Complementary and Alternative Medicine – Description, Epidemiology, Treatment, Ongoing care and Complications

Basics

Complementary and alternative medicine (CAM) are medical and health care systems, practices, and products that are not presently considered part of conventional medicine. The National Center for Health Statistics (NCHS) 2007 survey reports that 38% of adult Americans and 12% of children use some form of CAM, and this percentage is increasing as CAM healing practices and products become better known and more accessible. Medical professionals who incorporate CAM into their medical practice will often refer to their health care model as “integrative medicine.”

Description

  • Definitions and additional terms:
    • Complementary medicine is used with conventional medicine to address a health concern. For example, massage plus physical therapy to address low back pain, or medication plus osteopathic manipulation to address recurrent headaches.
    • Alternative medicine is used in place of conventional medicine to promote healing of conditions that cannot be explained by the conventional biomedical model or for which the effectiveness of therapy is not yet established by clinical research.
    • Integrative medicine is the combination of allopathic medicine with CAM, and may be provided to the patient by a single licensed medical professional versed in CAM or by a group of diverse health care providers. For example, a nurse on the oncology unit who integrates healing touch into the care of the patient.
    • Holistic is a descriptive term for a practitioner’s approach to patient care. A holistic practitioner assesses the emotional, spiritual, mental, and physical state of wellness of the client and then works to provide comprehensive care. A holistic practice may include practitioners of different disciplines to best address all aspects of wellness or illness.
  • Biologically based therapies: Diets, herbals, vitamins, supplements, flower essences
  • Manipulative and body-based methods:
    • Massage therapy is the manipulation of the soft tissues of the body whereby the licensed practitioner uses knowledge of anatomy and physiology to restore function, promote relaxation, and relieve pain. There are several different types of massage.
    • Osteopathic manipulative medicine focuses on the musculoskeletal system. It includes indirect techniques, e.g., muscle energy, myofascial release, osteopathy in the cranial field, and strain-counterstrain approach, as well as direct action techniques (high-velocity thrusts).
    • Craniosacral therapy is a gentle manual treatment focusing on the release of bony and fascial restrictions in the craniosacral system, which includes the cranium, sacrum, spinal cord, meninges, and cerebrospinal fluid. Cranial osteopathy was developed in the early 1900s by American osteopath Dr. William Sutherland, who researched the subtle movements of the cranial bones and developed techniques to help release restrictions between sutures.
    • Chiropractic therapy is a discipline that focuses on the musculoskeletal and nervous systems and how imbalances in these systems can affect general health. It is most often used to treat back pain, neck pain, and joint pain. Doctors of chiropractic (DCs) complete 4–5 years of intensive training in anatomy, physiology, and manipulation.
  • Mind-body medicine:
    • Meditation, traditionally a form of spiritual practice, is a practice of detachment in which a person sits quietly, generally focusing on the breath while releasing all thoughts from the mind with the intention to center the self, restore balance, and enhance well-being.
    • Spiritual practices/prayer
    • Yoga is an exercise of mindfulness, meditation, strength, and balance with the goal of achieving enlightenment. It is comprised of asanas (postures) and pranayamas (focused breathing). The discipline of yoga originated in India and has been practiced for thousands of years. Variations of yoga including Hatha, Raja, Jnana, Bhaki, and Tantra.
    • Aromatherapy utilizes highly concentrated plant extracts to stimulate physical, emotional, and energetic healing processes. These aromatic oils are rubbed on the skin, aerosolized, or used in compresses.
    • Tai chi and qigong are Chinese exercise systems that combine meditation, regulated breathing, and flowing dancelike movements to enhance and balance chi (qi), or life force energy.
  • Alternative medical systems:
    • Traditional Chinese medicine incorporates Chinese herbs and acupuncture. Acupuncture is the practice of regulating chi by inserting hair-thin needles at specific points along meridian pathways of the body. Chi movement is responsible for animating and protecting the body; relieving pain; and regulating blood, oxygen, and nourishment to every cell.
    • Ayurvedic medicine originated in India and is one of the world’s oldest medical systems. It utilizes healing modalities and herbs to integrate and balance the body, mind, and spirit.
    • Homeopathy is a system of therapy based on the concept that very dilute quantities of an offending agent can stimulate the body’s own immune system to produce a reaction against this offense, thereby healing itself. In general, homeopathic remedies are considered safe and unlikely to cause serious adverse reactions.
    • Naturopathy is based on providing natural and minimally invasive options for prevention and treatment of disease. Treatment regimens can include herbs, vitamins, supplements, dietary counseling, homeopathic remedies, manipulative therapies, acupuncture, and hydrotherapy. 4-year doctoral training programs are available; however, because only 16 states have licensing laws for naturopathic physicians, patients are encouraged to research their prospective naturopath’s credentials.
  • Energy therapies:
    • Reiki, which means source energy, from Japan. Laying hands lightly on the patient or holding the hands just above the body, the Reiki practitioner facilitates spiritual and physical healing by replenishing and strengthening the patient’s life force energy.
    • Healing touch designed by a registered nurse. Practitioners use their hands to clear, energize, and balance a patient’s energy field to enhance well-being.
  • Common reasons patients choose CAM:
    • Conventional medicine has been unsuccessful in fully addressing ailment.
    • Preventative health care
    • Desire for a holistic and natural approach to well-being
    • Preference for noninvasive treatment options
    • Concern about side effects of prescription medication
    • Desire for spiritual support to be incorporated into healing practice
    • Cultural or familial belief system may be more aligned with “natural” solutions not provided for or supported by the standard allopathic model of health care.

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Epidemiology

  • All ages use CAM, but is most prevalent among adults aged 30–69 years
  • Gender ratio: Female predominance
  • College graduates and residents from Western states are more likely to use CAM.
  • 10 most utilized CAM therapies based on the NCHS 2007 survey; prayer is also reported. These 10 CAM therapies were used by the indicated percentage of survey participants:
    • Prayer/self (43%)
    • Prayer/others (24.4%)
    • Natural products (17.7%)
    • Deep breathing (12.7%)
    • Prayer group (9.6%)
    • Meditation (9.4%)
    • Chiropractic and osteopathic (8.6%)
    • Massage (8.3%)
    • Yoga (6.1%)
    • Diet-based therapies (3.6%)
    • Progressive relaxation (2.9%)
    • Guided imagery (2.2%)
    • Homeopathic treatment (1.8%)

Treatment

  • Evidence supports both safety and efficacy:
    • Meditation for lowering blood pressure (1)
    • Acupuncture for chronic low back pain (2)
    • Spinal manipulative therapy for prophylactic treatment of headaches
    • Manipulation, massage, and mobilization for acute low back and posterior neck pain
    • Massage therapy to promote weight gain in preterm infants
    • Acupuncture for nausea and vomiting
    • Tai chi for improving balance and decreasing the risk of and fear of falling in elderly (3)
    • Aromatherapy massage for temporary relief of anxiety or depression in cancer patients (4)
    • Mind-body techniques for migraines, chronic pain, and insomnia
    • Homeopathic remedy for the treatment of chemotherapy-induced stomatitis in children (5)
    • Riboflavin for migraine prophylaxis (6)
    • Horse chestnut seed extract to improve lower leg venous tone, pain, and edema
    • Glucosamine and chondroitin sulfate for osteoarthritis and knee pain
    • Yoga and meditation appear to improve endothelial function in patients with CAD.
    • Yoga can have a potential beneficial effect on depressive disorders.
  • Evidence supports safety, but evidence regarding efficacy is inconclusive:
    • Saw palmetto for benign prostatic hyperplasia
    • Acupuncture for recurrent headache
    • Homeopathy for induction and augmentation of labor
    • Dietary fat reduction for certain types of cancer
    • Mind-body techniques for metastatic cancer
    • Copper and magnetic bracelets for pain
  • Evidence supports efficacy, but evidence regarding safety is inconclusive:
    • St. John’s wort extract for depression
    • Ginkgo biloba for cognitive function in dementia
  • Evidence indicates serious risk:
    • Delay in seeking medical care or replacement of curative conventional treatments
    • Injections of unapproved substances
    • Use of toxic herbs or substances
    • Known herb-drug interactions

Ongoing Care

Patient Education

  • National Library of Medicine: Alternative medicine (www.nlm.nih.gov)
  • The National Center for Complementary and Alternative Medicine (nccam.nih.gov)

Complications

  • Potentially toxic herbs:
    • Serious adverse events from herbal remedies remain extremely rare.
    • Some ethnic medicines, as those prescribed by practitioners of Ayurveda or traditional Chinese medicine, may intentionally contain heavy metals or other toxic substances. These are usually listed by their pharmacopial names, e.g., qian dan = lead oxide.
    • Bitter orange (Citrus sinensis): Sympathomimetic; increases heart rate (HR), blood pressure (BP)
    • California poppy (Eschscholzia californica): May cause respiratory depression, drowsiness; contains opioids
    • Cascara sagrada (Frangula purshiana): Depletes serum potassium
    • Chaparral (Larrea tridentata): Hepatotoxic
    • Ephedra (Ephedra species): Sympathomimetic; increases HR, BP; insomnia, gastric distress
    • Ginkgo (Ginkgo biloba): Extravasation, increased bleeding time
    • Guarana (Paullinia cupana): Tachycardia, hypertension; contains caffeine
    • Kava (Piper methysticum): Decreases utilization of niacin; possibly hepatotoxic
    • Licorice (Glycyrrhiza species): Long-term use depletes serum potassium
    • Lily of the valley (Convallaria majalis): Contains cardiac glycosides
    • Poke root (Phytolacca species): Strong gastric irritant, may cause sedation
    • Senna (Cassia senna): Depletes serum potassium
    • Snakeroot (Aristolochia species): Nephrotoxic
    • Wormwood (Artemisia absinthum): Elevates serotonin level, may raise BP
    • Yohimbe (Pausinystalia yohimbe): Elevates BP
  • Important herbal–medication interactions:
    • Ginkgo and St. John’s wort account for most herb–drug interactions described in the medical literature.
    • Angelica, dong quai (Angelica species): Additive effect with calcium channel blockers
    • Bitter melon (Momordicacharantia): Additive effect with other hypoglycemic agents
    • Cascara sagrada (Frangula purshiana): Shortens transit time of intestinally absorbed drugs; Potential for causing hypokalemia may potentiate digoxin toxicity
    • Chamomile (Anthemis, Matricaria species): Antagonistic interaction with benzodiazepines
    • Echinacea (Echinacea species): May counteract immunosuppressants
    • Garlic (Allium sativum): Modest anticoagulant effect; decreases levels of saquinavir
    • Guarana (Paullina cupana): Contains caffeine; may inhibit platelet aggregation
    • Ginkgo (G. biloba): Dangerous synergistic effect with anticoagulants (1)
    • Ginseng (Panax species): Potentiates dopaminergic drugs; counteracts phenothiazines
    • Kava (Piper methysticum): Additive effect with sedatives
    • Kelp (Laminaria species): May interfere with thyroxine and liothyronine
    • Lemon Balm (Melissa officinalis): Additive effect with sedatives; binds TSH and may interfere with thyroid testing and function
    • Licorice (Glycyrrhiza species): Increases potential for digoxin toxicity; depletes potassium
    • Lobelia (Lobelia species): Potentially counteracts β2adrenergic bronchodilators
    • Meadowsweet (Filipendula ulmaria): Increased anticoagulant effect; contains salicylates
    • Motherwort (Leonurus cardiaca): Can potentiate digoxin; contains cardiac glycosides
    • Milk thistle (Silybum marianum): Might accelerate clearance of liver-metabolized drugs
    • Pumpkin seed (Cucurbita pepo): Elevates levels of androgenic drugs
    • Red clover (Trifolium pratense): Partial agonistic/antagonistic interaction with estrogens
    • Saw palmetto (Serenoa repens): May potentiate or antagonize androgenic drugs
    • Soy isoflavones (Glycine max): Partial agonistic/antagonistic interaction with estrogens
    • St. John’s wort (Hypericum perforatum): Induces CYP450 pathways, reducing levels of many drugs (2)
    • Tobacco (Nicotiana tabacum): May counteract β-blockers
    • Uva ursi (Arctostaphylos uva-ursi): Interferes with action of other diuretics; may cause faster clearance of kidney-metabolized drugs
    • Valerian (Valeriana officinalis): Potential for interference with valproic acid derivatives
    • Willow bark (Salix alba): Additive effect with anticoagulants; contains salicylates
  • Vitamins and minerals with potential toxicity:
    • Iron is a leading cause of accidental poisoning in children under 6. Minerala (i.e., potassium, calcium, magnesium, zinc, copper, and selenium) may cause toxicity
    • Fat-soluble vitamins have the potential to cause hypervitaminosis
      • Vitamin A is most common cause of hypervitaminosis
      • β-carotene may have a limited potential for overdose.
    • Vitamin A: Pseudotumor cerebri, hepatic damage, loss of appetite, osteomalacia
    • Vitamin D: Constipation, hypercalcemia
    • Vitamin E: Coagulopathy, fatigue, pain in extremities

References

1. Anderson JW, Liu C, Kryscio RJ. Blood pressure response to transcendental meditation: a meta-analysis. Am J Hypertens.2008;21:310–6.

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2. Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651–63.

3. Sattin RW, Easley KA, Wolf SL, et al. Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults. J Am Geriatr Soc. 2005;53:1168–78.

4. Wilkinson SM, Love SB, Westcombe AM, et al. Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: a multicenter randomized controlled trial. J Clin Oncol. 2007;25:532–9.

5. Oberbaum M, Yaniv I, Ben-Gal Y, et al. A randomized, controlled clinical trial of the homeopathic medication TRAUMEEL S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation. Cancer. 2001;92:684–90.

6. Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial.Neurology. 1998;50:466–70.

Additional Reading

Bent S et al. Herbal medicine in the United States: review of efficacy, safety, and regulation: grand rounds at University of California, San Francisco Medical Center. J Gen Intern Med.2008;23:854–9.

Rakel D, Faas N. Complementary Medicine in Clinical Practice.Boston: Jones and Bartlett, 2006.

Codes

Snomed

  • 225423004 complementary therapy (regime/therapy)
  • 305626005 seen by complementary therapist (finding)

Clinical Pearls

1/3 of adults and >10% of children use CAM; best evidence examples include:

  • Meditation for lowering blood pressure (1)
  • Acupuncture for chronic low back pain (2)
  • Spinal manipulative therapy for prophylactic treatment of headaches

About the author

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