Therapeutic modalities in integrative medicine

Published on 17/03/2015 by admin

Filed under Basic Science

Last modified 22/04/2025

Print this page

This article have been viewed 1260 times

chapter 3 Therapeutic modalities in integrative medicine

INTRODUCTION

In general practice, time and training can limit us to using only a narrow range of modalities in order to promote wellbeing or manage a patient’s illness. This could be likened to using only one or two octaves of a keyboard. The medical and surgical options are like one octave that we are familiar with, and lifestyle factors may be another, but a range of other modalities can be made available, given time, training and some rearranging of the practice.

This chapter examines some of the language and the main modalities used in integrative medicine. Many of these are outlined in more detail in other chapters, in the context of particular conditions and systems. One important distinction in the mind of the GP will be to determine which are effective and, even more importantly, which are safe and which are not. It is vital to help patients make informed decisions that will increase their wellbeing wherever possible, or at least not to cause them harm. There are legitimate concerns if patients forgo effective medical therapies in order to use complementary therapies that might be unsafe or of lesser efficacy.

DEFINITIONS

This section explains the following terms, which are commonly used in integrative medicine and complementary therapies:

• integrative medicine

• orthodox (conventional) medicine

• unorthodox medicine

• alternative medicine

• complementary medicine

• complementary and alternative medicine

• natural medicine

• holistic medicine.

INTEGRATIVE MEDICINE

As has been discussed previously, integrative medicine (IM) refers to the practice of medicine that incorporates evidence-based and safe therapies, whatever their origin. There is particular emphasis on safety, holism and complementarities. IM uses conventional medical care, but lifestyle interventions and evidence-based complementary medicine are also given a significant level of attention and may be used as a range of possible alternatives or as adjuncts. Used properly, IM is not ‘alternative practice’ but ‘best practice’.

ORTHODOX (CONVENTIONAL) MEDICINE

The term orthodox medicine (OM) (also called conventional medicine) is used to denote what is widely taught in medical schools, and is accepted clinical practice by most practitioners. Definitions of OM generally link it with being ‘scientific’ or ‘evidence-based’ but this is not always a good distinguishing factor between orthodox and unorthodox therapies. One would not have to search too far to find instances of widely used and promoted orthodox therapies not being based on science or evidence, or examples of therapies that have been shown by long-term follow-up studies to have caused more harm than anticipated.

UNORTHODOX MEDICINE

The term unorthodox medicine is sometimes used to denote those therapies that are not generally taught in medical schools or widely accepted in clinical practice. They are also sometimes referred to as unconventional medicine. By definition, unorthodox therapies are ‘non-scientific’ or not based on credible science or evidence, because if they were then they would be orthodox. However, this is not always the case, as there are an increasing number of examples of treatments that are not widely accepted or practised but are well supported by evidence. The boundary between orthodox and unorthodox therapies is shifting and often indistinct. For example, acupuncture would have been outside the boundary 30 years ago, but today, with a significant evidence base and approximately 90% of Australian GPs referring patients for acupuncture, it could no longer be considered an unorthodox therapy.

ALTERNATIVE MEDICINE

Alternative can have a number of meanings. It can mean that there are a number of potentially useful approaches to treatment which could be employed, such as whether to use a benzodiazepine, meditation or melatonin for insomnia, or taking glucosamine instead of NSAIDs for osteoarthritis. It can also denote that a patient wishes to reject conventional healthcare and prefers instead to use an alternative approach to therapy. This latter situation may or may not be a problem. It is certainly a problem when the conventional treatment being offered is clearly efficacious and the preferred alternative treatment is not, such as wishing to reject primary surgery for malignant melanoma and preferring ozone therapy instead. In such a case, patient autonomy is going beyond the bounds of safety and reason—after having fully and respectfully listened to the patient’s point of view, the doctor needs to clearly inform the patient about the evidence, costs, benefits, risks and safety issues.

COMPLEMENTARY MEDICINE

The term complementary medicine (CM) is in far more common usage than ‘alternative medicine’ because it better reflects the attitude of most patients wishing to seek out such therapies. Most patients do not wish to reject conventional medical care but simply feel that it is incomplete and needs to be enhanced or broadened by other approaches. CM therefore denotes therapies that are used to complement, or be adjuncts to, conventional treatments so as to:

• enhance outcomes—e.g. a man taking pomegranate juice as a part of his management for prostate cancer

• minimise side effects—e.g. using acupuncture to help control nausea, or meditation to control stress

• reduce costs—e.g. using the Ornish lifestyle programs to minimise progression of heart disease.

COMPLEMENTARY AND ALTERNATIVE MEDICINE

Complementary and alternative medicine (CAM) is a less specific but widely used term, particularly in the United States. It encompasses both alternative medicine and CM.

NATURAL MEDICINE

Natural medicine generally relies on the use of naturally derived products such as herbs, diet or vitamins but can also encompass lifestyle and environmental issues. It can be seen as a philosophy as much as a form of medicine. These therapies are generally aimed at enhancing nature’s ability to heal (e.g. using diet to improve immunity) or boosting the body’s defences. It does not always distinguish well between conventional medicine and CM, because many therapies used in conventional medicine are ‘natural’ and some therapies used by CM practitioners may not be natural. Although most natural therapies do well in terms of safety, being ‘natural’ does not necessarily mean being safe. Some herbs or high doses of vitamins have interactions and side effects that can be problematic.

HOLISTIC MEDICINE

Holistic medicine generally denotes a philosophy that informs therapies or approaches to practice. The holistic approach encompasses body, mind, social, spiritual, lifestyle and environmental factors. It might be delivered by one therapist or a number of therapists working together. It does not necessarily distinguish between conventional medicine and CM, as many conventional therapies and practitioners are holistically oriented and some therapies used by CM practitioners may not be.

GP USE OF CAM

Primary care physicians in the developed world are integrating a range of complementary therapies into their practices either by delivering the therapy themselves or by referring patients to practitioners (Table 3.1). The therapies most integrated tend to be those that the doctor believes are based on good evidence and/or are safest.¹ Four therapies with particularly high referral rates are acupuncture, meditation, hypnosis and chiropractic. Herbal medicine, naturopathy and osteopathy also have referral rates of close to 30%. In terms of doctors practising complementary therapies, vitamin therapy is most frequently used, followed by acupuncture, meditation and hypnosis. Despite the increasing prevalence of use of CM, medical education has been slow to incorporate these topics into the curriculum.

TABLE 3.1 Rates of practice and referral for complementary therapies by Australian GPs

	Ever referred (%)	Have practised (%)
Acupuncture	89.6	19.0
Meditation	79.6	15.3
Hypnosis	81.6	8.7
Chiropractic	68.5	5.0
Herbal medicine	29.1	4.8
Naturopathy	29.7	3.2
Vitamin therapy	16.9	25.1
Homeopathy	19.2	2.5
Osteopathy	29.6	2.8
Aromatherapy	17.5	1.1
Spiritual healing	19.5	2.1
Reflexology	10.1	0.5

Source: Pirotta et al²

MODALITIES OF CAM

There are five categories of CAM, according to the most widely accepted classification from the National Center for Complementary and Alternative Medicine (NCCAM) in the United States:³

• alternative medical systems

• mind–body therapies

• biologically based therapies

• manipulative and body-based therapies

• energy-based therapies.

ALTERNATIVE MEDICAL SYSTEMS

Alternative medical systems are generally comprehensive healthcare systems, often embedded within a culture. They are holistic in focus and are underpinned by a philosophy of healthcare as much as by therapeutic techniques. These philosophies are naturalistic and generally metaphysical, with bioenergetic explanations for physical phenomena. Indigenous medicine, Ayurveda and traditional Chinese medicine are examples of such systems. Some would also classify naturopathy as an example of an alternative system. Embedded within them are generally a range of techniques including herbal medicine, contemplative practices, approaches to exercise, body-based therapies such as acupuncture, and even moral codes. These systems often have a long tradition with a strong emphasis on respect for the healing power of nature, including fostering the body’s defences, integration with the environment and the use of natural products. Their descriptions of the origin of and cures for diseases are often significantly at variance with conventional Western biomedicine. Regardless of whether we accept these explanations for the causes of and cures for diseases, undoubtedly these systems incorporate a wide range of effective therapies and strategies.

Ayurveda (from the Sanskrit ayur= life, veda= knowledge) is the traditional Indian healing system and incorporates lifestyle advice, herbs, meditation, body typing (doshas) and yoga. The yoga system is said to have eight ‘limbs’ or branches incorporating physical, psychological, mental, social and spiritual health, as well as disciplines such as meditation and lifestyle modification, and the more widely known postures and breathing techniques. Traditional Chinese medicine (TCM) is, again, more than just acupuncture and Chinese herbs. It also incorporates movement therapies (e.g. t’ai chi), breathing and meditation. Naturopathy can be seen by some as just the use of herbs but in its fullest sense it is underpinned by a ‘naturalistic’ philosophy. Patients will often use aspects of these alternative systems without adopting the underlying philosophy—such as using acupuncture for chronic pain—although in a purist sense, this would be seen as less congruent and less effective.

MIND–BODY THERAPIES

Many mind–body therapies are now considered largely mainstream and are used by the majority of doctors. They include stress management, relaxation therapies, meditation, imagery, biofeedback, prayer, humour, mindfulness, journal keeping and hypnosis. Support groups, family therapy and cognitive behaviour therapy can also be used to facilitate healing or for coping with physical illnesses and so these are also classified as mind–body therapies. Of all the modalities, mind–body probably has the most sound evidence base. A review of mind–body therapies found that:

Drawing principally from systematic reviews and meta-analyses, there is considerable evidence of efficacy for several mind–body therapies in the treatment of coronary artery disease, headaches, insomnia, incontinence, chronic low back pain, disease and treatment-related symptoms of cancer and improving post-surgical outcomes.^4a

This is not reflective of the limitations of mind–body therapies, but an indication of how far the research has progressed.

BIOLOGICALLY BASED THERAPIES

Biologically based therapies include those that use biologically active compounds, most of which are naturally occurring. These would most often include food, herbs, vitamins and supplements, but could also include things such as homeopathic remedies and essential oils used in aromatherapy. Much of the rationale for herbal therapies comes from the philosophy that whole-plant compounds include a range of co-factors, vitamins and nutrients that would not be available if one biologically active ingredient were isolated, measured and administered. Such an approach is said to improve efficacy and minimise side effects. Many pharmaceuticals, of course, are derived from plants, including aspirin, digoxin, penicillin, quinine and metformin, to name a few. Although most biologically based therapies are safer than their pharmacological counterparts, they are biologically active and can interact with drugs, and so it is important to know what patients are taking and to check potential interactions.

MANIPULATIVE AND BODY-BASED THERAPIES

These physical therapies are, like other categories, diverse and widely used. They include:

• chiropractic and osteopathy—both use spinal manipulation of high or low impact. Although these approaches can be effective for a wide range of back and neck complaints (disc prolapse would be considered a contraindication) as well as headache, it is less certain whether the chiropractic explanation—that the origin of most illnesses is related to spinal malalignment—is accurate, or whether chiropractic and osteopathy are effective for many other conditions for which they are commonly used

• massage—the many varieties can be broadly categorised into therapeutic massage and relaxation massage. Massage can be beneficial for a wide range of physical and psychological conditions and symptoms

• reflexology and shiatsu—these therapies rely on a combination of massage and pressure, and incorporate acupressure points and energy flow

• acupuncture—this is part of TCM and is said to work with changing ‘energy flow’ throughout the body, and therefore is also sometimes classified as an ‘energy’ therapy. It is clearly effective for many conditions, but not all for which it is used. Its mechanism of action is still not well understood.

ENERGY-BASED THERAPIES

There are two main types of energy therapies:

• biofield therapies—such as qi gong, reiki and therapeutic touch; these use the body’s own energy flow

• bioenergetic therapies—these generally involve the use of pulsed electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current and/or alternating and direct-current fields.

Energy therapies are probably the least researched and hardest to validate, although some positive outcomes have been found, mostly in controlling symptoms. The mechanisms of action are difficult to explain. Other philosophical systems that have ‘bioenergetic’ explanations include qi gong, acupuncture, TCM and yoga.

Alternative and Complementary Therapies and Journal of Alternative and Complementary Medicine. http://www.liebertpub.com/act. (main Medline-listed journals focusing on CAM)

Alternative Medicine Center. http://www.healthy.net/clinic/therapy/index.asp. (has a workable database and searches for practitioners)

Australasian Integrative Medicine Association. http://www.aima.net.au. (peak umbrella body for integrative medicine in Australasia)

Cochrane reviews, Medline, PubMed

IMgateway. http://www.imgateway.net/page.jsp?p_name=Home. (Australian organisation that collates data and networks people)

National Foundation for Alternative Medicine. http://www.nfam.org.

US government, National Center for CAM. http://www.nccam.nih.gov. (a good place to start, with guidance for therapists considering adopting CAM)

1 Cohen MM, Penman S, Pirotta M, et al. The integration of complementary therapies in Australian general practice: results of a national survey. J Altern Complement Med. 2005;11(6):995-1004.

2 Pirotta MV, Cohen MM, Kotsirilos V, et al. Complementary therapies: have they become accepted in general practice? Med J Aust. 2007;172(3):105-109.

3 National Center for Complementary and Alternative Medicine (NCCAM). What are the major types of complementary and alternative medicine? Online. Available: www.nccam.nih.gov.

4 Astin JA, Shapiro SL, Eisenberg DM, et al. Mind–body medicine: state of the science, implications for practice. Am Board Fam Pract. 2003;16(2):131-147. a p 131.

Related

General Practice