What Constitutes CIM

CIM encompasses a broad array of preventive, therapeutic, and palliative modalities, and the list of what constitutes CIM is ever-evolving. According to the National Center for Complementary and Alternative Medicine (NCCAM), complementary medicines are used concurrently with traditional medical and surgical interventions. They may be used for alleviation of symptoms, reduction of disability, improvement of overall quality of life, or promoting general wellness during treatment. Alternative therapies are used in lieu of traditional Western medicines. The practice of integrative medicine, on the other hand, involves combining allopathic medicine with complementary therapies for which there is scientific evidence of safety and efficacy. In response to the increased awareness of integrative medicine and its relevance to modern medical practice, the term “complementary and integrative medicine,” or CIM, has been used interchangeably with complementary and alternative medicine (CAM) in recent years. Although the distinction between these two is subtle, its importance should not be minimized. Although “CAM” continues to be the predominant abbreviation used throughout the medical literature, this review seeks to highlight the integrative nature of the therapies, and hence CIM is used throughout ( Table 1 gives a full list of CIM abbreviations).

CIM Usage

Although CIM is not typically taught in US and European medical schools, it has made significant gains in popularity among patients and practitioners in recent years. Indeed, approximately 38% of the general US population admitted to CIM use in a 2007 survey of more than 23,000 adults conducted by the Centers for Disease Control. The prevalence of CIM use is up nearly 10% when compared with 1991 data. This translates to roughly $34 billion in out-of-pocket CIM purchases. When patients visiting general otolaryngology clinics are evaluated as a separate group, more than 60% have been found to be CIM users in some series. Pediatric otolaryngology patients may also use CIM frequently, as evidenced by a recent study by Shakeel and colleagues. They report that nearly 30% of patients presenting to a pediatric otolaryngology clinic have used CIM. Oncology patients may be particularly amenable to CIM use. In large series, prevalence of CIM use ranges from 17% to 91% among this population. When patients with head and neck cancer are considered as a separate group, CIM usage prevalence ranges from 6% to 92%.

In response to the growing interest in, use of, and acceptance of complementary and alternative therapies, the US Congress established the NCCAM in 1998. As one of 27 centers within the National Institutes of Health (NIH), NCCAM funds and supports CIM-related research, disseminates CIM-related information, and assists with the integration of proved CIM therapies into medical practice. With an annual operating budget of nearly $128 million, NCCAM’s stated mission is “To define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.” As such, NCCAM serves as the NIH’s liaison to the public and the medical profession with regard to complementary and alternative therapies. They are a repository for CIM-related grant money and a resource for numerous clinical trials.

This review introduces otolaryngologists to several commonly encountered CIM modalities. The goal is to classify and define these entities as well as to provide a historical, cultural, philosophic, and physiologic background for them. The in-depth discussion of individual treatments and their applicability to specific otolaryngologic problems are discussed elsewhere in this issue.

What Constitutes CIM

CIM encompasses a broad array of preventive, therapeutic, and palliative modalities, and the list of what constitutes CIM is ever-evolving. According to the National Center for Complementary and Alternative Medicine (NCCAM), complementary medicines are used concurrently with traditional medical and surgical interventions. They may be used for alleviation of symptoms, reduction of disability, improvement of overall quality of life, or promoting general wellness during treatment. Alternative therapies are used in lieu of traditional Western medicines. The practice of integrative medicine, on the other hand, involves combining allopathic medicine with complementary therapies for which there is scientific evidence of safety and efficacy. In response to the increased awareness of integrative medicine and its relevance to modern medical practice, the term “complementary and integrative medicine,” or CIM, has been used interchangeably with complementary and alternative medicine (CAM) in recent years. Although the distinction between these two is subtle, its importance should not be minimized. Although “CAM” continues to be the predominant abbreviation used throughout the medical literature, this review seeks to highlight the integrative nature of the therapies, and hence CIM is used throughout ( Table 1 gives a full list of CIM abbreviations).

CIM Usage

Although CIM is not typically taught in US and European medical schools, it has made significant gains in popularity among patients and practitioners in recent years. Indeed, approximately 38% of the general US population admitted to CIM use in a 2007 survey of more than 23,000 adults conducted by the Centers for Disease Control. The prevalence of CIM use is up nearly 10% when compared with 1991 data. This translates to roughly $34 billion in out-of-pocket CIM purchases. When patients visiting general otolaryngology clinics are evaluated as a separate group, more than 60% have been found to be CIM users in some series. Pediatric otolaryngology patients may also use CIM frequently, as evidenced by a recent study by Shakeel and colleagues. They report that nearly 30% of patients presenting to a pediatric otolaryngology clinic have used CIM. Oncology patients may be particularly amenable to CIM use. In large series, prevalence of CIM use ranges from 17% to 91% among this population. When patients with head and neck cancer are considered as a separate group, CIM usage prevalence ranges from 6% to 92%.

In response to the growing interest in, use of, and acceptance of complementary and alternative therapies, the US Congress established the NCCAM in 1998. As one of 27 centers within the National Institutes of Health (NIH), NCCAM funds and supports CIM-related research, disseminates CIM-related information, and assists with the integration of proved CIM therapies into medical practice. With an annual operating budget of nearly $128 million, NCCAM’s stated mission is “To define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.” As such, NCCAM serves as the NIH’s liaison to the public and the medical profession with regard to complementary and alternative therapies. They are a repository for CIM-related grant money and a resource for numerous clinical trials.

This review introduces otolaryngologists to several commonly encountered CIM modalities. The goal is to classify and define these entities as well as to provide a historical, cultural, philosophic, and physiologic background for them. The in-depth discussion of individual treatments and their applicability to specific otolaryngologic problems are discussed elsewhere in this issue.

Traditional Chinese Medicine

TCM is an ancient practice and considers humans to be at the center of the universe and an essential link between the celestial and the earthly worlds. The world and the individual exist in a zero net gain state of homeostasis between yin and yang , or positive and negative energies. Disruptions in this equilibrium are thought to affect health and well-being. To restore harmony between yin and yang, the flow of 4 vital humors (blood, moisture, essence, and qi , or “life energy”) must be manipulated. Multiple different modalities are used by practitioners of TCM to balance yin and yang. Principal among these are meditation, acupuncture, and a large number of biologically based therapies. Despite the vast number of TCM modalities practiced for a myriad of diseases and conditions, there continues to be insufficient scientific evidence to support their widespread use, which is perhaps best evidenced by the work of Manheimer and colleagues in their 2008 query of the Cochrane database for systematic reviews of TCM. They found that most trials evaluating TCM modalities suffered from methodological flaws and heterogeneity, ultimately leading them to conclude that further rigorous investigation is warranted before definitive recommendations regarding TCM can be made.

Ayurveda

Ayurveda is perhaps the oldest medical system still in practice in the world today. It began in India several millennia ago and is still practiced by nearly 50% of India’s population. The name comes from the Sanskrit words ayur (life) and veda (knowledge). The principal tenets are that humans and their universe are interconnected and that all of material creation comprises 5 elements: space, air, fire, water, and earth. Each person possesses a unique proportion of these elements at birth—a ratio that is in turn the foundation for 3 governing life forces or doshas . It is the relationship between the 3 doshas that dictates each person’s biologic makeup and hence, their physical makeup, physiologic functioning, and psychological characteristics.

Each person has a predominant dosha, and the doshas must exist in their native state of balance for the maintenance of health. Exposure to anything that alters this delicate interplay manifests itself by disease. To restore balance, several different therapies are used. These have traditionally included biologically based modalities such as herbals and special diets. Purging treatments play a prominent role as well—with vomiting, nasal irrigation, enemas, and bloodletting used to “detoxify” in an attempt to restore balance. There is a strong mind-body component as well, with an emphasis on visualization techniques, oil massage, and yoga.

Homeopathy

Homeopathy was founded in the late 1700s by Samuel Hahnemann. It holds as its most basic tenet the notion that “Like cures like.” Homeopaths contend that the body may be stimulated to heal itself by being exposed to small doses of substances that would in larger doses cause symptoms akin to their disease. Homeopathic remedies are generated by performing serial dilutions while agitating the mixture to extract the “vital essences” of the offending substance. The most common denotation of a homeopathic preparation is __×, which refers to the number of 1:10 dilutions performed. A 6× would be a concentration of 1:10 ⁶ or 1 part per million (ppm). So miniscule is the dose delivered in most homeopathic remedies that they are exempt from much of the US Food and Drug Administration (FDA) oversight that is characteristic of other medications. However, the FDA does regulate that package inserts for homeopathic medicines include an ingredients list, instructions for safe use, at least one major indication, and the dilution. At present, 3 states offer licensure to practice homeopathy. Only one (Nevada) requires formal training before license application.

Despite the apparent lack of a measurable pharmacologic effect, a limited amount of evidence does support the efficacy of homeopathy in certain conditions treated by otolaryngologists. For instance, a systematic review suggests that it is effective in the treatment of chemotherapy-induced stomatitis, radiodermatitis, and general adverse events from radiotherapy. In a randomized double-blinded trial comparing the homeopathic remedy VertigoHeel, there was an observed reduction in the frequency, duration, and intensity of vertigo attacks that was equivalent to standard therapy with betahistadine. It has been argued that the placebo effect may be entirely responsible for the observed effects of homeopathy. However, other factors such as patient expectations and openness to the mind-body connection and practitioner empathy may also play a role in the observed benefits of these remedies.

Naturopathy

Naturopathy is a medical system that originated in the Western world. As a consequence, its practitioners do concern themselves with the pathophysiologic nature of disease and scientific method. However, at its core, naturopathy shares many of the philosophies and traditions of Eastern practices such as Ayurveda and TCM. Naturopathy emphasizes prevention and self-care to restore a “healthy internal environment.” Naturopathic practitioners believe that this in turn promotes the body’s innate self-healing mechanisms. Most treatment strategies rely on natural healing methods. Today, these consist primarily of herbal remedies, supplements, and special diets. Naturopathy is unique among the alternative medical systems in that the education and professional licensure criteria are stringent. A total of 17 states and 2 US territories now offer professional licenses to naturopathic physicians. There are numerous postbaccalaureate programs offering Naturopathic Doctor (ND) degrees. These programs are accredited by the US Department of Education and feature training in naturopathy as well as basic and clinical sciences traditionally taught in allopathic medical curricula.