Complementary and Alternative Medicine
Ann C. Cotter
Lisa Bartoli
Jay Rosenfeld
Robert Schulman
David Jung Seto
The practice of physical medicine and rehabilitation (PM&R) is inherently a holistic discipline which focuses on the patient as a whole human being, functioning on physical, emotional, mental, social, and spiritual levels simultaneously. PM&R is a leader in integrating the concepts of holism and a diverse spectrum of therapeutic modalities into the conventional medical paradigm. PM&R and complementary and alternative medicine (CAM) share several core principles, including patient-centered care, the concept that the wisdom of the team is greater than the sum of its parts, and clinician-patient partnership. These ideas are now more commonly being adopted in other areas of medicine. Because of the similarities between the theoretical underpinnings of PM&R and of the philosophies associated with CAM modalities, CAM fits easily into the rehabilitation model. According to the National Health Information Survey (NHIS) conducted in 2007, 83 million adults spent $33.9 billion out of pocket on CAM, and CAM costs are 11.2% of total out-of-pocket expenditures on health care. American adults are most likely to use CAM for musculoskeletal problems such as back, neck, or joint pain (1).
After World War II, the distinctive field of PM&R evolved in response to the fact that mainstream medicine was not providing adequate care and treatment for patients who had sustained injuries to the musculoskeletal and central nervous systems. In his pioneering book, The Knife Is Not Enough, Dr. Henry H. Kessler clearly espoused the need for what are today being called “complementary and alternative” therapies (2). He included not only physical and dietary interventions in his multidisciplinary approach, but he also recognized the important role that spirituality played in healing. This approach has marked PM&R with more openness to CAM than other specialties.
The NIH National Center for Complementary and Alternative Medicine (NCCAM) defines Complementary medicine as an approach to medical care that is used together with conventional medicine. Integrative medicine combines treatments from conventional medicine and CAM for which there is evidence of safety and effectiveness. Alternative medicine is an older term denoting the substitution of unconventional therapies for conventional modalities and is no longer current.
Because of the broad range of therapies within the realm of CAM, this chapter focuses primarily on those therapies that are currently applied in common rehabilitation conditions and settings. The goals of this chapter are to provide (a) a brief introduction to the major CAM therapies that may be employed by physiatrists and used by patients and (b) a theoretical and research basis and where appropriate, clinical strategies for use of CAM therapies in the PM&R setting.
The evidence base for many CAM therapies ranges from inadequate (energy therapies) to more robust (acupuncture). This chapter is written as a descriptive and practical guide for the physiatrist with literature cited for further reading.
Table 79-1 presents the classification system utilized by the NCCAM to categorize CAM therapies. This chapter uses this system for organizing the various complementary and alternative techniques applicable to the rehabilitation process.
WHOLE MEDICAL SYSTEMS
The NIH NCCAM describes whole medical systems as approaches to care that are built upon complete systems of theory and practice that have evolved independently of the conventional medical approach used in North America and Europe.
Examples of whole medical systems that have developed in Western cultures include homeopathic and naturopathic medicine. Examples of systems that have developed in non-Western cultures include Ayurveda and traditional oriental medicine.
Each of these approaches has relevance to PM&R, but the area within the whole medical systems category that currently plays the biggest role in the field of PM&R is Oriental Medicine.
Oriental Medicine
Oriental medicine is over 3,000 years old and is based on the theory that there is a vital life force (qi) that supports physiologic functioning. Qi is concentrated in multiple pathways or channels called meridians that run longitudinally throughout the body. Health is the state in which qi is flowing abundantly and harmoniously, and illness is believed to result from an improper amount distribution or imbalance of this energy, which then precipitates physiologic change (3). Acupuncture is the insertion of thin, noncutting needles into specific acupuncture points along the meridians in order to correct aberrant energy flow. Of all modalites under the heading of Whole Medical systems, acupuncture is the most widely used in PM&R and is discussed in detail. T’ai Chi, a movement
therapy, and qigong, an energy therapy, are all based on this concept and are discussed in separate sections.
therapy, and qigong, an energy therapy, are all based on this concept and are discussed in separate sections.
TABLE 79.1 Complementary and Alternative Techniques | |||||||||||||||||||||||||||||||||||||||||
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Acupuncture
Acupuncture has numerous applications in PM&R. It is utilized for both acute and chronic musculoskeletal and neurologic problems. Needles are placed both locally, near the anatomic location of the problem, as well as in other areas of the body. A typical acupuncture session lasts 30 to 60 minutes including examination and needle insertion. The number of sessions required depends on the intensity and chronicity of a condition as well as the age and general health of the patient. For an acute back spasm in a young and otherwise healthy individual, one to two sessions may be sufficient. For longstanding pain in lumbar spinal stenosis or motor recovery in hemiplegia secondary to cerebrovascular accident (CVA) in an older individual, up to 20 or more closely spaced sessions followed by less frequent maintenance may be required to achieve optimum results.
Recent research has begun to highlight promising avenues of exploration regarding the physiologic nature of the acupuncture channels and the points themselves (4). Histologic studies have suggested that some 80% of acupuncture points consist of a characteristic subcutaneous column of loose connective tissue, with a looped core bundle of neurovascular and lymphatic vessels that may help propagate the influence of superficial needle inputs to deeper structures (5). Decreased electrical resistance and increased capacitance have been reported between acupuncture points sharing energy channels (6). Additionally, nuclear medicine studies have shown that subcutaneous injection of technetium-99m into the low- resistance acupoints of humans and dogs results in a rapid migration of the radioactive tracer along the associated meridians; this movement is distinct from the trajectory of blood vessels, lymphatics, and peripheral nerves, and is not observed with nonacupuncture points (7,8). More recently, similar results using gadolinium injections and MRI have been reported in humans (9). There is substantial overlap in the locations and properties of myofascial trigger points, which react to needling with a local twitch response and predictable pain radiation patterns, and acupuncture points, which react to needling with a local ache (called “de qi”) and radiation of this sensation along the associated acupuncture channels (10). However, as acupoints are not always tender to palpation and are often used for other indications aside from local pain, debate exists about whether trigger points may merely represent a smaller subset of acupuncture points called “a shi” points (11, 12, 13).
Anatomic studies in vivo and postmortem section in the upper arm have revealed that more than 80% of acupuncture points and 50% of meridians correspond to intermuscular and intramuscular connective tissue cleavage planes (14). Microscopic images show that the tissue resistance “needle grasp” effect (a sensation of resistance felt by the practitioner when the acupuncture needle has been advanced to its desired depth in some acupoints) that is clinically recognized upon twisting an inserted needle actually corresponds to the winding of collagen fibers and fibroblasts in the connective tissue around the surface of that rotated needle (14, 15, 16, 17). Needle grasp of acupoints may thus propagate a mechanical stretch to the deeper fascial matrix, which ultimately invests structures such as the peritoneum of the viscera, the pleura, the perineurium, and the meninges (14). Mechanotransduction of this stretch converts into a potentially gene transcription-altering intracellular signal by deforming the cytoskeletons of fibroblasts and directly influencing actin and microtubule remodeling, as shown in a murine model (18,19). Related studies have demonstrated that cyclical stretching of fibroblasts in this fashion decreases TGF-b1 production and type 1 procollagen
deposition (both factors normally promote fibrosis), which begins to suggest a common hypothesis explaining the therapeutic benefits of fascial stretching modalities such as physical therapy, massage, osteopathy, Rolfing, yoga, and acupuncture (20,21).
deposition (both factors normally promote fibrosis), which begins to suggest a common hypothesis explaining the therapeutic benefits of fascial stretching modalities such as physical therapy, massage, osteopathy, Rolfing, yoga, and acupuncture (20,21).
It has long been known that acupuncture stimulation acts on the autonomic nervous system and causes the release of endogenous endorphins, enkephalins, monoamines, and other neurotransmitters that play central roles in acupuncture analgesia (5). More recently, neuroimaging has revealed a glimpse into the CNS networks that are manipulated via acupuncture stimulation (22). Studies using functional MR have shown that needling certain acupuncture points activates areas of the somatosensory cortex that do not correspond anatomically, but do correspond functionally under classical East Asian medical theory, although these data are still under debate (23, 24, 25, 26, 27, 28, 29, 30). Major acupuncture points traditionally needled for pain management have been shown on fMRI to modulate activity in areas such as the hypothalamus, prefrontal cortex, insula, limbic system, and periaqueductal gray matter (31, 32, 33, 34), which may help attenuate both the sensory and the emotional perception of pain and coordinate an autonomic response (22). Even after acupuncture stimulation is terminated, changes persist in the central connections among the limbic areas for pain, affect, and memory (35). These results may have significant implications for the rehabilitation of other disorders involving cerebral cortical remodeling, such as stroke, phantom limb pain, and neurodegenerative syndromes.
Controlled clinical trials have shown acupuncture to be effective for osteoarthritis (36), neurogenic pain following spinal cord injury (SCI) (37), neurogenic bladder (38), lateral epicondylitis, addiction, headache, tennis elbow, fibromyalgia, myofascial pain, low back pain, and carpal tunnel syndrome (39). Meta-analyses have reported that acupuncture has shown efficacy in the treatment of tension headache (40) in migraine prophylaxis (41), and as an adjunct to low back pain rehabilitation (42), but that further study is required to make conclusive statements regarding benefit or lack thereof in stroke rehabilitation (43, 44, 45) and rheumatoid arthritis (46). In practice, acupuncture is used to treat multiple conditions including osteoarthritis, lumbar spinal stenosis, tension headaches, muscle and ligament sprains, carpal tunnel syndrome, lateral epicondylitis, motor recovery after stroke, neurogenic pain, bowel and bladder dysfunction following SCI, early peripheral neuropathy, and migraine headaches among other conditions. Acupressure is a technique based on the concept of meridians and acupoints, but instead of needle insertion, pressure is applied to the acupoint. In practice, acupressure may be thought of as a weaker form of acupuncture. Patients may be given acupressure points as a part of their home exercise program to enhance the rehabilitation process.
Acupuncture has, generally, been found to be safe, and the rare complications can be minimized by using licensed practitioners (47). One study indicated that blood pressure should be monitored in SCI patient (48). Overall, acupuncture shows promise as a useful treatment modality in the PM&R setting.
Homeopathy
Homeopathy is the system of diagnosis and treatment developed by Samuel Hahnemann, MD, a German physician who viewed the symptoms of an illness as a reflection of the body’s attempts to regain homeostasis. He postulated that if we could properly interpret these symptoms, we could then direct the body’s own homeostatic mechanisms toward healing illness. Hahnemann reported that when a small test dose of a biological substance is given to a healthy person, it elicits a predictable array of signs and symptoms. Hundreds of substances have been tested in this manner (this is referred to as a “proving”) and logged in the Homeopathic Materia Medica. Homeopathic theory states that a dilute amount of this substance will help to direct the body’s innate healing mechanisms toward balance. When a patient becomes ill, symptoms are recorded and closely matched to the material that causes similar symptoms in a healthy person. The homeopath combines this information with past medical and social history, and examination in order to prescribe a homeopathic remedy. Prescription of remedies in homeopathy is highly individualized, since the mental-emotional pattern, general level of health, and particular physical attributes of the patient are all taken into consideration. The underlying theory is that the remedy will help to steer the body back to homeostasis.
Many medical doctors in the United States used homeopathy in the early 1900s, and there were 16 homeopathic medical schools in the United States at the beginning of the 20th century. Since then its popularity declined until recently and in 1997, 3.4 million visits to homeopathic providers were reported in the United States (49,50). Research in homeopathy using current double-blind placebo-controlled methods presents considerable difficulty. Two patients with the same allopathic diagnosis may have two completely different symptom complexes when the patient is examined from a homeopathic point of view. The result is that two different homeopathic remedies may be prescribed for two patients with the same allopathic diagnosis. Nonetheless, it has shown to be useful in the treatment of mild TBI (51) and some musculoskeletal problems (52, 53, 54). A meta-analysis of four trials on osteoarthritis concluded that although the clinical evidence appears promising, the small number of randomized clinical trials conducted to date, although favoring homeopathic treatment, did not allow a firm conclusion as to the effectiveness of homeopathic remedies in the treatment of patients with osteoarthritis (55).
Ayurveda
The indigenous healing system native to India, Ayurveda translates as the “science of life.” The basic principles of Ayurveda include the interconvertability of energy and matter and the interconnectedness of all life (56). Like the field of PM&R, Ayurveda teaches that disease and healing occur on all levels: physical, emotional, mental, and spiritual. Everything in the cosmos is believed to be made up of varying proportions of the five elements—earth, air, water, fire, and space. According to Ayurveda, these elements also occur in people in varying
proportions that are grouped into types functionally classified as doshas. These proportions make up the individual’s prakriti, or individual constitution, and determine the mental and physical makeup of each individual. Illness is thought to occur when there is an imbalance in the doshas. Each dosha has corresponding symptoms and illnesses that occur during imbalance. Treatments are individualized by constitutional type and include herbs, yoga postures, diet, pranayama or breathing techniques, purification techniques, meditation, and mantras (25).
proportions that are grouped into types functionally classified as doshas. These proportions make up the individual’s prakriti, or individual constitution, and determine the mental and physical makeup of each individual. Illness is thought to occur when there is an imbalance in the doshas. Each dosha has corresponding symptoms and illnesses that occur during imbalance. Treatments are individualized by constitutional type and include herbs, yoga postures, diet, pranayama or breathing techniques, purification techniques, meditation, and mantras (25).
Ayurveda is not well integrated into the PM&R setting at this time. However, one tool used by Ayurvedic practitioners, yoga, is discussed in separate sections below.
Naturopathy
Naturopathy is a system that stresses health maintenance and disease prevention through patient education and acceptance of responsibility for one’s own health. Underlying the various treatments in naturopathic medicine is the belief in the healing power of nature, and the innate intelligence of the body. Naturopathic physicians are trained in the medical sciences as well as combinations of disciplines such as herbology, nutrition, homeopathy, or acupuncture. A naturopathic doctor holds the degree ND and has 4 years of training followed by an internship. Naturopathic physicians are licensed in some states and Canadian provinces, and scope of practice for some includes limited drug prescription.
MIND-BODY INTERVENTIONS
The basic premise of mind-body interventions is that the mind and body are not dualistically distinct entities but exist on a continuum. Thus, thoughts and emotions influence the body, and physical processes have an impact on the mental, emotional, and spiritual state. Mind-body interventions may be separated into either a mental or physical process that influences this mind-body continuum. “Mind”-based techniques including visual imagery, art and music therapy, biofeedback, hypnosis, meditation, and prayer are designed to act through the mind to alter its state and thus physical conditions including muscle tension, endorphin levels, and pain. Body-based techniques use the body as a vehicle and act to increase strength, flexibility, and body awareness and in so doing, impact upon mental/psychological/spiritual states such as level of mental focus, anxiety, or compassion for self and others. Modern day usage and supporting evidence are listed for mind-body techniques separately below.
Hypnotherapy
Hypnotherapy works at the level of the subconscious mind to assist patients in making positive behavioral changes and to decrease symptoms. A clinical hypnotherapist makes use of therapeutic suggestion while an individual is in a highly relaxed and altered state of awareness. Hypnotherapy is used to improve self-esteem, improve mood, increase feelings of self-efficacy, and control and decrease negative behaviors and fears that interfere with recovery. In case reports of patients treated with hypnosis following a stroke, observations were made of increased movement in hemiplegic limbs and improved ambulation (57, 58, 59) as well as the return of normal speech (57,59). Hypnosis was used in the treatment of headache or vertigo following brain injury in a series of 155 patients, with half reporting resolution of symptoms and another 20% experienced significant symptom reduction (60). In the area of musculoskeletal rehabilitaion, hypnosis, when used, is largely for pain control. One NIH consensus review panel and one meta-analysis suggest that hypnotherapy may be a useful adjunct to the treatment of chronic low back pain and other neuromusculoskeletal conditions (61,62). Positron emission technology (PET) scanning reveals that the hypnotic state is related to the activation of a widespread set of cortical areas involving occipital, parietal, precentral, premotor, and ventrolateral prefrontal and anterior cingulate cortices (63).
Meditation
In some form, meditation has long been used in many cultures, both Eastern and Western. Originally, it was tied to religious practices and was performed with spiritual goals of enlightenment. Modern forms of meditation have separated the techniques from their religious contexts, and the goals for which meditation is used have become more concrete, for example, decreased anxiety and improved health. While there are many forms of meditation, most are intended to create a state of physical and mental relaxation. Most forms of meditation involve sitting or lying quietly while focusing on one or two stimuli, such as breathing patterns, a word, or an image.
The most robust finding on the impact of meditation is the success of meditation for reducing hypertension (64, 65, 66, 67). Research evidence for the effectiveness of meditation in the rehabilitation process is limited to anecdotal reports (68).
Meditation has been shown to improve cognitive functioning in college students and elderly adults who have no history of head injury (69,70). For pain and musculoskeletal conditions, studies indicate that the practice of meditation as part of a comprehensive treatment program can improve self-management of chronic pain (71), fibromyalgia symptoms (72) and perception of pain in arthritis (73). Although multiple studies have been performed on the effect of meditation on various conditions, for the most part, methodological quality has not been sufficient to allow conclusive statements on effectiveness (74).
Mind-Body Movement Therapies
Described here are six of the more popular therapeutic movement modalities in use today: yoga, T’ai Chi, the Alexander technique, the Feldenkrais method, Pilates, and body-mind centering (BMC). These techniques are similar in that they aim to improve a patient’s kinesthetic ability, coordination of motion and breathing, and ease, control, and joy in everyday movement. All may be useful for a wide spectrum of patients from severely physically challenged to high-performance athletes.
Yoga and T’ai Chi, are frequently referred to as “mindbody” techniques, because they actively seek to balance both
the physical and nonphysical aspects of the person. Both are meditative in nature and are part of a larger philosophy or way of life. Each is derived from a broader system of health with an underlying model differing from those of the West. The other five techniques described were developed in the 20th century. All of the techniques take a less focal and more global approach to rehabilitation of specific conditions based on the rationale that the whole body is involved in all movement. A summary of CAM movement therapies and indications is listed in Table 79-2.
the physical and nonphysical aspects of the person. Both are meditative in nature and are part of a larger philosophy or way of life. Each is derived from a broader system of health with an underlying model differing from those of the West. The other five techniques described were developed in the 20th century. All of the techniques take a less focal and more global approach to rehabilitation of specific conditions based on the rationale that the whole body is involved in all movement. A summary of CAM movement therapies and indications is listed in Table 79-2.
Yoga
Yoga is an ancient Indian art first brought to this country in the mid-1800s. In Sanskrit, the word “yoga” means “union” (with the Divine), and is a way of life involving a number of different spiritual practices and encompasses ethical conduct, social responsibility, nutrition, and physical health practices. The branch of yoga that is best known in the West is hatha yoga, and is often simply referred to as “yoga.” Originally intended to prepare the body for Divine experience, it is practiced in this country for the achievement of physical strength, flexibility, and relaxation through postures known as asanas (a-sa-nas). Pranayama (pra-na-ya-ma), or breathing techniques, and meditation are also often practiced along with hatha yoga. The many forms of yoga practiced in the United States are diverse in terms of focus, strenuousness, and applications. A few of the forms most relevant to PM&R are described in Table 79-2.
TABLE 79.2 Movement Therapies | |||||||||||||||||||||||||||||||||
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Yoga has been extensively studied both in India and the West, with thousands of studies reporting positive health effects, including lowering of blood pressure (75), and decreased cholesterol levels (76). Yoga has been applied to programs for rheumatoid arthritis (77), osteoarthritis (78), chronic back pain (79), cardiac rehabilitation (80), carpal tunnel syndrome (78), and improved athletic performance (81). Yoga is increasingly being integrated into the office and inpatient settings by instructors who are experienced in teaching rehabilitation patients (82). Individual sessions and classes are a convenient way to transition from physical therapy supervision to a home-based program (83).
T’ai Chi
T’ai Chi is a form of postures and movements that dates back to 17th century China. T’ai Chi is made up of a series of flowing contrasting movements, with constant weight shifting from one leg to another, changing of direction, and moving the limbs in space. Specific postures are linked together with the focus on achieving balanced and graceful movement. Since it is a slow, rhythmic and weight-bearing exercise, participants
are able to improve balance, coordination, concentration, and relieve stress in a safe manner. Randomized trials report that benefits of T’ai Chi include improved cardiorespiratory function, improved strength and balance, decreased falls in the elderly (84, 85
are able to improve balance, coordination, concentration, and relieve stress in a safe manner. Randomized trials report that benefits of T’ai Chi include improved cardiorespiratory function, improved strength and balance, decreased falls in the elderly (84, 85
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