduction in pain for a number of conditions when compared to placebos [14][15][16]. This may be due to a lack of high quality randomized control trials and small sample sizes, creating a requirement for large trials with valid and robust methodology.

Laser therapy in clinical and research settings is typically referred to as low intensity laser therapy, or low level laser therapy. It is used as a form of light amplifier to provide an enhancement of certain properties of light energy which when delivered to the targeted tissues, result in a generation of heat, chemical change, disorder of molecular bonds and creation of free radicals [10]. Clinically, it can be used for wound healing, inflammatory arthropathies, soft tissue injuries, and pain relief [10]. Its use for pain relief was assumed to be a secondary effect of reducing an inflammatory state, however, it may also be attributed to a direct effect with characteristics of nerve conduction [17].

Evidence for low level laser therapy have been found through meta-analysis which suggest a strong inclination for its use in the reduction of chronic pain across various aetiologies [18]. Another systematic review with meta-analysis investigated the modality’s effect on neck pain, which found that low level laser therapy can be used to immediately reduce acute neck pain as well as reduce pain intensity in chronic neck pain patients [19]. A more recent double blinded placebo control study found that low level laser therapy can improve pain and function in patient with knee pain as well [20]. Conversely, a meta-analysis performed in 1993 by Gam et al. when the clinical use of the modality was emerging, found no effect on pain in musculoskeletal conditions [21].

Thermal modalities

Thermal modalities include thermotherapy and cryotherapy and can also be referred to as conductive modalities. Thermotherapy includes superficial heating agents such as hydrocollator packs, paraffin wax baths, warm whirlpool, and fluidotherapy [22]. While cryotherapy produce a tissue temperature decrease which include application methods such as ice massage, cold hydrocollator packs, contrast baths, cold whirlpool, cold spray, ice immersion, cryo-cuff, and cryokinetics [22]. Thermal modalities can also be used as adjuncts to exercise therapy and/or electrophysical modalities, for a variety of therapeutic purposes. Physiological Effects of cold and heat can be found listed below adapted from [22].

Effects of Heat:

·      Increased local temperature superficially

·      Increased local metabolism

·      Vasodilation of arterioles and capillaries

·      Increased blood flow to targeted area

·      Increased leukocytes and phagocytosis

·      Increased capillary permeability

·      Increased lymphatic and venous drainage

·      Increased metabolic wastes

·      Increased axon reflex activity

·      Increased elasticity of muscles, ligaments, and capsule fibres

·      Analgesia

·      Increased formation of oedema

·      Decreased muscle tone

·      Decreased muscle spasm

Effects of Cold:

·      Decreased local temperature, in some cases to a considerable depth

·      Decreased metabolism

·      Vasoconstriction of arterioles and capillaries (initially)

·      Decreased blood flow (initially)

·      Decreased nerve conduction velocity

·      Decreased delivery of leukocytes and phagocytes

·      Decreased lymphatic and venous drainage

·      Decreased muscle excitability

·      Decreased muscle spindle depolarization

·      Decreased formation and accumulation of oedema

·      Extreme aesthetic effects

Looking at the evidence for these thermal modalities, a Cochrane review was performed in 2006 by French et al. investigating the effects of superficial cold and heat for nonspecific low back pain [23]. While heat and cold application is commonly recommended by clinicians for low back pain, the authors concluded that the evidence is not strong to support this common practice [23]. More specifically, they only found moderate evidence for continuous heat wraps to provide short term pain relief and improved function in acute and sub-acute back pain (≤ 3 months), with greater improvements with the addition of exercise to the thermotherapy. For cryotherapy, the evidence in this review for its treatment in non-specific low back pain was even more limited, and no conclusions could be drawn at the time of the review [23]. However, the results of this review was limited by many studies with poor methodologic quality. Since then, Dehghan and Farahbod conducted a randomized clinical trial in 2014 investigating both thermotherapy and cryotherapy’s effect on 87 patients with acute low back pain when compared to a routine pharmacologic control (naproxen) [24]. This study found that both cryotherapy and thermotherapy relieved the acute low back pain, and due to their few side-effects, low economical cost and ease of accessibility, they were suggested to be used alongside pharmacological treatments such as naproxen, as supplementary modalities to reduce acute low back pain [24]. All together, these findings corroborate with a more recent literature review for musculoskeletal injuries. The authors agreed that evidence for use of thermotherapy is limited, with the greatest effects seen with heat wrap therapy for short-term relief of acute low back pain and disability, and additionally provides significantly greater pain relief than cryotherapy when used for delayed onset muscle soreness [25]. The requirement for more sufficiently powered and high-quality randomized control trials exploring the efficacy of cold and heat therapy for pain in various musculoskeletal conditions is ongoing [23][25].

Manual Therapy

Manual therapy can be defined differently across health professionals but can be described as another non-pharmacological, non-surgical, conservative option for management of a range of musculoskeletal conditions. These skilled, hands on techniques can be applied to patients’ spine and extremities for purpose of assessment and treatment. There are a wide variety of techniques that can be grouped into four major categories: manipulation, mobilization, static stretching, and muscle energy techniques [26]. Commonly, manipulation and mobilization of the spine are used for treatment of low back pain by physiotherapists and other health professionals such as osteopaths and chiropractors [26]. Although the effectiveness of these techniques is dependent on the skills of the handling clinician, it is important to look at the available evidence when deciding to implement this option into a treatment plan.

A UK evidence report of manual therapies published in 2010 reviewed its effectiveness for the management of a variety of musculoskeletal and non-musculoskeletal conditions [27]. The report included 49 systematic reviews, 16 evidence based clinical guidelines, and 46 randomized controlled trials not included in the former reviews and guidelines. The report found some evidence that spinal manipulation and mobilization is effective for adults with low back pain of all durations, as well as migraines, cervicogenic headaches and cervicogenic dizziness [27]. Authors suggested manipulation and mobilization is effective for a variety of joint conditions in the extremities. Thoracic mobilization and manipulation is effective for acute and sub-acute neck pain. However, the report found inconclusive evidence for cervical manipulation and mobilization for neck pain at any duration, as well as manipulation and mobilization for mid back pain, sciatica, tension headaches, coccydyina, fibromyalgia, premenstrual syndrome, temporomandibular joint conditions, and pneumonia in older adults [27].

An update to this UK evidence report was published in 2014 to address the inconclusive and negative ratings in the previous report [26]. The updated report concluded that all together, there was limited high quality evidence to support the effectiveness of manual therapy. Reasons for these ratings and unreliable estimations are due to paucity, poor quality methodologies, and heterogeneity of studies, in addition to differences in experience, training and approaches of the clinical providers [26]. Further research in this area will need to include: qualitative methods to involve patient attitudes and opinions; greater consistency across research groups; more non-musculoskeletal disorders; and high quality, long-term, randomized clinical trials investigating clinical and cost-effectiveness [26].

Clinical readers interested in specific patient groups will find more information in these reports found here (2010) and here (2014)

Therapeutic exercise

Therapeutic exercise techniques include passive movements, active assisted movements, active movements, resisted movements and assisted resisted movements with aims to correct impairment, improve musculoskeletal function or maintain well-being [28]. To further a pain management approach, the option to perform these movements on land or in water can be explored. Therapeutic exercise can be prescribed to accomplish the following aims [28]:

·      Improve and enable ambulation

·      Release contracted muscles, tendons, and fascia

·      Mobilize joints

·      Improve circulation and respiratory capacity

·      Improve coordination

·      Reduce rigidity

·      Improve balance

·      Promote relaxation

·      Improve and maintain muscular strength and endurance

·      Improve exercise performance and functional capacity

Evidence supporting the use of therapeutic exercise is vast and dependent upon specific patient populations. The following is a summary of evidence for therapeutic exercise in patient populations for: stroke; multiple sclerosis; balance impairment; osteoarthritis; and mental health.

There have been several published studies showing the benefits of therapeutic exercise in post-stroke patients. In subacute stroke patients, prescribed exercises increased endurance, balance and mobility resulting in improved function and quality of life [29]. The same patient population also experienced improvement in depressive symptoms [30]. In other randomized control trials within this population, improvements in activities of daily living were found in subacute stroke patients, as well aquatic therapy improved gait in stroke patients with hemiplegia [31][32]. Furthermore, a systematic review found that progressive resistance exercise for acute and chronic stroke patients improves strength and activity without increasing spasticity [33].

Many types of therapeutic exercise have found to be beneficial for patients with multiple sclerosis as well, although for safe application, certain precautions are required including close supervision of a health professional [28]. Symptoms in this population are generally exacerbated in higher ambient temperatures, and therefore interval training and/or precooling before therapeutic exercise is recommended [28]. A Cochrane review published in 2005 revealed strong evidence for improvements in strength, mobility-related activities, and exercise tolerance, with possible benefits in mood and upper extremity function [34]. However, a 2013 systematic review could not conclude as many of these findings, but suggested exercise was safe and may be beneficial for this population [35]. As multiple sclerosis is a progressive condition, maintaining function with therapeutic exercise rather than improving it may be a more realistic goal for this population [36]. However, a smaller study investigating use of pilates for wheelchair-bound patients with moderate-to-severe multiple sclerosis did find improvements in back and shoulder pain and sitting balance [37].

Balance impairment is a major factor in the older population which can lead to falls and injury, and exercise has been a common recommendation in fall prevention [38]. A Cochrane review published in 2011 exploring exercise to improve balance in older people concluded at the time of publishing there was weak evidence that some types of exercise were moderately effective [39]. It was unclear which types of exercise were optimal for improving balance in the older population (≥60 years of age) living at home and residential care. However, in general, the more effective programmes ran three times weekly for three months and incorporated dynamic exercise in standing. The authors suggested the missing data and poor methods of many included studies highlighted a requirement for high-quality research in the area. A comprehensively tested and effective fall prevention exercise programme used by physiotherapists for older people is the Otago Exercise Programme [40][41]. The programme is an individualized, home-based strength and balance retraining programme for older adults which is delivered or supervised by a physiotherapist [41]. More information on the delivery of the Otago Exercise Programme can be found here.

Apart from therapeutic exercise, there are a number of non-pharmacological interventions that are of use to address falls in the elderly population which have been recently and robustly systematically reviewed, of which, exercise and multifactorial interventions emerged as optimal options in reduction of falls [9]. Further information regarding evidence of several non-pharmacological interventions for fall prevention in elderly populations across a variety of settings can be found here.

Osteoarthritic joints can also benefit from therapeutic exercise. Physiotherapists generally use therapeutic exercise in this population for purposes of improving strength, range of motion, and pain management. Systematic reviews published on this topic have shown that therapeutic exercises such as resistance and endurance training can reduce pain and improve balance in osteoarthritic knee patients [42][43][44]. Similar results are found when looking at individuals with osteoarthritis of the hip, where a systematic review revealed that physical function can improve as well as reduce falls risk when using a combination of functional and aquatic exercises [45].

Therapeutic exercise can also be of very strong benefit as a non-drug alternative for mental health issues [46][47][48]. Overall, positive effects have been shown for mental health, cognition and brain activity as a result of a variety of therapeutic exercise programmes [46]. Aerobic exercise has shown to significantly reduce depressive symptoms and state anxiety values in major depressive disorders, reduce negative symptoms severity of schizophrenic patients, and has been suggested to help reduce psychopathological symptoms and improve cognitive skills [47]. Furthermore, a recent meta-analysis found further support for exercise to improve neurocognitive function in people at risk of, or with, dementia [48].

Non-pharmacological options for referral and signposting

Therapeutic communities

Therapeutic communities come in many forms and each are tailored to address a variety of long term issues including personality disorders, mental health, learning disabilities, and substance abuse [49]. These communities are group-based with a participative approach in a residential or day unit setting. Since the target population for each therapeutic community varies, gaining access to one is best done by directly contacting the programme for a self-referral, however, in most cases you will require a referral from a doctor or social worker. In these cases, physiotherapists and other relevant health professionals would be wise to be aware of local therapeutic communities and their respective access procedures, in order to efficiently sign post patients that express long-term substance abuse concerns from overprescribed medications. Signposting these patients will likely require a discussion with the MDT or referring physician in order to determine if overprescription is an issue in the suspected addiction. A 2010 meta-analysis reviewing therapeutic communities’ effect for individuals with co-occurring substance abuse and mental disorders, found supporting evidence for significant treatment effects for substance use, mental health, crime, employment and housing [50]. More information about therapeutic communities can be found at The Consortium for Therapeutic Communities.

Mind-body therapies

While acute pain can resolve quickly with appropriate use of analgesics, medications and treatment of underlying causes, chronic pain can cause clinicians and patients significant concern. Human perception of pain is not purely somatic, it involves regions of the brain that register and modify pain signals including brain centres engaged with stress, emotion, attention, beliefs, conditioning, mood, and cognition [51]. Mind-body therapies can be described as interventions that change an individual’s mental and/or emotional state which aim to generate corresponding changes in the body, including pain perception. A variety of mind-body therapies can be used in the management of chronic pain as a sole treatment, however they may be better used as a complementary approach to other therapies [52]. When seeking a mind-body therapist for chronic pain, it is advisable to first consult a GP for a formal diagnosis, as many of these clinical practices are unregulated in the UK. The following is a summary of evidence on a few commonly used mind-body approaches for chronic pain management including: guided imagery; cognitive hypnotherapy; and cognitive behavioural therapy.

Guided imagery’s use in the management of chronic pain stems from relaxation, and distracting the individual’s mind from mental elaboration of pain, through use of therapeutic images. A systematic review revealed eight of nine randomized clinical trials found guided imagery results in significant reduction of musculoskeletal pain, however, the methodologies of included studies were graded medium to low and therefor the encouraging results were inconclusive [53]. Guided imagery is often paired with music therapy, and administered by Music Therapists who are required to be registered with the Health & Care Professions Council in the UK.

Cognitive hypnotherapy, also referred to as hypnosis, was one of the first mind-body therapies used for managing chronic pain. Exact definition of hypnosis can vary but it is considered a natural state of mind by those who practice it [54]. Using progressive relaxation techniques, service users can learn self-hypnosis for self-management as well. A 2012 review suggests there is evidence identified for chronic pain management in subjects with cancer, osteoarthritis, sickle cell disease, fibromyalgia, temporomandibular joint disorders, non-cardiac chest pain, and disability related chronic pain [55]. An earlier study found hypnotherapy may provide pain relief in irritable bowel syndrome with beneficial effects measured after 5 years [56]. Currently, hypnotherapy is not a regulated profession in the UK, however, the National Council for Hypnotherapy is one of the UK’s largest not-for-profit professional association, with fully insured members.

Cognitive behavioural therapy (CBT) is a talking therapy that can help manage issues beyond chronic pain by changing individuals’ perceptions and behaviours. Differing from other talking therapies, CBT focuses on individuals’ current problems rather than past problems, then uses practical ways to improve a daily state of mind [57]. There is a strong evidence base for CBT’s use in management of a variety of chronic pain conditions [58]. A 2012 narrative review also suggests that CBT is beneficial for treatment of nonspecific chronic low back pain and should be incorporated into MDT interventions for a more patient-centred approach [59]. Finally, a 2011 article published in Best Practice & Research Clinical Rheumatology, suggests CBT coupled with exercise should be integrated into a multi-component approach for chronic widespread pain conditions like fibromyalgia [60]. The article includes methods for how exercise and CBT can be combined using evidence-based guidelines. In the UK, CBT is free under the National Health Service (NHS) when referred from a GP. Although psychological therapies are unregulated at the moment in the UK, the British Association for Behavioural & Cognitive Psychotherapies keeps a register of accredited therapists.

Biofield Therapies

Biofield therapies is a term coined in 1992 in a United States National Institutes of Health Conference [61]. They can be described as non-invasive, non-pharmacological, practitioner-mediated therapies which utilize the biofield of the practitioner and service user to stimulate a response in the service user, sometimes referred to as a “healing response”. Common biofield therapies include Reiki, therapeutic touch, and healing touch, among many others. These therapies are not generally integrated into conventional clinical care, likely due to limited understanding of mechanisms and gaps in research base. While there may be pressure for these therapies to demonstrate plausible physiological mechanisms, an argument can be made that these mechanisms are important, however, not essential for conducting and analysing robust clinical trials. A systematic review on best evidence synthesis for biofield therapies published in 2010 found most studies were of medium quality and typically did not meet minimum standards for validity of inferences [62]. The review did report that there is strong evidence for reducing self-reported pain intensity in a variety of populations, including elderly patients with chronic pain. Another systematic review in 2009 explored the therapeutic effects of Reiki [63]. This review was unable to derive any definitive conclusions due to significant methodological and reporting limitations of existing studies investigating effectiveness of Reiki. While nine of the twelve included clinical trials found significant therapeutic effects using Reiki, the Jadad Quality score used in the review found eleven of the twelve studies were ranked as “poor”. It appears the consensus among relevant reviews in the area of various biofield therapies conclude that while the strongest evidence is found in symptom management of pain, there is a demand for high-quality studies for further investigation and recommendations [62][63][64].

Acupuncture

Acupuncture is a well-known and most prominent part of Chinese medicine in western medicine [65]. The aim of the practice is to affect body functions, as well as stimulate and restore the body’s own regulatory system through use of needles, pressure and/or heat on distinctive locations on the human body [65]. This non-pharmacological option is often incorporated in several clinical settings of conventional medicine, including qualified clinicians in physiotherapy [65]. There is extensive research exploring the use of acupuncture in the management of a variety of chronic pain conditions including low back pain, neck pain, and osteoarthritis, as well as tension-type and migraine headaches [66][67][68][69][70]. In 2015, an overview of systematic reviews for use of acupuncture on low back pain was published [66]. While overall methodological quality of reviews was low and external validity was weak, a number of conclusions were drawn. For acute low back pain, there was inconsistent evidence that acupuncture has a larger effect on pain relief and improved function compared to sham acupuncture. Conversely, for chronic low back pain, there was consistent evidence that acupuncture either used in isolation or with a conventional therapy, can provide short-term and clinically relevant improvements in pain and function. A recent systematic review with meta-analysis considering the effects of acupuncture on neck pain was published in 2017 [67]. Authors concluded that acupuncture for chronic neck pain has similar effects to conventional medicine for pain reduction and disability, when compared to each other, but is more effective for pain relief when both were used in combination. However, the review added that definitive conclusions were difficult to make due to high risk of bias and imprecision of the included studies. Research for use of acupuncture for osteoarthritis tends to focus around the knee joint. A systematic review regarding its effectiveness on knee joints suggest that acupuncture may play a role for treatment of this population, but currently there is insufficient evidence to determine its efficacy in comparison to conventional treatments [68]. Cochrane reviews have been published in 2016 for effects of acupuncture on both migraine attacks, and tension-type headaches [69][70]. The review for tension-type headaches found that acupuncture is an effective treatment for frequent episodic or chronic tension-type headaches, however due to the moderate quality of evidence, further trials are needed in comparing with conventional treatment options [69]. In regards to preventing migraine attacks, available evidence shows that acupuncture in combination with symptomatic treatment of migraine attacks, can reduce the frequency of migraine headaches, and may produce similar effects to pharmacological prophylactic treatment [70].

Overall, acupuncture is a valid and reasonable option to consider for individuals to manage certain chronic pain conditions, although, clinical guidelines are inconsistent regarding recommendations [66][67][68][69][70]. Acupuncture treatments for pain are mainly covered through private insurance companies in the UK, however, some treatments are also provided by the NHS [65]. A large professional and self-regulatory body for the practice of acupuncture is the British Acupuncture Council who are members of the Accredited Resister scheme run by the Professional Standards Authority. Clinical readers looking to ensure patients find a qualified professional in this area, can be directed to the British Acupuncture Council website. There are very few side effects from acupuncture when practiced by qualified practitioners, any minor side effects occurring are mild and self-correcting according to the British Acupuncture Council.

Massage Therapy

The terms massage and massage therapy have been defined and differentiated at a 2010 best practice symposium for the profession involving thirty-two experts in the field of massage therapy [71]. In general, massage is a patterned and purposeful soft tissue manipulation with or without emollients, liniments, thermal modalities or other external apparatus with aims of therapeutic change. Massage therapy includes the addition of non-hands-on components such as health promotion, and client education for self-care and maintenance [71]. Massage therapy is another non-pharmacological approach that has been extensively researched, although has been burdened by poor methodological studies. A 2006 systematic review of twenty studies evaluated the clinical effectiveness of therapeutic massage for symptomatic relief of musculoskeletal pain [72]. With positive results for massage compared to no treatment or sham treatment in many studies, the available evidence at the time was inconclusive due to small sample sizes, low methodological quality, and insufficient dosing [72]. Due to the large number of systematic reviews published on massage therapy’s effect on non-specific low back pain, a systematic review of nine systematic reviews was completed in 2013 [73]. The methodological quality of the reviews varied from poor to excellent, but the primary research informing the individual reviews was generally weak quality. Overall, the 2013 systematic review found that a small body of evidence emerged to support the use of massage therapy for short-term treatment of non-specific low back pain, although authors cautioned the interpretation of this conclusion due to the methodological limitations of the primary research [73]. Finally, a recent systematic review with meta-analysis was published in 2017, with fifteen studies exploring the efficacy of massage therapy for shoulder pain [74]. The author of the review suggested that massage therapy is effective for improving shoulder pain in the short-term, although, further research using randomized controlled trials with large sample sizes is required in order to make conclusive evidence-based recommendations. Massage therapy is another unregulated profession in the UK, however, the Complementary & Natural Healthcare Council is a UK voluntary regulator for various health practitioners including massage therapists. Their registered practitioners comply with the council’s standards of conduct, ethics and performance so service users can be confident the therapists are properly trained, qualified and insured.

Chiropractic

Chiropractic is also a non-pharmacological type of complementary and alternative treatment, as it is not considered conventional medical treatment. In these treatments, a chiropractor uses a hands-on approach to help relieve problems with bones, muscles and joints [75]. Similar to physiotherapists, the first visit entails an assessment to determine if the profession is suitable and which techniques may help. Techniques used by chiropractors include spinal manipulation, short and sharp thrusting movements, gradual joint movements and muscle stretches [75]. A variety of uses for chiropractic include pain for backs, necks, joint pains, tension-type headaches, migraine prevention and sports injury conditions [75]. A 2013 systematic review with meta-analysis explored the efficacy of manipulative therapy in adults with complaints of pain compared to sham manipulation, involving 19 studies [76]. Results included moderate level of evidence for manipulative therapy’s immediate effect on pain relief, but lower evidence at short-term follow up. Similar results were found in patients with musculoskeletal conditions [76]. Concluding statements were that manipulative therapy has a clinically relevant effect to reduce pain, but not disability. In regards to non-specific low back pain, a 2016 systematic review of six pragmatic studies found moderate evidence to support chiropractic care in producing similar results to other types of care, including physical therapy [77]. However, similar conclusions could not be made when compared to medical care and exercise therapy [77].

Chiropractic is generally very safe when receiving treatment from trained and registered clinicians. Besides minor adverse effects from the treatment such as aches and pains, stiffness or tiredness, a more serious risk is of stroke. Case reports and studies have suggested an association between chiropractic neck manipulation and cervical artery dissection, leading to stroke. However, a 2016 systematic review with meta-analysis performed on the subject has since concluded that the association of the two events is small and there is no evidence of direct causation [78].

All chiropractors in the UK are required by law to be registered with their regulatory body - The General Chiropractic Council. The council checks that registered chiropractors have current professional indemnity insurance, have met mandatory continuing professional development, and remain in good health and good character. Chiropractic is not widely available in the NHS, but is provided in some areas. Discussion with a patient’s GP can provide this information, or by contacting a local clinical commissioning group.
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