Alternative and Complementary Approaches

Overview and Description

Alternative and complementary approaches to rehabilitation

Alternative and Complementary Approaches to Rehabilitation

The National Center for Complementary and Integrative Health (NCCIH), which is the governing body for non-conventional approaches to medical conditions uses the term “complementary health approaches” (CHA) to define four subgroups of alternative and complementary approaches based on their primary therapeutic mode of “input” or delivery: (1) Nutritional, (2) Psychological, (3) Physical, and (4) Combination of Approaches.¹⁴

Nutritional CHA includes natural products such as herbs and supplements, probiotics, vitamins, and minerals.¹⁴ Physical and/or psychological CHA include acupuncture, massage, meditation, mindfulness, movement therapies, relaxation techniques, spinal manipulation, osteopathic manipulation, and others not specifically listed.¹⁴ Often times, physical and psychological CHA are intertwined as mind-body practices and may even be incorporated into combined holistic healing systems. Ayurvedic medicine, traditional Chinese medicine, acupuncture, homeopathy, natural healers, functional medicine, and naturopathy fall into a “combined” approach since they are whole body approaches to treating the patient. In this paper, we subdivide CHA into 5 primary therapeutic modes of delivery. See table 1 below and “Relevance to Clinical Practice” for more details.

Table 1: Complementary Health Approaches (CHA) Subgroups¹⁴

According to the 2020 National Health Interview Survey (NHIS), about 36.7% US adults used some type of complementary health approach.² The approaches included acupuncture, chiropractic, guided imagery/progressive muscle relaxation, massage therapy, meditation, naturopathy and yoga.¹⁶ A significant growth was seen in meditation, yoga and massage therapy.² The most used complementary approach was meditation, with about 17.3% of adults.² Pain was specifically assessed and results showed adults using these methods for pain management increased from 42.3% in 2002 to 49.2% in 2020.²

The 2022 NIHS revealed that yoga increased from 5% in 2002 15.8% in 2022.² Meditation was the most used approach and increased from 7.5% in 2002 to 17.3% in 2022.² Acupuncture, with its increased coverage by insurance, also saw an increase from 1% in 2002 to 2.2% in 2020.²

Physical medicine and rehabilitation (PM&R) providers care for a significant number of conditions for which people seek complementary and integrative health (CIH) treatments. Complementary and integrative health (CIH) treatments are a wide array of non-conventional health care practices, systems, tools, and resources. Complementary medicine involves the use of non-conventional techniques or treatments in conjunction with conventional medicine.

Alternative medicine is used in place of conventional medicine.¹ Integrative medicine is a combination of conventional medicine with complementary and/or alternative medicine. PM&R has an interdisciplinary nature in the way they train and practice. They have a leading role in managing back, neck, and joint pain for which they should embrace complementary health modalities and become leaders in this area.

Complementary health approaches and western medical treatments differ dramatically in the environment in which care is delivered. While western medical settings are almost sterile, complementary health approaches include surroundings that are comfortable and relaxing, encouraging patients to participate fully in their sessions. The atmosphere may be established by providing a temperate climate, using dim lighting, soft music, warm room decorations, and even a mild pleasant aroma. Many hospitals are beginning to incorporate some of these concepts into their waiting rooms and grounds.

Complementary and Integrative Health (CIH): Today’s approach to Complementary and Alternative Medicine (CAM)

Complementary and integrative health (CIH) is a holistic, interdisciplinary approach designed to treat the person and not just the disease. It is a partnership between the patient and his or her providers, where the goal is to treat the mind, body, and spirit. CIH combines treatments of conventional medicine with elements of complementary and alternative medicine. There is strong evidence of safety and effectiveness in bringing them together in an integrated fashion.

Patients and providers work together in the treatment and wellness plan. Ideally, this approach is more wellness-based and preventative, whereas the current model of health care is more reactive and disease-based, treating the patient in an uncoordinated fashion with the hope of controlling a process that is already well established. Complementary and integrative health can be applied to the treatment of disease, but would do so through a coordinated, interdisciplinary, patient-centered model.

Complementary and integrative health encompasses east and west, mind and body, and individual and family. Most importantly, the approach is patient centered. It transforms the current medical model to a more personalized, proactive, patient-driven approach, which enables engagement with life in accordance with how an individual wants to live. It focuses on empowering the person through comprehensive education regarding their health and wellness, thereby encouraging active participation in one’s own wellbeing.

Relevance to Clinical Practice

Nutritional

Natural Products, Herbs, & Supplements

The National Center for Health Statistics reported that the use of natural products and dietary supplements is common among the U.S. adult population. Over 40% adults used supplements from 1988 to 1994, and this number increased to over 50% from 2003 to 2006.⁸ During 2017–2018, 57.6% of adults aged 20 and over reported using dietary supplement in the past 30 days.³⁵ A higher percentage of women (63.8%) reported dietary supplement use than men (50.8%). Among adults aged 20 and over, 42.4% used none, 22.5% used one, 13.8% used two, 7.5% used three, and 13.8% used four or more dietary supplements in the past 30 days.³⁵

The top three most common types of dietary supplements used by adults were consistent among all age groups. These were multivitamin-mineral (24.0% for ages 20–39, 29.8% for 40–59, and 39.4% for 60 and over), vitamin D (6.7% for ages 20–39, 17.4% for 40–59, and 36.9% for 60 and over), and omega-3 fatty acids (5.4% for ages 20–39, 12.5% for 40–59, and 21.8% for 60 and over). The fourth most common type of dietary supplement used was vitamin C for those aged 20–39 (5.2%), botanicals for those aged 40–59 (8.3%), and calcium for those aged 60 and over (19.2%). The fifth most common type of dietary supplement was botanicals for those aged 20–39 (5.1%), calcium for those 40–59 (7.7%), and vitamin B12 for those aged 60 and over (12.4%).³⁵

From 2007–2008 through 2017–2018, the percentage of adults reporting dietary supplement use increased in all age groups. A high level of dietary supplement use can contribute substantially to nutrient intake in the United States, potentially mitigating nutrient shortfalls as well as increasing the risk of excessive intake, especially with high concurrent use of more than one product.^9,35

Herbs and supplements are utilized for both health and wellness, and although research doesn’t support many, there is a growing level of clinical evidence for some. It is important for the medical practitioner to ask about herb and supplement use and to also know where to look for information on specifics of their use. The Natural Medicines website is a good resource to provide evidence-based information about complementary and integrative health, including dietary supplements and integrative therapies.¹¹ The NCCIH also provides evidence-based information for health care providers.¹

Psychological

Spirituality, Psychotherapy, & Guided Imagery

Spirituality or spiritual healing, whether religious or not, may play a role in helping improve psychological well-being and self-awareness, and offers palliative care patients a sense of peace and quality of life during difficult and struggling times and situations.^60-62 Psychotherapy has been helpful for reducing depression⁶³ but may be no better in treating major depressive disorder than antidepressants 64 and is an adjunct to conventional management of chronic pain.⁶⁹ Guided imagery or visualization therapy is purported to help reduce stress and anxiety and postoperative pain especially in perioperative children undergoing minor surgery through visualization of well-being and relaxation.^65,68 Guided-imagery has an unknown role in enhancing the body’s immune system⁶⁶ and may have a role in reducing pain, dyspnea, sleep, and fatigue in heart failure patients.⁶⁷ Studies on guided-imagery for improving symptoms associated with fibromyalgia are mixed.⁷⁰ Interestingly, a 2021 small exploratory controlled trial used a brief form of guided-imagery (as opposed to the conventional 20 minute guided-imagery) with significant improvements in mood and quality of life in women with chronic fibromyalgia.⁷¹

Mindfulness

Mindfulness-based interventions appear to be some of the most rapidly growing areas within complementary health with Yoga, Tai Chi, and Qigong being common examples. Still, much of the recent focus has been on mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) programs, both of which are derived from ancient Buddhist and yoga philosophies. MBCT combines mindfulness practices with cognitive behavioral techniques to help identify and alter negative thought patterns. While MBSR is used to help manage stress and anxiety through mindfulness meditation and gentle yoga.

These approaches are also used in psychotherapy and can also be applied in the management of pain. Mindfulness has been shown in the literature to improve pain tolerance, but did not help with pain-related stress, pain-threshold, or pain severity.⁷² These techniques are particularly effective for preventing relapse and promoting more effective emotional regulation in response to pain; essentially allowing one to cultivate a different relationship with their sensations.

Additionally, García-Muñoz et al. found that tai chi was effective in improving motor function and independence in stroke patients, although the evidence for improvements in health-related quality of life and sleep was inconclusive.⁷⁶ This review also highlighted the benefits of tai chi, yoga, and qigong in improving balance performance in neurological conditions, including stroke.

Physical

Manipulative & Body-Based Practices

Osteopathic Medicine was founded in the 19th century by Andrew Taylor Still, MD, DO. Osteopathic medicine includes manual manipulation of the spine, joints, and soft tissues and has been at the forefront of integrative medicine. Dr. Still stressed the importance of the connection between mental, physical, emotional, and spiritual health and taught that each plays an important role in the patient’s overall health.

The evidence for manual therapy, as many refer to it, is not overwhelming; however, there does appear to be a role for osteopathic medicine in the management of pain, particularly if treated early. A 2011 Cochrane review looking at the use of manual therapy in low back pain showed improved pain and disability in the short term and pain in the medium term for acute/subacute low back pain.¹¹ OMM has shown promise in improving pain management, functional outcomes and possibly cerebral perfusion in patients with stroke, spinal cord injury, and brain injury.^77-80 However, the evidence is still emerging and requires further high-quality studies in order to establish efficacy and optimize its use.

Massage encompasses a range of techniques involving the pressing, rubbing, and manipulation of the skin, muscles, tendons, and ligaments to promote relaxation and facilitate recovery from injuries. Typically performed by trained massage therapists using their hands and fingers, massage may also involve the use of forearms, elbows, and even feet.

Types of Massage

• Swedish Massage: Primarily aimed at relaxation, Swedish massage is the most common type found in spa settings. It uses long, flowing strokes to soothe the body and mind.
• Thai Massage: Rooted in traditional Thai medicine, this technique incorporates assisted stretching and is influenced by principles from Traditional Chinese Medicine (TCM).
• Shiatsu: A Japanese method, Shiatsu utilizes finger pressure applied along specific meridians, often corresponding to acupuncture points, to restore balance and promote healing.
• Deep Tissue Massage: This technique targets trigger points and aims to release chronic muscle tension, providing relief from persistent discomfort.
• Sports Massage: Tailored for athletes, sports massage can be beneficial at various stages: as a warm-up before events, to alleviate cramps during competition, and as a cool-down afterwards.

Enhancements

To further enhance the massage experience, heat can be integrated into any of these treatments using warmed stones, topical ointments, creams, or other soothing emollients, promoting deeper relaxation and relief.

By understanding these various techniques and their benefits, individuals can make informed choices about the type of massage that best suits their needs.

Physical/Psychological

The Mind-Body Connection

Research over the past several decades has identified interactions between the brain and the immune system, suggesting that the mind-body connection is real,³ and a study noted that physicians believed in this connection.⁴ Complementary and integrative health attempts to address this connection to assist and improve a person’s wellbeing. Examples of this are Qigong, Tai Chi, and yoga, which actively engage the mind and body using breathing and mindfulness techniques.

Movement Therapies

Transitional aquatics utilize aerobic exercise, stretching, and yoga poses. Tai Chi can be done both in and out of the water. Participants use the buoyancy and support that an aquatic environment provides to exercise. Once muscle tone, flexibility, and balance improve, patients can transition to land-based activities or do both land and aquatic therapies to enhance their rehabilitation.^46,47

Tai Chi involves performing a series of postures or movements in a slow, graceful manner. It is often referred to as meditation in motion. Each posture flows into the next without pause, ensuring that the body is in constant motion. All forms of Tai Chi include rhythmic patterns of movement, synchronized with breathing to help achieve a sense of inner calm. Tai chi was found to be as effective as physical therapy for osteoarthritis.¹²

Qigong is a moving mindfulness practice, which uses slow, refined movements, often with coordinated breathing to promote the circulation of Qi within the human body, to enhance overall health, relaxation, and mental focus.^36-42 Qigong can be performed in standing, sitting, and lying positions, some with little or no movement at all; not all forms use breath control techniques.

Similarly, yoga is a practice that was developed in ancient India and centers around mind, body and spiritual elements. Yoga combines pranayama (breathwork) with a series of poses (asanas) as well as meditative components. There are many different types of yoga including Hatha, vinyasa, Ashtanga, Iyengar, Bikram, yin, and restorative yoga. All these styles have been adopted and or modified from ancient teachings.

Yoga is used for the treatment of many health conditions such as improving musculoskeletal joint strengthening and flexibility, enhance breathing and circulation, for relaxation, and mild-moderate major depression, and for overall well-being.^51-54 Yoga may be beneficial for musculoskeletal strengthening and flexibility. It may have a role in improving functional fitness outcomes in middle-aged and older adults by participants using their body for exercise through practice of postures and learning to balance muscle groups in these postures.⁵² Yoga may help depression and anxiety hypothetically through many mechanisms such as hypothetical gamma-aminobutyric acid (GABA) or hypothalamic-pituitary-adrenal axis and/or the experience of mastery the art itself and increase in self-esteem.⁵³

Combined

Whole Medical Systems

Chinese Medicine is an ancient energy-based system for health which focuses on the concept of Qi (pronounced “chee” or “ki” – a life force which flows in the body), Yin/Yang (breakdown of Qi with its opposing and harmonious forces), and 5 elements (further breakdown of Yin/Yang energies). The goal of Chinese medicine is to balance all these energies in the human body for healthy living and prevention of pathological conditions. It utilizes specific diagnostic evaluations, such as pulse and tongue assessment, as well as treatments that include specialized herbal prescriptions, and interventions such as acupuncture.

Acupuncture is one such medical modality under Chinese Medicine that suggest physiologic changes can enact neurologic and neurochemical effects leading to clinical improvement.

Although it is not a panacea, acupuncture does appear to be appropriate for pain and stress.^73,74 Acupuncture, as a form of energy medicine and one of the more common and most researched of the complementary and alternative modalities, shares a conceptual framework like those of Tai Chi and Qigong, in that Qi is thought to be circulating through all parts of the body via channels, called meridians. These meridians connect the exterior to the interior as well as the organs to each other and the exterior. Pain and illness are believed to occur when the flow of Qi becomes blocked or unbalanced. Acupuncture is one of the treatments utilized to reestablish the course of Qi by placing needles at points along the meridians, thus allowing the body to return to a homeostasis, easing the ailment for which it was prescribed.

Communication and education

Key elements within complementary health approaches and integrative medicine are communication and education.^43-45 An open dialogue occurs between the provider and the patient to align the patient’s expectations with what can realistically be achieved. The goal is to empower patients to take control of their own health and wellness, laying the foundation for successful, permanent change.

Topics, such as sleep hygiene, nutrition, activity can be discussed in detail after reviewing logs of these topics from each patient with their physician. This allows for one-on-one patient-centered, individualized programs. These interventions place an emphasis on the patient’s responsibility in their own health and wellbeing.

Cutting Edge/Unique Concepts/Barriers to these approaches

Cutting edge    

Virtual reality (VR) in rehabilitation is a promising alternative and complementary therapy for diagnosis and intervention in the rehab setting.⁶ It has been studied in the diagnosis of postural stability in Alzheimer’s patients and balance impairment in mild traumatic brain injury patients.⁶ In the older population, VR has been shown as an intervention for functional deficits such as, gait performance, balance deficits, postural sway, upper extremity functional reach and grasp, endurance, or phantom limb pain.6 VR may have a role in pain management in reducing opiate use³¹ and may be helpful for those with sickle cell disease³² and is being investigated for at home treatment of low back pain³³ and complex regional pain syndrome.³⁴ In regards to chronic neck pain, a systematic review and meta-analysis of randomized control trials were reviewed.⁷ Results showed that VR demonstrated improvements in both short term and long term neck disability index scores and short term pain intensity.⁷

Unique concepts

Balneotherapy, a comprehensive form of healing with water through bathing and water massage, is being investigated as having possible rehabilitative benefits in chronic musculoskeletal pain, cardiac diseases, dermatological diseases, and metabolic syndrome.¹⁷

Osteopathic craniosacral therapy is currently being investigated for some rehabilitative role in temporomandibular disorders¹⁸ and post-acute concussion and post-concussion syndrome.¹⁹ A single blinded case series combined craniosacral therapy with neural and visceral manipulation techniques to improve quality of life and post-concussive symptoms.²⁰

Acupuncture continues to be investigated as having a potential role in helping to rehabilitate stroke survivors with dysphagia, post-stroke pain, spasticity, shoulder pain, and insomnia.²¹

In one randomized single blinded trial, the Feldenkrais method, a form of holistic movement therapy, was shown to be better than core exercises for non-specific low back pain.²²

Dance Movement Therapy (DMT), a therapy which involves creative artistic movements, may have some psychological (depression), cognitive (dementia), and physical benefits (Parkinson’s and cerebral palsy motor impairments, and hypertension) for patients.^23-30

Barriers to these approaches and their solutions

The unsafe use of supplements can lead to drug interactions putting patients at increased risk of bleeding or thrombosis, altered drug metabolism or allergic reactions.⁵⁶ Access to trained professionals may also be limited in rural or underserved areas as well. Manual therapies, especially high velocity low amplitude techniques (HVLA) or “cracking” of spinal joints in the cervical region, provided by untrained practitioners or if contraindicated can increase the risk of internal bleeding, hematoma, subluxations, dislocations, vessel dissections, and soft tissue injuries.^{57, 58} Some of these contraindications include vascular compromise, bony compromise, neurological issues, or if the technique poses increased risk of harm to the patient.⁵

These complementary health approaches can pose extra financial burdens without proven efficacy.⁵⁹ Many complementary approaches are not covered by insurances, although the coverage has increased, most remain as out-of-pocket expenses. Another barrier to these approaches is the lack of evidence based research surrounding them. This lack creates an uncertainty regarding their effectiveness or safety. Herbs and supplements for example may interact with conventional therapies or can cause side effects that we are currently unaware of. Lastly, some patients and healthcare providers may view these approaches as pseudoscientific and less legitimate than other methods. There is a limited understanding amongst the population about the benefits and appropriate uses of these approaches, which significantly can hinder their integration into their rehabilitation process.

The solution to most of these barriers will require systemic efforts. These include policy changes to help broaden and improve insurance plan coverage, increased research funding in order to adequately and safely test other modalities in a controlled setting, and education initiatives for providers and patients. Government or private health insurances could provide funding or subsidies to make these approaches more affordable. Public health campaigns can be launched aiming to educate the masses about the benefits as well as the limitations to these modalities. Promoting cultural competence among healthcare providers can reduce bias against traditional and alternative practices. And ultimately, regularly evaluating the impact these approaches have on outcomes will ensure that they remain relevant and effective.

Conclusion

Complementary and alternative medicine has been incorporated as a component of integrative health and medicine. Patients who are referred to and undergo integrative medicine are participants in this approach to their medical care.^48, By recognizing the connection between mind, body, spirit, and how an individual interacts within their community, the interdisciplinary team offers comprehensive, individualized attention facilitated through dynamic dialogue between the consumer and his/her providers. This in turn can lead to greater satisfaction with
services offered, an increase in active participation in one’s own health care, and most importantly, lifestyle changes that lead to a better sense of overall well-being.⁴⁹

Gaps in Knowledge/Evidence Base

Complementary and alternative medicine is becoming more popular in a considerable number of patients. Not all complementary health approaches have proven safety and efficacy standards in treating medical conditions. As a result, doctors will need to inquire about the use of any complementary health approaches by patients in both outpatient and inpatient settings. It is necessary to educate patients about the risks and benefits of complementary health approaches to avoid harmful effects and provide them with evidence-based treatment options.⁵⁰

Physicians should directly ask patients for use of any complementary health approaches in history taking. In turn, physicians can provide patients with a list of safe and effective available complementary health approaches. They can also provide referrals to properly trained and licensed providers who can explain risks and benefits of each therapy, allowing for one-on-one patient-centered, individualized programs. Proper training of providers is usually through educational programs (bachelor’s or master’s degrees or certificates) which offer comprehensive or holistic approaches to care (acupuncture, massage, yoga, and/or herbology, meditation, Tai Chi, or Qigong). Providers are licensed after passing a state exam usually for their intended complementary and alternative medicine profession. A physician can also go for additional courses and hours of training in medical acupuncture. They can obtain a certificate and later a license as a medical acupuncturist or in Chinese Medicine.⁵⁵

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Original Version of Topic

David F. Drake, MD, Deborah Daimaru, RKT. Alternative and complementary approaches. 9/20/2013.

Previous Revision(s) of Topic

David F. Drake, MD, Deborah Daimaru, RKT. Alternative and complementary approaches. 3/22/2017.

Lawrence Chang, DO, MPH MD, Breanna Benjamin, DO, MD, Shirin Ardeshirzadeh, MD. Alternative and Complementary Approaches. 11/17/2021.

Author Disclosure

Melissa Mafiah, MD
Nothing to Disclose

Kaitlyn Hansen, MD
Nothing to Disclose

Hefdadeen Mashrah, DO
Nothing to Disclose