Complementary And Alternative Medical Therapies Research Articles

Use of complementary and alternative medicine by patients with hypermobile Ehlers-Danlos Syndrome: A qualitative study.

Patients with hypermobile Ehlers-Danlos Syndrome (hEDS) often make use of complementary and alternative medical (CAM) techniques to manage their chronic pain and other symptoms. Nevertheless, how they use CAM, which techniques they favor, and how CAM use affects their allopathic care remain unclear. The purpose of this qualitative study was to understand patients' personal experiences with CAM and its role in their symptom management. Thirty individuals living with hEDS completed a brief online survey related to their CAM use. Thereafter, in-depth interviews were conducted with 24 of the survey respondents, qualitatively investigating their experiences with CAM. Data were analyzed using thematic analysis. Participants described massage therapy (N = 21), medical cannabis (N = 12), and mindfulness (N = 13) as some of the most useful CAM modalities for managing symptoms related to hEDS, but they expressed a general interest in pursuing any treatment that could potentially reduce their chronic pain. They suggested an overall trust in CAM modalities and practitioners and ascribed greater empathy to CAM practitioners than to conventional medical providers. However, they also described a critical skepticism of CAM (and conventional) therapies and recounted instances of injury from such treatments. Participants made extensive use of CAM therapies. They described both critical benefits as well as harms from the use of these non-conventional modalities. These results underscore the importance of clinicians maintaining communicative and compassionate relationships with their patients, and of an openness to the discussion and use of CAM treatments.

The Effects of Traditional Chinese Medicine-Associated Complementary and Alternative Medicine on Women with Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) is a touchy clinical and public health problem worldwide, which adversely affects women's health and health-related comorbidities for lifetime, and represents a tremendous burden for both the family of the patient and for society. According to the diagnostic criteria used and the population studied, the prevalence rate of PCOS is between 6% and 21%. However, current conventional modern medicines for PCOS are only moderately effective at controlling the signs and symptoms, while they are not thoroughly able to prevent complications. Therefore, many patients have turned to complementary and alternative medical (CAM) treatments. CAM use is wide spread among patients with PCOS, and more than 70% of patients use CAM at one point during their diseases. The patients' primary motivations include dissatisfaction with available medications, perceive higher risk of drug side effects and crushing health burden and economic costs, desire for symptom relief, pursuit of shortening the course of disease, and the belief that CAM therapy is in accordance with the patients' values and beliefs. At present, several CAM methods have been used in women with PCOS, which has achieved obvious effects. However, biologically plausible mechanisms of the action of traditional Chinese medicine- (TCM-) associated CAM for PCOS have not been systematically reviewed. This review briefly summarizes the current progress of the impact of herbal medicine on the outcomes of PCOS and introduces the mechanisms.

Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon.

In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. To examine changes in CAM utilization following the policy and variations in utilization across patient populations. A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. Adult Medicaid patients with back pain. The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). Use of CAM services. Use of any CAM service increased from 7.9% (95% CI 7.6-8.2%) prior to the policy to 30.9% (95% CI 30.4-31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CAM service utilization increased among back pain patients following implementation of Oregon's policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.

Anxiety: a Primer for the Pediatrician

This paper focuses on the assessment and treatment of pediatric anxiety disorders targeted at pediatricians. It reviews the prevalence, role of the pediatrician in differentiating anxiety disorders from age-appropriate fears or normative responses to stressors, use of assessment tools, evidence-based treatment, and provides psychoeducation resources for children, parents, and clinicians. It reviews considerations for treatment modality and evidence for use of cognitive-behavioral therapy and psychopharmacology. First-line treatment of mild severity anxiety disorders is guided by well-established evidence and supported by randomized controlled trials that includes psychoeducation and psychotherapy, particularly cognitive-behavioral therapy (CBT). When anxiety is moderate to severe in intensity or impairment, initiation of psychopharmacology is considered in combination with CBT. Selective serotonin reuptake inhibitors (SSRIs) have the most evidence in randomized double-blind placebo-controlled trials and are recommended as first line for anxiety disorders, starting with low doses. It is important to discuss and monitor for potential adverse effects. Complementary and alternative medical (CAM) therapies are often used by youth, though there is limited evidence for benefit in children and adolescents with anxiety disorders, and potential risks need to be considered. Pediatric anxiety disorders are among the most common psychiatric disorders in children and adolescents and can result in significant impairment and morbidity. Pediatricians have an important role in identifying and facilitating treatment for youth with anxiety disorders, and CBT and psychopharmacology, particularly SSRIs, have the most evidence. However, accessing CBT for many families remains challenging. Pediatricians can provide psychoeducation and resources as a first step and initiate medications if indicated. Further research into integration of mental healthcare in pediatric settings could increase access to CBT and decrease morbidity. In addition, more randomized controlled trials and comparison studies for medications, CAM therapies, and combination treatments for pediatric anxiety disorders are needed.

The complementary and alternative medicine for endometriosis: a review of utilization and mechanism.

Endometriosis (EM) is one of the common gynecological conditions causing menstrual and pelvic pain and affects 10%–15% of women of reproductive age. In recent years, the complementary and alternative medical (CAM) treatment for EM has become popular due to the few adverse reactions reported. The CAM therapy for EM includes several different treatments such as herbs (herbal prescription, extract, and patent), acupuncture, microwave physiotherapy, and Chinese herb medicine enema (CHM enema). These CAM therapies are effective at relieving dysmenorrhoea, shrinking adnexal masses, and promoting pregnancy, with less unpleasant side effects when compared to hormonal and surgical treatments. In this review, we focus on the status quo of CAM on EM and try to identify therapeutic efficacy and mechanisms based on some clinical and experimental studies. We hope to provide some instructive suggestions for clinical treatment and experimental research in the future.

Use of Complementary and Alternative Medical Therapies Among Youth With Mental Health Concerns

BackgroundUse of complementary and alternative medical (CAM) therapies is common among adults with mental health concerns, but little is known about CAM use among adolescents with mental health concerns. MethodsData from the 2007 National Health Interview Survey were analyzed for youth from 7 to 17 years old. The study focused on 3 common mental health conditions: attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression. CAM therapy use was identified by criteria from the National Institutes of Health National Center for Complementary and Alternative Medicine. ResultsIn a sample of 5651 individuals, representing 7 million youth, with 1 or more mental health concerns in the past 12 months, 28.9% used 1 or more types of CAM therapy, excluding vitamins/minerals. In contrast, only 11.6% of those without mental health concerns reported CAM therapy use (P < .05). Among youth with 1 or more mental health conditions, the most commonly used CAM therapies were mind–body therapies (16.3%) and biologically based therapies (11%); use was higher for therapies that could be directly accessed (18.6%) than for therapies delivered in groups (11.8%) or through a health professional (10.2%). In the multivariable regression model, demographic factors significantly associated with CAM therapy use were higher household income, higher parental education, having other chronic health conditions, use of prescription medications, and difficulty affording mental health counseling. ConclusionsReadily accessible CAM therapies are commonly used by youth with ADHD, depression, and anxiety, particularly those who have comorbid chronic health conditions, receive prescription medications, and have difficulty affording counseling. Clinicians can use these data to guide inquiries and counseling. Researchers should explore the longitudinal relationship between access to coordinated care within a medical home and use of CAM therapies among youth with mental health concerns.

OA11.02. A model of integrative care for low back pain

Purpose While previous studies focused on the effectiveness of individual complementary and alternative medical (CAM) therapies, the value of providing patients access to an integrated program involving multiple CAM and conventional therapies remains unknown. Our objective is to explore the feasibility and effects of a model of multidisciplinary integrative care for subacute low back pain (LBP) in an academic teaching hospital.

A Model of Integrative Care for Low-Back Pain

While previous studies focused on the effectiveness of individual complementary and alternative medical (CAM) therapies, the value of providing patients access to an integrated program involving multiple CAM and conventional therapies remains unknown. The objective of this study is to explore the feasibility and effects of a model of multidisciplinary integrative care for subacute low-back pain (LBP) in an academic teaching hospital. This was a pilot randomized trial comparing an individualized program of integrative care (IC) plus usual care to usual care (UC) alone for adults with LBP. Twenty (20) individuals with LPB of 3-12 weeks' duration were recruited from an occupational health clinic and community health center. Participants were randomized to 12 weeks of individualized IC plus usual care versus UC alone. IC was provided by a trained multidisciplinary team offering CAM therapies and conventional medical care. The outcome measures were symptoms (pain, bothersomeness), functional status (Roland-Morris score), SF-12, worry, and difficulty performing three self-selected activities. Over 12 weeks, participants in the IC group had a median of 12.0 visits (range 5-25). IC participants experienced significantly greater improvements at 12 weeks than those receiving UC alone in symptom bothersomeness (p=0.02) and pain (p=0.005), and showed greater improvement in functional status (p=0.08). Rates of improvement were greater for patients in IC than UC in functional status (p=0.02), bothersomeness (p=0.002), and pain scores (p=0.001). Secondary outcomes of self-selected most challenging activity, worry, and the SF-12 also showed improvement in the IC group at 12 weeks. These differences persisted at 26 weeks, but were no longer statistically significant. It was feasible for a multidisciplinary, outpatient IC team to deliver coordinated, individualized intervention to patients with subacute LBP. Results showed a promising trend for benefit of treating patients with persistent LBP with this IC model, and warrant evaluation in a full-scale study.

Effectiveness of therapeutic massage for generalized anxiety disorder: a randomized controlled trial

Although massage is one of the most popular complementary and alternative medical (CAM) treatments for anxiety, its effectiveness has never been rigorously evaluated for a diagnosed anxiety disorder. This study evaluates the effectiveness of therapeutic massage for persons with generalized anxiety disorder (GAD). Sixty-eight persons with GAD were randomized to therapeutic massage (n=23), thermotherapy (n=22), or relaxing room therapy (n=23) for a total of 10 sessions over 12 weeks. Mean reduction in anxiety was measured by the Hamilton Anxiety Rating Scale (HARS). Secondary outcomes included 50% reduction in HARS and symptom resolution of GAD, changes in depressive symptoms (Patient Health Questionnaire (PHQ-8)), worry and GAD-related disability. We compared changes in these outcomes in the massage and control groups posttreatment and at 6 months using generalized estimating equation (GEE) regression. All groups had improved by the end of treatment (adjusted mean change scores for the HARS ranged from -10.0 to -13.0; P<.001) and maintained their gains at the 26-week followup. No differences were seen between groups (P=.39). Symptom reduction and resolution of GAD, depressive symptoms, worry and disability showed similar patterns. Massage was not superior to the control treatments, and all showed some clinically important improvements, likely due to some beneficial but generalized relaxation response. Because the relaxing room treatment is substantially less expensive than the other treatments, a similar treatment packaged in a clinically credible manner might be the most cost effective option for persons with GAD who want to try relaxation-oriented CAM therapies.

Differences Between Older and Younger Cancer Survivors in Seeking Cancer Information and Using Complementary/Alternative Medicine

The purpose of this study was to describe the differences between younger and older cancer survivors in seeking cancer information, using complementary and alternative medical (CAM) services, and using conventional support services. Participants were 836 survivors of adult cancers (6 months-43 years since completion of primary cancer treatment) in New Zealand who answered a mailed questionnaire between April 2007 and January 2008. Younger survivors (aged <60 years at diagnosis) were more likely to seek information from sources beyond their physicians and used different sources for that information, compared to older survivors. Older and younger survivors used similar conventional support services, but different CAM services. In logistic regression analyses, information-seekers were 5.9 times more likely to use CAM than those who did not seek cancer information (p = 0.02), but the association between information-seeking and CAM use depended on age (p = 0.02). Older cancer survivors who did not seek information from sources beyond that provided by physicians were less likely to use CAM. Physicians should consider talking to older cancer survivors about their use of information sources or CAM therapies. A conversation between physician and patient may uncover inaccurate information or CAM use that has potential for adverse effects, while allowing the physician to encourage CAM that is potentially useful. Even a brief conversation may be sufficient to encourage older cancer survivors to take action themselves to find services that support their recovery from cancer and cancer treatment.

보완대체의학의 윤리적 성찰*

The increasing use of complementary and alternative medical (CAM) therapies by patients, health care providers, and medical institutions has made it imperative that physicians consider their ethical obligations when recommending, tolerating, or proscribing these therapies. When CAM and conventional medical therapies intersect, there is the potential for serious physician–patient conflicts as well as harm to patients. Some CAM therapies in and of themselves can be hazardous, but harm can also occur indirectly when patients choose less effective CAM treatments instead of conventional methods that have demonstrated efficacy. Physician–patient conflicts arising from issues related to CAM therapies are common, but the physician-patient relationship is more likely to remain intact if physicians are willing to engage creatively with patients when problems seem unsolvable. Even in the absence of scientific evidence for CAM therapies, providers can formulate a plan that is clinically sound, ethically appropriate, and targeted to the unique circumstances of individual patients. Physicians are encouraged to remain engaged in problem-solving with their patients and to attempt to clarify the patient’s core values and beliefs when counseling about CAM therapies. The commitment to joint problem-solving over time, which is a central obligation of the physician–patient relationship, becomes even more important when considering the use of CAM therapies. A long-standing, carefully nurtured partnership between a physician and a patient that has grown over time may be strained or completely destroyed if common ground in such situations cannot be found. The way forward for physicians involves not only preventing negligence and fraud, but also facilitating therapeutic exchanges between various healthcare providers and their patients. The use of case-based reasoning in questions of CAM therapy allows a fuller appreciation of the way in which circumstances play an intrinsic role in moral judgments. This paper presents two prototypical cases that illustrate the challenges already discussed as well as other ethical challenges that will arise as CAM therapies gain popularity in Korea.

Asthma: A Review of Complementary and Alternative Therapies

1. Cecilia Bukutu, PhD* 2. Christopher Le* 3. Sunita Vohra, MD, FRCPC, MSc* 1. *Complementary and Alternative Research and Education (CARE) Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada. On behalf of the American Academy of Pediatrics Section on Complementary and Integrative Medicine Although effective medications for managing asthma exist within conventional Western medicine (eg, inhaled corticosteroids and bronchodilators), some parents turn to complementary and alternative medical (CAM) therapies to treat their children's asthma. (1) Some reasons cited for using CAM therapies include concern about the long-term effects of steroid use; frustration that asthma does not resolve with conventional therapies; dissatisfaction with physician-patient interactions; belief that CAM is natural and, therefore, safe; and desire to have autonomy in making health choices. (1)(2) This review of published scientific literature assesses the efficacy and safety of some common CAM therapies in preventing and treating pediatric asthma. Natural health products (NHPs), including vitamins, minerals, herbal remedies, and other dietary supplements such as fish oil and probiotics, are used widely to prevent and treat asthma. (3) Like conventional therapies, NHPs used to treat asthma can be categorized as having anti-inflammatory, bronchodilator, and other effects. Few of these NHPs have been evaluated in pediatric trials. ### Vitamin C Vitamin C is an important antioxidant found in abundance in the extracellular fluid lining of the lung. Low intake of vitamin C is associated with pulmonary dysfunction. (4) Several observational studies in children have reported a beneficial relationship between a high fruit intake and improved lung function. (5)(6) However, a 2004 Cochrane systematic review of eight randomized, controlled trials (RCTs) concluded that evidence was insufficient to recommend a specific role for vitamin C in treating asthma. (4) Of the eight included studies, three small studies (fewer than 41 participants each) concluded that vitamin C supplementation was beneficial; five studies, including the largest trial (n=210), showed little or no beneficial effect. Larger, long-term RCTs are needed to clarify the possible role of vitamin C in the treatment of asthma. Most researchers have used daily doses of 500 to 1,000 mg. …

Patient‐based evaluations of primary care for cardiovascular diseases: a comparison between conventional and complementary medicine

Patients with chronic diseases, including cardiovascular conditions, increasingly rely on complementary and alternative medical (CAM) therapies. The Swiss Program for Complementary Medicine Evaluation offers a unique opportunity to analyse cardiovascular patients' satisfaction with CAM and conventional medical (COM) therapies. The treatment choices of doctors certified in conventional as well as complementary therapies also could be studied. A national observational evaluation on treatment satisfaction of patients consulting COM or CAM doctors. Out of this evaluation project, data related to patients with cardiovascular diseases were specifically analysed for patient satisfaction with treatment and outcome when treated by COM or CAM doctors. Of 199 included doctors (78 COM, 121 CAM) treating cardiovascular patients, COM doctors treated twice as many cardiovascular patients per doctor than CAM doctors. CAM doctors treated less than 1/3 of their cardiovascular patients solely by CAM, while they treated 42% exclusively by COM therapies. Patients seeing a CAM doctor had a significantly longer consultation and were more likely to be highly satisfied with overall treatment outcome and patient-practitioner communication. Moreover, patients seeing a CAM doctor and being treated solely by a CAM therapy more often report 'complete fulfilment of outcome expectation' and 'high overall satisfaction with treatment', although their symptoms less often disappear totally than those of COM therapy-treated patients. CAM therapies are not the first treatment choice for cardiovascular diseases. However, even though CAM doctors preferentially apply COM therapies, cardiovascular patients treated by CAM doctors are more likely to be satisfied with the overall treatment outcome, possibly because of the longer and better patient-practitioner interaction.

Crataegus Orientalis Associated Multiorgan Hypersensitivity Reaction and Acute Renal Failure

Patients, especially those with chronic disease and disorders are increasingly relying on complementary and alternative medical therapies (CAMT). Because the use of CAMT is escalating worldwide, it is essential to be aware of the clinical and adverse effects, doses and potential drug-herb interactions. Crataegus orientalis or hawthorn is a small tree with red fruits. A number of studies appear to demonstrate that Crataegus spp. have a clinically detectable positive cardiac inotropic action. The ingredients, characteristics of metabolism and elimination, and adverse effects of hawthorn remain largely unknown. We report a case of multisystem hypersensitivity reaction and progressive acute renal failure associated with the consumption of Crataegus orientalis.

Complementary, Holistic, and Integrative Medicine

1. Lawrence D. Rosen, MD* 2. Cecilia Bukutu, PhD† 3. Christopher Le† 4. Larissa Shamseer† 5. Sunita Vohra, MD, MSc† 1. *Chair, Integrative Pediatrics Council, Old Tappen, NJ 2. †Complementary and Alternative Research and Education (CARE) Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada. On behalf of the American Academy of Pediatrics Provisional Section on Complementary, Holistic, and Integrative Medicine According to the Wessel criteria, infantile colic is defined as excessive crying for more than 3 hours a day at least 3 days a week for 3 weeks or more in an otherwise healthy baby. (1) As many as 26% of infants are diagnosed with colic, (2) making the condition one of the most common reasons for infant visits to primary care practitioners today. Colic is a self-limiting condition that resolves in approximately 50% of cases at about 3 months of age. (3) Due, in part, to poor understanding of its causes, (2) there is no widely accepted conventional treatment, and families often turn to complementary and alternative medical (CAM) therapies. (4) The largest systematic review to date of treatments for colic found little evidence to support many conventional therapies, while noting that some nutritional- and botanical-based approaches were relatively safe and effective. (5) This review of published scientific literature assesses the efficacy and safety of common CAM therapies in treating infantile colic. Natural health products have been used historically to treat infantile colic, due, in part, to presumed antispasmodic and anti-inflammatory activity. (6)(7) However, few of these products have been assessed in terms of efficacy and safety for use in infants through well-designed clinical trials. ### Fennel Seed Oil The effectiveness of fennel ( Foeniculum vulgare ) seed oil in treating infantile colic was investigated in a randomized controlled trial (RCT) in Russia of 125 colicky infants between the ages of 2 and 12 weeks. (8) Infants were assigned randomly to receive 5 to 20 mL of a 0.1% fennel seed oil emulsion and 0.4% polysorbate-80 or a placebo (0.4% polysorbate-80 in water) up to four times per day for 1 week. Parents recorded symptoms in a diary for 3 weeks that included the week before, the week during, and the week after the trial. …

Patterns of Complementary and Alternative Medical Therapy Use in Children Diagnosed with Autism Spectrum Disorders

Previous studies suggest that complementary and alternative medical (CAM) therapy use in children with chronic illnesses is higher than in children in the general population. In this study, we investigated patterns of CAM therapy use in children diagnosed with autism spectrum disorders (ASD, n = 50) as compared to a control population of children with no ASD (n = 50). Over half of the parents in the ASD group reported using, or had used at least one CAM therapy for their child (52%) as compared to 28% of the control group (P = 0.024). Seventy percent of therapies used in the ASD group were biologically based therapies comprised of special diets or supplements, and parents felt that 75% of the therapies used were beneficial.

Legal and Ethical Issues Relating to Use of Complementary Therapies in Pediatric Hematology/Oncology

Pediatricians increasingly are asked to advise pediatric patients and their families concerning integration into conventional care (including hematology and oncology) of complementary and alternative medical (CAM) therapies such as chiropractic, massage therapy, and herbal medicine. Inclusion of CAM therapies in pediatric oncology and hematology--as in any medical subspecialty--is not itself "unethical," clinically inadvisable, or legally risky; the danger comes from over-reliance on one or more CAM therapies (particularly those with evidence of danger and/or paltry evidence of success) to the exclusion of conventional care that is curative and imminently necessary. Pediatricians can help address potential malpractice liability issues by evaluating the level of clinical risk, engaging the patient in shared decision making and documenting this in the medical record, continuing to monitor conventionally, and being prepared to intervene conventionally when medically required.

Complementary and Alternative Medical Therapy Use Among Chinese and Vietnamese Americans: Prevalence, Associated Factors, and Effects of Patient–Clinician Communication

We examined the use of complementary and alternative medical (CAM) therapies among Chinese and Vietnamese Americans who had limited proficiency with the English language and explore the association between patient-clinician discussions about CAM therapy use and patient assessments of quality of care. We surveyed Chinese and Vietnamese Americans who visited 11 community health centers in 8 major cities throughout the United States. Of the 4410 patients surveyed, 3258 (74%) returned completed questionnaires. Two thirds of respondents reported they had "ever used" some form of CAM therapy; however, only 7.6% of these patients had discussed their use of CAM therapies with clinicians. Among patients who had used CAM therapies during the week before their most recent visits, clinician-patient discussions about CAM therapy use were associated with better overall patient ratings of quality of care. Use of CAM therapies was common among Chinese and Vietnamese Americans who had limited proficiency with the English language. Although discussions about CAM therapy use with clinicians were uncommon, these discussions were associated with better ratings of quality of care.

Pediatric Use of Complementary Therapies: Ethical and Policy Choices

Many pediatricians and parents are beginning to integrate use of complementary and alternative medical (CAM) therapies with conventional care. This article addresses ethical and policy issues involving parental choices of CAM therapies for their children. We conducted a literature search to assess existing law involving parental choice of CAM therapies for their children. We also selected a convenience sample of 18 states of varying sizes and geographic locations. In each state, we inquired within the Department of Health and Human Services whether staff were aware of (1) any internal policies concerning these issues or (2) any cases in the previous 5 years in which either (a) the state initiated proceedings against parents for using CAM therapies for their children or (b) the department received telephone calls or other information reporting abuse and neglect in this domain. We asked the American Academy of Pediatrics and the leading CAM professional organizations concerning any relevant, reported cases. Of the 18 state Departments of Health and Human Services departments surveyed, 6 reported being aware of cases in the previous 5 years. Of 9 reported cases in these 6 states, 3 involved restrictive dietary practices (eg, limiting children variously to a watermelon or raw foods diet), 1 involved dietary supplements, 3 involved children with terminal cancer, and 2 involved religious practices rather than CAM per se. None of the professional organizations surveyed had initiated proceedings or received telephone calls regarding abuse or neglect concerning parental use of CAM therapies. Pediatric use of CAM therapies raises complex issues. Clinicians, hospitals, state agencies, courts, and professional organizations may benefit from a policy framework to help guide decision making.

Legal Issues in Caring for Patients With Kidney Disease by Selectively Integrating Complementary Therapies

Clinical integration of complementary and alternative medical (CAM) therapies, such as acupuncture and traditional oriental medicine, chiropractic, herbal medicine, massage therapy, and "mind-body" therapies, into conventional health care raises important legal and risk management issues. Understanding which CAM therapies patients use is legally prudent, as conventional treatment advice may interact with patients' own efforts toward self-care. In addition, nephrologists may limit potential liability for medical malpractice by classifying any given therapy as follows: (1) the medical evidence supports both safety and efficacy--recommend; (2) the medical evidence supports safety, but evidence regarding efficacy is inconclusive-accept but monitor; (3) the medical evidence supports efficacy, but evidence regarding safety is inconclusive-accept but monitor; and (4) the medical evidence indicates either serious risk or inefficacy--avoid and discourage. Applying this framework whether a therapy is labeled "conventional" or "CAM" is consistent with the key recommendation of the recent report by the Institute of Medicine at the National Academy of Sciences on Complementary and Alternative Medicine, namely, to apply the same principles and standards of evidence of treatment effectiveness to all treatments. Liability risk management also includes going beyond legal and ethical informed consent requirements by engaging the patient in shared decision making concerning all material treatment options, including CAM therapies, if supported by evidence. Physicians further should familiarize themselves with documentation standards suggested by the Federation of State Medical Board Guidelines and whether these are applicable in their state or home institution. These steps aim to enable nephrologists to respond to patient interest in CAM therapies in a way that is clinically responsible, ethically appropriate, and legally defensible.