Richard "Sal" Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor and Chairman, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Complementary and alternative medicine (CAM) covers a wide variety of healing philosophies, approaches, and therapies, including acupuncture, naturopathy, herbal medicine, homeopathy, massage therapy, and the use of physical energy to produce homeostatic alterations in the body. It has emerged as an important concept for the healthcare industry. Why? Because consumers of healthcare today are more interested in, and more educated about, options outside the traditional boundaries of healthcare. This month's continuing education article, "Wound Bed Preparation and Complementary Alternative Medicine," on page 226 addresses a variety of CAM options.
In the United States, approximately 38% of adults (about 4 in 10) and approximately 12% of children (about 1 in 9) are using some form of CAM. It is accepted that CAM is deeply rooted in the traditions in non-Western cultures and therefore may indeed be the norm in those cultures. Moreover, conventional medicine-allopathic/osteopathic medicine-may be thought of as alternative and complementary to what they perceive as normal practices.
The growing exploration of CAM led Congress in 1992 to mandate establishment of the Office of Alternative Medicine as part of the National Institutes of Health. In 1998, Congress further mandated establishment of the National Center for Complementary and Alternative Medicine (NCCAM). The purpose of the NCCAM is to facilitate evaluation of alternative therapies to determine their effectiveness. The NCCAM collaborates with other government agencies in this effort to include the Food and Drug Administration (FDA). The FDA regularly reevaluates rules and regulations governing research on devices, acupuncture needles, herbs, and homeopathic remedies. The NCCAM also serves as an information clearinghouse for the public, media, and healthcare professionals; facilitates and conducts research; and provides funding opportunities in response to requests for proposals from the field. For example, NCCAM corresponds with alternative medicine organizations to keep them aware of opportunities for research support and development.
CAM is nothing new to wound care practitioners. The history of wound care is replete with examples of alternative practices. Numerous case reports in the literature, for example, describe wound treatment with various substances such as honey, sugar, iodine, and meat tenderizer. Reports on maggot therapy continue to appear in the literature, yet this therapy has failed to maintain a position as widely "clinically accepted" in this country, mainly because of aesthetics.
Seaweed, Aloe vera, and other plant products have become standard ingredients impregnated into various wound dressings, which are approved for use by the FDA. Paradoxically, FDA approval is not required when these substances are sold over-the-counter, as they are not considered to be pharmaceuticals. In addition, FDA-approved medications-including aluminum/magnesium antacid and phenytoin-have been used off-label by practitioners to manage wounds.
In recent times, electrical stimulation and magnetic therapies have emerged as accepted modalities in the treatment of chronic wounds; acupuncture and electroacupuncture havealso gained a following. Massage therapy has been advocated as a treatment strategy for a number of chronic conditions, and there is research to back up some of the claims. However, according to the clinical practice guidelines on pressure ulcers published by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), massage is not recommended in the treatment of pressure ulcers. Interestingly, the evidence to support this "nonrecommendation" is lacking.
The number of unproven CAM strategies and options for wound healing provides us with a tremendous opportunity to reexamine old treatments and apply them in the current environment. We are faced with consumers (our patients) who are demanding more information, more options, and more ability to participate in treatment decisions. It is important for us to remember that the concept of evidenced-based medicine does not apply only to mainstream wound management. We owe it to our patients to apply the same scientific rigor to CAM to ensure that these practices are safe and efficacious.
For more information on the NCCAM and complementary and alternative therapies, visit http://nccam.nih.gov.
Richard "Sal" Salcido, MD