Integrative Medicine in Rehabilitation

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Chapter 22 Integrative Medicine in Rehabilitation

Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. These therapies are either complementary to standard medical therapies (used with) or alternative to (used in place of) orthodox treatments. CAM is popular in both North America16,49 and Europe. The U.S. National Institutes of Health organized the National Center for Complementary and Alternative Medicine (NCCAM; nccam.nih.gov/)17,101,103 in 1998 to advance the study of these therapies.

The term integrative medicine is now widely used to describe the practice of combining mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.17,101,103 Although many CAM treatments have not been properly studied, there are many that can be safely integrated into physical medicine and rehabilitation practice.

CAM therapies have been categorized by NCCAM17,101,103 into the following groups:

Alternative Medical Systems

Alternative medical systems often incorporate concepts and ideas that can be quite different from conventional medicine precepts. They are generally based on empiric observation, and underlying scientific principles often have yet to be verified through well-designed scientific studies. Given the empiric nature of some allopathic and osteopathic treatments, the boundary between CAM and conventional medicine is often indistinct.

Many different schools of thought regarding optimal practice have developed over time. As a result, there can be considerable variability between alternative medicine providers. Most systems posit an innate ability of the body to heal itself, and attempt to stimulate or enhance that natural ability. All the systems discussed in this chapter are holistic, created to treat the entire person rather than a single complaint. Some incorporate elements of cultures that are quite different from our own, and many have an extensive history dating back thousands of years.

Chiropractic

Chiropractic is a profession founded on the theory that minor spinal misalignments can detrimentally affect the neurologic function of spinal nerves and the organs and structures supplied by those nerves (see Chapter 19). These misalignments are often called subluxations. The chiropractic use of the term subluxation is not congruent with the medical definition, which requires partial dislocation of a joint. This disparity not uncommonly leads to confusion between practitioners and patients when discussing their condition. Chiropractors treat subluxations with various interventions, the most common being spinal manipulation. Although much is written about subluxations, there is little agreement among chiropractors on how to define, detect, or treat them. Because these proposed lesions cannot be reliably measured or detected (and are therefore difficult to study), their effect on health is unclear. Despite this, there are many randomized controlled studies of chiropractic treatments for various conditions, particularly musculoskeletal disorders such as back pain and neck pain. Spinal manipulation is considered to be the active intervention in most of those studies.

Chiropractors often incorporate other techniques, such as massage and exercise prescription, in treatment. They also use radiography to aid in diagnosis. Chiropractors do not dispense prescription medications or perform surgery or invasive treatments. A comprehensive report has detailed the chiropractic profession in the United States.38 There were approximately 53,000 chiropractors practicing in the United States in 2006.6 Many others practice in countries such as Australia, New Zealand, the United Kingdom, Japan, and most northern European countries.

Homeopathy

Homeopathy originated as a medical system in Germany in the late 1700s based on the theories of a physician, Samuel Hahnemann. Immunization against smallpox was being successfully demonstrated at about the same time, and it is likely that the theories of immunology influenced the theories underlying homeopathy. Much of the development of homeopathy occurred in Europe and culminated in a decision in 1996 by the European Commission’s Homeopathy Medicine Research Group to integrate homeopathy into medical practice.

Homeopathy’s central tenets are the principle of similars and the principle of dilution. The principle of similars, or “like begets like,” can be found in many systems of magical thought. In application the idea is that small quantities of an agent can ameliorate the same symptoms that are evoked in a healthy patient when given in larger quantities. For some practitioners, determination of the causative agent is as critical as matching the symptoms that are being treated (i.e., the complaint might not have been caused by a bee sting, but the patient is responding just like he or she was stung). The principle of dilution states that highly dilute solutions have biologic activity, and the more dilute the solution, the more potent the remedy. Some remedies are diluted but still possess measurable biologic activity. Others might be diluted to the point that efficacy could not be explained by conventional science (a solution could be so dilute that not every dose contains a single molecule of the active substance). Although most of these remedies are safe, their potential for interaction with other ingested substances can be difficult to predict. Homeopaths typically seek to identify substances or agents that can reproduce the patient’s symptoms. Many substances are studied and cross-referenced in the homeopathic literature. Computerized tools are available for matching symptoms to a specific remedy to aid the homeopath in the selection of an appropriate treatment. Despite this practice being incongruent with science, there is some evidence of effect. A double-blind, randomized controlled trial demonstrated benefit from homeopathic treatment of mild traumatic brain injury.37 Another trial found benefit in treating tendinopathy.121 Other studies have not found benefit. A study of homeopathic therapy after knee ligament reconstruction failed to find benefit.109 Similarly, a trial of homeopathy to improve muscle tone in children with cerebral palsy also failed to find a significant effect.120 Although there are some intriguing possibilities represented in the literature, current evidence does not appear to be sufficient to suggest a significant role for homeopathy in medical practices.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) is a system of health care based on traditional Chinese beliefs about the universe. One of the fundamental principles of this system is that two opposite forces (yin and yang) balance in nature. Disease states reflect a disturbance in the balance of yin and yang that can be extrinsic or intrinsic to the body.

Proper function of the human body requires proper functioning in physical, energetic, and spiritual aspects of an individual. TCM posits energy, called qi, that infuses living tissue. Qi is not a homogenous entity, as there are many different types of qi in the body. Each has different functions, from aiding in digestion to protecting against harmful outside agents. These energies support the material substances of the body such as blood and tissues. There is a complex interaction between the different types of qi and the symptoms that are produced by disturbances in qi.

Disease can manifest in a number of different ways. Sometimes disturbances have a material manifestation, altering blood, tissues, or the organs. At other times they manifest as more energetic (qi) symptoms such as fatigue, anxiety, or depression. Diagnosis of disease focuses on eliciting a history to determine the underlying disturbance. The TCM examination might include determining the characteristics of pulses at specific locations on the body, the appearance of the tongue, and the characteristics of olfaction, as well as carefully palpating the body. This information aids the TCM practitioner in the diagnosis of an individual’s complaint. A diagnosis in TCM (such as ascending fire of the liver or kidney qi deficiency) might have no analog in the allopathic model.

The primary goal of TCM is the restoration of the balance of these forces. This rebalancing can be achieved through a number of different therapeutic options, including diet, exercise, herbal medicines, massage, and acupuncture. Although treatments are initiated to treat disease states, they are also designed to preserve health. Qi gong and t´ai chi were developed as methods of strengthening the qi or energy of the body to prevent disease and prolong life. A proper balance in diet promotes the harmonious flow of energy through the body. Although acupuncture is the most well-known modality used in TCM, it is only a single aspect of it and is often used in combination with other modalities.

Mind-Body Therapies

NCCAM identifies mind-body practices as those that “focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health.”103 Included in this group are such therapies as cognitive-behavioral therapy, meditation, prayer, and guided imagery, and therapies using creative outlets (e.g., art, music, and dance therapies).

Meditation

The definition of the act of meditation according to the American Heritage Dictionary2 is ”to train, calm, or empty the mind, often by achieving an altered state, as by focusing on a single object.” Meditation is also frequently described as self-regulation of attention. It is perhaps one of the most commonly used mind-body modalities and is a significant component of many of the world’s major religions. There are numerous types of meditation (e.g., transcendental, mindfulness, and focused meditation). Much of the current interest in meditation can be traced to the 1970s work of Dr. Herbert Benson, who studied the physiologic responses to meditation. It was this early work by Benson22 that led to the identification of the “relaxation response.” Most patients use meditation to help manage stress and anxiety.18,34,116 However, there are numerous specific applications such as helping deal with pain,13 improving quality of life after brain injury,20 and improving irritable bowel syndrome.71 A small study found that older adults with chronic back pain benefited from meditation.98 A study of practitioners of transcendental meditation revealed that over a span of 5 years, health care utilization was significantly reduced in those who meditated regularly.108

Expression- and Art-Based Therapies

The American Art Therapy Association defines art therapy as the “therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development.”4 It uses creative activities to help patients with physical and emotional problems. Proponents claim that both the creative process and the final work can help express and heal trauma. Patients can create paintings, drawings, sculptures, and other types of artwork, and can work individually or in groups. Art therapists typically have a master’s degree in art therapy or a related field. They help patients express themselves through the art they create. They also discuss emotions and concerns that patients might identify as they work on their art.

Music therapy is the use of specific music (with specific vibration frequencies) to promote relaxation and healing. Although most healing music is soft and soothing, individual patient preferences (jazz, classical, etc.) can also be relaxing and healing to that individual. Music is used to help patients express deep-set emotions, both positive and negative. It is thought to be helpful in treating autism, mentally or emotionally disturbed children and adults, elderly and physically challenged persons, and patients with schizophrenia, nervous disorders, or stress. Music therapists design music sessions for individuals and groups based on individual needs and tastes. Some aspects of music therapy include music improvisation, receptive music listening, song writing, lyric discussion, imagery, music performance, and learning through music. Individuals can also perform their own music therapy at home by listening to music or sounds that help relieve their symptoms.80,141

Dance therapy is “the psychotherapeutic use of movement to promote emotional, cognitive, physical and social integration of individuals.”12 It is sometimes also referred to as movement therapy. From a physical standpoint, dance therapy can provide exercise, improve mobility and muscle coordination, and reduce muscle tension. From an emotional standpoint, dance therapy has been reported to improve self-awareness, self-confidence, and interpersonal interaction, and is an outlet for communicating feelings.66

Biologically Based Therapies

Patients undergoing rehabilitative treatment are just as likely to use dietary supplements as the rest of the population. In fact, most studies suggest that patients with chronic disorders are even more likely to use CAM therapies, including herbs. Therefore it is important to have a basic understanding of herbs and dietary supplements, so that helpful information can be shared with patients to enable them to make informed decisions. Because the possible number of supplements a patient can use is practically endless, this review focuses only on the dietary supplements most likely to be encountered in a physiatric practice. Specific attention is paid to herbs and dietary supplements used for arthritis and pain.

Select Dietary Supplements Frequently Encountered in Physical Medicine and Rehabilitation Practice

Chondroitin Sulfate

Evidence

Numerous studies have been conducted on chondroitin, chondroitin and glucosamine, and glucosamine. Most indicate that these two supplements, either in combination or by themselves, are modestly effective at relieving symptoms of osteoarthritis. The multicenter, double-blind, placebo- and celecoxib-controlled Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) reported on 1583 patients with knee arthritis.42 Significant effects were seen in the subgroup of patients with the most severe pain, but not in those with lesser symptoms. Although it was reported as a “negative” trial, several concerns emerged after the study was reported, including that the placebo response was unexplainably high. Consequently there is still active debate about the proper role of these agents in the management of arthritis symptoms.

Proponents believe that chondroitin acts as a substrate needed for joint matrix structure.72 If this mechanism is indeed correct, the finding that it could require at least 2 to 4 months of therapy before significant improvement is noted is not surprising.84 A number of studies have suggested that adding chondroitin sulfate to a conventional analgesic or nonsteroidal antiinflammatory drug (NSAID) is synergistic, possibly allowing reduction or elimination of those agents.84,99

Glucosamine Sulfate

Evidence

Studies of efficacy have been centered on knee osteoarthritis. Most studies evaluating glucosamine sulfate for knee osteoarthritis have been positive.96 Glucosamine was found to be effective for osteoarthritis of the lumbar spine in one study.53 Some studies suggest efficacy equivalent to certain NSAIDs.90 Like chondroitin, onset of relief is generally delayed, requiring up to 8 weeks for full effect. In addition to symptom control, glucosamine might also have disease-modifying properties. Long-term studies suggest that treatment with glucosamine might result in significantly less joint space narrowing and knee joint degeneration as compared with placebo.115

Camphor (Cinnamomum camphora)

Evidence

Camphor is Food and Drug Administration–approved as a topical analgesic. A topical cream containing camphor, glucosamine sulfate, and chondroitin sulfate was found to provide reduction in pain caused by osteoarthritis.43 Because there is no evidence that glucosamine and chondroitin can be absorbed topically, the relief might have resulted from the counterirritant effect of camphor, but these data should be considered inconclusive.

Devil’s Claw (Harpagophytum procumbens)

Evidence

A growing body of evidence suggests that devil’s claw decreases osteoarthritis-related pain.31,37,42,140,142 As with glucosamine and chondroitin, a reduction in the need for NSAIDs might be possible with devil’s claw after several weeks of use.

Adverse Effects

Although generally well tolerated, Devil’s claw has been associated with diarrhea.36 Other reported side effects include nausea, vomiting, and abdominal pain.

Evening Primrose Oil (Oenothera biennis)

Evidence

In a double-blind, placebo-controlled study of rheumatoid arthritis, evening primrose oil resulted in a significant reduction of symptoms.21 Evening primrose oil contains γ-linolenic acid), which is thought to have antiinflammatory properties.