- Email: [email protected]
Complementary and Alternative Medicine
CHAPTER 47
COMPLEMENTARY AND ALTERNATIVE MEDICINE Robert A. Duarte, MD, and Charles E. Argoff, MD 1. What is the definition of complementary and alternative medicine? There is no one prototype definition of complementary and alternative medicine (CAM), because the therapies keep changing, as well as moving from alternative to mainstream. At present, the term applies to a number of modalities that are not routinely taught in medical schools and are not generally part of conventional medicine. Presumably, as some of these modalities are shown to be useful, they will enter mainstream teaching and no longer be ‘‘alternative,’’ much as use of nitroglycerine and digitalis did. Chiropractic, osteopathy, and biofeedback have already entered the mainstream and are no longer considered strictly alternative. However, the general philosophy of complementary and alternative medicine is that your body has the ability to heal itself and that prevention of disease, above all, is most important. 2. How prevalent is the use of CAM in the United States? Most surveys show that about 40% of the U.S. population use one type or another of complementary medicine during a given year. Over 65% use at least one type of CAM therapy in their lifetime. About 70% of younger patients report having used some type of CAM therapy by age 33. 3. What are the major types of CAM therapies? The National Center for Complementary and Alternative Medicine (NCCAM) divides CAM into the following five categories: & Alternative medicine systems & Mind-body interventions & Biologically based techniques & Manipulative and body-based methods & Energy therapies 4. What are the major precepts of Traditional Chinese Medicine? Traditional Chinese Medicine (TCM) is a holistic approach to health and disease that views both states as part of a continuum. The body is a system of balance, with a primary vital energy called ‘‘qi’’ (pronounced chee) that needs to circulate properly through the body, along lines called ‘‘meridians.’’ There is a complex system of these channels, and most techniques are aimed at establishing appropriate flow and movement of qi. TCM formulates a diagnosis based on eight principles: internal/external, yin/yang, hot/cold, excess/deficiency. 5. What are the major modalities used in TCM? The most commonly used techniques in TCM involve the insertion of acupuncture needles, diet through proper nutrition, preparing and ingesting Chinese herbs, and massage. Exercising the body through such activities as qigong and tai chi (movement exercises) are also thought to be vital.
364
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 365 6. How is acupuncture applied? Acupuncture is literally translated into acus = needle and punctare = penetration. Medically, it refers to skin puncture with needles to produce a given effect. The selection of puncture points varies depending on the underlying pathology. Acupuncture is one of the oldest forms of recorded medical therapy, with documented cases going back more than 4000 years. It is applied by the simple insertion of metal needles along the meridians (i.e., channels) and at local points known as ah shi points. There are different types of acupuncture stimulation, including manual, application of heat, electrical stimulation, moxa (gum wort), or laser. It is unclear that any specific type of acupuncture is superior to another, although anecdotal evidence suggests that electroacupuncture may be useful for myofascial pain syndromes and auriculotherapy for drug addiction. 7. What are some of the variants of acupuncture currently employed for pain management? TCM acupuncture focuses on meridians or channels and intervention at specific sites—depending on the goal, e.g., surgical anesthesia, relief of pain, therapeutic purposes—is presumed to reestablish appropriate energy flow. Other schools support the use of trigger point manipulation with needles, or use of the ear, hand, and scalp as representative points. 8. What are the proposed mechanisms of action for acupuncture analgesia? TCM holds that the mechanism of action for acupuncture analgesia is release of stagnation of qi (the vital force). Needling also produces an increase in blood flow and a decrease of local prostaglandin and histamine release. Many studies reveal that electrostimulation produces effects on the spinal cord, midbrain, and pituitary. Following insertion of an acupuncture needle, there is a release of enkephalin, endorphins, and possibly gammaaminobutyric acid (GABA) at the spinal site; a release of enkephalin, serotonin, and norepinephrine at the midbrain site; and a release of endorphins at the pituitary site. At least three studies have shown that naloxone, an opioid antagonist, can partially reverse the analgesia caused by acupuncture, advocating the strong possibility that at least some of the analgesia is mediated by endogenous opioids. There continues to remain a few skeptics that believe acupuncture works through a placebo effect. 9. What were the conclusions from the U.S. National Institute for Health Acupuncture Consensus Panel meeting in 1997? The U.S. National Institute for Health Acupuncture Consensus Panel’s statement in 1997 held that evidence supported acupuncture for adult postoperative pain (including dental pain), myofascial pain, and low back pain. There was reasonable or promising evidence for acupuncture as a treatment for pain caused by menstrual cramps, tennis elbow, fibromyalgia, osteoarthritis, carpal tunnel syndrome, and headache. There was no evidence to support acupuncture for weight reduction or smoking cessation. 10. True or false: The scientific evidence that acupuncture is effective for fibromyalgia is convincing. False. In 2005, a randomized controlled trial of acupuncture in fibromyalgia showed no difference compared to sham acupuncture. In 1988, a systematic review reported three randomized, controlled studies and four cohort studies involving 300 subjects. Although the overall quality of the studies was considered highly variable, it was felt that there was enough data to analyze. In one of the randomized, controlled studies, acupuncture was effective for relieving pain in five out of eight measures. However, the other studies were inconclusive, and the long-term benefits of acupuncture for fibromyalgia remain unknown.
366 CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 11. Is there any scientific evidence supporting acupuncture for other chronic pain conditions? Yes. Recent studies suggest that acupuncture may be as effective as any active therapy for patients with osteoarthritis of the knee and low back pain. In addition, evidence is emerging that acupuncture may be equally effective with less adverse events in preventing migraines compared to some pharmacological migraine agents. 12. List the contraindications and precautions to be taken in acupuncture. Acupuncture complications are uncommon in trained hands. Of particular importance is appropriate placement of needles near the chest, to avoid the possibility of a pneumothorax. Obviously, infection is a concern, and only disposable needles should be used to avoid transmission of hepatitis B or C or HIV. A transient increase in pain, euphoria, or sedation is not uncommon, but this usually resolves within a day. Anticoagulation therapy is a relative contraindication, although gentle needling can be performed by a skilled practitioner with an acceptable side-effect profile. Patients with a pacemaker should not receive electroacupuncture. 13. Does magnetic therapy have a place in pain management? As with many other CAM therapies, a definitive answer is not available as to whether magnetic therapy is useful in pain management. There are anecdotal reports of efficacy for magnets aimed at diabetic neuropathy, burning feet syndrome, carpal tunnel syndrome, and headaches. There have also been some negative studies in low back pain. Magnetic therapy is considered a relatively safe alternative, without significant side effects. The placebo effect may also be significant. However, it is probably better to avoid magnetic therapy in patients with an implanted pacemaker or other electronic device. 14. What is meant by ‘‘bioenergetic therapy’’? Also called polarity therapy, bioenergetic therapy is a combination of Ayurveda, TCM, and Western medicine that attempts to produce balance of all systems. Some bioenergetic therapies, such as reiki, qigong, tai chi, and therapeutic touch, are specifically used for painful conditions. Reiki proposes that energy flows from the practitioner’s hands into the patient’s body, over 12 body locations, with the patient fully clothed. Qigong and tai chi are structured, choreographed, slow movements that are designed to reestablish proper circulation of qi (energy). Therapeutic touch is another modality in which the goal is an energy flow between the patient and the practitioner, without actual contact. One recent double-blind study of therapeutic touch found no evidence of effectiveness. 15. What is Ayurveda? The term Ayurveda is a Sanskrit word that translates into ‘‘knowledge’’ (veda) of ‘‘life’’ (ayur). In its truest sense, it is meant to promote health, rather than fight disease. An original text on Ayurveda, which appeared between 1500 and 1000 B.C., addressed arthritis, rheumatism, and disorders of the nervous system. Chopra quoted one of the original texts that described pain treatment: ‘‘The patient lying on the bed moistened with the dews of moonrays covered with flax and Lotus leaves and fanned with breeze cooled by contact of sandy beach should be attended by the love and sweet-spoken women with their breasts and hands pasted with sandal and with cold and pleasing touch who remove burning sensation, pain, and exhaustion.’’ Ayurveda combines diet, exercise, spiritual activities, and herbal medicines in a holistic healing system. Its focus in on cleansing to remove toxins and balancing influences on the body to ensure a long life. 16. Which bioenergetic therapies are in common use in western medicine? Thermal therapies are very common in Western medicine. However, despite the enormous sales of heating pads, there are relatively few studies that show any clear benefit of heat for pain. However, anyone with a sore muscle will tell you that a hot bath or a vigorous shower
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 367 provides some pain relief. Cryotherapy (icing an injured muscle) also is popularly accepted, but there is little support in the literature for beneficial effects. Transcutaneous electrical nerve stimulation (TENS) has enjoyed enormous popularity, but metaanalysis has not been uniformly positive. Ultrasound is widely used but similarly unsupported by good studies. 17. What is the role of spinal manipulation in treating back pain and headache? Systematic reviews related to the role of spinal manipulation in treating back pain and headache are inconclusive. However, in uncomplicated acute neck and back pain, spinal manipulation has been shown to provide significant temporary relief. The picture is far less clear in chronic conditions. Patient satisfaction is higher after manipulative therapy than after most other contacts with practitioners. Although neurological and vascular complications are cited by practitioners of allopathic medicine, they are quite rare. 18. What are some of the ‘‘mind-body’’ modalities that are used to treat pain? Biofeedback is very popular for the treatment of headache and back pain. However, there is no evidence to show that it is any better than simple relaxation techniques. Biofeedback has been used successfully to treat headache, complex regional pain syndrome, and low back pain. Guided imagery may be effective to help patients cope with stress and pain. Progressive relaxation techniques are also used to relieve muscle tension and headache. Music therapy, breathing techniques, cognitive-behavioral therapy, visualization, hypnosis, and psychotherapy all have a role in chronic pain management. 19. True or false: A few vitamin and supplement therapies have shown promise for treating headaches. True. A randomized, placebo-controlled study using vitamin B2 (riboflavin) at 400 mg per day (recommended daily dose is 1.8 mg per day) was more effective than placebo in migraine and tension-headache control over a 3-month period. Although statistically valid, these results have not been widely replicated. Intravenously administered magnesium can be an effective abortive agent in patients with acute migraine. Chronic magnesium replacement has also been recommended for recurrent migraine, although well-controlled studies have not supported its use as a prophylactic agent. Any patient taking a magnesium supplement should probably also take calcium. 20. What is the role of feverfew and butterbur in headaches? Tanacetum parthenium (feverfew) is a plant cultivated throughout Europe and the United States. Its principal activity is the creation of parthenolide, which is thought to have an effect on platelets and the inhibition of proinflammatory compounds. Controlled studies have yielded mixed results. Feverfew is combined with magnesium and vitamin B2 in products known as Migreleve and Migrehealth. In 2004, Petasites hybridus root (butterbur) was shown to be more effective than placebo in a randomized, placebo-controlled study for chronic headache. 21. List potential interactions between herbs and analgesics. & NSAIDs—ginger, willowbark, feverfew, horse chestnut & Opioids—valerian root, kava, chamomile 22. To what scientific standards should CAM techniques be held? Keep in mind that many ‘‘standard’’ practices have not been established through truly evidence-based medicine. Truly randomized trials for surgery in low back pain are lacking; epidural steroid injections remain controversial; and the appropriate primary preventive treatments for stroke (with the exception of blood pressure reduction) are still being worked out. Practitioners of Traditional Chinese Medicine may well wonder why their 4000-year-old therapies are being questioned and held to the standards of Western medicine,
368 CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE which has a history of only a few hundred years. The fact that something is standard in one place and considered alternative in another does not mean that either side has the correct answer. 23. How can a clinician minimize clinical and legal risk when treating a patient with CAM? Cohen and Eisenberg proposed a framework that classifies therapies according to the strands of evidence regarding safety and efficacy. Clinicians are advised to determine the clinical risk level, document the literature supporting the therapeutic choice, provide adequate informed consent, continue to monitor the patient conventionally, and inquire about the confidence of other practitioners in the particular modality.
KEY POINTS 1. The general philosophy of complementary and alternative medicine (CAM) is that your body has the ability to heal itself and that prevention of disease is of the greatest importance. 2. Numerous CAM therapies are currently used with varying degrees of medical evidence to support their use. 3. Potentially significant herb-drug interactions may occur with concurrent use; therefore, all health care practitioners must take an adequate medication history so that these can be avoided.
BIBLIOGRAPHY 1. Allais G, DeLorenzo C: Acupuncture as a prophylactic treatment of migraine without aura: a comparison with flunarizine, Headache 44(9):855-861, 2002. 2. Berman BM, Lao L, et al : The effectiveness of acupuncture as an adjunctive therapy in OA of the knee, Annals of Internal Medicine 141(12): 901-910, 2005. 3. Birch S, Hesselink JK: Clinical research on acupuncture. Part 1. What have the reviews on the efficacy and safety of acupuncture told us so far? J Altern Complement Med 10(3):468-480, 2004. 4. Chopra A, Doiphode VV: Ayurvedic medicine: core concept, therapeutic principles, and current relevance, Med Clin North Am 86(1):75-89, 2002. 5. Cohen MH, Eisenberg DM: Potential physicial malpractice liability associated with complementary and integrative medical therapies, Ann Int Med 136:596-603, 2002. 6. Cohen MH, Hrbek A, et al: Emerging credentially practices, malpractice liability policies, and guidelines governing complementary and alternative practices and dietary supplement recommendations, Arch Int Med 165(3):289-295, 2005. 7. Eccles NK: A critical review of randomized controlled trials of static magnets for pain relief, J Altern Complement Med 11(3):495-509, 2005. 8. Ernst E, Pittler MH: The efficacy and safety of feverfew (Tenacetum parthenium L.): an update of a systemic review, Public Health Nutr 3(4A):509-514, 2000. 9. Kaptchuk TJ, Eisenberg DM: Varieties of healing. 2: A taxonomy of unconventional healing practices, Ann Intern Med 135(3):196-204, 2001. 10. Khadikar A, Milne S, Brosseau L, et al: Transelectrical nerve stimulation (TENS) for chronic low back pain, Cochrane Database Syst Rev 3:CD003008, 2005. 11. Lipton RB, Gobel H: Petasites hybridus root (butterbur) is an effective preventative treatment for migraine, Neurology 63(12):2240-2244, 2004. 12. Maizels M, Blumenfeld A, et al: A combination of riboflavin, magnesium feverfew for migraine prophylaxis: a randomized controlled trial, Headache 44(9)885-890, 2004.
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 369 13. Mazzata G, Sarchielli P, Alberti A, Gallai V: Electromyographical ischemic test and intracellular and extracellular magnesium concentration in migraine and tension type headache patients, Headache 36(6):357-361, 1996. 14. Montazeri K, Farahnakian M: The effect of acupuncture on the acute withdrawal symptoms from rapid detoxification, Acta Anaesthesiol 40(4):173-175, 2002. 15. Nestler G: Traditional Chinese Medicine, Med Clin N Am 86(1):63-73, 2002. 16. Park J, Ernst E: Ayurvedic medicine for rheumatoid arthritis, Semin Arthritis Rheum 34(5):705-713, 2005. 17. Schoenen J, Jacquy J, Lenaerts M: Effectiveness of high dose riboflavin in migraine prophylaxis, Neurology 50(2):466-470, 1998. 18. Tindle HA, Davis RB, et al: Trends in the use of complementary and alternative medicine by US adults, Altern Ther Health Med 11(1):42-49, 2005. 19. Tsui MLK, Cheing GLY: The effectiveness of electroacupuncture in the management of chronic low back pain, J Altern Compl Med 10:803-809, 2004. 20. Vickers AJ: Statistical reanalysis of four recent randomized trials of acupuncture for pain using analysis of covariance, Clin J Pain 20:319-323, 2004.
COMPLEMENTARY AND ALTERNATIVE MEDICINE Robert A. Duarte, MD, and Charles E. Argoff, MD 1. What is the definition of complementary and alternative medicine? There is no one prototype definition of complementary and alternative medicine (CAM), because the therapies keep changing, as well as moving from alternative to mainstream. At present, the term applies to a number of modalities that are not routinely taught in medical schools and are not generally part of conventional medicine. Presumably, as some of these modalities are shown to be useful, they will enter mainstream teaching and no longer be ‘‘alternative,’’ much as use of nitroglycerine and digitalis did. Chiropractic, osteopathy, and biofeedback have already entered the mainstream and are no longer considered strictly alternative. However, the general philosophy of complementary and alternative medicine is that your body has the ability to heal itself and that prevention of disease, above all, is most important. 2. How prevalent is the use of CAM in the United States? Most surveys show that about 40% of the U.S. population use one type or another of complementary medicine during a given year. Over 65% use at least one type of CAM therapy in their lifetime. About 70% of younger patients report having used some type of CAM therapy by age 33. 3. What are the major types of CAM therapies? The National Center for Complementary and Alternative Medicine (NCCAM) divides CAM into the following five categories: & Alternative medicine systems & Mind-body interventions & Biologically based techniques & Manipulative and body-based methods & Energy therapies 4. What are the major precepts of Traditional Chinese Medicine? Traditional Chinese Medicine (TCM) is a holistic approach to health and disease that views both states as part of a continuum. The body is a system of balance, with a primary vital energy called ‘‘qi’’ (pronounced chee) that needs to circulate properly through the body, along lines called ‘‘meridians.’’ There is a complex system of these channels, and most techniques are aimed at establishing appropriate flow and movement of qi. TCM formulates a diagnosis based on eight principles: internal/external, yin/yang, hot/cold, excess/deficiency. 5. What are the major modalities used in TCM? The most commonly used techniques in TCM involve the insertion of acupuncture needles, diet through proper nutrition, preparing and ingesting Chinese herbs, and massage. Exercising the body through such activities as qigong and tai chi (movement exercises) are also thought to be vital.
364
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 365 6. How is acupuncture applied? Acupuncture is literally translated into acus = needle and punctare = penetration. Medically, it refers to skin puncture with needles to produce a given effect. The selection of puncture points varies depending on the underlying pathology. Acupuncture is one of the oldest forms of recorded medical therapy, with documented cases going back more than 4000 years. It is applied by the simple insertion of metal needles along the meridians (i.e., channels) and at local points known as ah shi points. There are different types of acupuncture stimulation, including manual, application of heat, electrical stimulation, moxa (gum wort), or laser. It is unclear that any specific type of acupuncture is superior to another, although anecdotal evidence suggests that electroacupuncture may be useful for myofascial pain syndromes and auriculotherapy for drug addiction. 7. What are some of the variants of acupuncture currently employed for pain management? TCM acupuncture focuses on meridians or channels and intervention at specific sites—depending on the goal, e.g., surgical anesthesia, relief of pain, therapeutic purposes—is presumed to reestablish appropriate energy flow. Other schools support the use of trigger point manipulation with needles, or use of the ear, hand, and scalp as representative points. 8. What are the proposed mechanisms of action for acupuncture analgesia? TCM holds that the mechanism of action for acupuncture analgesia is release of stagnation of qi (the vital force). Needling also produces an increase in blood flow and a decrease of local prostaglandin and histamine release. Many studies reveal that electrostimulation produces effects on the spinal cord, midbrain, and pituitary. Following insertion of an acupuncture needle, there is a release of enkephalin, endorphins, and possibly gammaaminobutyric acid (GABA) at the spinal site; a release of enkephalin, serotonin, and norepinephrine at the midbrain site; and a release of endorphins at the pituitary site. At least three studies have shown that naloxone, an opioid antagonist, can partially reverse the analgesia caused by acupuncture, advocating the strong possibility that at least some of the analgesia is mediated by endogenous opioids. There continues to remain a few skeptics that believe acupuncture works through a placebo effect. 9. What were the conclusions from the U.S. National Institute for Health Acupuncture Consensus Panel meeting in 1997? The U.S. National Institute for Health Acupuncture Consensus Panel’s statement in 1997 held that evidence supported acupuncture for adult postoperative pain (including dental pain), myofascial pain, and low back pain. There was reasonable or promising evidence for acupuncture as a treatment for pain caused by menstrual cramps, tennis elbow, fibromyalgia, osteoarthritis, carpal tunnel syndrome, and headache. There was no evidence to support acupuncture for weight reduction or smoking cessation. 10. True or false: The scientific evidence that acupuncture is effective for fibromyalgia is convincing. False. In 2005, a randomized controlled trial of acupuncture in fibromyalgia showed no difference compared to sham acupuncture. In 1988, a systematic review reported three randomized, controlled studies and four cohort studies involving 300 subjects. Although the overall quality of the studies was considered highly variable, it was felt that there was enough data to analyze. In one of the randomized, controlled studies, acupuncture was effective for relieving pain in five out of eight measures. However, the other studies were inconclusive, and the long-term benefits of acupuncture for fibromyalgia remain unknown.
366 CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 11. Is there any scientific evidence supporting acupuncture for other chronic pain conditions? Yes. Recent studies suggest that acupuncture may be as effective as any active therapy for patients with osteoarthritis of the knee and low back pain. In addition, evidence is emerging that acupuncture may be equally effective with less adverse events in preventing migraines compared to some pharmacological migraine agents. 12. List the contraindications and precautions to be taken in acupuncture. Acupuncture complications are uncommon in trained hands. Of particular importance is appropriate placement of needles near the chest, to avoid the possibility of a pneumothorax. Obviously, infection is a concern, and only disposable needles should be used to avoid transmission of hepatitis B or C or HIV. A transient increase in pain, euphoria, or sedation is not uncommon, but this usually resolves within a day. Anticoagulation therapy is a relative contraindication, although gentle needling can be performed by a skilled practitioner with an acceptable side-effect profile. Patients with a pacemaker should not receive electroacupuncture. 13. Does magnetic therapy have a place in pain management? As with many other CAM therapies, a definitive answer is not available as to whether magnetic therapy is useful in pain management. There are anecdotal reports of efficacy for magnets aimed at diabetic neuropathy, burning feet syndrome, carpal tunnel syndrome, and headaches. There have also been some negative studies in low back pain. Magnetic therapy is considered a relatively safe alternative, without significant side effects. The placebo effect may also be significant. However, it is probably better to avoid magnetic therapy in patients with an implanted pacemaker or other electronic device. 14. What is meant by ‘‘bioenergetic therapy’’? Also called polarity therapy, bioenergetic therapy is a combination of Ayurveda, TCM, and Western medicine that attempts to produce balance of all systems. Some bioenergetic therapies, such as reiki, qigong, tai chi, and therapeutic touch, are specifically used for painful conditions. Reiki proposes that energy flows from the practitioner’s hands into the patient’s body, over 12 body locations, with the patient fully clothed. Qigong and tai chi are structured, choreographed, slow movements that are designed to reestablish proper circulation of qi (energy). Therapeutic touch is another modality in which the goal is an energy flow between the patient and the practitioner, without actual contact. One recent double-blind study of therapeutic touch found no evidence of effectiveness. 15. What is Ayurveda? The term Ayurveda is a Sanskrit word that translates into ‘‘knowledge’’ (veda) of ‘‘life’’ (ayur). In its truest sense, it is meant to promote health, rather than fight disease. An original text on Ayurveda, which appeared between 1500 and 1000 B.C., addressed arthritis, rheumatism, and disorders of the nervous system. Chopra quoted one of the original texts that described pain treatment: ‘‘The patient lying on the bed moistened with the dews of moonrays covered with flax and Lotus leaves and fanned with breeze cooled by contact of sandy beach should be attended by the love and sweet-spoken women with their breasts and hands pasted with sandal and with cold and pleasing touch who remove burning sensation, pain, and exhaustion.’’ Ayurveda combines diet, exercise, spiritual activities, and herbal medicines in a holistic healing system. Its focus in on cleansing to remove toxins and balancing influences on the body to ensure a long life. 16. Which bioenergetic therapies are in common use in western medicine? Thermal therapies are very common in Western medicine. However, despite the enormous sales of heating pads, there are relatively few studies that show any clear benefit of heat for pain. However, anyone with a sore muscle will tell you that a hot bath or a vigorous shower
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 367 provides some pain relief. Cryotherapy (icing an injured muscle) also is popularly accepted, but there is little support in the literature for beneficial effects. Transcutaneous electrical nerve stimulation (TENS) has enjoyed enormous popularity, but metaanalysis has not been uniformly positive. Ultrasound is widely used but similarly unsupported by good studies. 17. What is the role of spinal manipulation in treating back pain and headache? Systematic reviews related to the role of spinal manipulation in treating back pain and headache are inconclusive. However, in uncomplicated acute neck and back pain, spinal manipulation has been shown to provide significant temporary relief. The picture is far less clear in chronic conditions. Patient satisfaction is higher after manipulative therapy than after most other contacts with practitioners. Although neurological and vascular complications are cited by practitioners of allopathic medicine, they are quite rare. 18. What are some of the ‘‘mind-body’’ modalities that are used to treat pain? Biofeedback is very popular for the treatment of headache and back pain. However, there is no evidence to show that it is any better than simple relaxation techniques. Biofeedback has been used successfully to treat headache, complex regional pain syndrome, and low back pain. Guided imagery may be effective to help patients cope with stress and pain. Progressive relaxation techniques are also used to relieve muscle tension and headache. Music therapy, breathing techniques, cognitive-behavioral therapy, visualization, hypnosis, and psychotherapy all have a role in chronic pain management. 19. True or false: A few vitamin and supplement therapies have shown promise for treating headaches. True. A randomized, placebo-controlled study using vitamin B2 (riboflavin) at 400 mg per day (recommended daily dose is 1.8 mg per day) was more effective than placebo in migraine and tension-headache control over a 3-month period. Although statistically valid, these results have not been widely replicated. Intravenously administered magnesium can be an effective abortive agent in patients with acute migraine. Chronic magnesium replacement has also been recommended for recurrent migraine, although well-controlled studies have not supported its use as a prophylactic agent. Any patient taking a magnesium supplement should probably also take calcium. 20. What is the role of feverfew and butterbur in headaches? Tanacetum parthenium (feverfew) is a plant cultivated throughout Europe and the United States. Its principal activity is the creation of parthenolide, which is thought to have an effect on platelets and the inhibition of proinflammatory compounds. Controlled studies have yielded mixed results. Feverfew is combined with magnesium and vitamin B2 in products known as Migreleve and Migrehealth. In 2004, Petasites hybridus root (butterbur) was shown to be more effective than placebo in a randomized, placebo-controlled study for chronic headache. 21. List potential interactions between herbs and analgesics. & NSAIDs—ginger, willowbark, feverfew, horse chestnut & Opioids—valerian root, kava, chamomile 22. To what scientific standards should CAM techniques be held? Keep in mind that many ‘‘standard’’ practices have not been established through truly evidence-based medicine. Truly randomized trials for surgery in low back pain are lacking; epidural steroid injections remain controversial; and the appropriate primary preventive treatments for stroke (with the exception of blood pressure reduction) are still being worked out. Practitioners of Traditional Chinese Medicine may well wonder why their 4000-year-old therapies are being questioned and held to the standards of Western medicine,
368 CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE which has a history of only a few hundred years. The fact that something is standard in one place and considered alternative in another does not mean that either side has the correct answer. 23. How can a clinician minimize clinical and legal risk when treating a patient with CAM? Cohen and Eisenberg proposed a framework that classifies therapies according to the strands of evidence regarding safety and efficacy. Clinicians are advised to determine the clinical risk level, document the literature supporting the therapeutic choice, provide adequate informed consent, continue to monitor the patient conventionally, and inquire about the confidence of other practitioners in the particular modality.
KEY POINTS 1. The general philosophy of complementary and alternative medicine (CAM) is that your body has the ability to heal itself and that prevention of disease is of the greatest importance. 2. Numerous CAM therapies are currently used with varying degrees of medical evidence to support their use. 3. Potentially significant herb-drug interactions may occur with concurrent use; therefore, all health care practitioners must take an adequate medication history so that these can be avoided.
BIBLIOGRAPHY 1. Allais G, DeLorenzo C: Acupuncture as a prophylactic treatment of migraine without aura: a comparison with flunarizine, Headache 44(9):855-861, 2002. 2. Berman BM, Lao L, et al : The effectiveness of acupuncture as an adjunctive therapy in OA of the knee, Annals of Internal Medicine 141(12): 901-910, 2005. 3. Birch S, Hesselink JK: Clinical research on acupuncture. Part 1. What have the reviews on the efficacy and safety of acupuncture told us so far? J Altern Complement Med 10(3):468-480, 2004. 4. Chopra A, Doiphode VV: Ayurvedic medicine: core concept, therapeutic principles, and current relevance, Med Clin North Am 86(1):75-89, 2002. 5. Cohen MH, Eisenberg DM: Potential physicial malpractice liability associated with complementary and integrative medical therapies, Ann Int Med 136:596-603, 2002. 6. Cohen MH, Hrbek A, et al: Emerging credentially practices, malpractice liability policies, and guidelines governing complementary and alternative practices and dietary supplement recommendations, Arch Int Med 165(3):289-295, 2005. 7. Eccles NK: A critical review of randomized controlled trials of static magnets for pain relief, J Altern Complement Med 11(3):495-509, 2005. 8. Ernst E, Pittler MH: The efficacy and safety of feverfew (Tenacetum parthenium L.): an update of a systemic review, Public Health Nutr 3(4A):509-514, 2000. 9. Kaptchuk TJ, Eisenberg DM: Varieties of healing. 2: A taxonomy of unconventional healing practices, Ann Intern Med 135(3):196-204, 2001. 10. Khadikar A, Milne S, Brosseau L, et al: Transelectrical nerve stimulation (TENS) for chronic low back pain, Cochrane Database Syst Rev 3:CD003008, 2005. 11. Lipton RB, Gobel H: Petasites hybridus root (butterbur) is an effective preventative treatment for migraine, Neurology 63(12):2240-2244, 2004. 12. Maizels M, Blumenfeld A, et al: A combination of riboflavin, magnesium feverfew for migraine prophylaxis: a randomized controlled trial, Headache 44(9)885-890, 2004.
CHAPTER 47 COMPLEMENTARY AND ALTERNATIVE MEDICINE 369 13. Mazzata G, Sarchielli P, Alberti A, Gallai V: Electromyographical ischemic test and intracellular and extracellular magnesium concentration in migraine and tension type headache patients, Headache 36(6):357-361, 1996. 14. Montazeri K, Farahnakian M: The effect of acupuncture on the acute withdrawal symptoms from rapid detoxification, Acta Anaesthesiol 40(4):173-175, 2002. 15. Nestler G: Traditional Chinese Medicine, Med Clin N Am 86(1):63-73, 2002. 16. Park J, Ernst E: Ayurvedic medicine for rheumatoid arthritis, Semin Arthritis Rheum 34(5):705-713, 2005. 17. Schoenen J, Jacquy J, Lenaerts M: Effectiveness of high dose riboflavin in migraine prophylaxis, Neurology 50(2):466-470, 1998. 18. Tindle HA, Davis RB, et al: Trends in the use of complementary and alternative medicine by US adults, Altern Ther Health Med 11(1):42-49, 2005. 19. Tsui MLK, Cheing GLY: The effectiveness of electroacupuncture in the management of chronic low back pain, J Altern Compl Med 10:803-809, 2004. 20. Vickers AJ: Statistical reanalysis of four recent randomized trials of acupuncture for pain using analysis of covariance, Clin J Pain 20:319-323, 2004.