The NCCAM groups CAM practices into broad categories. These include: 1) natural products, 2) mind-body medicine, 3) manipulative and body-based practices, and 4) other CAM practices (
NCCAM, 2008a). Each of these categories encompasses a wide range of subcategories. Many CAM practices may fit into more than one category.
Natural Products
Natural products include a variety of herbal medicines (also known as botanicals), vitamins, minerals, and other “natural products.” Many of these products are sold as dietary supplements. Natural products also include probiotics—live microorganisms (usually bacteria) that are similar to microorganisms normally found in the human digestive tract. Probiotics are available in foods such as yogurts or in dietary supplements. In the 2007 NHIS survey, this category of CAM was the most frequently used with 17.7% of those surveyed using natural products (
Barnes et al., 2008).
The federal government regulates dietary supplements primarily through the U.S. Food and Drug Administration (FDA). The regulations for dietary supplements are not the same as those for prescription or over-the-counter drugs. In general, the guidelines are less strict. For example, a manufacturer does not have to prove the safety and effectiveness of a dietary supplement before it is marketed. Once a dietary supplement is on the market, the FDA monitors safety and product information, and the Federal Trade Commission (FTC) monitors advertising (
NCCAM, 2008a).
The NCCAM website provides a series of fact sheets on herbs and botanicals and includes common names, uses, potential side effects, and other resources for more information. The fact sheets are included in a free booklet published by
NIH and NCCAM (2011e).
The National Standard (http://www.naturalstandard. com) was founded by healthcare providers and researchers to provide quality evidence-based information about CAM. Each Natural Standard monograph on CAM is prepared using a variety of electronic databases including the Cochrane Library and MEDLINE. Their findings on herbs and supplements is compiled in a book,
Davis’s Pocket Guide to Herbs and Supplements (
Ulbricht, 2011). This source includes information on more than 600 products. It is organized like a traditional pharmacology pocket guide.
Another source of information about natural products is the Natural Medicines Comprehensive Database (http://naturaldatabase. therapeuticresearch.com/). This website states it is unbiased, scientific clinical information on complementary, alternative, and integrative therapies.
Dietary supplements are defined under the Dietary Supplement Health and Education Act of 1994 (
Zarowitz, 2010a). Manufacturers need to register themselves pursuant to the Bioterrorism Act with the FDA before producing or selling supplements. The United States Pharmacopeia (USP) is also involved in CAM because it has established criteria for levels of evidence that can be used to evaluate the literature on efficacy and safety of dietary supplements. Only products with moderate to high quality evidence are approved by the USP (p. 125).
Older adults are the largest per capita consumers of prescription medications and over-thecounter (OTC) complementary and alternative medicines in the United States (
Qato et al., 2008). Part of this could be due to the increase in chronic disease as we age, as well as efforts to counter undesirable effects of the aging process. The combination of an OTC dietary supplement and a prescribed medication could have serious side effects, particularly in the older adult. In a Mayo Clinic study of 1795 adults averaging 55 years of age, there were 107 dietary supplement-drug interactions of significance (cited in
Zarowitz, 2010b), The five supplements accounting for 68% of the interactions were kava, garlic, ginkgo
biloba, St. John’s wort, and valerian. The prescription medications most frequently implicated included: warfarin, sedatives/hypnotics, antidepressants, insulin, oral antidiabetic agents, hepatotoxic medications, oral contraceptives, and tramadol. Additionally, more than 78 dietary supplements have some effect on the CYP enzymes most commonly involved with drug metabolism (
Zarowitz, 2010b).
Mind-Body Medicine
For practitioner-based therapies, there is no standardized, national system for credentialing CAM practitioners. The extent and type of credentialing vary greatly from state to state. Some CAM practitioners (e.g., chiropractic) are licensed in all or most states. Other CAM practitioners are licensed in few states or not at all (
NCCAM, 2008a).
Mind-body practices focus on interactions among the brain, mind, body, and behavior. The intent is to use the mind to affect physical functioning and thus promote health. There are a wide variety of practices within this category. The main practices include: meditation, yoga, acupuncture, deep-breathing exercises, guided imagery, hypnotherapy, progressive relaxation, Qigong, and tai chi (see
Table 18.1). Acupuncture is also a component of energy medicine, manipulative and body-based practices, and traditional Chinese medicine (
NCCAM, 2008a). Use of three of these practices—deep-breathing exercises, meditation, and yoga—increased significantly in the 2007 NHIS survey compared with the 2002 NHIS survey.
Acupuncture has been practiced in China and other Asian countries for thousands of years. It has been practiced in the United States for 200 years. The FDA approved the acupuncture needle as a medical device in 1996 (
National Cancer Institute, 2011). Acupuncture has been used in a
wide variety of chronic conditions. A review of the Cochrane Database reveals three systematic reviews on acupuncture. Reviews include depression, chronic asthma, and stroke rehabilitation. The 2010 update of the original 2005 systematic review of acupuncture for depression now includes data from 30 studies. These 30 studies included 2812 participants in the meta-analysis. Two clinical trials found acupuncture may have an additive benefit when combined with medication compared to medication alone. However, the authors’ conclusion was that there was insufficient evidence to recommend the use of acupuncture for people with depression. Further, the results are limited by the high risk of bias in the majority of trials meeting inclusion criteria (
Smith, Hay, & Macpherson, 2010).
An updated review of a 2003 review of randomized clinical trials of acupuncture for chronic asthma included 12 studies with 350 participants meeting the inclusion criteria. Trial reporting was poor and trial quality inadequate. The conclusion of the authors was there was no change in the 2003 conclusion of insufficient evidence to make any recommendations of acupuncture in asthma treatment. (
McCarney, Brinkhaus, Lasserson, & Linde, 2009)
Five clinical trials of 368 participants met the inclusion criteria in a systematic review of acupuncture and stroke rehabilitation. These trials included both ischemic and hemorrhagic stroke in the subacute or chronic stage. There was no evidence of any effects of acupuncture on subacute or chronic stroke. This was an update to a 2006 Cochrane review (
Wu et al., 2009).
Manipulative and Body-Based Practices
These practices focus on the structures and systems of the body and include the bones and joints, soft tissues, and circulatory and lymphatic systems. Spinal manipulation (chiropractic) and massage therapy are the primary practices within this area. (
NCCAM, 2008b). See
Table 18-2.
Massage therapy is based on the principle that body tissues will function at optimal levels when arterial supply and venous and lymphatic drainage are unimpeded. Massage is designed to reestablish proper fluid dynamics through the skin, muscles, and fascia, although nerve pathways may sometimes be included (
Coughlin & Delany, 2011). Massage is generally applied in the direction of the heart to stimulate increased venous and lymphatic drainage from the involved tissues with muscles being addressed in groups. Different combinations of techniques are used depending on the objectives of the treatment; however, all five basic techniques are of the passive variety, meaning that the practitioner does all of the work (
Coughlin & Delany, 2011).
A 2011 review of Cochrane Systematic Reviews revealed several reviews of massage therapy, all associated with a specific disorder. One condition that is typically associated with the use of massage therapy is low back pain. Massage in the Cochrane review was defined as soft tissue manipulation using hands or a mechanical device on any body part. Thirteen randomized trials with 1596 participants were included in the review (
Furlan, Imamura, Dryden, & Irvin, 2008). The authors concluded that massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education.
The main emphasis of chiropractic care is on the spine and its effects to the central nervous system, the autonomic nervous system, and the peripheral nervous system. Chiropractors
emphasize that adjusting the spinal joints and resolving subluxations restore normal nerve function and optimal health (
Freeman, 2009). A Cochrane systematic review examined 12 studies involving 2887 participants with low back pain who were using combined chiropractic interventions. The authors concluded that combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute lower back pain. However, there is no current evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability when compared with other interventions (
Walker, French, Grant, & Green, 2010).
