Complementary and alternative medicine (CAM)also referred to as integrative The NCI Office of Cancer Complementary and Alternative Medicine …
Thinking about Complementary and Alternative Medicine?
An Introduction for People with MS on How to Find and Evaluate Claims about Complementary and Alternative Medicine
WRITTEN BY THOMAS M STEWART, JD, MS, PA-C AND ALLEN C BOWLING, MD, PHD
MSAA Monograph 1
This monograph is dedicated to Jack Burks, MD, by MSAA and the monographs sponsor, Berlex Dr Burks currently holds the position of vice president and chief medical officer for MSAA Dr Burks is an internationally recognized expert in the field of MS and has a longstanding commitment to MSAA and its goal to provide individualized patient-focused care This is why dedicating this monograph to Dr Burks is so appropriate; he has spent a lifetime helping those with MS to better understand the disease and obtain information to better manage it Providing valuable information is the focus of this monograph
Funding for this monograph has been generously donated through a grant from Berlex The staff and Board members of MSAA would like to
express much appreciation for this kind and purposeful gift
Gratitude also goes to the authors of this monograph, Thomas M Stewart, JD, MS, PA-C and Allen C Bowling, MD, PhD of the Rocky Mountain MS Center in Englewood, Colorado Other individuals involved with the editing of this monograph include: Dr Jack Burks, Robert Rapp, Andrea Borkowski, and Susan Wells Courtney Information used for the captions in this monograph was taken from Dr Allen C Bowlings book, Alternative Medicine and Multiple Sclerosis Demos Medical Publishing Inc, 2001
Copyright Multiple Sclerosis Association of America, 2006 All rights reserved This booklet is protected by copyright No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from MSAA
Thinking about Complementary and Alternative Medicine?
An Introduction for People with MS on How to Find and Evaluate
Claims about Complementary and Alternative Medicine
Written by Thomas M Stewart, JD, MS, PA-C and Allen C Bowling, MD, PhD
C
omplementary and alternative medicine CAM is a vast topic, so it is impossible to provide a detailed review of the topic in a short booklet Instead, our main focus is to provide a framework for finding and evaluating claims about CAM We will also describe some background, such as what CAM means, how many people use CAM, and how to balance the risks of CAM therapies with the evidence of benefit
politically dominant health system Both of these definitions are similar because CAM is essentially defined as that which is other than conventional medicine To understand CAM, it is important to begin by understanding conventional medicine Conventional medicine treatments may be thought of as what is generally recommended by conventional healthcare practitioners; for people with MS, the focus of conventional treatments in medical clinics is on medications,
rehabilitation physical therapy, DEFINITIONS AND EXAMPLES OF CAM occupational therapy, and speech therapy, The National Center for Complementary and psychotherapy Of course, there are excepand Alternative Medicine NCCAM defines tions For example, conventional healthcare CAM as a group of diverse medical and providers will often recomhealthcare systems, pracAlternative medicine refers to mend calcium for the pretices, and products that are unconventional treatments vention of osteoporosis or not presently considered to that are used instead of fiber supplements to amebe part of conventional conventional medicine liorate constipation In genmedicine that is, mediComplementary medicine eral, however, recommendacine as practiced by holders refers to unconventional tions regarding medications of MD medical doctor or treatments used in addition and rehabilitation are the DO doctor of osteopathy to conventional medicine staples of conventional degrees and their allied healthcare practitioners
recommendations health professionals, such as physical theraSo, to oversimplify a bit, it may make sense pists, psychologists, and registered nurses to think of CAM as therapies other than Another, more flexible definition defines medications, rehabilitation, and psychotherapy CAM as all health systems, modalities, and A few other details about the terms practices other than those intrinsic to the
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COMPLEMENTARY AND ALTERNATIVE MEDICINE The National Center for Complementary and Alternative Medicine NCCAM has done an impressive job organizing the enormous topic of CAM According to the NCCAM, CAM therapies may generally be grouped into five overlapping categories: Mind-body medicine uses a variety of Biologically-based practices use subtechniques designed to enhance the minds stances found in nature, such as herbs, speability to affect bodily function and sympcial diets, or vitamins in doses outside toms Examples of CAM therapies within those used in conventional medicine this
category include relaxation, hypnosis, Energy medicine involves the use of energy visual imagery, meditation, yoga, biofeedfields, such as magnetic fields or biofields back, and spirituality energy fields that some believe surround Alternative or whole medical systems and penetrate the human body are built upon complete systems of theory Manipulative and body-based practices and practice Often, these systems have are based on manipulation or movement of evolved apart from and earlier than the one or more body parts This category conventional medical approach used in includes practices such as chiropractic and the United States One example of a whole osteopathic manipulation, massage therapy, medical system is traditional Chinese reflexology, and Rolfing Also known as medicine, which includes acupuncture as structural integration, Rolfing uses softwell as Ayurvedic medicine, one of Indias tissue manipulation to ease pain and stress traditional systems of medicine while improving
performance complementary and alternative medicine are also useful to know Alternative medicine refers to unconventional treatments that are used instead of conventional medicine Complementary medicine refers to unconventional treatments used in addition to conventional medicine varied considerably among the surveys Because the lists vary, it is difficult to compare the results from different surveys With that in mind, studies done in North America suggest that, excluding prayer and exercise, the lifetime use of CAM among people with MS ranges from 50 to 60 percent This is similar to CAM use in the general population As in the general population, people with MS who use CAM tend to be disproportionately female, better educated, and have a higher income In the general population as well as among people with MS in particular, CAM is used in a complementary rather than an alternative fashion However, although there are superficial
FREQUENCY AND PATTERNS OF CAM USE AMONG PEOPLE WITH
MS
Surveys have been done to identify the number of people with MS who use CAM therapies To measure this, most surveys have asked participants to indicate whether they have used one or more items from a specific list of CAM interventions, but these lists have
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AN INTRODUCTION FOR PEOPLE WITH MS Minimally Persuasive similarities between CAM use in the general Anecdotal Evidence: Anecdotes are basipopulation and in the MS population, there cally stories An anecdote by someone you do may be significant differences as well For not know well, who is selling a product, may example, people with MS may visit practitionbe considered the weakest evidence of all ers of CAM such as acupuncturists, massage Anecdotes may be somewhat more persuasive therapists, or chiropractors more often than when told by credible sources, such as close people in the general population; people with friends, family members, or MS may also use dietary it is reasonable for people healthcare providers, but in
supplements more frequentwith MS to expect that they the end, anecdotes are mere ly, and are more likely to can comfortably discuss this stories and should generally use different kinds of topic with their conventional be considered as weak evidietary supplements healthcare providers and dence The precise number of that education and research Laboratory Evidence: people with MS using related to CAM is supported Laboratory evidence is usuCAM, the number using by MS organizations ally done under very conspecific kinds of CAM, and trolled conditions, such as the precise characteristics of in a test tube or in a Petri dish For example, CAM users are less important to understand a particular treatment studied in the laboratothan the fact that CAM is widely used in the ry may be found to suppress certain immune MS community Accordingly, it is reasonable cells While such experiments may be highly for people with MS to expect that they can valuable for certain purposes, it would be comfortably
discuss this topic with their conunacceptable to simply assume that such a ventional healthcare providers and that educatreatment would be good for people with MS tion and research related to CAM is supportWith actual testing of the compound in peoed by MS organizations ple with MS, it might be found that it has no effect whatsoever For this reason, laboratory EVALUATING THE EVIDENCE evidence is not very persuasive evidence of Obviously, not all CAM therapies are efficacy in MS effective merely because they are claimed to be effective One of the most important steps Moderately Persuasive in evaluating CAM claims or any other Animal Evidence: This type of informahealth claim is to look for the basis of the tion may be more reliable than anecdotal evirecommendation In other words, one of the dence, but nevertheless cannot be considered first questions to ask is, How persuasive is highly persuasive Often, before money is the evidence in support of the claim? There invested in clinical
trials involving people, are many different levels of evidence and it is investigators study the effects of a therapy in important to be able to understand the relaanimals with an MS-like disease known as tive strengths and weaknesses of each
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COMPLEMENTARY AND ALTERNATIVE MEDICINE
Herbal medicine has been used for thousands of years and has experienced a renewed popularity among Americans since the mid1990s Unlike conventional drugs, herbs consist of many chemical compounds, which can be beneficial, harmful, or have unknown effects Individuals with MS need to be cautious as clinical trials with herbs, especially with MS specifically, have been very limited Certain herbs can interact with medications, worsen ones MS by over-stimulating the immune system, or may damage organs including the heart and liver While some herbs may potentially help certain MS symptoms, such as St Johns wort for depression or cranberry for the prevention of urinary tract infections, individuals with MS
should always consult their physician before taking an herb or participating in any CAM therapy
EAE experimental allergic encephalomyelitis Effectiveness in the animal model of MS, while encouraging, is still not a guarantee for efficacy in people with MS In fact, there is a long list of potential MS therapies that looked very promising in animal studies, but ultimately proved to be ineffective for treating the disease Importantly, a few therapies that were effective in the animal model of MS actually worsened MS in people For this reason, animal evidence should not be considered highly persuasive Rather, animal evidence may be considered hypothesis generating, useful for generating ideas for more systematic study
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Observational Evidence: As the name implies, observational studies involve an investigator whose role is limited to observing without intervening For example, a researcher might note the frequency of MS in regions of the world varies in relation to a particular kind of
diet While interesting, this is not highly persuasive The variation may have nothing to do with diet but may instead be related to other factors, such as genetics For this reason, observational evidence is also best considered to be hypothesis generating
AN INTRODUCTION FOR PEOPLE WITH MS Most Persuasive Experimental Clinical Evidence: Experimental clinical evidence refers to evidence in people and, when designed correctly, is often the most persuasive kind of evidence The best type of clinical evidence is obtained through studies known as multi-center, randomized, double-blind, placebo-controlled clinical trials RCCT What this means is that a large number of people are randomly assigned to receive either a placebo or an active treatment randomized, placebo-controlled; neither the patients nor the evaluators know who received the placebo or the active treatment double-blind; and the study is carried out at multiple institutions multi-center If people who receive the active treatment
do better than those who receive the placebo, in a way that would not be expected to occur by chance alone, then the treatment should probably be accepted as effective All of the FDAapproved MS medications have been found effective for some measures in at least some groups of people in multi-center RCCTs RCCTs, and many have low risk to the user and little cost involved for the treatment For example, consider different types of mindbody medicine, such as yoga Properly done, yoga is safe, inexpensive, and enjoyed by many regardless of disease If one person with MS finds yoga helpful for MS-related fatigue and recommends it to another person with MS, it may be perfectly reasonable for the second person to try yoga on this basis alone even though the recommendation was nothing more than a minimally persuasive anecdote Experimental clinical evidence refers to evidence in people and, when designed correctly, is often the most persuasive kind of evidence On the other hand, consider the
following example An alternative medicine clinic advertises an expensive, multi-day treatment involving the administration of IV fluids, claiming to alter the immune system and produce dramatic results in slowing the progression of MS In this situation, highly persuasive evidence should be demanded because the treatment is expensive, invasive, and depending on what fluids are introduced, possibly even dangerous Furthermore, in this example the therapy was touted as a treatment to slow the disease process While it might be easy for an individual to perceive the effect of a treatment on a symptom, such as fatigue, it would be very difficult for an individual to measure a change in the rate of disease progression over time Finally, a therapy that is claimed to alter the immune system through a biological process warrants additional continued on page 7
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CONSIDER RISK, COST,
AND
OTHER FACTORS
It is reasonable to demand that some therapies be proven effective in RCCTs before being used
The currently approved MS therapies are good examples They are all expensive and can have serious side effects Moreover, they are all patented agents so the manufacturers have a financial incentive to pay the enormous cost of conducting a RCCT What about CAM therapies? Should people demand RCCTs before using these therapies? It depends For some CAM therapies, there is limited financial incentive to conduct
COMPLEMENTARY AND ALTERNATIVE MEDICINE
FINDING INFORMATION
ABOUT
CAM
camonpubmedhtml maintained jointly There are a number of ways for people with by the NCCAM and the National Library MS to learn about CAM, including books on of Medicine, and 2 the International the topic, individual experts, and the interBibliographic Information on Dietary net But be warned: finding high-quality Supplements IBIDS Database information about CAM for people with MS odsodnihgov/databases/ibidshtml can be difficult A survey conducted through maintained by the National Institute of the Rocky
Mountain MS Center demonstrates Health Office of Dietary Supplements this The sections on MS were reviewed in ODS Although searching such databases 50 different CAM books found in two large will sometimes yield highly technical and book stores in Denver, Colorado In these difficult-to-read results, the information books, MS was sometimes defined incorrectly will usually be of high quality as a form of muscular dystrophy; five to six Of course, it can be helpful to go to your different therapies were generally recomlocal library, especially a medical library if mended; and no two books had the same one is available, and talk with a librarian recommendations In addition, it was rare This is usually an excellent way to identify for the use of any CAM therapy to be disreliable sources of information on CAM couraged, while dangerous therapies were topics that interest you sometimes recommended Clearly, consumers Finally, general internet search engines need to exercise healthy skepticism
when such as Google wwwgooglecom, Yahoo reading about CAM therapies wwwyahoocom, and MSN Search A few general suggestions may be helpful: searchmsncom can be powerful tools To begin, a healthcare provider should be for finding information Such search consulted This is a good idea for a numengines generate results through technical ber of reasons For instance, a healthcare means that may include keyword density provider may be knowledgeable about the the number of times a keyword appears specific topic of interest to you; he or she on a site and traffic the number of visitors may also know of the risks involved, and to a website It is important to keep in can possibly discuss any interactions that mind that search results are also affected might occur with other medications by sponsorship In other words, some Consider using databases of peerwebsites, often commercial in nature, reviewed scientific literature that are pay to be ranked near the top of certain accessible on the internet
Two helpful searches, which may lead searchers to databases in this regard are: 1 CAM on biased, commercial information PubMed wwwnlmnihgov/nccam/
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AN INTRODUCTION FOR PEOPLE WITH MS the level of evidence that should be demanded before trying a CAM therapy depends on the risks, cost, and effort involved, as well as the inherent appeal of the activity and the way that the treatment works continued from page 5 caution, because it is possible that some immune system changes may worsen MS or antagonize the effects of conventional disease-modifying medications At the time of this writing, approved disease-modifying medications include interferons Avonex, Betaseron, and Rebif, glatiramer acetate Copaxone, mitoxantrone Novantrone, and natalizumab Tysabri Thus, the level of evidence that should be demanded before trying a CAM therapy depends on the risks, cost, and effort involved, as well as the inherent appeal of the activity and the way that the treatment works, ie, whether the treatment
uses substances to alter the immune system In the appropriate situation, it may be reasonable to consider the use of CAM when the risks and costs are low even in the absence of highly persuasive evidence of efficacy On the other hand, it is unreasonable to use a form of CAM that has high risks or costs and a difficult-to-measure outcome unless there is highly persuasive evidence of benefit
Acupuncture is a component of traditional Chinese medicine and more than one million Americans are estimated to use acupuncture each year Chinese medicine proposes that energy flows through 14 main pathways and disease is thought to result from a disruption in this energy Acupuncture involves inserting thin, metallic needles into patients along these pathways For individuals who are uncomfortable using needles, other therapies, such as acupressure which uses finger pressure on these pathway points are available In small and preliminary studies, individuals with MS may experience improvements in
anxiety, depression, dizziness, pain, bladder difficulties, and weakness, although drowsiness may occur as a side effect While adverse events are rare, serious complications can result if the acupuncturist is poorly trained or negligent Individuals with MS should consult their physician before seeing an acupuncturist
EVALUATING THE CREDIBILITY INFORMATION ABOUT CAM
OF
The internet has become a major source of information for consumers of healthcare Of those with internet access, about 80 percent have searched broadly for health-related infor7
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Yoga was developed thousands of years ago in India to unite mind, body, and spirit through a series of body postures, movements, and breathing exercises The different postures may be adapted to fit the capabilities of individuals with physical limitations, even those with severe arm and leg weakness Studies with yoga are very limited, but some individuals with MS have reported improvements in anxiety,
stress, and muscle stiffness; some may potentially experience beneficial effects in emotional and physical functioning A recent study found that yoga improved fatigue for individuals with MS Yoga is associated with few adverse effects, although difficult positions or vigorous exercise should be done with caution, particularly if pregnant or if other conditions exist, such as heat sensitivity, mation on the web, 66 percent have looked for information about specific diseases, and 28 percent have looked for information about CAM Impressively, about a quarter of those with internet access report that the web has influenced their decision about how to treat their illness People with MS may be especially likely to use the internet to obtain healthrelated information; MS has been found to be among the twenty most commonly searched diseases on the internet Although increased access to health information is certainly a good thing for consumers, it also creates new responsibilities One of these
responsibilities is to be able to critically evaluate web-based information because not all information on the internet is
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impaired balance, heart or lung disorders, or bone conditions Individuals with MS should consult their physician before participating in any new physical activity accurate This is true of health information in general, but may be especially true for those looking for information about CAM Distinguishing good and bad information on the internet is difficult and no precise formula for this exists Making such distinctions will always require judgment Credibility of Sources: Important aspects of this judgment will include an evaluation of the credibility of the source of the information as well as the content itself There is no easy way to evaluate the credibility of a source, but, as an example: 1 a panel of MS experts working together on statements within their expertise will usually be very credible; 2 similarly, well-regarded MS organizations will usually be
considered authoritative when
AN INTRODUCTION FOR PEOPLE WITH MS speaking about aspects of MS care within their expertise; considerations of sponsorship and bias are also important; 3 a university or government-run website designed for educational purposes may be more reliable than a commercial website designed to sell products; and 4 a number of third-party quality endorsements for health-related websites exist and these may sometimes assist in determining whether information is credible One such health-related website is HONcode The Health on the Net Foundation Code of Conduct, at wwwhonch/HONcode, which specifies eight principles intended to improve information standards and disclosures Although participation is voluntary and the number of participating sites small, sites displaying the foundations symbol are probably of relatively high quality Other third-party quality endorsements include the Internet Health Care Coalition wwwihealthcoalitionorg and Hi Ethics
wwwbillingscliniccom/bodycfm?id433 Credibility of Content: When evaluating content, perhaps the most important consideration is whether the authors describe the facts upon which conclusions are based References should usually be made available and should generally be to original sources If the website describes treatments, priority should be given to certain kinds of evidence, as described earlier Ideally, the content should be dated because information can quickly become outdated There are other considerations too, of course For example, be highly suspicious of fanciful claims such as a miracle cure, quick cure, or new discovery The idea that someone has found a cure for MS with secret products and without publicity in the mainstream media newspapers, television news is quite unlikely For more information on evaluating web content, please see the Medical Library Associations MLA Users Guide to Finding Health Information on the Web wwwmlanetorg/resources/userguidehtml, as well as
Criteria for Assessing the Quality of Health Information on the Internet http://hitiwebmitretekorg/docs/ criteriahtmlcredibility; the latter is an approach that has also been endorsed by the MLA Although this section has focused on internet claims, many of the same principles apply to evaluating CAM claims obtained from books or from individuals Pay careful attention to the nature of the content and credibility of the source and stay away from miracle cures
SPECIAL CONSIDERATIONS RELATING TO BIOLOGICALLY BASED FORMS OF CAM
The 1994 Dietary Supplement Health and Education Act, or DSHEA often pronounced de-shay set up a framework for FDA regulation of dietary supplements Under this framework, the FDAs role in the regulation of dietary supplements, such as herbs and vitamins, is much more limited than it is for other products it regulates, such as prescription and over-thecounter medications This means that consumers and manufacturers have an increased responsibility for evaluating the
safety of dietary supplements and for determining the truthfulness of label claims
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COMPLEMENTARY AND ALTERNATIVE MEDICINE Individuals should realize that the term natural appearing on a label does not guarantee that a product is safe In fact, some supplements are inherently unsafe, such as comfrey or chaparral, and should be avoided
CONCLUSION
Exploring the world of CAM can be rewarding for many reasons At its best, CAM can open doors to a new kind of wellness; it can be a way to take charge of your own health; and it may even be a way to manage some symptoms But there are also risks Many CAM therapies, like medical therapies, can cause harm What is different is that the responsibility for identifying risks and rewards and for making decisions falls squarely on you, the consumer of healthcare Take that responsibility for education and decision-making seriously and carefully To follow are some good resources for educating yourself about CAM in general and for MS in
particular
Safety will depend, in part, on the quality of the ingredients in a particular supplement as well as the particular manufacturing processes used For this reason, you should pay attention to the reputation of the manufacturer or distributor Supplements made by a nationally known food and drug manufacturer, for example, may be more likely to have been made under tight controls because these companies already have high manufacturing standards in place Individuals should realize that the term natural appearing on a label does not guarantee that a product is safe In fact, some supplements are inherently unsafe, such as comfrey or chaparral, and should be avoided The FDA maintains a list of some dangerous supplements on its website wwwfdagov/fdac/features/1998/dietchrthtml Another difficulty with dietary supplements or other forms of CAM that involve ingesting substances is that medication interactions are possible However, often there will be no information about whether a
particular substance interferes with the medications used in MS There is no easy way around this problem You should factor in this uncertainty and, to minimize the risk as much as possible, consult your healthcare provider
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RESOURCES
Websites wwwmsaacom This is the official website of the Multiple Sclerosis Association of America, providing general information about MS, its symptoms, and its treatments The website also includes a host of other useful information, such as: MSAAs publications; MSAAs regional events and activities; MSAA programs and services; news updates; and links to additional MS-related websites MSAAs Helpline consultants may be contacted by calling 800 532-7667 wwwms-camorg This site is maintained by the Rocky Mountain MS Center and contains MS-specific information about CAM therapies Registration allows for participation in surveys to further research into CAM and MS
AN INTRODUCTION FOR PEOPLE WITH MS
Massage has been used as a healing method for thousands
of years in ancient China and Egypt, although many forms of massage used in the United States today come from Swedish massage Massage is usually performed in a warm and quiet room with soft lighting and relaxing music Oil or lotion is typically added to keep movements smooth, and different techniques include pressing, rubbing, and tapping While studies with MS are very limited, beneficial effects may include improvements in anxiety, depression, muscle stiffness, pain, and possibly self-esteem and overall quality of life Care must be taken to avoid massage to areas affected by injury, infection, or other conditions As with all CAM therapies, consulting ones physician will help avoid any adverse effects
nccamnihgov This is an excellent starting point to learn about CAM in general as well as particular CAM treatments wwwfdagov, wwwcfsanfdagov, and wwwfdagov/opacom/7alertshtml The FDA is a good source of information about dietary supplements in particular
wwwnationalmssocietyorg/spotlight-camasp The National Multiple Sclerosis Society NMSS offers information on CAM therapies and related issues that may be of interest to members of the MS community
wwwftcgov and wwwftcgov/bcp/ menu-healthhtm The Federal Trade Commission is a good site to access to see if there are any fraudulent claims or consumer alerts regarding any therapy wwwnlmnihgov/nccam/camonpubmedhtml CAM on PubMed, maintained jointly by the NCCAM and the National Library of Medicine provides access to peer-reviewed scientific articles on CAM therapies
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COMPLEMENTARY AND ALTERNATIVE MEDICINE odsodnihgov/databases/ibidshtml The International Bibliographic Information on Dietary Supplements IBIDS Database, maintained by the National Institute of Health Office of Dietary Supplements ODS provides access to peer-reviewed scientific articles on CAM therapies Books: Bowling AC Alternative Medicine and Multiple Sclerosis New York, NY: Demos Medical Publishing, 2001 Provides a
review of diverse CAM therapies in relation to MS Bowling AC, Stewart TM Dietary Supplements and Multiple Sclerosis: A Health Professionals Guide New York, NY: Demos Medical Publishing, 2004 Provides a review of dietary supplements in relation to MS Jellin JM, Batz F, Hitchens K Natural Medicines Comprehensive Database Stockton, CA: Therapeutic Research Faculty, 2005 Provides general information on dietary supplements Sarubin-Fragakis A, American Dietetic Association The Health Professionals Guide to Popular Dietary Supplements 2nd ed Chicago, IL: American Dietetic Association, 2003 Provides general information on dietary supplements References: Burks JS, Johnson KP Multiple Sclerosis Diagnosis, Medical Management, and Rehabilitation New York, NY: Demos Medical Publishing, 2000 Fox, S 2005 Health Information Online Retrieved September 18, 2005, from wwwpewinternetorg/pdfs/PIP_Healthtopics_ May05pdf Fox, S, and Rainle, L 2002 Vital Decisions Retrieved September 19, 2005, from
wwwpewinternetorg/pdfs/PIP_Vital_ Decisions_May2002pdf OConnor, et al Defining and describing complementary and alternative medicine Panel on Definition and Description, CAM Research Methodology Conference, April 1995 Altern Ther Health Med 1997;32:49-57 MLA Medical Library Associations MLA Users Guide to Finding Health Information on the Web [online] Available at: wwwmlanetorg/resources/userguidehtml Accessed February 1, 2006 NCCAM National Center for Complementary and Alternative Medicine [online] Available at: nccamnihgov/ Accessed February 1, 2006 Taylor, H 1999 Explosive Growth of a New Breed of CyberChondriacs Retrieved September 19, 2005, from wwwharrisinteractivecom/ harris_poll/indexasp?PID34
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The mission of the Multiple Sclerosis Association of America MSAA is to enrich the quality of life for everyone affected by multiple sclerosis MSAA accomplishes its mission by offering many vital programs and services to members of the MS community MSAAs free programs and services
include: toll-free telephone Helpline with trained consultants English and Spanish; MSAA publications; Equipment Distribution Program; Cooling Equipment Distribution Program; MRI Institute and MRI Diagnostic Fund; Barrier-Free Housing Program; regional events and activities; Networking Program; Lending Library; and other programs Please call the Helpline at 800 532-7667 or visit MSAAs website at wwwmsaacom for information and assistance Help or support to MSAA in any way is truly appreciated To inquire about volunteering, fundraising, or making donations, please contact MSAA at 800 532-7667 or visit MSAAs website at wwwmsaacom for information and assistance
National Headquarters 706 Haddonfield Road, Cherry Hill, New Jersey 08002 Phone: 800 532-7667 Fax: 856 661-9797 Email: msaa@msaacom Website: wwwmsaacom
Source:msassociation.org
