Which CAM modalities are worth considering?

,; ,; ,; ,

Applied Evidence

Which CAM modalities are worth considering?

J Fam Pract. 2014 October;63(10):585-590

Roger Zoorob, MD, MPH, FAAFP

Sangita Chakrabarty, MD, MSPH, FACOEM

Heather O’Hara, MD, MSPH

Courtney Kihlberg, MD, MSPH, FACPM

This review—with a handy at-a-glance guide—examines 8 modalities, the level of evidence behind them, and the adverse effects you’ll need to keep in mind.

PDF Download

References

1. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;10:1-23.

2. American Holistic Medicine Association. Integrative medicine centers. American Holistic Medicine Association Web site. Available at: http://www.holisticmedicine.org/content. asp?pl=30&sl=2&contentid=74. Accessed September 8, 2014.

3. Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’ Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444-1453.

4. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

5. Berman BM, Langevin HM, Witt CM, et al. Acupuncture for chronic low back pain. N Engl J Med. 2010;363:454-461.

6. Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009;79:1067-1074.

7. Eslik GD, Howe PR, Smith C, et al. Benefits of fish oil supplementation in hyperlipidemia: a systematic review and meta-analysis. Int J Cardiol. 2009;136:4-16.

8. Miller M, Stone NJ, Ballantyne C, et al; American Heart Association Clinical Lipidology, Thrombosis, and Prevention Committeeof the Council on Nutrition, Physical Activity, and Metabolism; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease. Triglyceride and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011;123:2292-2333.

9. Bays HE. Safety considerations with omega-3 fatty acid therapy. Am J Cardiol. 2007;99:35C-43C.

10. Brasky TM, Darke AK, Song X, et al. Plasma phospholipid fatty acids and prostate cancer risk in the SELECT trial. J Natl Cancer Inst. 2013;105:1132-1141.

11. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;(2):CD002946.

12. Sawitzke AD, Shi H, Finco MF, et al. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis. 2010;69:1459-1464.

13. Dostrovsky NR, Towheed TE, Hudson RW, et al. The effect of glucosamine on glucose metabolism in humans: a systematic review of the literature. Osteoarthritis Cartilage. 2011;19:375-380.

14. Walker LG, Walker MB, Ogston K, et al. Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. Br J Cancer. 1999;80:262-268.

15. Thünker J, Pietrowsky R. Effectiveness of a manualized imagery rehearsal therapy for patients suffering from nightmare disorders with and without a comorbidity of depression or PTSD. Behav Res Ther. 2012;50:558-564.

16. Marc I, Toureche N, Ernst E, et al. Mind-body interventions during pregnancy for preventing or treating women’s anxiety. Cochrane Database Syst Rev. 2011;(7):CD007559.

17. Jing X, Wu P, Liu F, et al. Guided imagery, anxiety, heart rate, and heart rate variability during centrifuge training. Aviat Space Environ Med. 2011;82:92-96.

18. Arora S, Aggarwal R, Moran A, et al. Mental practice: effective stress management training for novice surgeons. J Am Coll Surg. 2011;212:225-233.

19. Posadzki P, Ernst E. Guided imagery for musculoskeletal pain: a systematic review. Clin J Pain. 2011;27:648-653.

20. Posadzki P, Lewandowski W, Terry R, et al. Guided imagery for non-musculoskeletal pain: a systematic review of randomized clinical trials. J Pain Symptom Manage. 2012;44:95-104.

21. Arvola T, Laiho K, Torkkeli S, et al. Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study. Pediatrics. 1999;104:e64.

22. Johnston BC, Goldenberg JZ, Vandvik PO, et al. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2011;(11):CD004827.

23. Williams NT. Probiotics. Am J Health-Syst Pharm. 2010;67:449-458.

24. Sacks FM, Lichtenstein A, Van Horn L, et al; American Heart Association Nutrition Committee. Soy protein, isoflavones, and cardiovascular health: an American Heart Association Science Advisory for professionals from the Nutrition Committee. Circulation. 2006;113:1034-1044.

25. Qin Y, Niu K, Zeng Y, et al. Isoflavones for hypercholesterolaemia in adults. Cochrane Database Syst Rev. 2013;6:CD009518.

26. Shelton RC, Keller MB, Gelenberg A, et al. Effectiveness of St John’s wort in major depression: a randomized controlled trial. JAMA. 2001;285:1978-1986.

27. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev. 2008;(4):CD000448.

28. Cramer H, Lauche R, Haller H, et al. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29: 450-460.

29. Ward L, Stebbings S, Cherkin D, et al. Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis. Musculoskeletal Care. 2013;11:203-217.

30. Saper RB, Boah AR, Keosaian J, et al. Comparing once- versus twice-weekly yoga classes for chronic low back pain in predominantly low income minorities: a randomized dosing trial. Evid Based Complement Alternat Med. 2013;2013:658030.

31. Uitterlinden EJ, Koevoet JLM, Verkoelen CF, et al. Glucosamine increases hyaluronic acid production in human osteoarthritic synovium explants. BMC Musculoskelet Disord. 2008;9:120.

32. Calamia V, Ruiz-Romero C, Rocha B, et al. Pharmacoproteomic study of the effects of chondroitin and glucosamine sulfate on human articular chondrocytes. Arthritis Res Ther. 2010;12:R138.

33. Rovati LC, Girolami F, Persiani S. Crystalline glucosamine sulfate in the management of knee osteoarthritis: efficacy, safety, and pharmacokinetic properties. Ther Adv Musculoskelet Dis. 2012;4:167-180.

34. National Center for Complementary and Alternative Medicine. Oral probiotics: An introduction. National Center for Complementary and Alternative Medicine Web site. Available at: http:// nccam.nih.gov/health/probiotics/introduction.htm. Updated December 2012. Accessed August 29, 2013.

35. Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307:1959-1969.

36. Thomas DW, Greer FR; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126:1217-1231.

37. Bazzano LA, Thompson AM, Tees MT, et al. Non-soy legume consumption lowers cholesterol levels: a meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis. 2011;21:94-103.

38. Huang J, Frohlich J, Ignaszewski AP. The impact of dietary changes and dietary supplements on lipid profile. Can J Cardiol. 2011;27:488-505.

39. Messina M, Redmond G. Effects of soy protein and soybean isoflavones on thyroid function in healthy adults and hypothyroid patients: a review of the relevant literature. Thyroid. 2006;16: 249-258.

40. National Center for Complementary and Alternative Medicine. St. John’s Wort. National Center for Complementary and Alternative Medicine Web site. Available at: http://nccam.nih.gov/ health/stjohnswort. Accessed October 14, 2013.

41. Schulz V, Hänsel R, Tyler VE. Rational Phytotherapy: A Physicians’ Guide to Herbal Medicine. Berlin: Springer; 2001:62-81.

42. Mischoulon D. Update and critique of natural remedies as antidepressant treatments. Obstet Gynecol Clin North Am. 2009;36: 789-807.

43. Hanssen MM, Peters ML, Vlaeyen JW, et al. Optimism lowers pain: evidence of the causal status and underlying mechanisms. Pain. 2013;154:53-58.

44. Eremin O, Walker MB, Simpson E, et al. Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: a randomised controlled trial. Breast. 2009;18:17-25.

PRACTICE RECOMMENDATIONS

› Consider referring your patients for guided imagery to reduce anxiety or pain. A
› Recommend a trial of glucosamine sulfate 1500 mg/d for 3 months for patients with osteoarthritis. B
› Consider acupuncture as a treatment option for patients with chronic pain. B
› Use probiotics to prevent antibiotic-associated diarrhea in pediatric patients, except for those who are immunocompromised or have an indwelling medical device. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › Bob F, age 54, seeks care for chronic low back pain. The conservative treatments you have prescribed, including physical therapy, regular exercise, and an over-the-counter nonsteroidal anti-inflammatory drug, have provided minimal pain relief. Mr. F is reluctant to take a prescription pain medication and has expressed interest in trying a complementary and alternative medicine (CAM) therapy, such as acupuncture or yoga. What should you tell him?

Almost 40% of Americans use CAM modalities to treat specific conditions or for overall well-being,¹ and these practices are increasingly becoming a part of our approach to health care, as evidenced by the nearly 50 of facilities across the country that boast integrative health care programs, which combine CAM modalities with conventional medicine.² Emerging evidence suggests several integrative practices may offer health benefits, and primary care physicians must become well-versed in these modalities to effectively communicate potential benefits and harms to patients. In this article, we present evidence from Cochrane reviews and other studies of 8 commonly used CAM therapies, including dietary interventions, a psychotherapeutic modality, and other treatments (TABLE).^1,3-30 And while motivational interviewing technically is not a form of CAM, we also review this modality, which has proven useful in the treatment of patients for substance use. (See “Motivational interviewing for substance abuse.”)

Fish oil for hypertriglyceridemia

High triglyceride levels are a risk factor for cardiovascular disease and a component of metabolic syndrome.⁸ A 2008 review of 47 randomized controlled trials (RCTs) that included 16,511 participants found that omega-3 fatty acid (fish oil) supplements significantly reduced triglyceride levels compared to placebo.⁷ The American Heart Association recommends 2 to 4 g/d of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) to lower triglyceride levels.⁸

Most studies have found that fish oil supplements are associated with few adverse effects; gastrointestinal (GI) complaints are most common. However, these supplements should be discontinued following an acute bleeding event, such as hemorrhagic stroke, due to their anticoagulant properties.⁹ Some evidence suggests that the risk for prostate cancer is increased in men with high blood levels of omega-3 fatty acids.¹⁰

Glucosamine for osteoarthritis

The AHA recommends 2 to 4 g/d  of EPA plus DHA to lower triglyceride levels.Glucosamine is an amino sugar that is a building block of cartilage proteoglycans. Although it occurs naturally in the body, the glucosamine used in supplements is typically harvested from seashells. Glucosamine stimulates the metabolism of synovial cells and chondrocytes in articular cartilage and may delay joint degeneration.^31,32

Glucosamine is widely used in the United States as a dietary supplement, most often as glucosamine sulfate but also as n-acetyl glucosamine and glucosamine hydrochloride, although there is limited evidence of effectiveness for the latter formulations.³³

Most studies have examined the effects of oral glucosamine sulfate, 500 mg taken 3 times a day for 30 to 90 days. Once-a-day dosing as high as 1500 mg also has been used.

A Cochrane review of 25 studies with 4963 patients concluded that oral glucosamine sulfate may reduce osteoarthritis (OA) pain and improve functionality, without many adverse effects.¹¹ A 2-year double-blind RCT compared the effects of glucosamine hydrochloride 500 mg tid, chondroitin sulfate 400 mg tid, glucosamine plus chondroitin, celecoxib 200 mg/d, or placebo in 662 patients with knee OA.¹² While all groups experienced early and sustained symptomatic relief, the odds of achieving a 20% reduction in pain and improved functioning were highest with celecoxib and glucosamine.

Oral glucosamine sulfate can cause mild GI effects, but drowsiness, skin reactions, and headache also have been reported. Shellfish allergy also is a concern; however, shellfish allergies occur due to the proteins in the meat, and not from the shell from which glucosamine is derived. Glucosamine may increase glucose levels and the anticoagulant effects of warfarin.¹³

Probiotics to prevent antibiotic-associated diarrhea

Antibiotic-associated diarrhea (AAD) is a common problem.²¹ Probiotics—microorganisms found in oral supplements, yogurt, and other food—are commonly used to help maintain the balance of intestinal flora.³⁴ A recent Cochrane review of 16 RCTs that included approximately 3400 patients found evidence that probiotics can prevent AAD.²² A 2012 systematic review and meta-analysis of 63 RCTs with more than 11,000 participants concluded that probiotics lowered the relative risk of developing diarrhea compared to control groups.³⁵ The American Academy of Pediatrics supports the use of probiotics, citing results from a meta-analysis that found probiotics reduced the risk of developing diarrhea from 28.5% to 11.9% compared to placebo.³⁶