1

2 Perspectives about
3
4 Complementary and
5
6 Alternative Medicine
7
8 in Rheumatology
9
10
11 Rosy Rajbhandary, MDa, Samir Bhangle, MDa, Sheetal Patel, MD
a
,
12 Deepali Sen, MDa, Adam Perlman, MD, MPHa,b,
13 Richard S. Panush, MD, MACPc,* Q3 Q2
14 Q5 Q4
15
16 KEYWORDS
17  Complementary medicine  Alternative medicine
18  Complementary and alternative medicine  Scope
19  Epidemiology  Demographics  Trends  Safety  Risks
20  Adverse effects  Appeal  Costs Q8
21
22
23 All who drink of this remedy are cured, except those who die. Thus, it is effective
24 for all but the incurable.
25 Galen
26 “I didn’t say it was good for you,” the king replied. “I said there was nothing like
it.”
27
Lewis Carroll. Through The Looking Glass
28
29 Perspectives about complementary and alternative medicine (CAM), and CAM thera-
30 pies, particularly for the rheumatic diseases have changed dramatically over the past
31 several decades.1–20
32 The usage, popularity, and costs of CAM have increased, and the terminology has
33 changed. CAM has become acceptable and perhaps even mainstream. All these
34 developments have occurred despite little documentation of efficacy for the treatment
35 of patients with rheumatic diseases. The authors review these aspects of CAM in this
36 article, mindful of the accompanying articles in this issue.
37
38 TERMINOLOGY AND DEFINITIONS
39
40 It wasn’t that long ago that “quackery” denoted what is today termed CAM. Other
41 terms included dubious, unconventional, unproven, questionable, nonstandard, and
42
43 a
Department of Primary Care, School of Health Related Professions, University of Medicine
44 and Dentistry of New Jersey, Newark, NJ, USA
b
Q6
Integrative Medicine, Saint Barnabas Medical Center, Livingston, NJ, USA
45 c
Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of
46 Southern California, 2011 Zonal Avenue, HMR 711, Los Angeles, CA 90032, USA Q7
47 * Corresponding author. Saint Barnabas Medical Center, Livingston, NJ 07039.
48 E-mail addresses: rspanush@sbhcs.com; panush@usc.edu

Rheum Dis Clin N Am - (2010) -–-

doi:10.1016/j.rdc.2010.11.008 rheumatic.theclinics.com
0889-857X/10/$ – see front matter Ó 2010 Elsevier Inc. All rights reserved.

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2 Rajbhandary et al

49 irregular therapies. Complementary and alternative have been generally used, but not
50 always rigorously or appropriately.14,16–18 Many today prefer to call this treatment inte-
51 grative medicine, to reflect the inclusion of evidence-based therapies, regardless of
52 their origin, in conventional practice.14,16–18 There is even taxonomy for CAM.21 The
53 authors have favored the terms mainstream and nonmainstream therapies because
54 there have certainly been routine practices that were not supported by evidence or
55 proven safe (ie, tonsillectomy and adenoidectomy, certain arthroscopic and back
56 operations, and even the recent popularity and use of nonsteroidal antiinflammatory
57 drugs [NSAIDs]) and others that are evidence-based but eschewed by given cultures
58 (ie, balneotherapy).14,16–18,22 However, for purposes of this discussion the authors
59 largely use the term CAM.
60
61
WHO USES CAM AND WHY
62
63 Most patients, particularly those with chronic diseases use CAM. Indeed, the popu-
64 larity of CAM therapies has led to their incorporation into the medical curriculum at
65 many schools23,24 and hospitals25 and to serious efforts to study them scientifically
66 (and the authors have elsewhere praised certain of those individuals18,19), to the estab-
67 lishment of a CAM center at the National Institutes of Health (despite opposition from
68 the scientific community), and an increasing aura of legitimacy.14,16–18
69 CAM therapies are widely used throughout the world across geographic, ethnic,
70 social, and economic boundaries. Table 1 illustrates this generally and for the patients
71 with rheumatic disease specifically.26–30
72 Box 1 summarizes the prevalence of use and the cost of CAM in the United
73 States.31–33 CAM users tend to be women, well educated, and economically
74 comfortable.34
75 CAM therapies are used for chronic as opposed to life-threatening medical
76 conditions,35 including cancer, AIDS, gastrointestinal problems, chronic renal failure,
77 depression, and eating disorders. In particular, CAM therapies are frequently used by
78 patients with rheumatologic conditions, such as arthritis, chronic back pain, and other
79 painful musculoskeletal disorders.36,37 There are now more patient visits to CAM prac-
80 titioners than to primary care physicians in the United States.38 As has long been
81 documented to be the case, most CAM users do not inform their medical doctors of
82 their use of alternative therapies. Almost 50% of users do so without any professional
83 supervision.27,39 Patients are likely to choose nonpractitioner-based CAM therapy
84 over practitioner-based CAM therapy.40
85 The use of CAM increases with the number of patients’ medical conditions and the
86 number of physician visits. Patients who reported poor health had substantially higher
87 rates of use of CAM therapies than those who perceived themselves to be in better
88
89
90 Table 1
91 Prevalence of CAM use
92 CAM Use
93
Patients With Rheumatic
94 Country General Population (%) Diseases (%)
95
United States 33–90 28–94
96
United Kingdom 46 60
97
Australia 52.2 40–52
98
99 Canada 15–32 47–91

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 Perspectives about CAM in Rheumatology 3
Q1

100 Box 1
101 Contemporary CAM trends in the United States Q14
102
103  About 38% of adults use CAM.
104  An expenditure of $34 billion per year is incurred on products and for practitioners.
105  There is an annual expenditure of $121.92 per person for CAM.
106
 CAM constitutes 1.5% of the total health care expenditure and 11.2% of the total out-of-
107 pocket expenditure on health care.
108
109
110
111 health (52% vs 33%).38 Studies of patients with specific rheumatologic conditions,
112 such as fibromyalgia, osteoarthritis, and systemic lupus erythematosus, demon-
113 strated that most CAM users were generally people with chronic disease, poorer func-
114 tional status, and higher levels of pain.40
115 Patients use CAM therapies because these therapies (1) are consonant with their
116 lifestyle and/or belief system, (2) produce a sense of a holistic approach to medical
117 care, (3) are perceived to be safer and more natural than prescription drugs, (4) help
118 them to achieve greater control over their illness and its management and reflecttheir
119 rejection of or dissatisfaction with conventional medical care (for many reasons
120 including perceived impersonal skills of practitioners, cost and toxicities of main-
121 stream therapies, and uncertainties about outcomes).14,16–18,41 Practitioners of CAM Q9
122 are often considered more available, more empathetic, more caring, as investing
123 more time with patients, and as conveying more confidence and optimism about
124 outcomes than regular physicians. Studies have shown that patients preferring CAM
125 tended to be more psychologically distressed and considered their health poorer
126 than that of others. Most patients use CAM to complement conventional care rather
127 than to substitute for it.14,16–18,42
128
129 TRENDS
130
The frequency of use of the different CAM modalities has changed over the past
131
several decades. The 1960s saw a growth in the use of diets, megavitamins and
132
self-help groups. The 1970s featured an increase in the use of biofeedback, energy
133
healing, folk remedies, herbal medicine, homeopathy, hypnosis, and spiritual healing
134
and imagery. In the 1980s, massage and naturopathy became popular and interest in
135
yoga decreased. Aromatherapy, energy healing, herbal medicine, massage, and yoga
136
became more prevalent in the 1990s.43 The usage of CAM has remained stable
137
since.37,44–46
138
Although it is beyond the scope of this article to review all CAM therapies used by
139
patients with rheumatic diseases, some of the major modalities and the authors’
140
assessments of their efficacy have been summarized in Box 2. (The authors appre-
141
ciate that others may interpret the available evidence differently.)
142
143
SAFETY OF COMPLEMENTARY AND ALTERNATIVE THERAPIES
144
145 The misconception that CAM therapies are natural and harmless is prevalent in
146 patients using them. However, CAM may or may not be so.38,47 CAM products can
147 be harmful. Patients have suffered, and a few, fortunately rarely, have died, of infec-
148 tions, injections, and contaminants of CAM modalities, such as arsenic, lead, mercury,
149 caffeine, analgesics, phenylbutazone, steroids, NSAIDs, and ephedrine.14,16–18,48–52
150 There are potential interactions between many herbal therapies and conventional

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 4 Rajbhandary et al

151 Box 2
152 Efficacy of various CAM modalities for patients with rheumatic diseases
153
154 Therapies known not to be a clinical benefit
155 Apheresis
156 Antibiotics (except minocycline for rheumatoid arthritis)
157
Copper bracelets
158
159 Glucosamine1 Q15

160 Therapies not studied

161 Shark cartilage
162
Cetyl myristeolate Q16
163
164 Methylsulfonylmethane Q17

165 Therapies with preliminary, incomplete, or inconsistent evidence of benefit but not (yet)
166 adequately studied
167 Ginger
168
Ayurveda
169
170 Yoga
171 Homeopathy
172 Photopheresis
173
Magnets
174
175 Pulsed electromagnetic fields
176 Oral collagen
177 Q18
SAMe
178
179 Venoms
180 Diet and nutritional regimens
181 Herbal therapies
182
Prayer/distant healing
183
184 Zinc
185 Manipulation
186 Diacerhein
187
188 Massage therapy
189 Therapies generally accepted of proven value
190 Spa/balneotherapy
191
Exercise
192
193 Mind-body therapies
194 Fish/botanic oils
195 Acupuncture
196
Modified from Panush RS. Questionable remedies. Up-To-Date In Medicine. PH Schur, Section
197
editor for rheumatology, B Rose, Editor-in-Chief. Wellesley (MA); 1997 (updated quarterly,
198 revised annually).
199
200
201

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 Perspectives about CAM in Rheumatology 5

202 Box 3
203 Principles of complementary and alternative therapies for rheumatic diseases
204
205  If it sounds too good to be true, it is.
206  If you have not read about it in the scientific literature, it is not validated.
207  There are no secrets in good science or good medicine.
208
 There have been no “breakthrough,” important advances in rheumatology from
209 complementary and alternative medicine.
210
211  The question regarding trying complementary and alternative therapies should not be why
not but why?
212
213  Discuss complementary and alternative therapies with patients.58
214  We believe in science, scientific methods, and a single high standard of good evidence-based
215 medicine for all patients.
216 Modified from Panush RS. Questionable remedies. Up-To-Date In Medicine. PH Schur. Section
217 editor for rheumatology, B Rose, Editor-in-Chief. Wellesley (MA); 1997 (updated quarterly,
218 revised annually); and Panush RS. Shift happens. Complementary and alternative medicine
219 for rheumatologists. J Rheumatol 2002; 29: 656–8.
220
221
222 medications, some clinically important, which are not always recognized. There are
223 also direct adverse effects of certain CAM therapies, such as bleeding, pain, hema-
224 toma, rarely pneumothorax from acupuncture53 and headache, local discomfort, dizzi-
225 ness, and a rare cerebrovascular accident from manipulation.54 Some patients
226 received up to 19 remedies, discontinued their formal treatment 11 times, visited
227 CAM providers up to 180 times, and spent the equivalent of 1.3 days’ wages on
228 CAM, all of these in one year.55 Also, there are the obvious consequences of patients
229 not communicating with their rheumatologist (or other physicians) about CAM
230 use.14,16–18,56,57 The authors do not recommend the use of CAM therapies except
231 for evidence-based indications of anticipated clinical benefit.
232
233
234 SUMMARY
235
236 CAM treatments are considered nonmainstream therapies. Their popularity and wide-
237 spread usage reflects the inadequacies of the current understanding and manage-
238 ment of rheumatic and musculoskeletal (and other) diseases, despite significant
239 progress. The authors believe, like Bertram Russell, that “what science cannot tell
240 us, mankind cannot know”; better science in the future will relegate certain CAM ther-
241 apies to the margins of medicine or to history and perhaps see the adoption of others
242 into mainstream medicine. Despite the recent increased interest in CAM, particularly
243 for rheumatic diseases, perhaps derived in part from the hope of identifying new
244 and useful approaches, few clinically important contributions have emerged thus
245 far. The authors therefore developed recommendations regarding CAM treatments
246 for their patients, which are reflected in Box 3.
247
248
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249
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 6 Rajbhandary et al

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Our reference: RDC 491 P-authorquery-v8

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ROSY RAJBHANDARY, MD, Junior Assistant Resident, Department of Primary Care, School of Health
Related Professions, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
SAMIR BHANGLE, MD, Senior Assistant Resident, Department of Primary Care, School of Health
Related Professions, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
SHEETAL PATEL, MD, Senior Assistant Resident, Department of Primary Care, School of Health
Related Professions, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
DEEPALI SEN, MD, Senior Assistant Resident, Department of Primary Care, School of Health Related
Professions, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
ADAM PERLMAN, MD, MPH, Chair, Department of Primary Care, Endowed Professor of
Complementary and Alternative Medicine, School of Health Related Professions, University of Medicine
and Dentistry of New Jersey, Newark, New Jersey; Director, Integrative Medicine, Saint Barnabas Medical
Center, Livingston, New Jersey
RICHARD S. PANUSH, MD, MACP, Professor of Medicine, Division of Rheumatology, Department of
Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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PubMed: Complementary and alternative medical (CAM) treatments are considered nonmainstream
therapies. The popularity and widespread usage of CAM reflects the inadequacies of the current
understanding and management of rheumatic and musculoskeletal (and other) diseases despite significant
progress. The authors believe, like Bertram Russell, that “what science cannot tell us, mankind cannot
 know”; better science in the future will relegate certain CAM therapies to the margins of medicine or to
history and perhaps see the adoption of others into mainstream medicine. Despite the recent increased
interest in CAM, particularly for rheumatic diseases, few clinically important contributions have emerged
thus far.
Q6 As there was no separate affiliation supplied for Rosy Rajbhandary, Samir Bhangle Sheetal Patel, and
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