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Behavioral Medicine Behavioral Medicine Meets Complementary, Meets Complementary, Alternative and Alternative and Integrative Medicine: Integrative Medicine: Is there common Is there common ground? ground? CHIP, UCONN CHIP, UCONN April


  1. Behavioral Medicine Behavioral Medicine Meets Complementary, Meets Complementary, Alternative and Alternative and Integrative Medicine: Integrative Medicine: Is there common Is there common ground? ground? CHIP, UCONN CHIP, UCONN April 24, 2008 April 24, 2008

  2. Complementary, Alternative and Integrative Medicine � Medical and health care practices that are: - Outside the realm of conventional medicine - Yet to be validated using scientific methods � Complementary : with conventional practices � Alternative : in place of conventional practices � Increasingly referred to as Integrative Medicine

  3. Integrative Medicine Domains

  4. Parallels in Conventional Medicine � Biologically- Based � Pharmaceuticals � Energy Medicine � ECG, fMRI � Manipulative � Physical therapy � Mind-Body � Psychotherapy

  5. Complementary and Integrative Medicine Use - USA � National Health Interview Survey in 2002 � National random sample of 31,044 adults � CAM use in last 12 months 62%, including prayer for – health reasons – 36%, excluding prayer Barnes et al., CDC ADR , 2004

  6. Most Common % � Natural products* 19 � Deep breathing 12 � Meditation 8 � Chiropractic 8 � Yoga 5 � Massage 5 � Diet-based therapies** 4 Barnes et al., CDC ADR , 2004 * Omega-3 fatty acids / ** weight loss

  7. Most Common Natural Products % � Echinacea 40 � Ginseng 24 � Ginkgo biloba 21 � Garlic supplements 20 � Glucosamine 15 � St. John’s Wort 12 � Fish Oils 12 Barnes et al., CDC ADR , 2004

  8. Complementary and Integrative Medicine in US Hospitals � Hospitals offering services 8% in 1998 – 17% in 2002 – 27% in 2005 – � Key reasons – Patient demand 87% – Reflect mission 62% – Clinical effects 61% – Attract patients 38% AHA Health Forum, 2006

  9. Services Offered Services Offered Massage 71% Tai Chi, Yoga 47% Relaxation 43% Acupuncture 39% AHA Health Forum, 2006

  10. University of Maryland Integrative Medicine Incorporated in Cancer Center Cardiology Family Medicine VA Hospital Shock Trauma Center • Pain • Inflammation • Traumatic brain injury • Post-traumatic stress

  11. Growth of the North American Growth of the North American Academic Consortium Academic Consortium 45 40 Number of Institutions 35 30 25 20 15 10 5 0 1999 2000 2001 2002 2003 2004 2005 2007 2008 before consortium formation after consortium formation

  12. Integrative Medicine Programs rams Integrative Medicine Prog Remain Controversial – – Remain Controversial Pressure from Both Sides Pressure from Both Sides Conventional Conventional Medicine Medicine

  13. The plural of claims is not not The plural of claims is evidence evidence

  14. The Answer: Research The Answer: Research � Safety � Efficacy � Mechanism

  15. 1999 ~ Congressional Mandate for National Institutes of Health to Create the National Center for Complementary And Alternative Medicine

  16. NCCAM’s Mission � Conduct rigorous research on CAM practices � Train CAM researchers � Inform consumers and health professionals

  17. Biologically Based Practices � Dietary supplements � Herbal therapies � Animal products � Special diets

  18. Dietary Supplements: DSHEA* � Products that supplement diet � Contain one or more of � Vitamin or mineral � Herb or other botanical � Amino acid � Any other dietary substance � For oral intake as a concentrate, metabolite, extract, constituent, or combination * Dietary Supplement Health & Education Act - 1994

  19. Biologically Based Practices - Challenges � Safety is assumed, not proven � Lack of product standardization � Labeling may not be accurate � Some products are contaminated

  20. GAIT: Glucosamine/Chondroitin GAIT: Glucosamine/Chondroitin Arthritis Intervention Trial Arthritis Intervention Trial � 1583 patients, arthritis knee � 5 - arm study 1500 mg glucosamine (G) – 1200 mg chondriotin sulfate (C) – G & C – 200 mg Celecoxib – Placebo – � 28 weeks (Clegg, et al., NEJM 2006)

  21. Glucosamine/chondroitin Effective Glucosamine/chondroitin Effective for Moderate- -to to- -Severe Arthritis Severe Arthritis for Moderate � Outcome % pts that report 20% improvement in pain at 24 weeks � Results did not show effectiveness for Glucosamine and Chondroitin overall

  22. GAIT GAIT WOMAC Pain 301- WOMAC Pain All patients 400mm 125-300mm 60% Placebo 54% 62% Celebrex 70% ** 69% ¶ 70%* Glucosamine 64% 66% 64% Chondroitin 65% 61% 67% Glucosamine+ 67% + 79% # 63% chondroitin ¶ p = 0.06 CE vs. P ** p= 0.008 Celeb vs. P # p = 0.002 * p= 0.04 CE vs. P + p= 0.09 (G+C vs. P) (G+C vs. P) Data = % pts that report 20% improvement in pain at 24 wks (Clegg, et al., NEJM 2006) (Clegg, et al., NEJM 2006)

  23. GAIT GAIT WOMAC Pain 301- WOMAC Pain All patients 400mm 125-300mm 60% Placebo 54% 62% Celebrex 70% ** 69% ¶ 70%* Glucosamine 64% 66% 64% Chondroitin 65% 61% 67% Glucosamine+ 67% + 79% # 63% chondroitin ¶ p = 0.06 CE vs. P ** p= 0.008 Celeb vs. P # p = 0.002 * p= 0.04 CE vs. P + p= 0.09 (G+C vs. P) (G+C vs. P) Data = % pts that report 20% improvement in pain at 24 wks (Clegg, et al., NEJM 2006) (Clegg, et al., NEJM 2006)

  24. Glucosamine/chondroitin Effective Glucosamine/chondroitin Effective for Moderate- -to to- -Severe Arthritis Severe Arthritis for Moderate � Results did not show effectiveness for Glucosamine and Chondroitin overall BUT ….. � Secondary analyses indicated benefit for those with “moderate to severe” osteoarthritis

  25. Echinacea to Prevent and Treat Colds � 437 students � Complex, 7- arm study � 7 days prophylaxis, rhinovirus challenge, 5 days treatment � 900 mg/day E. angustifolia vs. placebo (Turner, et al., NEJM 2005)

  26. Echinacea to Prevent and Treat Colds � Echinacea did not prevent or help treat symptoms of virus given to participants � Preparation – E. angustifolia � Dose – equivalent to 900 mg per day, may have been too low for this Echinacea species � But the message heard …

  27. “Doesn’t Work” Echinacea –

  28. Complexity: Echinacea � 3 Species E. angustifolia E. purpurea E. pallida � Extract, tea or tincture � Roots, stems or flowers � Dose ? � Treatment or prevention ?

  29. Lessons Learned to Optimize Research � Obtain well-characterized and standardized clinical trial materials � Expect very high placebo condition � Place greater emphasis on preclinical and early phase clinical studies – - Dose

  30. Dose - Response Curve

  31. Manipulative Body-based Practices � Massage � Chiropractic � Pilates, Feldenkrais

  32. Massage Challenge – many types of massage � Best evidence – when massage is applied to specific conditions - Low back pain � Massage & exercise, better than massage alone Cherkin, DC, et al, Annals of Internal Med, 2003

  33. Energy Medicine * � All living things possess & emit energy - Light therapy - Electromagnetic fields � “Life force” - Healing Touch - Qi gong, Reiki * “ Biofield Medicine ”

  34. Energy Medicine – NCCAM Position � Must apply same standards for designing experiments in other scientific disciplines � Need to investigate with physicists, biophysicists cell biologists, physical chemists, engineers

  35. Whole Medical Systems � Traditional Chinese Medicine � Acupuncture - Herbs - Meditation � Ayurveda � Homeopathy

  36. Acupuncture � Originated in China over 2,000 yrs ago � Stimulation of anatomical points on body, most often using needles manipulated by hand or electrical current � Use by US adults 8.2 million have “ever used” 2.1 million have “used in last 12 mos.”

  37. Acupuncture � 1996 FDA approved needles for use by licensed practitioners � Promising results for chemotherapy nausea, postoperative dental pain � Some evidence for use with addiction, stroke rehab, headache, fibromyalgia, myofascial pain,carpal tunnel, and asthma

  38. Mechanism ? “Western View” � Acupuncture produces its effects through impact on the nervous and immune systems � In particular, the effects on pain are likely to be achieved by release of endorphins

  39. Acupuncture Treatment of Knee Osteoarthritis � RCT- Brian Berman University of Maryland � Efficacy of acupuncture in improving function and decreasing pain � 570 patients, age > 50 years � Followed 26 months

  40. Acupuncture Treatment of Knee Osteoarthritis � Treatments: – Acupuncture – Sham acupuncture – Education

  41. Sham Acupuncture

  42. Acupuncture Treatment of Knee Osteoarthritis � Treatments: – Acupuncture – Sham acupuncture – Education � Outcomes: – WOMAC index – Function

  43. Acupuncture Treatment of Knee Osteoarthritis Berman, et al., Annals Internal Med, Dec 2004, 901-911

  44. Domain of Mind-Body Medicine is closely related to Medical Psychology

  45. …and a topic of and a topic of … considerable public interest considerable public interest

  46. Mind-Body Medicine Research and practices focused on interrelationships � mind, brain, � body systems - endocrine, immune - nervous systems � behavior

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