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Integrative Medicine as an Adjunct to Orthopaedic Surgery

Ficke, James, R., MD; Moroski, Nathan, M., MD; Ross, Steven, D., MD; Gupta, Ranjan, MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: January 15, 2018 - Volume 26 - Issue 2 - p 58–65
doi: 10.5435/JAAOS-D-16-00134
Review Article

Patients often seek nontraditional forms of treatment, including alternative/complementary medical options, such as chiropractic care and acupuncture, to meet their personal needs. In the United States, interest has grown in methods to reduce pain and improve function through Ayurvedic medicine, which uses plant-based supplements, such as turmeric. Traditional allopathic medicine attempts to provide patients with evidence-based therapeutic regimens for their musculoskeletal conditions. Integrative medicine often is used to prevent and manage the sequelae associated with injuries and illnesses; however, competitive athletes and military personnel use complementary medicine for performance enhancement. Thus, physicians should be aware of the evolving field of integrative medicine, including the reported benefits as well as any potential drawbacks, to facilitate an educated discussion with their patients.

From the Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD (Dr. Ficke), and the Department of Orthopaedic Surgery, University of California, Irvine, CA (Dr. Moroski, Dr. Ross, and Dr. Gupta).

Dr. Ficke or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association, and the Southern Orthopaedic Association. Dr. Ross or an immediate family member serves as a board member, owner, officer, or committee member of the California Orthopaedic Association. Dr. Gupta or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Society for Surgery of the Hand, and the Orthopaedic Research Society. Neither Dr. Moroski nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Received February 16, 2016

Accepted July 17, 2016

Integrative medicine, previously known as complementary and alternative medicine (CAM), has become increasingly popular in the United States since the early 1990s. Integrative medicine is defined by the National Center for Complementary and Integrative Health (NCCIH) as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.”1 In 2012, CAM was used by approximately one third of the US population (approximately 33.2%; Table 1).2 Here, we identify the forms of integrative medicine used most frequently by patients with musculoskeletal conditions and we address potential interactions and evaluate the supporting literature to provide the orthopaedic surgeon with a base of understanding of this growing trend in medicine that can affect treatment methods.

Table 1

Table 1

The most frequent users of integrative medicine are people in the 45- to 64-year-old age group (36.8% of users).2 By ethnic group, non-Hispanic white adults are the most frequent users of integrative medicine (37.9%); the least frequent users are nonHispanic black adults (19.3%). By education level, the highest prevalence of users of some form of integrative medicine was among the most well educated, with 42.6% achieving college-level education or higher, and the lowest prevalence was among those without a high school diploma (15.6%). The use of integrative medicine by income level showed that nonpoor adults were the most frequent users compared with poor adults, who were the least frequent users (38.4% and 20.6%, respectively). In terms of insurance status, the most frequent users were those with private insurance and the least frequent users were the uninsured (38% and 22.9%, respectively).2

Integrative medicine use among patients with musculoskeletal conditions has been reported to be as high as 70%.2 One study reported that 64% of patients underreported their use of integrative medicine.3 In another study of patients visiting an outpatient osteoporosis clinic, only 44% of actual current integrative medicine use was disclosed to a medical doctor.4 Reasons cited for not reporting integrative medicine include patients’ belief that reporting its use is not important, patients’ perception of prejudice by physicians, lack of direct questioning regarding integrative medicine use, and physician ignorance of herbal medications and other forms of integrative medicine.3 , 4 In some instances, physicians choose not to record the use of integrative medicine even when it is reported by the patient.3 , 4

Although the general public often uses integrative medicine to prevent and treat sequelae from injury and illness, some populations, such as competitive athletes and military personnel, use integrative medicine for performance enhancement. Determining the exact extent of use among competitive athletes is difficult, but some literature indicates that athletes may have the highest prevalence of integrative medicine use.5 Integrative medicine may be used by athletes because it is perceived as more natural and is erroneously assumed to not be considered as potential doping. The true prevalence of doping in competitive athletics is unknown; however, previous questionnaire-based research has yielded estimates between 1% and 70%.6 Controlled tests yielded approximately 1% to 2% positive results for doping. A recent review using the Randomized Response Technique estimated that 14% to 39% of current elite athletes “intentionally used doping.”6 Among collegiate athletes, the use of integrative medicine appears to be especially high. A survey of 309 Division I intercollegiate student athletes showed that 56% of subjects used some form of CAM.7 The use of CAM among military personnel also appears to be higher than use among the general US population.

The high prevalence of integrative medicine use in military personnel is of particular interest because this segment of society is considered to be younger and nonpoor and typically has an education level beyond high school. The largest and most comprehensive survey of integrative medicine use to date included data from >16,000 subjects and showed that approximately 36% of active-duty personnel from all military branches reported using at least one form of integrative medicine, excluding self-prayer, in the previous 12 months.8 A large variety of integrative medicine methods have been used by active-duty personnel, including mind-body therapies, biologically based therapies, and manipulative or body-based therapy.

The definition of integrative medicine/CAM has two parts: complementary, which is the use of nonmainstream approaches together with conventional medicine, and alternative, which is the use of a nonmainstream approach in place of conventional medicine. Among the US population, it appears that most patients use the complementary form; in a survey of 1,035 persons that had a response rate of 69%, only 4.4% of patients relied primarily on alternative therapies.9 Research has consistently shown that CAM users have more education and are more active overall than nonusers are.9 Other predictors of CAM use include higher education, poorer health status, holistic orientation to health, having a transformational experience that changed a person’s worldview, commitment to environmentalism, commitment to feminism, and an interest in spirituality and personal growth psychology. Dissatisfaction with conventional medicine was not a predictor of CAM use.9

Substantial controversy exists regarding integrative medicine. In 1998, Fontanarosa and Lundberg10 stated that “there is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.” However, despite the controversy, more practitioners are using integrative medicine. In addition, more studies are closely examining the effectiveness of integrative medicine and its uses.

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In 2007, the US population spent an estimated $33.9 billion out-of-pocket on integrative medicine.11 An estimated $14.8 billion was spent in 2007 on natural products, such as fish oil, glucosamine, and Echinacea.11 This is approximately one third of the total out-of-pocket amount spent on prescription drugs that year.

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Regulation and Marketing

In 1994, the Dietary Supplement Health and Education Act (DSHEA) classified dietary supplements as food.12 This classification prevents the US FDA from regulating supplements strictly as drugs with respect to their efficacy, safety, or marketing claims. The passage of DSHEA also eliminated the requirement that the FDA review efficacy and safety data for these products, provided that no manufacturer claims were made by the product or manufacturers to diagnose, treat, cure, or prevent disease. The United Nations also supports what is referred to as the “highest attainable health,” concluding that it is a state’s responsibility to refrain from prohibiting or impeding traditional preventive care and healing practices unless on an exceptional basis.12

With regard to marketing regulations for supplements, a supplement’s label may not claim to treat a specific disease or condition. However, marketing statements that suggest an effect on the “structure or function of the body” are allowed. For example, Echinacea products can be promoted as supporting immune health (as a function) but not as preventing or curing colds.12

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Established Forms of Integrative Medicine

The National Center for Complementary and Integrative Health (NCCIH), which was originally known as the Office of Alternative Medicine, was first established in 1991. This is one of 27 institutes and centers that comprise the NIH. The role of the NCCIH is to fund research on integrative medicine as well as to support clinical trials of integrative medicine techniques. According to the NCCIH, integrative medicine can be broken down into two main categories: natural products and mind-and-body practices. Natural products include a variety of biologically based products including herbs, plants and botanic derivatives, and probiotics, as well as nonvitamins and nonminerals. Mind-and-body practices include a large, diverse group of procedures and techniques including yoga, manipulation (eg, chiropractic, massage, osteopathic), meditation, relaxation techniques, aroma therapy, and energy therapy (eg, Reiki, magnets, tai chi, qigong). These two groups define most complementary health approaches; however, approaches that do not fit well into the first two groups (eg, Ayurvedic medicine, traditional Chinese medicine, homeopathy, naturopathy) are part of a third group: “alternative medical systems”2 , 12 (Table 2).

Table 2

Table 2

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Natural Products

Sales of herbal dietary supplements increased by 7.9% in 2013.26 The top-selling herbal supplement in 2013 was horehound (Marrubium vulgare; Table 3). It is used for the treatment of asthma and nonproductive cough and is thought to possess hypoglycemic, vasorelaxant, antihypertensive, analgesic, anti-inflammatory, and antioxidant properties. Horehound has traditionally been used as an expectorant and continues to be found in cough lozenges and cold preparations. This supplement is currently used as flavoring in liqueurs and cough drops. In a double-blind clinical trial, M vulgare was given to patients with type 2 diabetes who were nonresponsive to conventional medicine.27 Subjects receiving M vulgare along with conventional medicine were found to have reduced blood glucose as well as reduced cholesterol and triglycerides. In an animal study, hypertensive rats were given either M vulgare or amlodipine.13 Both treatments resulted in a similar decrease in systolic blood pressure. A limited number of human clinical trials have examined the efficacy and safety of M vulgare. Potential side effects are thought to be hypoglycemia, hypotension, and arrhythmia.

Table 3

Table 3

Turmeric was another top-selling herbal dietary supplement in 2013.26 The principal curcuminoid of turmeric is curcumin (Curcuma longa). Turmeric spice is a member of the ginger family, is orange-yellow in color, and is often used in curry powder. It has long been used in alternative medicine as a treatment of inflammatory conditions and other ailments. Investigators at MD Anderson Cancer Center have studied this compound and its anticarcinogenic properties and have suggested that turmeric has an effect on melanoma, breast, lung, and pancreatic cancers.28 , 29 The anti-inflammatory and free radical–scavenging properties of curcumin have been well documented. Curcumin was first shown to exhibit antibacterial properties in 1949.28 , 30 Since then, this polyphenol has been shown to possess anti-inflammatory, hypoglycemic, antioxidant, wound-healing, and antimicrobial activities.30 Curcumin has been shown to have anti-inflammatory properties by its suppression activation of nuclear factor kappa-light-chain-enhancer of activated B cells, which is induced in various inflammatory stimuli. Belcaro et al14 reported on the use of curcumin to treat osteoarthritis (OA) in humans. Compared with control subjects, those receiving treatment showed a substantial decrease in Western Ontario and McMaster Universities Osteoarthritis Index score as well as a decrease in the levels of serum markers of inflammation (interleukin [IL]-1β, IL-6, and erythrocyte sedimentation rate).

Turmeric is safe for most adults. High doses or long-term use can cause indigestion, nausea, or diarrhea. In animal studies, turmeric has been shown to cause potential liver problems at high doses; however, this has not been shown in human trials.28 , 29 Patients with gallbladder disease should avoid using turmeric because it can worsen the condition.14

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Mind-and-Body Practices

Chiropractic treatment is defined by the World Federation of Chiropractic as “a health profession concerned with the diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the function of the nervous system and general health.”31 One survey reported that 5.4% of the US population used chiropractors in 2008.32 The researchers estimated that 19% of patients seeking care for low back pain used chiropractic treatment. In Australia, chiropractic ranks second behind medical practitioner for patients who seek care for low back pain.31 , 32 A literature review that examined the efficacy of chiropractic interventions on low back pain found slightly improved pain and disability in both the short and medium term for acute and subacute low back pain.15 However, no evidence supported or refuted that these interventions provided clinically meaningful differences for pain or disability in people with low back pain compared with other interventions. Only 2 of 12 studies reported adverse events; of these 2 studies with adverse events, 15.1% of patients reported minor or transient exacerbations of symptoms. No serious adverse effects were reported.15 To date, 26 deaths have been reported following chiropractic treatment;15 most of these are thought to occur as a result of a vascular accident due to vertebral artery dissection. A review of these cases concluded that the risks of chiropractic treatment outweigh its benefit.33

Osteopathic manipulation techniques are based on an ideology of the existence of a myofascial continuity, that is, a tissue layer that connects all parts of the body. Practitioners attempt to diagnose and manage somatic dysfunction by manipulation and thus address a variety of ailments. This technique is most commonly used for back pain but also is used for other musculoskeletal issues and other systemic diseases. Licciardone et al16 conducted a randomized controlled trial on the efficacy of osteopathic manipulative treatment compared with both sham manipulative treatment and no treatment. Patients who received osteopathic manipulation reported greater improvements in back pain, greater satisfaction with care, better physical functioning and mental health, and fewer cotreatments. Patients who received sham treatment also reported greater improvements in back pain and physical functioning and greater satisfaction than the no intervention group. The authors concluded that no substantial benefit existed with osteopathic manipulation versus sham manipulation. In a meta-analysis, Franke et al17 reviewed 15 studies on osteopathic manipulative treatment for nonspecific low back pain. This treatment has clinically relevant effects for reducing pain and improving functional status in patients with acute and chronic nonspecific low back pain and in pregnant and postpartum women ≥3 months after treatment. The authors of the study recommended larger, high-quality randomized controlled trials with robust comparison groups.

Cheng and Huang18 performed a meta-analysis of 15 randomized controlled trials that examined the efficacy of massage therapy on pain and dysfunction in patients with neck pain. Patients who received massage therapy had better immediate effects on pain and relief compared with inactive therapies. No evidence was found that massage therapy improves dysfunction. The authors concluded that additional high-quality randomized controlled trials are needed, especially studies that compare massage with other active therapies.

Vickers et al19 performed a meta-analysis of 29 randomized controlled trials that examined the efficacy of acupuncture for chronic pain. Acupuncture was found to be markedly superior to both sham and non–acupuncture-based treatment for back and neck pain, OA, and chronic headache. The authors concluded that acupuncture is effective for the treatment of chronic pain. Because of modest but important differences between sham and true acupuncture, the authors suggest that factors beyond the specific effects of needling are important to the results of treatment. In another meta-analysis, Collins et al34 found that acupuncture was effective when used as a second-line treatment modality for anterior knee pain.

A survey reported that 20.4 million Americans practice yoga, which indicates a 29% increase in 4 years.35 Yoga practitioners spend an estimated $10.3 billion per year on classes and products. Holtzman and Beggs20 conducted a meta-analysis of eight randomized controlled trials examining the effect of yoga on chronic low back pain and found it may be an efficacious adjunctive treatment of low back pain. The strongest and most consistent evidence was found for short-term benefits on functional disability. Additional high-quality randomized controlled trials that include active control groups are needed.

Relaxation techniques, such as deep breathing exercises, meditation, biofeedback, and guided imagery, are other forms of integrative medicine used to manage a large variety of disorders, including fibromyalgia, pain, rheumatoid arthritis, asthma, anxiety, and other systemic conditions. Posadzki and Ernst21 systematically reviewed nine randomized controlled trials examining the effect of guided imagery on musculoskeletal pain; the results of eight trials suggested that guided imagery results in a substantial reduction in pain.

Relaxation techniques are generally considered safe. However, anxiety, intrusive thoughts, or fear of losing control have been reported.21 Reports of worsening of symptoms, especially in patients with epilepsy or certain psychiatric conditions, are rare.21

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Integrative Medicine in the Military Health System

The use of integrative medicine in active military members and veterans has been studied for overall utilization and to determine which modalities are most common.8 , 36 Recent reports on the efficacy of integrative medicine have been published, but they relate less to musculoskeletal conditions than to behavioral health and wellness.8 , 37 A US Department of Defense Veterans Affairs taskforce identified pain management best practices and published the Pain Management Task Force Report: Final Report in 2010 and the validation in 2012.38 The Comprehensive Pain Management Campaign Plan called for the establishment of an interdisciplinary pain management center at each Army medical center.38 These pain management centers would be staffed with MD/DO physicians, psychologists, pharmacists, physical therapists, occupational therapists, chiropractors, licensed acupuncturists, massage therapists, and yoga therapists. One study analyzed use among Iraq and Afghanistan War veterans extracted from a database of >20,000 US servicemembers and noted patterns largely consistent with civilian use of integrative medicine: mostly women, nonpoor, and those who are white.39 The conditions treated in the study focused on back problems and chronic pain, and the modalities most commonly sought were chiropractic manipulations, acupuncture, and relaxation. Currently, the US Army has employed chiropractors and alternative medicine specialists qualified in acupuncture in several sites across the Military Health System. Data collection has begun on the comparative effectiveness of multimodal interdisciplinary pain management strategies used at these sites, but no published data are yet available. Given the large population and utilization patterns similar to civilian reports, these efforts present the possibility to critically assess outcomes for chronic pain conditions.

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Other Integrative Medicine Practices

Homeopathic treatment of low back pain was recently examined by Witt et al22 in prospective multicenter observational study of 129 patients. The authors of the study noted several reports of marked and sustained improvement of symptoms following homeopathic treatment. Quality of life improved based on the Medical Outcomes Study 36-Item Short Form questionnaire. The use of conventional treatment and health services decreased markedly. The number of patients using medication decreased by 50%. The authors concluded that homeopathy is an effective treatment for low back pain.

Tai chi is a Chinese martial art practiced both for its defense training and its health benefits. Peng23 recently reviewed the effectiveness of tai chi in treating chronic pain, including OA, fibromyalgia, rheumatoid arthritis, low back pain, and headache. Trials were mostly low quality. Tai chi was concluded to be an effective intervention in OA, low back pain, and fibromyalgia. The authors noted the considerable limitations that exist in the literature and the need for high-quality studies.

Qigong is a type of spiritual practice intended to align body, breath, and mind for health meditation; it has roots in Chinese medicine, philosophy, and martial arts. Qigong is practiced for recreation, exercise, relaxation, preventive medicine, alternative medicine, and training for martial arts. Sawynok and Lynch24 conducted a meta-analysis examining the effect of qigong in patients with fibromyalgia. Regular qigong practice produced improvements in pain, sleep, and physical and mental function that were maintained for 4 to 6 months compared with nonactive groups. However, little difference was shown between the actively treated and the control groups; the active control group had significant improvement over the inactive group. In another systematic review of randomized clinical trials, greater pain reductions were demonstrated in groups who practiced qigong compared with control groups.40 The authors concluded that the effectiveness of qigong is encouraging and further studies are warranted.

Ayurvedic medicine is one of the world’s oldest medicinal systems. It is a system of medicine that has its roots in traditional Hindu medicine. “Ayurveda” combines the Sanskrit words “ayur,” meaning life, and “veda,” meaning science or knowledge; it originated in India >3,000 years ago and remains one of the country’s traditional healthcare systems. Ayurveda promotes the use of herbal compounds, special diets, and other unique health practices for health and treatment of disease. Ayurvedic products have the potential to be toxic, and many substances used have not been studied for safety. Of 193 Ayurvedic products purchased over the internet and manufactured in either the United States or India, 21% contained levels of lead, mercury, or arsenic that exceeded standards for acceptable daily intake.41

Most clinical trials of Ayurvedic approaches have been small, have had problems with research design, or lacked appropriate control groups. However, in a randomized controlled trial comparing Boswellia serrata gum resin with placebo in patients with OA of the knee, patients in the treatment group had significant improvements in pain scores and physical function scores compared with those in the placebo group.25 In addition, Furst et al42 conducted a double-blind randomized controlled trial that compared Ayurvedic medicine with methotrexate for the treatment of rheumatoid arthritis. The Ayurvedic treatment included 40 herbal compounds. The results showed approximately equivalent outcomes in efficacy in the study group, justifying the need for future inquiry and study.

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The use of integrative medicine is widespread in the United States, with approximately one third of the population using some form of integrative medicine. Although much of integrative medicine remains unproved by robust double-blind randomized controlled trials, this does not discount the potential usefulness of integrative medicine for some patients, as well as the need for the clinician to be aware of what a particular patient is using and the potential interactions with various orthopaedic treatments. We have highlighted the vast array of CAM, its many uses, and the need for physicians and surgeons to inquire more diligently about the use of integrative medicine by patients. Integrative medicine may offer alternative treatment modalities for chronic issues that have been nonresponsive to other well-established treatments.

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Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 24, 25, 32, 33, and 41 are level I studies. References 13, 14, 16-20, 23, 27, 28, and 39 are level II studies. Reference 37 is a level III study. Reference 29 is level V expert opinion.

References printed in bold type are those published within the past 5 years.

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38. Buckenmaier CC III, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM: Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. Pain Med 2013;14(1):110–123.
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integrative medicine; turmeric; chiropractic; physical manipulation

© 2018 by American Academy of Orthopaedic Surgeons