"Alternative Medicine And Physical Therapy": A Course

Many of you know that I am a retired physical therapist and am very vocal against alternatives to medicine in general and chiropractic in particular.  In an attempt to be "Fair and Balanced", this post is a course I presented on-line to physical therapists for Continuing Education credit shortly after I retired in 2008.  Even with the several-year gap, all of it is essentially still pertinent and accurate.  ça se lit bien (it's a good read).

Alternative Medicine and Physical Therapy

Thomas Rafferty (PT Retired)

An objective, rational and logical analysis of non-traditional physical treatments:  Is there a place for them in a physical therapy practice?

Participants will learn to:

·         Understand the history and basics of selected alternative medicine practices

·         Understand the basics of the scientific method as it applies to medicine

·         Understand the terms and definitions used in alternative medicine

·         Identify the various synonyms of alternative medicine

·         Identify the techniques and jargon used by alternative medicine practitioners to  promote their activities

Identify "alternatives to medicine" procedures supported by evidence for effectiveness!!!

·    Mr. Rafferty earned a BS degree from Springfield College and a Post-Graduate Certificate in Physical Therapy from the University of Pennsylvania.  He is a retired Licensed Physical Therapist (NC#4422) and had over 38 years of clinical and management experience in a wide variety of physical therapy and rehabilitation settings. 

Included in Mr. Rafferty’s background are Directorship positions in CARF-Certified Work Hardening/Industrial Rehab Centers, an Orthopedic Rehab Facility, a Family Practice PT Center and Hospital-Based Rehab Centers.

Introduction

This section is designed to answer some basic question concerning alternative medicine.  An individual with some background in alternative medicine and/or Evidence-Based Medicine may want to skim through this introduction as desired. 

Following this introduction will be detailed sections on many examples of treatments that have at least some elements of what is commonly known as alternative medicine.  At the end of each section will be a summary and comments.  Understand that such comments are this author's personal opinions only.  However, they are based on clinical experience and the worldview that science is the most important tool in the obtaining of knowledge and truth.  Does science have all the answers?  No, but any claims made in opposition to known science fall into the area of "extraordinary claims require extraordinary evidence" in order for this author to accept them.

What is Alternative Medicine?

There are many definitions of "alternative medicine", for example:

Any of various medical methods and practices used in place of, or as well as, conventional medicine.[1]

Practices not generally recognized by the medical community as standard or conventional medical approaches and used instead of standard treatments ...[2]

A variety of therapeutic or preventive health care practices, such as homeopathy, naturopathy, chiropractic, and herbal medicine, that do not follow generally accepted medical methods and may not have a scientific explanation for their effectiveness.[3]

Another term frequently used when discussing alternative medicine is complimentary medicine.  In fact, it is commonly mentioned together under the umbrella of "CAM" (complimentary and alternative medicine).  Following is a statement differentiating the two concepts:

Complementary medicine is different from alternative medicine. Whereas complementary medicine is used together with conventional medicine, alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a physician.[4]

The same document also stated that complementary medicine includes a large number of practices and systems of health care that, for a variety of cultural, social, economic, or scientific reasons, have not been adopted by mainstream Western medicine.

Following are some quotations from individuals who essentially place little or no value in alternative medicine:

           

"'Alternative' is a slogan often used for promotional purposes, not a definable set of methods. Methods should be classified into three groups: (1) those that work, (2) those that don't work, and (3) those we are not sure about. Most described as "alternative" fall into the second group. But the only meaningful way to evaluate methods is to examine them individually"[5]

"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking."[6]

"'Alternative' has two possible meanings. Correctly employed, it refers to methods that have equal value for a particular purpose. (An example would be two antibiotics capable of killing a particular organism.) When applied to unproven methods, however, the term can be misleading because methods that are unsafe or ineffective are not reasonable alternatives to proven treatment."[7]

"By definition, “alternative” medicine consists of treatments that have not been scientifically proven."[8]

What is the difference between alternative medicine and quackery?

Unproven methods are not necessarily quackery. Those consistent with established scientific concepts may be considered experimental. Legitimate researchers and practitioners do not promote unproven procedures in the marketplace but engage in responsible, properly-designed studies. Quackery is the promotion of unsubstantiated methods that lack a scientifically plausible rationale. Promotion usually involves a profit motive. Unsubstantiated means either unproven or disproven. Implausible means that it either clashes with well-established facts or makes so little sense that it is not worth testing.[9]

Are there other names for alternative medicine?

Besides complimentary medicine and quackery described above, there are other synonyms describing the same worldview as alternative medicine. (W)holistic medicine and integrative medicine are the most common examples.

What is the relationship between alternative medicine and the New Age movement?

The New Age movement is a decentralized Western social and spiritual movement that seeks Universal Truth and the attainment of the highest individual human potential. It combines aspects of cosmology, astrology, esotericism, complementary and alternative medicine, various religious practices, collectivism, nature, and environmentalism. New Age Spirituality is characterized by an individual approach to spirituality, while rejecting religious doctrine and dogma. Widespread use of the term New Age began in the mid 1970s.  The term was further popularized by the American mass media to describe the alternative spiritual subculture, including activities from meditation, channeling, reincarnation, crystal healing, and psychic experience to holistic health or environmentalism, or belief in anomalous phenomena or for other “unsolved mysteries” such as UFOs, Earth mysteries, and crop circles.[10]

Why do people use alternative medicine?

In 1998, JAMA (Journal of the American Medical Association) conducted a national study to answer this question.  The conclusion was that, along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.[11] In a contest for patient satisfaction, art will beat science nearly every time. Quacks are masters at the art of delivering health care.[12]

Could this be a wakeup call to conventional medicine to do a better job in educating the public and in interacting with patients on a personal basis?

What's wrong with alternative medicine?

Consistent in the literature critical of alternative medicine are the following negatives:

·         Treatments probably are ineffective, outside of the placebo effect

·         Treatments may deny the patient effective treatments

·         There are increased risks of harm since safety has not been effectively evaluated

Why are some patients apparently helped from alternative medicine?

Many problems that lead individuals to both conventional and alternative medicine are self-limiting.  Correlation between improvement and the application of a treatment does not necessarily mean one "caused" the other.  In addition, the setting and the interaction of the patient and practitioner can be a powerful reinforcer of a natural self-healing process, the placebo effect.

What is the placebo effect?

The placebo effect may be defined as an apparently beneficial result of inactive therapy that occurs because of the patient’s expectation that the therapy will help.[13]  This is no small factor in medicine:

"If you take a hard look at the tens of thousands of clinical trials involving prescription drugs, surgical procedures, and various forms of therapy carried out over the last hundred years, you'll find that no drug and no surgery comes even close to the power of the placebo. In a very matter-of-fact, scientific way, the placebo effect has been proven to be the single most effective healing tool anywhere. The studies prove it: the placebo effect cures approximately 30% of everything"[14]

"Historians of medicine believe that placebo effects were responsible for the efficacy of most medicine until the twentieth century. Placebos are also widely used in contemporary healthcare."[15]

There is some debate regarding whether utilization of the placebo effect in treatment is ethical.  Since virtually every medical treatment has some placebo effects, such is unavoidable.  However, most reputable practitioners agree that it is unethical to administer a treatment that is known to have only a placebo effect.  Since many alternative medicine procedures have been studied and have been found to be no more effective than a placebo, there are ethical concerns in this area.

How does skepticism fit into the evaluation of alternative medicine?

Reliance on physical therapy, or any medical treatment, that has scientific support is the hallmark of a practitioner who adheres to the tenents of modern skepticism.  The following clarifies skepticism:

"Some people believe that skepticism is rejection of new ideas, or worse, they confuse 'skeptic' with 'cynic' and think that skeptics are a bunch of grumpy curmudgeons unwilling to accept any claim that challenges the status quo.  This is wrong.  Skepticism is a provisional approach to claims.  It is the application of reason to any and all ideas - no sacred cows allowed.  In other words, skepticism is a method, not a position.  Ideally, skeptics do not go into an investigation closed to the possibility that a phenomenon might be real or that a claim may be true. When we say we are 'skeptical', we mean that we must see compelling evidence before we believe.--- Modern skepticism is embodied in the scientific method."[16]

What is the scientific method?

The scientific method is an objective attempt to find the truth within the natural world.  it assumes that the laws of physics and nature are regular and can be studied.  It does not "prove" something is true.  It has been said that "science does not prove; mathematics 'prove'".  The results of the scientific method can only suggest that something is true at a certain level of confidence. It can never absolutely verify (prove the truth of). It can only falsify (declare or prove to be false).[17]

The scientific method is not a recipe: it requires intelligence, imagination, and creativity.[18]It is also an ongoing cycle, constantly developing more useful, accurate and comprehensive models and methods.  Following is one guideline:[19]

            1. Define the question

            2. Gather information and resources (observe)

            3. Form hypothesis

            4. Perform experiment and collect data

            5. Analyze data

6. Interpret data and draw conclusions that serve as a starting point for new hypothesis

            7. Publish results

            8. Retest (frequently done by other scientists)

What are the alternatives to the scientific method?

Unlike the scientific method, which attempts to understand systems by dividing them into the smallest elements (reductionism), holistic science is an approach to research that studies complex systems.  The holistic method is not necessarily at odds with the scientific method but it is controversial.  Practitioners of alternative medicine may use holism to explain negative results under the scientific method and to immunize their claims against testing.[20]  Within this method is the tendency to reject recent evidence in the field of physics.[21] 

Any practitioner not adhering to the scientific method may be said to be functioning in the world of pseudoscience (a body of knowledge, methodology, belief, or practice that is claimed to be scientific or made to appear scientific, but does not adhere to the scientific method[22][23]) and/or protoscience (any philosophical discipline that existed prior to the scientific method[24]), for example alchemy before chemistry and astrology before astronomy.  Essentially, this is the worldview of alternative medicine. This movement embraces the postmodernist doctrine that science is not necessarily more valid than pseudoscience.[25]

What is Evidence-Based Medicine?

Essentially, there is no difference between Evidence-Based Medicine (EBM) and Evidence-Based Physical Therapy Practice (EBPTP).  Evidence-based physical therapy practice is "open and thoughtful clinical decision-making" about the physical therapy management of a patient/client that integrates the "best available evidence with clinical judgement" and the patients/client's preferences and values, and that further considers the larger social context in which physical therapy services are provided, to optimize patient/client outcomes and quality of life.[26]  This approach to patient care is not solely reliant on published articles but includes utilizing evidence in the context of the individual patient's situation.  This text is recommended as a good consolidation of information found in many texts into one practical guide.

What are the levels of evidence?

There are many systems currently in use that look at the quality of clinical studies.  Essentially all of these systems categorize the quality of the evidence into "levels".  One good example is the following:[27]

1 (Highest)      Well-designed randomized controlled trials (RCT) and prospective (looking ahead) studies (double-blinded with placebo)                       

2                                            Cohort studies (subjects who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation.  This is non-randomized and prospective)

(*In some cases, cohort studies are preferred to randomized experimental design. For instance, since a randomized controlled study to test the effect of smoking on health would be unethical, a reasonable alternative would be a study that identifies two groups, a group of people who smoke and a group of people who do not, and follows them forward through time to see what health problems they develop.)

Also includes poorly controlled RCTs

3                      Case-controlled studies (A retrospective study looks backwards and examines exposures to suspected risk or protection factors in relation to an outcome that is established at the start of the study)

4                      Case-series; poorly designed cohort studies; poorly designed case-controlled studies

5                      Anecdotal evidence; animal research; bench research; unpublished clinical observations

Where does physical therapy research fall on a scale of levels of evidence?

Unfortunately, even most conventional physical therapy activities are not supported by the higher levels of evidence.[28],[29],[30],[31],[32],[33],[34],[35]  Thus, the ethical clinician must be careful and thoughtful in utilizing procedures found under the umbrella of alternative medicine, as evidence for the safety and effectiveness of such is even thinner.

What procedures currently used in some physical therapy practices may be considered alternative medicine?

Some procedures are clearly alternative medicine.  Others have elements of both conventional and alternative medicine.  A few may be considered conventional but the way they sometimes are presented to the public can cross the line into alternative medicine as least to some degree.  This course will discuss a good sample of these types.  It is not exhaustive.  The reader is advised to understand the concepts and examples presented so that he/she may be more sensitive to the ethics of alternative medicine.

Myofascial Release (MFR)

Myofascial release is a form of massage therapy that uses sustained pressure to loosen or release tightness in connective tissues (fascia). It is thought that tightness within the fascia causes restriction of muscle and other tissues, resulting in pain and loss of motion. Injuries, stress, inflammation, trauma and poor posture supposedly contribute to this tightness[36]. Myofascial Release Therapy, like many alternative therapies, promotes the philosophy that the mind and body work together to maintain health. Effectively this supports the understanding that the mind and body are one and the same. The body has the ability to remember postural positions, actions and emotions without the brain reminding it to do so. Throughout the body's fascial system flow microscopic cells containing energy which have the ability to retain memory.[37]

Myofascial release has been used to improve the health of the muscles and fascia, improve circulation and restore good posture. It has been used to treat back strain, chronic back pain, low back pain, thoracic back pain, carpal tunnel syndrome, chronic cervical pain, complex pain complaints, dizziness, vertigo, fibromyalgia, fibrositis, headache, myofascial pain dysfunction, plantar fasciitis, post polio symptoms, thoracic outlet syndrome, temporomandibular joint (TMJ) dysfunction, trigger points, tender points, and whiplash. [38]

There are some synonyms used for this manual treatment.  For example, terms such as acutherapy, myotherapy, bodywork, trigger point therapy and soft tissue mobilization have been used interchangeably in describing MFR.

The term myofascial was first used by Janet G. Travell M.D. in the 1940s referring to musculoskeletal pain syndromes and trigger points. In 1976 Dr. Travell began using the term "Myofascial Trigger Point" and in 1983 published the famous reference "Myofascial Pain & Dysfunction: The Trigger Point Manual". Some practitioners use the term "Myofascial Therapy" or "Myofascial Trigger Point Therapy" referring to the treatment of trigger points, this is usually in medical-clinical sense.[39]

Following is a more detailed description of the techniques involved in this treatment:

In each MFR technique the practitioner finds the area of tightness. A light stretch is applied to the tight area. When the tissue relaxes the stretch is increased. The process is repeated until the area is fully relaxed. Then, the next area is stretched.

The therapist is guided by feedback he feels from the patient's body. This feedback tells the therapist how much force to use, the direction of the stretch and how long to stretch. Small areas of muscle are stretched at a time. Sometimes the therapist uses only two fingers to stretch a small part of a muscle.

The therapist will be able to find sore spots just by feel. Often, patients are unable to pinpoint some sore spots or have grown used to them until the physical therapist finds them. The size and sensitivity of these sore spots, called myofascial trigger points, will decrease with treatment.

Overall, myofascial release is a gentle therapy. Some patients fall asleep during treatment or take a nap afterwards.37

John F Barnes, PT is the most noted practitioner of MFR and claims to be the founder of the MFR Approach. He describes MFR as Therapeutic Artistry, separating it from science. Ironically, Mr. Barnes claims a scientific rationale for MFR. He is very critical of traditional science and states that quantum physics demonstrates that there is no objectivity.  He states that traditional science was built on quicksand.  He found that his patient's fascial system was full of life, memories, emotion and consciousness.  He supports his philosophy by quoting a book called "Energy Medicine in Therapeutics and Human Performance" by James L. Oschman, PhD, in which it is stated that there is no such thing as a disease.  He paraphrases from Dr. Ervin Laszlo to support the ideas that: there is a universal information field that is the source of all reality; science has had a negative impact on society and is an antiquated and obsolete worldview.  He does not believe the brain is the source of consciousness and states that our innate intelligence flows through the fascial matrix, which is --- capable of storing more information than the brain[40].

Carol M. Davis, in her book discussing the efficacy of complimentary therapies, found a paucity of peer-reviewed studies on MFR.  Most of the studies quoted were of the case study variety.  A few studies did suggest a positive effect. However, there was no mention of comparitive studies with other forms of manual deep-tissue therapies.  In her summary regarding MFR, Ms. Davis stated that

"--- fascia is not accessed by traditional mechanical methods such as joint mobilization modalities or traditional stretching methods.  Fascia, instead, responds to the combination of the intentional application of endogenous bioelectromagnetic energy fields and the sustained mechanical pressure at the myofascial barrier from within the therapist, through the palms and fingers of the therapist's hands to soften the molecular structure of the fascia, and the gentle, sustained mechanical pressure of the therapist's hand at the myofascial barrier, facilitating a yielding or release of its barriers or restrictions.  The mind seems to store memories and experiences in restricted fascia , for upon the release of restrictions, patients commonly become transported back to an injurious experience and with simular emotion, relate the experience in detail.  Once the trauma is completely experienced and the fascial restrictions have given way, healing can commence.  We have yet to learn the cellular mechanism of the healing process, but it is believed that once restrictions are removed from the fascia, body energy, blood, lymph, neurotransmitters, neuropeptides and steroids are free to flow, restoring balance, homeostasis and health to the system. 

--- the emerging new explanatory theory of mind-body holism, based on the quantum theory of the behavior and characteristics of atoms and molecules, offers explanations for these and many other 'unexplanable' outcomes.  The science of energy medicine is rapidly helping to answer many of the questions that have eluded us for decades.[41]

The American Cancer Society has addressed MFR and has concluded that there is little scientific evidence to support its use.  It did mention two studies that seemed to be supportive of MFR but both of them included other treatments along with MFR.[42]

A literature search was conducted recently to assess the current state of scientific knowledge about MFR.  Twenty-three studies were found.  The reliability of diagnostic procedures or the efficacy of treatment procedures could not be confirmed.  It was recommended strongly that further studies by conducted to answer questions regarding this method of therapy.[43]

Summary and comments

Anyone who values science as a tool to obtain knowledge and truth cannot support the rationale behind this form of treatment.  The basic premises of MFR are based on an anti-science worldview.  While there is such a thing as quantum mechanics, it is typical of alternative medicine practitioners to misconstrue what science knows about such.

The following comments, as well as similar comments regarding MFR found on MyPhysicalTherapySpace, have this author's full support:

" --- More physical impossibilities and blatant ignorance rolled up with marketing and designed to prey on those in pain".

"Everyone should realize that the foundation laid by energy healing, repressed memories in the tissue, the misunderstanding of quantum mechanics, and a good dose of postmodern thinking leads directly to all sorts of outlandish claims in the world of [John F. Barnes and Myofascial Release]".[44]

It is this author's conclusion that MFR probably has some clinical benefit but no more that other deep-tissue massage techniques and/or prolonged stretching.

Cranial-Sacral Therapy (CST)

Dr. William G. Sutherland developed cranial osteopathy in the early 1930s. John E. Upledger, DO, developed craniosacral therapy, a derivative of Sutherland's work, in the 1970s. Upledger opened the Upledger Institute of Florida, where thousands of health care professionals attend his

program every year to learn about releasing stresses in the skull and the membranes surrounding the brain.

Craniosacral therapy practitioners touch areas of the patient lightly to sense the cranial rhythm impulse of the cerebrospinal fluid (CSF), said to be similar to feeling the pulse of blood vessels. Practitioners then use subtle manipulations over the skull and other areas with the aim of restoring balance by removing restrictions to CSF movement, a process that is proposed to help the body heal itself and improve a wide range of conditions. Treatment sessions usually last between 30 and 60 minutes. Craniosacral therapy may be practiced by osteopathic doctors, chiropractors, naturopathic doctors, physical therapists or massage therapists.[45]

Upledger describes several techniques which may be used in a craniosacral therapy session. The first is energy cyst release. "This technique is a hands-on method of releasing foreign or disruptive energies from the patient's body. Energy cysts may cause the disruption of the tissues and organs were they are located." The therapist feels these cysts in the client's body and gently releases the blockage of energy.[46]

Although there are anecdotal reports of successful treatment for stress, headaches and tension using CST, there have been few well-controlled clinical studies of this method.[47]

The underlying theory of CST is false because the bones of the skull fuse by the end of

adolescence and no research has ever demonstrated that manual manipulation can move the individual cranial bones.[48]  Three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon.[49] Another study compared the "craniosacral rate" measured at the head and feet of 28 adults by two examiners and found that the results were

highly inconsistent.[50]

In 1999, after doing a comprehensive review of published studies, the British Columbia Office of Health Technology Assessment (BCOHTA) concluded that the theory is invalid and that practitioners cannot reliably measure what they claim to be modifying. The 68-page report concludes that "there is insufficient evidence to recommend craniosacral therapy to patients, practitioners, or third party payers".[51]  In 2002, two basic science professors at the University of New England College of Osteopathic Medicine concluded that "our own and previously published findings suggest that the proposed mechanism for cranial osteopathy is invalid and that

interexaminer (and, therefore, diagnostic) reliability is approximately zero. Since no properly randomized, blinded, and placebo-controlled outcome studies have been published, we conclude that cranial osteopathy should be removed from curricula of colleges of osteopathic medicine and from osteopathic licensing examinations".47

Summary and Comments

Note the comments made by Dr. Upledger concerning "energy cyst release" of foreign or disruptive energy from the patient's body.  It is typical of alternative medicine to talk about "energy fields" that never have been scientifically verified.

The following comments posted anonymously by a physical therapist on the quackwatch.com website page discussing CST sums up this author's opinion:

Too many patients and therapists have been duped by this so-called therapy. If these therapist were ever to suggest to any self-respecting neurosurgeon, that they could move the sutures of the skull with ounces of force, they would get laughed right out of the room. I have personally witnessed how saws and drills are needed (with more than a few ounces of force) to alter the structure of the adult skull. To tell patients that you have the ability to analyze the cerebral spinal fluid flow with your fingertips and then "normalize" it by mobilizing the cranial sutures is not just quackery but malpractice. They should lose their license[52].

Spinal Manipulation (SM)

SM has been defined in chiropractic and osteopathic medicine as moving a joint beyond its passive range of motion limit by means of a sudden thrust or impulse, usually accompanied by an audible "popping" sound.[53]  This is consistent with the accepted definition of "high grade"/"thrust" (4 or 5, depending on the Method) accessory movements in the physical therapy world.

Spinal manipulation is a therapeutic intervention that has roots in traditional medicine and has been used by various cultures, apparently for thousands of years. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic medicine and chiropractic. Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.[54]

Chiropractic uses manipulation ("adjustment") to correct "subluxations" (small mal-alignments) in the spine.  Osteopathy uses it to restore mobility of a joint.  Initially, both claimed that this technique could effect the nerves going to the body's organs, thus removing the cause of disease.  Presently, many use this tool exclusively to improve musclo-skeletal pain.

A "review of reviews” published in the Journal of the Royal Society of Medicine (JRSM), led by Professor Edzard Ernst, of the University of Exeter, looked at 16 reviews of the evidence on SM.  For neck pain it was “not of demonstrable effectiveness”. Even for back pain it was no better than conventional treatments, such as exercise. “There is little evidence that SM is effective in the treatment of any medical condition, ” it concluded. "SM has been associated with frequent, mild adverse effects and with serious, probably rare implications," write the authors. "Therefore the risk-benefit balance does not favour SM over other treatment options such as therapeutic exercise.".[55]

A systematic review looked at 29 studies of spinal manipulation in people with short-term back pain.  The summary found that spinal manipulation can help to reduce back pain. But in the long term, spinal manipulation had no effects on pain or how disabled people were by their back pain.

Spinal manipulation worked better than some treatments known to be harmful, such as bed rest and not having treatment. But it didn't work any better than the usual treatments you'd get from a GP (typically painkillers), taking exercise, getting physiotherapy or having classes at back schools.[56]

More than 50 mostly qualitative, nonsystematic reviews that address the role of spinal manipulation and mobilization in the treatment of patients with low back or neck pain have been published since 1979. Many of these reports were of inadequate methodologic quality. Spinal manipulation and/or mobilization may be a viable option for the treatment of patients with low back pain. However, there have been few high-quality trials distinguishing between patients with acute and chronic symptoms of low back pain.  Regarding neck pain, it was concluded that spinal manipulation offers at best similar pain relief to high-technology rehabilitative exercise in the short term and long term.[57]

Regarding manipulation of extremity joints, outside of manipulation under anesthesia for adhesive capsulitis, his author was unable to find any studies concluding that the use of forceful, high grade manipulation is more effective than traditional physiological plane movements or more gentle accessory plane movements.

Summary and comments

The founders of chiropractic and osteopathy postulated that disease was caused by pressure on spinal nerves going to the organs and by manipulating the spine to relieve this pressure disease can be cured.  In the light of current scientific understanding of anatomy, physiology and disease, this belief is unsupported.

It is the opinion of this author that the role of spinal manipulation, as defined in this section, has a very limited place in the physical therapist's tool box.  Perhaps, after less forceful techniques have been helpful, but without fully satisfactory results, then such may be helpful.  However, this author has had very few of these cases.

Rolfing®

Rolfing® is named after its creator, Ida P. Rolf, Ph.D. (1896-1979), an organic chemist who also studied yoga and chiropractic treatments. According to Rolf, her technique allows a person to re-align their own energy fields with that of the earth and gravity: "Rolfers make a life study of relating bodies and their fields to the earth and its gravity field, and we so organize the body that the gravity field can reinforce the body's energy field".[58]

Rolfing (trademarked by the Rolf Institute of Structural Integration) is essentially a very deep and very vigorous massage (proponents describe it as "soft tissue manipulation"). This is not in itself bad, and when it comes to back and neck problems it may have some therapeutic (as opposed to curative) effect. However, proponents make much more exaggerated claims for it, for example saying that it may cure illness, although there is no scientific evidence to back up such claims.[59]

There is no clear evidence on how exactly Rolfing works. There are, however, several theories. Firstly there is the thixotropic or gel-sol-gel theory. Basically, this theory states that touch/pressure is thought to generate heat and that this heat softens or liquefies connective tissue and turns it from a gelatinous to a liquid substance. Once the tissue is softened, it may become more malleable and can be more easily reorganized and manipulated. While in this plastic state it may form a new relationship to the surrounding muscular and bony structures. Pressure of the type applied by Rolfers may also activate sensory receptors (neurological theory). These receptors are thought to send signals to the brain which in turn allows the affected tissue to change its tensile strength and make it easier to manipulate. Other Rolfers have argued for a hybrid theory which incorporates elements of both the neurological and thixotropic models.  Another way of answering this is to state that Rolfing is thought to balance the body in all directions: front to back; side to side; and inside to outside. It purports to integrate all layers and types of connective tissue.[60]

Because Rolfing® structural integration involves deep, aggressive manipulation of tissues, some people should avoid this technique.  This source mentions several precautions.[61]

This author could find no research in support of Rolfing being more effective than any traditional soft tissue massage/manipulation technique.  The research cited by the Rolf Insitute of Structural Integration[62] is of low quality and/or the improvements noted were relatively insignificant.

Summary and comments

Rolfing® structural integration promotion materials include the usual holistic, disease-curing and mysterious energy jargon of alternative medicine.  There is no credible research supporting it as better than any traditional deep-tissue massage/manipulation treatment.  There are significant questions regarding the safety of this aggressive deep-tissue process.  All of this leads this author to conclude that no practitioner should be using this method of treatment.

Reflexology

Reflexology was introduced into the United States in 1913 by William H. Fitzgerald, M.D. (1872-1942), an ear, nose, and throat specialist who called it "zone therapy."  He used vertical lines to divide the body into 10 zones. Eunice D. Ingham (1899-1974) further developed reflexology in the 1930s and 1940s, concentrating on the feet .  Mildred Carter, a former student of Ingham, subsequently promoted foot reflexology as a miraculous health method.[63],[64],[65],[66]

Reflexology is a treatment that uses pressure on specific areas of the feet (or the hands) with the goal of relieving a variety of problems and balancing the flow of vital energy throughout the body.  Reflexology is based on the theory that reflex points, located in the feet or hands are linked to various parts of the body and organs.  According to this theory, stimulation of these points is thought to affect the connected organ or body part. By stimulating these reflex points, reflexologists claim that they can relieve a wide variety of health problems and promote well being and relaxation.  There is early scientific evidence that reflexology may be useful for relaxation and reducing some types of pain and anxiety in some patients. Available scientific evidence does not support reflexology as a treatment for cancer or any other disease. [67]

Many proponents claim that foot reflexology can cleanse the body of toxins, increase circulation, assist in weight loss, and improve the health of organs throughout the body. Others have reported success in treating earaches, anemia, bedwetting, bronchitis, convulsions in an infant, hemorrhoids, hiccups, deafness, hair loss, emphysema, prostate trouble, heart disease, overactive thyroid gland, kidney stones, liver trouble, rectal prolapse, undescended testicles, intestinal paralysis, cataracts, and hydrocephalus (a condition in which an excess of fluid surrounding the brain can cause pressure that damages the brain). Some claim to "balance energy and enhance healing elsewhere in the body."[68]

Barbara & Kevin Kunz, reflexologists,  conducted a Reflexology Research Project looking at the scientific evidence for such.  They reviewed 45 studies through May 2004 and found significant evidence for the efficacy of reflexology in a wide variety of medical conditions.[69]  However, a recent systematic review of the efficacy of reflexology concluded that there is no evidence for a specific effect on any condition, with the exception of urinary symptoms associated with multiple sclerosis.[70]  Of note, most of the research systematically reviewed was concluded to be

low-quality or anecdotal and only 5 studies qualified for inclusion into this review.  It is assumed by this author that the studies cited by Barbara & Kevin Kunz were included in this review, as both of these reviews included international studies.

A summary of investigations conducted by five competent researchers concluded that there was no connection between reflex points and body parts or medical diagnosis and reflexologist's finding.  There were no positive findings above the placebo effect.[71]

Summary and comments

Reflexology presents itself with the usual holistic, disease-curing and mysterious energy jargon of alternative medicine.  There is no quality evidence that it does anything more that a traditional foot massage.  This author cannot recommend this treatment, although there does not appear to be significant safety issues.

Acupuncture

Most people assume that acupuncture is an ancient Chinese treatment.  However, consider the following historical account by Harriet Hall MD:

From studying the earliest documents, Chinese scholar Paul Unschuld suspects the idea may have originated with the Greek Hippocrates of Cos and later spread to China. It’s definitely not 3000 years old. The earliest Chinese medical texts, from the 3rd century BCE, do not mention it. The earliest reference to “needling” is from 90 BCE, but it refers to bloodletting and lancing abscesses with large needles or lancets. There is nothing in those documents to suggest anything like today’s acupuncture. We have the archaeological evidence of needles from that era — they are large; the technology for manufacturing thin steel needles appropriate for acupuncture didn’t exist until about 400 years ago.

The earliest accounts of Chinese medicine reached the West in the 13th century: they didn’t mention acupuncture at all. The first Westerner to write about acupuncture, Wilhelm ten Rhijn, in 1680, didn’t describe acupuncture as we know it today: he didn’t mention specific points or “qi;” he spoke of large gold needles that were implanted deep into the skull or “womb” and left in place for 30 respirations.

Acupuncture was tried off and on in Europe after that. It was first tried in America in 1826 as a possible means of resuscitating drowning victims. They couldn’t get it to work and “gave up in disgust.” I imagine sticking needles in soggy dead bodies was pretty disgusting.

Through the early 20th century, no Western account of acupuncture referred to acupuncture points: needles were simply inserted near the point of pain. Qi was originally vapor arising from food, and meridians were channels or vessels. A Frenchman, Georges Soulie de Morant, was the first to use the term “meridian” and to equate qi with energy — in 1939. Auricular (ear) acupuncture was invented by a Frenchman in 1957.

The Chinese government tried to ban acupuncture several times, between 1822 and World War II during the time of the Chinese Nationalist government. Mao revived it in the “barefoot doctor” campaign in the 1960s as a cheap way of providing care to the masses; he did not use it himself because he did not believe it worked. It was Mao’s government that coined the term “traditional Chinese medicine” or TCM.

In 1972 James Reston accompanied Nixon to China and returned to tell about his appendectomy. It was widely believed that his appendix was removed under acupuncture anesthesia. In reality, acupuncture was used only as an adjunct for pain relief the day after surgery, and the relief was probably coincident with the expected return of normal bowel motility. A widely circulated picture of a patient allegedly undergoing open heart surgery with acupuncture anesthesia was shown to be bogus. If acupuncture is used in surgery today, it is used along with conventional anesthesia and/or pre-operative medication, and it is selected only for patients who believe in it and are likely to have a placebo response.

As acupuncture increased in popularity in the West, it declined in the East. In 1995, visiting American physicians were told only 15–20% of Chinese chose TCM, and it was usually used along with Western treatments after diagnosis by a Western-trained physician. Apparently some patients choose TCM because it is all they can afford: despite being a Communist country, China does not have universal health coverage.

There were originally 360 acupuncture points (loosely based on the number of days in a year rather than on anatomy). Currently more than 2000 acupuncture points have been “discovered”, leading one wag to comment that there was no skin left that was not an acupuncture point. There were either 9, 10, or 11 meridians — take your pick. Any number is as good as another, because no research has ever been able to document the existence of acupuncture points or meridians or qi.[72]

Does acupuncture work?  Dr. Hall continues:

Acupuncture works in the same manner that placebos work. It has been shown to “work” to relieve pain, nausea, and other subjective symptoms, but it has never been shown to alter the natural history or course of any disease. Today it’s mostly used for pain, but early Chinese acupuncturists maintained that it was not for the treatment of manifest disease, that it was so subtle that it should only be employed at the very beginning of a disease process, and that it was only likely to work if the patient believed it would work. Now there’s a bit of ancient wisdom!

Studies have shown that acupuncture releases natural opioid pain relievers in the brain: endorphins. Veterinarians have pointed out that loading a horse into a trailer or throwing a stick for a dog also releases endorphins. Probably hitting yourself on the thumb with a hammer would release endorphins too, and it would take your mind off your headache.

Acupuncture failed as a useful adjunct to a course of individualised, exercise based physiotherapy for older adults with knee osteoarthritis in one study.[73]  A review of studies of acupuncture in chronic back pain concluded that acupuncture may be of short term benefit in chronic low-back pain and may be a useful adjunct to conventional therapies.  However, this review admitted that there were significant weaknesses in the studies cited.[74],[75],[76]

A recent Cochrane Review of 33 separate trials found traditional acupuncture effective in preventing headaches, but so is a sham form.  The sham form involved the insertion of needles but not into traditional "energy"/chi points on "meridians".  Dr Klaus Linde, from the Centre for Complementary Medicine Research at the Technical University of Munich in Germany, said that much of the benefit for both might be due to a "placebo effect".[77]

Summary and comment

Note acupuncture's promotion of stimulation of "energy"/chi points on "meridians" to improve health.  Again, alternative medicine's use of mysterious energy not supported by science.

It is this author's opinion that most of the effectiveness of acupuncture is due to a combination of counter-stimulation of sensory nerves coupled with the placebo effect.  There are plenty of conventional modalities available capable of sensory counter-stimulation (i.e. heat, cold, electricity, manual oscillation techniques, etc.).  These modalities, coupled with a positive interaction between the practitioner and patient, probably provides all that acupuncture has to offer.

Massage Therapy

Massage therapy involves skilled application of manual techniques  that include applying fixed or moveable pressure, holding and/or causing movement of body tissues, using primarily the hands and may include instruments.  Therapeutic techniques include but are not limited to effleurage, petrissage and/or tapotement (stroking, compression, percussion) applied to one or more areas.  These techniques affect the musculoskeletal, circulatory-lymphatic and nervous system of the body with the intent of reducing pain or discomfort, reducing edema and improving function.  It has been an accepted physical therapy treatment, based on fairly sound evidence.[78],[79],[80],[81]  Its history extends back throughout recorded history.

Why has this author chosen to include this modality in the discussion of alternative medicine?  The following is taken from the website www.quackwatch.com:[82]

Many therapists make claims that go far beyond what massage can accomplish. And even worse, massage therapy schools, publications, and professional groups are an integral part of the deception.  There is no evidence-based reason to believe that massage can influence the course of any disease. Yet the American Massage Therapy Association (AMTA) Web site has claimed that that therapeutic massage can help with allergies, asthma, bronchitis, spastic colon, constipation, diarrhea, and sinusitis.[83]  The site also suggests that "massage is to the human body what a tune-up is to a car" and that "therapeutic massage can be part of your regular healthcare maintenance." And a 1997 AMTA booklet falsely states that massage can promote easier breathing, assist with removal of metabolic wastes, strengthen the immune system, and help prevent disease.[84]

Many massage therapists provide at least some of the following, which have no rational place in the practice of massage therapy:  acupressure/shiatsu; colonic irrigation; CST; polarity therapy; reiki; reflexology; therapeutic touch.  Aromatherapy is also used, which is fine if no medical claims are made and care is used with those who may be allergic to the products used.

The main standard-setting organization for massage therapists is the American Massage Therapy Association (AMTA), which was founded in 1943 and represents about 47,000 massage therapists in 30 countries. AMTA's official publication, Massage Therapy Journal, has four issues per year. Most issues contain articles that advocate quack treatments, and all issues contain ads for dubious courses and products. The second largest professional group, the Associated Bodywork and Massage Professionals (ABMP), has about 37,000 members and publishes an equally low-quality magazine called Massage & Bodywork. A 2001 survey of ABMP members found that 44.6% of respondents said they used reflexology, 37.9% said they used "energy healing," and 30.4% said they used shiatsu.[85]

In 1989, AMTA established the Commission on Massage Therapy Accreditation (COMTA) which accredits massage therapy training programs. COMTA's accreditation standards do not required that teachings be scientifically valid or that quack assertions be accompanied by disclaimers. In other words, if a school wants to teach that nonmaterial "energies" exert therapeutic effects, it is not required to inform students that no such forces have ever been scientifically demonstrated. But even worse, if a school elects to offer a program in "Body Therapies of Asia," it is required to teach a long list of notions that do not correspond to scientific knowledge of human anatomy, physiology, health, and disease[86].  And competency standards established in 2003, endorse these notions in even greater detail, as well as the use of sound and color therapies[87].  As of May 7, 2002, 19 schools were participating members of AOBTA's Council of Schools and Programs (COSP). The AOBTA Web site describes 13 methods which it says are "based upon traditional Asian medical principles for assessing and evaluating the energetic system and use of traditional Asian techniques and treatment strategies to primarily affect and balance the energetic system for the purpose of treating the human body, emotions, mind, energy field and spirit for the promotion, maintenance and restoration of health".[88]

In 1992 AMTA initiated creation of the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB).   More than 40,000 massage therapists are now certified.[89]  Its candidate handbook indicates that certification candidates are expected to answer approximately 15 questions about metaphysical concepts of traditional Chinese medicine, palpation to assess "craniosacral pulses" and "energy blockages," therapeutic touch, "energetic effects of nutrition," "manual contact and manual manipulation to affect . . . the energy system," and several other practices based on quack concepts.[90]

Al Wuthnow, MS, CMT, who practices in Mill Valley, California, has summed up the situation very succinctly:

    I've been astounded over the years at the outlandish claims made by many body workers. It's wonderful to get a great massage. It does increase circulation, gives temporary relief to pain, provides a sense of well being, and promotes relaxation, but I don't know of anything (other than the blues) that it has ever cured. People need to realize that just because it is a wonderful pleasure that does not make it good medicine.

Summary and comments

I think the above is clear.  Traditional massage based on known science can be helpful.  Massage based on non-scientific principles has no place in physical therapy, or other, practices.

Reiki

The following is a good summary of Reiki:[91]

The word, Reiki, is of Japanese origin. Rei means "universal spirit, unlimited," and ki refers to the "life force" or "energy." Proponents credit a Dr. Mikao Usui with "re-discovering" Reiki some time around 1846 as part of his search of "sacred texts."

It is clear from proponents' descriptions that Reiki is but a variation of other healing superstitions such as "pranic healing" (ritual of ancient fertility religion, Wicca [ie, witchcraft]), qigong (based upon traditional Chinese medicine), Therapeutic Touch (a pseudomedical practice done by 20th Century American nurses), and unnamed shamanic healing practices that involve hand-waving, or laying-on-of-hands, healing rituals. Such rituals are magical practices that purport to manipulate unseen "spiritual" forces.

First degree Reiki practitioners learn to treat through a series of 12 specific hand positions placed gently on the body. This allegedly facilitates the flow of Reiki energy through the practitioner, said to be manifested by a heightened feeling of warmth in the hands. The practitioner is said to merely serve as a conduit for the Reiki energy. A second degree Reiki practitioner allegedly "learns to send Reiki over distance through the use of special symbols which involve the opening up to the experience of the energy and listening to one's inner voice." The third level is Reiki Master, a process lasting a year or more while working as an apprentice with another Reiki Master. During this time the apprentice learns to embody the energy and is then able to teach Reiki to others."

There is no evidence that clinical Reiki's effects are due to anything other than suggestion, or that they are superior to massage or any other healing ritual. Reiki's metaphysical beliefs may be in conflict with an individual patient's religious beliefs. Full disclosure of the belief system should precede its use in any setting. An investigation of proponent literature casts serious doubt as to whether Reiki practitioners can be trusted with such full disclosure. Reiki literature presents misinformation as fact, and instructs practitioners on how to skirt the law in order to protect themselves from regulation and accountability.

Proponents of this practice essentially admit that the evidence for its efficacy is essentially anecdotal and/or from poorly-designed studies, with many giving several reason why it cannot be studied by RCTs.[92],[93],[94] Essentially, Reiki has not been well-studied scientifically is considered to be scientifically implausible, does not meet professionally accepted standards, and lacks research and literature for efficacy and/or utility.[95].[96].[97].[98]

Summary and comments

Reiki, and all other non-touch/"energy-balancing" practices, have no place in the scientific world.  All are clearly in the category of alternate medicine and have not demonstrated any reason to be considered part of a legitimate medical or therapy practice.

Magnetic Therapy

The use of magnets to treat illness has been described historically in many civilizations, and was suggested by ancient Egyptian priests and in the 4th century BC by Hippocrates. The 15th century Swiss physician and alchemist Paracelsus theorized that magnets may be able to attract diseases and leach them from the body. In modern times, magnetic fields play an important role in Western medicine, including use for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques.  Constant (static) magnets or pulsed electromagnetic fields may be applied to areas of the body affected by illness, or to the entire body.[99]

Magnetic therapy involves the use of thin metal magnets attached to the body alone or in groups. They are sometimes mounted on bracelets and necklaces, or attached to adhesive patches that hold them in place. Some magnets are placed in bands or belts that can be wrapped around the wrist, elbow, knee, ankle, foot waist, or lower back. There are even magnetic insoles, blankets, and slumber pads. These magnets may be worn for just a few minutes or for weeks, depending on the condition being treated and the practitioner.  Proponents claim magnetic therapy can relieve pain caused by arthritis, headaches, migraines, and stress, and can also heal broken bones, improve circulation, reverse degenerative diseases, and cure cancer. They also claim that placing magnets over areas of pain or disease strengthens the body's healing ability. Some believe that magnetic fields increase blood flow, alter nerve impulses, increase oxygen being sent to cells, decrease fatty deposits on artery walls, and realign thought patterns to improve emotional well being.[100]

Although there are countless testimonials in fitness magazines, internet sites and various books vouching for the effectiveness of this age-old form of alternative therapy, there is a profound lack of overall proof of the legitimacy of magnetic therapy in peer-reviewed medical literature.[101]

While research may someday find magnetic therapy beneficial, to date there's little medical evidence to back up health claims, and the therapy is still considered experimental".[102]

Summary and comments

While there is evidence that low-amperage electrical currents may have a healing effect in bones, wounds and even soft-tissue injuries,[103],[104],[105],[106],[107],[108],[109] there is no similar evidence for static magnets.  Thus, this author does not recommend use of static magnets for the achievement of therapeutic goals.

Low-Level Laser Therapy (LLLT)

Low-Level Laser Therapy (LLLT) refers to the use of red-beam or near-infrared lasers with wavelength between 600 and 1000nm power and 5-500 milliwatts.  In contrast, lasers used in surgery typically use 300 watts.  These lasers are non-thermal.  Due to the low absorption by human skin, it is hypothesized that the laser light can penetrate deeply into the tissues where it may have a photobiostimulation effect.  It is also referred to a cold laser therapy, among other terms.  These lasers have been advocated for a wide variety of conditions, such as wound healing, smoking cessation, tuberculosis, TMJ disorders, and a wide variety of musculo-skeletal conditions.[110]

Three systematic reviews of LLLT versus standard care or sham treatment for pressure ulcers was conducted and reported in the British Journal of Medicine.  It was concluded that LLLT was no better than sham or conventional treatment.  They stated that the quality of evidence was low.  In comparison with ultrasound plus ultraviolet laser treatment and comparison with ultrasound plus ultraviolet light treatment, LLLT seems to be equally effective in increasing healing at 12 weeks.  They stated that the quality of evidence was moderate.[111]

United Healthcare/Oxford Health Plans has concluded that there is insufficient clinical evidence to support LLLT for wound healing.[112]  

A recent review of studies capturing all RCTs concerning the effectiveness of LLLT in low back pain concluded that there is not enough evidence to confirm or refute that it is beneficial in treating patients with non-specific low-back pain. More high quality studies evaluating different lengths of treatment and dosages were recommended.[113] 

Cigna recently published its medical coverage policy, in which there was an extensive review of the literature on LLLT.  While there were some positive findings for some musculo-skeletal conditions, the quality of studies was low and treatment methods were varied.  Further investigation was recommended to determine its effectiveness.  Interestingly, the findings in support of this modality was lower for wound healing than in musculo-skeletal conditions.  They concluded that this treatment presently is experimental, investigational or unproven110.

There is some interesting research being conducted in the use of LLLT for the treatment of cancer and spinal cord injury.  However, presently it is only in the working hypothesis stage and studies have only been conducted on cancer cells in laboratory conditions and spinal cord injuries in rats.[114]

Summary and comments

Fortunately, LLLT has not been promoted by alternative medicine proponents like other treatments discussed thus far.  However, because of its low level of energy, there is the potential for this promising modality to be overly-promoted through unscientific claims.  For example,  some practititors are calling it low-level laser acupuncture and discussing its effects using Traditional Chinese Medicine (TCM) terms.  If one is exposed to a practitioner used these terms, it is recommended that your "quack detector" be tuned in.

LLLT may be an effective tool in the treatment of many conditions.  However, presently this modality must be considered experimental.  Thus, this author does not recommend its use for other than research purposes.

Biofeedback

The American Cancer Society describes Biofeedback as follows:[115]

Biofeedback is a treatment method that uses monitoring devices to help people consciously control physical processes such as heart rate, blood pressure, temperature, sweating, and muscle tension that are usually controlled automatically. 

Biofeedback is used to help a person regulate specific body functions. By helping a patient change heart rate, skin temperature, breathing rate, muscle control, and other such activity in the body, biofeedback can reduce stress and muscle tension from a number of causes. It can promote relaxation, help correct urinary incontinence, treat migraines and less serious headaches. It helps people with Raynaud's disease (problems of blood circulation in the fingers and toes which makes them feel very cold) increase the temperature of their hands and toes. Through a greater awareness of bodily functions, it can help a person regulate or alter other physical functions that may be causing discomfort. Biofeedback is useful also in retraining muscles after injury, or in teaching other muscles to take over.

Monitoring devices are used to provide information to amplify physical processes that are hard to detect without help. This information is then "fed back" in the form of a continuous signal (such as a tone or image readout). The person can adjust his or her thinking, emotional state, or other mental processes in order to control bodily functions by focusing on changing the signal.

Under the guidance of a biofeedback therapist, the patient concentrates on changing a specific physical process, such as heart rate, temperature, perspiration, blood flow, brain activity, or muscle tension.  A monitor connected via electrodes to the patient's skin measures changes in whichever function is to be altered. Tones or images produced by the monitor inform the patient when he or she achieves the desired results. The process is repeated as often as necessary until the patient can reliably use conscious thought to change physical functions. After this is learned, the biofeedback equipment is no longer needed, although some patients return to have their condition monitored and repeat their biofeedback sessions.

For centuries, followers of ancient eastern practices such as meditation and yoga have claimed they could control physical processes usually considered beyond the power of conscious thought. Studies on how biofeedback works were not conducted until the 1970s. Originally, it was used by counselors, psychologists, and other therapists. Today, physicians and other health care professionals in the United States use biofeedback as a complementary therapy to promote relaxation, and treat headaches, migraines, and insomnia.

In past statements, The American Pain Society had determined that biofeedback is effective, but probably no better than other less expensive and less instrument-oriented treatments such as progressive muscle relaxation training and coping skills training.  While not changing that stance appreciably, presently it states that biofeedback training does provide subjects with information that enables them to control voluntarily some aspect of their physiology that may contribute to the pain experience. However, because pain is a complex behavior and not merely a pure sensory experience, it states that biofeedback is most beneficial for patients when used as one adjunctive component of an interdisciplinary pain management program.[116]

Although many studies have evaluated biofeedback, most of them suffer from inadequate design.[117]  Of all the medical conditions for which biofeedback has been advocated, the best studied is hypertension. However, a review of the literature published in 2003, which found 22 controlled trials of acceptable quality, concluded that real biofeedback is not more effective than fake biofeedback.[118]  A study published subsequent to this review did report benefits, but it was poorly designed.[119] 

At least one controlled study supports the use of biofeedback for each of the following; anxiety,  chronic low-back pain, female stress incontinence, insomnia, and, possibly, rehabilitation from strokes.  It was note that the evidence of benefit with biofeedback was not definitive for any of these conditions, and in many cases there are also studies with negative outcomes.[120]

In a detailed review of multiple controlled studies researchers concluded that biofeedback is useful for tension headaches, particularly when combined with other relaxation therapies.[121]  In another review of 94 studies, researchers concluded that biofeedback is capable of significantly reducing the frequency for both migraine and tension-type headaches, among other benefits. However, it is important to note that not all of the studies they used to arrive at this conclusion were randomized, placebo-controlled trials.[122]  The balance of the evidence suggests that biofeedback is not effective for asthma[123] and no more than marginally effective for Raynaud’s disease.[124],[125]

Summary and comments

Biofeedback was included in the discussion because of its roots in ancient eastern meditative and yoga practices.  Because of such, alternative medicine proponents may over-promote its value.  In fact, many so-called "integrative" therapy/medicine practices include it as a staple of treatment.

Biofeedback may have some value in the treatment of some conditions seen by physical therapists.  However, this author does not recommend it as a first-line treatment in any condition.  Perhaps in the context of a multi-disciplined approach, biofeedback can be useful for those individuals who are not obtaining satisfactory results from more traditional modalities.

Yoga

The American Cancer Society describes Yoga as follows:

Yoga is a form of non-aerobic exercise that involves a program of precise posture, breathing exercises, and meditation. In ancient Sanskrit, the word yoga means "union."

Yoga is promoted as a system of personal development. It is a way of life that combines ethical standards, dietary guidelines, physical movements, and meditation to create a union of mind, body, and spirit. Yoga is said to cultivate prana, which is similar to qi (or chi) in traditional Chinese medicine meaning vital energy or life force. People who practice yoga claim it leads to a state of physical health, relaxation, happiness, peace, and tranquility. There is some evidence which shows that yoga can lower stress, increase strength, and provide a good form of exercise.

Supporters also claim yoga can be used to help stop smoking, eliminate insomnia, and increase stamina. They further claim that the mastery of yoga can give people supernormal mental and physical powers. Yogis, who are masters and teachers of yoga, claim they can obtain heightened senses, overcome hunger and thirst, and develop almost total control over physical processes such as heart rate and breathing.

Yoga is one of the oldest mind-body health systems in existence and was first practiced in India over 5,000 years ago. In the United States, yoga was first practiced by the Concord transcendentalists in the 1840s but it did not become well known until the 1880s when the English translation of Yoga Sutras was published. This ancient book gave a detailed description of yoga techniques and the quest for samadhi, which is central to yoga beliefs.

Four traditional yoga paths are meditative (Raja Yoga), service (Karma Yoga), wisdom (Jnana Yoga), and devotional (Bhakti Yoga). Hatha Yoga is based on a part of Raja Yoga, and is the best known form of yoga. In the US, it is what most people mean when they refer to yoga.[126]

There is preliminary evidence that yoga may be beneficial when it is added to standard treatments for several conditions, including anxiety disorders or stress, asthma, high blood pressure, heart disease and depression. It is not clear if yoga is any more or less effective than other forms of exercise. Damage to nerves or discs in the back have been reported, and caution is warranted in some individuals.[127]

Between March and June 2004, a systematic review was carried out of the research evidence on the effectiveness of yoga for the treatment of anxiety and anxiety disorders. Eight studies were reviewed. They reported positive results, although there were many methodological inadequacies. Owing to the diversity of conditions treated and poor quality of most of the studies, it is not possible to say that yoga is effective in treating anxiety or anxiety disorders in general. However, there are encouraging results, particularly with obsessive compulsive disorder. Further well conducted research is necessary which may be most productive if focused on specific anxiety disorders.[128]

In the first randomized trial of Iyengar yoga and back pain, 60 participants were placed in either a yoga group or an educational group. Both programs lasted 16 weeks. Participants had experienced low back pain for an average of 11.2 years, and 48% used pain medication. At the end of the study and at a three-month follow-up, those in the yoga group had significant reductions in pain intensity, functional disability (including spinal range of motion), and use of pain medication. The results compare favorably with results obtained with physical therapy.[129]

Although there is some evidence that yoga may offer medical benefits, in general, this evidence is not strong. There are several reasons for this but one is fundamental: it isn’t possible to fit yoga into a double-blind, placebo-controlled study. While it might be possible to design a placebo form of yoga, it would be quite difficult to keep participants and researchers in the dark regarding who is practicing real yoga and who is practicing fake yoga![130]

Yoga, like Tai Chi, has been advocated as a means of increasing strength, balance, and physical function in seniors. However, there is as yet little scientific proof that yoga offers such benefits or that it is superior to generic exercises such as walking.[131]

42 people with  carpal tunnel syndrome were randomly assigned to receive either yoga or a wrist splint for a period of 8 weeks.  The results indicated that use of yoga was more effective than the wrist splint. However, participants in the control group were simply offered the wrist splint and given the choice of using it or not; it would have been preferable for them to have received a more believable placebo, like other forms of meditative exercise.[132]

In a randomized, controlled trial, 8 weeks of daily supervised yoga was modestly more effective than a similar amount of supervised physical exercise in relieving menopausal symptoms  (eg, hot flashes), decreasing psychological stress, and improving cognitive abilities among 120 perimenopausal women.[133],[134]

To date, only weak evidence has been reported regarding the possible usefulness of yoga for  depression,[135] obsessive-compulsive disorder,[136] low back pain,[137],[138] general well-being,[139],[140] migraine headaches,[141] osteoarthritis[142] and congestive heart failure.[143]

Some evidence suggests that hatha yoga is not helpful for chemical dependency[144] or high blood pressure.[145]

Summary and comments

Yoga was included in the discussion because of its roots in ancient eastern meditative practices and use of terms involving mystical energy.  Because of such, alternative medicine proponents may over-promote its value. 

Even though the evidence is weak, Yoga may be helpful in aiding in the improvement of relaxation, mobility and balance.  Thus, this author has no problem including elements of Yoga in a comprehensive management of problems in this area.  Care should be taken, however, to avoid injury from over-stretching.

Meditation

Aetna InteliHealth decribes meditation as follows:[146]

Different types of meditation have been practiced for thousands of years across the world. Many types have roots in Eastern religions.

Meditation can generally be defined as the self-regulation of attention to suspend the normal stream of consciousness. A common goal of meditation is to reach a state of "thoughtless awareness," during which a person is passively aware of sensations at the present moment. It is this goal that distinguishes meditation from relaxation. Various types of meditation may use different techniques. Techniques that include constant repetition of sounds or images without striving for a state of thoughtless awareness are sometimes called "quasi-meditative."

* Mindfulness — This involves focusing on a physical sensation. When thoughts intrude, the meditating individual returns to the focus. Key elements of mindfulness meditation have been used in cognitive therapy, pain control, and stress reduction programs. Mindfulness-based stress reduction (MBSR) is a structured, standardized group program originally developed for chronic pain patients.

* Breath mediation — This involves focusing on the process of breathing. Breathing exercises taught in childbirth classes are based on this technique. Counting while breathing may provide a meditative focus.

                        * Visualization — This involves focusing on specific places or situations.

* Analytical meditation — This involves an attempt to comprehend the deeper meaning of an object of focus. Analytical meditation differs from other forms in that the practitioner does not repeat a word over and over, but rather strives to comprehend the deeper meaning of the object of focus.

* Guided meditation — Guided meditation or guided imagery is a technique that directs the imagination towards a conscious goal. Yoga nidra or yogic "sleep" is considered to be a form of guided meditation.

* Walking meditation — This Zen Buddhist form of meditation called kinhin involves focusing on the sensation of the feet against the ground. Sitting meditation is similarly practiced.

* Transcendental Meditation® (TM®) — This involves focusing on a mantra (a sound, word or phrase that is repeated over and over, either aloud, as a chant or silently). Maharishi Mahesh Yogi introduced TM to the West in the late 1950s, and this practice was well publicized because of its famous followers such as the Beatles. A goal of TM is to reach a state of relaxed awareness. Intruding thoughts may be noticed passively before returning to the mantra. The claimed health benefits are controversial, such as improved IQ and reduced violent tendencies. It has been debated as to whether TM should be classified as a religion, because some people assert that TM constitutes a cult or a religious sect. TM® is a registered trademark with centralized administration of training at Program Centers worldwide.

There are a number of theories about how meditation works and its potential health benefits. One hypothesis is that it reduces activity of the sympathetic nervous system (responsible for the fight-or-flight response), leading to a slower heart rate, lower blood pressure, slower breathing and muscle relaxation.

Several preliminary studies of transcendental meditation have noted these types of effects, although the research techniques were of poor quality, and the results cannot be considered conclusive. Changes in hormone levels, lactic acid levels, blood flow to the brain and brain wave patterns have been reported in some studies that were of poor quality. Better research is necessary to make a firm conclusion.

There's no definitive evidence that meditation eases health problems, according to an exhaustive review of the accumulated data by Canadian researchers.[147] "There is an enormous amount of interest in using meditation as a form of therapy to cope with a variety of modern-day health problems, especially hypertension, stress and chronic pain, but the majority of evidence that seems to support this notion is anecdotal, or it comes from poor quality studies," concluded researchers Maria Ospina and Kenneth Bond of the University of Alberta/Capital Health Evidence-based Practice Centre, in Edmonton.

The Agency for Healthcare Research and Quality has released an evidence-based report, Meditation Practices for Health: State of the Research. The most recent in a series requested and funded by NCCAM, the report is based on 813 studies across five broad categories: mantra meditation, mindfulness meditation, yoga, tai chi, and qi gong. The study focuses on high blood pressure, other cardiovascular diseases, and substance abuse disorders, the conditions for which meditation has been most studied.  The authors, from the University of Alberta Evidence-Based Practice Center in Canada, conclude that because of problems with methods used in the studies (for example, insufficient detail, poor design, or variation between the patient groups studied), it cannot be determined whether meditation practices are effective therapies for these three conditions or which type of meditation is the most effective. The authors suggest more research of higher quality and provide specific recommendations.[148]

The University of Alberta Evidence-based Practice Center reported to the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services the results of a comprehensive search of over 17 databases on 5 categories of meditation practices.  It was concluded that there are many uncertainties surrounding the practice of meditation and that the research appears to lack a common theoretical perspective, with poor methodological quality.  Firm conclusions could not be drawn based on the available evidence.[149]

However, a randomized, controlled and blinded study was conducted with 80 Chinise students, comparing meditative practice (using integrative body-mind training, IBMT) with relaxation training (the control group). The researchers found that five 20-minute sessions of IBMT mediation led to greater improvement in scores assessing conflict resolution, anxiety, depression, anger, fatigue, and vigour. They also found that meditation practice reduced the amount of cortisol that was released in response to the stress test.[150]  There was some discussion whether the results of this Chinese study would be reproducible in a western culture.

Summary and comments

Meditation was included in the discussion because of its roots in ancient eastern religions.  Because of such, alternative medicine proponents may over-promote its value.

This author has no firm recommendation regarding meditation.  There does not appear to be a direct safety issue with meditation.  Its use as part of a general healthy lifestyle may be appropriate but, presently, claims for health benefits cannot be clearly made based on scientific evidence.

Tai chi

The American Cancer Society describes tai chi as follows:[151]

Tai chi is an ancient Chinese martial art that is part of Qigong (see Qigong). It is a mind-body, self-healing system that uses movement, meditation, and breathing to improve health and well being.

People who practice the deep breathing and physical movements of tai chi report it makes them feel more relaxed, younger, and agile, and they say it helps their circulation. The slow, graceful movements of tai chi, accompanied by rhythmic breathing, relax the body as well as the mind. Research has found that tai chi can reduce stress, lower blood pressure and reduce the risk of heart disease. There is also evidence that tai chi is particularly suited for older adults or for others who are not physically strong or healthy.

Aetna InteliHealth clarifies that in traditional Chinese medicine, it is believed that illness is a result of imbalance between two opposing life forces, yin and yang. Tai chi aims to reestablish balance, create harmony between body and mind and connect an individual with the outside world.  It further states that numerous anecdotes and preliminary scientific studies report health benefits of tai chi, however, effectiveness and safety of tai chi have not been proven over other forms of exercise.[152]

Although there is some evidence that tai chi may offer medical benefits, in general, this evidence is not strong. There are several reasons for this but one is fundamental: it isn’t possible to fit yoga into a double-blind, placebo-controlled study. While it might be possible to design a placebo form of tai chi, it would be quite difficult to keep participants and researchers in the dark regarding who is practicing real tai chi and who is practicing fake tai chi![153]

According to most (but not all) studies, tai chi can improve balance and decrease risk of falling.[154],[155],[156] Tai chi may mildly improve flexibility and cardiovascular health, presumably because it is a form of moderate exercise.[157] However, one fairly large (207-participant) and long-term (1-year) study that compared tai chi to resistance exercise (weight lifting) found that while resistance exercises measurably improved one measure of cardiovascular risk (insulin sensitivity), tai chi did not affect any measures of cardiovascular risk.[158] In a review of 26 published studies examining the effectiveness of tai chi for high blood pressure , 85% demonstrated a reduction in blood pressure.  However, only 5 of these 26 studies were of acceptable quality.[159] One study found that patients with congestive heart failure can benefit from tai chi, but there was no adequate control group.[160] In two controlled studies, tai chi produced some benefit in bone density, suggesting the possibility that it might be helpful for preventing osteoporosis.[161],[162] A few studies provide inconsistent evidence for the usefulness of tai chi as a treatment for osteoarthritis[163],[164], and a highly preliminary study suggests it may be beneficial for mild to moderate rheumatoid arthritis.[165] In one randomized study, a certain form of tai chi was more effective than health education after 25 weeks in subjects with moderate insomnia.[166]

A review of 4 RCTs looking at the effects of tai chi in the senior population concluded that there was a significant reduction in the risk of falling, a reduction in the rate of functional limitations and dependency and more enjoyment than with traditional exercises.[167]

Summary and comments

Tai chi was included in the discussion because of its roots in Traditional Chinese medicine.  Because of such, alternative medicine proponents may over-promote its value.

There is some evidence that tai chi may be of value in several conditions.  However, much of this evidence is weak due to the poor quality of most studies.  Its use as part of a general healthy lifestyle may be appropriate.  For a physical therapist, it may have its main value as a complimentary treatment within a balance/fall prevention program.

NOTE: The following three methods or approaches to exercise are lumped together because they are named after their originators, were founded around the same time and are promoted in similar ways.  Summary and comments will follow after brief descriptions of all.

Pilates

A Pilates Instructor's Course describes this exercise method as follows:[168]

Pilates originated as a body building regime which incorporated mental focus, breathing and relaxation, Over the past 75 years it has evolved into a complex conditioning program valuable for physical training and general well-being, as well as for rehabilitation and injury prevention.

The method was developed by Joseph Pilates, a physical trainer, who studied Eastern and Western mind-body applications and spent more than 50 years refining his technique. Pilates was estabilished in New York in the 1930s and since then centers have opened in the US, Canada, England and Australia in the 1980s.

While there is some anecdotal and case study evidence for its effectiveness, there is no higher-level research that supports Pilates as an approach superior to more conventional strengthening/"stabilizing" exercises.[169],[170],[171],[172]

Feldenkrais Method

Aetna IntelHealth described the Feldenkrais Method as follows:[173]

The Feldenkrais Method was developed by Moshe Feldenkrais (1904 – 1984), a Russian-born Israeli physicist who was disabled from a knee injury. Dr. Feldenkrais called on his formal training in science and in the martial arts to develop an approach that aimed to help the body move in more natural and comfortable ways.

The technique involves stretching, reaching and changing posture in specific patterns. In some cases, it includes a form of massage. In general, the emphasis of the Feldenkrais Method is to provide supportive therapy or physical rehabilitation. The Feldenkrais Method has not historically been viewed as a curative approach to most diseases. Recently, the Feldenkrais Method has been studied as a means to improve muscle and joint pain, to improve quality of life in chronic conditions such as multiple sclerosis, and to reduce anxiety levels. Research is still early in these areas, without definitive answers.

The Feldenkrais Method is based on the concept that improving patterns of movement may enhance overall physical and psychological performance or recovery from disabling conditions. There are two basic components of the Feldenkrais Method: Awareness Through Movement and Functional Integration. These approaches may be used alone or in combination with each other.

Awareness Through Movement is an approach to body movement that is taught in group sessions by Feldenkrais practitioners. Practitioners verbally lead participants through a series of slow movement sequences that may involve everyday motions such as standing up, sitting down or reaching, but may also involve abstract movements. These sessions often last between 30 and 60 minutes and may be customized to the ability of individual participants. There are hundreds of Awareness Through Movement patterns, which vary in complexity and difficulty. The goals of Awareness Through Movement are to increase awareness of what types of movements work best for a participant, to find sequences of movement to replace uncomfortable or habitual patterns and to improve flexibility and coordination.

Functional Integration involves a hands-on private session with a Feldenkrais practitioner. Participants are fully clothed and may be in a lying, sitting or standing position. As with Awareness Through Movement, the emphasis is on helping participants develop patterns of movement that are efficient and comfortable. The practitioner may touch the participant and move muscles and joints gently within the normal range of motion. Movement sequences are customized to the individual, and through touch, the practitioner may demonstrate new movement patterns. An aim of these sessions is to help identify patterns of movements that are natural and comfortable. It is believed that by leading the body through more functional patterns of movement, the body may learn to move in beneficial ways, resulting in improvements in everyday activities or in symptoms related to medical conditions. Sessions generally last from 30 to 60 minutes.

Awareness Through Movement and Functional Integration are considered by Feldenkrais practitioners to be equivalent and complementary means of achieving improvements in movement patterns.

Feldenkrais sessions may play a role in the treatment of musculoskeletal pain, anxiety and physical rehabilitation. However, little scientific research exists in this area, and more studies are needed to provide answers that are more definitive.

A well-known physical therapist, Sandy L. Burkart PT, OCS, PhD, utilizes the Feldenkrais Method but only supports such with case studies.[174]  A review of supporting research for this method conducted in 2003 did not find significant support for it over more conventional movement approaches for musculo-skeletal conditions.[175]  It’s not well researched and there is no compelling evidence for effectiveness for any condition.[176]  The Internation Feldenkrais Foundation (IFF) admits that it method has not been adequately studied and calls for more research.[177]

Alexander Technique (AT)

Wikipedia describes the Alexander Technique as follows:[178]

The Alexander Technique is a technique of body re-education and coordination, accomplished through physical and psychological principles. The technique focuses on the self-perception of movement and is promoted for the alleviation of back pain, rehabilitation after accidents, improving breathing, playing musical instruments and singing.

The technique takes its name from F. Matthias Alexander, who first formulated its principles between 1890 and 1900.   Alexander developed the Technique as a personal tool to alleviate pain and hoarseness that affected his ability to pursue a career as a Shakespearean actor. Alexander taught his technique for 30 years before creating a school to form other teachers of the technique. All current Alexander Technique teachers have participated in the 3-year, 1600-hour training, all with a pedagogical ancestry traced to Alexander himself.

The technique is taught in lessons, through a combination of hands-on coaching and verbal explanation. During lessons, which may last from 30 minutes to an hour, students, guided by the teacher, inhibit habitual reactions and instead find newer and more efficient ways to perform simple tasks, like walking, standing, and sitting.

Historically taught in private lessons, its principles have also been adapted to be taught in groups, often using short individual lessons which, in turn, act as examples to the rest of the class.

In 1999, Dennis ran a controlled study of the effect of AT on the "Functional Reach" (associated with balance) of women older than 65 and found a significant improvement in performance after 8 sessions but this improvement was not maintained in a one-month follow up.[179]  In 2004,  Maher concluded that "Physical treatments, such as ... Alexander technique ... are either of unknown value or ineffective and so should not be considered" when treating lower back pain with an evidence-based approach.[180] While there is an abundance of anecdotes which suggest that AT instruction contributes to improved vocal quality and vocal health, only 2 poor-quality studies were found, thus, it was suggested that the placebo effect may have been demonstrated.[181],[182]  Claims made for reducing the need for medication in patients with asthma was not supported by the evidence.[183] 

In 2002, Stalibrass et al. published the results of a significant controlled study into the effectiveness of the technique in treating Parkinson's disease. Four different measures were used to assess the change in severity of the disease. By all four measures, Alexander Technique was better than no treatment, to a statistically significant degree (both P-values < 0.04). However, when compared to a control group given massage sessions, Alexander technique was only significantly better by two of the measures. The other two measures gave statisticially insignificant improvements (P-values of approximately 0.1 and 0.6). This appears to lend some weight to the effectiveness of the Technique, but more studies and data are required.[184]

However, a 2008 randomized controlled trial published in the British Medical Journal found marked improvement in addressing back pain with this technique.[185]  In addition, 2 other fairly recent studies stated that the tentative evidence is positive for AT.[186],[187] 

Summary and comments regarding Pilates, the Feldenkrais Method and the Alexander Technique

All three of these exercise methods/approaches are based on body-mind awareness and control.  While the language used is not as openly unscientific as some of the previously-discussed alternative medicine, much of the stated principles have not thoroughly been studied.

That being said, this author has the follow opinions:

·         Pilates and the Feldenkrais Method have not demonstrated enough support for their effectiveness over and above more traditional exercise.  Thus, these are not acceptable as either a primary or complimentary exercise for neuro-musculo-skeletal conditions.

·         The Alexander Technique has demonstrated some evidence for its effectiveness in neuro-musculo-skeletal conditions, thus, its use as complimentary exercise is acceptable.

      *Therapeutic Ultrasound and Transverse Friction Massage

 * An addendum the original course.  Therapeutic ultrasound and transverse friction massage are common physical therapy procedures.  However, both of them lack good research. (here and here)

Final Thoughts

Holistic medicine has been included under the umbrella of alternative medicine in this course because the term is commonly, but erroneously, used by such to portray science as focusing only on the "parts" and minimizing the "whole".  However, (w)holistic medicine can be good medicine if it accepts science.   Our "Self"/"Mind" is more that the sum of its parts.  There is a strong connection between the mind, brain and body.  Recent legitimate research is very interesting in this area (see Ginger Campbell MD's Podcasts --- http://brainsciencepodcast.libsyn.com/).

The term quantum mechanics, like holistic medicine, is also commonly misused by alternative medicine practitioners to support their unscientific concepts of mysterious energy fields.  Indeed, there may be unknown energy fields but, until the scientific method supports them having an effect on us, there is no reason to believe.  Legitimate quantum mechanics is involved with exciting research in the area of atomic and sub-atomic particles and energy.  The reader is urged to perform a web search in this area for further information.

Physical therapy must decide whether it is going to continue to accept alternative medicine practices into its tool box.  Is it going to practice within the bounds of the real world of science or is going to allow unscientific activities promoted by whose not accepting of such?  Would you accept surgery from a physician with an unscientific worldview? 

It is the challenge of alternate medicine practitioners and promoters to present why their unscientific claims should be accepted.  What is their alternative to the scientific method?

It is the hope of this author that this course has been informative and thought-provoking.  For further information on this topic, the following websites/podcast sites should be helpful:

www.quackwatch.com

http://www.ebm-first.com

www.theskepticsguide.org/

http://pointofinquiry.org/

http://www.skepticality.com/

http://brainsciencepodcast.libsyn.com/

---

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