Alternatives in Cancer Pain Treatment:
The Application of Chiropractic CareThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Semin Oncol Nurs 2005 (Aug); 21 (3): 184–189
Ronald C. Evans, DC, FACO, FICC and Anthony L. Rosner, PhD, LLD (Hon)
Foundation for Chiropractic Education and Research,
Norwalk, IAOBJECTIVES: To review written resources disclosing reliable facts and knowledge in chiropractic services in cancer pain management.
DATA SOURCES: Conventional and biomedical and complementary and alternative medicine journals, electronic media, full text databases, electronic resources, books in print, and newsletters.
CONCLUSION: The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall.
IMPLICATIONS FOR NURSING PRACTICE: Clinicians should assess and support the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in cancer pain management.
From the FULL TEXT Article:
Background
Almost 1.37 million people (710,000 men, 662,870 women) will be diagnosed with cancer in 2005. [1] In the United States, nearly 46% of men and 38% of women will be diagnosed with cancer in their lifetime, with 80% of all cancers diagnosed at ages 55 and older. [1] The direct medical costs of treating cancer are estimated to be about $60 billion per year.
Table 1 Statistics show that one out of three cancer patients suffers from pain, either from the primary lesion or secondary to its treatment; if the cancer has advanced or metastasized, the chances of a patient experiencing pain are even higher. [2] The gamut of pain expression (dull, aching, sharp, constant, intermittent, mild, moderate, or severe sensations) may be the result of cell infiltration or necrosis of tissue near the primary lesion. In terms of medical treatment, there are other potential sources of pain such those as shown in Table 1.
Partly because of the prospect of side effects and additional pain encountered during therapy, cancer pain is often undertreated. Interrelating factors that might contribute to the undertreatment of pain include: (1) physician knowledge, (2) patient reluctance, (3) fear of addiction, and (4) fear of side effects.
CANCER SURVIVORS
Despite the aforementioned widespread prevalence of cancer in the United States, the number of cancer survivors is actually growing such that there are currently 8.9 million individuals in the United States living with cancer. Mortality rates for most major cancers are declining such that today more people survive cancer than ever before. Among the growing ranks of cancer survivors are the following groups [1, 3, 4]:(1) 2 million women are breast cancer survivors;
(2) 1 million men are prostate cancer survivors;
(3) 5–year survival rates of children with cancer increased from 56% in the early 1970s to 79% for those diagnosed in 1995– 2003; and
(4) the 5–year survival rate for all cancers increased from 51% in the early 1970s to nearly 66% from 1995–2000.As a result of this increased survival in cancer, the focus of treatment has now been able to shift toward the management of pain issues, acute and chronic, both during and after medical therapies. Given the prospect of pain accompanying standard treatment options alluded to above and given the multifactoral nature of pain, [5] the patient may harbor attitudinal barriers to effective pain management that could be overcome with novel interventions.
Nearly all patients with cancer-related pain experience have used medications at one time or another to treat their pain, but pharmacologic treatments are neither suitable for all patients nor universally effective. Drug treatments may also produce undesired side effects. Largely for these reasons, significant interest has developed among both patients and health care providers in alternative treatments for cancer pain.
Physical treatments for pain most frequently studied are chiropractic, (largely but not exclusively dominated by spinal manipulation), physiotherapy, and acupuncture. [6] If effective and available, these nonpharmacologic treatments may be the first choice for patients and may also be best suited for those patients who:(1) have poor responses to medical treatment or medical contraindications for further pharmacologic treatment;
(2) wish to become pregnant or are nursing;
(3) have a history of long-term, frequent, or excessive use of analgesic or pain-abortive medications that can aggravate other problems; or
(4) simply prefer to avoid the use of medications. [7]Based on the strength of research findings, its accreditation, its safety, and its widespread recognition, chiropractic management of pain such as that experienced in cancer patients would appear to be one of the leading alternatives to standard medical treatment for one to consider seriously. For reasons that will become apparent, the remainder of this article will address this very issue.
DEFINITIONS AND THEORETICAL BASIS OF CHIROPRACTIC
In its 109–year history, chiropractic has achieved distinction in addressing disorders of the musculoskeletal system and how these aberrations may impinge upon the nervous system, subsequently affecting our general health. This branch of health care is concerned with the diagnosis, treatment, and prevention of these disorders primarily (but not exclusively) through the application of manual treatments, which include spinal manipulation. [8]
The cardinal clinical feature of musculoskeletal disorders is pain. To no great surprise, both the rationale and outcomes of chiropractic management have always revolved around the relief of pain. Indeed, this conjecture is supported in both theory and fact. If such documentation can be found to be convincing, and if the risks of chiropractic interventions are found to be minimal compared with its benefits, a strong case can be made for considering chiropractic as a treatment option for controlling pain associated with cancer.
Table 2 The theoretical basis of chiropractic in alleviating pain can best be demonstrated by a variety of mechanisms that have been buttressed with evidence in the literature (Table 2). It can be seen that the effects of spinal manipulation have been proposed to be multifaceted, ranging from the reduction of nerve root encroachments to the release of trapped meniscoid fluids to the suppression of inflammatory mediators to possibly the release of analgesic opioids. The net effect of all of these is to reduce pain generation, [9–13, 18, 19–23] its sensation, [14–18] or its aggravation caused by anxiety. [24]
EMPIRICAL BASIS FOR CHIROPRACTIC
In just the past 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English literature. Even more remarkable is the fact that the majority of these have been published in general medical and orthopedic journals. These trials address not only back pain, but also headache and neck pain, the extremities, and a surprising variety of nonmusculoskeletal conditions.
When spinal manipulation is used, the majority of these trials have shown positive outcomes with the remainder yielding equivocal results. There are 43 trials addressing acute, subacute, and chronic low back pain, with 30 trials showing that manipulation is more effective than control or comparison treatments and the remaining 13 reporting no significant differences between treatment groups. None of these studies appears to have produced a negative outcome and none indicate that manipulation is any less effective than any comparison intervention. [25, 26]
SAFETY
As with any therapeutic intervention, contraindications exist for chiropractic, however rare. The two primary complications that have been reported are (1) cauda equina syndrome following manipulation in patients with lumbar disc herniation, consisting of neurogenic bowel and bladder disturbances, saddle anesthesia, bilateral leg weakness, and sensory changes; and (2) cerebrovascular accidents as a result of cervical manipulations.
The symptoms of cauda equina syndrome have been extensively described [27, 28]; a review of the world’s medical literature indicates that 16 of the 26 reported cases occurred with the far more vigorous manipulation applied under anesthesia. Of the remaining 10 cases, only four have been reported in North America. [29] Estimates of the frequency of cauda equina syndrome range from 2 per million [30] to 1 per 12 million adjustments. [31]
As established by researchers from both the medical and chiropractic professions, the risk of cerebrovascular accidents was traditionally regarded to be as low as one case per million treatments, 31 ranging upwards to 2 to 4 per million. [32, 33] The more recent data from the RAND Corporation suggests the rate of vertebrobasilar accident or other complications (cord compression, fracture, or hematoma) to be 1.46 per million manipulations, with the rates of serious complications and death from cervical spine manipulation estimated to be 0.64 and 0.27 per million manipulations, respectively. [34]
The most recent and definitive calculation of the likelihood of a treating chiropractor being made aware of an arterial dissection following a cervical manipulation is 1 per 5.85 million (0.17 per million) cervical manipulations. [35] These rates are 400 times less than the death rates observed from gastrointestinal bleeding caused by the use of nonsteroidal anti-inflammatory drugs [36] and 700 times lower than the overall mortality rate for spinal surgery. [37]
RECOGNITION OF THE CHIROPRACTIC PROFESSION
Nearly 110 years in existence, chiropractic has become the third largest profession of health care delivery in the world. It is recognized and licensed in every state and province in North America, as well as in Australia, New Zealand, and many jurisdictions in Europe, Africa, and the Middle East. Interest is increasing in other parts of the world where access to expensive medical and surgical modalities is limited.
The increasing acceptance of chiropractic as a legitimate health care profession has occurred in part through the increasing emphasis on research by professional organizations and colleges with funding by outside agencies. It also stems from the accrediting and review of educational curricula at chiropractic colleges around the world, 16 of which are accredited by the Council for Chiropractic Education. The Council for Chiropractic Education has accrediting agency status with the US Department of Education (since 1974) and the Council on Postsecondary Accreditation (since 1976).
With over 55,000 licensed practitioners in the United States, chiropractic has taken its place as the foremost profession through which spinal manipulations have been administered — primarily in the treatment of back pain. Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged in just the past two and a half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders. [38]
Nearly 30 years later, back pain management has been assessed by government agencies in theUnited States, [39]
Canada, [40]
Great Britain, [41]
Sweden, [42]
Denmark, [43]
Australia, [44] and
New Zealand. [45]All of these reports are highly positive with respect to spinal manipulation. It would seem that spinal manipulation, at least for back pain, appears to have vaulted from last place to first as a treatment option.
Other recent major accomplishments relating to the chiropractic profession within the United States have included:
The appearance of a variety of favorable systematic literature reviews [7, 46, 47];
The establishment of the first federally funded chiropractic Center for Excellence at Palmer University by the National Institute of Health’s National Center for Complementary and Alternative Medicine in 1997;
The publication of the Headache Report by Duke University in 20017;
The securing of over $20 million in federal grants within the past decade, when in 1991 this accomplishment was considered unlikely [48];
The establishment of chiropractic services within the military; and
The historic signing of Public Law 107–135 on January 23, 2003, mandating the establishment of a permanent chiropractic health benefit within the Department of Veterans Affairs health care system.
CHIROPRACTIC TREATMENT STRATEGIES
Although a great multiplicity of chiropractic techniques have been described, [49] over half of practicing chiropractors have reported using just a half-dozen different adjusting methods. [50] When combined with soft tissue techniques such as in the successful management of fibromyalgia [51] or with exercise in the treatment of low back [52] or neck pain, [53] spinal manipulation has been found to be particularly effective in reducing pain and increasing functionality. It may very well be that the potentially beneficial effects of spinal manipulation in managing cancer pain would be enhanced by being combined with adjuvant therapies used in acupuncture or physiotherapy.
CONCLUSION
The increased survivorship seen in cancer patients in the United States in recent years indicates that more and more individuals are experiencing pain, to which cancer treatments are becoming increasingly devoted. Given the prevalence, research documentation, relative safety, uniform licensure and accreditation, cost-effectiveness, and high patient satisfaction observed in the chiropractic management of musculoskeletal pain, the choice of chiropractic care as an alternative in the treatment of cancer pain becomes a highly attractive one. Its judicial use would seem to offer many economical possibilities for reducing the pain and suffering of cancer patients as well as providing the potential to improve patient health overall. [18, 24]
IMPLICATIONS FOR NURSING PRACTICE:
Clinicians should assess and support the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in cancer pain management.
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