1. OVERVIEW AND DESCRIPTION
Alternative and Complementary Approaches to Rehabilitation
The National Center for Complementary and Integrative Health (NCCIH) uses the term “complimentary health approaches” (CHA) and defines two specific subgroups, natural products, mind-body practices and offers a third, other complimentary health approaches.
Natural products are herbs and supplements, such as probiotics, vitamins and minerals. Mind-body practices include a very diverse large group of techniques or procedures that include acupuncture, massage, meditation, mindfulness, movement therapies, relaxation techniques, spinal manipulation, and others not specifically listed. Ayurvedic medicine, traditional Chinese medicine, homeopathy, and naturopathy are examples of approaches that fall into the other complimentary health sub-group1.
Complementary medicine involves the use of non-mainstream techniques or treatments in conjunction with conventional medicine. Alternative medicine, on the other hand, is the use of CHA in place of conventional medicine1.
According to the 2012 National Health Interview Survey, approximately 33% of American adults and 12% of children used some type of complementary health approach during the prior 12 months. The most commonly used complementary approach was natural products (dietary supplements other than vitamins and minerals), with about 18% of adults and 5% of children using them. The mind and body approaches most commonly used by adults included yoga, chiropractic or osteopathic manipulation, meditation, and massage therapy, with 9.5% percent of adults practicing yoga, an increase from 6.1% in 2007. Adults who took natural products or who practiced yoga were more likely to do so for wellness reasons rather than for treating specific health conditions. In contrast, people who had spinal manipulation did so more often for treatment. The same survey shows that approximately 59 million Americans spent up to $30.2 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.
Physical medicine and rehabilitation (PM&R) providers care for a significant number of problems for which people seek CIH treatments. Given the interdisciplinary nature in which PM&R physicians train and practice, and the leading role they’ve taken in back, neck, and joint pain, they should embrace complementary health modalities and become leaders in this area.
One area where CHA and western medicine treatments differ dramatically is the environment in which care is delivered. While western medicine settings are almost sterile, CHA surroundings are intended to be 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 CAM 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, CIH is more wellness-based and preventive, whereas the current model of 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. CIH can be applied to the treatment of disease, but would do so through a coordinated, interdisciplinary, patient-centered model.
CIH encompasses east and west, mind and body, and individual and family. Most importantly, CIH is patient-centered. It transforms the current medical model to a personalized, proactive, patient-driven approach, which enables engagement with life in accordance with how an individual wants to live. CIH focuses on empowering the consumer through comprehensive education regarding their health and wellness, thereby encouraging active participation in one’s own wellbeing.
2. RELEVANCE TO CLINICAL PRACTICE
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 notes that physicians believe in this connection.4 CIH attempts to address this connection to assist and improve a person’s wellbeing. Many of the CHA mentioned actively engage the mind and body, such as the breathing and mindfulness techniques utilized in Qigong, Tai Chi, and yoga.
Complementary Health Practices
Whole Medical Systems
TCM is probably the best known of the whole medical systems. It utilizes specific diagnostic evaluations, such as pulse and tongue assessment, as well as treatments that include herbal prescriptions, and interventions such as acupuncture.
Acupuncture is an ancient medical modality, with physiologic changes that appear to suggest neurologic and neurochemical effects that can lead to clinical improvement. Although it is not a panacea, acupuncture does appear to be appropriate for pain and stress.5,6,7
Acupuncture is a form of energy medicine and is one of the more common and most researched of the CAM modalities. It shares a conceptual framework similar to those of Tai Chi and Qigong, in that a life force, called Qi (pronounced chee), is thought to be circulating though 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.
Mindfulness-based interventions (MBIs) appear to be some of the most rapidly growing areas within complementary health. Yoga, Tai Chi, and Qigong are a few common MBIs, but 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 being used in psychotherapy and can also be applied in the management of pain.
Natural Products, Herbs and 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% used supplements from 1988 to 1994, and over 50% used supplements from 2003 to 2006.8 Adults’ use of fish oil, probiotics or prebiotics, and melatonin increased between 2007 and 2012, while their use of glucosamine/chondroitin, Echinacea, and garlic decreased over the same time period. While multivitamins, calcium, folate, and vitamin D remain among the most widely used supplements, fish oil was the most commonly used natural product among adults and children. An estimated 40.6 million US adults reported herb and supplement use in 2012. However, the rate of herb and supplement use dropped from 18.9% in 2002 to 17.9% in 2012. This decline in use was more pronounced among women, racial or ethnic minorities, and adults with low incomes. 9
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’s 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 therapies10 The NCCIH also provides evidence-based information for health care providers.1
Manipulative and Body-Based Practices
Since it’s founding in the 19th century by Andrew Taylor Still, MD, DO, Osteopathic Medicine, which includes manual manipulation of the spine, 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.
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, they can transition to land-based activities, including gaming techniques commonly found in homes, such as the Wii system, and eventually to classes offered in the community.
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. In a recent study, tai chi was found to be as effective as physical therapy for osteoarthritis12
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. 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.
3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
Communication and Education
Key elements within CHA and integrative medicine are communication and education. 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.
CAM has been incorporated as a component of integrative health and medicine. It is probably more appropriate to refer to patients as participants in the integrative medicine approach to medical care. 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.
4. GAPS IN KNOWLEDGE/EVIDENCE BASE
- 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
- NCHS Data Brief No. 61, April 2011.
- 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
Original Version of Topic
David F. Drake, MD, Deborah Daimaru, RKT. Alternative and complementary approaches. 09/20/2013.
David F. Drake, MD
Nothing to Disclose
Deborah Daimaru, RKT
Nothing to Disclose