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Dancing: Alternative Therapies


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Dancing: Alternative Therapies

  1. 2. Complementary and Alternative Therapies (CAM) Deborah Rothman, Ph.D. , M.D. Shriners Hospital for Children Springfield, MA JA 2011 National Conference Arlington, VA
  2. 4. Why is there so much interest in CAM? <ul><li>Dissatisfaction with current therapies : </li></ul><ul><li>Side effects </li></ul><ul><li>Possible long term adverse effects </li></ul><ul><li>The appeal of a “natural” remedy </li></ul>
  3. 5. How does this apply to children with arthritis? <ul><li>Is there a way to feed my child that will make her arthritis better? </li></ul><ul><li>Is there a special supplement that will help? </li></ul><ul><li>Do certain foods make arthritis worse? </li></ul>
  4. 6. Goals <ul><li>Give you tools to help you make decisions </li></ul><ul><li>about CAM with your child’s physician: </li></ul><ul><li>Is there evidence that this is effective? </li></ul><ul><li>Is there evidence that this is harmful? </li></ul><ul><li>Where I am getting this information? </li></ul>
  5. 7. How do we know something helps? <ul><li>There is a great deal of information on the </li></ul><ul><li>Internet about alternative therapies for JIA. </li></ul><ul><li>The volume of information is </li></ul><ul><li>overwhelming. </li></ul><ul><li>How can you possibly evaluate all of the </li></ul><ul><li>suggested alternative therapies? </li></ul>
  6. 8. Reliable Sources: <ul><li>Tufts University Health and Nutrition </li></ul><ul><li>Letter ( [email_address] ) </li></ul><ul><li>International Bibliographic Information on Dietary Supplements </li></ul><ul><li>(IBIDS) ( </li></ul><ul><li>NIH Clinical Nutrition Service </li></ul><ul><li>( ) </li></ul><ul><li>PDR for Herbal Medicines </li></ul><ul><li>PDR for Nonprescription Drugs and Dietary </li></ul><ul><li>Supplements </li></ul><ul><li> (organic vs nonorganic ) </li></ul>
  7. 9. Not so Reliable Sources <ul><li>Random sites on the internet </li></ul><ul><li>Jenny McCarthy </li></ul><ul><li>• Sites that end in .com </li></ul><ul><li>• Wikipedia </li></ul><ul><li>Friends, relatives, total strangers </li></ul><ul><li>Infomercials </li></ul>
  8. 10. Warning <ul><li>The information that is readily </li></ul><ul><li>available on the internet may have </li></ul><ul><li>been put there by people whose </li></ul><ul><li>motivation is primarily financial. It is </li></ul><ul><li>completely unregulated. </li></ul>
  9. 11. Suggestions <ul><li>• Download anything from the internet that you want to try and send to your doctor so you can discuss it at your child’s next appointment. </li></ul><ul><li>• If you are using alternative therapies let your doctor know. </li></ul>
  10. 12. What is the evidence that this is effective? <ul><li>Has it been studied in children and the </li></ul><ul><li>results published in a peer-reviewed </li></ul><ul><li>journal? </li></ul>
  11. 13. How do we know a therapy is effective ? <ul><li>Randomized placebo-controlled trials </li></ul><ul><li>(RCTs) are the gold standard for evaluating </li></ul><ul><li>medications and therapies. </li></ul>
  12. 14. What is a RCT? <ul><li>The intervention is compared to a placebo </li></ul><ul><li>( fake drug or inactive supplement ) with </li></ul><ul><li>neither the patient, the parent or the </li></ul><ul><li>investigator knowing who is receiving the </li></ul><ul><li>active drug or the placebo (blinded). The </li></ul><ul><li>data is then analyzed to see if there is a </li></ul><ul><li>significant difference between the two </li></ul><ul><li>groups. </li></ul>
  13. 15. Diet I <ul><li>Vegetarian diet </li></ul><ul><li>Fasting </li></ul><ul><li>Fish oil </li></ul><ul><li>Borage oil </li></ul>
  14. 16. Vegetarian Diet <ul><li>No controlled trials in children. </li></ul><ul><li>Poorly controlled study in adults with RA showing slight improvement </li></ul><ul><li>Vegetarian diets can be healthful for children but may be limited in iron, protein, calcium and certain vitamins. </li></ul>
  15. 17. Types of Vegetarian Diets <ul><li>Vegan : Exclude meat, poultry, fish, eggs, dairy </li></ul><ul><li>Lacto-vegetarian : Exclude meat, poultry, fish, eggs, allows dairy </li></ul><ul><li>Lacto-ova vegetarian : Excludes meat, poultry, fish, allows dairy and eggs </li></ul><ul><li>Pesco -vegetarian: Allows fish </li></ul><ul><li>Pollo-vegetarian: Allows chicken </li></ul><ul><li>Snickers-Vegetarian </li></ul>
  16. 18. Vegetarian Diet <ul><li>If you are considering a vegetarian diet for </li></ul><ul><li>your child ask for a referral to a Registered </li></ul><ul><li>Dietician who can review a safe and </li></ul><ul><li>nutritious vegetarian diet. She </li></ul><ul><li>can also review drug/nutrient interactions. </li></ul><ul><li>Example: calcium and steroids, </li></ul><ul><li>methotrexate and folic acid. </li></ul>
  17. 19. FASTING <ul><li>Short-term modified fasting in adults for </li></ul><ul><li>7-10 days showed improvement in RA </li></ul><ul><li>activity. Clin Exp Rheumatol 2000:18, 357. </li></ul><ul><li>No studies done in children </li></ul><ul><li>Children with S-JIA have profound </li></ul><ul><li>anorexia with no improvement </li></ul>
  18. 20. Fish Oil <ul><li>Adult studies: Multiple RCT’s showing </li></ul><ul><li>improvement in RA </li></ul><ul><li>Pediatric studies: </li></ul><ul><li>Several RCT’s showing modest improvement: decreased CRP, able to decrease NSAID dose </li></ul>
  19. 21. Fish Oil Caveats <ul><li>Fish oil thins the blood so could increase </li></ul><ul><li>the risk of bleeding if also taking NSAIDs </li></ul><ul><li>Challenging to get children to swallow the </li></ul><ul><li>supplements </li></ul><ul><li>Mercury </li></ul>
  20. 22. Fish Recommendations <ul><li>Good fat: mackerel, herring, sardines, anchovies, albacore tuna, salmon </li></ul><ul><li>BUT for young children NO mackerel </li></ul><ul><li>Up to 12 oz/week of seafood that’s low in mercury: shrimp, salmon (wild), canned light tuna (albacore has 3x more mercury) </li></ul>
  21. 23. Botanical (Plant) Oils <ul><li>Borage Oil: GLA (gammalinolenic acid) </li></ul><ul><li>-> DGLA-> Prostaglandin E1 which has </li></ul><ul><li>antiinflammatory and immunoregulatory </li></ul><ul><li>properties. It has been shown to reduce </li></ul><ul><li>synovitis in adults with RA. </li></ul>
  22. 24. Borage Oil <ul><li>One RCT in children with JRA showed </li></ul><ul><li>modest but statistically significant </li></ul><ul><li>improvement in children treated with </li></ul><ul><li>borage oil compared to a placebo. </li></ul><ul><li>A&R 42 (Suppl): S229, 1999. </li></ul>
  23. 25. GLA suppresses acute and chronic inflammation in animal models of arthritis. It has also been shown in placebo-controlled double-blind trials to reduce synovitis in adults with rheumatoid arthritis These promising results were the basis for this clinical trial to study borage oil for the treatment of JIA.
  24. 26. What does this mean? <ul><li>There appears to be an effect of this oil in </li></ul><ul><li>animal studies. Does that translate to </li></ul><ul><li>children? </li></ul><ul><li>There appears to be an effect in adults with </li></ul><ul><li>RA. Does that translate to children? </li></ul>
  25. 27. Study Design I <ul><li>The study was multi-center, randomized, </li></ul><ul><li>double-blind, and placebo-controlled. </li></ul><ul><li>The study duration was 12 months with </li></ul><ul><li>the first 6 months on borage oil or </li></ul><ul><li>placebo and then cross over for the last </li></ul><ul><li>6 months. </li></ul>
  26. 28. What does this mean? <ul><li>The groups had to be comparable </li></ul><ul><li>There had to be a placebo </li></ul>
  27. 29. Study Design II <ul><li>Patient selection: </li></ul><ul><li>All patients included in the analysis </li></ul><ul><li>fulfilled the ACR criteria for JRA. </li></ul><ul><li>Study drugs: </li></ul><ul><li>GLA in borage oil (23%) at 40 mg/kg/day BID </li></ul><ul><li>Safflower oil placebo given in equal volume </li></ul>
  28. 30. Results
  29. 31. Outcome Variable Borage Oil Placebo P value Physician ’ s global assessment (0-4) 0.38 (1.02) 0.92 ( 1.20) 0.002 Parent ’ s global assessment (0-100) 10.82 (13.78) 17.46 (22.40) 0.069 Functional ability scale (0-3) 0.34 (.40 ) 0.42 (.47) 0.113 Number of joints with active arthritis 4.39 ( 9.75) 5.68 ( 9.85) 0.045 Number of joints with limited range of motion 2.75 (5.37) 3.54 (4.80) 0.117 Number of swollen joints 4.25 ( 9.72) 5.46 (9.91) 0.371 Number of tender joints 0.57 (2.10) 0.25 (.84) 0.825
  30. 32. Changing Gears
  31. 33. Diet II <ul><li>Nutritional Elimination Diets </li></ul><ul><li>Nightshade vegetables </li></ul><ul><li>Wheat </li></ul><ul><li>Milk/dairy products </li></ul>
  32. 34. Elimination: Nightshade Vegetables <ul><li>Potatoes, tomatoes, peppers, eggplant </li></ul><ul><li>All reports from same author and from a </li></ul><ul><li>non-scientific review article </li></ul><ul><li>Many hits on the internet about this </li></ul><ul><li>Courtesy Barbara Ostrov, M.D. </li></ul>
  33. 35. Elimination: Wheat <ul><li>If your child has celiac disease then wheat </li></ul><ul><li>and gluten need to be eliminated from </li></ul><ul><li>her/his diet. </li></ul><ul><li>1.5 -10% of JIA co-exists with celiac </li></ul><ul><li>disease. (Rheum 2005: 44, 517) </li></ul><ul><li>Resolve/improve on gluten-free diet </li></ul><ul><li>Celiac disease is a medical </li></ul><ul><li>diagnosis. </li></ul>
  34. 36. Elimination: Milk <ul><li>Fewer than 10% of those who believed they were sensitive showed consistent effect of manipulation of milk in diet in PCRCT ( Ann Rheum Dis 1992:51, 298) </li></ul><ul><li>True cow’s milk allergy needs to be diagnosed by an allergist </li></ul>
  35. 37. Recommendations <ul><li>Restrictive diets can deprive children of </li></ul><ul><li>valuable nutrients. </li></ul><ul><li>They can isolate children and limit their </li></ul><ul><li>ability to socialize with their peers. </li></ul><ul><li>For those rare children who require </li></ul><ul><li>restrictive diets, work with your physician </li></ul><ul><li>and a registered dietician. </li></ul>
  36. 38. Safe Nutrition Interventions <ul><li>Cook with olive oil </li></ul><ul><li>Eat fish 2x/week </li></ul><ul><li>Vegetarian diets can be safe </li></ul><ul><li>Borage oil supplements </li></ul>