I’ve been meaning to write this post for a long time, and [...]]]> I am constantly struggling with which of the words in the title to choose when labeling posts and therapies (and the entire blog for that matter). Turns out I am not the only one – there is a lot of confusion surrounding these terms.

I’ve been meaning to write this post for a long time, and was reminded of it again recently when I was contacted by Brooke Marsh, an Animal Physiotherapist in Australia, who disagreed with my choice of “Alternative” in the title of the list of Australian practitioners, saying it was inaccurate. Her reason for this was that, and I quote, “Physiotherapy in Australia is considered complementary medicine as opposed to alternative as we are so strong in evidence practice.”

I thought that was very interesting and, in order to clarify things for myself, set out on a hunt for the definite definition of each of these terms. But it wasn’t that easy – there doesn’t seem to be any clear definitions. And to make things even more confusing, some are used slightly differently in different parts of the (English speaking) world.

I did make a few useful discoveries, and thought I’d share them here, and perhaps also start a bit of a discussion. What do you call the modality (-ies) you practice?

First, I looked for the definition of alternative medicine in the US, it is most often used in conjunction with complementary medicine, and the whole things is abbreviated CAM (more on that further down). But I did find a few separate definitions:

According to the Oxford English Dictionary, alternative medicine is “medical practice encompassing various techniques regarded as unorthodox or scientifically untested by practitioners of conventional Western medicine”

The Centers for Disease Control and Prevention (CDC) defines alternative medicine as: “health care other than conventional, scientifically tested, medicinal treatment; includes herbal remedies, yoga, meditation, acupuncture, and other practices intended to maintain or improve health.” However, they do not have a definition for complementary medicine.

Princeton’s worldnet web search engine offers the following definition of alternative medicine: “the practice of medicine without the use of drugs; may involve herbal medicines or self-awareness or biofeedback or acupuncture.”

According to NIH’s National Center for Complementary and Alternative medicine (NCCAM), “alternative medicine refers to the use of approaches that are not part of conventional medicine as replacements for, rather than complements to, conventional treatment.”

Dr. Weil says: “Any therapy that is typically excluded by conventional medicine, and that patients use instead of conventional medicine, is known as “alternative medicine.” It’s a catch-all term that includes hundreds of old and new practices ranging from acupuncture to homeopathy to iridology. Generally alternative therapies are closer to nature, cheaper and less invasive than conventional therapies, although there are exceptions. Some alternative therapies are scientifically validated, some are not.”

In The UK
In the UK, an alternative therapy is a scientifically unproven modality that is used instead of conventional Western medicine (examples can be special diets such as Gerson therapy, or supplements like Shark Cartilage). Complementary therapies are used together with conventional medicine (massage therapy, acupuncture, yoga, etc. fall under this classification).

As classified by the House of Lords Science and Technology Select Committee, Alternative disciplines “Embraces those other disciplines which purport to offer diagnostic information as well as treatment and which, in general, favour a philosophical approach and are indifferent to the scientific principles of conventional medicine, and through which various and disparate frameworks of disease causation and its management are proposed. These therapies can be split into two sub-groups. Group 3a includes long-established and traditional systems of healthcare such as Ayurvedic medicine and traditional Chinese medicine. Group 3b covers other alternative disciplines which lack any credible evidence base such as crystal therapy, iridology, radionics, dowsing and kinesiology.”

They also separate out what they describe as “Professionally organised alternative therapies” which is defined: “Therapies that may be called the principal disciplines, two of which, osteopathy and chiropractic, are already regulated in their professional activity and education by Acts of Parliament. The others are acupuncture, herbal medicine and homeopathy. These therapies claim to have an individual diagnostic approach and are considered to be the ‘Big 5′ by most of the CAM world.”

AUSTRALIA
Similarly, in Australia, alternative therapies are used instead of Western medicine and have not been tested (examples include ozone therapy, magnet therapy, microwave therapy, coffee enemas, etc.).

As we saw above, everybody seems to be in agreement that a therapy (and indeed many alternative therapies) is considered complementary medicine when it is used alongside conventional Western medicine, but again, definitions vary.

The Oxford English Dictionary defines complementary medicine as: “Designating or pertaining to medicine seen by its practitioners as complementary to traditional or orthodox medicine but not based on modern scientific knowledge and not recognized by the majority of medical practitioners. “

In Princeton’s worldnet web, complementary medicine is defined as “the practice of medicine that combines traditional medicine with alternative medicine.”

NCCAM states” The term complementary medicine refers to a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine. Complementary medicine includes natural products, such as dietary supplements, herbs, and probiotics, as well as mind and body practices, such as meditation, chiropractic, acupuncture, and massage.”

The American Social Health Association describes complementary medicine as “Non-mainstream health care provided in addition or instead of standard medical practice. See also Alternative Medicine.”

According to the University of Texas’ MD Anderson Cancer Center, complementary medicine is “Practices often used to enhance or complement standard treatments. They generally are not recognized by the medical community as standard or conventional medical approaches. Complementary medicine may include dietary supplements, megadose vitamins, herbal preparations, special teas, acupuncture, massage therapy, magnet therapy, spiritual healing and meditation.”

In the UK:
“Complementary medicine: Non-biomedical healing traditions such as herbalism, acupucture or aromatherapy founded on principles other than modern science, e.g. humoral balance or energy meridians.”

From the BMJ (formerly the British Medical Journal): “Complementary medicine refers to a group of therapeutic and diagnostic disciplines that exist largely outside the institutions where conventional health care is taught and provided.”

Prof. Edzard Ernst (retired from Exeter University), the world’s first professor of complementary medicine, offers the following definition: “Complementary medicine is diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine”

The House of Lords Science and Technology Select Committee defines Complementary therapies as follows: “Therapies which are most often used to complement conventional medicine and do not purport to embrace diagnostic skills. It includes aromatherapy; the Alexander Technique; bodywork therapies, including massage; counselling; stress therapy; hypnotherapy; reflexology and probably shiatsu; meditation and healing.”

AUSTRALIA
In Australia, complementary therapies are used in conjunction with Western medicine and have been scientifically proven to be effective. Examples include acupuncture, chiropractic, homeopathy, chiropractic, meditation, and somewhat surprisingly (to me anyway) music therapy, etc.

From the Australian Government, Department on Health and Ageing: “complementary medicine – therapeutic goods consisting wholly or principally of one or more designated active ingredients, each or which has a clearly established identity and traditional use OR any other use prescribed in the regulations” Designated active ingredients are: amino acid;
charcoal; choline salt; essential oil; plant or herbal material (or a synthetically produced substitute for material of that kind), including plant fibres, enzymes, algae, fungi, cellulose and derivatives of cellulose and chlorophyll; homoeopathic preparation; a microorganism, whole or extracted, except a vaccine; a mineral including a mineral salt and a naturally occurring mineral; a mucopolysaccharide; non-human animal material (or a synthetically produced substitute for material of that kind) including dried material, bone and cartilage, fats and oils and other extracts or concentrates; a lipid, including an essential fatty acid or phospholipid; a substance produced by or obtained from bees, including royal jelly, bee pollen and propolis; sugar, polysaccharide or carbohydrate; a vitamin or provitamin”

From The (Australian) National Institute of Complementary Medicine (NICM): “There is no universally agreed definition of complementary medicine. Nomenclature varies, with terms including complementary, alternative and traditional medicine. The NICM definition uses the term complementary medicine as including the concepts of:

• Complementary medicine (as in health and medical systems, practices and products not currently recognised as a part of conventional or mainstream western medicine practiced by medical doctors, nurses and allied health professionals);
• Alternative medicine (complementary medicine used in place of mainstream western medicine);
• Traditional medicine (indigenous medicines and practices); and
• Integrative medicine (complementary medicine used together with mainstream western medicine).

Also from NICM: “Complementary Medicine (CM) is an inclusive term that incorporates Complementary Medicines and Complementary Therapies (Modalities / Systems). The term complementary medicine is considered to be inclusive of historically used names such as alternative medicine, natural medicine and traditional medicine. CM is concerned with both the maintenance of wellness and the treatment of illness.”

Melbourne Holistic Health: “Complementary medicine (CM) generally refers to a wide range of health care practices that do not use drugs or invasive techniques. Treatments may include herbal medicines, homoeopathic medicines or nutritional and other supplements. In Australia, the common complementary therapies practiced are: naturopathy, herbal medicine, homoeopathy, acupuncture and Chinese Medicine, aromatherapy, all of the massage therapies, osteopathy and chiropractic. These disciplines generally share a common belief in the holistic philosophy of health, and the principles associated with this.”

In light of what we have seen so far, I think the term CAM makes great sense, because it really sounds like you could be practicing the exact same therapy and it would be called ‘alternative” if the owner does not also have their animal treated with conventional medicine, and “complementary” if they do. Of course, we all know that pet owners need to check with their vet before starting any other therapy, but theoretically speaking… So how is CAM defined?

According to NIH (NCCAM), “Defining CAM is difficult, because the field is very broad and constantly changing. NCCAM defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between CAM and conventional medicine are not absolute.”

They also list what they consider types of CAM:

• Natural Products (herbs, probiotics, certain vitamins, etc.)
• Mind & Body medicine (meditation, acupuncture, yoga, deep-breathing exercises, guided imagery, hypnotherapy, progressive relaxation, qi gong, and tai chi)
• Manipulative and body-based practices (spinal manipulation and massage therapy)
• Other (which includes Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, Trager psychophysical integration, magnet and light therapy, qi gong, Reiki, and healing touch). “Other” also covers what NCCAM calls “whole medical systems”, and this group includes Ayurvedic medicine, traditional Chinese medicine, homeopathy and naturopathy.

The Cochrane Collaboration defines CAM as: “a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period”.

The WHO states: “The terms “complementary medicine” or “alternative medicine” are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system.”

The American Veterinary Medical Association (AVMA) has the following to say about Complementary and Alternative Veterinary Medicine (CAVM): “The identification of standard and broadly accepted definitions applicable to CAVM, including the definition of CAVM itself, is challenging.” and have developed a set of guidelines: “These guidelines identify CAVM as a heterogeneous group of preventive, diagnostic, and therapeutic philosophies and practices. The theoretical bases and techniques of CAVM may diverge from veterinary medicine routinely taught in North American veterinary medical schools or may differ from current scientific knowledge, or both. It is not the intent of these guidelines to determine or describe the relative value of the individual modalities. The evidence pertaining to, and the practice of, individual CAVM modalities differ. Current examples of CAVM include, but are not limited to, aromatherapy; Bach flower remedy therapy; energy therapy; low-energy photon therapy; magnetic field therapy; orthomolecular therapy; veterinary acupuncture, acutherapy, and acupressure; veterinary homeopathy; veterinary manual or manipulative therapy (similar to osteopathy, chiropractic, or physical medicine and therapy); veterinary nutraceutical therapy; and veterinary phytotherapy.”

In the UK
The Committee for Complementary Medicine of The House of Lords states “Complementary and Alternative Medicine (CAM) is a title used to refer to a diverse group of health-related therapies and disciplines which are not considered to be a part of mainstream medical care. Other terms sometimes used to describe them include ‘natural medicine’, ‘non-conventional medicine’ and ‘holistic medicine’. However, CAM is currently the term used most often. CAM embraces those therapies that may either be provided alongside conventional medicine (complementary) or which may, in the view of their practitioners, act as a substitute for it. Alternative disciplines purport to provide diagnostic information as well as offering therapy.”

It is worth noting that The Committee defines Massage and Aromatherapy as ‘complementary’ because they ‘do not purport to embrace diagnostic skills’.

The British Medical Association states “In the 1970s and 1980s, Complementary and alternative medicine (CAM) therapies were viewed mostly as being alternative to conventional health care and were often described as ‘alternative medicine’. The term ‘complementary medicine’ developed as CAM therapies began to be used more alongside and in conjunction with orthodox medical treatment, for example acupuncture, osteopathy and chiropractic. By contrast, ‘alternative’ therapies could be seen as those given in place of conventional medical treatment, such as herbal medicine, which may be used as an alternative to conventional drugs. Most CAM appears to be supplementary or additional to conventional care, rather than an alternative. The distinction between complementary and alternative is, however, problematic. Most forms of CAM can, in some circumstances, be used as an alternative or a supplementary form of treatment.”

AUSTRALIA
The Medical Journal of Australia quotes NIH (NCCAM)’s definition “healthcare practices that are not an integral part of conventional medicine. As diverse and abundant as the peoples of the world, these practices may be grouped within five major domains: alternative medical systems; mind-body interventions; biologically-based treatments; manipulative and body-based methods; and energy therapies” but “as CAM is increasingly included in the teaching programs in medical schools and in medical practice, this distinction is becoming problematic. Further, the diversity of practices included under the rubric of CAM lessens its usefulness as a definition.”

They continue: “All the CAM groups subscribe, in one way or another, to the principle of “vitalism” — that all living organisms are sustained by a vital force that is both different from and greater than physical and chemical forces. There are numerous ways of expressing this vitalism (Qi, life force, yin-yang, prana, universal intelligence, innate, etc). However, it should be noted that many of the therapies of the traditional paradigms have been incorporated into current practice without adopting vitalistic principles. Even within particular CAM groups there are both weaker and stronger versions of vitalism. In the extreme form the vital force is supernatural, while the more moderate form assumes vis medicatrix naturae (“the healing power of nature”), and the physician merely facilitates this. Such a position contrasts with materialism, which holds that disease can be explained entirely in terms of materialistic factors (usually biological ones in the case of biomedicine), so there is no need to invoke vitalistic forces. Vitalism leads to a different philosophy about health, healthcare and the role of the healthcare provider. It is the basis of the claim that biomedicine and CAM are distinct paradigms.”

The issue of what to call the CAM group has important social and political ramifications. To term the group of modalities alternative may be to claim too much for their role in healthcare, but to term them complementary may make their role seem secondary to primary medical care. To call them integrative implies some process in which integration or convergence will eventually occur. Last, but not least, to define them in terms of “otherness” – that is, by what they are not (as in “not taught in medical schools” or “not practised by conventional medicine”) – is arguably useless. We do not define allopathic medicine by what it is not.

Interesting point.

Another acronym is eCAM which stands for evidence-based complementary and alternative medicine. As the name implies, it is an evidence-based approach, and such research is being done by agencies like the U.S. Department of Health and Human Services Agency for Healthcare and Research Quality (AHRQ). The WHO is working on setting up guidelines for and promoting the use of evidence-based traditional medicine / CAM, and publications like the Evidence-based Complementary and Alternative Medicine Journal (Oxford University) and the Journal of Evidence-Based Complementary & Alternative Medicine (JEBCAM) are publishing peer-reviewed papers from medical professionals that focuses on the results of contemporary Western medicine-style research and clinical trials of alternative and complementary therapies.

A lot of information, some conflicting, some not. I contacted the American Holistic Veterinary Medical Association (AHVMA) to see what their take was on all this, and Nancy Scanlan, Executive Director of AHVMA, replied “Actually, we are getting away from the term “Alternative,” but there are still veterinarians who use the term, because they view it as an alternative to what they do. The whole idea of “holistic” or “complementary” or “integrative” medicine is that you take the best of all methods of treating a patient, including some methods not currently part of the whole veterinary curriculum. So the best term is either “complementary” or “integrative.”

So what’s the conclusion of all this? Lots of overlap, no clear definitions, just guidelines which also vary quite a bit. There will be a part 2 to this post, where we take a look at “holistic”, “integrative”, “traditional”, “allopathic” and “conventional” medicine, so stay tuned!