By Julie A. Dodds, MD
The popularity of Complementary and Alternative Medicine (CAM) has brought new terms such as "naturopath" and "homeopath" to the vocabulary of many patients seeking care for musculoskeletal problems. The general scope of practice of chiropractors and acupuncturists is familiar to most orthopaedic surgeons, but few are aware of the training and background of these providers.
As 40 percent of the patients receiving care from orthopaedic surgeons also are utilizing "complementary" forms of treatment, it is imperative that orthopaedic surgeons understand the training and regulation of the practitioners treating their patients. Following are summaries of the training and credentialing for health practitioners who most frequently utilize CAM treatments.
AcupuncturistAcupuncture originated in ancient China and is a method of pain control that utilizes the stimulation of "acupoints" by various methods. It is based on the theory that an essential life energy called "qi" flows through the body along invisible meridians. Stimulation of points along these meridians corrects the flow of qi to optimize health or block pain.
Acupuncturists can be certified by one of two methods. Educational training can include a formal, full-time educational program including 1,725 contact hours, with at least 1,000 didactic hours and 500 clinical hours or an apprenticeship program requiring 4,000 contact hours in a 3-6 year period. They also must have completed a "Clean Needle Technique" approved course. Medical doctors can complete 220 hours of training in acupuncture to be considered for board certification.
Certification for formally trained acupuncturists is through the National Certification Commission for Acupuncture and Oriental Medicine (www.nccaom.org). Medical doctors (MD, DO, or ECFMG certified) are certified through the American Academy of Medical Acupuncture and must possess a valid medical license.
As of January 2001, of the 40 states that regulate the profession of acupuncture, 37 required NCCAOM certification for licensure. Organizations representing the profession are the American Association of Oriental Medicine (www.aaom.org) and the American Academy of Medical Acupuncture (www.medicalacupuncture.org).
Ayurvedic PractitionerAyurveda is a form of health care developed in ancient India that focuses on wellness and healthy living through diet, exercise, moderation and meditation. The practitioner is an advisor who suggests lifestyle and health practices to restore or optimize mental, physical and spiritual well-being. There are few ayurvedic practitioners in the United States. There is no U.S. national standard for certifying ayurvedic practitioners. Graduates of an Indian ayurvedic medical program will have a degree of BAMS (Bachelor of Ayurvedic Medicine and Surgery) or DAMS (Doctor of Ayurvedic Medicine and Surgery) granted by a qualified ayurvedic university in Asia.
ChiropractorChiropractic is based on the theory that misalignment of vertebrae is the cause of most neuromuscular and related functional diseases and disorders. It was developed in the United States in 1885. Chiropractors complete a four-year program at one of 17 accredited chiropractic colleges. While they mainly focus on musculoskeletal issues, they are also trained in general diagnostics and health promotion, utilizing nutrition, exercise and lifestyle modification in their practices. Certification is through the National Board of Chiropractic Examiners (www.nbce.org) and board exams are taken in parts, with Part I taken in the sophomore year of chiropractic school, and Part II in the junior or senior year. Chiropractors are licensed in all 50 states and many foreign countries. The initials DC or "Doctor of Chiropractic" will identify a licensed chiropractor. Chiropractors are neither licensed to perform surgery or to prescribe drugs. Their national professional organization is the American Chiropractic Association (www.amerchiro.org).
Chinese HerbalistsThe practice of Chinese medicine involves restoring balance to the body by various means. Preparations of herbs are prepared as pills, potions and liniments and are "prescribed" by herbalists in attempt to restore balance. Chinese herbalists may go through formal schooling at an accredited Oriental Medicine education program including 2,175 contact hours, 1,450 of which are didactic and 500 clinical. An apprenticeship program can also be completed with 4,000 contact hours in a 36 year period and a minimum of 500 patient visits by more than 100 patients each year of the apprenticeship.
Certification is through the National Certification Commission for Acupuncture and Oriental Medicine (http://www. nccaom.org/). No licensing is currently required in the United States to practice Chinese herbal medicine. The national organization of Chinese medicine is the American Association of Oriental Medicine (www.aaom.org).
HomeopathsHomeopathy was developed in the 18th century in Germany and is based on the theory that "like cures like." Miniscule amounts of natural substances such as herbs, minerals and animal products are used to induce the body of a sick person to heal an illness through their administration in a serially diluted preparation.
Three U.S. states (Ariz., Conn., Nev.) license homeopaths and they require a DO or MD degree as well as certification in the study of homeopathy. Minnesota also enacted the Complementary and Alternative Health Care Bill in July of 2001, which allows practitioners of complementary and alternative modalities to practice in the state with protective jurisdictions in place in case of harm and imminent risk of harm. While a board examination is offered by the National Board of Homeopathic Examiners (www.nbhe. com), it is not required for licensing. Certification is offered through the Council for Homeopathic Certification (www.homeopathicdirectory.com).
The national organization for homeopaths is the North American Society for Homeopathy (www.homeo pathy .org). Five hundred training hours in classical homeopathy or 2,000 hours of an apprenticeship are required for membership. Members of the American Institute of Homeopathy (www.homeopathyusa.org) are medical personnel and health profession students interested in or currently practicing homeopathy.
Massage TherapistsMassage is one of the most-used complementary therapies in the United States. In order to become certified, massage therapists must complete a minimum of 500 hours of supervised education in a formal therapeutic massage bodywork program. They may also be considered for certification after 100 hours of training in anatomy, physiology and kinesiology, 200 hours of formal education in bodywork and /or massage (including two hours of ethics), and 200 hours of related education or professional experience in bodywork or massage. Board certification is through the National Certification Board for Therapeutic Massage and Bodywork (www.ncbtmb.com) and is required for licensing in at least 20 of the 29 states that regulate massage therapists. The professional organization for massage therapists is the American Massage Therapy Association (www.amtamassage.org).
NaturopathsNaturopathy began in European spas in the 19th Century. The underlying principles of naturopathy revolve around encouraging healthy living habits and allowing the body to heal itself. Naturopathic physicians are noted for their expertise in nutrition. They frequently work with a physician or other health care provider. They can treat wounds and are trained in minor surgery.
Naturopathic physicians (NDs) undergo a four-year training program that includes nontoxic therapies such as homeopathy, clinical nutrition, manipulation, herbal medicine and hydrotherapy. They often may have additional training in Chinese medicine (acupuncture and herbs). Naturopaths are licensed in 12 U.S. states and their certification exam is administered by the North American Board of Naturopathic Examiners (www.nabne.org). Their professional organization is the American Association of Naturopathic Physicians (www.naturopathic.org).
Credentialing for CAM providers
Professional licensing and the regulation of CAM providers vary across the country and are each states choice. Some states have regulated certain CAM professionals by requiring licensure, certification or registration in order to legally practice in their states. Requirements for licensure may include graduation from an accredited training school, the acquisition of a minimum number of hours of training, examination and assessment of knowledge and practice techniques and knowledge of ethical and professional standards.
States may rely on multiple organizations to assist in their licensing process. Some may create licensing boards comprised of professionals in the field, legal advisors and government representatives to create licensing regulations, collect licensing and application fees and determine policies regarding suspension, renewal and professional behavior. In addition, national professional organizationssetting standards for training, curriculum hours and professional conductmay offer examinations to graduates preparing to enter practice. Acupuncturists, nutritional counselors, massage therapists, naturopaths and homeopaths are the professions most commonly regulated by the states.
The professional/occupational office of your states government should have credentialing information regarding each occupation it regulates. This information is offered on most state websites.
Julie A. Dodds, MD, is a member of the AAOS CAM Committee. She serves on the faculty at the College of Human Medicine Michigan State University in East Lansing, Mich.