Journal of Gerontological Nursing

Feature Article 

Complementary and Integrative Therapies for Persistent Pain Management in Older Adults: A Review

Patricia Bruckenthal, PhD, APRN-BC, ANP, FAAN; Marie Ann Marino, EdD, RN; Lisa Snelling, BSN, RN

Abstract

Management of persistent pain in older adults is challenging given the prevalence of multiple comorbid painful conditions, polypharmacy, age-related changes restricting pharmacological options, and socioeconomic factors. The influences of these factors along with current concern for the use of opioid analgesics highlight the importance of incorporating complementary and integrative medicine approaches. Evidence suggests efficacy and satisfaction with integrating complementary pain management strategies for older adults, especially yoga, massage, and natural products. Nurses and other providers, given their emphasis on holistic care, are in a unique position to lead the transformation of pain management to a patient-centered, self-management style that integrates complementary therapies. [Journal of Gerontological Nursing, 42(12), 40–48.]

Abstract

Management of persistent pain in older adults is challenging given the prevalence of multiple comorbid painful conditions, polypharmacy, age-related changes restricting pharmacological options, and socioeconomic factors. The influences of these factors along with current concern for the use of opioid analgesics highlight the importance of incorporating complementary and integrative medicine approaches. Evidence suggests efficacy and satisfaction with integrating complementary pain management strategies for older adults, especially yoga, massage, and natural products. Nurses and other providers, given their emphasis on holistic care, are in a unique position to lead the transformation of pain management to a patient-centered, self-management style that integrates complementary therapies. [Journal of Gerontological Nursing, 42(12), 40–48.]

Effective management of pain is challenging in any age group, but may be even more so in older adults due to the prevalence of multiple comorbid painful conditions, polypharmacy, age-related changes, and socioeconomic factors restricting pharmacological options. The influence of these factors highlights the importance of incorporating complementary and integrative medicine (CIM) approaches, either alone or with conventional treatment options, to effectively manage persistent pain in this population. CIM approaches have the potential to minimize the associated risks of pharmacological interventions, while providing effective treatments to older adults with persistent pain. In addition, strategies that encourage self-management optimize patient engagement.

Definitions of complementary and integrative health have been evolving over the past several years. The National Center for Complementary and Integrative Health (NCCIH) differentiates these terms. Complementary health approaches refer to practices and products of non-mainstream origin. Conversely, integrative health refers to the incorporation of complementary approaches into mainstream health care (NCCIH, 2008). Most approaches fall into either the natural product (e.g., herbs, vitamins, minerals, probiotics) or mind and body practice (e.g., yoga, meditation, acupuncture, relaxation techniques, exercise) subgroups. Other alternative approaches including Ayurvedic medicine, traditional Chinese medicine, homeopathy, and naturopathy are beyond the scope of the current article.

To optimize therapeutic outcomes, adherence to recommended CIM is essential. This adherence frequently requires lifestyle and behavioral modifications. Strategies to improve CIM engagement that involve education and persuasion alone do not take into account characteristics unique to an older adult population such as social, economic, cognitive, and psychological factors. Strategies that promote self-efficacy can be enhanced through patient empowerment and improve engagement in CIM. In addition, providers need to take into account physical and cognitive impairments when suggesting CIM strategies for older adults with painful conditions. Despite these challenges, strategies such as message, tai chi, music therapy, and cryo/thermotherapy are potential options when modifications are considered to account for these deficits.

Prevalence and Preference of Complementary and Integrative Medicine for Older Adults

Trends in the use of complementary and integrative therapies reported in the 2012 National Health Interview Survey (NHIS) indicate a fairly stable use of complementary health approaches for adults. Overall use in 2002 was 32.3%, and 33.2% in 2012 (Clarke, Black, Stussman, Barnes, & Nahin, 2015) (Figure 1). Specifically, 31% of middle-aged and older adults reported using complementary health approaches, and adults ages 65 to 70 (43%) reported the most use in individuals older than 50. The most common approaches in middle-aged to older adults were herbs and dietary supplements (19% to 37%), chiropractic and massage (7% to 22%), and yoga and other mind–body approaches (6% to 9%) (AARP, 2011; Johnson, Jou, Rhee, Rockwood, & Upchurch, 2016) (Figure 2). These trends suggest an interest and ability to engage in self-management of health and wellness in a large proportion of the older population.


Use of yoga among adults in the past 12 months, by age groups: United States, 2002, 2007, 2012.
Reprinted from Clarke, T., Black, L.I., Stussman, B.J., Barnes, P.M., & Nahin, R.L. (2015). Trends in the use of complementary health approaches among adults: United States, 2002–2012. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf

Figure 1.

Use of yoga among adults in the past 12 months, by age groups: United States, 2002, 2007, 2012.

Reprinted from Clarke, T., Black, L.I., Stussman, B.J., Barnes, P.M., & Nahin, R.L. (2015). Trends in the use of complementary health approaches among adults: United States, 2002–2012. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf


Percentage of adults 50 and older reporting use of complementary health approaches, 2012.
Reprinted from Peregoy, J.A., Clarke, T.C., Jones, L.I., Stussman, B.J., & Nahin, R.L. (2014). Regional variation in use of complementary health approaches by U.S. adults (NCHS data brief, no. 146). Hyattsville, MD: National Center for Health Statistics.

Figure 2.

Percentage of adults 50 and older reporting use of complementary health approaches, 2012.

Reprinted from Peregoy, J.A., Clarke, T.C., Jones, L.I., Stussman, B.J., & Nahin, R.L. (2014). Regional variation in use of complementary health approaches by U.S. adults (NCHS data brief, no. 146). Hyattsville, MD: National Center for Health Statistics.

Specific use of CIM for pain relief in older adults is prevalent. Of individuals older than 50, 73% used CIM to help reduce pain or treat a painful condition (AARP, 2011). Musculoskeletal conditions, such as arthritis and low back pain, are common conditions among older adults. Mind–body therapies including yoga, massage, thermotherapy, and activity pacing were used most often in these conditions (Gong, Li, Li, & Mao, 2013).

Several factors contribute to the likelihood that individuals will engage in CIM, including higher education, higher socioeconomic status, younger age, White race, better physical health, and being married (Blanch, Rudd, Wright, Gall, & Katz, 2008; Bruce, Lorig, & Laurent, 2007). Interestingly, in a study that compared generational differences in CIM use, Baby Boomers (1946–1964) were more likely than the silent generation (1925–1945) to use CIM for painful conditions (Ho, Rowland-Seymour, Frankel, Li, & Mao, 2014). This finding suggests an opportunity for CIM engagement among older adults.

The purpose of the current article is to review the existing trends and issues associated with use of CIM for pain management and highlight potential areas of opportunity for providers to advance the management of persistent pain in older adults. A thorough literature search was conducted using key words specific to self-management (for background data and recommendations) and the CIM modalities specific to older adults. PubMed and CINAHL were searched using terms “CAM or CIM” and “older adults or elderly” and “pain,” and limited to the past 5 years, randomized controlled trials (RCTs), and English only. The same strategy was applied for each CIM identified as preferential for older adults. For example, “yoga” and “older adults or elderly” and “pain,” “massage” and “older adults or elderly” and “pain” were systematically searched in both databases. The most recent, high-quality (i.e., RCTs) evidence specific to older adults engaged in CIM strategies alone was considered to highlight CIM interventions when available. No comparative effectiveness trials with drugs were identified.

The following sections describe evidence for each of the two subgroups for CIM strategies—mind–body practices and natural products. A brief description of each strategy is followed by the results of featured studies. Suggestions for clinical application are included.

Mind-Body Practices

Guided Imagery

Guided imagery is a form of focused relaxation used to enhance an individual's coping resources through visualization and direct suggestion. Pleasant imagery is a form of guided imagery where all senses are engaged by having participants imagine themselves in a pleasant scene while voice cues, offered by a coach, focus attention on visual, auditory, and tactile images. Although only one recent study specific to older adults was found, reduction in pain and pain medication was demonstrated. Patients who listened to a 12-minute guided imagery audiotape, twice daily for 4 months, had significant reductions in pain scores and medication use (0.65 doses per day) from baseline to Month 4 (Baird, Murawski, & Wu, 2010). Although occasionally individuals report negative experiences, such as anxiety or fear of losing control, pleasant imagery is usually considered safe. Providers remind participants that they are in control throughout the experience to manage this possibility. It should be noted that the ability to follow facilitated directions to engage and guide the participant is needed; hence, cognitive ability is a factor in use of this intervention. Individuals with mild cognitive impairment may benefit from the distraction and calming voice tones that induce the relaxation response.

Massage

Massage therapy involves manual manipulation of muscle, connective tissue, tendons, and ligaments with the aim of improving an individual's health and well-being. Relaxation massage, also known as Swedish massage, is often practiced in wellness and spa-like settings. Rehabilitative massage, also known as deep tissue, clinical, or therapeutic massage, is practiced in clinical settings.

Swedish massage with aromatic ginger oil was compared with traditional Thai massage in older adults with chronic low back pain and disability in a RCT. Both massage types produced significant improvements in pain intensity and disability in short-term (6 weeks) and long-term (15 weeks) assessments. Swedish massage with aromatic ginger oil was more effective in reducing pain and improving disability at both short- and long-term assessment periods (Sritoomma, Moyle, Cooke, & O'Dwyer, 2014). Hand massage with and without aromatherapy produced decreased persistent pain intensity in patients living in long-term care facilities (Cino, 2014).

Message therapy has few risks when performed by a licensed trained therapist. Deep tissue massage should be avoided in individuals with bleeding disorders, oversensitive skin, or over a tumor mass. Hand massage can be used by caregivers who are taught this intervention to improve pain management at home.

Acupuncture

Acupuncture is a technique for balancing the flow of energy (i.e., chi) along meridians within the body. Acupuncture involves penetrating the skin with needles to stimulate nerves, muscles, and connective tissue along these meridians. Whether acupuncture balances the flow of energy (i.e., chi) or stimulates the flow of blood and endorphins is unclear, but multiple studies on adults show evidence of efficacy for different types of pain. Physiological changes in older adults, such as decreasing neurochemicals and opioid receptors, as well as neuroprocessing changes, may account for the paucity of studies specific to older adults (Cole, Farrell, Gibson, & Egan, 2010). Few studies have been conducted specific to older adults with pain. A pilot study examined the effects of acupuncture on musculoskeletal pain of 3 or more months' duration in hospitalized older adults (Couilliot et al., 2013). Participants (N = 60; mean age = 83 years; 55% with dementia diagnosis) received eight acupuncture sessions and were assessed for pain (verbal and behavioral) and pain-related symptoms (i.e., sleep disorders, tiredness, and anxiety). After eight sessions, behavioral and verbal pain scores decreased significantly.

Although the mechanism of action for acupuncture is not totally understood, it is a reasonable option for consideration of pain relief, especially osteoarthritis, in older adults. Complications such as infection or damaged organs can result from use of non-sterile needles and improper technique (Wu et al., 2015).

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) for pain management is focused on exploring relationships between an individual's thoughts, feelings, and behaviors to gain insight on how these patterns may influence pain and stress. Participants treated with CBT engage in sessions with a CBT practitioner who works with them to teach skills in self-exploration, including relaxation, activity pacing, problem solving, distraction, changing negative thought patterns, and goal setting.

In one study, nurse practitioners used a pain coping skills training (PCST) intervention, a form of CBT, which consisted of 10 weekly sessions in community-dwelling older adults with osteoarthritis persistent hip or knee pain (Broderick et al., 2014). Patients were taught and practiced a new pain coping skill each week. PCST participants showed significant improvement in pain intensity, physical functioning, psychological distress, use of pain coping strategies, self-efficacy, and reduced use of pain medication (Broderick et al., 2014). Similarly, Nicholas et al. (2013) found that outpatients with persistent pain who participated in a pain self-management program reported less pain distress, disability, and unhelpful pain beliefs than older adults who did not participate in a program.

Group CBT for low-back pain was evaluated for effectiveness in decreasing back pain disability in adults with troublesome subacute or persistent low-back pain (Lamb et al., 2010). Although this study was not specific to older adults, mean age of participants (N = 701) was 54 years (age range = 18 to 85 years). Compared to advice alone, CBT plus advice was associated with improvements in all outcome measures with effects present at 12 months. Important directions for further research are investigations that evaluate feasibility and implementation of CBT for older adults using technologically delivered sessions and the optimal dose of CBT needed to achieve treatment effects.

Yoga

Yoga involves suppressing all activities of the body and mind to harmonize the mind, body, and spirit. This harmony is accomplished through prescribed body poses, breathing, and meditation techniques that provide the participant with physical and mental benefits. The use of yoga to intervene with musculoskeletal conditions or persistent pain typically involves activities that align posture, enhance strength, and increase flexibility; and achievement of a meditative state.

There is limited evidence examining the efficacy of yoga as a targeted intervention to reduce persistent pain in older adults. Interestingly, however, there is a growing base of evidence that yoga increases gray matter mass in the brain that improves memory and cognitive functioning and reverses some of the atrophic changes in the brain brought on by chronic pain (Hariprasad et al., 2013; Villemure, Ceko, Cotton, & Bushnell, 2015). Schmid, Miller, Van Puymbroeck, and DeBaun-Sprague (2014) enrolled 47 individuals with chronic stroke (>6 months) to therapeutic yoga (n = 37) or wait-list control (n = 10). The yoga program consisted of 1-hour therapeutic yoga sessions, twice weekly, for 8 weeks. Individuals randomized to the yoga intervention demonstrated statistically significant reductions in pain scores after 8 weeks of yoga when compared with controls. A pilot study (Ferrari, Thuraisingam, von Kanel, & Egloff, 2015) assessed whether group yoga classes (once weekly for 6 weeks) could reduce pain levels in a group of older adults (N = 23). Participants were predominantly minority (87%) and low income (100%) individuals with joint pain and/or stiffness secondary to osteoarthritis (n = 19) or lower back pain as a result of caregiver duties for bedridden spouses (n = 4). Of participants diagnosed with osteoarthritis, decreased pain levels and improvements in stiffness were reported. Participants were highly satisfied with the intervention; many participants asked that the classes continue.

It should be noted that there may be an influence of nonspecific effects of yoga practice, namely socialization benefits from group yoga classes and increased attention from class facilitators on pain levels. Providers should consider these potential benefits when suggesting this intervention.

Mindfulness Meditation

Mindfulness is defined as an intentional awareness that results from paying purposeful attention in the present moment and nonjudgmentally to the unfolding of moment-by-moment experience (Gotnick, Meijboom, Vernooij, Smits, & Hunink, 2016). Brain imaging studies of practitioners of mindfulness meditation, and who have experienced reductions in pain levels, have shown brain-related changes in regions associated with pain modulation (Gotnick et al., 2016; Singleton et al., 2014).

Recent evidence from well-designed studies on the effect of mindfulness-based meditation on pain in young, middle-aged, and older adults has demonstrated efficacy of mindfulness meditation as a strategy to reduce pain. The effectiveness of a mindfulness-based stress reduction (MBSR) program on physical function and pain was evaluated in a sample of community-dwelling older adults, where participants were randomized to an 8-week MBSR intervention or an 8-week health education program. A greater proportion of participants in the intervention group had a clinically meaningful 30% improvement on measures of current pain intensity when compared with the control group both immediately and 6 months following program completion. The MBSR group had similar significant results for most severe (in the past week) pain intensity when compared to controls both immediately and at 6 months (Morone et al., 2016).

Tai Chi

Tai chi is an Ancient Chinese practice that promotes mind–body relaxation and balance through movement, meditation, and deep breathing. Tai chi has long been used in Chinese culture and has become increasingly popular as an adjunct to Western medicine, including the management of persistent pain (Chen, Hunt, Campbell, Peill, & Reid, 2016). It is a low impact form of mild to moderate intensity aerobic exercise, which makes it especially valuable to older adults with persistent pain conditions. Tai chi is inexpensive, requires no special equipment, can be performed in almost any setting, and can be done alone or as part of a group. Classes are available in many communities, and are typically facilitated by an instructor and offered in fitness centers and senior centers.

Several well-designed studies have shown tai chi to be effective at reducing pain and improving physical functioning in patients with persistent pain. A recent study showed that 12 weeks of performing tai chi was comparable to engaging in 6 weeks of physical therapy followed by 6 weeks of monitored home exercises at reducing pain and stiffness, improving quality of life, and reducing depression in patients with knee osteoarthritis. The benefits were maintained at 52-week follow up (Wang et al., 2016). Older adults with osteoarthritis and cognitive impairment showed reductions in pain and stiffness after engaging in tai chi classes three times per week for 20 weeks, and cognitive ability was not associated with the positive effects of tai chi (Tsai, Chang, Beck, Kuo, & Keefe, 2013). Finally, Tsai et al. (2013) recruited community-dwelling older adults with osteoarthritis and cognitive impairment (N = 55; mean age = 78.91 years) and randomly assigned them to either tai chi classes (n = 28) or a control group (n = 27). There was a significant difference between pain and stiffness scores between groups. Scores from the tai chi group for pain and stiffness improved significantly more over time compared to controls. Cognitive ability was not associated with the favorable effects of tai chi.

Cryotherapy and Thermotherapy

Cryotherapy and thermotherapy are frequently used in the management of persistent pain conditions. The therapeutic benefits of cryotherapy include decreased inflammation and edema, reduction of pain, and relief of muscle spasms. Similarly, the therapeutic effects of heat include reduction of pain and relief of muscle spasms, in addition to decreasing joint stiffness and potentiating the extensibility of collagen tissue (Nadler, Weingand, & Kruse, 2004). These treatments are inexpensive, widely available, and many can be easily applied by an individual at home (Garra et al., 2010), but caution must be exercised to prevent thermal injury due to age-related skin changes, such as thinning of epidermal layers and loss of sensitivity.

The evidence is inconsistent regarding the benefits of cryotherapy and thermotherapy in the treatment of persistent pain conditions; however, both modalities have been used to successfully reduce pain. One type of thermotherapy, deep heat therapy (DHT) using microwave diathermy, applies electromagnetic radiation to tissues and is administered by a practitioner. Andrade Ortega, Cerón Fernández, García Llorent, Ribeiro González, and Delgado Martínez (2014) demonstrated how DHT was efficacious in reducing pain and disability and improving quality of life in patients (N = 149) with persistent nonspecific neck pain. DHT has also been used to successfully decrease pain, increase muscle strength, and improve functional ability in individuals with knee osteoarthritis, and the benefits of therapy have been shown to persist beyond the course of treatment (Rabini et al., 2012).

Evidence supporting use of superficial thermotherapy for treatment of persistent pain is limited. The use of this type of heat therapy as an adjuvant to standard treatment in patients with knee osteoarthritis can help alleviate pain (Yildirim, Filiz Ulusoy, & Bodur, 2010).

Superficial cryotherapy has been shown to relieve joint and muscle pain and decrease inflammation and increase pain tolerance (Fouladbakhsh, Szczesny, Jenuwine, & Vallerand, 2011). Patient education and provision of individualized instructions are essential when recommending cryotherapy and thermotherapy to eliminate potential injury.

Music Therapy

Music is noninvasive, inexpensive, and easily accessible, which has facilitated its use in the treatment of persistent pain conditions. Music has been used successfully in many settings to promote relaxation of muscles, decrease apprehension, encourage movement in physical rehabilitation, and encourage positive mood. The effect of listening to music compared to environmental sounds was investigated in patients with fibromyalgia while at rest and during physical activity (Mercadíe, Mick, Guétin, & Bigand, 2015). Although not specific to older adults, the mean age of the sample was 51.4 years (SD = 10.4 years) (N = 22, 100% female). Participants recorded their pain using a visual analog scale before, after, and 10 minutes post-intervention. Individuals who listened to music or environmental sounds for 20 minutes while at rest experienced a reduction in pain lasting up to 10 minutes post-intervention. Participants who used the same intervention while engaged in physical activity did not show a significant reduction in pain severity. Of note, pain intensity did not increase among those engaged in physical activity from the level reported prior to the intervention. In addition, participants who engaged in physical activity reported less fatigue despite having been active (Mercadie et al., 2015). Listening to pleasant music and environmental sounds had a similar effect on pain and fatigue. Whether the effect of listening to music on pain reduction is related to distraction from pain or some other mechanism is not known.

Music therapy combined with a music therapist–led autogenic relaxation intervention demonstrated pain reduction in middle-aged and older adults in an inpatient palliative care setting (Gutgsell et al., 2013). The same soothing harp pieces chosen by the music therapist were played for all patients in the intervention group. Adjusting the lights, providing a warm blanket, and turning off telephones were implemented in both groups. Although both the intervention and control groups reported significant decrease in pain intensity scores, the percent change was greater for the music therapy group. Functional pain score ratings were significantly different for the music intervention group compared to controls. This study is unique in that most music therapy studies provide patient-preferred music selections, whereas all patients in this study received the same music selection (Gutgsell et al., 2013). The benefit of music as a therapeutic treatment appears to be short lived, with the most benefit seen while listening to music and in the period of time immediately after the intervention. Limited information exists regarding the sustainability of the effects of treatment. Moreover, the literature on music therapy as a method for pain control in older adults is scarce.

Spirituality

Spirituality is a sense of belonging to something bigger than oneself and a quest to find meaning and purpose in one's life. It is a deeply personal experience that provides the basis for how individuals view the world and how they experience, interpret, and cope with the things that are happening in their lives (Astrow, Puchalski, & Sulmasy, 2001). Spirituality can be expressed through religious practice or a set of philosophical principles; one's relationship to nature, music, and the arts; or personal relationships (Wachholtz & Pearce, 2009). Spirituality and/or religiosity may be an influencing factor in the lives of patients with persistent pain.

Spiritual distress can impact how individuals experience and respond to pain (Dedeli & Kaptan, 2013). Studies have shown that many patients (94%) would like their provider to address issues related to spirituality and place importance on having a clinician who is able to relate to them in this area (Puchalski, 2001). Some providers shy away from addressing issues regarding spirituality because of their lack of comfort and knowledge in handling these issues. In addition, the current health care climate poses a challenge to incorporating spiritual issues into an overall plan of care as appointment times are short, leaving little to no time to address these issues. Providers can address spirituality by asking patients about the importance of religiousness, spiritual coping, and spiritual distress and connect patients with resources within the community to further guide and assist them with these issues (Wachholtz & Pearce, 2009). Spirituality and prayer have been shown to provide positive health benefits to patients with persistent pain conditions (Wachholtz & Pearce, 2009). Because faith plays an important role in coping with adversity, including pain, in the lives of older African Americans, the use of culturally sensitive spiritual music and participation in prayer services may help these older adults cope with pain (Booker, 2015).

Natural Products and Supplements

There are a variety of herbal products and supplements available. Some of those used for painful conditions include chondroitin, glucosamine, methylsulfonylmethane, S-adenosyl-L-methionine, and omega-3 fatty acids (Nahin, Boineau, Khalsa, Stussman, & Weber, 2016). Given the limited evidence for use in older adults, only glucosamine and chondroitin are addressed. Yet, many older adults report use of others, highlighting the need for more research in this area. Providers can access additional information on the use of herbal and supplement products by accessing websites (e.g., http://www.arthritis.org/living-with-arthritis/treatments/natural; https://medlineplus.gov/druginformation.html; https://nccih.nih.gov/health/pain/ebook) or smartphone applications (apps) that address adverse interactions with pharmacological therapies.

Glucosamine and chondroitin are supplements that are most commonly used in combination to treat osteoarthritis symptoms. There has been considerable research conducted to determine the effectiveness of glucosamine for use in persistent pain conditions. Evidence for glucosamine producing a pain-reducing effect in patients with osteoarthritis is inconsistent; variations in formulations used or industry bias are contributing factors. Studies using formulations of glucosamine sulfate have seen more success than those using glucosamine hydrochloride; however, pain reducing benefits are still unclear (Kwoh et al., 2014; Stuber, Sajko, & Kristmanson, 2011; Wilkens, Scheel, Grundnes, Hellum, & Storheim, 2010). Further research is needed to demonstrate consistent evidence of the benefits of glucosamine in this population. No recent studies specific to older adults and use of natural products were identified.

General Limitations and Gaps in the Literature

There are some general limitations among the examples noted in many of the studies in the current review. These limitations include limited sample size, lack of long-term follow up to determine sustainability of positive outcomes, control of use of pharmacological pain relief agents across samples, attrition rate among participants, adherence to treatment, and lack of description to insure fidelity to interventions. These factors reduce the generalizability of evidence. Studies on application and use of CIM that specifically target older adults or include older adults as a sub-sample are notably lacking in the literature, even though they are high users of these approaches.

Recommendations for Positioning CIM in the Pain Management Plan

Given the limitations of pharmacological therapy alone in many older adults, providers are encouraged to shift the emphasis on this sole approach to those combined with mind, body, and spiritual elements as well as those that encourage social interaction (Arnstein & Herr, 2015). Because CIM was discussed in provider–patient encounters only 33% of the time, and in those encounters the discussion was initiated by the provider only 25% of the time (AARP, 2011), emphasis on using CIM approaches for self-management of persistent pain should be a focus during these interactions. Often adopting a new treatment approach for a chronic condition, such as pain, requires individuals to make long-term behavioral changes to engage in self-management CIM strategies. Approaches that promote self-efficacy and those that include social support have the potential to improve engagement in self-management activities directed at pain management in older adults. Foundational work on self-management for older adults (and others) can be attributed to work by Lorig and Holman (2003). Numerous studies highlight the benefits achieved in pain management and other quality of life outcomes from participation in Lorig's Arthritis Chronic Disease Self-Management Program (Nunez, Keller, & Ananian, 2009; Nolte & Osborne, 2013). Peer-to-peer mentoring provides emotional support, appraisal, and information for community-dwelling older adults and those who reside in long-term care facilities with persistent pain (Cooper, Schofield, Klein, Smith, & Jehu, 2016; Tse, Lee, Ng, Tsien-Wong, & Yeung, 2014).

When introducing the concept of CIM therapies for pain management, addressing issues of patient preference, level of interest in the therapy, location and transportation issues, and cost are important considerations. This level of discussion is the first step in patient engagement and should be followed by a shift in the style of conversation to one where patients will intrinsically develop the plan for integrating a CIM modality. One way to do this is by adopting an approach that incorporates the principles of motivational interviewing.

The foundational components and skills inherent in motivational interviewing train the health care professional to move away from a traditional style of trying to persuade patients to change behavior and toward asking thought-provoking questions that prompt desire, ability, reasons, and need to change (Miller & Rose, 2015). Combining motivational interviewing with a physical exercise program for community-dwelling adults with persistent pain is a feasible approach to decreasing pain, promoting activity, and increasing self-efficacy (Tse, Vong, & Tang, 2013). A patient-centered approach, such as motivational interviewing, builds self-efficacy and has the potential to improve the likelihood that patients will engage in self-management strategies. Nurses are encouraged to explore this style of health coaching to improve patient outcomes.

Summary

Evidence on the efficacy of various CIM strategies for persistent pain management exists for older adults. These strategies are mostly mind–body therapies, but include some natural products. Therapies most preferred by older adults include yoga, massage, and dietary supplements. Approaches that take place in a group setting, such as yoga and group CBT, may have the additional benefit of social interaction. Promoting self-management and continued engagement in CIM is essential to improve outcomes. Provider strategies such as motivational interviewing can enhance patient engagement and promote patient self-efficacy.

To optimize engagement in CIM strategies for older adults, providers need to consider (a) patient preferences; (b) potential barriers such as cost, transportation, and physical and cognitive impairment; and (c) potential benefits such as social and family engagement. Providers can create a resource guide that contains local senior center offerings of interventions such as yoga and tai chi, as well as credentialed practitioners in various strategies. There are many smartphone apps for chronic pain management that many older adults can use on mobile devices. Many patient advocacy groups, such as the American Chronic Pain Association, Arthritis Foundation, and others, have valuable resources including meditation and pleasant imagery practices. It is helpful to recruit family members as part of the team to enhance use of CIM. Nurses, given their unique perspective on holistic health care, are well-positioned to lead the transformation of pain management that emphasizes non-drug, complementary integrative care for older adults with persistent pain.

References

  • AARP. (2011). AARP and National Center for Complementary and Alternative Medicine Survey Report: What people aged 50 and older discuss with their health care providers. Retrieved from https://nccih.nih.gov/research/statistics/2010
  • Andrade Ortega, J.A., Cerón Fernández, E., García Llorent, R., Ribeiro González, M. & Delgado Martínez, A.D. (2014). Microwave diathermy for treating nonspecific chronic neck pain: A randomized controlled trial. Spine Journal, 14, 1712–1721. doi:10.1016/j.spinee.2013.10.025 [CrossRef]
  • Arnstein, P. & Herr, K. (2015). Persistent pain management in older adults. Iowa City, IA: The University of Iowa College of Nursing John A. Hartford Foundation Center of Geriatric Nursing Excellence.
  • Astrow, A.B., Puchalski, C.M. & Sulmasy, D.P. (2001). Religion, spirituality, and health care: Social, ethical, and practical considerations. American Journal of Medicine, 110, 283–287. doi:10.1016/S0002-9343(00)00708-7 [CrossRef]
  • Baird, C.L., Murawski, M.M. & Wu, J. (2010). Efficacy of guided imagery with relaxation for osteoarthritis symptoms and medication intake. Pain Management Nursing, 11, 56–65. doi:10.1016/j.pmn.2009.04.002 [CrossRef]
  • Blanch, D.C., Rudd, R.E., Wright, E., Gall, V. & Katz, J.N. (2008). Predictors of refusal during a multi-step recruitment process for a randomized controlled trial of arthritis education. Patient Education and Counseling, 73, 280–285. doi:10.1016/j.pec.2008.06.017 [CrossRef]
  • Booker, S.Q. (2015). Older African Americans' beliefs about pain, biomedicine, and spiritual medicine. Journal of Christian Nursing, 32, 148–155. doi:10.1097/CNJ.0000000000000152 [CrossRef]
  • Broderick, J.E., Keefe, F.J., Bruckenthal, P., Junghaenel, D.U., Schneider, S., Schwartz, J.E. & Gould, E. (2014). Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial. Pain, 155, 1743–1754. doi:10.1016/j.pain.2014.05.024 [CrossRef]
  • Bruce, B., Lorig, K. & Laurent, D. (2007). Participation in patient self-management programs. Arthritis and Rheumatism, 57, 851–854. doi:10.1002/art.22776 [CrossRef]
  • Chen, Y.W., Hunt, M.A., Campbell, K.L., Peill, K. & Reid, W.D. (2016). The effect of tai chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: A systematic review and meta-analyses. British Journal of Sports Medicine, 50, 397–407. doi:10.1136/bjsports-2014-094388 [CrossRef]
  • Cino, K. (2014). Aromatherapy hand massage for older adults with chronic pain living in long-term care. Journal of Holistic Nursing, 32, 304–313. doi:10.1177/0898010114528378 [CrossRef]
  • Clarke, T.C., Black, L.I., Stussman, B.J., Barnes, P.M. & Nahin, R.L. (2015). Trends in the use of complementary health approaches among adults: United States, 2002–2012. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf
  • Cole, L.J., Farrell, M.J., Gibson, S.J. & Egan, G.F. (2010). Age-related differences in pain sensitivity and regional brain activity evoked by noxious pressure. Neurobiology of Aging, 31, 494–503. doi:10.1016/j.neurobiolaging.2008.04.012 [CrossRef]
  • Cooper, K., Schofield, P., Klein, S., Smith, B.H. & Jehu, L.M. (2016). Exploring peer-mentoring for community dwelling older adults with chronic low back pain: A qualitative study. Physiotherapy. Advance online publication. doi:10.1016/j.physio.2016.05.005 [CrossRef]
  • Couilliot, M.F., Darees, V., Delahaye, G., Ercolano, P., Carcaille, M., Vytopilova, P. & Vicaut, E. (2013). Acceptability of an acupuncture intervention for geriatric chronic pain: An open pilot study. Journal of Integrative Medicine, 11, 26–31. doi:10.3736/jintegrmed2013005 [CrossRef]
  • Dedeli, O. & Kaptan, G. (2013). Spirituality and religion in pain and pain management. Health Psychology Research, 1, e29. doi:10.4081/hpr.2013.e29 [CrossRef]
  • Ferrari, M.L., Thuraisingam, S., von Kanel, R. & Egloff, N. (2015). Expectations and effects of a single yoga session on pain perception. International Journal of Yoga, 8, 154–157. doi:10.4103/0973-6131.158486 [CrossRef]
  • Fouladbakhsh, J.M., Szczesny, S., Jenuwine, E.S. & Vallerand, A.H. (2011). Non-drug therapies for pain management among rural older adults. Pain Management Nursing, 12, 70–81. doi:10.1016/j.pmn.2010.08.005 [CrossRef]
  • Garra, G., Singer, A.J., Leno, R., Taira, B.R., Gupta, N., Mathaikutty, B. & Thode, H.J. (2010). Heat or cold packs for neck and back strain: A randomized controlled trial of efficacy. Academic Emergency Medicine, 17, 484–489. doi:10.1111/j.1553-2712.2010.00735.x [CrossRef]
  • Gong, G., Li, J., Li, X. & Mao, J. (2013). Pain experiences and self-management strategies among middle-aged and older adults with arthritis. Journal of Clinical Nursing, 22, 1857–1869. doi:10.1111/jocn.12134 [CrossRef]
  • Gotnick, R.A., Meijboom, R., Vernooij, M.W., Smits, M. & Hunink, M.G. (2016). 8-week mindfulness based stress reduction induces brain changes similar to traditional long-term meditation practice: A systematic review. Brain Cognition, 108, 32–41. doi:10.1016/j.bandc.2016.07.001 [CrossRef]
  • Gutgsell, K.J., Schluchter, M., Margevicius, S., DeGolia, P.A., McLaughlin, B., Harris, M. & Wiencek, C. (2013). Music therapy reduces pain in palliative care patients: A randomized controlled trial. Journal of Pain and Symptom Management, 45, 822–831. doi:10.1016/j.jpainsymman.2012.05.008 [CrossRef]
  • Hariprasad, V.R., Varambally, S., Shivakumar, V., Kalmady, S.V., Venkatasubramanian, G. & Gangadhar, B.N. (2013). Yoga increases the volume of the hippocampus in elderly subjects. Indian Journal of Psychiatry, 55(Suppl. 3), S394–S396. doi:10.4103/0019-5545.116309 [CrossRef]
  • Ho, T.F., Rowland-Seymour, A., Frankel, E.S., Li, S.Q. & Mao, J.J. (2014). Generational differences in complementary and alternative medicine (CAM) use in the context of chronic diseases and pain: Baby boomers versus the silent generation. Journal of the American Board of Family Medicine, 27, 465–473. doi:10.3122/jabfm.2014.04.130238 [CrossRef]
  • Johnson, P.J., Jou, J., Rhee, T.G., Rockwood, T.H. & Upchurch, D.M. (2016). Complementary health approaches for health and wellness in midlife and older US adults. Maturitas, 89, 36–42. doi:10.1016/j.maturitas.2016.04.012 [CrossRef]
  • Kwoh, C.K., Roemer, F.W., Hannon, M.J., Moore, C.E., Jakicic, J.M., Guermazi, A. & Boudreau, R. (2014). Effect of oral glucosamine on joint structure in individuals with chronic knee pain: A randomized, placebo-controlled clinical trial. Arthritis & Rheumatology, 66, 930–939. doi:10.1002/art.38314 [CrossRef]
  • Lamb, S.E., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E.J., Nichols, V. & Underwood, M.R. (2010). Group cognitive behavioural treatment for low-back pain in primary care: A randomised controlled trial and cost-effectiveness analysis. Lancet, 375, 916–923. doi:10.1016/S0140-6736(09)62164-4 [CrossRef]
  • Lorig, K.R. & Holman, H.R. (2003). Self management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1–7. doi:10.1207/S15324796ABM2601_01 [CrossRef]
  • Mercadíe, L., Mick, G., Guétin, S. & Bigand, E. (2015). Effects of listening to music versus environmental sounds in passive and active situations on levels of pain and fatigue in fibromyalgia. Pain Management Nursing, 16, 664–671. doi:10.1016/j.pmn.2015.01.005 [CrossRef]
  • Miller, W.R. & Rose, G.S. (2015). Motivational interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioural and Cognitive Psychotherapy, 43, 129–141. doi:10.1017/S1352465813000878 [CrossRef]
  • Morone, N.E., Greco, C.M., Moore, C.G., Rollman, B.L., Lane, B., Morrow, L.A. & Weiner, D.K. (2016). A mind-body program for older adults with chronic low back pain: A randomized clinical trial. JAMA Internal Medicine, 176, 329–337. doi:10.1001/jamainternmed.2015.8033 [CrossRef]
  • Nadler, S.F., Weingand, K. & Kruse, R.J. (2004). The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician, 7, 395–399.
  • Nahin, R.L., Boineau, R., Khalsa, P., Stussman, B. & Weber, W.J. (2016). Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings, 91, 1292–1306. doi:10.1016/j.mayocp.2016.06.007 [CrossRef]
  • National Center for Complementary and Integrative Health. (2008). Complementary, alternative, or integrative health: What's in a name?. Retrieved from http://nccam.nih.gov/health/whatiscam
  • Nicholas, M.K., Asghari, A., Blyth, F.M., Wood, B.M., Murray, R., McCabe, R. & Overton, S. (2013). Self-management intervention for chronic pain in older adults: A randomised controlled trial. Pain, 154, 824–835. doi:10.1016/j.pain.2013.02.009 [CrossRef]
  • Nolte, S. & Osborne, R.H. (2013). A systematic review of outcomes of chronic disease self-management interventions. Quality of Life Research, 22, 1805–1816. doi:10.1007/s11136-012-0302-8 [CrossRef]
  • Nunez, D., Keller, C. & Ananian, C.D. (2009). A review of the efficacy of the self-management model on health outcomes in community-residing older adults with arthritis. Worldviews on Evidence-Based Nursing, 6, 130–148. doi:10.1111/j.1741-6787.2009.00157.x [CrossRef]
  • Peregoy, J.A., Clarke, T.C., Jones, L.I., Stussman, B.J. & Nahin, R.L. (2014). Regional variation in use of complementary health approaches by U.S. adults (NCHS data brief, no. 146). Hyattsville, MD: National Center for Health Statistics.
  • Puchalski, C.M. (2001). The role of spirituality in health care. Baylor University Medical Center Proceedings, 14, 352–357.
  • Rabini, A., Piazzini, D.B., Tancredi, G., Foti, C., Milano, G., Ronconi, G. & Marzetti, E. (2012). Deep heating therapy via microwave diathermy relieves pain and improves physical function in patients with knee osteoarthritis: A double-blind randomized clinical trial. European Journal of Physical and Rehabilitation Medicine, 48, 549–559.
  • Schmid, A.A., Miller, K.K., Van Puymbroeck, M. & DeBaun-Sprague, E. (2014). Yoga leads to multiple physical improvements after stroke, a pilot study. Complementary Therapies in Medicine, 22, 994–1000. doi:10.1016/j.ctim.2014.09.005 [CrossRef]
  • Singleton, O., Hölzel, B.K., Vangel, M., Brach, N., Carmody, J. & Lazar, S.W. (2014). Change in brainstem gray matter concentration following a mindfulness-based intervention is correlated with improvement in psychological well-being. Frontiers in Human Neuroscience, 8, 33. doi:10.3389/fnhum.2014.00033 [CrossRef]
  • Sritoomma, N., Moyle, W., Cooke, M. & O'Dwyer, S. (2014). The effectiveness of Swedish massage with aromatic ginger oil in treating chronic low back pain in older adults: A randomized controlled trial. Complementary Therapies in Medicine, 22, 26–33. doi:10.1016/j.ctim.2013.11.002 [CrossRef]
  • Stuber, K., Sajko, S. & Kristmanson, K. (2011). Efficacy of glucosamine, chondroitin, and methylsulfonylmethane for spinal degenerative joint disease and degenerative disc disease: A systematic review. Journal of the Canadian Chiropractic Association, 55, 47–55.
  • Tsai, P.F., Chang, J.Y., Beck, C., Kuo, Y.F. & Keefe, F.J. (2013). A pilot cluster-randomized trial of a 20-week Tai Chi program in elders with cognitive impairment and osteoarthritic knee: Effects on pain and other health outcomes. Journal of Pain and Symptom Management, 45, 660–669. doi:10.1016/j.jpainsymman.2012.04.009 [CrossRef]
  • Tse, M.M., Lee, P.H., Ng, S.M., Tsien-Wong, B.K. & Yeung, S.S. (2014). Peer volunteers in an integrative pain management program for frail older adults with chronic pain: Study protocol for a randomized controlled trial. Trials, 15, 205. doi:10.1186/1745-6215-15-205 [CrossRef]
  • Tse, M.M., Vong, S.K. & Tang, S.K. (2013). Motivational interviewing and exercise programme for community-dwelling older persons with chronic pain: A randomised controlled study. Journal of Clinical Nursing, 22, 1843–1856. doi:10.1111/j.1365-2702.2012.04317.x [CrossRef]
  • Villemure, C., Ceko, M., Cotton, V.A. & Bushnell, M.C. (2015). Neuroprotective effects of yoga practice: Age-, experience-, and frequency-dependent plasticity. Frontiers in Human Neuroscience, 9, 281. doi:10.3389/fnhum.2015.00281 [CrossRef]
  • Wachholtz, A.B. & Pearce, M.J. (2009). Does spirituality as a coping mechanism help or hinder coping with chronic pain?Current Pain and Headache Report, 13, 127–132. doi:10.1007/s11916-009-0022-0 [CrossRef]
  • Wang, C., Schmid, C.H., Iversen, M.D., Harvey, W.F., Fielding, R.A., Driban, J.B. & McAlindon, T. (2016). Comparative effectiveness of tai chi versus physical therapy for knee osteoarthritis: A randomized trial. Annals of Internal Medicine, 165, 77–86. doi:10.7326/M15-2143 [CrossRef]
  • Wilkens, P., Scheel, I.B., Grundnes, O., Hellum, C. & Storheim, K. (2010). Effect of glucosamine on pain-related disability in patients with chronic low back pain and degenerative lumbar osteoarthritis: A randomized controlled trial. Journal of the American Medical Association, 304, 45–52. doi:10.1001/jama.2010.893 [CrossRef]
  • Wu, J., Hu, Y., Zhu, Y., Yin, P., Litscher, G. & Xu, S. (2015). Systematic review of adverse effects: A further step towards modernization of acupuncture in China. Evidence-Based Complementary and Alternative Medicine, 2015, 432467. doi:10.1155/2015/432467 [CrossRef]
  • Yildirim, N., Filiz Ulusoy, M. & Bodur, H. (2010). The effect of heat application on pain, stiffness, physical function and quality of life in patients with knee osteoarthritis. Journal of Clinical Nursing, 19, 1113–1120. doi:10.1111/j.1365-2702.2009.03070.x [CrossRef]
Authors

Dr. Bruckenthal is Associate Dean for Research, Dr. Marino is Associate Dean for Academic Affairs and Strategic Partnerships, School of Nursing, and Ms. Snelling is Adult-Gerontological Graduate Student, Stony Brook University, Stony Brook, New York.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Patricia Bruckenthal, PhD, APRN-BC, ANP, FAAN, Associate Dean for Research, School of Nursing, Stony Brook University, HSC L2 Room 246, Stony Brook, NY 11794-8240; e-mail: patricia. bruckenthal@stonybrook.edu.

Received: July 21, 2016
Accepted: October 27, 2016

10.3928/00989134-20161110-08

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