Use of alternative therapies is still rare, but interest continues to grow
July 1, 1999 7 minutes read
Use of alternative therapies is still rare, but interest continues to grow
Acupuncture is the most popular and a good option for some patients
The use of alternative therapies such as acupuncture and homeopathy is gaining in popularity in the United States, but few occupational health programs offer any form of these treatments because they are considered unproven and on the margin of real medicine. That would even be a generous appraisal from some mainstream occupational health professionals, but there are some who say it is time to at least consider adding such treatment options to your program.
The addition of alternative therapies to occupational medicine is just a natural offshoot of the general interest in the country, says Robert Naparstek, MD, medical director and CEO of Good Samaritan Occupa tional Health Services in Avon, MA. Naparstek is a strong advocate of employing alternative therapies, but he readily admits that he is in the minority. Very few occupational health programs employ alternative therapies at all, he says.
"There’s still an undercurrent of criticism that I have to face when I present these ideas to my colleagues, whether it’s a funny look or just a pouty posture that tells me they don’t think any of this is very scientific," he says. "Society, in general, is much more accepting, and I’ve seen some movement within occupational health to take a look at these therapies as something that might really help our patients. At least I’m no longer called weird."
Naparstek says it helps that he comes from a very traditional medical background with board certifications in internal medicine and occupational medicine and his clinic is "very typical in every other way." Colleagues might accept his interest in alternative therapies more easily when they realize that he’s a traditional occupational medicine physician, except that he often prescribes acupuncture and hypnotherapy. "Patients are sometimes surprised and sometimes relieved when I suggest acupuncture, for instance," he says. "They don’t expect it from a doctor in a white coat."
Different therapies, different values
Part of the problem of advocating alternative therapies is that the term encompasses so many different treatments. Some of them are more scientifically validated than others, which can complicate the situation. Skeptics may point to the modalities that are least proven and dismiss the entire idea. In addition to acupuncture and hypnotherapy, alternative therapies may include herbal therapy, homeopathy, biomagnetism, naturopathy, spirituality, prayer, and any number of lesser known therapies.
For occupational health, Naparstek mostly advocates acupuncture and hypnotherapy. He has used acupuncture since 1983 and says it is particularly effective for treating nonspecific low back strain — "one of the biggest and best bangs for your buck, preferably on the day of the injury." He also says acupuncture works well with carpal tunnel syndrome and other repetitive motion injuries, asthma, sinusitis, and headaches. (See p. 75 for more on the benefits of acupuncture, and p. 76 for some of the key research involving alternative therapies.) He recently has started seeing good results with using hypnotherapy to treat chronic pain and as an aid to smoking cessation and weight loss. Some of the other ways Naparstek uses alternative therapies include:
• Relaxation tapes can help patients deal with chronic pain or speed recovery after an injury.
• Herbal remedies can be useful for a number of maladies, such as St. John’s Wort for the relief of mild depression following an injury.
• High doses of vitamin C might be useful for carpal tunnel syndrome, he says. "There’s no good evidence for it yet, but it can’t hurt, and the patient should enjoy the other benefits of high vitamin C doses."
Naparstek points out that alternative therapies are only a part of his practice. Even though he advocates a wider adoption of the alternatives, he still relies on the traditional occupational health therapies. "I write prescriptions all day, inject joints, do all of those conventional things that you think of as occupational medicine," he says. "These therapies are complementary medicine. You don’t have to give up what you know is good medicine to try some alternatives that might work in different ways."
Consider alternatives, look at evidence
There is nothing wrong with considering alternative therapies in occupational medicine, but you should research the proven value of each option and avoid those that are unproven, suggests William Patterson, MD, FACOEM, MPH, chair of the medical policy board at Occupational Health and Rehabilitation in Wilmington, MA. He reports seeing many more patients recently who are either using alternative therapies like St. John’s Wort on their own or who ask about the use of alternative therapies for their occupational illness or injury.
Patients ask about acupuncture, Patterson says, and he replies that it might help. He also has had patients tell him that they had good experiences with magnet therapy, in which magnets are used to supposedly affect a person’s natural magnetic field and thus promote healing. Patterson says he doesn’t use any alternative therapies in his own practice, but he’s not opposed to considering them. "The task of the occupational health physician is to keep an appropriately open mind for beneficial new therapies while remaining grounded in the science of medicine," he says. "Given the high cost of workers’ comp injuries, it’s sometimes reasonable to try alternative treatments, especially in patients who are not recovering as you would hope."
But Patterson also points out that keeping an open mind has its limits. "It is important to monitor these treatments carefully, to not continue treatments that are not definitely helping. And you have to be appropriately skeptical of therapies which have not been shown to be beneficial by published studies."
Naparstek says he does not disagree with that outlook. Though he is interested in a number of treatments, he sticks mainly to acupuncture, chiropractic, hypnotherapy, and herbal treatments.
"I once had someone try to sell me a big deal about biomagnetism," Naparstek says. "It seems that magnetic forces should affect the human body, but I’m not yet convinced that the people selling these devices have demonstrated any true clinical effect. That’s the kind of thing I wouldn’t do because I haven’t seen any evidence that it works, even if it’s safe."
Choose providers carefully
Naparstek suggests exercising caution when choosing local providers of alternative therapies. For most of the therapies in question, Naparstek works with local providers experienced in that therapy, such as acupuncture. When looking for a local provider, he offers these tips:
• Verify the person’s credentials yourself. Do not take the provider’s word that he or she is trained in the therapy.
• Visit the provider’s office several times and watch the person work with patients. What you see should assure you that the person is a trained professional and meets the same standards you would expect in your own practice.
As you might expect, insurers and employers often balk at paying for alternative therapies. Naparstek says he is successful in obtaining payment for acupuncture and hypnotherapy in most cases, partly because he has established a relationship with them and has convinced them that alternative therapies actually are cost-effective.
Insurers sometimes take a long time to approve alternative therapies because case managers do not feel comfortable approving them and kick the decision up to a supervisor. In many cases, the insurers resist paying because they want to see that the patient has been through conventional therapies without good results. That runs counter to what Naparstek says is the best way to use acupuncture, for instance, because the best results are obtained by starting the treatment immediately. They are also less expensive than many conventional treatments, he says. Acupuncture costs about $40 per session, and Naparstek recommends no more than 14 treatments. The acupuncture is discontinued if there is no improvement after three sessions.
About 75% of his patients have a favorable response to acupuncture. Naparstek admits that some patients respond favorably to alternative therapies for psychological rather than physiolog ical reasons, but he says there is nothing wrong with that effect since many problems, such as chronic pain, have a psychological origin.
"Most people come back from their treatment enthused. Some have a spiritual experience, which I think is more a statement of their faith than anything about the treatment," he says. "It is fundamentally the doctor/patient relationship that does the healing. The worker often feels powerless, and these therapies make patients feel that someone is working to protect them. That alone often is enough to induce healing."
Patterson suggests that occupational health providers not put too much faith in being reimbursed for alternative therapies. Even if you think an alternative therapy such as acupuncture is worth a try, you may have to tell the patient that the workers’ comp system is unlikely to pay for it. Perhaps the employer will pay for it directly if you can make a good argument for its value, but it may be up to the patient to foot the bill.
"Most workers’ compensation laws cover what’s usual and customary, and it may be hard to argue that some of these therapies are usual and customary," he says. "At a minimum, I’d say that occupational health providers should educate themselves about these alternatives and know what your patients may be seeking on their own."
[For more information, contact:
Robert Naparstek, Good Samaritan Occupational Health Services, 75 Stockwell Drive, Avon, MA 02322. Telephone: (508) 427-3900.
William Patterson, Occupational Health & Rehabilitation, Wilmington, MA. Telephone: (978) 657-3826.]
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