39 vitamin E, Ginkgo, and fjsh oil, can afgect platelet function and - - PDF document

CHAPTER 39 COMPLEMENTARY AND ALTERNATIVE MEDICINE

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39

COMPLEMENTARY AND ALTERNATIVE MEDICINE

ADAM PERLMAN Tie National Institutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM) has defjned complementary and alternative medicine (CAM) as “ a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of con- ventional medicine.” Tie use of CAM by the general public has continued to

• grow. In the United States, approximately 12% of children and 38% of adults

are using some form of CAM, and when the use of megavitamins as well as the use of prayer specifjcally for health reasons is added, the number increases to 62%. Use of CAM is higher in women and those with more education, but CAM use cuts across all socioeconomic levels, races, and ethnicities. In certain populations, such as patients with cancer or rheumatologic condi- tions, use of CAM can be signifjcantly higher. In one study, 75% of cancer patients surveyed had used at least one CAM modality, and 58% of those using CAM initiated use afuer they were diagnosed.1 Perhaps motivated by growing patient interest in an era of increased con- sumerism in health care or frustration with the current evolution of health care, many conventional providers have developed interest and expertise in the integration of CAM into patient care. However, it is important to difger- entiate between integrating CAM and another growing fjeld within health care, integrative medicine. Integrative medicine has been defjned as “an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual, and environmental infmuences that afgect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs, and circumstances, it uses the most appropriate interventions from an array of scientifjc disciplines to heal illness and disease and help people regain and maintain optimum health.”2 Integrative medicine and integrative medicine programs are increas- ingly prevalent within the academic medical community. Formed in 1999, the Consortium of Academic Health Centers for Integrative Medicine now includes more than one third of all Academic Health Centers in North America. Many of the principles as defjned in Table 39-1 are not unique to integra- tive medicine, and interest in them has been increasing as a part of the evolv- ing transformation of the U.S. health care system. Tiis has led to a growing interest in integrative medicine as well as CAM and the need for physicians and all health care providers to have, at a minimum, a basic understanding of

• CAM. Health care providers must be comfortable engaging in a dialogue with

patients about their potential use of CAM and the evidence base or lack thereof for the more popular CAM modalities as well as any potential safety concerns. Most recently, NCCAM has used the term complementary health approaches to describe the practices and products that are studied as a part of NCCAM’s research portfolio. In general, that portfolio can be separated into two main subgroups: natural products and mind and body practices.

NATURAL PRODUCTS

Natural products, ofuen referred to as dietary supplements, include vitamins and minerals, herbs or botanicals, and a category referred to as nonvitamin, nonmineral natural products. Afuer prayer, use of natural products was the most common complementary health approach among adults surveyed in 2007, with 17.7% of adults having reported using natural products during the previous 12 months. Tie 2007 National Health Interview Survey (NHIS) also revealed that 83 million U.S. adults spent almost $44 billion dollars out

• f pocket on visits to CAM practitioners and purchases of CAM products,

classes, or materials. Of that out-of-pocked spending, $14.8 billion, or 43.7%, was for nonvitamin, nonmineral natural products (Table 39-2). Commonly used natural products in adults include such substances as fjsh

• il, glucosamine, and probiotics, and in children, fjsh oil, probiotics, and
• Echinacea. Tiere is a growing body of research literature on numerous natural

products with mixed conclusions regarding effjcacy. As with any substance that has a physiologic efgect on the body, many natural products, although typically safe, do have the potential for side efgects as well as the potential to interact with medication. Many commonly used dietary supplements, such vitamin E, Ginkgo, and fjsh oil, can afgect platelet function and therefore lead to an increased risk for bleeding. Patients are ofuen unaware of these potential side efgects or interactions with medications. Currently, natural products are regulated under the Dietary Supplement Health and Education Act (DSHEA). Enacted by Congress in 1994, this act gives the U.S. Food and Drug Administration (FDA) the power to regulate both fjnished dietary supplement products and dietary ingredients. Dietary supplements are defjned as products (other than tobacco) that are intended to supplement the diet and include one or more of the following ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, a substance for use by humans to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients. Manufacturers are responsible for ensuring that products are safe before bringing them to market, and the FDA is responsible for taking action against any unsafe product afuer it has reached the market. Although the FDA has a system in efgect for the collection and review of adverse efgects linked to dietary supplements, that system is voluntary, and concerns have been raised that the agency does not have adequate resources to ensure safety of products currently on the market in a timely and efgective way.

CHAPTER 39 COMPLEMENTARY AND ALTERNATIVE MEDICINE

182 DSHEA also established the Offjce of Dietary Supplements (ODS) at the National Institutes of Health. Tiis Mission of ODS is to “strengthen knowl- edge and understanding of dietary supplements by evaluating scientifjc infor- mation, stimulating and supporting research, disseminating research results, and educating the public to foster an enhanced quality of life and health for the U.S. population.”

MIND AND BODY PRACTICES

As defjned by NCCAM, mind and body practices “include a diverse group

• f procedures or techniques administered or taught by a trained practitioner
• r teacher.” Mind and body practices include such therapies as meditation,

acupuncture, massage therapy, movement therapy, relaxation techniques, spinal manipulation, tai chi, yoga, and various energy therapies, such as healing touch, Reiki, or qi gong. Mind and body practices as defjned by NCCAM should not be confused with the commonly used term mind-body

• medicine. Mind-body medicine is typically used to describe techniques that

are specifjcally designed to enhance the mind’s ability to cause physiologic efgects that will lead a positive therapeutic outcome, such as decreased pain

• r anxiety.

Meditation Meditation, which involves various techniques to self-regulate atuention, has been used for thousands of years by various religions and cultures, primarily in Asia, to increase awareness and ultimately improve self-understanding, inner peace, and enlightenment. In Western culture, meditation has gained in popularity since the 1960s and is ofuen used without a religious context to help manage stress and improve overall health. Tie physiologic efgect of meditation has been extensively studied. Medita- tion has been shown to increase activity of the autonomic nervous system and bring about what Benson has termed “the relaxation response.”3 Tiis response can lead not only to the subjective sense of decreased stress but also to measurable efgects such as a lowering of blood pressure and heart rate. Other investigators have found evidence of increased blood fmow in the brain and altered brain chemistry (see Relaxation Techniques, later). Regular med- itation is associated with increased α-wave activity as well as decreased levels

• f hormones associated with stress, such as cortisol and epinephrine, and

increased levels of melatonin. Many meditation techniques exist, and meditation can be taught in indi- vidual or group sessions. Meditation has been shown to have potential ben- efjts for managing conditions such as stress, anxiety, cognitive function in elderly people, gastrointestinal disorders, chronic pain, addictions, and even

• psoriasis. A1 Although some techniques, such as transcendental meditation,

have been more extensively studied, evidence comparing the potential efgec- tiveness of various techniques is largely lacking. Although safe for most patients, limited evidence suggests that meditation should be approached cautiously for anyone at risk for seizures, symptomatic low blood pressure, or psychotic illness. In one small study of meditators involved in an intensive meditation retreat, more than half of the participants experienced at least one adverse efgect. Acupuncture Practiced in China for more than 5000 years, acupuncture involves the inser- tion of very fjne needles at specifjc points in the body. Tiese approximately 360 acupoints reside along 14 channels in the body called meridians. In Chinese medical theory, the insertion of the needles is intended to stimulate

• r improve the balance of the fmow of “life energy” or qi (pronounced chi).

Symptoms or disease are thought to be related to a blockage of fmow or imbalance of qi. Although very difgerent from a Western medical view of pathophysiology, acupuncture has been shown to have various physiologic efgects on the body, including stimulation of endorphins and various brain centers. Tiere is a growing body of research investigating the potential benefjts of acupuncture for a number of conditions. To date, there is evidence suggesting that acupuncture may be benefjcial for pain from conditions such as dental pain, fjbromyalgia, and headache,4 as well as benefjcial in stroke, analgesia during childbirth, and infertility treatment. A meta-analysis suggests that stimulation of the P6 acupuncture point at the wrist is a potentially efgective intervention for reducing postoperative nausea and vomiting.5 Randomized trials evaluating acupuncture for osteoarthritis of the knee show confmicting results, in part depending on study design A2 , but a recent carefully controlled, blinded trial showed no benefjt. A3 It is important to explain to patients interested in a trying acupunc- ture, that the needles are typically ultra-fjne and ofuen not painful. An

Data from Horrigan, B, Lewis, S, Abrams D, et al. Integrative Medicine in America: How Integrative Medicine Is Being Practiced in Clinical Centers across the United States. Encinitas, CA: Tie Bravewell Collaborative; 2012.

TABLE 39-1 DEFINING PRINCIPLES OF INTEGRATIVE MEDICINE

Tie defjning principles of integrative medicine are as follow: Tie patient and practitioner are partners in the healing process. All factors that infmuence health, wellness, and disease are taken into consideration. Tie care addresses the whole person, including body, mind, and spirit in the context of community. Practitioners use all appropriate healing sciences to facilitate the body’s innate healing response. Efgective interventions that are natural and less invasive are used whenever possible. Because good medicine is based in good science, integrative medicine is inquiry driven and open to new models of care. Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount. Care is individualized to best address the person’s unique conditions, needs, and circumstances. Practitioners of integrative medicine exemplify its principles and commit themselves to self-exploration and self-development.

TABLE 39-2 USE OF COMPLEMENTARY OR ALTERNATIVE MEDICINE BY U.S. ADULTS IN 2007

MODALITY PERCENTAGE OF ADULTS WHO USED IT BIOLOGICALLY BASED THERBPIES Herbal or natural products 17.7 Dietary supplements N/A Diet-based therapy 3.5 BODY-BASED PRBCTICES Chiropractic or osteopathic manipulation 8.6 Massage 8.3 Movement therapies* 1.5 MIND-BODY THERBPIES Biofeedback 0.2 Hypnosis 0.2 Meditation 9.4 Guided imagery 2.2 Progressive relaxation 2.9 Deep breathing 12.7 Yoga 6.1 Tai chi 1.0 Qi gong 0.3 ENERGY MEDICINE† Reiki, biofjeld, and other therapies 0.5 WHOLE MEDICAL SYSTEMS Naturopathy 0.3 Homeopathy 1.8 Ayurveda 0.1 Traditional Chinese medicine (acupuncture) 1.4 Traditional healers 0.4

*Pilates, Trager, Feldenkrais, and Alexander.

†Energy medicine is based on the theory that there are energy fjelds surrounding and penetrating

the human body. Energy therapies are intended to manipulate these energy fjelds.

DSHEA also allowed for the enactment of regulations to ensure that manu- facturers follow good manufacturing practices. In addition, the act clarifjed which claims are permissible for dietary supplement labels. It does not allow claims that a dietary supplement will “diagnose, prevent, mitigate, treat, or cure a specifjc disease” but does allow assertions that a dietary ingredient will afgect the structure or function of the body. Tie Federal Trade Com mission has responsibility and authority to regulate advertising for dietary supplements.

CHAPTER 39 COMPLEMENTARY AND ALTERNATIVE MEDICINE

183 (asana), breathing exercises (pranayama), and meditation or relaxation (dharana). Popular forms of yoga in the West include Ashtanga, a vigorous style ofuen taught in the United States as power yoga; Bikram, practiced in rooms heated to about 100° F; Iyengar, a slow form of yoga with strict atuen- tion to posture and alignment; Kundalini, a more spiritual form using pos- tures combined with hand positions, breathing, and meditation; and Hatha, which has a focus on postures and breathing exercises to promote a balance

• f physical health and mental calmness.

Numerous studies have explored the potential health benefjts of yoga. A study in the United Kingdom involving 313 adults with chronic low back pain found that yoga led to more improvement in function than usual care when

• fgered once a week for 3 months. A5 In a meta-analysis, yoga reduced low back

pain and back-specifjc disability but did not improve overall health-related quality of life compared with usual care, educational programs, and exercise

• programs. A6

When guided by a well-trained instructor, yoga is generally safe for most healthy individuals. People with certain chronic conditions, such as glau- coma, hypertension, neck pain, or sciatica, should modify or avoid certain poses, as should women who are pregnant. Certain forms of yoga may be safer

• r more appropriate for people with particular conditions. For example,

Bikram, or hot yoga, is best avoided in individuals with known heart disease, lung disease, or history of heat stroke. A review of comparison studies of yoga and exercise concluded that yoga may be as efgective or superior to exercise in improving a number of health-related outcomes in both healthy and patient populations.7 Tai chi, also know as tai chi chuan, is an ancient Chinese practice involving a series of movements coordinated with breathing and practiced to strengthen the physical body, improve mental sharpness, and enhance the fmow of energy

• r qi. Tie healthy fmow of qi or this vital energy is thought to be a critical

aspect of maintaining health in traditional Chinese medicine. A gentle form

• f movement that emphasizes continuous slow, ofuen symmetrical fmexion

and extension of the upper and lower body, tai chi can ofuen be practiced even by individuals with conditions such as heart disease or arthritis as well as by seniors at risk for falls. Tai chi has been studied as an adjunct to conventional treatments for a number of conditions. A systematic review of the effjcacy of tai chi for mostly healthy seniors found limited evidence that tai chi is efgective in decreasing falls or blood pressure. A systemic review of tai chi for osteoarthritis came to a similar conclusion. Tiere was some encouraging evidence to support effj- cacy, but future trials with larger patient samples and longer treatment periods were needed. However, a randomized trial in patients with fjbromy- algia found that a 12-week course of tai chi compared with wellness education and stretching exercises led to signifjcant improvement in pain as well as quality of life. A7 Another randomized controlled trial in patients with mild to moderate Parkinson disease found that tai chi, compared with resistance training or stretching, reduced balance impairments, with additional benefjts

• f improved functional capacity and reduced falls. A8

As with other movement therapies, tai chi is best practiced under the guid- ance of a trained instructor, although it can be learned from videos or books. Safe for most populations, guidelines for appropriate practice of tai chi are the same as those for other land-based exercise programs. Relaxation Techniques Relaxation techniques involve a broad range of therapies and techniques, including meditation, yoga, and tai chi, which have been practiced for thou- sands of years for their purported mental, physical, and spiritual benefjts. In more modern times, a number of techniques have been developed with the intent of eliciting the “relaxation response.” Tie relaxation response leads to decreased sympathetic nervous system activation and has been shown to increase α waves on electroencephalogram. Tirough an efgect on the limbic system and its infmuence on the hypothalamic-pituitary-adrenal axis, there is a subsequent slowing of heart rate and respiratory rate, as well as numerous

• ther neuroendocrine efgects, including decreased plasma cortisol. Common

techniques include progressive relaxation, breathing exercises, guided visual- ization, biofeedback, and autogenic training. Although commonly used to control or manage stress, relaxation tech- niques have been studied for a number of medical conditions, including anxiety, pain, irritable bowel syndrome, diabetes, premenstrual syndrome, tension headaches, and smoking cessation. Relaxation techniques and medi- tation programs can provide small to moderate reductions in stress from a wide range of conditions. Relaxation techniques can lead to improvement in both acute and chronic pain, but litule evidence exists that the improvement is sustained over time.8 acupuncturist’s assessment of the patient will determine the exact location of the needles to be placed. Repeat treatment most commonly occurs once a week, and it ofuen requires 8 to 10 treatments to assess whether acupuncture will have a therapeutic efgect. Modern acupuncture using primarily sterile, disposable needles is gener- ally safe. Risk for infection, although rare, does exist, and electro-acupuncture, which involves stimulation of the acupuncture point by passing a very weak electrical current along the needle, should be avoided in patients with elec- tronic implantable devices such as pacemakers. Massage Therapy Massage therapy is perhaps one of the oldest healing modalities. Hippocrates is quoted as saying “the physician must be experienced in many things, but most assuredly in rubbing.” Massage is most commonly used to relieve pain from musculoskeletal and other conditions as well as to improve function or relieve stress and aid in relaxation. However, there are more than 80 difgerent types of therapeutic massage, and certain techniques may be more benefjcial than others for specifjc conditions or complaints. Massage has a high use and acceptability in the United States, with approximately 18 million U.S. adults receiving massage in 2007. Tie exact mechanism by which massage may exert a therapeutic efgect is not clear. Massage is reported to improve local circulation, tone of supportive musculature, and joint fmexibility. One commonly held belief was that lactic acid build-up led to delayed-onset muscle soreness and that massage removed lactic acid from muscle. Lactic acid is only present substantially during and immediately afuer high-intensity anaerobic exercise. It is metabolized within 60 minutes afuer such exercise ceases and converted back to pyruvate for processing in the Krebs cycle to produce further energy. Some research has suggested that massage may impair lactic acid removal from muscle afuer strenuous exercise by mechanically impeding blood fmow. One study found that massage appeared to exert a clinical benefjt by reducing infmammation and promoting mitochondrial biogenesis.6 In a study of 11 young male ath- letes, massage was found to activate the mechanotransduction signaling path- ways, focal adhesion kinase (FAK) and extracellular signal–regulated kinase 1/2 (ERK1/2), potentiate mitochondrial biogenesis signaling (nuclear per-

• xisome proliferator–activated receptor γ coactivator 1α [PGC-1α]), and

mitigate an increase in nuclear factor κB (NFκB) (p65) nuclear accumula- tion caused by exercise-induced muscle trauma. Massage was also found to decrease the production of the infmammatory cytokines, tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), and to reduce heat shock protein 27 (HSP27) phosphorylation, ultimately decreasing the cellular stress result- ing from muscle fjber injury. Massage is also believed to decrease emotional stress through activation of the autonomic nervous system, leading to a variety of neuroendocrine efgects. Clinically, massage has been shown to be of potential benefjt for a number of conditions, including neck pain, low back pain, constipation, high blood pressure, lymphedema, stress, and depression. A randomized controlled trial of massage for osteoarthritis of the knee found that an 8-week course of massage decreased pain and improved function, with many

• f the efgects persisting for weeks afuer cessation of treatment. A4 Massage

appeared to be a viable option as an adjunct to more conventional treatment modalities. Massage is safe in most setuings. Although massage is not entirely risk free, serious adverse events are probably true rarities. Massage should be avoided

• ver rashes, open wounds, fractures, blood clots, or a tumor and is contro-

versial in patients with lymphatic malignancies. Massage can result in increased soreness or bruising and should done with caution in anyone with a bleeding disorder such as thrombocytopenia. Movement Therapy Movement therapy is a term used to describe a broad category of approaches that address health and disease by focusing on restoring balance to the body using physical movement. It includes such therapies as yoga, tai chi, Alexan- der Technique, Feldenkrais Method, and others. Although some therapies involve complex movements and require a trained instructor, others can be self-directed using instructional materials such as videos or books. Yoga and tai chi in particular have gained in popularity in the West and have a growing body of research suggesting positive health benefjts. Originating in India, yoga has been practiced for more than 5000 years. Tiere are hundreds of difgerent types of yoga, which typically involve prin- ciples of proper exercise, relaxation, breathing, diet, and meditation and were traditionally practiced to develop one physically, emotionally, and spiritually. In the West, yoga practices have focused on exercise or physical postures

CHAPTER 39 COMPLEMENTARY AND ALTERNATIVE MEDICINE

184 modalities, particularly in the nursing practice literature, few well-conducted studies existed. A 2008 study funded by NCCAM assessed the effjcacy of qi gong in the treatment of osteoarthritis of the knee. Tiis randomized con- trolled trial comparing two qi gong masters and a “sham” master found that although qi gong may have benefjt for patients with osteoarthritis of the knee, the two healers were not equivalent.10 Tiis study points out the challenge of determining the qualifjcation and competency of energy therapy providers for those interested in pursuing energy therapies as a possible therapeutic

• modality. Despite the lack of defjnitive research, energy therapies remain

popular with patients, and putative energy therapies are generally regarded as ofgering no measurable risk.

WHOLE MEDICAL SYSTEMS

It is important to recognize that many of the therapies and approaches described previously come from complete systems of healing, or whole medical systems. Tiese systems, with their own particular paradigm or way of viewing disease and health, include systems such as traditional Chinese medi- cine, Ayurvedic medicine, homeopathy, Native American healing, and naturopathy.

CONCLUSION

Although still controversial, use of CAM by both patients and conventionally trained providers has continued to increase. As evidenced by the growth of the Consortium of Academic Health Centers for Integrative Medicine, as well as such events as the Institute of Medicine’s 2009 Summit on Integrative Medicine and the Health of the Public, integration and acceptance of the concepts and principles of integrative medicine into the mainstream and academic medical setuings has also grown. Tiis is perhaps a result of a realiza- tion that many of the principles of integrative medicine, such as a partnering

• f patients and providers, care that addresses the whole person, and an

emphasis on not only treatment but also the broader concepts of health promotion and illness prevention, ofger at least part of the solution to the challenges of our evolving health care system. All health care providers, present and future, should be familiar with these concepts, including the safe and appropriate use of a broad range of healing sciences and providers to facilitate the body’s innate healing response, relieve sufgering, and optimize vitality. Relaxation techniques are a safe, typically low-cost option for patients in need of managing stress more efgectively or as a part of an overall plan to manage any of a myriad of stress-related conditions. Given the broad diversity

• f options, it is important for patients to fjnd a technique that feels most

comfortable to them based on goals, personality, beliefs, and lifestyle. Spinal Manipulation Spinal manipulation is a method based on the belief that misalignment of the spine can have deleterious efgects on health. Tie technique typically involves correction of a subluxation of the spine by applying a sudden force to the vertebrae or other joint while the patient is lying in various positions on an examining table. Chiropractic manipulation is similar to osteopathic manual therapy practiced by osteopathic physicians. However, osteopaths are medical physicians who may or may not use manipulation as a part of their treatment

• ptions. Whereas chiropractors may use a range of modalities, their main

focus is on manipulation and restoring of proper alignment of the spine. According to the 2007 NHIS study, more than 18 million adults and more than 2 million children had undergone chiropractic or osteopathic manipula- tion during the previous 12 months. Tie effjcacy of manipulation has been studied for a number of diverse conditions, with most studies focused on musculoskeletal disorders. A review

• f the evidence concluded that manipulation was efgective for acute, sub-

acute, and chronic low back pain; migraine and cervicogenic headache; cer- vicogenic dizziness; several extremity joint conditions; and acute or subacute neck pain.9 Tie existing evidence was found to be inconclusive for cervical neck pain of any duration, and for mid-back pain, sciatica, tension-type head- ache, cocydynia, temporomandibular joint disorders, fjbromyalgia, premen- strual syndrome, and pneumonia in older adults. Although minor side efgects such as soreness or light-headedness are not uncommon, overall the risk for a serious adverse event is very low. Concern has been raised that manipulation of the cervical spine may put patients at increased risk for vertebrobasilar artery stroke. However, any small increased risk for such a stroke associated with both chiropractic care and visits to primary care physicians may be because such patients were already having headaches or neck pain because of impending or ongoing vertebral artery dissection. Energy Therapies Energy therapies include a number of approaches in which the practitioner intends to channel healing energy (typically through the hands) into the person seeking help in order to restore balance of energy in the body and

• health. Tie core concept is that all humans have a subtle vital energy or bio-

fjeld that fmows through them and can be manipulated or used to infmuence

• health. Examples of therapies that use this concept are therapeutic touch,

healing touch, Reiki, qi gong, and intercessory prayer (prayer for an indi- vidual that is specifjcally directed at that person’s health). NCCAM distinguishes two categories of energy therapies or energy medi- cine: the veritable and the putative. Veritable energy therapies involve energy that can be measured, such as light therapy or electromagnetic radiation (radiation therapy), and are not considered CAM. Putative energy therapies are not measurable in a reliable way and involve theoretical manipulation or modulation of the vital force or biofjeld as described previously. Putative energy therapies have been challenged as being nonplausible bio- logically and as such are perhaps among the more controversial therapies categorized as CAM. Despite that, prayer for health was the most commonly used intervention in the 2007 NHIS report, with approximately 30% of respondents having had others pray for their health. Approximately 1% had used Reiki and 0.5% qi gong. A review of the literature on energy healing and pain, focused on Reiki, therapeutic touch, and healing touch, concluded that despite interest in these Grade A References

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CHAPTER 39 COMPLEMENTARY AND ALTERNATIVE MEDICINE

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