Giannitrapani K, Holliday J, Miake-Lye I, et al. Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain. Pain Med. 2019 May 9. pii: 5487508. doi: 10.1093/pm/pnz068. (Systematic review)

OBJECTIVE: Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.

DESIGN: We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an "evidence map," or a visual display, of the literature size and broad estimates of effectiveness for pain.

RESULTS: Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.

CONCLUSIONS: There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

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Comments from MORE raters

Physician rater

This is a review of the literature on acupuncture, massage, Tai Chi, and mindfulness in the treatment of different types of pain. There were separate reviews by the same group in the past, but this work adds up to 5 years more of literature review and puts all the data into one graphic. Assuming that their methods for determining strength of evidence were solid, this graphical representation makes it easy to find patterns - such as massage appears more useful for pain in the shoulder, neck, and head region than in the low back.

Physician rater

The authors suggest in the introduction that possibly complementary therapies may be relevant as alternative for opioids. However, the paper does not give insight in the clinical relevance of the therapies and only for the statistical significance. This especially regards acupuncture where we know that the results of many studies are not clinically relevant. The only conclusion of this review should be that for certain complaints some methods can be tried. The nice figure 1 can be helpful for that aim.
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