ALTERNATIVES IN CANCER PAIN TREATMENT: THE APPLICATION OF CHIROPRACTIC CARE
 
   

Alternatives in Cancer Pain Treatment:
The Application of Chiropractic Care

This 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, IA


OBJECTIVES:   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 the

United 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:

  1. The appearance of a variety of favorable systematic literature reviews [7, 46, 47];

  2. 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;

  3. The publication of the Headache Report by Duke University in 20017;

  4. The securing of over $20 million in federal grants within the past decade, when in 1991 this accomplishment was considered unlikely [48];

  5. The establishment of chiropractic services within the military; and

  6. 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.



References:

  1. Jemal A, Murray T, Ward E.
    Cancer statistics 2005.
    CA Cancer J Clin 2005;55:10-30.

  2. Moynihan T. Mayo
    Foundation for Medical Education and Research, October 20, 2003. CNN Interview. Available at:
    http://www.cnn.com/health/CA/0021.html.

  3. Atlas of Cancer Mortality in the United States, 1950-94,
    a survey of cancer-specific mortality rates in all 3,000 U.S. counties.
    Washington, DC; National Cancer Institute Surveillance,
    Epidemiology, and End Results (SEER) report; 2001.

  4. National Cancer Institute Surveillance,
    Epidemiology, and End Results (SEER) report, 2001.

  5. Raj PR.
    Pain Medicine. A Comprehensive Review.
    St Louis, MO; Mosby-Year Book; 1996.

  6. Fontanarosa PB (ed.).
    Alternative Medicine: An Objective Assessment.
    Chicago, IL; American Medical Association; 2000.

  7. McCrory D.C., Penzien D.B., Hasselblad V., Gray R.N.
    Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
    In: Duke University Evidence-based Practice Center CfCHPR, editor.
    Foundation for Chiropractic Education and Research; Des Moines, IA: 2001.

  8. Chapman-Smith D. The Chiropractic Profession.
    West Des Moines, IA;
    National Chiropractic Mutual Insurance Company Group; 2000; 1.

  9. Giles LG, Harvard AR.
    Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints.
    Br J Rheumatol 1987;26:362-364.

  10. Bogduk N, Jull G.
    The theoretical pathology of acute locked back: A basis for manipulative therapy.
    Manuelle Medizin 1985;23:77-81.

  11. Bogduk N, Tynan W, Wilson AS.
    The nerve supply to the human lumbar intervertebral disks.
    J Anatomy 1981;132:39-56.

  12. Arkuszewski Z.
    Joint blockage: A disease, a syndrome, or a sign.
    Manual Med 1988;3:132-134.

  13. Lantz CA.
    The vertebral subluxation complex.
    In: Gatterman MI (ed.). Foundations of Chiropractic Subluxation.
    St Louis, MO; Mosby; 1995:149-174.

  14. Bolton, PS.
    Reflex Effects of Vertebral Subluxations: The Peripheral Nervous System. An Update
    J Manipulative Physiol Ther 2000 (Feb); 23 (2): 101–103

  15. Dishman JD, Burke JR.
    Spinal reflex excitability changes after cervical and lumbar joint manipulation. A comparative study.
    Spine J 2003;3:204-212.

  16. Budgell BS.
    Reflex effects of subluxations: The autonomic nervous system.
    J Manipulative Physiol Ther 2000; 23:104-106.

  17. Suter E, McMorland G, Herzog W, et al.
    Conservative lower back treatment reduces inhibition in knee-extensor muscles:
    A randomized controlled trial.
    J Manipulative Physiol Ther 2000;23:76-80.

  18. Haldeman S.
    Neurological effects of the adjustment.
    J Manipulative Physiol Ther 2000;23:112-114.

  19. Irving R.
    Pain and the protective reflex generators.
    J Manipulative Physiol Ther 1981;4:69-71.

  20. Vernon HT, Dhami MSI, Howley TP, et al.
    Spinal manipulation and beta-endorphin: A controlled study of the effect of a spinal manipulation
    on plasma beta-endorphin levels in normal males.
    J Manipulative Physiol Ther 1986;9:115-123.

  21. Wagnon RJ, Sandefur RM, Ratliff CR.
    Serum aldosterone changes after specific chiropractic manipulation.
    Am J Chiropractic Med 1988;1:66-70.

  22. Rocha R, Rudolph AE, Frierdich GE, et al.
    Aldosterone induces a vascular inflammatory phenotype in the rat heart.
    Am J Physiol Heart Circ Physiol 2002;283:H1802-H1810.

  23. Kokjohn K, Schmid DM, Triano JJ, et al.
    The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea.
    J Manipulative Physiol Ther 1992;15:279-285.

  24. Ali S, Hayek R, Holland R, McKelvy S-E, Boyce K, Curson P.
    Effect of Chiropractic Treatment on the Endocrine and Immune System in Asthmatic Patients
    Proceedings of the 9th International Conference on Spinal Manipulation.
    Des Moines, IA: Foundation for Chiropractic Education and Research. In press, 2002.

  25. Meeker WC, Mootz RD, Haldeman S.
    Back to basics . . . The state of chiropractic research.
    Top Clin Chiropractic 2002;9:1-13.

  26. Meeker, W., & Haldeman, S. (2002).
    Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
    Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227

  27. Kleynhans AM.
    Complications of and contraindications to spinal manipulative therapy.
    In: Haldeman S (ed): Modern Developments in the Principles and Practice of Chiropractic.
    New York, NY; Appleton-Century Crofts; 1980:359-384.

  28. Laderman JP.
    Accidents of spinal manipulations.
    Ann Swiss Chiropractic Assoc 1981;7:161-208.

  29. Haldeman S, Rubinstein SM.
    Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.
    Spine 1992;17:1469-1473.

  30. Terrett AGL, Kleynhans AM.
    Complications from manipulations of the low back.
    Chiropractic J Australia 1992; 22:129-140.

  31. Hosek RS, Schram SB, Silverman H, et al.
    Cervical manipulation (letter to the editor).
    JAMA 1981;245:22.

  32. Hamann G, Haas A, Kujat C, et al.
    Cervicocephalic artery dissections due to chiropractic manipulations.
    Lancet 1993;341:764-765.

  33. Dvorak J, Orelli F.
    How dangerous is manipulation of the cervical spine?
    Manuel Med 1985;2:1-4.

  34. Hurwitz EL, Aker PO, Adams AH, Meeker WC, Shekelle PG.
    Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature
    Spine (Phila Pa 1976) 1996 (Aug 1); 21 (15): 1746–1760

  35. Haldeman S, Carey P, Townsend M, Papadopoulos C.
    Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience
    Canadian Medical Association Journal (CMAJ) 2001 2001 (Oct 2); 165: 905–906

  36. Dabbs V Lauretti WJ
    A Risk Assessment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain
    J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536

  37. Deyo RA, Cherkin DC, Loesser JD, et al.
    Morbidity and mortality in association with operations on the lumber spine:
    The influence of age, diagnosis, and procedure.
    J Bone Joint Surg Am 1992;74:536-543.

  38. Goldstein M (ed):
    Monograph No. 15. The Research Status of Spinal Manipulation.
    Washington, DC; US Department of Health, Education, and Welfare; 1975.

  39. Bigos S, Bowyer O, Braen G, et al.
    Acute Low Back Pain in Adults. Clinical Practice Guideline No. 14.
    AHCPR Publication No. 95-0642. Rockville, MD:
    Agency for Health Care Policy and Research, Public Health Service,
    U.S. Department of Health and Human Services. December 1994.

  40. Manga P, Angus D, Papadopoulos C, et al.
    A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic: Management of Low-Back Pain
    Ministry of Health, Government of Ontario Canada
    Richmond Hill, Ontario; Kenilworth; 1993.

  41. Rosen M.
    Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain.
    London; Her Majesty’s Stationery Office; 1994.

  42. Commission on Alternative Medicine, Social Department. Legitimization for Vissa Kiropraktorer;
    Stockholm. 1987;12:13-16.

  43. Danish Institute for Health Technology Assessment.
    Low-Back Pain Frequency, Management and Prevention from an HTA perspective
    Danish Health Technology Assessment 1999;1.

  44. Thompson CJ.
    Second Report, Medicare Benefits Review Committee,
    Chapter 10 (Chiropractic).
    Canberra, Australia; Commonwealth Government Printer; 1986.

  45. Hasselberg PD.
    Chiropractic in New Zealand: Report of a Commission of Inquiry.
    Wellington, New Zealand; Government Printer; 1979.

  46. Kjellman GV, Skagren EI, Oberg BE.
    A critical analysis of randomized clinical trials on neck pain and treatment efficacy:
    A review of the literature.
    Scandinavian J Rehab Med 1999;31:139-152.

  47. Bronfort G, Assendelft W, Evans R, Haas M, Bouter L.
    Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
    J Manipulative Physiol Ther 2001 (Sept); 24 (7): 457–466

  48. Corporate Health Policies Group.
    An Evaluation of Federal Funding Policies and Programs and Their Relationship to the Chiropractic Profession.
    Arlington, VA; Foundation for Chiropractic Education and Research; 1991.

  49. Cooperstein R, Gleberzon BJ.
    Technique Systems in Chiropractic.
    New York, NY; Churchill Livingstone; 2004.

  50. Christensen MG, Kerkhoff D, Kollasch MW.
    Job Analysis of Chiropractic
    Greeley (CO): National Board of Chiropractic Examiners, 2000.

  51. Blunt KL, Rajwani MH, Guerriero RC.
    The effectiveness of chiropractic management of fibromyalgia patients: A pilot study.
    J Manipulative Physiol Ther 1997;20:389-399.

  52. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV.
    Trunk Exercise Combined with Spinal Manipulative or NSAID Therapy
    for Chronic Low Back Pain: A Randomized, Observer-blinded Clinical Trial

    J Manipulative Physiol Ther. 1996 (Nov); 19 (9): 570–582

  53. Gross AR, Hoving JL, Haines TA, et al, for the Cervical Overview Group.
    A Cochrane Review of manipulation and mobilization for mechanical neck disorders.
    Spine 2004;29: 1541-1548.

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