Acupuncture, chiropractic, massage therapy, and herbal medicine:
these are some of the forms of alternative medicine that are starting
to make inroads into Kaiser Permanente (KP). Dissatisfaction with conventional
medicine in treating some chronic conditions and a move toward wellness
are driving both patient and provider to seek broader treatment modalities
than are currently offered in allopathic, traditional medicine. Different
regions of KP are independently creating alternative medicine offerings
in response to member and provider demands.
Complementary and alternative medicine (CAM) first became
recognized as a major player in health care delivery when David Eisenberg
et al published their 1993 New England Journal of Medicine study.1
This landmark article demonstrated that one-third of his survey population
used some form of CAM treatment, spending 13.8 billion dollars--mostly
out of pocket--during the study year. This figure exceeded the total
amount spent on inpatient hospitalizations for the same period. KP members
demonstrate the same usage patterns discovered by Eisenberg et al: somewhere
between 20 and 33% of members are either interested or are actively
using some form of CAM therapy. This has been validated in three different
internal studies over the past several years (Gordon in Northern California
[unpublished material], Whitlock2 in the Northwest, and the
Starr Member Satisfaction Study in Mid-Atlantic3). The recently
released KP Consumer Segmentation Report4 from National Communications,
Marketing, and Sales Development found that about 20% of those surveyed
(non-Kaiser Permanente members) would be interested in joining a health
plan that covered alternative methods, suggesting that Kaiser Permanente
members are no different then the general population in their interests
and usage patterns. Regional differences exist as to which CAM modality
is most popular.
Complementary and Alternative Medicine
So, what is alternative medicine? The NIH Office of Alternative
Medicine defines a broad range of healing philosophies, approaches,
and therapies as those forms of medicine not traditionally taught in
medical school.5 These modalities may be used alone, often
referred to as alternative, or in combination with other alternative
therapies or with traditional allopathic therapies, often referred to
as complementary or integrative. CAM modalities generally include manual
therapies (osteopathic, chiropractic, and therapeutic massage), acupuncture
and acupressure, mind/body medicine (eg, meditation, guided imagery,
stress reduction), biofeedback and hypnosis, nutritional therapies (supplements,
diets), herbs, homeopathy, movement (yoga, tai chi), and self-help groups.
For a more detailed description, see Marie Mulligan's (Kaiser Permanente,
Santa Rosa, CA.) excellent review below.
The Provider Perspective
Provider resistance is slowly changing as a growing body
of scientific evidence becomes available. For example, in November 1997
an NIH consensus panel made recommendations on the use of acupuncture
based on a review of articles which they determined merit scientific
credibility.6 These included treatment for nausea and vomiting
after chemotherapy, nausea due to pregnancy, and postoperative dental
pain. Other conditions such as headaches and back pain were considered
likely to be helped with acupuncture, but the data were insufficient
for a full endorsement. Proponents suggested that the acupuncture process
probably releases endogenous opioids, whereas skeptics felt results
were solely due to the placebo effect. However, the NIH consensus statement
added validity to acupuncture, making it more acceptable to some of
those providers who had been previously hesitant.
Aside from many providers still being reluctant to use
these modalities, many are unaware which therapies might offer benefit
to patients. In some markets where new benefits include CAM modalities,
educational seminars are often being offered to providers.
Lastly, providers may be unaware that their patients are
seeking care in the CAM arena, because many patients do not tell them.
In her 1997 study, Gordon found that only approximately 25% of providers
asked their patients if they used some form of complementary and alternative
medicine. She also noted that 20% of patients who used CAM modalities
did not tell their provider. This lack of communication between patient
and provider can easily create therapeutic dilemmas when patients are
using a CAM modality of which their provider is unaware.
The Patients Who Use CAM
Traditional high-technology Western medicine excels in the treatment
of acute illness and injury, whereas CAM's strong hand is in treating
the following three populations of patients, who tend to be the highest
utilizers of CAM:
- The chronically ill
- The chronic pain patient
- The patient seeking wellness/prevention
The dichotomy between CAM and traditional Western medicine
is starting, however, to merge into a field currently coined Integrative
Medicine. Here the best of both modalities are used together. As an
example, low back pain patients use acupuncture or chiropractic care
along with their NSAIDs. In another example, headache patients can use
lower doses of their medications because these patients are trained
Kaiser Permanente Across the Country
Table 1 is a partial listing of KP providers from different
Regions who are active in research, education, and health care delivery.
Many have chronic pain programs that act as a springboard in providing
CAM services. Many Health Education Programs in different Regions also
provide "wellness" classes in such fields as yoga, tai chi,
After speaking with numerous providers within KP, and CAM
providers outside the Program, I would make the following recommendations:
- Internalize services where possible.
- Provide an integrated format so providers of different types can
evaluate patients as a team. The language barrier is much greater
between an acupuncturist and an internist than between an orthopedic
surgeon and an internist.
- Include mental health/behavioral medicine and self-help group
models to empower patients' awareness of their ability to manage
their own health.
- Create an interregional task force/network for providers to create
best practices in this newly emerging field (see sidebar at the
conclusion of this article). Include on the task force interested
health plan administrators who would strengthen our position in
the marketplace and provide a basis for coordinated care.
We need to continue exploring methods of integrating the
most valuable aspects of complementary and alternative medicine into
our operations. A collaborative effort between the Medical Group and
the Health Plan both nationally and locally will demonstrate Kaiser
Permanente as taking a lead in change in the ever-evolving world of
1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco
TL. Unconventional Medicine in the United States: Prevalence, costs,
and patterns of use. NEJM 1993;328(4):246-252.
2. Whitlock E, Russell A. "1995 Current Membership Study"
Center for Health Research, Portland Oregon.
3. Segal LS, Evans DL. "1997 Starr Member Satisfaction Survey Results
of the Mid Atlantic Region" Permanente Medical Group, Mid-Atlantic
4. Swanson K. "Consumer Segmentation Report" National Marketing,
Sales and Business Development, Dec. 1997, Oakland CA.
5. National Institute of Health Office of Alternative Medicine. June
1996, General Information Package: Statement on Alternative Medicine,
7. NIH Consensus Statement on Acupuncture, November 1997 3-5;15(5).
In press. Also available on the NIH-OAM website.
Guide to Alternative
Medical Practices and Alternative Medical Systems
By Marie Mulligan, MD; Kaiser Permanente Medical Center,
Santa Rosa, California
Alternative Systems of Medical Practice
Acupuncture involves stimulating specific anatomic points in
the body for therapeutic purposes by using acupuncture needles, moxa,
impulses of electromagnetic energy, friction, suction, or pressure.
Acupuncture is used to regulate the flow of chi to restore health, and
is part of the therapeutic armamentarium of traditional Chinese medicine.
Traditional Chinese Medicine
This is a complete medical system which has diagnosed, treated,
and prevented illnesses for over 23 centuries. There are 4 basic branches
to Chinese medicine: herbalism, food cures, acupuncture, and manipulative
therapies. Herbalism and food cures are part of the system of internal
medicine. Acupuncture and manipulative therapies are included in the
system of external medicine. Diagnosis involves observation, history
taking, palpation of radial pulses, observation of the tongue, and palpation
of sensitive body parts.
This is India's natural system of medicine which has been practiced
for over 5,000 years. Ayurveda provides a complete, integrated approach
to the treatment and prevention of illness by dealing with imbalance
and stress in the individual's consciousness, attending to diet and
digestive issues, using breath and movement therapies including pranayama
and yoga, and using numerous herbal and mineral medicines.
Homeopathy is based on the work of Samuel Hahnemann, a German
doctor who founded this healing system in the 18th century. Homeopathic
substances are medicines that when used in large doses will produce
symptoms in a healthy person that will cure these identical symptoms
in a sick person. Additionally, homeopathic medicines are diluted to
concentrations that are sometimes lower than avogadro's number. Critics
of homeopathy contend that such extreme dilutions are beyond the point
at which any active molecules can be found in the medicine. However,
homeopathic practitioners suggest that there may be energetic reasons
why these remedies may be effective. Homeopathic medicine is practiced
worldwide, especially in Europe, Asia, and Latin America.
Naturopathic medicine is an American health care profession
that is nearly 100 years old. It incorporates use of herbal or botanical
opathy, and chiropractic. Naturopathic providers are in many ways the
family practitioners or generalists of Western alternative medicine.
Naturopaths attempt to assist the body's innate healing properties,
without the use of pharmaceutical medicines whenever possible.
Environmental medicine is a very controversial alternative modality.
It is an extension of conventional western medicine. Practitioners are
MDs who believe that many common foods and chemicals trigger the onset
of acute and chronic illness, even when the exposure is at low levels.
They frequently work with diet, especially elimination diets, and use
megavitamin therapy, including megadoses of vitamin C. They also use
a variety of other nonconventional pharmaceutical and biological treatments,
including chelation therapy.
People involved in Christian Science healing are usually members
of the Christian Science Church. Prayer and attitudinal healing are
the main focus in this system.
Anthroposophical medicine is an extension of conventional Western
medicine, with its roots in the philosophy of Rudolph Steiner. Herbal
medicine and homeopathy are also incorporated into this system.
Meditation is a practice for relaxing the body and mind that
involves focusing the attention on different objects. Concentration
practices can involve focusing on a sound, a repeated word or mantra,
visual image, or body sensation. Mindfulness meditation involves attending
to the sensations of breathing to cultivate concentration and calming
of body and mind. Once some relaxation has occurred and some concentration
has been developed, the person then directs their attention to whatever
thought or emotion might arise with a nonjudgmental attitude. Various
meditation techniques have been demonstrated to be useful in treating
Many areas are covered by psychoeducation, including couples
communication classes and parenting classes. One of the most powerful
areas includes cognitive therapy for treating mild to moderate depression.
The person identifies negative automatic thoughts and retrains their
mind to reinforce true and helpful thoughts. This technique has been
demonstrated to be effective in treating mild to moderate depression
and to reduce relapse rates.
There are many schools of psychotherapy. Each addresses a person's
emotional and mental health, which in turn can affect physical wellbeing
and capacity for self care. Conventional psychotherapy uses a variety
of psychologic methods, including psychoanalysis, suggestion, persuasion,
and education. All of these therapies can be undertaken either in a
group or individual setting.
Yoga has its origins in India. It is a 5,000-year-old practice
that includes ethical precepts, dietary prescriptions, physical exercise,
and breath work. Yogic meditation has been shown to reduce anxiety levels
and to be helpful in treating stress related disorders.
Tai Chi, Chi Goin
Both of these modalities involve movement, breath work, and
directing the attention. They arose out of the 4,000-year-old Chinese
system of healing and, like yoga, have been found to be useful in the
treatment of stress related disorders.
Imagery has been popularized by the Simontons. It is a mental
process using thought representing a sensory quality, which can be visual,
aural, tactile, olfactory, proprioceptive, and kinesthetic. Imagery
has been shown to successfully treat nausea and vomiting associated
with chemotherapy and is also successful in treating stress related
Prayer and Mental Healing
There are several types of prayer. Healing can happen either
in the presence of the person being healed, or from a distance. This
can involve directed prayer requesting a specific outcome, or nondirected
prayer requesting the best possible outcome. Some suggest that this
second kind of prayer may be more effective in generating positive outcomes.
Dance, Art, Music, and Movement Therapy
There are many schools of dance, art, music and movement therapy.
They are all a means for the patient to foster self awareness, reconcile
emotional conflicts, and express unspoken or unconscious concerns about
either emotional or physical problems.
Biofeedback uses a variety of monitoring instruments to feedback
to the patient physiologic information about which they are normally
unaware. It is basically an educational device for patients to gain
more control over their psychophysiologic responses to stress.
Hypnotherapy includes the induction of trance states and the
use of therapeutic suggestion. Increased relaxation, rapport, internal
focus, and receptivity to ego-syntonic suggestions are hallmarks of
therapeutic trance states. Hypnosis can be done with groups or individually.
It has been shown to be helpful in treating stress-related disorders.
Manual Healing Methods
Chiropractic is concerned with investigating the relationship
between structure and function of the human body to restore and preserve
health, with an emphasis primarily on the spine and nervous system.
Manual procedures and interventions are used to the exclusion of surgical
and chemotherapeutic procedures. Recent research suggests that chiropractic
treatment can be useful in treating acute low back pain.
Of note is that the majority of osteopathic physicians are involved
in primary care. They receive 2,000-3,000 hours of hands-on training
in manipulative modalities as part of their education. Classically,
osteopaths have focused more on soft tissue problems than chiropractors
There are numerous methods of massage therapy. Massage consists
of a group of manual techniques to apply fixed or movable pressure to
the body. Massage therapists are licensed in 19 states, including California.
There are many modalities of body work. Feldenkrais, developed
by Moishe Feldenkrais, focuses on sensory motor awareness and teaches
patients to both hold their bodies in more healthful postures and to
move in new and healthful ways. Somatics is an extension of Feldenkrais
developed by Thomas Hanna. The Somatics Institute is located in Novato,
California. Its goal is to move the person from amnesia of sensory motor
input to an awareness of sensory motor input, which allows the person
to have a greater choice in reducing the wear and tear on the body over
Rolfing was developed by Ida Rolf and involves deep body work.
It works with fascial layers to bring about what is described as "structural
Rosen Body Work
Rosen body work was developed by Marian Rosen, a physical therapist.
Her institute is located in Berkeley. The goal of this very gentle body
work is to help the person be in touch with the authentic self. The
person experiences emotional relief by contacting and releasing emotional
contractions held in the body.
Touch for Health
Touch for Health is quite popular among nurses in this country.
It can involve touching the person directly or holding the hands out
a short distance from the body. It is used primarily for stress reduction.
Reflexology is a body work system that involves massage of the
feet with the intention to affect not only the feet, but other parts
of the body. It has been shown to be helpful for stress-related disorders.
Physical therapy is an example of a modality which has moved
into the mainstream. It involves a variety of methods, including hands-on
therapy and the use of physical modalities, eg, ultrasound. It is often
used to assist injured patients to regain function and to increase their
Pharmaceutical "Botanical Medicine"
Botanical and Herbal Treatments
All cultures have a long history of folk medicine traditions.
Currently in the West, there is a resurgence of interest in identifying
the biologically active agents from botanical sources to treat a variety
of conditions; for example, garlic oil for treatment of mild hypertension.
The German FDA regulates the use of herbs, and the German Commission
E monographs delineate the safety, efficacy, indications, and dosing
of herbs. These monographs will be available in English in early 1996.
Nutritional Dietary Therapies
There are a variety of nutritional dietary therapies. The best
known include: the very-low-fat diets, including Pritikin, McDougal,
and Dean Ornish programs; supplements, including vitamins, plant extracts,
and antioxidants. One of the most widely publicized supplement includes
melatonin, currently available over the counter and used for jet lag,
among other indications.
Aromatherapy is the use of aromatic oils for a variety of conditions
and, most often for stress reduction. It is popular among many British
nurses to help increase the comfort level of many patients.
Chelation therapy is primarily used by physicians who practice
environmental medicine. They use either parenteral or oral chelating
agents to treat chronic degenerative conditions. Chelation therapy is
shown to be safe; however, its efficacy is hotly disputed.
Native American Indian Healing
Native American Indian healing is a community-based system that
uses certain rituals and practices, including sweating and purging (usually
done in a sweat lodge), use of herbal medicines, and certain shamanic
Latin American Healers (Curanderos)
Curanderos use a system of folk medicine that includes a model
for classifying food, drugs, activity, and illnesses, usually based
on whether a condition is hot, cold, dry, or moist. Currently there
are no formal effectiveness studies done on this system.
Southeast Asian Folk Medicine
An example of Southeast Asian folk medicine: In Cambodia there
are folk healers called kru khmer who are highly respected members of
an aristocratic class. They use coining, cupping, herb teas, sauna,
and massage to facilitate healing. They are usually trained through
apprenticeship. Almost without exception, these healers are older men.
Creation of an Interregional Task Force
on Alternative Medicine
A number of people have expressed an interest in
developing an interregional task force/network to communicate
on issues of benefits, service delivery, and education for providers
and for patients. If you are interested in learning, teaching
or exchanging ideas, please con-tact Lydia Segal, MD at (703)
536-1487, or via e-mail at firstname.lastname@example.org.