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Complementary and Alternative Medicine
Paul Crawford, MD
image BASICS
  • Complementary and alternative medicine (CAM) are medical and health care systems, practices, and products not presently considered part of conventional medicine.
  • The National Center for Health Statistics (NCHS) 2012 survey (1) reports nonvitamin, nonmineral dietary supplements, chiropractic or osteopathic manipulation, yoga, and massage therapy were the most common complementary health approaches used.
  • 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 trained in CAM or by a group of diverse health care providers.
    • 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, 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 body's soft tissues, 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 (cranium, sacrum, spinal cord, meninges, CSF).
    • Chiropractic therapy focuses on the musculoskeletal and nervous systems and how imbalances in these systems can affect general health. It is used to treat back, neck, and joint pain. Doctors of Chiropractic (DCs) complete 4 to 5 years of intensive training in anatomy, physiology, and manipulation.
  • Mind-body medicine
    • Meditation 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. Mindfulness meditation involves making oneself aware of the most immediate of activities in order to gain control over actions and anxiety.
    • Spiritual practices; for example, prayer
    • Yoga is an exercise of mindfulness, meditation, strength, and balance. It is composed of asanas (postures) and pranayamas (focused breathing).
    • Aromatherapy uses highly concentrated plant extracts to stimulate healing processes. These aromatic oils are rubbed on the skin, aerosolized, or used in compresses.
    • Relaxation techniques include breathing exercises, progressive muscle relaxation, and guided imagery.
    • Tai chi and qi gong are Chinese exercise systems that combine meditation, regulated breathing, and flowing dance-like 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 uses 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. Only three states license homeopaths.
    • 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. Four-year doctoral training programs are available; however, only 20 states/territories have licensing laws for naturopathic practitioners.
  • Energy therapies
    • Reiki, which means “source energy,” is a healing practice 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 stimulating a patient's life force energy.
  • Common reasons patients choose CAM
    • Additive therapy to address aspects not provided for in conventional medical treatment
    • Conventional medicine has been unsuccessful in fully addressing ailment.
    • Preventive health care
    • Desire for a holistic and natural approach to well-being
    • Preference for noninvasive treatment options
    • Concern about side effects of 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.
EPIDEMIOLOGY
  • All ages use CAM, but it is most prevalent among adults aged 30 to 69 years.
  • Gender ratio: female > male
  • College graduates and residents from western states are more likely to use CAM.
  • Cancer survivors are more likely than the general population to use CAM.
  • Six most used CAM therapies based on the NCHS 2012 survey. These CAM therapies were used by the indicated percentage of survey participants:
    • Nonvitamin, nonmineral dietary supplements (17.9%)
    • Chiropractic and osteopathic manipulation (8.5%)
    • Yoga (8.4%)
    • Massage (6.8%)
    • Meditation (4.1%)
    • Special diets (3.0%)
image TREATMENT
  • Variable evidence supports safety and efficacy of
    • Meditation for lowering BP (2)[C]
    • Acupuncture for chronic low back pain (3)[B]
    • Acupuncture to improve fertility (4)[C]
    • Spinal manipulative therapy for prophylactic treatment of headaches
    • Ginger for nausea, including that associated with chemotherapy
    • Manipulation, massage, and mobilization for acute low back and posterior neck pain
    • Massage therapy to promote weight gain in preterm infants
    • Massage (30 minutes × 3) during labor shortens the second stage and reduces pain (5)[A].
    • Acupuncture for chemotherapy-induced nausea and vomiting
    • Tai chi for improving balance and decreasing the risk of and fear of falling in elderly
    • Mind-body techniques for migraines, chronic pain, and insomnia
    • Homeopathic remedy for the treatment of chemotherapy-induced stomatitis in children
    • Riboflavin for migraine prophylaxis
    • Horse chestnut seed extract to improve lower leg venous tone, pain, and edema
    • Glucosamine for osteoarthritis and knee pain
    • Yoga and meditation appear to improve endothelial function in patients with CAD and can have potential beneficial effects on depressive disorders.
    • Yoga throughout pregnancy shortens labor by 140 to 190 minutes
    • P.217

    • Exercise in both preconception and early pregnancy reduces chance of gestational diabetes mellitus (6)[A].
    • Breast stimulation in late pregnancy increases successful induction of labor (NNT 3.2) and reduces postpartum hemorrhage (NNT 19) (7)[A].
    • Oral probiotics in preterm infants to decrease necrotizing enterocolitis and reduce mortality (8)[A].
    • Oral probiotics to prevent URIs in children and influenza in the elderly (9,10)[A]
    • Oral probiotics to shorten the duration of acute and antibiotic-associated diarrhea and as prophylaxis for traveler's diarrhea (10),(11)[A],(12,13)
    • Vitamin D 800 IU/day may reduce falls and fractures in the elderly (14)[A].
    • Acupuncture for recurrent headache
  • Evidence supports safety, but evidence regarding efficacy is inconclusive:
    • Homeopathy for induction and augmentation of labor
    • Chondroitin sulfate is ineffective for osteoarthritis.
    • Sterile water injections do not reduce pain in labor.
    • Omega-3 fatty acids may reduce inflammation and anxiety in young healthy adults.
    • Dietary fat reduction for certain types of cancer
    • Mind-body techniques for metastatic cancer
    • Copper and magnetic bracelets for pain
    • Vitamin D levels >30 ng/mL correlate with lower risk of some cancers. Adequate vitamin D intake may decrease atopy and asthma symptoms.
  • Evidence supports efficacy, but evidence regarding safety is inconclusive:
    • St. John's wort extract for short-term treatment of depression in adults
    • Licorice for gastritis
  • Evidence indicates serious risk:
    • Black cohosh, blue cohosh, and evening primrose oil are unsafe to induce labor.
    • Delay in seeking medical care or replacement of curative conventional treatment
    • Use of toxic herbs or substances
    • Known herb-drug interactions
image ONGOING CARE
PATIENT EDUCATION
The National Center for Complementary and Integrative Health (https://nccih.nih.gov/)
REFERENCES
1. Peregoy JA, Clarke TC, Jones LI, et al. Regional variation in use of complementary health approaches by U.S. adults. NCHS data brief, no 146. Hyattsville, MD: National Center for Health Statistics; 2014.
2. Anderson JW, Liu C, Kryscio RJ. Blood pressure response to transcendental meditation: a metaanalysis. Am J Hypertens. 2008;21(3):310-316.
3. Manheimer E, White A, Berman B, et al. Metaanalysis: acupuncture for low back pain. Ann Intern Med. 2005;142(8):651-663.
4. Park JJ, Kang M, Shin S, et al. Unexplained infertility treated with acupuncture and herbal medicine in Korea. J Altern Complement Med. 2010;16(2):193-198.
5. Mortazavi SH, Khaki S, Moradi R, et al. Effects of massage therapy and presence of attendant on pain, anxiety and satisfaction during labor. Arch Gynecol Obstet. 2012;286(1):19-23.
6. Tobias DK, Zhang C, van Dam RM, et al. Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis. Diabetes Care. 2011;34(1):223-229.
7. Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of labour. Cochrane Database Syst Rev. 2005;(3):CD003392.
8. AlFaleh K, Anabrees J, Bassler D, et al. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. 2011;(3):CD005496.
9. Guillemard E, Tondu F, Lacoin F, et al. Consumption of a fermented dairy product containing the probiotic Lactobacillus casei DN-114001 reduces the duration of respiratory infections in the elderly in a randomised controlled trial. Br J Nutr. 2010;103(1):58-68.
10. Hojsak I, Snovak N, Abdović S, et al. Lactobacillus GG in the prevention of gastrointestinal and respiratory tract infections in children who attend day care centers: a randomized, double-blind, placebo-controlled trial. Clin Nutr. 2010;29(3):312-316.
11. Johnston BC, Supina AL, Ospina M, et al. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2007;(2):CD004827.
12. Hickson M, D'Souza AL, Muthu N, et al. Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial. BMJ. 2007;335(7610):80.
13. McFarland LV. Meta-analysis of probiotics for the prevention of traveler's diarrhea. Travel Med Infect Dis. 2007;5(2):97-105.
14. Makariou S, Liberopoulos EN, Elisaf M, et al. Novel roles of vitamin D in disease: what is new in 2011? Eur J Intern Med. 2011;22(4):355-362.
Codes
&NA;
Z76.89 Persons encountering health services in other specified circumstances
Clinical Pearls
&NA;
  • Oral probiotics reduce respiratory and diarrheal infections and reduce mortality in preterm infants.
  • Acupuncture is effective for back pain, headaches, and infertility.
  • Yoga and breast stimulation shorten labor.
  • Ginkgo and St. John's wort account for most herb-drug interactions described in the medical literature.