Transcript THE IMPACT OF INTERNET USE ON HEALTH OUTCOMES IN …

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
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.
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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.
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Types of CAM
• 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.
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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.
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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.
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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.
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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.
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ACUPUNCTURE DEFINITION
• 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
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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.
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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.
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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.
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MASSAGE AND OSTEOPATHIC
MASSAGE THERAPY
• Massage-therapists manipulate muscle and connective
tissue to enhance function of those tissues and promote
relaxation and well-being.
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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.
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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.
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CLINICAL TRIALS AND CAM: What to
Look for (Cont)
• 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.
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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 earback 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.
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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.
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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.
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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.
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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.
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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.
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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):13342, 2002.
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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
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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)
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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
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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.
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Stimulating re-growth of axons
• Grow Axons and make the proper connections and reestablish functioning synapses.
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• 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.
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• 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
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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.
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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.
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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%)
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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
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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.
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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
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Spinal Cord Pain Syndromes
Pathology
• 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.
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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
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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.
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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
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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)
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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
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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 &Copyright
traditional
medicine
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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
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Incorporating Non-Pharmacological PainRelieving 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
& NERSCIC
non-traditional approaches
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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
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• Once ID’d, conduct intervention
to increase willingness
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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
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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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