Integrative Medicine as an Adjunct to Orthopaedic Surgery

James R. Ficke, MD; Nathan M. Moroski, MD; Steven D. Ross, MD; Ranjan Gupta, MD


J Am Acad Orthop Surg. 2018;26(2):58-65. 

In This Article

Abstract and Introduction


Patients often seek nontraditional forms of treatment, including alternative/complementary medical options, such as chiropractic care and acupuncture, to meet their personal needs. In the United States, interest has grown in methods to reduce pain and improve function through Ayurvedic medicine, which uses plant-based supplements, such as turmeric. Traditional allopathic medicine attempts to provide patients with evidence-based therapeutic regimens for their musculoskeletal conditions. Integrative medicine often is used to prevent and manage the sequelae associated with injuries and illnesses; however, competitive athletes and military personnel use complementary medicine for performance enhancement. Thus, physicians should be aware of the evolving field of integrative medicine, including the reported benefits as well as any potential drawbacks, to facilitate an educated discussion with their patients.


Integrative medicine, previously known as complementary and alternative medicine (CAM), has become increasingly popular in the United States since the early 1990s. Integrative medicine is defined by the National Center for Complementary and Integrative Health (NCCIH) as "a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine."[1] In 2012, CAM was used by approximately one third of the US population (approximately 33.2%; Table 1).[2] Here, we identify the forms of integrative medicine used most frequently by patients with musculoskeletal conditions and we address potential interactions and evaluate the supporting literature to provide the orthopaedic surgeon with a base of understanding of this growing trend in medicine that can affect treatment methods.

The most frequent users of integrative medicine are people in the 45- to 64-year-old age group (36.8% of users).[2] By ethnic group, non-Hispanic white adults are the most frequent users of integrative medicine (37.9%); the least frequent users are nonHispanic black adults (19.3%). By education level, the highest prevalence of users of some form of integrative medicine was among the most well educated, with 42.6% achieving college-level education or higher, and the lowest prevalence was among those without a high school diploma (15.6%). The use of integrative medicine by income level showed that nonpoor adults were the most frequent users compared with poor adults, who were the least frequent users (38.4% and 20.6%, respectively). In terms of insurance status, the most frequent users were those with private insurance and the least frequent users were the uninsured (38% and 22.9%, respectively).[2]

Integrative medicine use among patients with musculoskeletal conditions has been reported to be as high as 70%.[2] One study reported that 64% of patients underreported their use of integrative medicine.[3] In another study of patients visiting an outpatient osteoporosis clinic, only 44% of actual current integrative medicine use was disclosed to a medical doctor.[4] Reasons cited for not reporting integrative medicine include patients' belief that reporting its use is not important, patients' perception of prejudice by physicians, lack of direct questioning regarding integrative medicine use, and physician ignorance of herbal medications and other forms of integrative medicine.[3,4] In some instances, physicians choose not to record the use of integrative medicine even when it is reported by the patient.[3,4]

Although the general public often uses integrative medicine to prevent and treat sequelae from injury and illness, some populations, such as competitive athletes and military personnel, use integrative medicine for performance enhancement. Determining the exact extent of use among competitive athletes is difficult, but some literature indicates that athletes may have the highest prevalence of integrative medicine use.[5] Integrative medicine may be used by athletes because it is perceived as more natural and is erroneously assumed to not be considered as potential doping. The true prevalence of doping in competitive athletics is unknown; however, previous questionnaire-based research has yielded estimates between 1% and 70%.[6] Controlled tests yielded approximately 1% to 2% positive results for doping. A recent review using the Randomized Response Technique estimated that 14% to 39% of current elite athletes "intentionally used doping."[6] Among collegiate athletes, the use of integrative medicine appears to be especially high. A survey of 309 Division I intercollegiate student athletes showed that 56% of subjects used some form of CAM.[7] The use of CAM among military personnel also appears to be higher than use among the general US population.

The high prevalence of integrative medicine use in military personnel is of particular interest because this segment of society is considered to be younger and nonpoor and typically has an education level beyond high school. The largest and most comprehensive survey of integrative medicine use to date included data from >16,000 subjects and showed that approximately 36% of active-duty personnel from all military branches reported using at least one form of integrative medicine, excluding self-prayer, in the previous 12 months.[8] A large variety of integrative medicine methods have been used by active-duty personnel, including mind-body therapies, biologically based therapies, and manipulative or body-based therapy.

The definition of integrative medicine/CAM has two parts: complementary, which is the use of nonmainstream approaches together with conventional medicine, and alternative, which is the use of a nonmainstream approach in place of conventional medicine. Among the US population, it appears that most patients use the complementary form; in a survey of 1,035 persons that had a response rate of 69%, only 4.4% of patients relied primarily on alternative therapies.[9] Research has consistently shown that CAM users have more education and are more active overall than nonusers are.[9] Other predictors of CAM use include higher education, poorer health status, holistic orientation to health, having a transformational experience that changed a person's worldview, commitment to environmentalism, commitment to feminism, and an interest in spirituality and personal growth psychology. Dissatisfaction with conventional medicine was not a predictor of CAM use.[9]

Substantial controversy exists regarding integrative medicine. In 1998, Fontanarosa and Lundberg[10] stated that "there is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking." However, despite the controversy, more practitioners are using integrative medicine. In addition, more studies are closely examining the effectiveness of integrative medicine and its uses.