Integrative medicine

Integrative medicine, according to the Columbia University School of Medicine, deals with the optimal combination of mainstream and complementary and alternative medicine. Traditional medicine, when differentiated from more modern techniques of complementary medicine, can also be part of integrative medicine. 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

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.

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.

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."

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. 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. 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; 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, 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.

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. The U.K. government is also examining additional ways to get meaningful evidence.

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. 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.

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: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.
  • Conventional medicine
  • Osteopathy, as distinct from osteopathic medicine
  • 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

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. 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. 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.	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.	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, 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.

Co-management

Examples from chiropractic

Interdisciplinary consensus panels have found that chiropractic has demonstrated safety and efficacy for low back pain. 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.

Red flag

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.

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 Unstable acquired bleeding disorders Inadequate physical examination

Another category where chiropractic may be used, but not directly over an area afflicted with:

Avoid local area

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:

Medical referral indicated

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.

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.