chapter 12- integrative medicine

Given recent statistics on prayer from the 2002 NHIS and Gallup Polls over the past six decades (showing that more than 90% of Americans believe in God or a universal spirit), it is not surprising that proponents and critics have agreed that taking a spiritual history is essential to a comprehensive and culturally sensitive medical consultation. Just as challenging as asking patients about substance abuse, domestic violence, and sexual practices, a spiritual history helps elucidate how spiritual beliefs or religious practices may impact health and health-related choices. Such discussions may be most relevant during times of a new diagnosis, loss of a loved one, onset of depression, or terminal illness. Continuity of care and sensitivity to the biopsychosocial aspects of a patient's life foster the rapport to facilitate such discussion. Such inquiry may also help engage support systems or identify deep conflicts. Although not all physicians may be comfortable addressing spirituality with their patients, referrals to colleagues in pastoral care and chaplaincy are options to consider. Interviewing seven physicians recognized as leaders in the field of healing research, Egnew (2005, pp 258 and 255) found that "healing was defined in terms of developing a sense of personal wholeness that involves physical, mental, emotional, social and spiritual aspects of human experience." The central theme in the responses provided an operational definition of healing: "Healing is the personal experience of the transcendence of suffering." Various models have been suggested as guides to taking the spiritual history (Table 12-8) (Anandarajah and Hight, 2001; Kinney, 1999; Puchalski and Romer, 2000).

ACUPUNCTURE, YOGA, AND HOMEOPATHIC REMEDIES Three areas of CAM are most likely to be encountered in the family physician's office: acupuncture, yoga, and homeopathic remedies. As shown in Table 12-9, these three areas are components of whole systems or nonallopathic medical systems of care: acupuncture within traditional Chinese medicine (TCM), yoga as a part of Ayurveda, and homeopathic remedies as the mainstay of homeopathy. Many family

Nonallopathic Medical Systems TRADITIONAL CHINESE MEDICINE Philosophy: Qi and other substances flow through the body through various channels, or meridians. Yin and yang (i.e., passive and active) and the five elements (i.e., wood, fire, earth, metal, and water) have competing influences on various body parts. Excesses or deficiencies of these cause illness. Pain is blocked qi. Diagnostics: A specific diagnosis is not needed. Information is gathered by the four kanbing: looking (i.e., observation of posture, coloring, gait, demeanor, appearance of the tongue); asking about the status of the 11 basic areas, including body temperature, sleep, fluid metabolism, pain, and digestion; listening to the body's sounds, including breathing, voice, and peristalsis; and palpation of the affected site and the pulse. The pulse is thought to have three parts that correlate with the status of different parts of the body. Therapeutics: Acupuncture is the insertion of needles into various points along the qi meridians. Moxibustion is the burning of moxa (Artemisia vulgaris) on or near meridian points. Gua sha is pressing the skin with a hard, round-edged instrument to create petechiae. Cupping is the creation of a vacuum in a cup and applying the vacuum pressure to the skin. Tui na is manipulation or massage with specific hand movements. Plum blossom is a cluster of needles that is moved along a meridian. Herbal therapies typically are combinations of multiple herbs mixed specifically for the individual patient.

AYURVEDA Philosophy: The concept emerged in India 5000 years ago, and it incorporates five elements and three types of energy, or doshas. Vata is the dosha associated with movement, pitta governs metabolism, and kapha maintains structure. Diet, lifestyle, and relationships shape a person's energy and define health status. Ancient texts divide illnesses according to subspecialties, many of which are the same as for biomedicine. Diagnostics: Factors that may have weakened the person's defenses are considered, such as genetics, trauma, diet, habits, seasonal affects, climate, age, balance of the doshas, emotions, metabolism, and acts of God. A full physical examination includes evaluation of pulses, speech and voice, eyes, tongue, and the appearance of the urine and feces. Therapeutics: Approaches include prevention, detoxification, reestablishment of one's unique constitutional balance. Foods, emotions, and behaviors are used to adjust dosha levels. Panchakarma is used to remove aggravated doshas and toxins. Components of panchakarma include therapeutic vomiting, use of purgatives or laxatives, nasal administration of medications, blood purification (traditionally by blood-letting, now more often with teas), and therapeutic enemas.

Complementary and Alternative Medicine (CAM) Terms

Acupuncture Family of procedures involving stimulation of anatomic points on the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Alexander technique Movement therapy that uses guidance and education on ways to improve posture and movement. The intent is to teach a person how to use muscles more efficiently to improve the overall functioning of the body. Examples of the Alexander technique as CAM are using it to treat low back pain and the symptoms of Parkinson disease. Alternative provider, alternative practitioner Someone who is knowledgeable about a specific alternative health practice. This person provides care or gives advice about its use and usually receives payment for his or her services. For some practices, the provider may have received formalized training and has been certified by a licensing board or related professional association. For example, a practitioner of biofeedback (biofeedback therapist) usually has received training in psychology and physiology and may be certified by the Biofeedback Certification Institute of America

Complementary and alternative medicine are terms often used to mean the array of health care approaches with a history of use or origins outside of mainstream medicine. NCCAM generally uses the term "complementary health approaches" when discussing the practices and products we study for various health conditions. Although some scientific evidence exists, the list of what is considered to be CAM changes continually as the therapies that are proved to be safe and effective become adopted into conventional health care and as new approaches to health care emerge. ■ Alternative medicine refers to using a non-mainstream approach in place of conventional medicine. ■ Complementary medicine generally refers to using a non-mainstream approach together with conventional medicine. ■ Integrative medicine and integrative health care combine this array of non-mainstream health care approaches together with conventional medicine. The NCCAM has classified CAM into five categories, or domains (Figure 12-1). Currently NCCAM finds it useful to consider these approaches as falling into one of two subgroups: natural products or mind and body practices. Examples of alternative or whole medical systems include homeopathy, naturopathy, and Ayurveda (eAppendix 12-1 provides a glossary of CAM terms). Although there are a variety of approaches to the complex taxonomy of CAM (Kaptchuk and Eisenberg, 2001b), the NIH system is most often used.

Another term, holistic medicine, also describes these practices and philosophy. The American Holistic Medical Association (AHMA), founded in 1978, is a membership organization for physicians and other health professionals seeking to practice a broader form of medicine than that currently taught in allopathic medical schools (Table 12-1). "Holistic medicine is the art and science of healing that addresses care of the whole person—body, mind, and spirit

ENERGY MEDICINE: FRONTIER SCIENCE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE The practice of CAM presents many challenges to Western science. How does acupuncture work, and what is qi? How can dilute homeopathic remedies induce effects on biologic systems? What are the chakras, or energy centers, so integral to yoga and Ayurveda? These mysteries present us with opportunities for new discoveries and an expansion of our healing capacities (eAppendix 12-3). Many scientists are showing how research in biophysics and biomagnetism is helping to elucidate the subtle energies of biologic systems, including those of humans. Advanced technologies such as functional magnetic resonance imaging and infrared thermography are demonstrating amazing images that seem to correlate with empiric knowledge (eAppendix 12-4). Open-minded scientists are helping to bridge the worlds of CAM and conventional medicine by linking research findings to those of clinical practice (Oschman, 2002). "Let us document each of these fascinating clues. We will connect the dots by describing an information system in the body that is the missing link for many phenomena that have seemed hopelessly inexplicable in the past. It is a system that is responsible for extraordinary feasts of perception, movement, and healing" (Oschman, 2003, p. xiv).

Conclusion Complementary and alternative medicine is an evolving area of health care used by approximately 4 in 10 adults and 1 in 9 children in the United States. As a diverse system

Mind-Body Experiential and Mindfulness Research: Mindfulness Meditation Practice CD

Content Awareness of breathing (approximately 15 minutes) Bringing the breath into everyday life (approximately 15 minutes) Production Copyrighted 1999 Led by Saki F. Santorelli, EdD, Executive Director Center for Mindfulness in Medicine, Health Care, and Society University of Massachusetts Medical School 55 Lake Avenue North Worcester, MA http://www.umassmed.edu/content.aspx?id=41252

MIND-BODY MEDICINE The area of CAM with perhaps the most extensive research base is mind-body medicine, which encompasses a diverse array of practices that overlap many traditions and whole systems of care. Astin and colleagues (2003, p 131) concluded, "There is now considerable evidence that an array of mind-body therapies can be used as effective adjuncts to conventional medical treatment for a number of common clinical conditions." They found strong evidence to support mind-body approaches in the treatment of low back pain, coronary artery disease, headache, insomnia, preparing for surgical procedures, and in the management of disease-related symptoms of cancer, arthritis, and urinary incontinence. Given the relative ease of learning and employing such techniques, NCCAM has made research into mind-body medicine a priority. Mind-body medicine approaches may enhance healing and optimize health. They may be recommended to most patients for health maintenance and disease management and could easily be incorporated into a PCMH through group visits or health coaches. In addition, a study of 70 primary care physicians who participated in an intensive mindfulness education program over 1 year showed dramatic improvements in mindfulness skills, burnout, mood disturbance, and empathy (Krasner et al., 2009). An accompanying editorial noted that the study "demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work." Also, recognizing and enhancing the meaning derived from the practice of medicine using these skills may "protect against burnout and promote

Guidelines in Prescribing an Antiinflammatory Diet 1. Omega-3 and omega-6 fatty acids are essential polyunsaturated fatty acids (i.e., they cannot be made by the human body). 2. The ratio of omega-6 to omega-3 fatty acids in the average Western diet has steadily increased in the past 100 years. The standard American diet has a ratio of omega-6 to omega-3 of more than 20 : 1, but the ideal range is less than 4 : 1. 3. To follow an antiinflammatory diet, take the following steps: a. Decrease red meat, poultry, and dairy intake. b. Increase the intake of omega-3 fatty acids, such as cold-water fish, flaxseed, walnuts, and green leafy vegetables. c. Even one meal of cold-water fish weekly reduces the risk of cardiac arrest. Consuming fish twice each week is ideal. If this is not possible, fish oil supplements can be taken at a dose of 500-2000 mg twice daily. d. An alternative is ground flax seeds or flaxseed oil. Flax should be freshly ground because it can spoil after exposure to light or heat. Supplementation can be provided with 500-2000 mg of flax oil twice daily. e. Reduce foods that contain omega-6 fatty acids, including the following: (1) Margarine. (2) Oils made from corn, cottonseed, grapeseed, peanut, safflower, sesame, soybean, or sunflower (avoid partially hydrogenated oils). (3) Foods with a long shelf life, such as crackers and chips. f. Cook with monounsaturated oils such as olive or canola oil. 4. Consider this dietary approach to treat the following: a. Heart disease or associated risk factors b. Inflammatory rheumatic disorders c. Autoimmune diseases d. Chronic pain 5. Low-carbohydrate, high-protein diets tend to have high omega-6 fat content and should be used with caution. 6. It may take up to 6 months to see the full clinical effects of an antiinflammatory diet

NATUROPATHY Philosophy: The body is able to heal itself by means of the healing power of nature. Healing occurs through a diet of natural, unrefined foods; adequate exercise; avoidance of environmental toxins; proper elimination of body wastes; and positive thoughts and emotions. Key principles in patient care include doing no harm, taking a preventive approach, and focusing on maintenance of health rather than just on the treatment of disease. The naturopath's goals are to educate, empower, and motivate. Diagnostics: Methods may draw from any number of approaches, including laboratory testing not commonly performed in a biomedical setting. Therapeutics: Approaches can include nutrition, botanicals, homeopathy, Chinese medicine, physical medicine (e.g., ultrasound, massage, manipulation), hydrotherapy (e.g., baths, steams, wraps, colonic irrigation), and various detoxification regimens.

HOMEOPATHY Philosophy: Homeopathy is based on the law of similars, which holds that medicines can produce the same symptoms in healthy people that they cure in those who are ill. Remedies are used in the smallest quantity possible, which can often mean they are diluted to the point that not even a molecule of the original therapeutic substance remains in solution. Diagnostics: A detailed history is taken relating to the specific nature of symptoms. For example, otitis media is treated differently based on the mood of the child, which ear is sore, the nature of the fever, and the nature of the pain. Therapeutics: A remedy that has elicited a similar set of symptoms in a healthy patient is given in minute quantity to the ill person. The degree to which a remedy is diluted is given as a Roman numeral. For example, a 6X solution has been diluted to one-tenth of its strength six times (i.e., to 10−6 of the original strength), and a 200C solution has been diluted to 1/100 of its original strength 200 subsequent times (i.e., to 10−400 of its original strength).

What Is Complementary and Alternative Medicine? Various definitions have been used to describe the array of approaches and philosophies commonly referred to as CAM. As the field has evolved, so has the terminology. Unconventional, unproven, alternative, complementary, holistic, integrative, and integral are some of the most common examples of terms in current use

Historically, medical pluralism has long existed in the United States (Kaptchuk and Eisenberg, 2001a). Over the past few decades, alternative medicine has become a more recognized entity within conventional medicine. Because of the public's growing use of CAM, the National Institutes of Health (NIH) created an Office of Alternative Medicine (OAM) in 1992, with the intention of bringing its scientific expertise "to more adequately explore unconventional medical practices" (NCCAM, 2000). Because of Americans' ongoing and increasing use of CAM, the OAM was expanded to the National Center for Complementary and Alternative Medicine (NCCAM) in 1998, guided by the following mission statement (2000, p 17): "We are dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training researchers, and disseminating authoritative information to the public and professional communities." After a decade of work in the field, NCCAM has become a leading resource for helping the public and health professionals better understand this rapidly growing area of medicine. The center's name has led to the more widespread use and recognition of CAM as the defining term for this field. NCCAM's free website contains a wealth of information, including the following definitions (2014):

Recurring Perspectives from the Institute of Medicine Summit on Integrative Medicine and the Health of the Public Vision of optimal health Alignment of individuals and their health care for optimal health and healing across a full life span. Conceptually inclusive Seamless engagement of the full range of established health factors—physical, psychological, social, preventive, and therapeutic. Life span horizon Integration across the life span to include personal, predictive, preventive, and participatory care. Person-centered Integration around, and within, each person. Prevention-oriented Prevention and disease minimization as the foundation of integrative health care. Team-based Care as a team activity, with the patient as a central team member. Care integration Seamless integration of the care processes, across caregivers and institutions. Caring integration Person- and relationship-centered care. Science integration Integration across approaches to care (e.g., conventional, traditional, alternative, complementary), as the evidence supports. Policy opportunities Emphasis on outcomes, elevation of patient insights, consideration of family and social factors, inclusion of team care and supportive follow-up, and contributions to the learning process.

How the Physician of the Future Will Function The Care Process Is ... The Doctor's Role Will Be ... Patient-centered A navigator Team based Part of a multidisciplinary team High touch, high tech Grounded in the community Genomic and personalized Preventive Integrative Support of social and environmental policies promoting health And Supports Patients Through ... And Will Follow ... Complementary and alternative practices Evidence-based, outcomefocused practices Belief that the body helps heal itself Principles for creations of healing environments The lead of empowered patients

INSTITUTE OF MEDICINE 2005 REPORT AND 2009 SUMMIT The Institute of Medicine (IOM) of the National Academy of Sciences acts as a private, nonprofit society of scholars engaged in research dedicated to the promotion of science and technology for the public good. Because of the American public's increasing use of CAM and the many concerns regarding safety, efficacy, and information access, a report was commissioned and a committee charged to explore the emerging scientific, policy, and practice questions. The 300- page report released in 2005 gave specific recommendations in the domains of research, education, and clinical care; new and innovative approaches to research were considered essential. The IOM Committee Chair placed a "call to action" to researchers (Bondurant and Sox, 2005, p 150): Ignoring CAM is not an option. The widespread use of CAM by patients is a mandate to the scientific community to improve our relatively weak scientific understanding of CAM practices. Moreover, health professionals have a duty to their patients to bring these 2 worlds of contemporary medical practice together. The path to this outcome begins with adopting the same standards of evidence

In 2009, IOM and the Bravewell Collaborative convened a 3-day summit, Integrative Medicine and the Health of the Public. More than 600 scientists, academic leaders, policy experts, health practitioners, advocates, and other participants from various disciplines examined the practice of integrative medicine, its scientific basis, and its potential for improving health. Note how the recurring themes and shared values listed in Table 12-5 resonate with the principles of family medicine and the foundations of the PCMH. Family physician Victor Sierpina shared a vision for integrative medicine and the physician of the future (Table 12-6). NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE STRATEGIC PLAN 2010 Now in its third cycle of 5-year strategic planning, NCCAM continues to explore CAM healing practices in the context of science, train CAM researchers, and disseminate authoritative information to public and professional communities. NCCAM's course for 2010-2014 is to create priority areas of CAM research to focus efforts that would best serve public need while meeting fiscal realities, as guided by four factors: (1) scientific promise, (2) extent and nature of practice and use, (3) amenability to rigorous scientific inquiry, and (4) potential to change health practices. A recent, new research priority is focused on symptom management, specifically the role of mind-body interventions in managing pain and common chronic disease symptoms. (Briggs and Killen, 2013) Nahin and Strauss (2001) and Ahn and Kaptchuk (2005) discuss the unique challenges that CAM presents to conventional research approaches in evidence-based medicine.

The practice of holistic medicine integrates conventional and complementary therapies to promote optimal health and to prevent and treat disease by addressing contributing factors" (AHMA, 2014). In 1981, the nursing profession, guided by a group of nurses dedicated to bringing the concepts of holism to every arena of nursing practice, founded the American Holistic Nursing Association (AHNA). "Holistic nursing is defined as 'all nursing practice that has healing the whole person as its goal' (AHNA, 1998). Holistic nursing is a specialty practice that draws on nursing knowledge, theories, expertise, and intuition to guide nurses in becoming therapeutic partners with people in their care. This practice recognizes the totality of the human being—the interconnectedness of body, mind, emotion, spirit, social/cultural, relationship, context, and environment" (AHNA, 2014). Integrative medicine, a term brought into popular use by Andrew Weil, MD, founder and director of the innovative University of Arizona Center for Integrative Medicine, describes how CAM and conventional medicine is practiced together (Rakel and Weil, 2003, p 6

Integrative medicine is healing oriented and emphasizes the centrality of the doctor-patient relationship. It

Many CAM study therapies are complex and heterogeneous compared with the more familiar single-drug trial of biomedicine. As such, innovative research strategies, such as those for sham acupuncture, will need to be continually developed. CAM may help the science of medicine to further evolve, as reflected on by Linde and Jonas (1999): The continuing interface between orthodox and unorthodox medicine today provides the opportunity for new research strategies and methodologies to arise. By purposefully maintaining a creative tension between the established and frontier, we can advance scientific methods and more clearly define the boundaries and purpose of the scientific process for medicine

Key Points ■ Nutrition, mind-body medicine, and spirituality are core elements of integrative medicine practice. ■ Strong evidence supports mind-body medicine for coronary artery disease, low back pain, and headache. ■ Acupuncture is a safe and efficacious adjunctive treatment for several musculoskeletal conditions. ■ Energy medicine researchers use current technologies to explore the frontiers of CAM. Because the field of CAM and integrative medicine is so broad and includes so many different approaches and modalities, this section reviews core elements and then explores three common CAM modalities with evidence of efficacy: acupuncture, yoga, and homeopathy. Energy medicine, an important frontier of the CAM field, is also discussed

been significant increases in some therapies, including acupuncture, deep-breathing exercises, massage therapy, meditation, naturopathy, and yoga (see Figure 12-3). Several factors may account for this growth, including increasing state licensure of some of the practices and greater public awareness of their use through the press and Internet resources. Characteristics of adult and pediatric CAM users are similar in that education, poverty status, geographic region, number of health conditions, physician visits in the prior year, and delaying or not receiving conventional care because of cost are all associated with CAM use. Overall reasons for CAM use fall into two equal categories: (1) treating a variety of health problems, especially pain, and (2) promoting general health and wellness. Much of CAM use is "self-care" and is mostly used with conventional care.

Key Points ■ The White House Commission on complementary and alternative medicine (CAM) created a blueprint for public policy and health care transformation in 2002. The Institute of Medicine's 2005 CAM report and 2009 summit called for expanding research, education, and clinical application. ■ CAM challenges conventional research methods. ■ CAM creates opportunities for innovative studies. ■ The National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine 2010 Strategic Plan sets an agenda for more CAM research

Key Points Explain and explore options and preferences. ■ Almost 40% of U.S. adults and 12% of children use complementary and alternative medicine (CAM) therapies. ■ The number of adult Americans using CAM rose by 38% between 1990 and 1997 and has remained stable between 2002 and 2007. ■ CAM is used more by women, by those with higher levels of education and income, and by those who were recently hospitalized. ■ Most patients do not disclose CAM use to their physicians. ■ Most patients use CAM and conventional care together. The first major study of CAM use in the United States was conducted in 1990 by David Eisenberg and colleagues (1993), who published a landmark paper in the New England Journal of Medicine. Serving as a wake-up call to conventional medicine, the data from this national telephone survey of 1539 English-speaking adults estimated that one of three Americans (34%) had used a CAM therapy in the prior year. The study estimated that those using CAM had made 425 million visits to complementary medicine practitioners—more than all office visits to primary care physicians in that same time frame! The out-of-pocket costs for these CAM services were approximately $14 billion a year. The striking statistics alerted mainstream medicine and prompted further inquiry into the growing phenomenon of the public's use of CAM. In 1997, Eisenberg and colleagues conducted a follow-up to the 1990 study, again using a national telephone survey of English-speaking adults (2055). The findings, published in the Journal of the American Medical Association in 1998, showed that the number of Americans using CAM rose by 38% (60 to 83 million) and that visits to CAM practitioners increased from an estimated 427 million to 629 million. Overall, 42% of Americans were estimated to be using at least one CAM therapy in the prior 12 months. With regard to costs, conservative estimates put expenditures for CAM professional services at $21.2 billion, with approximately $12.2 billion paid as out-of-pocket expenses (Eisenberg et al., 1998)

Most concerning was the finding that although CAM use had increased over the 7-year period, the number of patients informing their doctors of such use had not changed— approximately 60% to 70% of CAM users in 1990 and 1997 did not discuss their use of CAM with their physicians. Lack of communication was noted again in a 2006 NCCAM/American Association of Retired Persons (AARP) survey of adults 50 or older revealing only one-third of CAM users had talked to their physicians about their CAM use (NCCAM/AARP, 2007). Given this fact and the potential for untoward side effects, it is essential that physicians and all other health professionals ask patients about their

Hypnosis Altered state of consciousness characterized by increased responsiveness to suggestion. The hypnotic state is attained by first relaxing the body, then shifting attention toward a narrow range of objects or ideas as suggested by the hypnotist or hypnotherapist. The procedure is used to effect positive changes and to treat numerous health conditions, including ulcers, chronic pain, respiratory ailments, stress, and headaches. Macrobiotic diet Low-fat diet that emphasizes whole grains and vegetables and restricts the intake of fluids; of particular importance is the consumption of fresh, nonprocessed foods. Massage Manipulation of muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being. Meditation Group of techniques, most of which started in Eastern religious or spiritual traditions. In meditation, persons learn to focus their attention and suspend the stream of thoughts that normally occupy the mind. This practice is believed to result in a state of greater physical relaxation, mental calmness, and psychological balance. Practicing meditation can change how a person relates to the flow of emotions and thoughts in the mind. Native American healer Traditional healer who uses information from the "spirit world" to benefit the community; patients especially seek to find relief or a cure from illness or to find spiritual guidance; also called medicine man. Naturopathy Alternative medical system that proposes that a healing power in the body establishes, maintains, and restores health. Practitioners work with patients to support this power through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine (TCM).

Nonvitamin, nonmineral, natural products Taken by mouth, these natural products contain a dietary ingredient other than vitamins and minerals, intended to supplement the diet; examples include herbs or herbal medicine (as single herbs or mixtures), other botanical products (e.g., soy or flax products), and dietary substances (e.g., enzymes). Among the most popular are echinacea, Ginkgo biloba, ginseng, feverfew, garlic, kava, and saw palmetto; garlic has been used to treat fever, sore throat, digestive ailments, and arteriosclerosis

Guiding Principles: 2002 White House Commission on Complementary and Alternative Medicine Policy 1. A wholeness orientation in health care delivery 2. Evidence of safety and efficacy 3. The healing capacity of the person 4. Respect for individuality 5. The right to choose treatment 6. An emphasis on health promotion and self-care 7. Partnerships are essential for integrated health care 8. Education as a fundamental health care service 9. Dissemination of comprehensive and timely information 10. Integral public involvement

Over the past two decades, several important reports have addressed CAM and integrative medicine in the United States. This section summarizes the major themes and recommendations. WHITE HOUSE COMMISSION 2002 REPORT The White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) 2002 report was the culmination of 18 months of in-depth work of a committee of 20 appointed commissioners. Their task was to provide the president, through the secretary of Health and Human Services, with a report containing legislative and administrative recommendations that would ensure a public policy that maximized the potential benefits of CAM to all. Specifically, the commission addressed the coordination of research to increase knowledge about CAM products; the education and training of health care practitioners in CAM; the provision of reliable and useful information about CAM practices and products to health care professionals; and guidance regarding appropriate access to and delivery of CAM. Table 12-4 lists the 10 guiding principles the commission endorsed for their process of making recommendations. The final report lists 29 recommendations and more than 100 action steps as a blueprint for shaping future CAM policy

Ornish diet High-fiber, low-fat vegetarian diet that promotes weight loss and health by controlling what is eaten, not by restricting the intake of calories. Fruits, beans, grains, and vegetables can be eaten at all meals; nonfat dairy products such as skim milk, nonfat cheeses, and egg whites are consumed in moderation. Products such as oils, avocados, nuts and seeds, and meats are avoided. Osteopathic manipulation Full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well-being

Pilates Movement therapy that uses a method of physical exercise to strengthen and build control of muscles, especially those used for posture. Awareness of breathing and precise control of movements are integral components of Pilates. Special equipment, if available, is often used. Progressive relaxation Technique used to relieve tension and stress by systematically tensing and relaxing successive muscle groups. Qi gong Ancient Chinese discipline combining the use of gentle physical movements, mental focus, and deep breathing directed toward specific parts of the body. Performed in repetitions, the exercises are normally performed two or more times a week for 30 minutes at a time. Reiki Energy medicine practice that originated in Japan. The practitioner places the hands on or near the person receiving treatment, with the intent to transmit ki (qi), believed to be life-force energy. Shaman Traditional healer who is said to act as a medium between the invisible spiritual world and the physical world. Most gain knowledge through contact with the spiritual world and use the information to perform divination, influence natural events, and heal sick or injured persons

Health concerns regarding the sources of U.S. food and recommendations for organic and wild food are discussed. The Healing Foods Pyramid is available as a webbased interactive version (http://med.umich.edu/umim/ food-pyramid/index.htm). The top is left open to be filled in by what individuals feel may complete and customize their pyramid. A particular aspect of nutrition that has received increasing attention for its value in lessening inflammation is that of fish oil (i.e., omega-6 and omega-3 fatty acids). Omega-3 fatty acids consist of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and are mostly found in fatty fish, such as herring and salmon. Because inflammation plays a role in several common conditions, such as cardiovascular disease, asthma, arthritis, psoriasis, and inflammatory bowel disease, research has explored the role of omega-3 fatty acids in reducing symptoms and improving outcomes

Practical applications for recommending fish oil in the primary care setting included the following (Oh, 2005): 1. The American Heart Association recommends 1 gram (g) per day for all patients with documented coronary artery disease through diet or through supplementation. 2. For patients with mild or persistent hypertriglyceridemia, use of 2 to 4 g per day of fish oil may lower levels by 20% to 50% to reach NIH National Heart, Lung, and Blood Institute (NHLBI) Adult Treatment Panel (ATP) III goals. 3. For those with rheumatoid arthritis, doses of 2.6 to 6 g per day for at least 8 to 12 weeks are optimal and may reduce or eliminate nonsteroidal antiinflammatory drug (NSAID) use. Monitoring for clinical bleeding and for low-density lipoprotein (LDL) cholesterol and glycemic response should be considered for patients taking doses higher than 3 g/day, especially if they are diabetic. Unfortunately, because our waters are polluted with heavy metals, avoiding fish known to have high methyl mercury levels (especially by women who are pregnant and of childbearing age) is an important precaution when discussing fish oil use with patients (Williams, 2005). Along with fish oil consumption, other dietary modifications are also known to help lessen inflammation; Table 12-7 shows guidelines for prescribing an antiinflammatory diet (Rakel, 2003; Rakel and Rindfleisch, 2006).

and number of physician visits in the previous year. When concerned about cost or unable to pay for conventional care, adults were more likely to use CAM. For children, the 2007 data show no gender difference. For all therapies combined, CAM use was highest among adolescents age 12 to 17 years (16%) versus children age 5 to 11 years (11%) or preschool children age 0 to 4 years (8%). Children's use of CAM increased as their parents' education or income level increased, and when families were unable to afford conventional medical care. Children with a parent or other relative who used CAM were about five times as likely (23%) to use CAM as children whose parent did not (5%). Figure 12-4 shows the disease or condition for which adults and children are most likely to seek CAM. The 2002 survey also addressed the important question: Why do people use CAM? Previous studies revealed general issues of the overuse of technology and a reductionist approach to care, managed-care time constraints limiting visits and eroding the physician-patient relationship, and the explosion of Internet-based information on CAM. Astin (1998) found that along with being more educated and reporting poor health status, most alternative medicine users were not dissatisfied with conventional medicine but rather found these health care alternatives to be more congruent with their own values, beliefs, and philosophic orientations toward health and life. Only 4.4% reported relying primarily on CAM therapies for their health care. A subsequent study of patients using both CAM and conventional care also found that use of CAM did not primarily reflect dissatisfaction with conventional care (Eisenberg et al., 2001). Reasons for CAM use reported in the 2002 NHIS study are shown in Figure 12-5, with slightly more than one-half of all respondents believing CAM combined with conventional medicine would be helpful.

TRENDS IN COMPLEMENTARY AND ALTERNATIVE MEDICINE USE The 2002 and 2007 NHIS data show that although the overall prevalence of CAM use by adults had remained relatively stable (36% and 38%, respectively), there have

As shown in Figure 12-2, CAM use increased from 36% of U.S. adults in 2002 to 38% in 2007, or almost 4 of 10 adults (Barnes et al., 2004, 2008). For the first time, the 2007 survey collected data on CAM use in children (<18 years), showing 12% use, or 1 in 9 children. The top 10 CAM therapies for both adults and children are shown in Figure 12-3. Significant increases in adults' use of deep breathing, meditation, massage, and yoga occurred over the 5 years of the study. Another notable NCCAM/AARP study focused on CAM use in adults older than 50 years. Approximately two-thirds (63%) had used one or more CAM therapies (NCCAM/AARP, 2007). The most common reasons cited for not discussing CAM included: the physician never asked (42%), the patient did not know they should ask (30%), and there was not enough time during the office visit (19%). Of those using CAM, 66% did so to treat a specific condition and 65% for overall wellness. For details on CAM costs in the United States, see eFigures 12-1 to 12-3 online

WHO IS MORE LIKELY TO USE COMPLEMENTARY AND ALTERNATIVE MEDICINE AND WHY? Consistent with data from the 2002 NHIS study, CAM use by adults in 2007 was more prevalent among women; adults age 30 to 69; those with higher education level, not poor, or living in the West; former smokers; and those hospitalized in the prior year (Barnes et al., 2008). CAM use was positively associated with number of health conditions

prepare the body for higher states of consciousness. Hatha yoga, as described in Table 12-10 along with other types of movement therapies, has many different styles and is the most popular form taught and practiced in the United States today. Because most yoga instructors are not medical professionals, it is recommended to refer a patient to a teacher with several years' experience. A study of the efficacy of yoga on pregnancy outcome (N = 335) concluded that an integrated approach to yoga during pregnancy was safe and that it improved birth weight and decreased preterm labor and intrauterine growth retardation with no complications (Narendran et al., 2005). A recent study of 90 patients with chronic low back pain who participated in a 24-week trial of yoga twice a week showed those receiving the yoga intervention experienced decreased levels of pain, functional disability, and depression (Williams et al., 2009). The International Association of Yoga Therapists (IAYT) is a worldwide organization for yoga teachers, therapists

and researchers (www.iayt.org). The Yoga Alliance (www .yogaalliance.org), formed in 1999, sets minimum training standards for yoga teachers. Both organizations provide sound resources for professionals and the public. Perhaps the most controversial of CAM therapies, homeopathy seems to defy biomedicine's attempts to decipher its mechanism of action. Particularly perplexing is the concept that the more dilute the remedy, the more potent is its effect. Founded by the German physician Samuel Hahnemann (1755-1843), homeopathy is still widely accepted and practiced in Europe and is now experiencing a renaissance in the United States. A brilliant linguist and scholar, Dr. Hahnemann developed the Principle of Similars, in which "like cures like" based on his medical translation work and personal experience of malaria symptoms after taking Cinchona bark, which was then the treatment for the disease. A critical overview of homeopathy by Jonas and colleagues (2003) reviewed the research regarding specific conditions

Commonly Used Movement Therapies Therapy* Description Research Hatha yoga Focuses on the use of postures (asanas) and breathing exercises (pranayama); traditionally used in India to purify the body and maximize the impact of meditation practice; many different schools; must be used with caution by those with glaucoma, retinal detachment, or at high risk for muscle strain or fracture. Most trials are quite small. Positive benefits likely for musculoskeletal and other types of pain; lowering autonomic nervous system sympathetic tone; decreasing histamine effects of FEV1 in asthmatic patients; reducing blood pressure; improving headaches, diabetes, osteoarthritis, rheumatoid arthritis; overall improvement in balance, endurance, and vitality. Tai chi Developed more than 5000 years ago; movement and breathing, often associated with specific flowing movement patterns, are used to affect the flow of energy, or qi. Useful adjunctive therapy for arthritis and cardiovascular disease. Helpful for improving postural stability and decreasing fall risk in older adults. Qigong (Qi gong) Part of traditional Chinese medicine; also used to cultivate qi; includes breathing exercises, meditation, and physical movement; used in the martial arts and to generate energy to be used in healing. Most studies conducted in China. Potentially useful for hypertension, decreasing overall stroke and mortality rates compared with controls, decreasing peripheral vascular resistance, increasing bone density; improvement of blood flow to brain (e.g., adjunctive treatment for memory loss, dizziness, insomnia, vertigo); improvement of cardiac output, ejection fraction, and valve function. Feldenkrais Developed by Moshe Feldenkrais in the 1950s; gentle movements and manipulation enlisted to retrain the body with new movement patterns. Limited randomized trial-based research. Used to promote flexibility and posture, decrease back pain, and improve vocal cord function.

and the placebo effect. After analyzing systematic reviews of clinical trials, the authors concluded, "Despite skepticism about the plausibility of homeopathy, some randomized, placebo-controlled trials and laboratory research report unexpected effects of homeopathic medicine. However, the evidence on the effectiveness of homeopathy for specific clinical conditions is scant, is of uneven quality, and is generally poorer quality than research done in allopathic medicine" (p 397). Known for his groundbreaking research showing homeopathic treatment of allergic rhinitis more effective than placebo (Taylor et al., 2000), David Reilly of Glasgow, Scotland, commented on the increasing scientific validation for homeopathy over the past decade. Noting that studies reviewed show positive evidence for overall effect and citing the growing prospective, observational research that indicates beneficial outcomes, Reilly (2005) points out that homeopathy can offer therapeutic options when conventional care has failed or reached a plateau, no conventional treatments exist, conventional treatments are contraindicated, side effects of conventional treatments are not tolerated, and patients are reluctant to accept conventional care. An important distinction clouds other areas of medical research: "The two dimensions of care need to be considered: the direct effects of the remedy and the therapeutic impact of the method of approach on the patient" (p 30). Believing that the homeopathic approach is helping to reintroduce a holistic perspective in medical practice, Reilly concludes, "The evidence mosaic for homeopathy reinforces clinicians' and patients' experiential knowledge that this approach can make a valuable contribution to care, especially when applied with a whole person perspective and integrated with conventional knowledge" (p 31).

About the Center for Mindfulness Directed by Dr. Saki F. Santorelli, the Center for Mindfulness is an innovative leader in mind-body medicine and the integration of mindfulness into key areas of modern life, including mainstream medicine, health care, academic medical and professional education, public and private school education, corporate and nonprofit leadership, and service to broad segments of society. Established in 1995, the Center emerged as an outgrowth of the acclaimed Stress Reduction Clinic, the oldest and largest academic medical center-based stress reduction program in the world, founded by Dr. Jon Kabat-Zinn in 1979. For more than 30 years, the Center has pursued an active research program that has focused on understanding the potential efficacy of mindfulness and the mechanisms through which mindfulness may work, publishing many peer-reviewed papers as well as scientific abstracts and books. Each year the Center hosts an annual international scientific conference attended by professionals from six continents. In the course of three decades, more than 20,000 people have completed the Stress Reduction Program. They have

been referred by more than 5000 physicians and, as well, through self-referral. Likewise, more than 9000 health care professionals and educators have participated in training programs through Oasis—the Center's institute for mindfulness-based professional education and innovation. In parallel, the Center has developed a range of innovative programs for leaders in business, government, and nonprofit organizations, educators, attorneys and judicial officials, inmates and correctional staff, clergy, and Olympic and professional athletes. This work has encouraged the creation of more than 250 mindfulness-based stress reduction (MBSR) programs worldwide and has inspired researchers across the planet to investigate the potential efficacy of MBSR and other mindfulness-based interventions. The work of the Center has been featured in the PBS Bill Moyers' documentary, Healing and the Mind, on NBC Dateline, and on ABC's Evening News and Chronicle programs, as well as on the Oprah Winfrey Show.

focuses on the least invasive, least toxic, and least costly methods to help facilitate health by integrating allopathic and complementary therapies. These are based on an understanding of the physical, emotional, psychologic, and spiritual aspects of the individual. In general, the terms holistic and integrative seem to best convey the ideal blending of conventional and unconventional medicine "in that both imply a balanced, wholeperson- centered approach and involve a synthesis of conventional medicine, CAM modalities, and other traditional medical systems, with the aim of prevention and healing as a basic foundation" (Lee et al., 2004, p 10). The term integral has recently emerged in the literature. First noted several decades ago in the book Mind, Body and Health: Toward an Integral Medicine (Gordon et al., 1984), its original use may be traced to the work of Sri Aurobindo, an Indian mystic and political leader. The term has been popularized by contemporary philosopher and transpersonal psychologist Ken Wilber (2005), as applied in the context of his integral theory. Many thought leaders in the field of health and healing, including the Institute of Noetic Sciences (IONS), support these concepts and encourage further research into what may be considered the beginnings of a paradigm shift in medicine (Schiltz, 2005). The following excerpt captures the essence of the deep change and transformation that integral medicine calls for (Wilber, 2005, pp xxx-xxxi): The crucial ingredient in any integral medical practice is not the integral medical bag itself—with all the

conventional pills, and the orthodox surgery, and the subtle energy medicine, and the acupuncture needles— but the holder of that bag. Integrally informed healthcare practitioners, the doctors, nurses, and therapists, have opened themselves to an entire spectrum of consciousness—matter to body to mind to soul to spirit—and who have thereby acknowledged what seems to be happening in any event. Body and mind and spirit are operating in self and culture and nature, and thus health and healing, sickness and wholeness, are all bound up in a multidimensional tapestry that cannot be cut into without loss. Family physicians know this to be true. They practice with the intention to care for the whole patient within the context of a continuous healing relationship while honoring the rich complexity and interplay of family, community, and environment. They acknowledge the personal and interpersonal effects of health and illness and are trained to consider the behavioral and social aspects of a person's life as well as the biomedical factors. Now is the time not only to reclaim its roots, but also to move primary care into expanded dimensions and possibilities of health and healing. Family medicine is the ideal discipline to champion this movement and to actualize changes that will begin to heal the failing U.S. health care system. Whether it is called holistic, integrative, or integral, family physicians are collectively evolving toward a more compassionate and sustainable system of care that may ultimately be called good medicine

KEY TREATMENT • Fish oil supplementation can benefit heart health (Bucher et al., 2002; Wang et al., 2004), hypertriglyceridemia (Balk et al., 2004), and rheumatoid arthritis (Fortin et al., 1995; MacLean et al., 2004) (SOR: A). • Acupuncture should be considered as a treatment option for common painful conditions such as chronic low back pain (Furlan et al., 2005; Yuan et al., 2008), neck pain (Fu et al., 2009, Trinh et al., 2006), and headache (migraine, tension) (Linde et al., 2009a, 2009b) (SOR: A). • Green tea is associated with decreased risk of stroke and cardiovascular disease (Kuriyama et al., 2006) and may help prevent cancer of the breast (Sun et al., 2006a

gastrointestinal tract (Sun et al., 2006b), and prostate (Kurahashi et al., 2008) (SOR: B). • Yoga reduces functional disability, pain, and depression in people with chronic low back pain (Williams et al., 2009) (SOR: B). • Mindful communication may improve physician wellbeing and attitudes associated with patient-centered care (Kearney et al., 2009; Krasner et al., 2009) (SOR: C

Progressive relaxation Technique used to relieve tension and stress by systematically tensing and relaxing successive muscle groups. Qi gong Ancient Chinese discipline combining the use of gentle physical movements, mental focus, and deep breathing directed toward specific parts of the body. Performed in repetitions, the exercises are normally performed two or more times a week for 30 minutes at a time. Reiki Energy medicine practice that originated in Japan. The practitioner places the hands on or near the person receiving treatment, with the intent to transmit ki (qi), believed to be life-force energy. Shaman Traditional healer who is said to act as a medium between the invisible spiritual world and the physical world. Most gain knowledge through contact with the spiritual world and use the information to perform divination, influence natural events, and heal sick or injured persons. Sobador Traditional healer who uses massage and rub techniques to treat patients. Tai chi Mind-body practice that originated in China as a martial art. The person moves the body slowly and gently while breathing deeply and meditating (tai chi is sometimes called "moving meditation"). Many practitioners believe that tai chi helps the flow throughout the body of a proposed vital energy called qi. A person practicing tai chi moves her body in a slow, relaxed, and graceful series of movements. Persons can practice on their own or in a group. The movements make up what are called forms (or routines). Traditional healer Person who employs any of a number of ancient medical practices based on indigenous theories, beliefs, and experiences and handed down from generation to generation. The methods employed by each type of traditional healer have evolved to reflect the different philosophical backgrounds and cultural origins of the healer. Trager psychophysical integration Movement therapy in which practitioners apply a series of gentle, rhythmic rocking movements to the joints. They also teach physical and mental self-care exercises to reinforce the proper movement of the body. The intent is to release physical tension and increase the body's range of motion. An example of Trager psychophysical integration as CAM is using it to treat chronic headaches. Vegetarian diets Vegetarian diets are totally devoid of meat, red or white. There are, however, numerous variations on the nonmeat theme. For example, some vegetarian diets are restricted to plant products only, whereas others

include eggs and dairy products. Another variation limits consumption to raw fruit, sometimes supplemented with nuts and vegetables. Finally, a number of vegetarian diets prohibit alcohol, sugar, caffeine, or processed foods. Yerbera Practitioner with knowledge of the medicinal qualities of plants; also called hierbero. Yoga A combination of breathing exercises, physical postures, and meditation to calm the nervous system and balance body, mind, and spirit. The sessions last about 45 minutes and usually are performed in classes once a week (or more often).

Precautions in Complementary and Alternative Medicine 1. Primum non nocere (first, do no harm). 2. Patients may encounter complications if they abandon effective, conventional therapies in favor of complementary and alternative medicine (CAM). 3. Medicolegal issues and certification or qualification requirements of practitioners are important topics, not covered in this chapter.

of varied approaches and philosophies of healing, CAM is usually incorporated into conventional health care as integrative medicine. CAM presents opportunities to expand the current research paradigm to meet the challenges of studying its multidimensional approach to health and healing. Prominent organizations such as the IOM and World Health Organization (WHO) have placed a call to action to the medical community to advance knowledge and clinical applications in this field. Family physicians, specialists in caring for the whole person though a continuous, healing relationship, are in the ideal discipline to advance the integration of safe and effective CAM into their repertoire to optimize the health of their patients (Table 12-11). Ultimately, complex terminology will subside as the essence of integrative medicine becomes good family medicine.

CORE ELEMENTS OF INTEGRATIVE MEDICINE Nutrition, mind-body medicine, and spirituality are considered core elements of an integrative medicine approach and often are applied during patient consultation. These elements also tend to be cost-effective and patient empowering. Considered the foundation of good health and enhanced healing, nutritional principles are key elements in most treatment plans. The adage "food is medicine" is becoming ever more important as the United States, as well as other world populations, face impending epidemics of diabetes and obesity. Research has shown the health benefits and costeffectiveness of the Mediterranean diet for primary and secondary prevention of metabolic syndrome (Kastorini et al., 2011). When the new food pyramid was released by the U.S. federal government (MyPyramid.gov), critics such as Walter Willett commented, "This is a huge lost

opportunity to convey information about healthy food choices that could benefit Americans enormously. ... The pyramid tells nothing of healthy food choices" (Mitka, 2005, p 2581). Other options are considered in the Healing Foods Pyramid (Figure 12-6). While developing the best nutrition advice for the diverse people seen at the University of Michigan's Integrative Medicine Clinic, family physician Monica Myklebust found various recommendations for the prevention and treatment of obesity, mood disorders, heart disease, diabetes, chronic pain, and inflammation. The result of her work is a user-friendly tool that brings all of these data together. Omega-3 fatty acids, antioxidants, medicinal seasonings, soy, chocolate, and tea are all considered. For example, green tea offers a variety of health benefits, with emerging evidence for prevention of cancer, stroke, and cardiovascular disease (Schneider and Segre

Spiritual Assessment Tools FICA MNEMONIC F: Faith or belief—What is your faith or belief? I: Importance and influence—Is it important in your life? How? C: Community—Are you part of a religious community? A: Awareness and addressing—What would you want me as your physician to be aware of? How would you like me to address these issues in your care? HOPE MNEMONIC H: Hope—What are your sources of hope, meaning, strength, peace, love, and connectedness? O: Organized—Do you consider yourself part of an organized religion? P: Personal spirituality and practices—What aspects of your spirituality or spiritual practices do you find most helpful? E: Effects—How do your beliefs affect the kind of medical care you would like me to provide? THREE QUESTIONS 1. What helps you get through tough times? 2. Who do you turn to when you need support? 3. What meaning does this experience have for you

physicians have pursued professional training in these fields and are now integrating new skills and perspectives into their practice. The Society of Teachers of Family Medicine (STFM) Group on Hospital Medicine and Procedural Training has proposed that acupuncture become an advanced procedure within the scope of family medicine training (Kelly, 2009). Although challenging to research, trials have shown acupuncture efficacious as an adjunctive therapy in osteoarthritis of the knee (Berman et al., 2004) and as a complement to standard therapy for the debilitating effect of pelvic girdle pain during pregnancy (Elden et al., 2005). Cochrane reviews have shown that acupuncture benefits patients with chronic low back pain, neck pain, and headache (migraine and tension) (Kelly, 2009). A meta-analysis evaluating 33 randomized controlled trials (RCTs) of acupuncture for acute and chronic low back pain concluded that acupuncture effectively relieves chronic low back pain, although no evidence suggests that it is more effective than other active therapies (Manheimer et al., 2005). A more recent review found acupuncture a reasonable referral option for chronic pain (Vickers et al., 2012). Excellent reviews of acupuncture's theory, efficacy, and practice (Kaptchuk, 2002; Nielsen and Hammerschlag, 2004) cite the 1997 NIH Consensus Development Panel findings on acupuncture. After reviewing all available evidence from RCTs up to 1997, the panel concluded that clear evidence shows that acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and for postoperative dental pain. The panel also reported that acupuncture should be considered a useful adjunct for addiction, stroke rehabilitation, osteoarthritis, headache, low back pain, tennis elbow, menstrual cramps, carpal tunnel, and fibromyalgia (NIH, 1998). Yoga, a widely popular and rapidly increasing CAM practice in the United States, has its roots in ancient India and is a Sanskrit word that means "yoke" or "union." The original goal of practicing these postures was to purify and

by the Biofeedback Certification Institute of America. Ayurveda System of medicine that originated in India several thousand years ago. In the United States, Ayurveda is considered a type of CAM and a whole medical system. As with other such systems, it is based on theories of health and illness and on ways to prevent, manage, or treat health problems. Ayurveda aims to integrate and balance the body, mind, and spirit (thus some view it as "holistic"). This balance is believed to lead to contentment and health and to help prevent illness. However, Ayurveda also proposes treatments for specific health problems, whether they are physical or mental. A chief aim of Ayurvedic practices is to cleanse the body of substances that can cause disease, and this is believed to help reestablish harmony and balance. Biofeedback Technique that uses simple electronic devices to teach clients how to consciously regulate bodily functions, such as breathing, heart rate, and blood pressure, to improve overall health. Biofeedback is used to reduce stress, eliminate headaches, recondition injured muscles, control asthmatic attacks, and relieve pain. Botanica Traditional healer who supplies healing products, sometimes associated with spiritual interventions. Chelation therapy Chemical process in which a substance is used to bind molecules, such as metals or minerals, and hold them tightly so that they can be removed from a

system, such as the body. In medicine, chelation has been scientifically proven to rid the body of excess or toxic metals. For example, a person who has lead poisoning may be given chelation therapy to bind and remove excess lead from the body before it can cause damage. Chiropractic care Adjustment of the spine and joints to influence the body's nervous system and natural defense mechanisms to alleviate pain and improve general health. It is primarily used to treat back problems, headaches, nerve inflammation, muscle spasms, and other injuries and trauma. Chiropractic manipulation Form of health care that focuses on the relationship between the body's structure, primarily of the spine, and function. Doctors of chiropractic, who are also called chiropractors or chiropractic physicians, use a type of hands-on therapy called manipulation (or adjustment) as their core clinical procedure. Complementary and alternative medicine (CAM) Therapies not usually taught in U.S. medical schools or generally available in U.S. hospitals. Also called integrative, these therapies include a broad range of practices and beliefs such as acupuncture, chiropractic care, relaxation techniques, massage therapy, and herbal remedies. They are defined by the National Center for Complementary and Alternative Medicine as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine

Curandero Type of traditional folk healer. Originally found in Latin America, curanderos specialize in treating illness through the use of supernatural forces, herbal remedies, and other natural medicines. Deep breathing Slow and deep inhalation through the nose, usually to a count of 10, followed by slow and complete exhalation for a similar count. The process may be repeated 5 to 10 times, several times a day. Energy healing therapy Channeling of healing energy through the hands of a practitioner into the client's body to restore a normal energy balance and, therefore, health. Energy healing therapy has been used to treat a wide variety of ailments and health problems and is often used with other alternative and conventional medical treatments. Espiritista Traditional healer who assesses a patient's condition and recommends herbs or religious amulets to improve physical or mental health or to help overcome a personal problem. Feldenkrais Movement therapy that uses a method of education in physical coordination and movement. Practitioners use verbal guidance and light touch to teach the method through one-on-one lessons and group classes. The intent is to help the person become more aware of how

the body moves through space and to improve physical functioning. Guided imagery Series of relaxation techniques followed by the visualization of detailed images, usually calm and peaceful in nature. If used for treatment, individuals will visualize their body free of the specific problem or condition. Sessions typically are 20 to 30 minutes and may be practiced several times a week. Hierbero Traditional healer or practitioner with knowledge of the medicinal qualities of plants; also called yerbera. Homeopathy System of medical practices based on the theory that any substance that can produce symptoms of disease or illness in a healthy person can cure those symptoms in a sick person. For example, a person with insomnia may be given a homeopathic dose of coffee. Administered in diluted form, homeopathic remedies are derived from many natural sources, including plants, metals, and minerals.

The level of integration of conventional and CAM therapies is growing. That growth generates the need for tools or frameworks to make decisions about which therapies should be provided or recommended, about which CAM providers to whom conventional medical providers might refer patients, and the organizational structure to be used for the delivery of integrated care. The committee believes that the overarching rubric that should be used to guide the development of these tools should be the goal of providing comprehensive care that is safe and effective, that is collaborative and interdisciplinary, and that respects and joins interventions from all sources. (IOM, 2005) Many countries now recognize the need to develop a cohesive and integrative approach to health care that allow governments, health care practitioners and, most importantly, those who use health care services, to access T&CM [Traditional & Complementary Medicine] in a safe, respectful, cost-efficient and effective manner. A global strategy to foster its appropriate integration, regulation and supervision will be useful to countries wishing to develop a proactive policy towards this important—and often vibrant and expanding—part of health care. (WHO, 2013) In these tumultuous times of health care reform, family physicians find themselves on a threshold: a place of great

through this historic doorway with newfound meaning and professional identity? Will they create new practice models, new ways of delivering care, and new methods of collaborating across the spectrum of healing practices and health professionals? Work is already underway with initiatives such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). In addition, the field of family medicine has taken the lead and is currently pioneering work bringing complementary and alternative medicine (CAM) and integrative medicine into residency training and clinical care (Benn et al., 2009; Lebensohn et al., 2012; Locke et al., 2013). How will these relatively new and evolving areas of health care optimize and revitalize the practice of family medicine? This chapter describes these new fields, assesses proposals by U.S. medical organizations, and addresses the challenges for practitioners applying current research techniques to these diverse and complex healing approaches and systems. Core principles and specific examples of CAM encountered by the practicing family physician are presented with relevant evidence and helpful tips. Complementary and alternative medicine is based on multiple healing traditions practiced long before conventional Western medicine. Emerging from diverse cultural traditions worldwide, these approaches to health and healing offer the wisdom of their unique perspective on the human condition. Many traditional practices, including those of conventional medicine, share common roots and philosophies and uphold the sacred call to relieve the suffering of others. Family physicians should keep an open mind as they explore these dimensions of CAM.

Guidelines for Advising Patients Who Seek Alternative Therapies Ask; don't tell. Be willing to listen and learn. Communicate and collaborate. Diagnose. Key Points Explain and explore options and preferences

use of CAM. In addition to NCCAM's "Time to Talk" campaign, several approaches have been suggested (Eisenberg, 1997); Table 12-2 lists an ABC format especially useful for the busy clinician (Sierpina, 2001). Complementary and Alternative Medicine Use in the 21st Century Data on the U.S. population's use of CAM was collected in 2002, 2007 (published), and 2012 (publication pending). Considered the most comprehensive and reliable findings on Americans' use of CAM, these studies were conducted by the NCCAM and the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC). For the first time, detailed questions regarding CAM were added into the 2002 edition of the NCHS National Health Interview Survey (NHIS), an annual study interviewing tens of thousands of Americans about their health- and illness-related experiences. The 2002 and 2007 studies were completed by approximately 30,000 families through adults 18 years or older who spoke English or Spanish. The study reflected CAM use during the 12 months before the survey. The 2007 survey included expanded questions on 36 types of CAM therapies commonly used in the United States: 10 practitioner-based therapies, such as acupuncture, and 26 other, self-care therapies not requiring a practitioner. CAM therapies included in the surveys are listed in Table 12-3, and the terms are defined in eAppendix 12-1.

patient-centered care for the benefit of both physicians and their patients" (Shanafelt, 2009, p 1340). A recent abbreviated mindfulness intervention adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress (Fortney et al., 2013) and a multicenter study found that clinicians who rate themselves more mindful engage in more patientcentered communication and have more satisfied patients (Beach et al., 2013). Online eAppendix 12-2 highlights a well-known and well-studied mind-body technique called mindfulness-based stress reduction (MBSR) and includes a short audio sample of mindful breath work for the interested reader to try. SPIRITUALITY Another area thought to be integral to a whole-patient integrative medicine approach to care is spirituality. This broad and controversial subject is well reviewed (e.g., Sierpina and Sierpina, 2004); some key issues are considered here. Working definitions and terms from the Samueli Conference on Definitions and Standards in Healing Research (Dossey, 2003) include the following: ■ Spirituality encompasses the feelings, thoughts, experiences, and behaviors that arise from a search for that

which is generally considered sacred or holy. Spirituality is usually considered to involve a sense of connection with an absolute, imminent, or transcendent spiritual force, however named, as well as the conviction that meaning, value, direction, and purpose are valid aspects of the universe. ■ Religion is the codified and ritualized beliefs and behaviors of those involved in spirituality, usually taking place within a community of like-minded individuals. ■ Prayer is communication with an absolute, imminent, or transcendent spiritual force, however named. Such communication may take a variety of forms and may be theistic or nontheistic in nature, as in some forms of Buddhism. Intercessory prayer is an appeal to such a force to influence another person or thing. Healing prayer is an appeal to such a force for the healing and recovery of self or others. Directed prayer is offered with a specific outcome in mind. Nondirected prayer is offered with no specific outcome in mind, such as, "Thy will be done," or "May the best outcome prevail."