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Integrative Medicine: What
the Health?
Lisa W. Corbin, MD, FACPMedical Director, Integrative Medicine
University of Colorado Hospital and Health Sciences Center
Associate Professor, Rehabilitation and Internal Medicine
ObjectivesAfter this talk, you should be able to:
– Define “CAM”, “Integrative Medicine”– Discuss the basic background, risks, and
benefits* of some common CAM therapies– Discuss CAM with your doctor / patient– Identify qualified CAM practitioners – List resources for finding more information– Describe the Integrative Medicine program at
UCDHSC
What is Integrative Medicine?
What is Integrative Medicine?
Real Definitions Please…• CAM
– Complementary / Alternative Medicine– Therapies not usually associated with
hospitals or medical schools• Acupuncture, Massage Therapy, Chiropractic…
• Integrative Medicine – CAM therapies coordinated with conventional
medical treatments
Integrative Medicine
• Reaffirms patient / practitioner relationships
• Considers the “whole” person
• Is informed by evidence
• Considers all appropriate therapies, practitioners, and disciplines
• Promotes “optimal wellness”From Consortium of Academic Health Centers for Integrative Medicine(www.imconsortium.org)
Who Uses CAM Therapies?
Barnes PM. www.cdc.gov/nchs/data/ad/ad343.pdf
Adults, 2002 incidence of CAM use:
•Over 80% also using conventional medicine•Less than 35% discuss with physician – why?
CAM: Potential Risks
• Directly harmful treatment• Indirectly harmful treatment
– Reducing efficacy of conventional treatment
– Replacing curative conventional care
• Cost
CAM: Potential Benefits
• Symptom control– Reduce use of medications
with side effects – Better tolerance of curative
conventional care
• Empowering to patient• Less cost• Less risk
Balancing Risks and Benefits• Discuss CAM openly
– Enhance doc / patient relationship– Improve health
• Dissuade from harmful practice
• Encourage beneficial treatments
• Integrate care with all providers– Take ownership of your health and health care
• Be informed about specific risks and benefits
CAM Considerations
• Avoid harmful practices
• Use evidence-based, safe therapies
• Consider plausible, safe modalities
Sugarman J, Burk L. Physicians’ ethical obligations regarding alternative medicine. JAMA 1998;280(18):1623-1625.
Hippocrates : “First, do no harm”
Harmful CAM Therapies• Colonic enemas• Chelation therapy• IV therapies• Restrictive diets• Megavitamins• Some herbs / supplements
– Direct toxicity– Indirect: drug interactions– Stimulate tumor growth, immune system
• Anything used IN PLACE OF proven, curative, conventional treatments
Therapies to Highlight
• Mind / body techniques– Sleep– Exercise
• Acupuncture
• Massage
• Chiropractic
• Herbs and supplements
Why Mind-body?• Perception of pain requires processing by the
mind; mind-body therapies can alter perception• Stress / anxiety perceived as a threat,
processed by the mind as equivalent to pain• Insomnia worsens pain• Mind-body therapies are generally safe
– Caution with “blame the victim”
Mind-body Therapies• Cognitive Behavioral Tx• Relaxation techniques• Breathing techniques• Stress management• Biofeedback / heart math• Art, music, pet therapy• Mindfulness / Meditation• Imagery / visualization• Yoga / tai chi• Hypnosis
Mind-body Details• Typically meet with therapist 5 – 10 visits
• Patient needs to practice at home
• Not all therapists comfortable with all methods
• Often covered by insurance• Workbook:
– Caudill, Margaret. Managing Pain Before It Manages You, Revised Edition (Paperback)
Mind-body: Highlighted Uses• Stress reduction
• Anxiety, depression, insomnia
• Grieving / acceptance
• Behavior change
• Symptom management– Pain (FM, muscle pain, HA)– Dyspnea (COPD, VCD)– Nausea
Get Some Sleep!• Restorative sleep improves pain, fatigue, and mood• Sleep deprived “normals” develop chronic pain• Links: breast cancer, weight gain• Behavioral approaches:
– Don’t eat, drink, exercise just before bed– Avoid late day caffeine , too much alcohol– Get consistent exercise earlier in the day– Pay attention to room environment– Establish consistent sleep times– Get out of bed if not tired– Don’t nap
Exercise: Highlighted Uses• Improves sleep, depression, anxiety -
improving overall health• Duh – cholesterol, weight, BP, DM• Wow!
– Decreased pain in arthritis– Decreased hot flashes– Improvement in BMD– One of the cornerstone treatments for
fibromyalgia and chronic fatigue– Dramatic reduction of breast CA recurrence– Improvement in immune function
• Too much – decreased immunity
Exercise Instruction: FIT• F requency
– Exercise every day
• I ntensity– Break a sweat; increase difficulty of exercise
• T ime– Start with 5 minutes daily, increase by 1 minute
daily each week; goal 30 minutes / day
AcupunctureChinese Medicine Background
– Health = balance of yin and yang– Qi = energy force created by interaction
of yin and yang– Meridians = channels that carry qi throughout the body;
each corresponds with a specific organ– Excess, deficiency, or stagnant flow of qi results in
disease– Examples of TCM diagnoses:
• Yin deficiency and yang predominance with reduced kidney qi• Stomach qi rebelling
AcupunctureWestern Medicine Background
– Osler, 19th century “best treatment for lumbago”
– James Reston, China, 1971 – Biological effects
• Local nerve activation• Endorphins, ACTH, endogenous opiods (reversal of
analgesia with naloxone)– SPECT scanning: increased activity and reversal of
asymmetry in chronic pain patients in thalamic and prefrontal cortex during acupuncture over baseline
Han JS. Neurosci Lett 2004;361(1-3):258-61.
Newberg AB et al. J Neuroimaging 2005;15(1):43-9
Mayer (1977) Brain Res
General Advice: Acupuncture• Acupuncture is generally safe
– Adverse events: minor or rare (pain, bleeding, fatigue)– Disposable needles, alcohol wipes to avoid infection
• Practitioners – State to state variability (www.acupuncture.com/statelaws)– TCM: National Certification Commission for Acupuncture and Oriental
Medicine (www.nccaom.org)– MD: American Academy of Medical Acupuncture
(www.medicalacupuncture.org)• Costs
– Initial / follow up: $80 (MD $175) / $55 (MD $100)– Covered by some insurances
Acupuncture: Highlighted Uses• WHO - Chronic pain of any etiology
– Fibromyalgia / myofascial pain – Low back, neck pain– Headaches– Carpal tunnel – Osteoarthritis
• IBS• Depression / anxiety • Fertility / menstrual irregularity• Nausea (chemo, pregnancy, post op)
Acupuncture. NIH consensus statement 1997;15(5):1-34.
Massage Therapy• Developed by almost
all cultures• Many different forms• Emphasis on
improving circulation, releasing muscle tension, calming and relaxing patient
General Advice: Massage• Generally safe. Use caution with:
– Congestive heart failure– Infections– Blood clots / bleeding disorders– Osteoporosis or bone metastases– Pregnancy
• A license is NOT required in Colorado– Look for “CMT” or “LMT”– Look for involvement in AMTA (www.massagetherapy.org)
• $60+++ / hour, occasionally covered
Massage Therapy: Highlighted Uses
• Relaxation, improved QOL
• Post-operative wound healing
• Lymphedema treatment
• Pain management– Musculoskeletal complaints– Tension headaches– Fibromyalgia
Chiropractic• “Manipulation” referenced by
Hippocrates; Galen• Daniel David Palmer, 1895
– “Normalization of the nervous system” is key to health
• CAM vs. subspecialty
•Manipulation; often exercises, fitness, general health advice; acupressure, supplements•Practice styles, practice philosophies vary
Chiropractic: General Advice• Safety
– Generally safe– Local discomfort, headache, fatigue– Excessive xrays from some DCs– Stroke, dislocation, fracture rare but possible
• Risk of serious complication estimated at 6.39 per 10 million cervical manipulations (3.2 per 1000 for NSAIDS)
• Avoid high velocity neck manipulation
– Caution: cerebrovascular disease, osteoporosis, rheumatoid arthritis, metastatic cancer, bleeding disorders
Chiropractic: General Advice• Practitioners
– 4 year accredited school– Philosophies and styles vary widely – Licensing required in 50 states; scope of practice
variable
• Costs / reimbursement– Initial / follow-up $35 - 150 / $25 - 50– OMT usually covered; chiropractic often covered
Chiropractic: Highlighted Uses
• Back pain
• Neck pain
• Headaches
• Other msk complaints
Herbs and Supplements• Three types of medicines:
– Prescription (Rx)– Over-the-counter (OTC)– Dietary Supplements
• Unlike Rx and OTC, supplements:– Are not required to prove safety or efficacy
• Burden of proof on FDA to show unsafe
– Are not required to enforce quality control• GMP to be required by 2008
– Can vary in concentration of ingredients
• Natural safe
• Use extra caution when taking prescriptions– Herb / drug interactions may be dangerous
• Use trustworthy resources for information
• If you choose to take or recommend supplements:– Look for well-labeled brands– Avoid combination products, MLM sales products– Tell your health care providers / ask your patients
General Advice: Supplements
Supplements to Avoid
• Vitamin E– No proof of benefit, meta-analysis with concerns of
toxicity
• St. John’s wort– Too many drug interactions, ? DNA damage
• Pre-op– Blanket statement – stop all products 2 weeks
prior to surgery / upon hospital admit• Beware of metabolic / pharmacokinetic implications
Supplements to Consider• Multivitamin
– But latest data doubts benefit; good diet better
• Calcium (women)– 1500 mg / day total
• Vitamin D– Most Americans deficient– Cancer prevention, muscle pain
• Fish oil (Omega 3 FA)– Heart disease, TG, HTN, HA, weight
loss, depression, cancer prevention
Supplements to Consider• Probiotics
– Infectious diarrhea, IBD, IBS, antibiotic associated diarrhea
• Coenyme Q10– Deficiencies: beta blockers,
statins, CHF– Helps statin-associated muscle
pain, reduces doxirubicin cardiac toxicity
Finding a Good Practitioner
• Training and licensure
• Experience with symptom
• Risks
• Costs / reimbursement
• Time frame / progress assessment
• Ability to work with conventional physicians
What the Health!• Integrative medicine coordinates CAM
with conventional care
• Don’t use harmful CAM therapies
• Use beneficial, safe therapies
• Consider TCFIM at the University of Colorado Hospital as a resource
University of Colorado Hospital Anschutz Medical Campus• 720-848-1090• www.uch.edu/integrativemed
The Center for Integrative Medicine
Conception • Group of interested faculty presented
proposal to UCH/HSC administration, late 1990’s
• Administrator hired March, 2001• Steering committee drawn from all 4
UCHSC schools• “Clinical first, then education / research”• First clinical services December, 2001
General Assessment / Oversight• Lisa Corbin, MD
Traditional Chinese Medicine• Daisy Dong, L.Ac • Mel Drisko, L.Ac
Massage therapy• Rose Patch, CMT• Molly Monahan, CMT• Ann Mathews, CMT
Nutritional Counseling• Colleen Gill, RD• Pamela Ham, RD
Pharmaceutical / Herbal Consults• Susan Paulsen, Pharm D
Chiropractic• Brian Enebo, DC
Behavioral Medicine / Biofeedback• Bennett Leslie, PsyD• Denise McGuire, PhD
Clinical Care
Access to Services• Referrals
– Self referred– UCH physician or provider referred– Outside physician or provider referred
• Insurance / authorizations checked• Visits scheduled
– With specific practitioner, and / or– With Medical Director to explore all options and
make a personalized plan
Integration of Care
• Notes for each visit available in EMR
• Referral letter written to physicians, other providers, and patient
• Formal case reviews– Integrates the care from within TCFIM– Further integration with other care providers
• www.imconsortium.org
• 39 member schools in US, Canada
• Collaboratively working to promote Integrative Medicine care, education, and research
• Resource to learn from each other
Education: UCHSC• Resident elective (est. 1999)• Medical student elective (2003)• Medical student required lectures
– Herbal pharmacology / small groups– Chiropractic theory and practice– Advising patients on use of CAM
• Formal classroom teaching in PT and Pharmacy Schools (required courses)
• Lectures in CHA/PA training
Education
• Other medical professionals / CME
• Public education – support groups
• School of Nursing, Metro – separate courses
• Half-day shadowing experiences
Research
• CAMPUS group
• REST study
• Demographic descriptive articles
• Reviews
Clinical Care• Expand outpatient services• Develop satellite programs
Education• CME conferences, lectures• Hands-on time
Future directionsResearch• Participate in campus-
wide projects• Fund small grants• Follow treatment-
specific clinical outcomes data