HLST 301 Complementary and Alternative therapies

HLST 301 Complementary and Alternative therapies UNIT 1: DEFINING CAM - Tough to provide a clear cut definition since in one country it may be considered alternative and another it may not be o For example acupuncture is a complementary here in Canada but in Chine it is considered a mainstream medicine - Definition if of CAM is: Which is outside conventional medicine - No clear dividing line between complementary and alternative medicine o If a therapy is used in addition to a conventional medicine, it is complementary o If a therapy is used instead of a conventional medicine, it is alternative KEEP FOLLOWING QUESTIONS IN MIND - 1. What is the basic definition of CAM - 2. What is it about CAM therapies that attract people - 3. Why is it difficult to evaluate CAM therapies PREVELANCE OF COMPLEMENTARY AND ALTERNATIVE THERAPIES - CCHS found 12.4% tried an alternative medicine in past year while 78% saw family physician - Most common were massage (62.9%), acupuncture (18.3%), Homeopathy (18.2%), Chiropractic (11.3%), Herbalist (5.2%), reflexology (2.4%) and spiritual healing (1.0%) - Twice as common in women - Use increased with household income, education and residence in western province - Surveys in the US and UK find that it is more common there and that they are especially used for chronic healing conditions WHY DO PEOPLE USE COMPLEMENTARY AND ALTERNATIVE THERAPIES - Studies find it ranges from dissatisfaction with conventional medicine to the philosophy of the holistic treatment - Outline of philosophies that attract people to CAM o Energies and forces: An inherent life force is a simple and appealing concept vs the complex medical system o Self-healing: Properties of the body can combat chronic and acute disease o Holistic: Entire patient is treated including mind body and spirit o Unifying hypothesis of disease: Universal theories why disease is occurring, for example Chinese practinoers think there is a misbalance of the ying and yang, Chiropractors think is is due to the mal aligned spine, naturopath think is is when you build up toxins o Natural: Natural is appealing however it does not mean safe o Traditional: Appealing since they have been used for hundreds of years, which is opposite of current medicine which gets rid of old evidence for new ones o Exotic: They seek miracles and put hope in something, especially those with complex disease o Individual attentions: CAM are more attentive to their clients than a conventional practitioner therefore the personal involvement is huge o Taking on the big companies that spew lies o CAM are more optimistic where health care professionals follow a code of ethics where they must explain the prognosis and how they think it will play out, where CAM this is not a question and they act like it will make a big difference o Control: Patient can somewhat control outcome o Non-Toxic: Not like painkillers and anti inflammatory they “restore balance” and “enhance mood” so they think its better for the body - Other factors were dissatisfaction with conventional medicine but in Europe they also just wanted to try all options to be cured and hoping to be cured without the side effects - Other factors were o Seek health promotion and disease prevention o Exhausted all conventional option o Conventional have side effects o Conventional has no spiritual benefit o Word of mouth - US has best medical system in the world? o Not true, die from iatrogenic causes, so causes inadvertently from medical treatment o This is the third leading cause of death in the US - Tough to evaluate the values of CAM o The practioner wants to make a good salary o They believe heavily in the therapy o Or both, which makes it challenging for those who consider service READ: - Pages 4-8 - Pages 13-17 Unit 2: EVALUATING THE EFFECTIVENESS OF COMPLEMENTARY AND ALTERNATIVE THERAPIES The Science of Complementary and Alternative therapies - It is difficult to determine the effectiveness of CAM therapy because of the confusing nature of the evidence as they have little to no medical research and no idependent research trials - It is also difficult since they are based mostly on testimonials by those in the business - Don’t be so quick to look away at the benefits though, there is reason why these have been practiced for so long - List of questions for research into CAM therpies o Does the therapy have a beneficial effect on any individual disease or disorder? o Does the therapy have any advantage over existing therapies in terms of efficacy, safety, patient preference, cost, and availability? o Is the effect of the therapy a placebo, or is there some specific treatment effect? o What mechanisms underlie the therapy’s action? - To get a scientific basis for a therapy one should show that the therapy is effective in a controlled trial and that the symptoms are related to an objective measure o EX: is a disorder is caused by hyperglycemia then when the blood sugar is low symptom’s should be there and when the blood sugar is normal the symptom’s should disappear Methods for Investigating CAM therapies - Two main methodologies used to investigate medical therapies, this includes CAM therapies o Observation research, the simple description of the apparent effectiveness of the therapy in practice o Controlled clinical trials - The first method provides the most available evidence for CAM therapies, the only issue is they are done by practitioners of CAM therapies who are biased to report success, how reliable are they though? Observational research - Also known as descriptive research. - It involves observing the methodology, collecting data through observation o Case report involves on case o Case series involves more than one subject o They can be studied through interview, survey - Ex includes asking a CAM prac about their experiences with people of one condition and comparing it to the normal response to no treatment or conventional treatment - If the subjects are the target population in a random fashion they it can have good reliability. - Pitfalls of observational evidence o Bias, practioner may have spent a lot of time using this therapy and would be convinced of its effectiveness, exaggerate the improvement etc. o Distortion of learning from one specific experience, such as a herbalist using a treatment and findig it effective and then it works for everyone according to her. This happens in doctors who diagnosed something which was then found by surgery but then he diagnoses this rare disorder all the time and causes unnecessary treatments - Outlined factors to consider when looking at anecdotal information or case reports o 1. Natural history of disease ▪ Diseases often follow a natural course, don’t think a disease was cured if it was just running its course o 2. Fluctuations in disease ▪ Know how diseases can have periods of remission, some believe CAM therapy cured them even though the disease is just going up and down ▪ Freireich Experimental Plan is when a patient improves the treatment was effective, if they are stable it is working, if they are remission the dose was inadequate and last of all if they die they came to them too late, zero failure rate o 3. Premature follow up ▪ Patient who appear to be getting better is cleared and said to be cured when the disease can get worse later o 4. Spontaneous regression ▪ It can just disappear such as cancer o 5. Misinterpretation of information ▪ They may misunderstand what the practitioner is saying and how medicine is not an exact science, for example the doctor may have said they have 6 months to live and then have lived fineand say CAM therapy saved them when in reality the doctor gave their best guess on the normal outcomes of that cancer o 6. Wrong information ▪ Could have been diagnosed wrong by both and they just think they were healed of something they didn’t have o 7. Simultaneous conventional therapy ▪ Impossible to know what worked if it was the CAM, conventional or both working together which helped the success - Findings should be investigated further about particular conditions but information currently is seldom to demonstrate CAM therapies’ are causing recoveries and not coincidental or due to confounding variables - Placebo effect Is an important factor that can lead to healing effect as well, which is common in CAM therapies as the way the CAM practitioner interacts with their clients are likely to boost the effect o When the CAM person believes in their treatment and convinces someone they are likely to have an effect even if it doesn’t treat the osteoarthritis o Doctors in Africa lend into this by dress crazy to seem like they know what they doing and boosting the effects of the placebo o EX: study found 60% of participants with osteoarthritis reported pain relief when given a placebo ▪ Clearly powerful the random fluctuation in the disease obviously played a role - Expiations for Placebo Effect o Physiological mechanisms, such as fear and anxiety produce adrenaline and noradrenaline which modulates pain response o Classical conditioning where pairing an conditioned and unconditioned stimuli results in the conditioned stimulus producing same response as unconditioned o Autonomic nervous system which effects neurohormones and endorphins o Psychological effects such as mental imagery and behavioural attitudes of the health care practitioner - Internal mammary aterery ligation was thought to improve angina, but it was found that a sham operation produced the same results - Placebos are normally consequence to the therapist patient relationship, so it depends on the psychological state of the patient, their expectation and the belief of the efficacy of the treatement as well as the therapists biases, attitudes, expectations and communication Read 103-112 and 201 as well as Kienle, G.S., & Kiene, H. (1997). The powerful placebo effect: Fact or fiction? Journal of Clinical Epidemiology, 50(12), 1311–1318. Randomized controlled trials - Experimental research that is of great important o Involves a hypothesis which is testing regarding a casual relationship. It has to be specific and testable by experiments o It must involve a control group, where all variables are constant o Experimental group there is one variable which is manipulated the effect between groups is measured o Examples is Franscesco Redi used the scientific method to demonstrate that maggots do not arise from meat spontaneously - Randomized controlled trial is where subjects are randomized in two or more groups one of which is a control group and one is experimental o Ex is looking at sodium intake and blood pressure, experimental group is given more salt in their diet and the effects are described between the experimental and control to see if the sodium increase increased blood pressure - When planning the trial it is important to select inclusion, such as features that may add people to the study, and exclusion cirteria, features tat can exclude people from the study. Example is study on herbal medicine and depression and it includes only people with mild depression, so you set that as an inclusion criteria - Control groups can be given two types of treatment o Standard treatment, so you can compare how the herbal is superior to the standard drug treatment o No active treatment, this is done when there is currently no effective treatment available yet - The use of the placebo is obviously important as it can help show whether the experimental group has not improved because of the placebo - Double blind is when the investigators nor subject know who is receiving the treatment. This is important to blind since you can be sure the results are not just because of the placebo effect of someone believing that their treatment should work o Double blind are obviously the most reliable for investigating drugs however are not alwys feasible such as massage there cannot be a sham method but it is possible for the assessor to know the person did not receive a massage, therefore is a single blind study o Sham acumpuncture is when they insert in locations which are not the same as classic locations, and it produces between 40-50% analgesic effect where real one produces 60% - Example of a controlled trial for subjects who receive cam and who receive convetional is some receive drugs and some receive acupuncture, then they are given a questionnaire which is then looked over by an investigator. This is single blind since the people know what they took but the researchers didn’t Ethical review - Approval by an ethics committee is required for all research involving humans o Informed written consent o Right to privacy o Right to self dignity o Assured confidentiality o Freedom from harm o Right to withdraw from trial at any time Other types of research - Can look at the effect of the treatment on the body such as the brain activity or the pain tolerance through hypertension of blood etc. - No study can for sure prove the use but more clinical observations can help form conclusions for particular therapies Evaluation of research - First step is to check if the author is biased in anyway, such as receives funding from somewhere and this change what they would conclude - Is it published in a reputable location? - Is the populating comparable to one you are using the data for? - Is the data significant? o 1. Larger difference in control and experimental the lower the P value o 2. Larger sample size the less likely it is to chance o 3. Need high quality data, if it is a bad set up the study will be bad and the data is useless - Type 1 statistical errors occur where there was a significant difference reported but this was due to chance - Type 2 errors occur when a real difference exists but the number studied is inadequate to demonstrate a significance so it wasn’’t a big enough sample etc. Publication bias is also type 2 since 20 studies are done and 19 find no difference but 1 study does find a difference and if published shows it works when in reality this is just a random chance - Ensure you look at how the data was collected, such as forms of evidence like HIV markers in blood for people with HIV rather then “patient is recovering” which holds little weight - Reality is inconsistent findings are regulary reported in medicine, the accepted method is to experts in a field review all the findings and make an overall assessment o Weighted average is when RCTs with more subjects are given more weight than smaller studies when comparing all studies o Problem is weighted averages ignore metholodgical between studies can cause outcomes - Systematic reviews look for all published studies on the particular topic and comparing all them - Read Page 200 figure 14-2 - CAM therpies range in plausibility so the ones that are very unlikely are important to be unrefusable evidence, for example when they found a particle that moved faster than light the study was under heavy scrutiny and they have to redo the study and look for errors all over the place to make sure. VS a fish that’s found in the pacific where its not needed proof - Homeopathy goes against all evidence of scientific laws so we have to be very careful before we accept validity - Acupuncture is the opposite because it makes no sense but works, where there are some things in theory that should work but these don’t - Ockhams razor: Simple explanation are generally better than complex ones Media coverage - Things go so quickly and people push news when its not really true, such as media reports being a lot more entusaitic and contined insfficient information about the risks of the medication they were reporting about UNIT 3 MIND-BODY INTERVENTIONS READ: pages 88-97 Mind, Body and Health - Will not be tested on pages up to heading on page 93 - Effectiveness of various techniques such as yoga can be tested on READ: Pages 100-103 and 114-136 Mediation is used t improve mental and physical functioning rather than a therapy, very comparable to exercise or eating properly - Two types of meditation o Transcendental meditation o Mindfulness meditation - No clear line dividng the conventional and the CAM, where transcendental is CAM while mindfulness is conventional Hypnosis, biofeedback and guided imagery are all accepted by conventional medicine They go over some studies, an eample is one where it shows people who use Transcendental meditation have lower health care costs but this does not take into account that people who use TM probably live lives different from general population such as a healthier lifestyle The next study was one which included guided imagery as there were no blinding and a small sample size which could have introduced bias. Placebo effect was seen and it is interesting to look and see was it the intervention or the placebo Unit 4: THE ARTS AND HUMOR IN MEDICINE Read: 157-171 The arts as Therapy - Music therapy has been shown in studies with schizophrenia to be improve their global state, mental state and social functioning - It as also been shown to have value for depression - Cancer patients have been shown to improve mental health through music therapy Read: Page 175 Humour as therapy - Humour can play a valuable role in medical care of patients - It is thought to be unprofessional and inappropriate however it can diffuse stressful situations and aid recovery The main goal of these therapies is stress management, but it is important to realize the one size fits all approach is not appropriate as some people love singing but hate dancing, some people love jokes and others don’t etc. Also it is obviously very important that care must be taken when medical staff joke with patients Therapies such as dancing and humour may be allowed in some hospitals but not in others, this is why it functions ina