Topics: Alternative Medicine

Alternative medicine

In Western culture, the term Alternative medicine refers to any healing practice "that does not fall within the realm of conventional medicine", or "that which has not been shown consistently to be effective." Alternative medicine is often based on the belief that a particular health regimen has efficacious effects even while there isn't a body of evidence to support such a belief under the rigorous standards of evidence based medicine. In practice, alternative medicine encompasses therapies with a historical or cultural, rather than a scientific, basis. Commonly cited examples include naturopathy, chiropractic, herbalism, traditional Chinese medicine, Unani, Ayurveda, meditation, yoga, biofeedback, hypnosis, homeopathy, acupuncture, and diet-based therapies, in addition to a range of other practices. It is frequently grouped with complementary medicine, which generally refers to the same interventions when used in conjunction with mainstream techniques, under the umbrella term complementary and alternative medicine, or CAM. Some significant researchers in alternative medicine oppose this grouping, preferring to emphasize differences of approach, but nevertheless use the term CAM, which has become standard.

Alternative medicine practices are as diverse in their foundations as in their methodologies. Practices may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, or newly conceived approaches to healing Jurisdictions where alternative medical practices are sufficiently widespread may license and regulate them. The claims made by alternative medicine practitioners are generally not accepted by the medical community because evidence-based assessment of safety and efficacy is either not available or has not been performed for many of these practices. If scientific investigation establishes the safety and effectiveness of an alternative medical practice, whereupon it becomes mainstream medicine and is no longer "alternative", and will therefore become widely adopted by conventional practitioners. Because alternative techniques tend to lack evidence, some have advocated defining it as non-evidence based medicine, or not medicine at all. Some researchers state that the evidence-based approach to defining CAM is problematic because some CAM is tested, and research suggests that many mainstream medical techniques lack solid evidence.

A 1998 systematic review of studies assessing its prevalence in 13 countries concluded that about 31% of cancer patients use some form of complementary and alternative medicine. Alternative medicine varies from country to country. Dr. Edzard Ernst believes that in Austria and Germany CAM is mainly in the hands of physicians, while some estimates suggest that at least half of American alternative practitioners are physicians. In Germany, herbs are tightly regulated, with half prescribed by doctors and covered by health insurance based on their Commission E legislation.

Definitions and categorizations

There is no clear and consistent definition as to the exact nature of alternative or complementary medicines. In a 2005 report entitled Complementary and Alternative Medicine in the United States the Institute of Medicine (IOM) adopted this definition:

"Complementary and Alternative Medicine (CAM) is a broad domain of resources that encompasses health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society or culture in a given historical period. CAM includes such resources perceived by their users as associated with positive health outcomes. Boundaries within CAM and between the CAM domain and the domain of the dominant system are not always sharp or fixed."

Other groups and individuals have offered various definitions and distinguishing characteristics. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as "a group of diverse medical and health care systems, practices, and products, that are not currently part of conventional medicine." NCCAM has developed what the IOM calls "[o]ne of the most widely used classification structures" for the branches of complementary and alternative medicine. The Cochrane Complementary Medicine Field says:

"What are considered complementary or alternative practices in one country may be considered conventional medical practices in another. Therefore, our definition is broad and general: complementary medicine includes all such practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well-being. These practices complement mainstream medicine by 1) contributing to a common whole, 2) satisfying a demand not met by conventional practices, and 3) diversifying the conceptual framework of medicine."

David M. Eisenberg defines it as "medical interventions not taught widely at US medical schools or generally available at US. hospitals," while Richard Dawkins sardonically defines it as a "set of practices which cannot be tested, refuse to be tested, or consistently fail tests."

The term "alternative medicine" is generally used to describe practices used independently or in place of conventional medicine. The term "complementary medicine" is primarily used to describe practices used in conjunction with or to complement conventional medical treatments. NCCAM suggests "using aromatherapy therapy in which the scent of essential oils from flowers, herbs, and trees is inhaled in an attempt to promote health and well-being and to help lessen a patient's discomfort following surgery" as an example of complementary medicine. The terms "integrative" or "integrated medicine" indicate combinations of conventional and alternative medical treatments which have some scientific proof of efficacy; such practices are viewed by advocates as the best examples of complementary medicine. Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship." The combination of orthodox and complementary medicine with an emphasis on prevention and lifestyle changes is known as integrated medicine. The Washington Post reports that a growing number of traditionally trained physicians practice integrative medicine, which it defines as "conventional medical care that incorporates strategies such as acupuncture, reiki and herbal remedies."

Relation to evidence-based medicine

Some scientists reject the use of the classification of any therapy as 'alternative medicine' on the grounds that "[t]here is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work." These scientists advocate a classification based on scientific evidence, and state that "[w]hat most sets alternative medicine apart, in our view, is that it has not been scientifically tested and its advocates largely deny the need for such testing." The US Institute of Medicine analyzed this approach to defining alternative medicine, which it called normative, and found it problematic because some CAM is tested, and much of mainstream medicine lacks strong evidence. The IOM found that in a study of 160 Cochrane systematic reviews of mainstream techniques, 20% were ineffective and 21% had insufficient evidence. The IOM therefore defined alternative medicine broadly as the nondominant approach in a given culture and historical period. A similar definition has been adopted by the Cochrane Collaboration, which is the leading body of evidence-based medicine, and official government bodies such as the UK Department of Health. This definition does not take into account the Off-Label use of drugs- use which has not been scientifically tested. Off-label use of medications is very common. Up to one-fifth of all drugs are prescribed off-label and amongst psychiatric drugs, off-label use rises to 31% 

Well-known proponents of evidence-based medicine, such as the Cochrane Collaboration and Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, use the term alternative medicine but agree that all treatments, whether "mainstream" or "alternative", ought to be held to standards of the scientific method. Their view is that evidence-based medicine is an ideal state which has not yet been achieved by either current mainstream or alternative medicine. Ernst characterizes the evidence for many alternative techniques as weak, nonexistent, or negative, but states that compelling evidence exists for others, particularly certain herbs and acupuncture – although this evidence does not mean these treatments are mainstream, especially not worldwide. What is alternative varies by discipline as well and country. For example, biofeedback is commonly used within the Physical Medicine & Rehabilitation community, but is considered alternative within the medical community as a whole, and some herbal therapies are mainstream in Europe, but are alternative in the United States.

Criticisms of CAM by mainstream physicians have been numerous. Barrie R. Cassileth has succinctly summed up the situation:

"Not all mainstream physicians are pleased with CAM, with current efforts to integrate CAM into mainstream medicine, or with a separate NIH research entity for "alternative" medicine. Vigorous opposition to CAM as "pseudo science" based on "absurd beliefs" continues to be voiced. CAM's deviation from basic scientific principles, implicit, for example, in homeopathy and therapeutic touch, are decried. A 1997 letter to the US Senate Subcommittee on Public Health and Safety signed by four Nobel Laureates and other prominent scientists deplored the lack of critical thinking and scientific rigor in OAM-supported research."

According to the NCCAM, formerly unproven remedies may be incorporated into conventional medicine if they are shown to be safe and effective. Several scientists share this point of view and state that "[o]nce a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted." According to them it is possible for a method to change categories (proven vs. unproven) in either direction, based on increased knowledge of its effectiveness or lack thereof. Prominent proponents of this position are George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA), and Phil B. Fontanarosa, Senior Editor of JAMA,"Richard Dawkins, Professor of the Public Understanding of Science at Oxford, Edzard Ernst and Simon Singh, and Stephen Barrett, founder and operator of Quackwatch, who argues that techniques currently labeled "alternative" should be reclassified as "genuine, experimental, or questionable. Genuine alternatives are comparable methods that have met science-based criteria for safety and effectiveness. Experimental alternatives are unproven but have a plausible rationale and are undergoing responsible investigation. ... Questionable alternatives are groundless and lack a scientifically plausible rationale. ... Blurring these distinctions enables promoters of quackery to argue that because some practices labeled "alternative" have merit, the rest deserve equal consideration and respect. Enough is known, however, to conclude that most questionable "alternatives" are worthless. Many CAM methods are criticized by the activist non-profit organization Quackwatch.

M.R. Tonelli argues that CAM cannot be evidence-based unless the definition of evidence is changed. He states that "the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials." Further, A review of Michael L. Millenson's book Demanding Medical Excellence: Doctors and Accountability in the Information Age described it as "a wake up call to both medicine and nursing" due to what Millenson calls a "lack of scientific-based medical practice". According to the review, the book states that "85% of current practice has not been scientifically validated" and that it suggests that users of the research presented by Medline should question research articles rather than assuming they are accurate simply because of where they are published. The review states that Millenson's thesis and conclusion call for all health researchers and policy makers to do a better job in assuring valid methodology and avoidance of bias in published research. Michael Dixon, the Director of the NHS Alliance stated that “People argue against complementary therapies on the basis of a lack of evidence. But I’d say only 10 per cent of what doctors do in primary care is evidence-based."Angell and Kassirer acknowledge that "many treatments used in conventional medicine have not been rigorously tested, either" but say that the scientific community is generally aware that this is a failing that needs to be remedied."

Oxford University Press publishes a peer-reviewed journal entitled Evidence-based Complementary and Alternative Medicine (eCAM).

NCCAM classifications
 NCCAM classifies complementary and alternative therapies into five major groups. The classification are rather loose, and there can be some overlap.

* Whole medical systems cut across more than one of the other groups; examples include Traditional Chinese medicine and Ayurveda.

* Mind-body medicine takes a holistic approach to health that explores the interconnection between the mind, body, and spirit. It works under the premise that the mind can affect "bodily functions and symptoms".

* Biologically based practices use substances found in nature such as herbs, foods, vitamins, and other natural substances.

* Manipulative and body-based practices feature manipulation or movement of body parts, such as is done in chiropractic and osteopathic manipulation.

* Energy medicine is a domain that deals with putative and verifiable energy fields:
o Biofield therapies are intended to influence energy fields that purportedly surround and penetrate the body. No empirical evidence has been found to support the existence of the putative energy fields on which these therapies are predicated.
o Bioelectromagnetic-based therapies use verifiable electromagnetic fields, such as pulsed fields, alternating-current or direct-current fields in an unconventional manner. 


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Source: Wikipedia

Alternative medicine
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo : Suharaya Heisuke kanko, Kyoho gan 1716).