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Complementary and Alternative Therapies
The use of complementary and alternative treatments has continued to increase in the United States (National Center for Complementary and Alternative Medicine [NCCAM], 2008a
). What motivates an individual with chronic illness to try nontraditional therapies? If the traditional allopathic approach is not able to provide a treatment that relieves human suffering and improves quality of life, should healthcare providers help individuals with chronic illnesses find nonallopathic treatments that may help? What is the role of government in balancing the safety of healthcare treatments with an individual’s right to access alternative or complementary treatments? Addressing these questions in a scholarly, evidence-based manner assists the healthcare professional in providing improved health care for clients with chronic illnesses.
The National Health Interview Survey (NHIS) provides rich data on the use of CAM. The 2007 survey of 23,393 adults was conducted to determine usage. Nearly 4 of 10 adults (38.3%) and 11.8% of children under age 18 had used CAM therapies in the last 12 months (Barnes, Bloom, & Nahin, 2008
). The 2007 survey expanded the 2002 survey by increasing the number of CAM therapies in the survey from 27 to 36 as well as the number of diseases treated with CAM from 73 to 81. The structure of this survey was quite different from the 2002 survey. The 36 CAM therapies were grouped into five broad categories: alternative medical systems, biologically based therapies, manipulative and body-based therapies, mind-body therapies, and energy healing therapies. This survey followed the taxonomy of
unconventional health care proposed by Kaptchuk and Eisenberg (2001)
, meaning that folk medicine practices, stress management courses, support groups, and religious (faith) healing—for example, praying for one’s own health or having others pray for one’s health—were not included in the definition of CAM in this report (Barnes et al., 2008
; Nahin, Barnes, Stussman, & Bloom, 2009
). This differs significantly from the 2002 NHIS survey where prayer for self and prayer for others were included. The most frequently cited therapies in the 2007 survey included: nonvitamin, nonmineral natural products (17.7%); deepbreathing exercises (12.7%); meditation (9.4%); chiropractic or osteopathic manipulation (8.6%); massage (8.3%); and yoga (6.1%) (Barnes et al., 2008, p. 2
). From 2002 to 2007, there was increased use of mind-body therapies, acupuncture, massage therapy, and naturopathy. There was a significant decrease in the use of the Atkins diet.
Reasons for Use
Individuals with chronic illnesses often feel frustrated with disease-focused, fragmented, timelimited traditional allopathic care. As a result, they may turn to alternative or complementary practitioners, who may take more time to listen and evaluate not only their health problems but their entire lives. Specifically, these nontraditional healthcare services are noted for extensive clinical evaluations that focus on understanding individuals and their experiences in dealing with a chronic illness; continuity with care providers over time; active participation in care by clinicians, patients, and their family members; choice of individualized services; provision of hope; open communication and information sharing; and an emphasis on the meaning and spiritual components of dealing with chronic illnesses (Bezold, 2005
; Oguamanam, 2006
; Saydah & Eberhardt, 2006).
The most commonly reported health problems treated by CAM in the 2007 NHIS survey included: musculoskeletal problems, including back pain or problems (17.1%); neck pain or problems (5.9%); joint pain or stiffness or other joint condition (5.2%); arthritis (3.5%); and other musculoskeletal conditions (1.8%) (Barnes et al., 2008, p. 4
). These data are relatively unchanged from 2002. The use of CAM to treat head or chest colds showed a marked decrease from 2002 to 2007 (9.5% to 2.0%). A small increase in CAM use was seen in treating cholesterol problems. Lastly, data from the 2007 survey were consistent with the 2002 data demonstrating that CAM use was more prevalent among women, adults aged 30 to 69; higher levels of education; individuals who were not poor; adults living in the West; former smokers; and adults who were hospitalized within the last year (Barnes et al., 2008, p. 4
More than two-thirds of CAM users do not tell their physicians or healthcare providers about using these therapies (Briggs, 2007
). Perhaps this is because when clients do tell their clinicians about their choices, they might scold them, become angry and defensive, or dismiss clients’ reasons for seeking additional care instead of exhibiting understanding behaviors. This lack of empathy may result in future reluctance to tell conventional practitioners about nonstandard treatments as well as loss of trust in allopathic providers (Oguamanam, 2006
; Sleath, Callahan, DeVellis, & Sloane, 2005
In 2007 adults in the United States spent $33.9 billion dollars out of pocket on visits to CAM practitioners and purchases of CAM products,
classes, and materials. Practitioner costs totaled $11.9 billion dollars (35.2%). The remaining $22.0 billion dollars (64.8%) included costs associated with relaxation techniques; homeopathic medicine; yoga, tai chi, and qigong classes; and self-care costs to include nonvitamin, nonmineral natural products (Nahin et al., 2009, p. 3
). Approximately 75% of visits to CAM practitioners and total costs related to visits to CAM providers were associated with manipulative and body-based therapies (chiropractic or osteopathic manipulation, massage, and movement therapies) (p. 6).
Overview of NCCAM
A national initiative established in 1991 to evaluate alternative treatments led to the establishment of the Office of Alternative Medicine (OAM) at the National Institutes of Health (NIH). In 1998 the OAM became the National Center for Complementary and Alternative Medicine (NCCAM).
The role of the NCCAM is to explore CAM practices using rigorous scientific methods and build an evidence base regarding the safety and effectiveness of such practices. This mission is achieved through basic, translational, and clinical research; research capacity building and training; and education and outreach programs. There are four foci of the NCCAM: 1) advancing scientific research, 2) training CAM researchers, 3) sharing new information, 4) supporting integration of proven CAM therapies (NCCAM, 2010a
). The NCCAM has authored a number of pamphlets/publications, which can also be found online, for the public to further describe CAM, including Evaluating Web-based Health Resources
(2011a); Selecting a CAM Practitioner
(2011b); and Using Dietary Supple-ments Wisely
(2011c). Many other patient and family materials are available.
The NCCAM receives its budget through the National Institutes of Health (NIH). The budget rose steadily from 1999 (when it became an institute) to 2005; the financial year (FY) budget in 2005 was $123.1 million dollars and for FY2010 it was $128.8 million dollars. The NCCAM (2011d)
recently released its third strategic plan, Exploring the Science of Complementary and Alternative Medicine: Third Strategic Plan 2011-2015
. The five strategic objectives include:
Advance research on mind and body interventions, practices, and disciplines
Advance research on CAM natural products
Increase understanding of “real world” patterns and outcomes of CAM use and its integration into health care and health promotion
Improve the capacity of the field to carry out rigorous research
Develop and disseminate objective, evidence-based information on CAM interventions (NCCAM, 2011d
As one can see, many of the strategic objectives are focused on research. In exploring the literature for this chapter, the lack of rigorous research was evident. Textbooks on CAM seem somewhat incomplete, with old references or a lack of references. Because of these concerns, the research cited in this chapter has been carefully screened.
Common Treatment Modalities
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 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 (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
). 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 (naturaldatabase
). 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
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.
Table 18-1 Mind-Body Medicine
Refers to a group of techniques such as mantra meditation, relaxation response, mindfulness meditation, and Zen Buddhist meditation; elements include a quiet location, specific comfortable position, focus of attention, and an open attitude
Practice is believed to result in a state of greater calmness and physical relaxation and psychological balance due to person learning to focus attention
Combines physical postures, breathing exercises, meditation, and the spirit
Enhances stress-coping mechanism and mind-body awareness
Thin needles are inserted superficially on the skin in various patterns and left in place for 8 to 20 minutes
Points along channels of energy are manipulated to restore balance; acupuncture is part of Traditional Chinese Medicine
Sources: National Center for Complementary and Alternative Medicine. (2007a). Acupuncture: An introduction. Retrieved August 30, 2011, from: nccam.nih.gov/health/acupuncture/introduction.htm; National Center for Complementary and Alternative Medicine. (2008c). Yoga for health: An introduction. Retrieved August 30, 2011, from: nccam.nih.gov/health/yoga/introduction.htm#keypoints; National Center for Complementary and Alternative Medicine. (2006a). Meditation: An introduction. Retrieved August 30, 2011, from: nccam.nih.gov/health/meditation/overview.htm#keypoints.
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
Table 18-2 Manipulative and Body-Based Practices
Encompasses many techniques. Therapists press, rub, and manipulate the muscles and other soft tissues of the body.
Numerous theories about how massage therapy may affect the body. One is the gate control theory that suggests that massage helps to block pain signals to the brain. Other theories suggest that massage stimulates the release of certain chemicals in the body
A practice in which pressure is applied to points on the foot and sometimes the hand with the intent to promote relaxation or healing in other parts of the body
There are “reflex” areas on the feet and hands that correspond to specific organs (e.g., tips of the toes and the head)
Adjustments, high-velocity, and lowamplitude thrusts are made on the spinal column. Focuses on the relationship between body’s structure, mainly the spine, and its functioning
Rearranging displaced structures promotes healing, improves functioning, and decreases pain.
Source: National Center for Complementary and Alternative Medicine. (2006c). Massage therapy: An introduction. Retrieved August 30, 2011, from: nccam.nih.gov/health/massage/massageintroduction.htm; National Center for Complementary and Alternative Medicine. (2010b). Irritable bowel syndrome and CAM: At a glance. Retrieved August 30, 2011, from: nccam.nih.gov/health/digestive/IrritableBowelSyndrome.htm; National Center for Complementary and Alternative Medicine. (2007b). Chiropractic. Retrieved August 30, 2011, from: nccam.nih.gov/health/chiropractic/; National Center for Complementary and Alternative Medicine. (2006b). What is reflexology? Retrieved August 30, 2011, from: altmedicine. about.com/od/therapiesfromrtoz/a/Reflexology.htm
Other CAM Practices
This broad category includes:
Western and Eastern movement therapies such as Pilates, Rolfing, and the Feldenkrais method
Manipulation of energy fields, such as magnet therapy, qigong, Reiki, and healing touch
Whole medical systems such as Ayurvedic medicine, traditional Chinese medicine, homeopathy, and naturopathy (see Table 18-3
Table 18-3 Other CAM Practices
Self-initiated moving meditation consisting of movement, self-massage, meditation, and breathing. It is a combination of Qi (life-force, energy, creativity, consciousness, breath, function) and gong (cultivation or practice over time).
Qigong puts the body into the relaxation/regeneration state where the autonomic nervous system is predominately in the parasympathetic mode.
Traditional Chinese medicine
All aspects of the person are interconnected and interact with the environment. Acupuncture, herbs, and nutrition are used to promote health and internal and external balance.
Health and healing result from determining and resolving imbalances of energy flow in the body. Central to TCM is yin-yang theory; qi which circulates in the body through a system of pathways called meridians; the use of 8 principles to analyze symptoms and categorize conditions and 5 elements to explain how the body works (these elements correspond to organs and tissues in the body)
A whole medical system based on the principle of similars (or “like cures like”). Remedies are made from naturally occurring substances from plants, minerals, or animals. Common remedies include red onion, arnica, and stinging nettle plant.
This whole medical system seeks to stimulate the body’s ability to heal itself by giving very small doses of highly diluted substances based on the principle of similars.
Japanese technique for stress reduction and relaxation that promotes spiritual healing and self-improvement; administered through laying on of hands
An unseen “life force energy” flows through us and is what causes us to be alive. If that energy is low, the likelihood of getting sick or feeling stress is high. Reiki is not taught in the traditional sense of the word, but is transferred to a student during an “attunement” in a Reiki class given by a Reiki master.
Sources: Qigong Institute. (2004-2011). What is Qigong? Retrieved August 30, 2011, from: www.qigonginstitute.org/html/qigonghealth.php#AboutQigong; International Center for Reiki Training. (1990-2011). What is Reiki? www.reiki. org/FAQ/WhatIsReiki.html; NCCAM. (2009b). Traditional Chinese medicine: An introduction. Retrieved September 11, 2011, from nccam.nih.gov/health/whatiscam/chinesemed.htm; NCCAM. (2009a). Homeopathy: An introduction. Retrieved September 11, 2011, from nccam.nih.gov/health/homeopathy/; NCCAM. (2006d). Reiki: An introduction. Retrieved September 11, 2011, from nccam.nih.gov/health/reiki/introduction.htm
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