Complementary and Alternative Medicine
Anthony I. Beutler
David K. Gordon
Wayne B. Jonas
WHAT IS COMPLEMENTARY AND ALTERNATIVE MEDICINE?
Many different medical systems and medical practices exist in the world today including traditional Oriental medicine, Native American practices, Ayurveda, and Western biomedicine (to name only a few).
Western biomedicine is the medicine practiced in American hospitals and taught in American medical schools. Western biomedicine is neither the oldest nor the most widely used medical system in the world today. The World Health Organization estimates that a substantial portion the world’s population receives their medical care outside the Western biomedical system (43).
The term “complementary and alternative medicine (CAM)” is Western biomedicine’s term for all medical practices that lie outside its boundaries. CAM’s boundaries are imprecise and constantly changing as Western scientific methods are applied to study and establish the efficacy of “outside” medical practices in the treatment of Western biomedical disease states. For instance, is massage therapy an adjunct to standard athletic care or a CAM treatment? Is glucosamine supplementation for osteoarthritis (OA) pain a Western biomedical therapy or a CAM therapy (43)? Some practices are both.
CAM is often called “traditional” or “indigenous” medicine. Most recently, the term “integrative medicine” has been proposed for general use. Because the National Institutes of Health (NIH) still uses the CAM terminology, this chapter will refer to these diverse systems and practices as CAM.
WHO USES COMPLEMENTARY AND ALTERNATIVE MEDICINE?
Many developing countries rely on CAM practices to provide most of the health care for their citizens.
Americans spend more than $33 billion each year (most of it unreimbursed by insurance) on CAM practices. Visits to U.S. CAM practitioners rose from 400 million per year in 1990 to 600 million per year in 1996 and have continued to increase steadily. Approximately 40% of the U.S. population (compared with 75% of the population of France) report using a CAM practice at least once during the year (8,20).
Among Western CAM consumers, 95% use CAM in a “complementary” fashion or in addition to Western biomedicine. Only 5% use CAM exclusively, or as an “alternative” to Western biomedicine (7).
Studies reveal that CAM users in the United States tend to be more educated, more affluent, more holistic in their view of health care, and more likely to have chronic pain or a chronic disease than nonusers of CAM (7,12,20). Past reports indicated that some minorities, such as African Americans, were less likely to use CAM. However, a more recent study specifically designed to assess CAM use among minorities found no difference in CAM use among ethnic groups (42). Women consistently use CAM more than men, as they do all medical care.
CAM therapies are popular for both major and minor illnesses. Roughly half of patients with human immunodeficiency virus (HIV) and half of patients diagnosed with cancer will try CAM therapies to combat their illnesses. However, CAM therapies are less commonly used to treat diseases for which Western biomedicine offers safe, effective treatments. For instance, although 57% of patients with diabetes mellitus type 2 report using CAM treatments, only 20% report trying CAM therapies to treat their diabetes (75).
DO ATHLETES USE COMPLEMENTARY AND ALTERNATIVE MEDICINE?
No comprehensive study of CAM use among athletes is available (72). One study at a single Division I National Collegiate Athletic Association (NCAA) institution found that 56% of athletes (67% of women, 49% of men) used CAM. Eighty percent of these athletes used CAM in addition to traditional Western medicine (48). Common sense and common experience suggest that CAM use should be regarded as the rule, not the exception, in athletes.
According to the 2002 National Health Interview Survey (NHIS), CAM use is more prevalent in adults who engage in physical activity during leisure time (8).
Athletes may use CAM therapies to enhance performance, decrease recovery time after workouts, or speed return to play following an injury.
Examples of CAM treatments commonly used by athletes to enhance performance include caffeine (guarana), creatine, ginkgo biloba, hormone supplements, and ephedra. Examples of CAM treatments typically used for pain control or accelerated return to play include iontophoresis, microcurrent, spinal manipulation, homeopathic arnica, and acupuncture.
The high pressure and high stakes of athletic competition, together with the exceptionally small margin that separates success from failure, demand that sports medicine physicians exercise great vigilance in protecting the athletes entrusted to their care.
WHERE CAN I FIND GOOD EVIDENCE ON COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES?
The best type of evidence to use in evaluating a CAM therapy depends on:
Risks posed by the therapy
Cost of the therapy
Information preference of the individual patient
Availability of other proven, effective, and safe therapies for the patient’s condition
Randomized controlled trials (RCTs) are important for evaluating high-risk and/or high-cost therapies because RCTs provide essential safety and risk-benefit data. However, RCTs have some important limitations. RCTs are difficult and expensive to sustain for long periods of study. Additionally, the results of an RCT depend greatly on the careful selection of the all-important “control” group (38).
Clinical outcomes research is another, less recognized type of research trial that is useful in studying CAM therapies. Outcomes research is more similar to clinical practice than RCTs: It involves a wider range of patients over longer periods of time and allows for variations in care caused by interactions with multiple providers. Outcomes research examines the probability that a therapy will produce a beneficial effect and provides an estimate of how large that effect will be in everyday clinical practice. For long-term, chronic conditions and their therapies, outcomes research often provides the only relevant evidence (67).
Table 80.1 lists a number of sources for obtaining quality evidence on specific CAM therapies and practices.
The patient’s individual beliefs and personality can affect the likelihood of therapeutic efficacy. If a patient believes that a specific therapy will alleviate their condition, this “prior plausibility” has its own therapeutic effect.
If conventional medicine offers a safe, proven therapy that is acceptable to the patient, any potential CAM therapy must pass equally stringent evidence standards for efficacy and safety before being considered as a viable treatment option.
Table 80.1 Internet Resources — Reliable Complementary and Alternative Medicine (Cam) Evidence for Physicians
The Cochrane Library
The library contains a database of systematic reviews featuring randomized controlled trials of CAM and conventional therapies, as well as a controlled trials register that provides bibliographic listings of controlled trials and conference proceedings.
Abstracts of the reviews and trials are available free of charge at http://www.cochrane.org
Full text copies of all materials are available through several subscription services including http://gateway.ovid.com
PubMed
The most comprehensive and popular medical search engine has a new “clinical queries” filter to assist in limiting your search results to CAM. The most comprehensive search is obtained by using the key words “complementary medicine.”
Free access at multiple Web sites including http://www.pubmed.org
National Center for Complementary and Alternative Medicine (NCCAM)
The clinical trials section contains an index of trials by treatment or condition. The index can also be accessed via www.clinicaltrials.gov or through PubMed.
The NCCAM Web site is http://www.nccam.nih.gov
National Library of Medicine
Powerful search engine allows searches across all government guidelines, plus PubMed. “Synonym and related terms” search option is very helpful for CAM therapies with multiple common names.
The search engine may be accessed free of charge at http://hstat.nlm.nih.gov
Individual guidelines from many government agencies can be found at http://www.guideline.gov or http://www.cdc.gov/publications
Natural Medicines Comprehensive Database
The online database contains comprehensive listings and cross-listings of natural and herbal therapies, including very helpful sections on “all known uses” and “herb-drug interactions.” The database also offers an extensive review of the available pharmacologic evidence.
From the publishers of The Prescriber’s Letter, the database can be accessed via a purchased subscription at http://www.naturaldatabase.com
ePocrates Rx Pro
Listing of alternative medicines for mobile devices, but does not contain information on nonmedicinal modalities (acupuncture or manipulation). Provides names, common uses, suggested dosages, and a multicheck feature that checks the patient’s medical regimen for drug-drug, herb-herb, and drug-herb interactions.
Alternative medicine content is available only with the purchase of ePocrates Rx Pro, not with the free version of ePocrates Rx. http://www.epocrates.com
HOW DO I ADVISE MY PATIENTS ABOUT COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES?
Ninety-five percent of patients who use CAM therapies also use conventional, Western biomedicine. However, over 60% of these patients do not inform their physicians of their CAM therapy use (19). This “CAM communication gap” results
in a wasteful, and potentially dangerous, patient-physician environment.
Patients who use CAM practices possess character traits that incline them to active participation and partnering in their medical care (20). A physician who refuses to discuss and denies any knowledge of CAM treatments does not alter the patient’s need for partnering, but merely forces them to seek association elsewhere — thus widening the already precipitous CAM communication gap.
Protecting from Harm
Many CAM practices are inherently low risk when performed or prescribed by competent providers. However, herbal remedies and high-dose vitamin supplementation (both very popular CAM therapies) can cause serious or fatal consequences (17).
“Natural” does not equal “safe,” contrary to the popular conceived connotation. Herbs and vitamins have real effects, real side effects, and real toxicities. Even without direct toxicity, herb-herb and herb-drug interactions can be severe. Other quality issues such as contamination, varying potencies, and differing absorption rates abound in the poorly regulated domain of nutritional supplements (17).
Biofeedback, meditation, prayer, and acupuncture pose minimal risk for direct toxicity. However, even these “safe” practices may indirectly result in harm if used in place of more effective treatments. The physician should detail the risks and benefits (both direct and indirect) of all therapeutic options.
Ephedra (or ma huang) especially in combination with caffeine (or guarana), chromium picolinate, and pulsed magnetic field therapy are examples of therapies from which patients should be protected. (See later section on specific CAM treatments.)
Permitting Unproven, Nontoxic Therapies
Physicians may experience trepidation in allowing patients to engage in unproven practices or therapies. But if the therapy has no toxicity and is not used in place of a proven effective treatment, the practice can be safely permitted and may be encouraged.
The physician’s ultimate goal should be to relieve patient suffering. Patients welcome relief — and physicians should do likewise — even should relief come through nonquantifiable means (spiritual effect, placebo effect, belief, prior plausibility) (46).
Homeopathic arnica, acupuncture, spinal manipulation, ginkgo biloba supplementation, and many other CAM therapies can be safely permitted when properly administered and appropriately prescribed.
Promoting Proven Treatments
Physicians should promote safe, effective treatments regardless of their medical system of origin. Western biomedicine has adopted and should continue to incorporate proven techniques and therapies from other systems of medical care (37).
Glucosamine supplementation is a prime example of a CAM therapy that should be promoted for individuals with knee OA. Acupuncture and massage for back pain are other examples of proven CAM therapies to be promoted.
WHAT’S THE CURRENT EVIDENCE FOR OR AGAINST SOME POPULAR COMPLEMENTARY AND ALTERNATIVE MEDICINE TREATMENTS?
Summaries of the evidence for and against a few of the most popular CAM treatments used by athletes and the general population appear in the following sections. They are organized into the sections of Prevent, Permit, and Promote.
Prevent
Herbs and Supplements
Primary use: Weight loss or enhanced athletic performance, endurance. Less commonly used for respiratory conditions or asthma.
Evidence: Ephedra can potentiate a small weight loss of 2-5 kg over 6 weeks to 6 months, but only in patients with body mass index over 30. The weight loss is typically transient and often requires combination with other stimulants (i.e., caffeine or guarana). Multiple studies show no performance-enhancing effect unless combined with caffeine/guarana or used in very high dosages.
Toxicity: High dosages and combination with caffeine known to increase toxicity. High dosages can cause dizziness, restlessness, anxiety, palpitations, hypertension, myocardial infarction, seizure, stroke, and psychosis, among other conditions (18,24,34,36,47,69). Fatal events have been reported. Newer evidence suggests that toxicity can occur with short-term use in low doses as well (24,34). Capsules have been found to contain many impurities, including banned substances.
Regulated/banned: Banned by the Food and Drug Administration (FDA) and the International Olympic Committee (IOC) (25).
Conclusion: Ephedra products, especially ephedra/guarana combinations, are banned substances, are not safe, and have been demonstrated to cause considerable harm. As negative publicity builds, “ephedra-free”
versions of products appear, but there is no evidence that these will be any safer than the original formulations.
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