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Manipulative and body-based methods

–Massage therapy is manipulation of the body’s soft tissues, using knowledge of anatomy and physiology to restore function, promote relaxation, and relieve pain. There are different types of massage.

–Osteopathic manipulative medicine includes indirect techniques (e.g., muscle energy, myofascial release, osteopathy in the cranial field, and strain–counterstrain approach) as well as direct action techniques (highvelocity thrusts).

–Craniosacral therapy is a gentle release of bony and fascial restrictions in the craniosacral system (cranium, sacrum, spinal cord, meninges, CSF).

–Chiropractic therapy focuses on the musculoskeletal and nervous systems and how imbalances in these systems can affect general health. It is used to treat back, neck, and joint pain. Doctors of chiropractic (DCs) complete 4 to

5 years of intensive training in anatomy, physiology, and manipulation. Mind–body medicine

–Meditation is a practice of detachment in which a person sits quietly, generally focusing on the breath, while releasing thoughts from the mind with the intention to center the self, restore balance, and enhance wellbeing. Mindfulness meditation involves making oneself aware of the most immediate of activities in order to gain control over actions and anxiety.

–Spiritual practices (e.g., prayer)

–Yoga is an exercise of mindfulness, meditation, strength and balance, composed of asanas (postures) and pranayamas (focused breathing).

–Aromatherapy uses highly concentrated plant extracts to stimulate healing. Aromatic oils are rubbed on the skin, aerosolized, or used in compresses.

–Relaxation techniques include breathing exercises, progressive muscle relaxation, and guided imagery.

–Tai chi and qi gong are Chinese exercise systems that combine meditation, regulated breathing, and flowing dance-like movements to enhance and balance chi (qi)—life force energy.

Alternative medical systems

–Traditional Chinese medicine incorporates Chinese herbs and acupuncture. Acupuncture is the practice of regulating chi by inserting thin needles at specific points along meridian pathways of the body. Chi movement is responsible for animating and protecting the body; relieving pain; and regulating cellular blood flow, oxygen delivery, and nourishment.

–Ayurvedic medicine originated in India and is one of the world’s oldest medical systems. It uses healing modalities and herbs to integrate and balance the body, mind, and spirit.

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–Homeopathy is based on the concept that very dilute quantities of an offending agent can stimulate innate immunity. In general, homeopathic remedies are considered safe and unlikely to cause serious adverse reactions. Only three states license homeopaths.

–Naturopathy regimens include herbs, vitamins, supplements, dietary counseling, homeopathic remedies, manipulative therapies, acupuncture,

and hydrotherapy. 4-year doctoral training programs are available; however, only 20 states/territories have licensing laws for naturopathic practitioners.

Energy therapies

–Reiki, which means “source energy,” is a healing practice from Japan. Laying hands lightly on the patient or holding the hands just above the body, the reiki practitioner facilitates spiritual and physical healing by

stimulating life force energy. Common reasons patients choose CAM

–Additive therapy to address issues not covered by conventional medical treatment

–Conventional medicine has been unsuccessful in fully addressing ailment.

–Preventive health care

–Desire for a holistic or natural approach to well-being

–Preference for noninvasive treatment options

–Concern about medication side effects

–Desire to include spiritual support into healing

–Cultural or familial belief system more aligned with “natural” solutions not provided for or supported by the standard allopathic model of health care

EPIDEMIOLOGY

All ages use CAM, but it is most prevalent among adults aged 30 to 69 years.

Gender ratio: female > male

College graduates and residents of western states are more likely to use CAM.

Cancer survivors are more likely than the general population to use CAM. Six most used CAM therapies:

–Nonvitamin, nonmineral dietary supplements (18%)

–Chiropractic and osteopathic manipulation (8.5%)

–Yoga (8%)

–Massage (7%)

–Meditation (4%)

–Special diets (3%)

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TREATMENT

Variable evidence supports safety and efficacy of

–Meditation for lowering BP

–Acupuncture for chronic low back pain (1)[B]

–Acupuncture to improve fertility

–Spinal manipulative therapy for prophylactic treatment of headaches

–Ginger for nausea, including that associated with chemotherapy

–Manipulation, massage, and mobilization for acute low back and posterior neck pain

–Massage therapy to promote weight gain in preterm infants

–Massage (30 minutes × 3) during labor shortens the second stage and reduces pain.

–Acupuncture for chemotherapy-induced nausea and vomiting

–Tai chi for improving balance and decreasing the risk of and fear of falling in elderly

–Mind–body techniques for migraines, chronic pain, and insomnia

–Cognitive-behavioral therapy is highly effective for the treatment of insomnia (2)[A].

–Homeopathic remedy for the treatment of chemotherapy-induced stomatitis in children

–Riboflavin for migraine prophylaxis

–Horse chestnut seed extract to improve lower leg venous tone, pain, and edema

–Glucosamine for osteoarthritis and knee pain

–Yoga and meditation appear to improve endothelial function in patients with CAD and can have potential beneficial effects on depressive disorders.

–Yoga throughout pregnancy shortens labor by 140 to 190 minutes.

–Exercise in both preconception and early pregnancy reduces chance of gestational diabetes mellitus.

–Exercise has a small to moderate effect in reducing symptoms in persons with diagnosed anxiety disorders.

–Breast stimulation in late pregnancy increases successful induction of labor (NNT 3.2) and reduces postpartum hemorrhage (NNT 19).

–Oral probiotics in preterm infants to decrease necrotizing enterocolitis and reduce mortality (3)[A]

–Oral probiotics to prevent URIs in children and influenza in the elderly

–Oral probiotics to shorten the duration of acute and antibiotic-associated

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diarrhea and as prophylaxis for traveler’s diarrhea

–Vitamin D 800 IU/day may reduce falls and fractures in the elderly.

–Acupuncture for recurrent headache

–Ginkgo biloba extract EGb 761 improves cognition in patients with dementia (4)[A].

Evidence supports safety, but evidence regarding efficacy is inconclusive:

–Homeopathy for induction and augmentation of labor

–Chondroitin sulfate is ineffective for osteoarthritis.

–Sterile water injections do not reduce labor pain.

–Fish oil might be an effective treatment for hypertriglyceridemia.

–Omega-3 fatty acids may reduce inflammation and anxiety in young healthy adults.

–Dietary fat reduction for certain types of cancer

–Mind–body techniques for metastatic cancer

–Copper and magnetic bracelets for pain

–Vitamin D levels >30 ng/mLcorrelate with lower risk of some cancers. Adequate vitamin D intake may decrease atopy and asthma symptoms.

Evidence supports efficacy, but evidence regarding safety is inconclusive or poor:

–St. John’s wort extract for short-term treatment of depression in adults

–Licorice for gastritis

–Goldenseal

Evidence indicates serious risk:

–Black cohosh, blue cohosh, and evening primrose oil are unsafe to induce labor.

–Delay in seeking medical care or replacement of curative conventional treatment

–Use of toxic herbs or substances

–Known herb–drug interactions

ONGOING CARE

PATIENT EDUCATION

The National Center for Complementary and Integrative Health (https://nccih.nih.gov/)

COMPLICATIONS

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ALERT

Ginkgo, goldenseal, and St. John’s wort account for most reported herb–drug interactions.

Herbs with possible adverse effects

–Serious adverse events from herbal remedies remain uncommon.

–Some ethnic medicines, as those prescribed by practitioners of Ayurveda or traditional Chinese medicine, may intentionally contain heavy metals or other toxic substances. These are usually listed by their pharmacopeial names, for example, Qian Dan = lead oxide.

–Bitter orange (Citrus sinensis): sympathomimetic; increases heart rate (HR), BP

–Black cohosh (Actaea racemosa) reduces effectiveness of statins.

–California poppy (Eschscholzia californica): may cause respiratory depression, drowsiness; contains opioids

–Cascara sagrada (Frangula purshiana): depletes serum potassium

–Chaparral (Larrea tridentata): hepatotoxic

–Ephedra (Ephedra spp.): sympathomimetic; increases HR, BP; insomnia, gastric distress

–Ginkgo (Ginkgo biloba): extravasation, increased bleeding time

–Goldenseal (Hydrastis canadensis) interferes with nearly all prescription drugs.

–Guarana (Paullinia cupana): tachycardia, hypertension; contains caffeine

–Kava (Piper methysticum): decreases use of niacin; possibly hepatotoxic

–Licorice (Glycyrrhiza spp.): Long-term use depletes serum potassium.

–Lily of the valley (Convallaria majalis): contains cardiac glycosides

–Poke root (Phytolacca species): strong gastric irritant; may cause sedation

–Senna (Cassia senna): depletes serum potassium

–Snakeroot (Aristolochia spp.): nephrotoxic

–St. John’s wort (Hypericum perforatum): numerous drug interactions; induces CYP(3a4) pathway, speeding metabolism of cyclosporine, tacrolimus, warfarin, protease inhibitors, theophylline, venlafaxine, digoxin, and oral contraceptives

–Wormwood (Artemisia absinthium): elevates serotonin level, may raise BP

–Yohimbe (Pausinystalia yohimbe): elevates BP

Geriatric Considerations

Ginkgo biloba commonly interacts with Coumadin.

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Pediatric Considerations

Iron is a leading cause of accidental poisoning in children <6 years of age. Minerals (i.e., potassium, calcium, magnesium, zinc, copper, and selenium) may cause toxicity.

Vitamin Ais the most common cause of hypervitaminosis.

β-Carotene has a limited potential for overdose.

REFERENCES

1.Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142(8):651–663.

2.Kligler B, Teets R, Quick M. Complementary/integrative therapies that work: a review of the evidence. Am Fam Physician. 2016;94(5):369–374.

3.Alfaleh K, Anabrees J, Bassler D, et al. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. 2011;(3):CD005496.

4.Asher GN, Corbett AH, Hawke RL. Common herbal dietary supplement-drug interactions. Am Fam Physician. 2017;96(2):101–107.

CODES

ICD10

Z76.89 Persons encountering health services in other specified circumstances

CLINICALPEARLS

Oral probiotics reduce respiratory and diarrheal infections and reduce mortality in preterm infants.

Acupuncture is effective for back pain, headaches, and infertility.

Cognitive-behavior therapy reduces insomnia.

Yoga and breast stimulation shorten labor.

Ginkgo, goldenseal, and St. John’s wort account for most herb–drug interactions described in the medical literature.

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COMPLEX REGIONALPAIN SYNDROME

Dennis E. Hughes, DO, FAAFP, FACEP

BASICS

DESCRIPTION

Complex regional pain syndrome (CRPS) is a pain syndrome that can be chronic and debilitating. It is divided into two subtypes and can have significant physical and psychosocial shortand long-term disability. Most cases are a result of a physical insult to an extremity such as trauma or surgery.

–Type I: no nerve injury (reflex sympathetic dystrophy [RSD])

–Type II: associated with a demonstrable nerve injury (causalgia)

Synonym(s): traumatic erythromelalgia; Weir Mitchell causalgia; causalgia; RSD; posttraumatic neuralgia; sympathetically maintained pain

EPIDEMIOLOGY

Incidence of 5.46/100,000 for type I and 0.82/100,000 for type II in United States (1)

Peak age 50 to 70 years

Predominant gender: female > male (3:1, 60–81%), favoring postmenopausal

Recent studies found 3.8% occurrence after wrist fracture and 7% occurrence after intra-articular ankle fracture—both independent strong risk for CRPS (2) [B].

More prevalent in patients that report higher than usual expected pain in early phases of trauma (2)

ETIOLOGYAND PATHOPHYSIOLOGY

Poorly understood activation of abnormal sympathetic reflex that lowers pain threshold

–Increased excitability of nociceptive neurons in the spinal cord; “central sensitization”

–Exaggerated responses to normally nonpainful stimuli (hyperalgesia, allodynia)

Other than known nerve injury (type II or causalgia), no known definitive pathogenesis

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Genetics

No known genetic pattern

RISK FACTORS

Minor or severe trauma (upper extremity fracture noted in 44%)

Surgery (particularly carpal tunnel release)

Lacerations

Burns

Frostbite

Casting/immobilization after extremity injury

Penetrating injury

Polymyalgia rheumatica

Myocardial infarction (MI)

Cerebral vascular accident

GENERALPREVENTION

Early mobilization after fracture, stroke, and MI has proven benefit in reducing incidence of CRPS.

One study of wrist fractures found that addition of 500 mg/day of vitamin C lowered rates of CRPS.

There is evidence that limiting use of tourniquets, liberal regional anesthetic use, and ensuring adequate perioperative analgesia can reduce the incidence of CRPS-I.

COMMONLYASSOCIATED CONDITIONS

Serious injury to bone and soft tissue

Herpes zoster

Postherpetic neuralgia results from partial or complete damage to afferent nerve pathways.

Pain occurs in dermatomes as a sequela of herpes zoster.

DIAGNOSIS

Unprovoked pain is the hallmark of the condition, and the diagnosis of CRPS is excluded by the existence of conditions that would otherwise account for the degree of symptoms. Clinical diagnostic criteria (1)

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HISTORY

Continuing pain which is disproportionate to any inciting event One reported symptom in three of the four following categories:

–Sensory: hyperalgesia and/or allodynia

–Vasomotor: skin, temperature, color asymmetry

–Sudomotor/edema: edema, sweating changes, or sweating asymmetry

–Motor/trophic: decreased range of motion or motor dysfunction and/or trophic changes (hair, nail, skin) (2)

PHYSICALEXAM

At least one sign at evaluation in two of the following:

Sensory: hyperalgesia (to pinprick) or allodynia (to light touch, pressure, or joint movement)

Vasomotor: evidence of temperature, skin, color asymmetry

Sudomotor/edema: evidence of edema or sweating changes or asymmetry

Motor/trophic: decreased range of motion; motor dysfunction; or trophic changes in hair, nails, skin (2)

DIFFERENTIALDIAGNOSIS

Infection

Hypertrophic scar

Bone fragments

Neuroma

CNS tumor or syrinx

Deep vein thrombosis or thrombophlebitis

Thoracic outlet syndrome

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC

Erythrocyte sedimentation rate (ESR)

Plain radiographs may show patchy demineralization within 3 to 6 weeks of onset of CRPS that are more pronounced than would be seen from disuse alone.

Three-phase bone scanning has varying sensitivity but is most accurate for support of the diagnosis when there is diffuse activity (especially on phase 3). Bone density

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Diagnostic Procedures/Other

Electromyelography (EMG) shows nerve injury with type II CRPS.

Sudomotor function testing (resting sweat testing, resting skin temperature, quantitative sudomotor axon reflex testing; all related to increased autonomic activity of the affected limb)

Test Interpretation

Partial or complete damage to afferent nerve pathways and probably reorganized central pain pathways

Nerves most commonly involved are median and sciatic.

Atrophy in affected muscles Incomplete nerve plexus lesion

TREATMENT

GENERALMEASURES

Discourage maladaptive behaviors (pain medication seeking, secondary gain). Principal of functional restoration is a stepwise and multidisciplinary approach.

MEDICATION

First Line

NSAIDs recommended early in course but mixed support in literature

The following have literature support of either limited or suggestive benefit in treatment of CRPS-I:

–Corticosteroids (prednisone 30 mg/day × 2 to 12 weeks with taper) are the only class of drugs that have direct clinical trial support early in the course. Arecent retrospective case review found that patients showed significant improvement with various measurable physical parameters after treatment with prednisolone (30 mg starting dose tapering by 5 mg every 3 days for a total of 3 weeks treatment) (3)[C].

–Gabapentin 600 to 1,800 mg/day for 8 weeks following diagnosis

–50% DMSO cream applied to affected extremity up to 5 times daily

–N-Acetylcysteine 600 mg TID

–Bisphosphonates (alendronate) at 40 mg/day (however, optimal dose uncertain)

–Nifedipine 20 mg/day showed benefit early in the course of the condition.

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