Chiropractic: origins, controversies, and contributions.

Chiropractic is an important component of the US health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic's position in society is contradictory, and we reveal a complex dynamic of conflict and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Externally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic's most important contribution may have to do with the patient-physician relationship.

Patterns of use, expenditures, and perceived efficacy of complementary and alternative therapies in HIV-infected patients.

BACKGROUND: Complementary and alternative medicine (CAM) use is common in the general population, accounting for substantial expenditures. Among patients with human immunodeficiency virus (HIV) infection, few data are available on the prevalence, costs, and patterns of alternative therapy use. METHODS: We carried out detailed telephone surveys and medical chart reviews for 289 active patients with HIV in a general medicine practice at a university-based teaching hospital in Boston, Mass. Data were collected on prevalence and patterns of CAM use, out-of-pocket expenditures, associated outcomes, and correlates of CAM use. RESULTS: Of 180 patients who agreed to be interviewed, 122 (67.8%) used herbs, vitamins, or dietary supplements, 81 (45.0%) visited a CAM provider, and 43 (23.9%) reported using marijuana for medicinal purposes in the previous year. Patients who saw CAM providers made a median of 12 visits per year to these providers compared with 7 visits per year to their primary care physician and nurse practitioner. Mean yearly out-of-pocket expenditures for CAM users totaled $938 for all therapies. For the main reason CAM was used, respondents found therapies "extremely" or "quite a bit" helpful in 81 (81.0%) of 100 reports of supplement use, in 76 (65.5%) of 116 reports of CAM provider use, and in 27 (87%) of 31 reports of marijuana use. In multivariable models, college education (odds ratio [OR]=3.7, 95% confidence interval [CI]=1.9-7.1) and fatigue (OR=2.7, 95% CI=1.4-5.2) were associated with CAM provider use; memory loss (OR=2.3, 95% CI=1.1-4.8) and fatigue (OR=0.4, 95% CI=0.2-0.9) were associated with supplement use; and weight loss (OR=2.6, 95% CI=1.2-5.6) was associated with marijuana use. CONCLUSIONS: Patients with HIV infection use CAM, including marijuana, at a high rate; make frequent visits to CAM providers; incur substantial expenditures; and report considerable improvement with these treatments. Clinical trials of frequently used CAMs are needed to inform physicians and patients about therapies that may have measurable benefit or measurable risk.

The use of complementary and alternative therapies to treat anxiety and depression in the United States.

OBJECTIVE: This study presents data on the use of complementary and alternative therapies to treat anxiety and depression in the United States. METHOD: The data came from a nationally representative survey of 2,055 respondents (1997-1998) that obtained information on the use of 24 complementary and alternative therapies for the treatment of specific chronic conditions. RESULTS: A total of 9.4% of the respondents reported suffering from "anxiety attacks" in the past 12 months; 7.2% reported "severe depression." A total of 56.7% of those with anxiety attacks and 53.6% of those with severe depression reported using complementary and alternative therapies to treat these conditions during the past 12 months. Only 20.0% of those with anxiety attacks and 19.3% of those with severe depression visited a complementary or alternative therapist. A total of 65.9% of the respondents seen by a conventional provider for anxiety attacks and 66.7% of those seen by a conventional provider for severe depression also used complementary and alternative therapies to treat these conditions. The perceived helpfulness of these therapies in treating anxiety and depression was similar to that of conventional therapies. CONCLUSIONS: Complementary and alternative therapies are used more than conventional therapies by people with self-defined anxiety attacks and severe depression. Most patients visiting conventional mental health providers for these problems also use complementary and alternative therapies. Use of these therapies will likely increase as insurance coverage expands. Asking patients about their use could prevent adverse effects and maximize the usefulness of therapies subsequently proven to be effective.

Alternative medicine use in older Americans.

OBJECTIVES: Because there are few data describing alternative medicine use in older populations, we analyzed a nationally representative survey to quantify and characterize the use of alternative medicine in people aged 65 and older. DESIGN: We utilized data collected in a nationally representative, random, telephone survey of adults, measuring use of conventional medical services and use of 20 alternative medicine therapies in the last 12 months. PARTICIPANTS: A total of 2,055 adults, 311 of whom were aged 65 and older and who constituted our sample of older Americans. RESULTS: Overall, 30% of people aged 65 and older used at least one alternative medicine modality in the last year compared with 46% of those less than age 65 (P < .001), and 19% of older people saw a provider of alternative medicine within the past year compared with 26% of those less than age 65. The alternative medicine modalities used most commonly by those aged 65 and older were chiropractic (11%), herbal remedies (8%), relaxation techniques (5%), high dose or mega-vitamins (5%), and religious or spiritual healing by others (4%). Older persons with a primary care provider used alternative medicine more frequently (34% vs 7% P < .05) than those with no primary care provider. Patients who saw their physician more frequently were more likely to use alternative medicine (0 visits 7%, 1-2 visits 22%, 3-6 visits 35%, 7 or more visits 44% P < .05). Six percent of older patients were taking both herbs and prescription drugs. Of older patients who used alternative medicine, 57% made no mention of their use of any alternative modality to their doctor. CONCLUSIONS: Thirty percent of Americans aged 65 and older reported using alternative medicine (amounting to 10 million Americans based on extrapolations to census data) and 19% visited an alternative medicine provider (making 63 million visits based on extrapolations to census data) within the past year. The two modalities used most commonly were chiropractic and herbs, both of which may be problematic in older patients. Physicians should ask all patients, including those aged 65 and older, about their use of alternative medicine, and in those aged 65 and older, physicians should ask specific questions about the user of chiropractic and herbal medicine.

Talking with patients about alternative and complementary medicine.

The growing use of alternative and complementary therapies in the United States as well as other parts of the world is a trend that the responsible rheumatologist cannot ignore. With chronic musculoskeletal conditions being the leading indication for the use of alternative and complementary therapies, rheumatologists must become experts on talking to patients and advising them about the use or avoidance of such therapies. Currently, there is a growing body of literature on the safety and efficacy of the multiple alternative and complementary therapies available. Much of this information is reliable and of high methologic quality; however, much of it is not. With an increase in the budget of the Office of Alternative Medicine from $20 to $50 million in 1999 and the status of the office changing to an independent center, an important step has been taken to try to assure improved research in the near future to validate or disprove many of the current alternative and complementary therapies. In the meantime, our patients are using these therapies and are likely to continue to do so, with or without our guidance. We must get beyond the "don't ask, don't tell" approach that characterizes many physicians' attitudes toward the subject of alternative and complementary therapies. Although all discussions need not end in agreement, they are still opportunities for shared decision making and "relationship-centered care." Ultimately, we should not be concerned with practicing what is perceived to be traditional versus alternative and complementary medicine or biomedicine versus naturalistic medicine but only with what is truly "good" medicine.

Brief communication: detecting depression: providing high quality primary care for HIV-infected patients.

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment.

Physician-patient communication about complementary and alternative medical therapies: a survey of physicians caring for patients with human immunodeficiency virus infection.

OBJECTIVE: To examine frequency and correlates of physicians' reports of discussions with patients with human immunodeficiency virus (HIV) about complementary and alternative medical (CAM) therapies. DESIGN: Mailed physician survey. SETTING: The setting was Eastern Massachusetts. PARTICIPANTS: Participants included 89 physicians caring for patients with HIV. MEASUREMENTS AND MAIN RESULTS: Physicians were asked how common the use of CAM therapies was among their patients, how useful these therapies were, how often they discussed the use of CAM therapies with new and follow-up patients, and whether they had used a CAM therapy themselves in the last year. We also collected information on physicians' sociodemographic and practice characteristics. Sixty-eight percent (89/130) of physicians responded, and 26% and 5% reported discussing CAM therapies with HIV-infected patients at most new and follow-up visits, respectively. Respondents' attitudes toward the use of CAM therapies were generally positive, and they believed their HIV-infected patients used CAM therapies more than their non-HIV infected patients. The majority (63%) believed that CAM therapies may be helpful for HIV-infected patients. Thirty-six percent (36%) had used a CAM therapy themselves in the last year. In multivariate analyses, only the belief that CAM therapies are helpful was correlated with discussion of CAM therapies (p = 0.006). Respondents' demographic characteristics, training, personal use of CAM therapies, reported visit length, and satisfaction with visit length were not associated with discussion of CAM therapies. CONCLUSIONS: Despite awareness that their HIV-infected patients commonly use CAM therapies and positive attitudes towards such therapies, most of these physicians did not routinely discuss CAM therapies with them. Barriers to physician-patient communication about CAM therapies merit further investigation.

Inability of an "energy transfer diagnostician" to distinguish between fertile and infertile women.

CONTEXT: Various forms of "energy healing" have become popular in the United States. OBJECTIVE: To test the assertion that an energy healer can, without physical contact, distinguish the presence or absence of internal organ pathology in individuals who lack overt physical findings. DESIGN: Observational randomized study, in which we tested the assertion by a well-recognized alternative healer that he had particular skill in using energy transfer to detect the presence or absence of fertility disorders in women. PATIENTS: Convenience sample of 37 women, 28 of whom had documented pathology resulting in infertility, and 9 of whom were fertile. OUTCOMES: The healer was provided with no medical history and performed diagnostic evaluations without physical contact with the blindfolded, clothed, and silent subjects. We compared to random chance the ability of the healer to establish a diagnosis of fertility or fertility disorder. SETTING: Teaching hospital. MAIN RESULTS: The healer was unable to distinguish the presence or absence of fertility disorders in the study subjects. CONCLUSION: This study points to further need for fair yet rigorous assessment of claims that energy transfer can lead to accurate clinical diagnoses.

Advising patients who seek alternative medical therapies.

Alternative medical therapies, such as chiropractic, acupuncture, homeopathy, and herbal remedies, are in great public demand. Some managed care organizations now offer these therapies as an "expanded benefit." Because the safety and efficacy of these practices remain largely unknown, advising patients who use or seek alternative treatments presents a professional challenge. A step-by-step strategy is proposed whereby conventionally trained medical providers and their patients can proactively discuss the use or avoidance of alternative therapies. This strategy involves a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and follow-up visits to monitor for potentially harmful situations. In the absence of professional medical and legal guidelines, the proposed management plan emphasizes patient safety, the need for documentation in the patient record, and the importance of shared decision making.

Varieties of healing. 1: medical pluralism in the United States.

Medicine has become interested in unconventional healing practices, ostensibly because of recent demographic research that reveals a thriving medical market of multiple options. This essay presents a historical overview of medical pluralism in the United States. Consistent evidence is examined suggesting that unconventional medicine has been a persistent presence in U.S. health care. Despite parallels with the past, the recent widespread interest in alternative medicine also represents a dramatic reconfiguration of medical pluralism-from historical antagonism to what might arguably be described as a topical acknowledgment of postmodern medical diversity. This recent shift may have less to do with acknowledging "new" survey data than with representing shifts in medicine's institutional authority in a consumer-driven health care environment. This essay is an introduction to a discussion of a taxonomy of contemporary U.S. medical pluralism, which also appears in this issue.

Varieties of healing. 2: a taxonomy of unconventional healing practices.

The first of two essays in this issue demonstrated that the United States has had a rich history of medical pluralism. This essay seeks to present an overview of contemporary unconventional medical practices in the United States. No clear definition of "alternative medicine" is offered because it is a residual category composed of heterogeneous healing methods. A descriptive taxonomy of contemporary unconventional healing could be more helpful. Two broad categories of unconventional medicine are described here: a more prominent, "mainstream" complementary and alternative medicine (CAM) and a more culture-bound, "parochial" unconventional medicine. The CAM component can be divided into professional groups, layperson-initiated popular health reform movements, New Age healing, alternative psychological therapies, and non-normative scientific enterprises. The parochial category can be divided into ethno-medicine, religious healing, and folk medicine. A topologic examination of U.S. health care can provide an important conceptual framework through which health care providers can understand the current situation in U.S. medical pluralism.

The persuasive appeal of alternative medicine.

Alternative medicine has a major presence and persuasive attraction in the industrialized western world. The extent to which these practices have clinical efficacy according to biomedical criteria is a matter of ongoing research and debate. It may be that independent of any such efficacy, the attraction of alternative medicine is related to the power of its underlying shared beliefs and cultural assumptions. The fundamental premises are an advocacy of nature, vitalism, "science," and spirituality. These themes offer patients a participatory experience of empowerment, authenticity, and enlarged self-identity when illness threatens their sense of intactness and connection to the world. A discussion of these themes may enable conventionally trained clinicians to better understand their patients' attraction to and acceptance of alternative medical therapies.

Courses involving complementary and alternative medicine at US medical schools.

CONTEXT: With the public's increasing use of complementary and alternative medicine, medical schools must consider the challenge of educating physicians about these therapies. OBJECTIVES: To document the prevalence, scope, and diversity of medical school education in complementary and alternative therapy topics and to obtain information about the organizational and academic features of these courses. DESIGN: Mail survey and follow-up letter and telephone survey conducted in 1997-1998. PARTICIPANTS: Academic or curriculum deans and faculty at each of the 125 US medical schools. MAIN OUTCOME MEASURES: Courses taught at US medical schools and administrative and educational characteristics of these courses. RESULTS: Replies were received from 117 (94%) of the 125 US medical schools. Of schools that replied, 75 (64%) reported offering elective courses in complementary or alternative medicine or including these topics in required courses. Of the 123 courses reported, 84 (68%) were stand-alone electives, 38 (31%) were part of required courses, and one (1%) was part of an elective. Thirty-eight courses (31%) were offered by departments of family practice and 14 (11%) by departments of medicine or internal medicine. Educational formats included lectures, practitioner lecture and/or demonstration, and patient presentations. Common topics included chiropractic, acupuncture, homeopathy, herbal therapies, and mind-body techniques. CONCLUSIONS: There is tremendous heterogeneity and diversity in content, format, and requirements among courses in complementary and alternative medicine at US medical schools.

Inability to demonstrate physiologic correlates of subjective improvement among patients taught the relaxation response.

OBJECTIVE: To assess whether the regular elicitation of the relaxation response produces sustained physiologic changes coincident with symptomatic relief or improved psychological state. DESIGN: Prospective, cohort pilot study. SETTING: Clinical research center within a teaching hospital. PATIENTS: Thirteen athletic men, mean age 44.8 years, with borderline or labile hypertension, taking no medication. All 13 completed the study. INTERVENTIONS: Three baseline assessments of psychological state, symptom checklist, and assessment of autonomic response to infusion of beta agonist (isoproterenol). Daily relaxation response exercises for five consecutive weeks followed by repeat assessment of all parameters. Discontinuation of relaxation exercises for subsequent five weeks followed by repeat assessment of all parameters. MEASUREMENTS AND MAIN RESULTS: After eliciting the relaxation response, subjects demonstrated significant decreases in anxiety (p less than 0.014) and somatic symptoms (p less than 0.02). Psychological and somatic variables returned toward baseline after the subsequent discontinuation of relaxation exercises. No significant concomitant change in urinary catecholamines, heart rate response to isoproterenol, blood pressure, pulse rate, or serum cholesterol was demonstrated. CONCLUSION: The regular elicitation of the relaxation response can improve psychological performance and reduce symptoms. However, the physiologic mechanism whereby these psychological and symptomatic improvements occur remains poorly understood and warrants further investigation.

Alternative health care: its use by individuals with physical disabilities.

OBJECTIVE: This research investigated the use of alternative therapies by individuals with physical disabilities. DESIGN: A telephone survey of a cross-sectional convenience sample of people with disabilities. SETTING: An urban, outpatient rehabilitation facility specializing in vocational services. PARTICIPANTS: A convenience sample of 401 working-age individuals. MAIN OUTCOME MEASURE(S): Self-reported use of alternative therapy. RESULTS: More of this sample of individuals with physical disabilities than a randomized, national sample of the general population used alternative therapies (57.1% vs 34%) and saw providers of those therapies (22% vs 10%). Among individuals in the current sample, significant positive relationships between use of alternative therapies and education and income levels were discovered. The use of alternative therapies by this sample, however, was not associated with racial identity, gender, or age. Compared with the general population, this study's respondents reported a higher proportion of chronic pain (14% vs 8%) and depression (14% vs 8%), and a lower proportion of severe headache (9.2% vs 13%). Alternative therapies were chosen more often than conventional therapies by those with physical disabilities for pain (51.8% vs 33.9%), depression (33.9% vs 25%), anxiety (42.1% vs 13.1%), insomnia (32.3% vs 16.1%), and headaches (51.4% vs 18.9%). CONCLUSION: Physically disabled individuals are more likely to use alternative therapies than the general population and to see providers for them, have their use recommended by their physicians, and be reimbursed by their health insurance for them. A high prevalence of dysphoria is found among those with disabilities, for which a combination of alternative and conventional therapies is often used.

Delays in protease inhibitor use in clinical practice.

OBJECTIVE: To determine the clinical factors associated with delayed protease inhibitor initiation. DESIGN: Chart review and telephone survey. SETTING: General medicine practice at an academic medical center in Boston, Mass. PATIENTS: One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml. MEASUREMENTS AND MAIN RESULTS: The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56). CONCLUSIONS: HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.

Medical malpractice implications of alternative medicine.

Although use of alternative therapies in the United States is widespread and growing, little is known about the malpractice experience of practitioners who deliver these therapies or about the legal principles that govern the relationship between conventional and alternative medicine. Using data from malpractice insurers, we analyzed the claims experience of chiropractors, massage therapists, and acupuncturists for 1990 through 1996. We found that claims against these practitioners occurred less frequently and typically involved injury that was less severe than claims against physicians during the same period. Physicians who may be concerned about their own exposure to liability for referral of patients for alternative treatments can draw some comfort from these findings. However, liability for referral is possible in certain situations and should be taken seriously. Therefore, we review relevant legal principles and case law to understand how malpractice law is likely to develop in this area. We conclude by suggesting some questions for physicians to ask themselves before referring their patients to alternative medicine practitioners.

Unconventional medicine in the United States. Prevalence, costs, and patterns of use.

BACKGROUND: Many people use unconventional therapies for health problems, but the extent of this use and the costs are not known. We conducted a national survey to determine the prevalence, costs, and patterns of use of unconventional therapies, such as acupuncture and chiropractic. METHODS: We limited the therapies studied to 16 commonly used interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. We completed telephone interviews with 1539 adults (response rate, 67 percent) in a national sample of adults 18 years of age or older in 1990. We asked respondents to report any serious or bothersome medical conditions and details of their use of conventional medical services; we then inquired about their use of unconventional therapy. RESULTS: One in three respondents (34 percent) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The latter group had made an average of 19 visits to such providers during the preceding year, with an average charge per visit of $27.60. The frequency of use of unconventional therapy varied somewhat among socio-demographic groups, with the highest use reported by nonblack persons from 25 to 49 years of age who had relatively more education and higher incomes. The majority used unconventional therapy for chronic, as opposed to life-threatening, medical conditions. Among those who used unconventional therapy for serious medical conditions, the vast majority (83 percent) also sought treatment for the same condition from a medical doctor; however, 72 percent of the respondents who used unconventional therapy did not inform their medical doctor that they had done so. Extrapolation to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of unconventional therapy. This number exceeds the number of visits to all U.S. primary care physicians (388 million). Expenditures associated with use of unconventional therapy in 1990 amounted to approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. This figure is comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States. CONCLUSIONS: The frequency of use of unconventional therapy in the United States is far higher than previously reported. Medical doctors should ask about their patients' use of unconventional therapy whenever they obtain a medical history.