Conversatorio med alternativa
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  • 2. • Interest in complementary and alternative medicine (CAM) has increased significantly • The Cochrane Collaboration describes CAM as “a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems in a particular society or culture in a given historical period” • As of 1997, 64% of United States medical schools included elective or required CAM courses. • Between 1994 and 2010, the number of CAM practitioners in the United States is projected to increase by 88%, and the number of conventional physicians who incorporate CAM into their practices will increase by 16%
  • 3. • The National Institutes of Health established the Office of Alternative Medicine in 1993. • In 1998, this agency was elevated to the level of a center and renamed the National Center for Complementary and Alternative Medicine (NCCAM), with the mission of sponsoring research in the various CAM fields. • The NCCAM research budget increased from $2 million in 1993 to $68.7 million in 2000
  • 4. • Adolescent use of CAM ranges from 10% to 70%, depending on where the adolescent lives or what illness he/she has. • CAM use is considerably higher in specific groups of children and adolescents, such as those who have cystic fibrosis, cancer, or arthritis, and in those undergoing surgery. • Guidelines on CAM use have been published by the American Academy of Pediatrics Committee on Children with Disabilities
  • 5. • According to a 2001 study, although most parents in the Washington D.C. area reported being satisfied with their children's conventional medical care, 21% had treated their children and adolescents with some form of CAM; vitamins, herbs, supplements, and dietary modifications were the most common treatments reported. • A separate study reported that 81% of parents indicated that they would have liked to discuss CAM with their pediatricians, although only 36% had done so. • Pediatric pain management centers in the United States and Canada that offer CAM use biofeedback (63%), imagery (60%), relaxation therapy (60%), massage (49%), hypnosis (44%), meditation (44%) and acupuncture (40%). • Primary care providers are resources for advice and recommendations about using CAM. Many adult and pediatric primary care providers maintain an open attitude toward CAM, make referrals to CAM providers, and use CAM themselves.
  • 6. “ La principal obligación de cada nueva era es formar a los nuevos hombres para que establezcan sus libertades, logren el éxito material y así rompan los candados y cadenas oxidadas de las costumbres muertas que evitan el crecimiento próspero. ¡Es posible que las teorías e ideas que para nuestros antepasados representaron vida, esperanza y libertad sean ahora, para nosotros, destrucción, esclavitud y deshonor¡” ASL
  • 7. ACUPUNCTURE • Acupuncture has increased in popularity and is used extensively in adults and children. • Recent studies have shown that between 1990 and 1997, a large proportion of the population paid out-of-pocket for acupuncture. • Approximately 11,000 acupuncturists are licensed in the United States. • A review of pain treatment services at North American children's hospitals reported that one third offered acupuncture services.
  • 8. • In 1997, a National Institutes of Health consensus conference concluded that acupuncture was effective for treating certain types of pain in adults, such as dental pain, migraine headaches, back pain, and dysmenorrhea. • The conference also concluded that acupuncture was effective in treating adult postoperative and chemotherapy-related nausea and vomiting, and would probably be effective for nausea associated with pregnancy • Postoperative nausea or vomiting (PONV) remains one of the most common side effects in children and adolescents after outpatient surgery. • Much has been reported about the effectiveness of acupuncture at the P6 point for adult PONV and chemotherapeutic nausea. • One study indicated that laser stimulation of P6 in children undergoing eye muscle surgery decreases the incidence of PONV. • A separate study did not show a decrease in PONV in tonsillectomy subjects or after strabismus surgery. A study of acupressure versus acupuncture in a pediatric population undergoing tonsillectomy showed no diminution of PONV in either group
  • 9. • One study looked at the usefulness of acupuncture for upper respiratory infections (URI); acupressure at a nasal point was not statistically significantly better than a control when looking at nasal airway resistance scores, although the subjective sensation of symptoms improved significantly. • In an observational study of 46 infants treated with mild moxibustion over acupuncture points, there was a slight reduction in symptoms, including rhinorrhea, fever, and sore throat.
  • 10. • In one small crossover study, acupuncture may be helpful in treating sickle crisis pain. • Ten subjects who had sickle cell anemia received either acupuncture point or sham site treatments during 16 painful crises in two extremities. • In 15 of these 16 cases, equal pain relief was obtained by subjects receiving sham or real acupuncture. • The conclusion was that needling of either acupuncture or sham site may be an effective tool for pain relief.
  • 11. • Acupuncture and hypnotherapy were compared in one study looking at chronic pain in children. Thirty-one children received acupuncture, along with a 20-minute hypnotherapy session, over a 6-week period of time. • Reports of pain-associated disability (in physical activity and social interactions) from subjects and parents and the subjects' pain ratings were assessed before and after each of the six weekly sessions. • The study subjects experienced an average 46% reduction in pain and a 32% reduction in pain-related disability. This study was limited in that acupuncture and hypnotherapy were not evaluated individually, and there was no control group.
  • 12. • When perceived efficacy and acceptance of acupuncture in 47 pediatric subjects was reviewed, it was found that 70% of subjects (average age 16, 79% female) reported that the treatments helped the symptoms, and 67% rated the therapies as pleasant. • The predominant problems presenting in this population were migraines, endometriosis, and reflex sympathetic dystrophy. • Helms compared real acupuncture, placebo acupuncture, weekly MD visits, and no treatment in 43 women who had primary dysmenorrhea. • After 1 year, improvement was seen in 90.9% (10/11) of the real acupuncture group. Pain relief was noted in 36.4% (4/11) of the placebo acupuncture group. In the no-treatment group, pain improvement was noted in 18.2% (2/11). Only 10% (1/10) experienced pain relief in the physician visit only group. • Analgesic medication use was reduced by 41% in the real acupuncture group, with no change or increased use of medication in the other groups.
  • 13. • A recent Cochrane review of 26 trials supported the use of acupuncture for headache. • For tension headaches, a single case design study compared true with sham acupuncture in 14 subjects; no significant difference was noted in this study, although there was a trend toward reduction in pain scores in those who received true acupuncture. • Acupuncture can provide relief for depression, as noted in a study of adult women. Thirty-eight women were assigned randomly to one of three groups: (1) “specific to depression” acupuncture; (2) “nonspecific to depression” acupuncture; and (3) wait list. • Those who received specific acupuncture treatments improved significantly more than those who received nonspecific acupuncture treatments, and slightly more that those on the wait list
  • 14. • In the United States, acupuncture is a treatment option for those with a diagnosis of substance abuse. • Two adult studies, one of chronic alcoholics and the other of illegal substance abusers, reported more abstinence in those groups that received acupuncture as an adjunctive treatment. However, in a randomized, single-blind, controlled study looking at cocaine addiction, acupuncture was no more effective than a sham needle insertion or relaxation training in reducing cocaine use. • Acupuncture has been evaluated as a possible treatment option for other conditions. • Laser acupuncture, more applicable to adults than to children, has unpublished pilot data for attention deficit hyperactivity disorder (ADHD). • Multiple studies have looked at the effect of acupuncture on nocturnal enuresis in children, some with promising results
  • 15. COMPLICATIONS • Acupuncture has lower adverse effects than many drugs used for similar. • The single death reported from acupuncture was caused by toxic shock syndrome. • In a prospective study involving 32,000 acupuncture treatments, only 11 serious adverse events occurred, including pneumothorax, angina, septic sacroiliitis, and epidural and temporomandibular abscess. • These occurred at a rate of 684 adverse events per 10,000 treatments. • Ernst revealed the most common adverse effects from acupuncture to be pain, fatigue, and bleeding. More adverse events may occur when those performing acupuncture are poorly trained, as reported in a Japanese paper
  • 16. • Hippocrates wrote, “The physician must be experienced in many things, most especially in rubbing”. • The western world has become knowledgeable in massage therapy only recently, although touch therapies, such as those practiced in China and in Indian Ayurvedic medicine, have a long and renowned history. • Massage therapy may release muscle tension, remove toxic metabolites, and facilitate oxygen transport to cells and tissues. • The four different massage therapy techniques include: traditional European or Swedish massage , performed on a massage table or chair, which is the most common; sports massage, which is deep- muscle or deep-tissue massage; body work, which integrates movement and structure, and uses deep-tissue massage to correct posture problems and movement imbalances; and reflexology, an energy form of massage, which focuses on the hands, feet and ears. MASSAGE
  • 17. RESEARCH EVIDENCE • Numerous studies have looked at the efficacy of massage in children and adolescents. In a benchmark study, 20 preterm infants who received massage therapy gained 47% more weight, became more socially responsive, and were discharged 6 days earlier at a hospital cost savings of $3,000 per infant, in comparison with 20 matched controls. • In another study, 24 children and adolescents who had diabetes were assigned to receive either massage or relaxation therapy. Over a 30-day period, mean blood glucose decreased from 159 to 118 in the massage group. In a study of pediatric asthma, 32 subjects were assigned randomly to receive either massage or relaxation therapy. Forced expiratory flow improved from 25% to 75% in those who received massage. • The younger population who received massage therapy showed an immediate decrease in behavioral anxiety and cortisol levels after massage, and the older subjects reported lower anxiety after the massage. A Cochrane review of three randomized control trials in adults and children produced insufficient evidence in favor of, or opposed to, massage for asthma. •
  • 18. • One study showed that children and adolescents who had mild to moderate juvenile rheumatoid arthritis, massaged daily by their parents, had less anxiety, pain, and lower stress hormone levels over a 30-day period. • In atopic dermatitis, affect and activity levels improved after massage therapy, as did skin redness, lichenification, excoriation, and pruritus. • Cystic fibrosis patients may also benefit from massage therapy. For children and adolescents who are depressed, massaged patients have reported less anxiety and had lower saliva cortisol levels. • Massage may be helpful in a variety of medical conditions. Different studies have shown that massage may also enhance attempts at smoking cessation. • A study of adult gay men showed that massage may improve the numbers of natural killer T cells. • Eating disorder patients seem to be affected positively by the addition of massage therapy to their treatment regimens. •
  • 19. • Massage and aquatherapy were used by approximately 25% of 213 pediatric cerebral palsy subjects seen in the University of Michigan rehabilitation medical clinic. • Spasticity and muscle tightness were the most commonly cited reasons for which families of these patients sought CAM. Similarly, a survey conducted by the University of Arizona revealed that, of 376 children seen at a facility serving those with special health care needs, those who had cerebral palsy and spina bifida were the most likely to seek out physical manipulation that included massage. • In one study of pain treatment in adults with cerebral palsy, out of 19 pain interventions listed, only massage and a hip dislocation procedure were rated as optimally helpful. • In the one trial of massage in children who had cerebral palsy, 20 children were randomized to either massage or to the attention control of being read to by an adult for 30 minutes twice weekly for 12 weeks. • Conclusions were that massage decreased spasticity, and improved muscle tone, range of motion, cognition, fine and gross motor skills, and social functioning.
  • 20. • Four randomized, controlled, clinical trials have been conducted in which massage was tested as a monotherapy for low back pain. • A meta-analysis of these studies concluded that methodological flaws existed in all of the trials and that too few trials of massage therapy exist for a reliable evaluation of its efficacy. However, massage does seem to be an effective therapy for low back pain. • In depressed adolescent mothers and in their infants, massage improved the mothers' moods, enhanced parent–child interactions, and had fewer reported pediatric complications. • Infants of depressed mothers were randomized to receive either an intervention, conducted from 3 to 6 months, consisting of free daycare for the infants, and a rehab program (social, educational, and vocational) plus several mood induction interventions for the mothers, including relaxation therapy, music mood induction, massage therapy, or mother–infant interaction coaching. Although the mothers who received the intervention continued to have more depressive symptoms than the nondepressed mothers, their interactions improved significantly and their biochemical values and vagal tone normalized. •
  • 21. • Their infants also showed more positive interactions, better growth, fewer pediatric complications, and normalized biochemical values, and by 12 months their mental and motor scores were better than those of the infants in the control group. COMPLICATIONS • None reported
  • 22. YOGA • Yoga, around for centuries, was developed in India as a spiritual, mental, and physical practice. • Originally made popular in the western world in the 1960s, interest waned until its recent reemergence as a form of healing and mindfulness. The many different types of yoga include: bhakti, a practice of devotion; guru, which involves the dedication to a master; and hatha, a disciplined physical practice that attempts to balance body and mind, with enlightenment as the ultimate goal. Ashtanga is a more athletic form of hatha. Bikram followers practice in rooms with temperatures near 100 degrees Fahrenheit. Jnana is a practice of wisdom, karma is self-transcending action, mantra is practice of a powerful sacred sound, raja is the royal eightfold path to enlightenment, and tantra is the practice of continuity. • Multiple studies have looked at evidence of improved cognitive function, heart rate, and focus in children and adults who practice yoga. • Boys who have ADHD improved behavior and attention was noted . These important, but small, studies indicated significant improvement; however, more extensive research needs to be performed. • This is an important form of treatment with implications for children who have epilepsy, asthma, and eating disorde • rs.
  • 23. SPIRITUALITY • Faith and spiritual practices characterize the CAM therapy most frequently used in the United States. • Sixty two percent of adults have used prayer specifically for health reasons, according to data obtained from the 2002 National Health Interview Survey. • In a study looking at pediatrician beliefs about spirituality, most pediatricians believed that these issues might have important health implications, yet few asked their patients about spirituality. • Those who did appeared more comfortable with their patients' and families' needs and requests for this intervention. Multiple studies and papers have reviewed spirituality and its place in the health model and the therapeutic relationship that practitioners build with their patients. • Further studies are warranted to evaluate the role of spirituality as a source of support and positive health outcomes for adolescent patients and their families.
  • 24. HERBAL MEDICINE • The use of herbal medicines has increased dramatically over the past several years, with excellent reviews documented in the literature. Herbal sales during the first quarter of 1998 increased by more than 100% over the previous year. • The Dietary Supplement Health and Education Act of 1994 defines herbal medicines as supplements. They are not tested according to the same safety and efficacy requirements and regulations as are prescription and over-the-counter drugs. Supplements cannot be marketed for the diagnosis, treatment, cure, or prevention of disease, and deceptive claims are not allowed. • Some herbal medicines have been associated with serious negative outcomes, especially when used in conjunction with conventional medications. • People who have allergies may be sensitive to the flowers and oils of certain herbal products. Chamomile, a member of the ragweed family, may induce severe anaphylaxis in the susceptible patient.
  • 25. • Herbal preparations may be contaminated with heavy metals, bacteria, or fungal organisms while being manufactured or stored. • The consumption of Chinese herbal medicine correlated significantly with elevated blood lead levels in children who were screened for increased blood lead concentrations in Taipei. • Fungal contamination also may be a problem: 62 samples of medicinal plant material and 11 samples of herbal tea were examined in Croatia, 18% of the medicinal plant samples and 9% of the herbal tea samples contained molds such as aspergillus, penicillium, mucor or absidia.
  • 26. • Documented contaminants and adulterants found in herbal therapies • Aluminum Arsenic Aspirin Cadmium Caffeine Corticosteroids Diazepam Indomethacin Lead Mercury Theophylline Thiazide diuretics Zinc • Data from Ernst E. Harmless Herbs? A review of the recent literature. Am J Med 1998;104(2):170–8.
  • 27. ST. JOHN'S WORT • Traditionally, St. John's wort has been used for depression. • The predominant mechanism of action may be serotonin reuptake inhibition, using two active ingredients, hypericin and hyperforin; other mechanisms may include monoamine oxidase inhibition, interference with melatonin secretion, and uptake of norepinephrine. • In a systematic review of St. John's wort for mild or moderate depression, it was noted that St. John's wort was superior to placebo and as effective as low doses of tricyclic antidepressants. However, this herb was not as effective with major depression. Side effects include gastrointestinal (GI) symptoms, confusion, and dizziness. • St John's wort has been shown to induce the cytochrome P450 system, and can increase the metabolism of drugs that use this enzyme pathway, including indinavir, estradiol, oral anticoagulants, and cyclosporine. The serotonin syndrome may be precipitated when St. John's wort is used with conventional antidepressants. • Use in pregnancy and lactation is contraindicated
  • 28. VALERIAN ROOT • Valerian root has been used for centuries as a sedative agent and sleep aid. Recently, it has been used mainly as an aid for insomnia and jet lag. It also is used for migraine headaches, fatigue, and intestinal cramps. • Valerian root, like kava, may affect GABA receptors, which leads to its sedative effects. Several human trials confirm a mild sedative effect. • Few studies exist regarding the anxiolytic effects of valerian root in vivo. Side effects may include headache, excitability, uneasiness, and cardiac disturbances. • Valerian root should not be combined with other sedatives
  • 29. CHAMOMILE • Chamomile has been used historically for GI discomfort, peptic ulcer disease, pediatric colic, and mild anxiety. • It is felt that chamomile may act by binding to central benzodiazepine receptors. • Several small human trials have noted that chamomile has hypnotic-sedative properties; however, none of these trials have been randomized or controlled. • Several cases of significant allergic reactions to chamomile have been reported, no significant toxicity has been reported.
  • 30. GINSENG (PANAX GINSENG) • Ginseng has been touted as enhancing mental and physical strength. It may affect nitric oxide synthesis in the endothelial tissue of the lung, heart, and kidney. • Effects on serotonin and dopamine may be responsible for its actions. Adverse effects may include irritability, insomnia, and GI disturbance. • Ginseng may interact with oral anticoagulants, antiplatelet agents, corticosteroids, and hypoglycemic agents. •
  • 31. HOMEOPATHIC MEDICINE • Anecdotal support of the efficacy of homeopathy has been replaced with more scientific evidence. • The article, “Treatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua,” by Jacobs and colleagues , published in Pediatrics in 1994, was a randomized, double- blind, clinical trial from 1991 where homeopathic remedies were compared with placebo in children who had diarrhea. • The treatment group had a statistically significant (P<.05) decrease in the duration of diarrhea and number of stools. • In a response to that article, Sampson and London had many concerns, including: (1) the diagnostic scheme was unreliable and unproven; (2) the product adulteration was not controlled; (3) the treatment selection was arbitrary; (4) the data sets were grouped oddly, without explanation; (5) the results were not clinically significant; (6) the inference of a public health significance was not founded; (7) the selection of references was incomplete and biased to support the claims of the article, and references were quoted inaccurately; and, finally, (8) the editorializations were inaccurate.
  • 32. • In a meta-analysis of 185 adult trials comparing the effects of homeopathic treatments with the effects of placebo, 89 had adequate data for meta- analysis, and two sets of trials were used to assess reproducibility. • The results of this meta-analysis were not compatible with the hypothesis that the clinical effects of homeopathy are caused completely by placebo. However, these studies did not provide enough evidence on the efficacy of homeopathy for any single clinical conclusion. • A separate meta-analysis of 32 adult trials showed individualized homeopathy to be significantly more effective than placebo. However, when the analysis was restricted to methodologically sound trials, no significant effect was seen. • The results of the available randomized trials suggest that individualized homeopathy has some effect over placebo, but the evidence is not convincing because of methodological shortcomings and inconsistencies . Reilly reproduced the evidence found in earlier trials, that homeopathy, more than placebo, improved the daily symptom score in subjects who had allergic asthma. • Considerable controversy continues to exist, with several meta-analyses demonstrating inconclusive or unfavorable results
  • 33. • A randomized, placebo-controlled trial was initiated to evaluate the efficacy of homeopathy in reducing symptoms of otitis media in children. • Seventy-five children, aged 18 months to 6 years, entered into the study and received either an individualized homeopathic medicine or placebo. After 5 days, 2 weeks, and 6 weeks, the group receiving homeopathy had fewer treatment failures, although these findings were not significant . • In a separate case series of 24 children receiving homeopathic remedies, 2% were considered treatment failures. No adverse effects were reported
  • 34. • The effect of homeopathic medicines on the daily burden of symptoms, use of antibiotics, and need for adenoidectomy or tonsillectomy in children and adolescents who had recurrent URIs showed no statistically significant difference in the daily symptom score between the treatment group and the placebo group. • Both groups reduced their use of antibiotics and there was no difference in the incidence of adenoidectomy or tonsillectomy. • Forty-three children and adolescents who had ADHD were assigned alternately to either placebo or homeopathic treatment in a double- blind, partial crossover study, to determine the effectiveness of homeopathy for this disorder. • Statistically significant differences were found for both comparisons, supporting the hypothesis that homeopathic treatment is superior to placebo treatment for ADHD
  • 35. • In a different study comparing homeopathy with methylphenidate on children and adolescents who had ADHD, 86 (75%) responded to homeopathy, reaching a clinical improvement rating of 73% after an average treatment time of 3.5 months. • COMPLICATIONS • A review of the literature on homeopathic remedies reveals that complications are reported rarely. • These may include a transient aggravation of symptoms, occurring in 10% to 20% of patients after taking a homeopathic medicine. • Because of the dilute nature of the remedies, toxicity is not a complication . • However, one infant developed infantile botulism after being given the natural homegrown chamomile tea colic remedy contaminated with Clostridium botulinum spores .
  • 36. SUMMARY • The field of CAM is broad and diverse, comprising numerous therapeutic modalities. • CAM therapies are viewed as either an adjunct or a complement to conventional treatment. • Patients and their parents can make various health care choices; physicians need to understand and respect these options, and support them if safe and effective.
  • 37. Talking with your patients about CAM • Be open-minded. Most patients are reluctant to share information about their use of CAM therapies because they are concerned their physicians will disapprove. By remaining open-minded, you can learn a lot about your patients' use of unconventional therapies. These strategies will help foster open communication: • Ask the question. • The author recommends asking every patient about his/her use of alternative therapies during routine history taking. One approach is to inquire simply, “Are you doing anything else for this condition?” It is an open-ended question that gives the patient the opportunity to tell you about his/her use of other health care providers or therapies. Another approach is to ask, “Are you taking any over-the-counter remedies such as vitamins or herbs?” • Avoid using the words “alternative therapy,” at least initially, to help you to avoid appearing judgmental or biased.
  • 38. • Don't dismiss any therapy as placebo. • If a patient tells you about a therapy that you are unaware of, make a note of it in the patient's record and schedule a follow-up visit after you have learned more, when you will be in a better position to negotiate the patient's care. If you determine the therapy might be harmful, you will have to ask the patient to stop using it. If it is not harmful and the patient feels better using it, you may want to consider incorporating the therapy into your care plan. • Discuss providers as well as therapies. • Another way to help your patients negotiate the maze of alternative therapies is by stressing that they see appropriately trained and licensed providers and knowing whom to refer them to in your area. Encourage your patients to ask alternative providers about their background and training and the treatment modalities they use. By doing so, your patients will be better equipped to make educated decisions about their health care. • Discuss CAM therapies with your patients at every visit. • Charting the details of their use will remind you to raise the issue. It may also help alert you to potential complications before they occur.
  • 39. “El separatismo, que ha nacido del orgullo, es el error de un intelecto sin compasión. La docta ignorancia de un saber que no sabe nada de totalidades y por ello ha perdido su integridad, surge en el contexto de una autosuficiencia donde ya no hay lugar para la humildad” Jorge iván carvajal posada