Given the high complexity and lack of a definitive treatment to overcome the range of sequelae of traumatic brain injury (TBI), patients and families often turn to complementary therapies to assist in recovery from TBI. Complementary alternative medicine (CAM) can offer patients treatment options to assist in a variety of these sequelae, which include overall functional recovery, mental health issues (including anxiety and depression), fatigue, pain relief, and cognitive deficits. CAM therapies also offer a preventive approach in improving health and quality of life overall after a TBI.
Definitions
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CAM: According to the World Health Organization (WHO), it is defined as set of healthcare practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant healthcare system.
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Integrative medicine combines conventional and CAM treatments for which there is evidence of safety and effectiveness.
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Evidence-based medicine (EBM) is a systematic approach to clinical problem solving with three core principles:
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Awareness of best clinical evidence
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Individual expertise
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Patient values and expectation
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Given the high use of CAM among the general population, it is essential for the clinician to be aware of various CAM approaches and to use EBM to evaluate potential benefit or risk of CAM practices for persons with brain injury.
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The clinician must weigh the possible benefit versus any harms or risks associated with treatment and the overall cost. As a whole, large randomized control trials are lacking for CAM, so the clinician must use best EBM approaches in decision making.
Epidemiology
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As of 2007, 35.5% of adults are using some form of CAM.
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Natural products are the most commonly used CAM modality ( Fig. 57.1 ).
• Fig. 57.1
Centers for Disease Control and Prevention data of the most commonly used complementary and alternative medicine modalities in 2012.
(Adapted from Barnes PM, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;12:1-23.)
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CAM use is highest in American Indian/Alaska Native populations ( Fig. 57.2 ).
• Fig. 57.2
Complementary and alternative medicine use by race/ethnicity from 2002 to 2012, per National Health Statistics Reports.
(Adapted from Clarke TC, Black LI, Stussman BJ, et al. Trends in the use of complementary health approaches among adults: United States, 2002 – 2012. Natl Health Stat Report. 2015;79:1-16.)
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CAM use among adults is greater among women and those with higher levels of education and higher incomes, and use of CAM has been generally increasing over the past decade (from 2002 – 2012).
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Musculoskeletal complaints are the most common reason for use of CAM.
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In a national health survey in 2012, an estimated 59 million persons ages 4 years and older had at least one expenditure for some type of complementary health approach, resulting in total out-of-pocket expenditures of $30.2 billion.
Natural products
According to the Dietary Supplement Health and Education Act (DSHEA), dietary supplements are defined as a category of food, which puts them under different regulations than US Food and Drug Administration (FDA)–approved drugs. Examples include a wide variety of herbs, vitamins, minerals, and probiotics. They are considered safe until proven otherwise.
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The most commonly used natural product is fish oil.
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Manufacturers are not required to test new ingredients or supplements in clinical trials. There is no controlled system for reporting adverse reactions because natural products are usually self-prescribed. Moreover, products such as herbs can often be contaminated or contain a substance other than what is written on the label. In this way, herbal medicines can thus cause adverse effects; may not be safe during pregnancy, in children, or in the elderly; and may damage specific organ systems.
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There is limited evidence for use of omega-3 fatty acids, zinc, magnesium, creatine, and vitamins D, E, and B3 in TBI.
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Increased production of free radicals leading to oxidative stress can play a role in the pathogenesis of TBI, and treatment with antioxidants such as vitamin E can theoretically prevent tissue damage and improve outcome.
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Antiinflammatory supplements such as curcumin resveratrol and lipoic acid have been shown to reduce inflammation in animal models but not studied in clinical trials.
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Animal models have shown omega-3 fatty acids reduce reactive oxygen species after TBI and reduce TBI-related injuries in areas such as mitochondrial malfunction, excitotoxicity, and oxidative stress.
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Acupuncture
The use of acupuncture can be traced back more than 2000 years in China and includes stimulation of anatomical points on the body by a variety of techniques, involving penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. It is based on the principles of traditional Chinese medicine in terms of a vital energy called qi that circulates between organ channels called meridians .
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The mechanism may involve triggering endogenous opioids or stress-related hormones.
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A Cochrane review of 30 Chinese studies found a high risk of bias and very low methodological quality, although studies suggested that results were efficacious in improving overall function after TBI.
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It is generally well tolerated and safe.
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Acupressure is another form of traditional Chinese medicine that involves the application of pressure to specific points using hands, fingers, or thumbs instead of needles.
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Although limited evidence exists of use in patients with TBI, acupressure treatment has been associated with lowering stress and anxiety and improving sleep measures in other patient populations.
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Hyperbaric oxygen therapy
Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than 1 atmosphere absolute (ATA). It involves placing the patient in an airtight vessel, increasing the pressure within that vessel, and administering oxygen for respiration. The goal with HBOT is to improve oxygen supply to the injured brain and reduce the swelling associated with low oxygen levels, thus reducing death and disability after TBI.
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In a Cochrane review of seven studies with 71 people, routine use of HBOT in brain-injured patients could not be justified by the findings of this review, although limited evidence was found for use after acute brain injury.
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Although HBOT may reduce the risk of death and improve the final Glasgow Coma Scale (GCS) score based on some studies, there was no evidence of survivors having a good outcome.
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Side effects include otic trauma, risk of seizures, and pulmonary injury.
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A double-blind, randomized control trial with sham treatment of 60 military members with a combat-related mild TBI found no evidence for efficacy of HBOT.
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Overall, there is insufficient evidence to support use of HBOT in brain injury.
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It is not currently covered by insurance.
Mind-body medicine
Mind-body practice uses the power of thoughts and emotions to influence physical health and vice versa. Mindful-based stress reduction is a method that identifies thoughts without passing judgment to thoughts, and tai chi and qi gong involve certain postures and gentle movements with mental focus, breathing and relaxation. They are both considered a safe form of exercise. Qi gong is a moving mindfulness practice, whereas tai chi can also be used as a form of martial arts combat. Yoga combines gentle movement and stretching with breathing exercises and meditation. Other relaxation techniques include guided imagery and humor therapy (therapeutic humor), which refers to finding ways to increase smiles and laughter to reduce anxiety and possibly boost the immune system.
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Mindful-based stress reduction may regulate autonomic function by regulating parasympathetic tone.
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Tai chi may help after a cerebrovascular accident (CVA) to improve balance and controlled movement in a community-based setting.
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Yoga can potentially help in improving overall function and decreasing anxiety, although evidence is limited.
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Evidence is lacking overall, but mind-body medicine is thought to be safe and may be of benefit in improving quality of life and symptomatology in those with brain injuries.
Music interventions
Music interventions can be categorized into music therapy and music medicine interventions. Music therapy requires implementation by a trained music therapist, whereas music medicine intervention is defined as listening to prerecorded music.
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Music interventions use after stroke:
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Studies have been done for those with acquired brain injuries, including a Cochrane review with rhythmic auditory stimulation (RAS) showing a benefit in improving gait parameters after stroke, including gait velocity, stride length, and cadence.
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Music therapy was found to reduce agitation and improve orientation level in stroke patients.
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Music interventions use in TBI:
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In patients with disorders of consciousness, music therapy has been studied in recovery, although with poor methodological quality.
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A study investigating Familiar Auditory Stimulus Training showed it to have some benefit with changes in functional magnetic resonance imaging (fMRI).
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Overall studies with music interventions have shown a high rate of bias for those with TBI, and more studies are needed to demonstrate efficacy.
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Biofeedback
Biofeedback involves sensors that allow the wearer to detect and learn to control functions that are normally autonomous, including heart rate, blood pressure, and muscle tension.
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Systematic reviews indicate biofeedback may help lessen anxiety but is not effective treatment for posttraumatic stress disorder, which may be a concomitant condition after TBI. It is also used to treat tension-type headaches, but studies with posttraumatic headaches specifically are limited.
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There are very few studies in TBI and very small sample sizes, so there is insufficient evidence to justify support, although biofeedback is safe and not associated with any side effects.
Manual therapies
Massage therapy includes various forms of light touch to deep touch modalities to improve pain and reduce anxiety. It can also be an adjunct to other therapeutic interventions. Craniosacral osteopathy was developed by William Sutherland, DO, as osteopathy in the cranial field in the 1930s, which is taught as part of osteopathic medical school curriculum. Craniosacral therapy was later adapted by John Upledger, DO, who expanded teachings to nonphysician practitioners. The overall general principle is that there is physiological motion in the cranial bones, and practitioners can assess for structural dysfunctions in the physiological motion of those bones and return the structures to normal balance, inducing overall healing.
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Studies are limited, but there is potential use for craniosacral therapy for pain syndromes after TBI and for posttraumatic headaches.
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Given the traumatic nature of brain injury and theoretical alteration in the motion of the cranial bones, craniosacral therapy has potential in restoring proper motion resulting in improved function after TBI.
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Research has included case reports and small randomized controlled trials, but the methodology of all studies is poor.
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Naturopathy
Naturopathy is a healthcare profession emphasizing health and prevention and treatment through methods that encourage a person’s inherent self-healing. Naturopathic doctors (NDs) are trained at accredited, 4-year postgraduate naturopathic medical programs. Principles include an inherent power in self-healing process, identifying and removing the cause of illness, emphasizing prevention, and minimizing harm. Treatments include nutrition, homeopathy, natural products, acupuncture, massage, and Traditional Chinese Medicine.
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Most treatments are safe, but natural products may carry risk because they are not Food and Drug Administration regulated or may cause drug interactions.
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Modalities could theoretically improve function after brain injury, given significant overlap with multiple other CAM modalities.
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Medical physicians should be cognizant of types of treatment offered by naturopathic physicians.
Homeopathy
Homeopathy is a form of natural medicine developed by Samuel Hahnemann at end of the 18th century that stimulates the body’s self-healing mechanisms to treat illness. The cornerstone principle is similia similibus curantur, which means “let likes cure likes.” Other principles include the single remedy, in which only one homeopathic remedy is given at one time and the minimum dose principle, in which a tiny dose of medicine is given after a dilute extract is made.
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Theoretical uses after brain injury are to improve overall function, pain, anxiety, and depression and to increase overall health.
Review questions
- 1.
Which of these is correct regarding complementary and alternative medicine (CAM)?
- a.
It is more commonly used in males compared with females,
- b.
Its use increased from 2002 – 2012
- c.
It is more common in those with lower incomes,
- d.
It is more common in those with a lower level of education.
- a.
- 2.
What is the most common CAM therapy used among adults?
- a.
Meditation
- b.
Yoga/tai chi
- c.
Massage
- d.
Natural products
- a.
- 3.
What is the most common ethnicity in the United States to use complementary and alternative medicine?
- a.
White
- b.
Asian
- c.
Black
- d.
American Indian/Alaska Native
- a.
Answers on page 403.
Access the full list of questions and answers online.
Available on ExpertConsult.com
- 4.
What is the most commonly used natural product in the United States?
- a.
Fish oil
- b.
Probiotics
- c.
Glucosamine
- d.
Melatonin
- a.
- 5.
Which of these is correct regarding hyperbaric oxygen therapy (HBOT)?
- a.
There are no risks or side effects associated with the treatment.
- b.
Randomized controlled studies have shown it is effective in chronic mild traumatic brain injury (TBI).
- c.
It involves placing a patient in an airtight vessel with 100% oxygen.
- d.
It is currently covered by Medicare insurance.
- a.
- 6.
Tai chi differs from qi gong in that tai chi:
- a.
can also be practiced as a martial art.
- b.
involves gentle movements that are mindfully based.
- c.
can improve balance.
- d.
carries significant risk of injury.
- a.
- 7.
A form of CAM therapy that involves the use of sensors to allow the wearer to detect and learn to control functions that are normally autonomous to monitor and improve physiological parameters is called
- a.
transcutaneous electrical stimulation.
- b.
transcranial magnetic stimulation.
- c.
biofeedback.
- d.
cranial electrical stimulation.
- a.
- 8.
A Cochrane analysis of music interventions after brain injury showed it
- a.
may improve gait parameters after stroke.
- b.
may be helpful for aphasia after TBI.
- c.
has no benefit in those with disorders of consciousness.
- d.
may worsen agitation in those with acute stroke.
- a.
- 9.
Which of these is true regarding use of natural products?
- a.
They are US Food and Drug Administration (FDA) approved and regulated.
- b.
They are always safe and without any side effects.
- c.
Use is rare in the general population.
- d.
They are not required to be tested in randomized controlled trials.
- a.
- 10.
A patient asks you about taking a homeopathic medication. What is the most appropriate response for this patient from an evidence-based medicine approach?
- a.
Tell the patient that because there is no evidence for this in literature, you would highly not recommend the patient to take this.
- b.
Tell the patient that because it is an herbal medication, there are likely no side effects or harm associated with this medication.
- c.
Tell the patient that there is no evidence, and you do not have expertise on the issue, and warn him/her about the risks associated with the medication taking to account the patient’s values and expectations.
- d.
Tell the patient that he or she is not to take this medication under any circumstances because it is not regulated by the FDA.
- a.
References
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