184 Seminars in Oncology Nursing, Vol 21, No 3 (August), 2005: pp 184-189

OBJECTIVES:

To review written resources dis- closing reliable facts and know- ledge in chiropractic services in ALTERNATIVES IN cancer pain management.

DATA SOURCES: CANCER PAIN Conventional and biomedical and complementary and alternative TREATMENT:THE journals, electronic me- dia, full text databases, electronic resources, books in print, and newsletters. APPLICATION OF CONCLUSION: CHIROPRACTIC The judicial use of chiropractic services in cancer patients ap- pears to offer many economical and effective strategies for reduc- CARE ing the pain and suffering of can- cer patients, as well as providing the potential to improve patient health overall. RONALD C. EVANS AND ANTHONY L. ROSNER

IMPLICATIONS FOR NURSING LMOST 1.37 million people (710,000 men, PRACTICE: 662,870 women) will be diagnosed with cancer in Clinicians should assess and sup- 2005.1 In the United States, nearly 46% of men port the use of chiropractic services and 38% of women will be diagnosed with cancer in cancer patients. Chiropractic is in their lifetime, with 80% of all cancers diagnosed one of the leading alternatives to Aat ages 55 and older.1 The direct medical costs of treating cancer standard medical treatment in can- are estimated to be about $60 billion per year. cer pain management. 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 From the Foundation for and Research, Norwalk, IA. sensations) may be the result of cell infiltration or necrosis of tissue Ronald C. Evans, DC, FACO, FICC: near the primary lesion. In terms of medical treatment, there are Trustee, Foundation for Chiropractic Edu- other potential sources of pain such those as shown in Table 1. cation and Research, Norwalk, IA. An- thony L. Rosner, PhD, LLD (Hon): Director Partly because of the prospect of side effects and additional pain of Research and Education, Foundation encountered during , cancer pain is often undertreated. for Chiropractic Education and Research, Interrelating factors that might contribute to the undertreatment Norwalk, IA. Address correspondence to Ronald C. of pain include: (1) knowledge, (2) patient reluctance, Evans, DC, FACO, FICC, 1441 29th St, (3) fear of addiction, and (4) fear of side effects. Suite 100, West Des Moines, IA 50266; e-mail: [email protected] CANCER SURVIVORS

© 2005 Elsevier Inc. All rights reserved. espite the aforementioned widespread prevalence of cancer in 0749-2081/05/2103-$30.00/0 Dthe United States, the number of cancer survivors is actually doi:10.1016/j.soncn.2005.04.007 growing such that there are currently 8.9 million individuals in the ALTERNATIVES IN CANCER PAIN TREATMENT 185

the first choice for patients and may also be best TABLE 1. Common Groups of Oncologic suited for those patients who: (1) have poor re- and Pain Expressions sponses to medical treatment or medical contra- indications for further pharmacologic treatment; Medical Treatment Pain Expression (2) wish to become pregnant or are nursing; (3) have a history of long-term, frequent, or excessive Surgery Often painful, recoveries use of analgesic or pain-abortive medications that protracted in compromised patients. can aggravate other problems; or (4) simply prefer Radiation therapy Associated with post-treatment to avoid the use of medications.7 regional pain sensations of Based on the strength of research findings, its burning. Scars are often accreditation, its safety, and its widespread recog- painful. nition, chiropractic management of pain such as Chemotherapy Associated with potentially painful side effects, including that experienced in cancer patients would appear nerve damage. to be one of the leading alternatives to standard medical treatment for one to consider seriously. For reasons that will become apparent, the re- mainder of this article will address this very issue. United States living with cancer. Mortality rates for most major cancers are declining such that DEFINITIONS AND THEORETICAL BASIS today more people survive cancer than ever be- fore. Among the growing ranks of cancer survivors OF CHIROPRACTIC are the following groups1,3,4: (1) 2 million women are breast cancer survivors; (2) 1 million men are n its 109-year history, chiropractic has prostate cancer survivors; (3) 5-year survival rates Iachieved distinction in addressing disorders of of children with cancer increased from 56% in the the musculoskeletal system and how these aber- early 1970s to 79% for those diagnosed in 1995- rations may impinge upon the , 2003; and (4) the 5-year survival rate for all can- subsequently affecting our general health. This cers increased from 51% in the early 1970s to branch of is concerned with the diag- nearly 66% from 1995-2000. nosis, treatment, and prevention of these disor- As a result of this increased survival in cancer, ders primarily (but not exclusively) through the the focus of treatment has now been able to shift application of manual treatments, which include toward the management of pain issues, acute and .8 chronic, both during and after medical therapies. The cardinal clinical feature of musculoskeletal Given the prospect of pain accompanying stan- disorders is pain. To no great surprise, both the dard treatment options alluded to above and given rationale and outcomes of chiropractic manage- the multifactoral nature of pain,5 the patient may ment have always revolved around the relief of harbor attitudinal barriers to effective pain man- pain. Indeed, this conjecture is supported in both agement that could be overcome with novel inter- theory and fact. If such documentation can be ventions. found to be convincing, and if the risks of chiro- Nearly all patients with cancer-related pain ex- practic interventions are found to be minimal perience have used medications at one time or compared with its benefits, a strong case can be another to treat their pain, but pharmacologic made for considering chiropractic as a treatment treatments are neither suitable for all patients nor option for controlling pain associated with cancer. universally effective. Drug treatments may also The theoretical basis of chiropractic in alleviat- produce undesired side effects. Largely for these ing pain can best be demonstrated by a variety of reasons, significant interest has developed among mechanisms that have been buttressed with evi- both patients and health care providers in alter- dence in the literature (Table 2). It can be seen native treatments for cancer pain. that the effects of spinal manipulation have been Physical treatments for pain most frequently proposed to be multifaceted, ranging from the studied are chiropractic, (largely but not exclu- reduction of nerve root encroachments to the sively dominated by spinal manipulation), physio- release of trapped meniscoid fluids to the suppres- therapy, and .6 If effective and avail- sion of inflammatory mediators to possibly the able, these nonpharmacologic treatments may be release of analgesic opioids. The net effect of all of 186 EVANS AND ROSNER

trials have shown positive outcomes with the re- TABLE 2. Proposed Mechanisms of Spinal Manipulation mainder yielding equivocal results. There are 43 trials addressing acute, subacute, and chronic low Action Mechanism pain, with 30 trials showing that manipula- tion is more effective than control or comparison Mechanical/anatomic Alleviation of entrapped facet treatments and the remaining 13 reporting no joint inclusion of meniscoid that has been shown to be significant differences between treatment groups. heavily innervated.9,10 None of these studies appears to have produced a Mechanical/anatomic Repositioning of a fragment negative outcome and none indicate that manip- of posterior annular ulation is any less effective than any comparison material from the intervention.25,26 innervated disc.10,11 Mechanical/anatomic Alleviation of stiffness induced by fibrotic tissue SAFETY from previous injury or degenerative changes that may include adaptive s with any therapeutic intervention, contra- shortening of fascial indications exist for chiropractic, however 12,13 A tissue. Neurologic/mechanical Inhibition of excessive reflex rare. The two primary complications that have activity in the intrinsic been reported are (1) cauda equina syndrome spinal musculature or following manipulation in patients with lumbar limbs and/or facilitation of disc herniation, consisting of neurogenic bowel inhibited muscle activity.14-17 and bladder disturbances, saddle anesthesia, bilat- Neurologic/mechanical Reduction of compressive or irritative insults to neural eral leg weakness, and sensory changes; and (2) tissues.18 cerebrovascular accidents as a result of cervical Biochemical Release of endogenous manipulations. opioids.19,20 The symptoms of cauda equina syndrome have Biochemical Suppression of aldosterone, been extensively described27,28; a review of the which promotes inflammation.21,22 world’s medical literature indicates that 16 of the

Biochemical Suppression of PGE2a, 26 reported cases occurred with the far more believed to cause uterine vigorous manipulation applied under anesthesia. cramping.23 Of the remaining 10 cases, only four have been Psychoneurochemical Reduction of anxiety (which reported in North America.29 Estimates of the aggravates pain sensation).24 frequency of cauda equina syndrome range from 2 per million30 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 re- these is to reduce pain generation,9-13,18,19-23 its garded to be as low as one case per million treat- 14-18 sensation, or its aggravation caused by anxi- ments,31 ranging upwards to 2 to 4 per million.32,33 ety.24 The more recent data from the RAND Corporation suggests the rate of vertebrobasilar accident or EMPIRICAL BASIS FOR CHIROPRACTIC other complications (cord compression, fracture, or hematoma) to be 1.46 per million manipula- n just the past 20 years, at least 73 randomized tions, with the rates of serious complications and Iclinical trials involving spinal manipulation from cervical spine manipulation estimated have made their appearance in the English litera- to be 0.64 and 0.27 per million manipulations, ture. Even more remarkable is the fact that the respectively.34 The most recent and definitive cal- majority of these have been published in general culation of the likelihood of a treating chiroprac- medical and orthopedic journals. These trials ad- tor being made aware of an arterial dissection dress not only , but also headache and following a cervical manipulation is 1 per 5.85 , the extremities, and a surprising vari- million (0.17 per million) cervical manipula- ety of nonmusculoskeletal conditions. When spi- tions.35 These rates are 400 times less than the nal manipulation is used, the majority of these death rates observed from gastrointestinal bleed- ALTERNATIVES IN CANCER PAIN TREATMENT 187

ing caused by the use of nonsteroidal anti-inflam- have vaulted from last place to first as a treatment matory drugs36 and 700 times lower than the option. overall mortality rate for spinal surgery.37 Other recent major accomplishments relating to the chiropractic profession within the United States have included: RECOGNITION OF THE CHIROPRACTIC 1. The appearance of a variety of favorable sys- PROFESSION tematic literature reviews7,46,47; 2. The establishment of the first federally funded early 110 years in existence, chiropractic has chiropractic Center for Excellence at Palmer N become the third largest profession of health University by the National Institute of Health’s care delivery in the world. It is recognized and National Center for Complementary and Alter- licensed in every state and province in North native Medicine in 1997; America, as well as in , New Zealand, and 3. The publication of the Headache Report by many jurisdictions in Europe, Africa, and the Mid- Duke University in 20017; dle East. Interest is increasing in other parts of the 4. The securing of over $20 million in federal world where access to expensive medical and sur- grants within the past decade, when in 1991 gical modalities is limited. this accomplishment was considered unlikely48; The increasing acceptance of chiropractic as a 5. The establishment of chiropractic services legitimate health care profession has occurred in within the military; and part through the increasing emphasis on research 6. The historic signing of Public Law 107-135 on by professional organizations and colleges with January 23, 2003, mandating the establish- funding by outside agencies. It also stems from the ment of a permanent chiropractic health ben- accrediting and review of educational curricula at efit within the Department of Veterans Affairs chiropractic colleges around the world, 16 of health care system. which are accredited by the Council for Chiro- practic Education. The Council for Chiropractic CHIROPRACTIC TREATMENT STRATEGIES Education has accrediting agency status with the US Department of Education (since 1974) and the lthough a great multiplicity of chiropractic Council on Postsecondary Accreditation (since A techniques have been described,49 over half 1976). of practicing chiropractors have reported using With over 55,000 licensed practitioners in the just a half-dozen different adjusting methods.50 United States, chiropractic has taken its place as When combined with soft tissue techniques such the foremost profession through which spinal ma- as in the successful management of fibromyalgia51 nipulations have been administered—primarily in or with exercise in the treatment of low back52 or the treatment of back pain. Despite the fact that neck pain,53 spinal manipulation has been found chiropractic has existed as a formal profession to be particularly effective in reducing pain and worldwide for over a century, most of what we increasing functionality. It may very well be that consider to be rigorous, systematic research in the potentially beneficial effects of spinal manip- support of this form of health care has emerged in ulation in managing cancer pain would be en- just the past two and a half decades. In 1975, hanced by being combined with adjuvant thera- Murray Goldstein of the National Institute of Neu- pies used in acupuncture or physiotherapy. rological Diseases and concluded that there was insufficient research to either support CONCLUSION or refute chiropractic intervention for back pain and other musculoskeletal disorders.38 Nearly 30 he increased survivorship seen in cancer pa- years later, back pain management has been as- Ttients in the United States in recent years sessed by government agencies in the United indicates that more and more individuals are ex- States,39 Canada,40 Great Britain,41 Sweden,42 periencing pain, to which cancer treatments are Denmark,43 Australia,44 and New Zealand.45 All of becoming increasingly devoted. Given the preva- these reports are highly positive with respect to lence, research documentation, relative safety, spinal manipulation. It would seem that spinal uniform licensure and accreditation, cost-effec- manipulation, at least for back pain, appears to tiveness, and high patient satisfaction observed in 188 EVANS AND ROSNER

the chiropractic management of musculoskeletal to offer many economical possibilities for reduc- pain, the choice of chiropractic care as an alter- ing the pain and suffering of cancer patients as native in the treatment of cancer pain becomes a well as providing the potential to improve patient highly attractive one. Its judicial use would seem health overall.18,24

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