Chapter 9
Complementary and Alternative Medicine

The National Center for Complementary and Alternative Medicine (NCCAM; formerly the Office of Alternative Medicine, established in 1992) is an institute of the National Institutes of Health (NIH). The center was created because consumers of complementary and alternative medicine (CAM) and health care practitioners wanted to know whether available alternative medical options were safe and effective. NCCAM is "committed to the clinical study of promising CAM substances and modalities before knowledge becomes available about their active ingredients, mechanisms of action, stability, and bioavailability," and the organization uses a hierarchy of evidence to determine a method or product's effectiveness and safety. Studies indicate that data on the efficacy and safety of CAM therapies span a continuum ranging from anecdotes and case studies through encouraging information obtained from large, well-developed clinical trials. (See Table 9.1.)

NCCAM defines alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine." Although there is some overlap between them, the NCCAM further distinguishes between "complementary," "alternative," and "integrative" medicine in the following manner:

• Alternative medicine is therapy or treatment that is used instead of conventional medical treatment. One example of alternative medicine is the treatment of depression with St. John's wort (hypericum), a botanical, herbal medicine, rather than with conventional antidepressant drugs such as Prozac.
• Complementary medicine is alternative therapy or treatment that is used along with conventional medicine, not in place of it. An example of complementary medicine is the addition of relaxation techniques or movement awareness therapies (such as the Alexander Technique, Pilates, and the Feldenkrais Method) to the traditional approaches of physical and occupational therapy used to rehabilitate people who have had a stroke. Complementary medicine appears to offer health benefits, but there is generally no scientific evidence to support its utility.
• Integrative medicine is the combination of conventional medical treatment and CAM therapies that have been scientifically researched and have demonstrated that they are both safe and effective. An example of integrative medicine is teaching stress management and relaxation techniques to people with high blood pressure and heart disease along with the use of traditional approaches such as weight management, exercise, and prescription drugs to reduce the risks and complications of heart disease.

Despite the classification system outlined by the NCCAM, CAM continues to be known by a variety of names—nontraditional medicine, unorthodox medical practices, and holistic health care—and reflects a wide range of philosophies, including the need for or reliance on scientific evidence of effectiveness. Generally, alternative therapies tend to be untested and unproven, whereas complementary and integrative practices that are used in conjunction with mainstream medicine are often those with a substantial scientific basis of demonstrated safety and efficacy.

GROWING POPULARITY OF CAM

Many people have turned to CAM approaches out of frustration that mainstream medicine cannot meet all their expectations and needs. Helping this movement along is information technology, enabling easy access to sources of CAM information on the Internet and in print and electronic media, and advertising and marketing of new CAM products and methods. In 2002 the NCCAM reported that as many as 62% of Americans used CAM approaches, including megavitamins and prayer, to

satisfy their health needs in the past twelve months. (See Figure 9.1.)

Dr. David Eisenberg in "Trends in Alternative Medicine Use in the United States, 1990–1997: Results of a Follow-Up National Survey" (Journal of the American Medical Association, 1998) reported on the use of alternative medicine in the United States. The findings revealed that more than four in ten Americans had used at least one alternative therapy. The survey revealed that approximately 42% of Americans used alternative medicine in 1997. Further, about $27 billion was spent out of pocket (not paid by insurance) for alternative medicine, a number that was comparable to

what Americans paid out of pocket for conventional treatments from physicians in the same year. The researchers reported that the highest rates of CAM use were among college graduates living in the Western United States, ages thirty-five to forty-nine, with incomes greater than $50,000 per year.

Although the majority of CAM services are provided by alternative medical practitioners, CAM also is provided by some traditionally trained physicians. The Centers for Disease Control and Prevention (CDC) in "National Ambulatory Medical Care Survey: 2003 Summary" (Advance Data from Vital and Health Statistics, 2005) reported that "therapeutic and preventive services" (not including medication therapy) were ordered or provided at 41.5% of all office visits. Visits that included counseling or education related to diet or nutrition (14.3%) and exercise (10.1%) were made most frequently. (See Table 9.2.)

Americans' Use of Complementary and Alternative Medicine is Not Just a Fad

Researchers from the Harvard Medical School and Center for Alternative Medicine Research and Education studied long-term trends in the use of CAM therapies in the United States and published their findings in the August 21, 2001, issue of the Annals of Internal Medicine. The researchers conducted more than two thousand surveys and examined historical patterns of CAM utilization dating back to the 1960s. They questioned survey respondents about twenty different CAM practices, such as acupuncture, aromatherapy, biofeedback, energy healing, massage, and yoga.

The study found that since the 1960s nearly all of the twenty CAM therapies had increased in popularity, with interest surging during the 1960s and 1970s. The researchers observed that specific CAM therapies gained acceptance during each decade. In the 1960s Americans embraced diet programs, vitamins, and self-help support groups, and in the 1970s they turned to herbal medicine, biofeedback, and energy healing. The 1980s saw growing popularity of massage and naturopathy, and during the 1990s the appeal of massage increased again along with interest in aromatherapy, energy healing, herbal medicine, and yoga.

In contrast with earlier studies, including Dr. Eisenberg's research, which found CAM users to be mostly educated adults living in Western states, the researchers found the use of alternative therapies was unrelated to education attained, gender, or ethnicity. They observed that the increases in both acceptance of CAM and its use during the past fifty years suggest that demand for CAM therapies will continue in the foreseeable future.

In the twenty-first century, many CAM practices have joined the ranks of mainstream medicine. Steve Fall in "Survey Shows Alternative Becoming Mainstream" (Atlanta Business Chronicle, November 28, 2005) reports on the results of a Kaiser Family Foundation/Health Research & Educational Trust survey that found that the percentage of employers offering coverage for acupuncture rose from 33% in 2002 to 47% in 2004. The percentage covering chiropractic benefits also grew, from 79% in 2002 to 87% in 2004. Many health plans also offer a range of CAM therapies. For example, Aetna covers acupuncture as an alternative to anesthesia for certain procedures, chiropractic manipulation, massage therapy, and nutritional counseling as well as vitamins and aromatherapy (the use of essential oils—extracts or essences—from flowers and herbs to promote health and well-being). Blue Cross and Blue Shield of Georgia offers chiropractic benefits along with a discount program called HealthyExtensions for alternative therapies such as acupuncture, massage therapy, and chiropractic (for members without the benefit). The program also includes discounts for nutritional supplements, weight loss centers, and fitness clubs.

Who Uses Complementary and Alternative Medicine?

The 2002 National Health Interview Survey (NHIS) gathered data about Americans' use of CAM. The NHIS findings were released in May 2004 by the NCCAM and the National Center for Health Statistics (NCHS is part of the CDC). The NHIS posed questions about various types of CAM therapies commonly used in the United States. These included acupuncture, hypnosis, and chiropractic, as well as natural products, special diets, and megavitamin therapy.

The NHIS found that CAM use was greater among women than men, and among persons with higher educational attainment as well as those who had been hospitalized during the year preceding the survey. Interestingly, CAM use also was greater among former smokers, compared with current smokers or persons who have never smoked.

When CAM practices included megavitamin therapy and prayer, African-Americans reported the highest level (71.3%) of use; however, when these modalities were excluded their CAM use fell to 26.2%—lower than Hispanics (28.3%), whites (35.9%), and Asians (43.1%). (See Figure 9.2.)

Why Do People Seek CAM?

People turn to CAM for many different reasons. One of the most attractive features of CAM is an emphasis on the "whole person," rather than simply the diseased organ or body part. CAM therapies and practitioners tend to consider patients as human beings rather than simply physical bodies, and nearly all emphasize the mind-body connection and pay attention to emotional wellness and spirituality.

People turn to CAM seeking relief from a wide range of symptoms and diseases. The NHIS found that Americans were most likely to use CAM practices for back pain (16.8%), head colds (9.5%), neck pain (6.6%), joint pain (4.9%), arthritis (4.9%), anxiety or depression (4.5%), gastrointestinal disorders (3.7%), headaches (3.1%), recurring pain (2.4%), or insomnia (2.2%). (See Figure 9.3.) CAM is most often used to treat musculoskeletal problems and conditions involving chronic or recurring pain.

Some patients seek alternative therapies when conventional medicine fails to relieve their symptoms or when traditional treatment produces unpleasant side effects. The 1998 study conducted by Dr. Eisenberg found that nearly half of CAM visits were to chiropractors and massage therapists for symptoms of pain associated with chronic conditions such as back and neck problems, headaches, and arthritis.

Other CAM users cite distrust of physicians, historically poor communication and interactions with physicians, the impersonality of traditional medical care, and the desire for practitioner-patient partnerships characterized by shared decision making (rather than traditional physician-patient relationships in which physicians assume sole responsibility for decisions about patient care) for their interest in CAM.

The NHIS asked respondents to choose one or more reasons from a list of five to describe why they used CAM. (See Figure 9.4.) The survey respondents opined that:

• CAM would improve health when used in combination with conventional medical treatments (54.9%)
• CAM would be interesting to try (50.1%)
• Conventional medical treatments would not help (27.7%)
• A conventional medical professional suggested trying CAM (25.8%)
• Conventional medical treatments are too expensive (13.2%)

Dr. Andrew Weil, a renowned physician and expert in CAM practices and director of the Program in Integrative Medicine at the University of Arizona School of Medicine, believes that one reason for the renewed popularity of CAM is that modern Western medicine has focused on technology and ignored simple, natural, and inexpensive ways to influence health and disease that were used by previous generations and are still used in other cultures. Dr. Weil contends:

People all over the world are increasingly concerned about the harm inflicted by modern, technological medicine, especially adverse reactions to pharmaceutical drugs that are now so common. In deciding what to put in their bodies, they are more inclined to pay attention to the wisdom of nature and be wary of all that is artificial.

TYPES OF CAM

The NCCAM has categorized CAM practices into four domains. (See Figure 9.5.) There is some overlap between these CAM domains:

• Mind-body interventions—Mind-body medicine is a range of practices that aims to use the power of the mind to influence symptoms of disease and healing. Increasingly, this type of alternative medicine has gained acceptance among medical professionals. Mind-body therapies—such as support groups for people suffering from a variety of medical problems; relaxation techniques; and art, dance, and music therapies—are now widely used by practitioners of conventional medicine. Less widely accepted mind-body techniques include meditation, breathing, hypnosis, and prayer.
• Biologically based therapies—This type of treatment uses organic (naturally occurring) substances such as herbs, food, and vitamins to treat symptoms of disease and improve health and wellness. Examples of biologically based therapies include dietary supplements, herbal remedies, and the hotly debated use of hormones such as human growth hormone (HGH) and dehydroepiandrosterone (DHEA, the most plentiful steroid hormone in the body) to combat disease and to slow aging.
• Manipulative and body-based practices—Movement therapies, manipulative methods, and bodywork are another type of CAM. Examples of these methods are massage therapy, chiropractic, and osteopathic manipulation (also referred to as craniosacral manipulative therapy).
• Energy medicine—These techniques aim to influence energy fields that practitioners of this form of CAM believe exist in and around the body. Also called "biofield therapies," some are "touch" therapies and others do not involve direct contact with any part of the body. Reiki and Qi Gong are examples of biofield therapies. Other forms of energy therapies known as bioelectromagnetic-based therapies use magnetic energy, electromagnetic fields, pulsed fields, alternating current, or direct current fields to influence "energy flow."

The NCCAM also considers whole medical systems. Many of these alternative medical systems developed before conventional Western medicine or independent of it. Alternative medicine systems are based on different beliefs and philosophies and, as a result, approach both diagnosis and treatment of disease quite differently from traditional Western medicine. Examples of alternative medicine systems that began in Western cultures are homeopathy and naturopathic medicine. Alternative medicine systems that developed in other cultures include acupuncture, Ayurvedic medicine, and traditional Chinese medicine. The NHIS found that just 2.7% of respondents said they used whole medical systems. (See Figure 9.6.)

When prayer is included in the scope of CAM practices, mind-body medicine is the most frequently used (52.6%) of the NCCAM domains. (See Figure 9.6.) According to the NCCAM in The Use of Complementary and Alternative Medicine in the United States (2004, http://nccam.nih.gov/news/camsurvey_fs1.htm), when prayer is not included, biologically based therapies (21.9%) are more popular than mind-body medicine (17%) Prayer for oneself (43%) and others (24.4%) is the most commonly used CAM practice, followed by natural products (18.9%) and deep breathing (11.6%). (See Figure 9.7.)

ALTERNATIVE MEDICINE SYSTEMS

Practically every culture has a medicine system; some developed more than one system, tradition, or philosophy to explain the causes of disease and suggest therapies to relieve symptoms. This section considers two alternative medicine systems that had their origins in Western culture—homeopathy and naturopathic medicine—and three that developed in non-Western cultures—acupuncture, Ayurvedic medicine, and traditional Chinese medicine.

Homeopathic Medicine

Homeopathic medicine (also called homeopathy) is based on the belief that "like cures like" and uses very diluted amounts of natural substances to encourage the body's own self-healing mechanisms. Taken in higher doses or stronger concentrations, the natural substances used by homeopathy to stimulate self-healing likely would produce the symptoms the diluted substance aimed to relieve.

Homeopathy was developed by German physician Dr. Samuel Hahnemann in the 1790s. First experimenting on healthy subjects and himself, Dr. Hahnemann discovered that he could produce symptoms of particular diseases by injecting small doses of various herbal substances. This discovery inspired him to try another experiment—giving sick people extremely diluted formulations of substances that would produce the same symptoms they suffered from in an effort to evoke natural recovery and regeneration.

Dr. Hahnemann believed that homeopathic remedies—substances that caused symptoms similar to those caused by the disease but not diluted forms of the disease-causing agents—worked by activating the "vital force," the organizing energy system that governs health in a human being. There is no comparable belief in Western medicine, but the ideas of vital force bears some resemblance to the Ayurvedic concept of prana and to qi in Chinese medicine.

Homeopathy gained a foothold in the United States during the 1830s when it appeared able to stem some epidemics, such as cholera (a devastating infectious disease that produces severe diarrhea), but by the 1900s it fell out of favor as traditional medical practice experienced greater success treating the diseases of the day. During the 1970s there was renewed interest in homeopathy in the United States, and by 2006 believers credited homeopathy with gentle, effective, and nontoxic treatment of many infections, emotional problems, and learning disorders. Although proponents assert that homeopathic medicine speeds healing, it cannot treat traumatic injuries, such as broken bones, or genetic diseases.

According to an April 2003 report by the NCCAM, research studies on homeopathy have yielded contradictory findings. Some have concluded that there is no strong evidence that supports homeopathy as an effective treatment for any clinical condition. Others have found positive effects from homeopathy, but these effects are not readily explained in scientific terms.

Clinical professor of medicine at Stanford University School of Medicine and director of the NIH-funded Complementary and Alternative Medicine Program at Stanford, Dr. Kenneth Pelletier writes in The Best Alternative Medicine: What Works? What Does Not? (2000) that homeopathy has proved effective for a variety of ailments. Dr. Pelletier presents the findings of scientific research documenting the safety and efficacy of nearly every form of CAM. Dr. Pelletier reports that clinical trials of homeopathy find it effective for the treatment of disorders such as seasonal allergies, asthma, childhood diarrhea, fibromyalgia, influenza, and rheumatoid arthritis.

More recently, Claudia M. Witt et al in "Homeopathic Medical Practice: Long-term Results of a Cohort Study with 3981 Patients" (BMC Public Health, November 3, 2005) conducted a study of nearly four thousand patients diagnosed with a variety of chronic conditions such as allergic rhinitis (inflammation and swelling in the nose and sinuses due to allergy), headache, and atopic dermatitis (red, itchy, dry skin that results from exposure to an allergan or irritant) and found that homeopathic treatment was beneficial. The investigators observed that the improvements in disease severity, symptoms, and quality of life were maintained throughout the twenty-four months following treatment.

Naturopathic Medicine

As its name suggests, naturopathic medicine, or naturopathy, uses naturally occurring substances to prevent, diagnose, and treat disease. This alternative medicine system, one of the oldest, has its origins in Native American culture and also draws from Greek, Chinese, and Indian philosophies of health and illness.

Like homeopathy, naturopathy was introduced in the United States by a German physician, Dr. Benedict Lust, and its popularity rose, declined, and was rekindled in the same time period as homeopathy. Dr. Lust opened a school of naturopathic medicine in New York City, and with Dr. James Foster, a physician in Idaho using natural healing techniques, they christened their blend of herbal medicine, manipulative therapies, homeopathy, nutrition, and psychology "naturopathy."

The overarching principles of modern naturopathic medicine are "first, do no harm" and "nature has the power to heal." Naturopathy seeks to treat the whole person because disease is seen as arising from many causes rather than a single cause. Naturopathic physicians are taught that "prevention is as important as cure" and to view creating and maintaining health as equally important as curing disease. They are instructed to identify and treat the causes of diseases rather than acting only to relieve symptoms. Naturopathy also requires practitioners to serve as teachers to encourage patients to assume personal responsibility for their health and actively participate in self-care.

Naturopathic physicians' treatment methods include nutritional counseling and the addition of dietary supplements, herbs, or vitamins to a patient's diet; hydrotherapy (water-based therapies, usually involving whirlpool or other baths); exercise; manipulation; massage; heat therapy; and electrical stimulation. They are trained to prescribe herbal medicines and homeopathic remedies, perform minor surgical procedures such as setting broken bones, and offer counseling services to help patients resolve emotional problems and modify their lifestyles to improve their health and wellness. Because naturopathy draws on Chinese and Indian medical techniques, naturopathic physicians often use Chinese herbs, acupuncture, and Ayurvedic medicine to treat disease.

Dr. Pelletier's research found studies demonstrating that naturopathy was effective for a variety of conditions including asthma, atherosclerosis, back pain, some cancers, depression, diabetes, eczema (a skin condition), middle-ear infections, migraine headaches, natural childbirth, and osteoarthritis. Dr. Pelletier observed that licensed naturopathic physicians are among the best-trained CAM practitioners, and he predicted that research would continue to confirm the benefits and efficacy of the safe, inexpensive, and low-risk therapies provided by naturopathic physicians.

The NCCAM reports that while there is virtually no published research examining the efficacy of naturopathy as a system of treatment, some studies have been conducted to evaluate the individual therapies frequently recommended by naturopathic physicians. For example, diet and lifestyle changes have proved extremely valuable in treating heart disease, and the use of acupuncture to treat pain has gained widespread acceptance. Michael E. Sarrel et al. in "Efficacy of Naturopathic Extracts in the Management of Ear Pain Associated with Acute Otitis Media" (Archives of Pediatric and Adolescent Medicine, July 2001) show that a naturopathic extract containing Allium sativum, Verbascum thapsus, Calendula flores, and Hypericum perforatum in olive oil was as effective as anesthetic ear drops and relieved pain associated with middle-ear infections. Similarly, Darren M. Lynch in "Cranberry for Prevention of Urinary Tract Infections" (American Family Physician, 2004) reports several studies have considered the effectiveness of naturopathic cranberry tablets compared with a placebo to prevent urinary tract infections. Compared with the placebo, the cranberry tablets decreased the number of urinary tract infections.

Acupuncture

Acupuncture is a Chinese practice that dates back more than five thousand years. Although Sir William Osler called acupuncture the best available treatment for low back pain in the late 1800s, it was not widely used to treat pain in the United States until the 1970s. Chinese medicine describes acupuncture—the insertion of extremely thin, sterile needles into any of 360 specific points on the body—as a way to balance qi (also called chi), the body's vital life force that flows over the surface of the body and through internal organs. Traditional Western medicine explains the acknowledged effectiveness of acupuncture as the result of triggering the release of pain-relieving substances called endorphins, which occur naturally in the body, and neurotransmitters and neuropeptides, which influence brain chemistry.

According to the NIH Consensus Statement on Acupuncture, there have been many studies on acupuncture's potential usefulness, but results have been mixed because of complexities with study design and size. Acupuncture has, however, proven effective in reducing postoperative and chemotherapy nausea and vomiting as well as in the treatment of addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low-back pain, carpal tunnel syndrome, and asthma. An NCCAM-funded study showed that acupuncture provides pain relief, improves function for people with osteoarthritis of the knee, and serves as an effective complement to traditional medical care.

Curtis L. Taylor in "Acupuncture May Ease Pain of Childbirth" (The Detroit News, January 19, 2006) states recent research has demonstrated that acupuncture may be used to relieve the pain associated with childbirth. Its use can significantly reduce pain, shorten labor, and reduce the amount of anesthesia used in an epidural (a procedure in which medication is administered into the spine). A case-controlled study conducted at Lutheran Medical Center in New York from February to September 2005 found that women who received acupuncture also had a lower rate of Cesarean section (the delivery of a baby through an abdominal incision).

Ayurvedic Medicine

Ayurvedic medicine (also called Ayurveda, which means "science of life") is believed to be the oldest medical tradition and has been practiced in India and Asia for more than five thousand years. With an emphasis on preventing disease and promoting wellness, its practitioners view emotional health and spiritual balance as vital for physical health and disease prevention. Ayurveda also considers diet, hygiene, sleep, lifestyle, and healthy relationships as powerful influences on health.

Practitioners aim to balance the three doshas—fundamental human qualities that they believe reside in varying concentrations in different parts of the human body. The doshas are thought to be disturbed by improper diet, sleep deprivation, travel, coffee, alcohol, or excessive exposure to the sun and are balanced with diet, exercise, detoxification (ritual cleansing of toxins), yoga, spiritual counseling, herbal medicine, breathing exercises, and chanting.

Dr. Pelletier's research found evidence that Ayurveda was used successfully to treat many chronic diseases, including cardiovascular disease, neurologic disorders, arthritis, musculoskeletal pain, gastrointestinal disorders (such as irritable bowel syndrome), diabetes, and mental health problems. Like other CAM, Ayurveda encourages patients to assume responsibility for their health and promotes self-care.

The NCCAM, however, reports that the quality of the published clinical research about the efficacy of Ayurvedic medicine generally does not meet current, rigorous research standards in terms of the requirements for randomization, adequate sample size, and controls.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) combines nutrition, acupuncture, massage, herbal medicine, and Qi Gong (exercises to improve the flow of vital energy through the body) to help people achieve balance and unity of their minds, bodies, and spirits. TCM has been used for more than three thousand years by about one-fourth of the world's population, and in the United States it has been embraced by naturopathic physicians, chiropractors, and other CAM practitioners.

One diagnostic technique that is noticeably different from Western medicine is the TCM approach to taking pulses. TCM practitioners take pulses at six different locations, including three points on each wrist, and pulses are described using twenty-eight distinct qualities. Reading the pulses enables practitioners to evaluate qi.

TCM views balancing qi as central to health, wellness, and disease prevention and treatment. TCM also seeks to balance the feminine and masculine qualities of yin and yang using other techniques such as "moxibustion"—stimulating acupuncture points with heat—and "cupping"—increasing circulation by putting a heated jar on the skin of a body part.

Herbal medicine is the most commonly prescribed treatment; herbal preparations may be consumed as teas made from boiled fresh herbs or dried powders or in combined formulations known as patent medicines. More than two hundred herbal preparations are used in TCM, and several, such as ginseng, ma huang, and ginger, have become popular in the United States. Ginseng is supposed to improve immunity and prevent illness; ma huang is a stimulant used to promote weight loss and relieve lung congestion; and ginger is prescribed to aid digestion, relieve nausea, reduce osteoarthritic knee pain, and improve circulation.

Many modern pharmaceutical drugs are derived from TCM herbal medicines. For example, ma huang components are used to make ephedrine and pseudo-ephedrine. GBE, made from ginkgo biloba, is used to treat cerebral insufficiency (lack of blood flow to the brain). During 2000 ginkgo biloba was shown to improve memory and slow the progression of dementia in some patients.

Research to determine the effectiveness of TCM has focused on the efficacy of specific herbs and combinations of herbs. For example, tripterygium wilfordii Hook F (Chinese Thunder God vine) has been used to treat autoimmune and inflammatory disorders such as arthritis. The first double blind, placebo-controlled trial of the extract conducted in the United States reported a significant dose-dependent response in patients with rheumatoid arthritis. (A double blind study involving a placebo is one in which neither the researchers nor the patients know who is receiving the experimental agent and who is receiving the inactive agent.) The findings of the joint research, sponsored by the NIH and the University of Texas, were reported in the July 2002 issue of Arthritis and Rheumatism.

MIND-BODY INTERVENTIONS

Mind-body interventions are practices based on the belief that mind, body, and spirit are connected with one another and environmental influences. Mind-body medicine aims to improve physical, mental, and emotional well-being. According to Dr. Pelletier, the other guiding principles of mind-body medicine are as follows:

• Stress and depression contribute to the development of, and hinder recovery from, chronic diseases because they create measurable hormonal imbalances.
• Psychoneuroimmunology explains how mental functioning provokes physical and biochemical changes that weaken immunity, lowering resistance to disease.
• Overall health improves when people are optimistic and have positive outlooks on life. Health and wellness are harmed by anger, depression, and chronic stress.
• The placebo effect—improved health and favorable physical changes in response to inactive medication such as a sugar pill—confirms the importance of mind-body medicine and is a valuable intervention.
• Social support from family, friends, coworkers, classmates, or organized self-help groups boosts the effectiveness of traditional and CAM therapies.

This section looks at three types of mind-body interventions—meditation; the Alexander Technique, a movement therapy; and biofeedback. Other commonly used mind-body interventions include music and dance therapies, cognitive behavioral therapy, hypnosis, guided imagery and visualization, and a Chinese exercise discipline called Tai Chi Chuan.

Meditation

Historically, meditation has been used in religious training and practices and to enhance spiritual growth, but it also is a powerful self-care measure that may be used to relieve stress and promote relaxation. Transcendental meditation, an Indian practice that involves sitting and silently chanting a "mantra" (a word repeated to quiet the mind), aims to produce a healthy state of relaxation.

During the 1960s Dr. Herbert Benson studied meditation, and he and his colleagues at Harvard University Medical School showed that people who meditate could reduce heart and respiration rates, lower blood levels of the hormone cortisol, and increase alpha waves in the brain. Dr. Benson developed a relaxation technique loosely based on transcendental meditation that he dubbed the "relaxation response," and this technique quickly gained recognition in the United States and Europe.

There have been many studies performed to evaluate the physical responses to meditation, and its benefits are universally accepted in the CAM and conventional medical communities. Examples of the favorable effects of meditation include the following:

• Reduced blood pressure—meditation consistently has demonstrated the ability to lower systolic and diastolic blood pressure readings (both the top and bottom numbers of a blood pressure measurement)
• Reduced stress, anxiety, and pain
• Reduced use of health care services—patients enrolled in meditation programs tend to make fewer visits to health care practitioners
• Improved circulation and ability to exercise—studies of patients with coronary artery disease found that after eight months of meditation, circulation and exercise tolerance increased

Richard J. Davidson et al in "Alterations in Brain and Immune Function Produced by Mindfulness Meditation" (Psychosomatic Medicine, August 2003) notes that recent studies using imaging have enhanced the understanding of mind-body mechanisms. For example, meditation has been shown to produce significant increases in left-sided anterior brain activity, which is associated with positive emotional states. The same study found that meditation was associated with increases in antibody concentrations to influenza vaccine, suggesting potential linkages among meditation, positive emotional states, localized brain responses, and improved immune function.

The Alexander Technique

The Alexander Technique is hands-on teaching to retrain the mind and body to stand, sit, lift, and move correctly. It is not an exercise program, nor is it traditional touch therapy. During lessons intended to improve posture, body mechanics, and alignment, the teacher's hands gently direct movements that are light, organic, and fluid.

Lessons involve practice performing everyday activities such as sitting at a keyboard, carrying groceries, lifting a child, and reaching the top shelf of a bookcase; they aim to change the way people think about moving. By avoiding habitual muscle tightening and poor posture, injuries may be prevented or allowed to heal. Mindful movement, correct breathing, balance, and poise result from training in the Alexander Technique.

Although the Alexander Technique encourages students to let go of unhealthy habits, the objective is release rather than relaxation. The body that has mastered the Alexander Technique is at once flexible, easy, flowing, and energized. The process of giving up old habits is gradual and respectful. It involves acknowledging and accepting responsibility for misuses and bad habits before attempting to change them.

PERFORMERS USE THE TECHNIQUE

Although the Alexander Technique often is used as a form of treatment, its true strength lies in prevention. It is simpler to learn to move calmly and correctly than to unlearn years of bad habits. Nearly anyone can benefit from the Alexander Technique, but historically it has been favored by people who rely on physical agility and ability to perform work—actors, athletes, dancers, dentists, hairdressers, musicians, computer users, etc.

Taught at the Juilliard School of Performing Arts in New York and the Royal Academy of Dramatic Arts in London, the Alexander Technique has attracted a celebrity following. Musicians Yehudi Menuhin, James Galway, Paul McCartney, and Sting, along with actors Julie Andrews, John Cleese, James Earl Jones, John Houseman, William Hurt, Kevin Kline, Ben Kingsley, Paul Newman, Keanu Reeves, Patrick Stewart, and Joanne Woodward have publicly endorsed the Alexander Technique.

The popularity of the Alexander Technique in the entertainment industry may be because its founder, Frederick Matthias Alexander, was an actor in Australia at the end of the nineteenth century. Alexander began his career performing works by William Shakespeare, but he began to suffer from chronic laryngitis. After hours of self-observation, he determined that his problem was caused by muscular tension in his neck. He was his own first patient, successfully releasing the tension in his neck by changing the way he thought about his breathing, movements, and actions.

Frederick Alexander attributed some chronic health problems to accelerated technological and societal changes. He believed that the pace and stress of modern life, especially mindless rushing to the market or toward a career objective, can render people virtually unconscious and unaware of their bodies. The adage he coined, "use affects functioning," affirms that the way people use their bodies affects their health and well-being. He also decried "endgaining"—rushing toward a goal without any attention to the manner of achieving it.

THE TECHNIQUE IS SHOWN TO BE EFFECTIVE

Although there are few controlled studies of the effectiveness of the Alexander Technique, there are many case studies extolling its benefits. The few controlled clinical trials of the Alexander Technique yield encouraging but not convincing evidence of its efficacy. E. Ernst and P. H. Canter in "The Alexander Technique: A Systematic Review of Controlled Clinical Trials" (Complementary Medicine, December 2003) systematically reviewed the evidence for or against the effectiveness of the Alexander Technique. They found two rigorous studies that suggest that the technique is effective in reducing the disability of patients suffering from Parkinson's disease and in improving pain and disability in patients with back pain.

Chloe Stalibrass et al in "Randomized Controlled Trial of the Alexander Technique for Idiopathic Parkinson's Disease" (Clinical Rehabilitation, 2002) detailed a controlled trial of the Alexander Technique as a treatment for persons disabled by Parkinson's disease. They found that lessons in the technique provided sustained benefits including improved posture, balance, walking, and speech as well as stress reduction and increased energy and self-confidence.

Timothy Cacciatore et al in "Improvement in Automatic Postural Coordination Following Alexander Technique Lessons in a Person with Low Back Pain" (Physical Therapy, June 2005) described the use of the technique to improve postural coordination by using conscious processes to alter automatic (the autonomic nervous system controls body functions that are not under conscious control such as heartbeat and breathing) and ongoing muscular activity, and to reduce low back pain.

Biofeedback

Biofeedback training is designed to help people learn to regulate body functions such as heart rate and blood pressure. Generally, sensitive monitoring devices are attached to the individual to measure and record a variety of physical responses such as skin temperature and electrical resistance, brain-wave activity, and respiration rate. There are also devices to monitor other functions such as bladder activity and acid in the stomach. By observing their own responses and following instructions given by highly trained technicians, most people are able to exert some degree of conscious control over these body functions.

Biofeedback is especially effective for helping people learn to manage stress, and it has become mainstream medical treatment for conditions such as high blood pressure, asthma, migraine headaches, and some types of urinary and fecal incontinence (inability to control bladder or bowel functions). Although it has been used only for about thirty years, biofeedback therapy has been applied to more than 150 medical conditions.

BIOLOGICALLY BASED THERAPIES

The principal treatments in biologically based therapies are herbal medicines and remedies, dietary supplements, and the use of hormones to combat disease and improve health. Because herbal medicines are used in a variety of other CAM practices, such as homeopathy, naturopathy, Ayurveda, and traditional Chinese medicine, this section will describe two greatly contested biologically based therapies—dietary supplements and the use of hormones.

Dietary Supplements

Most CAM practitioners and many conventional medical practitioners agree that food sources are the best way to obtain nutrients. They do, however, allow that it is impossible for some people to get all the nutrients they need, or sufficient quantities of specific vitamins or minerals, from their daily diets. For example, many researchers and nutritionists feel that the diets of the majority of Americans do not contain enough chromium and most women do not consume adequate amounts of iron. Further, the CAM principle of treating each patient as an individual with unique physiological and biochemical needs suggests that some individuals may need more of specific nutrients than others.

Advocates of dietary supplements feel that the recommended dietary allowances (RDAs) are too low for some vitamins and minerals, and they observe that it is difficult to obtain higher than the RDA of certain vitamins without also consuming an excess of fat and calories. An example of this dilemma is vitamin E, an antioxidant found in high-fat vegetable and seed oils. Dr. Pelletier in The Best Alternative Medicine points out that for men to get the RDA (fifteen IU [international units]) of vitamin E, they would have to eat "248 slices of whole wheat bread, sixteen dozen eggs, or twenty pounds of bacon." Several studies suggest that far higher doses—twenty to thirty times greater than the RDA—may protect against heart disease or some cancers, but to obtain such doses from diet alone is impossible.

Whether to prescribe diets supplemented with vitamin E is one of many questions about this particular issue. Another concern is the form of vitamin E available—supplements contain only alpha tocopherol instead of the variety of tocopherols available in foods. Is it better to take higher doses of one form of vitamin E at the risk of losing other, perhaps equally valuable forms of vitamin E? Critics of dietary supplements use this question to support their view that people should attempt to obtain as many needed nutrients from food sources as possible, without relying on dietary supplements. Further, there is no consensus about dosages higher than the RDA, although it is known that some vitamins and minerals, such as vitamins A and E and chromium, are toxic in high doses. For example, more than four hundred IU of vitamin E taken daily may increase the risk of stroke, and high doses of vitamin E are generally not advised for people taking medications to reduce blood clotting, such as Coumadin.

Unlike drugs, dietary supplements do not need to be approved by the Food and Drug Administration (FDA) and therefore go to market with far less testing and scrutiny. This has caused debate and may lead to the ultimate FDA banning of certain supplements, as in the case of the herb ephedra, a dietary supplement used for weight loss that was taken off the market in 2004 after it was linked to 155 deaths and dozens of heart attacks and strokes.

USE OF DIETARY SUPPLEMENTS

According to the Natural Marketing Institute (NMI) 2005 Dietary Supplement Consumer Insight Report (Harleysville, PA), based on research from more than twelve thousand U.S. consumer households, Americans are most likely to use supplements to prevent the following diseases and conditions:

• Heart disease (77%)
• Vision problems (75%)
• Obesity/overweight (72%)
• Arthritis/joint disease (72%)
• High cholesterol (71%)
• High blood pressure (68%)
• Memory/concentration problems (66%)
• Diabetes (60%)

The NHIS found that nearly one-fifth (18.9%) of survey respondents used natural products. (See Figure 9.7.) The most frequently used natural product was echinacea (40.3%), followed by ginseng (24.1%), ginkgo biloba (21.1%), garlic supplements (19.9%), glucosamine (14.9%), and St. John's wort (12%). (See Figure 9.8.)

ARE DIETARY SUPPLEMENTS EFFECTIVE?

Many dietary supplements have undergone rigorous testing to determine whether they are effective for the conditions they claim to address. For example, Vincent Morelli and Roger Zoorob in "Alternative Therapies: Part I. Depression, Diabetes, Obesity" (American Family Physician, September 1, 2000) detailed studies comparing dietary supplements to placebos. St. John's wort (Hypericum perforatum) has been shown to help relieve symptoms of depression in persons suffering from mild or moderate, but not severe, depression. Similarly, in some studies, S-Adenosylmethionine (also known as SAMe), has been shown to be better than placebo in the treatment of depression.

Recent research has, however, questioned the efficacy of several popular dietary supplements. The combination of glucosamine (thought to play a role in cartilage formation) and chondroitin (which helps give cartilage elasticity, taken as a supplement to relieve arthritis pain) was found to be no more effective than a placebo. Elizabeth Agnvall in "Joint Dispute" (Washington Post, November 22, 2005) discusses the preliminary results of the NIH-sponsored Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), which found that among persons with moderate to severe arthritis the supplement combination was somewhat more effective but cautioned that even this modestly optimistic finding was not conclusive and required further investigation.

Similarly, Ronald B. Turner et al in "Ineffectiveness of Echinacea for Prevention of Experimental Rhinovirus Colds" (Antimicrobial Agents and Chemotherapy, June 2000) conducted a study to assess the effectiveness of echinacea (extracted from a perennial herb) for prevention of common colds and found that echinacea had no significant effect on either the occurrence of infection or the severity of illness. Klaus Linde et al in "Echinacea for Preventing and Treating the Common Cold" (Cochrane Library, 2005) conducted a comprehensive review that assessed the available evidence from clinical trials investigating the effectiveness of echinacea extracts for prevention and the treatment of the common cold. The results were more favorable than the earlier study, suggesting that some echinacea preparations may be better than placebo, for both treatment and prevention of colds, and may be more effective for treatment when taken at the onset of symptoms. The review did, however, call for additional research to confirm these findings.

Does DHEA Slow or Reverse Aging?

Dehydroepiandrosterone (DHEA) is the most plentiful steroid hormone in the body. It is produced in the adrenal glands, brain, and skin; in the body it is converted into other hormones such as estrogen and testosterone (the primary female and male sex hormones, respectively) and other steroid hormones. DHEA levels may be measured using a blood test. The amount of DHEA in the body starts to decline gradually at about thirty years old; it is also reduced during periods of illness. Laboratory research (as opposed to research conducted on human subjects) reveals that low DHEA levels are linked to heart disease and certain cancers.

In view of these findings, some CAM practitioners favor supplementing DHEA for people who no longer have peak levels of the hormone. They claim that studies support the findings that DHEA replacement increases physical stamina, muscle mass, immune functions, and emotional well-being while simultaneously promoting weight loss and reducing bone loss from osteoporosis. Skeptics cite other studies showing that taking DHEA may cause excessive, unwanted hair growth; a reduction in high-density lipoprotein (HDL), the lipid that protects against heart disease; and resistance to insulin, the hormone involved in glucose metabolism. They caution that replacing any hormone that normally declines with advancing age is perilous, especially because some cancers, such as breast and prostate cancers, thrive in the presence of hormones.

MANIPULATIVE AND BODY-BASED METHODS

Manipulative therapies, such as osteopathic manipulation and chiropractic, and body-based methods (also known as bodywork), such as therapeutic massage, are CAM practices that have been tremendously popular during the last two decades. Some observers feel that enthusiasm for these CAM practices is because of their demonstrated ability to relieve aches and pains associated with musculoskeletal injuries and stress more effectively than treatment prescribed by conventional medical practitioners. This section describes chiropractic, a relatively well-known manipulative therapy, and zero balancing, a lesser-known gentle form of bodywork.

Chiropractic

The American Chiropractic Association (ACA) defines chiropractic as "a branch of the healing arts that is concerned with human health and disease processes. Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, nutritional, emotional, and environmental relationships" (http://www.amerchiro.org/level2_css.cfm?T1ID1/410&T2ID1/4117). Doctors of chiropractic (also known as chiropractors or DCs) do not use or prescribe pharmaceutical drugs or perform surgery. Instead they rely on adjustment and manipulation of the musculoskeletal system, particularly the spinal column.

Many chiropractors use nutritional therapy and prescribe dietary supplements, and some use a technique known as applied kinesiology to diagnose and treat disease. Applied kinesiology is based on the belief that every organ problem is associated with weakness of a specific muscle. Chiropractors who use this technique claim they can accurately identify organ system dysfunction without any laboratory or other diagnostic tests.

In addition to manipulation, chiropractors also use a variety of other therapies to support healing and relax muscles before they make manual adjustments. These treatments include the following:

• Heat and cold therapy to relieve pain, speed healing, and reduce swelling
• Hydrotherapy to relax muscles and stimulate blood circulation
• Immobilization such as casts, wraps, traction, and splints to protect injured areas
• Electrotherapy to deliver deep-tissue massage and boost circulation
• Ultrasound to relieve muscle spasms and reduce swelling

According to the ACA, chiropractic is the third-largest specialty group of health care professionals after medicine and dentistry. The ACA predicts that there will be nearly twice as many practicing doctors of chiropractic by 2010 as there were in 1997, when approximately thirty million patients sought care from slightly more than fifty thousand chiropractors. Visits to chiropractors are most often for treatment of low back pain, neck pain, and headaches. The U.S. Agency for Healthcare Research and Quality reports that chiropractors are seen for low back pain one-third more often than are primary care physicians. In fact, after one hundred years of practice, chiropractic often is referred to as "mainstream medicine," and many health insurance companies cover chiropractic care.

Critics of chiropractic are concerned about injuries resulting from powerful "high velocity" manual adjustments, and some physicians question chiropractors' abilities to establish medical diagnoses. Others worry that people seeking chiropractic care instead of traditional allopathic medical care may be foregoing lifesaving diagnoses and treatment.

Effectiveness of Chiropractic

Although a 2003 NCCAM review of the relevant literature concluded that most patients received some benefit from chiropractic treatment, six of eight studies the NCCAM reviewed found chiropractic and conventional treatments similar in terms of effectiveness (2003, http://nccam.nih.gov/health/chiropractic/). One study found greater improvement in the chiropractic group than in groups receiving either placebo manipulation or back school (instruction in body mechanics, exercise, and ergonomics to prevent injury and back strain). Another trial found treatment at a chiropractic clinic to be more effective than outpatient hospital treatment. Nonetheless, the overall assessment of the available research concluded that spinal manipulation was more effective than sham (placebo) therapy but no more or no less effective than other treatments.

Zero Balancing

Zero balancing (ZB) is diagnostic and therapeutic bodywork that traces and aligns energy in the skeletal system. Grounded in anatomy, physics, mechanics, and psychology, ZB integrates Eastern philosophy, meditation, and the realignment of vibratory energy fields with practical, hands-on bodywork. Along with relief of physical stress, pain, and dysfunction, ZB aims to enhance emotional equilibrium, concentration, and objectivity.

Developed more than twenty years ago by Frederick (Fritz) Smith, an osteopathic physician, this treatment modality was the culmination of studies Smith completed to earn his master of acupuncture certification. ZB practitioners touch bones to facilitate the flow of skeletal energy (called chi) through three vertical pathways. In the first pathway, energy flows from the skull to spine, pelvis, legs, and feet. In the second pathway, energy flows from the shoulders and vertebral transverse processes to rejoin the central flow at the pelvis. The third pathway travels from the shoulders out through the arms and hands.

Working directly with energy they feel is located in the bones, the densest structures in the body, practitioners assess, balance, and reassess energy flow. Performed on fully clothed people, ZB is relaxing as joints and fulcrums—meeting points of energy and structure—of the musculoskeletal system are gently palpated (touched). Gentle pressure, manipulation, and support of the joints are applied to release tension and ease movement and energy flow. ZB practitioners attend closely to observe responses to treatment. During a ZB session, subjects are said to enter a "working state" with observable signs that energy is shifting, balancing, reorganizing, or integrating. These signs may include a trance state, rapid eyelid fluttering, shallow breathing, bowel sounds, swallowing, and involuntary muscle movements.

Who Practices Zero Balancing?

Practitioners from a variety of disciplines, including traditional allopathic and osteopathic medicine, psychotherapy, chiropractic, acupuncture, massage, and physical therapy, use ZB to locate, isolate, and relieve stress patterns, sources of physical pain, and skeletal imbalance. Many practitioners use ZB in combination with other forms of therapy. Performed before a massage, physical therapy session, or other healing therapy, it relaxes subjects, enabling them to make greater progress in treatment. Used following treatment, it helps to sustain and prolong the benefits of chiropractic, acupuncture, physical, or massage therapy.

ENERGY THERAPIES

Energy therapies that purport to influence energy fields in and around the body are among the CAM practices that arouse the most suspicion from the conventional medical community. Some skeptics attribute the health benefits reported by patients who have received energy therapies to the placebo effect (a perceived beneficial result that occurs from the therapy because of the patient's expectation that the therapy will help). Despite widespread lack of understanding and acceptance from traditional health care practitioners, some hospitals and pioneering practitioners are incorporating energy therapies into their treatment programs.

Reiki

An ancient Japanese technique, Reiki is bioenergetic healing intended to restore physical, emotional, mental, and spiritual balance. The unique therapy takes its name from two Japanese words. Rei means higher power, wisdom, and all that exists, and ki is energy—the life force that emanates from re.

Based on the teachings of Dr. Makao Usui (1865–1926), Reiki is a universal healing vibration that flows from practitioner to client. The practitioner acts as a channel for Reiki energy, and as it passes through practitioners, it acts to strengthen and harmonize them simultaneously as it heals their clients.

There are more than a dozen styles of Reiki, each with its own subtle variations. Students studying with Usui Reiki masters receive a series of "attunements" and may progress through three levels or degrees of training. Level I connects the practitioner to the Reiki channel and initiates the flow of healing energy. Level II teaches distance or remote healing. Level III initiates the practitioner to the role of master and teacher.

Some practitioners use a variety of other therapies, including meditation, prayer, chanting, breathing, and movement education. Most often performed as hands-on bodywork, Reiki is believed by its therapists to convey energy to calm nerves, relax muscles, and ease pain without any physical touch. During the second level of training, practitioners learn to deliver Reiki energy remotely, over long distances.

There are many case studies describing the effectiveness of Reiki to reduce anxiety and relieve discomfort, but as of 2006 there were no published reports of rigorous research designed to determine its efficacy. At the November 2003 annual meeting of the American Public Health Association (APHA), Patricia Ann Mc Partland, director of the Southeastern Massachusetts Area Health Education Center, reported that Canadian researchers were investigating the effects of Reiki in reducing the incidence of cancer chemotherapy side effects. Another study at Yale University is exploring uses of Reiki during pregnancy and childbirth to determine whether Reiki is useful in soothing childbearing women and their infants. At George Washington University researchers are studying the effectiveness of Reiki on persons suffering from AIDS, diabetes, and migraine headaches.

COMPLEMENTING TRADITIONAL MEDICINE

Increasingly, clinics and hospitals across the United States offer Reiki to women in labor, surgical patients, and those suffering from pain, anxiety, sleep disorders, headaches, asthma, and eating disorders. The Tucson Medical Center in Arizona has been the home of a Reiki clinic since 1995. Initially, the clinic focused exclusively on cancer patients. By 1999 it offered Reiki to patients throughout the hospital.

In conventional medical settings, Reiki usually is presented as "a technique to reduce stress and promote relaxation, thereby enhancing the body's natural ability to heal itself." To gain credibility with traditional physicians and other mainstream professionals, Reiki therapists often downplay the spiritual benefits of the practice and avoid mentioning other CAM practices.

Although its effectiveness has not been documented in scientific studies, Reiki has gained acceptance because it is viewed as a complement, rather than an alternative, to traditional Western medicine. Considered safe by many health care practitioners, it is well received by patients who seem to respond favorably to the time and attention, as well as the healing energy, offered by Reiki therapists.