Alternative Medicine. in the Academic. Medical Center. Academic medical centers are cur incorporating so-called “Alternative. Medicine” into the education pro …
Volume 2 No 2 Fall/Winter 2002
Alfred P Fishman, MD Editor-in-Chief Senior Associate Dean
STUDYING THE MEDITATING BRAIN
Andrew Newberg, MD, Assistant Professor of Radiology
Alternative Medicine in the Academic Medical Center
Academic medical centers are currently facing up to the challenge of incorporating so-called Alternative Medicine into the education programs of their scientifically-based institutions No longer is the question should it be done? Instead, the question is how to do it? Among the barriers to be overcome are the overcrowded medical curriculum, ambiguities in nomenclature, the unsettled contemporary medical scene, and mutual misunderstanding The typical curriculum is a conglomerate which is already bulging at the seams with the triumphs of scientific medicine Simply adding courses is neither feasible nor desirable Integration holds more promise for meaningful incorporation of alternative medicine into the medical curriculum than does addition
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T
he study of meditation, a complex mental task, is potentially one of the most important areas of research that may be pursued by medical science in the next decade This may not be an understatement since meditation offers a fascinating window into human consciousness, psychology, and experience; the relationship between mental states and body physiology; emotional and cognitive processing; and the biological correlates of religious experience In the past thirty years, scientists have explored the biological effects and mechanism of meditation in great detail Initial studies measured changes in autonomic activity such as heart rate and blood pressure as well as electroencephalographic changes More recent studies have explored changes in hormonal and immunological function associated with meditation While many of these studies have utilized peripheral measurements of different substances, they are consistent with a number of central neurochemical changes including observed changes
in blood concentration of cortisol, serotonin, norepinephrine, and vasopressin Studies have also explored the clinical effects of meditation in both physical and psychological disorders Functional neuroimaging has opened a new window into the investigation of meditative states by exploring the neurological correlates of these experiences The neuroimaging techniques include positron emission tomography PET, IN THIS ISSUE single photon emission computed tomography SPECT, and functional The Placebo Response page 3 magnetic resonance imaging fMRI A Medical Students Perspective Each of these techniques provide differpage 3 ent advantages and disadvantages in CAM at Penn: the study of meditation
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Integration or Pluralism? page 4
The Meditating Brain
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Our brain imaging studies see Figures of Tibetan Buddhist meditators showed measurable changes that occur during intense meditation and suggest several coordinated cognitive processes Specifically,
changes in the inferior frontal lobe and prefrontal cortex are suggestive of intense
Figure 2 Axial SPECT images, slightly higher up in the brain demonstrate decreased activity in the superior parietal lobe lower right shows up as yellow rather than the red on the left image during meditation compared to the resting state
Figure 1 The SPECT images were obtained during our study of the neurophysiological correlates of Tibetan Buddhist meditation These axial images show the results from a baseline scan on the left ie at rest and during a peak of meditation shown on the right The images demonstrate that the frontal lobes, usually involved in focusing attention, are more active during meditation increased red activity
concentration while decreases in the parietal lobe may be attributed to the subjective alterations in the sense of space and time described by subjects during meditation We also observed significant increases in activity in the thalamus, a key relay in the brain We hope
that our future studies will explore various types of meditation both within traditions and across traditions and also how meditation may affect various physical and mental health parameters
The Future of Herbal Medicine
By Michael D Cirigliano, MD, FACP Associate Professor of Medicine
C
onsumer use of herbal medicines has begun to slow over the past several years following a remarkable rise in popularity in the 1990s Despite this trend, clinicians continue to be confronted with the question of safety and efficacy on a daily basis Patients routinely present with a number of natural products along with their standard pharmaceutical agents This has historically led to both frustration and confusion amongst both patient and clinician For Western medical professionals, it has been tantamount to fitting a square peg into a round hole Well-designed clinical trials on herbal remedies are appearing more regularly in the mainstream medical literature However, many have failed to show a
significant benefit
to use and in fact, several have uncovered significant side effects adding to the dilemma for clinicians In addition, the question of safe manufacturing and regulatory standards continue to plague the industry Numerous case reports have found contaminants in natural products leading to adverse events For these reasons, the question remains as to where we go with herbal medicine? For many of us, the answer is simple Although scientific data has been mixed recently, the large body of historical information that exists and the thousands of years of use by cultures throughout the world have convinced many of us that there is a role for natural products in clinical practice Use of herbal remedies in selected
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A MEDICAL STUDENTS PERSPECTIVE
WHY US, WHY NOW?
by Jessica Buckley MS2
The Placebo Response
by Alfred P Fishman, MD
I
ts widely expected that we all want the best possible care and outcomes for our patients, but are we equipping ourselves
to provide it? Americans are opening their minds to treatments that arent written on prescription pads As their guides towards better health and quality of life it is our responsibility to expand our horizons with them As medical students, we believe that it is our responsibility to learn about ACE inhibitors and bisphosphonates, but what if a patient is taking St Johns Wort or Chondroitin Sulfate? In our classes we have picked up a few tidbits about altered distribution or metabolism as a result of herb-drug interactions, and perhaps we do feel well-informed about the preventative benefits of a healthy lifestyle Yet many of us also feel that there are further changes we would like to see incorporated into our education We would like to hear from holistic physicians, MDs who have chosen to incorporate aspects of CAM into their practices We would also like to hear from allopathic physicians about how they encounter CAM in their practices What is shiatsu, why do patients use it, is it
something that might be of benefit, could it harm them? We would like to discuss interdisciplinary collaboration Most importantly, where can we go to educate ourselves? As a child, I was chronically congested, but for fourteen years we were unable to establish a cause I was finally told that I was probably
allergic to dust mites and given a nasal inhaler though I have no memory of the name of the medication At that time my mother, who worked as an acupuncturists assistant, persuaded me to try an acupuncture session A few needles and an empty inhaler later, I could breathe easily through my newly cleared nasal passages Even now hardly a day goes by when I dont appreciate the ability to detect a subtle scent I dont know whether the acupuncture made a difference, or if I underwent a normal physiological change Its possible the medication stimulated endogenous antihistamine production, or that I believed in these interventions enough to experience the placebo effect personally Sitting
here writing this, I dont care what actually happened; I care that I can breathe easily Our patients are coming to us with much the same attitude They dont care what the biological mechanisms are, they just want to feel better, and will often take symptomatic relief into their own hands If we hope to achieve their best outcome we must be prepared to discuss this openly and knowledgeably with them and amongst ourselves, and we should start now
P
lacebos are usually regarded as substances on procedures that are biologically inert This is true only in the pharmacological sense This definition ignores the fact that placebos can alter psychological states and brain activity which can, in turn, elicit major changes in the functioning of body organs and tissues Over the years, a variety of psychological mechanisms, such as conditioning and expectation, have been invoked to explain the placebo response These studies have relied primarily on behavioral and electrophysiological studies in
normal and brain-damaged animals and humans However, recent technological advances in neuroimaging and computational modeling have provided new tools and fresh approaches to explore brain mechanisms involved in the placebo response, to map the involved brain circuitry and to display connections to the periphery which influence autonomic, endocrine and immune functions Neuroimaging studies have begun to illuminate the sites and mechanisms of the brain involved in the placebo response One particular target of recent studies has been clarification of the role played by expectation By manipulating expectation, areas of the brain which are responsive have been located, mediators and pathways that are excited by manipulations of expectation have been tracked, and the corresponding subjective experience documented and analyzed Studies of brain-systemic connections
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HEADS UP
CAM AT PENN: INTEGRATION OR PLURALISM?
By Paul Root Wolpe, PhD,Department of Psychiatry,
Department of Medical Ethics, Department of Sociology, Center for Bioethics The advances made by CAM over the last decade or so are startling On the federal level, the National Institutes of Health has established the National Center for Complementary and Alternative Medicine, and the National Cancer Institute has set up a similar Office of Cancer Complementary and Alternative Medicine Surfing through federal agency websites, you can find information about alternative therapies for diabetes from the National Institute of Diabetes and Digestive and Kidney Diseases, information about St Johns Wort from the National Institute of Mental Health, and the Agency for Healthcare Research and Quality would be happy to send you papers with titles like Ayurvedic Interventions for Diabetes Mellitus,Garlic: Effects on Cardiovascular Risks and Disease and Mind-Body Interventions for Gastrointestinal Conditions Most major medical schools now teach CAM in one form or another, and academic medical
cenWhich is, in itself, remarkable It was not that long ago that people who studied CAM, never mind advocating it, were seen as snake-oil salesman who had left their scientific rigor and their brains at the door, and who had somehow been bewitched by mantra-chanting vegans that did Tai Chi and took Chinese herbs Of course, now we realize that a vegan-type diet that eschews high carbohydrates, dairy products, and fatty meats is probably the most healthy for you; that meditation has profound stress-reduction effects that decrease blood pressure and a host of other risk factors; that Tai Chi is therapeutic in both stress reduction and overall physical health; and that herbs have profound healing properties Today, in contrast, CAM is increasingly seen as a valuable asset by scientific medicine Physicians are referring patients to massage therapists, acupuncturists, and yoga classes, and some centers are trying to bring those therapies into in-house clinical service It would seem that CAM
and scientific medicine have made their peace, and that all is left is for integrated medicine to become the standard of care at academic medical centers throughout the nation As in most things, however, the reality is not that simple There are resistances on both sides that must be understood before we can determine the appropriate relationship of CAM to establishment medicine On one side are the skeptics who have not changed their minds about alternative medicine broadly writ, and write about it in the same sentence as astrology, crop circles and alien abductions Despite the enormous scientific literature that supports certain CAM modal-
ters have set up clinics, programs, centers, and offices dedicated to CAM Conferences on integrating CAM into hospitals and medical centers are so common these days as to be almost unremarkable
ities and, most certainly, finds little value in some others, these skeptics prefer to lump all CAM modalities together and then shake their heads at the
credulity of the American public for believing in such nonsense It seems wholesale dismissal of CAM is easier than actually reading the literature Setting up CAM as a straw man is in reality a profoundly unscientific posture; medical history has shown over and over again that modalities that are dismissed as absurd without adequate scientific evidence too often turn out to the breakthroughs of the next generation Semmelweis lives with us still On the other hand, there are those in the medical establishment willing to engage CAM, but who do not understand its nature Anxious to quickly incorporate CAM modalities into the medical center, these advocates may end up undermining the very modalities they claim to champion The effectiveness of many CAM modalities is enhanced by the cultural and social contexts in which they are offered Going to the office of a massage therapist where there is music playing and incense burning, relaxing first in a lounge chair sipping organic juices, and then
engaging a therapist who can spend a full hour in slow hands-on healing cannot be duplicated easily at HUP Part of the appeal of acupuncture to some is precisely that it is a counter-cultural experience, and they may not be interested in obtaining it in the sterile institutional settings we can offer The point is not that Penn should give up on these modalities Rather, we need to choose carefully what we are offering and to whom, and be prepared to refer those who want a
different kind of experience to the community practitioners who are already providing the bulk of these services Of course, they must be screened, and only competent, well-trained practitioners should make up our referral base But integrated medicine need not mean imperial medicine, where the academic medical center becomes the sole locus of care A pluralistic system, where Penn offers a set of services but which also encourages community practitioners to continue to offer services in their own offices with referrals
from Penn medical staff may ultimately be the best answer to true medical integration
Acupuncture Alive and Well at UPHSPresbyterian and HUP Campuses
by Patrick J LaRiccia, MD, R Ac, Presbyterian Medical Center UPHS
A
cupuncture has been around for at least two thousand years It originated in China and spread to other Asian countries before heading to the West In the Orient acupuncture is a component of traditional Chinese medicine, ie it is part of a full system of medi-
tive dental pain Less conclusive evidence from sources other than randomized controlled trials existed for other medical conditions such as fibromyalgia, myofascial pain, and tennis elbow This evidence was similar to that which supported the use of non-steroidal-anti-inflammatory drugs NSAIDs and steroid injections However, acupuncture has a better safety profile In keeping with different schools of thought, there are many different ways to perform an acupuncture treatment These schools include Traditional
Chinese Medicine TCM, Japanese, Korean, French Energetics, Worsley Five Element, etc Successes and failures have occurred with each of these approaches However, the optimal method is difficult to establish since acupuncture is really a family of methods that uses needles to access a proposed system of pathways called meridians and places of focus called acupuncture points through which the proposed vital energy called Qi courses This makes the scientific study of acupuncture challenging Also, the different types of acupuncture are a source of confusion to the public and to researchers CURRENT ACUPUNCTURE RESEARCH AT PENN Currently, a variety of research projects at Penn are in progress These include: 1 A randomized placebo-controlled study of acupuncture and exercise physical therapy in the treatment of osteoarthritis of the knee; 2 Brain imaging of the effect of acupuncture on patients with chronic pain; 3 A pilot study of the use of acupuncture for the treatment of fatigue in cancer
patients receiving radiation therapy; and 4 A pilot study in use of acupuncture in reducing pain in breast cancer patients caused by photodynamic therapy The principle investigators in these studies include Abass Alavi, MD brain imaging, John Farrar, MD acupuncture and osteoarthritis of the knee; acupuncture treatment of fatigue in cancer patients, and Robert Lustig, MD the use of acupuncture in conjunction with photodynamic therapy Drs Abass Alavi and Andrew Newberg have been central to the research on acupuncture that involves brain imaging
cine In the United States its principal use until recently has been in the treatment of chronic pain However, considerable evidence from different parts of the world indicates that it can be applied to a variety of other medical problems In 1997 the National Institute of Health NIH held a consensus panel on acupuncture The consensus indicated that acupuncture is a safe form of treatment Indeed, based on records of severe adverse events,
acupuncture appears to be safer than Western pharmaceutical and surgical interventions The 1997 NIH consensus panel on acupuncture concluded that randomized controlled trials supported the use of acupuncture for post-chemotherapy nausea and vomiting, post-operative nausea and vomiting, and post-opera-
Alternative Medicine
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However, the process of integration requires understanding and accommodation by clinical scientists who are apt to be reluctant to make way for therapies which they regard as unconventional and unproven In a research university, promising and popular therapies can be evaluated for efficacy, efficiency and cost-effectiveness Ambiguity in terminology not only
hampers communication but also compromises research and education For medical educators, the designation Alternative Medicine entails the threat of displacing conventional medicine for the sake of unproven therapies from other medical traditions Moreover, although Alternative Medicine
covers a panoply of diverse therapies, it lacks the organization and processes of scientific medicine As a
practical expedient, the term Complementary is more relevant than Alternative for the missions of the research university The term signifies that a given therapy borrowed from another culture is an addition to, or an enhancement of, Western medical therapy and not a substitute As a corollary, once safety and efficacy are proven by Western criteria, complementary therapies become part of conventional medicine Even more pervasive than Complementary has become the abbreviation CAM Originally a by-product of the creation of a center at the National Institutes of Health for Complementary/Alternative Medicine, the abbreviation has become commonplace, more often used as a synonym for a complementary than for an alternative therapy Few would challenge that contemporary medicine is restless and undergoing dramatic change Forces outside of medicine are shaping the practice of medicine
while physicians, educated to deliver acute care, face novel demands imposed by the need for chronic care, unanticipated epidemics and increasingly diverse populations Meanwhile, scientific medicine and technologic advance are in high gear, rapidly generating new, albeit expensive, diagnostic methods and therapies In this unsteady state, how can the education of the physician with respect to complementary therapies contribute to the care of the patient?
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Herbal Medicine
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settings after a careful evaluation and proper diagnosis can be a useful adjunct to standard care Natural medicines not only can aid in specific biologically based illnesses but also can be a starting point for discussions about health in general and most importantly preventive medicine Some critics of complementary and alternative medicine may say that the placebo effect is at play and nothing else It is my firm belief that the true healing power of the body itself has yet to
be fully understood and remains the final frontier in overall health Much research and interest is being expended on the concept of placebo and its remarkable effects on health and more importantly, patient behavior In my own clinical practice, I have found that the overall benefits of herbal medicine and natural product use have far outweighed any negatives With proper knowledge of interactions and adverse effects, patients overall health and well-being have been enriched by the use of these agents as well as from the resulting discussions of health and well being The future of herbal medicine I believe is bright More research and better manufacturing standards will help propel us as healthcare providers into a more holistic and gentler form of healthcare delivery and patient care
The Placebo Response
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Alternative Medicine
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involved in the placebo response have also begun but these are still in their infancy Many studies of the placebo
response have dealt with the interplay between mind, brain, body and health This topic clearly relates to the patientdoctor relationship which, in turn, is one form of a placebo effect: a compassionate interplay between the health professional and the patient can promote health Oppositely, an ineffective relationship may not only be a lost opportunity for health care but even retard or impair healing, ie elicit a nocebo response
Health care practitioners of unconventional therapies are usually unfamiliar with the principles and practice of scientific medicine, just as practitioners of conventional medicine rarely have insights into the cultures and beliefs of those who practice unconventional therapies Many of the latter are not physicians Of the two deficiencies, the more readily remediable seems to be an increase in the appreciation of cultural diversity by Western physicians This insight would promise not only better utilization of therapies derived from other traditions, but also
better interplay with patients from diverse backgrounds Less corrigible for the immediate future is the lack of research
training by health professionals who practice unconventional therapies There is little question that complementary therapies are here to stay Indeed, their usage is on the increase Physicians need to be aware of the risk/benefit ratios of these therapies and take them into proper account with respect to providing added value for conventional therapies while avoiding adverse events
We would welcome your questions, comments and suggestions
For more information contact: Betsy Ann Bozzarello, Director, Office of Program Development University of Pennsylvania Health System 1320 Blockley Hall, 423 Guardian Drive Philadelphia, PA 19104-6021 Ph: 215-662-3195 Fax: 215-662-6393 Email: bozzarel@mailmedupennedu
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