ABPS Integrative Medicine cheat sheet

Integrative medicine combines conventional and evidence-informed complementary approaches, emphasizing the whole person, relationship, and shared decision-making.

The biopsychosocial model holds that biological, psychological, and social factors jointly determine health and illness.

Placebo and nocebo effects are measurable physiologic phenomena; expectation, conditioning, and context modulate outcomes in all interventions.

Salutogenesis (Antonovsky) centers on health-promoting resources and a sense of coherence rather than disease pathogenesis alone.

The therapeutic alliance is a modifiable variable correlated with adherence and symptom outcomes across modalities.

Integrative care is complementary (used alongside conventional care), not alternative (used instead of it).

Whole-systems research designs (e.g., pragmatic trials) evaluate multimodal care packages rather than isolated single ingredients.

Reductionist single-mechanism models often fail to capture multimodal interventions; mechanism and outcome evidence are assessed separately.

Energy density: 9 kcal/g fat, 4 kcal/g carbohydrate, 4 kcal/g protein, 7 kcal/g alcohol.

Mediterranean-style dietary pattern evidence is strongest for cardiovascular risk reduction among dietary patterns studied in RCTs.

Dietary reference intakes: RDA covers ~97.5% of healthy people; EAR is the median requirement; UL is the highest usual intake unlikely to cause harm.

Fiber target commonly cited: ~25-38 g/day for adults, adjusted by age and sex.

Supplements are regulated as foods (not drugs) in the US; efficacy need not be proven before marketing, but safety claims cannot be made.

Botanical standardization specifies a marker compound, not necessarily the active constituent; product variability across brands is substantial.

Key supplement-drug interactions: St. John's wort induces CYP3A4 and P-glycoprotein (reduces many drug levels); vitamin K antagonizes warfarin.

Potentially hepatotoxic botanicals include comfrey (pyrrolizidine alkaloids), kava, and high-dose green tea extract; monitor for liver injury signals.

Mind-body therapies include meditation, mindfulness-based stress reduction, yoga, tai chi, qigong, hypnosis, guided imagery, and biofeedback.

MBSR is a structured 8-week program with weekly group sessions and a day-long retreat; evidence supports reductions in perceived stress and anxiety.

Slow breathing at ~6 breaths/min increases heart rate variability via baroreflex and vagal modulation.

Cognitive behavioral therapy targets maladaptive cognitions and behaviors; effect sizes for chronic pain and insomnia are moderate and durable.

Biofeedback uses real-time physiologic signals (HRV, EMG, thermal) to train voluntary self-regulation.

Relaxation response (Benson) involves focused attention, passive attitude, and decreased sympathetic arousal.

Behavior change techniques with strongest evidence include self-monitoring, goal setting, action planning, and feedback on behavior.

Motivational interviewing is collaborative and directional, evoking the patient's own reasons for change; it is not confrontational.

Acupuncture needles are sterile, single-use, filiform; common depths 0.5-1.5 inches depending on site and body habitus.

Serious adverse events are rare; pneumothorax, infection, and needling injury are the principal risks with improper technique.

Anticoagulation and bleeding disorders raise bleeding risk; needle count and depth should be minimized.

De qi refers to the characteristic needling sensation (aching, heaviness, distension) often sought in traditional practice.

Traditional theory describes qi, yin-yang, five phases, zang-fu organs, and meridians; these are explanatory models, not validated anatomy.

Systematic reviews show acupuncture outperforms sham for some pain conditions but effect sizes are small and heterogeneity is high.

Electroacupuncture applies low-frequency (2-10 Hz) or high-frequency (50-100 Hz) current; frequency alters endogenous opioid release patterns in animal models.

Moxibustion burns Artemisia; smoke exposure is a concern for patients with respiratory disease.

Manual therapies include spinal manipulation, mobilization, massage, osteopathic manipulative treatment, and myofascial release.

Spinal manipulation carries a rare risk of vertebral artery dissection with cervical manipulation; incidence estimates are low but debated.

Red flags before manual therapy: fracture, infection, malignancy, cauda equina syndrome, progressive neurologic deficit.

Massage modalities: Swedish (effleurage, petrissage), deep tissue, trigger point, lymphatic drainage, and myofascial release.

Osteopathic cranial manipulation lacks robust evidence for its proposed cranial motion mechanism; evidence for efficacy is limited.

Manual therapy is best framed as an adjunct to active exercise and education for musculoskeletal pain.

Lymphatic drainage uses light pressure (superficial) to mobilize edema; contraindicated in decompensated heart failure and acute infection.

Physical activity guideline: 150-300 min/week moderate or 75-150 min/week vigorous aerobic activity plus 2+ days/week muscle strengthening.

Tobacco cessation: combination pharmacotherapy (varenicline or NRT) plus counseling yields the highest quit rates.

The 5 A's: Ask, Advise, Assess, Assist, Arrange; the 5 R's address motivation (Relevance, Risks, Rewards, Roadblocks, Repetition).

USPSTF screening examples: colorectal cancer from age 45, cervical cancer from 21, mammography from 40-74 (biennial).

Sleep recommendation for adults: 7-9 hours per night; short sleep is associated with cardiometabolic risk.

Alcohol: no universally safe level; risk increases with dose; screening with AUDIT-C is standard.

Transtheoretical model stages: precontemplation, contemplation, preparation, action, maintenance, (termination).

Social determinants (income, housing, food security, education) are strong predictors of preventive behavior uptake.

Chronic pain is best managed with a biopsychosocial, multimodal plan combining exercise, CBT, sleep, and selected complementary modalities.

Opioid-sparing strategies include NSAIDs, duloxetine, gabapentinoids, physical therapy, and behavioral therapy.

Low back pain guidelines favor nonpharmacologic care (exercise, CBT, spinal manipulation, yoga) before opioids.

Fibromyalgia evidence supports exercise, CBT, duloxetine, milnacipran, pregabalin, and selected mind-body therapies.

Migraine prevention: lifestyle regularity, selected supplements (magnesium, riboflavin, CoQ10), and prescription preventives.

Cardiovascular risk reduction integrates diet, exercise, stress management, and adherence to statins/antihypertensives.

Type 2 diabetes: lifestyle change with 5-7% weight loss reduces progression from prediabetes in landmark trials.

Integrative oncology uses acupuncture for chemotherapy-induced nausea and mind-body therapies for anxiety and fatigue as supportive adjuncts.

Pregnancy: avoid high-dose vitamin A (teratogenic), many botanicals, and unnecessary medications; folic acid 400-800 mcg preconception.

Nausea of pregnancy: ginger, vitamin B6, and doxylamine are commonly used first-line options.

Menopause: hormone therapy is the most effective treatment for vasomotor symptoms; individualized risk-benefit assessment applies.

Lactation: many herbs transfer into milk; consult lactation databases; avoid unsafe botanicals.

Pediatric use of supplements and botanicals requires weight-based dosing and caution about contaminants.

Older adults: polypharmacy raises herb-drug interaction risk; screen all supplements at each visit.

Feverfew and butterbur have limited evidence for migraine prophylaxis; butterbur requires PA-free products due to hepatotoxicity.

Perimenopausal sleep and mood symptoms respond to CBT-I and behavioral interventions.

Evidence hierarchy: systematic reviews/meta-analyses > RCTs > cohort > case-control > case series > expert opinion.

Randomization reduces selection bias; blinding reduces performance and detection bias; intention-to-treat preserves randomization.

Absolute risk reduction = control event rate minus intervention event rate; NNT = 1/ARR.

Specificity rules in a positive test (few false positives); sensitivity rules out disease when negative.

Publication bias overestimates effects; funnel plots and trial registries help detect it.

Adverse event reporting: use structured systems (e.g., NCCIH, MedWatch); causality assessment uses tools such as Naranjo.

P-value is the probability of data given the null, not the probability the null is true.

Confidence intervals convey precision; wide intervals indicate imprecision and weak inference.

US supplement regulation: DSHEA (1994) governs labeling; FDA acts after marketing for safety issues.

Adverse event reporting for supplements goes to FDA MedWatch; manufacturers must report serious events.

Informed consent requires disclosure of risks, benefits, alternatives, and the patient's right to refuse.

Scope of practice is defined by state licensure laws; credentialing varies by profession and jurisdiction.

Interprofessional collaboration: shared goals, role clarity, closed-loop communication, and mutual respect.

Conflicts of interest must be disclosed; industry funding can bias research and guideline development.

Cultural humility and shared decision-making improve equity and adherence.

Documentation should capture supplements, doses, and complementary therapies in the medication record.

Integrative medicine combines conventional and evidence-informed complementary approaches, emphasizing the whole person, relationship, and shared decision-making.

The biopsychosocial model holds that biological, psychological, and social factors jointly determine health and illness.

Placebo and nocebo effects are measurable physiologic phenomena; expectation, conditioning, and context modulate outcomes in all interventions.

Salutogenesis (Antonovsky) centers on health-promoting resources and a sense of coherence rather than disease pathogenesis alone.

The therapeutic alliance is a modifiable variable correlated with adherence and symptom outcomes across modalities.

Integrative care is complementary (used alongside conventional care), not alternative (used instead of it).

Whole-systems research designs (e.g., pragmatic trials) evaluate multimodal care packages rather than isolated single ingredients.

Reductionist single-mechanism models often fail to capture multimodal interventions; mechanism and outcome evidence are assessed separately.

Energy density: 9 kcal/g fat, 4 kcal/g carbohydrate, 4 kcal/g protein, 7 kcal/g alcohol.

Mediterranean-style dietary pattern evidence is strongest for cardiovascular risk reduction among dietary patterns studied in RCTs.

Dietary reference intakes: RDA covers ~97.5% of healthy people; EAR is the median requirement; UL is the highest usual intake unlikely to cause harm.

Fiber target commonly cited: ~25-38 g/day for adults, adjusted by age and sex.

Supplements are regulated as foods (not drugs) in the US; efficacy need not be proven before marketing, but safety claims cannot be made.

Botanical standardization specifies a marker compound, not necessarily the active constituent; product variability across brands is substantial.

Key supplement-drug interactions: St. John's wort induces CYP3A4 and P-glycoprotein (reduces many drug levels); vitamin K antagonizes warfarin.

Potentially hepatotoxic botanicals include comfrey (pyrrolizidine alkaloids), kava, and high-dose green tea extract; monitor for liver injury signals.

Mind-body therapies include meditation, mindfulness-based stress reduction, yoga, tai chi, qigong, hypnosis, guided imagery, and biofeedback.

MBSR is a structured 8-week program with weekly group sessions and a day-long retreat; evidence supports reductions in perceived stress and anxiety.

Slow breathing at ~6 breaths/min increases heart rate variability via baroreflex and vagal modulation.

Cognitive behavioral therapy targets maladaptive cognitions and behaviors; effect sizes for chronic pain and insomnia are moderate and durable.

Biofeedback uses real-time physiologic signals (HRV, EMG, thermal) to train voluntary self-regulation.

Relaxation response (Benson) involves focused attention, passive attitude, and decreased sympathetic arousal.

Behavior change techniques with strongest evidence include self-monitoring, goal setting, action planning, and feedback on behavior.

Motivational interviewing is collaborative and directional, evoking the patient's own reasons for change; it is not confrontational.

Acupuncture needles are sterile, single-use, filiform; common depths 0.5-1.5 inches depending on site and body habitus.

Serious adverse events are rare; pneumothorax, infection, and needling injury are the principal risks with improper technique.

Anticoagulation and bleeding disorders raise bleeding risk; needle count and depth should be minimized.

De qi refers to the characteristic needling sensation (aching, heaviness, distension) often sought in traditional practice.

Traditional theory describes qi, yin-yang, five phases, zang-fu organs, and meridians; these are explanatory models, not validated anatomy.

Systematic reviews show acupuncture outperforms sham for some pain conditions but effect sizes are small and heterogeneity is high.

Electroacupuncture applies low-frequency (2-10 Hz) or high-frequency (50-100 Hz) current; frequency alters endogenous opioid release patterns in animal models.

Moxibustion burns Artemisia; smoke exposure is a concern for patients with respiratory disease.

Manual therapies include spinal manipulation, mobilization, massage, osteopathic manipulative treatment, and myofascial release.

Spinal manipulation carries a rare risk of vertebral artery dissection with cervical manipulation; incidence estimates are low but debated.

Red flags before manual therapy: fracture, infection, malignancy, cauda equina syndrome, progressive neurologic deficit.

Massage modalities: Swedish (effleurage, petrissage), deep tissue, trigger point, lymphatic drainage, and myofascial release.

Osteopathic cranial manipulation lacks robust evidence for its proposed cranial motion mechanism; evidence for efficacy is limited.

Manual therapy is best framed as an adjunct to active exercise and education for musculoskeletal pain.

Lymphatic drainage uses light pressure (superficial) to mobilize edema; contraindicated in decompensated heart failure and acute infection.

Physical activity guideline: 150-300 min/week moderate or 75-150 min/week vigorous aerobic activity plus 2+ days/week muscle strengthening.

Tobacco cessation: combination pharmacotherapy (varenicline or NRT) plus counseling yields the highest quit rates.

The 5 A's: Ask, Advise, Assess, Assist, Arrange; the 5 R's address motivation (Relevance, Risks, Rewards, Roadblocks, Repetition).

USPSTF screening examples: colorectal cancer from age 45, cervical cancer from 21, mammography from 40-74 (biennial).

Sleep recommendation for adults: 7-9 hours per night; short sleep is associated with cardiometabolic risk.

Alcohol: no universally safe level; risk increases with dose; screening with AUDIT-C is standard.

Transtheoretical model stages: precontemplation, contemplation, preparation, action, maintenance, (termination).

Social determinants (income, housing, food security, education) are strong predictors of preventive behavior uptake.

Chronic pain is best managed with a biopsychosocial, multimodal plan combining exercise, CBT, sleep, and selected complementary modalities.

Opioid-sparing strategies include NSAIDs, duloxetine, gabapentinoids, physical therapy, and behavioral therapy.

Low back pain guidelines favor nonpharmacologic care (exercise, CBT, spinal manipulation, yoga) before opioids.

Fibromyalgia evidence supports exercise, CBT, duloxetine, milnacipran, pregabalin, and selected mind-body therapies.

Migraine prevention: lifestyle regularity, selected supplements (magnesium, riboflavin, CoQ10), and prescription preventives.

Cardiovascular risk reduction integrates diet, exercise, stress management, and adherence to statins/antihypertensives.

Type 2 diabetes: lifestyle change with 5-7% weight loss reduces progression from prediabetes in landmark trials.

Integrative oncology uses acupuncture for chemotherapy-induced nausea and mind-body therapies for anxiety and fatigue as supportive adjuncts.

Pregnancy: avoid high-dose vitamin A (teratogenic), many botanicals, and unnecessary medications; folic acid 400-800 mcg preconception.

Nausea of pregnancy: ginger, vitamin B6, and doxylamine are commonly used first-line options.

Menopause: hormone therapy is the most effective treatment for vasomotor symptoms; individualized risk-benefit assessment applies.

Lactation: many herbs transfer into milk; consult lactation databases; avoid unsafe botanicals.

Pediatric use of supplements and botanicals requires weight-based dosing and caution about contaminants.

Older adults: polypharmacy raises herb-drug interaction risk; screen all supplements at each visit.

Feverfew and butterbur have limited evidence for migraine prophylaxis; butterbur requires PA-free products due to hepatotoxicity.

Perimenopausal sleep and mood symptoms respond to CBT-I and behavioral interventions.

Evidence hierarchy: systematic reviews/meta-analyses > RCTs > cohort > case-control > case series > expert opinion.

Randomization reduces selection bias; blinding reduces performance and detection bias; intention-to-treat preserves randomization.

Absolute risk reduction = control event rate minus intervention event rate; NNT = 1/ARR.

Specificity rules in a positive test (few false positives); sensitivity rules out disease when negative.

Publication bias overestimates effects; funnel plots and trial registries help detect it.

Adverse event reporting: use structured systems (e.g., NCCIH, MedWatch); causality assessment uses tools such as Naranjo.

P-value is the probability of data given the null, not the probability the null is true.

Confidence intervals convey precision; wide intervals indicate imprecision and weak inference.

US supplement regulation: DSHEA (1994) governs labeling; FDA acts after marketing for safety issues.

Adverse event reporting for supplements goes to FDA MedWatch; manufacturers must report serious events.

Informed consent requires disclosure of risks, benefits, alternatives, and the patient's right to refuse.

Scope of practice is defined by state licensure laws; credentialing varies by profession and jurisdiction.

Interprofessional collaboration: shared goals, role clarity, closed-loop communication, and mutual respect.

Conflicts of interest must be disclosed; industry funding can bias research and guideline development.

Cultural humility and shared decision-making improve equity and adherence.

Documentation should capture supplements, doses, and complementary therapies in the medication record.