Alternative Modalities.docx

ALTERNATIVE MODALITIES OF CARE AND SYSTEM OF HEALTH INTRODUCTION A variety of terms have been used to describe health-related approaches that are considered outside the mainstream of the dominant system of health care. The terms currently used in Western cultures to describe such approaches include alternative, intergrative , nontraditional, unconventional ,holistic and natural.Currently ,the most frequently used term to refer to such modalities and practices is complementary and alternative therapies.

BASIC TERMS / CONCEPTS 

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Holism : It refers to the whole of the sick person including his mind , body,and the way of his living meaning that all these to considered while treating the sick person and not just the symptoms of the disease. Humanism : A system of thought that considers solving of the human problems with the help of religious beliefs. It emphasizes that the basic nature of humans is good. Balance: A situation in which all the things exist in equal , correct or good amount.

DEFINITIONS o Alternative/Complementary modalities have been defined as treatment techniques whose goals are to evoke healing, taking into account the body-mind-spirit connection of every individual . (Dossey,1995). o It is a group of diverse medical and health care system, practices, therapies and procedures that are not presently considered to be part of conventional medicine.

CLASSIFICATIONS According to the National Centre for Complementary and Alternative Medicine(NCCAM), Complementary and alternative medicine therapy is classified into following Categories :1. Whole Medical System o Ayurveda o Traditional Chinese Medicine (TCM) :Acupunture and acupressure o Unani o Siddha o Homeopathy o Naturopathy 2. Mind – body interventions o Meditation o Relaxation o Imagery o Biofeedback o Hypnosis

o Yoga o Aromatherapy 3. Biologically –based Therapies o Dietary supplements o Foods o Natural substances o Herbs o Vitamins 4. Manipulative and Body –based Methods o Chiropractic o Osteopathy o Massage o Tai chi 5. Energy Therapies o Biofield therapy o Bioelectromagnetic therapy 6. Other important modalities o Humor o Pet therapy o Music therapy o Hydrotherapy

1. WHOLE MEDICAL SYSTEM Alternative medical system involves complete methods of health- related theory and practice that have been developed within a specific culture. It includes the following:  AYURVEDAIt is a system of traditional medicine native to India and practiced in other parts of the world as a form of alternative medicine. In Sanskrit, the word ayurveda consists of the words ‘ayus’, meaning ‘longevity, and ‘veda’ meaning ‘related to knowledge’ or’ science.’ Its focus is on the balance of mind,body and spirit. Disease is viewed as an imbalance between a person’s life force (prana) and basic metabolic condition (dosha). Over the following centuries, ayurvedic practitioners developed a number of medicinal preparations and surgical procedures for the treatment of various ailments. Interventions used include diet, medicinal herbs, detoxification, breathing exercises, medication and yoga. Ayurveda stresses the use of plant-based medicines and treatments. Hundreds of plant –based medicines are employed, including cardamom and cinnamon. Some animal products may also be used ,for example, milk ,bones ,and gallstones . In addition, fats are used both for consumption and for external use. Minerals, including

sulfur, arsenic, lead ,copper sulfate and gold are also consumed as prescribed. This practice of adding minerals to herbal medicine is known as rasa shastra.

 UNANI Unani Medicine is based on the Greece philosophy. According to Basic Principles of Unani, the body is made up of the four basic elements, i.e. Earth, Air,Water,Fire which have different Temperaments,i.e. Cold ,Hot,Wet ,Dry.  Treatment dependent on the Temperament (Mizaj) ,hereditary effects, signs and symptoms, external observation, examination of the pulse (Nubz),urine and stool.  Dietotherapy (ilaj- bil- Ghiza), Climate therapy (Ilaj- bil- Hawa), regimental therapy (Ilaj-bit-Tadbir;includes venesection,diaphoresis,dieresis,massage,cauterization,emesis,exercise).  Pharmacotherapy (Ilaj –bid –Dawa) :Local herbal drugs.Only minor surgery is in vogue in this system.

 TRADITIONAL CHINESE MEDICATION (TCM) It is one of the most comprehensive medical systems. Practitioners of TCM view human beings in terms of five dimensions. These include Qi (energy resulting from interaction between Yin (cold, heavy,moist and negative) and Yang (hot ,dry, light and positive),Jing (genetic material of physical body),Shen (spirit),blood and Yin Ye fluids (lubricates the organs) . Additionally, the body is considered to be a series of energetic pathways known as Meridian system. Specific points along the pathways referred to as acupoints. Treatment includes acupuncture, Chinese herbal medicines ,diet, therapy,exercise and meditation.The most commonly used is acupuncture.

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ACUPUNTURE: It is an alternative medicine that treats patients by insertion and manipulation of needles in the body.Its proponents variously claim that it relieves pain,treats infertility,treats disease,prevents disease,promotes general health,or can be used for therapeutic purposes.The term ‘acupuncture’ is sometimes used to refer to insertion of needles at points other than traditional ones,or to applying an electric current to needles in acupuncture points. There are numerous theories about how acupuncture works:     

It stimulates the release of pain-relieving endorphins. It influences the release of neurotransmitters It influences the autonomic nervous system It stimulates circulation It influences the electrical currents of the body

Conditions that are benefitted from Acupuncture:     

Neurologic disorders:- migraine headaches,peripheral neuropathy and trigeminal neuralgia Gastroinstestinal disorders: Colitis ,constipation,gastritis,ulcers Respiratory conditions:- Asthma,Bronchitis,rhinitis Eye disorders :- Myopia,conjunctivitis Musculoskeletal disorders: Tennis elbow,sciatica

ACUPRESSURE:- It s an ancient healing art that uses the fingers to press key points on the surface of the skin to stimulate the body’s natural self-curative abilities.When these points are pressed,they release muscular tension and promote the circulation of blood and the body’s life force to aid healing.Acupunture and Acupressure use the same points,but acupuncture employs needles,while acupressure uses the gentle but firm pressure of hands(and even feet).  HOMEOPATHY Homeopthy is a form of alternative medicine in which practitioners trat patients using highly diluted preparations that are belived to cause healthy people to exhibit symptoms that are similar to those exhibited by the patient.The basic principle of homeopathy ,known as the “law of similar” is “let like be cured by like”.It was first stated by German Physician Samuel Hahnemann in 1976.His “law of similar “is taken on his word as an unproven assertion,and is not a true law of nature based on the scientific method. Homeopathic remedies are prepared by serial dilution with shaking by forceful striking on an elastic body,which homeopaths term succession.Each dilution followed by succession is assumed to increase the effectiveness.Homeopaths call this process potentization.Dilution often continues until none of the original substances remains.Aparts from the symptoms,homeopaths examine aspects of the patient’s physical and psychological state,then homeopathic reference books known as repertories are consulted,and a remedy is selected based on the totality of symptoms.  SIDDHA Siddha medicine is a form of medical treatment of diseases using substances of all possible origins in way that balances the possible harmful effect of each substance. This form of medicine was professed and practiced by siddhars who wrote their recipes on palm leaves for the use of future generations.Siddha medicine was developed by outstanding Dravidians(ancient Tamils),locally called Cittars. Preparations are made mainly out of the parts of the plants and trees such as leaves,bark,stem,root,etc, but includes also minerals and some animal substances. This form of medicine is still today well-known in South India. The use of metals like gold,silver and iron powders (Sanskrit bhasma) in some preparations is a special feature of siddha medicine,which claims it can detoxify metals to enable them to be used for stubborn diseases.This claim is especially relevant in the mercury which is relatively often used in the

system;medicine containing purified mercury should only be received ,if at all,from a highly qualified practitioner of the art.  NATUROPATHY Naturopathy is a system of man building in harmony with the constructive principles of Natureon physical,mental,moral and spiritual planes of living. According to the manifesto of British Naturopathic Association,”Naturopathy is a system of treatment which recognizes the existence of the vital curative force within the body.”It therefore ,advocates aiding human system to remove the cause of disease,i.e.toxins by expelling the unwanted and unused matters from human body for curing diseases.

2. MIND BODY INTERVENTION Mind-body medicine uses the power of thoughts and emotions to influence physical health.As Hippocrates once wrote,”The natural healing force within each one of us is the greatest force in getting well”.This is mind-body medicine in a nutshell. Methods by which an individual can, independently or with assistance, consciously control some functions of the sympathetic nervous system(e.g.heart rate, respiratory rate, blood pressure.) Leading mind-body technique are: a. Meditation It often involves invoking or cultivating a feeling or internal state, such as compassion,or attending to a specific focal point.Meditation is generally an internal,personal practice and done without any external involvement,except perhaps prayer beads to count prayers,though many practitioners of meditation may rely on external objects such as candle flames as points on which to focus their attention as an aid to the process.It is quieting of the mind by focusing attention on sound or image or own breathing. Health Benefits of Meditation include:           b.

Decreased respiration Decreased blood pressure Improved mood Heightened awareness Relaxation Improved functioning of the immune system Slowed heart rate Efficient and effective oxygen consumption Spiritual relief Reduced level of lactic acid Relaxation

Stands quite generally for a release of tension,a return to equilibrium .It is any method,process, procedure, or activity that helps a person to relax;to attain a state of

increased calmness;or otherwise to reduce levels of anxiety,stress or anger. Relaxation techniques are often employed as one element of a wider stress management program and can decrease muscle tension,lower the blood pressure and slow heart and breath rates,among other health benefits. It is therapeutic process incorporating the basic elements of meditation. Basic elements of relaxation technique are :    

A quit environment A comfortable position Focused attention A passive attitude, practice

It involves progressive muscle relaxation. Progressive relaxation is the alternate tensing and relaxing of muscles. Nurses can use relaxation techniques to reduce pain and stress in clients. c. Imagery A technique of using theimagination to visualize a smoothing,pleasant image.Benefits of this technique include: decreased physical tension,decreased anxiety,and decreased the adverse effects of chemotherapy. d. Biofeedback In this, people are trained to control certain bodily processes that normally occur involuntarily, such as heart rate or blood pressure.these processes can be measured and displayed on a monitor that the person watches. The monitor provides feedback about theinternal working of your body. You can then use this display to gain control over these “involuntary” activities lowering your blood pressure. It measures physiological responses such as muscle tension,skin temperature,and heart rate to improve health by using signals from client’s own body. It is effective for a number of conditions,including headaches,urinary incontinence,hypertension etc. e. Hypnosis The earliest definition of hypnosis was given by Braid,who coined the term” hypnotism” as an abbreviation for “neuro –hypnotism,or nervous sleep,which he opposed to normal sleep,and defined as:”a peculiar condition of the nervous system,induced by a fixed and abstracted attention of the mental and visual eye,on one object,not of an exciting nature. Therapeutic hypnosis: It induces an altered state of consciousness or awareness resembling sleep during which the person is more receptive to suggestion.Hypnosis also enhances clint’s ability to form images(for guided imagery). Uses of Hypnosis:  Pain management  Anesthesia

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Skin disease Habit control Quit smoking IBS Weight loss Smoothing anxious surgical patients Sports performance.

f. Yoga Traditional physical and mental disciplines in India.Sanskrit root “yuj” meaning “to control ,to unite,joining,uniting,conjunction and means.” Outside India ,yoga is typically associated with asanas(postures) or as a form of exercise. Goals – improving health to achieving moksha; liberation from all worldly suffering and the cycle of birth and death (samsara),at which point there is a realization of identity with the supreme Brahman. In Mahabharata,yoga is described as entering the world of brahma, as Brahman. g. Aromatherapy  Uses volatile plant materials (essential oils) and similar aromatic compounds for the purpose of improving a person’s mood,cognitive function or health.  Aroma therapist  Generic term; used by manufactures (of personal care and hygiene products),massage therapists,chiropractors,nurses and doctors.  OTC products that make use of essential oils (menthol) include mouthwashes,liniments and rubbing ointments (Vicks Vaporub)  Essential oils useful in the treatment of infectious disease  Used as medicines,with other herbal preparations,by doctors in France(commonly)  Used in pain management,anxiety/depression ,and Alzheimer’s disease.

3. BIOLOGICALLY- BASED THERAPIES Most common among the biologically –based therapies are:a. Diet Therapy According to this therapy,the food must be taken in natural form. Fresh seasonal fruits,fresh green leafy vegetables and sprouts are excellent. These diets are broadly classified into three thypes which are as follows: 

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Eliminative Diet o Liquids –Lemon ,Citric juices, Tender coconut water, Vegetable soups,Butter – milk etc. Smoothing Diet o Fruits,salads,Boiled /Steamed vegetables ,Sprouts,Vegetable chutney etc

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Constructive Diet o Wholesome flour, Unpolished rice, Little pulses,Sprouts,Curd etc.

Macrobiotic diet: Predominantly a vegan diet (no animal products except fish).Initially used in the management of a variety of cancers. Emphasis placed on whole cereal grains, vegetables and unprocessed foods. Orthomolecular medicines: Increased intake of nutrients such as Vitamin C and beta carotene. Diet used in treatment of cancer, schizophrenia and certain chronic diseases such as hypercholesterolemia and coronary artery disease. b. Ayurvedic Herbs Traditional Hindu system of herbs used for over 2000 years. The herbal products are used in the form of powder, tonic, etc. These could be a single herb or a mixture of many herbal products, depending on the disease and the treatment required. Some common herbal remedies include the following: o Garlic o Peppermint o Chamomile Phytochemicals: These are non-nutritive ,physiologically active compounds present in plants in very small amounts. They protect against cancer and prevent heart disease,stroke ,and cataracts. Main source for phytochemicals is fruits and vegetables. c. Antioxidants and Free Radicals Antioxidants: Substances that prevent or inhibit oxidation, a chemical process whereby a substance is joined to oxygen. Free radicals : Antioxidants prevent tissue damage related to these ,which are unstable molecules that alter genetic codes and trigger the development of cancer growth.

4. MANIPULATIVE AND BODY-BASED METHODS These methods use techniques of manipulating or moving various body parts to achieve therapeutic outcomes. It includes: Chiropractice: It emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders

affect general health via the nervous system. The main Chiropractice treatment technique involves manual therapy, including manipulation of the spine, other joints, and soft tissues; treatment also includes exercises and health and lifestyle counseling. It is based on the principle that the brain sends vital energy to every organ in the body via the nerves originating in the spinal column. The body is rebalanced and realigned using “spinal adjustment” techniques. Massage : It is use of the hands to direct or redirect the flow of the body’s energy fields and enhance balance within those fields. It includes touch,therapeutic touch or healing touch, acupressure, and reflexology. The means of perceiving or experiencing through tactile sensation. Touch in Nursing Practice     

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

Cultural Considerations of Touch   

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

Therapeutic Massage  

The application of hand pressure and motion to improve the recipient’s well-being. A back rub or massage results in relaxation ,increased circulation of the blood and lymph ,and relief from musculoskeletal stiffness, spasm,pain.

Therapeutic Touch   

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

Reflexology 

Art and science of enervating ovder 7,000 nerves in the feet believed to correspond to every muscle system and organ in the body

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Promotes health by relieving pressures and accumulation of toxins in the corresponding body part. Reflexology , or zone therapy is an alternative medicine involving the physical act of applying pressure to the feet, hands ,or ears with specific thumb,finger ,and hand techniques without the use of oil or lotion. It is based on what reflexologists claim to be a system of zones and reflex areas that they say reflect an image of the body on the feet and hands, with the premise that such work effects a physical change to the body.

5. ENERGY THERAPIES These are alternative therapies that involves the use of purported energy fields. These are two main types – biofield therapies, and bioelectromagnetic –based therapies. They are intended to affect energy fields that purportedly surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and /or manipulating the body by placing the hands in, or through ,these fields. Examples include Qigoing, Reiki, and Therapeutic touch. Reiki is a spiritual practice developed in 1922 by Japanese Buddhist Mikao Usui. It uses a technique commonly called palm healing as a form of complementary and alternative medicine and is ,sometimes ,classified as oriental medicine by some professional bodies.

Steps of palm healing         

Recipients lay down on a massage table and relax with loose, comfortable clothing. Practitioner enters a calm state of mind and mentally prepared for the treatment without talking. Practitioner placing his hands on the recipient in various positions. Hands kept still for 3 to 5 minutes before moving to the next position. General coverage of the head , the front and back of the torso, the knees,and feet. 12-20 positions are used ,with the whole treatment lasting 45 to 90 minutes. Some use a fixed set of hand positions ,while others use their intuition to guide them as to where treatment is needed,sometimes starting the treatment with a” scan”. Recipient often feels warmth or tingling ,even when a non- touching approach is used. Instantaneous “cures” of specific health problems are not usually observed.

Electromagnet therapy : It is a pseudoscientific alternative medicine practice involving the use of static magnetic fields.Practitioners claim that subjecting certain parts of the body to magnetostatic fields produced by permanent magnets has beneficial health effects. In this process ,the different positive forces of a magnet are taken into account to cure any kind of diseases. It is used to counter wrought by bleeding and for countering infertility among women. Products includes magnetic bracelets and jewelry; magnetic straps for wrists,ankles,knees ,and the back; shoe insoles ; mattresses; magnetic blankets (blankets with magnets woven into the material );

magnetic creams: magnetic supplements; plasters /patches and water that has been “magnetized”.Application is usually performed by the patient.

6. OTHER IMPORTANT MODALITIES 

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Aromatherapy: Therapeutic use of concentrated essences or essential oils extracted from plants and flowers. Aromas cause physiological, psychological , pharmacological reactions. These oils should be used intelligently and with caution. Humor: It determines the client’s perception of what is humorous. It can relieve anxiety , improve respiratory function, promote relaxation,enhance immunological function , and decrease pain by stimulating endorphin production. Pet therapy: It has many applications including overcoming physical limitations,improving mood,loweing blood pressure,and improving socialization skills and self- esteem. Music therapy: Pleasurable sound and music reduce stress, perception of pain, anxiety ,and feelings of isolation. Hydrotherapy: Hydrotherapy ,formerly called hydropathy, involves the use of water for pain-relief and treating illness. It continues to be widely used for burn treatment, although shower –based hydrotherapy techniques have been increasingly used in preference to full immersion methods,partly for the ease of cleaning the equipment and reducing infections due to contamination.

AYUSH AND NRHM (MAINSTREAMING AYUSH UNDER NRHM) Age – old acceptance and first line of treatment Recognized systems of medicine and integrated into the national health delivery system. Ayush medications included in the drug kit of ASHA At CHC two rooms provided for Ayush practitioner and pharmacist. Two doctor PHCS with Ayush practitioner. Objective:Mainstreaming of Ayush in the health care service delivery system to strengthen the existing public health system. Strategies: Integrate and mainstream ISM and H in health care delivery system including National Programs  Encourage and facilitate setting up of speciality centers and ISM clinics  Facilitate and strengthen quality control laboratory  Strengthening Research Activities on Ayush  Develop Advocacy for Ayush  Establish sectoral linkages for Ayush activities.

Activities : Availability of Ayush faculities and integrating it with the existing Health Care Service Delivery System  Integration of Ayush services in CHC /PHC with appointment contractual Ayush Doctors.  Appointment of a Data assistant to support the ISM and H Directorate.  Strengthening of Ayush dispensaries  Making provision for Ayush drugs at all levels  Establishment of specialized therapy centers in district hospitals.  Ayush doctors to be involved in all National Health Programs(IMR,MMR,JSY,Malaria,Filaria etc.)  Training of Ayush doctors in PHC  All Ayush institutions will be strengthened with necessary infrastructure  Block level School Health Programs to be conducted twice in ayear in two groups consisting of 100 students in each group. Integration of Ayush with ASHA o o o o

ASHA and ANMs training to be updated to incorporate Ayush. Necessary training material to be modified and provided accordingly Drug kit of ASHA will contain one Ayush preparation (iron supplement) But other drugs for treatment of common diseases,control of communicable diseases,drugs promoting the maternal and child health and improving quality of life could be included subsequently.

DRAWBACKS OF ALTERNATIVE MEDICINE 1. Not subjected to testing. Attempts to disprove this fact sometimes use the appeal,ie.”That which is natural cannot be harmful.” 2. Homeopathic remedies are extremely dilute,thus considered safe,but their products are exempt from goods manufacturing practice requirements(expiry date and identity and strength of products and their alcohol concentration). 3. Treatment delay 4. Danger increased when used as a complement to standard medical care.

THEORY APPLICATION Ludwig Von Bertalanffy General System Model System Theory was proposed in the 1940’s by the biologist Ludwig von Bertalanffy and furthered by Ross Ashby (1964). The system theory focuses on the organization as a whole,its interaction with the environment, and its need to achieve equilibrium.

I have applied Ludwig General System theory for reducing hypertension through yoga therapy. Input In this input refers to the demographic variables such as age ,sex, educational status, occupation ,duration of illness, family history ,food pattern. Through put In this throughput refers to the yoga therapy Output Output is any information that leaves the system and enters the environment through system boundary. In this output refers to the reduced blood pressure level. INPUT

DdDemograhic variables

agea

 Age  Gender dd  Educational status  Occupation  Duration of hypertension  Food pattern  Family history

Throughput

PpPre assessment of blood pressure level

YoYoga therapy

Output

Post asessment

Pain reduced Pain not reduced

Reassessment

JOURNAL ABSTRACT REALTED STUDY:Shilpa Babbar MD,Karen.B. Williams PhD,Dev Maulik MD PhD , Journal of Evidence–Based Integrative medicine, October 5 2016. Complementary and Alternative Medicine Use in Modern Obstetrics: A Survey of the Central Association of Obstetricians & Gynecologists Members.

The use of complementary and alternative medicine during pregnancy is currently on the rise. A validated survey was conducted at the Central Association of Obstetrician and Gynecologists annual meeting to evaluate the knowledge, attitude, and practice of general obstetricians and gynecologists and maternal-fetal medicine specialists in America. We obtained 128 responses: 73 electronically (57%) and 55 via the paper survey (43%). Forty-five percent reported personally using complementary and alternative medicine and 9% of women respondents used complementary and alternative medicine during pregnancy. Overall, 62% had advised their patients to utilize some form of complementary and alternative medicine in pregnancy. Biofeedback, massage therapy,meditation, and yoga were considered the most effective modalities in pregnancy (median [semi- Interquartile range] = 2 [0.5]). Maternal-fetal medicine specialists were significantly more likely to disagree on the use of complementary and alternative medicine for risk reduction of preterm birth compared to obstetricians and gynecologists (P = .03). As the use of complementary and alternative medicine continues to rise in reproductive-age women, obstetricians will play an integral role in incorporating complementary and alternative medicine use with conventional medicine.

CONCLUSION :We thus observe that the people are shifting their allegiance to the Indian alternative therapies, because these therapies are natural and have no side-effects. The western medicine has failed to deal with the chronic diseases as well as new, antibiotic resistant bacteria. Ancient therapies, by contrast, have an excellent record of curing the chronic diseases that do not respond well to western medicine.

MAR BASELIOS COLLEGE OF NURSING , BHOPAL

SUBJECT: ADVANCE NURSING PRACTICE SEMINAR ON ALTERNATIVE MODALITIES OF CARE AND SYSTEMS OF HEALTH

SUBMITTED TO:

SUBMITTED BY:

Mrs. Blesson Thomas

Mrs. Mariet Abraham

Associate Professor

M.SC. Nursing I Year Date : 18 / 03 /2019

BIBLIOGRAPHY BOOKS :-

1. Basheer,P. Shabeer “ Text book of Advance Nursing Practice”, India: EMMESS Medical Publisher. (2015), Page.no.355-364 2. Brar, Kaur Navdeep. & Rawat,HC , “A text book of Advanced Nursing practice.” Jaypee Brothers medical Publishers Ist edition, Daryaganj ,New Delhi (2015): page.no.933- 944. 3. K .Park , “Textbook of Preventive And Social Medicine “ , M/s Banarsidas Bhanot Publishers Jabalpur, 17 th Edition, 2002: 1-7.

JOURNAL:

Shilpa Babbar MD,Karen.B. Williams PhD,Dev Maulik MD PhD ,” A Survey of the Central Association of Obstetricians & Gynecologists Members,” Complementary and Alternative Medicine Use in Modern Obstetrics” Journal of

Evidence–Based

Integrative medicine, October 5, 2016.

INTERNET:1. https://www.slideshare.net/FIROZQURESHI/alternative-modalities-of-care 2https://www.slideshare.net/jalpaJalpa/alternative-modality-of-care