Classifications of Complementary and Alternative Medicine

The NCCAM has classified CAM therapies into five major but overlapping categories:

1. Alternative medical systems

2. Mind-body interventions

3. Biologically based therapies

4. Manipulative and body-based methods

5. Energy therapies

*Policies of House of Delegates-I-95; H-480.973; BOT Rep. 15-A-94, Reaffirmed and Modified by Sub. Res. 514, I-95.

Alternative medical systems are complete, complex systems of health-care practices that incorporate natural products, spiritual elements, diet, and other modalities. Some systems such as homeopathic medicine and naturopathic medicine have evolved in the Western world, whereas others, such as Chinese medicine and Ayurvedic medicine, have developed in non-Western cultures. Ayurvedic medicine was developed in India more than 5000 years ago and is the best known of the traditional approaches associated with Indian medicine. The system involves the use of diet and herbal remedies, with emphasis on the mind, body, and spirit in disease prevention and treatment. Homeopathic medicine is based on the belief that ''like cures like'': minute doses of highly diluted animal, vegetable, and mineral substances can cure the symptoms that would be caused by higher concentrations of the same substance in a healthy person. It is believed that these minute doses stimulate the body's own defense mechanism to fight off illness. These natural substances are nontoxic and nonaddictive and have no known side effects. Homeopathic medications are regulated by federal law, and most are sold over the counter. Naturopathic medicine is based on the concept of natural healing and uses only natural, gentle, nontoxic treatments with the goal of having the body heal itself. Some of the naturopathic processes include dietary modifications, mineral and herbal supplements, exercise, massage, and acupuncture.

Mind-body interventions entail a wide variety of techniques to improve the mind's capacity to affect bodily function and symptoms. Cognitive therapies, biofeedback, meditation, hypnosis, prayer, and creative outlets such as dance, music, and art are common examples of mind-body interventions.

Biologically based therapies involve herbs, vitamins, dietary supplements, and foods to treat disease. Around the world, these products are extraordinarily popular, and billions of dollars are spent on them in the United States alone. The assumption is that natural products are healthier and better than synthetic chemicals for treating disease. Dietary supplements are not considered drugs and therefore are not regulated and do not require U.S. Food and Drug Administration approval.

Manipulative and body-based methods include modalities that move one or more parts of the body. These methods include massage, chiropractic, osteopathy, and reflexology. Chiropractic is concerned with the relationship between structure and function. The primary structure is the spine, and the function is the nervous system;this relationship is thought to affect the restoration and preservation of health. The first chiropractic adjustment was given in 1895. The basic principle of chiropractic is that any interference with the transmission, reception, or application of impulses that travel over the nervous system causes functional abnormalities or disease. This interference may be the result of a vertebral subluxation. Over the years, numerous definitions have been formulated to describe the nature of subluxation. In all of these, there are at least four main criteria or characteristics:

1. Misalignment of the vertebra in relationship to the ones above and below it

2. Abnormal vertebral motion

3. Lack of joint play

4. Interference with the transmission of neural impulses

The vertebral subluxation may be the result of any of the following causes: trauma, toxins (infections, poisons), and autosuggestion (psychologic factors). Vertebral subluxation is treated with a chiropractic manipulation referred to as an adjustment. The chiropractic adjustment is a specific form of direct articular manipulation characterized by a dynamic, forceful highvelocity thrust of controlled amplitude. These adjustments may be administered by hand or instruments directed at specific articulations. It is believed that chiropractic adjustments energize the life force that connects the spine to all parts of the body to promote healing and restore health. Chiropractic has become one of the largest drug-free healing professions. According to a survey released by the Centers for Disease Control and Prevention, nearly 20% of the adult population in the United States has used chiropractic at least once.

Osteopathy focuses on diseases arising in the musculoskeletal system. The belief is that all the body's systems work together, and disturbances in one system affect functions in another. The field involves understanding the entire patient, physically, psychologically and emotionally, to uncover the underlying causes of symptoms. Osteopathic physicians use musculoskel-etal manipulation, recommendations about diet and exercise, and general preventive medicine to alleviate pain, restore function, and promote health.

Reflexology is a body-based therapy in which pressure is applied to the feet and hands to treat a variety of ailments and promote well-being and improved health. The therapist applies the tips of the fingers firmly to areas of the recipient's feet or hands to assess the state of health of every part of the body. In reflexology, it is believed that every organ or gland has a

Top of head/brain

Side of head/brain

Eyes

Eustachian tube

Shoulder

Top of head/brain

Shoulder

Kidney Ureter Bladder

Ileocecal valve

Diaphragm Liver Adrenal

Ascending colon

Ileocecal valve

Neck Parathyroid Thyroid

Lung

Solar plexus Stomach Pancreas Gallbladder

Kidney Ureter Bladder

Trachea Bronchus

Esophagus

Pituitary

Sinuses Ears

Pituitary

Trachea Bronchus

Esophagus

Descending colon

Sigmoid colon

Sciatic nerve

Pancreas

Transverse colon Small intestine Rectum

Heart Stomach Spleen

Waist

Descending colon

Sigmoid colon

Sciatic nerve

Figure 4—1 Reflexology foot maps. The densest concentration of reflex areas is found on the soles of the feet.

representation in a reflex point on the foot or hand that is linked through a series of longitudinal and transverse zones. The longitudinal zones run through both the arms and legs to the organ or gland. By manipulating the reflex area, most of which are found on the soles of the feet, as shown in Figure 4-1, the therapist can treat that area of the body.

Energy therapies, which involve the use of energy fields, are categorized into three types: biofield therapies, bioelectromagnetic-based therapies, and acupuncture. The term biofield was coined in 1994 at a meeting at the NIH, and the biofield hypothesis purports that all objects radiate an electromagnetic field. If an object such as part of a healer's body, a nutritional supplement, or an externally applied electromagnetic field is brought near to or inside the body of an individual, the frequencies radiated by the object or field would interact with the individual's field. Biofields have been described traditionally by the ancient Indians as prana, by the Chinese as qi (or chi), by the Japanese as ki, by Jewish mysticism as ''astral light,'' and by Christian painters as ''halos.'' Current practices involving biofield therapies are intended to affect a patient's energy field for the purpose of healing by having a healer place his or her hands in or through them; the therapist's healing force restores the patient. Examples of this type of energy therapy include Reiki, qi gong, and therapeutic touch. Reiki, a Japanese word meaning ''universal life energy,'' is an ancient form of healing by touch and is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patient's spirit is healed. It is a way of channeling this energy through one's hands, enabling the body to accelerate its own healing process. Qi gong is a Chinese technique that combines slow-moving meditative postures, meditation, stretching, and regulation of breathing to enhance the flow of qi in the body to enhance immune function and improve circulation.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields. Positioning external magnetic fields near or around the person, usually by placing magnets on the body, into clothing, or in mattresses, is an example of this type of therapy.

Acupuncture is a healing art in which needles are placed into the body to allow qi (energy) to flow unimpeded. Advances in acupuncture allow for the attachment of electrodes to the needles through which small currents are passed. The dominant form of therapy in traditional Chinese medicine is acupuncture. To understand acupuncture, the reader must first understand the concept of meridians. Meridians are a unique part of Chinese medical theory; they are the channels through which qi flows among the organs, adjusting and harmonizing their activities. The meridians, which are not blood vessels, are 20 to 50 mm in diameter and link together all the fundamental substances and organs. They are bilateral and exist beneath the surface of the skin. The places at which the branches reach the skin surface are designated as acupuncture sites.

Each meridian has an entry and exit point;energy enters through the entry point and flows through to the exit point. There are 12 primary meridians of the body, each running vertically, bringing qi and the other four essential substances to specific parts of the body. No part of the body is without qi; a blockage causes an imbalance in the flow of the life force. In Figure 4-2, a male model demonstrates where the meridians and acupuncture sites are indicated. Figure 4-3A depicts the clinician placing an acupuncture needle in the buttocks of a man with sciatica; Figure 4-3B shows all the needles in position.

Shen is the energy, unique to human life, that is responsible for the spirit, consciousness, emotions, and thoughts. It is associated with the force of human personality. Jing is the fluid that is the basis of reproduction and development. Xue (pronounced ''schwhey'') moves in the same channels as qi and is similar to blood but is produced by food, refined in the spleen, and transported to the lungs, where nutritive qi turns it into xue. Jin-ye is all fluids other than xue. It includes sweat, urine, saliva, mucus, bile, and gastric juice. These five essential substances constitute the basis for the Chinese traditional medical system.

Acupuncture is used for prevention and treatment of disease and for maintenance of health by manipulating the flow of qi and xue, or body fluids, through the body channels. Although most Western clinicians have heard of acupuncture, few understand it. The Chinese have used acupuncture for more than 6000 years to stimulate or awaken the natural power within the body. It is estimated that there are 9 to 12 million treatments a year in the United States. Acupuncture involves the use of nine fine needles, each with a specific purpose. There are as many as 2000 specific points, each 3 mm in diameter, along the meridian lines on the skin into which these needles can be inserted. Most acupuncturists use only 150 of these points. The Chinese have different names for each acupuncture point. Examples of the classic needles,

Figure 4—2 Meridians and acupuncture sites on male model.

Figure 4—2 Meridians and acupuncture sites on male model.

Figure 4—3 Acupuncture. A, Physician inserting needles into a patient with sciatica. B, Needles in position.

Figure

States.

Figure

States.

Classic acupuncture needles. 1 and 2, Thin filiform needles most commonly used in the United which also include scalpel and lancet-like instruments, are shown in Figure 4-4. The needles marked "1" and ''2'' are the most commonly used needles. The needles act as antennae to direct qi to organs of the body. At other times, the needles may drain qi when it is excessive.

Acupuncture has been used to treat illnesses from childhood to old age. Figure 4-5 depicts an acupuncture tray with supplies. While lecturing in Taiwan, I had the good fortune to visit the China Medical College in Taichung, where there is a special department for patients who wish to obtain traditional Chinese medical treatment. The child shown in Figure 4-6A was brought in by his mother, who stated that her son was having symptoms of a cold; the man in Figure 4-6B was complaining of sinus problems;and the older woman in Figure 4-6C was complaining of headaches. Figure 4-6D is the foot of the child shown in Figure 4-6A.

Ear acupuncture, known as auriculotherapy, is practiced by traditional Chinese acupuncturists for the diagnosis and therapy of organ system disharmony. This technique, however,

Figure 4—5 Acupuncture supplies.
Fort Iii Osteotomy
Figure 4—6 Acupuncture. A, Child with upper respiratory infection, under treatment. B, Man with sinus headache, under treatment. C, Woman with headache, under treatment. D, Foot of child with upper respiratory infection shown in A.

did not develop in China. A French physician, Paul Nogier, introduced this concept in 1958. Figure 4-7 shows the acupuncture sites of the ear. Auriculotherapy is based on the concept that there are specific parts of the ear that can be related to specific parts of the body and its functions. Although the specificity of ear acupuncture points has never been clearly demonstrated, most acupuncturists agree that ear acupuncture has a calming effect. Indeed, the most frequently cited ear point used in treatments is called shenmen, or spirit gate. The Handbook of Chinese Auricular Therapy (Chen and Cui, 1997) states of this point that ''It is used in numerous diseases of the neuropsychiatric system____The application of this point is fairly extensive and flexible, covering no less than 30 kinds of diseases or ailments.''

Moxibustion is a specific form of acupuncture in which herbs are burned to stimulate specific acupuncture sites. If a disease fails to respond to traditional acupuncture, moxibustion is used. Moxa leaves (Artemisia chinensis) are either rolled into a cigar-shaped stick or pulverized and made into a cone. The moxa stick is lit, and the glowing end is held over the vital spot to be treated;the cone is placed on the skin over the acupuncture site and ignited, letting it burn slowly near the skin, as shown in Figure 4-8A. Often, the rolled moxa cone is placed on the end of an acupuncture needle and then lit to enhance the acupuncture therapy; this is shown in Figure 4-8B in a patient complaining of lower back pain. Moxibustion is used for conditions in which there is an excess of yin and is contraindicated for heat and excess yang disharmonies.

In 1997, the NIH convened a panel of independent experts to review the clinical studies of acupuncture. The panel noted that the results of several studies, many sponsored by the NIH, were unclear because of design, sample size, and other factors, complicated by difficulties in

Figure 4—7 Acupuncture sites of the ear.

the use of appropriate control subjects. The panel did agree that acupuncture has been shown to be effective for relief of the following:

1. Adult postoperative nausea and vomiting

2. Nausea and vomiting secondary to chemotherapy

3. Postoperative dental pain

The panel determined that acupuncture may be useful as an adjunct treatment, as an acceptable alternative, or as part of a comprehensive management program for addiction, stroke

Figure 4—8 Moxibustion. A, Moxibustion cone. B, Moxibustion and acupuncture therapy in a patient with low back pain.

Figure 4—8 Moxibustion. A, Moxibustion cone. B, Moxibustion and acupuncture therapy in a patient with low back pain.

rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma. Further research is likely to uncover additional areas in which acupuncture interventions is useful.

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