Chapter 22 Integrative Medicine in Rehabilitation

Ralph E. Gay, Brent A. Bauer, Robert K. Yang

Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. These therapies are either complementary to standard medical therapies (used with) or alternative to (used in place of) orthodox treatments. CAM is popular in both North America ^16,⁴⁹ and Europe. The U.S. National Institutes of Health organized the National Center for Complementary and Alternative Medicine (NCCAM; http://nccam.nih.gov/)^17,^101,¹⁰³ in 1998 to advance the study of these therapies.

The term integrative medicine is now widely used to describe the practice of combining mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.^17,^101,¹⁰³ Although many CAM treatments have not been properly studied, there are many that can be safely integrated into physical medicine and rehabilitation practice.

CAM therapies have been categorized by NCCAM ^17,^101,¹⁰³ into the following groups:

• Alternative medical systems that are “built upon complete systems of theory and practice”

• Mind-body interventions, which include “a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms”

• Biologically based therapies that “use substances found in nature, such as herbs, foods, and vitamins”

• Manipulative and body-based therapies, which are treatment methods “based on manipulation and/or movement of one or more parts of the body”

• Energy therapies, which involve the use of energy fields and include both biofield therapies and bioelectromagnetic-based therapies

Alternative Medical Systems

Alternative medical systems often incorporate concepts and ideas that can be quite different from conventional medicine precepts. They are generally based on empiric observation, and underlying scientific principles often have yet to be verified through well-designed scientific studies. Given the empiric nature of some allopathic and osteopathic treatments, the boundary between CAM and conventional medicine is often indistinct.

Many different schools of thought regarding optimal practice have developed over time. As a result, there can be considerable variability between alternative medicine providers. Most systems posit an innate ability of the body to heal itself, and attempt to stimulate or enhance that natural ability. All the systems discussed in this chapter are holistic, created to treat the entire person rather than a single complaint. Some incorporate elements of cultures that are quite different from our own, and many have an extensive history dating back thousands of years.

Chiropractic

Chiropractic is a profession founded on the theory that minor spinal misalignments can detrimentally affect the neurologic function of spinal nerves and the organs and structures supplied by those nerves (see Chapter 19). These misalignments are often called subluxations. The chiropractic use of the term subluxation is not congruent with the medical definition, which requires partial dislocation of a joint. This disparity not uncommonly leads to confusion between practitioners and patients when discussing their condition. Chiropractors treat subluxations with various interventions, the most common being spinal manipulation. Although much is written about subluxations, there is little agreement among chiropractors on how to define, detect, or treat them. Because these proposed lesions cannot be reliably measured or detected (and are therefore difficult to study), their effect on health is unclear. Despite this, there are many randomized controlled studies of chiropractic treatments for various conditions, particularly musculoskeletal disorders such as back pain and neck pain. Spinal manipulation is considered to be the active intervention in most of those studies.

Chiropractors often incorporate other techniques, such as massage and exercise prescription, in treatment. They also use radiography to aid in diagnosis. Chiropractors do not dispense prescription medications or perform surgery or invasive treatments. A comprehensive report has detailed the chiropractic profession in the United States.³⁸ There were approximately 53,000 chiropractors practicing in the United States in 2006.⁶ Many others practice in countries such as Australia, New Zealand, the United Kingdom, Japan, and most northern European countries.

Osteopathic Medicine

Osteopathic medicine was founded in the United States in the late nineteenth century about the same time as chiropractic and has a similar underlying theory. Osteopathic theory holds that somatic lesions (similar in concept to the chiropractic subluxation) occur in the musculoskeletal system and can be treated by various forms of manual therapy, including spinal manipulation. In many ways osteopathic physicians are now indistinguishable from traditionally trained medical physicians because they have adopted most practices of Western medicine including prescription medicines and surgery. A subgroup of osteopaths, however, continues to use manual therapies to treat disease.

Homeopathy

Homeopathy originated as a medical system in Germany in the late 1700s based on the theories of a physician, Samuel Hahnemann. Immunization against smallpox was being successfully demonstrated at about the same time, and it is likely that the theories of immunology influenced the theories underlying homeopathy. Much of the development of homeopathy occurred in Europe and culminated in a decision in 1996 by the European Commission’s Homeopathy Medicine Research Group to integrate homeopathy into medical practice.

Homeopathy’s central tenets are the principle of similars and the principle of dilution. The principle of similars, or “like begets like,” can be found in many systems of magical thought. In application the idea is that small quantities of an agent can ameliorate the same symptoms that are evoked in a healthy patient when given in larger quantities. For some practitioners, determination of the causative agent is as critical as matching the symptoms that are being treated (i.e., the complaint might not have been caused by a bee sting, but the patient is responding just like he or she was stung). The principle of dilution states that highly dilute solutions have biologic activity, and the more dilute the solution, the more potent the remedy. Some remedies are diluted but still possess measurable biologic activity. Others might be diluted to the point that efficacy could not be explained by conventional science (a solution could be so dilute that not every dose contains a single molecule of the active substance). Although most of these remedies are safe, their potential for interaction with other ingested substances can be difficult to predict. Homeopaths typically seek to identify substances or agents that can reproduce the patient’s symptoms. Many substances are studied and cross-referenced in the homeopathic literature. Computerized tools are available for matching symptoms to a specific remedy to aid the homeopath in the selection of an appropriate treatment. Despite this practice being incongruent with science, there is some evidence of effect. A double-blind, randomized controlled trial demonstrated benefit from homeopathic treatment of mild traumatic brain injury.³⁷ Another trial found benefit in treating tendinopathy.¹²¹ Other studies have not found benefit. A study of homeopathic therapy after knee ligament reconstruction failed to find benefit.¹⁰⁹ Similarly, a trial of homeopathy to improve muscle tone in children with cerebral palsy also failed to find a significant effect.¹²⁰ Although there are some intriguing possibilities represented in the literature, current evidence does not appear to be sufficient to suggest a significant role for homeopathy in medical practices.

Naturopathy

Naturopaths use a multimodal approach to health problems. Most of the principles espoused by naturopaths are familiar to physicians: do no harm, identify and treat the cause of disease, prevent disease, and treat the whole individual. One primary difference is the belief in the healing power of nature as demonstrated in the ability of living things to heal themselves. The naturopath views the physician’s role as removing obstacles to health and fostering a supportive environment for healthy living. A naturopath might use many different techniques to achieve this objective. They range from common medical interventions such as diet and lifestyle counseling, to less accepted treatments such as acupuncture and homeopathy. This openness to diverse approaches to health care is integrative and often calls for several different modes of treatment. The profession uses scientific principles to help determine which treatments to administer.

Ayurveda

Ayurvedic medicine (literally means the science of life) developed in India. Early Ayurvedic texts date to 1500 BC. Ayurvedic philosophy describes a relationship between all the matter in the universe. There are three doshas (life forces or energies) that must be at equilibrium for good health. Imbalances in these doshas are responsible for disease. Both intrinsic and extrinsic factors can contribute to health problems. A very complex taxonomy categorizes the organization and interaction of matter, energy, and spirit.

Ayurvedic medicine often uses multiple modalities. The Ayurvedic concept of physical fitness refers as much to resistance to a hostile environment as to strength and flexibility. Diet, sleep, sexual activity, personal hygiene, and exercises such as yoga are used to increase physical fitness. Mental discipline and spirituality are also important components to maintaining good health. Ayurvedic medicines encompass a gamut of herbal and mineral preparations, and are prescribed based on the energetic qualities of the preparation.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) is a system of health care based on traditional Chinese beliefs about the universe. One of the fundamental principles of this system is that two opposite forces (yin and yang) balance in nature. Disease states reflect a disturbance in the balance of yin and yang that can be extrinsic or intrinsic to the body.

Proper function of the human body requires proper functioning in physical, energetic, and spiritual aspects of an individual. TCM posits energy, called qi, that infuses living tissue. Qi is not a homogenous entity, as there are many different types of qi in the body. Each has different functions, from aiding in digestion to protecting against harmful outside agents. These energies support the material substances of the body such as blood and tissues. There is a complex interaction between the different types of qi and the symptoms that are produced by disturbances in qi.

Disease can manifest in a number of different ways. Sometimes disturbances have a material manifestation, altering blood, tissues, or the organs. At other times they manifest as more energetic (qi) symptoms such as fatigue, anxiety, or depression. Diagnosis of disease focuses on eliciting a history to determine the underlying disturbance. The TCM examination might include determining the characteristics of pulses at specific locations on the body, the appearance of the tongue, and the characteristics of olfaction, as well as carefully palpating the body. This information aids the TCM practitioner in the diagnosis of an individual’s complaint. A diagnosis in TCM (such as ascending fire of the liver or kidney qi deficiency) might have no analog in the allopathic model.

The primary goal of TCM is the restoration of the balance of these forces. This rebalancing can be achieved through a number of different therapeutic options, including diet, exercise, herbal medicines, massage, and acupuncture. Although treatments are initiated to treat disease states, they are also designed to preserve health. Qi gong and t´ai chi were developed as methods of strengthening the qi or energy of the body to prevent disease and prolong life. A proper balance in diet promotes the harmonious flow of energy through the body. Although acupuncture is the most well-known modality used in TCM, it is only a single aspect of it and is often used in combination with other modalities.

Mind-Body Therapies

NCCAM identifies mind-body practices as those that “focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health.”¹⁰³ Included in this group are such therapies as cognitive-behavioral therapy, meditation, prayer, and guided imagery, and therapies using creative outlets (e.g., art, music, and dance therapies).

Cognitive-Behavioral Therapy

Although often included as a CAM therapy, cognitive-behavioral therapy has moved into the mainstream of conventional medical practice. It integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. A therapist typically works with patients to identify thoughts and behaviors that are maladaptive and attempts to change their thought patterns, leading to a change in behavior. Cognitive-behavioral therapy has been successfully used for a variety of conditions, including insomnia,¹³¹ fibromyalgia,¹⁴⁴ headache,³ pain,⁴⁷ and low back pain.^41,⁸⁹

Meditation

The definition of the act of meditation according to the American Heritage Dictionary² is ”to train, calm, or empty the mind, often by achieving an altered state, as by focusing on a single object.” Meditation is also frequently described as self-regulation of attention. It is perhaps one of the most commonly used mind-body modalities and is a significant component of many of the world’s major religions. There are numerous types of meditation (e.g., transcendental, mindfulness, and focused meditation). Much of the current interest in meditation can be traced to the 1970s work of Dr. Herbert Benson, who studied the physiologic responses to meditation. It was this early work by Benson²² that led to the identification of the “relaxation response.” Most patients use meditation to help manage stress and anxiety.^18,^34,¹¹⁶ However, there are numerous specific applications such as helping deal with pain,¹³ improving quality of life after brain injury,²⁰ and improving irritable bowel syndrome.⁷¹ A small study found that older adults with chronic back pain benefited from meditation.⁹⁸ A study of practitioners of transcendental meditation revealed that over a span of 5 years, health care utilization was significantly reduced in those who meditated regularly.¹⁰⁸

Guided Imagery

Guided imagery is a technique that uses images or symbols to train the mind to create a physiologic or psychologic effect. This process, often guided by a practitioner or audiotape, has been used to reduce anxiety and pain, and to relieve physical problems caused by stress. Studies suggest it might have benefit in treating headaches,⁹⁴ recurrent abdominal pain in children,¹⁴ depression,¹²⁸ and fibromyalgia.⁵⁴

Spirituality

Spirituality has been described as an awareness of something greater than the individual self. Some have argued against the inclusion of spirituality in the CAM realm, recognizing that spirituality is a part of normal life for a majority of people, regardless of cultural origin. The mind-body-spirit emphasis frequently found in CAM disciplines, however, has usually led to its inclusion in CAM therapy discussions. Although spirituality can take many forms, typically it involves prayer, either for one’s self or another. It can be pursued alone or in a group (e.g., church or synagogue). There are many possible psychologic benefits of spiritual awareness and focus, including reduction of stress and anxiety and the creation of a positive attitude. However, rigorous scientific studies of the effects of spirituality are relatively few. One study reported that spirituality can play an important role in rehabilitation.³⁵

Aromatherapy

Aromatherapy uses essential oils, distilled from plants, to improve mood, health, or both. Scents can be inhaled or applied in oil during massage. For inhalation a few drops of the essential oil are placed in steaming water, diffusers, or humidifiers that are used to spread the steam-oil combination throughout the room. They can also be added to bath water. For application to the skin, the oils are combined with a carrier, usually vegetable oil. Early clinical trials suggest aromatherapy might have some benefit as a complementary treatment in reducing stress, pain, and depression.^33,⁷⁶

Expression- and Art-Based Therapies

The American Art Therapy Association defines art therapy as the “therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development.”⁴ It uses creative activities to help patients with physical and emotional problems. Proponents claim that both the creative process and the final work can help express and heal trauma. Patients can create paintings, drawings, sculptures, and other types of artwork, and can work individually or in groups. Art therapists typically have a master’s degree in art therapy or a related field. They help patients express themselves through the art they create. They also discuss emotions and concerns that patients might identify as they work on their art.

Music therapy is the use of specific music (with specific vibration frequencies) to promote relaxation and healing. Although most healing music is soft and soothing, individual patient preferences (jazz, classical, etc.) can also be relaxing and healing to that individual. Music is used to help patients express deep-set emotions, both positive and negative. It is thought to be helpful in treating autism, mentally or emotionally disturbed children and adults, elderly and physically challenged persons, and patients with schizophrenia, nervous disorders, or stress. Music therapists design music sessions for individuals and groups based on individual needs and tastes. Some aspects of music therapy include music improvisation, receptive music listening, song writing, lyric discussion, imagery, music performance, and learning through music. Individuals can also perform their own music therapy at home by listening to music or sounds that help relieve their symptoms.^80,¹⁴¹

Dance therapy is “the psychotherapeutic use of movement to promote emotional, cognitive, physical and social integration of individuals.”¹² It is sometimes also referred to as movement therapy. From a physical standpoint, dance therapy can provide exercise, improve mobility and muscle coordination, and reduce muscle tension. From an emotional standpoint, dance therapy has been reported to improve self-awareness, self-confidence, and interpersonal interaction, and is an outlet for communicating feelings.⁶⁶

Biologically Based Therapies

Patients undergoing rehabilitative treatment are just as likely to use dietary supplements as the rest of the population. In fact, most studies suggest that patients with chronic disorders are even more likely to use CAM therapies, including herbs. Therefore it is important to have a basic understanding of herbs and dietary supplements, so that helpful information can be shared with patients to enable them to make informed decisions. Because the possible number of supplements a patient can use is practically endless, this review focuses only on the dietary supplements most likely to be encountered in a physiatric practice. Specific attention is paid to herbs and dietary supplements used for arthritis and pain.

Select Dietary Supplements Frequently Encountered in Physical Medicine and Rehabilitation Practice

Chondroitin Sulfate

Evidence

Numerous studies have been conducted on chondroitin, chondroitin and glucosamine, and glucosamine. Most indicate that these two supplements, either in combination or by themselves, are modestly effective at relieving symptoms of osteoarthritis. The multicenter, double-blind, placebo- and celecoxib-controlled Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) reported on 1583 patients with knee arthritis.⁴² Significant effects were seen in the subgroup of patients with the most severe pain, but not in those with lesser symptoms. Although it was reported as a “negative” trial, several concerns emerged after the study was reported, including that the placebo response was unexplainably high. Consequently there is still active debate about the proper role of these agents in the management of arthritis symptoms.

Proponents believe that chondroitin acts as a substrate needed for joint matrix structure.⁷² If this mechanism is indeed correct, the finding that it could require at least 2 to 4 months of therapy before significant improvement is noted is not surprising.⁸⁴ A number of studies have suggested that adding chondroitin sulfate to a conventional analgesic or nonsteroidal antiinflammatory drug (NSAID) is synergistic, possibly allowing reduction or elimination of those agents.^84,⁹⁹

Adverse Effects

Toxicity appears to be very limited. The most commonly reported side effects are gastrointestinal and include nausea and epigastric discomfort.

Glucosamine Sulfate

Evidence

Studies of efficacy have been centered on knee osteoarthritis. Most studies evaluating glucosamine sulfate for knee osteoarthritis have been positive.⁹⁶ Glucosamine was found to be effective for osteoarthritis of the lumbar spine in one study.⁵³ Some studies suggest efficacy equivalent to certain NSAIDs.⁹⁰ Like chondroitin, onset of relief is generally delayed, requiring up to 8 weeks for full effect. In addition to symptom control, glucosamine might also have disease-modifying properties. Long-term studies suggest that treatment with glucosamine might result in significantly less joint space narrowing and knee joint degeneration as compared with placebo.¹¹⁵

Adverse Effects

Mild gastrointestinal symptoms (e.g., nausea, heartburn, diarrhea, and constipation) are not uncommon, but are usually self-limited and rarely require discontinuation.

S-Adenosyl-L-Methionine

Evidence

A number of clinical trials suggest that S-adenosyl-L-methionine (SAMe) is superior to placebo and comparable to NSAIDs for decreasing symptoms associated with osteoarthritis.^59,^77,¹⁰² The full effect might require up to 1 month of treatment. The mechanism of action is thought to include stimulation of articular cartilage growth and repair.²⁷

Adverse Effects

Gastrointestinal symptoms (e.g., flatulence, nausea, diarrhea, and constipation), dry mouth, headache, mild insomnia, and nervousness have been reported.⁷

Bromelain (Ananas comosus)

Evidence

Bromelain, taken in conjunction with trypsin and rutin, resulted in decreased pain and improved knee function in patients with osteoarthritis.⁷³ A study of knee pain in otherwise healthy adults also showed evidence of benefit.¹³⁸ However, a subsequent trial of bromelain alone did not demonstrate any benefit in patients with knee osteoarthritis.³⁰

Adverse Effects

Gastrointestinal upset and diarrhea can occur.

Camphor (Cinnamomum camphora)

Evidence

Camphor is Food and Drug Administration–approved as a topical analgesic. A topical cream containing camphor, glucosamine sulfate, and chondroitin sulfate was found to provide reduction in pain caused by osteoarthritis.⁴³ Because there is no evidence that glucosamine and chondroitin can be absorbed topically, the relief might have resulted from the counterirritant effect of camphor, but these data should be considered inconclusive.

Adverse Effects

Occasional contact irritation has been reported.

Cat’s Claw (Uncaria tomentosa)

Evidence

Found in Peru, cat’s claw is a large vine with curved thorns, resembling the claws of a cat. It is touted as an effective remedy for a number of conditions. In the United States many patients have been attracted to claims of its antiinflammatory effects, but there are no well-designed studies in this regard. One study found that a freeze-dried cat’s claw extract relieved knee pain related to physical activity, but did not affect pain at rest.¹¹² Modest effects were seen in another trial of patients with rheumatoid arthritis.¹⁰⁰ The mechanism of action is uncertain but might be inhibition of the production of prostaglandin E₂ and tumor necrosis factor-α.

Adverse Effects

Adverse effects include headache, dizziness, and vomiting.¹¹²

Devil’s Claw (Harpagophytum procumbens)

Evidence

A growing body of evidence suggests that devil’s claw decreases osteoarthritis-related pain.^31,^37,^42,^140,¹⁴² As with glucosamine and chondroitin, a reduction in the need for NSAIDs might be possible with devil’s claw after several weeks of use.

Adverse Effects

Although generally well tolerated, Devil’s claw has been associated with diarrhea.³⁶ Other reported side effects include nausea, vomiting, and abdominal pain.

Evening Primrose Oil (Oenothera biennis)

Evidence

In a double-blind, placebo-controlled study of rheumatoid arthritis, evening primrose oil resulted in a significant reduction of symptoms.²¹ Evening primrose oil contains γ-linolenic acid), which is thought to have antiinflammatory properties.

Adverse Effects

There are no reports of significant side effects.

The Dietary Supplement Health and Education Act of 1994 created a separate supplement classification known as “dietary supplements” that covers the use of herbs, vitamins, amino acids, and even certain hormones such as dehydroepiandrosterone and melatonin. As dietary supplements, they are neither subject to the stringent food safety rules nor are they considered over-the-counter medications or drugs. This permits them to escape traditional oversight mechanisms in the United States. As a result, it is difficult for physicians to monitor patient use of these products. Further, the Act specifically states that manufacturers of dietary supplements are not required to prove the safety and efficacy of their products before going to market, which has created a true “caveat emptor” requirement on the part of the consumer when purchasing dietary supplements. Fortunately, in 2007, the United States Food and Drug Administration passed a Good Manufacturing Practices rule. This rule requires that dietary supplements sold in the United States be “manufactured consistently as to identity, purity, strength, and composition.”⁵ When fully implemented in 2010, this rule will help ensure the quality of these products in the United States.

Manipulation and Body-Based Therapies

Manipulation and body-based therapies typically affect health by the application of movement. This can be passive movement of a joint or tissue (e.g., massage, spinal manipulation or mobilization) or active movement of the body as a unit (e.g., Feldenkrais).

Manipulation and Mobilization

Manipulation (typically inferring to high-velocity thrust techniques applied to a joint) and mobilization (nonthrust, oscillatory techniques) have been used for centuries to treat various conditions. In North America and Europe, they are often used by chiropractors, physical therapists, and physicians to treat musculoskeletal conditions, most commonly low back pain. Although the systems of patient evaluation and treatment vary and the taxonomies are often different, the techniques used are remarkably similar. There is no evidence that manipulation or mobilization applied by one profession is more or less beneficial than when provided by a competing profession. The goal of these therapies is to normalize motion and tension about a joint. Some professions, chiropractic in particular, infer health benefits beyond the reduction of pain and improvement in musculoskeletal function, but evidence for these claims is very limited. (See also Chapter 19.)

Minor side effects of spinal manipulation are common. At least one unpleasant reaction was experienced after manipulation by more than half of patients, with the most frequent being local discomfort (53%), headache (12%), tiredness (11%), and radiating discomfort (10%). Reactions were mild or moderate in 85%, and were typically short-lived (74% resolved within 24 hours). Uncommon reactions such as dizziness and nausea accounted for less than 5% of the symptoms, and no serious complications were reported.¹²²

Spinal manipulation, although generally safe, is not risk free. Risks and complications have been thoroughly discussed in the literature, but estimates of complication frequency have typically been based on poorly designed surveys. Complications result almost exclusively from high-velocity manipulation. Complications rarely occur with low-velocity and mobilization techniques.

Complications of thoracic and lumbar manipulation are listed in Box 22-1. They are rare, and investigators agree that the risk-to-benefit ratio of manipulation for low back pain is acceptable in most patients.^8,¹¹⁴ The most serious complication of lumbar manipulation is cauda equina syndrome. About half of the reported cases occurred during manipulation under anesthesia.⁸ Haldeman and Rubinstein⁶³ noted 10 cases of cauda equina syndrome that were not associated with manipulation under anesthesia, and reported three additional cases. Those cases represented treatment by chiropractors, osteopathic and allopathic physicians. The frequency of cauda equina syndrome has been estimated to be one in several million treatments.^63,¹²⁴