April 2001 Bulletin

CAM gains wide acceptance by the public

Orthopaedists must know how, why patients are using herbs, other therapies

By John W. Wickenden, M.D.

Complementary and Alternative Medicine (CAM) is that range of healing philosophies, approaches, and therapies that mainstream, conventional, Western medicine does not commonly use, accept or make available. It includes chiropraxis, acupuncture, the use of herbal medicines and supplements, homeopathy, massage, traditional Chinese medicine, mind/body techniques, and many others.

During the last decade in the United States, demand for CAM has increased dramatically. Some form of CAM is used by almost half of all Americans. In 1997 there were 629 million visits to CAM providers (half of those to chiropractors and massage therapists), compared with 386 million visits for primary allopathic care.

In 1997, $12.2 billion was spent for CAM services, more than the out-of-pocket expenditures for all hospitalizations in the U.S. At least one out of five of the patients to whom we give prescriptions is also using herbal medicines or supplements. Many are receiving chiropractic manipulation. Few of them tell us. Do you know which of your patients use CAM?

Even if you believe that the use of CAM does not benefit your patients, you should know how and why your patients are using CAM. You need to know some of the potential problems posed—and benefits provided—by your patients’ avid use of CAM.

In order to better understand the phenomenon of CAM, Congress established in 1998 the National Center for Complementary and Alternative Medicine (NCCAM) within the National Institutes of Health (NIH). In the last federal budget the NCCAM received $89.2 million, a greater increase (29.3 percent) than any other unit of the NIH. In the same budget, the National Institute of Arthritis and Musculoskeletal and Skin diseases (NIAMS), received only a 13.5 percent increase—the lowest increase of any NIH unit. What’s more, Medicare, Workers’ Compensation, HMOs, and private insurance carriers have rapidly increased their coverage for CAM treatments.

In response to these realities, the AAOS Board of Directors established a Task Force on Alternative Care in February 1999. Under the chairmanship of James Buchholz, MD, it reported to the Board that "alternative care is more pervasive than any of us had previously imagined," and that "there is a present and increasing need for orthopaedic surgeons to be familiar with the various alternative modalities so that they will be able to intelligently answer patient’s questions regarding the effectiveness or potential dangers of these modalities."

The task force recommended and the Board approved the creation of the Committee on Complementary and Alternative Medicine in October 1999. During the last year, the committee has been responding to its mandate to identify, define, gather, evaluate and disseminate information about CAM as it relates to musculoskeletal care. Committee members have engaged in an extensive process of educating themselves so that they can carry meaningful advice to the Fellows of the Academy, and through them to our patients.

The CAM Committee presented a symposium at the 2001 Annual Meeting in San Francisco, moderated by Harris Gellman, MD, a CAM Committee member, who has particular knowledge of, and expertise with, acupuncture. The committee has also reviewed the Arthritis Foundation’s Guide to Alternative Therapies, which is available for sale through the AAOS. The medical editor of that book, William Arnold, MD, is a consultant member of our committee.

Plans for 2001-2002 include:

There is a vast amount of information about CAM. Much of it is in the lay press, anecdotal and highly subjective. Yet, through considerable public funding, there is evolving a considerable body of CAM research that is peer-reviewed and evidence-based. Our committee will follow the evidence. We are learning, sometimes to our surprise, that the evidence suggests value and efficacy in areas with which orthopaedic surgeons are unfamiliar.

We will approach our charges with objectivity. The committee recognizes the powerful social and cultural forces that are demanding recognition of CAM. We acknowledge the influence of CAM upon our practices and our patients. However, we will be guided by science as we survey and report the evidence about complementary and alternative medicine.

We accept the editorial challenge of Marcia Angell, MD, and Jerome Kassier, MD, in the New England Journal of Medicine (Sept. 17, 1998) that "There can not be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work."

Today there are two kinds of medicine—that which has good research-based evidence to support its efficacy, and that which does not. I have been humbled to learn that there is good research- based evidence to demonstrate the efficacy of about 30 percent of the treatment modalities which we use in allopathic medicine—just about the same as the percentage of CAM modalities for which there is such evidence.

CAM is medically, culturally, socially, economically, legally and ethically fascinating. We hope you will follow us as we pursue the evidence.

Did you know?

John W. Wickenden, MD is chairman of the Complementary and Alternative Medicine Committee


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