Complementary and alternative medicine

-By Miss Shweta Sharma
M.Sc. Nursing
II year
AIIMS,Jodhpur

Alternative therapies: It refers to a broad group
of natural and spiritual healing methods that are
different than the conventional western medicine
(or pharmaceutical medicine). Many of these
healing methods have been used for centuries in
many different cultures.
They are used instead of conventional or
mainstream medical modalities. Complementary
therapies are used in conjunction with
conventional or mainstream medical modalities.

Complementary therapy Alternative therapy
 Used together with conventional medicine.  Used in place of conventional medicine.
 An example of a complementary therapy is
using meditation to help lessen a patient's
discomfort following surgery.
 An example of an alternative therapy is using
a special diet to treat cancer instead of
undergoing surgery, radiation, or
chemotherapy that has been recommended by
a conventional doctor.

The field is very broad and constantly
changing. The National Centre for
Complementary and Alternative Medicine
(NCCAM) defines CAM as a group of diverse
medical and health care systems, practices,
and products that are not generally considered
part of conventional medicine.

Classifications according to NCCAM, complementary and alternative medicine therapy (CAM)
Whole medical systems Mind-body interventions Biologically based therapies Manipulative and body-
based methods
Energy therapies
Homeopathic, naturopathic,
traditional, Chinese,
ayurvedic, acupuncture
Meditation, relaxation,
imagery, biofeedback,
hypnosis
Dietary supplements, herbs,
foods, vitamins, natural
substances
Chiropractic, osteopathy,
massage
Biofield therapy,
Bioelectromagnetic therapy

It includes the following:
•Ayurveda
•Traditional Chinese Medicine (TCM): Acupuncture
and acupressure
•Unani
•Siddha
•Homeopathy
•Naturopathy

 It is a system of traditional medicine native to India and
practiced in other parts of the world as a form of alternative
medicine.
 The word ayurveda consists of the words ‘ayus’, meaning
‘longevity’, and 'veda', meaning 'related to knowledge' or
‘science’.
 Its focus is on the balance of mind, body and spirit.
 Disease is viewed as an imbalance between a person's life
force (prana) and basic metabolic condition (dosha). The
earliest literature on Indian Medical Practice appeared
during the Vedic period in India. The Suśruta Samhita and
the Charaka Samhita were influential works on traditional
medicine during this era.

 Ayurveda stresses the use of plant-based medicines
and treatments. Hundreds of plant-based medicines are
employed, including cardamom and cinnamon.
 Some animal products may also be used, for example,
milk, bones, and gallstones. In addition, fats are used
both for consumption and for external use. Minerals,
including sulfur, arsenic, lead, copper sulfate and gold
are also consumed as prescribed. This practice of
adding minerals to herbal medicine is known as rasa
shastra.

Unani Medicine is based on the Greece
philosophy. According to Basic Principles of
Unani, the body is made up of the four basic
elements, i.e. Earth, Air, Water, Fire which
have different Temperaments, i.e. Cold, Hot,
Wet, Dry.

 Treatment dependent on the Temperament (Mizaj),
hereditary effects, signs and symptoms, external observation,
examination of the pulse (Nubz), urine and stool.
 Dietotherapy (Ilaj-bil-Ghiza), Climatic therapy (Ilaj-bil-Hawa),
Regimental therapy (Ilaj-bit-Tadbir; includes diaphoresis,
diuresis, massage, cauterization, emesis, exercise).
 Pharmacotherapy (Ilaj-bid-Dawa): Local herbal drugs. Only
minor surgery is in vogue in this system.

It is one of the most comprehensive medical systems.
Practitioners of TCM view human beings in terms of
five dimensions. These include
•Qi [ energy resulting from interaction between Yin
(cold, heavy, moist and negative) and Yang (hot, dry,
light and positive)]
•Jing (genetic material of physical body)
•Shen (spirit)
•Blood
•Yin Ye fluids (lubricates the organs)

The body is considered to be a
series of energetic pathways known
as Meridian system. Specific points
along the pathways referred to as
acupoints.

Complementary and alternative medicine

It is an alternative medicine that treats patients by
insertion and manipulation of needles in the body. Its
proponents variously claim that it relieves pain, treats
infertility, treats disease, prevents disease, promotes
general health, or can be used for therapeutic
purposes.

 There are numerous theories about how acupuncture works:
It stimulates the release of pain-relieving endorphins.
It influences the release of neurotransmitters.
It influences the autonomic nervous system.
It stimulates circulation.
It influences the electrical currents of the body.

 Conditions that are benefitted from Acupuncture:
Neurologic disorders: Migraine headaches, peripheral
neuropathy and trigeminal neuralgia
Gastrointestinal disorders: Colitis, constipation, gastritis,
ulcers
Respiratory conditions: Asthma, bronchitis, rhinitis
Eye disorders: Myopia, conjunctivitis
Musculoskeletal disorders: Tennis elbow, sciatica

It is an ancient healing art that uses the fingers to
press key points on the surface of the skin to stimulate
the body's natural self-curative abilities. When these
points are pressed, they release muscular tension and
promote the circulation of blood and the body's life
force to aid healing. Acupuncture and acupressure
use the same points, but acupuncture employs
needles, while acupressure uses the gentle but firm
pressure of hands (and even feet).

Homeopathy is a form of alternative medicine in
which practitioners treat patients using highly diluted
preparations that are believed to cause healthy
people to exhibit symptoms that are similar to those
exhibited by the patient.
The basic principle of homeopathy, known as the
"law of similars", is "let like be cured by like".

Homeopathic remedies are prepared by serial
dilution with shaking by forceful striking on an
elastic body, which homeopaths term succussion.
Each dilution followed by succussion is assumed to
increase the effectiveness. Homeopaths call this
process potentization.
Dilution often continues until none of the original
substances remains. Apart from the symptoms,
homeopaths examine aspects of the patient's
physical and psychological state, then homeopathic
reference books known as repertories are
consulted, and a remedy is selected based on the
totality of symptoms.

 Siddha medicine is a form of medical treatment of diseases using
substances of all possible origins in a way that balances the possible
harmful effect of each substance. This form of medicine was
professed and practiced by siddhars who wrote their recipes on
palm-leaves for the use of future generations.
 Siddha medicine was developed by outstanding Dravidians (ancient
Tamils), locally called Cittars. Preparations are made mainly out of
the parts of the plants and trees such as leaves, bark, stem, root,
etc., but include also mineral and some animal substances.

This form of medicine is still today well-known in
South India. The use of metals like gold, silver
and iron powders (Sanskrit bhasma) in some
preparations is a special feature of siddha
medicine, which claims it can detoxify metals to
enable them to be used for stubborn diseases.
This claim is especially relevant in the case of
mercury which is relatively often used in the
system; medicine containing purified mercury
should only be received, if at all, from a highly
qualified practitioner of the art.

 Naturopathy is a system of man building in harmony with the
constructive principles of Nature on physical, mental, moral
and spiritual planes of living.
 According to the manifesto of British Naturopathic
Association, "Naturopathy is a system of treatment which
recognises the existence of the vital curative force within the
body." It therefore, advocates aiding human system to
remove the cause of disease, i.e. toxins by expelling the
unwanted and unused matters from human body for curing
diseases.

 Mind-body medicine uses the power of thoughts and
emotions to influence physical health.
 As Hippocrates once wrote, "The natural healing force within
each one of us is the greatest force in getting well." This is
mind- body medicine in a nutshell. Methods by which an
individual can, independently or with assistance, consciously
control some functions of the sympathetic nervous system
(e.g. heart rate, respiratory rate, blood pressure).

Leading mind-body techniques are:
Meditation
Relaxation
Biofeedback
Imagery
Hypnosis
Aromatherapy
Yoga

 It often involves invoking or cultivating a feeling or internal state,
such as compassion, or attending to a specific focal point.
Meditation is generally an internal, personal practice and done
without any external involvement, except perhaps prayer beads to
count prayers, though many practitioners of meditation may rely on
external objects such as candle flames as points on which to focus
their attention as an aid to the process. It is quieting of the mind by
focusing attention on sound or image or own breathing.

Health Benefits of Meditation Include:
 Decreased respiration
 Slowed heart rate
 Decreased blood pressure
 Improved mood
 Heightened awareness
 Efficient and effective oxygen consumption
 Spiritual calm
 Stress relief
 Relaxation
 Reduced level of lactic acid
 Improved functioning of the immune system

Stands quite generally for a release of tension, a
return to equilibrium. It is any method, process,
procedure, or activity that helps a person to relax;
to attain a state of increased calmness; or otherwise
to reduce levels of anxiety, stress or anger.
Relaxation techniques are often employed as one
element of a wider stress management program and
can decrease muscle tension, lower the blood
pressure and slow heart and breath rates, among
other health benefits.
It is a therapeutic process incorporating the basic
elements of meditation.

Basic elements of relaxation
technique are:
A quiet environment
A comfortable position
Focused attention
It involves progressive muscle
relaxation. Progressive relaxation
is the alternate tensing and
relaxing of muscles. Nurses can
use relaxation techniques to
reduce pain and stress in clients.

A technique of using the imagination to
visualize a soothing, pleasant image. Benefits
of this technique include: decreased physical
tension, decreased anxiety, and decreasing
the adverse effects of chemotherapy.

 In this, people are trained to control certain bodily processes
that normally occur involuntarily, such as heart rate or blood
pressure. These processes can be measured and displayed
on a monitor that the person watches.

It measures physiological responses such as
muscle tension, skin temperature, and heart rate to
improve health by using signals from client's own
body. It is effective for a number of conditions,
including headaches, urinary incontinence,
hypertension, chronic pain, etc.
Uses of biofeedback:
A restorative method in rehabilitation settings for
clients who have lost sensation and function as a
result of injury or illness
To relieve tension headaches, migraines and
backache
To lower blood pressure.

 The earliest definition of hypnosis was given by Braid, who coined
the term "hypnotism" as an abbreviation for "neuro- hypnotism", or
nervous sleep, which he opposed to normal sleep, and defined
as: "a peculiar condition of the nervous system, induced by a fixed
and abstracted attention of the mental and visual eye, on one
object, not of an exciting nature.
 Therapeutic hypnosis: It induces an altered state of
consciousness or awareness resembling sleep during which the
person is more receptive to suggestion. Hypnosis also enhances
client's ability to form images (for guided imagery).

Uses of hypnosis:
Pain management
IBS
Weight loss
Soothing anxious surgical
patients
Sports performance
Anaesthesia
Skin disease
Habit control
Quit smoking

 Sanskrit root "yuj" meaning "to control, to unite, joining,
conjunction and means." Outside India, yoga is typically
associated with asanas (postures) or as a form of exercise.
Goals- Improving health to achieving moksha; liberation from
all worldly suffering and the cycle of birth and death
(samsara), at which point there is a realization of identity with
the supreme Brahman. In Mahabharata, yoga is described as
entering the world of brahma, as brahman.

 Uses volatile plant materials (essential oils) and similar aromatic
compounds for the purpose of improving a person's mood, cognitive
function or health
 Generic term; used by manufacturers (of personal care and hygiene
products), massage therapists, chiropractors, nurses and doctors
 OTC products that make use of essential oils (menthol) include
mouthwashes, liniments and rubbing ointments (Vicks Vaporub)
 Essential oils useful in the treatment of infectious disease
 Used as medicines, with other herbal preparations, by doctors in France
(commonly)
 Used in pain management, anxiety/depression, and Alzheimer's disease.

Most common among the biologically-based therapies are:
 Dietary supplements
 Foods
 Herbs
 Vitamins
 Natural substances

Diet Therapy
According to this therapy, the food must be taken in
natural form. Fresh seasonal fruits, fresh green leafy
vegetables and sprouts are excellent. These diets are
broadly classified into three types which are as follows:
Eliminative Diet: Liquids-Lemon, Citric juices, Tender
coconut water, Vegetable soups, Butter-milk, Wheat
grass juices, etc.
Soothing Diet: Fruits, Salads, Boiled/Steamed
vegetables, Sprouts, Vegetable chutney, etc.
Constructive Diet: Wholesome flour, Unpolished rice,
Little pulses, Sprouts, Curd, etc.

 Macrobiotic diet: Predominantly a vegan diet (no animal
products except fish). Initially used in the management of
a variety of cancers. Emphasis placed on whole cereal
grains, vegetables and unprocessed foods.
 Orthomolecular medicines: Increased intake of
nutrients such as Vitamin C and beta carotene. Diet used
in treatment of cancer, schizophrenia and certain chronic
diseases such as hypercholesterolemia and coronary
artery disease.

Ayurvedic Herbs
The herbal products are used in the form of powder, tonic,
etc. These could be a single herb or a mixture of many
herbal products, depending on the diseases and the
treatment required. Some common herbal remedies
include the following:
 Garlic
 Peppermint
 Chamomile
Phytochemicals: These are non-nutritive, physiologically
active compounds present in plants in very small amounts.
They protect against cancer and prevent heart disease,
stroke, and cataracts. Main source for phytochemicals
is fruits and vegetables. Consumption of a wide variety
of fruits and vegetables provides best supply.

Antioxidants and Free Radicals
 Antioxidants: Substances that prevent or inhibit oxidation, a
chemical process whereby a substance is joined to oxygen.
 Free radicals: Antioxidants prevent tissue damage related
to these, which are unstable molecules that alter genetic
codes and trigger the development of cancer growth.

These methods use techniques of manipulating or
moving various body parts to achieve therapeutic
outcomes.
It includes:
Chiropractice
Osteopathy
Massage
Tai chi

 Chiropractice: It emphasizes diagnosis, treatment and
prevention of mechanical disorders of the musculoskeletal
system, especially the spine. The main chiropractic treatment
technique involves manual therapy, including manipulation of
the spine, other joints, and soft tissues; treatment also
includes exercises and health and lifestyle counseling. It is
based on the principle that the brain sends vital energy to
every organ in the body via the nerves originating in the
spinal column. The body is rebalanced and realigned using
"spinal adjustment" techniques.

Massage: It is use of the hands to direct or redirect
the flow of the body's energy fields and enhance
balance within those fields. It includes touch,
therapeutic touch or healing touch, acupressure, and
reflexology. The means of perceiving or experiencing
through tactile sensation.

Therapeutic Touch
 Based on the ancient practice of the laying on of
hands and using the hands to direct energy to
achieve a balanced state
 Non-contact Therapeutic Touch (NCTT), “Healing
Touch," or Distance Healing
 It is an energy therapy, practitioners say, promotes
healing and reduces pain and anxiety. Practitioners of
therapeutic touch state that by placing their hands on,
or near, a patient, they are able to detect and
manipulate the patient's energy field.

Touch in Nursing Practice
An integral part of assessment
Promotes bonding
An important means of communication
Assists in soothing, calming, and comforting
Helps keep the client oriented

Cultural Considerations of Touch
Ask permission before touching a client.
Tell the client what is going to happen.
The meaning of touch and the body areas
acceptable to touch vary from culture to
culture.

Reflexology
Art and science of enervating over 7,000 nerves in
the feet believed to correspond to every muscle
system and organ in the body.
Promotes health by relieving pressures and
accumulation of toxins in the corresponding body
part.
Reflexology, or zone therapy is an alternative
medicine involving the physical act of applying
pressure to the feet, hands, or ears with specific
thumb, finger, and hand techniques without the use
of oil or lotion.

These are alternative therapies that involve the
use of purported energy fields. There are two
main types-
Biofield therapy
Bioelectromagnetic therapy

They are intended to affect energy fields that
purportedly surround and penetrate the human body.
Some forms of energy therapy manipulate biofields
by applying pressure and/or manipulating the body
by placing the hands in, or through, these fields.
Examples include Qigong, Reiki, and Therapeutic
touch.
Reiki is a spiritual practice developed in 1922 by
Japanese Buddhist Mikao Usui. It uses a technique
commonly called palm healing as a form of
complementary and alternative medicine and is,
sometimes, classified as oriental medicine by some
professional bodies.

Steps of palm healing:
Recipients lay down on a massage table and
relax with loose, comfortable clothing.
Practitioner enters a calm state of mind and
mentally prepared for the treatment without
talking.
Practitioner placing his hands on the
recipient in various positions.
Hands kept still for 3 to 5 minutes before
moving to the next position.

General coverage of the head, the front and
back of the torso, the knees, and feet.
12-20 positions are used, with the whole
treatment lasting 45 to 90 minutes.
Some use a fixed set of hand positions, while
others use their intuition to guide them as to
where treatment is needed, sometimes
starting the treatment with a "scan".
Recipient often feels warmth or tingling, even
when a non-touching approach is used.
Instantaneous "cures" of specific health
problems are not usually observed.

Electromagnet therapy
It is a pseudoscientific alternative medicine practice
involving the use of static magnetic fields.
Practitioners claim that subjecting certain parts of
the body to magnetostatic fields produced by
permanent magnets has beneficial health effects.
Although hemoglobin, the blood protein that carries
oxygen, is weakly diamagnetic (when oxygenated)
or paramagnetic (when deoxygenated) the
magnets used in magnetic therapy are many orders
of magnitude too weak to have any measurable
effect on blood flow.

Products include magnetic bracelets and
jewelry; magnetic straps for wrists, ankles,
knees, and the back; shoe insoles; mattresses;
magnetic blankets (blankets with magnets
woven into the material); magnetic creams;
magnetic supplements; plasters/patches and
water that has been “magnetized”. Application is
usually performed by the patient.

Accelerated healing
Greater cellular energy (increased ATP)
Vasodilatation
Reduced inflammation and edema
Muscle relaxation
Cell membrane changes
Enhanced movement of calcium, sodium and
other ions
Bone formation

Improved oxygenation
Better sleep
Lysis of clots
Reduction in platelet adhesion
Increased fertility
Enhanced cognitive ability
 Improved central and peripheral nerve function
Reduced stress and better mood

Osteoporosis and Arthritis
Bioelectromagnetic Therapy has proven effective in
healing non-union fractures and stimulates the
formation of new bone with documented benefits
in osteoporosis and arthritis. With correct treatment,
significant increases of bone density have been
documented in remarkably short periods of time.
Osteoporosis patients frequently suffer from
"compression" fractures due to fragile bones.
Bioelectromagnetics has been reported to alleviate
pain, heal existing fractures and prevent future
breaks as normal bone density is restored.

Humor: It determines the client's perception of what
is humorous. It can relieve anxiety, improve
respiratory function, promote relaxation, enhance
immunological function, and decrease pain by
stimulating endorphin production.

Pet therapy: It has many
applications including
overcoming physical
limitations, improving
mood, lowering blood
pressure, and improving
socialization skills and
self-esteem.
Music therapy:
Pleasurable sound and
music can reduce stress,
perception of pain,
anxiety, and feelings of
isolation.

Hydrotherapy: It involves the use of water for pain-
relief and treating illness. It continues to be widely
used for burn treatment, although shower-based
hydrotherapy techniques have been increasingly
used in preference to full immersion methods, partly
for the ease of cleaning the equipment and reducing
infections due to contamination.

 These modalities give nurses additional tools to meet
client needs. For the theory of human care, the very
basis of nursing is interaction and connection between
two human beings. The modality of healing presence is a
significant, important technique to provide trust, support
and to initiate the caring encounter necessary for nursing
to take place.

Some of the modalities are compatible with the
principles and concepts of specific nursing
theories. In other cases, the theories themselves
provide a mandate for a specific kind of nursing
intervention. Nursing theory provides the concepts
to reflect on nursing care and on the use of
alternative/complementary modalities. Roy states
that the “nurse acts as a regulatory force to
modify stimuli affecting adaptation”.
Music therapy and aromatherapy are specific
modalities that change the environment in which
the client finds him/herself and are expressly
designed to change the context of care.

Selected nursing diagnoses and nursing interventions: Possible pairings of nursing concerns and
complementary/alternative interventions
Nursing diagnosis Nursing intervention Rationale
Impaired comfort Acupressure To decrease perceived pain
Disturbed sleep pattern Massage To promote relaxation/rest
Anxiety or fear Guided imagery, relaxation
therapy, biofeedback techniques
To reduce sense of anxiety

 Not subjected to testing. Attempts to disprove this fact
sometimes use the appeal, i.e. "That which is natural cannot be
harmful".
 Since 1938, the FDA regulated homeopathic products.
Homeopathic remedies are extremely dilute, thus considered
safe, but their products are exempt from goods manufacturing
practice requirements (expiry date and identity and strength of
products and their alcohol concentration).
 Treatment delay.
 Danger increased when used as a complement to standard
medical care: A Norwegian study examined the association
between the use of alternative medicine and cancer survival.
515 patients using standard medical care for cancer were
followed for 8 years. 22% of those patients used
complementary care. The study revealed that death rates were
30% higher in alternative medicine users than in those who did
not use alternative medicine (AM).

1.Complementary and alternative medicine in chronic neurological
pain
A study was done to evaluate the current recommendations for CAM
therapies in key neurological disorders by Shri Kant Mishra,
Bhavesh Trikamji, Elizabeth Togneri in 2015. Sources like PubMed,
Embase, UCLA libraries, USC libraries, and National Center for
Complementary and Alternative Medicine (NCCAM) books were searched
to gather data for this review. The current recommendations for CAM
therapies in headaches, neck pains, lower back pains, neuropathic pains,
and cancer-related pains were discussed. The CAM therapies discussed
include natural therapies, mind and body therapies, and several other
modalities. The study concluded that in spite of vast literature
available on the CAM therapies for neurological disorders; there is
little evidence for the most beneficial CAM remedies that target
common neurological disorders. Although new CAM modalities are
brought to light in addition to those that have existed for centuries,
further scientific data from evidence-based studies is needed to
accurately compare the CAM therapies amongst each other and
allopathic treatments.

2.Complementary and Alternative Medicine Use among U.S. Adults
with Common Neurological Conditions
A study was conducted by Rebecca Erwin Wells, Russell S. Phillips,
Steven C. Schachter, and Ellen P. McCarthy in 2010 to determine
patterns, reasons for, and correlates of complementary and
alternative medicine (CAM) use in United States (U.S.) adults with
common neurological conditions. The study compared CAM use
between adults with and without common neurological conditions (regular
headaches, migraines, back pain with sciatica, strokes, dementia,
seizures, or memory loss) using the National Health Interview Survey of
23,393 U.S. adults. Adults with common neurological conditions used
CAM more frequently than those without (44.1% vs. 32.6%). Nearly half
of adults with back pain, sciatica, memory loss, and migraines reported
use of CAM. Mind/body therapies were used the most; alternative
medical systems were used the least. Over 50% of adults with common
neurological conditions who used CAM had not discussed their use with
their health care provider. Significant correlates of CAM use among
adults with common neurological conditions include higher than high
school education, anxiety in the prior year, living in the west, being a
former smoker, and light alcohol use. The study concluded that CAM is
used more frequently among adults with common neurological
conditions than those without.

3.Cross-sectional survey of complementary and alternative
medicine used in Oregon and Southwest Washington to treat
multiple sclerosis: A 17-Year update
A survey was done in 2001 to see the complementary and alternative
medicine used in Oregon and Southwest Washington to treat
multiple sclerosis. In 2018, a revised survey in the same region was
administered to describe updated patterns of CAM use in pwMS and to
compare changes in use, perceived benefit, and patterns of
communication between participants and providers regarding CAM over
the past 17 years. 81% of respondents in 2018 (n = 1014) used a CAM
supplement (vitamins, minerals, herbs), 39% used mind-body therapies
(mindfulness, massage), 41% used specific diet, and 81% used exercise
to treat their multiple sclerosis. Since 2001, use of supplements,
exercise, and mind-body therapies have increased (65% to 81%, 67 to
81%, and 14% to 39%). Participants were also nine times more likely to
speak to their neurologists about CAM use (6.7% to 55.4%). In 2018,
factors associated with CAM use included female sex, progressive
disease, and longer time since multiple sclerosis diagnosis. These
findings highlight the high and increasing prevalence of CAM use
in pwMS and factors associated with CAM use, and underscore the
importance of research to investigate safety and efficacy of these
therapies.

 Complementary and alternative medicine treatments
are increasingly employed to supplement traditional
Western medicine treatments in neurology. These
include acupuncture, natural tactic medicine,
homeopathic medicine, massage, chiropractic
treatment, herbal medicine, exercise regimens, dietary
interventions, etc.

 Navdeep Kaur Brar, HC Rawat. Textbook of Advanced Nursing
Practice. Jaypee Brothers Publication. New Delhi. First edition. 2015.
Pg. no. 933-942.
 PubMed. Mishra SK, Trikamji B, Togneri E. Complementary and
alternative medicine in chronic neurological pain. Indian J Pain [serial
online] 2015 [cited 20 Aug 2020];29:73-81. Available from:
http://www.indianjpain.org/text.asp?2015/29/2/73/153594
 PubMed. Complementary and Alternative Medicine Use among U.S.
Adults with Common Neurological Conditions. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3050588/ [cited 20 Aug
2020]
 Oregon Health & Sciences University. “Cross-sectional survey of
complementary and alternative medicine used in Oregon and
Southwest Washington to treat multiple sclerosis: A 17-Year update”.
by Elizabeth Silbermann et al. Multiple Sclerosis and Related isorders
doi:10.1016/j.msard.2020.102041[cited 20 Aug 2020]

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