Alternative medicine: Implications for the surgeon

Abstract Practitioners of traditional medicine should be aware of what patients do to improve their health and sense of health. Consider, for example, a 55-year-old woman who delayed seeking traditional medical evaluation while undergoing 3 months of chiropractic manipulation for chronic neck pain. When she eventually sought the advice of her family physician, a 3.2 cm mass was discovered in her right breast. The etiology of her neck pain was eventually determined to be caused by metastatic ductal carcinoma. This cluster of articles may seem strange in Current Surgery . The growing use of nonconventional methods of care in the United States mandates that surgeons be aware that many individuals use it and that this form of alternative practice can have a profound impact on the health of individual patients. As such, nontraditional methods should be subjected to the same degree of scientific scrutiny as the treatment alternatives offered by conventional medical practice. Alternative medicine is a fact of life in the US and includes chiropractic therapy, massage therapy, herbal medicine, acupuncture, megavitamin administration, self-help groups, spiritual healing, folk medicine, hypnosis, energy healing, biofeedback, homeopathy, and other forms of nontraditional care. Eisenberg estimated in 1993 that 34% of Americans visited at least 1 alternative medicine practitioner a year. More recent data suggest that alternative medicine use increased by 47% in total visits to these providers from 1990 to 1997, or 427 to 629 million visits. Expenditures for alternative medicine were conservatively estimated at $21.2 billion in 1997, slightly more than half of which was paid out-of-pocket. This exceeds the out-of-pocket expenditures for all US hospitalizations in that year. The uneducated, prejudiced assumptions that those who seek alternative forms of health care are undereducated, are of lower socioeconomic status, or perhaps have limited or difficult access to conventional health care are challenged by the work of Astin discussed above. Burg and colleagues reported that 52% of physician faculty at a large health care complex, a population generally considered well educated with higher socioeconomic advantage, admitted to personal use of one or more types of alternative therapies. People seek alternative health care choices to complement conventional medicine, not as a substitute. Furthermore, patients rarely volunteer this information to their medical doctor. Considering the prevalence of this form of health care, it is prudent for the practitioner of conventional medicine or surgery to be informed about the practice and to query patients about its use. The first report of spinal manipulation that improved a condition not related to the musculoskeletal system was in 1895 when Daniel Palmer improved the hearing of a deaf patient by cervical manipulation. The premise on which spinal manipulation is based considers that vertebral subluxation irritates the spine or nerve roots, both somatic and autonomic, predisposing the patient to symptoms. Adjustment of this subluxation realigns the spine, removing the source of irritation. Improvement in central back pain (ie, pain without specific anatomical pathology) with chiropractic care is accepted by some as beneficial. However, neither the pathophysiological aberrations proposed nor the corrections induced by spinal manipulation therapy have undergone rigorous scientific biomechanical scrutiny. No compelling data exist in the reputable literature to support the use of chiropractic manipulation for diseases or conditions other than those of a limited musculoskeletal nature. It is estimated that over 12 million Americans receive spinal manipulation by practitioners of chiropractic therapy each year. The traditional contentious relationship between doctors of medicine and chiropractors is cooling, and in some areas chiropractors are being welcomed under the umbrella of conventional medical practice. Collegial relationships that benefit the patient are encouraged by our professional organizations. However, like any therapeutic intervention, complications and adverse outcomes can and do occur. Many are obvious, as described in the article by Lee et al. The most common vascular injury during cervical spinal manipulation appears to occur in the posterior circulation, the vertebral artery being prone to shear force as its position changes from a vertical to a horizontal course. Other complications have been reported and include visual field loss, cauda equina syndrome, and retinal artery embolism. The overall incidence of complications resulting from spinal manipulation therapy is unknown, but it is most certainly very low. This is an argument frequently used to support its use. If only a handful of adverse outcomes results from the over 12 million manipulations performed each year in the US, the argument may have superficial validity. The comparison of chiropractic care to some surgical interventions such as angioplasty, laparoscopic cholecystectomy, vena cava filter placement, carotid endarterectomy, or any other common surgical procedure or medical therapy would suggest that alternative medical treatment is safer. To the list of potential adverse outcomes one must add the delay in seeking traditional health care of proven benefit imposed by extended use of nonconventional therapies. The conclusion that spinal manipulation is generally benign is not a compelling or legitimate argument for its universal indication or application. Such a position is just as irrelevant as comparing a therapeutic option with the incidence of soiling your trousers during micturition. The fact that a treatment does little harm does not substitute for compelling data that it offers benefit or that it is anatomically or physiologically sound. Expecting improvement in childhood asthma by spinal manipulative therapy stretches intellectual tolerance beyond reason at least based on available knowledge. A study comparing children who wear black sneakers to those who wear blue ones with respect to the total dose of β-agonist therapy that is required over a period of time is just as appealing. This reviewer must be missing something, or is this truly a manifestation of the death of common sense? The potential to design a study completely devoid of bias that compares alternative forms of treatment to conventional medical practice for chronic illness is problematic. This is especially true of conditions that may be self-limiting, as in the case of low back pain, or that improve with age, as is the case with asthma. Secondly, careful scrutiny of the conditions that prompt individuals to choose alternative treatment plans discloses some interesting similarities. Most of the conditions are chronic in nature, such as low back pain, anxiety, depression, headache, insomnia, hypertension, allergies, and arthritis. These are conditions for which traditional medicine does not have a simple, accurate, inexpensive diagnostic test or a consistently effective and permanent treatment. It is not surprising, therefore, that patients seek alternatives. Emotional well-being and self-assurance have significant impact on many conditions, and improving psychological health by any means may improve chronic medical problems. Patients judge doctors primarily by their availability, affability, and ability (Griffin WO, personal communication). Practitioners who take the time to listen to their patients without being judgmental and express their empathy are generally revered. The negative impact of adverse outcome is diminished when the doctor establishes a solid professional relationship with the patient. Understanding the individual is just as important as understanding the disease process. As practitioners of conventional medicine, we need to remind ourselves of this periodically.