Alternative Medicine

Many practitioners of CAM present it to the public as invariably gentle, safe, and natural. However, some of the techniques or herbal remedies may be dangerous, or patients may resort to questionable measures instead of seeking effective conventional care.

Popular Types of CAM

The most popular forms of CAM are acupuncture, chiropractic, homeopathy, herbal medicine, massage, and naturopathy.

Acupuncture

Acupuncture is a branch of traditional Chinese medicine. Its underlying philosophy is that health is a state of harmony, or balance, of the opposing forces of nature. Disease represents an imbalance of these forces that leads to excesses or deficiencies of life energy in various organs, resulting in illness if not corrected. The life energy, called qi, is believed to flow through the body in pathways called meridians which connect its surface with the internal organs. Treatment consists of redirecting and balancing energy flow. Acupuncture has been used in China for more than 2,000 years. Although it has been applied in some Western countries since the late nineteenth century, it became popular in the United States only in 1971, when a New York Times columnist, James Reston, received acupuncture after surgery and wrote about the experience. Acupuncture practitioners usually insert fine needles through the skin at points along the meridians. Some practitioners may use pressure (acupressure, also called shiatsu), heat, friction, suction, or electromagnetic energy to stimulate these points. Although in China acupuncture is used to treat many conditions, in the United States, it is applied most often to relieve pain. There are more than 40 schools and colleges of acupuncture in the United States, 20 of which have either been approved, or are currently being reviewed for approval, by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine. An estimated 6,500 acupuncturists practice in the United States; of these, about 3,300 have taken the examination administered by the National Commission for the Certification of Acupuncturists. Thirty-two states regulate the practice of acupuncture, according to The Federation of State Medical Boards of the United States. Acupuncture may also be performed by naturopathic doctors or chiropractors "in at least 12 states," according to the Traditional Acupuncture Institute. An estimated 3,000 physicians have taken short courses in acupuncture and may use it in their practices. Several studies find that acupuncture is helpful in treating chronic low back pain, neck pain, arthritic pain of the knee, post-surgical pain, kidney-stone pain, menstrual cramps, and chronic angina. Other studies offer evidence that acupuncture can reduce the nausea and vomiting that accompany pregnancy, sea sickness, chemotherapy, or surgery. Acupuncture has also been documented as helpful to people who are withdrawing from substances they abuse. Studies have reported that acupuncture helps stroke patients, improves exercise performance in young men, and increases uterine contractions in pregnant women who are past their delivery dates. Some experts make a claim for the value of acupuncture in treating bladder instability, sinus problems, and migraine headaches. A conference convened by the National Institutes of Health in November 1997 reviewed the scientific and medical data on the use, risks, and benefits of acupuncture and issued a Consensus Development Statement. A panel of experts concluded that "there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value." Moreover, the panel found that in many cases, the "data supporting acupuncture are as strong as those for many accepted Western medical therapies."

Chiropractic

Practitioners assert that health is a state of balance, especially of the nervous and musculo-skeletal systems. They believe that disease is caused by misalignment of the spinal vertebrae, which leads to dysfunction of nerves, blood vessels, and organs. Manipulation of the spine by the chiropractor restores the body to normal function. Chiropractic was founded in 1895 by Daniel David Palmer, an American who treated the sick with various therapies, including "magnetic healing." As reported in Consumer Reports in 1994,"...as Palmer told it, he was consulted [in 1895] by a janitor who had gone deaf 17 years earlier while stooping in a mine." Palmer found what he called a "subluxed," or misaligned, vertebra, which he manipulated, thereby, allegedly, restoring the man's hearing. Palmer opened a school of chiropractic; his son, B.J. Palmer, actively promoted the movement. Rivals established other schools and advocated different techniques of spinal manipulation. Chiropractors use their hands to diagnose, adjust, and mobilize the various parts of the body, and they rely on two kinds of therapies: joint and soft tissue manipulation. They use those techniques most often to treat back, shoulder, and neck pain. Chiropractors have been criticized for taking unnecessary X-rays of the spine and for requiring frequent visits. A study at the University of North Carolina at Chapel Hill found that chiropractic treatment of an episode of back pain required anywhere from 10 to 15 visits, compared with three to five visits made to a physician. The 16 American chiropractic colleges graduate more than 2,800 chiropractors each year. Chiropractic education requires at least 60 undergraduate credit hours, including many in basic science, followed by a four- to five-year chiropractic curriculum. The colleges are accredited by the Council of Chiropractic Education. As of 1996, more than 71,000 licensed chiropractors practiced in every state, and in Puerto Rico and the Virgin Islands; their license, however, does not permit them to perform surgery or to prescribe drugs. Some chiropractors have additional training and what the American Chiropractic Association describes as advanced certification in a chiropractic specialty. These include chiropractic radiology, orthopedics, neurology, rehabilitation, behavioral health, family practice, nutrition, diagnostic imaging, occupational health, and sports injuries and physical fitness. A highly regarded randomized, controlled trial in the United Kingdom, published in 1990, was one of several studies that found chiropractic to be useful in treating acute low back pain. Other studies concluded that it is less effective in treating chronic back pain.

Herbal Medicine

Herbal medicine is also called herbology, phytomedicine, or botanical medicine. Because many plants have medicinal properties, about one quarter of pharmaceutical drugs are derived from plants. Drugs developed from plant sources include digitalis for heart problems, vincristine for leukemia, morphine for pain, and aspirin for aches, pains, and fevers. Herbs have been used for medicinal purposes in most cultures since ancient times, either as single entities or as complex mixtures of several herbs or of herbs and other substances. In industrialized societies, use of herbal medicines has declined since the development of powerful manufactured drugs. Herbal remedies are more widely used in Europe (particularly in Germany and France) and in Asia than in the United States. Because herbs cannot be patented, pharmaceutical companies are unlikely to invest the millions of dollars required to test them and then submit them to the FDA for approval as drugs. Moreover, unlike pharmaceutical companies, which isolate the active substances in herbs in order to produce standardized drugs, advocates of herbal remedies believe that the number or combination of substances in each herb results in a synergy that is superior to the singular impact of extracted drugs. A meta-analysis (review of pooled studies) of the herb St. John's wort (Hypericum perforatum) for mild and moderately severe depression, published in 1996 by German and American physicians, concluded that it was more effective than a placebo and was as effective as standard antidepressants but with fewer side effects. The authors raised questions about its methods and cautioned about its efficacy in seriously depressed patients. The active chemical in the herb, they claimed, was not appropriately standardized. Furthermore, the study only compared St. John's wort with anti-depressant drugs that were given at or below their lowest level of efficacy. And, finally, patients were treated for only 6 weeks. An accompanying editorial concluded that: "longer term studies are needed before it can be recommended in major depression." This report led Wayne Jonas of NIH's Office of Alternative Medicine to call for a trial comparing St. John's wort with the popular antidepressant fluoxetine (ProzacTM). The Office of Alternative Medicine (OAM), the National Institute of Mental Health (NIMH), and the Office of Dietary Supplements (ODS) are collaborating on a study to evaluate the efficacy and safety of a standardized extract of Hypericum in major depression. NIMH, the administering agency, issued a Request for Proposals (RFP) for a randomized controlled trial, and Duke University was awarded a three-year contract in the amount of $4.3 million to conduct the study. Consumers usually choose and administer herbal medicines themselves, following recommendations by friends, employees in health food stores, and the increasing numbers of books, magazines, and magazine articles devoted to the subject. Health food stores display publications by manufacturers that contain articles recommending the use of particular herbs. Traditional Chinese medicine and Ayurvedic practitioners usually blend several herbs into one mixture. These mixtures have been effective in treating, for example, atopic eczema and acute bronchiolitis caused by respiratory syncytial virus in infants. The National Certification Commission for Acupuncture and Oriental Medicine administers an examination in Chinese herbal medicine. Herbs that have been beneficial, according to researchers, also include: bromelain (reduced post-surgical pain and swelling); topical capsaicin from chili peppers (decreased tenderness and pain in osteoarthritis, fibromyalgia, diabetic neuropathy, and post-herpetic neuralgia); cranberries (decreased urinary tract infections); evening primrose oil (decreased breast pain, both cyclical and constant, reduced itching in atopic eczema, decreased use of painkillers in rheumatoid arthritis); feverfew (prevented severe migraines); garlic (lowered cholesterol, inhibited blood clotting); ginger (reduced nausea and vomiting); ginkgo (improved blood flow in small blood vessels); licorice (acted as an anti-inflammatory agent during treatment of stomach and intestinal ulcers); milk thistle (helped to restore diseased livers); saw palmetto (decreased symptoms of an enlarged prostate); sweet wormwood (decreased malaria parasites in the blood); and valerian (induced sleep). Some herbs, however, are either dangerous or can interact harmfully with prescription drugs.

Homeopathy

The system of homeopathy, founded early in the nineteenth century by German physician Samuel Hahnemann, is based on two ideas. The first is that like cures like (also called the Law of Similars). Hahnemann claimed that a natural substance that produced a given symptom in a healthy person would cure it in a sick person. Thus, the name for Hahnemann's method: homeo (Greek for "like") and patho ("disease" or "illness").

His second idea was that less is more (also called the Law of Infinitesimals). Hahnemann and his followers took one part of the natural substance that he believed caused the symptoms and thus would cure the disease, diluted it in nine parts of water or alcohol, and shook it vigorously. After further diluting this solution, they shook it, diluted it again, and shook it some more, acting on their conviction that the more dilute the solution, the more effective the remedy. Homeopaths claim that even if no molecules of the active ingredient remain, the solution still retains its "imprint" or "message". Repeated dilution removes all chance of chemical toxicity, allowing the homeopathic use of many substances that would otherwise not be safe to take as medicine.

The safety and non-toxicity of homeopathic remedies is reassuring; however, they still must be chosen carefully on the basis of specific information—and used correctly—or they may affect the symptoms only superficially, or have no effect at all. Homeopathic remedies are not selected simply to treat an isolated symptom or a named disease. To work correctly, they must be chosen to match the way an individual’s system expresses its unique response to the current stress and illness. Even within the same diagnosis, different people respond to different remedies.

The National Center for Homeopathy, a private organization, estimates that Americans are spending $165 million a year for homeopathic preparations and that sales are rising by 20 percent to 25 percent a year.

Homeopathic remedies are widely available in Western Europe and the United States. These remedies are not regulated by the FDA, which, however, permits marketing of substances listed in the Homeopathic Pharmacopeia as drugs, under the Food, Drug, and Cosmetic Act of 1938. Senator Royal Copeland of New York, a homeopathic practitioner, shepherded the act through Congress. Homeopaths treat both acute and chronic health problems and use their remedies to prevent disease and promote health in people who are not sick. They prescribe these remedies on the basis of physical, emotional, and mental symptoms. Since homeopathic remedies are highly individualized, people with the same diagnosis may be given different medicines.

Some scientists believe that any benefits produced by homeopathic medicines are due to a placebo effect, that is, to the act of intervention, rather than to a biological process. However, a meta-analysis of 105 clinical studies of homeopathy published in 1992 found that the majority of studies reported a positive result for homeopathic treatments. A clinical trial conducted in Scotland showed a benefit for hay fever patients.

A meta-analysis of 89 clinical trials published in September 1997 also found that homeopathic remedies have a more positive clinical effect than a placebo. However, there was insufficient evidence to conclude that homeopathy was effective for any single clinical condition.

Training in homeopathy is offered through professional courses at the National Center for Homeopathy in Alexandria, Virginia. Licensure to practice homeopathy varies among the states. Three states (Arizona, Connecticut, and Nevada) have special boards; in two states (Delaware and New Hampshire), medical boards regulate homeopaths. Other states regulate homeopathy through "scope of practice" guidelines issued by medical boards. As a result of such variable regulations, homeopathic practitioners include physicians, dentists, naturopathic physicians, chiropractors, veterinarians, acupuncturists, nurse practitioners, and physician assistants.

Massage

The goal of massage therapy is to achieve or increase health and well-being and to help the body heal itself through manipulation of soft tissues. Various techniques are used, and there are different schools of treatment. Massage, an ancient technique, was introduced into the United States in the mid-nineteenth century. The first known American practitioners were two New York physicians who had received training in Sweden. In the 1870's Swedish physicians opened clinics in New York. At first physicians performed massage, but they eventually delegated the technique to nurses and physical therapists. An upsurge of interest in the field began in the 1970's. Twenty-two states and the District of Columbia require massage therapists to have 500 or more hours of education from a recognized school, and some states also require them to pass a licensing examination. The American Massage Therapy Association Commission on Massage Training Accreditation/Approval (COMTAA) accredits 23 programs in 28 locations around the country. Forty additional programs have received approval for their curricula but will have to become accredited by March 1999 in order to remain affiliated with COMTAA. The National Certification Board for Therapeutic Massage and Body Work (NCB) administers the most widely used examination. NCB, which is accredited by the National Commission for Certifying Agencies, administered its first exam in 1992; by September 1997, 27,000 people were certified. Several states have accepted this examination as part of their licensing procedure. Massage therapists are currently licensed in 25 states and the District of Columbia. Some municipalities in states that do not require licensing -- for example, Tucson, Arizona, and Chicago, Illinois -- have passed licensing ordinances. Some studies indicate that massage helps premature babies gain weight more quickly, reduces swelling of the arm following radical mastectomy, and is effective in relieving pain in patients with soft tissue injuries. Therapeutic touch may be beneficial in wound healing and anxiety.

Naturopathy

Naturopathic medicine blends many approaches, including botanical medicine, clinical nutrition, homeopathy, acupuncture, traditional Oriental medicine, hydrotherapy, and naturopathic manipulative therapy. Naturopathic doctors (NDs) also take courses in basic medical sciences like anatomy, cell biology, and physiology. When naturopathy began as a formal health care system in the United States at the turn of the century, there were more than 20 naturopathic or "eclectic" schools. Naturopathic practitioners emphasize prevention and treatment of disease through a healthy lifestyle and control of risk factors, treatment of the whole person, and use of the body's natural healing abilities. They stress nutrition and the therapeutic use of foods to promote health, and to identify and treat the causes of chronic and degenerative disease. The two accredited U.S. naturopathic medical schools (the National College of Naturopathic Medicine in Portland, Oregon, and Bastyr University of Natural Sciences in Seattle, Washington) together graduate about 50 naturopathic doctors a year. Two additional colleges are candidates for accreditation: the Southwest College of Naturopathic Medicine in Scottsdale, Arizona, and the Canadian College of Naturopathic Medicine in Toronto, Ontario. A new program at the University of Bridgeport in Connecticut admitted its first students in September 1997. It has been granted a license to operate by the Connecticut Department of Higher Education, and at the end of one year will be eligible to apply as a candidate for accreditation. The Council on Naturopathic Medical Education, based in Eugene, Oregon, is the accrediting agency for naturopathic programs in the United States and Canada. More than 1,000 naturopathic doctors are licensed in the United States. Eleven states issue these licenses through special boards (Alaska, Arizona, Connecticut, Hawaii, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington). In these states, only licensed persons may use the designation "ND" after their name. Several other states allow the practice of naturopathic medicine. In states that do not have licensure laws, graduates of non-accredited schools, like those offering instruction through correspondence courses, may use the designation ND. They may give seminars, and advise people on lifestyle or nutrition, but they are not permitted to diagnose illness or to prescribe remedies. In New Hampshire, graduates of correspondence schools who were already practicing at the time the licensure law was enacted were allowed to continue doing so under a restricted license. In Tennessee and South Carolina, it is illegal to practice naturopathic medicine. States' Regulation of Health Professionals The states now regulate more than 1,100 professions and occupations in health and other fields, about 600 of them through licensure. However, half the states regulate fewer than 60 professions and occupations, according to the Council on Licensure, Enforcement and Regulation (CLEAR), an association of state and provincial officials from the United States and Canada. Of the various CAM practitioners, only chiropractors are required to be licensed in all states. State regulations for other CAM practitioners vary widely. Only chiropractic, acupuncture, and naturopathy have accrediting bodies recognized by the U.S. Department of Education.

The herb boswellia is thought to have some anti-inflammatory effects. An 8-week, double-blind, placebo-controlled trial of 102 people with Crohn’s disease compared a standardized extract of boswellia against the drug mesalazine. Participants taking boswellia fared at least as well as those taking mesalazine, according to a standard method of scoring Crohn’s disease severity.

Fish oil also has anti-inflammatory effects. However, the evidence regarding whether it is helpful for Crohn’s disease remains contradictory. A 1-year, double-blind trial involving 78 participants with Crohn's disease in remission who were at high risk for relapse found that fish oil supplements helped keep the disease from flaring up. However, a 1-year, double-blind, placebo-controlled trial that followed 120 people with Crohn’s disease did not find any reduction of relapse rates. These opposing results suggest that fish oil is at best modestly effective.

One preliminary double-blind study found indications that the probiotic yeast Saccharomyces boulardii may be helpful for reducing Crohn’s symptoms.

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