Chapter
23
Complementary, Alternative and
Integrative Therapies
Linda Moore, EdD,
Kathy Jones,
Introduction
An
alternative or complementary modality can be a healthy intervention considered
“unapproved” by allopathic providers. Alternative and complementary treatments
are sought by individuals often independent of their allopathic providers. Times
are changing and many allopathic providers are integrating alternative and
complementary therapies with western allopathic (evidence-based) treatments for
improved client outcomes.
Complementary and alternative medicine (
Complementary and alternative medicine is based on a
quote by Henry David Thoreau “Nature is doing her best each moment to make us
well. She exists for no other end.
Do not resist. With the least inclination to be well, we should not be sick.”
(Pizzorono & Murray, 1999, p.3.) This is the very foundation of naturopathic
medicine.
While much of the literature in
the past has referred to alternative therapies, this chapter will use the word
“alternative” when specifically described in the literature review; however,
medical schools teaching concepts of complementary/alternative therapies have
chosen to consider these as a part of integrative medicine to be used in
combination with the traditional western medicine. Alternative and complementary treatments
do not require a prescription by a traditional health care provider. In fact, the allopathic provider may or
may not be aware of complementary treatments with which the client is
participating.
Alternative and complementary therapies are not
new. They have been utilized for
thousands of years. Often these treatments were sole therapies for diseases
before antibiotics, physical therapy, chiropractic, and other treatment
modalities were available. As
an example, bloodletting is gaining resurgence for polycythemia, but has also
been used for many complaints and illnesses ranging from epilepsy, pneumonia and
hydrocephalus (Byard, 2001).
Leeching is being studied and utilized for its hemolytic treatment and in
improving venous supply for free-flap skin graphs (Thearle, 1998). Bloodletting of ancient times was
probably the precursor of the current concepts of therapeutic phlebotomy
(i.e.,in hemochromatosis, used to remove the excessive iron from the blood) and
plasmaphoresis (Rakel, 2000).
Complementary and alternative (CAM) therapies have
gained increasing popularity in this decade in the
The
inclusion of this chapter in this book is due to the fact that
nontraditional therapies (i.e.,
herbs, acupuncture, massage therapy) have increasing use in the
This chapter will focus on some
of the more popular complementary and alternative modalities that are used as
integrative therapies, while providing brief insight into some less commonly
used therapies. “Walking in
balance”, the Native American culture philosophy of peaceful coexistence and
harmony with all aspects of life (Fontaine, 2005), best describes how
complementary and alternative therapies blend with traditional Western
medicine.
Why Individuals Seek
Integrative/Complementary Treatments
Clients with chronic illness often live with
symptomotology such as chronic pain, shortness of breath, fatigue, or abdominal
discomfort. Traditional or
allopathic medicine may offer ‘relief’ to a certain degree, but tends to fall
short of long term relief or cure. The three most common conditions for which
adults used
Negative interactions with allopathic health care
professionals leave clients and families with a sense of distrust, therefore
rejecting treatments offered by allopathic providers. Once the client and family
trust and confidence is lost, it is difficult if not impossible to re-establish
that relationship. Belief and confidence in the practitioner is crucial for
adherence and treatment success (Selecting a
Most
recently published by the Centers for Disease Control (CDC), was a survey
conducted in the
Table 23-1
Prayer
45.2%
Prayer specifically for one’s own health
43.0%
Prayer by others for one’s own health
24.4%
Prayer groups for one’s own health
9.6%
Healing ritual for own health
2.0%
Nonvitamin, nonmineral, natural
products
18.9%
Deep breathing exercises
11.6%
Meditation
7.6%
Chiropractic care
7.5%
Yoga
5.1%
Massage
5.0%
Diet-based therapies
3.5%
Progressive Relaxation
3.0%
Megavitamin therapy
2.8%
Guided imagery
2.1%
Homeopathy
1.7%
Tai chi
1.3%
Acupuncture
1.1%
Energy healing/Reiki
0.5%
Source: Barnes et al., 2004, p
8
Since individuals were likely to use more than one type
of modality, the percentages exceeded 100% as this list is an accumulation of
various alternatives and complementary therapies used by the people
surveyed.
Problems and Issues Related to
Integrative and Complementary Modalities
There are many difficulties surrounding treatments with
integrative and complementary modalities. Seeking and finding a reputable and
competent clinician in the integrative arena can be daunting. Certain treatments
can conflict with spiritual, social, familial values, traditional medical
therapies and beliefs. Research with cannabis extracts (marijuana) has met with
opposition due to the social aspects of encouraging the use (smoking) of an
illegal substance. However,
research has found that cannabis extracts can improve neurogenic symptoms that
have been unresponsive to traditional therapies (Wade, Robson, et al., 2003:
Smith, 2004). Additionally,
the socially unacceptable therapy has been found to decrease the intraocular
pressure thereby aiding in the treatment of glaucoma (Duke, 1997).
The
treatments sought may be incongruent with allopathic treatment plans and may be
dangerous. Laird and Webb (2001) illustrated this in a case report where
undiagnosed dementia may predispose older adults to psychosis when taking
Not
only should there be concern about herbals and interactions with traditional
therapies, it has also been found that some persons have increased anxiety while
practicing relaxation techniques.
Lazarus and Mayne (1990) found that relaxation techniques had some
limitations and side effects that needed to be considered. Others have written about side effects
and negative responses to techniques for stress management (Astin, et al., 2004;
Woolfolk & Lehrer, 1993).
Many
available alternative therapies and modalities have no credible scientific
basis, therefore insurance companies may not recognize the treatment as a
reimbursable benefit. Patients assume that herbs for prevention and treatment
purposes are safe because they consider these therapies as “natural”, however,
that is certainly not always the case.
A lack of published research with herbals/alternative therapies leaves
the practitioner and insurance companies in a gray area of
treatment/non-treatment from these therapies (Zink & Chaffin, 1998). The lack of research and
documentation of research evidence for various treatment modalities is a
significant concern when it has been found that 8% to 10% of patients with
confirmed tissue biopsy for cancer seek alternative therapies immediately
(Cassileth, 1999; Cassileth & Deng, 2004).
The high rate of use
actually means enormous dollars spend on
Recently insurance companies are recognizing integrative
therapies as viable treatment alternatives which is a forward step as other
countries (i.e., Germany) has already found to be beneficial. Dr. Niki Knold, a German physician,
explains that alternative therapies are used before traditional medications
(personnel conversations, September, 2003, December 2003, and June 2004;
Blumenthal, 2000). One of the first insurance companies that has proven to be
supportive of integrative/complementary therapies is Blue Cross and Blue
Shield. They devised ALT MED BLUE
which provides a 25% reduction in the cost of selected integrative therapies
such as: massage, chiropractic care, stress management, biofeedback, yoga,
acupuncture, guided imagery, and nutrition education
(www.bcbsnc.com/blueextras/altmed). Other insurance companies may provide
similar programs in response to public outcry for treatment alternatives that
have scientific and clinical data supporting outcomes.
Previous arguments by insurance companies suggested
allopathic providers did not accept complementary modalities. This thinking
forces clients to take expensive medications that insurance will cover which may
have less than optimal outcomes.
This mindset prevents the client from making choices since they would
become responsible for the full cost of treatment. A common example is the
client with chronic back pain. Chiropractic care is scientifically reputable and
replicated and may provide better relief than pain medications and muscle
relaxers (Carey, Garrett, Jackson & Hadler, 1999). As with any therapy or medication,
insurance companies decide the amount of coverage, if any. While this can be seen as a problem for
alternative, it is also seen as a problem for traditional medicine. With the acceptance of alternatives
increasing among insurance companies, this is then seen as a positive approach
to holistic care. Reimbursement may be considered by insurance companies on a
case-by-case basis depending on the diagnosis and recognized data supporting the
therapy. This process can be time consuming and require a tenacious client and
health care professional to pursue coverage for an alternative treatment as they
would for traditional medications and treatments. Clients don’t always consider the cost
or interactions when selecting vitamins, herbals, or other modalities and that
they may have to cover the entire expense for “non proven” therapies. An example
of this is the herbal therapy Hawthorn.
This herb has been useful in treating hypertension. However, its cost and interaction with
other antihypertensives could be very detrimental (Duke, 1997).According to Dr
Julian Whitaker, a noted “wellness” MD in
Use
of complementary and integrative therapies is reaching a wide audience,
especially now that the National Institutes of Health have recognized the need
for further recognition as to documented benefits or the lack of significant
effects. Acceptance of
complementary therapies by health care professionals will benefit both the
client and the provider by encouraging individuals to inform the provider about
currently used therapies to be sure there are no interactions with therapies in
the plan of care and to actually discuss the benefits of certain therapies for
specific needs.
Evidenced Based
Practice
The National Center for Complementary and Alternative Medicine (NCCAM) at
the National Institutes of Health’s (NIH) mission have been to explore
complementary and alternative practices using rigorous scientific methodology,
train researchers and provide public with authoritative information (P.L.
102-170, October 1991). Eighteen
research centers, as of 2004, have been established to explore the safety and
efficacy of various therapies (http://nccam.nih.gov/). To expand the knowledge base of the use
of alternative and complementary therapies, NIH, NCCAM supports a broad-based
portfolio of research with educational grants, contracts and research funds (The
NIH Almanac-Organization,
In
addition to the NCCAM, the NIH Office of Dietary Supplements supports and
conducts research related to the role of dietary supplements and the influence
of these on health. Further
research is essential due to the rise of self-help books found in American
households, information on the internet and the proliferation of health food
stores that have information without research evidence (Office of Dietary
Supplements, http://dietary-supplements, info.nih.gov). The Office of Dietary Supplements (ODS)
originated from the Dietary Supplement Health and Education Act of 1994 (P.L.
103-417, DSHEA). The office was
developed to explore more fully the potential role of dietary supplements to
improve health care, to promote scientific study, and conduct and collect
results of scientific research
(dietary-supplements.info.nih.gov, retrieved 12/23/2004). While research
continues to support a scientific basis for alternative therapies for health
conditions, clinical evidence has long been a method of informal documentation
based on limited case reports for various alternative therapies. With the addition of the NCCAM at NIH,
more evidenced based practice will be determined for the appropriate use of
various modalities. In evaluating
literature and internet resources, one must be cognizant of the research
methodology to better analyze the information being presented. Often a marketing expert is the one
convincing the reader of the success of the product not a researcher.
The ideal study is experimental methodology that utilizes a control group
and an experimental group with similar characteristics. While the experimental group receives
the treatment modality, the control group does not and may be getting a
placebo.
There is more qualitative research being done to determine persons’
perceptions and the individual responses (Astin, Shapiro, et al., 2003). The qualitative studies build a body of
knowledge that describes characteristics and experiences that people have. The use of some complementary treatments
has continued from these experiences (Barnes, Powell-Griner, et al., 2004). However, some use of complementary
therapies is based on clinical effects.
This method is used by developing a perception of how persons
respond. If the modality seems to
work for a number of persons, the person using the modality will continue. This is not far from what is done in
medicine in the use of medicines considered to be “off label” where they are
prescribed for something not FDA approved. (Carey & Barrett,
2004).
Complementary and Alternative
Interventions
Alternative and complementary regimens may augment
allopathic treatments. In cancer, clients may benefit from dietary changes,
exercise, and different herbs (Redd, Montgomery & DuHamel, 2001; Syrjala,
Donaldson, et al, 1995). Cardiac patients may benefit from prayer that decreases
the length of their hospital stay and affects their mortality and morbidity
(Harris et al., 1999). It is beneficial to utilize all treatment modalities that
complement healing, stimulate immune function and reduce
inflammation.
Studies (Astin, 1998; Quinn, 2000) have demonstrated
specific reasons why consumers choose alternative therapies. Reasons include: seeking a degree of
wellness not supported in traditional medicine, quality of life issues,
involvement in the decisions about health and care, lack of effectiveness from
conventional medicines, avoiding toxicities of conventional medicine, and
identifying a healing system that is a part of one’s cultural background. Health
care professionals need to have a beginning level of understanding the various
types of therapies that clients may use. For example, current information is
on-line about the benefits and harm from using herbals (Sand-Jecklin, Hoggatt
& Badzek, 2004).
Holistic Health
Care
Holistic care considers all aspects of the mind, body and spirit.
Currently, there are few educational institutions that are educating physicians
in the use of complementary and integrative health care practices. However, centers of integrative health
have expanded across the country to provide individuals with the alternative of
managing health through an expanded use of traditional western medicine and
complementary and integrative care.
As of November 2004, there were 25 Centers as part of the Consortium of
Academic Health Centers for Integrative Medicine (Consortium of Academic Health
Centers, www.pcintegrativemedicine.org/documents/ConsortiumSummary.pdf). The
mission of the Consortium is to educate about and conduct research regarding
integrative medicine. Major universities are included in this list of 25
including some of the top medical schools in the country (Harvard,
Some alternative and complementary
therapies describe the concept of body and mind interaction in terms of
an aura or the energy field that surrounds the individual. Nursing has
recognized the importance of the cultural aspects of care and the holistic
concept of mind, body and spirit in the development of nursing art and science.
Nursing theories have focused on this concept of holistic care and energy fields
with the most well known being Martha Rogers with her nursing theory of unitary
human beings and the use of therapeutic touch (Rogers, 1990). There is a certificate program in
Healing Touch for Health Care Professionals offered by the American Holistic
Nurses Association (AHNA). This
program has expanded the concept of therapeutic touch (Fontaine,
2005).
Cultural
Integration
Inclusion of complementary and integrative health is an
area of care that may be associated with one’s culture and ethnic
background. Included in the
cultural area is the concept of spirituality that represents the wholeness of
life. Many alternative therapies
have originated through the traditions of spirituality (Krippner, 1995). Most spiritual traditions share the
concept that energy is the link between the spirit and the physical being
(Fontaine, 2005). Each culture has
a different view of this energy and describe it in terms of the connection to
provide a wholeness in one’s life.
Many
American subgroups continue to utilize aspects of their ancestry for healing and
comfort. These modalities can be spiritual, nutritional, behavioral, and
familial. Familiarity can be very comforting when one is challenged with a
life-threatening illness. Laying on of hands, spiritual prayers, and other
rituals can provide significant change in outcomes for patients. There is
profound comfort and rest when patients relinquish control to their “higher
power” Ayurvedic which is practiced
in
Many integrative therapies originated thousands of years ago and date
back to spiritual customs of various groups. Yoga, originally from
Chakras (the Hindu concept of energy) describes seven
energy centers that provide the electromagnetic activity and the circulation of
vital energy (Shang, 2001). This
concept is described by several South American cultures and many Eastern
cultures. The seven
chakras are vertically aligned through the center midline of the body and each
represent a focal point relating to physical, emotional and spiritual aspects of
one’s life. The purpose of chakras
is to maintain equilibrium of health and persons skilled in the techniques of
working with chakras can feel the energy source that is not in balance (Shange,
2001; Slater, 1995) .
This
concept has expanded to western culture with a program to reverse coronary
artery blockage prescribed by Dr. Dean Ornish. Ornish (1999) uses the heart chakra and
integrates diet, exercise, support groups and meditation into his
program.
While the United States is in the infancy of evaluating complementary and
alternative therapies, European countries have been consistently providing
information regarding alternatives to traditional medications. The most reputable source is from
Germany with the Commission E reports of alternatives (Blumenthal, 2000). The United States is providing source
titled PDR on Herbals (2000). This
volume is similar to the traditional Physicians Desk Reference (PDR). Several of the CAMs practiced today
relate to specific cultures.
Ayurved is practiced at the national level in India, and Kampo is the
herbal medicine system practiced in Japan.
Additionally, the multiple therapies from China (i.e., acupuncture,
acupressure, herbal medicine, tai chi, and qi qong) are a part of the national
system of health care in their countries
Barnes, et al., 2004)
Selecting a
practitioner
There are inconsistencies in licensure and certification
for many practitioners of integrative treatments (reference and provide an
example). For example, a licensed, (graduate from a board-certified massage
school) massage therapist can legitimately perform a massage, but it would be
best for the therapist to have a
national certification. This certification recognizes the same knowledge-base of
all massage therapists. There are state-by-state regulations for licensure and
practice. The various states boards
of medicine and the state laws provides detailed information on the
registration, licenses required to practice various forms of alternative and
complementary therapies (www.healthy.net/public/legal-lg/regulations/acustlaw.htm). It is difficult for the average health
care consumer to decide what provider is reputable and skilled. As previously
discussed, word of mouth and recommendations by trusted healthcare professionals
are excellent sources for referral. Contacting certification boards and schools
which teach a certain modality are other sources for reputable providers. Some insurance companies have limits on
coverage as they do with physical/occupational therapy and will cover only a
certain number of visits for therapies (i.e., acupuncture, massage). Clients may need to check with their
individual insurance companies as to reimbursement
Reputable and Competent
Clinicians
As
with allopathic medicine, there are “specialists” in integrative therapies. Many
clients have been to a “specialist” in allopathic medicine, and the same experts
exist in complementary medicine. Many complementary practitioners specialize in
one or two therapeutic options.
There are healthcare professionals that overlap in their skills, such as
a medical doctor or nurse practitioner who are also certified in acupuncture or
acupressure. Verification of credentialing and/or certification before utilizing
complementary providers is essential. Build a network of reputable integrative
providers and share it with your colleagues.
Tiedje (1998) provides guidelines to avoid certain healers:
·
If they say they
have all the answers;
·
If they maintain
that theirs is the only effective therapy;
·
If they promise
overnight success;
·
If they refuse to
include other practitioners as part of the healing team;
and
·
If they seem more
interested in money than in people’s well-being.
Treatment
Modalities
Healthcare professionals should assist clients in
decisions that will be therapeutic and beneficial for their particular symptoms
or diagnosis. Considering the therapies in Table 2 requires recognizing the
basic program of naturopathic healing (Murray & Pizzorno, 1991, Pizzorno
& Murray, 1999).
1.
The elimination of
evil habits (“over-eating, alcoholic beverages, drugs, tobacco, tea, coffee,
cocoa, meat eating, sexual and social aberrations, improper hours of living…”
(Murray & Pizzorno, 1991, p.5).
2.
Corrective Habits:
“Correct breathing, correct exercise, right mental attitude. Moderation in the
pursuit of health and wealth” (Murray & Pizzorno, 1991,
p.5).
3.
New Principles of
Living: “Proper fasting, selection of food, hydrotherapy, light and air baths,
mud baths, osteopathy, chiropractic and other forms of mechanotherapy…” (Murray
& Pizzorno, 1991, p.5).
Many
of the modalities and treatments can be grouped into several systems of
complementary care. For the purpose
of this chapter, the modalities will be grouped. This chapter is not all inclusive
but provides an overview of therapies.
TABLE 23-1 Complementary and Alternative Modalities
and/or Integrative Modalities
|
Category of
Modality |
Specific
Modalities |
|
MANUAL HEALING
THERAPIES |
Chiropractic Osteopathy Massage ( Myofascial,
Rolfing, Shiatsu,
Swedish) Therapeutic
Touch Laying on of
hands Acupressure
Acupuncture Reflexology Craniosacral
therapy |
|
MIND/BODY
THERAPIES |
Yoga/ Tai
Chi Meditation Hypnosis Light therapy
Color and/or Music
Therapy Relaxation |
|
SPIRITUAL |
Prayer Pet
Therapy Shamanism Imagery Ayurveda |
|
ENERGY
THERAPIES |
Biofeedback Reiki Magnets Crystals Aroma
therapy Polarity |
|
NUTRITION AND
SUPPLEMENTS |
Diets (Low sodium for
cardiac/
Hypertensive, Calorie
and
carbohydrate controlled for
diabetes
mellitus
Low fat diets for cholesterol
management
Weight control includes numerous
diets (Weight Watchers, South
Beach, Atkins, Zone) Herbals Vitamins, minerals and
specific foods Homeopathy
Chelation
Therapy |
|
MOVEMENT
THERAPIES |
Kinesiology Dance Aquatherapy Tai Chi
|
Manual Healing Therapies
There are a number of therapies involving physical touch
that have continued for generations.
Selected examples of these as noted in Table 1 are discussed in this
section.
Chiropractic
Medicine
Chiropractic practice considers the vertebral
manipulation an important practice to prevent and improve chronic pain, decrease
persistent drug use and avoid certain surgeries with regular treatments. Research indicates that a majority of
patients seek chiropractic care for musculoskeletal conditions of the back and
neck (Hurwitz, Coulter, Adams, Genovese & Shekelle, 1998). The majority of this care is reduction
of mal-alignment of the spinal bones.
Most patients continue with their primary care provider while seeing the
chiropractor for specific treatments (Sherman, Cherkin, et al., 2004). In a study by Sherman, et al.
(2004), chiropractic has been used by the largest fractions of respondents (54%)
primarily for back pain. Most
respondents in this study indicated they would “very likely” try chiropractic,
acupuncture or massage for back pain if their physician thought it was a
reasonable treatment modality or if they did not have to pay as out of pocket
expense (Sherman, Cherkin, et al., 2004).
Doctors of
Osteopathy
Osteopaths are trained in allopathic principles. Osteopaths treat the
whole person instead of one system or a specified ailment. Osteopaths believe
the structure of the body is intimately related to its function. Many forms of
movement modalities may be incorporated into the healing plan. Osteopaths can
prescribe medications as an adjunct to their movement and manipulation
therapies. Osteopathy originated in the US in the last of the nineteenth century
(Goldberg et al., 1994). Traditionally, the osteopath blends conventional
medicine with manipulative treatments to provide a comprehensive treatment plan.
(Goldberg et al., 1994). Typically
they use manual medicine techniques to relieve pain, restore range of motion and
enhance the body’s capacity to heal.
Doctors of Osteopathic Medicine (D.O.s) like their medical counterparts,
must pass a national or state board examination in order to obtain a license to
practice medicine. There are over
37,000 D.O.s in all 50 states and the District of Columbia (American Association
of Colleges of Osteopathic Medicine, 2004)
Mind/Body
Therapies
A number of these therapies had their beginnings thousands of years ago
in Asian countries (Barnes, et al, 2004).
Some of the more common therapies will be discussed, while others Table 2
can be reviewed in other sources.
Yoga
Yoga has been used for centuries. Yoga centers around meditation,
breathing and postures (Oken, Kishiyama, et al., 2004). There are several techniques of yoga
practiced, with the most common in the United States being Iyengar yoga. This form uses a stationary position and
then alternates isometric contraction and relaxation of various muscle groups
(Oken, et al., 2004). Oken et al.’s
study (2004) of 69 multiple sclerosis patients using yoga, exercise class and a
control group found that fatigue was improved compared to the exercise class and
control group (p< 0.001).
Studies have shown some success with yoga and carpal
tunnel syndrome. Symptoms were
significantly improved as compared to wrist splints or placebo effect, and there
was significant reduction of pain and increase in grip strength (Garfinkel et
al., 1998).
Meditation
Under mind-body therapies, meditation was listed as the
third highest use therapy after prayer and deep breathing exercises (Barnes et
al., 2004). Research has documented physiologic effects from the practice of
meditation (Goldberg et al., 1994). These effects include decrease blood
pressure, decreased heart and respiratory rates, decreased oxygen consumption,
increased elimination of carbon dioxide, increase in alpha brain waves,
decreased plasma cortisol, increased EEG alpha wave (Jevning et al., 1992,
Goldberg et al., 1994). Astin et
al. ( 2003) reported in a meta analysis of mind-body research that meditation
was one of the areas that had been researched for positive response to pain and
treatment-related symptoms of cancer. Deng et al (2004) supported the concept of
complementary therapies to decrease cancer-related symptoms. Others have found evidence of decreasing
risk factors in cardiovascular disease through the use of meditation and
specifically, transcendental meditation (Walton, Schneider & Nidich,
2004;Parati & Steptoe, 2004).
Hypnosis
Hypnosis is ancient treatment modality dating back to ancient Greece
where priests would give advice to persons while they were sleeping (Nash,
2001). Hypnosis can be defined as a
technique in which a trancelike state in which the individual is more responsive
to suggestions by another. There is
a change in perception, memory and voluntary control of action (Goldberg et al.,
1994). Research has indicated that
brain activity of the hypnotized person is that of a fully awake individual and
that there are specific changes in the activation and deactivation of specific
brain structures (Feldman, 2004).
Individuals seek assistance from a hypnotist to manage smoking cessation,
weight loss, stress management, insomnia, blood pressure control, and for
improving memory. There is board certification for hypnotherapists, which is the
preferred word for the neurobiological and sociocognitive perspectives of
hypnosis (Friend, 1999, Gruzelier, 2000, Feldman, 2004). There have been reviews of
research conducted with hypnosis (Green & Lynn, 2000) that provide mixed
reviews for specific uses such as smoking cessation. Other uses of hypnosis and existential
psychotherapy have been found to be beneficial in the treatment of patients with
terminal illnesses and intractable pain.
The study utilized 6 sessions of hypnosis to focus on symptom
management. Benefit from the
hypnosis was found to be significant following these sessions (Iglesias, 2004).
Chronic substance abusers have also benefited from hypnosis training. The study by Pekala, Maurer et al.
(2004) found that self-hypnosis training and the continued practice of this
decreased the relapse of drug usage and improved the participants
self-esteem.
Therapeutic
Touch
Therapeutic touch originates from the concept that an energy field
extends around the individual (Krieger, 1979). The focus of the therapeutic touch and
energy fields is that a transfer of energy occurs from the person acting as
healer to help the person alter the energy pattern to a better state (Krieger,
1979). This transfer of energy
helps correct imbalances and thus
aid healing. Research has been
conducted with therapeutic touch (TT)to include effects on pain, relaxation,
decreasing anxiety, and improving rest (Hughes et al., 1996; O’Mathuna,
2004; Heidt, 1990; Gagne & Toye, 1994). The use of TT has been examined as
a method of pain relief, especially with postoperative pain and headaches
(O’Mathuna,
2004; Kelly et al., 2004). According to studies, it alters enzymes activities,
increased hemoglobin levels and accelerated wound healing. Primarily it is used
for pain relief, stress and anxiety reduction (Kelly et al., 2004, Donnelly,
2004).
Light Therapy
Seasonal affective disorder (SAD) is a depression that
occurs during the long winter days when there is decreased sun and light. Further study into the alternations of
mood, indicated that not only was there evidence of depression, there is also
lethargy, inability to concentrate and difficulty sleeping which are usually
symptoms attributed to depression (Eagles, 2004; Johnson, 2000) SAD affects approximately 4-6 persons
per 100 people and usually female over the age of 20. Therapy can be from a light box source
or from a high-intensity fluorescent lamp that does not emit ultraviolet rays
(Keegan, 2001). The process of
exposure to white light has been effective. Szabo et al. (2004) found that light
therapy increased static visual contrast sensitivity in patients and may account
for a significant effect on seasonal affective disorder. Sher et al. (2001) also found that after
2 weeks of a 1 hour light therapy, improved atypical depressive symptoms. It was
suggested that long-term response to light therapy may be predicted by the early
responses (Sher et al., 2001).
Spiritual
Therapies
The
National Institutes of Health initiated a five year study in 2000 to determine
if prayer intervention would improve the health of clients with cancer. Since African-American (AA) women are
more likely to use spiritual healing than white women, the project has been
centered on AA women in the early stages of breast cancer. Dr. Diane Becker of Johns Hopkins
University and Dr. Harold Koenig of Duke University have been the
co-investigators on “Centering Prayer”.
With the report from the CDC indicating that prayer is the most commonly
used complementary therapy, it is important to determine the clinical and
spiritual benefits of this modality (Barnes et al, 2004).
McCaffrey and colleagues (2004) found that faith is a
critical part of health care and that physicians must consider this in their
plan of care. Intercessory prayer
(praying for others) has been suggested as an effective adjunct to standard
medical care in one study of patients in a coronary care unit (Harris, Gowda, et
al., 1999). The Cochrane Library
provided an analysis of the research conducted with intercessory prayer and
found that over 1400 subjects have been studied in this process of prayer. While the review did not find that physiological outcomes were
significantly improved, it was noted that the effects were psychologically
beneficial (Roberts, Ahmed & Hall, 2004).
Guided imagery has also been associated with spiritual
models. Lewandowski (2004) studied guided imagery as a modality for treating
pain . The author found that guided
imagery appeared to have a potential useful effect for chronic pain
sufferers. Others (Antall &
Kresevic, 2004) have also used guided imagery to manage pain in elderly
following orthopedic surgery with clinically and statistically significant
results. Additionally, Van Kuiken
(2004) conducted a meta-analysis to determine the significance of guided imagery
from research based studies. It was
found that 10 studies did indicated that guided imagery had a positive effect
over the first 5-7 weeks.
ENERGY
THERAPIES
Biofeedback
Biofeedback is useful in assisting the individual to
take conscious control of autonomic processes. The electronic equipment used in
biofeedback allows for measurement (i.e., muscle tension, brain wave patterns,
skin resistance, heart rate, and blood pressure) to provide information to the
individual of responses to visualization, muscle stimulation, imagery or
relaxation techniques (Keegan, 2001).
In addition to use for training individuals in stress reduction and
reduction of blood pressure and pulse, biofeedback has been used in the
management of urinary incontinence.
Initially, biofeedback was used for incontinence following prostatectomy
(Jackson, Emerson, Johnson, Wilson & Morales, 1996). Additional research has
expanded the concept for stress incontinence using vaginal probes to monitor
muscle tension and the use of biofeedback as one method that is effective
(Davila & Guerette, 2004).
Reiki
Reiki probably originated about 5000 years ago in Tibet, but the concept
and use of Reiki was renewed in the 1800s in Japan (Gallob, 2003). The word in Japanese means “universal
life energy”. It is based on the
concept of unseen energy flows that occur in all living things. Not only it is
based on energy flows, it also includes a method of spiritual healing. Reiki has been used to focus on helping
to heal the body, emotions, mind, and spirit. Light hand placement is used to channel
healing energies (Keegan, 2001).
NUTRITION AND
SUPPLEMENTS
Vitamins, Minerals and Specific
Diet Foods
Antioxidants
An
on-going study at the National Center for Complementary and Alternative Medicine
(NCCAM) is evaluating natural
antioxidants in the treatment of multiple sclerosis (MS). The specific treatments include
ginkgo biloba, alpha-lipoic acid, vitamin E, selenium and essential fatty
acids. Outcomes of this study
will be measured by the effects on the MS lesions as seen by gadolinium-enhanced
magnetic resonance imaging (http://www.clinicaltrials.gov/show/NCT00010842,
September 2004).
Basic information has been published by the National
Multiple Sclerosis Society on the use of vitamins, minerals and herbs in the
treatment of MS. The National
Multiple Sclerosis Society has several brochures on supplements and these can be
obtained through the organization.
Additionally, an introduction to vitamins, minerals, and herbs in MS is
available on the internet (http://www.nationalmsscoiety.org/Brochures-Vitamins.asp,
September 2004).
Vitamins have been used for generations to help maintain the body in
healthy balance. With the increased
availability of fast foods, today’s generation is more likely to consume a diet that does not meet all
of the vitamin essentials. The NCCAM has multiple clinical trials underway due
to clinical documentation of success with certain vitamins and minerals. The
entire list can be found under the government section from NIH and changes as
trials are started or recruitment of subjects is being sought (see resources at
end of chapter). In 2004, a 5 year
study was initiated and recruited over 32,000 participants to study selenium and
Vitamin E. Outcomes will be
measured on the prevention, quality
of life, and correlation with reduction of prostate cancer and other disease
processes such as Alzheimer’s disease, macular degeneration, and cardiovascular
events) (http://clinicaltrials.gov/show/NCT00056392).
The use of antioxidant vitamins has received wide discussion and research
evaluation in recent years. A
nationwide clinical trial, supported by the National Eye Institute of NIH, and
reported in the Archives of Ophthalmology in 2001, indicated that persons at
high risk for age-related macular degeneration could decrease this risk by 25%
with high-dose combination of vitamin C, vitamin, E., beta-carotene, and
zinc. These same nutrients had no
effect on the development or progression of cataracts according to the
Age-Related Eye Disease Study (AREDS, 2001).
There has been research conducted with Vitamin E and its relationship
with Alzheimer’s disease. Additional research may expands the use of Vitamin E,
as the current NCCAM research indicates the initiation of new studies. A 2004 study is evaluating the results
of this vitamin in aging persons with Downs’ syndrome. It has been hypothesized that Vitamin E
can improve quality of life in persons with Downs’ syndrome (http://clinicaltrials.gov/show/NCT00056329,
September 2004). Other research
sponsored by NCCAM is examining the effect of high does Vitamin E on carotid
artherosclerosis (http://www.clinicaltrials.gov/show/NCT00010699,
September 2004).
Vitamin B2 (Riboflavin) has been researched demonstrating a
significant but low efficacy as a preventative treatment for migraine
headaches. Research has complained
the efficacy of riboflavin to that of selective serotonin reuptake inhibitors
(SSRIs), calcium channel antagonists, gabapentin and topiramate (Silberstein
& Goadsby, 2002). Use of
riboflavin was suggested for prevention of headaches, however, it was noted that
significant research was lacking using controlled studies to provide this as
evidenced based practice. Mauskop
(2001) indicated that while the quantitative research has not been done, there
are case studies and smaller numbers of clinical evicence that does provide the
clinical support for the use of 200 mg riboflavin two times a
day.
Other
Supplements
Glucosamine and
Chrondroitin
Conflicting research results have led to the NCCAM to support a study
that evaluates the use of the dietary supplements, glucosamine, chrondroitin,
and a combination of glucosamine and chrondroitin as compared with Celecoxib and
a placebo. Results will examine
outcomes of persons with osteoarthritis and evaluate the reduction of pain and
improvement in movement. This study
has been concluded and data analyzed with results of the report due for
publication in the near future.
However, an issue that has arisen about this study is that it was only 6
months in length and cannot speak to long term benefits.(http://nccam.nih.gov/news/19972000/121100/qa.htm,
September 2004).
Diets, Food Sources and
Herbals
“We
are what we eat” is a commonly accepted phrase regarding choosing diets and food
sources. This chapter will not
include all of the diets as many books are written on specific diets; however,
diets cannot be overlooked in the concept of alternative and complementary
therapies as they are integrated with traditional medicine. What do we want to say about diets in
general?
In
addition to specific diets, there are various food sources that have been
researched to find either positive or negative aspects on disease processes or
interaction with treatment modalities.
Cranberry juice is one example of a supplement that has been reviewed in
the literature and studied for its physiological effect on urinary track
infections. Originally, it was
hypothesized that cranberry juice changed the pH of urine. Instead, it was found that cranberry
juice actually decreased the adherence of bacteria to cells thus helping with
prevention of UTIs (Raz, Chazan & Dan, 2004).
Grapefruit juice is an example of a food source that may have a negative effect
especially with certain medications (Lilley, 1998; Blumenthal,
1998).
Several remedies have been suggested by urologists for treatment of the
symptoms of an enlarged prostate gland.
The most popular is saw palmetto berry (Serenoa repens). It does not reduce the size of the
prostate gland, but it helps in managing symptoms (Blumenthal, 2000). Research has been mixed on the results
of the use of Saw Palmetto, and it is speculated that this may be due to amount
of herbal, the lack of controls or the length of the study (Braeckman, 1994;
Strauch, et al., 1994). Review in
Clinical Evidence Concise (2003) found that saw palmetto improves symptoms
compared with a placebo, but there was no difference in symptoms scores between
saw palmetto and finasteride.
Much has been discussed regarding other herbals in the management of
chronic conditions, and health care professionals need a reliable source for
herbals. Examples of clinical
indications of success with herbals that has not been documented with
significant research includes feverfew for migraines, chitosan for weight
loss, evening primrose oil for
premenstrual syndrome and for schizophrenia, Ginkgo biloba for intermittent
claudication, melatonin for jet lag
and peppermint for irritable bowel syndrome, just to name a few (Goldberg
et al., 1994). In the true spirit
of alternative medicine, Thomas Edison is quoted by naturopathic providers “ The
doctor of the future will give no medicine, but will interest his patients in
the care of the human frame, in diet, and in the cause and prevention of
disease”(Goldberg et al., 1994).
MOVEMENT
THERAPIES
Kinesiology
Kinesiology is the study of muscles and their movements. With this information, practitioners
analyze muscle function, posture, gait, and other movement activities that may affect health (Keegan, 2001). Currently, the research related to
applied kinesiology is still in its infancy (Gin & Green, 1997). There have been numerous articles about
kinesiology published, but results are not conclusive at this point since there
has been limited replication of studies (Schmitt & Leisman, 1998; Monti et
al., 1999). Applied kinesiology
uses acupressure to “reflex points” at specific muscles (Keegan,
2001).
Tai Chi
While Tai Chi is considered a mind/ body therapy due to the concentration
and the focusing required as an individual, it, in fact, can likewise belong to
movement therapies. As with
mind/body therapies, movement therapies deal with increasing mental awareness of
the body in order to improve posture and enhance muscle groups (Keegan,
2001). Tai Chi is a therapy
with extensive flowing moves with
graceful movements for health and meditation as well as self-defense ( Keegan,
2001). History of this Chinese therapy dates back to 3000 BC and has been noted
in cave paintings. Tai Chi (big, energy) is exactly that of generating and
feeling energy through movement.
This form of exercise has been documented to be beneficial in helping the
elderly with balance and movement (Wolf, et al., 1993; Wolfson et al.,
1993). In addition to improvement
in balance, results from a randomized trial found that Tai Chi had a positive
effect on blood pressure in older adults (Young, et al., 1999). Lan et al. (1999) likewise found the
positive benefits of Tai Chi on cardiorespiratory function of adultsfollowing
coronary artery bypass surgery.
Qigong
Qigong has it historical roots in China. (Kemp, 2004). The intent is to balance the flow of
vital energy (chi) along the acupuncture meridians or energy pathways. Qigong has been used for over 7000 years
(Kemp, 2004). The primary focus of
Qigong is “to reduce stress, improve blood circulation, enhance immune function
and treat a variety of health conditions” (Keegan 2001, p 199). Qigong is different
from Tai Chi in that it includes the breathing and relaxation exercises,
meditation and massage along with other natural methods (Keegan, 2001). To get
the maximum benefits, one should enroll in a program and continue this on a
consistent basis as it may take months to obtain desired benefits.
OUTCOMES
By developing increased awareness of alternative and complementary
therapies, clinicians can work together to provide an integrative approach to
health care. Cassileth (1999;
Cassileth & Deng, 2004) recognized the positives and negatives of
complementary and alternative therapies being used in cancer patients. Without a
clear understanding of both traditional, western medicine and various CAM
therapies, a person may select one or the other without recognizing the value
(either positive or negative) of each.
Some have delayed traditional cancer therapy in favor of alternatives and
others have chosen not to use researched methods (i.e., diet therapy,
meditation, biofeedback, yoga) to improve quality of life during cancer
treatment (Cassileth, 1999; Cassileth & Deng, 2004). It is anticipated with additional
research studies sponsored by NIH, more alternative and complementary therapies
will become a part of integrative health care. This would be the desired outcome of
combining therapies to treat the “whole” person in holistic care. It is all health care providers
responsibility to assess and understand alternative and complementary therapies
used by clients/patients in order to anticipate interactions with traditional
medicine and to support those therapies that are documented to be of benefit. A
problem is that it is very difficult to track outcomes, especially when
alternative therapies are being used with traditional, western therapies (Lewis,
deVedia, et al., 2003). An outcome of this chapter is to provide resources to
health care providers to expand knowledge of alternative and complementary
therapies as they are used in integrative medicine.
SUMMARY and
CONCLUSIONS
This chapter is not all inclusive of complementary and integrative
therapies. It is meant to stimulate
interest in further exploration of the kinds of therapies that people use and
the need for obtaining resources and research that provides current and reliable
information. An excellent start is
through the National Institutes of Health for Complementary and Alternative
Therapies (NCCAM) and the Office of Dietary Supplements.
Not
only does the NIH website provide information about research studies, there is
also specific information that is researched based provided through the Office
of Dietary Supplements of NIH. An
example of this is the information related to Vitamin A and Carotenoids which
includes information related to recommended dietary allowances, food sources,
current research information available on the deficiency of Vitamin A and the
possible negatives from excessive amounts.
It must be remembered that not all “natural” products are safe. With current research, we not know that
ephedra can cause detrimental effects on blood pressure, arrhythmias, and even
sudden death, therefore, obtaining this over the counter has been banned (http://www.consumerlab.com/). This should
be included earlier when you are talking about risks, benefits, etc.
Study
Questions
1.
How do
complementary and alternative therapies differ from traditional western
medicine?
2.
Why do most people
seek complementary therapies?
3.
Are complementary
therapies less expensive than traditional medicine?
4.
How does the nurse
respond to patients describing the use of alternative
therapies?
5.
What are the
benefits to incorporating complementary therapies with traditional
medicine?
6.
Can allopathic
providers utilize alternative therapies in their
practices?
7.
What are 2
governmental sources for reviewing pertinent data and information on CAM
therapies?
8.
Describe two
movement therapies.
9.
Do insurance
companies recognize CAM as legitimate alternatives or complements to allopathic
treatment? Do they reimburse for
these CAM treatments?
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