Rheumatoid Arthritis and Complementary and Alternative Medicine
Rheumatoid arthritis (RA) is a chronic disease that affects the joints, often those in a persons wrists, fingers, and feet. (Terms that are underlined are defined in the dictionary at the end of this report.) The common symptoms of RA are pain, stiffness, fatigue, sleep disturbances, and fever. There are treatments for RA in conventional medicine, but some people also try complementary and alternative medicine (CAM).* This report answers some frequently asked questions on this topic and suggests sources for more information. Key Points It is very important for people with RA to ensure that (1) their RA was diagnosed by a professional with substantial conventional medical training and (2) their condition is being followed by a rheumatologist (a physician who specializes in rheumatic diseases like RA). This is important to minimize damage to the joints and bones, as well as disability. There are many proven conventional treatments for RA. It is important not to replace them with a CAM treatment that is unproven. Many CAM therapies for arthritis are heavily advertised and make attractive claims, often based on personal stories (testimonials). However, it is important to find out whether any high-quality scientific research has been done on a CAM therapy. None of the CAM therapies discussed in this report have been proven to be of benefit for RA. Somesuch as thunder god vine (which is not currently available in a safe American-made product), gamma-linolenic acid, fish oil, and mind-body therapieshave shown some possibility of benefit for RA, but further studies are needed to answer this question for sure. This is discussed in more detail below.
CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as nurses, physical therapists, and dietitians. Some practitioners of conventional medicine are also practitioners of CAM.
It is important to tell your health care provider(s) about any CAM therapies you are using or considering for RA. This is for your safety and a comprehensive treatment plan.
What is rheumatoid arthritis? Rheumatoid arthritis (RA) is what is called an autoimmune disease. In this type of disease, a persons immune system (the system in the body responsible for fighting disease) mistakenly attacks the persons own body. In RA, the parts attacked are the linings of the joints (places in the body where two bones connect). The reasons that this happens are complex and not fully understood. RA causes pain, swelling, and stiffness in a persons joints and problems with functioning. However, RA affects different people in different ways, in terms of the symptoms they have, how serious the symptoms are, and how long the symptoms last. RA is different from other types of arthritis (such as osteoarthritis). For example: RA usually occurs in a symmetrical pattern; for example, if one hand is affected, usually the other will be, too. RA often affects the wrists and fingers, though it can affect other parts of the body. RA is an autoimmune disease affecting the entire body. A person with RA may feel tired and weak, have fevers at times, lose appetite, lose weight, and generally not feel well.

It is beyond the scope of this report to discuss the scientific evidence about all CAM therapies used for RA. The therapies listed below were selected because they are among those most frequently discussed in the scientific literature and inquired about at the NCCAM Clearinghouse. In reading about them, you will also see some general points to consider about similar therapies (for example, other botanicals). You can seek science-based information on any CAM therapy that interests you through some of the resources listed in For More Information.
Information on these or any other CAM therapies can be obtained from the NCCAM Clearinghouse (see For More Information). References for the discussions on therapies are listed at the end of this report. They consist of recent peer-reviewed literature in English in the National Library of Medicines PubMed database; two evidence-based databases on natural products; and other Federal Government publications. NCCAM -3
Therapies Discussed in This Report:
Discussion Starts on Page: 14 14
Botanical supplements and other dietary supplements Thunder god vine Gamma-linolenic acid (GLA) Fish oil Valerian Ginger Curcumin Boswellia Feverfew Glucosamine and chondroitin Special diets Acupuncture Magnets Hydrotherapy Homeopathy Selected mind-body techniques
About Dietary Supplements Dietary supplements were defined in a law passed by Congress in 1994. A dietary supplement must meet all of the following conditions: It is a product (other than tobacco) intended to supplement the diet, which contains one or more of the following: vitamins; minerals; herbs or other botanicals; amino acids; or any combination of the above ingredients. It is intended to be taken in tablet, capsule, powder, softgel, gelcap, or liquid form. It is not represented for use as a conventional food or as a sole item of a meal or the diet. It is labeled as being a dietary supplement.
Other important information about dietary supplements: They are regulated as foods, not drugs, so there could be quality issues in the manufacturing process. Supplements can interact with prescribed or over-the-counter medicines, and other supplements. Natural does not necessarily mean safe or effective. Consult your health care provider before starting a supplement, especially if you are pregnant or nursing, or considering giving a supplement to a child.

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What are some important points to keep in mind if I have RA and am thinking about using CAM? It is important to make sure you have been diagnosed with RA by a health care provider who has substantial conventional medical training and experience with arthritis patients. RA can be hard to diagnose, there is no single test for it, and its symptoms can be similar to those of other conditions. Proven conventional treatments for RA should not be replaced with a CAM treatment that is unproven. This is especially important in the early stages of RA, when researchers believe the most damage to joints and bones occurs. Tell your health care provider(s) about any supplements or medications (prescription or overthe-counter) that you are using or considering. Prescribed medicines may need to be adjusted if you are also using a CAM therapy. Supplements can interact with medications (whether prescription or over-the-counter) and can affect how the body responds to them. Pharmacists can also be a helpful source of information about dietary supplements (though their advice is not a substitute for that of your provider). If you decide to use supplements, what you see on the label may not reflect what is in the bottle. For example, some botanical supplements have been found to be contaminated with heavy metals or prescription drugs, and some have been found to have much more or much less of the featured ingredient than their label states. NCCAM has publications on these topics (see For More Information). The claims for many CAM therapies can be attractive, ranging from enhancing well-being, to helping with difficult chronic conditions, to achieving unbelievable results. It is important to know whether scientific research has proven that a therapy works and, if so, why. Women who are pregnant or nursing, or people who are thinking of using CAM to treat a child, should use extra caution and be sure to consult their health care provider.

What is known from the scientific research about whether these CAM treatments for RA are effective and safe? 1. Botanical Supplements and Other Dietary Supplements Overall, there is not much rigorous research available on the effectiveness and safety of botanical and other supplements that people try for RA. It is also important to know that while supplements are regulated by the U.S. Food and Drug Administration (FDA) as a category of foods, supplements made from plants and used for medicinal purposes (sometimes referred to as herbal medicines) can have effects as powerful as those of drugs. In fact, many conventional drugs first came from plants, such as digitalis (from the foxglove plant), used to treat heart failure and heart rhythm, and paclitaxel (from the yew tree), a cancer chemotherapy drug.

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It is important to be as informed as possible about the safety of any supplement you are considering or using. Some information already exists from a long history of botanical use outside conventional medicine. This knowledge is being strengthened as NCCAM supports rigorous studies on botanicals and other supplements that have shown promise in early studies to find out more about their molecular structure, their safety, how they may work, and for what diseases or conditions.

Thunder God Vine

Thunder god vine (TGV for short; botanical name Tripterygium wilfordii Hook F) is a perennial vine native to China, Japan, and Korea. Preparations made from the skinned root of TGV have been used in traditional Chinese medicine to treat inflammatory and autoimmune diseases. Interestingly, TGV also has a history of use to kill insects in farm fields.

Effectiveness and safety

Some anti-inflammatory and immune-system-suppressing activity for TGV has been seen in laboratory and animal studies. The first clinical trial on TGV in the United States (the earlier ones were done in China) was carried out at the University of Texas Southwestern Medical Center and the National Institutes of Health (NIH). Its results were published in 2002. Twenty-one patients for whom conventional RA treatment had not worked completed the trial. Eighty percent of those who received a high-dose TGV extract and 40 percent of those who received a low-dose TGV extract experienced improvement in RA symptoms and physical functioning. No one in the placebo group improved. Longer and larger studies are needed to confirm these findings and to find out more about TGV. Parts of the TGV plant are dangerous. The leaves, the flowers, the main stem, and the skin covering the root are poisonous, to a point that they could cause death. People should never try to make TGV medications themselves. Currently, there are no consistent, high-quality TGV products being manufactured in the United States. Preparations of TGV made outside the United States (for example, in China) can sometimes be obtained, but it is not possible to verify whether they are safe and effective. An expert from the University of Texas/NIH study advises that consumers not use TGV until reliable TGV preparations become available. If taken for a long time (according to one study, for more than 5 years), TGV may decrease the density of the minerals in womens bones, which would be of special concern for women who have osteoporosis or are at risk for it. If taken at high doses, TGV could suppress the immune system and increase the effects of immune-suppressing drugs. The TGV extract made for the NIH study discussed above was well tolerated by study participants. However, side effects can occur and may include stomach upset, diarrhea, skin rash, changes in menstrual periods, and hair loss.

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Certain species of fish can contain high levels of contaminants, such as mercury, from the environment. Thus, their oils could pose a health risk, especially for pregnant or nursing women and for children. The fish that the Federal Government has found to have the highest levels of mercury are shark, swordfish, king mackerel, and tilefish. People who decide to use fish oil should look for products made from fish with lower mercury levels. Government information on this topic is available.# You may have to contact the manufacturer to find out the type(s) of fish used in a product. Also, it is desirable to find out whether the manufacturer tests the product for contaminating substances and if the results of those tests are available. Another point to note about safety is that a product called fish liver oil can contain more vitamin A than the recommended daily dosage, which could cause problems. Generally, for low doses of fish oil supplements, the side effects are mild and can include a fishy aftertaste, belching, stomach disturbances, and nausea.

Valerian

The herb valerian has a history of use for sleep problems and anxiety disorders. Disrupted sleep has been called a common and often neglected symptom of arthritis. A large, nationally representative survey of people over 65 with arthritis in 2000 found that disruption of sleep, among all the disruptions of arthritis, was the main reason that people sought a variety of CAM, self-care, and conventional medical treatments. Valerian has also been taken for other reasons, such as the intent to relieve muscle and joint pain. The species of valerian most used in American supplements is Valeriana officinalis.
The evidence suggests that valerian has at least mild benefits for sleep problems in the general population, including insomnia. It has been theorized that valerian may have benefit for people with sleep problems from RA. However, research on valerian for RA specifically has not been done to answer this question. There is not much evidence on how long it is safe to take valerian and which dose to use. There is not enough reliable evidence to declare whether valerian is effective for muscle and joint pain, including pain from RA. There may be some biological basis for the theory that valerian could be beneficial for musculoskeletal pain. Valerian is considered generally safe. However, it should not be taken with sedative drugs (for example, alcohol, benzodiazepines, or narcotics) or other sedative herbs (such as melatonin, SAMe, or St. Johns wort). Valerian will increase sedative effects. People who are taking

Two Federal publications are Mercury Levels in Commercial Fish and Shellfish, available on the Web at www.cfsan.fda.gov/~frf/sea-mehg.html, and What You Need to Know About Mercury in Fish and Shellfish: Advice For Women Who Might Become Pregnant, Women Who Are Pregnant, Nursing Mothers, and Young Children, at www.cfsan.fda.gov/~dms/admehg3.html. They are copublished by the U.S. Department of Health and Human Services and the U.S. Environmental Protection Agency. NCCAM -8
antifungal drugs, statins, or certain anti-arrythmia drugs should not take valerian. Valerian may not be safe for people who have a liver disorder or are at risk for one. After taking valerian, caution should be used in driving or using dangerous machinery. Side effects of valerian can include drowsiness in the morning, headache, stomach problems, excitability or anxiety, and sleeplessness.

Four Other Botanicals

Three of the other botanicals marketed with claims to benefit arthritis pain are: Ginger Curcumin (a component of the spice turmeric) Boswellia (also called Indian frankincense, made from the resin of a tree that grows in India)
These three botanicals have a history of use in Ayurveda to treat inflammatory conditions. Based on some early findings that may indicate promise, NCCAM is supporting studies at the University of Arizona on these three botanicals, to increase scientific knowledge about them and determine whether they are helpful for chronic inflammatory conditions such as arthritis and asthma. A fourth botanical, feverfew, has been used in folk medicine with an intent to treat arthritis, migraine, and other conditions. One small published clinical trial was located for this report. It found no more benefit from feverfew than from the placebo. Overall, feverfew has not been proven to help RA symptoms.

Safety

Gingers possible side effects include stomach upset, diarrhea, and irritation to the mouth and throat. Ginger is not recommended for people who have a bleeding disorder, a heart condition, or diabetes. Ginger may further slow blood clotting when combined with other herbs and drugs that slow blood clotting; add to the blood-pressure-lowering effects of drugs for high blood pressure and heart disease; and add to the blood-sugar-lowering effects of diabetes drugs. Curcumin can have side effects of stomach problems, including nausea and diarrhea. Curcumin could add to the effects of other herbs and drugs that slow blood clotting. Curcumin can cause gallbladder contractions and should not be used by people with gallbladder disease or gallstones. Boswellia can have side effects of stomach pain, stomach upset, nausea, and diarrhea. It is not known whether boswellia interacts with any drugs, supplements, or diseases and conditions. Feverfew appears to be safe for short-term use, but the safety of long-term use is not known. Feverfew can cause an allergic reaction, especially in people who are allergic to the daisy family. Side effects can include diarrhea and other stomach upsets. Chewing fresh leaves of feverfew may cause mouth irritation and sores. Feverfew might interact with medications broken down by the liver and increase the actions of drugs that slow blood clotting. Pregnant women should not take feverfew.

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Glucosamine and Chondroitin
Glucosamine sulfate (glucosamine for short) and chondroitin sulfate (chondroitin) are popular dietary supplements for arthritis. They are sold separately, in combination with each other, and in other combinations. Glucosamine is a substance found in the fluid around the joints. It can also be obtained from the shells of shrimp, lobster, and crabs, or made in the laboratory. The body uses glucosamine to make and repair cartilage, a firm but flexible tissue that covers the ends of bones, keeps them from rubbing against each other, and absorbs the force of impact. Chondroitin is a substance found in the cartilage around joints. As a supplement, it is obtained from sources such as sharks and cattle.
Both glucosamine and chondroitin have shown anti-inflammatory effects in animal studies. In humans, they have been studied only for osteoarthritis so far, not for RA. Osteoarthritis is a different form of arthritis than RA, with different causes, although the symptoms are similar (such as joint pain and problems with function). One cannot assume that if a treatment is helpful for one type of arthritis, it will also be helpful for another type. The studies of glucosamine and chondroitin for osteoarthritis mostly found a modest benefit. However, some design flaws have been noted in those studies. In sum, there is no evidence that glucosamine and chondroitin are helpful for RA. Glucosamine appears to be safe for most people. However, it might worsen asthma through an allergic reaction. Also, glucosamine might cause higher blood sugar and insulin levels in people with diabetes, and those who decide to use it need to carefully monitor their blood sugar. Glucosamine could possibly decrease the effectiveness of certain medicationsacetaminophen, some anticancer drugs, and antidiabetes drugs. Generally, side effects of glucosamine can include mild stomach problems and nausea; less commonly, there can be sleepiness, a skin reaction, or a headache. Some people who are allergic to shellfish are concerned about an allergic reaction to glucosamine. However, most shellfish allergies are to proteins in the meat, not to the shell material from which glucosamine supplements are made. Chondroitin appears to be safe for most people. However, chondroitin may possibly worsen asthma (through an allergic response), blood clotting disorders, and prostate cancer. The side effects of chondroitin can include stomach pain and nausea; less commonly, diarrhea, constipation, swelling, and problems with heart rate. Both supplements could affect the action of the drug warfarin, but this is not definite.

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2. Special Diets Many people with RA are interested in whether certain foods can affect their symptoms. Examples of foods that are believed to possibly worsen the symptoms of arthritis (including RA) are the nightshade family of plants (white potatoes, tomatoes, eggplant, and peppers), dairy, citrus fruits, acidic foods, sweets, coffee, and animal protein. There are various theories about how foods may affect RA, including: The foods one eats and how the digestive system handles them are known to affect the immune system. Because RA is a disease of the immune system, a connection between diet and the disease has been proposed. Certain fats (mostly from animal sources, but also from corn and sunflower oils) break down in the body into substances that can cause inflammation. RA and/or medications to treat it may affect the way a persons digestive system handles foods. RA can affect a persons ability to prepare and eat food, leading to nutritional problems.

Effectiveness and Safety

There is no strong, reproducible evidence that any foods or diets have a specific role in causing or treating RA. It is important for people who have RA to eat a healthy, balanced diet. If one or more foods are eliminated from the diet, it is possible to miss key nutrients and not get enough calories. It is important to discuss any major dietary changes with your health care provider or a registered dietitian. A true food allergy may exist in a small percentage of patients with RA. Many people think they have food allergies when they do not have them or when they have a different condition called food intolerance. To find out more, see the National Institute of Allergy and Infectious Diseases in For More Information.
3. Acupuncture Acupuncture is a practice that developed as a part of traditional Chinese medicine. Some people try acupuncture to treat RA pain or to treat the RA itself. For more about acupuncture, see NCCAMs fact sheet Acupuncture.
Good research studies have shown that acupuncture can help relieve pain associated with osteoarthritis. However, not much is known about its effectiveness for symptoms of RA. A handful of small studies have been conducted, and the findings do not clearly answer this

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question. Issues with the studies have included design problems, a small number of participants, variations in where acupuncture was given on the body, and how many treatments were given and for how long. More and better research is needed. Acupuncture tends to have minimal side effects, if any. Relatively few complications from acupuncture have been reported to the FDA. If a person decides to use acupuncture, it is important to find a licensed and certified practitioner, as any complications have usually occurred from inadequate practitioner training and experience.

4. Magnets Magnets are objects that produce a type of energy called magnetic fields. The term magnets is also used to refer to consumer products that contain magnets. Examples include shoe insoles, clothing, wraps for parts of the body, and mattress pads. These are of a type called static magnets, because their magnetic fields are unchanging.
Effectiveness and Safety: Static Magnets
The research so far does not firmly support claims that static magnets are effective for treating pain, including pain from RA. In those cases where some benefit was seen, it has not been proven why; many scientists think it may be due to a placebo effect. If someone does experience a benefit from a magnet, it will tend to occur quickly. Static magnets should not be used by pregnant women; people who have a conditionsuch as an acute sprain, inflammation, infection, or woundthat could be affected by dilation of the blood vessels; and people who use a device such as a pacemaker, defibrillator, or insulin pump, or who use a medication patch.
The second type of magnets used for health purposes are called electromagnets (EMs), because they produce magnetic fields only when electric current flows through them. EMs are used in conventional medicine to treat bone fractures that have not healed well, and they are being studied in research settings for a number of other conditions (including cancer, epilepsy, RA, and mental disorders). Some consumer products using EMs are available.
Effectiveness and Safety: Electromagnets
EMs are being studied because there have been some encouraging early findings indicating the possibility of benefits for pain, physical function, and stiffness. However, it is too early to know for sure whether EMs are of benefit for patients with RA. EMs should not be used by pregnant women; people who have a conditionsuch as an acute sprain, inflammation, infection, or woundthat could be affected by dilation of the blood vessels; and people who use a device such as a pacemaker, defibrillator, or insulin pump, or who use a medication patch. It may be advisable for people who have a history of cancer or seizure disorder to avoid using EMs until more is known about their effects on these medical conditions.

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For more about magnets, see the NCCAM fact sheet Questions and Answers About Using Magnets To Treat Pain. 5. Hydrotherapy Hydrotherapy is the use of water for therapeutic purposes. A few examples of hydrotherapy include bathing in heated water, as from hot springs or the sea; mineral baths; and water-jet massages. Another term used for hydrotherapy baths is balneotherapy. Hydrotherapy dates back to ancient Greece and Rome. In recent centuries, it has been a popular treatment in Europe and Israel. Some forms of hydrotherapy are used in conventional medicine in the United States, such as whirlpool baths for athletic injuries and ice for sprains. As CAM, hydrotherapy is often combined with other treatments, such as exercises, massage, diets, herbs, and/or mud packs. It is used with the intent to benefit arthritis, circulation, and various other health issues, and to enhance feelings of relaxation and well-being. Some also claim that hydrotherapy detoxifies the body. In this report, the term hydrotherapy refers to external water treatments and not to internal treatments using water, such as colon irrigation or drinking specially treated water.

Is NCCAM funding research on CAM therapies for RA? Yes. Examples of recent studies include: Fish oil, borage seed oil, or a combination of both, to determine if they affect RA symptoms Mindfulness-based stress reduction (a type of meditation), to determine if it affects RA symptoms Low-strength electromagnetic fields, to see whether they have an effect on pain, fatigue, sleep quality, mood, and inflammation in postmenopausal women with RA
Recently published NCCAM-supported research on RA has included: A 2004 review of valerian for sleep disturbances from RA A 2003 review of studies on selected CAM therapies for arthritis-related pain, including RA pain A 2002 review of studies on mind-body therapies for RA
These and many other reports on NCCAM-supported research may be located in the CAM on PubMed database (see below).
In this study, spirituality was described as something often viewed as an intrinsic quality of the individual, a desire for personal connectedness with a transcendence reality. This was different from religiousness, an outward practice of a particular spiritual understanding and/or the framework of beliefs, values, and rituals, although the authors noted that this distinction is difficult. Spirituality was measured using a scale designed to evaluate the capacity of an individual to stand outside of his/her immediate sense of time and place and to view life from a larger, more detached perspective.

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Definitions
Acupuncture: A family of procedures that originated in traditional Chinese medicine. Acupuncture is the stimulation of anatomical points on the body by a variety of methods, including the insertion and manipulation of thin steel needles or the use of pressure from the practitioners hands. It is intended to remove blockages in the flow of qi. American practice of acupuncture incorporates medical traditions from China, Japan, Korea, and other countries. Botanical: A plant or plant part that is used for its flavor, scent, and/or therapeutic properties. Examples include flowers, leaves, bark, fruits, seeds, stems, and roots; substances produced by plants; and algae. Chiropractic: A whole medical system based on the concept that the body has a powerful selfhealing ability, and its structure (primarily the spine), function, and health are closely related. The goal of therapy is to correct structural alignment problems and allow the body to heal itself. Chronic disease: A disease that lasts a long period of time or comes back frequently. Clinical trial: A research study in which a treatment or therapy is tested in people to see whether it is safe and effective. Clinical trials are a key part of the process in finding out which treatments work, which do not, and why. Clinical trial results also contribute new knowledge about diseases and medical conditions. Herb: A plant or plant part used for its scent, flavor, and/or therapeutic properties. Also called a botanical. Herbal supplements are a type of dietary supplement that contains herbs, either singly or in mixtures. Inflammation: The bodys response to injury or infection. Chemicals are released from white blood cells to increase the blood flow to the area, which results in swelling, redness, and warmth. Insomnia: A condition in which a person cannot fall asleep, cannot remain asleep, or wakes up not feeling restored or refreshed after sleeping. Joint: The place where two bones meet. Mind-body therapies: Practices that focus on the relationships of brain, mind, body, and behavior and how they affect health. Examples include meditation and yoga. Omega-3 fatty acids: A group of polyunsaturated fatty acids that come from food sources, such as fish, fish oil, some vegetable oils (primarily canola and soybean), walnuts, wheat germ, and certain dietary supplements. Polyunsaturated fatty acids are one of the three types of fatty acids. They contain a chain of carbon atoms and hydrogen and oxygen molecules, with two or more double bonds between the carbon atoms.

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Omega-6 fatty acids: A group of essential fatty acids found in cereals, vegetable and seed oils, eggs, and poultry. Essential fatty acids are needed for human health and cannot be made by the body. Osteoporosis: A condition in which bones become thin and brittle and more likely to break. Placebo: A placebo is designed to resemble as much as possible the treatment being studied in a clinical trial, except that the placebo is inactive. An example of a placebo is a pill containing sugar instead of the drug or other substance being studied. By giving one group of participants a placebo and the other group the active treatment, the researchers can compare how the two groups respond and get a truer picture of the active treatments effects. In recent years, the definition of placebo has been expanded to include other things that could have an effect on the results of health care, such as how a patient and a health care provider interact and what the patient expects to happen from the care. Placebo effect: The physical or psychological benefits that can occur with the use of an inert or sham treatment (a placebo), such as a sugar pill. Relaxation techniques: Use of methods such as guided imagery to help calm the mind and release the muscles. It is used to reduce physical tension and promote emotional well-being. Rheumatic disease: A type of disease in which inflammation and loss of function are present in one or more connecting or supporting structures of the body. These diseases especially affect the joints, tendons, ligaments, bones, and muscles. Common symptoms are pain, swelling, and stiffness, and some rheumatic diseases can also involve internal organs. Rheumatologist: A medical doctor who specializes in treating conditions that affect the joints and muscles, such as rheumatoid arthritis. Sedative: A substance used for medicinal purposes (such as a drug or herb) that depresses the central nervous system, producing feelings of calmness, relaxation, and drowsiness. Tai chi: An exercise program that is part of traditional Chinese medicine. The exercises consist of a series of slow, gentle movements coordinated with breathing and meditation. Traditional Chinese medicine: A whole medical system that was documented in China by the 3rd century B.C. Traditional Chinese medicine is based on a concept of vital energy, or qi that is believed to flow throughout the body. It is proposed to regulate a persons spiritual, emotional, mental, and physical balance and to be influenced by the opposing forces of yin (negative energy) and yang (positive energy). Disease is proposed to result from the flow of qi being disrupted and yin and yang becoming unbalanced. Among the components of traditional Chinese medicine are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage.

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Danao-Camara TC, Shintani TT. The dietary treatment of inflammatory arthritis: case reports and review of the literature. Hawaii Medical Journal. 1999;58(5):126-131. Ernst E. Usage of complementary therapies in rheumatology: a systematic review. Clinical Rheumatology. 1998;17(4):301-305. Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology (Oxford). 2001;40(9):1052-1055. Fortin PR, Lew RA, Liang MH, et al. Validation of a meta-analysis: the effects of fish oil in rheumatoid arthritis. Journal of Clinical Epidemiology. 1995;48(11):1379-1390. Hafstrom I, Ringertz B, Spangberg A, et al. A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology (Oxford). 2001;40(10):1175-1179. Han A, Robinson V, Judd M, et al. Tai chi for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2004;(3):CD004849. Accessed at http://www.cochrane.org on July 21, 2004. Henderson CJ, Panush RS. Diets, dietary supplements, and nutritional therapies in rheumatic diseases. Rheumatic Disease Clinics of North America. 1999;25(4):937-968. Herman CJ, Allen P, Hunt WC, et al. Use of complementary therapies among primary care clinic patients with arthritis. Preventing Chronic Disease: Public Health Research, Practice, and Policy. 2004; 1(4). Also available at http://www.cdc.gov/pcd/issues/2004/oct/03_0036.htm. James MF, Proudman SM, Cleland LG. Dietary n-3 fats as adjunctive therapy in a prototypic inflammatory disease: issues and obstacles for use in rheumatoid arthritis. Prostaglandins, Leukotrienes and Essential Fatty Acids. 2003;68(6):399-405. Johnson, MT, Waite, LR, Nindl G. Noninvasive treatment of inflammation using electromagnetic fields: current and emerging therapeutic potential. Biomedical Sciences Instrumentation. 2004;40:469-474. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic diseases. Rheumatic Disease Clinics of North America. 2000;26(1):117-123. Jordan JM, Benard SL, Callahan LF, et al. Self-reported arthritis-related disruptions in sleep and daily life and the use of medical, complementary, and self-care strategies for arthritis: the National Survey of Self-care and Aging. Archives of Family Medicine. 2000;9(2):143-149. Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. Journal of the American Medical Association. 2004;292(12):1433-1439. Lewis C. Arthritis: timely treatments for an ageless disease. FDA Consumer. 2000;34(3):27-29, 31-33. Also available at http://www.fda.gov/fdac/features/2000/300_arth.html. Little C, Parsons T. Herbal therapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2004;(1):CD002948. Accessed at http://www.cochrane.org on January 26, 2004. Martin RH. The role of nutrition and diet in rheumatoid arthritis. Proceedings of the Nutrition Society. 1998;57(2):231-234. National Center for Complementary and Alternative Medicine. Acupuncture. National Center for Complementary and Alternative Medicine Web site. Accessed at http://www.nccam.nih.gov/health/acupuncture on November 23, 2004.

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National Center for Complementary and Alternative Medicine. Mind-Body Medicine: An Overview. National Center for Complementary and Alternative Medicine Web site. Accessed at http://www.nccam.nih.gov/health/backgrounds/mindbody on July 28, 2005. National Center for Complementary and Alternative Medicine. Questions and Answers About Homeopathy. National Center for Complementary and Alternative Medicine Web site. Accessed at http://www.nccam.nih.gov/health/homeopathy on November 23, 2004. National Center for Complementary and Alternative Medicine. Questions and Answers About Using Magnets to Treat Pain. National Center for Complementary and Alternative Medicine Web site. Accessed at http://www.nccam.nih.gov/health/magnet/magnet on July 28, 2005. National Center for Complementary and Alternative Medicine. Questions and Answers: NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). National Center for Complementary and Alternative Medicine Web site. Accessed at http://www.nccam.nih.gov/news/19972000/121100/qa on July 28, 2005. National Institute of Allergy and Infectious Diseases. Food Allergy: An Overview. Accessed at http://www.niaid.nih.gov/publications/pdf/foodallergy.pdf on May 5, 2005. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on Health: Rheumatoid Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site. Accessed at http://www.niams.nih.gov/hi/topics/arthritis/rahandout.htm on December 17, 2004. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Arthritis Treatment and Research: Rheumatoid Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH SeniorHealth Web site. Accessed at http://nihseniorhealth.gov/arthritis/rheumatoidarthritis/11.html on January 7, 2005. Natural Medicines Comprehensive Database. Black Currant. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on September 29, 2004. Natural Medicines Comprehensive Database. Borage Seed Oil. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on September 29, 2004. Natural Medicines Comprehensive Database. Chondroitin Sulfate. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on July 7, 2005. Natural Medicines Comprehensive Database. Evening Primrose Oil. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on September 29, 2004. Natural Medicines Comprehensive Database. Feverfew. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on July 7, 2005. Natural Medicines Comprehensive Database. Fish Oil. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on May 17, 2004. Natural Medicines Comprehensive Database. Gamma-Linolenic Acid. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on August 18, 2004. Natural Medicines Comprehensive Database. Ginger. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on July 7, 2005. Natural Medicines Comprehensive Database. Glucosamine Sulfate. Natural Medicines Comprehensive Database Web site. Accessed at http://www.naturaldatabase.com on July 7, 2005.

Acknowledgments

NCCAM thanks the following people for their technical expertise and review of this publication: Carol Pontzer, Ph.D., and Richard L. Nahin, Ph.D., M.P.H., NCCAM; Barbara Mittleman, M.D., and Peter E. Lipsky, M.D., National Institute of Arthritis and Musculoskeletal and Skin Diseases; Diana M. Taibi, M.S.N, R.N., and Cheryl Bourguignon, Ph.D., R.N., University of Virginia School of Nursing; Donald M. Marcus, M.D., Baylor College of Medicine; Barbara N. Timmermann, Ph.D., University of Arizona College of Pharmacy; and Robert Zurier, M.D., University of Massachusetts Medical School.
This publication is not copyrighted and is in the public domain. Duplication is encouraged.
NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM. National Institutes of Health U.S. Department of Health and Human Services

NCCAM -23

Created September 2005

DOI: 10.1111/j.1471-1842.2010.00888.x
Review Article An overview of 45 published database resources for complementary and alternative medicine
Katja Boehm*, Christa Raak*, Horst Christian Vollmar & Thomas Ostermann*
*Center of Integrative Medicine, University of Witten Herdecke, Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany and Institute for Research and Transfer in Dementia Care, Partner Site of the German Centre for Neurodegenerative Diseases, Helmholtz Association, Witten, Germany
Abstract Background: Complementary and alternative medicine (CAM) has succeeded to implement itself in the academic context of universities. In order to get information on CAM, clinicians, researchers and healthcare professionals as well as the lay public are increasingly turning to online portals and databases, which disseminate relevant resources. One specic type of online information retrieval systems, namely the database, is being reviewed in this article. Question: This overview aims at systematically retrieving and describing all databases covering the eld of CAM. One of the requirements for inclusion was that the database would also have to be published in a medical journal. Data sources: The databases AMED, CAMBASE, EMBASE, and MEDLINE PUBMED were searched between December 2008 and December 2009 for publications relevant to CAM databases. The authors specialist library was also searched for grey literature to be included. Study selection: All included databases were then visited online and information on the context, structure and volume of the database was extracted. Main results: Forty-ve databases were included in this overview. Databases covered herbal therapies (n = 11), traditional Chinese medicine (n = 9) and some dealt with a vast number of CAM modalities (n = 9), amongst others. The amount of time the databases had been in existence ranged from 4 to 53 years. Countries of origin included the USA (n = 14), UK (n = 7) and Germany (n = 6), amongst others. The main language in 42 of 45 databases was English. Conclusions: Although this overview is quite comprehensive with respect to the eld of CAM, certain CAM practices such as chiropractic, massage, reexology, meditation or yoga may not have been covered adequately. A more detailed assessment of the quality of the included databases might give additional insights into the listed resources. The creation of a personalised meta-search engine is suggested, towards which this overview could be seen as a rst step. Key Messages Implications for Practice A personalised meta-search engine for the eld of complementary and alternative medicine should be developed. More rigorous in-depth analysis of CAM databases, including quality assessment, should be carried out. Implications for Policy Medical database founders should be encouraged to publish articles about their databases in order to publicise these resources to researchers and health professionals.
Correspondence: Katja Boehm, Center of Integrative Medicine, University of Witten Herdecke, Gerhard-Kienle-Weg 4, D-58313 Herdecke, Germany. E-mail: drkatjaboehm@gmail.com
2010 The authors Journal compilation 2010 Health Libraries Group. Health Information and Libraries Journal, 27, pp.93105
Complementary and alternative medicine, Katja Boehm et al.
Database developers and providers should distinguish between CAM information for health professionals and lay persons. CAM information should be available in multiple languages via databases. CAM databases should provide the full text of articles wherever possible, to encourage citations within the eld. A seal of approval certication scheme should be developed for CAM information. Introduction In 1999, Zollman and Vickers dened complementary and alternative medicine (CAM) as a group of therapeutic and diagnostic disciplines that exist largely outside the institutions where conventional healthcare is taught and provided.1 According to a former denition from Ernst et al.,2 CAM complements mainstream medicine () by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine.2 Since then CAM not only succeeded in implementing itself in the academic context of universities but also increased its activities in various elds of research.3 This development went alongside with an increasing demand for information about CAM, as more and more patients and also physicians and other healthcare professionals want to keep informed about CAM therapies.4,5 In the past, the task of providing information was sufciently managed by the establishment of corresponding journals and available knowledge in manuals and textbooks. Thus, the traditional place for the completion of the highly responsible task of reposition and conservation of knowledge was the scientic library. This task involved classifying the knowledge units and making them available to the user by suitable cataloguing and indexing. The rst librarian catalogue system developed for this purpose dates back to the medieval age.6 With regard to complementary medicine, several books were published in that time and thus, it might not be surprising that the oldest CAM (and also medical) journal in Europe is the Allgemeine Homoopathische Zeitung founded in 1832.7 However, within the last decades, the pathways for information dissemination changed from classical media such as books and journals to new media. With the beginning of the 1960s, several initiatives on information retrieval were carried out and, in that time, one of the rst major machinereadable databases and batch retrieval systems for bibliographical data, the Medical Literature Analysis and Retrieval System (MEDLARS), was initiated at the National Library of Medicine.8,9 Nowadays, a database is thought of as an integrated collection of logically related records or les consolidated into a common pool that provides data for one or more multiple uses. Today the Internet is often the rst choice of medical information not only for patients but also for researchers, physicians and other healthcare professionals.10 Within this new direction of retrieving information, there are several options and of course some pitfalls to look at.11 With respect to the eld of CAM, several investigations of commercial CAM websites have found heterogeneous quality regarding the content presented, which might lead the patients in a wrong direction.12,13 As a consequence, several independent initiatives have been started to assist physicians and researchers in getting an overview on CAM research. Question In this context, within the last 10 years, one application of modern information technology is the establishment of CAM-related specialised databases. Unfortunately, information about these databases is disparate and often not known to researchers in the eld. Thus, there is a basic need to give an overview on published database resources for CAM. This article aims at giving such an overview. Only databases described in published papers were included in order to encourage people developing databases to write and publish articles so that it is easier for researchers and health professionals to learn about the databases available. Data sources Between December 2008 and December 2009 the databases AMED, CAMBASE, EMBASE, and MEDLINE PUBMED were searched for articles on the

development of databases for CAM. An initial search was carried out in December 2008 and one nal, updated search in December 2009. To get a rough overview, the rst step of the search process covered EMBASE and MEDLINE PUBMED using search terms that include keywords describing the most common CAM-related therapies and systems. As AMED and CAMBASE are CAM-specic databases,

Table 1 Search terms

only the term database* was searched. In a second step the interface gateway OVID was used to search the same databases in more detail including specic CAM-related search terms (see Table 1). In a third step the physical archives of the authors CAM specialist library were scanned for grey literature not listed in the above-mentioned databases.

CAMBASE

Database* acupunct*, alternative therapies, anthroposoph*, aromatherap*, art therapy, balneo*, chinese medicine, complementary therapies, herbal*, homeopath*, mind body, music therapy, naturopath*, osteopathy, physiotherapy, phyto*
Search terms relating to Naturopathy as applied in MEDLINE PUBMED, EMBASE [AND combination] Search terms relating to all CAM as applied in OVID (rst step)
Search terms relating to all CAM as applied in OVID (second step)
exp Complementary therapies or exp alternative medicine or exp complementary medicine or exp alternative therapies or exp acupuncture or exp acupuncture therapy or exp acupressure or acupunctur$.mp. or auricular therapy.mp. or auriculotherapy.mp. or acupressure.mp. or exp electroacupuncture or electroacupuncture.mp. or exp aromatherapy or aromatherap$.mp. or exp aroma therapy or exp essential oils or exp oils volatile or exp oils essential or exp volatile oils or exp chiropractic or chiropractic.mp. or exp manipulation chiropractic or chiropract$.mp. or exp herbal medicine or exp phytotherapy or exp plant medicinal or herb$.mp. or exp plant extracts or exp plants medicinal or phytotherapy.mp. or diet$ supplement$.mp. or exp dietary supplement or exp Nutritional supplements or exp health food or exp nutritional therapy or Nutritional supplement$.mp. or health food.mp. or nutritional therapy.mp. or exp reexology or reexolog$.mp. or zone ther! or apy.mp. or exp reexotherapy or relaxation.mp. or exp relaxation techniques or exp relaxation training or exp homeopathy or homeopath$.mp. or exp homeopathic drugs or exp homeopathic agent or exp homeopathic agents or homoeopath$.mp. or exp hypnosis or exp hypnotherapy or hypnosis.mp. or hypnotherap$.mp. or exp meditation or exp mindfulness or meditation.mp. or mindfulness.mp. or meditation.mp. or mindfulness.mp. or mbsr.mp. or exp massage or massage.mp. or exp osteopathy or osteopath$.mp. or exp manipulation osteopathic or exp yoga or yoga.mp. or exp alexander technique or exp Alexander therapy or alexander technique.mp. or Alexander therapy.mp. or Alexander principle.mp. or exp traditional chinese medicine or exp Ayurvedic medicine or exp Anthroposophical medicine or exp Unani medicine or exp traditional African medicine or traditional chinese medicine.mp. or Anthroposophical.mp. or Unani.mp. or Traditional African medicine.mp. or Ayurved$.mp. or exp naturopathy or naturopathy.mp. or ! exp biofeedback or biofeedback.mp. or exp imagery or imagery.mp. or exp art therapy or exp music therapy or exp dance therapy or art therapy.mp. or music therapy.mp. or dance therapy.mp. or exp magnetic therapy or exp laser therapy or magnet$ therapy.mp. or laser therapy.mp. or exp balneotherapy or balneotherapy.mp. or exp naprapathy or naprapathy.mp. or exp Tai Chi or Tai Chi.mp. or exp hydrotherapy or hydrotherapy.mp. or exp Qi Gong or Qi Gong.mp. or exp Doman Delcato patterning or Doman Delcato patterning.mp. or exp ower remedies or ower remedies.mp. or exp clinical ecology or exp colon cleansing or exp colonic irrigation or clinical ecology.mp. or colon$ cleansing.mp. or colon$ irrigation.mp. or exp sound therapy or sound therapy.mp. or exp shiatsu or shiatsu.mp. or exp autogenic training AND Database.m_titl exp databases or exp data base or exp Database Management Systems or database* AND exp complementary therapies or exp complementary medicine or exp alternative therapies or exp alternative medicine

Study selection All articles found were fully read and their reference lists were checked for further relevant publications. As the studies were quite heterogeneous and included a variety of perspectives, it was decided to classify them roughly at rst glance with respect to their content. After screening the title, and if possible the abstract, only the articles dealing with the establishment or use of a CAMrelated database or with relevant collections of web links and web resources were included. Articles in which the term database was only mentioned as a secondary source (e.g. citations of systematic reviews of CAM from the COCHRANE database) were excluded. Descriptions of websites which serve merely as portals were also excluded. Furthermore, databases which could only be accessed by contacting an email address or were only accessible via CD-ROM or videotext were also excluded from this overview. The included articles were then classied by using the following categories: whole medical system (i.e. homoeopathy, Chinese medicine, CAM in general) health condition description of content (i.e. size of database) actual status of database (i.e. expired, still available) language(s) country
being online and (b) being published in a peerreviewed journal. Table 3 shows reasons for excluding ALTMEDDEX,44 CISCOM,29 IBIS30 LEXI NATURAL,44 the SHANGHAI RAPESEED Database,OLIO+, IN-CAM, ACULARS and TCM TOXICOLOGY 62 database. Furthermore, there were seven duplicates of additional publications, discussing databases which had already been included. Subject and content From the data reported, the majority of the databases were dealing with herbal therapies (n = 11 databases, entries), followed by Traditional Chinese Medicine (TCM) (n = 9 databases, entries), all CAM (n = 8 databases, entries) and homeopathy (n = 4 databases, entries). Furthermore, three acupuncture databases were identied (entries), and two dietary supplement databases (entries). Art therapy, music therapy, naturopathy, manual therapy, physiotherapy, occupational therapy, qigong and herbal therapies combined with TCM were each represented once. Looking at the total number of entries, an overlap of articles and reports is expected as it is likely that, for instance, an article in one homeopathy database will also be found in another homeopathy database. Most of the databases were developed to store bibliographical metadata. Some of them, such as AMED or CAMBASE, concentrate on the broader scope of CAM in general and offer access to fulltext publications, whereas others are specialised in well-dened areas like clinical trials in acupuncture (ACUBRIEFS),14 art therapy (ARTHEDATA),18 basic research in homoeopathy (e.g. HOMBREX),35 or Traditional Chinese Medicine (e.g. CHINA NATIONAL KNOWLEDGE INFRASTRUCTURE Database).26 Particularly in TCM, there is a broad scope on storing publications. The WANFANG database, for instance, lists not only journals but also dissertations, conference proceedings, TCM companies and products, patents, standards and licensing, laws, policies and regulations.58 Accessibility Forty-one of the 45 databases (91.1%) still existed and were accessible as they were described in the

Main results As a rst step, a total of 2149 bibliographical records were screened (including duplicates). After removing duplicates, 1665 references were still included, which after thorough screening left 61 selected references for possible inclusion. After a second step of exclusion, articles describing a total of 45 different CAM-related databases remained.1458 Table 2 gives a detailed overview on the subject of the database, their name and website details, access, language, CAM health condition, size and country where it is based in (see Table 2).
Exclusion Nine databases were excluded from this overview, as they did not t the inclusion criteria of: (a)

Table 2 CAM databases

Name and website F S E E Acupuncture USA UK

Access

Language
CAM health conditions Size of database

Country

ACUBRIEFS
(http://www.acubriefs.com)
15 (http://www.ovid.com/site/products/ ovidguide/ameddb.htm)
>primarily electronic citations (February 2007) articles (Dec 2008)
and CAMPAIN16 (http://www. compmed.umm.edu./databases.html) 17 ARRCBASE (http://www.acupuncture.org. uk/content/library/organisations.asp) 18 ARTHEDATA (http://www.arthedata.de) 19 CAIRSS (http://imr.utsa.edu/cairss.html) CAMBASE20 (http://www.cambase.de) No longer available S E German E E and German E E E F F F F F F E
All CAM, Psychosomatic therapies, Diet and nutrition All CAM, acute and chronic pain Acupuncture references from 14 databases
USA UK Germany USA Germany International UK USA
21 CANCER (http://www.cam-cancer.org) 22 CAMEOL (http://www.rccm.org.uk/
>references on acupuncture and related practices 8000 bibliographical data sets >citations from 18 specialist journals >sets of bibliographical data from >40 mostly German speaking CAM-Journals. 17 current up-to-date summaries Not reported
cameol/default.aspx) CAM on PUBMED23 (http://www.nlm.nih.gov/ nccam/camonpubmed.html) F E All CAM, various health conditions
Art therapy Music therapy All CAM, various health conditions All CAM, cancer All CAM, various health conditions All CAM, various health conditions

CAMLIS

(http://www.cam.nhs.uk)
Dietary supplements Traditional Chinese Medicine Traditional Chinese Medicine

USA China

2010 The authors Journal compilation 2010 Health Libraries Group. Health Information and Libraries Journal, 27, pp.93105 PUBMED contains >11 million journal citations from >2700 journals in the MEDLINE database CAM on PUBMED contains >citations Research-relevant publications in CAM in the major European languages, evidence-based textbooks for practitioners in E as well as evidence-based publications for patient information (no numbers reported) 2351 federally funded research projects on dietary supplements 1685 randomised clinical trials on TCM in 352 journals >patent records, >TCM formulas S E, Russian, German Chinese Chinese and E China

25 (http://ods.od.nih.gov/research/ cards_database.aspx) CHINA NATIONAL KNOWLEDGE INFRASTRUCTURE Database26 (http://chmp.cnipr.cn/tcm_patent1/englishversion/ login/index.asp) CHINA TRADITIONAL CHINESE MEDICINE PATENT Database27 (http://chmp.cnipr.cn/tcm_patent1/ Eversion/help/help.html)

Table 2 (Continued)

Name and website E Herbal therapies specically for cancer
CAM health conditions Size of database Information on 527 anticancer herbal recipes, 937 individual ingredients, and 9366 small organic molecules isolated from herbal medicines

Country USA

CHMIS-C
(http://sw16.im.med.umich.edu/chmis-c/)

COCHRANE

Collaboration CM Field16 (http:// www.compmed.umm.edu/cochrane.asp) E All CAM, various health conditions F and S E
F of charge for researchers working for academic, governmental, or other non-prot institutions otherwise fee F

International

CUSTOMARY MEDICINAL KNOWLEDGE BASE30 (http:// biolinfo.org/cmkb/index.php) F F F and S S S E E E E E and German Herbal therapies specically of Aboriginal origin CAM, Naturopathy Acupuncture and electroacupuncture Herbal therapies Herbal therapies Homeopathy
CAM Reviews Through COCHRANE Library Issue 2 2009: n = 379 CAM Protocols Through COCHRANE Library Issue 2 2009: n = 209 Total of 528 species, 1898 specic medicinal information records

Australia

DATADIWAN
(http://www.datadiwan.de)
Germany UK <200 health conditions 24 herbs Detailed description of 221 plants UK USA Germany
32 (http:// www.electroacupunctureknowledge.com) 33 EXTRACT Database (http://www.plant-medicine.com/ grades/extract/main-menu.asp) HERBMED & HERBMEDPRO34 (http:// www.herbmed.org) HOMBREX35 (http://www.carstens-stiftung.org)

ELECTROACUPUNCTURE

>6000 bibliographic entries as well as 6000 addresses >8000 clinical studies

HOMEOINDEX

(http://bases.bireme.br/cgi-bin/ wxislind.exe/iah/online/?IsisScript=iah/ iah.xis&base=HomeoIndex&lang=e) F
E, Spanish and Portuguese

Homeopathy

Brazil
2010 The authors Journal compilation 2010 Health Libraries Group. Health Information and Libraries Journal, 27, pp.93105 E Homeopathy
HOM-INFORM37 (http://hominform.soutron.com)
1301 experiments in more than 997 original articles, including 1172 biological studies (>643 substances) Dozens of different items from each paper (24 journals indexed), no full texts almost 2400 papers from journals published all around the world Contains nearly indexed references to books and journal articles relating to homeopathy

Name and website E E Homeopathy Not reported Contains citations on the topic of dietary supplements from four major database sources

Country India USA

HOMEOWEB38
(http://antenna.nl/homeoweb)
(http: grande.nal.usda.gov ibids index.php)

No longer available F

MANTIS
(previously known as CHIROLARS) (http://www.healthindex.com/start.html)
Coverage: 1900 to present >records, >1000 journals

MEDFLOR INDIA ABIM

Dietary supplements Vitamins, minerals, herbs Botanical and agricultural science Phytomedicine Osteopathy, Chiropractic, Homeopathy, Manual therapy Herbal therapies
Between and records from around 700 medicinal herbs
(annotated bibliography of Indian medicine)41 (http:// indianmedicine.eldoc.ub.rug.nl/root/R/95965/ ?pFullItemRecord=ON) 42 NAPRALERT (http://www.napralert.org/default.aspx) S but search is F E Herbal therapies

F S S E and Spanish E

Herbal therapies
250 genera of plants records with data on natural products (Pharmacology, biological activity, taxonomic distribution, ethnomedicine, chemistry of plant, microbial, animal extracts and of secondary metabolites derived from natural sources) 4029 species from 243 different plant families 1100 individual natural ingredients 2133 entries for foods, herbs and supplements
USA USA USA Herbal therapies, TCM Foods, herbs, supplements, health, wellness, brand names
NATIVE AMERICAN ETHOBOTANY43 (http://herb.umd.umich.edu) NATURAL MEDICINES COMPREHENSIVE Database44 (http://www.naturaldatabase.com) 45 NATURAL STANDARD (http:// www.naturalstandard.com)
Name and website F Traditional Chinese Medicine for cancer
CAM health conditions Size of database 117 anticancer drugs and 166 complementary and alternative medicines

Country Singapore

ONCORX46 (http://www.onco-informatics.com/)
OTSEEKER47 (http://www.otseeker.com) F F F Herbal therapies Herbal therapies Qigong, other CAM Traditional Chinese Medicine Not reported E Herbal therapies E and Chinese Occupational therapy Physiotherapy Not reported
E, Spanish, French, Chinese, German, Portuguese, Malay, Tamil, Dutch, Italian E
Australia Australia India Germany Brazil
PEDRO48 (http://www.pedro.org.au)
PLANT DATABASE OF INDIA49 (http://221.135.191.194/ plantsindia/index.php) PLANTMARKERS50 (http://markers.btk./) No longer available F F E, Portuguese and Japanese E
>randomised trials, systematic reviews and clinical practice guidelines Not reported

51 PLANT

(http://www.brazilian-plants.com)
>4000 abstracts 1660 references (version 5.0) 2050 citations (version 6.0 available on CD) >2100 records
QIGONG Database52 (http://www.qigonginstitute.org/html/ database.php) SOCIETAS MEDICINAE SINENSIS LITERATURE database53 (http://www.tcm.edu/mitgliederbereich/ home.aspx) TCMGENEDIT54 (http://tcm.lifescience.ntu.edu.tw/) S German E Latin E Chinese E and Chinese (F)currently unavailable F S

Germany

>2000 TCM entries

Taiwan Singapore China

TCM-INFORMATION
(http://tcm.cz3.nus.edu.sg/ group/tcm-id/tcmid.asp) 56 TCMLARS (http://www.cintcm.com/index.htm)
Traditional Chinese Medicine Traditional Chinese Medicine Traditional Chinese medicine
2010 The authors Journal compilation 2010 Health Libraries Group. Health Information and Libraries Journal, 27, pp.93105 S E, Japanese and Korean Traditional Chinese Medicine
TRADIMED57 (http://www.tradimed.com)
1197 TCM prescriptions 4111 disease conditions 9862 ingredients >references and abstracts to literature on Traditional Chinese Medicine, including Chinese herbal medicines, acupuncture, Qigong, Chinese massage, health promotion, and other topics 3199 herbs, formulae, chemical compositions of herbs 4080 diseases
Country Table 3 Excluded databases China Name of excluded database

ACULARS

Reasons for Online? Published? exclusion 4 Not an online database CD-ROM only Search service only CD-ROM only Database on CAM outcome measures PDA use only Videotext only No longer covers CAM Not an online database
Journals 1024 titles Dissertations (144 318) Conference proceedings (papers) Companies and products (companies) Patents (110 618) Standards (7949) Laws, policies and regulations (14 628)

ALTMEDDEX

CISCOM IBIS IN-CAM

Size of database

LEXI NATURAL OLIO+

SHANGHAI RAPESEED

Database

TCM TOXICOLOGY

E and Chinese
articles, at the time the overview was conducted. From these databases, where the information was available, it was observed that the age of the databases from the time they were established until December 2009 ranged from 4 to 53 years. Please note that particularly older databases like MEDLARS in their early years were only accessible via xed mediums and were ported individually to common internet standards within the course of time. Countries based and languages Most of the databases included in this review were based in the USA (n = 14), followed by the UK (n = 7), Germany (n = 6), Australia (n = 3), China (4) and India (n = 3). Other databases originated in Brazil (n = 2), Singapore (n = 2), Korea (n = 1), Taiwan (n = 1) or were internationally based (n = 2). The language of choice for the majority of the 45 databases was English (n = 42). Two databases were in German only. However, other databases also provided additional services in Chinese, French, German, Japanese, Korean, Latin, Portuguese, Russian and Spanish. Limitations Although this overview is quite comprehensive with respect to the eld of CAM, there are some limitations to be mentioned. Firstly, certain CAM practices such as chiropractic, massage, reexology, meditation or yoga may not have been cov-

CAM health conditions

WANFANG Database58 (http://www.wanfangdata.com/medical/intr.asp)
Traditional Chinese medicine
F, free; S, subscription; e, English.

Name and website

ered adequately and thus there might still be published data which are not included. Although we tried to cover global quality markers such as availability of the website, a more detailed assessment of the quality of the included databases might give additional insights into the listed resources. Here, future research could make an effort to evaluate bibliographical databases according to standard criteria, for instance, as provided by an international seal of approval (such as, for instance, the health on the net or HONcodesee http://www.hon.ch/), which a database can only receive when a crosssection of its available literature has been examined by various experts. Perspectives Furthermore, it would be an opportunity to create a personalised meta-search engine including all the databases mentioned here, where retrieved databases are weighted according to a user-dened retrieval model, so that the user can easily navigate through the databases efciently for a specic health topic.60,65 The link list given here is a rst step in this direction (see Table 2). Additionally, one should distinguish between CAM information for clinicians and for lay people, as issues with the terminology used may arise. Finally, it should be mentioned that it might be desirable to make the search function in each database available in languages other than English, German, Spanish or Chinese. To avoid a broadening of the citation gap with respect to clinical study results, particularly in the eld of CAM, articles should be open access, to encourage inclusion in systematic reviews, for example.63 A useful database therefore may not only cover the bibliographical data but ideally should also provide the full-text document, as it could deliver ideas for protocol development or case studies. Conclusions This overview is the rst of its kind presenting a systematic summary of electronic literature databases in CAM. In this overview electronic databases regarding CAM were identied and listed according to specic criteria. The results showed that there
are a number of sources of literature databases; in this review 45 such databases were identied. There are other prototypes for similar CAM resources, such as Homoeowiki (http://www.homeowiki.org/index.php/Hauptseite), which is a German website where homoeopaths offer the description of drugs and drug studies, and describe cases from their own practice. This is an ongoing project and is free of charge. Nowadays a vast number of electronic literature databases are available through the Internet. Specic literature search engines are making use of various online literature databases in order to simplify literature research. There are also databases which not only contain information regarding specialised publications but may provide the actual content of the publication itself. Many of the included databases in this review contain a collection of publications on a specic area or topics of interestthese are also called bibliographical databases or topic indices. When researching CAM, researchers, healthcare professionals, as well as patients and relatives, can use CAM databases, such as those covered in this overview, in order to gather information from Web-based articles (full text or summaries) published in regularly released journals or magazines, peer-reviewed articles, academic publications, newsletters or conference proceedings. Acknowledgements Katja Boehm was supported by the Carstens Foundation, Germany. Furthermore, we thank Mrs Anelia Boshnakova and Dr Karen Pilkington for their input. The person(s) acknowledged are not held responsible for the content of the paper. References

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