Complementary and alternative medicine (CAM) is described by the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) as a group of unconventional medical systems, practices, and products not presently considered part of the conventional biomedical care provided by medical doctors and other conventionally trained health professionals . For most CAM therapies, there are unanswered questions regarding safety, cost-effectiveness, efficacy, and mechanisms of action. Facilitating the scientific evaluation of CAM is a key objective of NCCAM.
NCCAM groups CAM therapies into the following five categories: mind–body interventions, manipulative and body-based therapies, biologically based therapies, energy therapies, and alternative medical systems. Mind–body interventions aim to increase the mind’s capacity to enhance bodily function and reduce symptoms. Examples from this category include biofeedback, relaxation, meditation, hypnosis, and yoga and other movement therapies involving a component of mental focus. Spiritual approaches, such as prayer, are categorized as mind–body interventions. Additional mind–body interventions once considered to be outside of conventional medical or dental treatment have achieved integration into multidisciplinary pain treatment and mainstream care on the basis of evidence for their safety and improved treatment outcomes resulting from their inclusion in combined treatments . These include patient education, cognitive-behavioral coping skills training, and behavioral modification techniques such as habit reversal.
NCCAM defines manipulative and body-based therapies as physical modalities such as massage therapy, chiropractic adjustments, and osteopathic manipulations. Biologically based therapies include foods, vitamins, minerals, herbal products, and other natural substances used as dietary supplements. Energy therapies are of two types. In the first type, practitioners intend to manipulate biofields theorized to exist within and around the patient. The second type of energy therapy involves the unconventional use of electromagnetic fields for therapeutic purposes.
The final category delineated by NCCAM, the alternative medical systems, is comprised of complete systems of theory and practice, often predating modern Western biomedicine. These systems share an aim to support an innate tendency of the body toward health and can include interventions from all the other categories of CAM. Homeopathy and naturopathy are examples of alternative medical systems arising in Western culture. Homeopaths intend to stimulate the body’s capacity for healing by providing minute doses of natural products. Naturopaths may use nutritional modifications, dietary supplements, homeopathic remedies, hydrotherapy, massage, and counseling to prevent illness or to rebuild health. Traditional Chinese medicine uses mind–body therapies such as tai chi and chi gong, which are meditative movement therapies, along with natural products derived from plant and animal sources, therapeutic massage, and acupuncture to facilitate and balance energy flow, which is theorized to be central to health.
According to a comprehensive report produced in 2005 by the Institute of Medicine on CAM and what is known about Americans’ use of it, CAM is being integrated into conventional health care practice in hospitals and physicians’ offices, some health maintenance organizations are covering selected CAM therapies, and insurance coverage for CAM is increasing. The Institute of Medicine recommended that health care should strive to be comprehensive and evidence based, with conventional medical treatments and CAM held to the same standards for demonstrating clinical effectiveness .
Data on the use of complementary and alternative medicine
The most reliable data on the use of CAM by the general public in the United States come from a 2004 report based on the results of the 2002 National Health Interview Survey (NHIS). The NHIS, one of the major data collection systems of the National Center for Health Statistics of the Centers for Disease Control and Prevention, surveys nationally representative samples of civilian households in the United States. The 2002 NHIS included questions on the use of CAM and was administered by in-home, in-person interviews with 31,044 adults aged 18 and over, representing a response rate of 74%. Respondents were asked about their use (ever and during the past 12 months) of 27 different CAM therapies, including 10 provider-based therapies (eg, acupuncture, chiropractic, and massage therapy) and 17 CAM therapies for which a provider is not necessary (eg, natural products, special diets, megavitamin therapy, and prayer for one’s own health). For therapies used during the past 12 months, respondents were queried about the health problem or condition being treated with CAM therapy and the reason or reasons for choosing CAM.
NHIH 2002 results indicated that 36% of United States adults used some form of CAM during the prior 12 months when analyses did not include prayer for health. Musculoskeletal conditions, including back pain or back problems, neck pain or neck problems, and joint pain or stiffness, were the conditions for which CAM was most often used, confirming prior studies finding chronic or recurring musculoskeletal pain linked to CAM use . More than a quarter of those using CAM believed that conventional medicine would not help their health care problem. Consistent with earlier surveys on CAM use , the 2002 NHIS found that most CAM users also see medical doctors for conventional medical care. In addition to pain, predictors of increased CAM use included higher educational attainment, having private health insurance, living in an urban rather than rural area, having been a smoker in the past but not currently, and female gender.
Given these national data on the use of CAM by the Unites States population, it would seem by an extension of logic that there might be relatively high use of CAM by patients who have persistent facial pain because pain and female gender are predictors of CAM use, and women are at higher risk for persistent facial pain. Three published studies provide information on CAM use by clinic samples of patients who have facial pain.
Turp studied prior health care use by 206 consecutive patients referred to a tertiary care facial pain clinic and found that most patients had previously consulted between one and four health care providers. Several patients had seen more than four. Chiropractors had been consulted by nearly 15% of patients, acupuncturists by 4%, and massage therapists by 2%.
Raphael and colleagues indicated 22% of a sample of 63 women meeting Research Diagnostic Criteria for temporomandibular disorder (TMD) but never previously treated with intraoral appliance used one or more CAM therapy for their facial pain. The following treatment modalities were classified by the investigators as CAM: acupuncture, relaxation therapy, stress management, chiropractic, transcutaneous electrical nerve stimulator, and biofeedback. Patients reporting greater interference in social functioning due to pain had used more CAM. Patients for whom an accident was the initiating event for facial pain were seven times more likely to have used CAM. Although the investigators did not raise this possibility, it may be that access to CAM therapies was affected by the onset of facial pain being linked to an accident because CAM therapies are sometimes more readily covered by insurance when provided for injuries sustained in an accident and are otherwise usually paid for out of pocket. Pain severity, pain duration, and mood did not predict CAM use. The investigators noted that the fact that the women in their sample had not previously received an intraoral splint suggested that their sample may have received fewer health care interventions than many facial pain patients seen in tertiary care centers, and therefore estimates of CAM use from this sample might underestimate CAM use by patients who have more extensive treatment histories.
DeBar and colleagues surveyed 192 patients (91% female) with documented TMD meeting Research Diagnostic Criteria about CAM use. Participants had been part of pilot-phase focus groups or baseline assessment for clinical trials on CAM for facial pain. More than one third of the sample (35.9%) had used CAM for TMD, and nearly two thirds of the sample (64.1%) had used CAM for other health conditions, with more than half of these using CAM for another musculoskeletal condition (eg, back, neck, or shoulder problems). Of the 69 participants using CAM specifically for TMD, massage was the most commonly reported CAM therapy (66.7%). Chiropractic care (30.4%), biofeedback or visual imagery (39.1%), and over-the-counter herbal supplements (21.7%) were also used for TMD. Massage was reported as the most satisfactory CAM therapy for TMD, and naturopathic care, massage, and chiropractic care were most often rated very helpful for TMD. Herbal supplements and homeopathic remedies were rated among the least satisfactory and least helpful modalities used to treat TMD.
Among the most frequent reasons for using CAM for TMD in the study by DeBar and colleagues was a perceived failure of conventional treatment to relieve symptoms (44.9%). Participants using CAM for TMD tended to be older, were more likely to have a history of multiple medical problems, and reported more positive psychologic functioning relative to other participants. Noting the relatively high proportion of participants in their study using CAM, the investigators suggested that it might reflect a self-selection bias because all participants were willing to take part in research on CAM. Nonetheless, the investigators noted, their list of CAM therapies was relatively narrow compared with other studies reporting lower prevalence of CAM use with more inclusive definitions of CAM, and they concluded that it is important to include systematic assessment of CAM use when providing allopathic treatment of TMD.
Scientific evaluation of complementary and alternative medicine for persistent facial pain
Published reports
To ascertain the most rigorous evaluation of completed research on CAM therapies for persistent facial pain, published peer-reviewed clinical trials randomizing patients who had facial pain to a CAM intervention or to a control or comparison group and comparing outcome on at least one patient self-report measure of facial pain were sought in the medical literature using the PUBMED and CINAHL electronic databases. The strategy involved pairing the word pain with facial, TMJ, TMD, and temporomandibular and with terms drawn from the literature on CAM therapies used by facial pain patients: complementary, alternative, acupuncture, biofeedback, relaxation, herbal, massage, chiropractic, homeopathic, and naturopathic. Review articles were also sought in the same databases and in the Cochrane Library. Studies were excluded if a CAM modality was administered in combination with one or more other interventions (eg, relaxation training or biofeedback as a component of cognitive behavioral stress management training). Case studies were not sought.
Results
The present search strategy yielded 15 original research reports. Of these 15, eight tested biofeedback, three tested relaxation, and five tested acupuncture. (One tested biofeedback against relaxation.) Therefore, in terms of representation of the NCCAM classifications of CAM, interventions from the mind–body interventions (biofeedback, relaxation) and alternative medical systems (acupuncture) have been studied in controlled research available through the current search strategy. No published results of randomized controlled or comparison clinical trials were located testing the effects of manipulative or body-based therapies such as chiropractic, massage, or osteopathic manipulations, biologically based therapies such as dietary supplements or herbal remedies, or energy therapies.
Biofeedback
In a review of electromyographic (EMG) biofeedback treatment alone or in combination with stress management training for treatment of TMD, Crider and Glaros identified six trials with either a no-treatment or placebo control. Of the six no-treatment or placebo controlled trials, three assessed the effects of EMG biofeedback alone on patient report of pain. Hijzen and colleagues found biofeedback to be associated with significantly greater reduction in myofascial pain dysfunction (MPD) pain relative to intraoral splint or no-treatment control. Dohrmann and Laskin reported reduced pain and reduced masseter EMG levels in MPD patients who were provided instruction in EMG biofeedback (n = 16) as compared with placebo (n = 8). Dalen and colleagues reported significant reduction at follow-up in MPD pain intensity and pain duration after participation in eight biweekly EMG sessions (n = 10) or the control condition (n = 9). Findings from the three placebo or no-treatment control trials therefore indicated that biofeedback training was associated with reduced pain, relative to control.
Five comparative trials were located , three of which were previously summarized in Crider and Glaros . Olson and Malow randomly assigned MPD patients to masseter biofeedback (n = 6), frontalis biofeedback (n = 6), or frontalis biofeedback plus psychotherapy (n = 6). Relative to normative data from their patient population, the investigators reported that the three treatments were associated with reduced pain report and reduced tenderness upon examination. Frontalis biofeedback plus psychotherapy was associated with the greatest reduction in tenderness. In a sample of 30 patients, Dahlstrom and Carlsson found self-report of pain to be significantly reduced at 1 month and 12 months post-treatment with EMG biofeedback training or intraoral splint, with no significant difference between treatments. Mishra and colleagues compared biofeedback training (EMG and thermal), cognitive-behavioral skills training (CBST), combination biofeedback/CBST, and no-treatment control in 94 patients who had TMD who were randomly assigned to treatment. The biofeedback-only group showed the greatest improvement post-treatment, but participants in all three active treatments reported pain reduction relative to pretreatment. Combined biofeedback/CBST treatment was associated with the most improvement at 1-year follow-up. Erlandson and Poppen randomized female MPD patients to three groups: Group 1 received instruction in bilateral masseter EMG biofeedback, Group 2 received bilateral masseter EMG biofeedback plus instructions on placing the jaw in a resting position, and Group 3 received bilateral masseter EMG biofeedback plus intraoral prosthetic guides. Of the patients initially reporting pain, one in four patients in Group 1 reported a decrease in pain, four of five patients in Group 2 reported a decrease in pain, and three of four patients in Group 3 reported reduced pain. Given the study design, it is difficult to make direct comparisons between groups; however, it seems that in this study EMG biofeedback was more effective in combined treatment than as a sole treatment. Funch and Gale reported no between-group difference on outcomes post-treatment in patients who had chronic temporomandibular joint pain randomly assigned to biofeedback (n = 30) or relaxation training (n = 27).
To summarize the evidence from biofeedback studies, biofeedback was consistently superior to placebo or no-treatment control in terms of pain reduction in three trials. Results of comparison of biofeedback to other active treatments yielded mixed results in pain outcomes, with biofeedback alone sometimes superior to the comparison group, sometimes equivalent to comparison, and sometimes less effective than the comparison group. Participant samples were generally small in these biofeedback trials.
Scientific evaluation of complementary and alternative medicine for persistent facial pain
Published reports
To ascertain the most rigorous evaluation of completed research on CAM therapies for persistent facial pain, published peer-reviewed clinical trials randomizing patients who had facial pain to a CAM intervention or to a control or comparison group and comparing outcome on at least one patient self-report measure of facial pain were sought in the medical literature using the PUBMED and CINAHL electronic databases. The strategy involved pairing the word pain with facial, TMJ, TMD, and temporomandibular and with terms drawn from the literature on CAM therapies used by facial pain patients: complementary, alternative, acupuncture, biofeedback, relaxation, herbal, massage, chiropractic, homeopathic, and naturopathic. Review articles were also sought in the same databases and in the Cochrane Library. Studies were excluded if a CAM modality was administered in combination with one or more other interventions (eg, relaxation training or biofeedback as a component of cognitive behavioral stress management training). Case studies were not sought.
Results
The present search strategy yielded 15 original research reports. Of these 15, eight tested biofeedback, three tested relaxation, and five tested acupuncture. (One tested biofeedback against relaxation.) Therefore, in terms of representation of the NCCAM classifications of CAM, interventions from the mind–body interventions (biofeedback, relaxation) and alternative medical systems (acupuncture) have been studied in controlled research available through the current search strategy. No published results of randomized controlled or comparison clinical trials were located testing the effects of manipulative or body-based therapies such as chiropractic, massage, or osteopathic manipulations, biologically based therapies such as dietary supplements or herbal remedies, or energy therapies.
Biofeedback
In a review of electromyographic (EMG) biofeedback treatment alone or in combination with stress management training for treatment of TMD, Crider and Glaros identified six trials with either a no-treatment or placebo control. Of the six no-treatment or placebo controlled trials, three assessed the effects of EMG biofeedback alone on patient report of pain. Hijzen and colleagues found biofeedback to be associated with significantly greater reduction in myofascial pain dysfunction (MPD) pain relative to intraoral splint or no-treatment control. Dohrmann and Laskin reported reduced pain and reduced masseter EMG levels in MPD patients who were provided instruction in EMG biofeedback (n = 16) as compared with placebo (n = 8). Dalen and colleagues reported significant reduction at follow-up in MPD pain intensity and pain duration after participation in eight biweekly EMG sessions (n = 10) or the control condition (n = 9). Findings from the three placebo or no-treatment control trials therefore indicated that biofeedback training was associated with reduced pain, relative to control.
Five comparative trials were located , three of which were previously summarized in Crider and Glaros . Olson and Malow randomly assigned MPD patients to masseter biofeedback (n = 6), frontalis biofeedback (n = 6), or frontalis biofeedback plus psychotherapy (n = 6). Relative to normative data from their patient population, the investigators reported that the three treatments were associated with reduced pain report and reduced tenderness upon examination. Frontalis biofeedback plus psychotherapy was associated with the greatest reduction in tenderness. In a sample of 30 patients, Dahlstrom and Carlsson found self-report of pain to be significantly reduced at 1 month and 12 months post-treatment with EMG biofeedback training or intraoral splint, with no significant difference between treatments. Mishra and colleagues compared biofeedback training (EMG and thermal), cognitive-behavioral skills training (CBST), combination biofeedback/CBST, and no-treatment control in 94 patients who had TMD who were randomly assigned to treatment. The biofeedback-only group showed the greatest improvement post-treatment, but participants in all three active treatments reported pain reduction relative to pretreatment. Combined biofeedback/CBST treatment was associated with the most improvement at 1-year follow-up. Erlandson and Poppen randomized female MPD patients to three groups: Group 1 received instruction in bilateral masseter EMG biofeedback, Group 2 received bilateral masseter EMG biofeedback plus instructions on placing the jaw in a resting position, and Group 3 received bilateral masseter EMG biofeedback plus intraoral prosthetic guides. Of the patients initially reporting pain, one in four patients in Group 1 reported a decrease in pain, four of five patients in Group 2 reported a decrease in pain, and three of four patients in Group 3 reported reduced pain. Given the study design, it is difficult to make direct comparisons between groups; however, it seems that in this study EMG biofeedback was more effective in combined treatment than as a sole treatment. Funch and Gale reported no between-group difference on outcomes post-treatment in patients who had chronic temporomandibular joint pain randomly assigned to biofeedback (n = 30) or relaxation training (n = 27).
To summarize the evidence from biofeedback studies, biofeedback was consistently superior to placebo or no-treatment control in terms of pain reduction in three trials. Results of comparison of biofeedback to other active treatments yielded mixed results in pain outcomes, with biofeedback alone sometimes superior to the comparison group, sometimes equivalent to comparison, and sometimes less effective than the comparison group. Participant samples were generally small in these biofeedback trials.
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