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.

1. Alternative medical systems2. Mind-body interventions3. Biologically based therapies4. Manipulative and body-based therapies5. 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 non-steroidal

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 tension-type 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 dance-specific 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