Complementary and Alternative Medicine (CAM)

*Reiki / Therapeutic Touch* What early medical systems incorporated ideas of vitalism?

- Western Traditions (four temperaments or humors) - Eastern (Qi , Ki) - African (Ase) - Native American (spirit) CAM therapy uses the idea of "vitalism" to explain how their practices work --> Energy Therapies (Reiki/Therapeutic Touch/Healing Touch), Acupuncture, Chiropractic and Homeopathy (to a lesser degree)

NCCIH CAM categories

1. *Whole medical systems*: homeopathy (Germany), Chinese medicine (includes acupuncture), and ayurveda (India), naturopathy (the Western mix of all of these). 2. *Mind-body medicine*: meditation, prayer, mental healing, art therapy, music therapy, and dance therapy. 3. *Biologically based practices: dietary supplements*, dietary changes, herbal supplements. 4. *Manipulative/body-based practices*: chiropractic and massage. 5. *Energy therapies*: qigong, reiki/ therapeutic touch, and electromagnetic therapy

Principles of Chiropractic

1. Bones in the spine get out of place (i.e. subluxations). 2. Bony displacements cause nerve interference. 3. One can manipulate the spine, replace the bones, remove the interference, and allow "innate" or "vitalistic force" to flow and restore health.

When would using a placebo be a good idea?

Maybe --> if a CAM is safer than using other methods, then why not?

What database can we use to look up the research on supplements?

Natural Medicines Comprehensive Database

Is there evidence to support chiropractic?

No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.

What is the "currency" of alternative medicine?

Supplement industry --> direct to consumer!

*Chiropractic* Does it align w scientific understanding?

The Facts: - There is no single cause to all disease, no "vital force" that is impeded. - Chiropractic texts make basic anatomy and physiology errors (Ex: VIII cranial nerve does not travel through neck, thoracic and abdominal organs have craniosacral innervations, organ function is also under endocrine and circulatory control, etc.) - Chiropractic "subluxations" do not exist as a mechanism of disease. - Some chiropractors seek to abandon "subluxation theory" altogether. --> NOT based on any scientific knowledge; important to realize that chiropractory might seem plausible or scientific to the general public, even though we know it is not

Quote... that is crazy

"A subluxated vertebra is the cause of 95 percent of all diseases ... the other five percent is caused by displaced joints other than those of the vertebral column."

*Reiki / Therapeutic Touch* Can this be used to help a pt? benefits vs risks

*Benefits:* - RCT indicate the same outcomes in both real and sham Reiki groups. - Non-specific effects: comfort, well-being, relaxation, stress relief. - Systematic review... "the evidence is insufficient to suggest that reiki is an effective treatment for any condition". *Risk:* - No direct risk, this is very safe. - Must be clear with patient that "vital or universal energy" is not an accepted mechanism for disease. - Costs vary $25 - $240 per session.

*Reiki / Therapeutic Touch* what are the underlying principles of the therapy?

*Reiki: Rei (universal life) Ki (energy)* - Originated in Japan early 1900s by Mikao Usui. - Popularized in west 1930's by Hawayo Takatoa. - Proposes a "vital or universal life force" --> flow of energy in the body - If blocked/unbalanced = physical/emotional symptoms. *Therapeutic Touch* - 1970's by Dolores Krieger, PhD, RN & Dora Kunz. - Contemporary interpretation of Reiki. - Many nursing programs offer classes and certificates.

Risks vs Benefits of Using CAM Therapy for Pts

*Risks* - Direct (ex. medication interactions, disease related complications, cost)? - Indirect (ex. endorsement of ideas, delay of diagnosis or treatment)? *Benefits* - Are these benefits specific to the alternative medicine practice? - Can the patient receive the same benefits with less cost or risk?

*What does chiropractic look like today?* straights vs mixers

*The practice is divided between "straights" and "mixers"* *Straights* (follow the tradition of D.D. Palmer) - Postulate every disease in the human body is caused by "spinal subluxations" - By adjusting the spine one can cure asthma, migraines, hearing disorders, allergies, GI problems, etc. *Mixers* (are open to outside ideas). - Recognize there are other causes of disease (infections, genetic, etc). - Use aspects of straight chiropractic (subluxation theory) + advice about exercise and diet. Ok with conventional medicine, to varying degrees. - More common in past 50 yrs. Embrace "integration". - Currently advocating for PCP status and seeking prescription privileges in some states.

Advocates of NCCIH

- 40% of adults use CAM. - $34 billion is spent a year on CAM therapies. - Huge need to cure common conditions (back pain, HA, etc.). - People need to know which therapies are safe and effective. - CAM therapies offer alternatives to patients, which they should be free to choose from. - The therapies are often cheaper than conventional medicine and can decrease health care costs. - Alternative practitioners can fill the primary care shortage, function as PCPs

What is the placebo effect?

- Any health effect measured after an intervention that is something other than the response to a biologically active treatment. - When a person perceives an improvement based on the net effect of multiple observational cues and personal expectations.

Post-modernism & the internet's influence on pseudoscience

- At one point, it was fine for medical providers to be indifferent about popular pseudoscience ideas - BUT ever since the internet & post-modernism skepticism --> allows for dangerous/harmful pseudoscience beliefs to be easily accessed & spread to people - Why we now have measles outbreaks & ther bad science rampant in this modern day & age

National Center for Complementary and Integrative Health (NCCIH)

- Created in 1992 - Objectives of the Center: 1. Explore complementary and alternative healing practices. 2. Train complementary and alternative medicine clinicians and researchers. 3. Spread information about CAM to the public and professionals. - Center is controversial with scientists inside and outside NIH: clinicians, researchers and state medical boards have advocated for the center to be closed since its inception.

History of Chiropractic

- Daniel David Palmer (1845 - 1913). - Created chiropractic September 18th 1895. - Adjusted neck of Harvey Lillard which corrected his hearing. - Proposed all diseases are caused by the impedance of energy that flows from head --> toe through the spine.

What does it mean to say something is supported by "evidence" or "research" or "clinically proven"?

- It can mean many different things depending on who you ask (patient, medical provider, lawyer...) - Important to remember that as a PA, if we endorse ideas/practices/treatments, patients will likely trust what we have to say

What should you do when we see questionable medical practices?

- It may be our responsibility to speak up when there is questionable scientific information being taught on things like TV & internet - Raises a lot of questions on medical ethics

How important is it that the general public recognizes good science form pseudoscience?

- It's important, BUT if there are treatments/therapies that are psuedoscience & are safe, then why not? - As long as nobody is getting harmed, we should let pts have their beliefs/practices --> neutral position

What is involved with a placebo effect?

- MULTIPLE factors: motivation to feel better, expectations about an improvement, prior beliefs, changes just because they are part of a clinical trial or getting our attention, interest in satisfying the researcher or clinician, etc. - The more concrete and physiological the outcome being measured, the smaller the placebo response - Large placebo responses for self-reported outcomes (ex. pain, nausea), whereas little or none for most objective outcomes. *Most alternative medicine research uses self-reported outcomes*

*Chiropractic* Can this be used to help a pt? RISKS

- Minor complications are common: (30-60%) dizziness, HA, numbness, stiffness. - Lumbar manipulation likely safer than cervical. - 26 people (children and adults) have died from adjustments (ripping of vertebral artery). - Other serious effects: disk herniation and cauda equina syndrome. - Serious complications are rare (1 in 20,000 to 1 in a million). - Exposure to "aberrant beliefs".

*Chiropractic* Can this be used to help a pt? BENEFITS

- Most studies are of poor quality and have inconclusive results. - Some benefits for acute and chronic LBP. - May reduce the frequency in which some people get HA. - No compelling data supports the efficacy of chiropractic for non-musculoskeletal disorders. Important to realize that you cannot have blinded studies involving chiropractic adjustments --> difficult to prove in trials

Is it a good idea to use placebos as a *primary* tx?

- NO --> systematic review found that they did not have important clinical effects, but only improved self-reported outcomes - Ethical concerns: ethically dishonest, promotes deception in the patient-provider relationship, violates informed consent

*Chiropractic* Are the benefits of chiropractory any different than other practices (PT, physiatrists, OTs, athletic trainers...)?

- NO --> the good thigns about chiropratory are not unique to chiropractory - Other fields have stronger evidence/basis for their practices being beneficial

Do all health claims need to be supported by scientific research?

- Not necessarily: as long as they have that little box that says "These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease" there can be medical/scientific claims put on that may or may not have what we call "good" evidence - Supplement industry

When did mandatory adverse rxn reporting come into effect?

- Not until 2007 --> prior to that, poison control centers received 1.3 million reports of ARs - Between 2004 - 2013: estimated 23,000 ER visits/yr due to supplements

Stats on Chiropractic

- Possibly the most popular alternative medicine practice - Currently 17 chiropractic colleges in U.S. - Some states want chiropractors to be able to serve as PCPs

The Dietary Supplement Health and Education Act of 1994

- Product safety is manufacturer responsibility, then the FDA post-market. - Supplements make "structure/function" claims, not disease claims. - FTC collects 34 million in charges against misleading claims a year. - 64% of Americans take supplements, 84% trust supplement claims. - Americans spend 34 billion per year, 122 billion contributed to US economy. - 170-200/90,000 of supplements have had documented safety tests.

Critics of NCCIH

- Question conflicts of interest & ability to conduct rigorous research. - Negative findings do not change public behavior or opinion. - The presence of CAM in academic institutes gives legitimacy to unscientific ideas. - Lack of publications in peer-reviewed journals, failure to report clinical trials. - Large sums of money spent studying implausible treatments

What factors are involved in CAM?

- Social, cultural, political & technical/medical - Technical factors of medicine are JUST as important as the other factors when it comes to CAM

What supplements have known dangerous side effects?

- Thujone: neurological damage - Concentrated garlic: bleeding - Pennyroyal and capsaicin: infant deaths - Blue cohash: heart failure - Nutmeg: hallucinations - Monkshood and plantain: arrhythmias - Wormwood: seizures

*Reiki / Therapeutic Touch* Does it aligin w/ our scientific understanding?

- Unlikely mechanism of action (i.e. Emily Rosa experiment --> 9 year old that put self-proclaimed therapeutic touch experts to the test to see if they could feel the "energy" of her hand through a screen) - No scientific evidence of a "vital or universal life force" or ability to detect it, although is historically/culteurally evident

Complementary Medicine

- Used alongside conventional medicine - BUT providers are usually not communicating with each other

Integrative Medicine

- Used in coordination with conventional medicine - Providers are in communication

Alternative Medicine

- Used instead of conventional therapy - Not that common that patients use only alternative therapies

Important Takeaways for CAM

1. Pay attention to the very real concerns: - Replacement of conventional therapies with alternative therapies. - Unappreciated direct and indirect harms. - Largely unregulated products. - Giving legitimacy to unscientific ideas. - Public confusion over the nature of scientific claims. 2. CAM therapies are medical interventions and carry risks. They should be held to the same standards of safety and efficacy as conventional treatments. 3. Take into consideration the seriousness with which some of your patients believe in these treatments. 4. If your patient uses CAM therapy, know about the practice and practitioner.

How do we assess CAM therapy?

1. What are the underlying principles of the therapy? 2. Do the principles match our general understanding of the physical or social sciences? 3. Can we use this therapy to help a patient?

Key Points About CAM

1. When most CAM modalities are tested under rigorous conditions with adequate controls they tend to *perform no better than placebos.* 2. CAM therapies are *important to people*, they promote attractive lifestyle and heath philosophies, and sometimes are deeply *rooted in culture traditions.* 3. CAM *exists in popular culture and in our academic institutions* largely due to social, cultural and political reasons. 4. Your *colleagues likely know very little about CAM therapies* or what they claim to do. Many assume these therapies are useful or harmless.