Integrative Medicine

Integrative Medicine

Narda G. Robinson


Integrative veterinary medicine (IVM), a field also known as “complementary and alternative veterinary medicine,” “holistic medicine,” “unconventional,” and “natural medicine,” first began in the 1970s in North America and has expanded ever since. IVM “describes the combination of complementary and alternative therapies with conventional care and is guided by the best available evidence. Veterinarians frequently encounter questions about complementary and alternative veterinary medicine (CAVM) in practice, and the public has demonstrated increased interest in these areas for both human and animal health” (Memon et al. 2016).

IVM presents a gamut of opportunities and difficulties when it comes to ethical practice. Even the title that one employs to describe it carries a considerable amount of nuance and implications as to its relationship with the “other,” “conventional,” “allopathic,” or “mainstream” methodologies. The cumbersome nomenclature reflects the difficulty in separating diverse types of practices, each with their own origins from human medicine, scientific and unscientific foundations, proponents, and critics. Both “sides” should eschew the term “traditional” medicine as it introduces confusion. That is, is the speaker referring to “traditional” in the modern sense, talking about contemporary treatment with pharmaceuticals and surgery, or are they commenting on indigenous folk-medicine approaches that predate the scientific era?

Most veterinarians who incorporate techniques outside of those typically taught in veterinary curricula prefer the term “integrative.” This sidesteps the awkwardness of “CAVM” as well as excludes the name “alternative,” which implies treatments other than mainstream methodologies. “Holistic,” which is missing its “w” (“wholistic”), suggests that its practitioners consider the entire patient. However, this invites a backlash from “conventional” veterinarians, who also insist that they view patients in their entirety. “Natural” medicine may have sufficed decades ago, but highly technical approaches such as photomedicine, pulsed electromagnetic field therapy, and electroacupuncture are not found in nature. So, in keeping with the prevailing opinions as to the ideal terminology, this chapter will use the term IVM when provided by veterinarians, and IM (minus the “V”) for those situations in which a nonveterinarian or individuals with unknown credentials deliver this type of care. It contains an overview of the field, the pros and cons of each modality, and a case study that illustrates the ethical opportunities and pitfalls that IVM treatments present. The ethics of IVM impact the patient, the client, the profession, veterinary education, and scope of practice.

Expanding Acceptance of IVM

As scientific support for IVM grows, its legitimacy and acceptance are similarly expanding. In fact, the convergence of science-based integrative medicine, fear-free veterinary care, integrative rehabilitation, and bond-centered practice is producing a new vision of what constitutes “typical” veterinary practice. Furthermore, veterinarians are encountering a burgeoning level of enthusiasm among clients for IVM for a wide range of problems in their animals. A survey of 423 horse owners found that 96% had used integrative medicine approaches (whether provided by a veterinarian or not) on their horse (Thirkell and Hyland 2017). The most popular therapies included massage (71%), chiropractic manipulation (59%), and magnet therapy (54%). Most (81%) expressed openness to instituting new treatments without consulting their veterinarian. This is concerning as it can result in potential harm to the treated horse and/or riders. Notably, only half of those surveyed stated that they were “very satisfied” with their “regular” veterinarian. A recent study of 204 horse owners found that 52% contacted an IM therapist before a veterinarian for back pain (Gilberg et al. 2021). Only 10–15% did not use any IM method for prevention or after injury.

Most veterinary teaching hospitals provide IVM services (Memon et al. 2021). Shmalberg et al. (2019a) analyzed the nature of canine and feline patients referred for acupuncture and herbal therapy to an academic veterinary teaching hospital. This two-year retrospective study found dogs (92%) far more frequently referred for treatment than cats (8%) and the most common problems noted were musculoskeletal (27%), neurologic (17%), oncologic (15%), and dermatologic (11%) in nature. Acupuncture in its various forms (dry needling (95%), electroacupuncture (26%), and pharmacopuncture (the injection of vitamins into points) (24%) was the most common therapy provided, followed by herbal supplements (76%). It should be noted, however, that one of the authors is also a manufacturer of Chinese herbal mixtures in addition to working as a professor at the same institution. The same authors published a three-year retrospective analysis of equine patients referred for acupuncture and herbal medicine (Shmalberg et al. 2019b). The three most common problems for which horses presented included musculoskeletal issues (62%), gastrointestinal dysfunction (9.5%), and anhidrosis (6%). Once again, acupuncture constituted the most common treatment (90%). A report of IM therapists treating dogs in Sweden found that the most frequently used methods were massage, stretching, and acupressure (Sohlberg et al. 2021).

Veterinary students who receive exposure to IVM during school or earlier may decide to pursue this type of work upon graduation. Some even report that this was the driving force for their pursuing a career in veterinary medicine (personal communication). More seasoned veterinarians may transition to IVM after they have grown weary with corporate pressures (see Chapter 17) and the limited and sometimes stressful treatment options that may cause the patient to fear the practitioner. Many welcome the opportunity to learn new ways to help their patients heal that provide comfort, restore functional homeostasis, and have a rational basis with evidence of effectiveness. On the other hand, some veterinarians pursue treatment methods that fail to meet requirements for a scientific basis and supportive evidence, whether IVM or “conventional.”

Choosing “Conventional” vs. IVM Approaches

Scientific evidence of effectiveness cannot be the only criterion of what constitutes “good care.” Other relevant factors include risks of treatment, potential complications, pain, and debility that may arise, costs, recovery time, and client’s informed consent. Ethically, clients should receive a complete picture based on evidence of the range of options available. However, surgeons, for example, may not have studied the effectiveness of nonsurgical options, including IVM techniques such as medical acupuncture, massage, movement therapy, and photomedicine. Moreover, veterinary orthopedic surgeries can earn practitioners thousands of dollars for each procedure, with the tibial plateau-leveling osteotomy (TPLO) costing $5000 or more. Could this also constitute a conflict of interest between what is best for the patient and best for the practice’s “bottom line”?

How do results compare between the TPLO and a nonsurgical approach with IVM and rehabilitation for patients with injured cranial cruciate ligaments? To date, no research exists that directly compares a multimodal IVM protocol with the TPLO. Furthermore, IVM methodologies offered by one practitioner may vary in number and type from those of another, in addition to tailoring treatment selections for each patient’s individual needs. A study comparing the TPLO with something as simple as a custom-made stifle joint orthotic indicated “high owner satisfaction rates for both interventions” (Hart et al. 2016). In this case, if a brace that costs under $1000 could allow patients to avoid the risk of severe and costly complications, even without the addition of IVM, why are veterinarians not learning more about nonsurgical options? Could this stem, at least in part, from the limited to nil exposure to IVM that most veterinary schools offer students? Only 30% of veterinary colleges reported offering a formal course in IVM and only 77% offered “some level” of instruction in IVM, with acupuncture and rehabilitation as the most popular modalities covered in the curriculum (Memon et al. 2021). Could a conflict of interest on the part of a teaching institution that nets high profits from TPLOs dissuade faculty from promoting nonsurgical options, especially given the heavy reliance that academia has developed on corporate funding? Where are the ethical discussions on this?

In addition to the pain and invasiveness of the TPLO, the procedure may lead to numerous complications, some severe, painful, and debilitating in an unacceptably (to this author) high percentage of patients. As stated by Bergh and Peirone, “Ten to 34% of TPLO surgical procedures are reported to experience a complication and approximately two to four percent require revision surgery to address a complication” (2012). Soft tissue complications include laceration of regional blood vessels, ligaments, and tendons. Severe blood loss may result from damage to local arteries. Measures instituted to reduce the risk of soft tissue damage, such as the introduction of gauze sponges to decrease iatrogenic tissue trauma, may deposit debris into the wound and lead to tissue reactions, infections, and the formation of a draining tract. Intraoperative complications range from tibial and/or fibular fracture to broken hardware, i.e. bits of screws, pins, drill bits, etc. The authors list over 20 postoperative complications, ranging from meniscal tear to patellar tendonitis, pivot shift, delayed union, internal tibial torsion, implant failure, and more. In contrast, medical acupuncture, photomedicine, massage, and movement therapy all have extremely low rates of injury and complications.

An IVM approach for cranial cruciate ligament injury offers a multimodal, relatively pain-free treatment series that addresses the plural causalities of ligamentous deterioration and its consequences instead of altering the limb’s configuration. As we apply critical scrutiny to all practices, we should also weigh the ethical pros and cons of the physiologic considerations, pain and stress, financial impacts, and long-term risks of each approach. An exhaustive comparison of conventional and IVM procedures for common problems in veterinary practice would be a worthy undertaking but is beyond the scope of this chapter.

Types of IVM Care

For all IVM therapies, the first step in treating animals safely and effectively involves an accurate assessment and delineation of the patient’s problems. Human practitioners who apply their techniques to animals have neither the requisite veterinary education nor the experience in the field that veterinarians do. Clients who take their animal to a human acupuncturist, chiropractor, or massage therapist often fail to recognize the vast differences and the risks involved. These issues reinforce the need for all IM and IVM providers to maintain a science-based, evidence-informed perspective and to eschew archaic methodologies.


The scientific approach to acupuncture often called “medical acupuncture,” evolved from ancient Asian methods during the 1980s with the development of the American Academy of Medical Acupuncture and other physician acupuncturist groups in Europe. A British group defines “Western” medical acupuncture as “a therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology, and pathology, and the principles of evidence-based medicine” (White 2009).

Mechanism of Action

Acupuncture involves inserting thin, sterile, solid needles into specific sites on the body called “acupuncture points.” Acupuncture points, arranged in lines called “channels” (or “meridians”), typically follow neurovascular routes or myofascial cleavage planes. The anatomic structures within the needle’s vicinity activate a cascade of autoregulatory and physiologic responses within the central, peripheral, and autonomic nervous systems. The nature of the effects engendered corresponds to the “job” of the structure activated. That is, needling an acupuncture point on the face alters the resting tone of the trigeminal and facial nerves. Most often, the outcomes of needle stimulation include analgesia, reversal of central or peripheral sensitization, and normalization of myofascial tone and function. This phenomenon is called neuromodulation. Electroacupuncture (EA) amplifies the neurophysiologic changes engendered by needling: an electrical lead attaches to the shaft of the acupuncture needle, which then functions as an electrode which delivers a stimulus of varying frequencies that modulate neuronal activity.

These modern, biologically based mechanisms replace the metaphorical concepts of chi (Qi), i.e. what Traditional Chinese Medicine (TCM) practitioners call “energy,” which they claim circulates throughout the body through invisible “meridians.” TCM providers allude to prescientific-era metaphorical causes of disease such as wind, heat, cold, dampness, and dryness. Furthermore, TCM practitioners utilize primitive, folkloric assessments such as tongue diagnosis and pulse diagnosis to determine their acupuncture and herbal prescriptions, despite the lack of validation of these methods for all species. This amounts to prescribing treatments based on faith or empirical observations, leading to less-than-ideal results. Whereas a scientifically trained medical acupuncturist selects points in a systematic manner, seeking to restore proper function in central, peripheral, and autonomic nervous system pathways, a TCM practitioner relies either on point “formulae” that are general in nature or a set of bizarre, exotic ideations and rituals of examination, such as Yamamoto Scalp Acupuncture, Korean Hand Acupuncture, Five Elements, etc.

Fortunately, the effects of needling provide sufficiently strong homeostatic influences that even if a TCM-based practitioner believes they are working through quasi-religious processes, the effects on the body may nevertheless be helpful. That said, a more precisely designed needling protocol assembled by a medical acupuncturist would more directly and profoundly address patients’ specific problems.


Research on acupuncture to treat naturally occurring disease most commonly includes dogs with intervertebral disc disease (IVDD) and horses with back pain or laminitis. For thoracolumbar (TL) IVDD in dogs, EA combined with conventional medical treatment led to a shorter time to recover both ambulation and deep pain sensation than did conventional care alone (Hayashi et al. 2007). Other studies indicate that EA for dogs with TL IVDD decreased pain, reduced incidence of relapse, and facilitated return to function (Laim et al. 2009; Han et al. 2010). Researchers typically evaluate EA rather than dry needling alone, finding that EA yields superior results for this condition (Dragomir et al. 2021).

Equine research has revealed similar outcomes, as EA outperformed phenylbutazone for the alleviation of TL back pain (Xie et al. 2005). Treatment with dry needling, hemoacupuncture (bleeding of points with a lancet), or aquapuncture (or “pharmacopuncture,” if involving the injection of medication or vitamins into points) resulted in a significant reduction in the severity of lameness (Faramarzi et al. 2017).

Additional indications for acupuncture, as shown for humans, include chronic pain (Yuan et al. 2016; Vickers et al. 2018), neurologic injury or disease (Fan et al. 2018), immune dysfunction (Kim and Bae 2010), digestive disorders (Li et al. 2015), reproductive disturbances (Zhu et al. 2018), cancer-related pain (Chiu et al. 2017), and more.


Acupuncture has a strong safety record, and few contraindications exist including pregnancy, tumor or infection in sites chosen for needling, bleeding disorders, and conditions wherein introducing a sharp object into the body could be injurious, such as in aggressive or extremely fearful patients.

Adverse Effects

When performed by a scientifically based, anatomically aware practitioner, acupuncture has a low rate of complications in my experience. The scientific background and knowledge of anatomy should inform the acupuncturist about safe depths of needling: this helps to avoid severe complications such as organ puncture and injury to large vessels (Peuker et al. 1999).

Manual Therapies

Manual therapies refer to interventions involving the hands. Two common examples in veterinary medicine include massage (Gilberg et al. 2021) and chiropractic. While applications of manual therapies frequently relate to musculoskeletal discomfort and/or dysfunction, other indications include lymphedema, immune dysregulation, nerve compression, and visceral dysfunction.


Massage techniques vary widely ranging from light to heavy pressure and from slow to invigorating techniques and styles. A common approach called Swedish massage incorporates several maneuvers such as effleurage (stroking and gliding), tapotement (percussion), petrissage (kneading), and friction massage (vigorous rubbing in a targeted zone requiring special attention).

Mechanism of Action

Massage focuses on soft tissue elements – muscles, fascia, tendons, nerves, and other intervening soft tissues. The neuromodulatory and homeostatic effects of massage regulate the autonomic nervous system and confer analgesia: many of the mechanisms overlap with those described for acupuncture. Furthermore, mechanical influences of massage can alleviate tissue swelling and lymphatic congestion.


Benefits of massage include pain and stress reduction, improved gastrointestinal motility, immune regulation, and mood elevation. Numerous applications thus arise in intensive and palliative care, oncology, pain medicine, rehabilitation, and sports medicine (Formenton et al. 2017). An uncontrolled, retrospective study on the effects of massage therapy on pain and quality of life in dogs concluded that treatment reduced the severity of myofascial and musculoskeletal pain (Riley et al. 2021).


Certain conditions and types of patients may preclude the safe and effective delivery of massage therapy to small animals, compelling the provider to either avoid a problematic area or select a different modality. Patients who are especially fragile or ill need to receive briefer and gentler treatments with less digital pressure and compression. One should avoid massage directly to neoplastic lesions, recent surgical sites, highly inflamed tissue, and infected areas. Animals that are aggressive, febrile, or in shock are typically considered unsuitable for massage.

Adverse Effects

As with acupuncture, thorough and science-based education in massage would make injury from the intervention unlikely. Those who provide massage should tailor treatment for certain conditions and types of patients. A massage therapist with insufficient awareness of nonhuman anatomy and tolerance for pressure could injure an animal with excessive force, especially if that patient has medical issues such as disk disease, spinal instability, or cancer (Miwa et al. 2019). For these reasons and more, jurisdictions that allow human massage therapists to work with animals need to ensure that the practitioners work closely with veterinarians. This may translate to a requirement for supervision, whether direct or indirect.


The terms “animal chiropractic,” “veterinary manual therapy,” and “animal adjusting” typically refer to a procedure called high velocity low amplitude thrusting. Those that provide the service may claim that this technique improves a wide variety of problems but, when pressed, fail to be able to explain how it works or show any evidence of efficacy or safety.

Mechanism of Action

Chiropractors claim to treat “subluxations,” which in this parlance describes minor misalignments of the vertebrae or ribs, in contrast to the standard medical definition of a partial dislocation. However, the idea that one is “putting back into place” a rib or a vertebra has amassed criticism. More likely, the sudden forces applied to a joint incite a volley of mechanoreceptor firing and create conditions that may restore joint motion, safely or unsafely. No one chiropractic technique has been shown to be superior to another, and as aforementioned, little to no chiropractic research is available on animals, so safety and effectiveness remain in question.


Limited data exist for chiropractic in dogs, cats, or horses. This has not stopped animal chiropractors and their veterinary proponents from promoting chiropractic for a gamut of problems including idiopathic lameness, intervertebral disc disease, wobbler syndrome/cervical vertebral insufficiency, spondylosis, cauda equina syndrome, urinary incontinence, neuropathies, postsurgical rehabilitation, trauma, and organ pathology (Taylor and Romano 1999; American Veterinary Chiropractic Association 2021). However, many of these conditions may constitute contraindications.


Contraindications for chiropractic include conditions that weaken bone or other structural elements such that applying a rapid thrust to a vulnerable spine or limb could lead to serious injury. Examples include deossifying or destabilizing conditions such as hyperadrenocorticism, neoplasia, secondary renal hyperparathyroidism, degenerative joint disease, and disc disease.

Adverse Effects

The way that an “animal chiropractor” or “animal adjuster” performs the therapy on an animal varies widely. They may only use their hands or rely on a mechanical device. Force may be minimal or much greater, as when a chiropractor “adjusts” a horse with a mallet and a block of wood. Excessive pressure from forceful thrusts of chiropractic has the potential to injure organs, vessels, neural tissue, and/or bones (Swait and Finch 2017).

Injuries from chiropractic usually result from trauma to the spinal cord or brain that arise from blood vessels, discs, or nervous tissue that have been damaged with the thrust (Boucher and Robidoux 2014). Human neurological and neurosurgical reports have revealed an association between stroke and upper cervical manipulation (Turner et al. 2018). The mechanism of injury often involves arterial dissection or spasm (Gomez-Rojas et al. 2020). The author has been informed about anecdotal incidents involving horses being injured and expiring following cervical spinal adjustments.


In addition to the risk of injury, the lack of a clear mechanism of action, and unknown effectiveness, controversy arises from the fact that manual therapies may be delivered by nonveterinarians. While scope of practice challenges apply to every other treatment mentioned in this chapter, the damage that chiropractic can do to an animal supersedes most other IM care.

Furthermore, nonveterinarians’ lack of familiarity with animal behavior, with veterinary medicine and zoonotic diseases, and proper restraint techniques can pose risks to therapists, bystanders, and patients. Lay chiropractors, specifically, may not have suitable liability insurance coverage for such incidents, exposing the veterinarian supervising their work to unexpected malpractice claims. Finally, one must consider, as with Traditional Chinese Veterinary Medicine (TCVM), whether veterinary schools should teach IVM methods that lack evidence of safety and effectiveness. This includes chiropractic.


Photomedicine involves the application of light to the body to support healing and lessen pain. Photomedicine devices may deliver the light as a laser beam (“laser therapy”) or light-emitting diodes (LEDs). As with acupuncture and massage, laser therapy provides analgesia, myofascial relaxation, and circulatory support. In contrast to the physical stimulation of needling and hands-on therapy, photomedicine accomplishes its healing influences through photons that act on cells. Therefore, treatment effectiveness and the types of responses seen depend heavily on if and how light enters living tissue.

Mechanism of Action

For tissue to absorb light and alter its physiology, a photochemical or photobiologic event must take place. A “photoacceptor” molecule, also known as a “chromophore,” responds to light by initiating a series of physiologic responses. When a chromophore (such as cytochrome c oxidase in the mitochondrial respiratory chain) absorbs a photon, a series of reactions takes place that influence oxidative states, tissue growth, circulation, and various signaling pathways related to phenomena such as the modulation of immunologic and inflammatory responses (Chung et al. 2012; Mokmeli and Vetrici 2020). The term “photobiomodulation” describes these events, incorporating in its name the impact of photons on the individual’s biology, with the outcome of modulating, or normalizing, physiologic states.


Photomedicine, whether with laser therapy or LEDs, has shown effectiveness for the following conditions in humans and experimental animals:

  • Musculoskeletal pain (postsurgical, sports injury, fracture, etc.) (Gendron and Hamblin 2019);
  • Inflammation and edema (e.g. mastitis, otitis, soft tissue trauma, etc.) (Hamblin 2017);
  • Joint disease (cranial cruciate ligament disease or injury, arthritis, elbow dysfunction, etc.) (Al Rashoud et al. 2014);
  • Wound healing, especially when delayed (Tatnatsu-Rocha et al. 2016);
  • Alopecia (Avci et al. 2014);
  • Central nervous system injury and degeneration (Hashmi et al. 2010);
  • Peripheral nerve injury (Sasso et al. 2020);
  • Internal organ dysfunction (Liebert et al. 2017);
  • Oral mucositis in cancer patients (Zadik et al. 2019).


One should avoid applying laser therapy to a neoplastic or malignant tumor, a hyperactive thyroid gland, areas of active hemorrhage, the eye, and the pregnant uterus. Laser is also contraindicated in cases of lymphoma and for patients on immunosuppressive medications as laser therapy has immunostimulatory effects. In immature patients, higher-powered laser therapy devices may stimulate premature closure of epiphyses. This caution is warranted over long bones in animals less than one year old. For patients on photosensitizing pharmaceuticals or botanicals, treatment intensity should be lowered. For example, photosensitizing agents such as hypericin in Saint John’s wort may augment the dermatologic impact of laser light (Cotterill 2009).

Adverse Effects

The main risks of laser therapy pertain to eye damage and thermal burns. Laser light can damage the retina and other components of the eye. Laser goggles, too frequently omitted for those in the vicinity, protect against indirect exposure but not direct. Tattoos, when lasered, can become extremely painful due to the absorption of light and the generation of heat at the tattoo site. Questions remain about the ability of laser therapy to stimulate neoplastic growth and if so at what wavelengths and powers.


Questions remain about proper “dosing” of light in nonhuman species, as well as the long-term safety of high-powered treatment such as that delivered by Class IV units in veterinary medicine. Too few users (veterinarians and veterinary technicians) understand the scientific basis of photobiomodulation and the different tissue responses to a spectrum of wavelengths, pulsing regimens, and other treatment parameters. They default to a “point and shoot” approach, aware of little more than how to turn on the machine and where to aim the applicator. This does a disservice to animals, who may experience thermal burn or vision loss from an improperly applied beam (Ma et al. 2019).

Botanical Medicine

Herbal (botanical) medicine refers to the practice of prescribing plant products for the treatment of disease. Herbal medicine is one of the oldest forms of treatment; even animals self-medicate with plants. Some researchers have suggested exploring how and why animals self-medicate to elucidate ways that humans might also derive benefits and discover novel treatments for problems such as cancer (Dominguez-Martin et al. 2020).

The indications, contraindications, and adverse effects of botanical medicine would directly correspond to their pharmacologic actions, dose administered, herb–drug interactions, manufacturing quality or lack thereof, patient health or illness, and more.

Evidential support concerning use of plant products in veterinary patients remains scarce (Shmalberg et al. 2019b). Consequently, for veterinarians who seek a science-based rationale for their botanical recommendations, one tends to make inferences from human studies, realizing the risks and limitations of doing so. However, one area of veterinary herbal research, i.e. cannabis-derived hemp extracts, is expanding rapidly (Cital et al. 2021). Indications including pain management, mechanisms of action, guidelines for quality control verification, and doses are becoming available. In fact, laws are beginning to change to allow veterinarians to discuss and/or prescribe products such as cannabidiol (CBD) (Nolen 2021).

On the other hand, while practitioners apparently feel quite comfortable recommending a Chinese herb called Yunnan Paiyao to prevent hemorrhage, little rigorous research exists to support this practice (Robinson 2016). Nonetheless, one can earn a certification in Traditional Chinese Veterinary Herbal Medicine (TCVHM) wherein one can make diagnoses and select remedies based heavily on folkloric assessments such as tongue and pulse diagnosis. Both methods lack validation and reliability across all species, including human.

Additional Controversies with TCVHM

Chinese herbal mixtures may contain endangered flora or fauna (Cheung et al. 2020) as well as insects, worms, heavy metals, undisclosed pharmaceuticals (St-Onge et al. 2015), and a host of other undesirable ingredients (Bi et al. 2020). Some TCVHM remedies contain undisclosed quantities of herbal strychnine (a potent neurotoxin) or aconite (both cardiotoxic and neurotoxic). The identity and/or amount of each constituent in a product may be kept secret by the manufacturer. Proprietary compounds put patients and practitioners at risk because the veterinarian has no knowledge of the full list or amount of ingredients in a product. This violates the American Veterinary Medical Association (AVMA) Principles of Veterinary Medical Ethics (PVME), which advise against recommending or prescribing products with secret ingredients: “Veterinarians shall not promote, sell, prescribe, dispense, or use secret remedies or any other product for which they do not know the ingredients” (AVMA n.d).

When manufacturers keep their recipes secret, this raises the possibility of liability and injury if the patient or a human in the household (toddler, etc.) ingests tablets with an unknown quantity of highly toxic ingredients. This becomes even more problematic when the label lists strychnine and aconite by their Pinyin, rather than English, names, thereby disguising the nature of the bottle’s contents.

Chinese “herbal” medicine is actually a misnomer, as Chinese “herbs” may not be derived from plants at all. Animal-based ingredients such as testis, penis, placenta, and horn found in Chinese herbal medicines harbor potential for zoonotic disease transmission. In addition to health concerns, products from animals in Chinese so-called “herbs” contribute significantly to animal mistreatment and the endangerment of species such as the tiger and rhinoceros. The benefits of these illegally derived compounds are unproven and typically folkloric, exacerbating the misery caused by wildlife poaching and trafficking in Asia and Africa.


Homeopathy is a practice initiated in the late eighteenth century by the German physician Samuel Hahnemann. Hahnemann based homeopathy on the notion that “like cures like” (National Center for Complementary and Integrative Health 2021). He posited that a small amount of a substance could cure the symptoms a patient was showing that that very same substance would produce, if provided in larger amounts.

Mechanism of Action

No known, or even credible mechanisms of action exist by which extremely dilute homeopathic preparations might have a therapeutic effect. Indeed, researchers struggle to convincingly demonstrate clinical differences between homeopathic remedies and placebo in rigorously designed studies (Doehring and Sundrum 2016; Cukaci et al. 2020). As a result, most authorities consider that any clinical outcomes obtained from homeopathic remedies are based on a placebo effect.

Indications and Contraindications

Although largely unsupported by research, homeopaths contend that their remedies can benefit patients with almost any condition, including cancer, despite having little to no rigorous research to support their claims. We should not be asking what homeopathy should or shouldn’t be used for: instead, we should ask why anyone is using this in animals at all (AVMA 2013, 2017).

Adverse Effects

The most likely adverse effect of homeopathy would be delay of proper diagnosis and treatment, as those who practice “classical” homeopathy advise against mixing the “subtle healing energies” of the remedy-coated sugar pills with pharmaceuticals or other healing interventions. This type of mindset lands homeopathy in the alternative medicine camp rather than IVM, in that it dissuades combining techniques to give the animal the best chance of recovery.


Ethical questions arise when practitioners prescribe unapproved and untested homeopathic remedies for animals who are ill, infectious, and/or painful. It is unethical and misleading to offer an ineffective treatment to patients and their caregivers. The unscientific premise of homeopathy calls into question its legitimacy.

Regulatory and Legal Concerns

Each year, states and provinces across the United States and Canada, respectively, face pressure to allow nonveterinarian healthcare providers direct access to animals. These practitioners range from chiropractors and acupuncturists to massage therapists and physical therapists. Too often, laws change to grant these rights before veterinary medical associations can organize an effort to stop the process. In 2019, the AVMA updated an overview of scope of practice laws regarding CAVM and other practice act exemptions (AVMA 2021). Keep in mind that rarely does a practice act become more restrictive. Instead, the ingress of human practitioners into companion animal and equine practice steadily grows.

Sometimes, this arrangement represents a compromise between the human profession (in this case, chiropractic) and the veterinary profession’s representatives in the state in which the change in law is up for debate. Some veterinarians would prefer not to relax laws and allow nonveterinarians to work on animals without direct supervision, citing issues of potential problems such as misdiagnosis and maltreatment. Others welcome more providers to treat animals: they may feel that animals are underserved (a claim that chiropractors have been known to make) and that clients should have the “right” to seek whatever types of treatments and practitioners they want to treat their animals (another contention made by chiropractors to state regulatory authorities).

Chiropractors will also cite “restraint of trade” when pushing to gain entry to animal work – the same argument they lodged successfully against the American Medical Association in the mid-twentieth century. However, several differences exist between treating humans as a human-trained healthcare provider and demanding access to nonhumans. Obviously, the human biped’s form and function differ from the horse, dog, and cat. Moreover, nonhumans experience a wide range of diseases and injuries that veterinarians learn how to diagnose and treat, but chiropractors do not. With practically no studies on the safety and effectiveness of chiropractic manipulation in nonhumans, how can one argue that animals will benefit and not be injured? (And how can veterinary schools allow faculty to practice and promote chiropractic when they are precisely the ones who should be performing research to test these approaches before instituting them in a veterinary teaching hospital?)

In some instances, as with chiropractic, for example, states may require a special “certification” that requires a human chiropractor to have satisfied requirements from a self-proclaimed certifying body. They may have to attend a specific number of hours of coursework, complete testing by an “approved” course, and agree to practice in accordance with the guidelines set forth by the certifying body and the state board of chiropractic. So, what is “certification”? Essentially, anyone can “certify” anyone in anything. On the one hand, dedicating 50–150 hours to learning a rational, evidence-informed technique such as medical acupuncture has a science-based foundation as strong as many other practices taught to veterinarians during their professional school years. On the other hand, one can spend five minutes on the internet and obtain certification as a Reiki (energy healing) master. In their work, they may claim to connect with an animal’s “spirit” guides. This involves “interspecies telepathic communication” as the Reiki master “listens” to what the patient communicates to them. If the animal “dislikes” taking antiepileptic medication every day, for example, the practitioner may relay this to the client, who then has a quandary. Do they listen to what the animal “wants” or rely on their primary care veterinarian’s recommendations?

Thus, while a veterinarian’s license to practice veterinary medicine usually allows them to include IVM, more nonveterinarians are gaining access to treating animals by applying continual pressure to state regulatory authorities. Legislators may possess little background in science and animal healthcare, so arguments made by veterinarians about the need to protect the health and safety of veterinary patients may make little impact. Even state veterinary boards may seem ineffectual to resist the ongoing onslaught of human healthcare providers in this regard. Their “customer” is the consumer, and veterinarians that volunteer their time to serve on the state board have limited capacity to resist organized assaults on the state’s practice act, at least over time. This explains why, in jurisdiction after jurisdiction, more nonveterinarians are advertising their nonhuman work. They may make unjustified claims and try to convince the public that they are the true experts in each modality. Veterinarians who seek training or “certification” from courses taught by these human healthcare providers (such as chiropractors) who are seeking more rights to work with animals lend credence to these practices.

Changing laws to ease access to animals by nonveterinarians may invite a host of unintended consequences. With chiropractic, for example, beyond the wide array of manipulative approaches they may apply to an animal, they may make nutritional recommendations, sell clients supplements for the animal, discourage vaccines, and perform their own kind of “diagnosis,” which they disguise by using a term, “functional neurology.” Functional neurology represents a means by which they employ a surrogate (often the client) to touch the animal. With the client touching the animal, the chiropractor tests the strength of the client’s deltoid muscle of the other outstretched arm. This supposedly indicates the vitality of an “energy circuit” going through the animal to the client. The chiropractor may ask the client to hold a vial that has a supplement (nutraceutical) or vitamin. If the client can resist the chiropractor’s downward pressure on the outstretched arm, that reflects strengthened “energy” and the chiropractor will recommend that the client purchase that supplement. While this scenario sounds outlandish, this method of selling supplements has existed for decades within the chiropractic profession.

So, what if problems arise related to IM, whether one holds a veterinary license or not? What if a client makes a complaint to the state veterinary board or pursues other legal recourse? As stated by Pugliese et al. (2019), “In veterinary malpractice litigation, standards of care expressed in guideline statements could influence the civil and penal courts in the decision-making process.” However, they also indicate, “Despite their popularity, clinical practice guidelines (CPGs) are not used often in clinical practice and their use remains controversial.” Furthermore, “The majority of CPGs are based on trials considering homogenous populations.” In veterinary medicine this is a limiting factor in their application, because in clinical practice, patients are rarely homogenous (i.e. species, breed, body weight, etc.). This author would also add that those who develop CPGs may, like many veterinary healthcare professionals, lack an adequate understanding of what IVM is, the pitfalls of unscientific practices, and how a rational IVM approach to a clinical condition may provide superior results, even if the evidence is only now emerging. As such, an implicit bias against IVM practice may exist based on lack of knowledge about the discipline’s complexity and those modalities that do meet scientific muster.

In a commentary, “A new look at standard of care,” Block (2018) exposes the fluidity and confusion surrounding what standard of care (SOC) constitutes. He cites a definition from 1837, one of the oldest legal references available, as what “an individual under a duty of care must have proceeded with such reasonable caution as a prudent man would have exercised under such circumstances” (Vaughan vs. Menlove, cited in Block 2018). By 1966, in veterinary case law, Block recounts the SOC definition as “the standard of care required of and practiced by the average reasonably prudent, competent veterinarian in the community” (Dyess vs. Caraway, cited in Block 2018). He notes that one court emphasized that SOC fails to outline clear, practical, clinically relevant recommendations and instead alludes to what the average practitioner would do – not the best or the most well-informed. As such, SOC does not constitute “best practices,” the “gold standard,” or “ideal care.” Instead, SOC compares a veterinarian’s action to prevailing community standards. In other words, SOC can vary according to geography, and not on scientific or evidential reasoning. Focusing too much attention on SOC, rather than quality of care, could put animal health and welfare in jeopardy. In this case, “majority rule,” as opposed to factual analysis, may exert a downward pressure on practice standards and keep outdated, unnecessarily invasive procedures in place when equally or more effective IVM approaches warrant broader introduction into first-line care.

Consequently, veterinarians navigating the multimodal field of IVM face a steep challenge when designing documents on informed consent (see Chapter 5). Listing every potential benefit and adverse effect for each modality offered, for the specific condition(s) an animal has, may quickly become insurmountable. That said, it is unlikely that many/any veterinarians also list all the potential complications of the TPLO, or present the comparative, evidence-based outcomes of a surgical vs. nonsurgical approach to presumed cranial cruciate ligament injury.

Ethical Aspects

While veterinarians have responsibilities to meet standards of accountability to their patients, clients, society, public health, and the profession, do human healthcare professionals who push to legally work with animals? And who writes these standards, publishes them, with what biases, industry connections and conflicts of interest, and based on what evidence? In fact, the term “evidence-based medicine” is glaringly absent from the AVMA PVME (AVMA n.d.).

“Allopathic” practitioners often press veterinary IVM providers for more research proof. However, does the veterinary profession expect the same degree of evidence from them, for their “conventional” treatments involving drugs and surgery? A recent commentary notes a lack of such standards for many common invasive procedures (Vigano et al. 2019):

What’s the strongest evidence in surgery? The lack of evidences [sic] to guide practice. Several justifications have been advanced, including difficulty randomizing patients for surgical interventions, large benefits from innovative procedures that do not need confirmation, and peculiarities of surgical patients that preclude applicability of any fixed rule. In this scientific anomaly, surgical education became studded with myths that inappropriately gained the rank of evidences [sic].

The veterinary profession has little evidence to support many of its routine practices. Rarely do surgeons select techniques based on double-blind, controlled studies. Furthermore, how forthcoming are veterinary school faculty members about the funding they receive from pharmaceutical or surgical supply companies, and how do these affiliations impact what they teach?

Potential for “Opportunism”

Some critics have suggested that IVM practitioners may be opportunistic when offering clients treatments that support comfort, quality of life, and mobility near the end of life. This represents a narrow and uninformed view of what IVM care offers and what motivates IVM practitioners. The evidence for IM benefits (Kogan et al. 2017) throughout the life cycle and especially in a hospice setting underscores the value of having these methods available for clients to improve their animal’s welfare in the last months of life and aid owners in preparing for end-of-life decisions. In many areas of the country, IVM has become so popular and sought after that veterinarians find their practices overbooked: they are not seeking to add “hopeless” cases to their rosters.

Instead, though, we might ask what constitutes a “hopeless” case. Is this a patient for whom medications and surgery were tried and didn’t work? If so, could other healing methods have produced better outcomes? Why weren’t they offered earlier? If we are to provide a balanced view of the ethics of IVM, then the notion that drugs and surgery are “legitimate” whenever offered and that promoting IVM is “opportunistic” and “baseless” needs to shift and is doing so.

To wit: more clients are seeking nonsurgical approaches for their animals with IVDD and cranial cruciate ligament degeneration. While “doing nothing” is an option for both approaches, and some animals recover spontaneously, most suffer from ongoing pain and debility that IVM could successfully address in several ways. For both conditions, IVM eliminates the risk of surgical complications and euthanasia from failed surgery. And yet, in many settings, clients are not even informed about IVM options (Case Study 16.1).

Oct 22, 2022 | Posted by in GENERAL | Comments Off on Integrative Medicine

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