Part 3 of a five-part USA TODAY series exploring chronic pain, the challenges of treatment and the scientific advances offering hope for the future.
The Rev. James Mitchell was skeptical the first time he watched a yoga class.
“Initially, I thought it was a joke. That’s for women and old people.”
But then Mitchell saw a fellow veteran in his 80s making movements he wasn’t sure he could do himself.
To avoid embarrassment, Mitchell waited until he got home to try some of the positions the older man held – and found he couldn’t.
“Maybe I need to try this yoga,” he said to himself.
So, five years ago, while still suffering the effects of two foot surgeries and nerve problems, he signed up for a class.
Regular yoga, along with acupuncture and visits to a chiropractor, have been transformative.
“I went from a walker to a cane to being mobile on my own,” said Mitchell, who lives in his hometown of Bluefield, West Virginia, near the Virginia border.
Now, he bikes 5 miles a day and is gearing up for a marathon. He promises to pedal the distance if his 66-year-old knees can’t handle the run.
Mitchell is one of more than 930,000 veterans who took advantage last year of the Veterans Health Administration’s Whole Health program, which offers non-pharmaceutical therapies like yoga, acupuncture, meditation and massage. Many, like Mitchell, come into the program to battle pain – and to avoid popping more pills.
Such approaches have become increasingly popular as doctors and patients look for ways to address pain that don’t involve medications.
A growing body of research shows the power of these kind of nondrug approaches, said Dr. Helene Langevin, director of the National Center for Complementary and Integrative Health. The conventional reflex of health care practitioners has been to prescribe a pill, but “I think that’s beginning to change,” she said.
The opioid epidemic is clearly driving that shift.
“Prescribing opiates, especially for chronic pain, can lead to trouble,” Langevin said. “They should be used when needed, but for chronic back pain, for example, there are other options that are much better.”
Paying for these nondrug approaches can be challenging, though, because most are not covered by insurance despite their proven effectiveness.
“We haven’t yet embedded these non-pharmaceutical approaches sufficiently enough so health systems and providers know how to make them available and pay for them,” said Dr. Wayne Jonas, a family physician, integrative health expert and one of Langevin’s predecessors at what is now the NCCIH.
Though a limited number of physical therapy sessions are generally covered by insurance, coverage is rare for other nondrug approaches, despite the evidence behind them. In 2020, Medicare started covering acupuncture for the treatment of lower back pain for the first time.
Yoga classes or a dozen acupuncture sessions cost more than a generic prescription for pain pills, and there’s a whole system set up to provide the drugs, Jonas said.
Because of those added costs, it’s not yet clear whether approaches like the VA’s Whole Health program will ultimately save money, said Dr. Ben Kligler, executive director for the Office of Patient Centered Care and Cultural Transformation with the Veterans Health Administration. A recent study was inconclusive on cost savings, and additional studies are underway.
But veterans who participated in Whole Health were able to reduce their average opioid use faster and by a significantly larger amount than veterans who didn’t use the program. Whole Health participants with chronic back pain were 20% to 30% less likely to need invasive spine procedures, like surgery or neurostimulation, than veterans who didn’t participate.
“If people do better, even if you don’t save money, it’s still the right thing to do,” Kligler said.
Mitchell, a preacher at Infirmity Prayer Services Memorial Chapel in Bluefield, had several steroid injections into his sciatic nerve.
“It helped some, but it was like a Band-Aid. It wasn’t a permanent fix,” he said. The nerve blocker gabapentin made a difference, too, but not enough. He was looking for something different. “I didn’t want to take a bunch of pills.”
That’s when his physical therapist suggested he check out the Whole Health program. He was offered yoga classes and sessions with a chiropractor and acupuncturist – and proceeded to try all three.
A chiropractor helped improve the mobility in his back and reduced the swelling in his leg. Acupuncture gave him some peace and stress reduction.
“Yoga is truly a blessed workout. You do work out in there,” said Mitchell, who was a food service specialist during his two years of service and then spent his career in a marketing desk job.
The yoga instructor made sure he wasn’t pushing himself too hard. “Mountain pose, down dog. Those things sound like they wouldn’t have an impact on you, but you do it repetitiously and it proves to have results,” he said.
Mitchell, now a Level 2 service officer and chaplain for the Disabled American Veterans Chapter 31, got into a virtuous cycle where the more he could move, the better he felt and the more he tried to do.
He learned how to listen to his body’s signals. “Don’t do nothing that’s going to hurt you. Don’t do anything you’re uncomfortable with,” he said. “Men try to be tough. I don’t try to be tough anymore.”
Dr. Nancy Ann Cotter, Whole Health director for New Jersey, said Mitchell’s response is exactly what the program hopes for.
“We’re trying to change people’s minds about what contributes to health and disease,” Cotter said.
“Your lifestyle is your medicine.”
Cotter, who practices acupuncture, said she has been amazed by the effectiveness of so-called battlefield acupuncture, a protocol developed by an Air Force doctor to use on service members in the field. Five tiny needles in each ear, which can stay in for up to five days and take five minutes to administer, can alter people’s relationship to pain, she said.
“When veterans get their first battlefield acupuncture treatment they cannot believe their pain has changed,” she said. “It changes their perception and therefore their idea of what is possible for them.”
Lots of studies have found acupuncture helpful for chronic pain, said Dr. Jun Mao, a physician acupuncturist at Memorial Sloan Kettering Cancer Center in New York City. Large clinical trials have supported its use for arthritis in the knee, lower back pain and cancer survivors in chronic pain, among others.
“Acupuncture produces clinically meaningful reduction in pain, in about 50% to two-thirds of the patients, and that reduction often persists for months,” he said.
Patients with advanced cancer or cancer survivors in pain often either don’t want to take more medications or their liver or kidneys can’t handle the drugs. For breast cancer patients, acupuncture can also relieve the joint pain that sometimes comes with aromatase inhibitors, he said, which allows some to continue on the lifesaving drugs.
Scientists are finally beginning to understand how acupuncture works, Mao said. In animals, the needles stimulate the release of natural pain-control hormones. In people, acupuncture has be shown to change activity patterns in brain areas involved in regulating learning and emotion, he said.
Other complementary approaches also have strong research support, including yoga and tai chi. Massage was found to reduce pain in a trial of more than 300 patients living with advanced cancer, and hypnosis can be helpful for people undergoing painful procedures.
Even the NFL now emphasizes approaches like acupuncture, yoga, blood flow restriction, cryotherapy and sensory deprivation chambers to help players recover without the side effects of pharmacologic treatments, said Dr. Allen Sills, the league’s chief medical officer.
“I think this is tremendous progress,” Sills said. “Fifteen or 20 years ago, these were not considered mainline therapies or certainly weren’t part of the day-to-day experience of players,” but now they’re locker room staples, he said.
Mindfulness can be a harder sell than massage, but it can be transformative, Cotter said. “It really teaches people a different way of being.”
It helps in part by encouraging people to direct their attention away from what hurts, she said. “That really changes people sense of control over their own pain.”
Nurse Patricia Lafontant would come home from a 12-hour shift in the operating room unable to enjoy her free time because of back pain.
Pain patches and creams provided only temporary relief. Her doctor prescribed muscle relaxants, which helped but left her drowsy. “I’d have to make sure I wouldn’t be working the next day when I took the medication,” Lafontant said.
So Lafontant, who lives in Port Washington, New York, jumped at the chance to join a clinical trial testing whether yoga, massage, both or neither could make a difference. “I was really excited to see if I could do something other than what I was doing.”
Exercise, physical therapy, yoga, meditation, massage and acupuncture and other modalities can all help some people, studies show, though none helps everyone.
Each person has to figure out what works for them, Langevin said. “It’s the individual who’s doing the work of healing. The treatment is really only assisting,” she said.
That was the point of the study Lafontant joined: to test whether individualizing pain treatment would yield effective results.
The 57 volunteers, all of them health care workers, were given two weeks to pursue their usual back pain management strategy, to receive in-home massages twice a week or to get in-home yoga instruction twice a week. Then it was switched and switched again, and the participants rated their pain and recorded the number of pain medications they took.
Each approach worked well for some and was a negative experience for others, said Karina Davidson, who led the research and directs the Institute of Health System Science at Northwell’s Feinstein Institutes for Medical Research.
It’s hard to detect the pattern of effectiveness yourself, Davidson said. Maybe your back hurts more one week because of stress related to your daughter or maybe it was the yoga class you took.
Rather than lumping everyone together and saying “yoga works” or doesn’t, the study aimed to let each participant figure out if it worked for them, she said.
Lafontant, who worked at North Shore University Hospital during the trial, said it helped her notice her back pain was worse on particularly long, hard days in the operating room, when she had been moving lots of equipment, lifting and positioning patients and standing for hours by a surgeon’s side.
For her, making time to focus on her physical, spiritual and emotional well-being made a profound difference. Yoga and massage were more effective than the medications, pushing her to recognize that her “crazy muscle spasms” were the result of emotional, not just physical stress.
Amazed by her own improvement, she took on two trainings, one in holistic nursing and one in nurse-health coaching, and now is embarking on a new phase of her career.
Participation in the trial “forever changed my approach to health and healing for my self and my patients,” she said. Now, she examines patients from a physical, emotional, social, mental and spiritual angle and helps them choose integrative health approaches that have fewer side effects before considering pharmaceuticals.
“Personally and professionally, it was a win.”
Jennifer Mokos, 39, of Champaign, Illinois, was skeptical when a specialist she saw for her sleep problems recommended she attend a pain clinic.
Mokos’ downward spiral had begun eight years earlier with a severe bout of food poisoning from salmonella. It left her so nauseous that she had to spend entire days stuck in bed with a bucket.
Then her ankles stopped working. She had trouble regulating her heart rate, blood pressure and other autonomic functions. Sleep came easily all day, but never at night.
By the time she saw the Mayo Clinic sleep specialist, she was using a wheelchair outside the house, hooked up to a feeding pump nonstop and downing 63 different medications a day, each with its own side effects. Nausea was a far bigger problem than pain.
On the first day of the Mayo Clinic’s pain rehabilitation center, she was asked for her biggest goal. What would allow her to consider the program a complete success? Mokos shot for the moon: She’d like to be able to eat solid food again for the first time in more than seven years and walk unassisted out of the house.
There are three primary dimensions to the chronic pain experience, explained Wesley Gilliam, the center’s clinical director.
Pain is sensory, experienced somewhere in the body and perceived as a specific intensity.
Pain also is a “profoundly emotional experience,” Gilliam said. Badly managed chronic pain strips people “of the things that make them who they are … of the valuable experiences that bring them joy. That in and of itself is depressing, anxiety-provoking.”
And finally, pain also has a cognitive component, he said, with people having to make sense of their experience. If people live with a loop in their head that “this pain is killing me,” it will become part of their pain, he said.
During Mokos’ intensive 40-hour weeks in the pain center, her blood pressure and heart rate were monitored several times a day. She went through intensive physical and occupational therapy sessions and two hours of pain psychology every day. Her opioids were tapered off.
“There were mornings when I would wake up in a cold sweat, shaking and shivering and not sure how I was going to make it out of bed.” But she did.
In biofeedback sessions, Mokos was taught deep, slow breathing “from the belly, not the chest.” This calms the nervous system and reduces stress hormones.
With careful oversight and taking one small taste at a time, Mokos was able to eat first a half-cup of applesauce, then smoothies and soup.
By the end of the month, she was eating full meals and able to switch to a nighttime-only feeding pump. She walked out of the clinic unassisted on Feb. 10, her last day.
“When I went into that program, it was such a pipe dream,” Mokos said.
Now, she’s back to playing violin in a pit orchestra for a community theater group. She sits down to breakfast with her 10-year-old son for the first time in his life. Her wheelchair is folded up in the basement.
“I feel like I’m back to 100% now,” she said. “I feel ‘normal’ again. It’s kind of crazy.”
Contact Karen Weintraub at [email protected].
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