Complementary and Alternative Medicine Part 2

Manipulative and body-based therapies

Chiropractic

Many would argue that chiropractic medicine should not be considered alternative therapy. Patients, physicians, and insurance companies have all shown some degree of support for chiropractic care in recent years. Between 10% and 20% of the population have used chiropractors.6 Health care insurance plans, including Medicare, cover many of the services performed during chiropractic visits. Most chiropractor visits are for musculoskele-tal problems, including low back pain, neck pain, and extremity pain. However, a small proportion of patients currently seek out chiropractic care for a variety of other conditions, as well as general health concerns.49 The tenets of chiropractic medicine place the spinal cord and nervous system at the center of a person’s well-being. The nervous system is thought to control and influence all other bodily systems. Malalignments (subluxations) of the vertebrae are thought to cause or perpetuate disease. Once these subluxations are identified and corrected (via manipulation), the body uses its natural healing abilities to restore physiologic balance and health. Chiropractors typically look for spinal pain, asymmetry, impaired range of motion, or abnormalities in tone, texture, and temperature when evaluating patients.50 Laboratory testing, including x-rays, electromyography (EMG), and ultrasonography, may be used to aid in diagnosis. Actual spinal manipulation is performed by direct or indirect delivery of thrusts to the spine. Frequently, the patient will experience a cracking noise. Some chiropractors may use adjunctive therapies, including massage, heat, and trigger-point injections.50

Chiropractic manipulation has been touted as treatment for a number of conditions, including hypertension, asthma, pelvic pain, and fibromyalgia. Very little data exist to support its use for these conditions.51,52 Use of chiropractic therapy for neck pain and headaches is also weakly supported.53,54 Much of the current use of chiropractic care stems from its utility in cases of low back pain. A number of controlled trials on chiropractic treatment for low back pain have been done, with conflicting results. A meta-analysis concluded that spinal manipulation appears to be more effective than sham therapy or treatments previously judged to be ineffective, but not to be superior to other standard treatments for acute or chronic low back pain, such as analgesics, physical therapy, or exercises.55 Patient satisfaction also seems to be high with such therapy.56

Serious complications from lumbar spinal manipulation seem to be uncommon, although there are reports of cauda equina syndrome.57 Many patients, however, experience mild to moderate side effects, including localized discomfort, headache, or tiredness. These reactions usually disappear within 24 hours.58 Brain stem or cerebellar infarction, vertebral fracture, tracheal rupture, internal carotid artery dissection, and diaphragmatic paralysis are rare but have all been reported with cervical manipulation.59

Table 3 Selected Mind-Body Interventions

Modality	Description	Potential Applications	Comments
Aromatherapy	The use of essential oils (e.g., jasmine, chamomile, lavender) to enhance physical or psychological well-being; often combined with massage	Anxiety, agitation	Long-term efficacy data (independent of massage) are lacking⁷¹
Biofeedback	Voluntary control of physiologic processes— e.g., brainwaves, smooth muscle contraction, vasodilation—learned and reinforced with the aid of instrumentation (EEG, EMG, skin temperature/sweat monitors)	Asthma, ADHD, back pain, fibromyal-gia, headache, hypertension, incontinence, neuromuscular disorders, Ray-naud disease	Effective for fecal incontinence⁷²; techniques utilized may vary between patients and practitioners; learning process can be slow, requiring multiple sessions with therapist and regular practice by patient
Guided imagery	Use of the imagination to positively stimulate the senses to bring about emotional and physiologic change	Chronic pain, perioperative management, headaches, nausea, posttrau-matic stress disorder	Small studies suggest a positive impact on surgical and cancer treatment outcomes⁷³
Hypnotherapy	The induction of a trancelike state to induce relaxation and susceptibility to positive suggestion; used as a diagnostic and therapeutic tool	Anesthesia, headache, irritable bowel syndrome, smoking cessation	Success of therapy may depend on patient susceptibility and attitude toward hypnosis; no conclusive data on most conditions
Intercessory prayer	Request to God (or other spiritual beings) for the benefit of others; can take place in the presence of the patient or at a distance	Cardiac disease, HIV infection, RA	Studies are conflicting and inconclu-sive⁷⁴; mechanism is unclear
Meditation	Release of the mind from attachment to discursive thought, typically aided by focusing on the breath or a mantra	Anxiety, chronic pain, hypertension, substance abuse	Many types of meditation exist; large-scale studies are needed to prove the absolute impact of this simple intervention on health
Music therapy	Use of music to improve psychological, physical, cognitive, or social functioning	Anxiety, dementia, chronic pain, Parkinson disease	Treatment is guided by a trained music therapist; may have a short-term effect on anxiety and mood during treatments or procedures⁷⁵
Writing therapy	Creative writing exercise about an emotionally traumatic event	General emotional health, asthma, RA, HIV infection	Short-term studies show positive response in asthma and RA⁷⁶⁷⁷

ADHD—attention-defirit/hyperactivity disorder

EEG—electroencephalography

EMG—electromyography

RA—rheumatoid arthritis

Table 4 Commonly Used Herbal Dietary Supplements

Herb	Suggested Uses	Potential Toxicity	Potential Drug Interactions	Comments
Black cohosh (Cimicifuga racemosa)	Menopausal symptoms	Gastrointestinal discomfort	None known	Scant efficacy data, long-term safety unknown⁷⁸
Chaste tree berries (Vitex agnus-castus)	Premenstrual syndrome, mastodynia	Pruritus	May have dopaminergic activity; therefore, avoid with use of dopamine-receptor antagonists (e.g., neuroleptics)	Small, short-term studies suggest efficacy⁷⁹
Cranberry (Vaccinium macrocarpon)	Urinary tract infections	Nephrolithiasis (with cranberry concentrate tablets)⁸⁰	Possible interaction with warfarin⁸¹	No clear role in treatment of UTIs; may be effective for prophylaxis⁸²
Dong quai (Angelica sinensis)	Menopausal symptoms	Rash	Increased INR in patients taking warfarin	No clinical evidence of efficacy⁷⁸
Echinacea (E. purpurea, E. pallida, E. angustifolia)	Upper respiratory infections	Hypersensitivity reactions	Theoretically, may antagonize the effect of immuno-suppressive medications	Variations in plant species studied, part of plant used, and extraction methods make conclusions regarding efficacy difficult⁸³
Ephedra (E. sinica, mahuang)	Asthma, congestion, weight loss	Hypertension, arrhythmia, myocardial infarction, stroke	Interaction with monoamine oxidase inhibitors and cardiac glycosides; potential for serious toxicity when combined with other stimulants	Banned by the FDA, effective April 2004, but still available internationally over the Internet
Evening primrose (Oenothera biennis)	Eczema, irritable bowel syndrome, mastalgia, premenstrual syndrome, rheumatoid arthritis	Nausea, vomiting, diarrhea, flatulence	Possible lowering of seizure threshold in patients taking antiepileptic medications⁸⁴	Conflicting efficacy data for a number of conditions
Feverfew (Tanacetum parthenium)	Migraine prophylaxis	Hypersensitivity reactions	Theoretical risk of increased bleeding when combined with anticoagulants	No clear evidence to support efficacy⁸⁵
Garlic (Allium sativum)	Cardiovascular protection	Gastrointestinal upset, bleeding	Theoretical risk of increased bleeding when combined with anticoagulants	Possible short-term improvement in cardiovascular risk factors, but impact on disease unknown; active ingredient unclear⁸⁶
Ginger (Zingiberis rhizoma)	Nausea, motion sickness, dyspepsia	None known	Theoretical risk of increased bleeding when combined with anticoagulants	May be useful for nausea and vomiting of pregnancy⁸⁷

Given the lack of efficacy data and the risk (although small) of catastrophic adverse events, it is difficult to advocate routine use of this technique for treatment of neck or headache disorders. Physicians should also recognize potential contraindications to chiropractic therapy. Patients with coagu-lopathy, osteoporosis, rheumatoid arthritis, spinal neoplasms, or spinal infections should be advised against such treatments.59

Massage Therapy

A number of different types of massage are in practice today. Many therapists combine aspects of Swedish massage (stroking and kneading), shiatsu (pressure-point manipulation), and neu-romuscular massage (total body, deeper therapy) to relieve stress, anxiety, and muscle tension, as well as improve circulation. Frequently, aromatic oils are employed to enhance the relaxation response. A number of small studies have suggested a potential beneficial effect of massage on fibromyalgia, headaches, and anxiety,60 although the paucity of data precludes definitive conclusions. Massage therapy does seem to be effective for subacute and chronic back pain.30 No significant adverse effects are seen with properly performed massage, although caution must be advised for patients with coagulation disorders.

Structural integration (rolfing) is a system of deep-tissue manipulation that involves stretching of the fascial planes. In this system, the fascia is thought to be the key supporting structure for bones and muscles. When injury or stress occurs, the fascia tends to become shorter and thicker. Manipulation of the fascia with fingers, thumbs, and elbows is supposed to relieve tension, restore structural integrity, and improve physiologic and psychological function. Limited data exist to support the efficacy of rolfing for any particular condition.

Energy therapies

Many traditional cultures describe the physical body as existing within a field of energy. Such energy is called prana by Indians and qi by the Chinese; English terms include subtle energy, vital energy, and life energy. Many ancient and modern CAM techniques involve the manipulation of this energy or the transfer of additional energy into the patient’s field in an effort to restore or maintain balance. Because the field extends beyond the body, energy therapies do not always involve physical contact between practitioner and patient. Further, the presumed connection of these individual fields with a universal field is believed to permit the use of some of these therapies at a distance.

Table 4

Herb	Suggested Uses	Potential Toxicity	Potential Drug Interactions	Comments
Ginkgo biloba	Dementia, claudication, tinnitus	Gastrointestinal upset, headache, dizziness, bleeding, seizure	Theoretical risk of increased bleeding when combined with anticoagulants	May have modest effects on cognitive performance and functioning in patients with Alzheimer disease or multi-infarct dementia⁸⁸; no evidence to support prevention of memory loss or dementia
Ginseng (Panax species; Asian ginseng, Korean ginseng, American ginseng)	Fatigue, diabetes	Generally considered safe; rare reports of hypertension, insomnia, headache, and mastalgia	May interact with mono-amine oxidase inhibitors and warfarin (decreased prothrombin time)	Currently, little data to support its use⁸⁹
Kava kava (Piper methysticum)	Anxiety	Rash, sedation, liver toxicity	May potentiate effects of benzodiazepines; best to avoid with other anxioly-tics or alcohol because of risk of excess sedation	Studies suggest efficacy for short-term treatment of anxiety⁹⁰; no data on addiction potential; banned in many European countries because of cases of hepatic failure
Kola nut (Cola nitida)	Fatigue	Irritability, insomnia	Caution when used with other stimulants	Contains caffeine
Milk thistle (Silybum marianum)	Chronic liver disease	Rare mild laxative effect, gastrointestinal upset	None known	Appears to be safe and well tolerated; efficacy data too limited to exclude a substantial benefit or harm⁹¹
Saw palmetto (Serenoa repens)	BPH	Mild gastrointestinal effects	None known	Short-term studies show improvement in symp-toms^89,92; no evidence for prevention of BPH or its complications, or prevention of prostate cancer
St. John’s wort (Hypericum perforatum)	Depression, anxiety	Headache, insomnia, dizziness, gastrointestinal irritation	Can decrease levels of cyclo-sporine, digoxin, oral contraceptives, theophylline, and indinavir; serotonin syndrome can occur when combined with prescription SSRIs	May be effective for mild to moderate depression^89,93
Valerian (Valeriana officinalis)	Insomnia	Headaches	Avoid use with benzodiaze-pines because of sedation	Efficacy data inconclusive⁹⁴; theoretical risk of addiction with prolonged use

BPH—benign prostatic hyperplasia

FDA—Food and Drug Administration

INR—international normalized ratio

SSRI—selective serotonin reuptake inhibitor

UTI—urinary tract infection

Qigong

Qigong is a branch of traditional Chinese medicine designed to affect the flow of energy (qi) to preserve health. This system combines relaxation techniques with movement to achieve a meditative state designed to ensure mental and physical health. Tai chi (tai chi chuan) is a type of movement-oriented qigong that utilizes a sequence of slow, dancelike maneuvers to enhance the flow of qi through the body. In the course of a tai chi session, the person shifts body weight constantly from one foot to the other. Studies of tai chi in elderly persons have shown that long-term regular practice may improve balance, flexibility, and cardiovascular fitness and, possibly, decrease the risk of falls in older individuals.61,62 Meditative qigong is accomplished without movement and is intended to establish inner harmony. Breathing exercises can also be part of qigong. They are designed to enhance circulation of qi and expel negative energy. Qigong has been used extensively in China for a number of conditions, including hypertension, anxiety, asthma, and nausea and vomit-ing.63 Data to support use for any individual condition are lacking, despite historical successes. Although the principles of qigong seem simple, it involves a complex set of processes that are not clearly understood. Inappropriate training has reportedly been associated with physical and mental disturbances.64

Yoga

Yoga is an ancient Indian philosophical practice that uses postures or stretching exercises (asanas), breathing exercises (prana-yama), and meditation to help unite the body and the mind. It was developed as a means of enlightenment through self-realization and self-mastery. Only recently, with its migration to the West, has yoga come to be seen as a means to heal illness or reduce anxiety. As with most CAM modalities, there are limited data for or against the use of yoga for particular conditions. Studies on the use of yoga in patients with carpal tunnel syndrome seem promising.65 Yogic breathing exercises may have some beneficial effect on the symptoms of asthma and may reduce bronchodilator use, but they do not decrease airway reactivity or improve lung function.66

Table 5 Commonly Used Nonherbal Dietary Supplements

Supplement	Common Uses	Potential Toxicity	Potential Drug Interactions	Comments
Coenzyme Q10	Heart failure, hypertension, angina, Parkinson disease	Nausea, heartburn, diarrhea	Decreased INR in patients on warfarin	Data inconclusive for treatment or prevention of cardiovascular dis-ease⁹⁵; early data promising for slowing the progression of Parkinson disease⁹⁶
Glucosamine and chondroitin	OA	Hyperglycemia in diabetic patients	Theoretical risk of increased bleeding in patients taking chondroitin and anticoagulants	Current data suggest symptomatic improvement for OA of the hips and knees,⁹⁷ with a slowed progression of joint space narrowing⁹⁸
Melatonin	Jet lag, insomnia	Fatigue, drowsiness, headache	Theoretical risk of bleeding in patients taking anticoagulants	Data suggest efficacy for jet lag⁹⁹; no data on long-term use
SAMe (S-adenosylme-thionine)	OA, depression, liver disease	Nausea, abdominal discomfort	Can lead to serotonin syndrome when used with tricyclic antidepressants	Early data promising¹⁰⁰; poor oral bioavailability; very expensive; marketed doses are much lower than studied doses

INR—international normalized ratio

OA—osteoarthritis

Therapeutic Touch

Therapeutic touch is the use of the hands, without actual physical touching, to influence or direct life energy throughout the body in an effort to promote healing. Therapeutic touch was codeveloped by a nurse, Dolores Krieger,67 and many of its practitioners are nurses who use the technique for hospital inpatients.

In a therapeutic-touch session, which generally lasts 20 to 30 minutes, the practitioner enters a meditative state (centering) and then assesses the patient’s energy field. To do so, the practitioner holds his or her hands a few inches from the patient’s body and moves from head to foot. Downward sweeping movements are then used to remove any blockages of energy and correct any energy-field imbalances. The practitioner then transfers energy to the patient’s field and finishes the session by smoothing the field.

A number of small trials have suggested a positive effect of therapeutic touch on conditions such as osteoarthritis, tension headache, and anxiety.43 However, most of these trials are quite small and suffer from methodologic weaknesses that make definitive conclusions difficult.68 A critical evaluation of relevant trials concluded that the data did not support the hypothesis that therapeutic touch promoted wound healing.69 More vigorous trials need to be performed to determine the true efficacy of this technique.

CAM and the Practicing Physician

The field of research in CAM is in its infancy. Current levels of evidence are insufficient to support or disprove a majority of CAM modalities. Despite these limitations, the public continues to embrace CAM therapies as alternatives or adjuncts to conventional care. Given that many patients currently do not inform their physician of their use of CAM, it is imperative that physicians take the lead in inquiring about such therapies. Open dialogue needs to be established to uncover the types of modalities being utilized, reasons for pursuing such therapy, and patient experiences. From there, a discussion of the current data on level of efficacy and toxicity can follow. Ultimately, primary care physicians may need

Table 6 Popular Uses for Common Dietary Supplements*

Use	Supplement
Anxiety	Kava kava, St. John’s wort, valerian
Benign prostatic hyperplasia	Saw palmetto, Pygeum africanum
Claudication	Ginkgo biloba
Dementia	Ginkgo biloba, pyridoxine
Depression	SAMe, St. John’s wort
Diabetes	Aloe vera, chromium picolinate, ginseng, Gymnema sylvestre
Fatigue	Ginseng, licorice root
Heart failure	Coenzyme Q10, hawthorn extract
Hypercholesterolemia	Fenugreek, garlic, guggulipid, red yeast rice
Hypertension	Coenzyme Q10, garlic
Insomnia	Melatonin, valerian
Irritable bowel syndrome	Acidophilus, aloe, evening primose, peppermint oil
Jet lag	Melatonin
Liver disease	Milk thistle, SAMe
Menopausal symptoms	Black cohosh, dong quai, red clover, soy
Migraine prophylaxis	Butterbur root, feverfew, riboflavin
Nausea and vomiting	Ginger, pyridoxine
Osteoarthritis	Ginger, glucosamine and chondroitin, SAMe
Premenstrual syndrome	Calcium, chaste tree berries, evening primrose, pyridoxine
Tinnitus	Ginkgo biloba
Upper respiratory infections	Ascorbic acid, Echinacea
Urinary tract infections	Ascorbic acid, cranberry
Weight loss	Chitosan, chromium picolinate, Garcinia cambogia

Table 7 Sources of Information on Complementary and Alternative Medicine

Medium	Listing	Description (Price)
Internet	Natural Medicine Comprehensive Database www.naturaldatabase.com	Monographs on a multitude of natural products ($92/year)
	Natural Standard www.naturalstandard.com	Monographs on a multitude of natural products and CAM modalities; grades the level of evidence currently available for each potential application ($99/year)
	Memorial Sloan Kettering Cancer Center Integrative Medicine www.mskcc.org/aboutherbs	Brief descriptions of popular herbs/supplements (free)
	National Center for Complementary and Alternative Medicine http://nccam.nih.gov/index.htm	Describes ongoing CAM research; contains links to governmental resources on popular modalities and supplements (free)
	United States Pharmacopeia (USP) www.usp.org	Dietary supplement verification program identifies ingredients and absence of contaminants of specific brands that undergo testing (free)
	ConsumerLab.com www.consumerlab.com	Tests individual supplements and reports on purity and accuracy of labeling ($24/year)
	National Cancer Institute PDQ Cancer Information Summaries: Complementary and Alternative Medicine www.cancer.gov/cancertopics/pdq/cam	Overviews of selected CAM products used in cancer treatment (free)
	Essentials of Complementary and Alternative Medicine. Jonas W, Levin J, Eds. Lippincott Williams & Wilkins, Philadelphia, 1999	Concise overview of popular CAM therapies
Print	Herbal Medicine: Expanded Commission E Monographs. Blumen-thal M, Goldberg A, Brinckmann J, Eds. American Botanical Council, Austin, Texas, 2000	Expanded English translation of the German compendium on herbs
Print	Evidence-Based Herbal Medicine. Rotblatt R, Ziment I, Eds. Hanley & Belfus, Philadelphia, 2001	Pocket-sized handbook that contains a summary of clinical trials as well as a rating of efficacy, evidence, and safety levels of common herbs

These steps should serve to strengthen the physician-patient relationship while limiting the potential for adverse outcomes.

Specific emphasis should be placed on the role of dietary supplements, which pose a risk of significant toxicity and drug interactions. To ensure patient safety, the medication history should include specific questioning about what vitamins, herbs, or other supplements the person is taking. Unfortunately, supplements are often sold as combination products that are identified only by their catchy trade names. Patients should be encouraged to bring in all new medications and supplements at each visit. Depending on their side-effect profile or potential for drug interactions, certain supplements should be discontinued in the perioperative pe-riod.70 Finally, any suspected adverse reactions or drug-supplement reactions should be reported to the FDA’s MedWatch program at their web site (http://www.fda.gov/medwatch) or by calling them at 1-800-FDA-1088.