COMPLEMENTARY AND ALTERNATIVE MEDICINE AND SPINAL CORD INJURY Dr. Steve Williams, MD Naomi Goodman,...

COMPLEMENTARY AND ALTERNATIVE MEDICINE AND

SPINAL CORD INJURY

Dr. Steve Williams, MD

Naomi Goodman, MPH

Dr. Kristin Gustafson, DO

Dr. Feng Wang, MD, MPH

Bethlyn Houlihan, MSW, MPH

Copyright 2006, NERSCIC Reproduction w/ permission only

What is “Alternative Medicine?”

• According to The National Center for Complementary and Alternative Medicine (NCCAM), part of the NIH: “Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”

• Scientific evidence exists regarding some CAM therapies, but for most there are key questions that are yet to be answered through well-designed scientific studies.

http://www.georgiapainphysicians.com/downloads/m1_slides/4.%20Spinal%20cord%20junctions.jpg


Types of CAM

• Complementary medicine is used together with conventional medicine.

• Alternative medicine is used in place of conventional medicine.

• Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.



• Alternative Medical Systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. One example is traditional Chinese medicine including acupuncture.

Types of CAM



Major Types of CAM

• Mind-Body Intervention uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms.

• Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy).

• Mind-body techniques still considered CAM: meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.



Major Types of CAM

• Biologically Based Therapies in CAM use substances found in nature, such as herbs, foods, and vitamins.

• Some examples include dietary supplements herbal products, and the use of other so-called natural but as yet scientifically unproven therapies.



Major Types of CAM

• Manipulative and Body-Based Methods

are based on manipulation and/or movement of one or more parts of the body.

• Examples include osteopathic manipulation, and massage.



Major Types of CAM

• Energy Therapies employ the use of energy fields and fall into two categories:– 1. Biofield Therapies intended to affect energy fields that

supposedly surround and affect the human body. Practitioners manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

– 2. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.



• Acupuncture is a method of healing developed in China at least 2,000 years ago.

• Today, acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques.

• The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

ACUPUNCTURE DEFINITION



ACUPUNCTURE THEORY

• Acupuncture posits the circulation of qi, or vital energy, within pathways throughout the body called meridians.

• Disturbances in the flow of qi may result in disease or injury.

• There are 14 major meridians; traumatic SCI is a result of injury to one of these meridians, causing the stagnation of Qi and blood circulation and the obstruction of the meridians.

Paola, F. and M. Arnold. Clinical Review: Acupuncture and Spinal Cord Medicine. The Journal of Spinal Cord Medicine. 2003;26:12-20.



ACUPUNCTURE THEORY

• The goals of acupuncture treatment of SCI are:– to clear and activate the meridians to restore the normal flow of

Qi in the major meridians and the smaller meridians into which they flow.

– To promote blood circulation by resolving blood stasis. – To reinforce the kidneys, helping the marrow recover from the

deficiency induced by the traumatic insult.

Paola, F. and M. Arnold. Clinical Review: Acupuncture and Spinal Cord Medicine. The Journal of Spinal Cord Medicine. 2003;26:12-20.



WHY USE ACUPUNCTURE?

• It is an effective way to control certain types of pain and has been recognized by the NIH as potentially useful for a variety of chronic pain conditions and for patients who do not respond to conventional treatment.

• There very few adverse effects associated with acupuncture in the general population.

Averill, A. et al. Blood Pressure Response to Acupuncture in a Population at Risk for Autonomic Dysreflexia. Arch Phys Med Rehabil 81: Nov 2000.



MASSAGE AND OSTEOPATHIC MASSAGE THERAPY

• Massage-therapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being.



CRANIO-SACRAL THERAPY

• Using a soft touch, practitioners release restrictions in the craniosacral system, comprised of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord, to improve the functioning of the central nervous system.

• CST is utilized for a wide range of medical problems associated with pain and dysfunction.

• Out of these therapies, it is the most controversial.



CLINICAL TRIALS AND CAM: What to Look for

• Population from which the sample is drawn: is it generalizable research? Is it appropriate for the population with which yo0u work?

• Study sample size- while statistically and clinically significant results can be found with a small study size, larger, multi-center studies tend more reliable, more generalizable, and more likely to find any possible adverse events.



• Placebo- investigators for acupuncture and massage studies have had difficulty finding effective placebos, which effect study blinding and analysis.

• CAM practitioners argue that sham acupuncture or massage actually stimulate different parts of the body and confound the results.

• If a placebo is not feasible, look for randomized trials with blinded assessors to minimize confounding.

CLINICAL TRIALS AND CAM: What to Look for (Cont)



Summary of CAM Research for Individuals with SCI

100 patients with acute traumatic SCI with ASIA impairment grading of A or B were randomized to acupuncture or standard care.

• The acupoints selected:– Hou Hsi-located at the end of the transverse crease of the fifth

metacarpophalangeal joint.– Shen Mo-located at the feet near the inferior lateral malleoli

areas.– Four acupoints at the antihelix, helix and lower portion of the

ear-back areas. • According to traditional Chinese medicine, these points stimulate

the meridian which is related to the spinal cord.

Wong, AMK et al. Clinical Trial of Acupuncture for Patients with Spinal Cord Injuries. Am J Phys Rehabil 2003; 82:21-27.



ACUPUNCTURE TRIAL (cont)

• Patients in the acupuncture group received electrical acupuncture therapy via adhesive surface electrodes at these points with a frequency of 75 Hz, a pulse duration of 200usec, and a magnitude of stimulation at 10mz.

• Additionally, acupuncture therapy to the bilateral ears was performed with small needles.

• For the intervention group, acupuncture was initiated during in ED or shortly after surgical intervention. The control group did not receive any additional treatment in the ED. Both groups received rehab therapy.

• 30 minute sessions, 5/per week.



RESULTS OF ACUPUNCTURE TRIAL

• In the acupuncture group all the sensory, motor, and FIM scores improved significantly when examined on the day of discharge from the hospital and 1 year after injury (p<.05).

• Compared to the control group, the acupuncture group had significant improvement in ASIA and FIM scores (p<.05)

• There was significant improvement in the sphincter function in the acupuncture group (p=.001).

• Conclusion: acupuncture when applied early in SCI, may improve patient outcomes.



CAUTIONS

• The application of needles during acupuncture might be a noxious stimulus causing autonomic hyperreflexia, especially in patients with higher level injury (Wong et al, 2003).

• Avoid this by using adhesive surface electrodes and auricular acupuncture therapy.



Autonomic Dysreflexia (AD) and Acupuncture Study

• Objective: To determine whether acupuncture could lead to autonomic dysreflexia when used to treat chronic pain in individuals with SCI.

• Intervention: 15 post-SCI individuals with chronic pain and complete and incomplete injuries of T8 or higher received half-hour sessions twice a week, for a total of 15 treatments. Blood pressure (BP) was measured before and after treatment.

• Results: No AD; Systolic BP, and DBP remained stable on average; 3 patients had acute elevation in SBP, one possibly due to comorbid hypertension.

• Recommendations: Monitoring BP and symptoms of AD should be a routine part of acupuncture treatments for those with SCIs above T8 in research and clinical settings.

Averill, A. et al. Blood Pressure Response to Acupuncture in a Population at Risk for Autonomic Dysreflexia. Arch Phys Med Rehabil 81: Nov 2000.



Telephone Survey of People with SCI and Chronic Pain

• Objective: to determine the use of CAM as a treatment for chronic pain.

• Of the 77 people surveyed, 40.3% had used at least one CAM technique to manage pain as a result of dissatisfaction with conventional medicine.

• Most frequently used was acupuncture, followed by massage, chiropractic manipulation, and herbal medicine.

• Acupuncture rated the lowest for satisfaction with pain relief and massage the highest.

• CAM use was significantly associated with a higher income. There were no significant differences in sex, race, or education.



Massage Therapy Trial

• Objective: To assess the effects of massage therapy on depression, functionality, upper body muscle strength and range of motion (ROM).

• Study Population: Twenty C5-C7 SCI individuals were assigned to a massage group or a ROM exercise group. Both groups participated in treatment x2/wk for 5wks.

• Both groups benefited from treatment, but the massage group showed lower anxiety and depression scores and significantly increased their muscle strength and wrist ROM.

• Diego, MA et al. Spinal cord patients benefit from massage therapy. Int. j of Neurosci. 112(2):133-42, 2002.


Acupuncture for Spinal Cord Injury

Review

Feng Wang MD, MPH


NINDS Research• Protecting surviving nerve cells from further damage • Replacing damaged nerve cells • Stimulating the re-growth of axons and targeting their

connections appropriately • Retraining neural circuits to restore body functions



Animal studies

• Olitis MJ, Kovchinski MA; 1990 • Beneficial effects of acupuncture treatment following

experimental spinal cord injury: a behavioral, morphological, and biochemical study.(a) B1.60 (within the depression dorsal to the lateral malleolus), (b) B1.54 (popliteal space) and (c) Gv.3 (intervertebral space between L4 and L5)



Controlling inflammation

• Stopping excitotoxicity • within the first 12 hours after injury, the first wave of

immune cells enters the damaged spinal cord to protect it from infection and clean up dead nerve cells. Other types of immune cells enter afterwards.

• cytokines and neurotrophic factors



A case report

• Cardoso T. MD, Mendez C. M. MD, Jimenez I.Centro• A 28-years-old woman patient with a spinal cord injury at T-5 after a

motor vehicle accident 3 years previously• One month treatment at Du Mai (Governor vessel) and Dai Mai

(Girdling vessel )• Sensation has descended to L4 and there were contractions of

muscles without movement more evident in quadriceps in both legs. Improved bowel and bladder function.



Stimulating re-growth of axons• Grow Axons and make the proper connections and re-

establish functioning synapses.



• Gao, 1996, Paralysis Institute, Shanxi Province, 261 cases treated beginning at 1 month post-onset to over 5 years post-onset. Basic recovery of functions of the nervous system with ability to walk freely, and almost voluntary urination. Improvement of nervous system functions with some limb movement, defecation and/or urination.



• Wang 1992, Institute of Health Preservation, Beijing, China 82 cases treated with acupuncture/electroacupuncture along the bladder meridian (paravertebral) for 5 months

• 76/82 cases or 93%, “Effective” • Includes improvement in lower limb paralysis and

bladder and bowel function



Laserpuncture

• Laserpuncture is more used in France and other parts of Europe as an alternative medicine treatment for spinal cord injury (SCI) and related physical disabilities. potential for restoring some function after SCI.



Retraining central pattern generators• animals' spinal cords contain networks of neurons called

central pattern generators (CPG) that produce rhythmic flexing and extension of the muscles used in walking

• Recent research showed these networks can be retrained after spinal cord injury to restore limited mobility to the legs in human.



Urinary incontinence in patients with chronic spinal cord injury • Honjo H, Kitakoji H, Kawakita K, etc; 1998• 8 cases, Detrusor hyperreflexia was confirmed by

urodynamic studies • bilateral BL-33 , 4 weeks treatment• incontinence was controlled completely in 3 (38%) and

partially in 3 (38%)



Urinary incontinence in patients with chronic spinal cord injury• maximum cystometric bladder capacity increased

significantly, from 42.3 +/- 37.9 ml to 148.1 +/- 101.2 ml by the treatment

• average maximum bladder pressure was not changed



Urinary incontinence in patients with chronic spinal cord injury

• Hisashi Honjo, Yoshio Naya, Osamu Ukimura, ect; in 2001• 13 cases• B Bladder 33• incontinence resolved in 2 (15%) and decreased to 50% or less

compared to baseline 6 (46%). • Maximum cystometric bladder capacity increased from 76.2 ± 62.3

to 148.1 ± 81.5 ml 1 week after the 4th acupuncture (p < 0.01). • bladder capacity decrease to 128.3 ± 93.4 ml in 1 month after the

4th acupuncture.



Improving bladder function

• Acupuncture: posterior and anterior sacral root stimulation for better coordination of bladder and sphincter

• Achieve suppression of reflex incontinence and clinically useful increases in bladder volume



• Stem from the spread of secondary damage to spinal cord segments above and below the injury site. Pain can be at the level of the injury or below the level of the injury, even in areas where sensation is limited or absent.

• Findings indicate that at-level (junctional) pain probably results from damage to grey and white matter one or more segments above the injury site, whereas pain below the injury results from the interruption of axon pathways and the formation of abnormal connections within the spinal cord near the site of injury.

Spinal Cord Pain SyndromesPathology



Neuropathic pain

• Transitional zone pain (also called segmental pain) : at injury level

• Radicular pain : nerve root• central pain, dysesthetic pain, or diffuse pain: below

the injury level



Treating Pain

Sangeetha Nayak and Wise Young on October 01, 2001

The efficacy of acupuncture in the treatment of pain following spinal cord injury

Secondary effects on depression, anxiety, quality of life and impact of pain on social, physical and emotional following SCI.



Future Directions for Research (& Practice)

• Need to improve quality of research on CAM and disability, starting w/ the general population– Integration & synergy concepts to guide research– Current clinical trials in general population

• Example: Innovative new directions in SCI– Holistic nursing and intervention programs w/ individuals w/ SCI– Synergistic relationships b/n pharmacological treatment & CAM

in pain for individuals w/ SCI– Determining factors that affect attitudes towards specific pain

treatment post-SCI



Integration & Synergy (Roca & James, 2001)• “The process of integration is philosophically and

metaphysically a synergistic phenomenon in which the provider and the individual join to create a path to health or wellness.” (p. 134)

• The weaving of therapies in synergistic fashion whole (health care) greater than sum of parts (each therapy)

• Past medicine focus = disease and treatment• Future = whole person, health & wellness, outcomes that

matter to the individual, coordinating all health care• Guiding future research

– Prioritizing based on individual values: focus on low-cost effective interventions, making CAM & info accessible

– Evaluate effectiveness based on individually defined outcomes – How to integrate all types of treatment (ex. pharm. w/ CAM)



Current Clinical Trials (General Population)

• Effects of Cranberry-Containing Products in Women w/ Recurring UTIs– Application to wheelchair users

• Nonpharmacologic Analgesia for Invasive Procedures– For pain & anxiety conditions

• Efficacy of Acupuncture w/ Physical Therapy for Knee Osteo-Athritis

• Functional Brain Imaging – Acupuncture and Osteoarthritis



Innovations: Holistic Nursing & Interventions in SCI (Oliver, 2001)• Premise: consumer-driven movement in recent years

– Individuals independently integrating traditional & nontraditional health treatments (esp. massage, relaxation, imagery)

• Healthy People 2010 Obj. 13-7: PCPs ask & record re: use of CAM, help make accessible

• Practitioner Training: American Holistic Nurses’ Assoc– Certification, exam

• CAM therapies now included in nursing fundamental textbooks– Ex. Imagery & massage for reducing stress, and more broadly

• Scientific evidence of efficacy of nursing interventions• Nurses as Health Care Coordinators to assist w/

integration of CAM & traditional medicine



Holistic Nursing: Research Recommendations• Assess pattern of CAM utilization for different outcomes,

types of CAM used by patients, used/recommended by practitioners

• Role of cultural practices• Safety of integration of various traditional & nontraditional

therapies• Ongoing assessment & evaluation

– Treatment– Patient education interventions for health promo, not just disease

prevention

• Nursing field offers model for classification, diagnosis, etc.• Ask pwSCI for priority development



Incorporating Non-Pharmacological Pain-Relieving Therapies in SCI (Budh & Lunenberg, 2004)

• Survey of treatment utilization• N=90 SCI patients; cross-sectional mail survey (82% response

rate)

• Matched for age, gender, level of lesion, completeness of injury

• Outcome measures: pain questionnaires, visual analog scale, anxiety & depression scale, life satisfaction

• Results:– 63.3% of patients tried non-pharm treatments: massage,

acupuncture, & transcutaneous electrical nerve stimulation.– Predictors: high pain intensity, aching pain, cutting/stabbing pain

• Massage & Heat reported as most efficacious• Need to combine traditional & non-traditional approaches



Willingness to Try Different Paint Treatments for ppl w/ SCI (Haythornthwaite et al, 2003)

• Questionnaire in person or via mail (N=150; 35% response rate)

• Two factors:– Willingness to use opiods– Willingness to use nonpharm treatments

• Persons w/ SCI pain – > willing to use pain treatments than those w/o current pain– > willing to use nonpharm than opiods

• Currently using opiods > willing to use opiods– Differed based on name of opiod

• ID accuracy of patient attitudes & how to affect attitudes to mediate behavior

• Once ID’d, conduct intervention to increase willingness



Future Research & Practice: Final Words

• Limitation of traditional med for individual patient Integration concept: – How to effectively integrate CAM for & with patients, reduce

segmentation?– What therapies work best together?

• Studies on CAM more popular, w/ application to pwd – Esp. in last 4-5yrs around pain in SCI

• Need to categorize pain outcome: above, at, below level of injury

– Need to look at other secondary conditions– Need to present evidence to insurance companies for

reimbursement; design studies with this goal in mind



Future Research & Practice: Final Words (cont’d)• Research w/ both gen. pop. & compared to pwd--

disability diagnostic types & functional categories, different types of CAM, different stages of disability progression

• Survey research, then intervention research (RCTs)– Start w/ therapies & outcomes research focus by pwSCI, &

where there is currently a lack of available health care dollars/resources

– NIH, NCDDR, CDC, NCCAM as funding agencies– Good placebo methods now available, esp. for acupuncture

• Also: accessibility of CAM to patients; provider knowledge, attitudes and practice trends


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