Complementary and Alternative Therapies

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Complementary and Alternative Therapies Janet Webb, BSc(Pharm), MSc Date of Revision: April 2013

Introduction

The promotion of wellness to prevent disease and enhance quality of life has engaged individuals in proactive self-care. Greater public awareness about the importance of attaining and maintaining wellness has been accompanied by a remarkable increase in the use of unconventional therapies in patient self-care. These therapeutic approaches bring with them terminologies and philosophies that can be confusing to those trained in the conventional medical sciences as practised in North America. A vital step in better understanding these approaches is recognition of the extent of use by Canadians, user demographics, reasons for use and patterns of use, all of which continue to evolve. Appreciating the diversity of treatments and the philosophies behind them, finding objective evidence to support their use and the efforts to integrate validated therapies into patient care are challenges facing Canada's health care professionals.

Prevalence

Increased human mobility and improved global communication has led to increased awareness of and exposure to unfamiliar therapies, and a greater exploration of these treatments by North Americans. Use has surged in developed nations, where these treatments are better known as complementary and alternative medicine (CAM).1 Although surveys of CAM use provide inconsistent findings because the definition of CAM varies (some include prayer in the definition), they can still be useful to identify trends and patterns.2 Between 1990 and 1997 in the United States, the use of herbal products increased by 380% and high dose vitamin use increased by 130%.3 A 2007 survey of Americans revealed approximately 38% of adults and 12% of children had used CAM (excluding vitamins and minerals) in the preceding 12 months.4 From 2002 to 2007 there was increased use of acupuncture, deep breathing exercises, massage, meditation, naturopathy and yoga. A survey performed in 2005 in the UK revealed 29% of respondents taking prescription drugs had used CAM in the preceding 12 months. The most commonly used therapies were massage, acupuncture, aromatherapy, and herbal medicine.5 General trends include higher prevalence rates of CAM in western regions, women, those with higher levels of education and income and, importantly, in those with chronic conditions.4,6,7,8,9,10,11 Certain populations are more likely to use CAM therapies. Surveys undertaken in various regions of Canada have demonstrated high use of CAM therapies by ethnic Chinese Canadians.12,13,14 First Nations communities also maintain traditional healing practices as demonstrated by a study in Nova Scotia, which found 66% of attendees to a clinic used Mi'kmaq medicine in addition to western medicine, and of these 92.4% did not discuss this use with their physician.15 A survey of Canadians visiting a CAM practitioner in the previous 12 months indicated 12% of the general population made such visits, whereas 15% of asthmatics, 19% of migraineurs, and 8% of diabetics participated. Surveyors hypothesized that patients with adequate control of their disease were less likely to seek alternatives.11 This theory is supported by an analysis of consultations with alternative health care providers (massage therapy, acupuncture, homeopathic/naturopathic treatment) in Ontario. Women with chronic conditions (fibromylagia, chronic fatigue, high blood pressure, and chemical sensitivities) were more likely to seek an alternative provider if they felt their health care needs were not being met.16 It is estimated that 57–80% of cancer patients use one or more CAM interventions.17 The incidence of lifetime use of a CAM product/therapy or visit to a CAM therapist was found in randomly selected breast cancer survivors in Ontario to increase in recent years (67% in 1998 versus 82% in 2005), with 41% of 2005 respondents reporting use of CAM to manage their cancers.18 A survey examining the use of herbal remedies by cancer patients in the UK found that usage increased with time since diagnosis.19 The use of CAM by pediatric cancer patients since diagnosis was 20-60% in the majority of studies included in a systematic review.20 Chronic, difficult to treat conditions prompt patients to seek alternatives, and those facing devastating diseases turn to

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CAM when conventional treatments have been exhausted (although most patients with life-threatening conditions do not use CAM exclusively).

Safety

Although Canadian consumers desire reliable information on CAM, they often base their choices on potentially unreliable or unsubstantiated sources. Claims by unscrupulous manufacturers and distributors can mislead and confuse consumers with pseudo-scientific jargon and rhetoric.21,22 In Canada, natural health products (NHPs) are sold without proof of effect, and verbal claims are made by health food store personnel despite lack of supporting evidence.23 A lack of knowledge of basic safety issues such as herb-drug interactions and contraindications increases the risks of an adverse outcome when such personnel provide advice.24 Of additional concern is the lack of accreditation or standards for alternative practitioners in Canada.25 A 2010 survey of Canadians regarding NHPs found that 73% of Canadians used NHPs (including vitamins).26 Notably, this survey demonstrated increasing public awareness regarding NHP safety issues, and that the most preferred NHP information sources were physicians and pharmacists. Nonetheless, many Canadian consumers are reluctant to discuss NHP usage with conventional health care providers, fearing lack of support in their decisions to choose NHPs and doubt regarding the consumer's values and beliefs.27 It has been estimated that less than 1% of those who use NHPs disclose this information to their pharmacist.28

Evidence

There is a gap between published randomized controlled trials (RCTs) finding CAM to be of little or no effect, and anecdotal reports of clinical benefit by CAM practitioners and their patients.29 Pharmacists are well placed to discuss CAM options with patients, especially NHP selection, but many feel ill equipped to provide reliable information based on sound research.30,31 This leads to frustration at the pharmacy, as less than half of patients surveyed thought that their pharmacist provided useful information about complementary therapies.32 In direct contrast to drug therapy where research precedes marketing approval, a lack of regulatory oversight in CAM has seen these therapies become embedded and diversified before clinical trials are conducted.23,29,30,33,34 For example, an assessment of published RCTs of herbal interventions found quality of the reports to be unsatisfactory, reinforcing the need for adoption of established reporting standards.35 Mainstream medicine has historically overlooked, ignored or rejected CAM, citing lack of convincing evidence, flawed methodology and bias in CAM research, but increasing use by patients demands greater understanding by practitioners. For health professionals to adopt any evidence into clinical practice they must be aware of research results, be able to assess and interpret research findings, then apply the evidence into clinical practice.36 Because CAM does not have a tradition of scientific research, there are obstacles to this approach (see Table 1). Application of scientific research findings into clinical practice by both conventional and CAM practitioners can be haphazard and inconsistent.37 Schools that teach CAM therapies do not have a tradition of research or research infrastructure, so in certain areas of practice (traditional Chinese medicine [TCM]) investigators are not familiar enough with clinical trial methodology to perform research that satisfies western reviewers. Developing an evidence base for CAM therapies is a well-recognized challenge being addressed internationally. To promote standards of practice in CAM, the World Health Organization has developed training benchmarks to ensure practitioners have adequate knowledge, skills and awareness of appropriate usage and safety in a variety of CAM practices, including TCM, Ayurveda, naturopathy, osteopathy and others.38 Additionally, the Cochrane group involved in CAM is distributing guidelines on trial design and reporting standards to CAM practitioners, with a particular focus on TCM.39 The National Center for Complementary and Alternative Medicine (NCCAM) within the National Institutes of Health of the United States government has invested US $2 billion to support CAM research.36 Education programs are underway both to educate CAM practitioners on clinical research methodology39 and to introduce conventional health care providers to CAM, to promote open dialogue with patients.40,41 Nonetheless, high-quality RCTs in CAM do exist,42 and can be designed.43 In Canada, collaborative projects to gather CAM evidence include the Canadian Institute of Natural and Integrative Medicine (www.cinim.org), and IN-CAM (the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research) (www.incamresearch.ca).

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IN-CAM also provides high-quality reviews of CAM therapies and natural health products (www.camline.ca). Systematic reviews are being used to gather and synthesize evidence and to identify potential areas of research. The Cochrane CAM Field is an international group dedicated to producing and disseminating systematic reviews of RCTs in numerous CAM areas (acupuncture, massage, chiropractic, homeopathy, herbal medicine, mind-body therapy).44 As of 2011 over 39,000 CAM-related controlled trials were identified for the specialized trial registry database.44 Although not without challenges (considering the heterogeneity of CAM therapies), nearly 600 systematic reviews involving CAM were listed in the Cochrane Library in 2012.45 Cochrane reviews of CAM treatments for specific conditions are made readily available as plain language summaries. Table 1: Challenges with CAM Evidence Locating published evidence34,46,47,48

lack of consistent CAM terminology and indexing headings publication bias in high-impact journals foreign language

journal reviewers may be unfamiliar with CAM methods

many CAM journals are not included in conventional databases (PubMed) Methodology and research design issues29,33,34,39,42,49,50,51 heterogeneity of products and practices

lack of standardization of biologic products hampers reproducibility

lack of regulation for various practices make effects of treatment difficult to measure

lack of regulation complicates ethical review board approval difficulties with blinding (e.g., acupuncture) expectation bias and placebo effect

lack of appropriate animal models for some areas of CAM lack of funding for large CAM trials

difficulty with quantifying certain CAM outcomes (e.g.,“personal growth”)

Integrative Medicine

Integrative initiatives are fostering closer collaboration between conventional medicine and CAM practitioners to deliver a more comprehensive approach to patient care. Integration can occur on different levels—as individual practitioners combine therapies (physicians performing acupuncture), or in integrative clinics and institutions where conventional and CAM practitioners work together.52 Greater collaboration between conventional and CAM practitioners will enable improved monitoring of adverse effects, identification of therapeutic benefit following an integrative approach and foster research.53 Additionally, working in a collaborative integrated environment positively impacts job satisfaction and personal growth of Canadian practitioners.54 In Alberta, the CAM in UME Project (Complementary and Alternative Medicine Issues in Undergraduate Medical Education) is underway to increase medical student awareness of and knowledge about CAM.41 Other Canadian examples of established clinical integrative programs include CARE (Complementary and Alternative Research and Education), which is an academic pediatric integrative medicine program in Edmonton (www.CARE.ualberta.ca) and InspireHealth, an integrative cancer care program with several centres in British Columbia (www.inspirehealth.ca). With the increasing use of CAM therapies, and the integration into mainstream medical practice, health care professionals must become familiar with relevant terminology. The following provides definitions and brief descriptions of some terms that health care providers may encounter in this evolving area.

Definitions

It is challenging to define the spectrum of CAM approaches. As western medicine becomes experienced with certain

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practices, the approaches become standard treatment and are no longer considered complementary or alternative. The National Center for Complementary and Alternative Medicine (NCCAM) in the United States defines CAM “as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between CAM and conventional medicine are not absolute, and specific CAM practices may, over time, become widely accepted.”55 Although the terms “complementary” and “alternative” medicine are often used interchangeably, they are considered distinct.55 Alternative medicine is used in place of western medicine (e.g., using herbs rather than antidepressants to treat depression), whereas complementary medicine is used in combination with western medicine (e.g., using acupuncture to reduce pain in cancer patients). Integrative medicine combines conventional western medicine and those complementary treatments for which there is sound evidence of effectiveness and safety, but does not replace conventional therapy (e.g., massage and guided imagery to ease pain).55,56

Categories of CAM

The National Center for Complementary and Alternative Medicine in the United States groups CAM therapies into 5 major categories (see also Table 2 and Table 3): Alternative Medical Systems55 These are complex and comprehensive systems of treatment, encompassing both theory and practice, which have developed outside the sphere of conventional medicine. Some have been in use for thousands of years (e.g., traditional Chinese medicine) while others have been developed more recently (e.g., homeopathy). These include traditional Chinese medicine, Ayurveda, homeopathy and naturopathic medicine (defined below). Mind-Body Interventions55,57,58,59 This type of therapy uses techniques meant to utilize the brain or mind to influence body function (see Table 2). The concept that the mind can influence illness is integral in the healing approaches of traditional Chinese and Ayurvedic medical systems.60 Evidence from RCTs and systematic reviews suggest a connection between the nervous system and other body systems (e.g., the immune, autonomic and endocrine systems), which can be employed to promote self-healing and well-being. Observed positive psychological effects and enhanced quality of life may be of particular use for individuals with chronic conditions and in need of palliative care. In cardiovascular care, the will to live, a supportive family/community and a strong spirit have been linked to positive outcomes (albeit from anecdotal reports).61 The connection between the mind and body has been explored in the use of support groups for cancer patients (now considered mainstream therapy) and in the effect of exercise on altered mood (e.g., depression). In pediatrics, hypnosis, guided imagery and biofeedback have been used effectively to manage pain, anxiety, stress and sleep disorders.42 Mind-body interventions are considered low risk. Natural Product-based Therapies (also known as Biologically-based Practices)55,61 This describes the use of natural/biologic products, which can be derived from plants (e.g., herbs) or animals (e.g., shark cartilage), and also includes vitamins, minerals, fatty acids, amino acids, proteins, prebiotics, probiotics, whole diets and functional foods (see Table 2). Orthomolecular and megavitamin therapies are in this category. Manipulative and Body-based Methods55,62,63,64 These manual therapies involve manipulation or movement of the body (see Table 2). Some methods propose that bodily function depends on proper body alignment, and that misalignment or asymmetry results in illness, possibly at a site distant from the distortion. Correction of body symmetry optimizes the balance between the sensory and motor nervous systems.62 Restoration of structural imbalance improves supply and draining of blood and lymph, promotes improved nutrition to tissues, and facilitates the body's ability to heal itself.62 Energy Therapies55 These methods seek to manipulate putative energy fields (biofields) within the body or those fields external to it (see

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Table 2). Traditional Chinese Medicine, refers to a vital force or energy as qi (pronounced “chee”) which circulates through the body in invisible pathways termed “meridians”. The theory of energy work maintains that the universe is permeated with a “life force” or “vital energy” that also surrounds and pervades the human body.65 Imbalance or blockages of the energy may result in disease, and therapy is aimed at correcting these problems. When treating the malady, a close, cooperative participation between the practitioner and the patient is required. Therapeutic touch, reiki and qigong are examples of energy therapies. Table 2: Major Groupings of Some Common CAM Approaches

a

Alternative Medical Systems Ayurvedic medicine

Traditional Chinese medicine Homeopathy Naturopathy

Japanese traditional medicine Tibetan traditional medicine Mind-Body Interventions Aromatherapy Biofeedback Hypnosis Imagery

Relaxation techniques Meditation Tai chi Yoga

Natural Product-based Therapies Herbalism

Nutrition therapy (includes diet therapy, dietary supplements) Hydrotherapy

Manipulative and Body-based Methods Chiropractic manipulation Craniosacral massage Massage

Osteopathic manipulation Reflexology Rolfing Tui Na

Energy Therapies

Acupuncture, Acupressure, Moxibustion Magnetic therapy Qigong

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Reiki

Therapeutic touch Derived from the Cochrane Collaboration Complementary Medicine Field60 and the National Center for Complementary and Alternative Medicine (NCCAM).55

a

Table 3: Examples of Delivery Methods for CAM

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Treatments Primarily Self-administered Herbal remedies

Nutritional supplements Health foods Meditation

Magnetic therapy Treatments Administered by Provider Acupuncture

Massage therapy Reflexology

Chiropractic manipulation

Osteopathic manipulation Treatments Self-administered Under Periodic Supervision or Guidance by Provider Ayurveda

Biofeedback

Homeopathy

Hydrotherapy

Nutritional therapy Tai chi

Derived from the Cochrane Collaboration Complementary Medicine Field and the National Center for Complementary and Alternative Medicine (NCCAM)55

a

Definition of Therapeutic Modalities Acupressure Acupressure is a manual therapy in which deep pressure is applied to certain acupuncture points.62,66 It is theorized that different noxious stimuli, including emotional trauma, cause energy to accumulate in particular pressure points situated along the channels or meridians through which qi flows. Application of pressure by the practitioner improves flow of qi, causing a release and dissipation of tension, alleviation of disease and relief of pain.62 It has been studied for the treatment of nausea of pregnancy, headache, backache, stroke and traumatic brain injury.66,67 Application of pressure to a particular point on the inside of the wrist has been promoted to alleviate motion sickness.68

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Acupuncture can describe either a therapeutic discipline or a technique, which can vary with different traditional approaches.69 Needles of various sizes, but commonly having a shaft of 25 mm and a diameter of 0.25 mm, are inserted at specific points on the body to regulate the flow of qi along chosen meridians.70,71 In a more conventional approach, these acupuncture points are termed “trigger points,” which correspond to areas of increased sensitivity that can produce referred pain in a characteristic manner.72 Anatomically, these points correspond to peripheral nerve junctions and are involved in pain transmission. The technique itself involves the insertion of several needles (usually 4–10), and may vary with respect to angle and depth of insertion, length of time retained (often 10–30 minutes), manipulation methods (e.g., twirling, electrical current) and frequency of treatment.72 Variations on needle therapy include Shiatsu, moxibustion, acupressure and electric currents. Areas of interest in acupuncture treatment include pain management, including postoperative dental pain, headache, substance abuse, nausea, asthma, urticaria and stroke rehabilitation.67,72,73,74,75 Neural pathways, neurotransmitters and hormonal factors are believed to be affected by acupuncture.76 Research supports the use of acupuncture in pain secondary to temporomandibular dysfunction, fibromyalgia, osteoarthritis, low back pain and idiopathic headache,77,78 including recurrent headache in children.42 Systematic reviews have concluded acupuncture is an option for chronic pain,79 migraine prophylaxis80 and tension-type headache.81 Compared to sham treatment, refractory pain in cancer patients has responded to acupuncture.17

Anthroposophic Medicine

Anthroposophic medicine is a medical system which includes spiritual and physical components when considering a disorder. Treatments include both passive (massage, diet, herbal and conventional medicines) and active modalities (art therapy, movement therapy).82,83

Applied Kinesiology

This chiropractic diagnostic technique is distinct from kinesiology, and uses acupressure points and muscle strength testing to identify health and nutritional problems.61,84 Practitioners assert that weakness in particular muscles corresponds to specific illnesses or deficiencies which can be corrected by manipulation or supplements.

Aromatherapy

Aromatherapy is a treatment method using volatile (essential) oils derived from plants whose fragrance or odour is deemed an integral part of therapy.85 The oils are extracted from plants, diluted with vegetable oil then often applied to the skin by massage, or they can be delivered in steam for inhalation of the scent.66 When applied externally, the fragrance, the massage itself and the dermal absorption of the constituents are all deemed beneficial,86 although a psychological component cannot be ruled out.57 In the United Kingdom, aromatherapy has been used in conventional settings such as hospices, palliative care units, cancer units and pediatric units.85

Ayurveda Ayurveda is a major medical system, originating in India, and possibly dating back 5000 years.55,66,87,88 It is a sophisticated, complex system of theory and practice, which considers the body, mind and spirit, and attempts to achieve harmony and balance between them. It is believed that the body is a miniature representation of the universe. The same elements that form the universe form the human body; when the elements are out of balance, ill health results. Patient assessment includes physical examination as well as consideration of mental and social factors. Treatment choices include manipulation, diet, yoga, meditation, purification to rid the body of toxins (possibly involving vomiting, purgation or enemas) and rejuvenation therapies to build the body's strength. Herbal therapies are employed, as well as minerals and metals, which might include heavy metals. Lead poisoning has occurred following the use of Ayurvedic remedies brought into Canada.89

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Biofeedback is a system that permits a patient to regulate body function (e.g., heart rate, blood pressure, degree of muscle contraction) by receiving feedback signals from instruments monitoring the function, and to adjust the physiologic process accordingly.66 It may be effective for varied conditions including irritable bowel, bladder disorders, asthma, headache, cardiac arrhythmias and hypertension.61,84

Chinese Herbal Medicine

Chinese Herbal Medicine is an integral part of Chinese medicine, which encompasses use of animal parts and minerals in addition to plant material.70,90 The Encyclopedia of Traditional Chinese Medicinal Substance, published in 1977, lists over 5000 entries. Substances are categorized according to their properties, for example heat clearing, wind dispelling or blood rectifying. The use of medicinal substances can be complex, with specific combinations selected considering their compatibility and complementary/synergistic effects.91 Typical combinations contain 2–40 herbs in differing amounts, and the combination will be adjusted during the course of treatment according to the clinical presentation.90 They are usually consumed as a decoction (simmered tea) but also may be dispensed in solid dosage forms or used externally. Be aware that some Chinese Herbal Medicine products may contain contaminants or be otherwise adulterated.

Chiropractic Chiropractic is a manipulative therapy aimed at correcting misalignment within the musculoskeletal system.64 Chiropractors apply a variety of manoeuvres, such as sharp thrusts, to the spine, pelvis and limbs in order to adjust alignment and correct disorders.92 Although formerly advocated for treating a wide variety of complaints, today it is limited primarily to treating musculoskeletal disorders. There is evidence for its use in acute low back pain and in tension-type and migraine headache.64,84 Rarely, stroke or vertebral artery dissection have followed manipulation of the neck.64

Craniosacral Therapy

Craniosacral therapy is a manual technique in which gentle pressure is applied to the skull to adjust and normalize rhythmic pulsations of the cerebrospinal fluid.93,94 It has been purported to relieve pain (e.g., headache) and vertigo.

Cupping and Bleeding

This is a component of Chinese medicine in which a warm glass or bamboo cup is placed on the skin. As it cools, the suction created draws blood and lymph to the skin surface. It is used to assist circulation and to remove “cold and damp” which are considered external causes of disease.70,93 Arab healers believed that cupping would relieve a variety of ailments, from toothache to elephantiasis.71

Dietary Supplements

This term has various interpretations. In the United States it is defined by the Dietary Supplement Health and Education Act (1994) as a product intended to supplement the diet which may contain one or more dietary ingredients including vitamins, minerals, amino acids, herbs or other botanicals and other substances.95 It is an oral dosage form (pill, tablet, capsule or liquid) and must be labelled as a dietary supplement. Its intended use is to resolve a nutritional deficiency or to improve or sustain the function of the body. If used to diagnose, prevent, treat or cure a disease it is considered a drug, and not a dietary supplement. The Act does not require proof of efficacy or safety or standardization.95 The accepted regulatory term in Canada is Natural Health Product, which is defined differently (see Natural Health Product (NHP)).

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According to Health Canada, “a functional food is similar in appearance to, or may be, a conventional food, is consumed as part of a usual diet and is demonstrated to have physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional functions.”96 Examples of foods which are thought to have benefit by supplying biologically active ingredients are eggs enriched with omega-3 fatty acids, cereals containing oat bran and tomatoes rich in lycopene.97

Functional Medicine

Functional medicine is a patient-centred care model which integrates conventional and CAM practices, and considers the interplay between environment, lifestyle, genetic and mind-body factors, and their influence on the health of an individual. Nutrition, diet and exercise are strategies emphasized in disease prevention; conventional diagnostic and treatment methods are combined as necessary with CAM therapies in treatment.98

Herbalism

Herbalism is an approach which uses plant materials not only as substitutes for pharmaceuticals, but to optimize health and wellness. The WHO has taken the position that, in the absence of opposing scientific evidence, the traditional and historical use of herbal remedies provides evidence of their efficacy and safety;99,100 they also published a document to guide quality control in herbal medicines.101 Medical herbalism has been a sustained therapeutic approach in numerous countries, including western nations such as Germany where modern pharmacology and herbalism successfully co-exist.1 The entire plant kingdom, including moss, algae and fungi may be utilized (although some herbal traditions also use animal parts, insects, metals, rocks, shells, etc.).102 Concepts include the belief that the therapeutic response to a plant will be different than the response to an individual chemical component of the plant.93 Growing conditions, collection and storage methods will also affect response, as will the expectations of the patient and the cultural significance of the plant (which may include a placebo component). Recognition is given to patients' involvement and responsibilities in their own self-care.

Holistic Medicine

This is an approach that takes into account the body, mind and spirit of an individual, as well as the interaction of the three to maintain health and well-being.93,103 Some argue that competent physicians have always done this, and that this is not the exclusive domain of alternative practitioners.56 What might be termed holistic approaches, involving multidisciplinary teams (physicians, spiritual healers and psychological counsellors) have been successfully incorporated into conventional medical practices.104,105

Homeopathy

Homeopathy is an alternative medical system, dating back to the early 19th century, which is based on the philosophy that the body has an innate ability to heal itself, and that “like cures like.”63,69,106,107 It teaches that symptoms are manifested when the body attempts to heal itself or to correct an imbalance. The constellation of symptoms guides therapy. A substance that produces a specific pattern of symptoms in a healthy person will, when given in minute doses, help fight an illness with identical symptomatology. By increasing symptoms, the body is thus encouraged further to overcome the affliction. When choosing a therapy, the homeopath considers the mental and emotional state of the patient, in addition to the physical. The closest match between the symptoms of the individual and the remedy are attempted, recognizing that different people will exhibit different symptom patterns. The homeopathic arsenal contains more than 2000 substances, derived from plants, minerals, metals, animal products and even diseased tissues. The substances are prepared in serial dilutions, which are vigorously shaken with each dilution, which is believed to increase potency. Potencies are typically noted as X or C, indicating 1:10 dilutions, or 1:100 dilutions, respectively (e.g., 6X will denote 6 dilutions of 1:10). Dilutions may be such that no molecules of the original substance exist in the final preparation. Paradoxically, the greater the dilution, the higher the potency. Preparations of highest potency are reserved for use under the direction of a homeopath. In North America, asthma, headache, depression, allergies, psychosocial problems and skin conditions are among the most frequent conditions treated by homeopaths. In the UK, homeopathy is often used in children to treat minor

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self-limiting conditions.108 The WHO has developed a document addressing safety issues in homeopathic remedies.109

Hydrotherapy

Hydrotherapy is the use of water as therapy, which encompasses a multitude of diverse applications including baths, saunas, douches, immersion, wraps and colonic irrigation.71,110

Hypnosis

Hypnosis is used to induce a state of relaxation by selective attentional focusing using imagery or distraction, where intrusive thoughts can be ignored.17,61,111 It includes a suggestive component where therapeutic goals can be introduced (e.g., a pain-free state). It is possible to maintain the behaviour once the hypnotic state has been terminated. Muscle relaxation, altered perception and cognitive distraction are possible mechanisms.111 It has been found useful in coping with pain, distress and anxiety in children with cancer undergoing bone marrow aspiration.17

Imagery

Patients are taught to use directed mental images to promote changes in attitudes or behaviour, relieve symptoms or to encourage physical healing. The process may be guided by a practitioner or patients can be instructed in its application. It is often used for alleviation of stress and its sequelae including insomnia.44 It is thought to reduce the need for the use of analgesics in cancer patients.17

Iridology Iridology is a discredited method of diagnosis which examines changes in the iris to determine state of health.57,66

Magnet Therapy

Magnet therapy involves the application of magnets to treat disorders by influencing ionic currents in the body causing stimulation of cells and enhanced blood flow.49,94 It is not to be confused with magnetic healing, which was a form of hypnosis. Unipolar or bipolar magnets are fastened into clothing, worn like jewelry (e.g., bracelets), held in place against the skin by adhesive or used in bedding. They have been promoted to treat musculoskeletal complaints such as chronic low back pain, muscle pain in post-polio syndrome and neuropathic pain in diabetes, although a systematic review did not support their use for pain relief.49

Massage Therapy

Massage therapy is a manipulative method that uses a variety of manual techniques (stroking, kneading, friction, vibration) applied to soft tissues.62,64 Human touch itself is considered to be a beneficial part of massage. It is used in traditional medical systems including Ayurveda and Chinese medicine. Massage is used to promote relaxation, relieve muscle tightness, alleviate pain, reduce anxiety and promote sleep. It is used to promote the growth and development of premature infants42 and might benefit patients suffering from chronic cancer pain and anxiety.17 It should not be used in patients with deep vein thrombosis, advanced osteoporosis, fractures or where skin is compromised.64

Meditation Meditation is one of the most commonly used mind-body interventions to induce relaxation and a sense of calm.84 Meditation has also been shown to reduce symptoms of anxiety.112 It is a self-directed practice that involves a

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conscious mental process of becoming aware of one's thoughts and achieving mastery over them. Functional magnetic resonance imaging has shown that meditation can activate areas of the brain involved in attention and in the control of the autonomic nervous system. It is a component of different traditions including yoga, qigong and tai chi. Preliminary evidence has found that some meditation techniques alter blood flow in the brain, lower blood pressure, slow respiratory rate, improve immune function, help with coping strategies and provide a positive emotional state.61,84,111

Moxibustion

Moxibustion is a component of Chinese medicine that involves the burning of dried and powdered leaves of artemesia vulgaris.70 It can be burned in very small amounts directly on the skin, on a mediating substance placed between the burning material and the skin surface or on the handle of an acupuncture needle. It is believed that the burning substance has the ability to warm and enter the meridians and affect the flow of qi. Moxibustion is used in combination with acupuncture for a wide variety of conditions.

Natural Health Product (NHP) According to Health Canada, the definition of a Natural Health Product includes both function and substance.113 Function captures substances for use in the diagnosis, treatment, mitigation or prevention of disease/disorder; restoring, correcting or modifying organic functions in a manner which maintains or promotes health. Acceptable substances include materials derived from plants, algae, bacteria, fungi and non-human animals. Numerous exclusions are listed such as antibiotics, blood products, tobacco, injectables, biologics, cannabis and others. Contamination is a frequent problem with imported NHPs due to lack of rigorous manufacturing standards. In particular, many Chinese herbal products are the subject of Health Canada warnings for containing undeclared medications, bacteria and fungi.114,115,116

Naturopathic Medicine

Naturopathic medicine is a system of treatment, defined by a broad scope of practice, that emphasizes the healing power of nature, and which draws from a wide variety of therapeutic approaches.110,117,118 The use of nutrition, herbs and natural products is fundamental, with treatments borrowed from Chinese medicine, homeopathy, herbalism, Ayurveda and manual therapies. As it does not identify with one particular mode of therapy, it is generally defined by its approach. This includes core principles of preventive medicine, treatment of the whole person and determination of the cause of the disease. Treatment combinations are individualized for each patient, in an effort to aid self-healing and restore normal body function, rather than attempt to focus on the treatment of symptoms. Interventions include natural products, nutritional counselling, acupuncture, naturopathic manipulation, traditional Chinese medicine, homeopathy, massage, fasting, visualization and many others.118

Nutraceutical

Health Canada defines a nutraceutical as “a product isolated or purified from foods that is generally sold in medicinal forms not usually associated with food. A nutraceutical is demonstrated to have a physiological benefit or provide protection against chronic disease.”96 The concentrated dosage forms can deliver ingredients in amounts exceeding those found in food.21

Orthomolecular Therapy

Orthomolecular therapy is a term derived from the Greek word “orthos,” meaning straight or correct, and was first used by Linus Pauling in 1968 to describe the treatment of disease with large quantities of nutrients, especially vitamins.66 It is similar to megavitamin therapy but minerals, amino acids, hormones and metabolic intermediates can also be administered. The amounts of nutrients administered may be 20–600 times the recommended daily intake.

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Osteopathic Medicine

Osteopathic medicine is a system that originated as a manipulative method, but which has evolved into mainstream medicine in the United States where practitioners receive a Doctor of Osteopathy (DO) degree and restrict themselves to conventional medicine.62,92,119 Underlying principles are based on an appreciation of the connection between the body's tissues, fluids and systems; treatment is aimed at restoring integrity of structures and improving interactions of the body's systems. Depending on the practitioner, manual techniques may include thrusting (similar to chiropractic methods), lymphatic drainage and craniosacral therapy. Osteopathic methods attempt to correct symmetry, motion restriction, tissue texture changes and tenderness. Musculoskeletal problems such as soft tissue trauma, temporomandibular joint dysfunction and lumbar and cervical pain are treated. In countries other than the United States, such as Great Britain, osteopaths earn Bachelor of Science degrees and have practices similar to that of chiropractors.

Qigong Qigong is an energy therapy that is a major branch of Chinese medicine and is aimed at manipulating qi.70 It involves a wide variety of activities to balance, regulate and harness qi in order to promote health, longevity, healing and spiritual development. An internal form has the patient acting alone using exercise, breathing or relaxation methods. In the external form, a practitioner projects his or her qi into the patient via their hands, the use of needles or visualization. In healthy volunteers, it has been shown to reduce cortisol levels, and might be of use to relieve stress.111 There is potential benefit in hypertension and respiratory disease.61 In hypertension, reduced stroke and mortality rates are suggested in preliminary studies.61 Short-term pain relief and prolonged reduction of anxiety have been seen in patients with complex regional pain syndrome.111 Qigong may also improve quality of life for cancer patients.120

Reflexology (Zone Therapy) This is a manual technique involving application of deep pressure to the feet.62,86 Different zones on the feet are thought to correspond to areas on the body (equated with meridians). Pressure is applied using the fingers and thumbs to enhance the flow of energy through the body. It has been tried to relieve symptoms of chronic conditions such as asthma, headache, bladder and bowel problems. It has been studied in stroke, brain injury and spinal cord injury patients.67

Reiki

Reiki is an energy therapy developed in mid-19th century Japan, whereby a practitioner channels reiki (universal life energy), attained through meditation and prayer, through their body to promote healing in another individual.62,65 Therapeutic goals include treatment of fibromyalgia, pain, cancer and depression, as well as overall well-being, but research has not confirmed usefulness for any condition.121

Relaxation Relaxation employs various techniques, approaches and modes of practice.61,84 Most involve repetitive action (focus on a word, sound, phrase, muscular activity, etc.), and adopting a passive attitude toward intruding thoughts with a return to focus. It has been studied in anxiety, depression, pain and irritable bowel syndrome.84

Rolfing Rolfing is a manipulation method that uses deep muscle massage to correct distortions in the body.62,65 It teaches that distortions in posture reflect a withdrawal response to past emotional and physical trauma, and restoring

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correct posture with manipulation will release the traumas, resulting in a feeling of lightness and well-being.

Shiatsu

Shiatsu is a Japanese massage technique in which pressure is applied to specific points on the body likened to acupuncture points.62,66,122 It may be combined with passive stretching to optimize the effect. It has been likened to acupressure in technique, but is used more for prevention of illness than treatment.

Tai chi

Tai chi is a series of precise, focused slow-moving postures accompanied by controlled breathing and a calm, relaxed mind, which involves physical and mental discipline.111 It is used to unite body and mind and promote balance in life. Evidence suggests lowered blood pressure and heart rate and stress reduction. Tai chi may be useful in osteoarthritis of the knee,123 prevention of falls in the elderly,124 and improving balance in patients with mild to moderate Parkinson's disease125, leading to a reduction in falls and improved functionality.

Therapeutic Touch

Therapeutic touch is an energy therapy developed in the late 1960s in which a provider moves their hands above the surface of a patient's body in an attempt to correct imbalance in the patient's energy field and facilitate healing.62,66,126 Practitioners believe that their hands can transfer energy from themselves to a patient to achieve energy balance within the patient. It is a popular treatment for pain, anxiety, Alzheimer's dementia and stress reduction; therapeutic touch is also used to improve well-being of cancer patients.84

Traditional Chinese Medicine (TCM)

TCM, also known as Traditional Oriental Medicine, is a comprehensive and major medical system, dating back to 3000 BC, which comprises many traditions, philosophies and approaches to treatment.63,66,69,90,127 It is based on fundamental concepts that can be difficult for the uninitiated to grasp. These include a balance between yin and yang (opposing yet complementary phenomena that exist simultaneously throughout the universe, including the body) and unimpeded flow of qi (pronounced “chee,” a vital force or energy, which circulates through the body in invisible pathways termed “meridians”). Health problems may reflect a lack of harmony within an individual, or between an individual and their environment, resulting in a blockage in the flow of qi and an imbalance of yin and yang. Diagnosis of the patient involves a multitude of techniques in addition to taking a medical history, which include assessing temperament, examining the tongue and properties of the pulse and noting qualities of speech and breath. The practitioner evaluates how illness manifests itself in the patient, and then treats the person, not the disease. Treatments are highly individualized, and employ various methods, to target the deep cause of the disease rather than only symptoms.90 Chosen methods of therapy include diet, herbal therapy, acupuncture, moxibustion, cupping and bleeding, tui na and qigong.

Traditional Medicine

The World Health Organization defines traditional medicine as “the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”128

Tui Na

Tui Na is a manipulative practice within Chinese medicine, which involves trained practitioners manipulating soft tissues and joints.62,70 Attention is given to the flow of qi along meridians, and acupuncture points are stimulated. It

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is commonly used in orthopedic and neurological applications, and can be used in situations where acupuncture is considered inappropriate (e.g., pediatrics).

Yoga

Yoga is one of the top CAM modalities used in North America and is intended to promote relaxation and achieve balance in mind, body and spirit through the use of physical postures, breathing exercises, meditation and a philosophical approach.84,129 The numerous schools of yoga incorporate these components in varying proportions.61,84,129 Rejuvenation, awareness, self-realization, stress reduction and building strength and flexibility are possible benefits. It is advocated as a way to increase the mind's flexibility and resilience when faced with stress. Research suggests that it may help with various conditions including asthma84, hypertension,84 depression,130 pain,131 anxiety and also improve overall fitness, strength and flexibility.129 Breast cancer survivors observed improvement of fatigue and other symptoms with yoga.132 Possible cardiovascular benefits include improved lipid profile, enhanced oxygen uptake and changes in progression of atherosclerosis.61 People with certain medical conditions (glaucoma, hypertension, severe osteoporosis) could be at risk with some postures.

Summary

Increasing focus on self-care and patient responsibility for their own health has led to greater exploration and selection of therapeutic options including CAM, and Canadian consumers look to pharmacists for reliable information. Understanding who uses CAM, the extent of use, the reasons for choosing particular therapies, and some familiarity with the treatments themselves will enable informed discussions about safe and effective health care choices. Scientific evidence to either disprove or support the perceived efficacy and hazards of CAM lags far behind that of conventional medicine, but efforts are underway to address this. Although some of these approaches have been used for thousands of years, when used outside of their traditional cultural context and without the supervision of experienced practitioners, both their historical value and safety may be altered.99 Given the multitude of diverse treatments and approaches, generalizations about the CAM efficacy and safety are not possible, but unbiased discussions with patients are important to encourage disclosure of CAM use and give credibility to advice from health care professionals.

Resource Tips

Arthritis Research UK. Complementary and alternative medicines for the treatment of rheumatoid arthritis, osteoarthritis and fibromyalgia. Available from: www.arthritisresearchuk.org/arthritis-information/complementaryand-alternative-medicines/complementary-and-alternative-medicines.aspx. Arthritis Research UK. Practitioner-based complementary and alternative therapies for the treatment of rheumatoid arthritis, osteoarthritis, fibromyalgia and low back pain. Available from: www.arthritisresearchuk.org/arthritis-information /complementary-and-alternative-medicines/complementary-and-alternative-therapies.aspx.

Suggested Readings

Deng GE, Frenkel M, Cohen L et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. J Soc Integr Oncol 2009;7:85-120. Kemper KJ, Vohra S, Walls R et al. American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics. Pediatrics 2008;122:1374-86. Monti DA, Sufian M, Peterson C. Potential role of mind-body therapies in cancer survivorship. Cancer 2008;112:2607-16. Rogovik AL, Vohra S, Goldman RD. Safety considerations and potential interactions of vitamins: should vitamins be considered drugs? Ann Pharmcother 2010;44:311-24.

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Siow YL, Gong Y, Au-Yeung KK et al. Emerging issues in traditional Chinese medicine. Can J Physiol Pharmacol 2005;83:321-34. Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol 2010:55:515-25. Vogel JH, Bolling SF, Costello RB et al. Integrating complementary medicine into cardiovascular medicine. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine). J Am Coll Cardiol 2005;46:184-221.

References 1. WHO Congress on Traditional Medicine and the Beijing Declaration. WHO Drug Info 2009;23:8-11. 2. Barnes PM, Powell-Griner E, McFann K et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;343:1-19. 3. Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569-75. 4. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;12:1-23. 5. Hunt KJ, Coelho HF, Wider B et al. Complementary and alternative medicine use in England: results from a national survey. Int J Clin Pract 2010;64:1496-502. 6. Park J. Health reports: use of alternative health care, 2003. Ottawa: Statistics Canada. The Daily 2005 Mar 15. Available from: www.statcan.gc.ca/daily-quotidien/050315/dq050315-eng-htm. Accessed November 4, 2009. 7. Statistics Canada. CANSIM. Canadian Community Health Survey. Table 105-0462. Contact with alternative health care providers in the past 12 months, by age group and sex, household population aged 12 and over, Canada, provinces, territories, health regions (June 2005 boundaries) and peer groups, every 2 years. Available from: cansim2.statcan.ca. Accessed February 3, 2010. 8. McFarland B, Bigelow D, Zani B et al. Complementary and alternative medicine use in Canada and the United States. Am J Public Health 2002;92:1616-8. 9. Miller MF, Bellizzi KM, Sufian M et al. Dietary supplement use in individuals living with cancer and other chronic conditions: a population-based study. J Am Diet Assoc 2008;108;483-94. 10. Ernst E. The public's enthusiasm for complementary and alternative medicine amounts to a critique of mainstream medicine. Int J Clin Pract 2010;64:1472-4. 11. Metcalfe A, Williams J, McChesney J et al. Use of complementary and alternative medicine by those with a chronic disease and the general population—results of a national population based survey. BMC Complement Altern Med 2010;10:58. 12. Quan H, Lai D, Johnson D et al. Complementary and alternative medicine use among Chinese and white Canadians. Can Fam Physician 2008;54:1563-9. 13. Lai D, Chappell N. Use of traditional Chinese medicine by older Chinese immigrants in Canada. Fam Pract 2007;24:56-64. 14. Roth MA, Kobayashi KM. The use of complementary and alternative medicine among Chinese Canadians: results from a national survey. J Immigr Minor Health 2008;10:517-28. 15. Cook SJ. Use of traditional Mi'kmaq medicine among patients at a First Nations community health centre. Can J Rural Med 2005;10:95-9. 16. Williams AM, Kitchen P, Eby J. Alternative health care consultations in Ontario, Canada: a geographic and socio-demographic analysis. BMC Complement Altern Med 2011;11:47. 17. Deng G, Cassileth BR. Integrative oncology: complementary therapies for pain, anxiety, and mood disturbance. CA Cancer J Clin 2005;55:109-16. 18. Boon HS, Olatunde F, Zick SM. Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005. BMC Womens Health 2007;7:4. 19. Damery S, Gratus C, Grieve R et al. The use of herbal medicines by people with cancer: a cross-sectional survey. Br J Cancer 2011;104:927-33. 20. Bishop FL, Prescott P, Chan YK et al. Prevalence of complementary medicine use in pediatric cancer: a

03-Mar-16 5:30 AM

Complementary and Alternative Therapies

16 of 20

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

systematic review. Pediatrics 2010;125:768-76. 21. Hollander JM, Mechanick JI. Complementary and alternative medicine and the management of the metabolic syndrome. J Am Diet Assoc 2008;108:495-509. 22. Cohen PA. DMAA as a dietary supplement ingredient. Arch Intern Med 2012;172:1038-9. 23. Koren G, Oren D, Rouleau M et al. Comparison of verbal claims for natural health products made by health food stores staff versus pharmacists in Ontario, Canada. Can J Clin Pharmacol 2006;13:e251-6. 24. Edwards L, Jefferies S, Healy B et al. What risk to consumers face when seeking medical advice from health food stores? N Z Med J 2011;124:81-8. 25. Vogel L. “Hodge-podge” regulation of alternative medicine in Canada. CMAJ 2010;182:E569-70. 26. Health Canada. Ipsos-Reid. Natural health product tracking survey—2010 final report. January 2011. Available from: www.hc-sc.gc.ca/dhp-mps/prodnatur/index-eng.php. Accessed October 28, 2012. 27. Walji R, Boon H, Barnes J et al. Consumers of natural health products: natural-born pharmacovigilantes? BMC Complement Altern Med 2010;10:8. 28. Wu CH, Wang CC, Kennedy J. Changes in herb and dietary supplement use in the U.S. adult population: a comparison of the 2002 and 2007 National Health Interview Surveys. Clin Ther 2011;33:1749-58. 29. Fonnebo V, Grimsgaard S, Walach H et al. Researching complementary and alternative treatments–the gatekeepers are not at home. BMC Med Res Methodol 2007;7:7. 30. Kwan D, Hirschkorn K, Boon H. U.S. and Canadian pharmacists' attitudes, knowledge, and professional practice behaviors toward dietary supplements: a systematic review. BMC Complement Altern Med 2006;6:31. 31. Walji R, Boon H, Barnes J et al. Reporting natural health product related adverse drug reactions: is it the pharmacist's responsibility? Int J Pharm Pract 2011;19:383-91. 32. Braun LA, Tiralongo E, Wilkinson JM et al. Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice. BMC Complement Altern Med 2010;10:38. 33. Sirois FM. Motivations for consulting complementary and alternative medicine practitioners: a comparison of consumers from 1997-8 and 2005. BMC Complement Altern Med 2008;8:16. 34. Shekelle PG, Morton SC, Suttorp MJ et al. Challenges in systematic reviews of complementary and alternative medicine topics. Ann Intern Med 2005;142:1042-7. 35. Gagnier JJ, Moher D, Boon H et al. Randomized controlled trials of herbal interventions underreport important details of the intervention. J Clin Epidemiol 2011;64:760-9. 36. Tilburt JC, Curlin FA, Kaptchuk TJ et al. Alternative medicine research and clinical practice: a US national survey. Arch Intern Med 2009;169:670-7. 37. Jonas WB. Scientific evidence and medical practice: the “drunkard's walk”. Arch Intern Med 2009;169:649-50. 38. World Health Organization. Medicines Publications and Documentation. Available from: apps.who.int/medicinedocs/en/. Accessed on October 26, 2012. 39. Manheimer E, Berman B. Producing and disseminating systematic reviews: a summary of the CAM-related work presented at the 13th international Cochrane Colloquium. J Altern Complement Med 2006;12:193-6. 40. Nedrow AR, Heitkemper M, Frenkel M et al. Collaboration between complementary and alternative medicine health professionals: four initiatives. Acad Med 2007;82:962-6. 41. CAM in UME Project. Complementary and alternative medicine issues in undergraduate medical education. Available from: www.caminume.ca/. Accessed November 16, 2009. 42. Kemper KJ, Vohra S, Walls R et al. American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics. Pediatrics 2008;122:1374-86. 43. Vohra S, Surette S, Mittra D et al. Pediatric integrative medicine: pediatrics' newest subspecialty? BMC Pediatr 2012;12:123. 44. Manheimer E. The Cochrane CAM Field at the University of Maryland Center for Integrative Medicine [leaflet]. 2011. Available from: www.compmed.umm.edu/cochrane_about.asp. Accessed September 7, 2012. 45. University of Maryland School of Medicine. Cochrane CAM Field. Complementary and Alternative Medicine Reviews in Cochrane Library 2012;10. Available from: www.compmed.umm.edu/cochrane_reviews.asp. Accessed October 30, 2012. 46. Pilkington K. Searching for CAM evidence: an evaluation of therapy-specific search strategies. J Altern Complement Med 2007;13:451-9. 47. Cogo E, Sampson M, Ajiferuke I et al. Searching for controlled trials of complementary and alternative medicine: a comparison of 15 databases. Evid Based Complement Alternat Med 2011;2011:858246.

03-Mar-16 5:30 AM

Complementary and Alternative Therapies

17 of 20

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

48. Bubela T, Koper M, Boon H et al. Media portrayal of herbal remedies versus pharmaceutical clinical trials: impacts on decision. Med Law 2007;26:363-73. 49. Pittler MH, Brown EM, Ernst E. Static magnets for reducing pain: systematic review and meta-analysis of randomized trials. CMAJ 2007;177:736-42. 50. Kaptchuk TJ. The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? Ann Intern Med 2002;136:817-25. 51. Mason S, Tovey P, Long AF. Evaluating complementary medicine: methodological challenges of randomised controlled trials. BMJ 2002;325:832-4. 52. Andrews JG, Boon H. CAM in Canada: places, practices, research. Complement Ther Clin Pract 2005;11:21-7. 53. Riva JJ, Krawchenko IE, Lam JM et al. Chiropractors and pharmacists in a family health team: unlikely allies in the collaborative management of pregnancy-related low back pain. Can Pharm J 2011;144:62-5. 54. Gaboury I, Lapierre LM, Boon H et al. Interprofessional collaboration within integrative healthcare clinics through the lens of the relationship-centered care model. J Interprof Care 2011;25:124-30. 55. National Center for Complementary and Alternative Medicine. CAM basics: What is complementary and alternative medicine? Bethesda: NCCAM, National Institutes of Health. Available from: nccam.nih.gov/health /whatiscam Accessed September 7, 2012. 56. Ernst E. Disentangling integrative medicine. Mayo Clin Proc 2004;79:565-6. 57. Ernst E. The role of complementary and alternative medicine. BMJ 2000;321:1133-5. 58. Dacher E. The development of an integrated medical model: toward a postmodern medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 57-71. 59. Gordon JS. Mind-body medicine: overview. In: Fontanarosa PB, ed. Alternative medicine: an objective assessment. Chicago: American Medical Association; 2000. p. 154-6. 60. Wieland LS, Manheimer E, Berman BM. Development and classification of an operational definition of complementary and alternative medicine for the Cochrane Collaboration. Altern Ther Health Med 2011;17:50-9. 61. Vogel JH, Bolling SF, Costello RB et al. Integrating complementary medicine into cardiovascular medicine. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine). J Am Coll Cardiol 2005;46:184-221. 62. Coughlin P. Manual therapies. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 100-27. 63. Micozzi MS. Translational issues in conventional and complementary medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 9-17. 64. National Center for Complementary and Alternative Medicine. Chiropractic: an introduction. Bethesda: NCCAM, National Institutes of Health. Available from: nccam.nih.gov/health/chiropractic/introduction.htm. Accessed September 7, 2012. 65. Hurwitz WL. Energy medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 238-56. 66. Cassileth BR. The alternative medicine handbook: the complete reference guide to alternative and complementary therapies. New York: Norton; 1998. 67. Diamond BJ, Shiflett SC, Schoenberger NE et al. Complementary/alternative therapies in the treatment of neurologic disorders. In: Spencer JW, Jacobs JJ, eds. Complementary/alternative medicine: an evidence-based approach. St. Louis: Mosby; 1999. p. 170-207. 68. Kronenberg F, Murphy PA, Wade C. Complementary/alternative therapies in select populations: women. In: Spencer JW, Jacobs JJ, eds. Complementary/alternative medicine: an evidence-based approach. St. Louis: Mosby; 1999. p. 341-62. 69. Cassidy CM. Social and cultural context of complementary and alternative medicine systems. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 18-42. 70. Ergil KV. Chinese medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 303-44. 71. Oumeish OY. The philosophical, cultural, and historical aspects of complementary, alternative, unconventional, and integrative medicine in the Old World. Arch Dermatol 1998;134:1373-86.

03-Mar-16 5:30 AM

Complementary and Alternative Therapies

18 of 20

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

72. Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ 1999;319:973-6. 73. NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518-24. 74. LaRiccia PL. Acupuncture: overview. In: Fontanarosa PB, ed. Alternative medicine: an objective assessment. Chicago: American Medical Association; 2000. p. 448-50. 75. Chen CJ, Yu HS. Acupuncture treatment of urticaria. Arch Dermatol 1998;134:1397-9. 76. Cooper EL. eCAM: a closer look at clinical analyses. Evid Based Complement Alternat Med 2009;6:279-81. 77. Berman BM. Integrative approaches to pain management: how to get the best of both worlds. BMJ 2003;326:1320-1. 78. Berman BM, Langevin HM, Witt CM et al. Acupuncture for low back pain. N Engl J Med 2010;363:454-61. 79. Vickers AJ, Cronin AM, Maschino AC et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. 80. Linde K, Allais G, Brinkhaus B et al. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev 2009;(1):CD001218. 81. Linde K, Allais G, Brinkhaus B et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev 2009;(1):CD007587. 82. University of Maryland School of Medicine. Cochrane CAM Field. Glossary of CAM terms. Available from: www.compmed.umm.edu/cochrane_glossary.asp. Accessed October 29, 2012. 83. Hamre HJ, Witt CM, Kienle GS et al. Anthroposophic therapy for children with chronic disease: a two-year prospective cohort study in routine outpatient settings. BMC Pediatrics 2009;9:39. 84. Natural Standard: the Authority on Integrative Medicine. Somerville: Natural Standard. Available from: www.naturalstandard.com. Accessed September 7, 2012. Subscription required. 85. Stevensen CJ. Aromatherapy. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 146-58. 86. Vickers A, Zollman C. ABC of complementary medicine. Massage therapies. BMJ 1999;319:1254-7. 87. Zysk KG, Tetlow G. Traditional ayurveda. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 345-65. 88. Lad DV. Ayurvedic medicine. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 200-15. 89. Gair R. Heavy metal poisoning from Ayurvedic medicines. B C Med J 2008;50:105. 90. Siow YL, Gong Y, Au-Yeung KK et al. Emerging issues in traditional Chinese medicine. Can J Physiol Pharmacol 2005;83:321-34. 91. Koo J, Arain S. Traditional Chinese medicine for the treatment of dermatologic disorders. Arch Dermatol 1998;134:1388-93. 92. Vickers A, Zollman C. ABC of complementary medicine. The manipulative therapies: osteopathy and chiropractic. BMJ 1999;319:1176-9. 93. Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. 94. Spencer JW, Jacobs JJ, eds. Complementary/alternative medicine: an evidence-based approach. St. Louis: Mosby; 1999. 95. National Institutes of Health, Office of Dietary Supplements. Background information: Dietary supplements. Available from: ods.od.nih.gov/factsheets/DietarySupplements.asp. Accessed September 6, 2012. 96. Health Canada. Therapeutic Products Programme and the Food Directorate from the Health Protection Branch. Policy paper–Nutraceuticals/functional foods and health claims on foods. Available from: www.hcsc.gc.ca/fn-an/label-etiquet/claims-reclam/nutra-funct_foods-nutra-fonct_aliment-eng.php. Accessed September 6, 2012. 97. Jones PJ. Clinical nutrition: 7. Functional foods–more than just nutrition. CMAJ 2002;166:1555-63. 98. The Institute for Functional Medicine. What is functional medicine? Available from: www.functionalmedicine.org. Accessed October 30, 2012. 99. McGuffin M, Hobbs C, Upton R, eds. American Herbal Products Association's botanical safety handbook. Boca Raton: CRC Press; 1997. 100. World Health Organization. Regional Office for the Western Pacific. Research guidelines for evaluating the safety and efficacy of herbal medicines. Manila: WHO; 1993. 101. World Health Organization. Quality control methods for herbal materials. Geneva: WHO; 2011.

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19 of 20

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

102. Meserole L. Western herbalism. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 128-45. 103. Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548-53. 104. Watkins AD. Psychoneuroimmunology. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 200-14. 105. Zollman C, Vickers A. ABC of complementary medicine. Complementary medicine in conventional practice. BMJ 1999;319:901-4. 106. Jacobs J, Moskowitz R. Homeopathy. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 87-99. 107. Vickers A, Zollman C. ABC of complementary medicine. Homoeopathy. BMJ 1999;319:1115-8. 108. Erlewyn-Lajeunesse M. Homeopathic medicines for children. Arch Dis Child 2012;97:135-8. 109. World Health Organization. Safety issues in the preparation of homeopathic medicines. Geneva: WHO; 2009. 110. Pizzorno JE, Snider P. Naturopathic medicine. In: Micozzi MS, ed. Fundamentals of complementary and alternative medicine. 2nd ed. New York: Churchill Livingstone; 2001. p. 159-92. 111. Monti DA, Sufian M, Peterson C. Potential role of mind-body therapies in cancer survivorship. Cancer 2008;112:2607-16. 112. Chen KW, Berger CC, Manheimer E et al. Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depress Anxiety 2012;29:545-62. 113. Health Canada. Overview of the Natural Health Products Regulations guidance document. Available from: www.hc-sc.gc.ca/dhp-mps/prodnatur/legislation/docs/regula-regle_over-apercu-eng.php. Accessed September 6, 2012. 114. Health Canada. Advisories and Warnings. 101 Zhangguang Gold 101 Super Effective Hair Growth Agent and 101 Zhangguang Fabao 101D Doctor Zhao's Chinese Traditional Herbal hair Care Formula. Available from: www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_fpa-ape_2010/2010-200-eng.php. Accessed January 8, 2013. 115. Health Canada. Advisories and Warnings. “Fat Burner No. 1” (“Qian Mei Yin Zi”): unauthorized Chinese herbal weight loss product may pose serious health risks. Available from: www.hc-sc.gc.ca/ahc-asc/media/advisoriesavis/_2010/2010_214-eng.php. Accessed January 8, 2013. 116. Health Canada. Advisories and Warnings. Nine bacterial and fungal contaminated herbal products and teas. Available from: www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_fpa-ape_2008/2008_12-eng.php. Accessed January 8, 2013. 117. Murray MT, Pizzorno JE. Naturopathic medicine. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 304-21. 118. Verhoef MJ, Boon HS, Mutasingwa DR. The scope of naturopathic medicine in Canada: an emerging profession. Soc Sci Med 2006;63:409-17. 119. Goodman H. Osteopathy. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 289-303. 120. Oh B, Butow P, Mullan B et al. Impact of medical Qigong on quality of life, fatigue, mood and inflammation in cancer patients: a randomized controlled trial. Ann Oncol 2010;21:608-14. 121. National Center for Complementary and Alternative Medicine. Reiki: an introduction. Bethesda: NCCAM, National Institutes of Health. Available from: nccam.nih.gov/health/reiki/introduction.htm. Accessed September 7, 2012. 122. Field T. Massage therapy. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 383-91. 123. Hochberg MC, Altman RD, April KT et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthr Care Res 2012;64:465-74. 124. Tousignant M, Corriveau H, Roy PM et al. The effect of supervised Tai Chi intervention compared to a physiotherapy program on fall-related clinical outcomes: a randomized clinical trial. Disabil Rehabil 2012;34:196-201. 125. Li F, Harmer P, Fitzgerald K et al. Tai chi and postural stability in patients with Parkinson's disease. N Engl J Med 2012;366:511-9. 126. Rosa L, Rosa E, Sarner L et al. A close look at therapeutic touch. In: Fontanarosa PB, ed. Alternative medicine: an objective assessment. Chicago: American Medical Association; 2000. p. 202-11.

03-Mar-16 5:30 AM

Complementary and Alternative Therapies

20 of 20

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/...

127. Lao L. Traditional Chinese medicine. In: Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 216-32. 128. World Health Organization. Traditional medicine: definitions. Available from: www.who.int/medicines/areas /traditional/definitions/en/. Accessed September 6, 2012. 129. National Center for Complementary and Alternative Medicine. Yoga for health. Bethesda: NCCAM, National Institutes of Health. Available from: nccam.nih.gov/health/yoga/introduction.htm. Accessed September 6, 2012. 130. Ravindran AV, Lam RW, Filteau MJ et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Affect Disord 2009;117:S54-64. 131. Büssing A, Osterman T. Lüdtke R et al. Effects of yoga interventions on pain and pain-associated disability: a meta-analysis. J Pain 2012;13:1-9. 132. Stan DL, Collins NM, Olsen MM et al. The evolution of mindfulness-based physical interventions in breast cancer survivors. Evid Based Complement Alternat Med 2012;2012:75864. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 05:29 AM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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