A Guide to Evidence-based Integrative and Complementary Medicine by Kotsirilos, Vitetta and Sali


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A Guide to Integrative and Complementary Medicine for Health Practitioners is a comprehensive textbook on the non-pharmacological treatments for common medical practice problems, with the support of current scientific evidence. Non-pharmacological approaches include advice for lifestyle and behavioural factors, mind-body medicine, stress management, dietary changes, exercise and sleep advice, nutritional and herbal medicine, acupuncture, complementary medicines and the role of sunshine that may impact on the treatment of the disease(s). Only proven therapies from current research are included, particularly from Cochrane reviews and research from systematic reviews, randomized control trials and published cohort and case studies.

- Instant access to evidence-based clinical information on non-pharmacological treatments including complementary medicines, for common diseases/conditions.
- Instant access to prevention, health promotion and lifestyle advice.
- Each chapter of the textbook is summarised based on scientific evidence using the NHMRC guidelines grading system
- One/two page, patient summary sheet at the end of each chapter.
- Organised by common medical presentations

ALSO available as an eBook!

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A Guide to Evidence-based Integrative and Complementary Medicine by Kotsirilos, Vitetta and Sali

  1. 1. Chapter 1 IntroductionClinicians have always performed the role of In a study of 23 153 Germanhealth care providers, where the family doctor participants, aged 35 to 65 years, fromhas always been viewed as the logical interface the European Prospective Investigationwith the community’s health needs. Integrative Into Cancer and Nutrition–Potsdammedicine (IM) is an established paradigm shift study, found that adhering to justin medicine in areas such as the North American 4 lifestyle factors — namely, nevercontinent, India and China. Whereas in other smoking, having a body mass index lessareas of the world it is a developing movement, than 30, performing 3.5 hours/week orsuch as in continental Europe, especially more of physical activity, and adheringScandinavia, the Middle East and Australia. 1, 2 to healthy dietary principles (high intake Integrative medicine is recognised as the of fruits, vegetables, and whole-grainpractice of medicine in a way that relates to bread and low meat consumption) —complete patient care. IM includes practices significantly reduces the risk ofcurrently beyond the scope of conventional developing a chronic disease by up tomedical teachings. However, it neither rejects 78%.5conventional therapies nor uncritically accepts • The critical role of the doctor–patientalternative/complementary ones. It implicitly relationship. Throughout history peopleemphasises principles that may or may not be have accorded the doctor–patientassociated with complementary and alternative relationship special, even sacred, status.medicine (CAM) modalities such as: When a medically trained person sits with a patient and listens with full • Whole person medicine. IM views patients attention to his or her story, that alone beyond simply the physical picture of can initiate healing before any treatment their symptoms. They are managed is offered. This latter pattern of care as mental/emotional beings who are constitutes the basic essence of IM.3 members of communities and societies. These other dimensions of human life Western medicine and science has created are relevant to health since antiquity and some wonderfully useful ways of treating essential for the accurate diagnosis and diseases and developing skills in surgery. Our effective treatment of disease.3 goal should be not to replace conventional • The natural healing power of the organism. medicine, but to expand its boundaries and IM assumes that the body has an innate build a scientific foundation for integrating less capacity for healing. The primary goal of well understood approaches to improve the treatment should be to support, facilitate, functional status of patients and to provide a and augment that innate capacity. range of validated treatment options. • The importance of lifestyle to improve The medical profession is confronted by the wellbeing of the sick patient, not changing community attitudes, so a growing necessarily a cure. Health or disease results awareness of such therapies by the medical from interactions between genes and profession would seem to be in harmony all aspects of lifestyle and environment, with the growing public awareness for a more including diet, physical activity, rest, holistic form of health care. sunshine exposure, freshair and sleep, life stressors (the balance between pleasure events and distressful events),4 the quality Holistic health — caring for the of relationships and work. A plethora of whole person studies demonstrate that positive lifestyle The holistic model is traced back to the changes significantly reduce the risk and Hippocratic school of medicine (circa 400 BC) progression of a number of major chronic and the oath of Maimoides (circa the 12th diseases such as cardiovascular disease century AD) which have fashioned and (e.g. myocardial infarction and stroke), defined the unique obligations that clinicians diabetes, and cancer. have toward their patients and their medical 10001-KOTSIRILOS-9780729539081 3
  2. 2. 4 — Part One: Integrative and complementary medcinepractices. Disease and illness was viewed processes of the body. Natural medicines, whenas an ‘effect’ from imbalance and explored used properly, generally are well tolerated andcauses of disease from the environment and rarely cause side-effects. They generally supportnatural phenomena such as air, water, and the body’s healing mechanisms, rather thanfood. Early health practitioners used the term take over the body’s processes.6vis medicatrix naturae, meaning the healing It is important to remain open-minded andpower of nature, to describe the body’s ability flexible, both philosophically and in researchto heal itself. Furthermore, the Hippocratic methodology, with such an approach tooath states: ‘first, do no harm’. It is important treating individuals. We must recognise thatdespite which style of medicine we use, whether healing primarily comes from the individualit is a pharmaceutical agent, surgical approach and mostly depends on their motivation level.or a natural therapy, that we do no harm topatients. The World Health Organization (WHO) Integrative medicinedefinition for optimal health suggests this should Integrative medicine (IM) refers to the blendingbe inclusive of physical, social, psychological, of conventional and complementary medicinesemotional and spiritual wellbeing. The holistic and therapies with the aim of using the mostor health model looks at maximising or appropriate of either or both modalities to caresupporting all aspects of a person’s health, for the patient as a whole.7which will then lead to the disease being healed This closely reflects both the Hippocraticby the body. oath and the WHO definition discussed above. The health practitioner’s aim is to help However, although some may view IM asempower patients to be active participants in synonymous with CAM, this was never so,their own healing process and to encourage nor was it ever the case. CAM comprises manypersonal responsibility for their health to therapeutic modalities that are not taught inimprove quality of care and quality of life. The a conventional medical syllabus, based on thegoal is not just to treat the illness, but to focus ideas that range from those that are sensibleon promoting health and wellness. and worth including in mainstream medicine Establishing and maintaining optimal to those that are extremely imprudent and ahealth and balance is vital to prevention few that are very perilous. Neither the wordand treatment. Wellness is a state of being alternative nor complementary captureshealthy characterised by positive emotions, the essence of IM.8 The former suggests athoughts and actions. Wellness is inherent in replacement of conventional therapies byeveryone, no matter what ‘disease’ is present. others whereas the latter suggests therapies ofIf wellness is truly recognised, focused upon varying value that may be used as adjuncts.and experienced, the individual will heal more IM embraces a holistic approach to clinicalquickly, not just through direct treatment of the practice encouraging patient involvement in‘disease’ alone. self-health care, prevention and interventions Holistic medicine also includes the that focus on health maintenance by payingintegration of various safe, evidence-based attention to all relative components of lifestyle,complementary therapies and medicines that including diet, exercise, stress management,may provide a gentler, safer and, in some and the emotional wellbeing of the patient. IMcases, more empowering approach to health also integrates evidence-based complementarycare. Many medical and health practitioners medicines that are safe and may positivelyworldwide are integrating various ethical non- impact on the healing process and quality ofpharmaceutical modalities into their clinical life for the patient.practice as part of the holistic approach. These IM does not reject or compete withforms of therapies aim to enhance a healthy conventional health care but rather seeks tolifestyle, work with the natural healing process, broaden conventional health care by providingempower patients to be active participants the health practitioner, doctor and patientin their own healing process and nurture the with options to improve health that can workwhole person. Where such therapies can be alongside conventional health care.safely used, they include counselling, meditation IM emphasises a number of issues including:9and relaxation therapies, hypnosis, primarypreventative medicine and lifestyle management, • a focus on wellness and illnessacupuncture, nutritional medicine, herbal preventionmedicine, environmental medicine, and physical • being holistic in nature by focusing onand manipulative medicine. These therapies physical, psychological, spiritual, socialwork in harmony with the natural healing and lifestyle issues 10001-KOTSIRILOS-9780729539081
  3. 3. Chapter 1: Introduction — 5 • incorporating evidence-based, safe and As the evidence-base for some CAM increases, ethical complementary therapies and medical practitioners have a legal obligation medicines to inform patients of the efficacy of relevant • individualising the approach to any complementary therapies as treatment particular patient or clinical situation options, and to simultaneously be aware of the using the best of all available modalities in potential for adverse events and interactions conjunction with informed patient choice that CAMs, such as nutritional and herbal • integrating all of the above into supplements, may have when co-administered conventional medical care with pharmaceutical drugs or when a patient • acknowledging that advances in health denier good orthodox core for any unproven care will be dependent on scientific CAM.11 Knowledge in the efficacy of a advances, improvements in health care complementary medicine or therapy is essential delivery systems, and cultural change as when making clinical decisions for patient well as practitioner and patient education. care to help weigh against potential risks, such as adverse reactions or delays in useful When considering any therapy it is important conventional treatment. This highlights theto balance the risks, the benefits, the evidence, importance of medical practitioners havingthe costs, and the alternatives, such as other at least basic education in the area of CAMtherapies or doing nothing. to enable them to communicate and inform patients about what therapies are appropriateComplementary and alternative to the individual. Education on potential risks such as nutrient toxicity, especially with singlemedicine (CAM) nutrient use, and any potential interactionsComplementary and alternative medicine, with pharmaceuticals is also essential.as defined by the National Centre forComplementary and Alternative Medicine(NCCAM), is a group of diverse medical and Popularity of IM and CAMhealth care systems, practices, and products Worldwide reports demonstrate that a largethat are not presently considered to be part of proportion of the public are using CAM andconventional medicine (see Table 1.1).10 its popularity is increasing. For example, inTable 1.1 NCCAM classifications 10 NCCAM classifies natural, complementary and alternative medicines into 5 categories, or domains 1 Alternative medical systems Alternative medical systems are built upon complete systems of theory and practice such as homeopathic and naturopathic medicine, Traditional Chinese medicine and Ayurveda. 2 Mind–body interventions These interventions include counselling, patient support groups, meditation, prayer, spiritual healing, and therapies that use creative outlets such as art, music, or dance. 3 Biologically based therapies These therapies include the use of herbs, foods, vitamins, minerals, dietary supplements. 4 Manipulative and body-based methods These methods include chiropractic or osteopathic manipulation, and massage. 5 Energy therapies Energy therapies involve the use of energy fields. They are of 2 types: 1 biofield therapies such as qigong, reiki, therapeutic touch 2 bioenergetic therapies involving the use of pulsed electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current fields and/or alternating- and direct-current fields. 10001-KOTSIRILOS-9780729539081
  4. 4. 6 — Part One: Integrative and complementary medcineAustralia up to 70% of the population are IM strategies and healingusing CAM.12 In the United States, up to62% of adults use CAM.13 It is therefore vital A holistic approach to health care involvesthat health and medical practitioners are well giving comprehensive lifestyle advice that isinformed about the evidence in these areas. inclusive of physical, social, psychological, In many respects, the enthusiasm to use CAM emotional and spiritual wellbeing. In this way,is largely driven by the public. The community we are encouraging and promoting our patientshas greater access to information and various to take personal responsibility and be activecomplementary medicine practitioners and participants for their own health. The focustherapies. There are often various reasons needs to be on wellness, and not specificallywhy a patient will want to trial CAM. These on the disease. Positive lifestyle changes and ainclude philosophical and cultural reasons — typical integrative approach to assist healingwanting a more holistic approach to health that can work alongside conventional medicinecare, when there are no longer any other to improve health outcome or quality of life areorthodox approaches to assist in their health listed in Table 1.2.care, especially if they have suffered any adverseevents from orthodox treatments. Generally, Health practitioner/doctorpatients who use CAM are not rejectingorthodox medicine but are looking for options and patient satisfactionto improve wellbeing. Unfortunately, medical Holistic health care offers an enormous amountpractitioners underestimate the extent of use of of satisfaction and joy to the health practitioner,CAM by patients.14, 15 This is of great concern, working with patients to help restore goodconsidering the potential for adverse events such health. The patients are often satisfied withas herb–drug interactions and coordinating the this style of medicine and this, in turn, equallyoverall management of the patient. satisfies the doctors practising holistic health care. It empowers patients by providing themCultural aspects in determining type individually prescribed options for treating theirof CAM use health condition. Failure to treat or cure patientsThe WHO estimates that approximately 60% may occur due to a number of factors, suchof medicine that is practiced worldwide is as lack of motivation, not changing lifestyle,traditional medicine.16 Traditional Chinese choosing the wrong therapy, lack of commitmentmedicine (TCM) is practised in many Asian to the therapy for various reasons (e.g. financial,countries, Ayurveda medicine in India, Unani lack of support, peer pressure, non-believers etc).medicine in the Middle-East, Pakistan and It is important to be aware and sensitive to theseIndia, while Kampo medicine is used in Japan. factors by being intuitive and listening to patients’Biomedicine or conventional medicine is the needs carefully, and with clinical experience finepredominant medicine practised in developed tune treatment modalities accordingly.countries and its formation has also been Furthermore, patients and doctors needinfluenced by cultural factors.17 to have access to quality information about Many of these therapies have been used complementary medicine to make well-for centuries, and some for thousands of informed decisions.years, and have a long traditional use in some The health practitioner(HP)/doctor–patientsocieties and cultures, being highly entrenched relationship is precious, patient–centredin their health care system. There may be little and can result in a positive therapeuticscientific evidence for these therapies, but some outcome. It positively affects medical care andinherent safety considering long-term use, in patient satisfaction. The HP/doctor–patientsome cases up to 2000 years. relationship is based on: Although it is correct to offer patientsconventional medical treatment for acute • kindness, compassion, and respectillnesses, for a chronic illness though for which • genuine caring, honesty, and trustthere is no ‘right’ answer it is likely that the best • the intention to healtreatment is that which best matches the patient’s • empowering the patient (and the HP/belief systems and cultural understanding. For doctor)example, a patient of Asian background may • good communicationbe very keen to use either herbal medicine or • active listening and empathy.acupuncture. Under these circumstances it is Most studies actually indicate that overmandatory that the practitioner is aware of 80% of patients are satisfied with theirpossible toxicity, interactions with conventional general practitioner especially if they see themedicines and the cost of such therapy. same doctor frequently.18 A questionnaire 10001-KOTSIRILOS-9780729539081
  5. 5. Chapter 1: Introduction — 7Table 1.2 Summary of lifestyle and IM strategies Lifestyle suggestions Diet/exercise/stress management Behavioural changes (avoidance of smoking, alcohol) Fun, laughter, joy; being in touch with nature; forgiveness Religion; spiritual belief Creative activities Mind–body approaches Stress management, meditation, relaxation therapies; breathing techniques Counselling — attitudinal healing, cognitive behavioural therapy Social support and/or support groups Group therapy Hypnosis; self-hypnosis Imagery and creative visualising techniques; positive thinking; mind training Communication; self-expression Personal development Biofeedback Spiritual healing; religion; prayer; exploring meaning and purpose in life Environmental advice Clean Air Fresh filtered water Organic foods Sun exposure (more or less) Soothing, relaxing sounds Chemical exposure (work and home) Avoiding household and work surroundings Exercise Swimming, walking, cycling, yoga, tai chi, qigong Dietary suggestions Low glycaemic index diet Mediterranean diet Asian diet Low-fat diet Nutrient supplementation Vitamins Minerals Fish oils Amino acids Herbal therapies Herbs Aromatherapy Physical therapies Acupuncture Manipulation Massage TENS machine Hydrotherapy Energetic Reiki Reflexology Homeopathy 10001-KOTSIRILOS-9780729539081
  6. 6. 8 — Part One: Integrative and complementary medcineTable 1.3 Encourage patient responsibility Table 1.4 The well-informed patient The holistic health care practitioner The well-informed patient: encourages patient responsibility by: Chooses not to be passive Empowering patients to be active participants in their health care Actively sources material and information about their disease Promoting self-care Works together with their health care practitioner to Helping patients to make informed decisions and achieve common goals based on mutual respect choices Participates in their own health care Respecting choices Is motivated to get better Being honest about limitations Needs close monitoring and discussion if they refuse orthodox treatment — this requires careful documentation in clinical notesof 869 patients demonstrated that trust andcommitment was positively associated withadherence to treatment. Positive relationshipswere also associated with adherence to trained) if their knowledge is limited. Hence,treatment and commitment, and between trust there is a great need to further educate theand commitment, that led to positive lifestyle medical profession on the efficacy and safetychoices, such as healthy eating habits.19 The of CAM.researchers concluded: The other area of concern is if the patient is Patients’ trust in their physician and commitment led into particular CAM that is non-evidence to the relationship offer a more complete based and leads to delay of potentially useful understanding of the patient–physician relationship. In addition, trust and commitment favourably orthodox treatments. This situation is often influence patients’ health behaviours.18 seen in vulnerable groups, such as patients with It is also vital that patients are encouraged to cancer looking for cures.take responsibility for their health and be wellinformed about all treatments (conventional orcomplementary) that are safe and suitable for HP/doctor–patient relationshiptheir health care (see Tables 1.3 and 1.4). and the ‘doctor’ as the teacher Respect for the patient and their choice of The doctor–patient relationship also refers here totreatment, compassion, trust and empathetic the health practitioner–patient relationship as theunderstanding all positively influence the HP/ basic principles of care are similar. Interestingly,doctor–patient relationship, and help adherence the original meaning of the word ‘doctore’ isto therapeutic regimens (see Table 1.5).20, 21, 22 teacher. Thus as doctor’s we are also educator’s Other factors that influence the HP/doctor– for lifestyle and health. Patient needs vary frompatient relationship: one patient to another. Therefore, it is mandatory • the tone of the clinician’s voice to remain flexible and vary approaches using • the clinician’s stress levels treatment according to an individual’s needs at • the amount of talking by the clinician; is the time. Many studies demonstrate that active it excessive or not enough? listening, spending time with a patient, displaying • clinician self-awareness of: voice, body a sympathetic, understanding, caring and warm posture and any non-verbal cues attitude not only helps to develop patient trust, • do clinicians hold on to patients when but also enhances the healing response (also care is limited……? known as placebo). To achieve all of this requires longer consultations.Respect and care of the patientCare of any patient needs to be flexible and The value of long clinicalrespectful of their individual needs and choices. consultationsIt does require that the practitioner has a basic Longer patient-centred consultations are of benefitunderstanding of CAM and is willing to be for those patients with chronic disease or mentalhonest with the patient and consider referral health problems. The Australasian Integrativeto a trusted, appropriately trained health Medicine Association (AIMA) evaluated thepractitioner (medically or non-medically evidence of long clinical consultations and 10001-KOTSIRILOS-9780729539081
  7. 7. Chapter 1: Introduction — 9Table 1.5 Hallmarks essential to the HP/doctor–patient relationship Respect Compassion Trust Empathy Appropriate touch Philosophical Deep Integral to HP/ Empathy is Can convey beliefs awareness doctor– the capacity • sympathy Cultural of the patient to imagine • empathy background suffering relationship what another • reassurance Personal of another and influences person is Felt to be seen, heard, experiences coupled healthy feeling without understood Choices with the behaviour feeling it Be sensitive to the wish to patterns yourself; the patient — use touch relieve patient feels thoughtfully, not suffering understood automatically Varies person to person Varies consultation to consultationthe impact on quality of health. The results exercise, massage therapy, music therapy,demonstrated that long consultations:23 aromatherapy and art therapy, for stress reduction/management. • improved the therapeutic relationship, • Providing advice on lifestyle factors, trust, rapport, and answers to questions such as sleep restoration. There are • enhanced health outcomes various studies that demonstrate that • enhanced handling of psychosocial sleep deprivation can significantly problems contribute to the pathogenesis of fatigue, • decreased medication prescriptions depression, type II diabetes mellitus • increased lifestyle advice (T2DM) and cardiac disease. • reduced litigation • Providing advice on behavioural factors • enhanced both patient and doctor that may impact on disease outcomes e.g. satisfaction. drug, smoking and alcohol consumption. The thorough documentation of patient • Exercise and appropriate sunshinenotes was essential with all medical notes exposure. There are numerous studiesbut more so in particular with longer clinical that have reported on the important valueconsultations. Furthermore, it was reported of exercise, not only in the preventionthat it is essential to write accurate notes to of illness but in the treatment of illness.record informed choices made with patients, Combined with prudent sunlightincluding refusal of treatment and why; known exposure, this assists to provide increasedas informed refusal. levels of serotonin, melatonin and vitamin The IM consultation is extensive in order to D, all of which are essential for goodallow the following essential components to be health and enhanced immune function.included by the clinician. • Nutritional history. It is a well established fact that nutrition plays aMind–body medicine critical role in the prevention of almost • Evaluation of lifestyle stressors. A key all illnesses. aspect of the extended consultation is to • Nutritional and herbal supplements. ascertain the patient’s life stressors, which Evidence-based medicine supports the can be important cumulative risk factors for use of nutrition and herbal supplements. the pathogenesis of various chronic diseases. Supplements such as folic acid during • Providing advice on relaxation techniques pregnancy have been demonstrated to and stress reduction/management. prevent congenital abnormalities and Numerous recent studies have reduce the risk of cognitive deficits. Vitamin demonstrated a significant and efficacious D deficiency is common and widespread. effect afforded to patients by relaxation • Referral to other health professionals and meditation techniques in managing who can assist the patient with the lifestyle stressors. It should also be noted necessary specific expertise can be that there are many other stress-reduction essential in certain disease states (e.g. modalities that can be employed, such as meditation, yoga, acupuncture).24 10001-KOTSIRILOS-9780729539081
  8. 8. 10 — Part One: Integrative and complementary medcineThe plant analogy and learn to love oneself. If people are stressed and don’t care for themselves, they won’t follow ourIf given the ‘right conditions’, the body has an innate advice to exercise, eat right, to not smoke or drinkcapacity to heal. The body is equipped with natural alcohol. As health practitioners, we can play ahealing mechanisms. A good analogy of this is the vital role in helping to guide our patients towardssick plant. Most gardeners know that plants can better health, positive lifestyle changes andthrive well by providing the ‘right conditions’, such behaviour patterns through guidance, appropriateas: the right amount of sunlight; fresh air; nutrient- counselling and being suitable role models.dense soil (occasionally supplementing withnutrients through fertilising); a stable, nurturingenvironment free of chemicals; and adequate Communication with allied andwater. Even if a plant appears unwell, changing CAM practitionersany of these conditions can aid the recovery of It is well established that patients are notthe plant. If we apply this concept to the unwell communicating with medical practitionersperson, their needs are very similar. Human about the use of CAM.25, 26 What is notneeds for maintaining and restoring good health so well established is to what degree theinclude: plenty of fresh air; exercise; adequate CAM practitioners and regular doctors arewater; sunlight; good nutritious unprocessed communicating. Medical practitioners (MPs)foods; a peaceful environment free of chemicals, have an established tradition of communicatingexcessive noise and light; good quality sleep; with each other e.g. specialists (consultants)contact with nature and people; meaning and joy with general practitioners (GPs). A specialistin our lives; and minimising psychological stress. knows that in general the GP will have some idea about the content of what they areDis–ease communicating, as medical graduates would have had at least some exposure to do withThe term dis–ease literally means the person is the various medical specialties during theirnot at ease and illness is the body’s expression medical courses and postgraduate training.of imbalance that requires the necessary If a homeopath was to communicate with afundamental changes to bring about balance, GP there are major difficulties as most GPsease and wellness. It is important for the patient would either have no or little knowledge orto recognise that their current circumstances understanding of homeopathy and the languageand lifestyle have contributed to their current behind it. Many patients do not communicatehealth situation. Therefore, if patients are with their regular doctor about CAM use forexpected to gain maximum benefit from fear of being misunderstood or jeopardisingtreatment, they need to fully commit themselves their doctor–patient relationship. However,to a number of positive lifestyle changes. The studies indicate that patients prefer that GPsillness, therefore, should be viewed as positive, were more educated about the CAMs they use,as it is the body’s expression that changes so that they can then better communicate withare necessary and this is the opportunity to their doctors about their use of CAMs.12change one’s life and adopt healthier behaviour There is a greater need to have morepatterns to allow this to occur. interaction between CAM and doctors when the patient chooses to see a CAM practitioner. An increasing number of medical practicesStress include MPs plus various non-medical CAMMost illnesses have a psychological component practitioners and they are proving to be veryas a precipitator and/or as a consequence of popular with patients. Many of these medicalthe illness. Stress plays a major role in most practices have routine meetings to discussdiseases and stress management should be the management of the patient. Other meansregularly prescribed to our patients. A common of improving communication include letterquestion one should ask patients is: writing, emails or phone discussions, especially What was happening in your life at the onset with CAM practitioners at other clinics.of your illness? Referrals to regulated CAM practitioners such This question often gives us a good clue as to as osteopaths, chiropractors (in most states andwhat major stressors may have contributed to territories of Australia) and TCM practitionersthe onset or aggravation of the illness. Providing (Australia), reduces the risk of incompetentthe time listen to patients and learing their stories management. If the CAM practitioner is acan have profound lealing effects on them. member of a professional body this can provide It is important to emphasise to patients to evidence of at least some training, standards andlisten to their bodies, follow their own intuition guidelines for safe practise. 10001-KOTSIRILOS-9780729539081
  9. 9. Chapter 1: Introduction — 11 It is also reassuring to the MP if it is known that The abovementioned points serve as usefulthe CAM practitioner has adequate experience guidelines for MPs in consultations involvingand in particular is aware of their limitations CAM.and knows when to refer back to a MP. TheMP should initially be involved if a diagnosishas to be made but this would not be necessary Evidence-based medicine (EBM)if a patient wanted, for example, dietary advice The definition of evidence-based medicineor wanted to learn relaxation techniques which (EBM) is ‘the conscientious, explicit andcould be obtained from a CAM practitioner. As a judicious use of current best evidence in makingground rule, MPs differentiate between medical decisions about the care of individual patients’.31and CAM practitioners and have expressed EBM integrates the best external evidence withgreater confidence in medical colleagues who individual clinical expertise and patients’ choice.practice complementary medicine.27, 28 Furthermore it is noted that absence of evidence There are unresolved issues to do with does not mean a therapy does not work.32referrals by MPs to CAM practitioners and EBM is a common term described as:these include:29 the conscientious, explicit, and judicious use of current best evidence in making decisions about the • Should a doctor refer a patient so care of individual patients. The practice of evidence- the patient can be assessed regarding based medicine means integrating individual clinical suitability for a complementary therapy? expertise with the best available external clinical • What information should the patient be evidence from systematic research. By individual clinical expertise we mean the proficiency and given about the benefits and risks to do judgment that individual clinicians acquire through with the therapy? clinical experience and clinical practice.31 • Should the doctor forward personal This definition emphasises that whilst information to the therapist and vice versa? scientific evidence is important in clinical • When should a CAM practitioner refer judgment, clinical experience and expertise to a MP? also play a major role in the care and choice of • What are the circumstances under treatment for a patient. which a patient is referred by one CAM EBM encourages doctors to look for well- practitioner to another? structured, randomised placebo-controlled prospective studies (Level II evidence) andEthical and legal Issues systematic reviews of such studies (Level I evidence) to support clinical practice, but as yetA report on ethical and legal issues at the there are few of these for the majority of CAMs.interface of CAM and conventional medicine ‘Outcome studies’ may be more appropriatesuggests that when MPs are faced with patients for holistic models of health, such as TCM andwanting to trial CAM they should:30 traditional Ayurveda medicine, where a more • be honest with patient’s direct individualised and holistic approach to treatment questioning about CAM occurs. Randomised control trials (RCTs) may • establish the patient’s understanding of be suitable for the holistic approaches but need CAM and why they use it to be creative but still technically possible. Very • take into account the burden of the little good quality research exists for these patient’s illness and provide material of therapies. Lack of evidence is not necessarily their expressed preferences associated with lack of patient benefit. • discuss the risks and benefits of both CAM and orthodox treatment Biomedical focus on evidence- • adequately inform the patient about based medicine and evidence-based available CAMs that have been shown to research affecting IM and CAM be safe and effective, and those that are Scientific evidence is the basis and is pivotal to shown to be ineffective biomedicine. Evidence on efficacy and safety • become familiar with qualified and should be the basis of defining which CAMs competent CAM practitioners (both are useful and which are not. To date, research medical and non-medical) to whom in CAM has been limited due to a number referrals are made of factors such as funding, the type of CAM • continue their relationship with the used, the quality of the studies, the ability to patient, and continue to monitor their patent a product and so forth, to make any health firm conclusions about their potential role • keep communication with the patient in health care. In saying this, there is also a open and respectful. large body of scientific evidence emerging for 10001-KOTSIRILOS-9780729539081
  10. 10. 12 — Part One: Integrative and complementary medcineCAM worldwide. This evidence should be Table 1.6 NHMRC levels of evidencemade accessible to the health profession andpublic, and also integrated into recommended Level I From a systematic review of allnational guidelines of treatment for specific relevant randomised controlledhealth conditions. Once a therapy or medicine, trials, meta-analyses.be it orthodox or complementary, has scientific Level II From at least 1 properly designedevidence to prove its efficacy and safety, then randomised controlled clinical trial.the medical practitioner has a legal and ethicalobligation to use the best treatment possible Level IIIa From well-designed pseudo-for the individual patient. randomised controlled trials There are many CAMs that are not evidence- (alternate allocation or some otherbased to date. This may not mean that they method).are ineffective as funding may have not beenallocated to research these therapies/medicines. Level IIIb From comparative studies (includingHowever, until they are tested they need to be systematic reviews of suchused cautiously. studies) with concurrent controls and allocation not randomised,National and Health Medical Research cohort studies, case-control studies, or interrupted time seriesCouncil (NHMRC) guidelines to with a parallel control group.researchSince 1999, the National and Health Medical Level IIIc From comparative studies withResearch Council (NHMRC)33 has created historical control, 2 or more single-useful guidelines to identify the varying levels arm studies or interrupted timeof scientific evidence using a scale from I– series without a parallel controlIV. These guidelines help to identify which group.medicines or therapies carry greater weight in Level IV Opinions of respected authoritiesresearch, with Level I considered as superior based on clinical experience,research and Level IV considered the least descriptive studies or reports ofsuperior. Refer to Table 1.6 expert committees. To date, there is a growing body of clinicalstudies ranging from Level I–IV scientific evidence Level V Represents minimal evidence from(NHMRC guidelines) for complementary testimonials.medicines. Throughout this textbook referenceis made using the NHMRC guidelines. be allowed to make their choices as to whatCochrane collaboration treatment they wish to pursue if they are lowA worldwide network of researchers called the risk and have some proven efficacy. It is easierCochrane collaboration prepare, disseminate to recommend CAMs when they have evidenceand continuously update systematic reviews of for safety and efficacy. There is now a growingrandomised clinical trials in all areas of health body of scientific evidence to support CAMscare. A CAM field is set up and is bringing such as some herbal medicines, acupuncture,together evidence for CAM. This involves a nutritional medicine, and stress managementconjoint effort of many scientific researchers techniques which work with the natural healingand centres throughout the world. process of the body. A list of CAM Cochrane reviews and The basic principles of holistic health careprotocols can be accessed via: include: http://www.compmed.umm.edu/cochrane/ • the patient must be motivated and haveReviews2002.pdf an intention to heal, therefore the patient must be a willing participant in their own health careConclusion • the health practitioner and/or doctor should have an intention to help theThe use of CAM should have certain boundaries. patient with compassion, understandingIts use should not be to the exclusion of a clearly and kindnessindicated, safe, effective and superior orthodox • developing a good health practitioner/therapy. In making choices patients need to be doctor–patient therapeutic relationshipinformed about the range of reasonable options in a safe atmosphere is essential andof orthodox and complementary therapies. listening carefully and intently to whatBased on clear information patients should then they are saying 10001-KOTSIRILOS-9780729539081
  11. 11. Chapter 1: Introduction — 13 • all healing is self-healing; the CAM among adults: United States. Seminars in Integrative practitioner role is to empower patients to Medicine, June 2004;2(2):54–71. 14 Kristoffersen SS, cited in Drew AK, Myers SP. Safety help heal themselves, to take charge and issues in herbal medicine: implications for the health have personal responsibility of their health professions. MJA 1997;166:538–41. • recognising that illness can be seen 15 Nahin RL, Straus SE. Research into complementary as positive and is an opportunity for and alternative medicine: problems and potential. positive change and growth, such as BMJ 322 (7279):161. 16 World Health Organization. Media Centre fact developing positive behaviour patterns sheets. Online. Available: http://www.who.int/mediac • the health practitioner and/or doctor entre/factsheets/fs134/en/ (accessed Jan 2010) should be a role model for good health 17 Cassidy CM et. al. Commentary on terminology and always endeavour to educate and and therapeutic principles: challenges in classifying encourage the patient to adopt healthy complementary and alternative medicine practices. J Altern Comp Med 2002;8:893–5. behaviour patterns and a healthy lifestyle. 18 Potiriadis M, Chondros P, Gilchrist G, et. al. How This book summarises the key scientific and do Australian patients rate their general practitioner?management strategies using an IM approach A descriptive study using the General Practiceto treat common health problems faced by Assessment Questionnaire. MJA 2008;189(4):215–19.medical and health practitioners in everyday 19 Berry LL, Parish JT, Janakiraman R, et. al. Patients’medical practices. commitment to their primary physician and why it matters. Ann Fam Med 2008;6(1):6–13. 20 Marie-Thérèse Lussier, Claude Richard. FeelingReferences understood. Expression of empathy during 1 Kotsirilos V. Complementary and alternative medical consultations. Canadian Family Physician medicine. Part 2-evidence and implications for GPs. 2007;53:640–1. Australian Family Physician 2005;34(8):689–91. 21 Squier RW. A model of empathic understanding and 2 See websites for the Royal Australian College of adherence to treatment regimens in practitioner– General Practitioners (RACGP — http://www.racgp. patient relationships. Soc Sci Med 1990;30(3):325–39. org.au) and the Australasian Integrative Medicine 22 Branch WT, Malik TK. Using ‘windows of Association (AIMA — http://www.aima.net.au/). opportunities’ in brief interviews to understand 3 Snyderman R, Weil AT. Integrative medicine: patients’ concerns. JAIMA 1993;269(13):1667–8. bringing medicine back to its roots. Arch Intern Med 23 Cohen M, Kotsirilos V, Hassed C, et. al. Long 2002;162(4):395–7. Consultations and Quality of Care: AIMA Position 4 Vitetta L, Anton B, Cortizo F, et. al. Mind-body Statement. 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The use of 7 RACGP-AIMA Joint Position Statement of the alternative therapies by Auckland general practitioners. RACGP and AIMA, Complementary Medicine, 2004. NZ Med J 1990;103:213–15. Online. Available: http://www.racgp.org.au/Content 28 Pirotta Marie, Cohen Marc, Kotsirilos Vicki, et. al. /NavigationMenu/Advocacy/RACGPpositionstatemen Complementary therapies: have they become ts/2006compmedstatement.pdf (accessed 14-04-09) accepted in General Practice? MJA 2000;172:105–9. 8 Vitetta L. Integration is here to stay. Editorial. 29 Brophy E. Referral to CM practitioners — legal and J Compl Med 2008;7(6):7. ethical issues. J Comp Med 2003;2:42–8. 9 Integrative Medicine Statement. See Statement 30 Kerridge I, McPhee J. Ethical and legal issues at the Chapters in RACGP Curriculum for Australian interface of complementary medicine and conventional General Practice. Online. Available: http://www.racgp. medicine. Medical Journal of Australia 2004;181:164–6. org.au/curriculum (accessed 14-04-09) 31 Sackett DL, Rosenberg WMC, Muir Gray JA, et. al. 10 National Center for Complementary and Alternative Editorial: Evidence based medicine: what it is and Medicine (NCCAM). What is Complementary and what it isn’t. BMJ 1996;312:71–2. Online. Available: Alternative Medicine (CAM)?May 2002, USA. Last http://www.bmj.com/cgi/content/full/312/7023/71?eaf modified: 21 October 2002. Online. Available: http:// (accessed 13-01-09) nccam.nih.gov/health/whatiscam/ (accessed 14-08-09) 32 Douglas G Altman, J Martin Bland. Absence of 11 Brophy E. Informed consent and complementary evidence is not evidence of absence. BMJ 1995; medicine. J Comp Med 2003:223–8. 311: 19 August: 485. 12 Easton K. Complementary medicines: attitudes and 33 National Health and Medical Research Council information needs of consumers and health care (NHMRC). A guide to the development, professionals. Prepared for the National Prescribing implementation and evaluation of clinical practice Service Limited (NPS). July 2007. guidelines. Commonwealth of Australia, Canberra, 13 Patricia M, Barnes MA, Eve Powell-Griner, et. al. 1999. Complementary and alternative medicine use 10001-KOTSIRILOS-9780729539081