Overview and Description
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 “complimentary 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.13
Nutritional CHA includes natural products such as herbs and supplements, probiotics, vitamins, and minerals13. Physical and/or psychological CHA include acupuncture, massage, meditation, mindfulness, movement therapies, relaxation techniques, spinal manipulation, osteopathic manipulation, and others not specifically listed.13 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) Subgroups13
|Primary Therapeutic Input||Therapy||Therapeutic Overlaps|
|Nutritional||Probiotics, prebiotics, vitamins, minerals, phytochemicals, dietary spices/herbs/spices, any special diets, “natural products,” medicinal plants||Mindful eating, special diets (psychological) Dietary supplements, botanical drugs (drugs)|
|Psychological||Mindfulness, spiritualism, psychotherapy, guided imagery||May overlap with physical CHA|
|Physical||Manual therapies, cryotherapy, thermodynamic modalities, surgical||May overlap with psychological CHA|
|Physical and/or Psychological||Acupuncture, osteopathic and chiropractic manipulation, devices (virtual reality), light, electrical and magnetic stimulation, movement therapies, breathing and relaxation techniques, art, music, dance, yoga, tai chi, qi gong, Feldenkrais method, Alexander technique, Pilates, Rolfing structural integration, Trager psychophysical integration||Any of these can be incorporated into the combined approach|
|Combined||Homeopathy, Ayurvedic medicine, Chinese medicine, acupuncture (component of Chinese medicine), naturopathy, functional medicine, traditional healers||May include a component of nutritional, psychological, and physical aspects of CHA to diagnose and treat patients holistically|
According to the 2012 National Health Interview Survey (NHIS), about 33% of American adults and 12% of children used some type of complementary health approach during the prior 12 months.2 The most used complementary approach was natural products (dietary supplements other than vitamins and minerals), with about 18% of adults and 5% of children using them.2 About 25% of adults used natural products more than mind and body approaches for any musculoskeletal pain disorder.2
Adults who took natural products or practiced yoga were more likely to do this for wellness rather than for treating specific health conditions. In contrast, people who had spinal manipulation did this more often for treatment. The survey showed that approximately 59 million Americans spent up to about $30 billion a year out-of-pocket on complementary health approaches. That said, 60% of respondents reported at least some insurance coverage for chiropractic care. This dropped off dramatically for acupuncture (25%) and massage (15%).2
The 2012 NHIS revealed adults mostly practiced mind and body approaches such as yoga, chiropractic or osteopathic manipulation, meditation, and massage therapy. In contrast to this, the 2017 NHIS showed that more adults had practiced yoga which increased from about 10% to 14% and was the most common complementary health approach14. Adults who practiced meditation had also increased from about 4% to 14% and meditation became the number two most practiced in comparison to chiropractic care.14 Chiropractic care among adults increased about 1% in this time frame14. Women were more likely than men to practice yoga and meditation. Non-Hispanic white adults were most likely to utilize yoga, meditation, and chiropractic care.
Moreover, the 2017 NHIS revealed children had utilized yoga and meditation more since 2012. Children practicing yoga had increased from about 3% to 8%, while those practicing meditation increased from about 1% to 5%.15 Girls were more likely to practice yoga with no difference in use of meditation and chiropractic care among gender. Non-Hispanic white children were more likely to use yoga and chiropractic care.
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 medicine1.Integrative medicine is a combination of conventional medicine with complementary and/or alternative medicine. Given the interdisciplinary nature in which PM&R physicians train and practice, and the leading role they have taken in managing back, neck, and joint pain, 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, 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, all at the same time. CIH combines treatments of conventional medicine and elements of complementary and alternative medicine where there is strong evidence of safety and effectiveness, bringing them together in an integrated fashion, where the patient is the primary player, and all participants 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
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
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.60,61,62 Psychotherapy has been helpful for reducing depression63 but may be no better in treating major depressive disorder than anti-depressants64 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-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 and mindfulness-based stress reduction programs, both of which are derived from ancient Buddhist and yoga philosophies. 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
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
Massage is a general term for pressing, rubbing, and manipulating the skin, muscles, tendons, and ligaments to aid in relaxation and recovery from injury. Massage therapists typically use their hands and fingers but may also use their forearms, elbows, and even feet. Swedish massage is primarily used for relaxation and is most common in spa settings; Thai massage utilizes assisted stretching. It was developed in Thailand and influenced by TCM practices. Shiatsu is a Japanese technique utilizing finger pressure, often along meridians, which may correspond with acupuncture points. Deep tissue massage is used to target trigger points and release chronic muscle tension. Sports massage can be used before events as part of a warm-up, during the event in cases of cramping, and after the event as part of the cool-down. Heat can be added to any of these treatments via warmed stones, topical ointments, creams, or other emollients to aid in relaxation.
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.
Transitional aquatics utilize aerobic exercise, stretching, and yoga poses and Tai Chi that can be done both in and out of the water. Participants use the buoyancy and support that an aquatic environment provides to begin working out. 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, 37, 38, 39, 40, 41, 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, 52, 53, 54 Yoga may be beneficial for musculoskeletal strengthening and flexibility which may have a role in improving functional fitness outcomes in middle-aged and older adults by having the participants use their own body for exercise through practice of certain postures and learning to balance the body’s muscle groups in these postures.52 Yoga may help depression and anxiety hypothetically through many mechanisms such as hypothetical gamma-aminobutryic acid (GABA) or hypothalamic-pituitary-adrenal axis and/or the experience of mastery the art itself and increase in self-esteem.53
Whole Medical Systems
Traditional Chinese Medicine (TCM) is probably the best known of the 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 Chinse medicine is to balance these all these energies in the human body for a healthy living and prevent pathological sick 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.5,6,7
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, 44, 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, and activity, are discussed in detail after collecting sleep, nutrition, or activity logs from each patient, allowing 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/ Emerging Issues
Virtual reality (VR) in rehabilitation is a promising alternative and complementary therapy for improving function in stroke and Parkinson’s patients.16 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, complex regional pain syndrome and phantom limb pain.34
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.23,24,25,26,27,28,29,30
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 Manual therapies, especially high velocity low amplitude techniques (HVLA) or “cracking” of spinal joints in the cervical region, provided by untrained providers or if contraindicated can increase the risk of internal bleeding, hematoma, subluxations, dislocations, vessel dissections, and soft tissue injuries.57, 58 Some complementary health approaches can pose extra financial burdens without proven efficacy.59
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 the 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 or 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 wellbeing.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 include directly asking 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 (bachelors or master’s degrees or certificates) which offer comprehensive or holistic approaches to care (may learn 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 (medical doctor or osteopathic doctor) can also go for additional courses and hours of training in medical acupuncture and obtain a certificate and later a license as a medical acupuncturist or in Chinese/Oriental medicine.55
- National Center for Complimentary and Integrative Health (NCCIH) Web site. Available at: https://nccih.nih.gov/health/integrative-health. Accessed September 23, 2016.
- 2012 National Health Interview Survey Key Findings. https://nccih.nih.gov/research/statistics/NHIS/2012/key-findings). Accessed September 23, 2016.
- Saatcioglu F. Regulation of gene expression by yoga, meditation and related practices: a review of recent studies. Asian J Psychiatr. 2013;6:74-77.
- Sherman R, Hickner J. Academic physicians use placebos in clinical practice and believe in the mind-body connection. J Gen Intern Med. 2008;23:7-10.
- Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444-1453.
- Hollifield M, Sinclair-Lian N, Warner TD, Hammerschlag R. Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial. J Nerv Ment Dis. 2007;195:504-513.
- Hempel, S., Taylor, S. L., Solloway, M., Miake-Lye, I. M., Beroes, J., M., Shanman, R., Booth, M. J., Siroka, A. M., Shekelle, P. G. Evidence Map of Acupuncture. VAESP. Project #05-226; 2013
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- Wu CH, Wang CC, Tsai MT, Huang WT, Kennedy J. Trend and Pattern of Herb and Supplement Use in the United States: Results from the 2002, 2007, and 2012 National Health Interview Surveys. Evidence-Based Complementary and Alternative Medicine Volume 2014 (2014).
- Natural Medicines Web site. Available at: .https://naturalmedicines.therapeuticresearch.com/.Accessed September 23, 2016..
- Walker BF, French SC, Grant W, Green S. A Cochrane review of combined chiropractic interventions for low-back pain. Spine. 2011:36:230-242.
- Wang C, Schmid CH, Iversen MD, Harvey WF, Fielding RA, Driban JB, Price LL, Wong JB, Reid KF, Rones R, McAlindon T. Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Ann Intern Med. 2016 Jul 19;165(2):77-86
- Complementary, Alternative, or Integrative Health: What’s In a Name? National Center for Complimentary and Integrative Health (NCCIH) Web site. Updated April 2021. Accessed August 22nd, 2021. https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name
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- Triegaardt J, Han TS, Sada C, Sharma S, Sharma P. The role of virtual reality on outcomes in rehabilitation of Parkinson’s disease: meta-analysis and systematic review in 1031 participants [published correction appears in Neurol Sci. 2020 Jan 3;:]. Neurol Sci. 2020;41(3):529-536. doi:10.1007/s10072-019-04144-3
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- Gesslbauer C, Vavti N, Keilani M, Mickel M, Crevenna R. Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders – a pilot study. Disabil Rehabil. 2018;40(6):631-636. doi:10.1080/09638288.2016.1269368
- Kratz SV, Kratz DJ. Effects of CranioSacral therapy upon symptoms of post-acute concussion and Post-Concussion Syndrome: A pilot study. J Bodyw Mov Ther. 2021;27:667-675. doi:10.1016/j.jbmt.2021.05.010
- Wetzler G, Roland M, Fryer-Dietz S, Dettmann-Ahern D. CranioSacral Therapy and Visceral Manipulation: A New Treatment Intervention for Concussion Recovery. Med Acupunct. 2017;29(4):239-248. doi:10.1089/acu.2017.1222
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- Ahmadi H, Adib H, Selk-Ghaffari M, et al. Comparison of the effects of the Feldenkrais method versus core stability exercise in the management of chronic low back pain: a randomised control trial. Clin Rehabil. 2020;34(12):1449-1457. doi:10.1177/0269215520947069
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- Peng Y, Su Y, Wang YD, Yuan LR, Wang R, Dai JS. Effects of regular dance therapy intervention on blood pressure in hypertension individuals: a systematic review and meta-analysis. J Sports Med Phys Fitness. 2021;61(2):301-309. doi:10.23736/S0022-4707.20.11088-0
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- López-Ortiz C, Gaebler-Spira DJ, Mckeeman SN, Mcnish RN, Green D. Dance and rehabilitation in cerebral palsy: a systematic search and review. Dev Med Child Neurol. 2019;61(4):393-398. doi:10.1111/dmcn.14064
- Carapellotti AM, Stevenson R, Doumas M. The efficacy of dance for improving motor impairments, non-motor symptoms, and quality of life in Parkinson’s disease: A systematic review and meta-analysis. PLoS One. 2020;15(8):e0236820. Published 2020 Aug 5. doi:10.1371/journal.pone.0236820
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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
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Breanna Benjamin, DO MD
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Shirin Ardeshirzadeh, MD
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