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IntegratingComplementary andAlternative Medicine intoTreatment Interventions

MARJORIE A. KING, PHD, ATC, PTPROFESSOR ~ DEPARTMENT OF PHYSICAL THERAPYPLYMOUTH STATE UNIVERSITYMAKING1@PLYMOUTH.EDUNHMI SEPTEMBER ~ 2017

Overview

Content

Definitions

Resources*

Mechanisms (outcome measures)

Research

Other Considerations*

Implementation

What ARE Complementary &Alternative Medicine (CAM)

Allopathic Conventional of main stream medicine

Complementary medicine Medical practices outside of main stream medicine used in

conjunction with conventional medicine

Alternative medicine Medical practices outside of main stream medicine used without

any additional conventional medicine

Integrative medicine The blending of conventional and complementary medicine

https://nccih.nih.gov/health/integrative-health

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National Center forComplementary and AlternativeMedicine (NCCAM)

Five (5) Domains Alternative Medical Systems

Mind-body Interventions or techniques (facilitates mind’s effecton bodily functions and symptoms)

Biologically-based systems (such as herbalism)

Manipulative and body based methods (chiropractic,massage therapy)

Energy Therapies

https://www.nlm.nih.gov/tsd/acquisitions/cdm/subjects24.html

Mind Body Practices

Yoga

Chiropractic

Osteopathic manipulation

Meditation

Massage therapy

Tai chi

Qigong; Qi gong; Chi Kung/Gung

Healing touch

Hypnotherapy

Relaxation Techniques Breathing exercises

Guided imagery

Progressive muscle relaxation

Movement Therapies Feldenkrais method

Alexander techniques

Pilates

Rolfing Structural Integration

Trager psychophysical integration

Resources

Institutes Interdisciplinary Scholar’s Hub Journals News Letters

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InstitutesSCIENCE BASED

http://www.chi.is/indexhome

http://tiih.org/

http://www.miraglofoundation.org/

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Chopra Foundation

https://www.choprafoundation.org/

http://www.noetic.org/

http://cewm.med.ucla.edu/

Sara Lazar, Ph.D.Neuroscience of Yoga andMeditationNeuroscience of Yoga andMeditatioin

http://scholar.harvard.edu/sara_lazar

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https://nccih.nih.gov/

http://www.bumc.bu.edu/integrativemed/

http://www.umassmed.edu/cfm/

Department of Medicine, Division of Preventive and Behavior Medicine

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Benson-Henry Institute for MindBody Medicine

Katherine A. GallagherIntegrative Therapies Program

http://www.massgeneral.org/cancer/supportservices/integrative.aspx

AcupunctureArt Therapy

Massage TherapyMusic Therapy

ChigongTai Chi

http://www.massgeneral.org/bhi/

http://isharonline.org/ Interdisciplinary Scholar’s Hub

Integrative Studies Historical Archive & Repository

JOURNALS

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JOURNALS

The Journal of Alternative and Complementary Medicine http://www.liebertpub.com/acm

Evidence Based Complimentary and Alternative Medicine (2015 Impact Factor1.931) https://www.hindawi.com/journals/ecam/

Complimentary Therapies in Medicine http://www.journals.elsevier.com/complementary-therapies-in-medicine

Journal of Traditional and Complementary Medicine http://www.journals.elsevier.com/journal-of-traditional-and-complementary-

medicine/

Journals ~ cont.

Asian Journal of Complementary and Alternative Medicine http://www.literatipublishers.com/Journals/index.php?journal=

A-CAM

BioMed Central Complementary and Alternative Medicine https://bmccomplementalternmed.biomedcentral.com/

(Impact factor 1.375)

Global Advances in Health and Medicine http://www.gahmj.com/

MECHANISMS

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Familiar Aspects of Medicine

http://www.webmd.boots.com/pain-management/guide/shoulder-pain

http://www.webmd.com/pain-management/knee-pain/picture-of-the-knee

http://www.onehealth.co.uk/orthopaedics-procedures-tendonitishttps://www.pinterest.com/pin/431290101796810902/

Forgotten Aspects of Medicine

http://mskuksclass.weebly.com/lesson-2-forms-of-energy.html

Comfort Level….

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Energy Medicine

Comfort Level…..

Touch Screen Technology

“Unlike resistive touch screens, capacitivescreens do not use the pressure of yourfinger to create a change in the flow ofelectricity…they work with anything thatholds an electrical charge - includinghuman skin (…we are comprised of atomswith positive and negativecharges!)….when a finger hits the screen atiny electrical charge is transferred to thefinger to complete the circuit, creating avoltage drop on that point of thescreen….capacitive screens don’t workwhen you wear gloves; cloth doesnot conduct electricity…”http://scienceline.org/2012/01/okay-but-how-do-touch-screens-actually-work/

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Energy Medicine

Mechanism(s)

Information DeliveryElectricalHormonal

Information Delivery SystemNervous system (sympathetic,

parasympathetic, enteric) Information ReceiversReceptors

The Body’s Communication

Nervous system Autonomic

Sympathetic & parasympathetic & enteric

Communicate through receptors Eyes, ears, nose, tongue, skin

Receptors communicate Mechanically

Chemically

All of which create or redistribute energy….

Transportation systems – microtubles….

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Electrical: Neuron Depolarization

https://www.youtube.com/watch?v=qDUjVzVq7xEhttp://www.slideshare.net/andymartin/a2-nervesystemscolstons-29106121

https://www.unm.edu/~lkravitz/Exercise%20Phys/actionpotentialNEW.html

Nervous System Communication

Hormonal Communication

https://www.dreamstime.com/stock-illustration-activation-

stress-system-human-anatomy-image58736559

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Overviewof sites of thyroid

hormoneregulation ofmetabolism.

Rashmi Mullur et al. Physiol Rev 2014;94:355-382©2014 by American Physiological Society

Hypothalamic-Pituitary-Thyroid Axis

RECEPTORS

https://dtc.ucsf.edu/types-of-diabetes/type1/understanding-type-1-

diabetes/how-the-body-processes-sugar/blood-sugar-other-

hormones/

Cell Membrane ~ Protein Functions

http://www.proteinatlas.org/humanproteome/secretome

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Body Activity Takenfor GrantedDOWN STREAM EFFECT…..

EYE RECEPTORS

https://askabiologist.asu.edu/rods-and-cones

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TOUCH RECEPTORS

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EAR RECEPTORS

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SMELL RECEPTORS

http://droualb.faculty.mjc.edu/Course%20Materials/Physiology%20101/Chapter%20Notes/Fall%202011/chapter_10%20Fall%202011.htm

TASTE RECEPTORS

https://saurabhmaru.wordpress.com/images/gustatory_receptor_cell-final/

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Nervous SystemVOLUNTARY

INVOLUNTARY ~ AUTONOMIC

http://activateanddominate.com/sat-breathing-is-the-key-to-your-autonomic-

nervous-system/

AUTONOMIC NERVOUS SYSTEMS

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TWO CONTROL SYSTEMS

Brain GUT (ENS)

Furness, JB Nature Reviews Gastroenterology and Hepatology 9, 286-294 (May 2012) | doi:10.1038/nrgastro.2012.32

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Woo ~ Woo??

Electrical EnergyChemical/Hormonal Energy

Autonomic Nervous System (3)

Receptors

What to use for Outcome Measures??

Complimentary and AlternativeMedicine in Out-PatientOrthopedic Patient Care

Not a lot of evidence out there….

Pain Management

Anxiety Management

Cancer Care

Possible Modalities

Acupuncture

Cupping

Gua Sha

Fascial Tensegrity

Mindfulness & Meditation

Breathing

Yoga

Feldenkrais & Alexander Techniques Motor Learning

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Selected Outcome Measures

Pain

ROM

Functional movement

Performance

Balance

Whole person health

Performance of the overallsystem Quality of Life

Easier to sleep

Feel less tension

Hurts less

Measurement and Clinical “Importance” of Posture….

Acupuncture vs Dry Needling

Acupuncture Balance the energy flow within

the body Open up the channels of the

body meridians (5) Needle inserted into a meridian

point The body will heal itself Medical Acupuncture (MD, DO)

Dry Needling Orthopedic in Nature

Focuses on Trigger Points

Needle inserted into the triggerpoint of the muscle

Dry Needling Technique

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Dry Needling Mechanism

http://spinecenteratlanta.com/services/rehabilitation-center/dry-needling-treatment/

Acupuncture Meridians

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Mechanism of Acupuncture

No Consensus

Animal Models Release of endogenous opiates

Release of serotonin

Influence on receptors to excitatory amino acids at the spinalcord level

Regulation of the immune system through the autonomicnervous system

Lin, Jaung-Geng, and Wei-Liang Chen. "Acupuncture Analgesia: A Review of Its Mechanisms of Actions."The American Journal of Chinese Medicine 36.04 (2008): 635-45. Web.

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Mechanisms of Acupuncture

Local Pain relief through neuropeptides

Spinal Gate control

Supraspinal mechanisms Descending pain inhibitory system through the sympathetic

nervous system

Cortical Possibly placebo

Carlsson, C. "Acupuncture Mechanisms for Clinically Relevant Long-term Effects - Reconsideration and a Hypothesis."Acupuncture in Medicine 20.2-3 (2002): 82-99. Web.

Mechanism of Acupuncture

Vagus Nerve (autonomic nervous system) Anti-inflammatory: regulation of the inflammatory response

Protein regulation

Positively influences splenic tumor necrosis factor (alpha)

Lim, Hee-Don, Min-Hee Kim, Chan-Yong Lee, and Uk Namgung."Anti-Inflammatory Effects of Acupuncture Stimulation via the Vagus Nerve." Plos One 11.3 (2016): n. pag. Web.

Transport Mechanism: Microtubule

https://online.science.psu.edu/biol011_active002/node/4184

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CUPPING

http://backinhealthosteo.com.au/the-myths-truths-behind-myofascial-cupping-therapy/

• Heat the air inside the cup• Cooling of the air creates suction• Blood vessels expand ~ redness

Olympic Pseudo-Science

http://www.blackchiropractic.org/ba-guan-ancient-chinese-therapy/

Efficacy ~ Multiple Applications….

Pain ~ no consensus Kim, Jong-In, Myeong Soo Lee, Dong-Hyo Lee, Kate Boddy, and

Edzard Ernst. "Cupping for Treating Pain: A Systematic Review."Evidence-Based Complementary and Alternative Medicine2011 (2011): 1-7. Web.

Neck Pain ~ no consensus Chi, Lee-Mei, Li-Mei Lin, Chien-Lin Chen, Shu-Fang Wang, Hui-

Ling Lai, and Tai-Chu Peng. "The Effectiveness of CuppingTherapy on Relieving Chronic Neck and Shoulder Pain: ARandomized Controlled Trial." Evidence-Based Complementaryand Alternative Medicine 2016 (2016): 1-7. Web.

Potential Benefits Cao, Huijuan, Xun Li, and Jianping Liu. "An Updated Review of

the Efficacy of Cupping Therapy." PLoS ONE 7.2 (2012): n. pag.Web.

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Gua Sha

An instrument-assisted unidirectional press-stroking of alubricated area of the body surface to intentionally createtransitory therapeutic petechiae called ‘sha’ representingextravasation of blood in the subcutis.

Nielsen, Arya. "Gua Sha Research and the Language of Integrative Medicine." Journal of Bodywork and Movement Therapies 13.1 (2009): 63-72. Web.

http://www.pacificcollege.edu/news/press-releases/2015/05/05/science-gua-sha?mailaddress=true

Science of Gua Sha

Outcome Increase in micro-perfusion

Anti-inflammatory

Heme-oxygenase-1

Immune effect

Effects pain, stiffness, fever, chill, cough, wheeze, nausea, etc.

Effects acute and chronic internal organ disorders

http://www.pacificcollege.edu/news/press-releases/2015/05/05/science-gua-sha?mailaddress=true

Nielsen, Arya, Nicola T.m. Knoblauch, Gustav J. Dobos, Andreas Michalsen, and Ted J. Kaptchuk. "The Effect of Gua ShaTreatment on the Microcirculation of Surface Tissue: A Pilot Study in Healthy Subjects." EXPLORE: The Journal ofScience and Healing 3.5 (2007): 456-66. Web.

Add strain to the system and the deformation gets distributed across the structure

https://www.anatomytrains.com/fascia/tensegrity/

In the body – pain & disease – break down at the weakest link

TENSEGRITY

Structural Basis of Life

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RESOURCES (soft tissue)

Tensegrity Ingber,DE. “The Architect of Life”. Scientific American, 1998:48-57

Strolling Under the Skin https://www.youtube.com/watch?v=eW0lvOVKDxE&feature=you

tu.be

Mindfulness / Meditation

Alterations in Brain Function (cognition) Brain Changes = NEUROPLASTICITY Changes Neurobiology

Alterations in Brain and Immune Function doi: 10.1097/01.PSY.0000077505.67574.E3 Jon Kabat-Zinn ~

http://www.umassmed.edu/cfm/

Mindfulness: Brain & ImmuneChanges N = 48; two groups

Measures: Base line – 8 weeks

Meditation: 1 hr 6d/wk Mindfulness-Based Stress Reduction Training (Umass)

Increase in L sided anterior brain activity (EEG) Associated with decrease in anxiety

Increase in positive affect (more adaptive response tonegative/stressful response)

Increase in antibody titers upon exposure to vaccination(blood draw - hemagglutination inhibition assay)

Positive correlation between increase in brain activity &immune response (n=41)

DOI: 10.1097/01.PSY.0000077505.67574.E3

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Neuroplasticity – long time meditators

http://www.andrewnewberg.com/research/

Increase in frontal regionreflects increase in

focusing attention andconcentration

Single Photon Emission Computed Tomography

Neuroplasticity – long time meditators

http://www.andrewnewberg.com/research/

Decrease inOrientation toSpace & Time

Respond vs React

Meditation & Telomeres

http://articles.mercola.com/sites/articles/archive/2010/02/23/science-finally-reveals-how-you-can-actually-revese-aging.aspx

Increased Telomerase Activitydoi:10.1038/tp.2016.164

Alteration in Gene Expression-6 day residential program-Measures taken post

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Telomeres

http://www.ackc.org/kidney-cancer-information/aacr-conference-2011/telomeres-and-cancer-prevention/

• Telomeres protect the ends of the DNA• When telomeres are lostIt leaves the DNA unprotected against change• Broken DNA is dangerous (changes gene expression)

Mindfulness & Meditation

Meditation vs Vacation Effect

Improvements in Cellular Health (identified by bloodmarkers) Improved regulation of stress response

Improved regulation of immune function

Improved regulation of amyloid beta metabolism (amino acidinvolved with Alzheimer's; amyloid plaques)

doi:10.1038/tp.2016.164

Mindfulness ~ Meditation

Increase in Grey Matter Increase in Learning & Memory Processes

Improved Emotional Processing

doi:10.1016/j.pscychresns.2010.08.006

Results in Functional and Structural Plasticity doi:10.1093/scan/nss056

Hay house web site https://itunes.apple.com/us/podcast/hay-house-

meditations/id955266444?mt=2

Chopra Center http://www.chopra.com/online-

library#sm.0000094wm6zxyceonqz0ezdak4a54

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Other Considerations

Other Considerations

Breathing

Yoga

Imagery (Motor Learning Literature)

Systemic effect of Emotional Chemistry

Role of Micro-Biomes (environments) N Engl J Med 2016;375:2369-79.DOI: 10.1056/NEJMra1600266

Autism and Autism Spectrum

http://dx.doi.org/10.1016/j.cell.2013.11.035

Obesity

Cancer

Role of the western diet……environment……electronics……life style

Other Considerations

Epigenetics vs Genetics (5%)

Role of Inflammation Heart Disease

Cancer

Obesity

Alzheimer's

Whole Body Interventions Peterson, C. T. et al. Identification of Altered Metabolomic

Profiles Following a Panchakarma-based AyurvedicIntervention in Healthy Subjects: The Self-Directed BiologicalTransformation Initiative (SBTI). Sci. Rep. 6, 32609; doi:10.1038/srep32609 (2016).

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Identifying theMechanisms…

The Challenge…

Practice Integration ~ Be Creative!!

Patient Education Waiting room

Treatment rooms

Patient Handouts/Newsletters

Available Web Sites

Additional Support Services ~ Create a Team Work with Primary Care MD’s & Local Hospital

Local Acupuncturist

Local Nutritionist

Local Services (ex) Tai Chi/Chi Gong classes at Senior Center orYoga classes as YMCA

Local Massage Therapist (treatment cost vs co-pay)

Whole Person Health ~ MissionImpossible??

Less about providing the service

More about providing the information to round out patientcare…..

Open communication across health care practioners

Treatment intervention as a TEAM

Treat the Patient ~ not just theDiagnosis