Complementary and Alternative Medicine in Traumatic Brain Injury

Felise S. Zollman

BACKGROUND

Definitions

• Complementary and alternative medicine (CAM)—a group of diverse medical and healthcare systems, practices, and products that are not generally considered to be part of conventional medicine [1].

• Conventional medicine—current accepted Western medical practice.

• Complementary medicine—modalities that complement—but don’t replace—conventional medical interventions.

• Alternative medicine—modalities used in lieu of conventional medical interventions.

Partial Listing of CAM Practices

Homeopathy/naturopathy; herbal medicine; aromatherapy; relaxation techniques (meditation, hypnosis, music or humor therapy, guided imagery); biofeedback; energy-based therapies (healing touch, reflexology, Reiki, massage); craniosacral manipulation; electromagnetic therapy (transcranial magnetic stimulation, crystals); movement therapies (Alexander, Feldenkrais, Qi Gong, Tai Qi, Yoga); hyperbaric oxygen; Chinese medicine/acupuncture. This chapter will focus on those areas for which there is published data addressing use in those with TBI.

Published Data in TBI Exists for the Following:

Meditation (Mindfulness)

Basic principles:

• Mindfulness is a form of meditation, which involves attending to relevant aspects of one’s experience in a nonjudgmental manner. The goal of mindfulness is to maintain awareness moment by moment, disengaging oneself from strong attachment to beliefs, thoughts, or emotions, thereby developing a greater sense of emotional balance and well-being [2].

Mindfulness in traumatic brain injury (TBI):

• Trisha Meili (the “Central Park Jogger”) describes learning to “live inside again.” In contrast to prevailing medical views, Meili sees lack of memory and insight as an opportunity to develop the ability to focus on the present (“Here it is… . This is my situation”), not as an impairment to be overcome [3].

In a pilot intervention study, 10 subjects attended 12 weekly group sessions consisting of meditation, breathing exercises, guided visualization, and group discussion. Outcome: SF-36 (a widely recognized life satisfaction scale in which higher numbers indicate greater satisfaction) increased from 37 to 52 [4]. Another study looked at the role of meditation in addressing fatigue post-TBI, and found a beneficial effect [5].

Tai Qi/Qi Gong (Also Known as Tai Chi, Chi Gong, Qi Quong)

• Basic principles: Tai Qi, literally meaning “great energy,” is both a healing art and martial arts discipline. Qi Gong literally means “energy work.” Qi Gong generally involves slower movements, and is considered easier to perform; there is a specific focus on mindfulness and physical health.

• Tai Qi in TBI: while the literature is scant, two case series and two case/control studies showed beneficial effects with respect to motor function [6], mood [7,8], ability to attend to basic self care needs [9], and/or self-esteem [8].

Acupuncture

Basic principles:

• From a Chinese medicine perspective, the human body is viewed as a microcosmic reflection of the universe. The physician’s role is to aid in maintenance of harmonious balance, both internally and in relation to the external environment.

• Vital energy, known as “Qi,” flows through channels, or meridians, creating an interwoven network of circulation.

• Meridians are a multilayered, interconnecting network of channels or energy pathways that establish an interface between an individual’s internal and external environments. These energy pathways are named for organs whose realms of influence are expanded from their conventional biomedical physiologies to include functional, energetic, and metaphorical qualities. Pathology involves disharmony/disruption of energy flow [10]. The relationship between these organs and their broader spheres of influence is often represented via a table of correspondences:

The five-phases approach to diagnosis: The dynamic energy balance among pathways/organs can be viewed diagrammatically by arranging five elements, and the organs with which they are associated, as follows (Figure 68.1).

Any of the correspondences (e.g., emotions, organs) from Table 68.1 can be overlaid onto this construct to understand the relative influence of one to the other. For example, the emotion of water is fear, the emotion of wood is anger or irritability, and the emotion of fire is joy/mania. The five-phases relationship tells us that fear nourishes anger and controls (or mitigates) joy/mania.

Use of acupuncture in TBI:

• TBI from a Chinese medicine perspective: Two syndromes are typically recognized: Qibi (or blockage of Qi)—presents with an agitated, hyperadrenergic state; Qituo (or exhaustion of Qi)—presents with unresponsiveness. Additional factors may include Kidney Yin deficiency and Liver Yin deficiency/Liver Yang excess (capitalized organ names represent both associated characteristic energetic qualities and meridian pathway labels).

FIGURE 68.1 Five-phases relationships.

TABLE 68.1 Table of Correspondences

• Acupuncture has been reported to be of benefit in TBI with respect to improvement in level of consciousness and extent of injury recovery [11,12]. One study in particular, an interventional controlled study of subjects in coma, compared 17 subjects to 15 historical controls. Diagnoses included TBI and ruptured internal carotid artery. Subjects within 1 week of injury underwent four acupuncture treatments at 12-hour intervals: “A significantly greater number of patients in the acupuncture group (59%) had a greater than 50% neurological recovery, than the patients in the no acupuncture group (20%) (P = 0.025).” Study conclusion: Early acupuncture intervention may be a reasonable adjunctive treatment for brain-injured patients [12]. Acupuncture has also been shown to be of benefit in treating insomnia post-TBI [13]. Finally, a recent retrospective cohort study suggested that patients with TBI who receive acupuncture had fewer hospitalizations or emergency department visits in the first year after injury [14].

ASSESSMENT

• Determine candidacy for a particular intervention.

For meditation/mindfulness: Is the individual able to attend to the mindfulness exercise? Is trying to develop focused attention more likely to increase the patient’s frustration level, or is it valuable to him/her to hone this skill?

For Tai Qi/Qi Gong: Probably most appropriate for addressing balance/motor deficits, though there is a component of mindfulness about movement that might (theoretically) aid attention as well.

For acupuncture: (a) Will the patient tolerate needle placement? For a Rancho Level IV patient in particular, this may be a challenge. (b) What is the goal of treatment? It’s important to identify specific impairments or functional gains which are to be the focus of treatment and monitor progress accordingly.

• Ensure that appropriately trained/qualified providers are available to provide the service being considered. For example, acupuncturists may be (a) physicians trained in medical acupuncture, (b) licensed acupuncturists (typically trained as Oriental Medical Doctors), and occasionally (c) chiropractors. Physician acupuncturists may be located via the Academy of Medical Acupuncture website [see Electronic References]. Consider the medical complexity of the situation in identifying an appropriate provider: patients who have significant medical comorbidities (such as someone with a moderate to severe TBI) may be better served by seeing a physician acupuncturist, while someone with residual sequelae of a mild TBI (e.g., headaches, fatigue) may be just as well served by seeing a licensed acupuncturist.

TREATMENT

Meditation/Mindfulness:

• Fundamental principle involves attending to the present and to awareness of self. This process is undertaken in a nonjudgmental fashion, observing our natural tendency for our mind to stray, then returning to self-awareness [2].

• This process can be facilitated via breathing exercises, guided imagery, and use of external cues (e.g., meditative object).

Tai Qi/Qi Gong:

• Both disciplines incorporate smooth, balanced movement with mindfulness.

• Specific “forms” are intended to promote the smooth flow of Qi along certain meridians and/or (particularly with respect to Qi Gong) for the purpose of nourishing certain organs or organ qualities.

Acupuncture:

• The technique involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands, using a heat source, or by electrical stimulation [15].

• Acupuncture treatment is designed to restore the smooth balanced flow of Qi through meridian channels and their associated organs. This is accomplished through the manipulation of acupuncture points, primarily via the use of needles.

• Acupuncture needles have unique bioelectrical characteristics:

They are typically bimetallic (e.g., stainless steel shaft, copper/silver/bronze alloy handle) and therefore effectively create a battery. One needle inserted causes local agitation. Two or more needles cause a directional current flow. Current flow can be enhanced with the use of heat and electricity.

Once needles are placed, they may be manipulated in one of the following ways: (a) no manipulation/neutral/dispersion; (b) manual tonification (manipulation); (c) heat; or (d) electrical stimulation, which facilitates the directed flow of Qi (electrons) (Figures 68.2–68.4). Low-frequency electrical stimulation results in an endorphin-mediated generalized effect. High-frequency stimulation results in a monoamine-mediated, more rapid onset, segmental response [10].

• Risks/side-effects include bleeding/bruising, infection, needle shock/fainting, nerve irritation, and puncture of an organ/vital structure (very rare).

• In general, acupuncture is a very safe and well-tolerated procedure.

FIGURE 68.2 Dispersion. Source: From Ref. [10]. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. 1st ed. Berkeley, CA: Medical Acupuncture Publishers; 1995. Used with permission.

FIGURE 68.3 Tonification. Source: From Ref. [10]. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. 1st ed. Berkeley, CA: Medical Acupuncture Publishers; 1995. Used with permission.

FIGURE 68.4 Directed flow of Qi facilitated with electrical stimulation. Source: From Ref. [10]. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. 1st ed. Berkeley, CA: Medical Acupuncture Publishers; 1995. Used with permission.

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