Complementary and alternative medicine
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Complementary and alternative medicine

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Complementary and alternative medicine Complementary and alternative medicine Presentation Transcript

  • Complementary and Alternative Medicine Suzana Makowski, MD Melissa Fischer, MD MEd Images included may be copyrighted and are used for education under the Fair Use and TEACH Acts. Use for other purposes must conform to national copyright law.
  • I have personally used a complementary or alternative medical therapy.
    • Yes
    • No
  • I believe that most complementary and alternative therapies are effective.
    • Strongly agree
    • Agree
    • Neutral
    • Disagree
    • Strongly disagree
  • I feel as comfortable discussing CAM therapies with patients as I do conventional western medical therapies.
    • Strongly agree
    • Agree
    • Neutral
    • Disagree
    • Strongly disagree
  • I feel comfortable responding when a patient brings up CAM
    • Yes, definitely
    • Somewhat
    • I’m not sure
    • Not really
    • No way
  • Data re: use
    • 1720 (41.3%) completed phone interview regarding health practices
    • Aromatherapy, acupuncture, chiropractic, folk remedy, herbal, diet, massage, relaxation, self-help group, yoga, spiritual healing, biofeedback, energy, homeopathy, hypnosis, imagery, megavitamin, naturopathy, osteopathy, spiritual healing
            • Kessler et al. Ann Int Med. 2001;135:262-268
    • Use at any time
    • No measure of persistence
    • English-speaking only
  • Barriers to prescribing CAM therapies by conventional western medical practitioners
    • Lack of knowledge of efficacy
    • Lack of belief in efficacy
    • Shifting basis of evidence
    • Lack of consensus about use
    • Lack of comfort
    • Lack of interest in the topic
  • Potential harms from using CAM therapies
    • Physician-patient relationship strain
    • Harm from patient rejection of proven conventional western therapies
    • Innate hazard
            • Adams et al. Annals Int Med 2002
  •  
    • “ even physicians who are willing to consider CAM treatments in some circumstances find it difficult to know how to responsibly and ethically advise patients in this unfamiliar realm of medicine.”
            • Adams et al. Annals Int Med 2002
    • ==========================
    • “ EBM is the integration of best research evidence with clinical expertise and patient values.”
    • Sackett , et al . Evidence-based medicine: How to practice and teach EBM . 2000
  • Types/Catagories of CAM
    • Mind-Body
    • Herbal/Supplements
    • Manual
    • Energy
    • Systems
  • Factors in risk-benefit of CAM vs conventional medical therapy
            • Adams et al. Annals Int Med 2002
    Severity & acuteness Curability with conventional treatment (tx) Invasiveness, toxicity & side effects of conventional tx Evidence on safety & efficacy of CAM tx Understanding of risks & benefits of CAM tx Knowledge & acceptance of risks of CAM tx Persistence of patient’s intention to use CAM tx
  • Would you consider using lavender therapy to calm elderly demented pts?
    • Yes, definitely
    • Maybe
    • I’m not sure
    • I don’t think so
    • No way
  • Aromatherapy
    • Cross-over randomized trial
    • 70 Chinese adults with dementia (78)
    • 3 weeks lavender inhalation (at least 1 hr at night)
    • Cohen-Mansfield Agitation Inventory (CCMAI) & Neuropsychiatric Inventory (CNPI)
  • Lin et al, Int J Geriatr Psychiatry 2007; 22:405-410
  • Cochrane Review: Aromatherapy and Massage Therapy for Pts. with Cancer.
    • REVIEWERS' CONCLUSIONS:
    • Massage and aromatherapy massage confer short term benefits on psychological wellbeing, with the effect on anxiety supported by limited evidence.
    • Effects on physical symptoms may also occur.
    • Evidence is mixed as to whether aromatherapy enhances the effects of massage.
    • Replication, longer follow up, and larger trials are need to accrue the necessary evidence.
  • Would you consider using lavender aromatherapy in elderly demented pts?
    • Yes definitely
    • Maybe
    • I’m not sure
    • Probably not
    • No way
  • Mindfulness
    • Randomized wait-list controlled
    • 37 adults with chronic low back pain (74)
    • 90 minutes x 8 weeks
    • Pain, function and QOL questionnaires baseline, after intervention and 3 mos later
    • Physical function (SF-36) 42-46 (8, 12 mos)
    • Pain acceptance 72-76 (75 12 mos)
    • Continued meditation 76%, 72% recommended to others
    Morone et al. Pain 134(2008) 310-319
  • Depression: JAMA 2002 Effect of St. John’s Wort in Major Depressive Disorder
    • Objective : Test efficacy & safety of St. John’s Wort in Major Depressive Disorder
    • Study Design : Double blind, randomized, placebo controlled trial. N=340 randomized to: (a) Sertraline (b) St. John’s Wort (c) Placebo
    • Conclusion : Study fails to support efficacy of St. John’s Wort in moderately severe major depression
  •  
    • Comments from Table 2 (results section)
      • “ No significant differences between St. John’s Wort and placebo (p=0.21), or between Sertraline and placebo (p=0.26).
  • Summary of Discussion/Conclusion
    • “ No evidence of superior effect of St. John’s Wort relative to placebo. Neither St. John’s Wort or Sertraline could be differentiated from placebo on primary efficacy measures.”
    • Based on this data, “St. John’s Wort should not be substituted for standard clinical care”
    • But what if the standard care is Sertraline?
    • Respect of personal beliefs (pt s& own)
    • Seek middle ground
    • Time limited trial
    • Coordination of care
    • Abandonment
    • Comfort in counseling without evidence
  • An Approach
    • What is the likely risk of therapy patient is considering?
    • Build referral relationships with local CAM providers.
    • Become familiar with a few possible approaches that you can recommend (i.e. Center for Mindfulness.)
  • I believe that complementary and alternative therapies may be effective.
    • Strongly agree
    • Agree
    • Neutral
    • Disagree
    • Strongly disagree
  • I feel comfortable responding when a patient brings up CAM
    • Yes, definitely
    • Somewhat
    • I’m not sure
    • Not really
    • No way
  •  
    • Lifetime use of CAM therapy increasing steadily since 1950s
    • English speaking only
    • No measure of persistence
    • “ the challenge for physicians … is to provide ethical, medically responsible counseling that respects and acknowledges patient values.”
    • Adams et al. Annals Int Med 2002
  • Experiential Session
    • Mindfulness
    • Aromatherapy foot baths