MED2042 WEEK 4 - Complimentary medicine (summing up)

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List some key terms for complimentary medicine: Orthodox medicine (OM)
Alternative
Complementary
CAM
Integrative
Holistic
Unorthodox
Natural therapies
List some Modalities.: Philosophical systems
Manual
Medicinal
Mind-body
Bioenergetic
What are CM attitudes and usage?: - can't ignore CM
- 60-65% of Australian community use CM
- Most people want a balanced approach not rejection of OM
e.g. immunisation, cancer treatment
- Predictors of CM use
> younger
> more educated
> more affluent
> female
> cultural groups e.g. TCM, Ayurveda, indigenous medicine
- Chronic illness
- philosophical outlook
Why do people choose CM?: Unhappy with aspects of OM e.g.
costs
invasiveness
side-effects
lack of efficacy
superficial approach (e.g. pharmaceutical only)
lack of time
lack of relationship with therapist
What ethics are important to CM?: - need for informed consent
> uninformed doctors often have uninformed patients
> communication breakdown
- balance b/w beneficience and non-maleficence
- respect for autonomy
- resource allocation
- marketing
- research
- who is legally responsible
What evidence and research is there for CM?: - some good evidence arising
- methodological challenges
- many gaps (real and perceived)
> sometimes little research
> often poor quality or small trials
> Non-english journals
> methodological challenges
> poor funding
> poor penetration of information into medical education
> marketing and financial forces
> c/w pharmaceutical industry
What are some examples of CM in practice?: Holistic approaches for serious/chronic illness
- CM therapists place far more emphasis on holism and lifestyle
- ESSENCE

Using other treatments
- Supplements, herbs, mind-body, acupuncture etc
What is the ESSENCE model?: Education
Stress management
Spirituality
Exercise
Nutrition
Connectedness
Environment
What is Multiple sclerosis?: - commonest chronic degenerative neurological condition
- affects young adults
> autoimmune disease: immune cells attack myelin sheath (covering of nerve axons) affecting transmission of nerve impulses
- course follows relapses and partial recover
> eventual disability and incapacity
- no significantly effective medical therapies
> interferon most widely used (expensive and many side-effects)
What education is important for patient and carers?: Disease
Prognosis
Therapies
Self-help strategies
Describe Stress management (ESSENCE) in relation to MS.: - cardiovascular reactivity of MS patients determined
> 42% of life events assoc. with exacerbations in 6/52
> exacerbations more likely following life events
> independent of threat level and type of stressor
> autonomic tone and stress reactivity predictive (higher CV reactivity predicted greater number of exacerbations and proportion of weeks ill)
- chronic stress assoc. with significant increase in the number and severity of MS exacerbations
Describe "Spirituality" (ESSENCE) in relation to MS.: Finding meaning and deep sources of inspiration important when coping with a chronic and life-threatening disease like MS

"Positive reinterpretation of disease seems to be of outstanding importance of patients with life-changing diseases (MS)"
Describe Exercise (ESSENCE) in relation to MS.: - Improvement in fatigue
- Increased general fitness and strength
- Reduced disability
- Better mood and coping
- Less falls and fractures
- Social interaction
- Outdoor activities
- Improved immune function
Describe Nutrition (ESSENCE) in relation to MS.: - Prospective study on dietary intervention for MS
- over 34 year f/up, when other causes of death were excluded, only 31% of MS patients put on a low fat diet (less than 20g/day) had died compared to 80% of MS patients on a higher fat diet
- rates of disability and progeression of the disease were vastly different in the two groups
- omega-3 fatty acids associated with significant reductions frequency and severity of MS relapses (fish and flax-seed oils have anti-inflammatory properties)
Describe Connectedness (ESSENCE) in relation to MS.: Chronic psychosocial stressors (interpersonal conflicts, loss and complicated bereavement, low perceived social support, anxiety and depressive episodes) and MS exacerbations
- Unsupportive social environments associated with onset and exacerbation of autoimmune diseases
> social support buffers the effects of change in depression on IFN-gamma production.
- Social factors have a large effect upon coping, mental health, quality of life, activities of dail living, access to services
Describe Environment (ESSENCE) in relation to MS.: - countries with lower levels of sunshine have significantly higher incidences of MS
- benefits may be due to direct effects of sunlight on immune function, melatonin and vitamin D
- OR for death from MS was nearly halved for those with higher residential sun exposure and one quarter for those with high residential and occupational exposure
What are methods for "taking control of MS"?: - Lifestyle and self-help therapies for MS
- Most doctors and patients do not know about other therapies for MS
- Many patients go to CM practitioners for lifestyle and holistic advice
- raises many questions
- eventual medico-legal implications?
What are conventional therapies for MS?: Corticosteroids
- shorten duration of acute relapses
- doubtful long term benefits and many side effects

Interferons
- mainstay of longer term treatment
- reduce relapse rates possibly by 30%
- doubful reduction of progression of disability
- daily injections, expensive, many side effects (malaise, flu-like symptoms, depression, hepatic disease, leukopenia, severe sensitivity reactions

Have to weigh up costs and benefits
Describe glucosamine for OA.: - This review emphasizes the importance and role of nutritional factors such as glucose and glucose-derived sugars (i.e. glucosamine sulfate and vitamin C) in the development, maintenance, repair and remodeling of cartilage
- Americans spend more on natural remedies for osteoarthritis than for any other medical condition. Preliminary evidence indicates that it relieves pain to a degree similar to that of NSAIDs but with fewer side effects
- Recent research suggests that it may not only provide symptomatic pain relief, but may have a role in chondroprotection.

- Similar analgesic effect to NSAIDs
- Lower cost
> in Australia Natural product taxed by GST
> NSAIDs subsidised by PBS
- Fewer side-effects
> NSAIDS: GIT bleeds, 1/500 chance of death per patient-year of treatment plus increased risk of AMI
> minimal with natural product
- Which therapy would you choose?
- Which therapy would you prescribe?
Which of the following is associated with the greatest reduction in cardiac-specific and all-cause mortality?: A. resins
B. statins
C. n-3 fatty acids
D. niacin
E. fibrates
What evidence is there for lipid-lowering interventions?: - systematic review of RCTs
- comparing lipid-lowering interventions with placebo or usual diet with respect to mortality from all, cariac and non-cardiovascular causes
- A total of 97 studies (>275000 participants)
Describe the Mediterranean diet.: - Higher adherence to the Mediterranean diet by 2 units (/10) associated with 27% lower mortality rate among persons with CHD
> adjusted mortality ratio: 0.73 (CI: 0.58-0.93)
> reduced mortality was 31% when only cardiac deaths were considered
> independent of nationality
What literature review is there for CM and Asthma.: - review of 105 referenes
- sufficient evidence to suggest that many of these therapies can provide objective and subjective benefit
- in view of the increasing populatiry... there is now an urgent need for high-quality research
What kind of CM usage is there for asthma?: Most used therapies overall
- dietary and nutritional
- herbal remedies
- meditation
- homeopathy

Most commonly used for children
- massage
- relaxation exercises
- diet
- vitamins

Most used don't always equate with most effective
What evidence is there for CM and asthma?: Good accumulating evidence
- relaxation
- yoga
- psycho-education
- nutrition (e.g. N-3 f-a, antioxidants, vit C)

Largely safe with beneficial side-effects

CM for which there is some/ambiguous evidence:
- Buteyko method
- Qigong
- Acupuncture
- Homeopathy
- Some herbs
- Biofeedback and hypnosis
- Massage
What is the evidence of yoga and asthma?: - 53 patients matched with controls
- 2 weeks yoga training (65 minutes practice per day)
Results
- significantly less attackes per week
- improved scores for drug treatment
- improved PEFR

- 570 patients
- yoga training for 2-4 weeks (follow up for 3-54 mnths)
Results
- PEFR showed significant move towards normal
- near to 70% have reduced or stopped medication
Describe emotionally triggered asthma.: - review of 185 references
- panic and negative emotions affect asthma
> hyperventilation, increased autonomic lability, autonomic arousal and bronchoconstriction, poor health care behaviours
- panic and repressive coping style are risks for morbidity
- relaxation, EMG biofeedback, biofeedback improve sensitivity in perceiving symptoms
What is the psychological treatment of astham?: - relaxation/mediation - significant effects
- biofeedback - promising
- self-management and psycho-education - beneficial, cost-effective, improved adjustment, increased compliance, greater perceived self-competence, decreased use of medical services
- family therapy - useful for some
What are factors for paediatric asthma deaths?: 7 physical factors
- seizures with attack, large reduction in prenisolone etc

7 psychosocial factors
- depressive symptoms
- conflict (parent-staff, patient-staff, patient-parent)
- manipulative use of asthma
- emotional disturbance
- separation and loss
- family dysfunction
What is the literature review for psychoeducation and asthma?: - meta-analysis of 31 studies
- education, behavioural skills, cognitive therapy, counselling
- reduced asthma attacks, better lung function, adherence to treatment, utilisation of health care, psychological well-being, use of medication
What is the link between nutrition and asthma?: - Antioxidants (vitamines E&C) look to be beneficial - larger studies needed
- B6 low in asthmatics - supplements reduce need for medications
- low selenium strongly associated with asthma
- caffeine an dgreen tea reduce asthma symptoms possibly due to theophyllines
- diet rich in omega 3 f.a. beneficial
- high magnesium intake beneficial
- role of breast-feeding controversial
What is the evidence for nutrion and asthma?: - research now supports the role of increasing fish, fruits and vegetables
- school children who eat fish more than once weekly, have 1/3rd change of developing asthma than those hwo eat no fish
What is the evidence for vitamin C and asthma?: - debate about the role for vitamin C in asthma
> diet low in vitamin C is a risk factor for asthma
> diets high in vitamin C assoc. with better pulmonary function
- review of 11 studies: 7 showed significant improvement in resp. function following supplementation with 1-2g vit C
- It is clear that a diet low in vitamin C is a risk factor for the development of asthma but the effects of supplementation are less certain
- dosage, diet, duration?
What is the evidence for herbs and asthma?: - A clinical review of herbs for asthma showed 9 of the 17 trials positive
- reported clinically relevant improvement in lung function and/or symptom scores
- evidence promising in some cases but not yet definitive
What problem might use of CM cuase with emergency visits?: - 601 adults surveyed
- emergency visits associated with use of herbal treatments, coffee or black tea or OTC products
- higher rates among (herbal (OR 2.5), coffee or black tea or OTC products
- use of preparations may delay treatment
What are the non-pharmacologic measures of osteoporosis?: - balanced diet including adequate calcium and vitamin D intakes
- appropriate exercise
- smoking cessation
- avoidance of excessive alcohol intake
- fall prevention
- adequate sunlight exposure

Bioactive constituents e.g. phytoestrogens, in plants play a role in maintaining or improving skeletal health
> main consumable plant sources of phytoestrogens include isoflavones and lignans found mainly in soybeans and flaxseed, respectively
> flaxseed and dried plums are also rich sources of polyphenols
What CM is used for hot flushes?: - soy has modest benefit
- isoflavones possibly useful
- black cohosh may be effective
> lack of long term safety data
- dong quai, evening primrose oil, vitamin E and acupuncture not presently supported by evidence
What CM is used for depression?: Best evidence:
St. John's wort, physical exercise, slef help guides (e.g. CBT, bibilotherapy) and light therapy (winter depression)

Promising evidence:
folate, vitamin E, vitamin B6, vitamin D, SAMe (s-adenosyl methionine), phenyalanine, acupuncture, light therapy (non-seasonal depression), massage therapy, negative air ionisation (winter depression), relaxation therapy, yoga, dance, and reducing or avoiding alcohol, sugar and caffeine avoidance and possibly music therapy

Very little or no evidence:
- Aromatherapy, homeopathy, fish oil, lemon balm, ginseng, selenium, prayer, color therapy, progesterone cream, pets and chocolate.
What are some important lessons about CM?: - 'standard medical practice' sometimes contrary to guidelines and evidence
- financial outlays can be considerable for individuals and healthcare system
- industry, and not good evidence, often drives:
> inappropriate practice and over-prescribing
> a lack of promotion of effective strategies
- These issues are as relecant for conventional medicine as they are for CM
- Many people going elsewhere for holistic care
> we should not ignore the message

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