Integrative medicine: Difference between revisions
imported>Howard C. Berkowitz m (→NCCAM System) |
Pat Palmer (talk | contribs) mNo edit summary |
||
(35 intermediate revisions by 5 users not shown) | |||
Line 1: | Line 1: | ||
{{subpages}} | {{subpages}} | ||
{{TOC | {{TOC|right}} | ||
'''Integrative medicine''', according to the Columbia University School of Medicine, deals with the optimal combination of mainstream and complementary medicine.<ref name=ColNur>{{citation | '''Integrative medicine''', according to the Columbia University School of Medicine, deals with the optimal combination of mainstream and [[complementary and alternative medicine]].<ref name=ColNur>{{citation | ||
| title = Integrative Therapies in Primary Care | | title = Integrative Therapies in Primary Care | ||
| author = Columbia University School of Nursing | | author = Columbia University School of Nursing | ||
| url = http://www.nursing.columbia.edu/programs/itpc.html}}</ref> <ref name=napcam>Committee on the Use of Complementary and Alternative Medicine by the American Public, Board on Health Promotion and Disease Prevention. (2005) [http://www.nap.edu/catalog.php?record_id=11182 Complementary and Alternative Medicine in the United States (free full-text online)] Institute of Medicine of the National Academies, The National Academies Press. Washington, D.C. ISBN 978-0-309-09270-8. | | url = http://www.nursing.columbia.edu/programs/itpc.html}}</ref> [[Traditional medicine]], when differentiated from more modern techniques of complementary medicine, can also be part of integrative medicine. <ref name=napcam>Committee on the Use of Complementary and Alternative Medicine by the American Public, Board on Health Promotion and Disease Prevention. (2005) [http://www.nap.edu/catalog.php?record_id=11182 Complementary and Alternative Medicine in the United States (free full-text online)] Institute of Medicine of the National Academies, The National Academies Press. Washington, D.C. ISBN 978-0-309-09270-8. | ||
*'''<u>Description of report:</u>''' Integration of complementary and alternative medicine therapies (CAM) with conventional medicine is occurring in hospitals and physicians offices, health maintenance organizations (HMOs) are covering CAM therapies, insurance coverage for CAM is increasing, and integrative medicine centers and clinics are being established, many with close ties to medical schools and teaching hospitals. In determining what care to provide, the goal should be comprehensive care that uses the best scientific evidence available regarding benefits and harm, encourages a focus on healing, recognizes the importance of compassion and caring, emphasizes the centrality of relationship-based care, encourages patients to share in decision making about therapeutic options, and promotes choices in care that can include complementary therapies where appropriate....Numerous approaches to delivering integrative medicine have evolved. Complementary and Alternative Medicine in the United States identifies an urgent need for health systems research that focuses on identifying the elements of these models, the outcomes of care delivered in these models, and whether these models are cost-effective when compared to conventional practice settings....It outlines areas of research in convention and CAM therapies, ways of integrating these therapies, development of curriculum that provides further education to health professionals, and an amendment of the Dietary Supplement Health and Education Act to improve quality, accurate labeling, research into use of supplements, incentives for privately funded research into their efficacy, and consumer protection against all potential hazards.</ref> Appropriate complementary medicine involves methods that are not fully explained through current scientific methods, but do show some evidence of efficacy. Indeed, [[evidence-based medicine]] identifies some techniques that have been considered part of mainstream medicine, but actually have very little efficacy | *'''<u>Description of report:</u>''' Integration of complementary and alternative medicine therapies (CAM) with conventional medicine is occurring in hospitals and physicians offices, health maintenance organizations (HMOs) are covering CAM therapies, insurance coverage for CAM is increasing, and integrative medicine centers and clinics are being established, many with close ties to medical schools and teaching hospitals. In determining what care to provide, the goal should be comprehensive care that uses the best scientific evidence available regarding benefits and harm, encourages a focus on healing, recognizes the importance of compassion and caring, emphasizes the centrality of relationship-based care, encourages patients to share in decision making about therapeutic options, and promotes choices in care that can include complementary therapies where appropriate....Numerous approaches to delivering integrative medicine have evolved. Complementary and Alternative Medicine in the United States identifies an urgent need for health systems research that focuses on identifying the elements of these models, the outcomes of care delivered in these models, and whether these models are cost-effective when compared to conventional practice settings....It outlines areas of research in convention and CAM therapies, ways of integrating these therapies, development of curriculum that provides further education to health professionals, and an amendment of the Dietary Supplement Health and Education Act to improve quality, accurate labeling, research into use of supplements, incentives for privately funded research into their efficacy, and consumer protection against all potential hazards.</ref> Appropriate complementary medicine involves methods that are not fully explained through current scientific methods, but do show some evidence of efficacy. Indeed, [[evidence-based medicine]] identifies some techniques that have been considered part of mainstream medicine, but actually have very little efficacy. | ||
Integrative medicine does consider the quality of the interaction between patient and practitioners. It also encompasses disciplines that have evidence of efficacy, but not necessarily efficacy demonstrated only through [[randomized controlled trial]]s.<ref name=UKselect- | {{quotation|There are two kinds of medicine. Medicine that works, and medicine that does not work.|[[Marcia Angell]], MD, former Editor of the ''New England Journal of Medicine''}} | ||
As of 2024, integrative medicine as practiced by [[Joel Fuhrman]] and others and which includes nutritional interventions (unlike mainstream Western medicine) has increased in popularity, although insurance coverage for it in the [[United States of America|U.S.]] may be minimal or non-existent. Recent scientific studies have shown that nutritional interventions, combined with appropriate exercise, may be helpful in alleviating the symptoms of many so-called auto-immune conditions, in some cases arresting the downslide, and in other cases reducing the need for medications; it may be true also for bone conditions such as osteoporosis. This is apparently true for both types of [[diabetes (disambiguation)|diabetes]] and may also be true for other conditions such as asthma and irritable bowel syndrome. Nutritional interventions generally involve both dietary supplements and major changes in eating patterns to include more vegetables, fruits, and whole grains, and less processed food, including sugars, flours and bread. However, advanced diseases such as cancer generally still require mainstream medical intervention, even if complementary techniques do no harm and may emphasize healthy living overall. | |||
Integrative medicine is more likely to emphasize prevention of illness and not just treatment of illness that is already apparent. | |||
Following Dr. Angell's view, an argument can be made that integrative medicine is not merely a CAM-vs-mainstream issue, but also reflects proper use of medical specialties. [[Pain management]], for example, almost always involves a team approach that be led by subspecialty-trained [[pain medicine]] specialists, most often from [[anesthesiology]]. Pain management teams, however, often include [[psychiatry|psychiatrists]] and [[neurology|neurologists]], [[nursing]], [[physical therapy|physical]] and [[occupational therapy]], and other disciplines relevant to each case. Cancer treatment frequently involves the subspecialties of medical, surgical and radiation [[oncology]], as well as nonphysicians such as [[health physics|health physicists]]. Many pain management programs are affiliated with oncology programs. | |||
Public health includes a wide range of disciplines; these areas may be beyond the scope of this article, which is focused on clinical, patient-oriented health. | |||
This article is not intended to get into controversial matters of whether some complementary methods ''should or should not'' be included, but rather what ''are'' included in real-world programs at institutions including the [[Mayo Clinic]], [[Johns Hopkins University|Johns Hopkins Health System]], [[Columbia University|Columbia University School of Nursing]], [[Harvard University|Harvard Medical School]], [[Duke University|Duke Medicine]], [[Memorial Sloan-Kettering Cancer Center]] and the [[University of California at San Francisco]] (see [http://en.citizendium.org/wiki/Integrative_medicine/External_Links External Links]). Discussion of the merits of a technique that is not included by a program are more than welcome in the article on that specific discipline. | |||
Integrative medicine does consider the quality of the interaction between patient and practitioners. It also encompasses disciplines that have evidence of efficacy, but not necessarily efficacy demonstrated only through [[randomized controlled trial]]s.<ref name=UKselect-Research>{{citation | |||
| url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12315.htm | | url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12315.htm | ||
| author = Select Committee appointed to consider Science and Technology, U.K. Parliament | | author = Select Committee appointed to consider Science and Technology, U.K. Parliament | ||
Line 14: | Line 26: | ||
| date = 21 November 2000 | | date = 21 November 2000 | ||
}}</ref> | }}</ref> | ||
==Integrated vs. Complementary & Alternative== | ==Integrated vs. Complementary & Alternative== | ||
There is a difference between integrative medicine and the somewhat awkward term, [[complementary and alternative medicine]]. As used in the U.S. by the | There is a difference between integrative medicine and the somewhat awkward term, [[complementary and alternative medicine]]. As used in the U.S. by the National Center for Complementary and Alternative Medicine (NCCAM), "alternative" aspect rejects other disciplines. NCCAM also uses the term "whole systems" for approaches to healthcare that reject the use of any other discipline. ''Integrative medicine does not include "whole system" alternative medicine'', because whole systems, by definition, reject integration. <ref name=UKselect-summary>{{citation | ||
| url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm | | url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm | ||
| author = Select Committee appointed to consider Science and Technology, U.K. Parliament | | author = Select Committee appointed to consider Science and Technology, U.K. Parliament | ||
Line 57: | Line 70: | ||
| author = [[National Institutes of Health]] Consensus Development Program | | author = [[National Institutes of Health]] Consensus Development Program | ||
| title = Link to Archive of Older Conference Statements}}</ref></blockquote> | | title = Link to Archive of Older Conference Statements}}</ref></blockquote> | ||
==Evidence-based medical challenges== | |||
Integrative medicine relies on evidence, but some complementary disciplines, especially those involving body manipulation, do not lend themselves to the "gold standard" of [[randomized controlled trial]]s, the double-blinded study. This issue is not limited to complementary disciplines, as a similar problem exists for mainstream surgical techniques. Since anesthesia and incision are not without risk to the patient, "sham surgery" to provide a control arm for research studies is often considered unethical. The Institute of Medicine of the U.S. National Academies of Science recognize the need to develop scientifically rigorous, yet appropriate, | |||
methods to study modalities that do not lend themselves to blinding. <ref name=napcam /> The U.K. government is also examining additional ways to get meaningful evidence.<ref name=UKselect-Research /> | |||
Other complementary techniques, such as [[homeopathy]], also have problems with the double-blinded approach, since their methods are individualized to the patient and are difficult to fit into a conventional double-blind protocol. Whole systems research (WSR) is one approach to the need for evidence when double-blinding is unrealistic.<ref name=Verhoef2005>{{citation | |||
| journal = Complement Ther Med. | |||
| date = 2005 Sep | |||
| volume = 13 | |||
| issue =3 | |||
| pages = 206-12. | |||
| title = Complementary and alternative medicine whole systems research: beyond identification of inadequacies of the RCT. | |||
| author = Verhoef MJ, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A. | |||
| url = http://www.ncbi.nlm.nih.gov/pubmed/16150375?dopt=Abstract}}</ref> | |||
It emphasizes the importance of “model | |||
validity,” that is, congruence between research methodology | |||
and the paradigm of the system being investigated. NCCAM cosponsored a | |||
symposium on WSR in 2002.<ref name=Ritenaugh>{{citation | |||
| journal = Altern Ther Health Med | |||
| date = 2003 Jul-Aug | |||
| volume =9 | |||
| issue = 4 | |||
| pages = 32-6 | |||
| title = Whole systems research: a discipline for studying complementary and alternative medicine. | |||
| author = Ritenbaugh C, Verhoef M, Fleishman S, Boon H, Leis A. | |||
| url = http://www.ncbi.nlm.nih.gov/pubmed/12868250?dopt=Abstract}}</ref> | |||
==Categorizing disciplines== | ==Categorizing disciplines== | ||
To begin a discussion, it is necessary to define the scope of the problem. Two sources, one from the U.K. and one from the U.S. government, approach the scope issue differently. The U.K. study focuses more on the efficacy and the use of a clear diagnostic model in different disciplines, without trying to separate by methodology. The U.S. model separates primarily by methodology, and can allow whole therapies that have a fundamentally different philosophy than biologically based medicine; the U.K. model appears to require that for practical use, the disciplines need to agree on principles of evidence-based medicine and on a biomedical framework, or they are simply not comparable. Nevertheless, "novel methods that are acceptable to conventional science and that take into account concerns of both paradigms are being developed." | To begin a discussion, it is necessary to define the scope of the problem. Two sources, one from the U.K. and one from the U.S. government, approach the scope issue differently. The U.K. study focuses more on the efficacy and the use of a clear diagnostic model in different disciplines, without trying to separate by methodology. The U.S. model separates primarily by methodology, and can allow whole therapies that have a fundamentally different philosophy than biologically based medicine; the U.K. model appears to require that for practical use, the disciplines need to agree on principles of evidence-based medicine and on a biomedical framework, or they are simply not comparable. Nevertheless, "novel methods that are acceptable to conventional science and that take into account concerns of both paradigms are being developed." | ||
===U.K. System=== | ===U.K. System=== | ||
In a study of the field by a U.K. Parliamentary committee, three groups were defined within the category of CAM. This, however, is not a fully integrative approach, since "conventional" medicine, as a discipline, falls into Group 1:<ref name=UKselect-summary | In a study of the field by a U.K. Parliamentary committee, three groups were defined within the category of CAM. This, however, is not a fully integrative approach, since "conventional" medicine, as a discipline, falls into Group 1:<ref name=UKselect-summary />Disciplines in ''italics'' are not in the U.K. report. | ||
*Group 1 includes the most organised professions, which specifically include a formal approach to diagnosis. <ref name=UKselect-Ch2>{{citation | *Group 1 includes the most organised professions, which specifically include a formal approach to diagnosis. <ref name=UKselect-Ch2>{{citation | ||
| url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm | | url = http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm | ||
Line 84: | Line 117: | ||
**[[Aromatherapy]] | **[[Aromatherapy]] | ||
**[[Bach flower therapy]] | **[[Bach flower therapy]] | ||
**[[massage therapy]] | **[[Massage|massage therapy]] | ||
**Counselling stress therapy | **Counselling stress therapy | ||
**[[Hypnotherapy]] | **[[Hypnotherapy]] | ||
**[[Meditation]] | **[[Meditation]] | ||
**[[Reflexology]] | **[[Reflexology]] | ||
**[[Shiatsu]] | **[[Massage#Shiatsu|Shiatsu]] | ||
**[[Spiritual healing]] | **[[Spiritual therapies|Spiritual healing]] | ||
**[[Maharishi Ayurvedic Medicine]] | **[[Ayurveda|Maharishi Ayurvedic Medicine]] | ||
**[[Nutritional medicine]] | **[[Nutritional medicine]] | ||
**[[Yoga]] | **[[Yoga]] | ||
*Group 3 cannot be supported unless and until convincing research evidence of efficacy, based upon the results of well designed trials, can be produced. | *Group 3 cannot be supported unless and until convincing research evidence of efficacy, based upon the results of well designed trials, can be produced. | ||
**3a: Long-established and traditional systems of healthcare | **3a: Long-established and traditional systems of healthcare | ||
***[[Anthroposophy|Anthroposophical medicine]] | ***[[Anthroposophy#Anthroposophical medicine|Anthroposophical medicine]] | ||
***[[Ayurveda]] | ***[[Ayurveda]] | ||
***Chinese Herbal Medicine | ***Chinese Herbal Medicine | ||
Line 110: | Line 143: | ||
Certain of the Group 1 disciplines may be practiced in a "classic" manner, which defines them as "whole systems" that do not attempt to be complementary or integrative. Classic practice, including "pure" conventional medicine, is excluded from integrative medicine. | Certain of the Group 1 disciplines may be practiced in a "classic" manner, which defines them as "whole systems" that do not attempt to be complementary or integrative. Classic practice, including "pure" conventional medicine, is excluded from integrative medicine. | ||
===NCCAM System=== | ===NCCAM System=== | ||
Another model comes from the U.S. | Another model comes from the U.S. National Center for Complementary and Alternative Medicine. <ref name=NCCAM-WhatIs>{{citation | ||
| author = National Center for Complementary and Alternative Medicine | |||
| title = What is CAM? | |||
| url =http://nccam.nih.gov/health/whatiscam/ }}</ref>The unchanged table is in [[complementary and alternative medicine]]; the table below is a work in progress to harmonize with the U.K. work. [x] denotes the UK group assigned to the discipline, and ''italics'' identify items that variously are in one or the other but not both, or where there is no U.K. grouping but an attempt to apply it. | |||
{| class="wikitable" | {| class="wikitable" | ||
Line 119: | Line 156: | ||
! Subfield | ! Subfield | ||
|- | |- | ||
| '''Mind- | | '''[[Mind-body therapies]]''' uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms.<ref name=NCCAM-WhatIs /> Some of the "still considered CAM" techniques are more and more accepted. | ||
| '''Accepted as mainstream (not strictly CAM)''' include patient support groups and [[cognitive behavioral therapy]] | | '''Accepted as mainstream (not strictly CAM)''' include patient support groups and [[cognitive behavioral therapy]] | ||
| '''Still considered CAM''' include [[ | | '''Still considered CAM''' include [[relaxation techniques (complementary medicine)]], [[meditation (physiology)]] and [[imagery (psychotherapy)]], techniques; [[Emotional Freedom Techniques]], [[Eye Motion Desensitization Reprocessing]]; [[spiritual therapies|spiritual healing]] ''[2]]'', and creative outlets such as [[art therapy]] ''[2]]'', [[music therapy]]''[2]]'' and [[dance therapy]] ''[2]]'' | ||
|- | |- | ||
| '''Biologically based practices''' in CAM use substances found in nature. | | '''[[Biologically based health practices]]''' in CAM use substances found in nature.<ref name=NCCAM-WhatIs /> <ref name=Col-HNS>{{citation | ||
| title = Herbs, Nutraceuticals and Supplements for Advanced Practice Nursing | |||
| author = Joyce Anastasi, Columbia University School of Nursing | |||
| url = http://www.nursing.columbia.edu/programs/hns.html}}</ref> | |||
| '''Accepted as mainstream (not strictly CAM)''' include [[dietetics]] at the order of a physician, [1] and certain vitamins in pharmacologic doses (e.g., [[niacin]] for [[dyslipidemia]]. [1] | | '''Accepted as mainstream (not strictly CAM)''' include [[dietetics]] at the order of a physician, [1] and certain vitamins in pharmacologic doses (e.g., [[niacin]] for [[dyslipidemia]]. [1] | ||
| '''Still considered CAM''' include [[nutritional medicine]], [[aromatherapy]] (by inhalation), some vitamins and dietary supplements. [[Phytotherapy]][''1''] and [[homeopathy]][1] when used with other disciplines. [[naturopathy]] [3a] | | '''Still considered CAM''' include [[nutritional medicine]], [[aromatherapy]] (by inhalation), some vitamins and dietary supplements. [[Phytotherapy]][''1''] and [[homeopathy]][1] when used with other disciplines. [[naturopathy]] [3a] | ||
|- | |- | ||
| ''' | | '''[[Musculoskeletal manipulations]]''' involve the controlled use of force against parts of the body, or maneuvers that move body parts out of their usual range of motion. <ref>{{MeSH|Musculoskeletal manipulations}}</ref> | ||
| '''At least partially accepted as mainstream (not strictly CAM)''': [[osteopathy]][1], [[osteopathic medicine]] ''[1]'',[[chiropractic]][1] when not used as a whole system, some forms of [[massage therapy]] when ordered by a physician [1] | | '''At least partially accepted as mainstream (not strictly CAM)''': [[osteopathy]][1], [[osteopathic medicine]] ''[1]'',[[chiropractic]][1] when not used as a whole system, some forms of [[massage|massage therapy]] when ordered by a physician [1] | ||
| '''Still considered CAM''': | | '''Still considered CAM''': [[reflexology]] ''[2]]'' and other biofield-based methods. [2] [[Aromatherapy]] combined with [[massage|massage therapy]]''[2]'' | ||
|- | |- | ||
| '''Energy | | '''[[Energy medicine]]''' breaks into therapies that use forces that are, and are not, detectable with conventional scientific instrumentation. | ||
| '''Bioelectromagnetic-based therapies''' involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. | | '''Bioelectromagnetic-based therapies''' involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. | ||
| '''Biofield therapies''' are intended to affect energy fields that purportedly surround and penetrate the human body. These include [[qi gong]] (part of [[traditional Chinese medicine]]), [[reflexology]] [2], [[Bach flower therapy]] ''[2]]'', [[reiki]] ''[2?]]'', and [[therapeutic touch]] ''[2?]]'' | | '''Biofield therapies''' are intended to affect energy fields that purportedly surround and penetrate the human body. These include [[qi gong]] (part of [[traditional Chinese medicine]]), [[reflexology]] [2], [[Bach flower therapy]] ''[2]]'', [[reiki]] ''[2?]]'', and [[therapeutic touch]] ''[2?]]'' | ||
Line 139: | Line 179: | ||
Appendix A of the Institute of Medicine's 2005 report, ''Complementary and Alternative Medicine in the United States''<ref name=napcam/>, entitled "CAM Therapies, Practices, and Systems", provides a comprehensive list, with definitions, of therapies that "...may or may not be considered a part of CAM, depending on one’s accepted definition of CAM. Practitioners provided the individual therapy definitions..." One can review the list and definitions online free.<ref name=napcam/> | Appendix A of the Institute of Medicine's 2005 report, ''Complementary and Alternative Medicine in the United States''<ref name=napcam/>, entitled "CAM Therapies, Practices, and Systems", provides a comprehensive list, with definitions, of therapies that "...may or may not be considered a part of CAM, depending on one’s accepted definition of CAM. Practitioners provided the individual therapy definitions..." One can review the list and definitions online free.<ref name=napcam/> | ||
==Co-management== | |||
===Examples from chiropractic=== | |||
Interdisciplinary consensus panels have found that [[chiropractic]] has demonstrated safety and efficacy for low back pain.<ref name=Chou2007>{{citation | |||
| author = Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK. | |||
| title = Diagnosis and treatment of low back pain: a joint clinical practice guidelines from the American College of Physicians and the American Pain Society. | |||
| journal=Ann Int Med | |||
| year = 2007 | |||
| volume = 147 | |||
| issue = 7 | |||
| pages = 478-491. | |||
}}</ref> A medical primary care provider (PCP), such as a physician or nurse practitioner might reasonably refer a patient, complaining of low back pain, to a chiropractor working in an integrative manner. | |||
====Referral criteria among chiropractic and general medicine==== | |||
Since patients may self-refer to chiropractors, as the portal of entry into the health care system, the chiropractic profession has developed guidelines on when some chiropractic treatments may not be appropriate without consultation with appropriate medical practitioners, may be completely contraindicated ('''red flag''''), or need to be co-managed with an integrative team approach. <ref name=CCGPP2008>{{citation | |||
| url = http://www.ccgpp.org/delphi.pdf | |||
| title = Chiropractic Management of Low Back Disorders | |||
| author = Council on Chiropractic Guidelines and Practice Parameters | |||
| date = March 2008}}, pp. 17-18</ref> | |||
{| | |||
<center>'''Red flag'''</center> | |||
|- valign=top | |||
| | |||
* Region of local unstable fractures | |||
* Severe [[osteoporosis]] | |||
* [[Multiple myeloma]] | |||
* [[Osteomyelitis]] | |||
* Local primary bone tumors where osseous integrity is in question | |||
* Local metastatic bone tumors | |||
* [[Paget’s disease]] | |||
* Progressive or sudden (i.e. [[cauda equine syndrome]]) neurologic deficit | |||
* Spinal cord tumors that clinically demonstrate neurological compromise or require specialty referral.<ref>In cases where the neoplasm has been properly assessed and is considered to be clinically quiescent and/or perhaps distant to therapeutic target site, then chiropractic manipulative therapy may be utilized.</ref> | |||
| | |||
* Region of hypermobile joints | |||
* [[Rheumatoid arthritis]] in the active systemic stage, or locally in the presence of inflammation or atlantoaxial instability. | |||
* Inflammatory phase of [[ankylosing spondylitis]] | |||
* Inflammatory phase of [[psoriatic arthritis]] | |||
* [[Reactive arthritis]] (Reiter’s syndrome) | |||
* Unstable congenital bleeding disorders<ref name=comgt>typically requiring specialty comanagement</ref> | |||
* Unstable acquired bleeding disorders<ref name=comgt /> | |||
* Inadequate physical examination | |||
| | |||
|} | |||
Another category where chiropractic may be used, but not directly over an area afflicted with: | |||
{| | |||
<center>'''Avoid local area'''</center> | |||
|- valign=top | |||
| | |||
* Local open wound or burn. | |||
* Prolonged bleeding time/hemophilia. | |||
* Artificial joint implants. | |||
* Pacemaker (contraindicated modality - Electrotherapy ) | |||
| | |||
* Joint infection | |||
* Tumors/cancer | |||
* Recent/healing fracture | |||
* Increasing neurological deficit | |||
| | |||
|} | |||
Chiropractors themselves have flags for which they should refer: | |||
{| | |||
<center>'''Medical referral indicated'''</center> | |||
|- valign=top | |||
| | |||
*The patient's condition is not responding to the treatment rendered, when all reasonable alternative chiropractic methods have been exhausted. | |||
* The patient's condition is worsening with treatment. | |||
* The patient has a substantively, progressive infectious condition. | |||
| | |||
* The patient experiences a medical emergency (e.g., myocardial infarct, cerebrovascular accident, severe laceration, pneumothorax, etc). | |||
* Increasing neurological deficits (i.e. cauda equina syndrome) | |||
| | |||
|} | |||
Research has explored the role of chiropractic in non-musculoskeletal (NMS) conditions, such as [[migraine]].<ref name=Hawk2007>{{citation | |||
| journal = Journal of Alternative and Complementary Medicine | |||
| volume 13 | |||
| issue = 5 | |||
| year = 2007 | |||
| pages= 491–512 | |||
| DOI= 10.1089/acm.2007.7088 | |||
| title = Chiropractic Care for Nonmusculoskeletal Conditions: A Systematic Review with Implications for Whole Systems Research | |||
| url = http://www.ccgpp.org/2.pdf | |||
| author = Hawk, C. ''et al.''}}</ref> | |||
====Complementary methods for chiropractic==== | |||
Some techniques, considered CAM in general, may be especially appropriate to chiropractic, being used here as an example. For example, one chiropractor explained that while he was not fully trained in [[acupuncture]], he had been instructed in some very specific acupuncture techniques relevant to conditions he commonly treated. In like manner, both an acupuncture and a chiropractic specialist might make use of [[relaxation (physiology)]], [[meditation]] and [[imagery (psychotherapy)]] methods to assist a patient in [[pain management]]. These methods might be taught by the specialist, or another person in the integrative medicine practice. | |||
===Integrative veterinary medicine=== | |||
== References == | == References == | ||
{{reflist|2}} | {{reflist|2}}[[Category:Suggestion Bot Tag]] |
Latest revision as of 10:36, 2 September 2024
![](http://s9.addthis.com/button1-share.gif)
Integrative medicine, according to the Columbia University School of Medicine, deals with the optimal combination of mainstream and complementary and alternative medicine.[1] Traditional medicine, when differentiated from more modern techniques of complementary medicine, can also be part of integrative medicine. [2] Appropriate complementary medicine involves methods that are not fully explained through current scientific methods, but do show some evidence of efficacy. Indeed, evidence-based medicine identifies some techniques that have been considered part of mainstream medicine, but actually have very little efficacy.
There are two kinds of medicine. Medicine that works, and medicine that does not work. — Marcia Angell, MD, former Editor of the New England Journal of Medicine
As of 2024, integrative medicine as practiced by Joel Fuhrman and others and which includes nutritional interventions (unlike mainstream Western medicine) has increased in popularity, although insurance coverage for it in the U.S. may be minimal or non-existent. Recent scientific studies have shown that nutritional interventions, combined with appropriate exercise, may be helpful in alleviating the symptoms of many so-called auto-immune conditions, in some cases arresting the downslide, and in other cases reducing the need for medications; it may be true also for bone conditions such as osteoporosis. This is apparently true for both types of diabetes and may also be true for other conditions such as asthma and irritable bowel syndrome. Nutritional interventions generally involve both dietary supplements and major changes in eating patterns to include more vegetables, fruits, and whole grains, and less processed food, including sugars, flours and bread. However, advanced diseases such as cancer generally still require mainstream medical intervention, even if complementary techniques do no harm and may emphasize healthy living overall.
Integrative medicine is more likely to emphasize prevention of illness and not just treatment of illness that is already apparent.
Following Dr. Angell's view, an argument can be made that integrative medicine is not merely a CAM-vs-mainstream issue, but also reflects proper use of medical specialties. Pain management, for example, almost always involves a team approach that be led by subspecialty-trained pain medicine specialists, most often from anesthesiology. Pain management teams, however, often include psychiatrists and neurologists, nursing, physical and occupational therapy, and other disciplines relevant to each case. Cancer treatment frequently involves the subspecialties of medical, surgical and radiation oncology, as well as nonphysicians such as health physicists. Many pain management programs are affiliated with oncology programs.
Public health includes a wide range of disciplines; these areas may be beyond the scope of this article, which is focused on clinical, patient-oriented health.
This article is not intended to get into controversial matters of whether some complementary methods should or should not be included, but rather what are included in real-world programs at institutions including the Mayo Clinic, Johns Hopkins Health System, Columbia University School of Nursing, Harvard Medical School, Duke Medicine, Memorial Sloan-Kettering Cancer Center and the University of California at San Francisco (see External Links). Discussion of the merits of a technique that is not included by a program are more than welcome in the article on that specific discipline.
Integrative medicine does consider the quality of the interaction between patient and practitioners. It also encompasses disciplines that have evidence of efficacy, but not necessarily efficacy demonstrated only through randomized controlled trials.[3]
Integrated vs. Complementary & Alternative
There is a difference between integrative medicine and the somewhat awkward term, complementary and alternative medicine. As used in the U.S. by the National Center for Complementary and Alternative Medicine (NCCAM), "alternative" aspect rejects other disciplines. NCCAM also uses the term "whole systems" for approaches to healthcare that reject the use of any other discipline. Integrative medicine does not include "whole system" alternative medicine, because whole systems, by definition, reject integration. [4]
As the term integrative medicine comes into wider use, its advocates, as at Duke University, consider it
the very best of conventional medicine and cutting-edge diagnosis and treatment, with appropriate complementary therapies. Whenever possible, it favors the use of low-tech, low-cost interventions. All factors that affect health, wellness, and disease are considered, including the psychosocial and spiritual dimensions of a person's life. It brings patients and caregivers into a partnership to achieve the patient's optimal health and healing."[5]
An integrative medicine program at Johns Hopkins, recognized in the Flexner Report as the originator of science-based medical instruction in the U.S., does assume that all techniques used, mainstream or complementary, will be evidence-based, and with full information sharing to avoid dangerous interactions or missed diagnoses. [6] As in the Johns Hopkins example, the terminology can get confusing, when an integrative center speaks of "alternative programs", which are not synonymous with "alternative medicine".
Integrative medicine may be most useful with chronic disease that can be managed but not cured, and where the goal is to give the optimal quality of life to the patient. In some cases, diseases once quickly lethal can be sufficiently well managed to allow normal life. This may require an interdisciplinary approach to pain management, involving more than the subspecialty of pain medicine.[7] Hospice and palliative medicine is also part of integrative medicine, which recognizes there can be futile care; Memorial Sloan-Kettering offers fellowship training combining integrative with hospice & pain care;[8] this is the first integrative medicine training program funded by the National Cancer Institute of the National Institutes of Health.
Issues in non-integrated care
All too often,patients today see both conventional and CAM practitioners, with the patient perhaps not mentioning one type of therapist to the other. In integrative medicine, there is active consultation among the various practitioners and the patient. Integrative medicine also includes nurses, whose training emphasizes managing chronic diseases (e.g., compliance with monitoring and medicine), encouraging healthy lifestyles, and providing continuity.
Integrative medicine reduces some of the concerns that physicians have with patients who self-refer to practitioners of what are indeed complementary techniques, but which might interact with other treatments if all the prescribers are not aware of everything being done. Indeed, one of the challenges of many primary care physicians is simply to find out all the drugs their patients are taking, prescribed by different physician specialists who do not share information.
While some conventional physicians will reject any complementary method for which they do not know the exact mode of action, integrative medicine assumes teams of mainstream and complementary (but not whole system) practitioners. For example, it is quite common for pain medicine specialists to use complementary methods.
Simply to serve as an example that evidence-based methods can deal with complementary techniques, a 1997 NIH Consensus Conference on Acupuncture found evidence for its use for the nausea of cancer chemotherapy,[9] NIH does put a caveat on all of its consensus statements that are more than five years old:
This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong.[10]
Evidence-based medical challenges
Integrative medicine relies on evidence, but some complementary disciplines, especially those involving body manipulation, do not lend themselves to the "gold standard" of randomized controlled trials, the double-blinded study. This issue is not limited to complementary disciplines, as a similar problem exists for mainstream surgical techniques. Since anesthesia and incision are not without risk to the patient, "sham surgery" to provide a control arm for research studies is often considered unethical. The Institute of Medicine of the U.S. National Academies of Science recognize the need to develop scientifically rigorous, yet appropriate, methods to study modalities that do not lend themselves to blinding. [2] The U.K. government is also examining additional ways to get meaningful evidence.[3]
Other complementary techniques, such as homeopathy, also have problems with the double-blinded approach, since their methods are individualized to the patient and are difficult to fit into a conventional double-blind protocol. Whole systems research (WSR) is one approach to the need for evidence when double-blinding is unrealistic.[11] It emphasizes the importance of “model validity,” that is, congruence between research methodology and the paradigm of the system being investigated. NCCAM cosponsored a symposium on WSR in 2002.[12]
Categorizing disciplines
To begin a discussion, it is necessary to define the scope of the problem. Two sources, one from the U.K. and one from the U.S. government, approach the scope issue differently. The U.K. study focuses more on the efficacy and the use of a clear diagnostic model in different disciplines, without trying to separate by methodology. The U.S. model separates primarily by methodology, and can allow whole therapies that have a fundamentally different philosophy than biologically based medicine; the U.K. model appears to require that for practical use, the disciplines need to agree on principles of evidence-based medicine and on a biomedical framework, or they are simply not comparable. Nevertheless, "novel methods that are acceptable to conventional science and that take into account concerns of both paradigms are being developed."
U.K. System
In a study of the field by a U.K. Parliamentary committee, three groups were defined within the category of CAM. This, however, is not a fully integrative approach, since "conventional" medicine, as a discipline, falls into Group 1:[4]Disciplines in italics are not in the U.K. report.
- Group 1 includes the most organised professions, which specifically include a formal approach to diagnosis. [13]
- Conventional medicine
- Osteopathy, as distinct from osteopathic medicine[14]
- Chiropractic
- Homeopathy
- Acupuncture
- Phytotherapy (i.e., herbal medicine)
- Group 2 contains those therapies that most clearly complement conventional medicine.
- Alexander Technique
- Aromatherapy
- Bach flower therapy
- massage therapy
- Counselling stress therapy
- Hypnotherapy
- Meditation
- Reflexology
- Shiatsu
- Spiritual healing
- Maharishi Ayurvedic Medicine
- Nutritional medicine
- Yoga
- Group 3 cannot be supported unless and until convincing research evidence of efficacy, based upon the results of well designed trials, can be produced.
- 3a: Long-established and traditional systems of healthcare
- Anthroposophical medicine
- Ayurveda
- Chinese Herbal Medicine
- Eastern Medicine (Tibb)
- Naturopathy
- Traditional Chinese medicine
- 3b: Other alternative disciplines
- Crystal therapy
- Dowsing
- Iridology
- Kinesiology
- Radionics
- 3a: Long-established and traditional systems of healthcare
Certain of the Group 1 disciplines may be practiced in a "classic" manner, which defines them as "whole systems" that do not attempt to be complementary or integrative. Classic practice, including "pure" conventional medicine, is excluded from integrative medicine.
NCCAM System
Another model comes from the U.S. National Center for Complementary and Alternative Medicine. [15]The unchanged table is in complementary and alternative medicine; the table below is a work in progress to harmonize with the U.K. work. [x] denotes the UK group assigned to the discipline, and italics identify items that variously are in one or the other but not both, or where there is no U.K. grouping but an attempt to apply it.
Major field and Description | Subfield | Subfield |
---|---|---|
Mind-body therapies uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms.[15] Some of the "still considered CAM" techniques are more and more accepted. | Accepted as mainstream (not strictly CAM) include patient support groups and cognitive behavioral therapy | Still considered CAM include relaxation techniques (complementary medicine), meditation (physiology) and imagery (psychotherapy), techniques; Emotional Freedom Techniques, Eye Motion Desensitization Reprocessing; spiritual healing [2]], and creative outlets such as art therapy [2]], music therapy[2]] and dance therapy [2]] |
Biologically based health practices in CAM use substances found in nature.[15] [16] | Accepted as mainstream (not strictly CAM) include dietetics at the order of a physician, [1] and certain vitamins in pharmacologic doses (e.g., niacin for dyslipidemia. [1] | Still considered CAM include nutritional medicine, aromatherapy (by inhalation), some vitamins and dietary supplements. Phytotherapy[1] and homeopathy[1] when used with other disciplines. naturopathy [3a] |
Musculoskeletal manipulations involve the controlled use of force against parts of the body, or maneuvers that move body parts out of their usual range of motion. [17] | At least partially accepted as mainstream (not strictly CAM): osteopathy[1], osteopathic medicine [1],chiropractic[1] when not used as a whole system, some forms of massage therapy when ordered by a physician [1] | Still considered CAM: reflexology [2]] and other biofield-based methods. [2] Aromatherapy combined with massage therapy[2] |
Energy medicine breaks into therapies that use forces that are, and are not, detectable with conventional scientific instrumentation. | Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. | Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. These include qi gong (part of traditional Chinese medicine), reflexology [2], Bach flower therapy [2]], reiki [2?]], and therapeutic touch [2?]] |
Appendix A of the Institute of Medicine's 2005 report, Complementary and Alternative Medicine in the United States[2], entitled "CAM Therapies, Practices, and Systems", provides a comprehensive list, with definitions, of therapies that "...may or may not be considered a part of CAM, depending on one’s accepted definition of CAM. Practitioners provided the individual therapy definitions..." One can review the list and definitions online free.[2]
Co-management
Examples from chiropractic
Interdisciplinary consensus panels have found that chiropractic has demonstrated safety and efficacy for low back pain.[18] A medical primary care provider (PCP), such as a physician or nurse practitioner might reasonably refer a patient, complaining of low back pain, to a chiropractor working in an integrative manner.
Referral criteria among chiropractic and general medicine
Since patients may self-refer to chiropractors, as the portal of entry into the health care system, the chiropractic profession has developed guidelines on when some chiropractic treatments may not be appropriate without consultation with appropriate medical practitioners, may be completely contraindicated (red flag'), or need to be co-managed with an integrative team approach. [19]
|
|
Another category where chiropractic may be used, but not directly over an area afflicted with:
|
|
Chiropractors themselves have flags for which they should refer:
|
|
Research has explored the role of chiropractic in non-musculoskeletal (NMS) conditions, such as migraine.[22]
Complementary methods for chiropractic
Some techniques, considered CAM in general, may be especially appropriate to chiropractic, being used here as an example. For example, one chiropractor explained that while he was not fully trained in acupuncture, he had been instructed in some very specific acupuncture techniques relevant to conditions he commonly treated. In like manner, both an acupuncture and a chiropractic specialist might make use of relaxation (physiology), meditation and imagery (psychotherapy) methods to assist a patient in pain management. These methods might be taught by the specialist, or another person in the integrative medicine practice.
Integrative veterinary medicine
References
- ↑ Columbia University School of Nursing, Integrative Therapies in Primary Care
- ↑ 2.0 2.1 2.2 2.3 Committee on the Use of Complementary and Alternative Medicine by the American Public, Board on Health Promotion and Disease Prevention. (2005) Complementary and Alternative Medicine in the United States (free full-text online) Institute of Medicine of the National Academies, The National Academies Press. Washington, D.C. ISBN 978-0-309-09270-8.
- Description of report: Integration of complementary and alternative medicine therapies (CAM) with conventional medicine is occurring in hospitals and physicians offices, health maintenance organizations (HMOs) are covering CAM therapies, insurance coverage for CAM is increasing, and integrative medicine centers and clinics are being established, many with close ties to medical schools and teaching hospitals. In determining what care to provide, the goal should be comprehensive care that uses the best scientific evidence available regarding benefits and harm, encourages a focus on healing, recognizes the importance of compassion and caring, emphasizes the centrality of relationship-based care, encourages patients to share in decision making about therapeutic options, and promotes choices in care that can include complementary therapies where appropriate....Numerous approaches to delivering integrative medicine have evolved. Complementary and Alternative Medicine in the United States identifies an urgent need for health systems research that focuses on identifying the elements of these models, the outcomes of care delivered in these models, and whether these models are cost-effective when compared to conventional practice settings....It outlines areas of research in convention and CAM therapies, ways of integrating these therapies, development of curriculum that provides further education to health professionals, and an amendment of the Dietary Supplement Health and Education Act to improve quality, accurate labeling, research into use of supplements, incentives for privately funded research into their efficacy, and consumer protection against all potential hazards.
- ↑ 3.0 3.1 Select Committee appointed to consider Science and Technology, U.K. Parliament (21 November 2000), Chapter 7: Research and Development, Science and Technology, Sixth Report, Complementary and Alternative Medicine
- ↑ 4.0 4.1 Select Committee appointed to consider Science and Technology, U.K. Parliament (21 November 2000), Summary, Science and Technology, Sixth Report, Complementary and Alternative Medicine
- ↑ Duke University Integrative Medicine, What is Integrative Medicine?
- ↑ Johns Hopkins Medicine, Hopkins' Center for Integrative Medicine offers new alternative programs for patients
- ↑ Center for Integrative Medicine, George Washington University, Pain Management Program
- ↑ Memorial Sloan-Kettering Cancer Center, Integrative Medicine / Pain & Palliative Care Combined Fellowship
- ↑ Acupuncture. NIH Consensus Statement Online, vol. 15(5), November 3-5, 1997, at 1-34
- ↑ National Institutes of Health Consensus Development Program, Link to Archive of Older Conference Statements
- ↑ Verhoef MJ, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A. (2005 Sep), "Complementary and alternative medicine whole systems research: beyond identification of inadequacies of the RCT.", Complement Ther Med. 13 (3): 206-12.
- ↑ Ritenbaugh C, Verhoef M, Fleishman S, Boon H, Leis A. (2003 Jul-Aug), "Whole systems research: a discipline for studying complementary and alternative medicine.", Altern Ther Health Med 9 (4): 32-6
- ↑ Select Committee appointed to consider Science and Technology, U.K. Parliament (21 November 2000), Chapter 2: Disciplines examined, Definitions of the Various CAM Therapies, Complementary and Alternative Medicine
- ↑ Note the U.K. term "osteopathy" is not that of In the U.S., osteopathic physicians have the full training of "medical" physicians, with additional training that includes manipulative techniques. In the U.K., osteopaths are specialists in manipulative therapies, but do not have full conventional medical training.
- ↑ 15.0 15.1 15.2 National Center for Complementary and Alternative Medicine, What is CAM?
- ↑ Joyce Anastasi, Columbia University School of Nursing, Herbs, Nutraceuticals and Supplements for Advanced Practice Nursing
- ↑ Anonymous (2024), Musculoskeletal manipulations (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK. (2007), "Diagnosis and treatment of low back pain: a joint clinical practice guidelines from the American College of Physicians and the American Pain Society.", Ann Int Med 147 (7): 478-491.
- ↑ Council on Chiropractic Guidelines and Practice Parameters (March 2008), Chiropractic Management of Low Back Disorders, pp. 17-18
- ↑ In cases where the neoplasm has been properly assessed and is considered to be clinically quiescent and/or perhaps distant to therapeutic target site, then chiropractic manipulative therapy may be utilized.
- ↑ 21.0 21.1 typically requiring specialty comanagement
- ↑ Hawk, C. et al. (2007), "Chiropractic Care for Nonmusculoskeletal Conditions: A Systematic Review with Implications for Whole Systems Research", Journal of Alternative and Complementary Medicine (no. 5): 491–512, DOI:10.1089/acm.2007.7088