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Complementary and Integrative Health

Introduction

Complementary and integrative health (formerly referred to as complementary and alternative medicine) generally consists of products and practices that are not currently part of "mainstream" medicine. By referring to "health" instead of "medicine," the new term reflects the emphasis within this field on patient empowerment, preventive self-care, and wellness, in place of a reliance on medical treatment and intervention.

According to the National Center for Complementary and Integrative Health of the National Institutes of Health, more than 30 percent of American adults and about 12 percent of children use health care approaches developed outside of mainstream conventional medicine.

Technically, complementary health is used along with standard medical care, and alternative medicine is used in place of standard care. Integrative medicine refers to care that blends both mainstream and alternative practices.

The boundaries between complementary and integrative medicine and conventional medicine are not absolute, and specific practices in this area may, over time, become widely accepted.

Most complementary health approaches fall into one of two subgroups: natural products, which include herbs, vitamins and minerals, and probiotics; and mind and body practices such as yoga, meditation, massage therapy, acupuncture, and relaxation techniques.

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Selected Major Accomplishments

  • 2006: Learned that glucosamine and chondroitin sulfate, taken either alone or in combination, do not reduce pain effectively in patients with osteoarthritis of the knee
  • 2011: Reported that 90 percent of VA facilities offered complementary or integrative medicine therapies, or referred Veterans to licensed practitioners
  • 2014: Found that Vitamin E, an inexpensive treatment, can significantly delay functional decline among patients with mild to moderate Alzheimer's disease
  • 2015: Learned that mindfulness therapy may be more effective than standard group therapy in treating PTSD

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    New, Ongoing, and Published Research

    In VA, complementary and integrative health approaches are most commonly used to help Veterans manage stress, or to promote general wellness. They are also often used to treat posttraumatic stress disorder (PTSD), depression, back pain, headache, arthritis, fibromyalgia (long-term pain throughout the body), and substance abuse.

    One of the greatest challenges in this area of medicine is critically examining popular claims about the effectiveness of therapies that have not been rigorously tested in formal research. VA researchers are committed to filling in scientific gaps. They are conducting studies to determine which therapies are truly safe and effective, and for which conditions and populations they work best.

    ➤Integrative mental health treatments

    Mindfulness meditation—In 2015, a study of mindfulness meditation was found to be more successful than standard group therapy in treating PTSD. In the study, researchers with the Minneapolis VA Health Care System gave 58 Veterans nine sessions of mindfulness-based stress reduction therapy. This type of therapy focuses on teaching patients to attend to the present moment in a nonjudgmental, accepting manner.

    Another 58 Veterans received nine weekly group therapy sessions focused on current life problems. Two months after the sessions were completed, nearly half (48.9 percent) of those in the meditation group reported clinically significant improvement in the severity of their PTSD symptoms, compared with 28 percent of those who received group therapy. The study was published in the Journal of the American Medical Association (JAMA).

    Breathing meditation—Researchers at the VA Palo Alto Health Care System are enrolling Veterans with PTSD for a study comparing cognitive processing therapy with a breathing mediation technique called Sudarshan Kriya yoga. This form of yoga offers practical breath-based tools that, according to the study website, "decrease the stress, anxiety, and sleep problems that many returning Veterans experience."

    Mantram meditation—A 2016 study looked at the "mantram" form of meditation, a simple technique in which Veterans silently repeat a word or phrase that holds personal meaning for them. The study, involving 273 Veterans at six sites, was led by VA and University of California, San Diego, researchers. It evaluated the effectiveness of mantram repetition on depression, anxiety, and somatization (the phenomenon whereby psychological distress is expressed through physical symptoms).

    The team also looked at two different ways facilitators are trained to teach mantram meditation. They found that with either approach, Veterans using the technique showed significant improvements in all outcomes, and that Veterans were highly satisfied with the experience.

    Yoga treatment—In a 2015 study, researchers established the feasibility of using yoga to treat PTSD and depression symptoms in women Veterans who experienced military sexual trauma. This study of 42 female Veterans was conducted at the Atlanta VA Medical Center. The trauma-sensitive yoga treatment showed a trend toward reducing PTSD, depression, and chronic pain symptoms. The researchers are now conducting a larger, four-year trial to test the effectiveness of this treatment.

    Vitamin E supplements to treat Alzheimer's—In the Jan. 1, 2014, issue of JAMA, a VA research team reported that taking supplemental vitamin E significantly delayed the decline of cognitive functioning in patients with mild to moderate Alzheimer's disease. The five-year study showed that the vitamin added, on average, six months of better cognitive functioning for patients with this progressive disease.

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    ➤Complementary and integrative health care for pain

    Cost-effectiveness study—VA researchers are studying whether complementary and integrative health treatments are a cost-effective way to treat musculoskeletal-related pain in Veterans. By examining the extent of complementary and integrative health use and how much these treatments cost, the researchers hope to better understand how alternative treatment can be integrated into VA care.

    Improving pain management quality—A James A. Haley Veterans’ Hospital study aims to establish ways to assess complementary health approaches to pain management. VA currently uses a stepped-care model of pain management to document care. However, complementary health treatments are not easily coded into this system. By finding ways to assess new treatments, VA hopes to improve the management of integrated pain care.

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    ➤Expressive writing and reintegration

    In a 2015 study of nearly 1,300 returning Veterans reporting problems reintegrating into society, those who completed online expressive-writing sessions showed more improvements than their peers who had either not written at all or had engaged only in factual writing.

    The study was led by researchers from the Minneapolis VA Health Care System, VA's National Center for PTSD, and the University of Minnesota. Compared with no writing at all, expressive writing was better at reducing PTSD symptoms. It was also better than no writing for reducing anger, distress, reintegration problems, and physical complaints, and for improving social support. In terms of improving overall life satisfaction, no difference was seen between the study arms.

    Those in the two writing groups wrote for at least 20 minutes on up to four separate days within a 10-day period. The expressive writing group wrote about their thoughts and feelings relating to their transition from soldier to civilian, and the factual writing group wrote about the information needs of new Veterans.

    The team believes that this simple intervention may be a promising strategy for improving symptoms and functioning among Veterans who have had trouble reintegrating after their discharge.

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    ➤Transcranial magnetic stimulation

    VA researchers are looking at the potential benefits of transcranial magnetic stimulation (TMS) for a variety of conditions involving the brain. In TMS, clinicians take an electromagnetic coil, charge it with electricity, and apply it to specific points on the skull. The result is a targeted magnetic field that can affect brain cells in a specific area.

    TMS for persistent headaches—TMS is FDA-approved for major depression that doesn't respond to other treatments, and for certain types of migraines. In 2015, researchers at the VA San Diego Healthcare System studied 24 Veterans who had persistent daily headaches as a result of head trauma. Half received TMS three times within a week, and the other half got a sham treatment.

    In assessments a week later, about 58 percent of the real-treatment group showed at least a 50 percent reduction in headache intensity, versus only 17 percent of the sham group. After four weeks, the real-treatment group continued to show greater improvement.

    TMS for tinnitus—In another 2015 TMS study, researchers at the VA Portland Health Care System and Oregon Health and Science University found that TMS significantly improved tinnitus symptoms for more than half of those participating in a recent study.

    People with tinnitus hear a persistent sound that can range from ringing or buzzing to a hissing or white noise hum, when there is no external sound source. The distraction can impair people's ability to sleep or concentrate, and is sometimes disabling.

    The 64 participants enrolled in the study received either 2,000 pulses per session of TMS or a placebo for 10 consecutive workdays. Six months later, 56 percent of those receiving TMS were shown to have responded to the treatment, compared with 22 percent of those in the placebo group.

    The investigators assert that before this procedure can be clinically implemented, larger studies should be conducted to refine treatment protocols.

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    ➤Exploring integrative cancer treatments

    Curcumin, a key compound in the spice turmeric, is being explored for its anti-cancer activity. A lab team at the Atlanta VA Medical Center and Georgia State University, working with collaborators in China, reported in 2015 on a combination chemotherapy drug containing curcumin and campothecin, a compound derived from the bark and stems of the "happy tree," a tree native to China and Tibet. The team delivered the synergistic combination to colon cancer cells via a nanoparticle, which they say could prove to be viable way to target cancer cells without damage to other tissues.

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    ➤Complementary treatment for gastrointestinal issues

    Fecal transplants—In 2015, VA researchers and researchers with the University of Minnesota looked at a procedure that dates back thousands of years and found it can be an effective method for battling C. difficile infections. The procedure, called fecal transplantation, involves removing stool containing healthy bacteria from a donor and inserting it into a sick patient.

    The investigators' review looked at the results of studies involving data for more than 500 patients with C. difficile infections, and learned that fecal transplantation proved successful in treating 85 percent of patients with recurring infections. The researchers concluded that such transplantation is a safe and effective way to treat recurrent infections.

    Ginger nanoparticles—Ginger nanoparticles may soothe inflammatory bowel disease, according to researchers with VA and the Institute for Biomedical Sciences at Georgia State University. They have developed "edible ginger-derived nanoparticles" that they believe may be good medicine for Crohn's disease and ulcerative colitis, the two main forms of inflammatory bowel disease. The particles may also help fight cancer linked to colitis, according to experiments in mice.

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    ➤Uses of resveratrol

    Resveratrol is an antioxidant that's abundantly found in red grapes. Evidence suggests it can fight cancer, boost heart health, ease diabetes, and protect brain cells, among other benefits.

    When taken in isolation outside of a whole food, however, the compound is very poorly absorbed by the body. It is rapidly metabolized and excreted through urine.

    Pairing resveratrol with piperine—Researchers at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, and the University of Wisconsin are studying how to harness natural compounds to combat cancer. They have demonstrated that pairing resveratrol with piperine, the alkaloid that gives black pepper its pungency, can boost levels of resveratrol in the blood. The team is now analyzing results from a clinical trial they conducted on the subject.

    While supplement companies are already marketing products that include both resveratrol and piperine, the team cautions that until more preclinical and clinical studies are done, including long term studies, they cannot recommend that people try these supplements.

    Instead, they suggested in a 2015 article, it may be a better strategy for disease prevention and wellness to consume whole grapes instead of isolating specific chemicals found in them, whereas isolating these chemicals may be more effective in dealing with existing disease.

    Using resveratrol with brain electrodes—Other VA researchers, at the Advanced Platform Technology Center in Cleveland, are conducting animal experiments to test whether resveratrol can boost the performance of brain electrodes. Previous VA studies have shown that giving resveratrol and other antioxidants to stop inflammatory responses in the brain may extend the viability of implanted electrodes over time.

    The findings might benefit the work of other VA researchers who are developing brain-computer interfaces, using tiny electrodes implanted in the motor cortex, that enable people to move computer cursors with their thoughts, or to control robotic prosthetic limbs—or even their own paralyzed limbs. The work holds promise for those with spinal cord injury, stroke, ALS, traumatic brain injury, Parkinson's disease, and other conditions.

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    ➤Maggot therapy

    Although the healing properties of maggots have been written about since ancient times, the first therapeutic use of maggots is credited to Dr. J.F. Zacharias, a Confederate medical officer. Zacharias reported he had "saved many lives" by using maggots to clean wounds, and that they were "much better than any agents we had at our command for the task."

    In 2004, the U.S. Food and Drug Administration (FDA) granted permission to produce and market maggots for use in humans or animals as a prescription-only medical device for conditions including pressure ulcers, neuropathic foot ulcers, and non-healing traumatic or post surgical wounds. Now, researchers at the Malcolm Randall VA Medical Center in Gainesville, Fla., are testing how maggots—or larvae, as researchers prefer to call them—compare to standard wound-care treatment.

    Treating chronic diabetic ulcers with maggots—The study involves Veterans with chronic diabetic ulcers on their feet. The maggots being used are contained in fine mesh bags, have been sterilized in a laboratory, and are removed after a few days. The researchers are examining how well the wounds heal in each study group, and will also look at maggots' effects on harmful bacteria, which the larvae are known to ingest.

    Both groups in the study will receive treatment over the course of eight days. The team will also survey caregivers and clinical providers to learn more about their experience with the therapy. The research team also hopes that maggot therapy will catch on as an evidence-based way to treat other types of wounds, including deep skin wounds incurred in combat.

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    ➤Value of exercise

    Based on countless studies over decades, nearly all health care professionals believe that exercise poses significant health benefits. The health benefits of regular exercise and physical activity include weight control, improvements in mood, energy boosts, and better sleep.

    How exercise affects the brain—Exercise can also combat health conditions and diseases, including cardiovascular disease, stroke, and depression. Two researchers from the VA Palo Alto Health Care System and Stanford University are conducting a study to determine just what it is about exercise that is so beneficial to the brain—in the belief that pinpointing these mystery factors might help prevent common aging-related diseases such as Alzheimer's.

    According to the researchers, during exercise muscles secrete molecules that are beneficial to the body and the brain. Within those molecules are hormones, growth factors, and small proteins called cytokines that are integral for cell signaling.

    The study will be the first systematic attempt to tie these molecules to their specific effects on the brain and cognition. Investigators will take blood from an exercised animal and inject it into an unexercised animal, in hopes of seeing positive effects. They will then analyze the blood to see what factors are responsible for the changes.

    Exercise and Parkinson's disease—A 2014 study by researchers with the Iowa City VA Health Care System and other sites found that 60 patients with Parkinson's disease who walked briskly for 45 minutes three times a week for six months showed improvements in their Parkinson's symptoms. They were also less depressed and less tired than they had been before.

    The participants' motor function and mood improved by an average of 15 percent. Their tiredness was reduced by 11 percent, and their attention and response control improved by 14 percent.

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    More on Our Website

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    Selected Scientific Articles by Our Researchers

    Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, Bradley JD, Bingham CO 3rd, Weisman MH, Jackson CG, Lane NE, Cush JJ, Moreland LW, Schumacher HR Jr., Oddis CV, Wolfe F, Molitor JA, Yocum DE, Schnitzer TJ, Furst DE, Sawitzke AD, Shi H, Brandt KD, Moskowitz RW, Williams HJ. Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain. N Engl J Med. 2006 Feb 23;354(8):795-808.

    Vitamin D3 supplementation at 4000 international units per day for one year results in a decrease of positive cores at repeat biopsy in subjects with low-risk prostate cancer under active surveillance. Marshall DT, Savage SJ, Garrett-Mayer E, Keane TE, Hollis BW, Horst RL, Ambrose LH, Kindy MS, Gattoni-Celli S. Patients with low-risk prostate cancer under active surveillance may benefit from vitamin D(3) supplementation at 4000 international units per day. J Clin Endocrinol Metab. 2012 Jul;97(7):2315-24.

    Vitamin E, Memantine, and Alzheimer disease. Dysken MW, et al. Vitamin E can slow functional decline and decrease caregiver burden in patients with mild to moderate Alzheimer's disease. JAMA 2014 Jan 1;311(1):33-44

    Phase I/II randomized trial of aerobic exercise in Parkinson disease in a community setting. Uc EY, Doerschug KC, Magnotta V, Dawson JD, Thomsen TR, Kline JN, Rizzo M, Newman SR, Mehta S, Grabowski TJ, Bruss J, Blanchette DR, Anderson SW, Voss MW, Kramer AF, Darling WG. In patients with mild to moderate Parkinson's disease, an aerobic exercise program improves aerobic fitness, motor function, fatigue, mood, executive control, and quality of life. Neurology. 2014 Jul 29;83(5):413-25.

    Spinal manipulative therapy for chronic lower back pain in older Veterans: a prospective, randomized, placebo-controlled trial. Dougherty PE, Karuza J, Dunn AS, Savino D, Katz P. Spinal manipulative therapy did not result in greater improvement of chronic lower back pain in older Veterans, but it did demonstrate a slightly greater improvement in disability. Geriatr Orthop Surg Rehabil. 2014 Dec;5(4):154-64.

    Fecal microbiota transplantation for Clostridium difficile infection: a systematic review. Drekonja D, Reich J, Gezahegn S, Greer N, Shaukat A, MacDonald R, Rutks I, Wilt TJ. Fecal microbiota transplantation may have a substantial effect with few short-term adverse events for recurrent C. difficile infection. Ann Intern Med. 2015 May 5;162(9):630-8.

    Aspirin blocks growth of breast tumor cells and tumor-initiating cells and induces reprogramming factors of mesenchymal to epithelial transition. Malty G, De A, Das A, Banerjee S, Sarkar S, Banerjee SK. Aspirin not only prevents breast tumor cell growth in vitro and tumor growth in nude mice models, but also significantly reduces the self-renewal capacity and growth of breast tumor-initiating cells and delays the formation of a palpable tumor. Lab Invest. 2015 Jul;95(7):702-17.

    Repetitive transcranial magnetic stimulation treatment for chronic tinnitus: a randomized clinical trial. Folmer RL, Theodoroff SM, Casiana L, Shi Y, Griest S, Vacchani J. Application of repetitive transcranial magnetic stimulation treatment daily for 10 consecutive workdays resulted in a statistically significant greater percentage of improvement compared to a placebo for individuals who experience chronic tinnitus. JAMA Otolaryngol Head Neck Surg. 2015 Aug;141(8):716-22.

    Mindfulness-based stress reduction for posttraumatic stress disorder among Veterans: a randomized clinical trial. Polusny MA, Erbes CR, Thuras P, Moran A, Lamberty GJ, Collins RC, Rodman JL, Lim KO. Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect. JAMA. 2015 Aug 4;314(5):456-65.

    Honokiol inhibits the growth of head and neck squamous cell carcinoma by targeting epidermal growth factor receptor. Singh T, Gupta NA, Xu S, Prasad R, Velu SE, Katiyar SK. The chemotherapeutic effect of honokiol against head and neck squamous cell carcinoma is better than gifitinib, a commonly used drug for treating this cancer. Oncotarget. 2015 Aug 28;6(25):21268-82.

    Resveratrol, in its natural combination in whole grape, for health promotion and disease management. Singh CK, Liu X, Ahmad N. The grape fruit, or whole-grape products, seem to be safer choices for better health and disease prevention. However, for advanced disease conditions, individual grape ingredients or combinations of multiple ingredients appear to be better approaches. Ann NY Acad Sci. 2015 Aug; 1348(1):150-60.

    Randomized controlled trial of online expressive writing to address readjustment difficulties among U.S. Afghanistan and Iraq War Veterans. Sayer NA, Noorbaloochi S, Frazier PA, Pennebaker JW, Orazem RJ, Schnurr PP, Murdoch M, Carlson KF, Gravely A, Litz BT. Online expressive writing holds promise for improving health and functioning among Veterans experiencing reintegration difficulty. J Trauma Stress. 2015 Oct;28(5):381-90.

    Co-delivery of camptothecin and curcumin by cationic polymeric nanoparticles for synergistic colon cancer combination chemotherapy. Xiao B, Si X, Han MK, Viennois E, Zhang M, Merlin D. The study is the first report of a combinational application of chitosan-functionalized camptothecin and curcumin, with a one-step-fabricated co-delivery system for effective colon cancer combination chemotherapy. J Mater Chem B Mater Biol Med. 2015 Oct 21;3(39):7724-7733.

    Repetitive transcranial magnetic stimulation in managing mild traumatic brain injury-related headaches. Leung A, Shukla S, Fallah A, Song D, Lin L, Golshan S, Tsai A, Jak A, Polston G, Lee R. Repetitive transcranial magnetic stimulation appears to be a clinically feasible and effective treatment option in managing mild traumatic brain injury-related headache. Neuromodulation, 2015 Nov 10. (Epub ahead of print.)

    Therapeutic intervention of proanthocyanidins on the migration capacity of melanoma cells is mediated through PGE2 receptors and β-catenin signaling molecules. Vaid M, Singh T, Prasad R, Kappes JC, Katiyar SK. New understandings of the anti-melanoma cell migration activity of grape seed proanthocyanidins could serve as the basis for therapeutic approach against malignant melanoma in high risk individuals. Am J Cancer Res. 2015; 5(11): 3325-3338.

     

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    Complementary and Integrative Health

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