Complementary and alternative medicine, as. Complementary and alternative medicine, as medicine and alternative. Complementary medicine and alternative …
Famine in the Midst of Plenty
Integrative Medicine
David M Steinhorn, MD
Pulmonary and Critical Care Integrative Medicine Initiative Childrens Memorial Hospital Children Northwestern University Feinberg School of Medicine
d-steinhorn@northwesternedu
Satisfaction correlates strongly with factors beyond physical care Highest technical capabilities but frequent sense of impersonal interaction
Patient Satisfaction is Mulitfaceted
Physical needs
Environment: Clean, pleasant, friendly, non-threatening non Admission, diagnosis, treatment, discharge, follow-up follow-
Human needs
Treated with respect, reverence as a human being, one is heard and the system tries to respond to ones needs one Not just physical
eg children need to play, feel secure
conventional medicine has become separated from its roots of caring, engaging with patients and meeting their real needs
Ralph Snyderman, MD Chancellor for Health Affairs Duke University Medical Center
Religion one part of spiritual
needs
Loss of Idealism
Limited time, multiple demands Loss, grief, over-identification with overpatients and their families become emotionally hazardous aspects of our work Financial pressures Loss of sense of mission
Integrative medicine is a movement that addresses this latter threat by retraining physicians to understand their roles as healers
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NIH position on CAM:
Complementary and alternative medicine, as
defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine medicine
Complementary vs Alternative
Complementary medicine and alternative medicine are different Complementary: Alternative:
Complementary methods are used along with conventional therapy, eg acupuncture Used in place of conventional therapy
eg special diet to treat cancer rather than surgery and conventional chemotherapy
Historical Perspective
Complementary concept arose in Europe
The Whole
is the sum of parts
Integrative Medicine
Focus on the maintenance / restoration of health and healing Restore patient-physician dyad patient NCCAM: Combines mainstream medical
Alternative suggests good/bad duality
Consistent with western mindset, adversarial
Ultimately good medicine must be useful medicine
and can be recommended based upon evidence and judgmentnot anecdote or judgment historical use
therapies and CAM therapies for which there is some high-quality scientific evidence of highsafety and effectiveness
Trends in CAM Usage
JAMA 1998:280;1569-75 1998:280;1569 47 overall increase
Increased use from 338 - 421 Most common for chronic conditions
1539 adults in 1991 and 2055 in 1997
39 do not disclose use Pay out of pocket 60 Estimate: 27-34 billion out of pocket 27-
Back problems, anxiety, depression, headache
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Survey Results 16 Common Therapies
Insurance Reimbursement
Why Patients Seek Alternatives
Increased technology of medicine Dissatisfaction
/ Perceived abandonment
Managed care, decreased payment, increase paperwork Decreased time spent with patient Appears less true in pediatric practices Increased information leads to unfulfilled needs Internet, email, paid advertising
Unrealistic expectations Ease of access Cost
most patients want more than powerful medicine They want comfort and solace as well
Major Branches of CAM
Alternative Medical Systems
Homeopathy, Naturopathy, Chinese Medicine, Ayurveda
Alternative Medical Systems
Chiropractic Homeopathy
focuses on the relationship between bodily structure primarily that of the spine and function, and how that relationship affects affects the preservation and restoration of health like cures like natural healing forces within the body, with a goal of helping the the body heal from disease and attain better health Practices may include dietary modifications, massage, exercise, acupuncture, minor surgery, and various other interventions System of herbs, balance
of energies Chi Orignated in India; practiced for 5000 years Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment
Mind-Body Interventions Mind Meditation, prayer, music
Biologically Based Therapies
Herbs, foods, vitamins, supplements
Naturopathy
Manipulative and Body-Based Methods Body Massage, Physical Manipulation, Traditional surgery
Chinese Medicine Ayruveda
Energy Therapies
Biofield therapies: Reiki, Qi Gong, Therapeutic Touch Bioelectromagnetic-based therapies Bioelectromagnetic-
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Mind-Body Interventions
Meditation Prayer Mental healing Creative therapies
Biologically Based Therapies
Herbs Vitamins Supplements Probiotics
eg art, music, dance
Yoghurt Lactobacillus
Manipulative Body-based
Massage Chiropractic Osteopathic Rolfing Surgery
Energy Therapies
Biofield therapies
Reiki Qi gong Some martial arts practices Magnets Electric fields
Bioelectromagnetic-based therapies Bioelectromagnetic-
Pediatric Use of CAM
Up to 73 of children receive CAM therapie s
10 to 15 vs 30 to 45 in adults
Pediatric Use of CAM
Safety and efficacy not well studied
Purity, interactions, toxicity, efficacy, pharmacokinetics
Increasing use with increasing age More prevalent with chronic disease 50 of pediatricians ask about CAM use 50 of pediatricians would refer for CAM Wide range of conditions
eg asthma, allergies, autism, cerebral palsy
Growing number of healthy individuals use CAM treatments
Potential harm from restricted diets Lack of standardization makes comparison difficult eg provider training, technique Differences in children not well characterized Difficulty of controlling variables in environment, etc for mind-body studies mind-
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Pediatric Use of CAM
Parents well educated Often used in chronic, poorly responding conditions Most common techniques used:
Imagery, relaxation, hypnosis Copper
bracelets, diets, patent medicines Herbal treatments, aromatherapy Chiropractic, homeopathy, naturopathy Acupuncture
Treatment Goals
Curing disease Managing or minimizing symptoms Preventing disease Promoting wellness, minimizing stress Achieving inner peace and harmony
Folk remedies very prevalent amongst ethnic groups
Evidence???
Acupuncture for chronic asthma Acupuncture for smoking cessation Acupuncture for idiopathic headache Acupuncture for pain relief Acupuncture for nausea relief
Overall some benefit, methods inexact No clear evidence No clear evidence
Acupuncture Chronic Conditions
ReviewReviewMusculoskeletal pain- Positive painHeadache- Trend towards benefit HeadacheAsthma- Inconclusive AsthmaFibromyalgia- Trend towards benefit FibromyalgiaSmoking cessation- Negative cessationNausea and vomiting- Positive vomitingBerman BM Clinical Applications of Acupuncture: An Overview of the Evidence J Comp Alt Med 2001:7;S111-18 2001:7;S111-
Electroacupuncture
Prophylaxis of Postoperative Nausea and Vomiting following Pediatric Tonsillectomy with or without Adenoidectomy
Lynn M Rusy, MD, George M Hoffman, MD, Steven J Rusy, MD, MD, Weisman, MD Anesthesiology 2002; 96:3005 96:300 MD
Therapeutic Touch
Not the same as massage Utilized by increasing number of adults and children No known toxicity Commonly used for
Anxiety, sleep difficulty, chronic pain
Practitioner may benefit as well
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Therapeutic Touch
Technique
Clear intention to serve individual Ground in the moment Ground Light touch w/o deep palpation Communicate compassion to patient Empower patient and family
Herbals/Supplements/Vitamins
Not regulated by FDA Difficulty guaranteeing content, potency and purity of most compounds Some toxicities reported
Heavy metal contaminants Interactions with numerous prescribed medications including immunesuppressants, immunesuppressants, coumadin
Not recommended for breastfeeding mothers
Cautions
Potential harm from
restricted diets Lack of standardization makes comparison difficult eg provider training, technique Differences in children not well characterized Difficulty of controlling variables in environment, etc for mind-body studies mind Safety and efficacy not well studied
Purity, interactions, toxicity, efficacy, pharmacokinetics
Distant Healing
Sicher F, Targ E, Moore D, Smitt HS A Randomized
Double-Blind Study of the Effect of Distant Healing Doublein a Population with Advanced AIDS: Report of a Small Scale Study ISSSEEM Proceedings 1998
AIDS defining illnesses Illness severity score Physician visits No of Hospitalizations Days in Hospital Perceived Well-being WellCD4 counts: 01 versus 06 per patient P 004 08 versus 265, P 003 92 versus 130, P 001 015 versus 06, P 004 05 versus 34, P 004 -26 versus 14, P 002 No difference
Feher SD et al Increasing breast milk production for premature infants with a relaxation/imagery audiotape Pediatrics 1989;83:57-60
20 minute
relaxation tape used prior to use of breast pump in NICU Increased milk production 63-121 63-
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Integrative Medicine Initiative
Recently funded program to:
Perform high quality clinical research Educate the community Develop clinical services Medical Director Program Director Research Director
Integrative Medicine in the PICU
Interdisciplinary model
Research at CMH
All patients receiving therapies will be in IRB approved research protocols Perioperative use of acupuncture to reduce analgesia and sedation needs Effect of aromatherapy
Randomized, prospective, blinded Randomized, crossover study
Integrating Therapies in the ICU
Does Yoga benefit patients with CF?
The Patient
Health
Goals Fight or Flight Catecholamines Cortisol Catabolic state Vagal tone
Figure 2
Disease
ChildFamily Safety
Trauma Illness
ChildStress State
Return to Health
s es ke tr ra s S b te al ula ag reg Vr e e in nt ic ry ou ed e C M urg M S CA
Persistent Stress
ChildRecovery
Phase
ChildUncertain Outcome
Persistent Stress/Threat Defensive state Poor wound healing Immune dysfunction Organ failure
Death
To create a more positive healing environment surrounding the hospitalized child, ie to create a healing zone at the zone bedside Be role models of caring To understand the place of CAM therapies in the treatment of fragile, sick children and their families To support some of the still unmet inner needs of hospitalized children and their families in an open, culturally responsive manner
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Changing the culture of institutional medicine medicine
Demonstrating a Reverence for Life
A man is truly ethical only when life — plants, animals, his fellow man — is sacred to him, and when he devotes himself to all life that is in need of help help Reverence for life means to be in the grasp of the infinite, inexplicable, forward-urging Will in forwardwhich all Being is grounded grounded Reverence for life is an intrinsic motivating system that: drives a
man on as the whirling, drives thrashing screw forces a ship through the water The ultimate principle is compassion
Goals of Integrative Medicine
Re-focus on the patient as a whole and the Reprimacy of the patient-physician patientrelationship Involve patient as active partner Openness to value of all traditions Advocate for sound clinical research Provide compassionate attention to spiritual and emotional needs
Involving Families in Healing
Get them out of a victim mode Encourage them to be actively involved
Assess where they are emotionally Provide imagery
Let them know you are thinking of them when you are gone Enlist chaplains, childlife, social work childlife, Try even if it does not always work
Our Obligation re: CAM
Select the most appropriate therapies
Educate families to options
Need to know options Dialogue with colleagues Efficacy, minimal adverse aspects, cost effective
Dont judge the choices made by families Don Facilitate self-determination self
Be inclusive not exclusive
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Source:harthosp.org
