Complementary and alternative methods of treatment of neck pain

Complementary and alternative methods of treatment of neck pain

Phys Med Rehabil Clin N Am 14 (2003) 659–674 Complementary and alternative methods of treatment of neck pain Michael I. Weintraub, MD, FACP, FAAN Dep...

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Phys Med Rehabil Clin N Am 14 (2003) 659–674

Complementary and alternative methods of treatment of neck pain Michael I. Weintraub, MD, FACP, FAAN Department of Neurology and Medicine, New York Medical College, 325 South Highland Avenue, Briarcliff, NY 10510, USA

Comment Complementary and alternative medicine (CAM), like allopathic medicine, defies precise definition. It can be inclusive of many therapeutic approaches that we consider mainstream, such as counseling and psychotherapy, exercise therapies, the use of heat and cold, electromagnetic applications or massage– none of which, as Dr. Swenson so carefully documents, have been scientifically validated—to more esoteric treatments including acupuncture, which has some validity, and hypnotherapy, yoga, meditation, homeopathy, dietary prescriptions, chiropractics and balneotherapies, among many others that do not. Nonetheless, CAM therapeutics are beginning to receive more serious consideration, and, for some of the methodologies, increasingly wider acceptance. Dr Weintraub has enabled us to be more open to considering the alternatives and to complement our approaches to the patients in our care. As our co-authors consistently point out, our best efforts to substantiate the validity of the wide spectrum of accepted allopathic diagnostic and therapeutic strategies and interventions is a work in progress. Undergoing constant reassessment (this week’s journal reports that last week’s break-through either does not work or is potentially lethal), revision, and rejection, allopathic practices must be continuously carefully scrutinized, and we should also remain open to non-mainstream alternatives. –RLS Whiplash is a common condition that is readily accepted by the medical community. It is considered an acute musculoskeletal dysfunction arising from acceleration/deceleration injury to the cervical muscles, ligaments, tendons, disks, and joints. Trauma is the most common precipitating cause. Pain can be localized or can spread and be referred to the shoulders, arms, or head. After acute injury, most patients recover rapidly, and within 1 year 80% have become asymptomatic. Controversy exists as to whether or not 1047-9651/03/$ – see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S1047-9651(03)00031-7

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late whiplash syndrome exists [1]. Many argue that the terms are vague and unscientific. Most researchers agree that acceleration/deceleration and rotational forces can result in organic dysfunction and injury. The role of litigation and disability further complicates the picture. Thus, when physicians attempt to consider the merits of various therapies, one needs to separate acute conditions from chronic ones. For example, Balla [2] compared chronic pain from vehicular accidents in Australia and Singapore and noted that the late whiplash syndrome does not exist in Singapore. He attributed this difference both to culture and to lack of density of lawyers and insurance industry. Similar observations have been reported from Lithuania [3] and, with no-fault reform, from the Canadian providence of Saskatchewan [4]. Thus, the assessment of chronic pain is flawed and has various cultural, insurance, and legal ramifications [5]. The author has previously stated that the entity of late whiplash syndrome may or may not exist, depending on where the patient lives [1]. In addition, most patients with chronic pain do not have radiologic and electrophysiologic signs of damage and, on examination, many patients show symptom embellishment or malingering [5]. Undetected facet disease also complicates the issue [6]. Treatment of posttraumatic neck pain is diverse and traditionally includes analgesics, muscle relaxants, use of a cervical collar, physical therapy, and traction, among other measures. Most simple acute whiplash resolves within 90 to 180 days, making it difficult to assess accurately the precise influence of each specific CAM modality. Nonetheless, because neck pain has always been a major problem, there are various nontraditional approaches for relief of discomfort. This article discusses many complementary and alternative treatment approaches for relief of acute pain. In some instances, chronic pain is also discussed. Numerous treatments are available and are in use. In some cultural groups, minimal therapies also yield good results. The symptoms of protracted neck pain are often evaluated by neurologists, physiatrists, and orthopedists, and concern exists about causation and about whether the complaint is genuine or a reflection of litigation. The natural history of neck pain has been associated with CAM in different societies and in different eras, and it would be reasonable to consider this association in attempting to appreciate new approaches and issues of cost-effectiveness and safety. Massage and shiatsu Massage and shiatsu techniques have been present since civilization began. Written records date back to 3000 bc. The application of pressure, rubbing of muscles, and movement of joints with oils was described by the ancient Egyptians, Chinese, and Romans. It was believed that massage restored the nutritive fluids to their natural flow or movement. Techniques included the use of deep pressure with kneading (pe´trissage), striking

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(tapotement), gliding (effleurage), and vibration. Modern techniques are derived from the past but also use specific scientific, anatomic, and pathologic anatomic concepts. Various styles and techniques, such as Swedish muscle massage, European massage, and shiatsu, have evolved. Each technique can be designed for use in health and wellness or in illness. Massage can be combined with heat as well as with exercise and usually comes under the field of physical therapy and physiatry in a medical setting. Results were further enhanced with newer developments of diathermy, ultrasound, trancutaneous electrical nerve stimulation (TENS), and lasers. As medical progress occurred, newer devices were developed (eg, ionotropheresis) with less dependency on massage. The decline of massage led to the emergence of specific training schools and institutes relying only on massage and shiatsu. State education and licensing requirements have been developed, and the American Massage Therapy Association (AMTA) currently has more than 17,000 members in the United States. Massage can encompass many types of manipulation depending on pressure as well as on the anatomic sites addressed (ie, meridians, joints, and muscles). Thus, the manipulation of soft tissues can fall under the rubric of myofascial release, Feldenkrais massage, Rolfing, shiatsu, osteopathy, chiropractic, reflexology, and podiatric exercises. Despite widespread use of massage, there is a paucity of scientific data confirming its physiologic effects. Weintraub [7] studied the role of shiatsu treatment in spinal pain and found it to be cost effective in the treatment of neck and back injuries with improvement in more than 75% of cases. The results obtained with eight treatments were the same as those seen with 3 months of physical therapy. The role of placebo, however, is hard to eradicate and is one of the difficulties in assessing a hands-on technique. It has been estimated that 80 million massage sessions are given per year in the United States with integration into various clinical settings. Mechanism of action may differ depending on the technique or method used, but, as a generalization, it is believed that the touch is therapeutic and produces a change in the circulation of blood, reduces muscle tension, breaks down adhesions, improves vital signs and breathing, increases endorphins, increases range of motion in the joints, and speeds recovery of diseased muscles. The scientific manipulation of the soft tissues of the body for the purpose of normalizing tissues that are either injured or malfunctioning is easily directed toward individuals complaining of neck pain [8]. Massage is completely safe and can be repeated at various intervals or as needed, depending on complaints. Massage is versatile and can be applied superficially, with long gliding strokes as originally described in the Swedish method, or with greater pressure on the deep tissues as noted with Rolfing or the Japanese form of shiatsu [10]. These stroking techniques also involve aspects of acupressure along meridians and at specific points. Osteopaths and chiropractors often use these techniques to allow further manipulation of bones and soft tissues so as to correct so-called cranial and spinal imbalances or blockages.

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Calenda and Weinstein [9] have provided an excellent review of the history and benefits of therapeutic massage. The use of direct digital pressure on muscles in spasm helps decrease rigidity and allows greater mobility. Mennell [11] categorized the mechanisms of benefit of massage as mechanical, chemical, reflex, and psychologic. In 1944, Pemberton and Scull [12] summarized the physiologic effects of massage. Critical review indicates that the data suffer from methodologic flaws and poor reproducibility and, at times, are clearly controversial. Because acute pain is the result of active tissue damage and the release of inflammatory and analgesic mediators, the use of therapeutic massage with subsequent benefit suggests a reversal in these areas of pain generation [13,14]. Although critical analysis of the literature demonstrates the efficacy of massage for pain relief, placebo effect is relevant, and the design, lack of homogeneity of the cohort, and lack of biologic markers limits scientific specificity and general acceptance of the medical community on a scientific basis. Acupuncture Acupuncture is based primarily on traditional Chinese medicine (TCM) and has been used for centuries to treat pain [15–17]. The Taoist philosophy is that the human body is in a state of dynamic harmony with nature and the universe. This interaction or energy (yin and yang) should be in balance; if not, disease or symptoms develop. The body is divided into 12 imaginary lines, or meridians and 361 classic acupuncture points. When the body is in balance, there is a normal flow of vital energy, called qi, which penetrates the entire body and protects, maintains, and nourishes the organs and tissues. Each set of lines is functionally connected to corresponding yin and yang organs, which are expressed as opposites in nature. There are also transverse interconnections so that each of the major meridians and points are symmetrically represented in the body and follow a distinct pathway. It has been stated that when the channel systems become imbalanced (ie, there is insufficient or excessive qi), this imbalance produces disharmony and symptomatology. Based on the acupuncture examination of the tongue or triple-pulse method, an assessment of energy disharmony is made, and a specific meridian line is identified. Ultimately, the physician classifies all symptoms into the yin and yang theory. Treatment is then formulated to restore the body’s vital energy by stimulating specific points, thereby releasing energy blockade and reestablishing equilibrium. The specific tools used for treatment have changed over the centuries. In ancient times, pointed objects were made from stone, animal bones, wood, and other materials that allowed skin penetration. Later, needles were made of metals including silver, gold, copper, tin, bronze, and so forth. Currently, small stainless steel needles are the tool of choice and range in gauge from 26 to 34. Lengths also vary from 15 to 125 mm. The widths are quite narrow, from 0.22 to 0.44 mm. Thus, penetration can vary from a few millimeters to 5 cm. Because of the

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AIDS epidemic, sterilized stainless steel needles are used only once in the United States and most Western countries. The ultimate goal of treatment is to be effective and comfortable and to avoid infection or other complications. Thus, technique and knowledge of anatomy are crucial. Patients should also understand that there may not be an immediate positive effect and that there might be a rebound increase in symptoms for a few days. It should be noted that in certain cultures and doctrines, acupuncture is considered incomplete without the concurrent use of either moxibustion (moxa is the powdered leaves of Artemisia vulgaris or mugwort) or electric stimuli near or on the acupuncture point or on the handle of the acupuncture needle. Alternatively, electric stimulation, with or without rotation, is given by attaching electrodes to the handles of the needles to deliver a fixed current to the acupuncture point. Cold lasers can also be applied to specific acupuncture points to promote pain relief and wound healing [18]. Studies by the author and colleagues [19] indicate that using up to 9 joules of energy on specific acupuncture points (ie, laser acupuncture) leads to improvement and resolution of symptomatology in up to 85% of cases. Naeser and colleagues [18] have reported similar experience. Choice of points Traditional Chinese medicine considers 361 points, but Western acupuncture lists up to 1000 or 1500 points. Irrespective of which philosophy is being followed, various practitioners tend to use specific points more frequently, based on their perceived good results. Because acupuncture involves specific point-organ relationships, this theory of practice has been expanded to auricular acupuncture [20]. Additional sets of master points that can affect many different medical conditions are used. The first two master points, point 0 and shen men are used in almost all auriculotherapy treatment plans for the alleviation of most health disorders. Fig. 1 schematically shows several points, and Fig. 2 reveals the inverted somatotopic pattern. It should be noted that this point pattern representation differs slightly from Chinese ear acupuncture parts and the French system of auriculotherapy. The latter seems to be more accurate for relief of neck and back pain and muscle tension. Practitioners of auriculotherapy can use needle insertion or transcutaneous electrical stimulation or pressure pellets to evoke changes. The cervical spinal cord is represented on the lower helix tail, and the cervical spine is in between the upper and lower helix tail (Figs. 3, 4). Ayurvedic Ayurvedic is an ancient Indian medical system using herbal and mineral compounds to promote health. Dietary regimens, physical therapy, and surgery in association with yoga attempt to establish the harmony within the body. The basic philosophy is similar to Chinese traditional medicine,

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Fig. 1. The concept of an inverted fetus pattern represented on the external ear.

linking the universe with human and plant energy. Ayurvedic also uses Marma pressure on specific sensitive regions, and therapy can be either palliative or purifying with eradication of disease. Some of the drugs used are similar to homeopathy [21,22].

Fig. 2. Surface view of the anatomical areas of the auriculo indicating the location of master points on the ear. An open circle represents raised ridges on the ear, a closed circle represents deeper areas of the ear, and a black square represents hidden, vertical areas of the ear.

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Fig. 3. Hidden view of the anatomical areas of the auriculo indicating the location of master points on the ear. An open circle represents raised ridged on the ear, a closed circle represents deeper areas of the ear, and a black square represents hidden vertical areas of the ear. Retractors are used to suggest that the ear surface is pulled back to reveal underlying structures.

Yoga Yoga has evolved from Aryuvedic medicine based on the same ancient Vedic philosophy and culture. Yoga links the individual self to the universal

Fig. 4. Musculoskeletal disorders related to the vertebral spine and the head shown of specific areas of the antihelix, antitragus, and ear lobe.

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self, and therefore yoga has been used as a therapeutic modality [23,24]. Yoga consists of a combination of techniques including physical postures, breathing exercises, methodologies, and meditation to reach optimal health. Stretching and relaxing the neck muscles allows improved posture and circulation and therefore promote mobility of the spine. Ross [24] provides different postures and breathing techniques to achieve improvement (Fig. 5). Chiropractic Chiropractic seems to be one of the most popular alternative medicine treatments. There is a strong emphasis on homeostasis of the neuromuscular

Fig. 5. Illustrates various yoga postures discussed in this chapter.

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Fig. 5 (continued)

system through manipulation and other techniques. Although there have been many reports of reduction of neck pain following manipulation, most reports suffer from a lack of rigid design and control. Cassidy [25] reported results in 150 consecutive outpatients with unilateral neck pain comparing active manipulation versus mobilization. Both treatment groups displayed an increased range of motion, but manipulation had a significant effect in reducing pain. Hurwitz [26] examined four separate studies to determine if a short-term benefit occurred from cervical mobilization for acute neck pain and found benefit. Aker [27] conducted a meta-analysis and reached a similar conclusion. Recently, better-designed studies have been published suggesting that chiropractic is a useful treatment in acute cervical pain [28,29]. Complications have also been described including vascular, neural, and musculoskeletal complications. Recently, 25% of cervical arterial dissections have been reported to occur in association with chiropractic treatment.

Homeopathy Homeopathy is a system of medicine that enjoys worldwide use. It is based on the principals of similars. Thus, homeopathy postulates that a substance

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that can induce and cause symptoms in a healthy person could also reverse those symptoms if they occurred during illness when such a substance is used to promote self-healing [31,32]. The substances used are diluted past Avorado’s number, and critics have therefore dismissed any residual biologic activity. In their review, Merrill and Shalts [33] confirmed the difficulties in assessing homeopathic studies. Recent analyses with double-blind, placebocontrolled design reveal statistical improvement using homeopathy. Obviously, more rigorous studies with strong methodologic design are required. The debate regarding homeopathy continues in conventional medical circles, but the general public has been enthusiastic in its support. The author has used a homeopathic cream containing 11 active ingredients (Topricin, Tropical Biomedics, Rhinebeck, NJ) in patients with neuropathic pain with some anecdotal success (Weintraub MI, Cole S, unpublished data). Application four times per day has demonstrated reduction in pain. A current placebo-controlled trial in carpal tunnel syndrome is currently being concluded.

Herbal medicine Herbal medicine used in various ancient cultures has evolved to form the basis for modern pharmacology. The major obstacles in the use of herbal medicine are lack of standardization and the absence of strict protocols. Individuals likely to take herbal medicines are women who are college educated, middle-aged, and tend to be affluent. Many side effects, drug interactions, and toxicity from contaminants have been reported, producing local tissue damage and even death. Chavez [30] has written an excellent review. Devil’s claw (Arpagophytum procumbens) has been recommended for musculoskeletal pain. It is unclear if this herbal medication is effective, because there is an absence of double-blind, controlled studies.

Magnetotherapy Magnetotherapy, or the use of magnetic energy to treat pain, dates back to ancient humans who used natural sources of magnetism such as lodestones. Areas of local discomfort and also specific acupuncture points considered important in the local culture were directly stimulated by these stones. Similarly, electric energy from natural sources was used in ancient Egypt and in the Greek and Roman cultures; electric eels and electric rays were used to shock the regions of pain. These approaches using magnetic or electric energy were later refined. Permanent magnets generating static fields were developed and were applied by Mesmer and Hell over painful regions with dramatic results. Skepticism abounded, because their French contemporaries believed these results came from a placebo effect. Now, in the twenty-first century, static magnets are receiving increased interest and are

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applied as necklaces, chains, or bands, as well as in pulsed therapy (transcranial magnetic stimulation). Electrical energy has been refined over the years with battery-operated machines such as TENS and spinal stimulators [34–38]. Static magnetic energy has been increasingly studied in the laboratory and is now being studied clinically. Experiments with static magnetic fields in the range of 100 to 300 mT have demonstrated variable effects in different animal models. The weak fields that are generated dissipate inversely with distance. Several lines of evidence exist that certain magnetic designs are effective in reducing pain or protecting nerves. Using multipolar designs in peripheral neuropathy [39,40] and in carpal tunnel syndrome [41], the author was able to achieve pain resolution. In addition, in carpal tunnel syndrome, slight improvement in nerve conduction was also identified that was not thought to be a placebo effect. Vallbona and colleagues [42] used a bipolar design in postpolio pain and observed a quick response within 45 minutes. McLean and coworkers [43] tested sensory axons and found that they were more responsive to multipolar designs than to unipolar designs. Hong [44] looked at neck pain clinically and was unable to achieve benefits. The use of magnetic fields to treat pain is currently in its infancy. Observational reports on a variety of conditions have suggested that exposure to weak magnetic fields can lead to pain relief. As investigators use randomized, placebo-controlled designs with better endpoints, they will be able to determine if indeed the application of static magnetic fields to target neck pain, (ie, spasm, trigger points, arthritis, disks, or spasm) is effective. Only if convincing data were obtained in studies with homogeneous pathology and randomized, placebo-controlled designs would the scientific community accept the use of magnetic fields as a viable treatment option. Some critics have stated that there is a need to design magnetic placebos for masking, but in the author’s study, patients and investigators did not break the code over a 4-month period [51]. There is currently no significant risk in the application of static magnets except to keep the magnet 6 inches or more away from cardiac pacemakers. Problems of study design, lack of homogenous cohorts, lack of randomized, placebo-controlled trials, and the use of magnets of differing polarities and strengths have limited interpretation and have raised specific questions regarding endpoint parameters. Pain is subjective, and all studies tend to use some form of visual analogue scale. The endpoint that should be used and the duration of the study are matters of contention. Failure of bipolar magnets in chronic low back pain of more than 20 years’ duration was reported by Collacott [45] who used only 18 hours of application. Recently the author and colleagues, using a multipolar design in failed back syndrome, noted a similar lack of efficacy with use over a 2-month period of (Weintraub MI, Steinberg R, unpublished data). Complicating the possible scientific basis are the testimonials of benefit by professional sport figures.

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Laser therapy Laser, or photodynamic treatment, is also in its infancy although the application of light for purposes of healing has been used for thousands of years [46]. The ancient Greeks believed that exposure to sunlight induced strength and health. During the Middle Ages, the disinfecting properties of sunlight were used to combat plague and other illnesses, and in the nineteenth century, cutaneous tuberculosis (scrofula) was treated with ultraviolet exposure. Light therapy is also used to treat psoriasis, hyperbilirubinemia, and seasonal affective disorder. Light is electromagnetic energy and consists of photonic energy bundles provided by specific wavelengths. The visible spectrum is 400 to 700 nm; longer wavelengths such as infrared rays, microwaves, and others have been used medically. Albert Einstein provided the atomic theory that ultimately led to the discovery of lasers. In 1960, the first practical ruby red laser was developed by Naiman, who used crystals and mirrors to produce monochromatic, nondivergent light beams in which the waves were parallel and in phase. These characteristics were referred to as monochromaticity, collimation, and coherence. Laser light is artificial and represents light amplification by stimulated emission of the radiation. Today, a variety of cold lasers have been used for the treatment of pain. The most popular are the gallium aluminum arsenide (830 nm) and helium-neon. These visible and infrared lasers have powers of 30 to 90 nW and can deliver from 1 to 9 J/cm2 to treatment sites. Cold laser or low-level laser therapy (LLT) are nonthermal. Penetration depends on wavelength and can alter cellular functions. Because the original European studies on wound healing in animals were positive, the process was described as a biostimulation [47]. Researchers noted that light could be stimulatory at low powers and could elicit an opposite, inhibitory effect at higher powers. Musculoskeletal tissues seemed to have optic properties that respond to light between 500 and 1000 nm. The sufficient specific laser dosage and the number of treatments needed are still subjects of controversy. It is hypothesized that light-sensitive organelles or chromatophores absorb light and that ultimately the energy produces a biologic reaction. It has been postulated that these chromatophores exist on the myelin sheath and mitochondria and that monochromaticity, rather than coherency and collimation, induce the biologic change. Longer wavelengths tend to penetrate more deeply than shorter wavelengths; helium-neon (632 nm) penetrates only several millimeters into tissue, whereas the gallium aluminum arsenide (830 nm) allows photons to penetrate almost 2 inches. Several authors have stated that an infrared laser beam travels about 2 mm into tissue and that this value represents one penetration depth with loss of 1/e (37%) of its intensity. Karu [48] has demonstrated that application of 0.01 J/cm2 can alter cellular processes. Thus, it has been estimated that six penetration depths for helium-neon red light and about 24 mm for gallium aluminum arsenide are possible, because the strength of the beam drops from 9 J/cm2 to 0.01 J/cm2.

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Many claims have been made about the use of lasers to alleviate pain, and these claims have many critics. The Food and Drug Administration (FDA) has now accepted the pain-relieving benefits of 830-nm light in reversing carpal tunnel syndrome. A strong body of direct evidence indicates that cellular processes can be altered following specific treatment (Table 1). There is stimulation of collagen producing stronger scars, increased production of granulation tissue and fibroblasts, increased neovascularization, and faster wound healing. There is also analgesia, enhanced remodeling and repair of bone, and stimulation of endorphin release and prostaglandins. Basford [49] initially noted that he could influence normal median nerve function with just 1 J of energy. The author [50], using a similar laser of 830 nm but at a higher energy level of 9 joules, was able to achieve a 78% success rate in resolving symptoms of carpal tunnel syndrome. These results were subsequently reproduced, allowing FDA approval of 830-nm light therapy for carpal tunnel syndrome and pain. Naeser and coworkers [18] used a combination of two noninvasive, painless treatment modalities, helium-neon laser and microampere TENS, to stimulate acupuncture points on the infected hand. Up to a 92% reduction of pain was observed. They also used laser acupuncture points. The author [19] incorporated additional treatment points and laser acupuncture and achieved an 85% pain reduction from carpal tunnel syndrome. Thus, laser therapy, although in its infancy, plays a role in reducing pain. The recent approval by the FDA will allow more physicians in the United States to use this modality to treat carpal tunnel syndrome, various other pain syndromes, and arthritis. Soft tissue healing has also benefited by the application of laser treatment, which can be an excellent substitute for local trigger-point injections. Applications over the neck and specific trigger points can reduce tenderness and spasm and provide greater mobility. Specific protocols have not been developed, however. To date, no detrimental effects have been reported from the use of low-level laser therapy. Although most observations are anecdotal, several strong protocols have been approved by the FDA for use in humans and in veterinary medicine.

Table 1 Cellular effects altered by low-energy irradiation Phenomenon

Effect

Collagen and protein synthesis Cell proliferation and differentiation Cell motility Membrane potential and binding affinities Neurotransmitter release Prostaglandin synthesis ATP synthesis Phagocytosis Oxyhemoglobin dissociation

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In conclusion, alternative medicine is meeting with a great deal of enthusiasm with the public and is slowly gaining acceptance in the scientific community. The FDA, a major skeptic concerning alternative therapies, is now slowly recognizing the merits of acupuncture and laser therapy. Chiropractic and massage are now well accepted worldwide. Future strictly designed studies using different modalities will allow data generation and should provide patients with greater opportunities for relief and reduction in disability.

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