CHAPTER 18. Complementary Therapies
Susan A. Goodwin and Jane C. Dierenfield
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define the terms complementary therapies (CTs) and integrative medicine.
2. Discuss the influence of Eastern medicine, including Traditional Chinese Medicine and East Indian contributions.
3. Compare and contrast 27 commonly used herbs, vitamins, and dietary supplements.
4. Summarize six CTs that could be used in the perianesthetic period.
5. Briefly define additional CTs.
I. OVERVIEW OF COMPLEMENTARY THERAPIES (CTs)
A. Definitions
1. Conventional medicine—practiced by medical doctors or doctors of osteopathy, and other allied health professionals (e.g., registered nurses, psychologists, or physical therapists)
a. Taught at United States (U.S.) medical schools, and generally provided at U.S. hospitals
b. Commonly known as Western medicine and is based on biology and pathology
2. CTs: group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine
a. Used in conjunction with conventional medicine, or used by themselves without conventional medicine
b. Based on Eastern philosophy, which is based on balance and harmony
c. Oriental medicine began approximately 5000 years ago. The Yellow Emperor’s Classic of Internal Medicine was written 2000 years ago.
3. Integrative medicine—the eventual combination of CT and medicine
4. Reliable evidence of complementary medicine efficacy is needed before its integration into clinical practice.
B. Clinical trial articles of complementary medicine increased from 1987 through the present.
II. CURRENT UTILIZATION OF CTS
A. Terms
1. “Complementary and alternative medicines” (CAMs) commonly used.
a. In the medical literature
b. By the National Center for Complementary and Alternative Medicine (NCCAM)
2. The term CAMs will be used when referring to medical practice.
3. In this chapter, CTs will be used to describe these interventions, as this term more appropriately describes nursing practice.
B. Current use
1. Searches conducted in 2008 on Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Google Scholar revealed a plethora of articles on CAM. Diverse patient and ethnic populations represented, and treatment of a variety of diseases and conditions was detailed.
2. When health insurance plans offered CT coverage, it varied by state and was often limited. Most CTs were paid out-of-pocket.
3. Health insurance covers the following:
a. Chiropractic
b. Acupuncture
c. Massage
d. Biofeedback
e. Naturopathy
C. NCCAM
1. In 1992, the National Institutes of Health established the Office of Alternative Medicine (OAM).
a. Mission: to provide the Americans with reliable information about the CAM safety and effectiveness
b. Budget for 1992 was $2 million.
2. Congress expanded the OAM into the NCCAM in 1998.
3. The annual budget was increased to $121.6 million in 2008.
4. CAM is defined by the NCCAM as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.
5. A review of clinical trials listed on the NCCAM website lists 235 completed clinical trials, (90 that are beginning the recruiting process, and over 100 that are in progress as of March 2009).
D. Partial listing of CTs
1. Acupuncture/acupressure
2. Aromatherapy
3. Ayurveda
4. Chiropractic
5. Dietary supplements
6. Energy healing
7. Guided imagery
8. Herbal therapies
9. High-dose vitamin or megavitamin therapies
10. Homeopathy
11. Magnetic therapy
12. Massage
13. Meditation
14. Music
15. Naturopathy
16. Osteopathic
17. Prayer
18. Qigong
19. Reiki
20. Relaxation techniques
21. Therapeutic touch
22. Yoga
E. Recent trends in CTs in the U.S.
1. National surveys indicate that CTs are widely used and increasing in popularity.
2. Use of CTs tends to be higher among patients who are:
a. Female
b. Middle aged or younger, 35 to 49 years of age
c. White
d. Married
e. Employed
f. More affluent
g. Better educated, with some college education
h. Have more insurance
i. Live in the western part of the U.S.
3. People who use CTs also use medical doctors.
a. The more visits made to a medical doctor, the more likely he or she was to use CAM.
4. CTs are used less frequently by:
a. African Americans
b. Persons 65 years or older
5. CTs are used most frequently for:
a. Chronic pain
b. Anxiety and/or depression
c. Urinary tract problems
d. Back problems
e. Headaches
f. Allergies
g. Arthritis
h. Digestive problems
i. Cancer
j. Diabetes
k. Acquired immunodeficiency syndrome
l. Preventing future illness from occurring
m. Maintaining health and vitality
6. Unsupervised use, which is a form of expanded self-care, is the usual method of use for most CTs. There is usually no involvement of either a medical doctor or a complementary medicine practitioner.
7. The increasing use of CTs has occurred despite the fact that the majority of costs have been paid out-of-pocket.
F. Use of CTs throughout the world
1. In Denmark in 1987, 10% of the population used CTs.
2. In Australia in 1993, 49% of the population used CTs.
3. The United Kingdom spent $94 million on herbal remedies and $30 million on homeopathic remedies.
4. Germany spent $541 million on herbal remedies and $528 million on homeopathic remedies.
5. In Germany, herbal medicine is well integrated into the medical culture.
a. Tens of millions of prescriptions written by physicians for herbal medicines each year
G. Reasons for use of CTs
1. Dissatisfaction with conventional treatment
2. Desire to try all options, especially among cancer patients
3. Anecdotal information from friends or acquaintances
4. Belief that CTs are less harmful than conventional therapies
5. Many CTs are holistic and encompass a spiritual component, which is lacking in conventional medicine.
H. Implications for further study
1. The use of traditional randomized, double-blind, placebo-controlled clinical trials with CTs presents certain challenges.
2. It would be extremely difficult to design and implement randomized, double-blind, placebo-controlled clinical trials of all the CTs that are in use today.
3. Many of the CTs have been in use for thousands of years, with vast anecdotal success.
4. Treatment plans with CTs are often individualized and are thus hard to replicate.
5. CTs are increasingly being integrated with conventional medicine, rather than being used alone or in the place of conventional medicine.
6. Pharmaceutical companies invest between $350 and $500 million in a 10-year period to bring a new drug to market; when the drug is marketed, the money is recouped.
7. Obtaining financial support for research on herbs is difficult because there is no financial incentive for investment by pharmaceutical companies.
a. The herb is readily available, cannot be patented, and is thus not financially lucrative.
III. PREOPERATIVE ASSESSMENT OF PERIANESTHETIC PATIENTS
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A. Lack of report of CTs
1. A study of older adults residing in Minnesota revealed that 62.9% used CAMs, while only 53% disclosed their CAM use to their primary care providers.
2. The flourishing use of herbal preparations increases the need to question preoperative patients about their use of herbals.
3. Many people do not view herbals as “medicine” or may be reluctant to disclose their uses of CT to conventional practitioners, such as nurses or doctors.
4. The preoperative nurse must make specific and repeated inquires to the patient about the potential use of herbals.
B. Herbals
1. Are plant-derived products used for medicinal and health purposes (Table 18-1).
| BPH, Benign prostatic hypertrophy; FDA, Food and Drug Administration; GABA, gamma-aminobutyric acid; GERD, gastroesophageal reflux disease; GI, gastrointestinal; INR, international normalized ratio; MAOIs, monoamine oxidase inhibitors; MI, myocardial infarction; NSAIDs, nonsteroidal anti-inflammatory drugs; PMS, premenstrual syndrome; PONV, postoperative nausea and vomiting; SSRIs, selective serotonin reuptake inhibitors (such as nefazodone, sertraline, or paroxetine); TMJ, temporomandibular joint. | |||||
| Herb | Actions | Uses | Side Effects | Perianesthetic Implications | Preoperative Precautions |
|---|---|---|---|---|---|
| Aloe vera | Anti-inflammatory. Relieves pain, decreases inflammation and swelling, and may encourage wound contraction. May increase blood flow. Useful for first- and second-degree burns. May be useful in the treatment of psoriasis. | Topical: Emollient. Encourages healing of a wound, burn, hemorrhoids, insect bites, poison ivy or oak, rashes, sunburn, and yeast infections. Oral: Treats or prevents constipation. | Rare topical allergic reactions. Oral gel can reduce absorption of many drugs. | Oral use may cause hypokalemia due to cathartic effects. | Not necessary |
| Arnica | An immunostimulant. May increase macrophage activity and blood circulation to injured area. Has anti-inflammatory and mild analgesia properties. Is frequently combined with goldenseal. | Topical and Oral: Relieves muscle, joint, and cartilage pain from bruises, contusions, hyperextensions, bursitis, and arthritis. | Long-term topical use can lead to toxic skin reactions. Internal use has a very narrow dosing range. The FDA classifies arnica as unsafe for internal use. The German Commission E does not recommend internal use because of potentially toxic effects. | May be the source of preoperative skin irritations. May have minimal anticoagulant effects. | 2 weeks |
| Black cohosh | Estrogenic activity. Causes hypotensive effects via decreased vascular spasm. Has sedative, anti-inflammatory, and antispasmodic effects. | Approved by the German Commission E for the treatment of PMS, dysmenorrhea, and menopausal symptoms, including mood changes. May inhibit bone loss caused by menopause. Appears to increase the normal growth of vaginal cells, thereby reducing vaginal dryness and dyspareunia. Alleviates insomnia. Used as an anti-inflammatory for arthritis. (Remifemin, a European form of black cohosh, is available in the United States.) | GI discomfort, frontal headache, nausea, heaviness in the legs, weight problems, dilated pupils, and flushed face. Avoid use during pregnancy or lactation. | May cause hypotension and bradycardia. May potentiate antihypertensive medications. | 2 weeks |
| Chamomile | Mild sedative. Has antispasmodic, antibacterial, antipyretic, and anti-inflammatory activity. | Used as an antiemetic, for indigestion, to decrease cramping secondary to diarrhea, and as an aid for sleep. Used for dysmenorrhea and to treat arthritis. | Allergic reactions are common, especially in patients who are allergic to ragweed, and include contact dermatitis and pharyngeal edema. | May potentiate sedation. Anticoagulant effects due to platelet inhibition. | 2 weeks |
| Cranberry | Prevents Escherichia coli from adhering to bladder wall and the urinary tract. Acidifies the urine. | To acidify the urine and treat urinary tract infections. Decreases the incidence of urinary stones. | None with normal doses. Very large doses may result in diarrhea. | None known | Not necessary |
| Echinacea | Anti-inflammatory, immunostimulating, bacteriostatic, bactericidal, and free-radical scavenging effects. Causes activation of cell-mediated immunity. Enhances phagocytosis. Decreases the activity of viruses. | Used for the prophylaxis and treatment of bacterial and fungal infections. Begin use at the first sign of a cold to decrease cold symptoms and duration. If used for longer than 8 weeks, the effectiveness declines. Also used to treat chronic wounds, ulcers, and arthritis. Used in Germany along with chemotherapy to treat cancer. | Use longer than 8 weeks could cause immunosuppression and hepatotoxicity (some controversy exists about this). Should not be used with other hepatotoxic drugs, such as anabolic steroids, amiodarone, methotrexate, or ketoconazole. Do not give concomitantly with immunosuppressants. Can cause transplant rejection. Use with caution in patients with asthma or allergic rhinitis. May cause allergic responses in individuals allergic to ragweed. | Causes inhibition of hepatic enzymes. May affect many anesthetic agents. | 2 weeks |
| Evening primrose oil | Chemical constituents are prostaglandin precursors, which have anti-inflammatory properties. | Used for PMS symptom relief, diabetic neuropathy, numerous skin conditions, and chronic autoimmune diseases such as rheumatoid arthritis, Raynaud’s syndrome, and multiple sclerosis. | Lowers seizure threshold and increases anticonvulsant requirements. Nausea, softening of stools, and headache. | May interact with drugs that are anticonvulsants. Inhibits platelet aggregation. | 2 weeks |
| Feverfew | A prostaglandin inhibitor. Has been shown to suppress 86%-88% of prostaglandin production. | Used to treat migraines, other types of headaches. Can reduce the number as well as severity of migraines. Also used to treat fever, dizziness, stomachache, and rheumatoid arthritis. | NSAIDs may negate the effects of feverfew in the treatment of migraines. May cause mouth ulcers. | Anticoagulant effects due to platelet inhibition. | 2 weeks. Discontinuation after prolonged use can cause a rebound effect, resulting in symptoms of migraine, insomnia, and anxiety. A slow withdrawal may reduce these effects. |
| Garlic | Can lower the risk of developing atherosclerosis through its antihypertensive and anticholesterolemic effects, as well as platelet inhibition. Has antibacterial and antiviral properties. Appears to prevent some cancers. | Used to treat hypertension, hypercholesterolemia, atherosclerosis, and infection. | Inhibits platelet function and fibrinogen. Concomitant use with aspirin, NSAIDs, or anticoagulants is not recommended. May cause nausea, hypotension, and allergy. Bad breath is a common side effect. | Anticoagulant effects due to platelet inhibition. Can cause hypotension. | 2 weeks |
| Ginger | Has antiemetic, antispasmodic, and anti-inflammatory properties. A potent inhibitor of thromboxane synthetase. | Used to treat PONV, motion sickness, hyperemesis gravidarum, intestinal gas, indigestion, and arthralgias. | Inhibits platelet function. May cause GI upset when taken on an empty stomach. | Anticoagulant effects due to platelet inhibition. May cause hypotension or bradycardia. | 2 weeks. However, there have been studies in which ginger was given just before surgery to reduce PONV, and no increased bleeding was seen. |
| Ginkgo biloba (also sold under Bai Guo Ye, Baiguo, & Fossil Tree) | Its components act as antioxidants, alter vasoregulation, alter neurotransmitter and receptor activity, and inhibit platelet-activating factor. | Stabilizes and perhaps improves cognitive function in patients with dementia. Used for peripheral vascular disease, vertigo, tinnitus, and erectile dysfunction. Promotes vasodilation, improves mental function and sexual functioning. Slows macular degeneration and protects the retina, especially in diabetic retinopathy. | Mild GI upset and headache. Inhibits platelet function and fibrinogen. Concomitant use with aspirin, NSAIDs, or anticoagulants is not recommended. May diminish effectiveness of anticonvulsants. | Anticoagulant effects due to platelet inhibition. | 2 weeks |
| Ginseng | A number of ginseng products exist, whose effects vary widely. It is important to be familiar with which ginseng is used. In general, acts as an adaptogen, protecting the body against stress and restoring homeostasis. The underlying mechanism appears to be similar to steroids. Acts as an immunostimulant. Has a hypoglycemic effect. | Used to reduce stress and improve vitality. Can also be used for mild depression, chronic fatigue syndrome, fibromyalgia, and stress-induced asthma. Improves cognitive function, attention span, psychomotor performance, and concentration. | May cause headache, tremulousness, and insomnia. Avoid in patients with bipolar syndrome and psychosis. Avoid concurrent use with estrogens and corticosteroids due to additive effects. May lower blood glucose levels; should not be used in patients with diabetes. Concomitant use with aspirin, NSAIDs, or anticoagulants is not recommended due to inhibition of platelet function. | Anticoagulant effects due to platelet inhibition. Can cause hypertension or tachycardia. May potentiate sedation and hypoglycemia. | 2 weeks |
| Goldenseal | Has antibacterial properties. May reduce gastric inflammation. Frequently combined with arnica. | Used for its antibacterial and antifungal properties to treat conjunctivitis, gastric and duodenal ulcers, thrush, and strep throat. | Excessive doses can cause jaundice and elevated liver enzymes. Contraindicated with diarrhea, GI cramping, and nausea and vomiting. | Use cautiously with heparin. May augment or diminish effects of antihypertensives. | 2 weeks |
| Kava-kava | Acts as a sedative-hypnotic possibly by potentiating GABA inhibitory neurotransmission. Has mild analgesic and muscle-relaxing effects. Has abuse potential. | Alleviates stress, anxiety, tension, and nervousness. Used as an anxiolytic and sedative. Relieves tension headaches and muscle spasms (restless leg syndrome, TMJ pain). | Avoid concomitant use with barbiturates, alcohol, and benzodiazepines as excessive sedation can occur. Do not use with antiparkinsonian drugs. Decreases platelet function. Heavy use produces kava dermopathy, characterized by reversible, scaly, cutaneous eruptions accompanied by jaundice. The sale of kava has recently been banned in Canada and the United Kingdom because of reported liver damage. | Excessive sedation can occur with anesthetic drugs. Anticoagulant effects due to platelet inhibition. | 24 hours |
| Ma huang (ephedra) | Known as ephedra. Ephedrine, a sympathomimetic amine, is the predominant active compound. It increases heart rate and blood pressure, bronchodilates, has anti-inflammatory properties, and inhibits prostaglandins. | Commonly used as a decongestant for allergies and hay fever. Used to promote weight loss, increase energy, and treat bronchospastic disorders such as asthma or bronchitis. Also used as an aphrodisiac. | Cause dose-dependent increases in blood pressure and heart rate. Can cause palpitations, coronary spasm, MI, and stroke. Concomitant use of ephedra and MAOIs can result in hyperpyrexia and hypertension. The American Medical Association has called for a ban of ephedra in supplements. | May cause hypertension or arrhythmias. When given halothane, may cause ventricular dysrhythmias. | 7 days |
| Peppermint | Relaxes the lower esophageal sphincter. Antispasmodic, smooth muscle relaxant. | Used for nausea, rhinitis, heartburn, and flatulence. | Avoid in patients with hiatal hernia and GERD, as the relaxation of the lower esophageal sphincter may worsen symptoms. | None known | Not necessary |
| Saw palmetto (also called American dwarf palm tree, cabbage palm or ju-zhong) | Increases urinary flow, decreases nocturia, and decreases postvoid residual volumes. Acts as a urinary antiseptic. | Relief of BPH symptoms, such as frequent urination, difficulty in initiating urination, and high residual volume. Useful in chronic pelvic pain, bladder disorders, decreased sex drive, hair loss, and hormone imbalance. | Side effects uncommon, but may include mild GI distress, bleeding, and headache. Because of its antiplatelet effect, the use of aspirin on NSAIDs may increase bleeding risk. | May increase INR in patients receiving warfarin. | 2 weeks |
| St. John’s Wort | Acts similarly to MAOIs or SSRIs by inhibiting serotonin, norepinephrine, and dopamine reuptake by neurons. | Licensed in Germany for the treatment of anxiety, depression, nerve pain, and sleep disorders. Use for moderate depression may be more effective than a placebo. A 2005 study found that St. John’s Wort was more effective than fluoxetine (Prozac). | Avoid concomitant use with MAOIs and SSRIs, which could result in a serotonin syndrome. May inhibit the absorption of iron. Causes photosensitivity. Through enzyme induction, increases the metabolism of many drugs, including cyclosporine, alfentanil, midazolam, lidocaine, calcium channel blockers, warfarin, and SSRIs. Avoid in pregnancy. | May potentiate anesthetic effects. May affect blood pressure. | 7 days. Discontinuation is especially important in patients awaiting organ transplantation or who may require anticoagulation therapy postoperatively. |
| Valerian | Causes a significant decrease in sleep latency. Causes dose-dependent sedation and hypnosis. | Used for insomnia, anxiety, headache, irregular heartbeat, depression, or trembling. | Avoid concomitant use with barbiturates, alcohol, and benzodiazepines as excessive sedation can occur. Can cause “morning hangovers.” May cause paradoxical stimulation, GI upset, nervousness, disturbed sleep, and rare liver toxicity. | May potentiate sedation caused by anesthesia. | 7 days. Abrupt discontinuation in patients who are physically dependent may cause benzodiazepine-like withdrawal. Taper over several weeks. |
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