Integrative and Lifestyle Medicine to Manage Pain: What Does the Evidence Say?

A recent International Association for the Study of Pain Global Year webinar made the case for integrative and lifestyle approaches to improve pain. Image credit: yupiramos/123RF Stock Photo.

The IASP 2020 Global Year for the Prevention of Pain provided a webinar with Ziya Altug, a board certified physical therapist with 30 years of experience in treating musculoskeletal conditions (view the webinar recording here).

Altug made the case in favor of integrative and lifestyle medicine interventions to manage chronic pain. These include traditional Chinese medicine, Ayurvedic medicine and progressive muscle relaxation, movement – think Qigong, tai chi, and yoga – as well as nutrition, exercise, and sleep, among others. (Learn more about the 2020 Global Year for the Prevention of Pain. And to learn more about the 2021 Global Year About Back Pain, visit here).

Traditional Chinese medicine, Ayurvedic medicine and progressive muscle relaxation
Altug began by pointing out that many aspects of integrative and lifestyle medicine practices are aligned with the biopsychosocial model of pain, which posits that biological, psychological and social factors all contribute to the pain experience.

He then turned the audience’s attention to integrative medicine approaches for pain management, including traditional Chinese medicine, Ayurvedic medicine, and progressive muscle relaxation.

Traditional Chinese medicine is a system of practices that aims “to restore proper flow of life force (qi) in the body by balancing the opposing forces of yin and yang within the body,” as defined in the Merck Manual of Diagnosis and Therapy. Typically, it uses strategies such as acupuncture, massage, medicinal herbs, and Qigong exercise (see below) to restore health.

Ayurvedic medicine (or Ayurveda) also aims to restore balance within the body and is mainly practiced in Indian and South Asian countries. Ayurvedic practices include diet, herbs, massage, meditation, yoga, and therapeutic detoxification (using enemas, oil massages or nasal lavage) to restore balance.

Meanwhile, progressive muscle relaxation (PMR) is a technique developed by a psychiatrist named Edmund Jacobson and includes physical and mental versions. In the physical version, the person tenses muscles for five to ten seconds and then relaxes the muscles, in a systematic manner, and combines this with diaphragmatic breathing. In the mental version, which is a better choice for people with chronic pain who cannot tolerate tensing of muscles, the individual is instructed to imagine tensing and relaxing a muscle and perform diaphragmatic breathing.

Does progressive muscle relaxation work? Altug pointed to a randomized controlled trial published in 2016, which reported that cancer patients receiving chemotherapy had less fatigue, pain, nausea and vomiting after guided imagery (which uses mental images to improve mood and physical well-being) and progressive muscle relaxation. Similarly, a 2015 clinical trial showed that progressive muscle relaxation and mental imagery resulted in less phantom limb pain in subjects with lower limb amputation.

Get moving
Altug next focused on integrative movement for pain management, which includes techniques like Qigong, tai chi, and yoga.

Qigong is a traditional Chinese movement therapy that has roots in the ancient martial arts. It harnesses internal energy through movement, breathing exercises, relaxation and meditation and comes in many forms, including one known as eight strands of Brocade qigong (Baduanjin), which has eight different poses.

Altug pointed to two recent systematic reviews/meta-analyses (an approach that analyzes a group of studies together rather than just a single study) in support of the effectiveness of Qigong and other movement approaches for several chronic conditions. One review of 27 studies revealed that mindfulness-based Baduanjin exercise reduced pain and improved sleep in people with chronic musculoskeletal pain and chronic illness. Similarly, the other review found that mindfulness-based movement programs such as tai chi, Qigong and yoga were effective at reducing pain and improving disability in chronic low back pain, with tai chi emerging as the most superior treatment of the three.

Speaking of tai chi, it consists of a series of slow, controlled movements that help to improve balance, relaxation, and flexibility; sometimes tai chi is called meditation in motion. There are several forms of tai chi, with some forms having more than a hundred postures. In terms of the research evidence, a large randomized controlled trial published in 2018 reported that tai chi was as effective or better than an aerobic exercise program in patients with fibromyalgia.

Another study found that tai chi was a feasible and acceptable intervention among older adults with chronic pain from multiple body sites. Tai chi also improved pain severity, pain interference with daily activities, fear of falling, and gait better than light physical exercise did.

As for yoga, it is a system of traditional Hindu beliefs and activities that originated around 3000 B.C. and emphasizes the skill of “effortless effort.” In the Western world, yoga is associated with physical postures and breathing patterns and less so with the meditative components.

Does yoga help to improve pain? The evidence suggests favorable outcomes for pain and disability in chronic low back pain, and in knee osteoarthritis.

Lifestyle approaches
In the next part of his talk, Ziya discussed lifestyle medicine for pain management, focusing on nutrition, exercise, sleep, smoking and alcohol, stress and social connections.

Exercise has been proven to be effective in chronic pain conditions. As far as nutrition goes, a study published last year reported that a Western dietary pattern (characterized by higher intake of red meat, processed meat, refined grains and French fries, among others), was associated with worsening of knee osteoarthritis. At the same time, this study found that a dietary pattern characterized by higher intake of foods like vegetables, legumes, fruits, fish, and whole grains decreased the risk of knee osteoarthritis becoming worse.

The evidence also shows that sleep deprivation and improper sleep patterns contribute to chronic pain. Stress, too, is problematic for people with pain, and Altug said that reducing stress should be a key strategy to manage chronic pain. Studies have also revealed a strong association between pain intensity and the urge to consume alcohol, and between pain and smoking.

Finally, a systematic review published in the Journal of Physiotherapy in 2018 showed that people with low back pain pointed to social, work place and financial pressures as areas of need for effective management of their condition. Altug also referred to a perspective article published in the New England Journal of Medicine last year that made the case for the pain-relieving effects of “social prescribing” interventions such as group exercise classes, self-help groups and community gathering activities such as gardening and cooking. Altug then provided a case study of knee osteoarthritis to put into practice the approaches discussed during his talk for the treatment of pain.

Altug ended by emphasizing the importance of interprofessional collaborations for chronic pain management. He also stressed that integrative and lifestyle medicine strategies are simple and cost-effective solutions for pain management.

Y V Raghava Neelapala, PT, MPT, PhD student, School of Rehabilitation Science, McMaster University, Canada.