Complementary and Alternative Medicine

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[edit] Complementary and Alternative Medicine

Wadie Najm

Prior to the development of the current biomedical model of health care, people received the majority of their health care from folk healers and home remedies. As time progressed, immigrants relied on home remedies and Native American healing modalities for much of their health care. Today, a large portion of the population in developing countries rely on traditional healers, herbalists, birth attendants, and others for their primary health care needs. The World Health Organization (WHO) estimates that 95% of all rural births and 70% of urban births in developing countries are assisted by birth attendants. These therapeutic modalities are used either alone or in combination with other healing systems. In the United States, 100 million Americans supplement their diets with vitamins, minerals, herbs, and amino acids.

[edit] DEFINITION

The terminology and definition of complementary and alternative medicine (CAM) are constantly changing. Several terms have been used over the past decades, including unorthodox, traditional, folk, natural, quack, holistic,'alternative, complementary, and most recently complementary and alternative medicine.

The definition of CAM has been increasingly debated, and several definitions have been advanced, including:

• Modalities used in addition to what is currently known as Western medicine
  
• Modalities neither widely taught in U.S. medical schools nor generally available in U.S. hospitals
  
• Ways of protecting and restoring health that existed before the arrival of modern medicine
  
• Modalities usually outside the official health sector
  

As our understanding and acceptance of CAM evolves, so does its definition.

In April 1995, the National Institutes of Health's (NIH) Office of Alternative Medicine (OAM) assembled a panel of experts to define CAM. The panel defined CAM as a "broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well being. Boundaries within CAM and between CAM domains of the dominant system are not sharp or fixed."^[1]

Although the definition of CAM is comprehensive and intended to be applicable in all situations, it is too complex. This chapter defines CAM as healing practices and modalities not taught, practiced, or integrated in the current Western biomedical model of medicine.

CAM covers a number of health care modalities and practices. Table 12-1 presents the CAM classification system devised by the ad hoc Advisory Panel to the NIH's National Center for Complementary and Alternative Medicine (NCCAM).

Table 12-1 Complementary and Alternative Medicine Classifications and Therapies

✢Alexander technique: releasing muscle tension and correcting posture through gentle touch and verbal instructions.

†Reflexology: manipulating specific points on feet, hands, or limbs that correspond to different parts of the body to reestablish homeostasis.

‡Rolfing: a form of deep massage and postural retraining.

§Therapeutic touch: practitioners place hands over the body to detect energy field flow and blockage, and work to correct and replenish energy.

[edit] EPIDEMIOLOGY

Use of CAM is on the rise. Studies looking at the use of CAM in different clinics reported rates between 9% and 50%.^[2][3] In a 1997 national survey, Eisenberg et al reported that 42.1% of the adult population used CAM. Some 46.3% of CAM users visited an alternative medicine practitioner. The estimated number of visits to CAM providers in 1997 exceeded by 243 million the projected number of visits to all primary care physicians. Visits to chiropractors and massage therapists accounted for half of those visits. The out-of-pocket expenditure for alternative medicine was estimated at $34.4 billion, which is comparable to the 1997 out-of-pocket expenditure for all physicians' services. These results show a gradual increase in users and out-of-pocket expenditure compared with a similar survey in 1990. About 96% of individuals who saw a CAM provider for a principal medical condition saw a physician for the same condition. Few CAM users (38.5%) discussed these therapies with their physician.^[4]

CAM users are generally between 35 and 49 years old, well educated, in a higher-income bracket, and living in the west. Women are more likely to use CAM. African-Americans (33.1%) are less likely than other racial groups (44.5%) to use CAM. Users were found tohave a higher prevalence of chronic medical conditions, chronic pain, anxiety, and belief in holistic practices.^[5]

Over the last decades, the increase in consumer interest and demand of CAM prompted the medical community to develop an interest in this field. Several U.S. medical schools have incorporated CAM into their curriculum.^[6] The NIH established the NCCAM to evaluate these therapies.

[edit] NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE

Based on increased public and professional demand, a congressional mandate established the OAM in 1992. The office was given a minimal budget of $2 million dollars and a mandate to facilitate research in CAM, to act as an information clearinghouse, and to facilitate research training programs. As a result of the increased interest in and explosion of information about CAM, the office earned increased authority and status and was elevated to a "center" (NCCAM), with its 1999 budget increased to $50 million. Since its inception, the NCCAM has supported the development of 13 centers of research in CAM. These centers cover different aspects of medical care (Table 12-2). In addition, the center has funded several small and large grants to obtain preliminary data and experience in CAM research areas.

Table 12-2 Centers of Research in CAM Supported by the NCCAM

The NCCAM receives more than 1300 public inquiries per month covering a variety of topics, including nonspecific medical conditions (56%), general variety (32%), cancer (8%), chronic pain (3%), and the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) (1%). The center has accumulated an impressive database of more than 180,000 citations in coordination with the National Library of Medicine.

[edit] MODALITIES

[edit] Ayurveda

The word ayurveda is derived from the Sanskrit ayur, meaning long life, and veda, knowledge. One of the world's oldest traditional healing systems, it has been documented and practiced in India for thousands of years. Ayurveda is a holistic system that deals with every aspect of life: the mind, body, and spirit.

A basic theory states that everything in the material world is a manifestation of the unseen universe of energy or life force. The world was created from the unseen universe when the primordial sound created the five fundamental elements responsible for the material world: space, air, fire, water, and earth. These five elements manifest in the human physiology as three life energies called doshas. The three doshas are vata (space and air), pitta (fire and water), and kapha (water and earth). Each dosha, its subdivision, and underlying structures confer a particular characteristic and quality to each person. Each person is believed to be a unique combination of these three doshas, hence a unique entity.

Health is a state of balance between the mind, body, and consciousness. Several factors can disturb this balance, including congenital and genetic factors, natural tendencies, habits, seasonal factors, and internal and external traumas. The imbalance produced in the doshas disturbs the life force, producing the disease state.

Diagnosis is based on identifying the exact quality and nature of the imbalance and correcting it. This is accomplished through a detailed history, inspection, and examination. Radial pulses (three superficial and three deep pulses, bilaterally) and tongue, nail, and eye examinations, among others, are important parts of the ayurvedic diagnostic examination. Treatment consists of strengthening or reestablishing the body's balance through a combination of interventions, including lifestyle changes, diet modifications, meditation, yoga, breathing exercises, massage, aromatherapy, herbs, and detoxification.

Although the primary aim of ayurvedic medicine is prevention and health maintenance, it also helps in several acute and chronic medical conditions. Limitations include situations involving acute traumatic conditions, advanced disease, acute pain, and surgery.

Studies have documented the beneficial effects of regular meditation on reducing cardiovascular risk factors and stress. Studies investigating the effects of the herbal products on a wide variety of conditions including cancer, aging, and health promotion are encouraging.

Several CAM disciplines have origins in ayurvedic medicine. These include aromatherapy, homeopathy, and massage. There is no national standardization of training and credentialing of ayurvedic providers. A wide variance of training and experience exists among providers. Physicians interested in referring patients need to inquire about the extent of training, certification, and expertise of ayurvedic providers.

[edit] Traditional Chinese Medicine

Traditional Chinese medicine (TCM) is a comprehensive system of health care developed and refined over thousands of years. It operates on the notion that health is a dynamic process of perpetual balance and counterbalance between different forces. Man is represented as a union between heaven and earth. The laws of nature are used to help understand the inner functioning of the human body. It recognizes the influence of the mind, body, and spirit and their interaction with nature, nutrition, and the environment on the person's health. The focus of Oriental medicine is on health promotion and preventative care at every stage of the person's life.

Interaction between heaven and earth results in a life force called qi (pronounced chee). Several forms of qi exist. Blood (xue), mind (shen), essence (jing), and body fluids (jing-ye) are all part of vital energy. Health is present if vital energy flows freely and equitably among the different organs and along specific channels, called meridians. There are 14 meridian channels, 11 organs (six yang organs, five yin organs). In addition to the free flow of vital energy, health is the result of balance between opposed forces described as yin and yang. Yin and yang forces are seen everywhere and may apply to any topic. Disease is described as an imbalance between the yin and yang and in the flow of vital energy through the meridians.

Wood, fire, metal, water, and earth are five basic elements thought to be important to man; they are important constituents of the universe. Properties of these elements were assigned to everything in the material world. These elements are constantly interacting.

Evaluation is done through inspection of the tongue, palpating the pulse, listening to the voice, smelling the body, and taking a history. Once a diagnosis is reached, several therapeutic modalities are prescribed. These include diet, lifestyle changes, herbals, acupuncture, moxibustion, manipulative therapy, massage, exercise, bone setting, and bloodletting. Exercises include tai-chi (balances energy) and qi gong (builds energy).

[edit] Acupuncture.

Acupuncture was initially publicized in 1972, after President Nixon's visit to China. Over the last few decades, several studies have investigated the mechanism of action and the efficacy of acupuncture. Activation of endogenous opioids, cortisol, neurotransmitters, and afferent fibers through the nervous system have all been advanced as possible mechanisms of action.

Although acupuncture is part of the TCM therapeutic arsenal, it is currently being used as a stand-alone modality. Evaluations should be based on the recognition of imbalance using the TCM diagnostic method described above. Once the imbalance is recognized, a treatment plan is devised, and needles are placed in acupuncture points along the appropriate meridians to help restore the balance.

An NIH consensus panel assembled in 1997 to review the literature on acupuncture concluded that the quality and value of acupuncture studies are variable. Of great concern is the validity of controlled studies using sham-points. After review the panel reported that current scientific evidence indicates that acupuncture is helpful in certain conditions (Table 12-3). Research into the efficacy of acupuncture in the treatment of other medical conditions is in progress.^[7]

Table 12-3 Medical Conditions Helped by Acupuncture and Type of Research Available

[edit] Adverse Effects.

In the hands of qualified providers, acupuncture is a very safe and effective therapy. Possible side effects include syncope, drowsiness, organ puncture, and infection. Although rare, pneumothorax is the most common organ puncture reported. Infection from acupuncture needles is a major concern. Use of unsterilized needles has been responsible for reports of hepatitis B transmission. Although HIV infection is a major concern, there is no documented report of HIV transmission as a result of acupuncture.

Identifying anatomic structures, judicious clinical judgment, and use of disposable needles can greatly assist in avoiding many complications.^[8]

Requirements for providing acupuncture treatment vary greatly between states. Few states require licensed physicians to complete formal training in acupuncture. For nonphysicians, licensing requirements and the scope of practice also vary between states. In certain states, practice is limited to acupuncture itself, whereas others include herbalism.

Acupuncture is currently recognized and included as a benefit or as a rider to the health plan by several health insurance policies. Coverage and reimbursement vary between insurance companies and in different states.

[edit] Homeopathy

The word homeopathy is derived from the Greek homios, meaning like, and pathos, suffering. Descriptions of homeopathy have been found in the ancient Hippocratic writings, as well as in early Arab and Inca writings. The current principles of homeopathy are ascribed to Samuel Hahneman, a physician in the eighteenth century. Having become despondent with the practice of medicine, Hahneman concentrated his efforts in 1796 on research and translation of medical literature.

It was during his translation of Cullen's Materia Medica that Hahneman tested the effects of Peruvian bark on himself, developing symptoms consistent with malaria. Subsequent experiments confirmed his suspicion that quinine caused the same symptoms it was supposed to treat in malaria. After repeat testing using other products, he eventually came to the conclusion that the symptoms of an illness can be regarded as nature's way to healing, rather than fighting an illness. Hence the first doctrine of homeopathy: Simlia similbus curentar or Let like be treated by like.

In his experiments, Hahneman used simple, uncompounded substances from herbs, minerals, and snake venom. He found that diluting the amount used in a dose seemed to increase the potency, even when diluted to almost infinitesimal dilution. He was not able to explain why this system worked in a biomedically accepted model, other than to suggest that it rallied the body's defensive forces. He believed that diluted doses avoided the risk of stronger medications, which could affect both healthy and sick organs/tissues. This led him to the second doctrine: Microdose potentization.

Hahneman thought that a physician should build up the patient's strength and trust the life force to do the rest. Hence, in treating any kind of illness, the nature of the patient, as well as the disease, must be considered, so that the treatment could be regulated according to his or her needs. Since each patient has a different constitution, or temperament, knowledge of that person is a prerequisite of a successful handling of his or her disease. This led to the third doctrine: Treat the patient (rather than the disease).

From these three doctrines, the current system of homeopathy arose.

Dane Hans Graham introduced homeopathy in the United States in the 1820s. The first Hahneman society was founded in Philadelphia in 1833, and the American Institute of Homeopathy was founded in 1844. Soon after, homeopathic medical schools and hospitals began to appear and flourish by the end of the nineteenth century.

Opinions are divided on the merits of homeopathy. Much of the controversy arises from the difficulty in explaining its effects in conventional terms. A great number of studies have looked at the effects of homeopathic remedies. The quality of these studies is variable. Three meta-analyses of homeopathic trials have been published^[9][10][11] (Table 12-4). The quality of these studies and the methodology used for each are different. Although the overall results were slightly in favor of homeopathic remedies, because of the limited quality of the studies, no clear conclusions could be drawn about the effectiveness of homeopathy for any single medical problem or for any single remedy.

Table 12-4 Three Meta-Analyses of Homeopathic Trials

[edit] Chiropractic

The word chiropractic derives from the Greek words chier, meaning hands, and practicikos, meaning practitioner. Chiropractic care has its origins in the manipulative health care modalities. It was developed in 1895 by Daniel D. Palmer, a lay healer who established a successful practice and eventually a school centered on achieving health through manipulation of the spine. Chiropractic care struggled to establish its place in health care over the last 100 years. Over the last decade, chiropractic care has gained gradual acceptance and developed into a treatment and wellness modality that is practiced by 55,000 licensed practitioners and used by roughly 10% of the U.S. population. Chiropractic care is licensed in all 50 states, with 45 requiring insurers to include it in their plans. There is a wide variation in the scope of practice; certain states limit the practice to spinal manipulation, whereas others permit different procedures to be performed, such as acupuncture, electromyography, and laboratory diagnosis.

Education is provided at 16 accredited colleges. Since 1974 chiropractic education has been established with a 4-year curriculum monitored by the Council on Chiropractic Education (CCE). Admission requirements vary from school to school, although a minimum of 2 years of college education and specific science courses are required by all.^[12]

A chiropractic system of health is based on two principles: a testable principle, which suggests that the structure and condition of the body influence how the body functions and heals, and the untestable principle, which indicates that the mind-body relationship is instrumental in maintaining health and affects the healing processes. Hence the focus is on the body's ability to self-heal, on the nervous system's role in overall health, and on the interaction between body structure and the functioning of the nervous system.

Evaluation consists of taking a comprehensive history and physical examination. X-rays are taken as needed. Treatment plans consist of manual manipulation of the spine or extremities to correct the underlying problem and allow the body to heal.

The most common condition evaluated by chiropractors is low back pain. A 1992 meta-analysis by Shekelle^[13] included 9 studies looking at acute and subacute low back pain uncomplicated by sciatica. The study indicated that spinal manipulation is more efficacious than comparison treatments. However, data were insufficient to reach a conclusion for chronic low back pain or patients with sciatica. Review of 36 randomized clinical trials of spinal manipulation for low back pain^[14][15] concluded that it is not statistically proven that spinal manipulation is beneficial for any low back pain syndrome.

Fewer randomized controlled studies have looked at the efficacy of spinal manipulation for neck pain. Quality of these studies is variable. A recent meta-analysis^[16] looking at a variety of manual therapies for neck pain found a benefit for the manual therapy–treated group; however, because of the heterogeneity among treatment modalities and patients, direct conclusions cannot be extrapolated.

There are a small number of published studies looking at chiropractic care and nonmusculoskeletal health conditions such as asthma, hypertension, otitis media, dizziness, headaches, and infantile colic. Current data do not support the benefit of chiropractic care for any of these conditions (Box 12-1).

[edit] Naturopathic Medicine

The history of naturopathic medicine is not concise. Similar to other therapeutic modalities, elements of naturopathy can be found in the Hippocratic principle of life force. The recent history of naturopathy can be attributed to V. Priessnitz, a farmer in Austria, who used water and air treatments to enhance the healing power of nature. Benedict Lust, a German physician, introduced naturopathy to the United States. He used the term naturopathy (from natur, to indicate nature, and pathy from homeopathy) to encompass all the natural approaches to healing. Since then, several healing modalities have been added to the healing module to arrive at modern naturopathy.

Naturopathic medicine is far from being a single scientific discipline. The basic principle is that healing comes from within more than from without, and that medicine depends on the healing power of nature to cure. Naturopathy employs various natural means to empower the individual to reach the ability to self-heal. The tools include lifestyle modifications, nutrition, dietetics, herbs, education, and hydrotherapy. In addition, naturopaths may elect to use a variety of healing modalities, including acupuncture, botanicals, homeopathy, massage, Oriental medicine, and minor surgery.

Training includes undergraduate premedical coursework and completion of a 4-year curriculum in an accredited school. Currently only three schools are accredited in the United States. More than a dozen states license naturopaths. The scope of practice in each of those states is variable and state-specific. In general, naturopaths function as primary care providers. The emphasis of their practice is on prevention, education, and health maintenance.

[edit] Herbalism

[edit] General Considerations.

Herbs have been used for medicinal purposes for thousands of years. Almost one quarter of the current pharmacopoeia is derived from botanicals. Digoxin is derived from foxglove, aspirin is derived from willow bark, narcotics are derived from opium poppy, and birth control pills were developed from the Mexican yam. Current herbal preparations are sold mainly as nutritional products. They are sold over-the-counter (OTC), and are not subject to the same quality control process as pharmaceutical products. Producers are exempt from the Food and Drug Administration (FDA) regulations imposed on medicinal products, provided that the labels do not make any medicinal claims. Preparations can be found in a variety of forms: crude plants, freeze-dried, tea, dry powdered extracts, soft extracts, fluid extracts, and tinctures. Herbal medicines could utilize any part of the plant. As such, several variables could interfere with production.

The FDA regulates products considered as drugs. To market a product as a treatment, the manufacturer has to submit an Investigational New Drug (IND) application for FDA approval. This process goes through multiple stages requiring several years of testing at high cost before approval. Since nutritional therapies cannot be patented, companies do not invest time and resources into the FDA approval process. Hence these manufacturers cannot make health claims or market them as intended to treat or cure.

The Nutrition Labeling and Education Act (NLEA) was enacted by Congress in 1990 to provide a clear relationship of nutrition to disease. Under this act, disease-related health claims could be used on labeling of nutritional products, provided that there is agreement among qualified scientists that the claim made is valid. In 1994, Congress enacted the Dietary Supplement Health and Education Act (DSHEA). Dietary supplements include products that contain vitamins, minerals, herbs, amino acids, or other dietary products either alone or in combination. This act reaffirms that dietary supplements are foods, thus exempting them from the requirements of new drugs. However, the FDA can remove misbranded products from the market. For detailed information and a review of the other herbal products see Table 12-5.

Table 12-5 Outline of Current Knowledge about Commonly Used Herbs

[edit] SPECIFIC DISEASES

Increasing interest in the use of CAM for the treatment of a wide variety of medical conditions exists. Current evidence to support the efficacy of these modalities is mostly anecdotal. Studies to evaluate and validate these therapies are ongoing. The following is an overview of some of the therapies used in these medical conditions.

[edit] Cancer

Cancer is the major reason people inquire about CAM. Several surveys have demonstrated that approximately 22%of patients with cancer use CAM treatments. Dietary and psychologic therapies are most commonly used. Younger patients and being married were positive indicators of CAM use. About 75% of patients tried more than one therapy. The majority of patients learned about these therapies through family, friends, and personal research. Approximately 40% of patients did not discuss CAM therapies with their physician.^[17]

The current cancer therapies have limited efficacy in the majority of cancers and great side effects. Given these limitations and uncertainties, people are willing to try other therapeutic options. There has been a myriad of formulations, therapies, and claims made; however, to date scientific evidence does not exist to confirm those claims. More recently, studies have been undertaken to evaluate the effectiveness of shark cartilage on angiogenesis in tumor cells and the effect of antineoplastons in treatment of brain cancer in pediatric patients.

[edit] Antineoplastons.

Developed by Dr. S. Burzynkis, antineoplastons cause cancer cells to undergo differentiation and eventually cause them to die through programmed cell death. Current research does not support these claims.

[edit] Essiac.

Essiac is a combination of several herbs promoted initially by R.M. Caisse, a Canadian nurse. Since her death, several companies have marketed this product. The exact formulation is not clear and varies between producers. Research looking into its antitumor activity has been disappointing.

[edit] Hoxsey Treatment.

Hoxsey therapy consisted of an external application of a paste or powder and the oral intake of tonic formulated on a case-by-case basis. This product and its constituents have undergone review by the National Cancer Institute (NCI) and were not found to have antitumor activity.

[edit] Immunoaugmentative Therapy.

Developed by L. Burton, PhD, immunoaugmentative therapy consisted of injection of protein extracts that manipulates the immune defense system. Little or no data exist to allow a clear review and evaluation of this product. Analysis of some of the material given to patients showed no evidence of the effects claimed by Dr. Burton.

[edit] Laetrile.

Laetrile, a relative of amygdalin, also referred to as "vitamin B₁₇," was first used in California in the 1950s as a selective antitumor treatment. Data from several animal models did not support its claims as antitumor treatment. A 1982 multicenter study sponsored by the NCI failed to demonstrate any benefit.

[edit] Shark Cartilage.

Shark cartilage received wide publicity, particularly after the publication of Sharks Don't Get Cancer. Research at MIT (1983)^[18] and in Japan (1990)^[19] on ocular tumor sites in rabbit models showed antiangiogenesis effect. Research conducted at the NCI showed some antiinflammatory response. The response depended on the cancer site and the dose used. Further studies are still pending to evaluate its benefits and use.

Vitamins such as B₆, C, E, folic acid, and coenzyme Q₁₀ have been used for cancer treatment. The proposed mechanism of action is variable, but in general includes an antioxidant effect. Investigational studies looking into the effects of vitamins and minerals for treatment of cancer are pending. Some studies have demonstrated the benefit of acupuncture to alleviate postchemotherapy nausea.

[edit] AIDS

In many respects, patients with AIDS have been at the forefront of CAM. Studies looking at the use of CAM by patients with HIV indicate that approximately 70% of patients with HIV were using CAM therapies. The majority started using these therapies after learning that they were HIV-positive. Vitamins, herbal therapies, and dietary supplements were the most common therapies used. The major reasons CAM therapies were used were to boost immunity, fight infections, and treat nausea, diarrhea, and weight loss. Acupuncturists and massage therapists were the most common CAM providers visited. Pain relief, neuropathy, and stress relief were the major reasons for those visits. In addition to CAM therapies, 23.9% of patients with HIV reported using marijuana for nausea and weight loss. Patients learned about these therapies from friends, family, special organizations, newsletters, publications, and their physicians. Contrary to the general population, approximately 64% of patients with HIV infection informed their physicians about the visits and use of CAM therapies.^[20]

Several clinics, universities, and organizations across the United States have been pioneering CAM treatment for patients with AIDS. Evidence to validate these therapies is still sparse and controversial. These therapies include:

• Acetylcarnitine (2 to 3 gm/day) is used to treat lipodystrophy, a side effect of protease inhibitors.
  
• Glutamine (20 to 40 gm/day) has been used to treat "leaky gut" associated with the damage to intestinal tissue. Several herbs have been used alone or in combination to control viral load: bitter melon, curcumin extract of tumeric plant, glycyrrhiza, and boxwood extract SPV-30. Initial data showed some promises of antiretroviral effect; however, follow-up studies were nonconclusive.
  
• Meditation, yoga, and prayer have been used to decrease stress. Vitamins A, C, E, B₆, and B₁₂, zinc, selenium, coenzyme Q₁₀,l-carnitine, and dehydroepiandrosterone (DHEA) have been used to enhance the immune system and fight against oxidative stress. Evidence to support their use is controversial.
  
• Low glutathione and thiol levels have been noted in patients with HIV. Supplementation with N-acetylcysteine (NAC) and sulfur amino acids has been used to restore the levels of reduced glutathione (GSH). An increase in the levels of T cells and inhibition of tumor necrosis factor (TNF) have also been proposed. Vitamin C in high doses has been used to treat HIV patients. The mechanism of action proposed is an increase in intracellular glutathione, which protects the immune system function from oxidative damage and inhibits viral replication.
  

[edit] Asthma

Current observer blinded crossover studies looking at the efficacy of chiropractic manipulation in the treatment of asthma do not show any difference in the pulmonary function tests between sham manipulation and chiropractic care. New studies looking at chiropractic manipulation and asthma are in progress, and data are pending.

Studies looking at yoga suffer from several methodologic flaws and biases. Available studies show variable outcomes in respiratory function (peak expiratory flow rate [PEFR], forced expiratory volume in 1 second [FEV₁]) and decrease in heart and respiratory rates. Use of yoga, meditation, and biofeedback in stress-exacerbated mild to moderate asthma may be beneficial.

In Oriental medicine, asthma is due to a deficiency in lung, kidney, or spleen energy. The difference is based on the symptoms. In the majority of cases, acupuncture and herbal treatments (e.g., ma huang [Ephedra herba], astragalus, Ginkgo biloba, American ginseng, saiboko-to [herbal mixture]) are used. Information to support these therapies is minimal and controversial. The NIH consensus panel reviewing the world literature on acupuncture concluded that acupuncture is an acceptable adjunct treatment or could be helpful in a comprehensive treatment plan for asthma.

Naturopathic medicine considers that in addition to allergies, several factors impact chronic asthmatic conditions. These include hypoglycemia, hypothyroidism, hypochlorohydria, increased toxic load, decreased adrenal function, maldigestion, and inability to eliminate toxins. Treatment is directed toward addressing these factors. In addition to dietary and lifestyle changes, breathing exercises, stress reduction, aromatherapy, hydrotherapy, and supplements are used.

Antioxidants (vitamins A, C, and E, carotenes, and selenium) are also used to inhibit bronchial constriction and decrease the inflammatory response in asthma.

[edit] ETHICAL CONSIDERATION

CAM modalities derive from different cultures, health care principles, and paradigms. The therapeutics of many CAM modalities are not based on the biomedical principles but on several centuries of observations, trials, and errors. Until recently, most of the CAM modalities were practiced mainly by specific cultures, ethnic groups, and geographic areas. Incorporating these therapeutic modalities into the prevailing medical paradigm of a new culture and belief system may require a period of adaptation and modification.

The health care benefits of these different modalities may not be easily evaluated by the current scientific methods and principles. Certain modalities such as music therapy, imagery, and biofeedback are subject to personal attitudes, beliefs, and interpretation, and hence are very difficult to evaluate on the basis of the current biomedical and statistical methods.

Health care is regulated by the states. The definition of medical practice may differ between states. States license practitioners and define the scope of practice for different health care providers. Medical licensing offers a means of control by forcing providers to fulfill certain requirements before receiving a license to practice. By requiring a minimum level of competence, licensing provides some degree of quality control and protects consumers from charlatans. It also entails several risks, the groups involved in risk being (1) unlicensed providers, (2) physicians who refer patients to or employ unlicensed providers, and (3) licensed providers working outside the scope of their practice.

Patients have the right to quality-verified care. The patient's bill of rights states that patients have the right to receive information about the risks, benefits, costs, and alternative treatment modalities appropriate for their condition. In addition patients should receive guidance from their physician about the optimal treatment plan. Because the majority of CAM are not accepted as standards of care, physicians have no duty to inform their patients about therapy that is not generally recognized or accepted by the medical community. This opinion has been rendered by the courts in the case of Moore vs. Baker in 1992.

Recently some insurance companies included certain CAM modalities in their covered benefits. Chiropractic care and acupuncture are covered benefits in some plans.

What are the liabilities of physicians referring to a CAM provider The same considerations applicable to all referrals apply to referral to CAM. Physicians may be held liable (1) if they refer patients to CAM therapies that they know, or should know, have limited or no benefit to the patient, or (2) when the CAM therapist provides negligent or harmful care while practicing under the supervision of the physician.

State legislatures often look to professional organizations for guidance and oversight of licensing and accreditation. When recognized and licensed in a state, the courts apply the standards of care guided by standards from experts in that field of practice. If unlicensed by that state, the courts will tend to judge CAM practitioners according to the conventional standard of care. For guidelines for choosing a CAM provider see Box 12-2.

[edit] SUMMARY

The popularity and use of CAM is on the rise. WHO estimates that 80% of the world's population use traditional medicine for their care. In the United States 40% of the population use CAM as part of their health care. Over the last decade an increasing number of patients, physicians, and insurance carriers have embraced aspects of CAM. The current scientific literature is limited and controversial. The NCCAM at the NIH has funded several research centers across the United States to evaluate and review the merits of CAM. Research that provides sound scientific evidence to support or refute the therapeutic effectiveness of CAM is necessary. Until more scientific evidence is available, physicians should proceed with caution, as they would do with any new therapy or treatment. It is important to keep an open mind, being willing to learn and review scientific evidence about CAM. Several CAM therapies have been accepted and integrated into the current standards of care. As research and experience with CAM blossom, new modalities will be included for specific medical problems. The future of medicine will include an integrated health care system where scientifically proven CAM will be practiced and provided alongside the current dominant medical system. For information about resources for providers see Box 12-3.

[edit] REFERENCES

[edit] ADDITIONAL READINGS

[edit] General

• RA Elion, C Cohen: Complementary medicine and HIV infection. Prim Care 1997; 24 (4):905 - 919.
• WB Jonas JS Levin Essentials of complementary and alternative medicine. Baltimord: Williams & Wilkins; 1999:
• MS Micozzi: Fundamentals of complementary and alternative medicine New York: Churchill-Livingstone; 1996:
• JW Spencer, JJ Jacobs: Complementary/alternative medicine: an evidence-based approach St Louis: Mosby; 1998:
• C Vincent, A Furham: Complementary medicine: a research perspective New York: Wiley; 1997:

[edit] Herbals/Nutrition

• M Blumenthal, WR Buse, A Goldberg,et al.: The complete German Commission E monographs: therapeutic guide to herbal medicines Austin, TX: American Botanical Council; 1998:
• LD Lawson R Bauer Phytomedicines of Europe: chemistry and biology activity. Washington, DC: American Chemical Society; 1998:
• M McGuffin, C Hobbs, R Upton, A Goldberg: American Herbal Products Association's botanical safety handbook Boca Raton, Fla: CRC; 1997:
• The review of natural products 1999; 800: St Louis: Facts and Comparisons; 1999:223 - 0554.

[edit] Homeopathy

• E Ernst EG Hahn Homeopathy: a critical appraisal. Oxford: Butterworth Heinemann; 1998:
• B Leckridge: Homeopathy in primary care New York: Churchill-Livingstone; 1997:

[edit] Manual

• RB Phillips RD Mootz S Hadelman Contemporary chiropractic philosophy: principles and practice of chiropractic. ed 2. Norwalk, Conn: Appleton & Lang; 1992:

[edit] Ethics/Legal

• MH Cohen: Complementary and alternative medicine: legal boundaries and regulatory perspectives Baltimore: Johns Hopkins; 1998:
• JH Humber, RF Almeder: Alternative medicine and ethics Totowa, NJ: Humana Press; 1998:

[edit] Others

• H Benson: Timeless healing: the power and biology of belief New York: Fireside; 1996:
• J Boik: Cancer and natural medicine: a textbook of basic science and clinical research Princeton, Minn: Oregan Medical; 1996:
• L Dossey: Healing words: the power of prayer and the practice of medicine San Francisco: Harper Collins; 1993:
• JS Gordon: Manifesto for a new medicine: your guide to healing partnerships and the wise use of alternative therapies Reading, Ma: Addison-Wesely; 1996: