Essentials of Complementary and Alternative Medicine (June 1999)

P
HYSICAL
 M
EDICINE
Physical medicine refers to the use of physical measures in the treatment of an individual. It involves the use of physiotherapy equipment (e.g., ultrasound, diathermy, 
other electromagnetic devices), therapeutic exercise, massage, joint mobilization (manipulative) and immobilization techniques, and hydrotherapy.
D
ETOXIFICATION
Recognition and correction of endogenous and exogenous toxicity is an important theme in naturopathy. Liver and bowel detoxification, elimination of environmental 
toxins, correcting the metabolic dysfunction that causes the buildup of non-end-product metabolites are important ways of decreasing toxic load.
C
OUNSELING AND
 L
IFESTYLE
 M
ODIFICATION
A naturopath is formally trained in mental, emotional, and family counseling. A naturopath typically implements the following:
1. Interviewing and responding skills, active listening, assessing body language, and other contact skills necessary for the therapeutic relationship.
2. Recognizing and understanding prevalent psychological issues, including developmental problems, abnormal behavior, addictions, stress, and sexuality.
3. Various psychological treatment measures, including hypnosis and guided imagery, counseling techniques, correcting underlying organic factors, and family 
therapy.
THERAPEUTIC APPROACH
Use of Naturopathic Medicine for Treatment
Because naturopathic medicine encompasses numerous therapies, the naturopathic physician must select the best treatment option based on the patient and his or 
her condition and health status. The discussions of individual modalities throughout this book highlight their appropriateness, strengths, limitations, and 
contraindications for various health conditions. In general, naturopathic medicine is best suited for the typical problems seen in a general practice, with particular 
applicability in the prevention and treatment of chronic diseases, such as atherosclerosis-related vascular disease; hypertension; diabetes; osteoarthritis; 
osteoporosis; Alzheimer's disease; kidney stones; inflammatory bowel disease; psoriasis; eczema; benign prostatic hyperplasia; and autoimmune diseases, including 
rheumatoid arthritis, multiple sclerosis, and lupus. It is also well suited for helping patients enhance normal physiological processes and deal with stress, or for those 
with low immune function, chronic infections, digestive disturbances, liver disorders, allergies, hormonal disturbances, premenstrual syndrome, and fatigue. Scientific 
literature supports many (although not all) of the modalities naturopathic physicians commonly use in the treatment of these conditions, especially nutritional and 
botanical therapies (
2
).
Often, natural pharmacological agents, such as botanical preparations and nutritional supplements, are used as direct substitutes for conventional drugs. However, an 
important distinction must be made: the best use of these natural pharmacological agents involves promoting the healing process rather than simply alleviating 
symptoms. The use of glucosamine sulfate instead of nonsteroidal antiinflammatory drugs (NSAIDs) in the treatment of osteoarthritis illustrates this point.
Clinical and experimental research indicates that many NSAIDs used in the treatment of osteoarthritis may produce short-term benefit, but may accelerate the 
progression of the joint destruction by inhibiting the manufacture of glycosaminoglycans (GAGs), which are key components of the cartilage matrix (
3
, 
4
, 
5
, 
6
, 
7
, 
8
 and 
9
). In contrast, glucosamine sulfate has shown equal to or better results for improving pain scores and Lequesne's index scores in double-blind studies versus 
placebo or NSAID in patients with osteoarthritis. These results are accomplished primarily through enhancing GAG synthesis rather than analgesic or pain relieving 

effects (
3
, 
4
, 
5
 and 
6
). Although NSAIDs offer symptomatic relief, glucosamine sulfate appears to address an underlying causative factor of osteoarthritis—that is, 
reduced manufacture of GAGs. Glucosamine sulfate not only improves the symptoms, including pain, but may also help the body repair damaged joints. This effect is 
unique and consistent with naturopathic goals, especially when glucosamine's safety and apparent lack of side effects are considered.
Complementary Aspects of Naturopathic Medicine
In addition to being used as primary therapy, naturopathic medicine is useful as a complementary approach to conventional medicine, especially in more severe 
illnesses requiring pharmacological and/or surgical intervention, such as cancer, angina, congestive heart failure, Parkinson's disease, and trauma. For example, a 
patient with severe congestive heart failure requiring drugs (e.g., digoxin, furosemide) may benefit from the appropriate use of thiamin, carnitine, and coenzyme Q
10
 
(CoQ
10
) supplementation (
10
, 
11
, 
12
, 
13
, 
14
, 
15
 and 
16
). Although there are double-blind studies demonstrating the value of these agents as complementary 
therapies in congestive heart failure, they are rarely prescribed by conventional medical physicians in the United States.
Using Naturopathic Medicine as Prevention
Ultimately, the greatest value of naturopathic medicine is disease prevention. Naturopathic physicians are trained to teach patients the importance of adhering to a 
health-promoting lifestyle, diet, and attitude in a family practice setting. True primary prevention involves addressing a patient's risk for disease (especially for heart 
disease, cancer, stroke, diabetes, and osteoporosis) and instituting a course of action designed to reduce controllable risk factors.
The health benefits and cost-effectiveness of disease prevention programs have been clearly demonstrated. Studies have consistently found that participants in 
wellness-oriented programs reduced their number of days of disability (43% in one study), number of days spent in a hospital (54% in one study), and amount spent 
on health care (up to 76% in one study) (
17
).
The therapeutic approach of the naturopathic doctor is basically twofold: to help patients heal themselves, and to use the opportunity to guide and educate the patient 
in developing a more healthy lifestyle. Many supposedly incurable conditions, such as osteoarthritis, respond very well to naturopathic approaches.
Clinical Application of Naturopathic Principles
Although every effort is made to treat the whole person (not just a disease), this chapter is limited to a description of only typical naturopathic therapies of specific 
conditions in a simplified, disease-oriented manner. The following are a few examples of how the person's health can be improved, resulting in alleviation of the 
disease.
M
IGRAINE
 H
EADACHE
Although the pathophysiology of migraine headaches entails vasomotor dysfunction, from the naturopathic perspective the underlying cause is maldigestion and a 
damaged intestinal mucosa that leads to food intolerance and nutritional deficiencies.
Double-blind, placebo-controlled studies have demonstrated that the detection and removal of allergic or intolerant foods eliminates or greatly reduces migraine 
symptoms in the majority of patients. Depending on the detection methodology, success ranges from 30 to 93% (
18
, 
19
, 
20
, 
21
, 
22
 and 
23
). When not carefully 
selected for food allergy, only about 30% of patients respond (
18
). However, when food intolerance is included, response rate increases to 84% (
19
, 
20
, 
21
, 
22
 and 
23
). The key intolerant foods are cow's milk, wheat, chocolate, eggs, and the food additive benzoic acid.
Although maldigestion can result in nutritional deficiencies, only a few deficiencies have been studied in relationship to migraine headache. For example, several 
researchers have found a substantial link between low magnesium levels and both migraine and tension headaches (
24
, 
25
, 
26
 and 
27
). A magnesium deficiency 
increases vasomotor instability, setting the stage for the migraine attack. However, magnesium supplementation is only effective in migraine sufferers who are 
magnesium deficient (
28
, 
29
). Low tissue levels of magnesium are common in patients with migraine, but most cases go unnoticed because most physicians rely on 
serum magnesium levels to indicate magnesium levels; this serum measure is unreliable because most of the body's store of magnesium lies within cells, not in the 
serum. A low magnesium level in the serum reflects end-stage deficiency. More sensitive tests of magnesium status for migraine patients are the level of magnesium 
within the red blood cell (erythrocyte magnesium level) and the level of ionized magnesium (the most biologically active form) in serum.
Another possible benefit of magnesium in migraine sufferers may be its ability to improve mitral valve prolapse. Mitral valve prolapse is thought to be linked to 
migraines because it leads to damage to blood platelets, causing them to release vasoactive substances like histamine, platelet-activating factor, and serotonin. Up to 
85% of patients with mitral valve prolapse may have chronic magnesium deficiency, in which case magnesium supplementation is indicated (
30
). This 
recommendation is further supported by several studies showing oral magnesium supplementation improving mitral valve prolapse.
Many botanical medicines have a long history of being used as folk cures for migraine headache. The most widely researched of these is  Tanacetum parthenium 
(feverfew). A survey and several controlled studies have demonstrated moderately good clinical response with few side effects (
31
, 
32
, 
33
 and 
34
). However, from the 
naturopathic perspective, this is not a curative approach because it only relieves the symptoms without addressing the underlying causes.
B
ENIGN
 P
ROSTATIC
 H
YPERPLASIA
 (BPH)
Prostatic hyperplasia affects most older men and is, from the naturopathic perspective, not a natural sequelae of aging. Rather, it is associated with a life-long 
inadequate consumption of zinc and essential fatty acids (EFAs) combined, in some cases, with excessive exposure to several toxins, such as alcohol.
Adequate zinc intake and absorption are paramount to proper function of the prostate. Zinc supplementation has been shown to reduce the size of the prostate—as 
determined by rectal palpation, x-ray, and cystoscopy—and to reduce symptomatology in the majority of patients (
35
, 
36
). The clinical efficacy of zinc is probably 
caused by its critical involvement in many aspects of androgen metabolism. In addition, zinc has been shown to inhibit the activity of 5-alpha-reductase, the enzyme 
that irreversibly converts testosterone to dehydrotestosterone (DHT) (
37
, 
38
, 
39
, 
40
 and 
41
).
The administration of an EFA complex containing linoleic, linolenic, and arachidonic acids can result in significant improvement for many of these patients (
42
). In an 
uncontrolled study, all 19 subjects showed diminution of residual urine , with 12 of the subjects having no residual urine by the end of several weeks of treatment. 
These effects appear to be caused by the correction of an underlying EFA deficiency because these patients' prostatic and seminal lipid levels and ratios are often 
abnormal (
43
, 
44
).
Higher alcohol intake is associated with BPH. For example, a 17-year study of 6,581 men in Hawaii found that an alcohol intake of at least 25 oz/month was 
associated with the diagnosis of benign prostatic hyperplasia (
45
). Environmental toxins from pesticides and other contaminants (e.g., dioxin, polyhalogenated 
biphenyls, hexachlorobenzene, dibenzofurans) may increase 5-alpha reduction of steroids.
In addition to correcting the underling nutritional deficiencies and toxin exposure, the naturopathic physician helps facilitate the healing process with specific foods 
and botanical medicines. For example, soybeans, rich in phytosterols (especially beta-sitosterol) and the isoflavonoids genistein and daidzein, which have also been 
shown to improve BPH, may be recommended. In a recent double-blind study consisting of 200 men receiving beta-sitosterol (20 mg) or placebo three times daily 
(
46
), the beta-sitosterol produced an increase in maximum urine flow rate from a baseline of 9.9 mL/second to 15.2 mL/second and a decrease in mean residual 
urinary volume of 30.4 mL from 65.8. No changes were observed in the placebo group. An increased consumption of soy and soyfoods is also associated with a 
decrease in the risk of prostate cancer (
47
).
The liposterolic extract of the fruit of the palm tree  Serenoa repens (Saw palmetto, also known as Sabal serrulata), native to Florida, has been shown to significantly 
improve the signs and symptoms of BPH in numerous clinical studies. The mechanism of action is related to inhibition of DHT binding to both the cytosolic and 
nuclear androgen receptors, inhibition of 5-alpha-reductase, and interfering with intra-prostatic estrogen receptors. Roughly 90% of men with mild-to-moderate BPH 
experience improvement in symptoms, especially nocturia, during the first 4 to 6 weeks of therapy, with the condition continuing to improve with longer use (
48
, 
49
, 
50
, 
51
, 
52
, 
53
 and 
54
).

C
ARDIAC
 F
AILURE
The naturopathic approach to cardiac failure is to reverse the underlying causes: cardiac muscle degeneration secondary to poor blood supply and chronic nutritional 
deficiencies. Treatment focuses on improving myocardial energy production, because cardiac failure is characterized by an energy depletion status. This impaired 
energy production is often related to a nutrient or coenzyme deficiency, such as magnesium, thiamin, coenzyme Q
10
 (CoQ
10
), and carnitine.
Low magnesium levels (particularly white blood cell magnesium) are common findings in patients with cardiac failure. This association is particularly significant 
because magnesium levels have been shown to correlate directly with survival rates. In one study, patients with normal levels of magnesium had 1- and 2-year 
survival rates of 71% and 61%, respectively, compared with rates of 45% and 42% for patients with lower magnesium levels (
55
). These results are not surprising 
considering that magnesium deficiency is associated with cardiac arrhythmias, reduced cardiovascular function, worsened ischemia, and increased mortality in acute 
myocardial infarction. Magnesium deficiency in these patients is probably due to a combination of inadequate intake and increased wasting secondary to 
overactivation of the renin-angiotensin-aldosterone system.
In addition to providing benefits of its own in congestive heart failure (CHF), magnesium supplementation also prevents the magnesium depletion caused by the 
conventional drug therapy for CHF (i.e., digitalis, diuretics, and vasodilators such as beta-blockers and calcium channel blockers). Magnesium supplementation has 
even been shown to produce positive effect in CHF patients receiving conventional drug therapy, even if serum magnesium levels are normal (
56
). Finally, 
magnesium is a critical nutrient for the production of adenosine triphosphate (ATP).
The frank thiamin deficiency of “wet beriberi” is known to result in cardiovascular dysfunction (i.e., sodium retention, peripheral vasodilation, heart failure). Although 
severe thiamin deficiency is relatively uncommon (except in alcoholics), many Americans do not consume even the RDA of 1.5 mg, especially elderly patients in 
hospitals or nursing homes. Depending on the thiamin measurement, plasma versus red blood cell thiamin, low levels (defined as a level below the lowest reference 
range for younger aged groups) were found in 57% and 33%, respectively, in one study (
57
). Interestingly, furosemide (Lasix), the most widely prescribed diuretic, has 
been shown to cause thiamin deficiency in animals and patients with cardiac failure.
Although the first study to look at thiamin as a potential adjunct in the treatment of cardiac failure showed only modest benefits, several subsequent studies have 
shown that daily doses of 80 to 240 mg of thiamin daily improved left ventricular ejection fraction by 13 to 22% (
58
).
Normal heart function is critically dependent on adequate concentrations of carnitine and CoQ
10
. These compounds are essential in the transport of fatty acids into the 
myocardium and mitochondria for energy production. Although the normal heart stores more carnitine and CoQ
10
 than needed, cardiac ischemia rapidly depletes 
carnitine and CoQ
10
 levels. Several double-blind clinical studies have shown carnitine supplementation to substantially improve cardiac function in patients with 
cardiac failure (
59
, 
60
 and 
61
). In one double-blind study, only one month of treatment (500 mg three times daily) was needed to cause significant improvement in 
heart function (
60
). The longer carnitine was used, the more substantial was the improvement. After six months of use, the carnitine group demonstrated an increase 
in the maximum exercise time of 25.9% and a 13.6% increase in ventricular ejection fraction.
Studies have also shown that CoQ
10
 supplementation is effective in the treatment of cardiac failure, typically as an adjunct to conventional drug therapy. In an early 
study, 17 patients with mild congestive heart failure received 30 mg/day of CoQ
10
(
62
). All 17 patients improved, and 9 of them (53%) became asymptomatic after 4 
weeks. In a more recent double-blind Scandinavian study of 80 patients, participants were given either CoQ
10
 (100 mg/day) or placebo for 3 months and then crossed 
over. The improvements noted with CoQ
10
 were greater than those obtained from conventional drug therapy alone (
63
).
Preparations of Crataegus spp. (Hawthorne) appear to be useful in correcting one of the underlying problems of cardiac failure: poor blood supply and ischemic 
damage. Crataegus is especially useful in the early stages as a sole agent and in the latter stages in combination with digitalis cardioglycosides. The effectiveness of 
Crataegus has been demonstrated in double-blind studies (
64
, 
65
 and 
66
). In a recent study, 30 patients with congestive heart failure (NYHA Stage II) were assessed 
in a randomized double-blind study (
66
). The group receiving the Crataegus extract showed a statistically significant advantage over placebo in terms of changes in 
heart function as determined by standard testing procedures. Systolic and diastolic blood pressure were also mildly reduced. No adverse reactions occurred.
RESEARCH
Until the last decade, original research at naturopathic institutions has been limited. The profession has relied on its clinical traditions and the worldwide published 
health care research. The most comprehensive compilation of the scientific documentation of naturopathic philosophy and therapies can be found in  Natural Medicine 
(Churchill-Livingstone, 1998) coauthored and edited by this chapter's authors. First published in 1985, the textbook now comprises over 200 chapters and references 
over 10,000 studies from the peer-reviewed scientific literature. The profession publishes the peer-reviewed  Journal of Naturopathic Medicine.
The most current study of the efficacy of naturopathic practices evaluated 135 consecutive patients seen by naturopathic physicians in five clinics (
Table 17.3
). 
Patients in this survey showed a 53% decrease in those persistent health problems that were  not the primary focus of treatment. This result is an indication of the 
nonspecific effects of the naturopathic approach to comprehensive patient treatment and education—that is, improved health and well-being.
Table 17.3. Results of 135 Consecutive Patients Seen by Naturopathic Physicians in Five Clinics
Another promising study was the evaluation of an innovative health insurance program using naturopathic physicians as both wellness-educators and primary care 
providers. After one year, overall health care costs were decreased 30% (
67
).
There are a few studies that have directly compared patient satisfaction using natural medicines with patient satisfaction using conventional medicines. The largest 
study was done in the Netherlands, where natural medicine practitioners are an integral part of the health care system (
68
). This observational study compared 
satisfaction in 3,782 patients seeing either a conventional physician or a “complementary practitioner.” As shown in 
Table 17.4
, the patients seeing the natural 
medicine practitioner reported better results for most conditions. In this series, the patients seeing the complementary practitioners were somewhat sicker at the start 
of therapy; in 4 of the 23 conditions the conventional medical patients reported better results.

Table 17.4. Patient Satisfaction with Complementary Practitioners Compared With Medical Specialists
An in-depth review of evidence of safety, effectiveness, and cost-effectiveness of modern naturopathic medicine using government reviews and audits, insurance 
company statistics, clinical trials, and other studies demonstrated that naturopathic medicine can contribute to the improvement of several common health problems 
affecting Americans (
69
). These studies need cautious interpretation, however, because they did not involve actual case studies, the 125 consecutive patients were 
not controlled, and the Netherlands' study is not entirely relevant to naturopathic medicine in the United States. More carefully conducted outcomes studies are 
needed to fully show the effectiveness of naturopathic medicine.
In the past decade, Bastyr University, National College of Naturopathic Medicine, and Southwest College of Naturopathic Medicine have all developed active research 
departments. This has resulted in the publication of original research in several peer-reviewed journals, both alternative and mainstream. In October, 1994, Bastyr 
University was awarded a three-year, $840,000 grant by the United States National Institutes of Health's Office of Alternative Medicine to establish a research center 
to study alternative therapies for patients with HIV/AIDS.