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11830 Westline Industrial Drive
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COMPLEMENTARY AND ALTERNATIVE MEDICINE:

AN EVIDENCE-BASED APPROACH 0-323-02028-3
Copyright © 2003, Mosby, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health
Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239,
e-mail: healthpermissions@[Link]. You may also complete your request on-line via the Elsevier
Science homepage ([Link] by selecting ‘Customer Support’ and then ‘Obtaining
Permissions’.

NOTICE

Complementary and alternative medicine is an ever-changing field. Standard safety precautions

must be followed, but as new research and clinical experience broaden our knowledge, changes in
treatment and drug therapy may become necessary or appropriate. Readers are advised to check the
most current product information provided by the manufacturer of each drug to be administered to
verify the recommended dose, the method and duration of administration, and contraindications.
It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient,
to determine dosages and the best treatment for each individual patient. Neither the publisher nor
the author assumes any liability for any injury and/or damage to persons or property arising from
this publication.

Previous edition copyrighted 1999

International Standard Book Number 0-323-02028-3

Publishing Director: Linda Duncan

Publishing Manager: Inta Ozols
Publishing Services Manager: Pat Joiner
Associate Developmental Editor: Melissa Kuster Deutsch
Project Manager: Gena Magouirk
Designer: Mark A. Oberkrom
Cover Art: Harry Sieplinga

Printed in U.S.A.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors

Andrew Baron Cheryl Bourguignon, RN, PhD

Student, Assistant Professor and Postdoctoral
Temple University, Fellow,
Philadelphia, Pennsylvania Center for the Study of Complementary
and Alternative Therapies,
David A. Baron, MSEd, DO University of Virginia,
Professor and Chair, Charlottesville, Virginia
Department of Psychiatry and
Behavioral Science, Milton L. Bullock, MD
Temple University School of Director,
Medicine, Division of Addiction and Alternative
Philadelphia, Pennsylvania Medicine,
Department of Medicine,
Iris R. Bell, MD, PhD Hennepin County Medical Center,
Director of Research, Minneapolis, Minnesota
Complementary Medicine Program,
University of Arizona School of Opher Caspi, MD
Medicine, Faculty,
Tucson, Arizona Complementary Medicine Program,
University of Arizona School of
Kathleen M. Boozang, JD, LLM Medicine,
Associate Dean and Professor of Law, Tucson, Arizona
School of Law,
Seton Hall University, Chung-Kwang Chou, PhD
Newark, New Jersey Chief EME Scientist and Director,
Corporate EME Research Laboratory,
Tacey Ann Boucher, PhD Motorola Florida Research Laboratories,
Project Coordinator, Plantation, Florida
Center for Addiction and Alternative
Medicine Research, Ann C. Cotter, MD
Minneapolis Medical Research Medical Consultant,
Foundation, Center for Research in Complementary
Minneapolis, Minnesota and Alternative Medicine,
v
vi Contributors

Kessler Medical Rehabilitation Research Complementary and Alternative

and Education Corporation, Medicine Program,
West Orange, New Jersey Center for Research in Disease Prevention,
Stanford University,
Patricia D. Culliton, MA, Dipl Ac Palo Alto, California
Director,
Alternative Medicine Clinic, James F. Kleshinski, MD
Department of Medicine, Assistant Professor of Medicine,
Hennepin County Medical Center, Medical College of Ohio,
Minneapolis, Minnesota Toledo, Ohio

Karen D’Huyvetter, ND Fredi Kronenberg, PhD

Postdoctoral Fellow, Director,
Center for the Study of Complementary Center for Complementary and Alternative
and Alternative Therapies, Medicine in Women’s Health,
University of Virginia, College of Physicians and Surgeons,
Charlottesville, Virginia Columbia University,
New York, New York
Ellen M. DiNucci, MA
Project Coordinator, May Loo, MD
Complementary and Alternative Assistant Clinical Professor,
Medicine Program, Stanford University;
School of Medicine, Director,
Stanford University, Neurodevelopmental Program,
Palo Alto, California Santa Clara County Valley Medical
Center,
Daniel I. Galper, PhD San Jose, California
Postdoctoral Fellow,
Center for the Study of Complementary Frederic M. Luskin, PhD
and Alternative Therapies, Research Associate,
University of Virginia, Center for Research in Disease
Charlottesville, Virginia Prevention,
School of Medicine,
William L. Haskell, PhD Stanford University,
Director, Palo Alto, California
Complementary and Alternative
Medicine Program; Debra E. Lyons, RN, PhD, FNF
Deputy Director, Assistant Professor and Postdoctoral
Center for Research in Disease Prevention; Fellow,
Professor, Center for the Study of Complementary
School of Medicine, and Alternative Therapies,
Stanford University, University of Virginia,
Palo Alto, California Charlottesville, Virginia

Micah Hill Victoria Maizes, MD

Research Assistant, Faculty,
 Contributors vii

Complementary Medicine Program, National Institutes of Health,

University of Arizona School of Bethesda, Maryland
Medicine,
Tucson, Arizona Ru-Long Ren, MD
Department of Pathology,
Farshad F. Marvasti Ball Memorial Hospital,
Research Assistant, Muncie, Indiana
Complementary and Alternative
Medicine Program, Samuel C. Shiflett, PhD
Center for Research in Disease Prevention, Principal Investigator and Director,
Stanford University, Center for Health and Healing,
Palo Alto, California Beth Israel Hospital,
New York, New York
Angele V. McGrady, PhD
Professor and Administrative Director, Ann Gill Taylor, RN, EdD, FAAN
Complementary Medicine Center, Professor and Director,
Department of Psychiatry, Center for the Study of Complementary
Medical College of Ohio, and Alternative Therapies,
Toledo, Ohio University of Virginia,
Charlottesville, Virginia
Patricia Aikins Murphy, CNM, PhD
Consulting Epidemiologist, Christine Wade
Center for Complementary and Alternative Research Manager,
Medicine in Women’s Health, Center for Complementary and Alternative
College of Physicians and Surgeons, Medicine in Women’s Health,
Columbia University, College of Physicians and Surgeons,
New York, New York Columbia University,
New York, New York
Kathryn A. Newell, MA
Research Coordinator, Thanks to those who contributed to the
Complementary and Alternative first edition:
Medicine Program,
School of Medicine, Bruce J. Diamond
Stanford University, M. Eric Gershwin
Palo Alto, California Robert M. Hackman
Thomas L. Hardie
Phuong Thi Kim Pham, PhD James M. Horner
Program Director, Sangeetha Nayak
National Cancer Institute, James A. Peightel
National Institutes of Health, Cherie Reeves
Bethesda, Maryland Nancy E. Schoenberger
Leanna J. Standish
Aron Primack, MD Judith S. Stern
Health Scientist Administrator, Roberta C.M. Wines
Fogarty International Center, Diane Zeitlin
Preface

The initial reason for writing Complementary and Alternative Medicine: An Evidence-
Based Approach was the need to examine research evidence and claims purported by
advocates, clinicians, and researchers of complementary and alternative medicine
(CAM) regarding its effectiveness. Both of us had previous experience with certain of
these therapies since we had worked with American Indians who used alternative spir-
itual-indigenous medical approaches to health-related problems. Joseph Jacobs, a
Mohawk, grew up using many of these healing practices. Later, we were involved at a
national level establishing the first Office of Alternative Medicine (OAM) at the
National Institutes of Health (NIH). The office was set up as a mandate from Congress
to scientifically evaluate the claims made by the CAM community regarding treat-
ment efficacy and safety.
We have attempted to be sensitive to and aware of the continuing debate over
the need to study CAM. An early concern voiced by conventionally trained physicians,
health providers, and scientists that its evaluation was a waste of time, partially
because CAM had no scientific basis and partially because it simply was not useful,
and in some cases, safety concerns could be raised, is still heard today. Our first edition
evaluated many CAM therapies used for a variety of medical conditions. While there
was no definitive or consensual finding regarding treatment efficacy, this should not
be surprising given the paucity of research effort and financial expenditure for CAM
evaluation. Therapies such as acupuncture, massage, and “psychological” (biofeed-
back, meditation-relaxation) have been increasingly used by consumers and also
studied and evaluated, and a pattern of valid and reliable outcomes, under certain
conditions, appears to be evolving.
Our second edition provides updated information on CAM since the late 1990s,
as well as several new areas that are both important and relevant to the practice of
CAM. Our goals for this second edition remain unchanged from our earlier work.
We want the book to contain the most recent and updated material concerning
CAM and to be able to serve as a reference for physicians, health care providers, and
scientists. We recognize that this is a formidable task because of the huge and not very
well-defined areas of CAM. It is not possible to cover every study or therapy, but
we tried to establish some general guidelines within which therapies and medical
ix
x Preface

conditions were evaluated based on reported usage, recent demographic evaluations,

and study quality. We hope by providing an evidence base for CAM that we continue
to contribute to a database that allows the consumer, clinical scientist, and practicing
healthcare provider to make knowledgeable decisions about CAM usage. That knowl-
edge about healthcare practices regarding their integration with conventional medi-
cine, where appropriate, will benefit patients and make available the safest and highest
quality of medicine.

ORGANIZATION OF THE BOOK

We, as editors, have sought to allow the various chapter contributors the freedom to
review and discuss those therapies that in their opinion merit the most focus. We
have encouraged the use of as many databases as possible pursuant to establishing a
firm evidence base. Besides using the federal Medline NIH Database, each author
has supplemented their chapters differently. One major addition is our attempt to
allow for more discussion(s) regarding the quality of the studies with less emphasis on
simple quantity. We have also attempted in Appendices B and C to provide readers
with more information about where clinical and research data regarding CAM exist.
With such a quickly and continuously growing field, however, today’s information
about CAM is almost outdated by tomorrow.
Complementary and Alternative Medicine: An Evidenced-Based Approach is
organized around three major themes. The first part, Basic Foundations (Chapters 1
and 2), evaluates what is known about CAM focusing on definitional, usage,
and research (clinical and preclinical) strategies; positioning of evidence-based
medicine; and education/training. During the late 1990s, the movement by the
Cochrane group to provide more systematic reviews for CAM therapies is an encour-
aging sign to place more emphasis on stronger research methodology. Although there
are clear and major differences of opinion regarding the usefulness of certain research
methodologies, by allowing for closer scrutiny of many different types of designs we
suggest that a more relevant clinical and scientific outcome may evolve. The debate
concerning the “placebo response” is a noteworthy example of the many research and
clinical questions reviewed in this text. Its place in the healing process as well as its
“control” attributes cannot and should not be ignored. A greater knowledge base con-
cerning the potentially strong influence of the mind\brain in many healthcare issues
may be an outgrowth of the “placebo” study and debate.
The second and largest part, Clinical Research Outcomes: Use of Complementary
and Alternative Therapies in General Medicine, evaluates and reviews clinical research.
In Chapter 3, CAM’s role in treating asthma and allergies is presented carefully,
reviewing the evidence and allowing readers to form their own conclusions regarding
CAM contributions. Chapter 4 reviews and updates what has been done in the area of
cancer. Although there is no major change in the reported efficacy of CAM in the
treatment of cancer, potentially useful approaches may be on the horizon. Noteworthy
is the American Cancer Society’s recent contribution of common herbal use with can-
cer. Chapter 5 reviews atherosclerotic vascular disease, focusing on the importance of
both prevention and the integration of CAM to maximize benefit. Chapter 6 has more
 Preface xi

information on the use of herbs with diabetes mellitus. Quality of life remains an
important issue. Chapter 7 reviews CAM therapies in the treatment of neurological
conditions with an appropriate focus on rehabilitation issues. Chapter 8 evaluates
CAM in the field of psychiatry. Importantly, the continued tracking and review of the
use of St. John’s wort for the treatment of mild to moderate depression and the issue of
safety with kava-kava for anxiety management is featured. Chapter 9 discusses the use
of CAM in the treatment of alcohol and chemical dependency. While many therapies
have at times produced “positive findings,” there still remains a challenge in producing
consistency and replicable results. The complexity of many factors that are associated
with substance abuse and its treatment needs much more evaluation and clarification
in all treatment protocols. Chapter 10 directs attention to the ubiquitous area of pain
control by the use of CAM methods. Recent studies that have evaluated manipulation
procedures or the use of massage points to some useful findings. Also encouraging is
the work of acupuncture in the treatment of fibromyalgia. Chapters 11 to 13 feature
populations that increasingly constitute significant numbers of CAM consumers:
children, women, and the elderly. The uniqueness of these populations and their
importance in more accurately framing research questions around specific targeted
areas needs strong emphasis. Of special concern are attention-deficit disorder as a
possible medically overtreated health problem, the nausea and vomiting associated
with pregnancy, and Alzheimer’s and osteoarthritis and the important realm of qual-
ity-of-life issues.
In the final part, Future Directions and Goals for Complementary and Alternative
Medicine, a new chapter, Legal and Ethical Issues (Chapter 14), directs attention to
the impact and interaction(s) that must occur between CAM and the legal field, as
well as updating and reviewing the important issues of accreditation and licensing
of CAM providers. This is extremely relevant to the validation of CAM as being
clinically trustworthy and safe. A second new chapter, Integration of Clinical
Practice and Medical Training with Complementary and Alternative and Evidence-
Based Medicine (Chapter 15), features the place for CAM in the context of
integrative medicine and its part for healthcare and society. While one aspect of
an evidence-based medicine may arguably be the inclusion of science and exper-
imentally driven procedures such as statistics, the individual patient should not be
“left out of the equation.” Importantly, this concept and evidence-based medicine
as one part of CAM should be directed at medical students at various levels or stages
of training. Chapter 16 provides a review of the importance and needs of the con-
sumer in a driven business market. At the federal level, regulation of CAM for
both consumer protection and validation of usefulness and safety is necessary. A final
summary (Chapter 17) puts forward potential emerging CAM therapies that
should be tracked and watched for future outcomes. A list of goals that are attain-
able and relevant to the development of CAM and evidence-based medicine is
provided.
Note: John Spencer and Joseph Jacobs are writing as individuals, and as such
anything contained within does not reflect any present or past policy of the NIH or
any other organization/association they have been or are currently affiliated with.
Acknowledgments

Many people have provided varying degrees of assistance in the writing of this second
edition. In addition to those we listed in the first edition, many of whom were helpful
in this edition, we would like to acknowledge Karen Keating and Fern Ingber for their
help with Chapters 1 and 16 respectively. We are especially grateful to Jennifer
Watrous, Melissa Kuster Deutsch, Gena Magouirk, Kellie White, and Inta Ozols at
Elsevier Science.
We, as editors, would like to especially thank the following individuals for
reviewing chapters from the first and second editions of Complementary and
Alternative Medicine: An Evidenced Based Approach:
Marjorie Bowman Sadja Greenwood Neil Sonenklar
Laurel Archer Copp Robert Michael William Stuart
Richard Cumberlin David Scheim Jackie Wootton

John W. Spencer, PhD

Joseph J. Jacobs, MD, MBA
Fall, 2002

xii
CHAPTER 1

Essential Issues in
Complementary and
Alternative Medicine
JOHN W. SPENCER

T he debate between proponents and critics of complementary and alternative medicine

(CAM) continues to renew both old and new arguments and biases at the start of the
twenty-first century. The opinions of health providers, consumers, and researchers
remain divided on whether this “unproven form of medicine” can be or ever will be
demonstrated as being cost-effective, accessible, and most importantly, medically useful
and safe. Even writing about CAM, especially when using terminology not familiar to the
general public, can be fraught with difficulties and complexities. New sensitivities in med-
ical language need to evolve as CAM becomes better understood through its study, evalua-
tion, and ultimate acceptance or rejection. That is, definitions and descriptions of CAM
should remain flexible as more information about this evolving field becomes available.
This chapter discusses six areas that are important in shaping the best “descrip-
tors” of CAM: definitional, historical antecedents, usage-demographic factors, clini-
cal/research methodologies, evidence-based issues, and training/education. These
areas are not mutually exclusive but rather interact and are mutually influential.
Chapter 16 focuses on tangential but important areas of consumer involvement, the
CAM market, and federal/state regulations.

Definitional Considerations
Complementary or alternative medicine can be defined as a single or group of poten-
tially classifiable procedures that are proposed to either substitute for or add to more
conventional medical practices in the diagnosis/treatment or prevention areas of
health. A single definition of CAM cannot exist, however, without considering many
cofactors, and even these can be problematic. For example, consider the following:
2
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 CHAPTER 1: Essential Issues in Complementary and Alternative Medicine 3

COMPLEXITY OF FIELD
The field of CAM is multifaceted and multilayered in terms of its components. Many
disparate therapies help delineate CAM’s scope, including acupuncture, homeopathy,
herbal therapies, hypnosis, and systems such as naturopathy. The focus, theoretic
basis, and history of many therapies allow them to be grouped by a taxonomy or clas-
sification that becomes one part of their defining dimension.54 For example, CAM can
be part of a larger category of procedures, such as chiropractic, that is nested within a
licensed, regulated, and professionally independent system, whereas CAM therapies
of guided imagery and botanicals are placed in “mind-body” and “popular-health
reform” categories, respectively. (See Appendix A and Suggested Readings, especially
Novey, 2000.)
The assumption, however, that all of CAM is some type of a vague or “weird”
form of health practice that is generally excluded from more conventional medicine is
simply not true. Physical therapy, massage, biofeedback, hypnosis, and chiropractic
procedures form the basis of many common health therapies that are ancillary to
medicine as practiced by the vast majority of physicians who generally emphasize the
use of pharmaceuticals as first line treatment. It is true, however, that CAM therapies
are not at present partially or fully adopted as “standard treatments” by conventional
medicine.

SCIENTIFIC CREDIBILITY
Any description of CAM should acknowledge that CAM has not been proven to be
either completely safe or useful for many health-related areas. Attempts to show con-
vincing treatment efficacy through clinical research have failed in part because of poor
scientific quality and insufficient evidence (see later sections in this chapter and the
described evidence base in subsequent chapters including strategies for integration of
CAM with conventional medicine described in Chapter 14).

MEANINGFUL TERMINOLOGY
The actual terms alternative and complementary need to be closely evaluated because
their use in the clinical setting relative to conventional treatments can become an
important distinction. Words such as “alternative,” “untested,” “unproven,” “uncon-
ventional,” and “unorthodox” generally include medical or health therapies that
become replacement or substitute (alternative) therapies for orthodox treatments. An
example is shark cartilage used in place of more conventional therapy for cancer treat-
ments (radiation or chemotherapy).
Complementary therapies include those treatments that are used with and in
addition to conventional treatments, such as treatment of hypertension or diabetes by
the use of conventional medication and complementary biofeedback or relaxation
procedures. Thus biofeedback complements the biologic effects of blood pressure
medication, possibly allowing for lower doses and minimizing drug side effects while
optimizing treatment effects.
4 PART ONE: Basic Foundations

Use of chiropractic manipulation illustrates well the difficulty in attempting

to form an all-encompassing definition for CAM. Manipulation is typically used
for the treatment of low back pain. Good scientific evidence exists that chiropractic
procedures can significantly reduce associated pain.4,9 A measurable physical response
can be defined and directly linked with muscle-nerve interactions with known mech-
anisms of action that can be used to describe how manipulation produces its effect.
The question might be asked, “Just how alternative is this practice?” In terms of
general medicine, however, manipulation may still be considered an “alternative” to
surgery.
When chiropractic manipulation is used to treat medical conditions for which
minimal scientific data exist to support its use and for which no rationale exists that
would explain its physiologic action, the definition and use become more controver-
sial. For example, is there acceptable scientific evidence for the use of chiropractic
manipulation to treat psychiatric depression or otitis media? The second part of a
more complete definition must include how CAM use is framed or applied for a spe-
cific treatment.

INSURANCE AND SOCIETAL INVOLVEMENT

Health insurance plans for CAM continue to evolve and partly depend on the need
to document that particular therapies are useful and safe. Currently, medical
reimbursement for CAM service delivery overall is significantly less than for
conventional medicine. Societal considerations, including educational and
management characteristics about CAM, form a further part of the definition.
CAM is proposed to be part of a social process. Part of CAM’s definition includes
practices that are ongoing, evolving processes in which a procedure such as
acupuncture moves through and into classifications or categories based on use
and subsequent integration.115 Therefore CAM could be referred to as ancillary,
limited, marginal, “quasi,” or preliminary. As consumer demands change and
more information becomes available about treatment efficacy and safety, a
particular therapy or practice could move from one and through other
classifications.

DEFINITIONAL DESCRIPTION BY FEDERAL CONSENSUS

In the mid 1990s the then Office of Alternative Medicine at the National Institutes of
Health (NIH) convened a panel to provide a definition and description of CAM activ-
ities.75 CAM was described as “seeking, promoting, and treating health,” but it was
noted that the boundaries between CAM and other more dominant or conventional
systems were not always clearly defined. The panel concluded that CAM’s definition
must remain flexible.
The definitions of CAM described in this text and in clinical or research set-
tings are incomplete. Changes to any definition of CAM will continue as more infor-
mation becomes available about the entire CAM process,14 including study and
evaluation.
 CHAPTER 1: Essential Issues in Complementary and Alternative Medicine 5

Historical Considerations
ANCIENT TIMES TO TWENTIETH CENTURY
In ancient China a system of medical care developed as part of philosophical teaching.
Principles were recorded in and subsequently translated from The Yellow Emperor’s
Classic of Internal Medicine as follows110:
It is said that in former times the ancient sages discoursed on the human body and that
they enumerated separately each of the viscera and each of the bowels. They talked
about the origin of blood vessels and about the vascular system, and said that where the
blood vessels and the arteries (veins) met there are six junctions. Following the course of
each of the arteries there are the 365 vital points for acupuncture. Those who are experts
in using the needle for acupuncture follow Yin, the female principle, in order to draw
out Yang. And they follow Yang, the male principle, in order to draw out Yin. They used
the right hand in order to treat the illness of the left side, and they used the left hand in
order to treat the illness of the right side.

Normal activities of the human body resulted from the balance between yin and
yang. A breakdown of yin and yang balance was thought to be the general pathogene-
sis of all diseases. A patient with depression would be in a state of excessive yin,
whereas a patient with mania would have excessive yang. Restoration of yin and yang
balance led to recovery from illness.
Diagnosis involved close observation, listening, questioning, and recording var-
ious physiologic activities (Figure 1–1). Much of traditional Chinese medicine (TCM)
as practiced today contains many of these same assumptions, including the respect for
the unique aspect of the individual patient.
Chinese materia medica, an important part of TCM, is composed of materials
derived from plants, animals, and minerals. The classic Chinese textbook on materia
medica is Bencao Gangmu, written by Li Shi-Zhen during the Ming Dynasty
(1552–1578). It listed 1892 medical substances and contained more than 1000 illus-
trations and 10,000 detailed descriptions. Through trial and error, worthless and less
effective agents were eliminated from further consideration. The Chinese have accu-
mulated a vast experience on disease prevention and treatment by using the Chinese
materia. The 1990 edition of The Pharmacopoeia of the People’s Republic of China
collected 506 single drugs and 275 forms of complex preparations. One
hundred preparations or drugs are being studied in pharmacology, chemical analysis,
and clinical evaluation.66 Ethnobotany, as currently practiced, owes much to the early
accumulation of this information.
A similar but distinct system, Ayurveda, was developed on the Indian subconti-
nent more than 5000 years ago, emphasizing an integrated approach to both preven-
tion and treatment of illness. Again, “imbalance” was a major part of the explanation
of disease. A focus of awareness or level of consciousness was proposed to exist within
each individual. This “inner” force was a major part of the practice of good health.
Mental stress was involved in producing poor health, and techniques such as medita-
tion were developed to aid in healing. Other ayurvedic components included lifestyle
interventions of diet, herbs, exercise, and yoga.
6 PART ONE: Basic Foundations

FIGURE 1–1. Location of pulses on the radial artery. At each position, yin and yang organs are coupled.
The kidney pulse on the right is the kidney yang, or “vital gate.” At least 28 qualities of the pulse, such as
“superficial,” “deep,” and “short,” relate to certain medical diseases or syndromes (internal, cold, excess).
The seasons influenced the pulse, as did age, gender, and constitution. (From Helms JM: Acupuncture ener-
getics: a clinical approach for physicians, Berkeley, Calif, 1995, Medical Acupuncture Publishers.)

In the second century AD, the ideas of the Greek physician Galen shaped what
would eventually become modern scientific medicine. In his influential guide,
Anatomical Procedures, Galen noted the following reasons to study the human body90:
Anatomic study has one use for the man of science who loves knowledge for its own
sake, another for him who values it only to demonstrate that nature does naught in vain,
a third for one who provides himself from anatomy with data for investigating a
function physical or mental, and yet another for the practitioner who has to remove
splinters and missiles efficiently, to exercise parts properly, or to treat ulcers, fistulae and
abscesses.

Galen’s ideas eventually became the groundwork for evaluating and treating
patients by focusing on the use of visual and physical objectivity. This was subse-
quently emphasized in medical education during the twelfth century. Greek philoso-
phy and medicine were eventually incorporated into parts of Arabic and Latin
cultures in the western Mediterranean region.
During the Newtonian era of the eighteenth century, the emphasis was on an
objective approach to observations of any phenomenon. The replacement of the
 CHAPTER 1: Essential Issues in Complementary and Alternative Medicine 7

“rational philosophy” of the ancient tradition with the implementation of a stronger

“experimental documentation” was continuing. Anomalous events that could not be
explained by a theory were questioned or ignored.40 The following three examples
reflect this paradigm shift and illustrate foundational arguments that still exist
between proponents and critics of CAM:
1. French scientist Anton Mesmer observed that after electrical stimulation of nerves
and muscles, “forces” such as twitching could be recorded. He concluded that a
magnetic fluid flowed throughout the body and that disease was the result of too
much or too little fluid in one part of the body. His peers discredited Mesmer for
being unable to reproduce any result that would verify his suggestions. His clinical
results were said to result from “mental suggestion.”
2. Methodist minister John Wesley collected many “written ideas” for maintaining
health and healing based on what people told him was useful or produced healing.
No theory or observation could support any of his claims.
3. German physician Samuel Hahnemann tested many common herbal and medici-
nal substances to establish what medical symptoms they might produce in
humans. He experimented by diluting a solution and then subjecting it to vigorous
shaking, called succussion. The dilution limit (i.e., that point when volume of sol-
vent did not contain a single molecule of solute) was often exceeded. He treated
sick patients by prescribing the medicine that most closely matched the symptoms
of their illness, but in doses so small that their therapeutic value was questioned.
Most of Hahnemann’s results were not reproducible, and the subjectivity of his
“therapies” was questioned.
By the mid-1800s, medicine in the United States was a mix of many different
contributions and philosophies from various countries. The practice of medicine
changed greatly with the advent and use of vaccines and antibiotics.43 A second,
equally important change occurred at the beginning of the twentieth century.
Abraham Flexner, a U.S. educator, was charged with evaluating medical education.
His 1910 report, Medical Education in the United States and Canada, was partly
responsible for the diminution of CAM practice in the United States.56 Although the
study was intended to upgrade medical education in general, medical schools with a
biomedical focus were favored and positioned to receive most of the money from large
philanthropic organizations and foundations. By 1914 the number of U.S. medical
schools had, partly because of economic considerations, decreased by approximately
40%. Remaining institutions generally favored a biomedical approach. Other impor-
tant changes included the enactment of state licensing laws through the efforts of the
American Medical Association (AMA) and the passage of the Pure Food and Drug Act
of 1906.103
An important trend in early-twentieth-century medicine that influenced CAM
was the evolution of “manual manipulation” as a major ancillary health therapy to
general medicine,40 initially promoted by Andrew Still and David Palmer. Still was an
“osteopath” who advocated bone setting and manipulation of painful joints. Disease
was thought to be the result of misplaced bones within the spinal cord. Palmer helped
start the system called “chiropractic,” which held that all diseases were caused by
impingement of nerves passing through the spine. Most osteopaths were trained with
8 PART ONE: Basic Foundations

some emphasis on basic science and surgery. Osteopaths used findings from biomed-
ical research, including microscopic analysis of bacteria, antibiotics, analgesics, and
antiinflammatory drugs. Chiropractors were slower to expand into scientific inquiry,
although more recently this has changed with scientific evaluation of their proce-
dures.4

ETHNOLOGIC CONTRIBUTIONS
The cross-cultural, as distinct from the historical, record of systems of healing is volu-
minous. Anthropologists have studied a wide variety of “folk medical systems” (e.g.,
shamanism, magic) and native cultural theories of illness and curing. Even with wide
variations, however, it is possible to identify features common to other, non-modern
medical systems, especially those recorded in cultures of the developing world. These
theories are typically embedded in overarching native religious systems.25 The causes
of disease that are frequently described include the following:
●
Loss of one’s soul(s) in whole or in part
●
Spirit possession
●
Intrusion of human-filled object, where mana is an impersonal, supernatural force
●
Intrusion of illness-causing spirit
●
Violation of taboos, especially those involving correct relations to deities, including
one’s ancestors
●
Spirit attack, including capricious “jokester” spirits
●
Homeopathic and contagious magic
●
Disturbances or violation of social rules and relationships
At present the alternative medical practitioner in many cultures is likely to be as
much guru, shaman, and charismatic figure as physician in the mainstream Western
secular sense.
Illness and healing can take on a cultural meaning that is relative to specific
treatments,58 diagnostic issues,99 or both. For example, the healer/clinician in any soci-
ety offers treatment to patients who bring stories of their own illnesses and special
mental, emotional, and ethical concerns. The structure of the illness is really the man-
ner in which it is meaningful to patient, family, and healer. Illness is a form of suffering
that involves both mind and body. Self-awareness of pain or discomfort can be bound
by various cultural and religious beliefs and can involve a host of properties, many of
them psychologic. Symptoms of illness or enduring illness in one society may not be
as relevant in another.
A continual dichotomy, or differing emphasis, exists between conventional
medicine (and its treatment of the patient using modern scientific technology) and
the more culture-bound approach emphasized in many CAM therapies, in which ill-
ness is often tied to personal beliefs and complaints or patients’ judgment of illness.

NATIONAL INSTITUTES OF HEALTH

In 1991, Congress appropriated funds to start the Office of Alternative Medicine
(OAM) at the NIH. The establishment of the OAM was seen as demonstrating
 CHAPTER 1: Essential Issues in Complementary and Alternative Medicine 9

congressional and public intent to expand the range of available health treatment
modalities, especially for conditions treated unsuccessfully by conventional medicine,
such as cancer. Many scientists viewed the appropriation as a waste of taxpayers’
money, especially because of the negative stigma associated with alternative medicine
and “quackery.” Within this same time frame, however, the Office of Technology
Assessment (OTA) published a lengthy report expressing the need for more clinical
research evaluating alternative treatments for cancer.109
As a first step to “investigate and validate” alternative treatments as mandated
by the U.S. Congress, the OAM released its first Request for Applications (RFA) in
1993 for a one-time, 1-year, exploratory grant that could not exceed $30,000. The
purpose of this grant was to develop a foundation of scientific data that could lead to
more extensive studies, possibly through funding by specific institutes at the NIH.96
More than 450 applications were received and reviewed. Subsequently, 42 pilot projects
were funded, and a broad range of therapies and health conditions were evaluated
(Table 1-1).
Subsequently, about 25% of these studies were published in peer-reviewed jour-
nals. One lesson learned from this first program was the difficulty in completing any
research project with limited financial resources made available through individual
grants. This was most obvious in the costly areas of subject recruitment and data
analysis.
Later, a group of CAM centers were funded to conduct research on a variety of
health problems, including pain, asthma/allergies, human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS), cancer, women’s health,
drug abuse/alcoholism, stroke/neurologic conditions, aging, cardiovascular issues,
psychiatry, and pediatrics. More specialized centers evaluated chiropractic procedures
as well as the role of botanicals in health (see Appendix B). The World Health
Organization (WHO) designated the OAM itself as a collaborating center in tradi-
tional medicine. This involvement with WHO was seen as providing for the study of
more traditional healing practices and allowing relevant findings to be made available
to both the public and U.S. scientists.
In 1998 the OAM was elevated to “center” status and is now called the National
Center for Complementary and Alternative Medicine (NCCAM), with a budget
exceeding $70 million. Opportunities now exist for more funding of individual grants
(research, education/training) and centers, creating multiple opportunities for co-
funding with other institutes as well as establishing an intramural research compo-
nent for the evaluation of CAM on the NIH campus.
The involvement of the NIH has renewed interests, debates, and controversies
about CAM. Journals relevant to CAM include Alternative Therapies, Alternative
Therapies in Clinical Practice, Alternative Therapies in Health and Medicine, Journal of
Alternative and Complementary Therapies, Mind-Body Medicine, Acupuncture and
Electro-therapeutics Research, and Chinese Medical Journal. Many self-help books
devoted to health and healing and emphasizing CAM procedures are increasingly
available in bookstores. The Internet contains hundreds of websites on CAM. The
quality of this information is mixed, and little scientific evidence is presented for
claims made.
10 PART ONE: Basic Foundations

TABLE 1–1. COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) THERAPIES AND

MEDICAL/HEALTH CONDITIONS TREATED

CAM Therapy Medical/Health Condition

Acumoxa Breech birth

Acupuncture Unipolar depression
Osteoarthritis
Dental pain
Attention deficit
Acupuncture/herbs HIV (sinusitis)
HIV survey
Antioxidant vitamins Cancer cell function
Ayurvedic herbals Brain chemistry
Ayurvedic medicine Health status survey
Biofeedback Diabetes mellitus type 2
Pain survey
Dance therapy Cystic fibrosis
Electrochemical DC Cancer (preclinical)
EEG normalization Mild head trauma
Energetic therapy Basal cell carcinoma
Ethnomedicine Hepatitis survey
Herbal Hot flashes
Skin warts
Premenstrual syndrome
Homeopathy Health status survey
Mild brain injury
Hypnosis Bone fracture healing
Low back pain
Macrobiotic diet Cancer
Manual palpation Device evaluation
Massage Bone marrow transplant
Infant growth
HIV
Postoperative pain
Music therapy Head injury
Prayer Substance abuse
Qi Gong Pain
T’ai chi Balance disorder
Therapeutic touch Stress
Immune function
Transcranial electrostimulation Chronic pain
Visual imagery Asthma
Breast cancer
Immune function
Drug use
Yoga (hatha) Obsessive-compulsive disorder

From Exploratory Grant Program, Office of Alternative Medicine, U.S. National Institutes of Health, 1993, Bethesda,
Md.
HIV, Human immunodeficiency virus; DC, direct current; EEG, electroencephalogram.
 CHAPTER 1: Essential Issues in Complementary and Alternative Medicine 11

Clinical-Demographic Considerations
USE OF CAM THERAPIES IN THE 1990s
In the early and mid-1990s, numerous demographic surveys were published to better
understand CAM. The data obtained generally included numbers of patients using a
particular CAM therapy and demographic information. Often missing were use and
ways the particular therapy could be integrated with conventional medicine, follow-
up data on longer-term benefits, cost issues, and evaluation of population distribu-
tions using multivariate statistics. Still, the reported information was useful and
helped shape future research questions leading to efficacy studies.
Although surveys can produce important information about use of CAM thera-
pies, they can also be misleading if done improperly or incompletely. Great care must
to be taken to ensure that neither interviewer bias nor subject bias exists. Questions
that are vague, not validated, or not clinically relevant should be avoided. Subjects
with preconceived or negative views about CAM are not good candidates. Incorrect
survey information may be collected and results skewed when variables such as sam-
ple size, age, gender, ethnicity, education, and income are not carefully profiled and
analyzed. Depending on the question or hypothesis explored, either stratified or ran-
domized subject selection is useful. “Usage” does not imply that the therapy is always
efficacious for specific groups or sample populations. Surveys simply measure
impressions of individuals and are limited to what information they provide or
remember to provide. Surveys, however, can be the first step toward uncovering a gen-
eral degree of documentation about CAM usage.
Europe
The use of complementary therapies throughout Europe and Asia has been well
researched. Fisher and Ward37 reported that 20% to 50% of European populations
used complementary therapies. Consumer surveys indicate that in the Netherlands
and Belgium, use of CAM is as high as 60%, and in Great Britain, 74% are willing to
pay additional insurance premiums to cover complementary therapies. One CAM
therapy, homeopathy, has grown in popularity, especially in France, and remains
extremely popular in Great Britain. Reilly79 provided one of the early surveys of physicians
and medical students in Europe concerning their knowledge and use of CAM. He
reported that physicians had positive attitudes toward their patients’ use of CAM.
The most frequently used therapies included hypnosis, manipulation, homeopa-
thy, and acupuncture. Interestingly, physicians’ personal use of CAM therapies was
linked to greater interest in training. In Germany, 95% of physicians themselves
reportedly used herbal therapy or homeopathy.50 Of 89 physicians surveyed in Israel,
54% reported that certain complementary therapies might be clinically useful, and
42% had referred patients for specific treatments.84 German medical students indi-
cated a significant interest in learning about acupuncture (42%) and homeopathy
(55%) and thought that these therapies had the potential to be effective.7 Further, in
Canada, a cross section of 200 general practitioners revealed that 73% thought they
should have some knowledge about certain alternative treatments.111 Chiropractic
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