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A multidimensional model of chronic pain includes not only physiologic and psychological/emotional factors, but also the dimension of subtle energy. In this chapter, the subtle energy dynamics of chronic pain are explored by first outlining the subtle anatomy and energy physiology described in many healing traditions around the world. Then, specific pain conditions (myofascial pain, fibromyalgia, phantom pain, and complex regional pain syndrome) are reconceptualized as energy imbalances, and suggested interventions and clinical vignettes are described. A range of energy therapies is also described, including acupuncture, Reiki, Therapeutic Touch, and meridian-based psychotherapy.
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11
Energy-Based Therapies
for Chronic Pain
Eric Leskowitz
CONTENTS
Introduction
Energy Theory
Energy Anatomy
Hypothesis of Action: Energetic
Reconceptualization of Specific Pain Syndromes
Energy Therapies: Rationale for Use
Safety
Models of Integration
Scope of Practice
Cost Structure
Training Standards
Licensing and Liability
Resources for Training and Practitioner
Availability
Horatio: O day and night, but this is wondrous strange!
Hamlet: And therefore as a stranger give it welcome.
There are more things in heaven and earth, Horatio,
Than are dreamt of in your philosophy.
William Shakespeare (Hamlet, I,v, 165–168)
Summary
A multidimensional model of chronic pain includes not only physiologic and psychological/emotional
factors, but also the dimension of subtle energy. In this chapter, the subtle energy dynamics of chronic
pain are explored by first outlining the subtle anatomy and energy physiology described in many healing
traditions around the world. Then, specific pain conditions (myofascial pain, fibromyalgia, phantom
pain, and complex regional pain syndrome) are reconceptualized as energy imbalances, and suggested
interventions and clinical vignettes are described. A range of energy therapies is also described, including
acupuncture, Reiki, Therapeutic Touch, and meridian-based psychotherapy.
Key Words: subtle energy, chakra, meridian, energy psychology, chronic pain, phantom pain, qi, aura
From: Contemporary Pain Medicine: Integrative Pain Medicine: The Science and Practice
of Complementary and Alternative Medicine in Pain Management
Edited by: J. F. Audette and A. Bailey © Humana Press, Totowa, NJ
225
226 Part III / Therapeutic Techniques
1. INTRODUCTION
Hamlet’s friend Horatio is mystified by his encounter with a ghost because he
doesn’t believe in ghosts, and so Hamlet counsels his friend that life is too complex
to be fully understood within a single philosophical framework. This wise advice also
applies to the world of pain management. Medical theories are, after all, reflections
of the prevailing scientific model; they change as philosophies change. Over the past
30 years, the field of pain management has undergone a major shift from what could
be called a mechanistic model that focused exclusively on nociception, to a more
interactive mind–body model that ushered in the era of multidisciplinary pain clinics
and the reconceptualization of chronic pain as a behavioral syndrome. Despite the
acknowledged successes of this model, however (lowered costs, improved function,
and higher rates of return to work (1)), there is still “more to heaven and earth
than is dreamed of” by even this expanded mind–body model. In this chapter, a
multidimensional model of chronic pain will be proposed, in which the role of energy
medicine is highlighted. This aspect of health, though unacknowledged by Western
medicine, plays a central role in numerous other systems of healthcare, particularly in
the East, and has been called by many names, including “subtle energy,” “vital force,”
“qi” (in traditional Chinese medicine), and “prana” (in yoga theory).
Despite this lack of recognition by mainstream medicine, a substantial body of
evidence has been compiled in recent years that appears to validate ancient mystical
theories of life energy. This chapter will outline some of the evidence for the existence
of this subtle energy circulation system in the human body and will consider the ways
by which the disruption of this energy flow can result in the development of symptoms
and illnesses (including chronic pain) by a mechanism that might be called energy
physiology. Certain well-known pain syndromes will be examined through the lens
of subtle energy anatomy and physiology, and the range of energy-oriented therapies
that may be effective in treating these pain syndromes will be explored. Because data
on many aspects of this model have not yet been fully developed, this chapter will
at times adopt a more speculative tone than other sections of this textbook. However,
there seems to be sufficiently established individual data points to form an energy
physiology, a blueprint for future research and clinical developments in chronic pain.
2. ENERGY THEORY
In Western medicine, human beings are conceived of as extremely complex
machines. Metaphors to this effect pervade medical writings: the heart is a pump,
the eye is a camera, and the brain is a computer. There are unwritten assumptions
in this model. For example, if we learn to subdivide defective body parts into ever
more basic components, we will, presumably, be able to reconstruct a fully functioning
and asymptomatic machine. Symptoms tell us where the breakdown lies, so we can
appropriately repair the defective part, whether by surgery or redesigning the DNA
blueprint. If pain stems from unwanted or unpleasant internal communications, then
blocking those pathways can abolish it. This is the nociceptive model of pain. Within
this model, the sense of “I,” the individual awareness that we all experience, is simply
an artifact or byproduct of our incredibly complex nervous system and brain; there is
no independent self or Soul or consciousness.
In the energy model, however, human beings are conceived of as multidimensional
organisms, not simply as composite machines. The “I-ness” of consciousness is seen
Chapter 11 / Energy-Based Therapies for Chronic Pain 227
as primary, operating within the tripartite system of body, mind and spirit. Mind is
composed of thoughts and emotions, while spirit includes the transcendent level of soul
as well as the more tangible force of subtle energy. For example, the yogis described
a series of nested sheaths ranging from the densest one, the physical body, to the most
ethereal, the Spirit. One of these layers, the subtle energy sheath, has been called the
“breath body” and it parallels the acupuncture meridian system in traditional Chinese
medicine. The yogis considered this dimension to be merely another subdivision of
the physical body. In other words, energy and matter were thought of as poles of a
continuous spectrum of which Western medicine considers only a very limited portion.
3. ENERGY ANATOMY
The energy system is classically organized into three major components: the
containment vessel known as the energy field (popularly called the aura), the distri-
bution pathways known as the acupuncture meridians, and a series of energy centers
or transformers called “chakras.” Problems within each of these components of subtle
energy anatomy may contribute to the development of a particular pain syndrome to
be discussed in subsequent sections of this chapter. These structures will, therefore, be
described in more detail below.
3.1. The Energy Field
In everyday language we acknowledge the existence of a human energy field or aura
whenever we talk of our “personal space.” Just as magnets have electromagnetic fields
(EMF) that are distributed in space beyond their physical boundaries, so it is with
the human body; we don’t end at our skins, and we feel something unpleasant when
someone enters our personal space without our permission. Electronic measurements
show the existence of an EMF extending far beyond the body, strongest in the region
around the heart (2), and strengthened during meditation or healing practices (3).
“Healthy boundaries” is a psychological concept that denotes the ability to separate self
from other and to prevent psychological aggression and abuse. Perhaps these boundaries
are not just metaphorical but are based on the tangible energetic boundaries that provide
a protective layer at the outer reaches of our personal energy field. Therapeutic Touch
(TT), to be discussed in detail later, is the energy intervention most directly focused
on this energy field boundary.
3.1.1. Experiential Exercise
To have a personal experience of the type of energy we are discussing in this chapter,
begin by placing your arms out in front of you, hands facing each other about 12 inches
apart. Bring the hands close enough to feel the warmth but without making physical
contact. Then begin to slowly move the hands farther apart and closer together, and notice
any non-thermal sensations, especially when the hands are about a foot apart. By closing
your eyes, you can increase your sensitivity to these subtle sensations. Many people
describe a tingling or bouncing feeling, almost magnetic in quality. This is the sensation
that TT practitioners use to assess the status of the energy field of their patients.
3.2. The Energy Pathways
Perhaps the best-validated components of the subtle anatomy system are the
acupuncture points and meridians that were brought to Western attention by Chinese
228 Part III / Therapeutic Techniques
medical theory. These points were discovered and mapped in the pre-technological
era of imperial China, but modern electronic detection systems have validated the
existence of acupoints and meridians even though there appears to be no physical
structure that underlies their presence. For example, electrical conductivity is lower at
acupoints than in surrounding tissues (4), and thermography reveals the presence of
meridian pathways when selected points are activated by moxa heat stimulation (5).
Acupuncture, acupressure, and energy psychology using acupuncture meridians are the
treatment modalities most directly focused on the energy pathways.
3.3. The Energy Centers
Despite a religious prohibition against anatomical dissection, Hindu scientists
developed a map of the body that contained seven internal energy centers along the
vertical axis of the spinal column. These centers function as energy transformers,
regulating the “voltage” of universal life energy (“prana”) as it flows through the
human system. The functions of these energy centers range from survival and sexuality
at the base of the spine, to compassion at the level of the anatomic heart, to intuition
at the brow center (third eye), and enlightenment located at the crown of the head.
Intriguingly, these subtle centers correspond in location and function to the seven
endocrine glands of allopathic medicine, though yoga anatomists used only intro-
spection during meditation to locate these psychospiritual centers. Even non-meditators
have experienced their energy centers, as some common everyday sensations represent
our perception of highly energized chakras. For example, butterflies in the stomach
occur when our 3
rd
center is active (fear of public speaking), warmth in the heart when
we feel love, tingling in the scalp when we’re in awe (6). Table 1 shows these parallels.
Chelation and energy work (7,8) as taught by Rev. Rosalyn Bruyere and in the Barbara
Brennan School of Healing, are the treatment modalities that are most directly focused
on the energy centers.
Table 1
Energy/Endocrine Correspondence
Energy Center (Chakra) Endocrine Gland Emotional Function Energy sensation
Crown Pineal Bliss scalp tingling
Brown Pituitary Intuition inner ‘lightbulb’
Throat Thyroid Truth choking up
Heart Thymus Compassion broken heart
Solar Plexus Pancreas Personal power ‘butterflies’
Genital Gonads Sexuality sexual arousal
Root Adrenal survival ‘adrenaline rush’
Endocrine/energy center correspondences were discovered in introspective traditions that
did not allow dissection.
Psycho-endocrinology: the emotional functions of each energy center relates to physio-
logical functions of each corresponding endocrine gland.
Everyday experiences of intensified life energy flow represents the palpable interface of
subtle energy with gross physiology.
Chapter 11 / Energy-Based Therapies for Chronic Pain 229
3.4. Energy Physiology: Layers/Sheaths/Dimensions
Just as gross anatomy provides the substrate for understanding physiology in
allopathic medical schools, energy anatomy provides the substrate for understanding
energy physiology within the field of energy medicine. The dynamics of energy flow,
and its interaction with the body, are the focus here. As the Chinese said, “The mind
directs the qi (energy) and the qi directs the blood (the body).” The nature of the
link between mind and body has been the oldest philosophical and neurobiological
mystery facing modern Western medicine. However, this mind–body connection is a
given in energy paradigms; energy is the intervening variable that connects the two,
thereby resolving Cartesian dualism and the separation of mind and body. Energy
physiology also has an explanation for the symptom of pain. The traditional Chinese
medicine (TCM) formulation was bu tong, ze tong; tong ze, bu tong, which can be
translated as “free flow, no pain; blocked flow, pain.” In other words, any blockage
to energy flow creates friction, which will be perceived as uncomfortable to variable
degrees, depending on the severity of the blockage and the overall energy status of the
organism. Interestingly, in TCM, someone with an overall high level of energy, such
as a young athlete, may experience more significant pain than someone weakened by
age or chronic illness with a sudden energy blockage. However, because of the higher
level of energy in the body of the athlete, the treatment will be easier than in someone
that is energy deficient, where the stagnation of the free flow of energy cannot be as
easily overcome.
Another important principle of energy physiology was alluded to earlier, in the
discussion of the energy/matter spectrum. It’s helpful to think of consciousness as
analogous to H
2
O—a gas at high temperatures, a liquid at medium temperature, and
a solid at low temperatures. Similarly, consciousness at its highest vibrational level is
pure spirit, at a lower level is emotion and thought, and in its most condensed state is
biologic matter. This condensation analogy may help to better understand acupuncture.
This energy model is often dismissed as the indigenous, pre-scientific explanation of
acupuncture. Acupuncture, as the most intensively studied of the energy modalities, has
received the most theoretical attention as to possible mechanisms of action. Elsewhere
in this text, a fascial mechanism, as well as a neuromodulation theory, for acupuncture
are proposed; neither model requires nor negates the independent existence of subtle
energy.
I will briefly describe a highly speculative mechanism of action for acupuncture
that proposes a direct interaction between qi and neurons. The key component to
this model is the relatively neglected direct current, perineural system described by
neurosurgeon Robert Becker (9). In contrast to the familiar digital, on-off, synaptically
based neurological communication system, this analog system involves slower inter-
cellular interactions that occur via ion fluxes within the extracellular matrix of the glial
cells in the central nervous system (CNS) and along nerve sheaths in the peripheral
nervous system (PNS). Many physiologic processes, including wound healing and
possibly oncogenesis, are regulated by this system. Some healers believe this network
in the CNS and along the axon sheaths in the PNS is the physical carrier of healing
energy (10). It is possible that the electrically charged and highly ionized solution in
this matrix can be influenced by qi flow itself to induce action potentials, much like
fluxes in magnetic fields can induce electrical currents in a nearby conducting medium.
230 Part III / Therapeutic Techniques
Thus, the interface between qi and physiology, between electromagnetic charge and
perineural conduction, may be where the neurological mechanism of acupuncture lies.
4. HYPOTHESIS OF ACTION: ENERGETIC RECONCEPTUALIZATION
OF SPECIFIC PAIN SYNDROMES
Recent advances in the neuroanatomical model of pain include advanced imaging
technology and an improved understanding of neuroplasicity, including the molecular
biology (e.g., C-fos gene expression), and neurotransmitter-receptor activity (e.g.,
NMDA receptor linked wind-up of wide dynamic range neurons). However, a different
model of pain etiology emerges when the energy perspective is adopted. This section
will focus on the specific energy dynamics of four common pain diagnoses; myofascial
pain syndrome (MPS), fibromyalgia syndrome (FMS), complex regional pain syndrome
(CRPS), and phantom limb pain (PLP). The first two are characterized by specific
point disturbances in local tissue, which will be related to acupuncture point (acupoint)
imbalances, CRPS will be conceptualized as an imbalance with a particular deficiency
of emotional energy, and PLP will be described as a disturbance in the underlying
energetic matrix.
4.1. Myofascial Pain Syndrome
The key clinical finding in MPS is localized pain in a taut band of muscle called
a myofascial trigger point (MTrP) (see Chapter 5). MTrPs appear to be randomly
dispersed, according to the map of Western medicine, because they are found in anatom-
ically heterogeneous tissues and locations. However, from an energy medicine or TCM
perspective, they function as key acupoints. They were first linked to acupuncture points
30 years ago by Ronald Melzack, the pioneering pain psychologist (11), who found
>70% correlation of MTrPs with acupuncture points. In addition, the Western medicine
treatment of MPS via trigger point injections is remarkably similar to acupuncture.
The trigger points are inactivated, through injection of a range of substances (whether
steroids, anesthetics, or saline). A standard MPS treatment guide (12) shows just such
an injection into a MTrP in the brachii triceps tendon (see Figure 1). However, if
the practitioner were using a dry needling technique (without any injected liquid), the
procedure would in fact be remarkably similar to acupuncture needling of the Large
Intestine-10 (acupuncture point Shou San Li on the hand Yangming meridian).
The electromagnetic activity in acupoints and in MTrPs has been investigated (13,
14). The emerging consensus is that MTrPs are characterized by heightened sympathetic
activity. Therefore, the energetics of MTrPs are described as having an excess of qi
requiring dispersion, in contrast to the tender points of fibromyalgia which, as we’ll
see are deficient in qi and require tonification. From this point of view, MTrPs are
generated when a physical injury results in a local or regional energy blockage that
is frequently accompanied by underlying emotional factors. Unless these emotional
components are addressed the block may not be released despite treatment of the
physical MTrP (6). An upcoming patient vignette illustrates how the emotional root of
MPS can be treated via energy therapy.
4.2. Fibromyalgia Syndrome
Two key components of FMS are primarily energetic in nature: the profound fatigue
and the pathognomonic tender points. As with MTrPs, the location of FMS tender
Chapter 11 / Energy-Based Therapies for Chronic Pain 231
Fig. 1. Trigger point injection and similarity to acupuncture needling of acupuncture point Large
Intestine 10 (12).
points is somewhat mystifying from the anatomical perspective. The map of tender
points put forward by the American College of Rheumatology (ACR) correlates exactly
with key acupuncture points, including Bladder 10, Large Intestine 11, and Bladder 25
(see Figure 2).
The life history that precedes the diagnosis of FMS is often striking in the degree of
cumulative stress and attendant symptomatology that occurs before medical attention
is sought. From an energetic perspective, it seems likely that this accumulated physical
and emotional stress has totally depleted the FMS patient’s energy system. Western
medicine refers to adrenal exhaustion (15) as an indicator of a breakdown in the “Fight
or Flight” response to stress. The parallel energetic process would be a breakdown
in the root center, the chakra center that regulates survival issues. One well-known
experimental finding suggests that the energy drain of insomnia may create the
early symptoms of FMS. Healthy volunteers who are deprived of the restorative
phase of sleep known as slow wave sleep will reliably develop tender points, which
then disappear when normal sleep cycles are restored (16). In effect, this energetic
exhaustion leads to a breakdown of the root center (the foundation of the chakra
system’s house of cards), which snowballs into complete energetic and endocrine
collapse.
Comprehensive treatment of FMS must address all these issues. Classical
homeopathy sometimes succeeds in finding the unique silver bullet known as the consti-
tutional remedy that will specifically and directly resolve the underlying imbalance (17).
Dr. Jacob Teitelbaum’s comprehensive FMS treatment protocol addresses endocrine
dysfunction at all levels. It is one of the few FMS treatments that have shown statis-
tically significant benefit in double blind, controlled experiments (18). His protocol
involves supplementation or replacement of each endocrine gland’s hormonal product:
DHEA supplementation restores adrenal/root chakra function, thyroxine restores
232 Part III / Therapeutic Techniques
Fig. 2. American College of Rheumatology (ACR) fibromyalgia tender point map with acupuncture
point correlates (from Google Images).
thryoid/throat center function, melatonin restores crown/pineal function, and so on, as
the chakra/endocrine axis is reconstructed. While his model does not use subtle energy
terminology, it calls to mind the chakra/endocrine parallels outlined in Table 1.
4.3. Complex Regional Pain Syndrome
Complex regional pain syndrome (CRPS) is a pain syndrome occurring most often
in an extremity that is associated with abnormal autonomic nervous system activity
and trophic changes. The disorder has both nociceptive and neuropathic features and
is characterized by persistent pain, allodynia or hyperalgesia, edema, alterations in
skin blood flow, and sudomotor dysfunction (19). The underlying pathophysiology of
CRPS remains incompletely understood at this time. Until recently, the pain medicine
literature has suggested that CRPS involves a significant psychosomatic component.
Many now advocate that the psychological distress seen in CRPS is a late conse-
quence of unrelenting severe pain that makes concomitant anxiety and depression a
nearly universal finding in chronic CRPS. However, Ochoa and others have noted
(20) the strong placebo responsiveness in CRPS as evidence for the psychophysio-
logical reactivity of these patients. As of yet, the mind-body link in CRPS has been
explored only via survey instruments (i.e., the incidence of childhood trauma is 30%)
(21). The role of physically insignificant trauma as a precipitant for the syndrome has
been widely noted but not fully explored. In the course of in-depth psychodynamic
interviews, these physically insignificant initial traumas (sprained ankle, stubbed toe,
injection of medication) are, however, often revealed to be emotionally significant, and
at times even devastating, to the patient. By adopting a specific psychodynamically cued
Chapter 11 / Energy-Based Therapies for Chronic Pain 233
interview technique with CRPS patients, a significant degree of unaddressed emotional
pain is frequently uncovered (unreported findings by author). The intensity of these
psychological symptoms does not approach that seen in post-traumatic stress disorder
(PTSD) and the process can best be described as suppressed dysphoric emotion,
typically anger.
The energy model of CRPS proposes that the mildly injured body part becomes
so identified (often consciously) with emotional conflict that the patient chooses to
ignore or at least withdraw attention from that part of the body. In other words, the qi
is withdrawn from a specific region as a psychological defense against experiencing
the associated unpleasant emotions that are somatically embedded in that area of the
body. In time, the familiar sequence of CRPS symptoms develops—initially manifested
as disturbances of the autonomic nervous system (allodynia, vasomotor instability),
but ultimately progressing to frank tissue damage (loss of hair, cornification of nails,
and osteoporosis). Interestingly, these latter symptoms are all characterized by loss of
tissue vitality and can be readily reconceptualized as signs of chronic energy depletion.
This “qi withdrawal” model may explain why energizing therapies like exercise can
be so effective, particularly in younger/adolescent patients (22)—the vigorous aerobic
exercise re-establishes circulation into the affected area, not only of blood, but also
presumably of qi. Similarly, new work in graded motor imagery suggests that thinking
about the limb can also desensitize the pain, perhaps via qi release (as the Chinese
said, “the mind directs the qi”) (23). When patients are again emotionally balanced
enough to “reinhabit” the affected body part, symptoms will resolve.
4.3.1. Case Example
Micaela presented as a 20-year-old college student who had maintained a high level
of function despite unremitting CRPS pain since an ankle sprain during basketball
practice at age 11. At the time of her accident, she was taken to the local emergency
department where she was treated aggressively for her injury. This treatment included
an intramuscular injection by a physician whose manner clearly communicated to
Micaela disbelief in the legitimacy of her pain. Within minutes of that intervention, pain
began at the injection site and spread in characteristic CRPS fashion to the entire lower
extremity over the following months. Being a “good girl,” Micaela never expressed
her rage and hurt at the offending doctor, yet it came to the surface readily during
her initial evaluation. This case illustrates that the subjective meaning of the physical
injury to the patient may be more important than the degree of tissue damage incurred.
4.4. Phantom Limb Pain
PLP provides a challenge to the neuroanatomical model, if only because of its
poor response to nociceptively oriented treatments. The perceived phantom limb is
generally theorized to be a cortically induced perception (in other words, a halluci-
nation), but PLP’s responsiveness to certain energy therapies (24) suggests that an
energy mechanism is worth considering. Unfortunately, there is no well-established
and widely accepted method to visualize energy fields, so that field anomalies could be
correlated with symptoms. However, using a technique known as Kirlian photography
to image electrostatic fields around living organisms, some images appear to show
that an EMF exists around a leaf even after its tip has been cut off; this so-called
phantom leaf effect (25) has been compared to PLP. The energy field seems to be a
pre-existing matrix around which the leaf (or limb) is structured, rather than an artifact
234 Part III / Therapeutic Techniques
of the electrical activity that can be measured in living tissue. Analogously, iron filings
arrange themselves in alignment with invisible magnetic lines of force; the force does
not arise from the filings but is separate and independent. It has been hypothesized (26)
that phantom pain sensations may be generated by imbalances in this invisible energy
matrix that arise from the emotional trauma of the amputation. The energetic rebal-
ancing that comes with healing the pre-existing psychological trauma should relieve
the pain.
4.4.1. Case Example
Jeri was a 65-year-old administrative assistant with a 7-year history of PLP when she
was seen in clinic. She described the onset of phantom pain following a left below-knee
amputation surgery to save a limb whose circulation had been severely compromised
after a fall down a flight of stairs. Pain was manageable, averaging 6/10 on a numeric
pain scale with a regimen of short-acting opioid analgesics. The original treatment plan
to apply Emotional Freedom Technique (EFT) desensitization (described in the next
section) to her memories of the fall were changed when Jeri shared that the feeling
of falling had recapitulated what she had experienced in a swimming accident at age
nine when she fell into a pit of water at the beach. Instead, EFT was directed at the
swimming memory. After completion of the EFT treatment course, Jeri found that she
no longer had the swooning internal feeling that used to accompany this memory and
her leg pain had markedly decreased. She went on to experience her first pain-free
period in the 7 years since the surgery.
5. ENERGY THERAPIES: RATIONALE FOR USE
The following examples each focus on a specific energy therapy that has been
effective in treating chronic pain. Of course, many other energy therapies are not repre-
sented in this section, due to space limitations. Case vignettes and research citations
accompany the brief descriptive overviews.
5.1. Therapeutic Touch
Therapeutic Touch (TT) was developed by the partnership of a clinical nurse and
an energy healer more than 35 years ago, in an attempt to develop a healing method-
ology that would be acceptable in medical settings and that would build on nursing’s
tradition of compassionate hands-on caring. The technique involves no physical contact
but rather an assessment of the state of the energy field surrounding the patient by
using energy sensitivity of the practitioner’s hands. At the core of the practice is
the assumption by the practitioner of an attitude of centered compassion toward the
patient and adoption this state of mind is the key first step of the healing process (27).
The assessment phase is then followed by an unruffling/balancing process to clear
any perceived blockages in the field. There is a large body of experimental evidence
validating TT for a range of conditions, from pre-surgical anxiety to osteoarthritis.
Unfortunately, the two best-known TT studies are marred by controversy. Briefly, a
study published in JAMA in 1998 that claimed to show no benefit for TT (28) has been
shown to be methodologically flawed (29), while a 1990 study purporting to show that
TT accelerated wound healing in healthy human subjects (30) has recently been shown
to be fraudulent (31). Caveats aside, TT has been taught to more than 100,000 nurses
in North America and is available in many major medical centers.
Chapter 11 / Energy-Based Therapies for Chronic Pain 235
5.1.1. Case: TT and Phantom Limb Pain
Joe was a 35-year-old cargo loader whose leg had been crushed in a work injury,
necessitating an above-knee amputation five years before he presented to our clinic.
His chronic phantom limb pain was only marginally responsive to a regimen of antide-
pressants and opiates. He did not benefit from cognitive-behavioral retraining and was
offered a trial of TT, about which he knew nothing. During the assessment phase,
there was a similar energy presence sensed by the practitioner in the region of his
missing leg that was also felt around the remainder of his intact body (much like the
sensation from the Experiential Exercise in Section 3.1.1). At that moment, the patient
reported sensing his phantom limb being touched. As the treatment continued, Joe
reported that the pain sensations seemed to be draining out the bottom of his phantom
foot. Surprisingly, he asked for the treatment to be stopped before the pain could be
completely alleviated, saying that he feared becoming pain-free because this would
be proof to him that his leg was in fact missing. In other words, his pain served the
psychological function of defending him against the shock that would come with full
acceptance of his loss (for a more detailed discussion of this case, see reference 32).
5.2. Energy Psychology
The Emotional Freedom Technique (EFT) is the most widely taught and widely
used protocol (33) among the array of new techniques that fall under the umbrella
of energy psychology (EP). This relatively new discipline (34) derives from early
observations that acupuncture treatment can cause strong emotional reactions and that
certain meridians seemed to correlate strongly with specific emotions. Building on a
lineage that includes acupuncture, chiropractic, psychiatry, and martial arts, EP has
evolved a series of “tapping” protocols in which the major acupuncture meridians
are self-activated by finger tapping or pressure at the same time that psychologically
problematic material is being discussed or thought about by the patient. In a sort of
“flushing out” process, the EFT activations are thought to clear or balance negative
emotions. Anecdotal evidence is prolific, but well designed studies are few and far
between. The following vignette is illustrative of EFT’s potential in myofascial pain
syndrome. Figure 3 shows a common EFT protocol.
5.2.1. Case Example: EFT and Post Traumatic Stress Disorder
Maria was a 35-year-old woman who received mild concussion and cervical hyperex-
tension injuries in a boating accident. Her neck and shoulder pain syndrome was largely
myofascial in nature and responded only minimally to standard stress management
training and stretching/strengthening exercises in physical therapy. During a course of
EFT, she was able to access memories of the event (she was able to remember her
subjective experience of the time when she was outwardly appeared to be unconscious)
in a way that triggered a dramatic healing response. She described this recovery of
memory as being psychologically crucial to restoring her sense of wholeness. Within
minutes of completing the EFT process, she was able to demonstrate full range of
motion in her neck and shoulder, and her pain level almost completely disappeared
(for a more detailed discussion of the case, see reference 35).
5.3. Reiki
Reiki has become the most widely known of the hands-on energy therapies, in part
due to the apparent ease of training—typically attendance at a weekend workshop grants
236 Part III / Therapeutic Techniques
Fig. 3. Acupressure points used in EFT protocol (from E. Leskowitz: www.EnergyMedicine101.com).
the practitioner Level 1 mastery. No graduate-level training or clinical experience is
required, as it is not intended to be restricted to healthcare professionals; an estimated
80,000 Americans have been trained in the past year (36). A recent research review
(37) highlights the current challenges of working within a medical model. As with
TT, the most tightly controlled studies demonstrated subjective improvements rather
than organic changes. The method itself was introduced to America about 70 years
ago from Japan, and involves direct hand contact to transmit a healing energy that the
practitioner has been attuned to receive and transmit. No specific diagnostic steps are
taken, nor does the practitioner intentionally modify the healing energy in any way.
Distant healing is also felt to occur in certain forms of Reiki.
5.4. Homeopathy
Homeopathy is the energy modality that is most amenable to randomized controlled
trials (RCTs) with blinded methodology because the protocols can be adapted from
pharmaceutical testing. An extensive supportive literature exists, showing that in many
conditions—asthma, infant diarrhea, otitis, etc.—the benefits of homeopathy are clear
and not explicable by placebo or expectancy factors (38,39). However, the literature on
homeopathy for pain illustrates another common pitfall of assessing energy modalities.
In classic homeopathic prescribing, the clinician arrives at a designated individualized
remedy after detailed history taking; three patients with allopathically similar diagnoses
Chapter 11 / Energy-Based Therapies for Chronic Pain 237
(fever and productive cough, for example) might receive three different homeopathic
remedies. However, research protocols are often set up to offer only a limited number
of treatment options—in an extreme example with a widely reported negative finding,
500 marathon runners were all treated with the same remedy at identical dosages.
They did not respond positively to a statistically significant degree (39). However,
lack of individualized prescribing, and suboptimal dosing render these study results
meaningless.
By contrast, a more appropriately designed trial of homeopathy for fibromyalgia
(18) included fully individualized dosing and generated positive results in treating this
notoriously refractory condition. A subgroup of excellent responders was identified,
not only by clinical response, but also by using a novel form of EEG screening (alpha
concordance measurement) to identify likely positive responders to homeopathy.
5.5. Acupuncture
For a discussion of the wide range of clinical uses of acupuncture in pain
management, refer to Chapter 17.
6. SAFETY
Practitioners of energy medicine typically stress the safety of energy interventions
relative to allopathic medicine. The incidence of clinically significant side effects is
miniscule in such modalities as Reiki and TT, while homeopathy does acknowledge the
phenomenon of the “healing crisis” during which symptoms initially increase after a
treatment until the body’s innate vigor can overcome the symptom and return to a state
of greater balance. A similar process of initial symptom exacerbation is described in the
acupuncture and energy healing literature. However, emergent symptoms are usually
mild enough (headache, jitteriness, muscle soreness) that simple supportive measures
like fluid and bed rest are sufficient to resolve the problem. Hence, contraindications
are practically nonexistent for energy therapies.
There is, however, a distinct possibility of energy “overdose” in certain situations.
Patients must become familiar and comfortable with energy sensations in order to work
optimally with the healing process, and overzealous use of “high voltage” interventions
early on can backfire, with patient drop out a possible result. In addition, some patients
may become so enraptured with the internal energy states cultivated using techniques
like tai chi or qi gong that intensive practice regimens can lead to fairly violent
purgings, typically manifested in such psychological symptoms as anxiety and agitation.
Obviously, some patients will be more sensitive than others to these effects, and a
teacher, mentor or clinician should be available to attend to these dynamics.
There is another important caveat to be made in patient selection for some of the
hands-on forms of energy therapy. Specifically, patients with a prior history of abuse
(physical, emotional, or sexual) should be offered hands-on treatment only after careful
psychological screening. Manual treatments may sometimes be experienced, either
consciously or unconsciously, as boundary violations that re-traumatize the patient and
lead to a flare-up of PTSD symptoms or borderline personality behaviors.
Hence, psychological training should be a core component of any training program
for the energy practitioner. The growing subgroup of energy workers who hold
advanced degrees in mental health is at the forefront of this issue. In the absence of
such expert dually trained providers, a conventional clinician referring to an energy
238 Part III / Therapeutic Techniques
therapist should enquire about back-up psychological support. This may be available
in the form of psychologists or psychiatrists with whom the energy practitioner has an
ongoing collegial referral relationship.
6.1. Contraindications
As mentioned previously, hands-on therapies must be used with care in the presence
of co-morbid psychiatric conditions. One important psychiatric contraindication would
be a diagnosis of borderline personality disorder or history of abuse or PTSD (these
three often co-exist). A good outline of how to pursue psychotherapy of these patients
while remaining sensitive to their energetic boundary issues is available (40). Psychotic
states can sometimes be calmed by energy interventions, but their use depends on the
existence of a prior relationship of trust with the provider, and in general should be
approached very cautiously.
6.2. Precautions
In common with other passive therapies like massage or craniosacral treatment,
hands-on energy techniques like TT and Reiki can foster dependence in patients—not
in the sense of drug dependence or tolerance, but in the sense of reliance on others
for treatment. Given that most pain management programs stress the development of
self-management skills, this dependency potential can become an obstacle in patients
who gain secondary benefits from being in the passive patient role (i.e., increased
attention, decreased responsibility, etc.). Fortunately, most energy therapies can be
adapted to become self-administered, such as self-acupressure, self-Reiki, and qi gong
training. Their use, therefore, need not be in opposition to the overarching treatment
philosophy of patient independence.
Adverse interactions between energy therapies and traditional medical treatments are
rare. Prescription pharmaceuticals, however, are believed by many energy practitioners
to create their own disruptions of energy fields, and the treatment goal of energy therapy
is often to taper and ultimately discontinue prescription medications. Obviously, an
integrative and collaborative approach best serves the majority of patients. For example,
tapering off of opiate medications can sometimes proceed safely when the patient’s
innate energy flows are reconstituted by appropriate energy interventions. In general,
central nervous system depressants like opioids, tranquilizers, and hypnotic agents
impair the efficacy of energy therapies, with practitioners reporting a sense that energy
movement is more sluggish in these patients. Research on this issue has not developed
beyond the level of individual case reports.
7. MODELS OF INTEGRATION
One possible model of integration of energy therapies into a pain medicine practice
is to train the clinician members of an interdisciplinary pain treatment team in various
energy healing modalities. By developing and monitoring the plan of care for all
patients in regular Patient Care Conferences (PCCs), the interdisciplinary team, which
includes physicians, psychologists, nurses, and physical and occupational therapists,
functions as a forum where all aspects of healing can be addressed. When issues arise
that are outside an individual provider’s scope of expertise, a colleague’s assistance is
easily sought. For example, if emotional issues surface during the course of manual
Chapter 11 / Energy-Based Therapies for Chronic Pain 239
therapy with PT, a referral to the team psychologist can be made to help deal with the
underlying issues, whether trauma, depression, or secondary gain.
In such settings, a “cross-training” model of integration is frequently employed.
Staff energy medicine practitioners would all have expertise, credentials, and licensure
as conventional medical practitioners. For example, the team could consist of a Regis-
tered Nurse with Barbara Brennan Energy Healer training, an Energy Psychology
therapist who is a psychiatrist, a physician acupuncturist, and physical and occupational
therapists who practice Tai Chi, acupressure, and Reiki therapies.
8. SCOPE OF PRACTICE
In the above model, energy clinicians are dually trained, while operating under their
primary conventional license. They follow the scope of practice restrictions of their
conventional discipline, and use consultations with colleagues to address potential
boundary issues.
9. COST STRUCTURE
Billing issues can be problematic, given that energy therapies are not covered by
most health insurance plans as of yet. However, in inpatients settings, these services
can often be bundled into the day rates for hospital services so that the patients do not
accrue an additional charge. For example, the salaried RN can do TT without needing
to bill for it as a separate procedure. In the outpatient setting, patients may either be
charged out-of-pocket for an energy intervention (particularly acupuncture or Reiki),
or at other times energy treatments may be integrated into a procedure that is already
covered by insurance (i.e., EFT desensitization as part of psychotherapy). Within the
Worker’s Compensation system, it is sometimes possible to negotiate for coverage of
a course of energy therapy, especially acupuncture.
Other funding options include the use of a sliding scale to set self-pay rates and
obtaining foundation funding to either subsidize treatment costs or to pay directly for
a therapist’s salary. There is also the time-honored option of practitioners performing
their services pro bono. It should be remembered that after the initial consultation with
a homeopathic provider, the remedies themselves are often quite inexpensive, costing
only a few dollars per month.
10. TRAINING STANDARDS
Reiki: Level 1 after two weekend workshops (12 hours); Level 2 (distant healing)
requires an additional workshop. Different traditions within Reiki use the term “Master”
to refer to varying levels of training.
Barbara Brennan School of Healing: 4-year program with quarterly residential trainings
(5 days), including lectures and supervised practice; students are also required to undergo
a course of individual psychotherapy during their training. No state certification or
licensure is currently required or available.
Therapeutic Touch: 3 levels of certification, as practitioner, teacher and mentor.
Association of Comprehensive Energy Psychology (ACEP): Annual conference with
workshops: a program is being developed by ACEP for formal certification that requires
a minimum number of approved workshop attendance and clinical supervision hours.
240 Part III / Therapeutic Techniques
Healing Touch (HT): Five stages of training are required to become a fully certified
HT practitioner, totaling 100 hours; further training is required to be certified as an
instructor.
11. LICENSING AND LIABILITY
As of this writing, acupuncture and homeopathy practitioners are the only energy
therapists required by most state boards to obtain licensure. There is great variability
among the states in the development of licensure and liability standards for the range
of energy therapies. Several references provide specific information on the ethics,
malpractice issues and licensing process of various energy practices (41,42).
12. RESOURCES FOR TRAINING AND PRACTITIONER AVAILABILITY
Reiki: No nationally recognized central organization or clearinghouse exists;
www.reikialliance.com is a useful starting point.
Therapeutic Touch: www.therapeutic-touch.org
Barbara Brennan School of Healing: www.barbarabrennan.com
Energy Psychology (Association of Comprehensive Energy Psychology):
www.energypsych.org
Healing Touch: www.healingtouchinternational.org
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... Some disorders, like chronic pain, show energy dynamics that align with this proposed energy/emotion linkage: 59 In myofascial pain, the characteristic trigger points are palpable, painful knots in the fascia and muscle that are often located at common acupoints. 9 They are over-energized because of unacknowledged emotional distress 95 and can be "sedated" (TCM for "relaxed") by acupuncture and acupressure massage, or by dry needling and trigger point injections of saline solution (Western analogues of acupuncture). ...
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