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• U.S. Department of Health and Human Services
• National Institutes of Health

Use of Complementary Health Approaches for Pain by U.S. Adults Increased From 2002 to 2022

Over a 20-year period—from 2002 to 2022—U.S. adults not only increased their overall use of complementary health approaches but were also more likely to use complementary health approaches specifically for managing pain. The findings come from a new analysis by the National Center for Complementary and Integrative Health (NCCIH). The research was funded by NCCIH and recently published in JAMA .

The analysis used data collected from the 2002, 2012, and 2022 National Health Interview Survey (NHIS) to evaluate changes in the U.S. adult use of seven complementary health approaches: yoga, meditation, massage therapy, chiropractic care, acupuncture, naturopathy, and guided imagery/progressive muscle relaxation. The NHIS is a nationally representative household survey from the Centers for Disease Control and Prevention’s National Center for Health Statistics. 

Among the findings from the analysis:

• In 2002, 19.2 percent of people used at least one of the seven approaches, whereas in 2022, 36.7 percent of people did. 
• Use of yoga, meditation, and massage therapy increased the most from 2002 to 2022.
• Use of yoga increased from 5 percent in 2002 to 9 percent in 2012 to 15.8 percent in 2022.
• Meditation increased from 7.5 percent in 2002 to 17.3 percent in 2022, and it was the most used approach in 2022.
• Use of acupuncture, which was increasingly covered by insurance, increased from 1 percent in 2002 to 2.2 percent in 2022. 

The analysis also showed a significant increase over the 20 years in the proportion of U.S. adults using complementary health approaches specifically for pain management. Among participants reporting use of any of the complementary health approaches, the percentage reporting use for pain management increased from 42.3 percent in 2002 to 49.2 percent in 2022. The percentage of U.S. adults using yoga for pain increased from 11.4 percent in 2002 to 28.8 percent in 2022. The complementary health approach with the highest use for pain management was chiropractic (85.7 percent in 2022). 

According to the analysis, the shift toward using complementary health approaches over the 20 years, especially for pain, may have been propelled by the need to switch from using potentially harmful opioids to using non-opioid treatments, higher quality research suggesting some complementary health approaches offer low to moderate levels of pain management, and the incorporation of some complementary health approaches in clinical practice guidelines for pain. Also, enhanced insurance coverage of approaches like acupuncture expanded patient access. The authors noted that study limitations include decreasing NHIS response rates over time, possible recall bias, cross-sectional data, and differences in the surveys' wording to describe the complementary health approaches and their use for pain management.

For additional information, including graphics, visit nccih.nih.gov/research/national-health-interview-survey-2022 .

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• Nahin RL, Rhee A, Stussman B. Use of complementary health approaches overall and for pain management by US adults . JAMA . 2024;331(7):613-615.

Publication Date: January 25, 2024

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Research Results

• Open access
• Published: 14 January 2022

Acceptance and use of complementary and alternative medicine among medical specialists: a 15-year systematic review and data synthesis

• Phanupong Phutrakool   ORCID: orcid.org/0000-0003-0792-0275 1 &
• Krit Pongpirul   ORCID: orcid.org/0000-0003-3818-9761 1 , 2 , 3  

Systematic Reviews volume  11 , Article number:  10 ( 2022 ) Cite this article

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Complementary and Alternative Medicine (CAM) has gained popularity among the general population, but its acceptance and use among medical specialists have been inconclusive. This systematic review aimed to identify relevant studies and synthesize survey data on the acceptance and use of CAM among medical specialists.

We conducted a systematic literature search in PubMed and Scopus databases for the acceptance and use of CAM among medical specialists. Each article was assessed by two screeners. Only survey studies relevant to the acceptance and use of CAM among medical specialists were reviewed. The pooled prevalence estimates were calculated using random-effects meta-analyses. This review followed both PRISMA and SWiM guidelines.

Of 5628 articles published between 2002 and 2017, 25 fulfilled the selection criteria. Ten medical specialties were included: Internal Medicine (11 studies), Pediatrics (6 studies), Obstetrics and Gynecology (6 studies), Anesthesiology (4 studies), Surgery (3 studies), Family Medicine (3 studies), Physical Medicine and Rehabilitation (3 studies), Psychiatry and Neurology (2 studies), Otolaryngology (1 study), and Neurological Surgery (1 study). The overall acceptance of CAM was 52% (95%CI, 42–62%). Family Medicine reported the highest acceptance, followed by Psychiatry and Neurology, Neurological Surgery, Obstetrics and Gynecology, Pediatrics, Anesthesiology, Physical Medicine and Rehabilitation, Internal Medicine, and Surgery. The overall use of CAM was 45% (95% CI, 37–54%). The highest use of CAM was by the Obstetrics and Gynecology, followed by Family Medicine, Psychiatry and Neurology, Pediatrics, Otolaryngology, Anesthesiology, Internal Medicine, Physical Medicine and Rehabilitation, and Surgery. Based on the studies, meta-regression showed no statistically significant difference across geographic regions, economic levels of the country, or sampling methods.

Acceptance and use of CAM varied across medical specialists. CAM was accepted and used the most by Family Medicine but the least by Surgery. Findings from this systematic review could be useful for strategic harmonization of CAM and conventional medicine practice.

Systematic review registration

PROSPERO CRD42019125628

Graphical abstract

Peer Review reports

Medical specialist is a healthcare professional who has undertaken specialized medical studies to diagnose, treat and prevent illness, disease, injury, and other physical and mental impairments in humans, using specialized testing, diagnostic, medical, surgical, physical, and psychiatric techniques, through application of the principles and procedures of modern medicine [ 1 ]. The specialized and general medical care have dominated as ‘conventional’ medical care in several countries, including Thailand.

Complementary and Alternative Medicine (CAM) is defined as medicine or treatment which is not considered as conventional (standard) medicine. The National Center for Complementary and Integrative Health (NCCIH) categorized most types of complementary medicines under two categories: (1) natural products and (2) mind-body practices [ 2 ]. Natural products include herbs, vitamins, minerals, and probiotics whereas mind-body practices include yoga, chiropractic, massage, acupuncture, yoga, meditation, and massage therapy. Types of CAM may vary across studies, but they overlap in most senses.

CAM is used by people throughout the world. A study showed that the prevalence estimate of CAM usage from 32 countries from all regions of the world to be 26.4%, ranging from 25.9 to 26.9%. For example, in 2013, the prevalence use of CAM in Australia, the USA, UK, and China were 34.7%, 21.0%, 23.6%, and 53.3%, respectively. The prevalence estimate of CAM satisfaction was as high as 71.9%, ranging from 71.0 to 72.7% [ 3 ].

Although patients are highly satisfied with CAM treatment, professional health care providers who are medical doctors do not offer CAM because it is not part of the standard conventional medical care. Although the majority of physicians who have used CAM were pleased with the results [ 4 , 5 , 6 , 7 , 8 ] and were more likely to recommend it to patients, friends, and family [ 9 , 10 ] as a non-toxic treatment option; less than one third of the medical doctors were very comfortable in answering questions about CAM [ 9 , 11 , 12 , 13 ] so patients who do not have the option to use CAM instead of standard medical care might be lost to follow-up. Some doctors are still skeptical of CAM because of a lack of specific knowledge and qualification as well as a lack of evidence from high-quality experimental studies on the efficacy of the CAM treatments [ 4 , 12 , 14 , 15 ]. In the field of oncology, for example, the 5-year survival rate of breast cancer patients who refused standard treatment was 43.2%, compared with 81.9% of those who underwent the standard treatment [ 16 ]. When CAM was used, the 5-year survival rate was significantly worse. The 5-year survival rate of cancer patients who used CAM versus those who used standard treatment were stratified by cancer type were as follows: [ 17 ] for breast cancer 58.1% vs 86.6% ( p value < 0.01; HR = 5.68), lung cancer 19.9% vs 41.3% ( p value < 0.01; HR = 2.17), and colorectal cancer 32.7% vs 79.4% ( p value < 0.01; HR = 4.57). On the contrary, the 28-day mortality of patient with sepsis and acute gastrointestinal injury who received CAM bundle with conventional therapy was statistically significantly lower than those who received only conventional therapy (21.2% vs 32.5%, p value = 0.038) [ 18 ]. These differential clinical benefits of CAM across various medical specialties could be partly explained by how CAM is perceived by the medical specialists in conventional medicine dominated contexts.

Several studies have surveyed the acceptance and use of CAM from laypersons [ 19 , 20 , 21 , 22 ] to healthcare professional perspectives [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Nonetheless, these surveys did not cover all medical specialists so the findings could not reflect the comparative acceptance and use of CAM across medical specialties. Also, previous studies could not determine whether the acceptance and use of CAM by medical specialists differ across contexts (i.e., regions and economic levels of the country) and study designs (i.e., survey and sampling methods). A better understanding of how various medical specialists perceive of CAM is strategically essential for harmonizing CAM into conventional medicine practices. This systematic review aimed to identify relevant studies and synthesize survey data on the acceptance and use of CAM among medical specialists.

Materials and methods

Protocol and registration.

This systematic review has been registered in PROSPERO (CRD42019125628) and the protocol can be accessed at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019125628 .

Literature search

This systematic review was conducted and reported according to the PRISMA statement as well as the Synthesis Without Meta-analysis (SWiM) guidelines [ 30 ]. A systematic literature search was performed by two independent authors (PP and KP) using PubMed and Scopus databases. The search was limited to observational studies of human subjects and the English language. The medical specialist’s perspective related to CAM studies were focused. The search strategy was based on various combinations of words and focused on two main concepts: acceptance and usage of CAM. The last search was conducted on March 1, 2019.

For the PubMed database, the following combinations were applied: ("Traditional Medicine"[All Fields] OR "Alternative Medicine"[All Fields] OR "Complementary Medicine"[All Fields] OR "Acupuncture Therapy"[All Fields] OR "Holistic Health"[All Fields] OR "Homeopathy"[All Fields] OR "Spiritual Therapies"[All Fields] OR "Faith Healing"[All Fields] OR "Yoga"[All Fields] OR "Witchcraft"[All Fields] OR "Shamanism"[All Fields] OR "Meditation"[All Fields] OR "Aromatherapy"[All Fields] OR "Medical Herbalism"[All Fields] OR "Mind-Body Therapies"[All Fields] OR "Laughter Therapy"[All Fields] OR "Hypnosis"[All Fields] OR "Tai Ji"[All Fields] OR "Tai Chi"[All Fields] OR "Relaxation Therapy"[All Fields] OR "Mental Healing"[All Fields] OR "Meditation"[All Fields]) AND ("Health care provider"[All Fields] OR "Health care providers"[All Fields] OR "Health personnel"[All Fields]) AND ("2002/01/01"[PDAT]: "2017/12/31"[PDAT]) AND "humans"[MeSH Terms].

For the Scopus database, the following combinations were applied: (ALL("Traditional Medicine") OR ALL("Alternative Medicine") OR ALL("Complementary Medicine") OR ALL("Acupuncture Therapy") OR ALL("Holistic Health") OR ALL("Homeopathy") OR ALL("Spiritual Therapies") OR ALL("Faith Healing") OR ALL("Yoga") OR ALL("Witchcraft") OR ALL("Shamanism") OR ALL("Meditation") OR ALL("Aromatherapy") OR ALL("Medical Herbalism") OR ALL("Mind-Body Therapies") OR ALL("Laughter Therapy") OR ALL("Hypnosis") OR ALL("Tai Ji") OR ALL("Tai Chi") OR ALL("Relaxation Therapy") OR ALL("Mental Healing") OR ALL("Meditation")) AND (ALL("Health care provider") OR ALL("Health care providers") OR ALL("Health personnel")) AND PUBYEAR AFT 2001 AND PUBYEAR BEF 2018 AND DOCTYPE(ar) AND INDEXTERMS("Humans")

Selection of studies

The titles and abstracts of the primary studies identified in the electronic search were screened by the same two authors. Duplicated studies were excluded. For the meta-analysis, the following inclusion criteria were set: (1) medical specialist’s perspective, (2) prevalence of acceptance or usage of CAM, (3) observational study design, and (4) published between 2002 to 2017. The following exclusion criterion was set: (1) Not relevant to the practice. We contacted the authors for studies that had incomplete and unclear information. If the authors did not respond within 14 days, we proceeded to analyze the data we had. Any disagreement was resolved through discussion and the final determination was made by the first author (PP).

Data extraction and management

Two authors worked independently to review and extract the following variables: (1) general information, including the name of the studies, authors, and publication year, (2) characteristics of the studies, including the design of the studies, sampling method, country, and setting, (3) characteristics of the participants, including sample size, response, and type of specialty, and (4) outcomes, including the prevalence of acceptance, and usage of CAM. All relevant text, tables, and figures were examined for data extraction. Discrepancies between the two reviewers were resolved by the first author (PP).

Study quality/risk of bias

We used the tool developed by Hoy et al. [ 31 ] to evaluate the study quality/risk of bias of the studies included in the analysis. The tool has 11 items: (1) national representativeness, (2) target population representativeness, (3) random selection or census undertaken, (4) minimal non-response bias, (5) data collection direct from the subject, (6) definition of the case used, (7) valid and reliable instrument, (8) the same mode of data collection for all subjects, (9) length of shortest prevalence period, (10) appropriate numerator and denominator used, and (11) summary assessment. Items 1 to 4 assessed the external validity, items 5 to 10 assessed the internal validity, and items 11 evaluated the overall study quality/risk of bias. Each item was assigned a score of 1 (high quality/low risk) or 0 (low quality/high risk), and the scores were summed to generate an overall quality score that ranged from 0 to 10. According to the overall score, we classified the studies as having a high quality/low risk of bias (>6), moderate quality/risk of bias (4 to 6), and low quality/high risk of bias (<4). Two authors (PP and KP) independently assessed the study quality/risk of bias and any disagreement was resolved by discussion and consensus.

Conflict of interest

We assessed the conflict of interest of the authors’ declarations in the studies.

Statistical analysis

Unadjusted prevalence estimates of acceptance and usage of CAM were calculated based on the information of crude numerators and denominators provided by the studies and medical specialty [ 32 ]. Pooled prevalence was estimated from the prevalence as reported by the eligible studies. For each study and specialty, forest plots were generated displaying the prevalence with a 95% CI. The overall random-effects pooled estimate with its 95% CI were reported. To examine the magnitude of the variation between the studies, we quantified the heterogeneity by using I 2 and its 95% CI.

To assess the level of heterogeneity as defined in Chapter 9 of the Cochrane Handbook for Systematic Reviews of Interventions, the following I 2 cut-offs for 0 to 40% represented that the heterogeneity may not be important, 30 to 60% may represent moderate heterogeneity, 50 to 90% may represent substantial heterogeneity, and 75 to 100% represented that there was a considerable heterogeneity. For the X 2 test, statistical heterogeneity of the included trials was assessed with a p value of less than 0.05 (statistically significant). The random-effects meta-analysis by DerSimonian and Laird method was used, and statistical heterogeneity was encountered. The meta-analysis was performed using Stata/MP software version 15 (StataCorp 2017, College Station, TX).

Additional analysis

Meta-regression was performed to investigate the pooled prevalence differences between various regions (African region, region of the Americas, Eastern Mediterranean region, European region, Southeast Asia region, Western Pacific region, and mixed region) [ 33 ], economic levels of the country (low-income, lower-middle-income, upper-middle-income, high-income, and mixed-income) [ 34 ], and the sampling method (random and convenience sampling) for each study.

Selection of the studies

The literature search yielded 5628 articles. After 794 duplicates were removed, 4831 titles and abstracts were screened, and 4719 irrelevant articles were removed. Of 115 articles selected for full-text screening, 62 were excluded for the following reasons: two were not relevant to this study’s objective, 17 had the wrong target population, 22 did not have the study design required for this review, two study was not published in English, 19 did not have full-text available, and 28 did not provide the prevalence. Finally, a total of 25 articles, published between 2002 and 2017, fulfilled the selection criteria and were included in this meta-analysis (Fig. 1 ).

Characteristics of the studies

All included studies were cross-sectional. The publication years ranged from 2002 to 2017 in various countries: European region ( n = 11, 44%), region of the Americas ( n = 10, 40%), Western Pacific region ( n = 3, 12%), and mixed region ( n = 1, 4%). Twenty-three studies (88%) were from high-income countries, 2 (8%) from upper-middle income countries, and 1 (4%) was from mixed-economic level country. The included studies indicated which type of collection method was used: online survey ( n = 8, 32%), postal survey ( n = 8, 32%), online and postal survey ( n = 3, 12%), online and phone survey ( n = 1, 4%), and the collection method was not reported ( n = 5, 20%). The studies included a total of 7320 participants who were categorized as medical specialty ( n = 5445, 74%), and non-medical specialty ( n = 1875, 26%) (Table 1 ).

The included studies had the following medical specialties: internal medicine (11 studies, n = 2253), pediatrics (6 studies, n = 2,130), obstetrics and gynecology (6 studies, n = 707), anesthesiology (4 studies, n = 342), surgery (3 studies, n = 564), family medicine (3 studies, n = 296), physical medicine and rehabilitation (3 studies, n = 104), psychiatry and neurology (2 studies, n = 22), otolaryngology (1 study, n = 49), and neurological surgery (1 study, n = 24) (Table 2 )

Based on the specialty

Prevalence of cam acceptance.

The overall random-effect pooled prevalence of CAM acceptance in medical specialty was 52% (95% CI, 42–62%). The prevalence of CAM acceptance in Family Medicine was 67% (95% CI, 60–73%), Psychiatry and Neurology was 64% (95% CI, 35–85%), Neurological Surgery was 63% (95% CI, 43–79%), Obstetrics and Gynecology was 62% (95% CI, 36–82%), Pediatrics was 60% (95% CI, 41–77%), Anesthesiology was 52% (95% CI, 45–58%), Physical Medicine and Rehabilitation was 51% (95% CI, 42–61%), Internal Medicine was 41% (95% CI, 39–43%), and Surgery was 26% (95% CI, 22–30%). The overall heterogeneity was significant ( I 2 = 94.99%, p value < 0.001) (Fig. 2 ).

Forest plot of CAM acceptance by specialty

Prevalence of CAM usage

The overall random-effect pooled prevalence of CAM usage in medical specialty was 45% (95% CI, 37–54%). The prevalence of CAM usage in Obstetrics and Gynecology was 68% (95% CI, 63–73%), Family Medicine was 63% (95% CI, 58–68%), Psychiatry and Neurology was 55% (95% CI, 35–73%), Pediatrics was 44% (95% CI, 42–46%), Otolaryngology was 43% (95% CI, 30–57%), Anesthesiology was 42% (95% CI, 37–47%), Internal Medicine was 38% (95% CI, 36–41%), Physical Medicine and Rehabilitation was 32% (95% CI, 24–41%), and Surgery was 25% (95% CI, 22–29%). The overall heterogeneity was significant ( I 2 = 94.90%, p value < 0.001) (Fig. 3 ).

Forest plot of CAM usage by specialty

Based on the studies

The overall random-effect pooled prevalence of CAM acceptance was 54% (95% CI, 36–73%) (Fig. 4 a). Twelve studies provided CAM acceptance: five studies in the European region, five studies in the region of the Americas, and two studies in the Western Pacific region. The pooled prevalence of the European region, region of the Americas, and Western Pacific region that accepted CAM were 60% (95% CI, 36–83%), 54% (95% CI, 39–68%), and 20% (95% CI, 17–22%), respectively (Fig. 4 b). All 12 studies were done in high-income economic countries (Fig. 4 c). Based on the sampling method, the pooled prevalence of random sampling method, and non-random sampling method were 54% (95% CI, 30–77%), and 55% (95% CI, 44–67%), respectively (Fig. 4 d). The overall heterogeneity was significant ( I 2 = 99.14%, p value < 0.001) as was the between-group heterogeneity ( p value < 0.001). Meta-regression showed that there were no significant differences in the pooled prevalence of CAM acceptance by region, economic levels of the country, and the sampling method (Table 3 ).

Forest plot of CAM acceptance

The overall random-effect pooled prevalence of CAM usage was 52% (95% CI, 42–62%) (Fig. 5 a). Twenty-one studies provided CAM usage information: nine studies in the European region, eight studies in the region of the Americas, three studies in the Western Pacific region, and one study in the mixed region. The pooled prevalence of European region, region of the Americas, Western Pacific region, and mixed region that used CAM were 54% (95% CI, 37–71%), 59% (95% CI, 46–73%), 37% (95% CI, 18–56%), and 18% (95% CI, 11–27%), respectively (Fig 5 b). All 18 studies were conducted in high-income economic countries, two studies were conducted in upper-middle-income economic countries, and one study was conducted in a mixed-income economic country. The pooled prevalence of high-income economic countries, upper-middle-income economic, and mixed-income economic countries that used CAM was 52% (95% CI, 41–62%), 74% (95% CI, 67–80%), and 18% (95% CI, 11–27%), respectively (Fig. 5 c). Based on the sampling method, the pooled prevalence of the random sampling method, and non-random sampling method were 51% (95% CI, 39–64%), and 54% (95% CI, 38–70%), respectively (Fig. 5 d). The overall heterogeneity was significant ( I 2 = 98.29%, p value < 0.001) as was between-group heterogeneity ( p value < 0.001). Meta-regression showed that there were no significant differences in the pooled prevalence of CAM usage by region, economic levels of the country, and the sampling method (Table 3 ).

Forest plot of CAM usage

Assessment of study quality/risk of bias/conflict of interest

A total of 24 (96%) studies were categorized as high quality/low risk of bias, whereas one (4%) was categorized as moderate quality/moderate risk of bias. No study met the criteria of low quality/high risk of bias (Fig 6 ). Only five studies (20%) declared that there were conflicts of interest.

Study quality/risk of bias of the included studies

This study is the first of its kind to compare the acceptance and use of CAM across various medical specialties in different contexts. As nearly three-quarters of the specialties accepted CAM more than 50% whereas nearly a third were using CAM more than 50%.

The synthesis of all prevalence estimates of acceptance and usage was 52% and 45%, respectively. The highest prevalence of acceptance was in Family Medicine, followed by Psychiatry and Neurology, Neurological Surgery, Obstetrics and Gynecology, Pediatrics, Anesthesiology, Physical Medicine and Rehabilitation, Internal Medicine, and Surgery. The highest prevalence of usage was in Obstetrics and Gynecology, followed by Family Medicine, Psychiatry and Neurology, Pediatrics, Otolaryngology, Anesthesiology, Internal Medicine, Physical Medicine and Rehabilitation, and Surgery. These findings were useful in terms of improving care plan, decision-making processes, and communication in terms of CAM between the doctors and the patients.

All of the medical specialties mentioned above had a higher prevalence of acceptance than the prevalence of CAM use, except for Obstetrics and Gynecology because the gynecologic oncologists have used CAM to treat a large number of breast cancer patients [ 14 ]. There was a small difference in the prevalence (<5%) between the acceptance and the usage in Family Medicine (4%), Obstetrics and Gynecology (4%), Internal Medicine (3%), and Surgery (1%).

A highest difference of prevalence of CAM acceptance and usage was in the field of Physical Medicine and Rehabilitation (19%). This difference may be due to the reduction in the use of acupuncture in the academic hospitals [ 7 ] as well as personal use. Nearly two thirds of the rehabilitation physicians advised against the use of CAM as a therapeutic option [ 41 ]. The lowest prevalence of acceptance and usage of CAM was observed in Surgery. This relatively low prevalence compared to other medical specialties may be due to the belief that CAM products were ineffective. Many surgeons lacked information regarding CAM usage.

The acceptance of CAM was neutral in European region and region of the Americas. The World Health Organization reported that the prevalence of CAM usage in the European region, region of the Americas, and Western Pacific region in 2018 was 89%, 80%, and 95%, respectively [ 33 ], while this review found that the corresponding prevalence was 54%, 59%, and 37%, respectively. The lower prevalence may be from the dominating studies that were conducted before 2010 whereas CAM has used more often after 2010.

The variation of prevalence of CAM used was investigated in relation to the economic level of the countries. There was a higher prevalence of CAM use in the upper-middle-income economies than the high-income economies which may be due to cultural, historical influences, and implementation of CAM in the national health system as seen in Brazil [ 39 ] and Mexico [ 49 ].

Our study has some limitations that should be considered when interpreting the findings. Only two databases—PubMed and Scopus—were included so this review might have missed some relevant studies that were indexed elsewhere. Nonetheless, both databases were considered efficiently sufficient and most relevant to our research question within a specific domain [ 53 ]. While Web of Science and Scopus share several common features, Scopus is a relatively smaller database but covers more modern studies than Web of Science. The included studies did not cover some medical specialties that might have different acceptance and usage of CAM. Therefore, the prevalence of acceptance and usage of CAM in these populations need additional surveys. The prevalence of acceptance in some specialties like Neurological Surgery, Obstetrics and Gynecology, Otolaryngology, Pediatrics, and Psychiatry and Neurology was reported by a single study, thus limiting the generality of such findings. High heterogeneity of acceptance and usage of CAM between medical specialty referred to the variation in professional characteristic and practice, measurement methods, and study questionnaire. Most of the studies were from high-income economic countries. There were no studies from low-middle and low-income economic countries which is of concern. We found that no studies compared the relevant demographic characteristics between the responders and non-responders that would increase non-response bias when estimating the prevalence of CAM use. Although most of the studies demonstrated low risk of bias, over 88% of the studies did not use a validated instrument. Finally, the conflict of interest was not declared in more than 80% of the studies which may result in unintentional bias in the collection, analysis, and interpretation of the data. This can consequently lead to claims that the CAM used was beneficial because the researcher and/or entity may have a financial or management interest in the CAM used.

Conclusions

Acceptance and use of CAM varied across medical specialties. Based on available survey data, CAM was accepted and used the most by Family Medicine but the least by Surgery. Findings from this systematic review could be useful for strategic harmonization of CAM and conventional medicine practice.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

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Acknowledgements

We thank Dr. Kulthanit Wanaratna and Dr. Monthaka Teerachaisakul of the Department of Thai Traditional and Alternative Medicine, Ministry of Public Health for their administrative supports.

This study received financial support from the Ratchadapiseksompotch Fund, Faculty of Medicine, Chulalongkorn University (Grant Number RA62/059), and Department of Thai Traditional and Alternative Medicine, Ministry of Public Health. The sponsors have no involvement in the systematic search, abstract screening, data extraction, or manuscript preparation. Phutrakool P received the 90th anniversary of Chulalongkorn University Fund (Ratchadaphiseksomphot Endowment Fund).

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Phutrakool, P., Pongpirul, K. Acceptance and use of complementary and alternative medicine among medical specialists: a 15-year systematic review and data synthesis. Syst Rev 11 , 10 (2022). https://doi.org/10.1186/s13643-021-01882-4

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Insight into the characteristics of research published in traditional, complementary, alternative, and integrative medicine journals: a bibliometric analysis

• Jeremy Y. Ng   ORCID: orcid.org/0000-0003-0031-5873 1 , 2  

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Traditional, complementary, alternative and integrative medicine (TCAIM) can be described as diverse medical and healthcare interventions, practices, products, or disciplines that are not considered as part of conventional medicine. Inherent in its definition, TCAIMs are comprised of a wide variety of therapies with highly variable safety and effectiveness evidence profiles. Despite this, the use of many TCAIMs is highly prevalent among patients globally. The present study consists of a bibliometric analysis of TCAIM journals.

A single search of all International Standard Serial Number (ISSNs) of all journals categorized as “complementary and alternative medicine” (code 2707) based on the All Science Journal Classification (ASJC) was run on Scopus on April 17, 2021. All publication types were included; no further search limits were applied. The following bibliometric data were collected: number of publications (in total and per year), authors and journals; open access status; journals publishing the highest volume of literature and their impact factors; language, countries, institutional affiliations, and funding sponsors of publications; most productive authors; and highest-cited publications. Trends associated with this subset of publications were identified and presented. Bibliometric indicators of production were calculated, and bibliometric networks were constructed and visualized using the software tool VOSviewer.

A total of 172,466 publications (42,331 open access), were published by 219,680 authors in 143 journals from 1938 to 2021. Since the 1940s, an upward trend with respect to the volume of publications can be observed, with a steep increase observed between the mid-2000s and mid-2010s. The journal that published the largest number of publications was the Journal of Natural Products ( n  = 15,144). The most productive countries included China ( n  = 45,860), the United States ( n  = 29,523), and Germany ( n  = 10,120); a number of the most common institutional affiliations and funding sponsors also originated from these three countries.

Conclusions

The number of publications collectively published in TCAIM journals follows an upward trend. Given a high prevalence of TCAIM use among patients, increased acceptance of TCAIM among conventional healthcare providers, and growing interest in the research of TCAIM, future work should continue to investigate and track changes in the publication characteristics of the emerging research on this topic.

Peer Review reports

Complementary and alternative medicine is generally defined as a group of diverse medical and healthcare interventions, practices, products or disciplines that are not considered as part of conventional medicine [ 1 ]. Specifically, the National Center for Complementary and Integrative Health (NCCIH) defines “complementary” medicine as a non-mainstream practice used together with conventional medicine, whereas “alternative” medicine refers to a non-mainstream practice used in place of conventional medicine [ 2 ]. In contrast, “integrative health” is defined as the coordinated delivery of conventional and complementary approaches together [ 2 ]. These three words – complementary, alternative, and integrative – comprise the most common ways to refer to these types of therapies [ 3 ], in additional to “traditional medicine” which has been defined by the World Health Organization as “the sum total of the knowledge, skill and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness” [ 4 ]. For the purpose of the present study, these therapies will be referred to collectively as “traditional, complementary, alternative and integrative medicine” or “TCAIMs” hereafter. At present, a lack of consensus exists regarding how to categorize TCAIMs; in fact, by definition every therapy that falls under the umbrella of “TCAIM” exists as a result of being considered outside of the purview of conventional Western medical practices [ 3 ]. Therefore, one TCAIM therapy can be highly unrelated to another due to the fact that each originates from a different region in the world, culture, system of traditional medicine, and school of thought [ 4 , 5 ]. Despite these challenges, attempts have been made to categorize TCAIMs. For example, the NCCIH divides TCAIM therapies into two main types: 1) natural products and 2) mind and body practices. Within the former category, they include therapies such as herbs, vitamins and minerals, and probiotics, while in the latter, they include therapies such as yoga, chiropractic and osteopathic manipulation, and meditation, as well as acupuncture, relaxation techniques, tai chi, qi gong, and hypnotherapy, among others [ 2 ]. Despite these efforts, the NCCIH has stated, however, that some TCAIMs may not fit neatly into either of these two groups, citing many systems of TCAIM including practices of traditional healers, Ayurvedic medicine, traditional Chinese medicine, homeopathy, naturopathy, and functional medicine [ 2 ].

Regardless of how TCAIMs are categorized, these therapies are perceived to be of value by their proponents for their emphasis on a holistic, patient-focused approach to healthcare, which include mental, emotional, functional, spiritual, economic, and social aspects [ 2 , 6 ]. TCAIM is widely used around the world, with 88% of World Health Organization member states acknowledging their use, which by definition means that these 170 countries have formally developed policies, laws, regulations, programs and offices for TCAIM [ 4 ]. The prevalence of TCAIM use is high in many Western countries; for example, it is estimated that around 80% of Canadians have used TCAIM [ 7 ]. The prevalence of TCAIM use is also documented to be high among certain patient populations; in cancer patients, as many as 90% report using some type of TCAIM [ 8 , 9 , 10 ]. TCAIM is used by these patients for a variety of reasons, including symptom relief, improved quality of life, supplementing conventional therapy, supporting one’s philosophical orientations toward health, and achieving a sense of control over one’s care [ 11 , 12 , 13 ]. Integrative medicine (the use of complementary and conventional therapies) is becoming increasingly popular among patients and practitioners [ 14 , 15 ], and sub-specializations of integrative care for specific diseases/conditions have also been established, such as integrative oncology [ 16 , 17 ].

While some TCAIMs, such as meditation and yoga [ 18 , 19 ], have undergone more thorough testing and have been found to be generally safe and effective, others have not been adequately researched to determine their effectiveness, and some have been found to be potentially harmful or interact negatively with conventional medicines [ 20 , 21 , 22 ]. The belief among patients that “natural means safe and better” [ 23 ] is well-documented, however, evidence from the research literature suggests otherwise. Many herbal and dietary supplements can be harmful when taken in large quantities. Certain weight loss and bodybuilding supplements have been shown to cause hepatotoxicity or even hepatic failure at therapeutic doses [ 24 ]. Furthermore, systemized pharmacovigilance of TCAIMs is poorly coordinated on a national and international level, and TCAIM therapies are generally not held to the same standards of regulation as that of pharmaceutical medicines in terms of quality, effectiveness, and safety [ 20 ].

The increase in popularity and prevalence of TCAIM use among patients, and growing acknowledgement among conventional healthcare providers that a need exists to approach TCAIM therapies, their traditions, and their practitioners with respect, are among some of the reasons for an increase in TCAIM research productivity which has resulted in a growth in the volume of the published literature over the past few decades [ 25 , 26 , 27 ]. The application of a research method known as a bibliometric analysis can facilitate a better understanding of a given field, such as that of TCAIM. A bibliometric analysis involves the statistical assessment of scientific publications, to identify the characteristics and determine the impact of the literature published in a specific academic discipline [ 28 , 29 , 30 ]. This increased interest in TCAIM research has led to the establishment and indexing of multiple TCAIM journals. While a number of bibliometric analyses have made attempts to evaluate the characteristics of all publications published in the area of traditional, complementary, alternative, and/or integrative medicine through the use of various search strategies [ 31 , 32 , 33 , 34 , 35 ], no study has comprehensively assessed the characteristics of the publications found within these source titles to date. Thus, the purpose of the present study is to provide current insight into the characteristics of publications published across TCAIM journals through a bibliometric analysis.

Publication search and characteristics

The 2021 Scopus Source List [ 36 ] was downloaded, and all Scopus-indexed journals belonging to the “complementary and alternative medicine” category (code 2707) were identified based on the All Science Journal Classification (ASJC). A single search containing the International Standard Serial Numbers (ISSNs) of all of these journals was run on Scopus on April 17, 2021; the search strategy can be found in Table  1 . Search results were exported on the same day to prevent discrepancies between daily database updates. Searches were only conducted on Scopus because it is the largest abstract and citation database of peer-reviewed literature [ 37 ]; in comparison, Web of Science contains considerably fewer TCAIM-categorized journals, while OVID databases do not provide certain metrics such as publication citation counts [ 38 ]. All publication types were included, and no further search limits were applied. The following bibliometric data were collected: number of publications (in total and per year), authors and journals; open access status; journals publishing the highest volume of literature and their impact factors; language, countries, institutional affiliations, and funding sponsors of publications; most productive authors; and highest-cited publications. Trends associated with this subset of publications were identified and presented. Bibliometric networks were constructed and visualized using the software tool VOSviewer (version 1.6.16) [ 39 , 40 ]. All aforementioned steps were conducted by a single author (JYN).

Bibliometric indicators of production

Relative growth rates and doubling times were calculated for publications published between 1938 and 2020. The relative growth rate represents the increase in the number of publications published per unit of time. The relative growth rate was calculated based on the following equation: [ Relative Growth Rate = (log e W 2 - log e W 1 )/(T2 - T1)], where log e W 1 represents the log of initial number of articles, and log e W 2 represents the log of final number of articles after a specific period of interval. T2-T1 represents the unit difference between the initial time and the final time. Doubling time is defined as the amount of time required for the subject matter to double its production. The doubling time was calculated based on the following equation: [ DT = 0.693/Relative Growth Rate] . Price’s law was also applied to the subset of publications analysed [ 41 ]. This law proposes that the growth of scientific production follows an exponential function, and represents one of the most common indicators used to analyse productivity in a specific discipline or subset of publications. To assess whether the increase in data conforms to Price’s law of exponential growth, we carried out a linear adjustment of the values and another adjustment to an exponential curve.

A total of 172,466 publications (42,331 open access), were published by 219,680 unique authors in 143 journals from 1938 to 2021. Since the 1940s, an upward trend with respect to the volume of publications can be observed, with a steep increase observed between the mid-2000s and mid-2010s. This upward trend has continued with 2020 marking the year with the highest number of publications to date. The Journal of Natural Products ( n  = 15,144) published the largest number of publications indexed in Scopus, followed by Zhongguo Zhongyao Zazhi ( n  = 14,577), and Planta Medica ( n  = 10,793). All journals included within this bibliometric analysis were hand-searched on InCites Journal Citation Reports [ 42 ]. As of 2020, 83 journals were still active (57.6%), of which 35 had a 2019 impact factor (range from 0.200 to 5.487). Table  2 provides complete details of the journals included in this bibliometric analysis, including the journal name, ISSN, whether the journal is active or inactive (as of 2020), coverage period, title history indication, publisher name, number of publications indexed in Scopus, and the 2019 impact factor (if available).

The subject area containing the largest number of publications was medicine ( n  = 172,456), followed by pharmacology, toxicology and pharmaceutics ( n  = 86,902), then biochemistry, genetics and molecular biology ( n  = 40,262). Publications were primarily published in English ( n  = 135,718), followed by Chinese ( n  = 24,614), then German ( n  = 8611). The most common document types were article ( n  = 139,540) and review ( n  = 13,418); articles primarily include original research, while reviews include literature, scoping, and systematic reviews. The most productive countries included China ( n  = 45,860), the United States ( n  = 29,523), and Germany ( n  = 10,120). The most common affiliations were the China Academy of Chinese Medical Sciences ( n  = 3560), the Beijing University of Chinese Medicine ( n  = 2896), and the Chinese Academy of Sciences ( n  = 2896); the most common funding sponsors were the National Natural Science Foundation of China ( n  = 5711), the National Institutes of Health ( n  = 4055), and the US Department of Health and Human Services ( n  = 4032). The general characteristics of eligible publications are summarized in Table  3 . In addition, the 100 most highly published authors are provided in Table  4 , and the 100 highest-cited publications are provided in Table  5 .

Figure  1 depicts the number of publications published per year from 1938 to 2020, inclusive of an exponential and linear curve. Mathematical adjustment to an exponential curve (y = 30.699e 0.073x ), as shown in this figure, resulted in a correlation coefficient r  = 0.9698, which indicates that 5.94% of variability remains unexplained by this adjustment. In contrast, the linear adjustment (y = 97.915x - 1971.9) of the measured values provides an r  = 0.8160, and thus an unexplained variability of 33.42%. These results suggest fulfilment of Price’s Law, with scientific production within CAIM journals showing exponential growth. Additionally, the relative growth rate was found to range from 0.05 to 0.67. Doubling time was found to range from 1.04 to 15.02. Table  6 provides annual relative growth rates and doubling times.

Number of Publications in Scopus-Indexed TCAIM Journals per Year from 1938 to 2020

Bibliometric networks were constructed and visualized using the software tool VOSviewer, and include all 172,466 captured by the present study’s search. This added layer of analysis of the most influential subset of publications captured provides a greater understanding of the relationship that exists between certain items (i.e. countries, keywords, authors, journals, etc.). In each bibliometric network (figure), each item is represented in a network visualisation by a label and a circle; the weight of an item determines the size of the label and the circle of an item. Figure  2 depicts a co-authorship analysis of the 50 most productive countries. In a co-authorship analysis, the relatedness of items is determined based on the number of co-authored publications. From this figure, it can be seen that while China is the most productive country, Chinese authors tend to collaborate less with researchers in other countries as shown by the distance between lines. In contrast, American authors tend to collaborate with many countries internationally, while German authors tend to collaborate more with researchers in other European countries. Figure  3 depicts a co-occurrence analysis of the 500 most frequent author keywords used across all publications. In a co-occurrence analysis, the relatedness of items is determined based on the number of publications in which they occur together. From this figure, a number of clusters can be observed representing different TCAIM topics. The yellow, red and dark blue clusters represent a large network of keywords related to laboratory-based studies, while the green cluster represents keywords related to clinical research and review-type studies. The smaller light blue cluster also highlights research conducted on traditional and indigenous medicines. This figure also provides insights into some of the most highly studied diseases/conditions published in TCAIM journals, which include breast and lung cancer, diabetes, anxiety, and low back pain.

Co-Authorship Analysis of the 50 Most Productive Countries

Co-Occurrence Analysis of the 500 Most Frequent Author Keywords

The objective of the present bibliometric analysis is to capture the characteristics of the research literature published in TCAIM journals. The search conducted on Scopus yielded over 170,000 publications, representing the largest bibliometric analysis of TCAIM literature to date to the author’s knowledge. Since the 1940s, an upward trend with respect to the volume of publications can be observed, with a steep increase observed between the mid-2000s and mid-2010s. This upward trend has continued with 2020 marking the most productive year globally to date. Unsurprisingly, therefore, the production in this body of literature follows Price’s law of exponential growth, which is characteristic of fields of research which have experienced great and continued advances and interest from the international research community; other bodies of research literature that have experienced exponential growth include the topics of medical informatics [ 43 ], glaucoma [ 44 ], psychopharmacology [ 45 ], and antipsychotic drugs [ 46 ]. This growth in the volume of research published over the most recent decades can largely be explained by an increase in funding support by government and nongovernment sectors for TCAIM research [ 47 , 48 , 49 , 50 ]. In the present study, it was found that China was the most productive country with respect to TCAIM research at 45,860 publications, followed by the United States at 29,523 and Germany at 10,120. A vast amount of research continues to be conducted on traditional Chinese medicine in China [ 51 , 52 , 53 ], while the United States and Germany have both historically been the leading countries with respect to the research of various TCAIM therapies [ 31 , 32 , 33 , 34 ]. While the vast majority of publications were written in English, which is largely regarded as the international language of academic publication, it is also unsurprising that the second most common language was Chinese, and the third was German, as this corresponds with the national languages of the most productive countries. Of the top 20 institutional affiliations responsible for publishing this TCAIM research, 17 originated from China, with the remaining two from South Korea and one from Taiwan; a number of affiliations based in the United States and Germany existed as well, but below the top 20. Additionally, with respect to the top 20 funding sponsors, the countries with the largest number were China and the United States, with six organizations each.

In interpreting these results, the reader should be aware of a number of caveats. For example, authors who have spent more years working in research, and journals that have been publishing for a longer period of time and/or have a greater proportion of their archive indexed in Scopus, will have more publications, citations, and collaborations. Additionally, older publications will have an increased chance of receiving citations, as evidenced by only 15 of the most 100 cited articles being published since 2020. Additionally, it is worthwhile to note that while only the journal’s impact factor was reported in Table 2 , other indices are increasingly being used to rank the impact of journals (and authors), such as the H-index and SJR ranking, and differences may be observed based on the metric used.

Comparative literature

The findings from published bibliometric analyses specific to the TCAIM research literature can be compared to that of the present study. One of the first bibliometric analyses of the TCAIM research literature was published by Barnes et al. in 1999 [ 31 ]. Using a number of TCAIM-related keywords, the authors conducted searches on MEDLINE and analysed the literature published from 1966 to 1996. At the time, they reported that the volume of TCAIM publications per year rose between 1972 and 1986, and then remained stable and approximated 1500 per year up until 1996. Although in the present study a growth in the volume of literature is still observed from 1986 to 1996, the mean number of publications per year over this decade was approximately 1400, which aligns closely with the findings of the authors [ 31 ]. Fu et al. (2011) analysed 17,002 publications found in 19 complementary and alternative medicine journals over approximately three decades [ 32 ]. They found that the most productive countries included the United States, China, India, England and Germany, all of which fell within the top seven most productive countries in the present study. A number of institutions were also identified by both Fu et al. (2011) [ 32 ] as well as the present study to be among the most productive internationally, including China Medical University and Kyung Hee University. Danell et al. analysed four decades’ worth of complementary and alternative medicine publication activity from 1966 to 2007 [ 33 ], then later repeated their study again to include five decades from 1966 to 2016 [ 34 ]. In their more recent study, they analyzed 105,216 publications, which prior to the present study, was the largest bibliometric analysis on this topic. Unlike the present study which sought to characterize publications in TCAIM journals, Danell et al.’s (2020) inclusion criteria included publications that had “Complementary Therapies” as their Medical Subject Heading major topic, in the MEDLINE database [ 34 ]. Lastly, Youn et al. (2021) conducted a bibliometric analysis of the integrative medicine research literature based on a search query using two keywords joined by the Boolean operator “OR”: “complementary and integrative medicine” OR “integrative medicine”, retrieving and analysing a total of 4660 publications. Although their study’s focus was on integrative medicine, a number of their findings are shared with the present study; for example, they also identified United States, China, and Germany to be the most productive countries (albeit in this order), and they also found that cancer was one of the most commonly studied diseases/conditions [ 35 ].

In line with the findings made by Barnes et al. (1999) [ 31 ], Danell et al. (2009) [ 33 ], Fu et al. (2011) [ 32 ], Danell et al. (2020) [ 34 ], and Youn et al. (2021) [ 35 ], the present study also found an upward trend with respect to the volume of TCAIM research being published each year over the past decades. With respect to the number of publications captured, although Danell et al.’s (2020) study was published in 2020, their coverage of the TCAIM literature only extended up until 2016 [ 34 ]. In the present study, over 37,000 publications were found to be published between 2017 and April 2021, comprising over 20% of the entire body of literature analysed.

Future directions

Beyond the aforementioned comparative literature, it is worth noting that it has been far more common for bibliometric analyses to be conducted on a specific TCAIM-related topic. These have included acupuncture [ 54 , 55 , 56 ], aromatherapy [ 57 ], apitherapy [ 58 ], complementary and integrative oncology [ 59 ], ethnopharmacology [ 60 ], homeopathy [ 61 ], medicinal plants [ 62 ], qi gong [ 63 ], and yoga [ 64 , 65 ], as just some examples among others. Others have conducted bibliometric analyses specific to methodologies, such as clinical trials [ 64 , 66 , 67 ] or guidelines [ 55 ] in TCAIM. Bibliometric analyses of the TCAIM literature with specific sub-topics are more straightforward to conduct, as the keywords and searches applied are likewise also easier to standardize. One of the main challenges in conducting comprehensive bibliometric analyses of the TCAIM literature in its entirety is the fact that it is very difficult to operationalize a dynamic and unrelated group of therapies that have been defined on the basis that they lie outside of the purview of conventional Western medical care [ 68 , 69 ]. As a result, all of the bibliometric analyses of the TCAIM literature to date have been based on searches of TCAIM-specific journals or TCAIM-specific indexed headings, both of which unquestionably provide an incomplete picture of all the TCAIM literature. Thus, future directions of value include 1) the creation of an operational definition of TCAIM informed by a systematic search strategy, and 2) the development of standardized search strategies for major academic databases based on this operational definition.

Strengths and limitations

This present bibliometric study captured and analysed the characteristics of over 170,000 publications, making it the largest conducted to date with respect to the TCAIM literature, and the most comprehensive with regards to TCAIM journal inclusion. Searches were conducted on Scopus as this academic database has a larger coverage in comparison to other databases such as Web of Science. Despite this, it must be acknowledged that all academic databases contain gaps in their indexing, and this was realized at the point of analysis in the present study. Publication data collected from Scopus was not externally verified against another source, and it is also important to note that the number of publications reflect what was indexed by the database as of the search date, and not necessarily the true number of publications published by the included journals themselves. It should be noted that publications included in this bibliometric analysis were based on the fact that they were published in a journal belonging to the “complementary and alternative medicine” category (code 2707), identified based on the ASJC provided by Scopus; as evidenced by Table 2 , certain journals that changed names over their history were either not indexed in Scopus or were not included in the same ASJC category. Furthermore, it is always possible that some literature may not have been captured by not searching other databases, however, this would have introduced considerable complexities with respect to the ability to analyse search results efficiently (i.e. deduplication of such a large volume of publications, bibliometric network visualizations). The use of the software tool VOSviewer to create and visualize bibliometric networks serves as an additional strength to the present study, providing a deeper layer of analysis with respect to the strength and nature of relationships between different items (countries, keywords, authors, journals). Two final limitations include the fact that independent search results were extracted and analysed by a single author, and therefore, were prone to increased error as opposed to had the analysis been conducted in duplicate; additionally, results were not screened as this would have been impractical, and possibly unfeasible without the application of an operational definition of TCAIM. Without doing this, however, it is possible that this analysis also included non-TCAIM literature published in journals categorized as “complementary and alternative medicine” by Scopus.

The present study provides current insight into the characteristics of publications published across TCAIM journals, and represents the largest bibliometric analysis conducted to date with respect to the TCAIM literature. The most productive countries included China, the United States, and Germany; unsurprisingly, a large proportion of common institutional affiliations and funding sponsors associated with this subset of publications also originated from these countries. The volume of publications has increased steadily since the 1940s, and a steep increase was observed between the mid-2000s and mid-2010s, which is largely attributable to increased available funding for TCAIM research globally. This upward trend has continued with 2020 marking the year with the most publications to date. Beyond identifying the large diversity of TCAIMs studied, this study also highlights therapies which may be understudied and warrant further investigation. Given a high prevalence of TCAIM use among patients, increased acceptance of TCAIM among conventional healthcare providers, and growing interest in the research of TCAIM, future work should continue to investigate and track changes in the publication characteristics of the emerging research on this topic. The creation of an operational definition of TCAIM informed by a systematic search strategy, followed by the development of standardized search strategies for major academic databases based on this operational definition, may serve to achieve these goals more comprehensively.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

All Science Journal Classification

Complementary, alternative, and integrative medicine

National Center for Complementary and Integrative Health

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Ng, J.Y. Insight into the characteristics of research published in traditional, complementary, alternative, and integrative medicine journals: a bibliometric analysis. BMC Complement Med Ther 21 , 185 (2021). https://doi.org/10.1186/s12906-021-03354-7

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• Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad Med 2001;76: 1224-5 - PubMed
• Ernst E. Single-case studies in complementary/alternative medicine research. Complement Ther Med 1998;6: 75-8
• Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997;350: 834-43 - PubMed
• Ernst E, Resch KL. The “optional cross-over design” for randomized controlled trials. Fundam Clin Pharmacol 1995;9: 508-11 - PubMed
• Walach H, Jones WB, Lewith G. The role of outcomes research in evaluating complementary and alternative medicine. In: Lewith G, Jonas WB, Walach H, eds. Clinical Research in Complementary Therapies. Edinburgh: Churchill Livingstone, 2002: 29-45
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Traditional, Complementary and Integrative Medicine – Opportunities for Managing and Treating Neurodegenerative Diseases and Ischaemic Stroke

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About this Research Topic

Neurodegenerative diseases cover a broad range of medical conditions and pose a great burden to patients and their families. For example, Alzheimer’s disease (AD) has been a global challenge due to the increase in the aged population. FDA has approved 5 small molecular drugs and a couple of antibodies to treat AD, but whether they can halt the progression of AD is still unknown. Similarly, stroke is the 2nd leading cause of death worldwide and the 1st cause of death in China. Thrombolysis and endovascular thrombectomy are effective for patients with acute ischemic stroke within the time window. However, many of these patients do not meet the criteria for such treatments. Even for those who have received thrombolytic agents or endovascular thrombectomy, only less than 50% can fully restore their neurological functions. For the rest of the patients, they have no effective therapies to use. In addition, vertigo due to various reasons is even harder to manage due to unknown etiology. There is a surging demand to develop new therapeutics to deal with the conditions mentioned above. In traditional, complementary, and integrative medical systems, there are a large number of herbal recipes for ischemic stroke, cognitive decline, and vertigo generally not based on a specific diagnosis. Well-known examples are the diverse preparations used in Traditional Chinese Medicine as well as in Indian medical systems. Some of these recipes have been scientifically studied and reviewed by many groups. Animal studies have also shown promising pharmacological results for some preparations. However, no single bioactive compound has been identified to mimic the therapeutic effect of the entire herbal recipe on ischemic stroke. This raises the concern that the known targets we have been testing may not be fully responsible for the pathogenesis of the above conditions. New targets, such as signal pathways involved in the contraction, dilation, or even death of pericytes in the brain, might be key players as well. Further research is needed to screen more potent bioactive compounds or to discover new targets and corresponding therapeutics. There are assumptions that a single bioactive compound is unable to take the therapeutic effect, instead, it is the combination of multiple ingredients in the herbal recipe that restores the neurological functions of the patients. It is the goal of this Research Topic to collect original research, review, and meta-analysis to demonstrate the therapeutic effect of traditional, complementary, and integrative medicine on neurodegenerative diseases, stroke, and vertigo and to disentangle their underlying mechanisms. This is in line with the WHO’s strategic plan for future development. The scope will cover the following aspects, but is not limited to them: •Clinical studies assessing the therapeutic efficacy of traditional, complementary, and integrative medicine, like herb recipes, plant derivatives, and other natural products in managing neurodegenerative diseases, stroke and vertigo. •Basic original research on the underlying mechanisms of traditional, complementary, and integrative medicine in managing neurodegenerative diseases. •Systemic review or meta-analysis on the efficacy of certain recipes or individual bioactive compounds on the above conditions and their underlying mechanisms. We encourage the submissions of both in vitro and in vivo studies that will make a significant contribution to understanding underlying mechanisms of traditional, complementary, and integrative medicine, like herbal medicines, isolated metabolites, and other natural products in managing neurodegenerative diseases, stroke, and vertigo. These studies will pave the way to discovering new effective therapeutics to treat the above medical conditions. Please note: All the manuscripts submitted to the collection will need to fully comply with the Four Pillars of Best Practice in Ethnopharmacology (you can freely download the full version here ). Please self-assess your MS using the ConPhyMP tool , and follow the standards established in the ConPhyMP statement Front. Pharmacol. 13:953205 . Please note the traditional context including the primary background and modern uses with supporting references must be included in the manuscript introduction. Purely in silico approaches using complex mixtures (extracts) are generally not considered. You need to check your MS using ‘https://ga-online.org/best-practice’ and include a PDF in your resubmissions with the relevant tables of the tool filled (1 and 2a)(cf : Front. Pharmacol. 13:953205: https://doi.org/10.3389/fphar.2022.953205).

Keywords : neurodegenerative diseases, stroke, dementia, vertigo, herbs

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Complementary & Alternative Medicine

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Select Journals for Peer-Reviewed CAM Research

• Evidence-Based Complementary and Alternative Medicine This journal seeks to apply scientific rigor to the study of complementary and alternative medicine, emphasizing on health outcome, while documenting biological mechanisms of action.
• Complementary Therapies in Medicine This journal aims to publish valid, relevant and rigorous research and serious discussion articles with the main purpose of improving healthcare.
• BMC Complementary Medicine and Therapies This journal publishes original research on interventions and resources that complement or replace conventional therapies, with a specific emphasis on research that explores the biological mechanisms of action, as well as their efficacy, safety, costs, patterns of use and/or implementation.
• Journal of Alternative and Complementary Medicine Recently renamed the Journal of Integrative and Complementary Medicine , this journal provides scientific research for the evaluation and integration of complementary medicine into mainstream medical practice.
• Focus on Alternative & Complementary Therapies This journal aims to present the evidence on complementary and alternative medicine (CAM) in an analytical and impartial manner.
• Complementary Therapies in Clinical Practice This journal aims to provide rigorous peer reviewed papers addressing research, implementation of complementary therapies in the clinical setting, and more, in order to promote safe and efficacious clinical practice.
• Journal of Evidence-Based Integrative Medicine Formerly the Journal of Evidence-Based Complementary & Alternative medicine , this journal focuses on hypothesis-driven and evidence-based research in all fields of integrative medicine.
• CINAHL Complete This link opens in a new window Indexes over 1200 journals and publications related to nursing, physical therapy, health education, social service/healthcare, occupational therapy, and related disciplines.

Tips for Using CINAHL for CAM Research

Cinahl subject headings.

Read scope notes for various complementary/alternative therapies listed under the CINAHL Subject:  "Alternative Therapies."

If you "explode" (+) a subject heading, you include all the narrower subject headings under that term. So searching: MH "Alternative Therapies+" as exact subject heading (MH) retrieves records tagged with any subject heading for alternative therapies (e.g., MH "Mind Body Techniques" OR MH "Medicine, Herbal" OR MH "Aromatherapy" OR ...). 

Here's a sample search strategy for records describing articles about depression and alternative therapies: 

(MH "Alternative Therapies+") AND (MH "Depression+")

This search yields records for articles covering the topic alternative/complementary therapies AND records tagged for all types of depression

CINAHL Journal Subset: Alternative/Complementary Therapies

In CINAHL's Search Options, you can limit your results to only see records from journals that have been tagged by CINAHL as relating to CAM disciplines. 

For a list of journals that are included in the Alternative/Complementary Therapies subset, visit this EBSCO help page .

Directions for Limiting to a Journal Subset in CINAHL:

• Run a search for your topic of interest (perhaps the population or problem you are interested in)
• Navigate to the filters on the left side of the page ("Refine Results")
• Under 'Limit to" select "Show More"
• In the Search Options box, scroll to "Journal Subset"
• Select "Alternative/Complementary Therapies"
• Click 'Search' to apply the filter

Silent 20 second video clip illustrating the steps for filtering to the Alternative/Complementary Therapies journal subset in CINAHL. 

• Medline via PubMed This link opens in a new window Widely recognized as the premier source for bibliographic and abstract coverage of biomedical literature. Subjects covered include all aspects of clinical medicine (diseases and disorders, diagnostic and therapeutic techniques and equipment), basic biomedical sciences (anatomy, physiology, biochemistry, genetics, microbiology and pharmacology) as well as nursing, dentistry and clinical psychology.

Tips for Using PubMed to Find CAM Research

The is a Medical Subject Heading (MeSH term) for CAM therapies is "Complementary Therapies", and there are many more specific therapies named under that term in the hierarchy of the MeSH thesaurus (see the MeSH thesaurus entry ).  Read the scope notes for those therapies to determine the best subject to use in your search, or search "Complementary Therapies"[MeSH] to include all those terms in the search.  

Here is an example of a search query that looks for records that are tagged with a MeSH heading describing a CAM therapy and a MeSH heading describing a depressive disorder:

"Complementary Therapies"[Mesh] AND "Depressive Disorder"[Mesh]

Complementary Medicine Filter

Additionally, there is a complementary medicine 'hedge' or 'filter' you can use in your PubMed search.  

The strategy was created using terms from the Complementary Therapies branch of MeSH, as well as additional terms and names of MEDLINE journals provided by the National Center for Complementary and Integrative Health (NCCIH), NIH. It is provided to facilitate searching for subjects in the area of complementary and alternative medicine.  This search filter has not been updated since 2019, but can be accessed at PubMed Special Queries .

Additional Databases

• Cochrane Library (includes: CDSR, DARE, CCTR, HTA, NHSEED, CRG's) This link opens in a new window Some Cochrane systematic reviews have been conducted on topics that are classified as complementary & alternative medicine. To see all Cochrane reviews under this category, click "Browse">"Complementary & alternative medicine" Alternatively, search using keywords, and then "Filter your results> Topics> "Complementary & alternative medicine"
• ProQuest Central This link opens in a new window A multi-disciplinary resource, ProQuest Central is especially useful for research on contemporary topics or for the beginning stages of a research project. It offers citations from a wide range of English language academic journals, newspapers and magazines. Results can be narrowed by "related topic" to see terms related to alternative medicine, and limited to scholarly journals, including peer-reviewed.
• PsycINFO via Ovid This link opens in a new window To search alternative medicine topics in PsycINFO, try the Index Term "alternative medicine" Be sure to EXPLODE the subject term like this: exp alternative medicine/ AND [your topic] Example: exp alternative medicine/ AND depression
• EMBASE: Excerpta Medica 1974 – present (updated daily) This link opens in a new window Embase is a major biomedical and pharmaceutical database indexing over 3,500 international journals with selective coverage for alternative medicine. Try the Emtree subject heading "Alternative Medicine" and read scope notes for the more specific terms listed under that heading. Explode "Alternative Medicine" to include all those narrower terms (exp alternative medicine/).

Reference Resources

• Natural Medicines Comprehensive Database (NMCD) This link opens in a new window Natural Medicines (formerly Natural Standard and Natural Medicines Comprehensive Database) is an authoritative resource of monographs on dietary supplements, natural medicines, and complementary alternative and integrative therapies.
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• Last Updated: Aug 6, 2024 11:45 AM
• URL: https://guides.nyu.edu/complementary-and-alternative-medicine

Complementary and Alternative Medicine: Research Methods

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• Research Methods

Choosing a Topic

Forming and answering questions is a great way to determine a topic, narrow your search, and produce better results. This can come in the form of Who, What, When, Where, or How background questions. Below are a few examples related to Complementary and Alternative Medicine:

• Who would benefit from using probiotics? 
• What is the relationship between acupuncture and quitting smoking?
• How would relaxation techniques be used for anxiety? 

Want to narrow your topic even further? Using the PICO method is a great way to create a research question. This video created by Gumberg Library will guide you through the steps. 

Search Operators

Wondering when and what search operators to use? Here are some basic guidelines:

AND - Using AND will connect two different topics. Say you wanted to find articles about using probiotics for digestive issues . Using the AND operator between terms will help find resources where these two topics intersect.

OR - Using OR can help to broaden a search especially if two terms are interchangeable, such as dietary supplement and food supplement . Authors and journals may decide to use one term instead of another so only searching with one can limit your results. 

Gumberg Library has produced a video to help you in your use of search operators. Watch it here !

Searching in Different Databases

Have you chosen a topic? Great, time to search! The method will be similar moving between databases, but a few key differences exist between platforms. This example will assume you are searching for resources relating to using yoga to help relieve back pain . The operator AND will be used in each case to find where these topics intersect. 

Enter each term in separate search fields. 

The search will be entered in one search bar. Use an all upper case AND to separate the search terms. 

The search will be entered in one search bar. Put any terms that are two words in quotation marks to ensure it is searched as one phrase.

Gumberg Library: 

The Quick Search feature is located in the center of the screen on the Gumberg Library homepage. This will allow you to find a variety of resources including books, e-books, journals, and audiovisual materials.

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Controlled Vocabulary

Using a controlled vocabulary in databases allows you to search more effectively for resources relevant to your topic. This is especially important in Complementary and Alternative Medicines where there are many interchangeable or related terms. Herbs in particular can be referred to by different terms, such as a common name or scientific name. (Think St. John's Wort versus Hypericum ).

Here are two ways to start your search with controlled vocabularies: 

MeSH terms in PubMed:

The largest "umbrella" term to use in PubMed is  Complementary Therapies. 

Learn More About MeSH

PubMed Online Training Tutorials

Subject Headings in CINAHL: 

The largest "umbrella" term to use in CINAHL is Alternative  Therapies. 

Learn More About CINAHL Subject Headings

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• Last Updated: Feb 22, 2024 10:23 AM
• URL: https://guides.library.duq.edu/complementary_medicine

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Alternative Medicine

• Alternative Medicine Research

Start Learning About Your Topic

Create research questions to focus your topic, find articles in library databases, find web resources, cite your sources, key search words.

Search for Books & Articles:

Use the words below to search for useful information in books, ebooks, articles, and more.

To access eBooks if you're off campus , you'll need to log in using your MJC student ID (without the W) and your six-digit birth date.

• alternative medicine
• integrative medicine
• alternative treatment
• complementary therapies
• holistic medicine

Background Reading:

It's important to begin your research learning something about your subject; in fact, you won't be able to create a focused, manageable thesis unless you already know something about your topic.

This step is important so that you will:

• Begin building your core knowledge about your topic
• Be able to put your topic in context
• Create research questions that drive your search for information
• Create a list of search terms that will help you find relevant information
• Know if the information you’re finding is relevant and useful

If you're working from off campus , you'll need to sign in. Once you click on the name of a database, simply enter your student ID (without the W) and your six-digit birth date.

All of these resources are free for MJC students, faculty, & staff. 

• Gale eBooks This link opens in a new window Use this database for preliminary reading as you start your research. You'll learn about your topic by reading authoritative topic overviews on a wide variety of subjects.
• Gale Encyclopedia of Alternative Medicine This eBook covers all aspects of the subject including therapies, conditions/diseases, herbs/plants, and people. It identifies numerous types of alternative medicine being practiced today including reflexology, acupressure, acupuncture, chelation therapy, kinesiology, yoga, chiropractic, Feldenkrais, polarity therapy, detoxification, naturopathy, Chinese medicine, biofeedback, Ayurveda and osteopathy
• The Encyclopedia of Complementary and Alternative Medicine This eBook provides a comprehensive source of definitions, explanations, case studies, and perspectives on homeopathic therapies from ancient times to the present
• Issues & Controversies This link opens in a new window This is a great database to use when you want to explore different viewpoints on controversial or hot-button issues. It includes reports on more than 800 hot topics in business, politics, government, education, and popular culture. Use the search or browse topics by subject or A to Z.
• CQ Researcher Online This link opens in a new window This is the resource for finding original, comprehensive reporting and analysis to get background information on issues in the news. It provides overviews of topics related to health, social trends, criminal justice, international affairs, education, the environment, technology, and the economy in America.

Alternative medicine is a multi-dimensional topic that covers complex issues including social practices, health, the industry of health care, and more. You could concentrate on one set of issues and do in-depth research on that or use several of the questions below to focus on the topic of alternative medicine more generally.

• What do alternative, complementary, and integrative mean?
• What scientific studies have been done on the safety and effectiveness of complementary therapies?
• Are alternative medical treatments as effective as conventional medical treatments?
• Is alternative medicine more cost-effective than conventional medicine?
• What economic impact would reliance on alternative medicine have on our health care system?
• Are medical students being adequately introduced to alternative therapies in medical school?
• Can our health care system accommodate both alternative and conventional types of treatments?
• Based on what I have learned from my research what do I think about the issue of alternative medicine?

All of these resources are free for MJC students, faculty, & staff. 

If you're working from off campus, you'll need to sign in just like you do for your MJC email and Canvas classes.  

• Gale Databases This link opens in a new window Search over 35 databases simultaneously that cover almost any topic you need to research at MJC. Gale databases include articles previously published in journals, magazines, newspapers, books, and other media outlets.
• EBSCOhost Databases This link opens in a new window Search 22 databases simultaneously that cover almost any topic you need to research at MJC. EBSCO databases include articles previously published in journals, magazines, newspapers, books, and other media outlets.
• Nursing & Health Databases @ MJC Select a database from our list of nursing & health databases
• Facts on File Databases This link opens in a new window Facts on File databases include: Issues & Controversies , Issues & Controversies in History , Today's Science , and World News Digest .
• Access World News This link opens in a new window Search the full-text of editions of record for local, regional, and national U.S. newspapers as well as full-text content of key international sources. This is your source for The Modesto Bee from January 1989 to the present. Also includes in-depth special reports and hot topics from around the country. To access The Modesto Bee , limit your search to that publication. more... less... Watch this short video to learn how to find The Modesto Bee .

Search Google Scholar to find academic information on the Web:

Suggested Web Sites:

• Complementary and Alternative Medicine: MedlinePlus Produced by the National Library of Medicine, MedlinePlus brings you information about diseases, conditions, and wellness issues in language you can understand. MedlinePlus offers reliable, up-to-date health information, anytime, anywhere, for free.
• National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government’s lead agency for scientific research on the diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine

Your teacher should have told you what style you should use.

Click on a citation style below to learn how to cite your sources and format your paper using that style.

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• Last Updated: Apr 25, 2024 1:28 PM
• URL: https://libguides.mjc.edu/alternativemedicine

Except where otherwise noted, this work is licensed under CC BY-SA 4.0 and CC BY-NC 4.0 Licenses .

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Trust, human-centered AI and collaboration the focus of inaugural RAISE Health symposium

Artificial intelligence experts discuss how to integrate trustworthy AI into health care, why multi-disciplinary collaboration is crucial and the potential for generative AI in research.

May 17, 2024 - By Hanae Armitage

Fei-Fei Li and Lloyd Minor give opening remarks at Stanford Medicine's first RAISE Health Symposium on May 14.  Steve Fisch

Most people captured by artificial intelligence have all had something of an “aha” moment that opens their minds to a world of opportunities. During the inaugural RAISE Health symposium on May 14, Lloyd Minor , MD, dean of the Stanford School of Medicine and vice president for medical affairs at Stanford University, shared his.

Asked to summarize a discovery he’d made related to the inner ear, a curious Minor turned to generative AI. “I asked, ‘What is superior canal dehiscence syndrome?’” Minor told a group of nearly 4,000 symposium attendees. In seconds, a few paragraphs appeared.

“They were good — really good,” he said. “The information was brought together into a concise and, by and large, accurate and well-prioritized description of the disorder. It was quite remarkable.”

Minor’s excitement was shared by many at the half-day event, which was born of the RAISE Health initiative, a project launched by Stanford Medicine and the Stanford Institute for Human-Centered Artificial Intelligence (HAI) to guide the responsible use of AI in biomedical research, education and patient care. Speakers explored what it means to bring AI into the folds of medicine in a way that’s not just helpful for physicians and scientists, but transparent, fair and equitable for patients.

“We believe this is a technology to augment and enhance humanity,” said Fei-Fei Li , a professor of computer science at the Stanford School of Engineering who leads RAISE Health with Minor and is the co-director of HAI. From generating new molecular sequences that could give rise to new antibiotics, to mapping biodiversity, to uncovering hidden bits of basic biology, AI is accelerating scientific discovery, she said. But it’s not all beneficial. “All of these applications can have unintended consequences, and we need computer scientists to work with multiple stakeholders — from doctors and ethicists…to security experts and more — to develop and deploy [AI] responsibly,” she said. “Initiatives like RAISE Health show that we’re committed to this.”

The alignment of Stanford Medicine’s three entities — the School of Medicine, Stanford Health Care and Stanford Medicine Children’s Health — and its connection to the rest of Stanford University puts it in a unique position as experts grapple with AI development, governance and integration in health and medicine, Minor said.

“We’re ideally suited to be a pioneer in advancing and deploying AI in responsible ways, covering the gamut from fundamental biological discovery, enhancing drug development, making clinical trial processes more efficient, all the way through the actual delivery of health care and the way we run our health care delivery system,” he said.

What ethical integration looks like

Some speakers underscored a simple concept: Focus on the user — in this case, the patient or the physician — and all else will follow. “It’s putting patients at the center of everything that we do,” said Lisa Lehmann, MD, PhD, director of bioethics at Brigham and Women’s Hospital. “We need to be thinking about their needs and priorities.”

From left: Moderator Mohana Ravindranath of STAT News; Jessica Mega; Peter Lee of Microsoft Research; and Sylvia Plevritis, professor of biomedical data science, discuss the role of AI in medical research.  Steve Fisch

Speakers on one panel — which included Lehmann, Stanford Medicine bioethicist Mildred Cho , PhD, and Michael Howell, MD, chief clinical officer at Google — pointed to the complex nature of a hospital system, highlighting the need to understand the purpose of any intervention before implementing it and to ensure that all systems developed are inclusive, with input from the populations it’s meant to help.

One key to that is transparency — being explicit about where the data used to train the algorithm came from, what the algorithm was originally intended for and whether future patient data will continue to help the algorithm learn, among other factors.

“Trying to predict ethical problems before they become consequential [means] finding a perfect sweet spot of knowing enough about the technology that you can make some ascertainment of it, but getting to it before [an issue] spreads further,” said Danton Char , MD, associate professor of pediatric anesthesiology, perioperative and pain medicine. One of the key steps, he said, is to identify all the stakeholders who could be impacted by a technology and take note of how they would want those questions answered for themselves.

Jesse Ehrenfeld, MD, president of the American Medical Association, discussed four drivers of adoption for any digital health tool, including those powered by AI. Does it work? Does it work in my institution? Who pays for it? Who is liable?

Michael Pfeffer , MD, chief information officer for Stanford Health Care, highlighted a recent example in which many of those questions were tested with care providers at Stanford Hospital. Clinicians were offered assistance from a large language model that drafts initial notes to patient inbox messages. While the drafts weren’t perfect, the clinicians who helped develop the technology reported that the model lightened their workload.

“There are three big things that we’ve been focusing on: safety, efficacy and inclusion. We’re physicians. We take this oath to ‘do no harm,’” said  Nina Vasan , MD, clinical assistant professor of psychiatry and behavioral sciences, who joined a panel with Char and Pfeffer. “That needs to be the first way that we’re assessing any of these tools.”

Nigam Shah , MBBS, PhD, professor of medicine and of biomedical data sciences, kicked off a discussion with a jarring statistic, although he gave the audience fair warning. “I speak in bullet points and numbers, and sometimes they tend to be very direct,” he said.

To Shah, the success of AI hinges on our ability to scale it. “Doing the science right for one model takes about 10 years, and if every one of the 123 fellowship and residency programs wanted to test and deploy one model at that level of rigor, with our current ways of organizing work and [testing] it at every one of our sites to make sure it works properly, it would be $138 billion,” Shah said. “We can’t afford it. So, we have to find a way to scale, and we have to scale doing good science. The skills for rigor reside in one place, and the skills for scale reside in another, and hence, we’re going to need these kinds of partnerships.”

Associate dean Euan Ashley and Mildred Cho (at front table) attend the RAISE Health Symposium. Steve Fisch

The way to get there, according to a number of speakers at the symposium, is public-private partnership, such as that being modeled through the recent White House Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence and the Coalition for Health AI , or CHAI.

“The public-private partnerships [with] the most potential are [between] academia, the private sector and the public sector,” said Laura Adams, a senior advisor at the National Academy of Medicine. The government can bring public credibility, academic medical centers can bring legitimacy, and the technical expertise and compute time can come from the private sector, she noted. “All of us are better than any one of us, and we’re recognizing…that we don’t have a prayer of reaching the potential of [AI] unless we understand how to interact with each other.”

Innovating in AI, filling gaps

AI is also making an impact in research, whether scientists are using it to probe the dogma of biology, predict new synthetic molecular sequences and structures to underpin emerging therapeutics, or even to help them summarize or write scientific papers, several speakers said.

“There’s an opportunity to see the unknown,” said Jessica Mega , MD, a cardiologist at Stanford Medicine and co-founder of Alphabet’s Verily. Mega pointed to hyperspectral imaging, which captures features of an image that are invisible to the human eye. The idea is to use AI to detect patterns, for example, in pathology slides, unseen by humans that are indicative of disease. “I encourage people to push for the unknown. I think everyone here knows someone who is suffering from a health condition that needs something beyond what we can offer today,” Mega said.

There was also a consensus among panelists that AI systems will provide new means of identifying and combating biased decision making, whether it’s made by humans or AI, and opportunities to figure out where that bias is coming from.

“Health is more than health care,” was a statement echoed by multiple panelists. The speakers stressed that researchers often overlook social determinants of health — such as socioeconomic status, ZIP codes, education level, and race and ethnicity — when they are collecting inclusive data and enrolling participants for studies. “AI is only going to be as good as the data that the models are trained on,” said Michelle Williams , ScD, a professor of epidemiology at Harvard University and a visiting professor of epidemiology and population health at Stanford Medicine. “If we are looking for improving health [and] decreasing disparities, we’re going to have to make sure that we are collecting high-quality data on human behaviors, as well as the social and physical environment.”

Natalie Pageler , MD, clinical professor of pediatrics and of medicine, shared that cancer data aggregates often exclude data from pregnant people, creating inherent biases in models and exacerbating an existing gap in health care.

As with any emerging technology, there are ways that AI can make things better and ways it can make things worse, said David Magnus , PhD, professor of pediatrics and of medicine. The risk, Magnus said, is that AI systems learn about inequitable health outcomes driven by social determinants of health and reinforce them through their outputs. “AI is a mirror that reflects the society that we’re in,” he said. “I’m hopeful that every time we get an opportunity to shine a light on a problem — hold up that mirror to ourselves — it will be a spur for things to get better.”

If you weren’t able to attend the RAISE Health symposium, recordings of the sessions can be found here .

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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Good sleep habits important for overweight adults, study suggests

by Erik Robinson, Oregon Health & Science University

New research from Oregon Health & Science University reveals negative health consequences for people who are overweight and ignore their body's signals to sleep at night, with specific differences between men and women.

The study published this week in The Journal of Clinical Endocrinology & Metabolism .

"This study builds support for the importance of good sleep habits," said lead author Brooke Shafer, Ph.D., a postdoctoral researcher in the Sleep, Chronobiology and Health Laboratory in the OHSU School of Nursing. "Sleep practices, like going to bed when you're tired or setting aside your screen at night, can help to promote good overall health."

The study recruited 30 people, split evenly between men and women. All had a body mass index above 25, which put them into an overweight or obese category.

"Obesity and cardiometabolic disease are growing public health concerns," Shafer said. "Our research shows that disruptions in the body's internal biological clock could contribute to negative health consequences for people who may already be vulnerable due to weight."

Generally healthy participants contributed a saliva sample every 30 minutes until late in the night at a sleep lab on OHSU's Marquam Hill campus to determine the time at which their body started naturally producing the hormone melatonin . Melatonin is generally understood to begin the process of falling asleep, and its onset varies with an individual's internal biological clock.

Participants then went home and logged their sleep habits over the following seven days.

Researchers assessed the time difference between melatonin onset and average sleep timing for each participant, categorizing them into two groups: those who had a narrow window, with a short time duration between melatonin onset and sleep, and those with a wide window, with a longer duration between melatonin onset and sleep. A narrow window suggests someone who is staying awake too late for their internal body clock and is generally associated with poorer health outcomes.

The new study confirmed a variety of potentially harmful health measures in the group that went to sleep closer to melatonin onset.

It also found key differences between men and women. Men in this group had higher levels of belly fat and fatty triglycerides in the blood, and higher overall metabolic syndrome risk scores than the men who slept better. Women in this group had higher overall body fat percentage, glucose and resting heart rates.

"It was really somewhat surprising to see these differences present themselves in a sex-dependent manner," said senior author Andrew McHill, Ph.D., assistant professor in the OHSU School of Nursing, the School of Medicine and the Oregon Institute of Occupational Health Sciences at OHSU. "It's not one size fits all, as we sometimes think in academic medicine."

The next phase of research will determine sex-specific differences in groups that experience more severe changes in sleep patterns, such as workers pulling overnight shifts.

"We want to figure out possible interventions that keep this vital core group of the workforce healthy," Shafer said.

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• v.322(7279); 2001 Jan 20

Research into complementary and alternative medicine: problems and potential

Richard l nahin.

a Division of Extramural Research, Training and Review, National Center for Complementary and Alternative Medicine, National Institutes of Health, 9000 Rockville Pike, Bethesda MD 20892-2182, USA, b National Center for Complementary and Alternative Medicine

Stephen E Straus

The growing use of unsubstantiated complementary and alternative medicine therapies by people in the United States 1 along with its increasing coverage by third party payers 2 encouraged Congress to create the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. The centre's mission is “to explore complementary and alternative healing practices in the context of rigorous science; to educate and training CAM researchers; and to disseminate authoritative information to the public and professionals.” 3 To complete this mission, NCCAM supports publicly relevant and scientifically rigorous research to identify those complementary and alternative medicine practices that are safe and effective.

The centre's resources, although generous ($68.3m (£46m) for fiscal year 2000), are not sufficient to study all complementary and alternative medicine practices. NCCAM therefore developed criteria to help prioritise the many possible research opportunities (box). As part of the evaluation process, NCCAM seeks advice from its national advisory council, complementary and alternative medicine and conventional clinicians, members of the scientific research community, the public, sister federal agencies, and other stakeholders.

Summary points

• Many early clinical trials investigating complementary and alternative medicine have had serious flaws
• Clinical investigations of complementary and alternative medicine are made difficult by factors such as use of complex, individualised treatments and lack of standardisation of herbal medicines
• Other problems include difficulties in accruing, randomising, and retaining patients and in identifying appropriate placebo interventions
• Despite these complexities, rigorously designed clinical trials are possible, including pragmatic studies of complete complementary and alternative medicine systems
• Strong commitment is required from the research community to provide information about complementary and alternative medicines to the public and health professionals

Allocation of resources

Staff at the centre are often asked why limited resources are being spent on research that is perceived as replicating previously published work, especially when other western countries have already integrated some of these practices into standard care. Unfortunately, many of the studies have been small, their results variable or inconsistent, and their research designs inadequate. Systematic reviews have found that many clinical trials testing complementary or alternative medicine have major flaws, such as insufficient statistical power, poor controls, inconsistency of treatment or product, and lack of comparisons with other treatments, with placebo, or with both. These reviews typically conclude that larger, well designed studies are necessary before making authoritative recommendations. Specific examples of such reviews include the use of Hypericum perforatum (St John's wort) to treat depression 4 ; Ginkgo biloba to delay cognitive decline in patients with Alzheimer's disease 5 ; Serenoa repens (saw palmetto) to relieve symptoms associated with benign prostatic hyperplasia 6 ; and glucosamine and chondroitin sulphate to treat osteoarthritis. 7 NCCAM is currently supporting randomised controlled trials for these four dietary supplements that have been designed with the scientific rigour demanded by experienced scientists and the American public.

One reason for investing so much in research into dietary supplements is that their use is growing rapidly in the United States. Although consultations with complementary and alternative medicine practitioners (acupuncturists, chiropractors, naturopathic physicians, etc) remained stable on a percentage basis from 1993 8 to 1998, 1 use of dietary supplements greatly increased. Billions of dollars are spent on dietary supplements in the United States every year. The Dietary Supplement Health and Education Act, which was passed in 1994, made it easier to obtain these natural products. The act also loosened the federal control over dietary supplements, with the result that most commercially available products are not well characterised or standardised. Another issue is that the optimal dose, schedule, and route of administration of most dietary supplements have not been determined systematically; nor are the frequency and extent of drug reactions and interactions known. NCCAM therefore believes that most dietary supplements are not yet ready for large, expensive trials despite their wide use by patients. At a minimum, preclinical studies, pharmacokinetics testing, and developmental phase I and II trials are necessary before these products can be launched into definitive clinical trials. NCCAM is vigorously encouraging research in these areas through a series of focused initiatives. 9

Criteria for prioritising research opportunities

• Quantity and quality of available preliminary data to help determine the most appropriate type of research (basic versus clinical research; phase I or II clinical trial versus phase III trial)
• Extent of use by the US public (greatest weight given to interventions in wide use)
• Public health importance of disease being treated (greatest weight to diseases associated with highest mortality or morbidity or for which conventional medicine has not proved optimal)
• Feasibility of conducting the research
• Cost of research

Problems with research design

Although many people in the United States self medicate with dietary supplements, many others seek care from practitioners of traditional systems of medicine, including Ayurveda (from India), Kampo (from Japan), traditional Chinese medicine, Native American medicine, and more recently developed systems such as naturopathy and chiropractic. 1 , 10 – 12 Despite the diverse cultures, geographical locations, and beliefs from which these systems developed, they share several common characteristics such as the use of complex interventions often including botanical medications; individualised diagnosis and treatment of patients; an emphasis on maximising the body's inherent healing ability; and treatment of the “whole” patient by addressing their physical, mental, and spiritual attributes rather than focusing on a specific pathogenic process as emphasised in western biomedicine.

Despite this emphasis on multimodality treatment regimens, most research investigating traditional systems of medicine have examined only one, or perhaps two, interventions taken from a whole treatment system. For instance, there are hundreds of small studies examining the efficacy of acupuncture needling alone for treating asthma, pain, hypertension, or nausea. Yet in real practice, acupuncture needling would be just one of an arsenal of interventions used by a licensed acupuncturist including botanical potions, cupping, dietary changes, exercise therapy (such as Tai Chi or Qi Gong), moxibustion, and Chinese massage. Similarly interventions such as yoga, a single botanical medication, or meditation are just single components of complex systems of medicine. So investigators are faced with either designing a trial of a single intervention that does not accurately reflect true clinical practice or undertaking a multifaceted intervention trial that is complicated to design and implement.

Research design is further confounded by the wide variation in how many forms of complementary and alternative medicine are practised. For instance, there are multiple approaches of chiropractic medicine and acupuncture practised in the United States. Within these approaches the treatment may vary for individual patients presenting with the same conventional diagnosis because practitioners often focus on the symptoms of the disease rather than a primary pathology. Furthermore, the number and length of treatments and the specific treatment used may vary both between individuals and for an individual during the course of treatment. For example, when designing a randomised controlled trial for acupuncture, the investigator is faced with choices concerning the selection of points, the depth of needle insertion, and the frequency and scheduling of treatment. Unless these choices are made in an evidence based fashion, the trial will be compromised.

Difficulties in accruing, randomising, and retaining patients are other potential areas of concern. Some issues common to all clinical trials, such as the use of broad exclusion criteria and inadequate outreach to underserved populations, can limit patient participation and reduce generalisability. We also know that patients with a strong preference for a particular treatment will refuse randomisation. 13 – 15 Moreover, should patients accept randomisation, the easy access of dietary supplements and other complementary interventions in the open market greatly increases the likelihood of “cheating” by the control group. This problem has also been found in trials of dietary and behavioural interventions used in conventional medicine. 16

Finding appropriate placebos or shams for treatments such as acupuncture, chiropractic, massage therapy, or complex herbal mixtures is challenging. Complementary and alternative treatments typically involve extended and intensive interactions between the patient and the practitioner, which greatly increase the possibility of a placebo effect. 17 , 18 Double blinding of the interventions may not be possible because the experienced practitioner will know which treatment is sham and which the intervention. The practitioner, in turn, may consciously or unconsciously convey this information to the patient. The variability of practice also affects the choice of a placebo. 19 For instance, superficial insertion of acupuncture needles at valid acupuncture points has been used as a control in many acupuncture trials. 20 , 21 Yet, the Japanese school of acupuncture advocates that such superficial needling is effective, and some research supports this view. 22

Approaches to good design

Given the complex nature of diagnosis and treatment in traditional systems of medicine, how should we design clinical trials? Approaches vary from that of the typical pharmaceutical drug trial, in which strict, standardised diagnostic criteria are used with a defined and standardised treatment, to the other extreme, in which investigations of a whole system are undertaken in its proper context so that both the diagnosis and treatment may be highly individualised.

In studies of a system of traditional medicine to treat a specific disease the investigators consider the system as a whole, instead of a single core modality. These full spectrum studies can be done without identifying the underlying mechanism of action for each intervention, provided there is a clear, clinically relevant end point. For example, NCCAM is currently supporting a phase II randomised trial comparing three approaches to treating women with temporomandibular disorder: naturopathic medicine, traditional Chinese medicine, and usual conventional care. Patients randomised to receive either naturopathic or Chinese medicine are diagnosed and treated in the traditional manner. The end points for the study include validated measures of temporomandibular disease as well as reassessment of the naturopathic or Chinese medicine diagnosis, with all variables being analysed on an intention to treat basis.

A second approach is to study a specific modality adapted from a traditional system of medicine for treating a specific disease. NCCAM currently supports several such trials, including a double blind randomised controlled trial of acupuncture using traditional Chinese medicine needling points specific for depression. The treatment is compared with acupuncture at points that are used to treat other conditions and a waiting list control. The acupuncture treatments are individualised and based on the Chinese medicine diagnosis. Blinding is maintained by having different practitioners diagnose, treat, and evaluate the patients. Monthly assessment by the diagnosing acupuncturist allows for modifications of the treatment plan as needed. The outcome measures include both standard measures of depression (such as the Hamilton rating scale for depression) and reassessment of the Chinese medicine diagnosis, with all analysis done on an intention to treat basis.

A third approach is a trial of a single intervention, such as a herbal medicine to treat a conventionally diagnosed disease. This is the most common approach currently used to investigate complementary and alternative medicine, and ongoing trials are studying hypericum for depression; acupuncture for symptomatic relief of osteoarthritis; G biloba for preventing dementia; shark cartilage as an adjunctive therapy for non-small cell lung cancer; and glucosamine and chondroitin for osteoarthritis.

All of the above examples are randomised controlled trials. They show that despite increases in complexity and possibly cost, it is possible to design high quality trials investigating complementary and alternative medicine. However, the trials require much more preparation than trials of conventional medicine and individual trial components (blinding, placebo, consistency of intervention even if individualised, etc) often need extensive piloting before the trial.

Although randomised controlled trials are the accepted standard of clinical research, NCCAM values other types of high quality research, including careful observational studies. For many complementary and alternative therapies, there is no reliable information concerning the types of practices used for particular diseases or conditions; the numbers and types of patients who use them; how the practices are delivered (including dose used); how well patients respond to treatment; and relevant side effects. These issues can be investigated in observational studies. In addition, observational studies afford pragmatic ways of answering some types of questions, such as the evaluation of rare adverse events, as well as being a viable research option when randomisation of patients might be considered unethical or unacceptable.

The conduct of high quality research on complementary and alternative medicine requires a commitment by the research community, as well as sustained financial support from governments and industry. This commitment is essential if the public and healthcare providers are to have sufficient information on safety and efficacy to make informed decisions concerning use of complementary and alternative medicine. We envision that compelling data will facilitate meaningful interactions between conventional and complementary practitioners and ultimately lead to the development of interdisciplinary partnerships that incorporate validated complementary practices into patient care.

National Institutes of Health data show steep growth in expenditure on dietary supplements

  Competing interests: None declared.

VA funds IU School of Medicine research projects relevant to veterans’ health

Aug 22, 2024

stock.adobe.com - Ilgun

INDIANAPOLIS – I ndiana University School of Medicine researchers have cumulatively been awarded nearly $4 million in grant funding through the U . S . Department of Veterans Affairs' Merit Review Award and Career Development program s to support research on diabetes, skin inflammation, cancer and aging .

The Merit Review Award P rogram supports investigator-initiated research conducted by eligible VA investigators at either VA medical centers or approved sites. This program serves as the VA's primary method for funding basic, preclinical, and behavioral biomedical research as well as clinical research on illnesses and disorders that are significant to veterans' health.

The goal of the Merit Review Award program is to provide grant funding to applications that propose research that is scientifically exemplary and relevant to veterans' health.

Merit Review Awardees for the Spring 2024 cycle:

" Novel roles for RIP kinases in islet inflammation and beta-cell cytotoxicity in type 2 diabetes."

• Andrew T. Templin, PhD , assistant professor of medicine
• Amount : $1,124,281

" Immunomodulatory functions of insulin growth factor-like proteins in skin inflammation."

• Matthew J. Turner, MD, PhD , assistant professor of clinical dermatology and clinical microbiology and immunology
• Amount : $710,000

" Evaluating the impact of intermittent fasting in combination with checkpoint inhibitors in patients with non-small cell lung cancer."

• Shadia I. Jalal, MD , Lawrence H. Einhorn Professor of Oncology and professor of medicine
• Amount : $994,479

The Career Development P rogram attracts, develops, and retains talented researchers working in crucial areas to enhance the health and medical care of our nation's veterans. Awardees have gone on to lead long, successful careers as VA scientists, research administrators and c enter d irectors.

2024 Career Development Awardee :

" Using DNA r epair and d amage as a t ool in p ersonalizing a ging and a ging r elated d iseases"

• Nawar Al Nasrallah, MD , assistant professor of medicine
• Amount: $1,138,732

About the IU School of Medicine

The IU School of Medicine is the largest medical school in the U.S. and is annually ranked among the top medical schools in the nation by U.S. News & World Report. The school offers high-quality medical education, access to leading medical research and rich campus life in nine Indiana cities, including rural and urban locations consistently recognized for livability. According to the Blue Ridge Institute for Medical Research, the IU School of Medicine ranks No. 13 in 2023 National Institutes of Health funding among all public medical schools in the country.

Writer: Luke Norton, [email protected]

For more news, visit the IU School of Medicine  Newsroom: medicine.iu.edu/news

Follow us on X: @IUMedSchool

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