Complementary and Integrative Health
Charles A. Simpson
This chapter looks at therapies that historically have been classified as being “unorthodox,” “complementary,” or “alternative” to conventional medical interventions for pain. A contemporary definition of “complementary and integrative health” (IH) will be considered in the context of the complex and clinically challenging field of evidence-based pain medicine. A rationale for studying these unorthodox treatments of pain is presented. The challenges of an evidence-based approach to incorporating these “integrative” therapies into pain management are explored. And finally, a brief survey of several commonly available complementary and IH therapies and the evidence regarding their utility in pain treatment are provided.
What Is Complementary and Integrative Health?
Identifying and defining nonmainstream approaches to health and healing have been problematic for decades. How these various professions, therapies, and approaches to healing have been characterized by the dominant, conventional medical mainstream is emblematic of the history of antagonisms and misunderstandings between the two. How the IH disciplines have come to define themselves is also instructive of both their differences and similarities. Drawing meaningful distinctions between conventional biomedicine and the array of alternative methods may be useful to illuminate how each can contribute to better care for patients in pain.
Integrative medicine practitioners tend to consider their approaches as holistic and in contrast to a reductionistic approach that is ascribed to modern, specialty-driven biomedicine. Holistic practitioners use
Rather than focusing on illness or specific parts of the body, this ancient approach to health considers the whole person and how he or she interacts with his or her environment. It emphasizes the connection of mind, body, and spirit. The goal is to achieve maximum well-being, where everything is functioning the very best that is possible. With Holistic Health people accept responsibility for their own level of well-being, and everyday choices are used to take charge of one’s own health.1
In contrast, the reductionist approach of conventional medicine (CM) adheres to the theory that every complex phenomenon in medicine can be explained by reducing the complexity of health and disease into simple, basic, physical mechanisms and applying a treatment intended to correct the abnormalities, primarily through the use of drugs and surgery.
The Divide
The emergence of organized medicine early in the last century marginalized a large number of existing healing disciplines at that time. Some of these had enjoyed long and successful traditions treating the public. As Cohen2 points out,
Although American colonies began with pluralistic notions of health care, the poor state of science, paltry qualifications of many would-be physicians, general lack of medical standards, and a cornucopia of charlatans eventually led to state regulation of healers—largely through the mechanism of licensure—and thereby to the triumph of biomedicine over competing communities of healers such as naturopathic and homeopathic physicians. Legally, state statutes made unlawful practice of medicine a crime and defined medicine in broad terms, encompassing any activity that potentially could be construed as diagnosis and treatment.
As a result, Western, scientific, reductionist biomedicine became the “real” medicine in legal terms. The resulting cultural authority of CM discounted traditional healers. The hegemony of this dominant paradigm was not seriously challenged until the last few decades of the 20th century.
FRINGE MEDICINE AND QUACKERY
In the early 1960s, British author Brian Inglis developed a model in his book entitled Fringe Medicine.3 This title consigned nonstandard approaches to healing to the periphery of science and the health care system. Inglis3 considered such professions as homeopathy, bone setting, herbalists, and psychotherapy as fringe medicine. Being on the fringe implied that healers of this stripe were so far removed from the mainstream as to pose no threat to the public or to the dominance of biomedicine.
In the succeeding 30 years, many of these fringe approaches to healing persisted and grew despite persistent opposition from the dominant medical establishment. For example, in the 1950s, the American Medical Association (AMA) developed ethics policies that forbade physicians from interacting with “unscientific, cult practitioners” such as chiropractors. The AMA Committee on Quackery was formed in 1963 targeting vitamins, homeopathy, chiropractic, naturopathy, all alternative cancer treatments, and other practices which compete with the drug sales of pharmaceutical companies.4 The chiropractic profession fought back in the courts. In the case of Wilk v. American Medical Association, the AMA was found to have engaged in an unlawful restraint of trade under the Sherman Antitrust Act. And although the AMA’s Committee on Quackery was disbanded, other groups have taken up the charge to criticize and marginalize these therapies (see http://www.quackwatch.com).
“UNORTHODOX” MEDICINE
This unhappy stand-off persisted until Eisenberg et al.’s5 seminal study in 1993 revealed the depth and breadth to which these fringe practices had penetrated health care delivery. This paper reported a survey of respondents’ use of a variety of what Eisenberg termed “unorthodox medical practice.” These were defined by Eisenberg in exclusionary terms, that is, in terms of what these therapies are not. Unorthodox medicine in Eisenberg’s view is not taught in medical schools, not available in hospitals, and not generally considered real medicine.
Today, neither of these perspectives, fringe or unorthodox, provide meaningful distinctions between mainstream conventional biomedicine and those forms of healing that are different. Neither perspective bears up to careful scrutiny of the current state of complementary and alternative medicine. Eisenberg et al.5 amply demonstrated that the volume of visits for health
care delivered outside of the orthodox mainstream exceeds that of conventional care provided in physician offices—hardly an image of a fringe factor in the overall picture of the health care delivery system.
care delivered outside of the orthodox mainstream exceeds that of conventional care provided in physician offices—hardly an image of a fringe factor in the overall picture of the health care delivery system.
TABLE 94.1 Terminology | ||||||||||||||
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The popularity of complementary medicine with the public has not gone unnoticed by conventional medical institutions either. Health insurance plans, hospitals, and academic medical centers have integrated, to one extent or another, nontraditional health care providers and therapies into their programs. A 2001 survey of regional health plans in the northeast United States found nearly universal coverage for chiropractic, with just under half of insurers covering acupuncture (usually for chronic pain) and massage therapy (MT).6 A 2005 American Hospital Association survey revealed that 370 of 1,394 respondent institutions (26.5%) offer some form of complementary health care.7 A similar survey in 2010 found 42% of responding hospitals offered at least one integrative medicine service.8
Integrative medicine topics are being introduced into the curricula of up to 64% of US medical schools.9 The American Medical Student Association has developed the Educational Development for Complementary and Alternative Medicine program to promote medical school education on alternative medicine topics. The Academic Consortium for Integrative Medicine and Health is composed of 69 academic medical centers and health plans including Harvard, Duke, Stanford, Thomas Jefferson, and Yale medical schools as well as health plans including Cleveland Clinic, Mayo Clinic, Memorial Sloan Kettering, and Veterans Health Administration. The stated mission of the consortium is to “advance integrative medicine and health through academic institutions and health systems.” With a vision of “a transformed healthcare system promoting integrative medicine and health for all.”10
These developments indicate the trend of increasing integration of conventional and integrative medicine. Contemporary integrative medicine has moved well beyond the “unorthodox” label offered by Eisenberg.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
The fringe and unorthodox labels are a carryover from more contentious times. Over time, other labels have included “nontraditional” medicine in supposed contrast to traditional conventional medical care. However, considering that some of these nontraditional therapies predate conventional interventions, for example in the case of acupuncture by 3,000 years, traditional versus nontraditional seems irrational. “Integrative” and “integrated” medicines have had some currency as well. The term alternative medicine suggests that the therapies are used in place of CM. Integrative medicine often refers to alternative medicine therapies delivered by CM practitioners or at least in conventional medical settings. Integrated medicine implies the thoughtful collaboration of conventional and alternative medicine providers in the treatment of patients. The notion of complementary medicine is supported by evidence showing that most patients use both conventional and complementary interventions, seeking to integrate their own care. The favored terminology until 2015 by the National Institutes of Health (NIH) has been complementary and alternative medicine (CAM) with the National Center for Complementary and Alternative Medicine (NCCAM) (Table 94.1).
COMPLEMENTARY AND INTEGRATIVE HEALTH
Recognition of the growing volume of integrative medicine use, the accumulating research evidence, and how patients actually use the medicine ultimately led to a name change for NCCAM. The December 2014 Congressional omnibus budget measure renamed the Center the National Center for Complementary and Integrative Health (NCCIH). As the Center’s Web site notes,
The change was made to more accurately reflect the Center’s research commitment to studying promising health approaches that are already in use by the American public. Since the Center’s inception, complementary approaches have grown in use to the point that Americans no longer consider them an alternative to medical care. For example, more than half of Americans report using a dietary supplement, and Americans spend nearly four billion dollars annually on spinal manipulation therapy. The name change is in keeping with the Center’s existing Congressional mandate and is aligned with the strategic plan currently guiding the Center’s research priorities and public education activities.11
BRIDGING THE DIVIDE: ONE KIND OF MEDICINE
The work of NCCIH is reflective of increasing the quality of research-focused complementary and IH interventions. The current trend toward evidence-based medicine (EBM) may eventually point the way to a reconception and resolution of the distinction between CM and IH. IH is frequently dismissed by critics as being unscientific and without evidence of its safety, efficacy, and effectiveness. However, over the last decade, the emergence of complementary medicine on the national research agenda through the NCCIH and other institutions has furthered the development of academic and intellectual infrastructure of IH that can explore the scientific evidence which demonstrates the utility of complementary therapies.
Originally formed as the Office of Complementary Medicine, the federal budget for NCCIH grew from $2 million in fiscal year 1992 to $121.4 million in fiscal year 2007. The body of research is growing. There are currently thousands
of clinical trials of IH interventions. A 2000 survey of over 5,000 controlled trials found “The overall quality of evidence for IH RCTs is poor but improving slowly over time, about the same as that of biomedicine [emphasis added].”12 Systematic reviews of the IH literature are prevalent. There are hundreds of Cochrane Collaboration reviews of alternative therapies (see http://www.cochranelibrary.com/topic/Complementary%20%26%20alternative%20medicine/).
of clinical trials of IH interventions. A 2000 survey of over 5,000 controlled trials found “The overall quality of evidence for IH RCTs is poor but improving slowly over time, about the same as that of biomedicine [emphasis added].”12 Systematic reviews of the IH literature are prevalent. There are hundreds of Cochrane Collaboration reviews of alternative therapies (see http://www.cochranelibrary.com/topic/Complementary%20%26%20alternative%20medicine/).
Angell and Kassirer13 noted several years ago in The New England Journal of Medicine editorial that in the future, medicine will be divided into those approaches to health and healing that are backed by scientific evidence and those that are not. They conclude that “there cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset.”
A 2005 Institute of Medicine report on complementary medicine emphasizes, “The committee recommends that the same principles and standards of evidence of treatment effectiveness apply to all treatments, whether currently labeled as conventional medicine or CAM.”14 This evidence-based perspective will continue to erode the barriers between health care that is provided in the tradition of Western scientific medicine and the healing disciplines that, in some instances, predate modern medicine by millennia. This perspective may well put to rest the arbitrary and, at times, antagonistic differentiation between IH and CM.
WHAT IS DIFFERENT ABOUT COMPLEMENTARY AND ALTERNATIVE MEDICINE?
There clearly are differences between health care available in conventional medical physician offices, clinics, and hospitals and that provided by IH practitioners. There are three features of IH that tend to distinguish it from CM. In general, IH therapies are individualized to each patient rather than using a standardized clinical protocol. IH almost universally incorporates a philosophy of health that emphasizes and leverages the innate capacity for healing in every individual. And finally, IH tends to acknowledge the existence of properties of living systems that are resistant to understanding by contemporary reductionist scientific methods of inquiry.
These distinguishing features present significant challenges to research methods and thus to assembling meaningful evidence. They also create opportunities to develop more effective, efficient, and humanizing care for a very difficult population of patients—especially those with pain. Some have recognized the limitation of CM. For example, an editorial observation by Cicerone15 on evidence-based practice and the limits of rational rehabilitation points out that “we need to acknowledge the subjective meanings of illness and disability to the patients we serve. Any efforts to build our practice based on the best available systematic evidence are unlikely to succeed unless we include patients’ values and beliefs and incorporate this perspective into our rehabilitation research. This aspect of evidence-based rehabilitation raises important questions about our fundamental roles and how we will choose to practice and define our field in the future.”
Individualized treatment is a hallmark of most IH therapies. For example, an acupuncture practitioner may evaluate two patients, both with the same CM diagnosis, but develop two radically different treatment plans based on the oriental medicine (OM) examination findings and assessment. This approach seems to work well for patients as revealed by observational studies. Studies of patients who obtain care from IH practitioners reveal high levels of satisfaction with the practitioners and the outcome of the therapies. IH providers spend time with their patients, and they are successful in explaining to patients the nature of their health problems. Treatment planning tends to be collaboration between therapist and patient. Interventions are developed that are consistent with each patient’s own needs and preferences.
Philosophy of care is not something that most CM practitioners ponder extensively. However, philosophical discourse underlies many IH therapies. Chiropractic, for example, contains an extensive literature that can only be described as philosophy. Beginning with the founder, D. D. Palmer, chiropractic thinkers have historically focused on not so much the rational scientific underpinnings of this healing art but on the art itself. Innate intelligence is posited by Palmer and his successors as a fundamental life force that when fully expressed without interference, maximized expression of health occurs, naturally and without need of intrusion from outside agents like drugs and surgery. In this chiropractic philosophical worldview, the aim of the chiropractor is to locate and correct interferences with this natural expression of the life force. Other IH disciplines have identified this life force known as “qi” in acupuncture and oriental medicine (AOM), “prana” in yoga, “doshas” in Ayurvedic medicine, and “vix medica naturae” in naturopathic medicine, each discipline has elaborated some measure of a conceptual life force that guides and propels healing and health.
CM, with its intellectual traditions anchored in Western scientific thought, is understandably skeptical of notions of innate intelligence, qi, or other conceptualization of a putative life force. Finding no testable hypotheses to investigate a possible life force, CM has largely dismissed such philosophical musing. Oschman16 provides a comprehensive review of this seeming impenetrable intellectual barrier between the IH and CM worldviews.
WHO USES COMPLEMENTARY AND INTEGRATIVE HEALTH?
The research on IH utilization is often confusing and contradictory. Research is complicated by a number of factors, including a lack of consensus on what therapies, interventions, and practitioner types constitute IH. Varying methodologies for collecting data, the variety of populations, and settings in which data are gathered provide sometimes contradictory conclusions. Further challenges to IH research is when it is studied in different countries where the availability of IH may vary considerably due to tradition, licensure, and cultural acceptance.
However, despite the inconsistent nature of research efforts, it is certain that IH use is widespread across populations, clinical conditions, settings, and sociodemographic groups. In 1993, Eisenberg and colleagues’5 paper alerted the CM community to the magnitude of IH utilization. This discovery revealed an ongoing phenomenon in the general population that has been verified and replicated in many subpopulations. A search of PubMed for “IH utilization” returned over 1,500 citations.17 These include abstracts referring to various clinical populations (cancer, inflammatory bowel disease, autoimmune deficiency syndrome, diabetes, hypertension, allergies, rheumatic conditions, chronic fatigue, fibromyalgia, emergency department patients) and sociodemographic groups (veterans, racial and ethnic groups, geriatrics, women, children, athletes). In short, no matter what population is examined, IH use is prevalent.
IH use is particularly widespread among patients with chronic pain conditions. Nayak et al.18 reported on a small sample of spinal cord injury patients with chronic pain. About 40% of respondents had used some form of IH during the preceding year. Forty-four percent of chronic pain patients being treated with opioids reported concomitant IH use.19 Twenty-seven percent of veterans with cancer or chronic pain reported IH use.20 More veterans would have used IH had it been covered by insurance.
Tsao et al.21 found that, given a choice of several IH interventions, over 60% of pediatric patients (and their parents) opted to try at least one IH approach in addition to CM treatments. A survey of 43 pediatric anesthesia fellowship training programs showed 38 (86%) offered one or more IH therapies.22
Tsao et al.21 found that, given a choice of several IH interventions, over 60% of pediatric patients (and their parents) opted to try at least one IH approach in addition to CM treatments. A survey of 43 pediatric anesthesia fellowship training programs showed 38 (86%) offered one or more IH therapies.22
CATEGORIZING COMPLEMENTARY AND INTEGRATIVE HEALTH THERAPIES
There is considerable diversity in IH practices and deciding which discipline to include under the rubric IH and which to exclude can be problematic and markedly affects the study results of IH utilization. In 1993, Eisenberg et al.5 limited his survey inquiries to 16 commonly used interventions but included “relaxation therapy … lifestyle diets, spiritual or religious healing by others.” Eisenberg et al.5 do note a categorical difference, however, between IH therapies that are delivered by a professional, such as massage and acupuncture, and those that are largely self-administered without the involvement of a trained and licensed provider, such as lifestyle diets and intercessory prayer. Hospitals reporting the integration of IH most frequently identify massage, body movement therapies (qigong, yoga, tai chi), relaxation, acupuncture, guided imagery, and therapeutic touch (TT) as the IH modalities of choice.7 Conspicuous by their absence from the hospitals are some of the most frequently encountered IH modalities, such as chiropractic, nutraceutical, and herbal therapies.
NCCIH has categorized IH in two domains: natural products such as nutritional supplements, probiotics, and herbs and mind-body interventions such as massage, yoga, manipulation, acupuncture, and movement therapies.23 The array of CAM therapies can be further categorized by their intellectual and philosophical nature as being either essentially biologically based or energy-based. Biologically based therapies are explained and practiced fundamentally in ways that are familiar to practitioners trained in the CM model of Western scientific inquiry. Clinical conditions are mostly described in terms of disturbed anatomy and physiology. Treatment interventions are categorized by their physiologic effects. Outcomes are measured in objective clinical terms. These disciplines, such as chiropractic and natural medicine, often view themselves as being within the context of orthodox scientific thought. Many chiropractors, for example, have rejected the theories of Palmer. Some of these therapies have been rigorously scrutinized through the lens of conventional medical scientific investigation. Many of these disciplines are developing intellectual, administrative, and physical infrastructure to conduct research in the mold of CM as part of a commitment to evidence-based practices.
In contrast, energy-based therapies are most often founded on putative notions of natural systems of “invisible energetic relations and connections that govern living form and function.”16 Although some of these energy-based therapies have undergone scientific inquiry, most notably acupuncture, the fundamental worldview of energy-based healers has not been altered to conform to the understandings offered by rational reductionist methods. For example, science has attempted to understand the physiologic basis of acupuncture in terms of its neuroendocrine effects. However, few acupuncture practitioners endorse or, more importantly, practice within this intellectual context. Most acupuncture practitioners prefer instead to explain what they do in the language of AOM, such as the flow of chi throughout the meridians of the body.
For purposes of the discussion in this chapter, consideration of IH therapies is limited to those commonly accessible in the community to chronic pain patients and, for the most part, administered under the guidance of licensed health care professionals. Although this approach may exclude some valuable and frequently used therapies, it does encompass IH therapies that are in regular use by chronic pain patients, have been evaluated by research, are at least somewhat institutionalized, have been used or referred to by CM providers, and are capable of being integrated clinically and administratively into the CM care of chronic pain patients.
Why Consider Complementary and Integrative Health Therapies in Pain Management?
There is a compelling case for why CM physicians, especially in the challenging field of pain medicine, should better understand IH therapies. Based on the study results of IH utilization, it is quite likely that any given pain patient is using at least one IH therapy concurrently with CM treatments. Clinical inquiry into IH use is important because patients often fail to reveal their use of IH therapies to their CM providers. There are potential complications that arise with the combination of IH and CM therapies, and awareness of these enhances safety and quality of care. Understanding the rationale for and evidence that supports IH use in pain conditions places the clinician in a helpful role of providing objective information to pain patients. And, perhaps most significantly, integration of IH therapies can be effective and improve the quality of care for chronic pain patients.
Some 50 million Americans suffer from chronic or severe pain.24 It is estimated that 40% of them fail to achieve adequate relief.25 Surveys of IH users note a high prevalence of chronic conditions, including chronic pain. Observers of IH note that “consumers will continue to use IH, particularly in chronic conditions, in which patients struggle to find any treatment that may cure their condition or improve their quality of life.”26
Most IH interventions are “low-tech, high-touch” in nature. They are often perceived as inherently safe and natural by patients and practitioners. However, there is a growing body of evidence that illuminates adverse reactions to commonly used IH therapies either by themselves or when combined with CM. Drug-herb interactions, for example, present potential challenges to patient safety and compromises of therapeutic intent. In 1993, Eisenberg noted that patients use IH and CM concurrently for the same condition upward of 83% of the time however IH users failed to disclose IH use to CM physicians. Subsequent investigation by Eisenberg et al.27 indicates that this failure to disclose has not improved over time. Better understanding by both CM and IH practitioners of risks can modify the potential for adverse outcomes.
Avoiding adverse CM-IH interactions can obviously improve patient care. Asking patients about their use of IH, especially from an objective and evidence-based perspective, can enhance patient communication. The cultural competency of being able to provide nonjudgmental acknowledgment of IH use, particularly when it can be supported by objective evidence of safety and effectiveness, can reinforce a productive therapeutic relationship between patients and their CM physician.
It is well recognized that effective physician-patient communication is a critical element in predicting better patient satisfaction and compliance with chronic pain treatment.28 Moreover, as reliable evidence of IH effectiveness emerges, CM physicians may be in a position to better integrate evidencebased IH approaches in an active manner rather than passively accepting what chronic pain patients may already be attempting to integrate on their own.
CHALLENGES OF EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES
Developing the evidence about IH therapies for chronic pain is problematic from a number of perspectives. IH therapies are often inherently resistant to analysis by commonly used clinical research methods. For example, in the hierarchy of evidence, the randomized controlled trial (RCT) is considered to be the
criterion standard. Yet, many argue that this methodology, although well suited to the study of drugs, may not be the best research design to study complex, individualized treatments routinely offered by CAM practitioners.29,30
criterion standard. Yet, many argue that this methodology, although well suited to the study of drugs, may not be the best research design to study complex, individualized treatments routinely offered by CAM practitioners.29,30
For instance, trials of manipulative therapy have been plagued by the difficulty in developing a “sham” manipulation and concurrently controlling for the nonspecific effects of the hands-on practitioner-patient interaction with the theoretically inert sham treatment. Similarly, acupuncture research using sham acupuncture points irritates acupuncture practitioners who note that any needling at any point on the body affects the flow of chi and therefore cannot be considered an inert intervention in the same way that a placebo pill is used in a clinical trial of drug therapy. Functional magnetic resonance imaging and positron emission tomography imaging studies have demonstrated brain changes with sham acupuncture procedures compared to “true” acupuncture.31
Furthermore, evidence about treatment interventions for chronic pain is confounded by the complex nature of the condition itself. Patient selection is often a significant challenge to study validity. For example, aggregating patients with mechanical low back pain (LBP) into a conceptually uniform study group may satisfy a study methodology, but it ignores the wide variety of disorders that produce this pain population. Given this clinical heterogeneity, it is no wonder that trials with this fundamental design flaw frequently come up with equivocal results and fail to reveal significant differences in effectiveness between treatments. A conventional medical analog would be treating undifferentiated chest pain as gastroesophageal reflux disease (GERD).
The challenges of applying evidence of this nature to the practical realities of treating patients have been increasingly recognized.32 Fortunately, researchers in the IH fields are actively developing research methodologies that are more appropriate both for the individualized nature of CAM interventions and the complex, multifactorial nature of chronic pain. Pragmatic controlled trials, for example, evaluate interventions in real-world settings that involve the specific effects of the intervention as well as the nonspecific effects of the therapeutic relationship, expectations, values, and beliefs that combine to affect the clinical outcomes of interest.
Publication and indexing biases also are obstacles to assembling high-quality evidence about IH therapies.32 As is the case with CM, studies with positive results are more likely to be submitted for publication. Many studies of IH are in foreign language journals, thus limiting their exposure to English-speaking audiences. A subtler bias also is observed in CM-published research on IH. As one IH researcher put it, “A negative study of acupuncture concludes that ‘acupuncture doesn’t work.’ The analogue would be a negative drug trial that concluded ‘pharmaceuticals do not work’” (R. Hammerschlag, personal communication, February 20, 2005).
Despite these challenges in developing an evidence-based approach to the use of IH therapies in chronic pain conditions, clinical evidence is accumulating. Many formerly unproven and unscientific therapies have, in fact, been shown to be safe and effective. Achieving the goal of Angell and Kassirer’s13 “one kind of medicine” is becoming a reality in health care and in the treatment of chronic pain.
The Complementary and Integrative Health Therapies: The Evidence
The following is a brief overview of commonly available IH therapies and the evidence that supports them. Evidence from systematic reviews, especially from the Cochrane Collaboration (http://www.cochrane.org), and from clinical practice guidelines is noted. These therapies are categorized as biologically based and energy-based.
BIOLOGICALLY BASED THERAPIES
These therapies are based mainly on concepts of biology and physiology commonly accepted in conventional biomedicine. These therapies rely on clinical theories, therapeutic approaches, and rationales that are couched in terms consistent with current scientific understanding of biology and physiology familiar to CM.
Manipulation
Manipulation is the most frequently used IH therapy.33 It is widely practiced by a variety of specialties including doctors of chiropractic (DC), osteopathic physicians (DO), medical doctors (MD), physical therapists, and some lay practitioners. It is estimated that DCs deliver over 90% of all manipulative therapy.34 According to the 2007 National Health Interview Survey (NHIS), patients spent an estimated $3.9 billion on visits to practitioners for chiropractic or osteopathic manipulation.35 Chiropractic training in manipulative techniques is arguably the most extensive among manipulation practitioners.
Manipulation is thought to improve pain by locating and treating disturbed joint and muscle function described as dysfunction, subluxation, fixation, and other terminology that may vary by discipline, training, and technique. Manipulation practitioners primarily treat spine pain and dysfunction, but these techniques are also applied to the rest of the musculoskeletal system.
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