Transcript Alternative medical systems

Integrative
medicine
in rehab
• Complementary and alternative medicine
(CAM) is a group of diverse medical and
healthcare systems, practices, and products
that are not presently considered to be part of
conventional medicine.
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Alternative medical systems
Mind-body interventions
Biologically based therapies
Manipulative and body-based therapies
Energy therapies
ALTERNATIVE MEDICAL SYSTEMS
• Alternative medical systems often incorporate
concepts and ideas that are foreign or
antithetic to conventional medicine.
• They are generally based on empiric
observation, and underlying scientific
principles often have yet to be verified
through well-designed scientific studies.
Chiropractic
• Chiropractic is a profession founded on the theory that minor spinal
misalignments can detrimentally affect the neurologic function of spinal
nerves and the organs and structures supplied by those nerves.
• These misalignments are often called subluxations.
• Chiropractors treat subluxations with various interventions, the most
common being spinal manipulation(active intervention)
• Chiropractors often incorporate other techniques, such as massage
and exercise prescription, in treatment.
• They also utilize radiography to aid in diagnosis and treatment.
• Chiropractors do not dispense prescription medication or perform
surgery or invasive treatments.
Osteopathy
• focuses on utilizing the bones as manual levers to
remove bony and myofascial entrapment of
nerves and vascular structures, thus restoring
normal function.
• Today, osteopathic physicians (DOs) and
allopathic physicians (MDs) are relatively
indistinguishable in that both are fully licensed in
all realms of medicine including surgery,
obstetrics, and the prescription of medications.
Homeopathy
• Homeopathy's central tenets are the principle of similars and the principle
of dilution.
• The principle of similars:small quantities of an agent can ameliorate the
same symptoms that are evoked in a healthy patient when given in larger
quantities.
• The principle of dilution states that highly dilute solutions have biologic
activity and the more dilute the solution, the more potent the remedy
activity. Others might be diluted to the point that conventional science has
difficulty explaining their efficacy
• While most of these remedies are safe, their potential for interaction with
other ingested substances can be difficult to predict.
• this study suggests that homeopathic treatments might have a place in the
treatment of brain injury.
Naturopathy
• Most of the principles espoused by naturopaths
are familiar to physicians: do no harm, identify
and treat causes of disease, disease prevention,
and treatment of the whole individual.
• They range from the mundane, such as diet and
lifestyle counseling, to more unusual modalities
such as acupuncture and homeopathy
Ayurveda
• Ayurvedic medicine (literally means 'the science of life')
developed in India.
• relationship between all the matter in the universe.
• There are three doshas (life forces or energies), which must be
at equilibrium for good health.
• Diet, sleep, sexual activity, personal hygiene, and exercises
such as yoga are used to physical fitness
• Mental discipline and spirituality are also inportant
components to maintaining good health.
Traditional Chinese medicine
• One of the fundamental principles of this system is that two opposite
forces (yin and yang) balance in nature
• The TCM examination might include determining the characteristics of
pulses at specific locations on the body, the appearance of the tongue,
characteristics of olfaction, and careful palpation of the body.
• This rebalancing can be achieved through a number of different
therapeutic options, including diet, exercise, herbal medicines, massage,
and acupuncture.
• Qi gong and t'ai chi were developed as methods of strengthening the qi or
energy of the body to prevent disease and prolong life.
Mind-body therapies
• Cognitive behavioral therapy:
A therapist typically works with the patient to
identify thoughts and behaviors that are
maladaptive; and attempts to change the
thought patterns, leading to a change in
behavior.
• Successfully employed for :insomnia,
fibromyalgia, headache, and pain
Meditation
• defines the act of meditation as 'to train, calm, or empty the
mind, often by achieving an altered state, as by focusing on a
single object
• Meditation is also frequently described as self-regulation of
attention.
• There are numerous types of meditation (e.g. transcendental,
mindfulness, and focused meditation)
• manage stress and anxiety, deal with pain, improving quality
of life after brain injury, and improving irritable bowel
syndrome.
Guided imagery
• This is a technique that employs images or
symbols to train the mind to create a
physiologic or psychologic effect
• reduce anxiety and pain, and to relieve
physical problems caused by stress
• headaches. recurrent abdominal pain in
children, depression, and fibromyalgia
Spirituality
• Spirituality has been described as an
awareness of something greater than the
individual self.
• reduction of stress and anxiety, positive effect
of prayer on illness severity ratings in AIDs
patients and a positive effect of church
attendence on immune function.
Aromatherapy
• This modality uses essential oils distilled from
plants to improve mood and/or health.
• Scents can be inhaled or applied in oil during
massage.
• reducing stress, pain, and depression.
Expression- or art-based therapies
• art therapy as the 'therapeutic use of art making, within a professional
relationship, by people who experience illness, trauma, or challenges in
living, and by people who seek personal development.
• Music therapy is the use of specific music (with specific vibration freque
ncies) to promote relaxation and healing.
• It is helpful in treating autism; mentally or emotionally disturbed children
and adults; elderly and physically challenged people; and patients with
schizophrenia, nervous disorders, or stress.
• Dance therapy is 'the psychotherapeutic use of movement as a process
which furthers the emotional, cognitive, social and physical integration of
the individual.
Biologically based therapies
• Chondroitin sulfate:
Proponents believe that chondroitin acts as a substrate needed for
joint matrix structure
• it could require at least 2-4 months of therapy before significant
improvement is noted is not surprising
• adding chondroitin sulfate to conventional analgesic or nonsteroidal antiinflammatory drugs (NSAlDs) is synergistic, possibly
allowing reduction or elimination of those agents.
• (Oral: Doses of 200-400 mg 2-3 times/day or 800-1200 mg once
daily have been used. Higher doses (up to 2000 mg) appear to have
similar efficacy.)
• Adverse effects: nausea and epigastric discomfort.
Glucosamine sulfate
• efficacy have been centered on knee osteoarthritis.
• effective for osteoarthritis of the lumbar spine in one study·
• Some studies suggest efficacy equivalent to that of certain NSAIDs
• Like chondroitin, onset of relief is generally delayed, requiring up to 8
weeks for full effect.
• Long-term studies suggest that glucosamine might result in significantly
less joint space narrowing and knee joint degeneration than with placebo
• (Oral: 500 mg 3-4 times/day)
• Adverse effects Mild gastrointestinal symptoms (e.g. nausea, heartburn,
diarrhea, and constipation)
S-adenosyl-l-methionine
• is superior to placebo and comparable with NSAIDs for
decreasing symptoms associated with osteoarthritis.
• The full effect might require up to 1 month of treatment.
• Mechanism of action could include stimulation of articular
cartilage growth and repair.
• Adverse effects These are gastrointestinal symptoms (e.g.
flatulence, nausea, diarrhea, and constipation), dry mouth,
headache, mild insomnia, and nervousness.'
Bromelain (Ananas comosus)
• In a single study, bromelain taken in
conjunction with trypsin and rutin resulted in
decreased pain and improved knee function in
patients with osteoarthritis
• Adverse effects Gastrointestinal upset and
diarrhea can occur in patients taking
bromelain
Camphor (Cinnamomum camphora)
• A topical cream containing camphor,
glucosamine sulfate, and chondroitin sulfate
was found to provide reduction in pain due to
osteoarthritis
Cat's claw (Uncaria tomentosa)
• The mechanism of action might be inhibition of
the production of prostaglandin E2, and tumor
necrosis factor-a.
• One study found that a freeze-dried cat's claw
extract relieved knee pain related to physical
activity but did not affect pain at rest.
• Adverse effects are headache, dizziness, and
vomiting
Devil's claw (Harpagophytum
procumbens)
• when taken in conjunction with NSAIDs, devil's claw decreases
osteoarthritis-related pain.
• As with glucosamine and chondroitin, a reduction in the need for NSAIDs
might be possible with devil's claw after several weeks of use.
• Adverse effects: diarrhea,nausea, vomiting, and abdominal pain.
[Up tp date]
• Use of devil's claw is contraindicated in pregnancy and lactation
• Use caution in individuals with diabetes as devil's claw may lower blood
glucose levels. Use with caution in patients with gallstones as devil's claw
may increase bile production
• Osteoarthritis: 2-9 g/day crude extract or 600-1200 mg 3 times/day,
standardized to contain 50-100 mg of harpagoside, for 2-3 months
• Back pain: 2-9 g/day of crude extract or 600-1200 mg 3 times/day,
standardized to contain 50-100 mg of harpagoside
• Harpagoside has been shown to inhibit COX-2 expression
Evening primrose oil (Oenothera
biennis)
• In a double-blind, placebo-controlled study of
rheumatoid arthritis patients, a 12-month trial
of evening primrose oil resulted in significant
reduction of symptoms.
• Evening primrose oil contains a significant
amount of y-linolenic acid, and it is this
component that is thought to provide the
antiinflammatory action.
Manipulation and body-based
therapies
• Manipulation or mobilization:
Manipulation (typically inferring high-velocity thrust
techniques applied to a joint) and mobilization (non-thrust,
oscillatory techniques)
• There is no evidence that manipulation or mobilization
applied by one profession is more or less beneficial than when
provided by a competing profession.
• The goal of these therapies is to normalize motion and
tension about a joint
• Side effects of spinal manipulation:
• at least one unpleasant reaction was experienced
after manipulation by more than half of patients
• The most common side effects were local
discomfort (53%), headache (12%), tiredness
(11%), and radiating discomfort (1O%).
• Reactions were mild or moderate in 85%, and
most were short-lived (74% resolved within 24 h).
• Uncommon reactions, such as dizziness and
nausea, accounted for less than 5% of the
symptoms and no serious complications were
reported
• Spinal manipulation, although generally safe, is not risk-free
• Complications of thoracic and lumbar manipulation are rare, and
investigators agree that the risk: benefit ratio of manipulation for low back
pain is acceptable in most patients
• The most serious complication of lumbar manipulation is cauda equina
syndrome. About half the reported cases occurred during manipulation
under anesthesia
• The frequency of cauda equina syndrome has been estimated to be one in
several million treatments.
• Complications of cervical manipulation Although relatively rare, they are
more common and often more serious than those from lumbar or thoracic
manipulation.
• One of the most controversial issues concerning spinal manipulation is the
relationship between cervical manipulation and stroke.
• Cervical manipulation can cause mechanical stress on the vertebral
arteries, resulting in vertebrobasilar stroke. The most common site of
injury appears to be the extracranial third segment of the vertebral artery.
• For this reason, some have argued that the risk:benefit ratio
of cervical manipulation is unacceptable.
• it has been estimated to be 1:400000 to 1:3 million
• A screening test using neck extension and rotation has been
thought to predict patients at risk of vertebrobasilar stroke,
but its value is questionable at best
• disk herniation is often listed as a contraindication For lumbar
manipulation, but chiropractors and therapists commonly use
it to treat persons with disk herniation. Another possible
contraindication is lumbar spondylolisthesis, but these
patients appear to respond as well as those with normal
spinal anatomy
• It is sufficient to say that the best evidence supports the use of
manipulation for most types of uncomplicated low back pain, but there is
no compelling evidence that it is more efficacious than other commonly
used therapies.
• About cervical manipulation and mobilization:
1. there are very few high-quality studies;
2. there is some evidence for the effectiveness of manipulation and
mobilization for neck pain;
3. the rate of complications and side effects is very low.
• The use of spinal manipulation as treatment for headaches is predicated
on the cervical spine being a contributing factor in the etiology of
headaches.(two peripheral nociceptive convergence)
• Another possible connection between the cervical spine and headache is
an anatomic connection between the rectus capitus posterior minor and
the spinal dura via a dense connective tissue bridge at the level of the
atlantooccipital junction.
• When compared with some forms of medical prophylaxis for both tensiontype and migraine headaches, spinal manipulation appears to offer similar
relief
• Manipulation does not appear to be effective in aborting headaches.
• There is little evidence to suggest that manipulation and mobilization can
correct or reduce an idiopathic scoliotic curvature.
• There is, however, a suggestion that spinal manipulation therapy is helpful
in controlling chronic mechanical back pain associated with scoliosis
• Davis et al. compared medical treatment of carpal tunnel syndrome
(ibuprofen and nocturnal wrist splinting) to chiropractic treatment (spine
or extremity manipulation, wrist ultrasound and nocturnal wrist splinting)
in an uncontrolled randomized trial. Both groups improved, with no
difference between them.
• Randomized controlled trials of chiropractic treatment for asthma have
demonstrated no change in measured lung functions in either children or
adults.
• otitis media is sometimes treated by chiropractors,
• A review of the literature concluded that the effect of spinal manipulation
on enuresis is similar to the natural remission rate
• Primary dysmenorrhea has been reported to respond to spinal
manipulative therapy
• There is no evidence that manual therapies are beneficial for central
nervous system-based disorders such as epilepsy.
Movement therapies
• Feldenkrais method:
• The Feldenkrais method is a system of body movement
education that is believed to enhance awareness of
movement and improve functional movement.
• A small randomized study of the effect of Feldenkrais on pain
found the affective dimension (attitude toward the pain) to be
reduced, but no change was measured in other dimensions
• A small randomized trial found patients with neck and
shoulder complaints to benefit more from Feldenkrais than
from physical therapy.
Alexander technique
• The Alexander technique is a psychophysical reeducation
method that proposes to relieve muscular tension and
improve the efficiency of movement
• Alexander technique is often advocated in the treatment of
asthma, headaches, arthritis, and pain, and is often used by
performing artists·
• examination of posture, breathing, balance, and coordination,
and has three underlying principles
T'ai chi
• advocated as a therapeutic exercise,
particularly in the elderly.
• T'ai chi has been reported to improve balance
control, flexibility, and cardiovascular fitness in
geriatric patients
Pilates
• Pilates exercises were originally designed for
and used by performance artists, but have
enjoyed wider popularity in recent years.
• suggest pilates exercises are beneficial for
various musculoskeletal conditions, although
they have been primarily used for dancespecific rehabilitation regimens.
Yoga
• Although yoga is part mind-body therapy and
part stretching and breathing exercise, it is
most appropriately addressed with movement
therapies.
• It is commonly advocated as treatment for
musculoskeletal conditions, including arthritis‘
and carpal tunnel syndrome.(asthma,
hypertension and low back pain)
Energy therapies
• Acupuncture:
• Acupuncture consists of the insertion of thin flexible needles
into the body at specific points to improve health
• The needles are inserted to varying depths and angles, and
typically are inserted superficially
• The needle can be further stimulated in a number of different
ways, including twirling the needles, electrical stimulation,or
burning a herb placed on the end of the needle outside the
patient.
• used for analgesia or relief of pain, asthma, fatigue,
gastrointestinal disturbance, and infertility.
• Meridian-based acupuncture is invoked to
alter the flow of qi or energy through the
body.
• Qi flows through the body in specific patterns,
and these pathways are known as meridians.
• Another common style of acupuncture is
termed neuroanatomic acupuncture.
• For example, the point stomach 31 can relieve
lateral thigh pain and lies over the lateral
femoral cutaneous nerve
• Mechanism of action: direct local effects such as
vasodilatation, direct torsion of the connective tissue,
and changes in autonomic activity, to more remote
endocrine effects
• The endocrine effects include release of endorphins
and an effect on the hypothalamic pituitary axis.
• Remote neurologic effects can also occur, such as
changes on functional magnetic resonance imaging of
the brain from insertion of an acupuncture needle in
the first dorsal interosseous muscle (large intestine 4).
• Risks of acupuncture include bleeding,
infection, and organ puncture (including
pneumothorax)
• Needle shock is a side effect that is
uncommon but typically occurs during a first
acupuncture treatment.
Acupressure
• Acupressure is similar to acupuncture in terms of its analysis of the human
body, but it utilizes pressure rather than needles to achieve changes in the
human body.
• Direct manipulation of the tissues is believed to open up channels to the
flow of qi.
• Most obviously, the potential complications of bleeding and infection are
eliminated.
• patients who might benefit from this treatment, including individuals on
anticoagulants, the needle-phobic, or severely immunosuppressed
patients.
• There are some limited data to suggest that acupressure can be more
effective than either acupuncture or physical therapy.
Reiki and healing touch
• They both posit the ability of one human being to
positively influence the energy field of another
individual to improve their health.
• Healing touch does require some specific hand
positions for certain conditions, but this is not
always necessary.
• both of these modalities can be effective in
reducing psychologic sequelae of disease, as well
as speeding healing
Reflexology
• This is a natural healing art, based on the theory
that there are reflexes in the feet and hands
which correspond to every part of the body.
• One recent study found significant improvement
in spasticity, paresthesias, and urinary symptoms
of multiple sclerosis patients
• it was not helpful in the treatment of irritable
bowel syndromew
Electromagnetic fields and magnets
• Electromagnetic fields are very familiar to
physical medicine and rehabilitation physicians
and are used in testing, such as magnetic
resonance imaging scans, electromyography, and
electrocardiograms.
• Magnets are commonly used in the relief of pain.
• Recent radomized controlled trials showed that
magnetic insoles had no significant beneficial
effect in the treatment of plantar heel pain and
nonspecific foot pain
summary
• This would suggest that these modalities
would be appropriate only as second-line
therapies to be used when proven or better
studied treatments have not been shown to be
efficacious.
Masuleh-Gilan