TEXTBOOK OF COMPLEMENTARY

AND ALTERNATIVE MEDICINE

Second Edition
Notice to readers: Our knowledge of medicine is constantly changing as a result of new
developments. The editors, authors, and publishers have taken every care to provide updated
information compatible with standards at the time of publication, but cannot be responsible
for any omissions or inadvertent errors, nor can they warrant that the work is accurate in every
respect. The readers are advised to consult with their health-care professionals before the use
of any complementary and alternative therapies.
TEXTBOOK OF COMPLEMENTARY
AND ALTERNATIVE MEDICINE
Second Edition

Edited by

Chun-Su Yuan MD PhD

Cyrus Tang Professor
Director, Tang Center for Herbal Medicine Research
University of Chicago Pritzker School of Medicine
Illinois, USA

Eric J Bieber MD
Chair, Obstetrics and Gynecology
Chief Medical Officer, Geisinger Wyoming Valley and Geisinger South Wilkes-Barre
Senior Vice President, Geisinger Health Systems
Wilkes-Barre/Danville, Pennsylvania, USA

Brent A Bauer MD
Director
Complementary and Integrative Medicine Program
Associate Professor of Medicine at Mayo Medical School
Mayo Clinic, Rochester, Minnesota, USA
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Contents

List of contributors xi
Preface xvii
Acknowledgments xix
INTRODUCTION 1
Prevalence and impact of complementary and alternative medicine 3
on conventional medicine
B. A. Bauer, M. K. Ang-Lee, E. J. Bieber and C.-S. Yuan

SECTION I COMMONLY USED CAM THERAPIES 7

Dietary Supplements
1. Definitions and regulatory status 9
M. C. Lee
2. Commonly used herbal medicines 13
M. K. Ang-Lee and D. Basila
3. Overview of selected herbs 41
L. Dey and S. M. Wicks
4. Medicinal herbs of Latin America 45
D. Turner-Lloveras
5 Herbal medicine: identification, analysis, and evaluation strategies 51
C.-Z. Wang and Y. Shoyama
6. Ginseng: beneficial and potential adverse effects 71
J.-T. Xie, A. S. Attele and C.-S. Yuan
7. Green tea 91
D. D. McFadden
8. Evidence-based use of vitamin supplements 99
L. T. Shuster and J. Thielen
9. Herbal, food, and drug interactions 109
J. Moss

v
vi Textbook of Complementary and Alternative Medicine

10. The story of PC-SPES and prostate cancer 115

D. Sadava
11. Risks of ephedra-containing supplements 123
S. R. Mehendale, B. A. Bauer and C.-S. Yuan

Traditional Medical Systems and Therapies

12. Traditional Chinese Medicine 129
W. Xuan
13. Chinese herbal medicine and formulations 145
B. Xu
14. Acupuncture 157
Y. G. Wang
15. Tai Chi 177
S. Xutian, F. Sun and S. Tai
16. Qigong 199
N. J. Manek and C. Lin
17. Diet and nutrition in Traditional Chinese Medicine 211
M. E. Jones
18. Ayurvedic medical system of India 225
L. C. Mishra
19. Yoga 239
A. Sood
20. Homeopathy 247
T. Bark and D. Dwyer
21. Naturopathic medicine 257
D. Seely
22. Music therapy 271
D. S. Burns and S. L. Robb

Mind and Body Approaches

23. Meditation 281
H. Pokharna
24. Biofeedback 291
F. Shaffer and D. Moss
25. Religion, spirituality, and medicine 313
P. S. Mueller
26. Imagery 329
J. Aufenthie
27. Belief and the space of healing 337
S. Pessin

Energy Therapies
28. Energy medicine 347
F. M. Gulmen
 Contents vii

29. Magnet therapy 357

W. C. Mundell
30. Healing touch 363
J. Aufenthie

Manipulative and Body-based Therapies

31. Chiropractic 369
R. E. Gay
32. Massage 379
D. J. Engen
33. Osteopathic medicine 387
D. P. Russo

SECTION II CAM THERAPIES FOR COMMON MEDICAL CONDITIONS 397

Cardiovascular Disease
34. Prevention and treatment with CAM therapies 399
M. J. Sorrentino
35. Lipid disorders 407
P. O. Szapary
36. Herbal antioxidants: potential and pitfalls 419
T. L. Vanden Hoek and Z.-H. Shao
37. Hawthorn 433
Z.-H. Shao and W.-T. Chang

Respiratory Disease
38. Asthma 441
C. R. Weiler
39. Chronic sinusitis 449
R. S. Ivker

Gastro-intestinal Disease
40. Irritable bowel syndrome: a perplexing pain for patients and physicians 461
J. Udani
41. Constipation 471
N. P. Sykes and M. Gibbs

Metabolic Diseases
42. Obesity 479
L. Dey and C.-S. Yuan
43. Type 2 diabetes 487
L. Dey and A. S. Attele
44. Osteoporosis 499
F. A. Yao, T. T. Brown and A. S. Dobs
viii Textbook of Complementary and Alternative Medicine

Genitourinary and Reproductive Diseases

45. Male and female sexual dysfunction 509
H. H. Aung and V. Rand
46. Benign prostatic hyperplasia 517
E. M. Gong and G. S. Gerber
47. Mood disorders, premenstrual syndrome, and mastalgia 529
E. J. Bieber and J. S. Gell
48. Perimenopause and menopause 537
E. J. Bieber and J. S. Gell
49. Infertility 551
E. J. Bieber
50. CAM therapies in pregnancy 557
S. Wachob and E. J. Bieber

Central Nervous System

51. Migraine and tension headaches 571
K. Peters
52. Insomnia 579
A. S. Attele and C.-S. Yuan
53. Dementia 587
W. P. Aleman and K. C. Fleming

Psychiatric Disorders
54. Anxiety disorders 595
W. Warner
55. Depression 603
S. L. Paolucci and S. J. Paolucci

Musculoskeletal Disorders
56. Chronic fatigue syndrome 619
W. Warner
57. Fibromyalgia syndrome 627
D. L. Wahner-Roedler
58. Osteoarthritis 635
L. R. Bergstrom and B. A. Bauer

Cancer and AIDS

59. Natural products and cancer 645
W. Sampson
60. Chemotherapy-induced nausea and vomiting 655
S. R. Mehendale, H. H. Aung and C.-S. Yuan
61. Cachexia associated with cancer and AIDS 661
M.-Y. Song, A. S. Dobs and T. T. Brown
62. Boost AIDS patients’ immune systems 671
J. A. Wu and C.-S. Yuan
 Contents ix

Prevention and Special Populations

63. Preventive medicine 683
M. Hammerly
64. Pediatric population 693
N. A. Lass
65. Aging and geriatrics 705
N. G. Egger
66. RealAge and vitamins 717
M. F. Roizen
67. Herbal drug interactions in surgical patients 725
M. K. Ang-Lee, J. Moss and C.-S. Yuan
68. Sports medicine 737
P. J. Barrett

Ethical and Social Implications

69. Ethical implications for clinicians 753
P. S. Mueller and C. C. Hook
70. Information from the Internet: challenges for patients and physicians 765
B. A. Bauer and P. L. Elkin

Index 773
Contributors

W. Patricio Aleman PA Toni Bark MD LEEDAP

General Internal Medicine Department of Integrative Medicine
Mayo Clinic Good Shepherd Hospital
Rochester, MN Barrington, IL
USA USA

Michael K. Ang-Lee MD Patrick J. Barrett

Department of Anesthesia Pritzker School of Medicine
Western Washington Medical Group University of Chicago
Everett, WA Chicago, IL
USA USA

Anoja S. Attele DDS MD Daniel Basila

Department of Pathology Tang Center for Herbal Medicine Research
University of Illinois at Chicago University of Chicago
Chicago, IL Chicago, IL
USA USA

Judith Aufenthie RN MA CHTP CTC CHSMI Brent A. Bauer MD

Complementary and Integrative Medicine Complementary and Integrative Medicine Program
Mayo Clinic Mayo Clinic
Rochester, MN Rochester, MN
USA USA

Han H. Aung MD Larry R. Bergstrom MD FACP

Tang Center for Herbal Medicine Research General Internal Medicine
University of Chicago Mayo Clinic
Chicago, IL Rochester, MN
USA USA

xi
xii Textbook of Complementary and Alternative Medicine

Eric J. Bieber MD Peter L. Elkin MD

Department of Obstetrics and Gynecology Laboratory of Biomedical Informatics
Geisinger Wyoming Valley and Geisinger South Department of Internal Medicine
Wilkes-Barre Mayo Clinic, College of Medicine
Geisinger Health Systems Rochester, MN
Wilkes-Barre/Danville, PA USA
USA
Deborah J. Engen BS CMT
Todd T. Brown MD Occupational Therapy
Division of Endocrinology and Metabolism Mayo Clinic
Johns Hopkins University School of Medicine Rochester, MN
Baltimore, MD USA
USA
Kevin C. Fleming MD
Debra S. Burns PhD MT-BC FAMI General Internal Medicine
Indiana University School of Music Program at IUPUI Mayo Clinic
Indianapolis, IN Rochester, MN
USA USA

Wei-Tien Chang MD Ralph E. Gay MD

Department of Emergency Medicine Physical Medicine and Rehabilitation
National Taiwan University Hospital Mayo Clinic
National Taiwan University College of Medicine Rochester, MN
Taiwan USA

Lucy Dey MD Jennifer S. Gell

Diabetes/Endocrine Section Department of Obstetrics and Gynecology
Chicago Medical School at Rosalind Franklin Geisinger Health Systems
University Danville, PA
VA Medical Center USA
North Chicago, IL
USA Glenn S. Gerber MD
Section of Urology
Adrian S. Dobs MD MHS Department of Surgery
Division of Endocrinology and Metabolism University of Chicago
Johns Hopkins University School of Medicine Chicago, IL
Baltimore, MD USA
USA
Margaret Gibbs MSc MRPharmS
David Dwyer St. Christopher’s Hospice
American Renewable Sydenham, London
Chicago, IL UK
USA
Edward M. Gong MD
Norman G. Egger MD MS Section of Urology
General Internal Medicine Department of Surgery
Mayo Clinic University of Chicago
Rochester, MN Chicago, IL
USA USA
 Contributors xiii

Funda M. Gulmen MS David D. McFadden MD MPH

College of Naturopathic Medicine General Internal Medicine
University of Bridgeport Mayo Clinic
Bridgeport, CT Rochester, MN
USA USA

Milt Hammerly MD Sangeeta R. Mehendale MD PhD

Catholic Health Initiatives Department of Anesthesia and Critical Care
Denver, CO and Tang Center for Herbal Medicine Research
USA University of Chicago
Chicago, IL
C. Christopher Hook MD USA
Division of Hematology
Mayo Clinic Lakshmi C. Mishra M Pharm PhD MD (Ayu)
Rochester, MN Ayurvedic Health Care Center
USA Sequoia Inc.
Rockville, MD
Robert S. Ivker DO ABHM FAAFP USA
American Board of Holistic Medicine
Littleton, CO Donald Moss PhD
USA Saybrook Graduate School
Psychological Services
Monica E. Jones LAc MAcOM Grand Haven, MI
Holistic Health Professionals USA
Neptune, NJ
USA Jonathan Moss MD PhD
Department of Anesthesia and Critical Care
Nancy A. Lass MD FAAP FCP and Institutional Review Board
Department of Medicine and Committee on Clinical University of Chicago
Pharmacology Chicago, IL
University of Chicago USA
Chicago, IL
USA Paul S. Mueller MD
General Internal Medicine
Mark C. Lee MD Mayo Clinic
General Internal Medicine Rochester, MN
Mayo Clinic USA
Rochester, MN
USA Will C. Mundell MD
General Internal Medicine
Chunyi Lin MA IQM Mayo Clinic
Spring Forest Healing Center Rochester, MN
St. Louis Park, MN USA
USA
Stephen J. Paolucci MD
Nisha J. Manek MD Division of Psychiatry
Rheumatology Geisinger Medical Center
Mayo Clinic Danville, PA
Rochester, MN USA
USA
xiv Textbook of Complementary and Alternative Medicine

Susan L. Paolucci MD David Sadava PhD

Division of Psychiatry Department of Biology
Geisinger Medical Center Keck Science Center
Danville, PA Claremont University
USA Claremont, CA
USA
Sarah Pessin PhD
Department of Philosophy Wallace Sampson MD
University of Denver Stanford University School of Medicine
Denver, CO and The Scientific Review of Alternative Medicine
USA Los Altos, CA
USA
Kenneth Peters MD
Northern California Headache Clinic Dugald Seely ND
Mountain View, CA Department of Clinical Epidemiology
USA Canadian College of Naturopathic Medicine
Toronto, Ontario
Hemlata Pokharna PhD Canada
Department of Medicine
University of Chicago Fred Shaffer PhD
Chicago, IL Department of Psychology
USA Truman State University
Kirksville, MI
Victoria Rand MD USA
California Pacific Medical Center
San Francisco, CA Zuo-Hui Shao MD
USA Section of Emergency Medicine
Department of Medicine
Sheri L. Robb PhD MT-BC University of Chicago
Music Education/Music Therapy Chicago, IL
University of Missouri – Kansas City USA
Conservatory of Music
Kansas City, MO Yukihiro Shoyama PhD
USA Laboratory of Medicinal Resourses Regulation
Faculty of Pharmaceutical Sciences
Michael F. Roizen MD FACP Kyushu University
Division of Anesthesia, Critical Care Medicine, Fukuoka
and Comprehensive Pain Management Japan
Cleveland Clinic
Cleveland, OH Lynne T. Shuster MD FACP
USA Women’s Health Clinic
Mayo Clinic
David P. Russo DO Rochester, MN
Physical Medicine and Rehabilitation USA
Mayo Clinic
Rochester, MN
USA
 Contributors xv

Mi-Yeon Song OMD PhD Daniel Turner-Lloveras

Department of Oriental Rehabilitation Medicine University of Chicago Pritzker School of Medicine
College of Oriental Medicine Chicago, IL
Kyung Hee University USA
Dongdaemun-gu
Seoul Jay Udani MD
Korea Northridge Hospital Integrative Medicine Program
and UCLA/Geffen School of Medicine
Amit Sood MD Northridge, CA
General Internal Medicine USA
Mayo Clinic
Rochester, MN Terry L. Vanden Hoek MD
USA Section of Emergency Medicine
Department of Medicine
Matthew J. Sorrentino MD FACC and the Emergency Resuscitation Center
Section of Cardiology University of Chicago
Department of Medicine Chicago, IL
University of Chicago Pritzker School of Medicine USA
Chicago, IL
USA Shari Wachob
Department of Obstetrics and Gynecology
Feng Sun PhD MD Geisinger Health Systems
Department of Medicine Danville, PA
University of Alberta USA
Edmonton, Alberta
Canada Dietlind L. Wahner-Roedler MD
General Internal Medicine
Nigel P. Sykes MA FRCGP Mayo Clinic
St. Christopher’s Hospice Rochester, MN
and King’s College, London USA
UK
Chong-Zhi Wang PhD
Philippe O. Szapary MD Tang Center for Herbal Medicine Research
Cardiovascular Risk Intervention Program University of Chicago Pritzker School of Medicine
Institute for Translational Medicine and Therapeutics Chicago, IL
University of Pennsylvania Health System USA
Philadelphia, PA
USA Yong Gao Wang MD MBA LAc
Department of Physiology
Shusheng Tai PhD Loyola University of Chicago
Department of Medicine Maywood, IL
University of Alberta USA
Edmonton, Alberta
Canada Wendy Warner MD FACOG ABHM
Medicine In Balance, LLC
Jacqueline Thielen MD Langhorne, PA
General Internal Medicine USA
Mayo Clinic
Rochester, MN
USA
xvi Textbook of Complementary and Alternative Medicine

Catherine R. Weiler MD Wen Xuan MD

Allergic Diseases Chicago First Chinese Acupuncture and Medical
Mayo Clinic Center
Rochester, MN Chicago, IL
USA USA

Sheila M. Wicks MD MBA Stevenson Xutian PhD

Tang Center for Herbal Medicine Research Department of Medicine
University of Chicago University of Alberta
Chicago, IL Edmonton, Alberta
USA Canada

Ji An Wu PhD Fay A. Yao BS

Department of Pharmaceuticals and New Technology Division of Endocrinology and Metabolism
Pharmaceutical Products Division Johns Hopkins University School of Medicine
Abbott Laboratories Baltimore, MD
Abbott Park, IL USA
USA
Chun-Su Yuan MD PhD
Jing-Tian Xie MD Department of Anesthesia and Critical Care
Tang Center for Herbal Medicine Research and Tang Center for Herbal Medicine Research
University of Chicago University of Chicago Pritzker School of Medicine
Chicago, IL Chicago, IL
USA USA

Bob Xu CMD MS
American Chinese Medical Association
and Center for Holistic and Herbal Therapy
Plainfield, IL
USA
Preface
Complementary and alternative medicine (CAM) com-
prises those health-care practices that are not currently
considered an integral part of conventional therapies.
People who use CAM therapies do so for a variety of rea-
sons. Many are seeking ways to improve their health and
well-being. Some use CAM as a means to increase a sense
of control over health care. Others use CAM to relieve
the side-effects of conventional treatments. Yet many of
the therapies and modalities being chosen have not been
adequately studied. In many cases, the potential benefits
and risks remain only partially understood.
Thus, we recognize the need to study CAM therapies
to determine which are safe and effective and which
might lack efficacy or be harmful. Fortunately, many
CAM studies have been undertaken with increasing reg-
ularity in the past ten years. These studies have begun to
answer many of the questions raised about the most
common therapies. However, patients and consumers
have so far been unwilling to wait for science to ‘catch
up’ by undertaking such studies. The popularity of CAM
has risen sharply since the latter part of the twentieth
century. This patient/consumer-driven movement affects
all specialties of conventional medicine, influencing the
decision making and practice of allopathic physicians.
Often, medical professionals do not have an adequate
background in CAM or they lack access to the growing
body of evidence-based information that does exist.
They are therefore unable to provide informed responses
to CAM questions from their patients. It is vitally
important for today’s medical professionals to have a
xvii
general working knowledge of CAM and a familiarity
with the potential benefits and adverse effects of com-
mon CAM therapies. By being informed, physicians can
then inform their patients. Informed patients will be
empowered to make informed choices or to reject CAM
modalities. A collaborative approach between physicians
and patients is the key to ensuring that CAM fulfills its
potential of restoring the body, mind, and spirit of
patients.
The first edition of this book originated from a CAM
course offered to medical students at the Pritzker School
of Medicine at the University of Chicago, and other pro-
fessional CAM meetings, organized by faculty members
at the University of Chicago for the continuing medical
education of practicing physicians. For this new edition,
Dr Brent Bauer, Director of the Complementary and
Integrative Medicine Program at Mayo Clinic, joined
our editorial team. Encouraged by the reception given to
the first edition, we prepared the second edition to
incorporate the new research in the interim to continue
to meet our readers’ needs. As a result, the second edition
has added more than 30 new chapters. It is our intention
to provide comprehensive, contemporary, and evidence-
based CAM information in this text, which is designed
for practicing physicians, medical students, other health-
care professionals and interested individuals.
The work of this book was supported in part by
NIH/NCCAM grants AT002176 and AT002445, and
the Tang Foundation for Traditional Chinese Medicine
Research.
Chun-Su Yuan
Eric J. Bieber
Brent A. Bauer
Acknowledgments
This text was born of our hope that you, the reader, will
gain from the experience of its many contributors. We
have attempted to cover broad areas, often including
topics that may or may not be familiar, to present a sense
of the current state of the art. The broadly defined field
of complementary and alternative medicine (CAM) con-
tinues to expand at a rapid pace. Given that most physi-
cians practicing today have not received formal training
in CAM, we conceived this text both as a tool to develop
a knowledge of CAM and as a reference for those who
have experience in some areas of CAM.
The contributors have spent countless hours to pro-
vide current information. Without their input and ener-
gies this final product could not exist. We sincerely
appreciate the time spent and the wisdom shared in
bringing this project to fruition.
Many other individuals are also responsible for this
text. We thank Nick Dunton, Head of Medical Publish-
ing, Informa Healthcare, for his vision in seeing the
xix
value in this project and his continuing desire to dissem-
inate medical knowledge. Additionally, Pam Lancaster
has spent countless hours with the editors in finalizing
the text. We also thank Simon Harper for the cover
design and Kate Lancaster for the original drawings.
Finally, we thank our families for allowing us to take
time away from our precious minutes with them. To my
parents, Chengye Yuan and Zhenkun Wang, my wife,
Xiaoyu Wang, and daughter, Amanda, for your guidance
and inspiration (CSY). To my wife, Edie, and my chil-
dren, Brandon and Andrew, your untiring love has given
me the support and enthusiasm to chase my dreams. To
my parents, George and Audrey, and sister, Kris, your
constant encouragement to pursue knowledge in a tire-
less fashion and an unrelenting belief in me as a human
being laid the foundation for all that I have and will
accomplish (EJB). To my mother, Nancee, my wife,
Kristin, and my children, Jonathan, Elizabeth, and
David, with love, respect, and gratitude (BAB).
Chun-Su Yuan
Eric J. Bieber
Brent A. Bauer
References

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71–6 The alkaloids taspine and 3,4-O-dimethylcedrusin are
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sap. They are responsible for the anticancer and
anti-inflammatory activities, respectively, as well as for
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Preparations and dosage The recommended dosage of the
standardized extract of SP-303 is 250–500 mg, two to four
times daily or as needed 37 . Recommended dosages for
tinctures range from 10–30 drops up to three times daily,
and for dry extracts 20–60 mg mixed in water three times
daily. For sores apply externally.

secretory diarrhea by 21% without causing post

treatment constipation 37 . Extracts of dragon’s blood have

been shown to have

antiviral activity against influenza 45 , parainfluenza, and

the herpes simplex viruses I and II 46 . In a multicenter,

double-blind, placebo-controlled study, a topical prepa

ration of SP-303 was used to treat recurrent genital her

pes lesions in patients with AIDS. Viral culture showed

50% of the treated group and 19% of the placebo

treated patients became culture-negative at the end of

the 21-day trial 47 .

Phytochemistry and pharmacology

Dragon’s blood contains several simple phenols, diter

penes 46 , proanthocyanidins, phytosterols, the lignan 3,4

O-dimethylcedrusin 46 , and the alkaloid taspine 41 . These

last two compounds have antiviral and wound healing

properties that can potentially be useful in treating the

viral sores caused by herpes 46 . The extract SP-303 is an

effective medicine for those

suffering from diarrhea because it inhibits CFTR

mediated chloride secretion which is the primary cause

of diarrhea via cAMP-dependent hyperactivation of

CFTR. Currently, no drug treatments are available that

specifically target and block the CFTR chloride ion

channel 37 .

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approaches, diagnosis, treatment, therapeutic outcomes,
etc. Despite all of the differences, however, one thing is
common to them – they are both medicines. Chinese Medicine,
as an integral part of Chinese culture, is relatively new
to most people who have grown up in Western culture. To
them, the major component of Chinese Medicine – Chinese
herbal medicine – is still a mystery, and there are many
puzzling questions regarding Chinese Medicine and Chinese
herbal medicine. Because Chinese Medicine and Chinese
herbal medicine are new to many countries, many governments
do not have adequate information or preparation on how to
regulate them. Thus, they decide not to regulate them. The
decision not to regulate Chinese Medicine is based on a
misunderstanding about Chinese Medicine and Chinese herbal
medicine, and has played an important role in increasing
the occurrence of Chinese Medicine side-effects. In the
best interest of patients, and to protect the integrity of
the Chinese Medicine profession, we recommend that
regulations on the profession of Chinese Medicine should be
installed, either through the government or from the
Chinese Medicine profession itself. 1. Xu B. Mathematical
Herbal Medicine. Acupuncture Today 2005; 6 June

information on the optimum setting. Neither do they

provide information on the ‘dangerous’ settings. For the

above reasons, Chinese herbal medicine stud

ies are very complicated, difficult, costly, and time

consuming. There are thousands of formulae in Chinese

herbal medicine. However, up to today, there is still no

medical school, university, company, science foundation,

or even country that can afford a systematic, complete,

and rigorous study and research into one of the formu

lae in Chinese herbal medicine. This fact indicates the

challenges that lie ahead in the field of research and

study on Chinese herbal medicine. However, these only

reflect the defects and inadequa

cies in Chinese herbal medicine’s study and research

methodologies and approaches. As for the Chinese

herbal medicine itself, it is a complete, systematic, and

rigorous medicinal system.

CONCLUSION

Western medicine and Chinese Medicine differ in cul

ture, origins, history, philosophy, theory, principles,

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Tai Chi 15

justification for future controlled clinical study of the

benefits of Taiji intervention with individuals with

neurologic disease, particularly multiple sclerosis,

parkinsonism, neurodevelopmental motor performance

dysfunction, pulmonary insufficiency, and systemic

musculoskeletal disorders. It is anticipated from existing

research and the mind/body theoretic model that poten

tial benefits from Taiji practice could be expanded to

include both physical and behavioral applications.

CONCLUSIONS

Although most Western people know Taiji as a tradi

tional Chinese physical exercise, it is in fact a kind of

tra

ditional Chinese Yanshenshu (a mind–body harmony

technique for health improvement and longevity), an

important part of TCM, when it is practiced with Taiji

principles (the natural principles for harmonizing body

and mind). The scientific literature validating the physi

cal and physiologic therapeutic effects of regular Taiji

practice has increased exponentially. After practicing

Taiji, most people realize that Taiji is

not a regular physical exercise but a special body–mind

training technique, which is closely related to traditional

Chinese philosophy, culture, and medicine. The rela

tionship between the human body and mind, as well as

between human beings and the natural environment is

greatly emphasized in Taiji. According to TCM litera

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adolescence: a motivational perspective. In Featherman D,
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threats. In Cameron LD, Leventhal H, eds. The
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being earnest. Cogn Emot 1999; 13: 601–35

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on the behavior of hospitalized children in isolation:
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12. Robb S, Ebberts A. Songwriting and digital video

production interventions for pediatric patients undergoing
bone marrow transplantation. Part I: an analysis of
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13. Robb S, Ebberts A. Songwriting and digital video

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perception and their relevance in music therapy. In Unkefer
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Practical Introduction to the Secrets of Vitality from Both
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2003; 9: 70–4 13. Emoto, M. The True Power of Water. Beyond
Words Publishing, 2005 14. Sebastian, K. Baby’s Kneipp Cure
or The Care of Children in Health and Disease. Kessinger
Publishing, 1896

Cohen K. The Way of Qi Gong: The Art and Science of Chinese

Energy Healing. Ballantine Wellspring, 1997

Coulter HD. Anatomy of Hatha Yoga. Body and Breath Inc.,

2001

Iyengar BKS. Yoga: The Path to Holistic Healing. London:

Dorling

Kindersley Press, 2001

Jonas WB, Crawford C. Healing, Intention and Energy

Medicine:

Science, Research Methods and Clinical Implications.

Edinburgh:

Churchill Livingstone, 2003

Khalsa DS, Stauth C. Meditation as Medicine. New York:
Fireside,

2001

Liu Master H. The Healing Art of Qi Gong: Ancient Wisdom

from

a Modern Master. Warner Books, 1997

Magnet therapy 29

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Chiropractic 31

manipulation, the primary intervention in almost all tri

als of chiropractic treatment. There are no studies that

demonstrate that one manipulation/mobilization

method is more efficacious than another. The non

manipulation/mobilization methods have little or no sci

entific basis. The choice of technique a practitioner uses

is usually the result of experience and mentoring 75 .

Curtis and Bove have suggested guidelines for identi

fying a competent chiropractor 76 . Table 31.3 is adapted

from their article. Use of such guidelines tends to direct

patients and physicians away from chiropractors who

make treatment decisions based primarily on philosophy

as opposed to those who do so based on the strength of

the available evidence. Providers referring patients to

chiropractors should become familiar with the practice

philosophy and treatment style of individual DCs in

their area. CONCLUSIONS Chiropractic has become an

established health-care profession in the USA and many
countries. Although chiropractic practice was originally
based on philosophy only, it is an evolving profession
influenced by a growing body of evidence demonstrating the
efficacy of chiropractic for spine-related conditions.
Standardized education and licensure, in addition to
inclusion in the third party payment system, have allowed
chiropractic to grow to an impressive size. It is becoming
common to see DCs practicing alongside other providers,
both conventional and non-conventional. With the increase
in popularity of complementary and integrative therapies,
the role of chiropractic in the treatment of
musculoskeletal disorders is likely to expand.

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Osteopathic medicine 33

However, it may also be viewed as complementary to

mainstream medicine, by combining standard bio

medical interventions with other modalities considered

outside of the purvey of ‘conventional’ medicine. This

duality does not invalidate it as a medical philosophy,

but does make it difficult for researchers to measure its

contribution to health care. Osteopathic medicine’s

negotiation of its professional identity and status pro

vides an interesting study of the professional integration

of CAM-based theory and practice into the conventional

delivery of medical care and health services. To summarize,

as discussed above, osteopathic medi

cine first developed its unique and proprietary treatment

modalities in the early nineteenth century as a distinct

alternative to conventional medical practice. These

modalities moved through stages of discovery, develop

ment, refinement, and translation in order to be inte

grated into a modern biomedically-oriented osteopathic

educational curriculum. This curriculum was instituted

in largely free-standing educational institutions and

community hospitals and clinics. Both internal and

external competing interests shaped this process in a

largely serendipitous fashion. Today, osteopathic medicine

stands on the precipice of a new phase of its own
evolution. It is uniquely positioned as a bridge between
what is considered standard biomedical care versus
complementary and alternative. It has developed a network
of colleges, professional organizations,
federally-recognized accreditation standards, hospitals,
and health-care networks to deliver a package of health
services based on a distinct philosophy of patient care.
Simultaneously, it interfaces, cooperates, and allies
itself with the standard biomedical enterprise and
industries, while retaining its own distinct professional
identity. In order to secure its relevance in a modern,
integrated health-care system, osteopathic medicine’s
success will depend upon conscientious organizational
leadership, the stewardship of its academic community, and
continued long-term investment in research infrastructure
in order to demonstrate cost-effective, positive treatment
effects for the services it provides. Policymakers,
educators, and stakeholders in other CAM fields stand to
gain much insight from a careful analysis of the
osteopathic profession’s development when considering
issues of CAM integration and health services delivery.

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43 Irritable bowel syndrome: a perplexing
40 pain for patients and physicians

Mind–body therapies

Mind–body therapies likely operate on the gut–brain

axis. As previously described, the efferent pathways from

the CNS to the ENS are impacted by thoughts and emo

tions. The neurochemical alterations which occur in

these pathways during times of stress or distress can have

a real impact on the motor and nerve functioning of the

gut. Reductions in stress and distress can decrease the

somatization through this efferent pathway and result in

symptomatic improvements.

Hypnotherapy

Gut directed hypnotherapy has been shown consistently

to improve the symptoms of IBS (including abdominal

pain, constipation, and flatulence), improve quality of

life, reduce anxiety and depression 63,64 , and reduce

absenteeism from work 65 . This is accomplished within

the realm of the gut–brain axis, and it has been demon

strated that hypnotherapy has no effect on the physical

manifestations of IBS, including rectal pain and muscle

tone 66 . The effects of hypnotherapy appear to last

between 3 and 18 months after completion of ther

apy 67,68 with relapses effectively treated with additional

hypnotherapy. Treatment regimens appear to include weekly or

biweekly sessions as well as home based practice using

audio-tapes. A total of 12 sessions should be considered

a minimal amount of hypnotherapy for the treatment of

IBS.

Yoga

A single study of 22 male IBS-D patients was performed

comparing yoga to loperamide 69 for 2 months. The results

showed that both groups improved significantly from
baseline, but there was no difference between groups. This
pilot study illustrates the potential benefit of yoga in
male patients with IBS-D, but it is not generalizable to
the female or IBS-C population. Yoga is certainly safe in
the hands of skilled instructors; however, it is too early
to conclude that it can be helpful in IBS. HOW A PHYSICIAN
HELPS THEIR PATIENT CHOOSE THE RIGHT CAM TREATMENTS FOR IBS
Irritable bowel syndrome is frustrating for patient and
physician alike. Even though we are just beginning to
elucidate the neurochemical mechanisms of IBS, effective
treatments are few and far between. Given the concordance
of fibromyalgia and other difficult to diagnose and treat
diseases along with IBS, it is no wonder that so many
patients turn to CAM therapies for relief. The review of
evidence for these CAM therapies is surprising in that so
little has been tested, and even less has been shown to be
effective. Generally, most of the forgoing therapies are
safe and can likely be combined without sequelae. It is not
known whether the small effects which were seen in therapy
would be additive. Maintaining an open and ongoing dialog
with your patients is essential. That dialog should include
education and reassurance as well as the latest information
on mechanism of action and treatments. The more the
physician can provide to the patient, the less likely the
patient will turn to the clerk at the local health food
store for their medical care.

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Insomnia 52

efficacy in the treatment of insomnia in psychiatric

patients 62,63 . Controlled, clinical trials demonstrating

acupuncture’s effect on insomnia are rare. Many studies

provide only subjective evaluations of sleep. Since

acupuncture is an individualized treatment, controlled

studies are difficult to execute. Using scalp, body, and

ear acupuncture points, posi

tive effects appeared almost immediately after treat

ment 63 . The mechanisms by which acupuncture treat

ment modulates insomnia may be understood in terms

of the general mechanism by which it produces analge

sia. In addition, acupuncture treatment increased noc

turnal melatonin secretion and reduced insomnia and

anxiety 64 . Additional clinical studies are necessary to

elu

cidate how acupuncture can reharmonize a disturbed

sleep–wake cycle.

Low-energy emission therapy

LEET is a method of delivering low levels of amplitude

modulated radio-frequency electromagnetic fields to

humans. The LEET device consists of a signal generator,

microprocessor, and amplifier. The signal generator is

connected to a mouthpiece, which is held between the

tongue and palate for the duration of the treatment 65 .

Results of some investigations have suggested that LEET

may be a potential alternative therapy for chronic insom

nia that is refractory to conventional treatment. In

healthy volunteers, 15 min of LEET treatment induced

EEG changes, and was associated with objective and

subjective feelings of relaxation 66 . A double-blind,

placebo-controlled study showed that 12 LEET treat

ments over a 4-week period improved the sleep of

chronic insomniacs 67 . The mechanism underlying the effect

of LEET is poorly understood. Low levels of electromagnetic
field, such as those to which the brain is exposed during
LEET, affect in vitro and in vivo calcium release from
neural cells 68 , modify the release of GABA, and change
benzodiazepine receptor concentration in rat brains 69 . In
addition, low levels of electromagnetic field modify the
release of melatonin in mammals 65 . So far, the
administration of LEET treatment is confined to
sleep-disorder centers. Unlike conventional therapies, LEET
may be administered on an every-other-day basis, and
discontinuation does not appear to induce rebound insomnia
67 . LEET therapy-related side-effects have not been
reported. CONCLUSIONS Insomnia is the most common sleep
disorder. It is often associated with significant medical,
psychologic and social disturbances. The inability to
attain restful sleep in adequate amounts exacts a heavy
toll. Conventional treatment for insomnia includes
psychologic therapy and drugs that exert a depressant
effect on the CNS. Most of the drugs prescribed for
insomnia involve some risk of overdose, tolerance, and
addiction. Long-term use of frequently prescribed
medications can lead to habituation and problematic
withdrawal symptoms. As alternative therapies, herbal
products and other agents with sedative–hypnotic effects
are increasingly sought after by the general population.
The herbs commonly used for their sedative–hypnotic effects
are less likely to have the drawbacks of conventional
drugs. How alternative therapies compare to conventional
therapies warrants further investigation.

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APPENDIX 1

HON Code of Conduct (HONcode) for Medical

and Health Web sites Principles

(http://www.hon.ch/HONcode/Conduct.html\)

(1) Authority: Any medical or health advice provided and

hosted on this site will only be given by medically trained
and qualified professionals unless a clear statement is
made that a piece of advice offered is from a non-medically
qualified individual or organization.

(2) Complementarity: The information provided on this site

is designed to support, not replace, the relationship that
exists between a patient/site visitor and his/her existing
physician.

(3) Confidentiality: Confidentiality of data relating to

individual patients and visitors to a medical/health Web
site, including their identity, is respected by this Web
site. The Web site owners undertake to honour or exceed the
legal requirements of medical/health information privacy
that apply in the country and state where the Web site and
mirror sites are located.

(5) Justifiability: Any claims relating to the

benefits/performance of a specific treatment, commercial
product or service will be supported by appropriate,
balanced evidence in the manner outlined above in Principle
4.

(6) Transparency of authorship: The designers of this Web

site will seek to provide information in the clearest
possible manner and provide contact addresses for visitors
that seek further information or support. The Webmaster
will display his/her Email address clearly throughout the
Web site.

(7) Transparency of sponsorship: Support for this Web site

will be clearly identified, including the identities of
commercial and non-commercial organisations that have
contributed funding, services or material for the site.

(8) Honesty in advertising and editorial policy: If

advertising is a source of funding it will be clearly
stated. A brief description of the advertising policy
adopted by the Web site owners will be displayed on the
site. Advertising and other promotional material will be
presented to viewers in a manner and context that
facilitates differentiation between it and the original
material created by the institution operating the site.
APPENDIX 2 Guidelines for Medical and Health Information
Sites on the Internet
(http://www.ama-assn.org/ama/pub/category/1905.html#ONE)
Margaret A Winker et al. PRINCIPLES FOR CONTENT The AMA is
committed to providing medical and health information of
high quality via its Web sites. Visitors to AMA Web sites
will be given information, navigational direction, and
tools needed to judge the quality, reliability,
objectivity, sources, and funding of content and to make
effective use of content. Definition of Content Content is
defined as all material (including text, graphics, tables,
equations, audio, and video) and menu/ directional icons,
bars, indicators, listings, and indexes. These principles
also address functions that support content (e.g. links,
navigation, searches, calculations). Site Ownership Web
site ownership, including affiliations, strategic
alliances, and significant investors, should be clearly
indicated on the home screen or directly accessible from a
link on the home screen. Copyright ownership of specific
content should be clearly indicated on screen and on items
printed from the site. Site Viewing The site should
provide information about the platform(s) and browser(s)
that permit optimal viewing in a location that is easy to
find.

Viewer Access, Payment, and Privacy

Information about restrictions on access to content,

required registration, and password protection (if appli

cable) should be provided and easy to find. Information
about payment (i.e. subscriptions, docu

ment delivery, pay per view, etc) should be provided and

easy to find. See ‘Principles for E-commerce’ herein.

Information about privacy should be provided and

easy to find. See ‘Principles for Privacy and Confiden

tiality’ herein.

Funding and Sponsorship

Funding or other sponsorship for any specific content

should be clearly indicated and should comply with the

‘Principles for Advertising and Sponsorship’ herein.

Content should be easily distinguished from advertis

ing as described in ‘Principles for Advertising and Spon

sorship.’

Quality of Editorial Content

Guidelines for editorial content review, posting dates,

and sources were developed based on experience with the

AMA Scientific Publications’ sites. All scientific publica

tions and consumer site information adhere to these

guidelines. As of publication of these guidelines, content

posted on the AMA corporate site will adhere to these

guidelines as well.

Review

Content should be reviewed for quality (including orig

inality, accuracy, and reliability) before posting. Clinical

editorial content should be reviewed by content experts

not involved in creation of the content, and the content

should be revised appropriately in response to such

review. The method of review will be determined by

individual sites. (For example, Scientific Publications

sites include peer review. Other sites rely on review by

editorial boards.) The language complexity of the content

should be

appropriate for the site’s audience. Content should be

reviewed for grammar, spelling, and composition before

posting. A description of the editorial process and method

of

content review should be posted on the site. A list of

staff members and other individuals (e.g. edi

torial board) responsible for content quality, other than

anonymous peer reviewers, should be posted on the site.

Date of Posting, Revising, and Updating and Timeliness of
Editorial Content The dates that content is posted,
revised, and updated should be clearly indicated.
Procedures for updating and removing time-sensitive content
should be developed, implemented, and periodically reviewed
to ensure that the updating and review schedule is
appropriate. (For example, content can be sorted by date
posted and all content older than 6 months reviewed for
timeliness and accuracy.) An indication of significant
revisions to any specific content should be posted and may
include instructions to discard copies of versions
previously printed or downloaded. Sources of Editorial
Content Source for specific content should be clearly
identified (ie, author byline or names of individual,
organizational, departmental, institutional, agency, or
commercial provider/producer). Affiliations and relevant
financial disclosures for authors and content producers
should be clearly indicated. Individuals who post content
in online discussions, chat rooms, and e-lists should be
instructed to disclose financial interests and commercial
funding or affiliations related to the subject of the
posted content discussion, chat, or list. Reference
material used to develop content should be cited in a
manner appropriate for the site’s audience. Linking
Intrasite content links should be reviewed before posting
and maintained and monitored. If links are not functional,
links should be repaired in a timely manner. External site
links should be reviewed before posting and maintained and
monitored. If links are not functional, these links should
be repaired in a timely manner. External links to
commercial sites must comply with the ‘Principles for
Advertising and Sponsorship’. Intersite Navigation Sites
should not prevent viewers from returning to a previous
site. Sites should not redirect the viewer to a site the
viewer did not intend to visit. Sites should not frame
other sites without permission.

Downloading Files

If content can be downloaded in a portable docu

ment file (PDF) format, instructions regarding how to

download the PDF file and how to obtain the necessary

software should be provided and easy to find. A link to

such software should be provided.

Navigation of Content

Features that facilitate use of the site should be provided

and easy to find, and should include a site map or other

site organizational guide, a help function or frequently

asked-questions page, a feedback mechanism, and cus

tomer service information (if available). Each distinct

site should provide a search engine or appropriate
navigation tool to facilitate use. If the site provides a
search engine, instructions specifying how to use the
search function and how to conduct different types of
searches may be provided. Graphics files should include a
‘mouse over’ indication of the graphical content. For large
files, the space where the file resides should include the
size of the file. As a courtesy to the viewer, when
possible, when a large file can be downloaded by clicking,
the viewer may be informed of the size of the file before
the file begins downloading and should have the opportunity
to cancel the download.