complementary and alternative medicine
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Complementary and Alternative Medicine
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Suzana Makowski, MD
Melissa Fischer, MD MEd
I have personally used a complementary or alternative medical therapy.
1 2
0%0%
1. Yes
2. No
I believe that most complementary and alternative therapies are effective.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly agree
2. Agree
3. Neutral
4. Disagree
5. Strongly disagree
I feel as comfortable discussing CAM therapies with patients as I do conventional western medical therapies.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly agree
2. Agree
3. Neutral
4. Disagree
5. Strongly disagree
I feel comfortable responding when a patient brings up CAM
1 2 3 4 5
20% 20% 20%20%20%1. Yes, definitely
2. Somewhat
3. I’m not sure
4. Not really
5. 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
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
Adams et al. Annals Int Med 2002
Would you consider using lavender therapy to calm elderly demented pts?
1 2 3 4 5
20% 20% 20%20%20%
1. Yes, definitely
2. Maybe
3. I’m not sure
4. I don’t think so
5. 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?
1 2 3 4 5
20% 20% 20%20%20%
1. Yes definitely
2. Maybe
3. I’m not sure
4. Probably not
5. 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 othersMorone et al. Pain 134(2008) 310-319
Depression: JAMA 2002Effect 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.
1 2 3 4 5
20% 20% 20%20%20%
1. Strongly agree
2. Agree
3. Neutral
4. Disagree
5. Strongly disagree
I feel comfortable responding when a patient brings up CAM
1 2 3 4 5
20% 20% 20%20%20%
1. Yes, definitely
2. Somewhat
3. I’m not sure
4. Not really
5. 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
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