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Complementary and Integrative Healing Modalities

Carey S. Cadieux, PhD, RN, AHN-BC, RYT, FAAN

Pacific College of Health and Science

“It is health that is the real wealth, and not pieces of gold and silver.” – Mahatma Gandhi

 

Learning Objectives

• Distinguish between evidence-based health care and complementary and alternative health care.
• Determine the reasons for providing complementary and alternative health care in modern health facilities.
• Describe different types of complementary and alternative care.
• Understand the business case to provide some types of complementary and alternative care.

Introduction

The widespread use of complementary and integrative medicine (CIM) approaches to healing in the United States is of concern to health consumers, healthcare providers, policy makers, and researchers. In 2023, approximately 145 billion dollars were spent on such CIM modalities such as mind-body healing, energy modalities, supplements and botanicals, acupuncture, and massage, with a projected 25% global compound annual growth rate through the year 2030 (Grand View Research, 2024). Major boosts to this spending include both increased consumer spending as well as government interest in the efficacy of CIM approaches. This chapter focuses on defining CIM approaches and exploring the use of CIM in healthcare settings.

CIM stands in contrast to traditional or allopathic approaches to healthcare. The term allopathy was defined in 1832 to differentiate it from homeopathy. Allopathy is the modern medicine approach focusing on diagnosing illness and providing treatments to help manage symptoms of the illness or cure the illness (Merriam Webster, 2024), while homeopathy is a medical system based on the belief that the body can cure itself. In the United States, modern medicine consists of allopathic approaches, where medical doctors, nurses, and other healthcare providers treat health concerns, symptoms, and diseases with medications, surgeries, and radiation. Allopathic medicine has its roots in Ancient Greek approaches and has also been called biomedicine, conventional medicine, Western medicine, mainstream medicine, or orthodox medicine. Allopathic approaches rely on clinical exams, screening of symptoms, confirmation of diagnosis, and a focus on the patient’s symptoms. Health insurance in the US is aligned with the allopathic model.

Defining Complementary Medicine

Complementary medicine and therapies can be defined as health care approaches developed outside of mainstream Western, or conventional allopathic approaches to medicine (Duquesne Library, 2024). Considering this type of non-mainstream medicine, there are three terms that are used interchangeably, but may be identified separately: complementary, alternative, and integrative medicines.

• Alternative: a non-mainstream practice that is used in place of conventional medicine.
• Complementary: a non-mainstream practice that is used together with conventional medicine
• Integrative: bringing conventional and complementary approaches together in a coordinated way (Duquesne Library).

Today, the use of the term alternative medicine is uncommon, as the majority of people use these approaches in tandem with conventional allopathic approaches. The US Department of Health and Human Services created the National Center for Complementary and Integrative Health (NCCIH). NCCIH conducts and supports research into complementary and integrative modality (CIM) approaches and provides consumers and healthcare providers with information about CIM products and approaches (NCCIH, 2024). Furthermore, the mission of NCCIH is to “define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health and health care” (NCCIH, 2024).

Integrative approaches bring together complementary and allopathic approaches with an emphasis on treating the whole person (NCCIH, 2021). Integrative health strives for coordination of care to support patients’ growth toward optimal well-being by using all of the tools available for wellness. For instance, one might take medication and have surgery, but also receive acupuncture and psychotherapy to address chronic pain issues.

This chapter will review the growth of CIM, consider some of the basis of CIM modality approaches, and explore the future of CIM with the view that allopathic or traditional medicine has begun to embrace and integrate many of these approaches within its mainstream model. Several decades ago, modalities such as chiropractic care, mental health therapy, and acupuncture were not reimbursable with mainstream health insurance, and now it is quite common for some insurance plans to cover these services. It’s important that healthcare consumers, practitioners, and administrators be aware of the benefits and drawbacks of some of the commonly used CIM approaches as demand for these services continues to grow.

Types of CIM and The Evidence Base

The NCCIH initially placed complementary approaches into two categories, natural products and mind body practices (Lindquist et al, 2023). Natural products may include nutritional supplements such as probiotics, prebiotics, phytochemicals, dietary plants, herbs, spices, vitamins, and minerals. Mind-body approaches would include psychotherapy, meditation, breath work, art, music, dance, tai chi, Reiki, healing touch, and yoga. NCCIH now has other classifications, such as physical which are integrated into the mind-body practice category and includes manipulation techniques like acupuncture, chiropractic care, and massage. An “other” category houses more complex approaches such as Ayruvedic medicine, traditional Chinese medicine, naturopathy, homeopathy, and functional medicine (Lindquist). While classifying and categorizing approaches is helpful, one must also wonder about the efficacy of these approaches and the if/how/why/when of healthcare systems and insurance companies recognizing and integrating these practices with allopathic approaches.

According to the most recent national survey of adults using complementary approaches to manage their health, natural products other than vitamins and minerals were used by 17.7% of the population, deep breathing used by 10.9% of the population, and yoga/ tai chi/ qigong used by 10.1% of the population (NCCIH, 2016). Overall, 30% of adults and 12% of children use complementary modalities on a regular basis (NCCIH, 2016).

Efficacy of CIM

While CIM is being used, we must consider the efficacy of these approaches. While examining each of the most popular approaches in depth is beyond the scope of this chapter, the following section looks briefly at each category and offers a summary of our current knowledge and evidence regarding the modality.

Natural Products

Natural products have been defined by the NCCIH (n.d.a) as nutritional interventions with potentially positive biological activities, such as probiotics, dietary supplements, botanicals, and vitamins. Because these substances are complex and potentially have many active particles and compounds, there are often many methodological barriers to studying them closely. Currently, NCCIH (n.d.a.) is interested in studying natural products that can help to address opioid misuse and manage chronic pain, as well as understanding the basic biological mechanisms related to the effectiveness of natural products. The NCCIH (n.d.a.), would like to see progress made around how we can use technology to study natural products, and they remain concerned about drug-drug or natural product-drug interactions. The NCCIH (2024a), has a resources where consumers can view medicinal herbs and determine what the herb is best used for and we know about the herb from an evidence-based perspective: https://www.nccih.nih.gov/health/herbsataglance

Consumers should do their due diligence when it comes to selecting herbs and other natural products to ensure that the product they are purchasing is safe and effective. Despite a product being natural, there is no guarantee that it is safe and effective. Natural products are never to be used in place of allopathic care (Plotnikoff & Lillihei, 2023).

Deep Breathing

NCCIH categorizes deep breathing as a relaxation technique (NCCIH, June 2021). Deep breathing can be used at any time and in any situation to help manage stress responses. Deep breathing is a technique wherein the abdomen expands through use of the diaphragm, allowing for deeper breaths. This causes a slowing of the respiratory rate. Some individuals may also exhale with pursed lips, though it is not needed for the primary benefits (Evans & Bee, 2023). Slower deep breaths can help to activate the parasympathetic nervous system, bring about a state of relaxation, and deep breathing becomes most helpful when it is practiced multiple times per day, effectively becoming part of the person’s lifestyle (Evans & Bee).

While there are many variations on deep breathing techniques, we are beginning to focus on what some of the best approaches may be from an evidence-based perspective. For instance, Vierra et al. (2022) found that using a 4-7-8 breathing technique (inhale for 4 seconds, hold for 7 seconds and exhale for 8 seconds) helped to enhance heart rate variability and lower blood pressure.

Yoga

While many people use yoga as an exercise for physical and spiritual well-being, it was initially developed in India as an ancient approach to metaphysical well-being. Yoga, when performed correctly, is generally safe for human beings of all ages. Yoga emphasizes postures or poses, breathing, and meditation (NCCIH August, 2023). The many different styles of yoga make it difficult to study, and the NCCIH (August, 2023) stated that yoga may help with general well-being, sleep, balance, obesity, anxiety, menopause symptoms, substance use disorders, and chronic disease management. There is an inherent risk for injury with yoga practice, and individuals should always practice to their limits of the capabilities. The NCCIH (August, 2023) advises people to practice yoga under the guidance of a qualified instructor and exercise caution when one is pregnant, with hot yoga (so as not to dehydrate), and when modifications due to mobility or other issues are needed. As with any exercise, avoiding extremes as a new learner is important. The NCCIH (August, 2023) continues to fund research around the outcomes of yoga practice, and areas for focus include aligning specific yogic approaches or techniques with improved disease states or health issues, such as with chronic pain, substance use disorders, and hypertension.

Osteopathic Manipulation

Eseteves et al. (2022) defined osteopathy as a person-centered and whole person healthcare approach that emphasizes the body’s structure-function interrelationship as a source of health. The body is viewed as self-regulatory, and many have argued that osteopathic physicians have a guiding philosophy that supports this viewpoint. An osteopathic treatment consists of manual manipulation of bones, joints, and muscles. A recent review of the evidence demonstrated that osteopathy may be effective for musculoskeletal disorders, but other areas of effectiveness (such as for migraine, or irritable bowel syndrome) are not yet supported by the evidence (Bagagiolo, et al., 2022).

Meditation

Meditation is an Eastern traditional approach, with a history that goes back thousands of years. There are many different meditative techniques, and the term “meditation” includes a number of practices that focus on mental and physiological integration used to calm the mind and enhance overall well-being (NCCIDH, June, 2022). Meditation involves maintaining the mind’s focus on a particular sensation, such as breathing, a sound, a visual image, or a mantra (a repeated word or phrase) and bringing one’s focus back to the sensation when the mind wanders (NCCIH, June, 2022). Mindfulness is a form of meditation which involves maintaining attention or awareness on the present moment without making judgments, rather one focuses on observing the moment (NCCIH, June, 2022).

Meditation is generally safe, though there may be some harmful effects for some populations. The NCCIH (June, 2022) is currently examining how meditation may support an integrated approach to migraine care, opioid use disorder, and stress management. Individuals should always seek instructors who have expertise in this area.

Massage

Massage therapy is the manipulation of soft tissues to enhance well-being and health (NCCIH, May, 2019). There are many different types of massage available, though in the Western World, most people are familiar with classical or Swedish massage (NCCIH, May, 2019). Massage has been shown to support people with pain, enhancing the quality of life for cancer, fibromyalgia, and HIV-AIDS patients (NCCIH, May, 2019). The NCCIH (May, 2019) has funded research around massage for repetitive motion injuries and non-pharmacological pain management. Individuals should seek massage from licensed professionals, as there are some risks of injury when massage is done incorrectly.

Issues with Studying CIM

There are many issues with studying CIM, including having the available technologies to measure appropriate physiological outcomes, variations in techniques or products, and consistency of approaches. As we grow in our understanding of how these approaches work, the demand for CIM will also continue to grow. As evidence grows, issues of stronger regulation and insurance reimbursement for these therapies will also be brought forward.

Overview of Cost and Integration

The NCCIH (April, 2024) most recent data around cost of complementary health approaches is based on a 2012 survey. One can assume that costs have grown over time, as has interest in these modalities. The following depicts an overview of costs in the US. Complementary practitioner visits, self-care purchases, and natural products are the leading expenditures around this type of care (NCCIH, April 20, 2024).

The offering of CIM by large health systems continues to grow and now include larger systems like the Mayo Clinic, Mass General Brigham, University of California San Francisco, and smaller entities like Portsmouth Regional Hospital (Portsmouth, NH). The Osher Collaborative for Integrative Healthcare includes 11 academic health centers where the relationship between the practitioner and the patient is valued, as whole-person care is provided. Osher Centers also focus on rigorous scientific research to evaluate the effectiveness of care while determining the underlying mechanisms of efficacy (Osher Collaborative, n.d.).

Criticisms of CIM

Complementary medicine approaches are often critiqued for being pre-scientific, and for their popularity despite their lack of scientific basis. (Jarry, 2020). This lack of scientific basis for some approaches may have CIM construed as placebo or belief based interventions that are costly and potentially harmful or wasteful. Studies of complementary approaches are often with small populations and may be poorly designed; there is often a lack of consistency across any given approach or intervention which makes many CIMs hard to study with conventional scientific approaches. Individuals may suffer financial harm or bodily harm if complementary care approaches are used instead of conventional approaches that are evidence based (Jarry, 2020) .

Complementary medicine has been critiqued for a lack of regulations or clinical standards (Gray et al., 2019). Until these are established, colleges and universities are challenged to include complementary modality education in healthcare practitioner educational settings, having a clear global research agenda evaluating procedures, outcomes, and effectiveness of complementary medicine is needed (Gray et al., 2019).

Despite the critiques, CIM’s popularity means it is here to stay (Gray et al, 2019). Many experience a sense of well-being from including CIM in their treatment regime, and healthcare practitioners should have a baseline knowledge of CIM approaches in order to support individuals with their choices in treatment selection and healing approaches. Providers’ knowledge of the pros, cons, and safety concerns with any given complementary approach can help to ensure that patients are guided toward successful use of CIM.

Conclusion

It is likely that we will continue to see this realm of study and trends of growth in CIM offerings over time. We remain ethically obligated to practice beneficence (do only good) and non-maleficence (do no harm) as we support patient’s autonomy or right to make informed healthcare decisions. There may be the need to more highly regulate CIM, particularly if healthcare insurance providers become more involved with reimbursement and payment for CIM (Lindquist et al., 2023).

Due to the many side and adverse effects of traditional approaches, an aging population that relies heavily on polypharmacy, and the chronicity of care for people with heart disease, cancer, pain, and mental health issues, the desire for CIM and incorporating different modalities that support patient-centered and whole-person care approaches will continue to grow (Seetharaman, 2021). Healthcare providers and academic settings must commit to continuing to research the effectiveness of these modalities while also committing to including findings in academic offerings, so that providers can support patients in making informed decisions.

References

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Duquesne University. (February 24, 2024). Complementary and alternative medicine. Gumberg Library. https://guides.library.duq.edu/complementary_medicine/home

Esteves, J. E., Cerritelli, F., Kim, J., & Friston, K. J. (2022). Osteopathic care as (en)active inference: A theoretical framework for developing aniIntegrative hypothesis in osteopathy. Frontiers in Psychology, 13, 812926. https://doi.org/10.3389/fpsyg.2022.812926

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https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know

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