CAM comes to post-acute care.

Acupuncture, massage therapy, naturopathy, even chiropractic - some of these sound pretty "far out" in the professional healthcare field. Yet the use of complementary and alternative medicine (CAM) is increasing in the United States. Indeed, some of the most respected names in the healthcare industry, including Harvard, UCLA, Mercy Healthcare, Kaiser, the University of Washington and Johns Hopkins University, are offering CAM.

Earlier this year, Landmark Healthcare commissioned InterActive Solutions to conduct a study to gain more information about public perceptions of CAM. Some of the results were that: 42% of the participants reported using some type of CAM services in the previous year; 74% of those used alternative care along with traditional care; and, most revealing, 67% of respondents stated that the availability of alternative care was very or somewhat important in selecting a health plan.

Insurers, including managed care, are beginning to reimburse for CAM services. This new interest is motivated mostly by: 1) consumer demand, 2) a greater awareness of other cultures' practices, 3) a growing body of literature suggesting positive CAM outcomes, 4) an increased interest in prevention and wellness from baby boomers, 5) seniors expressing a desire to take fewer medications, 6) reduced treatment costs, and 7) the above-mentioned recognition from nationally renowned providers and organizations.

Even the states are mandating reimbursement for alternative providers. The data below is from The National Association of Insurance Commissioners Mandated Benefits Summary (1995):

State Mandates for CAM Reimbursement

                       Number of
Providers                States

Acupuncturists              8
Chiropractors              41
Massage therapists          1
Naturopaths                 3

Although very few post-acute care providers have expanded into CAM, it won't be long before many of them do. Not only is the baby-boom generation already availing itself of a wide array of these services, the current senior population is expressing an interest in CAM as well. That's why the savvy provider is learning about these services today in an effort to offer them tomorrow.

To seek helpful background on CAM, I spoke with Dr. Jie-Jia Li, on the staff of the West Los Angeles Center for Traditional Chinese Medicine and a researcher at the East-West Medical Clinic at the University of California at Los Angeles. He has received medical training in both Western and Eastern medicine.

Hyatt: Explain the philosophy of traditional Chinese (or Eastern) medicine (TCM).

Dr. Li: To answer this question, it is necessary to point out the philosophy of TCM has an origin that can be traced back about 4,000 years. TCM developed mainly through thousands of years of observation, not only of the human body, but also of its relationship to nature and the universe. It is hard for me within a short time to describe in detail the whole system because what TCM deals with is so broad, ranging from physiology and pathology, to diagnosis, prevention and treatment of diseases, to rehabilitation and restoration of health.

Briefly speaking, however, the core of TCM is based on traditional Chinese philosophical concepts of an organic balance of heaven and earth, termed Yin and Yang. Put in this perspective, human health should be treated as a science of systems that are always changing, but all together - cooperative phenomena. There is no division of body and mind; they are viewed as a whole. The environment will have an impact on both the body and the mind at the same time. Thus, good health results from a balance between Yin and Yang, whereas poor health is a sign of unbalanced Yin and Yang. Keeping the Yin and Yang in balance, therefore, is a major task of TCM.

Hyatt: Compare the philosophies of traditional Chinese medicine (TCM) and modern Western medicine (MWM).

Dr. Li: There are some major differences between TCM and MWM with regard to basic concepts and techniques in diagnosis and treatment. In my view, unlike MWM, TCM is based on the systems approach, placing an emphasis on the integrity of the human mind/body and its dynamic interaction with the environment. TCM can be characterized as holistic. It recognizes the importance of physical, nutritional, psychological and spiritual factors. The diagnosis and treatment is based on an overall analysis of signs and symptoms that manifest these disharmonies of the body.

While doing diagnosis, the TCM practitioner weaves together a comprehensive picture of the patient and his or her conditions, which is called the pathophysiologic state or pattern (zheng). The diagnosis methods of TCM include examining the signs and symptoms that are either manifested or not manifested yet, to find the state of Qi (energy/channel) of the body. The vital Qi of the body in TCM perspective provides the energy basic to the body's defense system against external pathogenic factors.

Hyatt: What are the goals and characteristics of TCM therapeutics as compared to MWM?

Dr. Li: A cornerstone of TCM therapeutics is the restoration of normal balance and flow in the body. While conventional Western medicine may be more effective in treating acute problems and achieving results much quicker, TCM therapeutics is especially adept at dealing with the underlying problems that give rise to the patient's illness.

The therapeutic modalities employed in TCM to achieve these goals are many. They include herbal medicine, massage, dietetics, acupuncture and related variants and the mental and physical exercises of Tai Chi and Qigong.

Unlike MWM, which stresses treatment over prevention, TCM pays more attention to prevention than treatment, with a focus on how to enhance the body's natural resistance to diseases in order to maintain good health and stop illnesses at their early stages. With its special emphasis on health promotion and disease prevention, TCM stresses the importance of homeostasis and the requisite nature of a normal flow of an adequate amount of energy to maintain it. According to TCM, diseases usually start at that level, then go on to the chemical and physiologic level, and eventually to the anatomic level, with most of the diseases showing their symptoms only after they have reached the anatomic level.

What distinguishes TCM from MWM is that the latter starts to deal with diseases only at the anatomic level. While MWM focuses on treating each symptom of disease, TCM emphasizes retention and promotion of health by looking at the human body early. TCM sees the human body functioning as a system of dynamic interactions, both with the outside environment and intrinsically between the organs, rather than as an ensemble of anatomic structures.

More specifically, MWM treats illness by isolating the diseased area and employing medications to alter and counteract each individual problem. Chinese medicine treats illness by identifying which parts of the whole are out of balance and the energy patterns that result, and then treats them with energetic therapies and herbal medications to correct the imbalance and bring the whole to balance.

Hyatt: Give a brief description of acupuncture, acupressure/Chinese therapeutic massage and Qigong.

Dr. Li: Qigong is the practice of breathing exercises created by the Chinese people in the fight against disease and aging. Qigong is quite unique in its way of training both body and mind through cultivating one's vital essence, vital energy and vital spirit. It has the functions of preventing and curing diseases, protecting and strengthening health and prolonging life. The Chinese character "Qi" means vital energy, while "Gong" means continuous regulation of one's respiration and posture, with the mind conducting the process. To put it simply, it is a method by which the practitioner gets physical and mental self-exercise through bringing into play his initiative.

To achieve this aim, the practitioner must associate his/her mind with postures and breathing. This actively regulates the functional activities of the organism and maintains a dynamic equilibrium. On the other hand, it enables the body to produce an "energy-storing" reaction to reduce energy consumption and increase energy accumulation. The result is to bring the organic potential into full play in the human body.

Qigong therapy is effective but mysterious, for there are still many phenomena that are difficult to explain by modern science. According to recent research, Qigong can reduce the excitability of the sympathetic nervous system and raise the excitability of the parasympathetic system, which is said to benefit health care of the elderly.

Tai Chi exercises, which are considered a kind of Chinese martial art, derived from Zhou yi, implying the meaning of the highest and the supreme. In general, Tai Chi exercises are characterized by gentle, slow and graceful physical movements, with one movement being followed by another in uninterrupted and circular continuity. Tai Chi is practiced as a means of physical workout to keep fit and adjust emotions. Regular practice of Tai Chi exercises can be of benefit to one's physical well-being and helps keep one energetic. Tai Chi can help strengthen heart functions by improving cardiovascular efficiency and the lymphatic system. Tai Chi can help increase respiratory function and enlarge vital capacity, as well as help to promote digestion and facilitate metabolism. In addition, Tai Chi can help strengthen ligaments and muscles around joints by increasing their flexibility and stability. For example, by improving balance and posture, Tai Chi exercises tremendously benefit those patients who have osteoporosis and arthritis.

Besides these benefits, Tai Chi has a number of other health advantages, such as reducing stress, improving peripheral circulation, and enhancing overall wellness and psychological status.

Acupuncture is an application of needles to certain points on the human body, manipulated by various techniques. This adjusts the Qi and blood flow in certain meridians and helps balance Yin and Yang inside the body. It is simply a method of sending a signal to the body (by needle or other means) to "turn on" its own self-healing or regulatory mechanisms.

With increasing scientific evidence demonstrating the effectiveness and safety of acupuncture, and recent favorable policies of the Food and Drug Administration (FDA) and National Institutes of Health (NIH), as well as the inclusion of acupuncture on increasing number of health plans, the usage of acupuncture has become widespread.

Chinese therapeutic massage has a long history, dating back to the ancient times. Archaeological studies in recent years have shown that it may date back as early as the late period of the New Stone Age, around 2700 BC. based upon the basic theory of TCM meridians, various techniques are used employing the hands or upper limbs to press, rub, push, pull, pinch, knead, rotate, roll or shake, etc. on the meridians and points on the body surface so as to circulate Qi and activate circulation.

Hyatt: How can these techniques be used to control pain?

Dr. Li: Acupuncture has the effects of promoting and regulating Qi and blood circulation to control vitality. There is a saying in the ancient book about TCM that says, "Many pains are caused by Qi. Pain is due to the blocking of flow of Qi and blood." But acupuncture can clear the meridian and regulate Qi and blood.

The doctors in ancient times further pointed out that "Shen is accompanied by Qi," and that there is an interrelation between Shen and Qi. What is Shen? It mainly refers to sensations associated with the nervous system. Acupuncture can control Shen and impel the flow of Qi and blood so that the pain can be stopped.

Recent studies show that the insertion of needles at certain points enables some parts of the brain to release certain chemical substances which, in turn, inhibit pain sensation. As a result, the pain is relieved or even disappears. The released chemical substances have been purified and some of them are mainly the natural substances resembling morphine called enkephalins. These findings strongly suggest that acupuncture can reduce pain.

As for therapeutic massage, TMC holds that the pain after injury is due to the blockage of Qi and resulting blood stasis. Since pain is caused by the stagnation of Qi, treatment should be carried out by means of relaxing muscles and tendons, removing obstruction in the meridian and promoting blood circulation. Massage can also relieve muscular tension and spasm through: 1) strengthening circulation at the local part of the body so as to favor the absorption of edema; 2) raising the pain threshold of the local tissues with the help of the actions of proper stimuli; and 3) relaxing the muscles in tension and spasm. Furthermore, medical tests have revealed that massage can enhance the release of enkephalins in the body. One test indicated that massage lasting for 15 to 20 minutes can increase the release of enkephalins by 7%.

Hyatt: How could this be applied to treating older patients?

Dr. Li: To answer this question, it is necessary to point out the characteristics of older persons' diseases. Older people are vulnerable to diseases, as aging weakens the constitution and lowers the body's resistance, particularly in those elderly with impaired functioning.

Replenishing Qi, preserving the essence, and cultivating the vitality are considered to be major methods of resisting aging and preserving health. Care must be taken to preserve vital Qi by such practices as doing more physical exercises, resorting to proper diet and enlivening daily life and mental activities. These are especially important issues as we age.

Hyatt: How is TCM cost-effective?

Dr. Li: TCM diagnosis usually involves a simple examination. Its treatment is less costly than conventional Western medicine. TCM treats patients differently because every patient has his/her own constitution, physical nature, surrounding environment and lifestyle. The resulting possible economies explain why many insurance companies are realizing the value of TCM.

Hyatt: Why should America use these and other methods of TCM along with Western medicine?

Dr. Li: Despite the fact that both medical traditions have their own respective, unique historical development and different approaches to healing, it is fascinating to discover the actual correspondence between the two. TCM and MWM are complementary in the sense that the strengths of one are, in some instances, the weaknesses of the other.

From this perspective, we may create a common understanding of the two medicines and learn not only alternative natural therapies to Western drugs, but also how the Chinese treat Western "incurable" diseases and energy imbalances which respond poorly to Western medications.

TCM may be able to allow for safer and probably more cost-effective therapy by preventing unnecessary surgery and intolerable side effects associated with potent drug therapy. Also, there is the possibility of treatment in situations where the prospects for Western medical diagnosis and treatment are elusive.

For example, conventional medicine is less potent and effective in dealing with many chronic problems. Generally, TCM concepts and techniques can be used as an alternative application for treating a wide spectrum of diseases, such as some symptoms of cancer and vascular diseases, as well as those of common illnesses such as infections and pain.

My thanks to Dr. Li for his enlightening words on a subject of growing importance to post-acute care of the elderly.

If you have suggestions or contributions for this column, please write to Laura Hyatt at 2956 Kelton Ave., Los Angeles, CA 90064. Please include your name, name of your organization, address and telephone number.