History behind alternative medicine
The terms "alternative medicine," "complementary medicine," or "unconventional medicine" refer to diagnostic methods, treatments and therapies that appear not to conform to standard medical practice, or are not generally taught at accredited medical schools. The scope of alternative medicine is broad, with widespread use among the public of a long list of treatments and practices, such as acupuncture, homeopathy, relaxation techniques, and herbal remedies. In an editorial about alternative practices in the New England Journal of Medicine, Murray and Rubel comment, "Many are well known, others are exotic and mysterious, and some are dangerous."1 This report will help to clarify and categorize the alternative medical systems most often used, create a context to assess their utility (or lack thereof), and discuss how physicians and the medical profession might deal with the issues surrounding these unconventional measures in health and healing. The Appendix lists various alternative systems and methods in common use.
I. Alternative Systems and Techniques
The adherents of these fields, however, state that "most alternative systems of medicine hold some common beliefs."2 Many theories of alternative medicine attempt to pose a single explanation for most human illness; the therapy is thought to correct the source of the problem, not merely treat its symptoms. The recuperative power of the human body and the potential for certain stimuli to enhance this natural healing are central to many therapies. Other unifying threads include:
Importance of spiritual values to health
Integration of individuals in the "stream of life"
Attribution of a causal, independent role to various "manifestations of consciousness"
Use of whole (unsynthesized) substances
Maintaining the injunction to "do no harm"
The philosophy that achieving and maintaining health is very different from fighting disease A belief that personal experience and anecdote are as reliable as scientific study in determining whether something is effective.
II. Theories of Alternative MedicineMind-body interventions
Much of alternative medicine deals with the relationship between the mind (as distinct from the brain and its biochemistry) and the body, with a chief goal of achieving a sense of psychological or spiritual well being in persons and a feeling of wholeness even in the face of a disease process or condition. Patients with a wide range of conditions and disorders benefit from applications of techniques in this area; cancer, chronic pain and burns, chemical dependence, several neurological and psychiatric conditions, blood pressure and cholesterol reduction, home births, and other problems have been the subject of this set of treatments.
Some of the therapy sounds very familiar to orthodox clinicians--stress management through meditation, music and art therapy, hypnosis, focused relaxation, and psychotherapy are all known to physicians as useful treatments. Biofeedback has been used for years in helping with anxiety and stress-related disorders, and for adjunctive therapy in blood pressure management. Some of the clinical applications of these techniques are, however, decidedly unconventional. Guided imagery to produce spontaneous remission of cancer, for example, or hypnotherapy for immune disorders and hemophilia fall into this category. Meditation is touted for its ability to increase intelligence and longevity, and yoga for better diabetic control.
Diet/nutrition
The knowledge that good nutrition and a balanced diet help maintain health is not new, or news. A cornerstone of belief in most alternative systems is the repudiation of the "modern, affluent diet" and its replacement with a diet rich in whole, "organic" products, often vegetarian in approach. Many healers maintain that certain diets promote anti-tumor immunity or cardiovascular health; other regimens advocate specific micronutrients or vitamins for particular conditions or overall longevity.
Much of the dietary intervention stressed by alternative healers is prudent and reasonable. Dietitians and nutritionists are licensed in many states, and are an invaluable source of advice to physicians and patients alike regarding nutrition and dietary management of a host of conditions. But the approach taken by some alternative practitioners encourages what many consider the excessive use of health foods and dietary supplements, often of a proprietary nature and meant to enrich them while promoting several myths:
It is difficult to get the nourishment one requires from ordinary foods
Vitamin and mineral deficiencies are common
Most diseases are caused by faulty diets and can be prevented by nutritional interventions
Any use of food additives and pesticides is poisonous
Herbal remedies
The use of herbs in medicine is ancient in its origins, and several examples are well known to both physicians and the public: foxglove as the treatment for "dropsy" and later, the source for digitalis, and quinine's origins in Cinchona bark. New therapies such as taxol continue to show the usefulness of plants as a source of our pharmacopoeia. Basic to the use of herbs in alternative medicine is the belief that whole plant material is superior to synthesized or isolated chemicals derived from plant sources. The material may be flowers, bark, roots, or leaves, used singly or in combination, often taken in the form of teas, or ground and taken as tablets, or used in salves. These compounds are thought to produce fewer unintended or dangerous effects, and a "balanced" action as opposed to single drugs. There is little evidence for this belief, however, and no standardization of the dose in herbal healing. The safety of many of the compounds is unknown, or the potential toxicity ignored.
Folk healers, herbalists, naturopaths, traditional Chinese healers, homeopaths, and a host of others in alternative practices commonly use herbal remedies. As with other nutrition therapies, herbs are prescribed to prevent or treat specific conditions, and are consumed by many persons to maintain health.
Manual healing methods
The healer's touch has been considered a therapeutic instrument for the entire history of medicine, dating back to instructions by Hippocrates about therapeutic massage. Ancient Chinese medicine has strong roots in this system, and several areas of alternative medicine are associated with manual healing methods. The major fields of manual healing include (1) methods that use physical touch, manipulation, and pressure--chiropractic and osteopathic manipulation are primary examples; (2) therapies that use an "energy field" that can influence healing; and (3) mixed interventions that use both physical touch and energy field therapy.
Osteopathy
Osteopathic physicians derive their theories from the work of Andrew Taylor Still (1828-1917), a physician's son who was trained as an apprentice to his father. After the Civil War, he began an empirical study of healing by manipulating bones and soft tissues to allow the free circulation of blood and lymph, and to restore the nervous system to what he considered a more normal function. Known as the "lightning bone-setter," he disdained the common practices of physicians in the last century such as venesection, emesis, and sedation with narcotics, preferring to use manipulation to enhance the body's innate ability to heal itself. Instead of using drugs, he believed that the solution to illness lay in treating the underlying condition, allowing the body’s natural forces to return the patient to health. He proposed that much more than headache and back pain could be treated with manipulation, and set forth a regimen of therapy that included treatment for serious conditions such as pneumonia, dysentery, and typhoid fever.
The first school of osteopathy was opened in Missouri in 1892, teaching a variety of methods: manipulation of soft tissue, isometric and isotonic muscle techniques, manipulation with varying "velocity," the use of the percussion hammer to strike the body to alleviate "restrictions" in the joints and muscles that allowed internal processes to function normally, and other unorthodox therapies. Since that time, osteopathic education and its practitioners have become nearly indistinguishable from their allopathic cousins, with the exception of manipulation techniques that continue to be integral parts of osteopathic diagnostic and treatment modalities. Modern osteopathic physicians are considered to be in the mainstream of medical practice, with rigorous standards for education and specialty training.
Chiropractic
As with many systems in alternative medicine, chiropractic holds that the innate ability of the body to heal itself can be optimized by achieving a "balance"; that proper function of the nervous system is key to this homeostasis; that "subluxations" of the spine and misalignment of joints impinge on nerves, causing imbalance in internal systems; and that manual release of these structural and functional joint pathologies can heal a number of conditions, and prevent illness as well.
Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, and some chiropractors limit their practices to these conditions. While precise statistics are not available, a majority of chiropractors adhere to the method’s original theories, and continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms
Energy healing
Biofield, or energy healing, is described by its proponents as "one of the oldest forms of healing known to humankind." Theories related to this practice involve transfer of energy from healer to patient in unknown ways, either from a supernatural entity or by manipulating the body's own "energy fields." Over 25 terms are used in various cultures to describe this life force. Biofield practitioners incorporate a holistic focus into therapy, and promote their methods as useful for stress and general improvement of health; relief of pain, edema, and acceleration of wound and fracture healing; improvement in digestion, appetite, and various emotional states; and treatment of conditions such as eating disorders, irritable bowel syndrome, and pre-menstrual syndrome.
Some unique conditions are "diagnosed" by biofield practitioners, such as "accumulated tension" and "congested energy" that, when released, supposedly lead to improved health. A common form of this therapy is used by nurses, and is called "therapeutic touch." It involves moving the hands over (but not in direct contact with) the patient's body either to create a general state of well-being by enhancing "energy flow" in the subject, or to release "accumulated tension" and induce balance and harmony.
Pharmacologic methods
The area of pharmacologic treatment is rife with both opportunity and peril, since many of the modalities in unconventional medicine that use pharmacologic and biologic treatment may truly be deserving of clinical trials and well-funded investigation. At the same time, many therapies in this area represent true health fraud. Some areas under investigation include immunotherapies, including the use of antitumor antibodies; alternative strategies to treat menopausal conditions; the use of local anesthetic injection into autonomic ganglia and other sites, such as acupuncture points for chronic pain; and several cancer and HIV treatments.
Some methods proposed for study and further dissemination have been associated with proponents using questionable methods and possibly fraudulent research. Several of these are cancer therapies, including "antineoplastons," popularized by a physician named Burzynski who claims he can "normalize" tumor cells by shutting off their undifferentiated growth using peptides extracted from urine.
III. Alternative Systems of Practice
Several distinct systems of alternative practice encompass many of the theories and methods described above.
Acupuncture
Acupuncture is an ancient technique with its origins in traditional Chinese medicine. The internal study of the body was forbidden in China, so structural anatomy as defined by dissection was unknown. Twelve organs, or "spheres of function," were thought present, having minimal equivalency to anatomic definitions used in Western medicine. Body function was described in theories of energy flow, orch'i, from one organ to another. Each of these organs is described as having a superficial "meridian" with many numbered points, originally derived from Chinese astrologic calculations. By inserting needles into these points, acupuncturists believe energy flows can be manipulated or imbalance corrected, resulting in therapeutic effects on corresponding internal systems.
Western practitioners have increasingly begun to use acupuncture, but many may not be using techniques that correspond to traditional Chinese teaching.
‘Several variations on the general theme exist, including the use of heated needles, passing low-voltage current into the acupuncture point, and applying lasers to acupuncture points. Proponents from different traditions (i.e., Korean vs. Chinese) often disagree as to the "correct" location of acupuncture points for treating a given condition.
Homeopathy
Homeopathy was begun in the early 1800s by Samuel Hahnemann (1755-1843), a traditionally trained German physician who renounced the practices of the day, such as bleeding and purging, taking an approach based in not inflicting harm. He studied the effect of drugs of the day on the body, and devised a new series of rules for their testing and later, their application. His primary theory is the "Law of Similars"--"like cures like." Coining the term homeopathy, he proposed that small amounts of a substance that could induce a set of symptoms in a patient could cure a disease with similar symptoms. This evolved into a highly structured, complex set of pharmacologic interventions or "provings" with formulation and administration of extremely dilute concentrations of substances and drugs, based in the "Law of Infinitesimals." Homeopaths believe that even extreme dilutions of a drug will have a salutary effect, and that the molecular structure of the diluent is somehow changed in the process of preparation, by vigorous shaking and striking the side of the flask containing the preparation. Then, the "memory" of the original drug is carried on even when, after multiple dilutions, none of the original substance could be theoretically present. Careful attention to the total history of the patient was emphasized, and the use of a single homeopathic remedy for a given condition or set of complaints was taught, based on detailed observations of the effects of these preparations.
Today, homeopathy is practiced mostly by persons licensed as physicians or holding another license allowing the prescription of drugs. Some lay healers use homeopathy, and homeopathic remedies abound in health food stores and many supermarkets that feature "organic" products. Some homeopathic healers continue the tradition of extensive patient interviews and the use of a single substance as instructed by Hahnemann's original treatises; others use several compounds simultaneously, and add other modalities to their range of treatments, such as massage and skeletal manipulation, acupuncture, and aromatherapy.
While most homeopathic remedies are not known to have harmed anyone (probably because of the extreme dilutions involved), the efficacy of most homeopathic remedies has not been proven. Some think it a placebo effect, augmented by the concern expressed by the healer; others propose new theories based on quantum mechanics and electromagnetic energy.
A randomized clinical trial of homeopathic remedies has been touted as showing the effectiveness of homeopathic treatments in childhood diarrhea. However, it has been criticized for inconsistent/incorrect data analysis; use of different diagnostic and treatment categories but combining them in the conclusions of efficacy; and lack of chemical analysis of different treatments. The clinical significance of the results, given the self-limiting condition being studied, has been called into question.
Homeopathy's adherents propose new trials of these therapies, systematic review of standard pharmacologic agents subjected to homeopathic dilutions and therapeutic application, and investigation into clinical outcomes following homeopathic treatment.
Naturopathy
Naturopathy is a term coined by John Scheel in 1895 to describe his methods of healing. A poorly developed set of principles and theories,
Ayurveda
Ayurveda is a mind-body set of beliefs and principles that has its roots in ancient India, and has been practiced for over 5000 years. Disease is thought to arise from imbalance or stress in an individual’s conciousness, and is exacerbated by unhealthy lifestyles. Three doshas determine one’s unique "body type," and combined with diagnostic readings of the radial pulse, guides the healer to determinations of dysfunction and corresponding treatment.
Specific lifestyle and dietary interventions are prescribed, as well as measures to rid the body of certain toxins and metabolic byproducts that are thought to accumulate, to the detriment of the body. Meditation, exercise, herbal oil massage, and other therapy are promoted, much of which is proprietary and marketed commercially.
. proposal for physicians:
Maintain an open-minded attitude about all potentially new therapeutic interventions that include those commonly referred to as alternative.
Encourage carefully performed and appropriately controlled studies of these new therapies.
Do not ignore or ridicule the potential of the placebo effect to produce marked therapeutic benefit.
Do not accept all new therapies as efficacious on first acquaintance. Practitioners of quack medicine continue to abound as in all earlier times. Claims of therapeutic efficacy should be rationally examined and tested.
Avoid hubristic and arrogant attitudes toward alternative medical practices because one might be embarrassed by the subsequent demonstrations of their clinical efficacy.
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