CAM Approaches to Health and Healing

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CAM Approaches to Health and Healing

• Ronald Schneeweiss MBChB
• Professor, Family Medicine
• Michael Ryan MD
• Associate Professor, Medicine

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HERE'S WHAT YOU NEED TO KNOW A Short History of
Medicine

• I have an earache
• 2000 B.C. -Here, eat this root.
• 1000 A.D. -That root is heathen. Here, say this
  prayer.
• 1850 A.D. -That prayer is superstition. Here,
  drink this potion.
• 1920 A.D. -That potion is snake oil. Here,
  swallow this pill.
• 1965 A.D. -That pill is ineffective. Here, take
  this antibiotic.
• 2000 A.D. -That antibiotic is artificial. Here,
  eat this root.
• (Nutrition News Focus, October 29, 1999.)

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Neolithic Trephining
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What is CAM?(Complementary/Alternative Medicine)

• Complementary and alternative medicine is a group
  of diverse medical and health care systems,
  practices, and products that are not presently
  considered to be part of conventional medicine.
• NCCAM definition www.nccam.nih.gov

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CAM Therapies/Domains (NCCAM)

• 1. Mind-Body Interventions
• 2. Biologically-based therapies
• 3. Manipulative/Body-Based Methods
• 4. Alternative Medical Systems
• 5. Energy Therapies

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CAM Use in the USA

• 42 of US population used CAM in 1997 (vs 30 in
  1990).
• In 97 there were 629 million visits to CAM
  providers vs 386 million visits to 10 MDs
• Expenditures on CAM in 2002 exceeded 26 billion
  (58 were out-of-pocket expenses).
• Use of dietary supplements has skyrocketed over
  the past 10-15 years (5 billion in 2002).

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• Why do Patients Use CAM?

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Why do Patients Use CAM?

• More congruent with values, beliefs,
  philosophical orientation towards health.
• More active participation in care.
• Perceived safety and lower cost.
• Conventional medicine options are exhausted, pose
  significant risks or are of indeterminate
  effectiveness
• e.g. terminal illness, chronic diseases,
  ill-defined painful conditions, chronic
  refractory symptoms of aging arthritis, benign
  forgetfulness, dementia.

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Characteristics of Adult CAM Users

• In USA
• Highly educated
• Holistic orientation to health
• FemaleMale31
• Higher socio-economic status
• WHO data indicates that 65-80 of the worlds
  population (developing countries) depend chiefly
  on
• plant medicine for their primary health care

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60 of patients do not tell their physician about
their CAM use?

Why Not?
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Why do patients not tell their physician about
their CAM use?

• 60 - My doctor never asked.
• 60 - It wasnt important for my doctor to
  know.
• 20 - My doctor wouldnt understand.
• 14 - My doctor would disapprove.
• 70 of patients see their MD before or
  concurrent with
• their visits to a CAM provider
• Eisenberg DM. Ann Int Med 2001135(5)344-51

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What do physicians need to know about CAM?

• Ask/counsel patients about their CAM use
• Philosophy of the major CAM disciplines
• Herbals/supplements (OTC use)
• Mind-Body approaches to self-care and patient
  care
• Placebo Effect
• Collaboration with alternative providers
• Nutrition

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Historic Background Alternative Medicine
vs Conventional Medicine

• Avoid treatments that might inhibit the healing
  power of nature (Vis medicatrix naturae
  -Hippocrates).
• Reliance on Nature - heal by supporting and
  stimulating nature.

• Active intervention - doing something active vs
  waiting.
• Heroic therapy - purgatives like calomel
  (mercurous chloride, emetics, bleeding,
  blistering).

1340 A.D.
400 BC
600 BC
Removing excess humors by vomiting.
Barber-surgeon bleeding a patient (removing
excess red bile)
Greek Music Therapy
Whorton JC. Nature Cures the History of
Alternative Medicine in America. 2002, Oxford
University Press.
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Historic Background Alternative medicine vs
Conventional medicine

• Illness is a condition unique to each individual.
• Natural physiological integrity maintained
  through proper diet, adequate rest and other
  correct habits of life is the only sure
  resistance to disease agents.

• Specific pathologies each produce a distinct
  disease that affects all its victims essentially
  in the same way.
• Focus on pathological changes that disease caused
  in specific organs. Disease is characterized in
  terms of its localized organic pathology.

Whorton JC. Nature Cures the History of
Alternative Medicine in America. 2002, Oxford
University Press.
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Historic Background Alternative medicine
vs Conventional medicine

• Alternative medicine follows an alternative
  science based on intuition, common sense,
  patience and observation.
• Restores people spiritually as well as
  physically.
• Approach is confident and definite.
• Patients given time and personal attention.

• Treatments change over time based on scientific
  studies RCTs, empirical clinical research
• Patients subjective experience subordinate to
  objective evidence of pathology.
• Scientific approach often with uncertainty about
  outcome.
• Increasing time constraints.

Thomas KB. General practice consultations Is
there a point in being positive?
BMJ 19872941200-2
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The Placebo Effect

• In various studies the placebo effect ranges
  from 5-70
• On average the placebo effect is about 35

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Assessing Evidence

• Levels of Evidence
• 1-Good quality patientoriented evidence (high
  quality RCTs, systematic reviews and
  meta-analyses of RCTs with consistent results)
• ------------
• 2-Lower quality patient-oriented evidence
  (retrospective cohort studies, case control
  studies, case series)
• -------------
• 3-Other evidence (consensus guidelines, clinical
  experience, expert opinion)

• Strength of Recommendation (SOR)
• A
• -----------------------
• B
• ---------------------------
• C

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of Conventional Medicine that isEvidence-based
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Dietary Supplements include

• Herbals e.g. Gingko, Saw palmetto
• Supplements e.g. Glucosamine, Co-Q10,
• Trace minerals e.g. Selenium, chromium, zinc
• Vitamins e.g. Vits B6, A, C, E, folic acid
• Hormones e.g. Melatonin, DHEA
• Amino-acids e.g. L-tryptophan,

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10 Best-selling Herbal Medicines USA, 2001 data
RANK HERB

• RETAIL SALES
• ( MILLIONS)

1 Ginkgo biloba 46 2 Echinacea 40 3
Garlic 35 4 Ginseng 31 5 Soy 28 6
Saw palmetto 25 7 St Johns wort 24 8
Valerian 12 9 Cranberry 10 10 Black
cohosh 10
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Dietary Supplement and Health Education Act
(DSHEA) - 1994

• If they occur naturally, products can go to
  market without testing of safety or efficacy.
• Companies do not have to prove that their
  products are safe only reasonable assurance
• Supplements do not have to be manufactured
  according to any standards

Slide 1
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Dietary Supplement and Health Education Act
(DSHEA) - 1994

• Labeling claims almost any claim can be made as
  long as no disease is named.
• FDA to have a very limited role in regulating the
  quality of individual products (can prohibit if
  safety concerns identified).

Slide 2
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Safe and Effective Herbals and Supplements(based
on good quality evidence)

• Echinacea -------------- Treat URI (?)
• Garlic powder-------------- Lowers
  cholesterol-modest (bad odor)
• Ginger root ---------------- Nausea
• Glucosamine, chondroitin-- Osteoarthritis
• Horse chestnut -------------- Venous
  insufficiency
• Peppermint oil -------------- Irritable bowel
  syndrome
• Red yeast rice -------------- ?T. cholest.,
  ?LDL, ? Trigl, ?HDL
• St. Johns wort ---------- Mild-moderate
  depression
• Note Serious drug interactions
• coumadin SSRIs, CCB,
  Anti-retrovirals, BCP

http//www.uwcam.org
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Safe and Likely Effective Herbals(based on
moderately good quality evidence)

• Black cohosh --------------- Menopausal hot
  flashes
• CoenzymeQ10 (CoQ10)-------- Ischemic heart
  disease (CHF)
• Feverfew ------------ Migraine
• Gingko ---------------- Dementia,
  peripheral vascular disease (PVD)
• Milk thistle ---------------- Cirrhosis,
  alcoholic hepatitis
• Omega-3 fatty acids ---------- Prevent coronary
  artery disease (CAD)
• Saw palmetto ---------------- BPH (?)
• Valerian ------------- Insomnia, (anxiety)

http//www.uwcam.org
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Quality of OTC Dietary Supplements

• www.consumerlab.com

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INFORMATION RESOURCES
ConsumerLab.com
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Reliable Information Sources

• UW Healthlinks
• Natural Medicines Comprehensive Database
• UW CAM website
• www.uwcam.org
• National Center for Complementary and
  Alternative Medicine
• www.nccam.nih.gov
• Consumerlab
• www.consumerlab.com
• Memorial Sloan-Kettering Cancer Center
• http//www.mskcc.org/mskcc/html/11570.cfm

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Integrative Medicine

• Integrative Medicine is the practice of medicine
  that reaffirms the importance of the relationship
  between practitioner and patient, focuses on the
  whole person, is informed by evidence, and makes
  use of all appropriate therapeutic approaches,
  healthcare professionals and disciplines to
  achieve optimal health and healing.
• Developed and Adopted by The Consortium, May 2004
  
• Edited May 2005

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• Time permitting I will present a brief overview
  of the major CAM disciplines and therapies. If
  you wish to read more please go to
• www.uwcam.org (select modalities)

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1. Alternative Medical Systems

• a. Traditional Chinese Medicine (TCM)
• b. Homeopathy
• c. Naturopathy

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1a. Traditional Chinese Medicine (TCM)
(AOM - Acupuncture and Oriental Medicine)

• Emphasizes the proper balance or disturbance of
  qi (chee) or vital energy, in health and disease.
• Consists of a group of techniques and methods
  including acupuncture, Chinese herbal medicine,
  oriental massage, and qi gong (combines movement,
  meditation, and regulation of breathing to
  enhance immune function).

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• Therapy
• Acupuncture
• Acupressure
• Herbals
• Meditation
• Manual therapy

• Diagnosis
• Detailed history
• Tongue examination
• Taking the pulse

Manual Therapies
Diagnostic statuette
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1b. HOMEOPATHY

• Founded in1770 by Dr. Samuel Hahnemann
• Like cures like (Law of Similars)
• the more a remedy is diluted the greater its
  potency (Law of Infinitesimal Dose)
• An illness is specific to an individual
• Similar cures exist for similar diseases
  dilution and succussion (shaking) potentiates
  medicines

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1c. NATUROPATHY

• Views disease as manifestation of alterations in
  the processes by which the body heals itself.
• Emphasizes health restoration, prevention, and
  self-responsibility.
• Examples of naturopathic treatments include
• diet, homeopathy, hydrotherapy, herbs,
• massage, detoxification, counseling,
• soft tissue and spinal manipulation.

St. Johns wort
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2. Manipulative and Body-based Methods

• Chiropractic and
• Osteopathic manipulation
• Massage therapy (e.g. conventional therapeutic
  massage, Feldenkrais, Alexander,
• Heller, Rolfing)

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2a. CHIROPRACTIC

• Founded in 1895 by D.D. Daniel David Palmer-
  (restored sense of hearing to a deaf janitor in
  Davenport, Iowa by adjusting a single cervical
  vertebra).
• Relates disease to malalignments (subluxations)
  of vertebrae which create nerve interference and
  block the innate intelligence of the body to
  heal itself. This is a controversial theory even
  among Chiropractors.

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3. Mind-body Interventions

• Employs a variety of techniques designed to
  facilitate the minds capacity to affect bodily
  functions and symptoms
• hypnosis, biofeedback,
• meditation, yoga, dance,
• music and art therapy,
• prayer, mental healing

Greek Music Therapy 600 B.C.
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4. Biologically-based Therapies

• Examples are herbals, special diets (Atkins,
  Ornish, Pritikin),
• Orthomolecular therapies employ vitamins,
  minerals and amino acids to create optimum
  nutritional content and balance in the body.
• Other biologic therapies include
• Shark cartilage to treat arthritis and cancer.
• Bee pollen to treat auto-immune and inflammatory
  disease.
• Chelation therapy with EDTA (IV) - purported to
  reverse atherosclerosis by removing calcium from
  atheromatous plaques.

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5. Energy Therapies

• Biofields
• At this time, the existence of bio-fields
  has not been proven.
• Reiki
• .by channeling spiritual energy through the
  practitioner, the spirit is healed which then
  heals the body.
• Therapeutic touch
• .the healing force of the therapist that
  affects the patients recovery and healing is
  promoted when the bodys energies are in balance.

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5a. Energy Therapies

• Bioelectromagnetic
• Pulsed electromagnetic fields to treat diseases
  such as depression, migraine headaches, multiple
  sclerosis (experimental).
• Static magnets to treat painful
• musculo-skeletal conditions
• (no convincing evidence of efficacy).