Alternative Sports Medicine
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 6 - JUNE 98
Many active patients and athletes use alternative medical therapies when conventional medicine fails to relieve their musculoskeletal symptoms. Research is expanding, and medical organizations and schools, insurers, and physicians are exploring the efficacy of these alternatives. Profiled here are several of the alternative therapies that are popular with athletes: acupuncture, chiropractic, hyperbaric oxygen, magnet therapy, massage, and relaxation techniques. Also included are tips on how to talk with patients about alternative therapies and resources for further information.
Besides sweaty workout clothes, just what do active patients have stashed in their gym bags these days? Anyone rummaging through a few would stand a good chance of turning up a relaxation tape, or the phone number of a chiropractor or massage therapist, or even a belt of magnets.
Interest in alternative or complementary medicine—commonly defined as medical interventions not widely taught in medical schools or generally available at hospitals—is booming. And, increasingly, active patients are running to unconventional providers to treat their aches and pains with an eclectic range of treatments, from chiropractic and acupuncture to magnets and meditation. In fact, in a recent study (1), musculoskeletal complaints, particularly back pain, were the top reason patients visited an alternative medicine clinic.
Athletes Seek Alternatives
Athletes may be leading the charge in exploring some alternative treatments. For example, C.T. Moorman III, MD, director of sports medicine at the University of Maryland School of Medicine in Baltimore, says athletes at the university have been "seeking out everything from hyperbaric oxygen treatment to acupuncture to manual medicine—all of which we would consider outside the realm of traditional allopathic medicine." The level of interest has prompted Moorman to survey National Football League team physicians about players' use of alternative therapies.
David Wang, MD, a team physician at the University of Minnesota in Minneapolis, has similar observations. "The population that we deal with is pushing the edge on a regular basis. They're a group that's very susceptible to ideas that are on the fringe, that are hearsay. When you're trying to optimize yourself, you don't want the guy next to you doing something that would give him an advantage. It can make them vulnerable to a lot of crazy suggestions."
Of course, the popularity of complementary medicine goes far beyond athletes and active patients. A landmark 1993 survey of the general population by Eisenberg et al (2) indicated that one in three respondents had used at least one unconventional therapy in the previous year. From this finding, the authors estimated that Americans made 425 million visits to alternative-therapy providers in 1990, exceeding the total visits—388 million—to primary care physicians. The authors also estimated that patients spent $13.7 billion in 1990 on alternative therapies. In the survey, back problems led the list of reasons patients turned to alternative therapies.
The status of back pain as a leading target of alternative therapies supports the assumption that this field flourishes most where conventional medicine is least successful. Where conventional medicine is effective, such as with many infectious diseases, diabetes, and various conditions requiring surgery, alternative therapies are little used. But for conditions like back pain, fibromyalgia, and lateral epicondylitis, patients may seek alternative remedies because they become frustrated with conventional medicine's inability to relieve their symptoms.
Most patients, though, don't talk to their physicians about their use of alternative treatments. The 1993 survey revealed that 72% of those who used unconventional therapy did not tell their physicians that they had done so. This means that many patients—about 20 million in 1990—use alternative therapies without any medical supervision.
The authors suggested that this lack of communication may stem from physicians' assumption that unconventional-therapy use is low or from a lack of knowledge about the therapies. Whatever the cause, the lack of patient-physician discussion could be harmful to patients. For guidance in these areas, turn to "Talking to Patients About Alternative Medicine," at left, and "Finding Information on Alternative Medicine," page 100.
Mainstream Medicine Responds
Physicians have traditionally been skeptical of unconventional therapies, but the widespread use of such treatments is forcing the medical profession to respond. "I think there's been a shift in attitude in the last 5 years toward more openness and less skepticism," observes Brian M. Berman, MD, director of the Complementary Medicine Program at the University of Maryland School of Medicine in Baltimore. "Physicians are saying, 'We'd like to know more information: what the evidence is, and the scientific rationale.'"
Coordinating research. With the acknowledgment of alternative medicine's existence and its growth, physicians and medical organizations are calling for increased scientific scrutiny of the field. To help coordinate the needed research, the National Institutes of Health's (NIH) Office of Alternative Medicine (OAM) has established 11 academic centers across the country to evaluate alternative medicine treatments. A 1994 OAM report (3) provides a comprehensive overview of alternative medicine practices and identifies research needs.
An American Medical Association (AMA) policy statement passed in 1994 (available through the AMA's Department of News and Information) encourages the OAM's efforts to "determine by objective scientific evaluation the efficacy and safety of practices and procedures of unconventional medicine." The statement also encourages AMA members to "become better informed regarding the practices and techniques of alternative or unconventional medicine."
Medical education. Some medical schools are offering survey courses to acquaint students with the history and philosophy of complementary treatments (4). Berman, who has been extensively involved with OAM initiatives, says that physicians are beginning to ask for more than just background information. They would like to know when a certain therapy might be appropriate for a certain kind of problem, but, he says, "There isn't anyone teaching those kinds of courses, and that's a frustration."
Whether organized medicine will grant continuing medical education (CME) credit for courses that help physicians take the extra step of putting theory into practice is still being debated (5).
Insurer recognition. The insurance industry is also beginning to take a look at whether to reimburse patients who seek out complementary practitioners (6,7). Some insurers are exploring the efficacy of complementary therapies by providing limited access to acupuncturists and chiropractors through pilot programs. Other insurers, such as Oxford Health Plan in Norwalk, Connecticut, offer patients a network of credentialed alternative providers. Washington was the first state to require insurance companies to cover the services of state-licensed alternative therapists and is home to the nation's first publicly funded alternative medicine clinic, the King County Natural Medicine Clinic in Kent.
Treatments for Musculoskeletal Problems
What follows is an overview of those complementary treatments most often discussed in reference to musculoskeletal injuries in active patients, with special attention to recent research and sports medicine involvement.
Acupuncture. Acupuncture is a traditional Chinese healing practice that involves placing thin needles at specific anatomic points to redirect the body's energy flow, known as Qi (pronounced "chee"). Acupuncture received a boost last year when an NIH consensus development statement (8) concluded that it may be useful as an adjunct therapy, an acceptable alternative, or part of a comprehensive treatment program for such conditions as tennis elbow, fibromyalgia, low-back pain, and carpal tunnel syndrome.
Acupuncture is making inroads in conventional medicine: An estimated 3,000 allopathic and osteopathic physicians have taken courses to incorporate acupuncture into their practices (3). A physician-only professional acupuncture society, the Los Angeles-based American Academy of Medical Acupuncture (AAMA), was founded in 1987 and conducts an annual symposium accredited for AMA Category 1 CME. A recent survey (9) of AAMA members showed that they most frequently used acupuncture to manage difficult pain.
Chiropractic. Chiropractors manage neuromusculoskeletal conditions primarily through spinal manipulation, though they also use exercise, rehabilitation procedures, and physical therapy. The clinical trial data on manipulation led a government panel in 1994 to sanction spinal manipulation as a treatment for acute low-back pain in adults (10).
Though chiropractic is the most established of the complementary medicine practices, an absence of federal funds has hampered research efforts to determine its efficacy. This trend is changing. The newest OAM research center, the Palmer Center for Chiropractic Research in Davenport, Iowa, will provide an infrastructure to organize future chiropractic research. William C. Meeker, DC, MPH, director of the center, says the center's research will be guided by a 1996 federal conference convened to develop a research agenda for the chiropractic profession (11).
The chiropractic profession has shown a special interest in sports. One thousand six hundred chiropractors belong to the American Chiropractic Association's Council on Sports Injuries and Physical Fitness, based in Annapolis, Maryland. The council cosponsors the quarterly Journal of Sports Chiropractic & Rehabilitation. In addition, the American Chiropractic Board of Sports Physicians (ACBSP) sponsors two certification programs: the Certified Chiropractic Sport Physician and the Diplomate of the ACBSP.
Hyperbaric oxygen therapy. In defined situations, such as decompression sickness and gas embolism, this is a standard medical practice in which pressurized oxygen is administered. Since hyperbaric oxygen can speed healing in crush injuries and compartment syndromes, it has begun to be used as an alternative therapy for sprains, ligament tears, and muscle injury (12). However, no research documents the effectiveness of hyperbaric oxygen for such musculoskeletal injuries; in fact, a recent randomized double-blind study (13) of 32 subjects with acute ankle sprains found that hyperbaric oxygen treatment had no effect on time to recovery.
Nonetheless, professional teams have been purchasing hyperbaric oxygen chambers with the aim of speeding players' recovery and even enhancing performance with pregame doses. The ankle-sprain study did not dampen this trend, in part because patients in the study did not receive treatment until an average of 34 hours after the injury occurred. If the hyperbaric chamber is located at the sports arena, treatment of professional players can begin much sooner and, advocates suggest, presumably produce better results.
The effects and effectiveness of this treatment are controversial. Stephen R. Thom, MD, PhD, president of the Undersea and Hyperbaric Medical Society (UHMS), Kensington, Maryland, warns that some team physicians appear to be unaware of the risks of hyperbaric medicine and stresses the need for proper medical clearance and supervision of the hyperbaric chamber (14). The UHMS also has a well-established recommendation that hyperbaric chambers should be hospital-based.
Magnet therapy. Magnet therapy is the latest rage among athletes, who claim it reduces muscle soreness and pain. It involves wearing high-powered magnetic disks or sleeping on magnetic mattress pads.
Though therapeutic magnets have been used for decades by some athletes, research on their effectiveness has barely begun. One current effort is being led by Ann Gill Taylor, EdD, RN, director of one of the OAM research centers, the Center for the Study of Alternative and Complementary Therapies at the University of Virginia in Charlottesville. Her double-blind, randomized, controlled study is evaluating how sleeping on a static magnetic mattress pad affects the pain of fibromyalgia patients.
Bioelectromagnetism, which involves extremely low-voltage electrical currents and magnetic fields, has been studied for its effects on pain relief and on soft-tissue wound healing (3). Perhaps the most striking possibility of this therapy is that it may promote healing in nonuniting bone fractures (15).
Massage therapy. Massage therapy, or manual soft-tissue manipulation, includes a variety of methods, from the long, gliding strokes of Swedish massage to the targeted pressure of deep-tissue massage. One study has shown that massage may reduce muscle soreness after exercise (16). Sports massage may be tailored to the pre- and postcompetition needs of athletes, but athletes also use regularly scheduled sessions to help them avoid injuries. Massage was included in the official medical services at the Olympics for the first time in Atlanta in 1996. The American Massage Therapy Association in Evanston, Illinois, conducts a written and practical exam to certify sports massage therapists.
Relaxation techniques. A 1997 NIH report "found strong evidence for the use of relaxation techniques in reducing chronic pain in a variety of medical conditions (17)." These techniques include autogenic training (which focuses on imagining a peaceful environment), meditation, progressive muscle relaxation, and paced or deep breathing. They share two basic components: "(1) repetitive focus on a word, sound, prayer, phrase, body sensation, or muscle activity, and (2) the adoption of a passive attitude toward intruding thoughts and a return to the focus (17)."
The mental focus involved in the practice of these techniques is familiar to many athletes, who may use directed thought patterns to enhance performance. Familiarity with such mental-focus methods may make athletes candidates for using relaxation techniques to lessen pain.
Room in the Black Bag?
Though some alternative therapies have found room in active patients' gym bags, their place in the physician's black bag is still limited. Time and research may change this. Meanwhile, as patients continue to use alternative therapies, physicians are seeing a need to educate themselves on the subject.
Talking to Patients About Alternative Medicine
Almost every patient who sees an alternative practitioner continues to consult conventional physicians. Using the following suggestions can help practitioners of conventional medicine maintain good communication with these patients.
Do your homework. Learn about complementary medicine treatments, paying special attention to safety issues.
Understand the patient's motivation. Support his or her goal of feeling healthier and preventing disease.
Keep an open mind. Ask nonjudgmental questions about the use of unconventional therapies as part of the standard medical history. Resisting the temptation to condemn will encourage patients to reveal more of what they're doing.
Discuss the risks. Be honest about scientific evidence. If a patient's practice poses no danger, don't discourage it. Stress the need for adequate medical supervision.
Encourage careful consumerism. Suggest that patients interview the provider much as they would any medical professional. Patients should avoid providers who order expensive tests at the initial visit, promise immediate relief from any ailment, boast of fantastic cure rates, or attribute all symptoms to a single problem.
Compromise. If a patient insists on using an alternative therapy you consider unsafe or ineffective, propose a time limit, after which the patient can try more conventional treatment.
Follow up. Regularly ask patients how they think their alternative treatment is progressing.
Finding Information on Alternative Medicine
Practical, reliable information on alternative or complementary medicine is scarce. According to a 1995 Office of Alternative Medicine panel (1), alternative medicine treatments "currently are unsuitable for the development of evidence-based practice guidelines, in part because of the lack of relevant outcomes data from well-designed clinical trials."
Directories available. One problem is that much of the information is scattered, so initial efforts have been directed at simply taking stock of available information. A recent report (2) compiled a directory of 56 databases for alternative medicine research in the United States, Europe, and Asia; many are available online. In addition, the Cochrane Collaboration, an international organization designed to help people make informed healthcare decisions, is including research on more than 200 complementary and alternative medicine options in its registry of controlled clinical trials (3,4).
Most published materials on alternative medicine fall fairly cleanly into two camps—the skeptical and the supportive.
Skeptics. Among the leaders of the skeptical camp is Wallace Sampson, MD, clinical professor of medicine at Stanford University and editor of the newly launched publication The Scientific Review of Alternative Medicine (Prometheus Books, 59 John Glenn Dr, Amherst, NY 14228-2197; telephone: 800-421-0351), which he plans to publish biennially. Says Sampson, "I put the word 'alternative' in quotation marks even though our journal does not. For the most part these things aren't alternative. Most of them don't work, or if they do work, they're of so little benefit that they're probably not worth doing."
Sampson is also a board member of the National Council Against Health Fraud (PO Box 1296, Loma Linda, CA 92354), which focuses on health fraud, misinformation, and quackery as public health problems. The council maintains a web site (www.ncahf.org/) that posts a newsletter as well as position papers on such treatments as acupuncture and chiropractic.
Supporters. Two leading journals that take a more sympthetic viewpoint are the bimonthly Alternative & Complementary Therapies and The Journal of Alternative and Complementary Medicine, both published by Mary Ann Liebert, Inc (2 Madison Ave, Larchmont, NY 10538; telephone: 800-654-3237). Readers of both journals benefit from the bibliographic skills of Jacqueline C. Wootton, MEd, informatics project director at the Richard and Linda Rosenthal Center for Complementary and Alternative Medicine at the Columbia University College of Physicians and Surgeons, New York City.
Updated resource listings of Wootton's research published in the Mary Ann Liebert journals are posted on the Rosenthal Center's web site: https://cpmcnet.columbia.edu/dept/rosenthal/AM_Information.html. The site offers links to alternative medicine research databases, academic centers, and professional associations.
Jacqueline White is a contributing editor of The Physician and Sportsmedicine.
Copyright (C) 1998. The McGraw-Hill Companies. All Rights Reserved