Tai Chi, Qi Gong, and Other Complementary Alternative Therapies for Treatment of the Aging Spine and Chronic Pain

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21 Tai Chi, Qi Gong, and Other Complementary Alternative Therapies for Treatment of the Aging Spine and Chronic Pain

Wei Huang, Alice Fann, Linqiu Zhou, Weibin Yang, Chunbo Cai, James J. Yue

KEY POINTS

• Various complementary alternative therapies based on movements, energy, and mind-body interactions are used in the treatment of older patients with spine conditions and chronic pain to decrease pain, improve function, and maintain general health. Many times, they are used in combination with more traditional treatment modalities.
• Movement-based therapies such as Tai Chi (“Tai Ji Quan”) incorporate balance training, mind concentration, breathing techniques, and core muscle strengthening to improve spine function and to promote general health.
• Energy-based therapies and mind-body interactions may take advantage of the use of attention in their effective management of chronic nonmalignant pain in older patients.
• Clinical application of these complementary alternative therapies is promising, but requires diligent guidance and monitoring from providers to ensure safety and benefits, as there are no definitive practice guidelines that are supported or not supported by currently available clinical trials.
• Mechanistic research on these modalities is challenging, due to the complex interplay of central, autonomic, and peripheral nervous systems when these therapies are applied.

Introduction

Among patients with spine conditions and chronic pain, there is an increasing use of complementary alternative therapies that are considered to be “holistic,” noninvasive, and nonpharmaceutical. Such therapies are either used as alternative options or as complementary modalities to medical techniques and/or pharmaceutical agents that are known and accepted by the majority of “conventional” medical practitioners. This chapter will introduce some of these referred complementary alternative therapies, including therapies based on movements, energy, and mind-body interactions. Although complete understanding of the physiologic basis for these therapies is still limited, this chapter provides basic concepts and clinical guidelines about Tai Chi, Qi Gong, and other energy-based therapies, as well as some mind-body interaction practice such as mindfulness meditation, guided imagery, and spirituality practice. It will also delineate some basic science studies that may explain some of their clinical effects. Using a clinical case example, we will demonstrate the selective use of such therapies in a comprehensive pain management plan to improve clinical success. Certain clinical practice-related issues will be reflected in case discussion. Readers are advised to view this chapter only as an introduction to these complementary alternative therapies; by no means do we try to cover all inspirations, debates, and scientific investigations of the topic.

Tai Chi

It is easy to associate Tai Chi with those slow, deliberate movements performed in synchronization by groups of elderly people in parks. Strictly speaking, so-called Tai Chi in the Western world should be Tai Ji Quan in the Chinese Pinyin system or Tai Chi Chuan in Wade-Giles transliteration. “Tai Chi” itself is, rather, a concept in Chinese Taoist philosophy where Yin and Yang, although being the two opposite “supreme ultimate” forces, infiltrate and reconcile each other to unite as a single universe. Tai Chi Chuan originated in China about 600 years ago as a form of martial arts and was once one of the most powerful forms of combat. It was named after Tai Chi as “the Supreme Ultimate Boxing” because its movements are based on Yin-Yang Tai Chi philosophy to feature a defense system that applies the force from an assailant to fend off the attack without deliberate killing. By convention, the term Tai Chi will be used to refer to Tai Chi Chuan in this chapter.

There are five main styles of Tai Chi: Chen, Yang, Wu (or Hao), Wu, and Sun. Although each style has different speeds and forms of movements, practicing any style of Tai Chi requires similar fundamentals, including (1) concentration with internal stillness and quick reaction time, (2) deep breathing skills to enhance its aerobic component, (3) strong leg support and good balance for constant body weight shifting during movements, (4) correct posture and spine alignment with relaxed muscles to maintain stability without unnecessary muscle tension, and (5) an agile torso (lumbar spine) with coordination among all body parts to perform the movements gracefully. Masters of Tai Chi build up internal energy that gives them not only the power needed during combat, but also health and longevity. The latter is the main reason why Tai Chi is widespread in the world, with many participants being attracted to it not for its combative content but for its health benefits. When it is performed for health reasons, the movements can be slow and deliberate with low exercise impact and, therefore, can be tolerated well by the elderly (Figure 21-1).

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FIGURE 21-1 When performed for health reasons, the movements of Tai Chi can be slow and deliberate, with low exercise impact.

Compared to other types of exercises, Tai Chi involves more weight bearing and strength training than yoga and a wider range of coordinated movements than other aerobic exercises. Even in low-impact Tai Chi, emphasis is placed on correct posture and spine alignment with appropriate muscle relaxation. Such features make Tai Chi a good therapy for patients with chronic back pain. Although no randomized controlled clinical trial was found in the literature using Tai Chi for spine conditions, clinical benefits have been observed including strengthened core muscles, increased functional range of motion, decreased pain level, and improved quality of life.

Even with simplified Tai Chi exercises, studies have demonstrated improvement in balance, reduced fear of falling, and decreased risk of falls in older adults.1 Tai Chi, like other forms of exercise, can also reduce blood pressure, improve heart failure, normalize blood lipids and glucose levels,2 and positively affect bone mineral density in postmenopausal women.3 In the older population, when compared to age and body size-matched sedentary controls, Tai Chi practitioners have higher oxygen uptake, greater flexibility, and a lower percentage of body fat.4

Clinical Practice Guidelines

Because there are different levels of Tai Chi forms, from those commonly practiced by the elderly to those practiced by combat martial artists, recommendations for patients with spine conditions have to be individualized. Basic Tai Chi forms can be tolerated well by the elderly who are not active or do not have good balance or coordination; these forms focus on lower body strength and good posture that will improve balance and coordination. Intermediate levels of Tai Chi forms can improve core muscle strength, cardiovascular tolerance, and pulmonary function. Combat levels of Tai Chi forms are not recommended until patients have developed excellent balance and coordination as well as strong core muscle strength; this form should only be practiced under the guidance of Tai Chi masters and with close monitoring of physicians because some of these forms can cause sports-related injuries.

Tai Chi instructors are certified after undertaking a certain amount of training and participating in teaching for a certain number of hours; however, the amount of each needed varies with the different certifying institutions. The certification process is not regulated by legislation. A good reference is important before sending your patients to a particular instructor, preferably one with experience in teaching patients with spine conditions.

From Qi Gong to Energy-Based Therapies

Qi Gong (“Training of Qi”) is a form of energy therapy, energy therapies being those that use and/or manipulate bioenergy or “Qi” fields for medical treatment purposes. The concept of energy therapy is based on the theory that there are patterns of Qi flow in human bodies; the disruption of such patterns of flow can lead to dysfunction and disorders. No one can observe Qi itself, but it has been claimed to be able to “move” around the body and to defend certain body areas. For example in Qi Gong performance, a practitioner resists a sharp weapon, such as the tip of a piercing spear, at his throat by moving his Qi towards that area. Qi has also been perceived when there is “blockage.” A clinical example of such is when a patient presents with a complaint of “having poor circulation.” The symptoms typically are cold, numb fingers and toes; conventional medical tests for nerve function, blood flow, vitamin levels, and endocrine pathology all turn out to be normal. In Traditional Chinese Medicine, such a patient has a problem of Qi “blockage”; therefore energy cannot “flow” toward the distal extremities. The principle of energy therapy is to restore the normal “flow” of Qi or the human bioenergy field for disease prevention or treatment.

Qi Gong originated in China, under the influence of meditation and martial arts practices. Qi Gong masters claim to be able to move energy along meridians for their own health and possibly to heal others’ illnesses. However, driven by financial profit, some inauthentic Qi Gong “masters” also claim to be able to heal and may fool the public. In those cases, certain clinical improvements of the treated patients are likely contributed by acupressure massage, mind-body interactions, psychological placebo effects, and/or the benefits of touch. Some personal conversation between one author (WH) and a well-known Qi Gong master revealed that using energy to heal others hurts the practitioners themselves and thus is rarely practiced except in emergency situations. Therefore, Qi Gong masters usually would rather teach people how to control their own Qi to run smoothly along meridians to maintain health and achieve self-healing.

Besides Qi Gong, other main types of energy-based therapies include Reiki (Japanese), Breema (American), and therapeutic touch (American). Some of these are critically questioned by the research community. For instance, in therapeutic touch, practitioners with their hands placed several inches to feet away from a patient claim that they can feel the energy field emanated by a human body and detect certain patterns of disruption; however, in one clinical investigation, they could correctly detect only 44% of the time (less than chance) the position of a child’s hand.5 Although this illustrates certain doubts on energy-based therapies for their bioenergy base, we are not rejecting their clinical effects as the possible effects may be achieved in other ways.

Clinical Practice Guidelines

Energy-based therapies have been used in chronic back pain in the elderly for myofascial release, pain relief and coping, and improvement of depression. Whether such therapies are truly bioenergy based is currently not clear. Clinical application should be practiced cautiously according to each individual’s condition.

Some forms of energy therapy such as Qi Gong are not recommended for self-practice without guidance. Cases of “energy maltracking during practice” with psychological reactions have been reported around the world. These cases present with symptoms interpreted by mainstream psychiatrists as psychosis or schizophrenia. In bioenergy-based theory, such incidences are thought to be induced by energy invasion into certain meridians without proper guidance. In the clinical psychiatry point of view, such incidences occur with meditation psychosis.

Mind-Body Therapies

Mind-body therapies use the power of the mind to make positive changes in the body and improve health. The practice of such power might be traced back to ancient Buddhist philosophy and practice; the use of it for healing has been recent, with various approaches. We will introduce here a few of the available therapies that are better known to the public.

Mindfulness Meditation

The mindfulness-based stress reduction (MBSR) program was developed at the University of Massachusetts Medical Center. Mindfulness meditation has three purposes: knowing the mind, training the mind, and freeing the mind. It calls for awareness of conscious and unconscious thoughts, feelings, and behaviors that underlie emotional, physical, and spiritual health, and cultivates greater awareness of one’s own bodily functions for the unity of mind and body. The mind is known to be a factor in stress and stress-related disorders. In mindfulness meditation, patients learn to distinguish between mind and awareness, learn to see how the mind dwells on anxiety and fear that burns up energy, learn to stay in the present moment while experiencing high levels of pain, and learn to distinguish between pain sensations and the mind’s creation of the experience of suffering. The practice thus brings nonjudgmental moment-to-moment awareness to thoughts, sensations, or emotions as they arise.

In one qualitative study, 27 older adults with chronic low back pain participated in a MSBR program.6 The authors found a report of improved attention, improved quality of sleep, and improved quality of life along with reduction in pain. In another randomized controlled study of 37 older adults with chronic pain, subjects were randomized into MSBR or wait-list control groups. MSBR participants were found to have improvement in pain acceptance, activity engagement, and physical functioning after 6 months.7 Both studies showed that MSBR was feasible and effective in the older adult population with spine conditions and chronic pain.

Mindfulness meditation is usually taught in weekly group classes that require daily practice outside the group setting for an intensive 8 weeks. It can include sitting, walking, loving-kindness, or body-scan type of meditation. The students are usually given guided meditation tapes for assisting with meditation techniques and are required to practice daily afterwards.

Guided Imagery

Guided imagery is based on the belief in the power of imagination and visualization, a healing tool used by ancient Greeks, by Tibetans, and later by Freud. It is the conscious use of imagination that occurs naturally to create positive images and bring about healthy changes in both body and mind. It uses imagery in a more purposeful and directed way and can control negative thoughts such as fears and concerns. The practice usually begins with a relaxation exercise, either with an individual trained in guided imagery or through the use of audiotapes/CDs, to focus the attention and relieve tension before the actual guided imagery. It involves a breathing exercise and, to start with, visualization of a safe place, followed by the creation of more specific guided images in the mind’s eye. Imageries can be used over and over again or change each time. Five types of guided imagery are usually practiced: (1) pleasant imagery such as imagery of a peaceful location; (2) physiologically-focused imagery such as imagery of white cells fighting disease or cancer cells; (3) mental rehearsal such as successfully performing a public task; (4) mental reframing such as imagery that reinterprets a past experience and its associated emotions; and (5) receptive imagery that involves scanning the body for diagnostic or reflective purposes.

There have been few studies on guided imagery in older subjects with pain. Morone and Greco8 reviewed two studies that were done over a short period of time with small numbers of subjects. Both found that guided imagery was feasible in older adults using the techniques at home, without difficulty and with good compliance, and the practice reduced pain and increased mobility in these subjects.

Spirituality and Religiousness

Spirituality and religiousness is the belief in a higher power than humans. Whereas spirituality may be practiced within an organized religion but, for some, may lack social context; religious beliefs tend to be practiced in a community of like-minded believers. These beliefs may increase social support, improve health behaviors, and improve psychological states. Stronger religious beliefs have been shown to decrease depression and to decrease stress, increase relaxation, and/or provide distraction from pain. Religious and spiritual beliefs improve outlook and function in people with chronic pain.

The role of spirituality and religiousness in health, viewed from a scientific perspective, has been yielding interesting, perhaps intriguing, results. In general, studies have reported fairly consistent positive relationships with physical health, mental health, and substance abuse outcomes, mostly using cross-sectional or prospective designs.9 There were few studies found in the literature regarding spirituality/religiousness in older patients with nonmalignant chronic pain. Baetz and Bowen10 polled 37,000 Canadians and found that those who reported stronger religious beliefs had fewer reports of pain and increased reports of psychological well being. Of those with chronic pain, those who reported more religious and/or spiritual beliefs were more likely to use positive coping mechanisms including attitudinal and activity strategies, and reported increased control and self-efficacy, which led to an increase in pain tolerance. They were also more likely to exercise.

Basic Science

The search for the underlying mechanisms of these complementary alternative therapies is challenging using conventional biological and pharmacological research models. However, breakthroughs in brain imagery and neural network have provided some insights in our understanding of the power of our mind. The well-studied autonomic nervous system in Western medicine is also getting renewed interests due to its involvement in many of these holistic therapies.

Attention and Pain

Chronic pain is associated with impairment of attentional processes. Attention can be thought of as the preferential processing of various types of cognitive information. The function of attention is the appropriate selection of stimuli, maintenance of concentration, and interactions with space and time.11 The anterior cingulate cortex (ACC) is needed for sustained attention, because it modulates one’s ability to concentrate over time by coordinating and integrating task-specific processes. The ACC has a pivotal role in executive processes, motivation, allocation of attentional resources, premotor functions, and error detection. It is activated by moderate-to-intense painful stimulation, and positron emission tomography studies have revealed a large concentration of opiate receptors in this region.12 The more intense and the longer the duration of painful stimuli, the more active the ACC becomes.

Pain may interrupt complex cognition and capture attention that might otherwise be allocated elsewhere; chronic pain may result in a person sustaining focus on the pain rather than other stimuli. Various studies have shown that persons reporting greater attention to pain also report higher pain intensity; persons engaging in attention-demanding tasks report lower pain intensity. Directing attention away from the pain decreases the perception of pain; this distraction away from pain decreases activity in the ACC, insular cortex, thalamus, and somatosensory regions.12–14

Another area of interest is the periaqueductal gray (PAG), which receives major inputs from the frontal cortex, hypothalamus, frontal granular, insular cortex, and amygdala. The PAG projects to the rostral ventromedial medulla, which in turn sends projections to pain-transmitting neurons in the dorsal horn of the spinal cord and the trigeminal nucleus caudalis.15 Within this complex neuronetwork, PAG plays an important role in the descending modulation of pain and in defensive behavior. A study using functional MRI assessed changes in the PAG region in normal subjects.15 Noxious and warm thermal stimuli were applied to the subjects, who were told whether or not to attend to pain. Increased activity within the PAG correlated with perceptual decreases in pain intensity; a greater change in PAG activity was found with a larger decrease in reported pain intensity. Activation difference in the PAG significantly correlated with the total pain score change, using visual analogue scale (VAS), between conditions; a greater change in PAG activity was found with a larger decrease in reported pain intensity. Increased activity within the PAG correlated with perceptual decreases in pain intensity.

Mind-body therapies are likely to exert their clinical effects through modulation of such attentional and emotional modulation. Mindfulness meditation calls for awareness of various conscious and unconscious thoughts, feelings, and behaviors; guided imagery focuses on peaceful and pleasant images; and spirituality engages people in giving up control over one’s life and giving in to a higher power. All these distract from painful, unpleasant physical experiences and potentially produce more positive feelings and less pain. Even Tai Chi and some energy-based therapies emphasize the experience of moving/regulating Qi, a strong distraction from a focus on focal illness or pain. We mentioned earlier some doubts on healing touch by the scientific community; however, from attention and distraction aspects, healing touch could still be effective in producing some pain relief by distracting patients’ attention and inducing positive feedback.

Regulation of the Autonomic Nervous System

Tai Chi, Qi Gong, and other energy-based therapies, as well as mind-body interaction, all claim to be able to lower blood pressure, provide a sense of relaxation and serenity, improve sleep, strengthen the immune system, and improve pain, physical activities, and quality of life. These can be viewed as positive effects on a range of autonomic physiological processes, confirmed by research studies that examined Tai Chi and mind-body interactions.16,17 The aforementioned neuronetwork, i.e., ACC and PAG, has also been found to modulate autonomic function.18,19 Therefore, future mechanistic research may help further understand the interplay among the central, peripheral, and autonomic nervous systems with the resultant clinical effects from these holistic therapies.

Clinical Case Example

A 67-year-old man was referred by his primary care physician for a consultation on chronic back pain that started during his military service and was present intermittently during his younger years. For the 10 years prior to being seen, the pain increased and became more constant; the pain intermittently radiated to his right gluteal region. It was exacerbated by bending either forward or backward, lifting, prolonged standing or walking, and was ameliorated with rest, topical heat application, or massage. At his initial visit, he reported more stiffness in the morning, difficulty with his usual back stretching, and intolerance to standing or walking for greater than 15 minutes. His average daily pain was rated at 9/10. Physical therapy that focused on a back program made the pain worse and he stopped going after one session. He took over-the-counter ibuprofen and acetaminophen until they were no longer effective. His primary care physician prescribed gabapentin 300 mg three times a day and tramadol 50 mg three times a day with reported minimal pain relief; he reported an increase in daytime drowsiness and two falls in the week prior to his presentation.

Past medical history was also significant for diabetes, hypertension, post-traumatic stress disorder (PTSD), and chronic insomnia due to a combination of pain, and nocturia. He had been successfully employed as a manager of a hardware store until 3 months prior to his presentation, when he was laid off due to the economy. At work, he had divided his time between a more sedentary desk job and a more active component in which he had to walk around the store, occasionally lifting some objects of no more than 60 pounds. He used to smoke cigarettes 2 packs a day for 25 years and quit about 20 years ago; he drank beers socially and denied a history of illicit drug use except for experimental marijuana use in high school.

Review of systems revealed chronic constipation that was treated with senna and fiber supplements. He had night sweats but without cough or fever. Chest x-ray was negative for pathology. There had been worsening depression since he lost his job; lately he rarely left the house, per him, due to pain.

On physical examination, he appeared his stated age. He had abdominal obesity and walked with a slow, wide-based gait that was not antalgic. He was able to stand on tiptoes and heels, although standing on heels aggravated his pain. He turned very slowly and lost his balance once during the turn. Lumbar spine had loss of normal curvature and range of motion was limited due to pain with flexion to about 60 degrees (complaining of “deep pain” in the L4-5 area, midline as well as paraspinals), extension to only about 10 degrees (complaining of “sharp pain” all over the low back), lateral rotations to about 45 degrees (complaining of “aching pain” all over the low back). Facet loading on the right reproduced radiating pain down the right lower extremity, traveling from the back to gluteal region and then stopped at the back of the knee.. Paraspinal muscles were tender to palpation in a diffuse area across the back. Straight leg raise produced pain in the posterior knees only. Neurological examination demonstrated manual muscle testing limited by pain; symmetrical deep tendon reflexes in both lower extremities; and intact pinprick sensation. Psychologically, he engaged in conversation with poor eye contact.

Magnetic resonance imaging (MRI) of the lumbar sacral spine showed multilevel lumbar spinal stenosis with L4-5 and L5-S1 degenerative discs. There was also bilateral L3-4, L4-5, and L5-S1 facet hypertrophy with mild neuroforaminal narrowing at L4-5 on the left. Cord signals were normal.

The assessment was a combination of myofascial and facetogenic pain. Although he also had degenerative disc disease, the clinical presentation did not suggest an acute lumbar radiculopathy. He was taught basic back/leg stretching exercises in the supine position and was referred for chiropractor manipulation of his lumbar spine.

At follow-up, he reported that the stretching exercises reduced his pain to a level of 7/10 and that he continued those daily. He also received two sessions of chiropractor manipulation, with significant symptom relief after the first session; however, the pain returned to baseline after only 2 days. He went back the second time and did not get much relief.

He was given trigger point injection and reported immediate 90% pain relief. However, a week later, he called and reported pain back to baseline after 3 days and sounded very distressed. He was referred for right L5-S1 facet injection.

Two weeks later, he reported only 1 week of 60% pain relief from the facet injection; therefore, he was not interested in injections any more. And, he reported, he was not happy with his psychiatrist who diagnosed him with severe depression. He stated, “Who wouldn’t be depressed with this kind of pain and nothing has helped.” He was more interested in holistic medicine but did not wish to get acupuncture since needles would be involved.

He was then referred to a basic Tai Chi class that involved mainly slow, coordinated hand and back movements while standing, and to a pain group headed by a psychologist who used coping strategies for pain and depression, including meditation and relaxation techniques.

He went to the Tai Chi class once a week (1 hour each) and practiced the movements 5 times per week (20 minutes each) at home, and attended the pain group therapy twice a month. Sleep hygiene was reviewed in the clinic and education about sleep schedule and environment was provided. He was also instructed to apply the learned relaxation skills prior to bedtime. After a month, he felt that he could transfer better in the morning time, sit longer, and had better tolerance of prolonged standing and walking. After 3 months, his pain was down to 1-2/10 with occasional exacerbation to 5-6/10 pain; therefore, he cut out all pain medications, except for occasional ibuprofen or acetaminophen. He felt stronger in his legs and back, and reported no more falls.

A year later, he reported a 30-lb weight loss; his pain was gone most days except during changes in weather. At night, it took less time for him to fall asleep, although his sleep was still fragmented. He also felt more energetic, with less need for diabetic medication, and experienced fewer nighttime sweats.

He started a higher level of Tai Chi with movements such as single-leg standing, turning, and stooping, walked 30 minutes a day, and continued meditation three times per week. He also found a part-time job and was extremely satisfied with the results.

Case Discussion

This case illustrates a common approach that has been adopted by many pain specialists: the application of a comprehensive pain management program that is layered, staged, and integrated. The treatment modalities were selected at different stages according to the progression of the symptoms, the responses the patient achieved, the invasiveness of the therapies, and the patient’s preferences.

It appears that the patient finally improved with the introduction of Tai Chi and pain group therapy. However, the patient already had some short-lasting pain relief from various modalities, such as stretching and topical heat. The return of his pain after various injections, regular physical therapy, and chiropractic manipulation, and the loss of his job fortified his misconception that his pain was very significant and permanent. Tai Chi became an appropriate choice of therapy as its movements and exercises were well tolerated by the patient and gradually built up his flexibility and strength; with noticeable functional changes, Tai Chi provided positive feedback to the patient and “started” the success.

Tai Chi is an exercise that is considered to be holistic because it integrates mind concentration with a high level of internal engagement and external movements. However, it is not the only exercise that should be considered holistic. In fact, any exercise, sport, or activity that requires such integration of mind and body would produce similar effects. The selection of the type lies in the provider’s experience and the patient’s preference. For instance, if the patient preferred to learn dancing, which also requires concentration, graceful posture, and poised movements, the clinical effects might be as significant as seen with Tai Chi.

Even with the improvements achieved by Tai Chi exercises, treatment of depression also played an important role in clinical progress. The contribution of depression to pain is often not recognized by patients. Depression can worsen pain symptoms, and effective treatment of depression can improve chronic pain.20 Active treatments and socialization are extremely important for treatment of depression as well as pain, to break the cycle of pain and depression. The socialization at the Tai Chi classes, along with pain group therapy that introduced chronic pain coping strategies that diverted the patient’s attention from pain to more positive images of his own health and condition, all contributed to his improvements in this clinical case.

The impact of sleep in chronic pain management has been often underestimated even by pain specialists. However, there are strong correlations between chronic pain and sleep difficulties.21 Education on sleep hygiene and the use of relaxation techniques helped improve this patient’s sleep, which contributed to decreased pain at morning time. Improved pain and function further provided improved sleep at night.

Most of these complementary alternative therapies require the active participation of patients and are, therefore, different from other medical modalities such as procedures, passive therapies, and medications. Because of this characteristic, they can pose certain clinical challenges in their delivery. Active engagement of patients in their own healthcare becomes an important task for providers to enhance the clinical efficacy of treatments.

Conclusion

The holistic concept has been the focus and attraction of most complementary alternative therapies that have demonstrated their clinical effects in the aging spine and chronic pain. Their promising clinical effects have earned their place in a comprehensive clinical management program as an integral part of reducing pain and improving function. Complementary and alternative medical practices can be blended with traditional evidence-based medicine to optimally promote a healing environment and overall patient well-being.22 Their underlying mechanisms prompt further investigation; however, use of the simple pharmacological model must be avoided due to their complicated involvement of multiple aspects of healing, such as active exercises, concentration, mind-body interaction, attention modification, and autonomic regulation.

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