By Wai, Mara
Part II of this feature will appear in the January/February 2006 issue of Viewpoint
What Is Complementary and Alternative Medicine?
Complementary and alternative medicine (CAM) is a categorical term used to describe a range of medical and health care systems and/ or therapeutic modalities, practices, and products that are not presently considered to be part of conventional medicine – medicine that is traditionally practiced by physicians and allied health professionals (such as physical therapists, psychologists, and nurses) (Caspi et al., 2003; The National Center for Complementary and Alternative Medicine [NCCAM], 2005). In 1998, the National Institutes of Health (NIH) recognized CAM use as both an alternative medical strategy and a supplemental or complementary health care strategy. CAM therapies used alone are often referred to as “alternative,” whereas when used in addition to conventional medicine, they are often referred to as “complementary” (NCCAM, 2005).
The National Center for Complementary and Alternative Medicine (NCCAM) was instituted by the NIH to address the increasing informational and practical demand for CAM by consumers. NCCAM classifies CAM therapies into five categories described below (Flaherty & Takahashi, 2004). As of 2001, more than 350 therapies met the defining CAM criteria (Milden & Stokols, 2004). The list of what is considered to be CAM is continuing to evolve as new health care strategies become known and as CAM therapies are proven to be safe, effective, and are adopted into conventional health care.
TYPES OF CAM TREATMENTS
Alternative Medical Systems
Alternative medical systems are built upon complete systems of theory and practice that have evolved independent of the conventional medical approach used in the United States. Two of the most popular alternative medical systems are Traditional Chinese Medicine (TCM) and India’s Ayurvedic Medicine. TCM is based on the concept of Chi, which is the life force that is said to run through all of nature. Some TCM treatment strategies include acupuncture, acupressure, and Chinese herbs. Each of these treatment modalities are used to decrease life-force (or Chi) imbalances that are thought to be the cause of specific problems that can manifest in a particular organ system. Other commonly used TCM treatment strategies to balance Chi include Qi Gong (pronounced “chee gung”) and Tai Chi, which are two Chinese movement strategies.
Ayurveda comprises ancient Indian healing techniques that are based generally on the classification of three predominant body types. Ayurvedic philosophy posits that mental, emotional, and physical qualities of an individual can be classified into one of these three body types. Overall, the sum of qualities possessed by an individual are often representative of one or two of the body types. Each body type is associated with specific disease as well as health-promoting treatment strategies. Ayurvedic recommendations for diet and lifestyle regimens differ among the three body types, and Ayurvedic healing strategies emphasize regular detoxification and cleansing of all physiologic systems.
A third example of an alternative system of healing is Homeopathic Medicine. This system employs the use of natural, unsynthesized, herbal remedies that are derived from plants, minerals, and other natural substances. Classical homeopathic treatment is based on the use of minute quantities of natural remedies that in larger doses produce effects similar to those of the disease being treated. Homeopaths define the underlying principle for this matching process as the “law of similars,” which is similar to the principle of immunizations.
Mind-Body Interventions
Mind-body interventions are based on the notion that physical health is influenced by the mind. Mind-body interventions employ various techniques designed to enhance the mind’s capacity to affect physiological symptoms and functions. Meditation and prayer are two widely used mindbody intervention strategies. Other types of mind- body interventions include imagery (use of imagination to visualize goals, relaxing situations) to promote relaxation and healing; biofeedback (employs an electronic device to monitor heart rate, blood pressure, muscle tension, and other parameters via the use of visual or audio feedback, which assists with the conscious control of these physiologic functions); yoga (the practice of physical postures, breathing techniques, meditation, and cleansing techniques); and Tai Chi (slow, mindful movement consisting of a sequence of postures that move smoothly from one to another).
Biologically Based Therapies
Biologically based therapies employ substances such as herbs, foods, and vitamins to promote healing or affect change in health symptoms and/or functioning. Examples of biologically based therapies include therapeutic doses of vitamins, special diets, and herbal products. Macrobiotics is a term for a special diet that adheres to the ancient principle of balance in which TCM is based. Macrobiotic diets include specific dietary and lifestyle regimens. The dietary component of macrobiotics emphasizes the use of whole, unprocessed foods such as whole grains, legumes, vegetables, fruits, nuts, and seeds. This special diet avoids meat, dairy, certain vegetables, and processed foods. The system of macrobiotics also emphasizes the maintenance of a balanced lifestyle that considers the importance of such factors as physical activity and mental outlook. Megavitamin therapy is another example of a biologically based therapy employing large doses of vitamins – sometimes up to hundreds of pills a day – or intravenous infusions of high-dose vitamins, which are used to treat disease. In megavitamin therapy, the use of vitamins is in doses that exceed the Recommended Daily Allowance (RDA), sometimes up to 10 times greater than the RDA dose. Both megavitamin and megadose therapies are often used preventatively based on the belief that intake of certain vitamins and minerals in amounts greater than the RDA approves may reduce the risk of developing some diseases.
Manipulative and Body-Based Methods
Manipulative and body-based methods are based on touching and/or manipulation or movement of one or more parts of the body. Massage therapy is an example of one such method that encompasses a wide variety of techniques that utilize hand manipulation of soft tissue. Massage therapy modalities are aimed at releasing tension in muscles and improving circulation or lymphatic flow. Chiropractic is a system of healing and health maintenance that uses manipulation of the spine, called adjustment, to correct medical conditions and promote health.
Energy Therapies
Energy therapies employ the concept of energy fields that are considered to be surrounding and penetrating the human body. Practitioners aim to balance patients’ energy fields to promote and restore health, and to relieve symptoms such as pain. These techniques are carried out by practitioners who use their own energy field (termed “biofield'”) or “CM” to affect change in their patients’ human energy fields. By way of energy transfer and manipulation of the patient’s human energy field, practitioners can unblock and re-balance the patient’s energy field and thereby promote his or her overall well being. Examples of energy therapies include Reiki and Qi Gong. Reiki is based on the belief that everyone has access to an unlimited supply of “life force energy” to improve health and enhance the quality of life. A simple technique to learn, a Reiki practitioner typically lays his or her hands on a patient (Reiki can also be done without physical contact) to move energy through the affected parts of the energy field and charge them with positive energy. Qi Qong, a TCM energy therapy, is usually defined as “cultivation of the ChL” It is a system involving energy movement-based exercises that are used to balance energy, and are ultimately understood to halt and reverse diseases. Qi Qong combines focused concentration with simple movements and balanced breathing in a controlled way.
APPROACHES TO CAM
Many CAM approaches can be described as emphasizing “holism,” which considers the health of an individual as a reflection of the combination of his or her physical, mental, emotional, social, and spiritual aspects (Caspi et al., 2003). Certain CAM modalities employ treatment interventions that target only one of these aspects of the “whole” system, and the effect of the treatment may or may not be thought to affect the “whole.” Barret et al. (2000) found that patients as well as health care practitioners who employ alternative therapies stressed the importance of a holistic approach to their health care practices; this is in contrast to the conventional medical viewpoint of treating a “composite of numerous biomedical attributes” (Barrett et al., 2000).
CAM USE IN THE UNITED STATES
Emerging literature depicts a dramatic rise in CAM use by individuals (Barrett et al., 2000; Cassileth, 1999; Chatwin & Tovey, 2004). The most comprehensive and reliable findings to date on the use of CAM by adult Americans come from the 2002 edition of the National Health Interview Survey (NHIS), an annual study administered to a representative sample of Americans about their health and illness-related experiences. The 2002 edition of the NHIS survey incorporated detailed questions about CAM including an extensive listof CAM therapies, a wide variety of health conditions and diseases for which CAM therapies may be used, and reasons for CAM use and satisfaction with CAM treatment. Study findings from this 2002 survey reveal an estimated 36% to 62% of adults having used some form of CAM therapy in the 12-month period prior to the survey (Barnes, Powell-Griner, McFann, & Nahin, 2004). Another study regarding the prevalence of CAM use found that alternative medicine use in the United States has increased from 33.8% in 1990 to 42.1% in 1997 – approximately 629 million individuals (Eisenberg et al., 1998). This estimate outnumbers visits to primary care physicians (388 million) by more than 60% (Barrett et al., 2000; Berman, Bausell, & Lee, 2002).
The 10 most commonly used CAM therapies found in the 2002 NHIS survey included:
* The use of prayer specifically for one’s own health (43%).
* Prayer by others for one’s own health (24.4%).
* Natural products (18.9%).
* Deep breathing exercises (11.6%).
* Participation in prayer group for one’s own health (9.6%).
* Meditation (7.6%).
* Chiropractic care (7.5%).
* Yoga (5.1%).
* Massage (5.0%).
* Diet-based therapies (3.5%).
Although CAM was found to be utilized by people of all backgrounds, according to the NHIS survey, CAM use was greater in:
* Women vs. men.
* Older vs. younger adults.
* People with higher educational levels.
* Patients hospitalized in the past year.
* Former smokers, compared with current smokers or those who have never smoked.
When examining the use of CAM more closely, particular patterns of use are noted (Barrett et al., 2000; Sleath, Rubin, Campbell, Gwyther, & Clark, 2001). The largest gender differential has been observed in the use of mindbody therapies, particularly regarding prayer used specifically for health reasons, with women engaging in prayer for health reasons more often than men. Younger women have been found to be less likely to use CAM than older women, suggesting that attitudinal differences or some other preferences may be driving these age differences. In addition, individuals with higher education who were more likely to use CAM were also more likely to have a “holistic philosophy” (Upchurch & Chyu, 2005).
When examining the prevalence of CAM use among Americans over the age of 65, CAM use was found to range from 41 % to 64%, with CAM use greater among older White Americans (61 %) compared with older African Americans (47%) (Flaherty & Takahashi, 2004). The most commonly used CAM therapies reported by this age group (excluding lifestyle, diet, prayer, and vitamins) are herbs, chiropractic, and acupuncture (Flaherty & Takahashi, 2004).
Overall, findings suggest that most patients who use CAM continue to utilize conventional medicine. However, studies of CAM use have shown that they often do not tell their traditional medicine-based providers about their CAM use (Sleath et al., 2001). Physicians attitudes have been revealed to play a crucial role in moderating patients’ beliefs about and use of CAM treatments (Milden & Stokols, 2004). As such, it is becoming increasingly important for primary care physicians and other health care practitioners to take proactive steps to understand and probe for the use of CAM by their patients to improve patient safety by eliminating potential adverse reactions between CAM and conventional medical approaches. Understanding this disconnect and facilitating better communication between patients and their physician about CAM use and the coordination of CAM with traditional medical regimens may fall within the nursing domain and/or other allied health professionals.
PREDICTORS OF CAM USE
Health
Patients are found to be using CAM for a wide array of diseases and conditions. The 2002 NHIS study (Barnes, Powell-Griner, McFann, & Nahin, 2004) findings reveal that Americans are most likely to use CAM for conditions involving chronic or recurring pain (such as back, neck, head, or joint aches), as well as other painful conditions. This is not surprising given that 25 to 33% of the adult population might be suffering from some form of chronic pain in a given year (Lipton, Steward, Daimond et al., 2002; Yelin, Herrndorf, Trupin, & Sonneborn, 2001). Back pain is reported to be the most common reason patients use CAM therapies, with chiropractic and massage as the most frequently used CAM modalities for this purpose (Sherman et al., 2004). There is evidence of the effectiveness and use of various CAM therapies (including the use of relaxation, meditation, gentle yoga, massage, qi gong, guided imagery, herbal and biological-based therapies, and acupuncture) for treating symptoms associated with cancer (Antman etal., 2001; Burstein, Gelber, Cuadagnoli, & Weeks, 1999; Carlson, Speca, Patel, & Goodey, 2003; Cassileth & Deng, 2004; Cassileth & Vicers, 2005; Davidson, Geoghegan, McLaughlin, & Woodward, 2004; Eng et al., 2003; Kinney, Rodgers, Nash, & Bray, 2003; Rosenbaum et al., 2004, Shen et al., 2002; Sparber & Wootton, 2001; Tatsamura, Maskarinec, Shumay, & Kakai, 2003), cardiovascular diseases (Chagan et al., 2005), and for improving post-surgical outcomes (Astin, Shapiro, Eisenberg, & Forys, 2003). Other medical conditions that are associated with the use of CAM include colds, gastrointestinal disorders, and sleeping disorders.
CAM therapies are also used to treat psychological conditions such as anxiety and/or depression. One study reveals that CAM treatments were utilized by the majority of psychiatric inpatients surveyed (63%) within the previous 12-months prior to inpatient treatment (Elkins, Rajab, & Marcus, 2005) Other research has shown that CAM treatments can be used to augment or even replace medications prescribed to individuals to treat anxiety and depressive symptoms (Parslow & Jorm, 2004). Mamtami and Cimino (2002) reported that individuals with psychiatric disorders are more likely to use CAM than those with other diseases.
Current literature (Barnes, Powell-Griner, McFann, & Nahin, 2004) indicates the following as the most commonly reported reasons for CAM use:
* Improve health when used in combination with conventional medical treatments (55%).
* Interest in trying CAM (50%).
* Belief that conventional medical treatments would not help or be inadequate (28%).
* Recommendation by a conventional medical professional (26%).
* Conventional medical treatments are too expensive (13%).
Despite these research findings, the current qualitative research base is limited in terms of the number of in-depth investigations aimed at exploring the actual reasons why patients choose to use complementary therapies (Chatwin & Tovey, 2004).
Ethnic and Cultural Differences
The relationship between CAM use and ethnic and cultural beliefs and practices has not been well-explored. Few studies exist that attempt to analyze this relationship. In one existing review of the literature of CAM use by ethnic and racial minorities, Struthers and Nichols (2004) found that the frequency of CAM use varies depending upon the population of interest. The 2002 NHIS Study revealed that CAM utilization is highest among African Americans (71.3%), followed by Asians (61.7%), Hispanics (61.4%), and Caucasians (60.4%) (Barnes, Powell-Griner, McFann, & Nahin, 2004).
With regard to socio-cultural differences across the use of CAM modalities, African and Native American elders were found to use home and folk remedies more often than European Americans (Arcury, Quandt, Bell, & Vitolins, 2002). Kuo, Hawley, Weiss, Balkrishnan, and VoIk (2004) observed the presence of racial/ethnic differences in herbal use among 322 multiethnic primary care patients. Patients who were most likely to use herbal remedies were nonAfrican American, had immigrant family histories, and reported herbal use among family members. Sleath et al. (2001) collected data revealing that Hispanics and Asians reported the highest rates of herbal use (50%), and were the least likely to disclose their use to health professionals. This study revealed an estimated 83% of minority patients overall who use CAM do not report this use to their physicians.
Culturally distinct worldviews held by different ethnicities can affect health information-seeking behavior and thereby impact the uptake of CAM. For example, Kakai, Maskarinec, Shumay, Tatsumura, and Tasaki (2003) revealed distinct ethnic differences in cancer patients in regard to their preferences in obtaining health information. Survey information collected from 140 cancer patients found that Caucasian patients preferred obtaining objective, scientific, and updated health-related information (including via medical journals, newsletters from research institutions, telephone information sources, and the Internet). In contrast, Japanese patients relied on media and commercial sources for obtaining such information (including via television, newspapers, books, magazines, and CAM providers), and non-Japanese Asians and Pacific Islanders used information sources involving person-to-person communication (such as with physicians, social groups, other cancer patients). These differences in preferences may be related to difference in CAM use between cultural groups.
CONCLUSION
Taken together, these findings suggest that healthcare providers need to understand the role of sociocultural differences and their influence on patterns of CAM interest and uptake. With this understanding, clinicians can assist minority patients in obtaining and synthesizing relevant health information in a meaningful and culturally-sensitive manner.
Objectives
This educational activity is designed for nurses and other health professionals who treat patients using complementary and alternative therapies. For those wishing to obtain CE credit, an evaluation form is available on the AAACN Web site. After studying the information presented in this activity, you will be able to:
1. Define complementary and alternative medicine (CAM).
2. Compare t\ypes of complementary and alternative medicine (CAM) therapies used.
3. Summarize the uses of CAM in the U.S.
4. State which people are most likely to use CAM.
This article, co-provided by AAACN and Anthony J. Jannetti, Inc., provides 1.0 contact hour. Anthony J. Jannetti, Inc. (AJJ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCCCOA). AAACN is a provider approved by the California Board of Registered Nursing Provider Number CEP 5336, for 1.0 contact hour. Licensees in the state of CA must retain this certificate for four years after the CE activity is completed.
This article was reviewed and formatted for contact hour credit by Sally S. Russell, MN, CMSRN, AAACN Education Director, and Rebecca Linn PyIe, MS, RN, Editor.
The CE Evaluation Form and Objectives for this article appear on the AMCN Web site (www.aaacn.org). Please complete and submit this form to the AAACN National Office to obtain CE credit.
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Mara Wai, MEd
Mara Wai, MEd, is a Program Manager, PENN Program for Stress Management, University of Pennsylvania, Philadelphia, PA. She may be contacted via e-mail at [email protected]
Copyright American Academy of Ambulatory Care Nursing Nov/Dec 2005
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