CHAPTER 75 • COMPLEMENTARY AND ALTERNATIVE MEDICINE 457
however, the potential for severe herb–herb and
drug–herb interactions—including serotonin syn-
drome—is greater with SJW. SJW can accelerate
the metabolism of drugs cleared by the P450
enzyme system and should not be used by those on
immunosuppressants or antiviral medications
without monitoring.
- Regulated/Banned: Not banned by athletic regula-
tory agencies; however, due to the risk of serious
drug interactions, the distribution of SJW was
recently banned in France. The governments of
Japan, the United Kingdom and other European
countries are considering similar bans.
- Conclusion: In monitored patients with mild–mod-
erate depression, SJW therapy is acceptable ifthe
patient has a simple, compatible medical regimen
and strongly prefers SJW to conventional drug
treatment.
•Creatine (Williams, Kreider, and Branch, 1999; Volek
et al, 1999; Vandenberghe et al, 1997)
- Primary use: Decrease workout recovery time;
improve muscular strength/athletic performance
2.Evidence: Many studies document increases in
repetitive strength tasks of less than 30 s duration.
Certain individuals who have low baseline levels of
creatine may experience a more pronounced effect.
- Toxicity: Common side effects include GI upset,
diarrhea, and mild muscle cramping. Case reports
have attempted to implicate creatine in everything
from cardiomyopathy to renal failure to rhab-
domyolysis, but these effects are difficult to distin-
guish from the effects of volume depletion and
heat illness. Creatine’s ergogenic effects are
largely negated by caffeine consumption.
- Regulated/Banned: Not a banned substance, but
the National Collegiate Athletic Association
(NCAA) prohibits universities from providing cre-
atine for their athletes.
- Conclusion: A discussion of risks and benefits is
critical to creatine. After thorough discussion with
an athlete, creatine use can be permitted in other-
wise healthy patients involved in strength-related
events. Creatine should not be used in pediatric
athletes (unclear safety), athletes with kidney dis-
ease, or athletes prone to dehydration (osmotic
action of creatine predisposes to dehydration and
intensifies subsequent heat illness). For most ath-
letes, creatine has no proven benefit. In fact, the
increased body mass (2–4 kg) caused by creatine
supplementation may impair performance in
endurance events.
- Homeopathy (Arnica) (Ernst and Barnes, 1998;
Vickers et al, 1997; Tveiten et al, 1995; Vickers et al,
- Primary use: Relief of delayed onset muscle sore-
ness (DOMS).
- Evidence: Homeopathic arnica is more properly
viewed as an alternative medical system with many
distinct, pharmacologic interventions. No single
homeopathic treatment has been conclusively
proven to be effective in reducing DOMS. Small
trials of diverse remedies offer contradictory con-
clusions for homeopathy in DOMS. Poor design,
differing methodologies, and differing definitions
of DOMS predictably plague these trials.
- Toxicity: No side effects above placebo levels have
been reported. Reports of severe allergic reactions
appear to be rare. Extreme dilution of homeopathic
remedies makes direct toxicity highly unlikely.
- Regulated/Banned: No. A few states credential
homeopathic physicians.
- Conclusion: The homeopathic system of medicine
is complex and has not yet been adequately evalu-
ated; however, its costs and toxicities are low in the
hands of trained professionals.
- Acupuncture (Green et al, 2002; Tulder et al, 2002;
NIH, 1997; Garvey, Marks, and Wiesel, 1989)
- Primary use: Relief of low back pain and lateral
elbow pain.
- Evidence: Like homeopathic arnica, acupuncture
may be considered as a separate medical system.
For lateral elbow pain, a recent Cochrane review
found insufficient evidence to make any recom-
mendations. RCTs of acupuncture for low back
pain are contradictory and poorly designed.
Acupuncture has been proven effective in reducing
pain and relief of nausea.
3.Toxicity: Broken needles, pneumothorax and
infectious disease transmission are anecdotally
reported, but unlikely in the hands of licensed pro-
fessionals. Pain, fatigue, bleeding, and fainting are
the most common side effects.
- Regulated/Banned: No. Over 30 states license
acupuncturists. The FDA has approved acupunc-
ture needles as experimental devices.
- Conclusion: Given the paucity of evidence, the
Cochrane review recommends that effective,
proven treatments be considered before acupunc-
ture; however, the costs and risks are sufficiently
low that acupuncture use—under the care of a
trained professional—can be permitted.
- Chondroitin (Leeb et al, 2000; Leffler et al, 1999;
Towheed and Anastassiades, 2000)
- Primary use: Improving pain and stiffness from
OA.
- Evidence: Several trials suggest (size and design
limiting) that chondroitin and ibuprofen are more
effective than ibuprofen alone for improving OA
