Integrative Medicine

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www.tabaye.ir 

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Integrative Medicine Caroline Oczachowski, PGY 2 Emory Family Medicine Adapted from Dr. J. Michelfelder at Loyola University in os 

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54 year-old female presents with peripheral ۳ shoulder tendonitis, and carpal tunnel syndrome about 15 months after completin: 3 for breast cancer. She is believed to be in complete remission currently. She states that she is exercising, doing physica therapy, taking a multi-vitamin and following all of the recommendations of her physicians, but feels like she could be doing more for her issues. What more do you want to know? What options would come to mind for you? How would you find information about those options? 

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Approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a 2007 nationwide government survey 

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Definitions “Complementary and Alternative Medicine is a Group of Diverse Medical and Health Care Systems, Practices, and Products That are Not Presently Considered Part of Conventional Medicine” NCCAM 

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Definitions * “Complementary Medicine is Used Together With Conventional Medicine. « “Alternative Medicine is Used in Place of Conventional Medicine.” NCCAM 

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Definitions “Integrative Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness.” NCCA M “Healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.” http://www.integrativemedicine.arizona.edu/ about2.html 

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* The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government's lead agency for scientific research on CAM. * They are 1 of the 27 institutes and centers that make up the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services. 

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The mission of NCCAM is to: * Explore complementary and alternative healing practices in the context of rigorous science. * Train complementary and alternative medicine researchers. * Disseminate authoritative information to the public and professionals. 

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1829 

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10 Most Common CAM Therapies Among Adults - 2007 Therapies with significant increases between 2002 and 2007 are 20022007 Deep breathing 11.6 2 Meditation 6 Massage 0 ‏دوم‎ 

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2002 19.9% 21.1% ommon 241% ost C 403% 

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ost Common Natural Products Among Adults 7.4% 

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۱ the conditions for w! ult pts most frequently seek CAM? 

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s for Which C/ sed Among Adults - 20 16388 

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Diseases/Conditions for Which CAM ls Most Frequently Used Among Adults - 2007 20 مود 21% ۰ 18% ‏عد‎ 1.8% j 1 | | "0۳۳ ‏هون‎ ‎ee ee ‏م‎ fill “Scce Bares Pt Bm 8 Nain ROC sonal ai Sess Rept #12. Congorentry and Aterave Meine ie Aron ‏عفص‎ ‎‘sel Che Ure Sut, 2007, ‏فد یت‎ 

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10 Most Common Therapies Among Children - 2007 39% 0 

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jat are the conditions for whi pediatric pts most frequently seek CAM? | 22? 

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Diseases/Conditions for Which CAM Is Most Frequently Used Among Children - 2007 Insomnia ‘ADHD 4.2% Other Musculoskeletal 6.7% BackINeck Pain Head or Chest Cold AnsetyiStess 

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Most Common Natural Products Among Children* - 2007 37.2% Echinacea Fish O1V0mega 3 Combination Flaxseed OWPills Werb Pls 

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Domains of CAM African, Middle Eastern, Tibetan, Central and South American cultures, Homeopathy, Naturopathy cognitive-behavioral approaches, meditation, hypnosis, dance, music, art therapy, prayer, mental healing, visual imagery dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen). chiropractic, osteopathic manipulation, massage, reflexology Alternative | Ayurveda, Chinese, Native American, Aboriginal, Medical Systems Mind-Body Interventions Biological Based Therapies Manipulative And Badyied by 

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Other CAM therapies Aromatherapy Colonic Irrigation Therapeutic Touch EDTA Chelation Cupping Primordial Sound Meditation 

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Definitions * Ayurveda - India's traditional, natural system of medicine that has been practiced for more than 5,000 years. Ayurveda provides an integrated approach to preventing and treating illness through lifestyle interventions and natural therapies. Ayurvedic theory states that all disease begins with an imbalance or stress in the individual's consciousness. Lifestyle interventions are a major ayurvedic preventive and therapeutic approach. Ayurvedic practices is to cleanse the body of substances that an cause ase, and this is believed to help pet ies ‏وی‎ balance. 

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Definitions * Homeopathy - a system of medical practices based on the theory that any substance that can produce symptoms of disease or illness in a healthy person can cure those symptoms in a sick person. For example, someone suffering from insomnia may be given a homeopathic dose of coffee. Administered in diluted form, homeopathic remedies are derived fram manvw natural sources —including ‏.اماع ب‎ 

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Definitions ٠ Naturopathy - an alternative medical system. Naturopathic medicine proposes that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the patient with a goal of supporting this power through treatments such as nutrition and lifestyle counseling, dietary supp medicinal plants, exercise, h treatments from traditional medicine. 

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Definitions * Qi gong - A component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and CO function. 

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Definitions * Reiki - A Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient's spirit is healed, which in turn heals the physical body. 

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thy Should We Care? 30,000 herbs on the market currently Estimates of $30-40 billion dollars spent annually Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575. Sales of Metabolite 356 approached $1billion in 1999 alternative Medicine Alert, January 2000 Avlimil - est. $100 million in sales in 2003 Herbal entrepreneur proving that sex sells: Local business reaps millions from supplements The Cincinnati Enquirer Relacor $23 Million; 900,000 bottles by July 06 Enzyte has 21,400 repeat customers at $99.9 a month for a whopping $2,138,930.00 a month in sales ($25,667,160.00 annually) USA today 

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Why Should We Care? * 600 Million Visits a year to CAM Providers - More Than to Primary Care Providers * An estimated 15 million adults took prescription medications concurrently with herbal remedies and/or high-dose vitamins Eisenberg D. et al, JAMA, Nov 11, 1998(18) 1569-1575 

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Why? What is Mainstream Medicine Not Offering to Our Patients? 

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Have We Missed the Boat? » Dissatisfaction with health care providers and medical outcomes * Side effects of drugs and treatments * High health costs ٠ Technology * Lack of control in their own health care practices * Time spent with practitioner Stephen Strauss, M.D., NCCAM Director 

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Have We Missed the Boat? Looking for “cures” Want to use “natural” products Patient feels empowered Focus on spirituality and emotional well-being Health Care Provider provides the 3 T’s: touch, talk, time Stephen Strauss, M.D., NCCAM Director 

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What about communication? Between 40 and 70% of CAM users do not disclose their use to their physician. Zisenberg 2007 

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Why do patients not tell their physician about their CAM use? ۶ 60% - “My doctor never asked.” ۶ 60% - “It wasn’t important for my doctor to know.” * 20% - “My doctor wouldn’t understand.” * 14% - “My doctor would disapprove.” Eisenberg DM. Ann Int Med 2001;135(5):344-51 

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What are our patients reading??? 

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PRESS RELEASE: + Medication errors are among the most common medical errors, harming at least 1.5 million people every year, ‘says a new report from the Institute of Medicine of the National Academies. The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional ealth care costs, the report says. - 10M July 2006 

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ression Treatments ‎&Herbs‏ شسسست ‎eure au‏ ‏لت ترا كنم | ‎From Harvard‏ ارت تن" ‎ 

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۳۰ ‏نلیتا‎ ey = -- bw ۱ ۱ لته 1 iy ‏ميسن‎ Attack — 4 11 < = 

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Evidence Based Medicine * Difficulties With CAM Research —Sham Acupuncture —Non Standardized Herbal Formulations — Difficult to Blind Patients and Practitioners — Treatments Very Individualized - Difficult to Formulate Protocols — Drug companies have to do studies to go on the market—supplement companies do not, so clinical trials sponsored by supplement companies are rare 

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Comparison * Mainstream Medicine — Large Double Blind Placebo Controlled Trials * Many Exclusions Such As Multiple Medicines, Other Illnesses, Female, Pregnant, Children, Race « “Placebo Effect” Discounted * Apply These Narrow Results to The Individual — Integrative Medicine * Very Individualized - “Placebo Effect” Not Discounted 

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۰ Patients are choosing integrative and alternative medicine, but what about physicians? 

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Physician’s Attitudes * Survey sent to 660 physicians at the Mayo Clinic (233 responded) * Three areas: utilization, familiarity and attitudes * Utilization: — 75% had never referred to CAM practitioner — 44% said they would consider if available at Mayo (<46 years or female more likely) — Less than 25% discussed benefits or risks with CAM — 57% thought incorporation of CAM would have a positive impact on pt satisfaction 

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Physician’s Attitudes * Familiarity: — Biofeedback, massage, chiropractic and relaxation therapies were the most familiar — 59% were unfamiliar with energy healing, 53% with naturopathic medicine — Of the 13 herbs listed, only 3 were commonly listed as familiar — 66% were not familiar with feverfew and 52% were not familiar with Kava — 49% of the physicians felt it was difficult or very difficult to find reliable information about herbs 

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Physician’s Attitudes 41% of the a yeiciatis neither agreed or disagreed that physician knowledge had an impact on patient’s health 52% felt physicians’ spiritual beliefs were important and 87% felt patients’ spiritual beliefs and practices were important 67% agreed some CAM therapies hold promise but 70% felt current practices of CAM was a “threat” to the public health Most important factors in changing physicianss attitudes were RCT’s and evidence demonstrating mechanism 70% of the physicians felt Mayo clinic should provide proven CAM therapies eCAM 2006;3(4) 495-501 

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Where Are We Today? + Academic Fellowships (Research) — Harvard University — Tufts — Boston University — Stanford — Duke Residencies in Integrative Medicine — Oregon Health Sciences University — Montefiore Medical Center (NY) * Clinical Fellowships: — University of Arizona (Founding Program) — University of Michigan — University of Maryland — University of Wisconsin — Maine Medical Center — Cooper Health System (NJ) — Lawrence MA — Beth Israel Medical Center — UCLA 

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Where Are We Today? MEMBERS CONSORTIUM OF ACADEMIC HEALTH CENTERS FOR INTEGRATIVE MEDICINE 

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CAHCIM Members Albert Einstein/Beth Israel Columbia University Duke University George Washington Georgetown Harvard Laval University Stanford Uni Yale University Wake Forest University University of Alberta University of CA/Irvine ity of Michigan ry of Minnesota ry of Pennsylvania Thomas Jefferson y of Pittsburgh UMDNJ ry of Texas-Galveston University of Arizona ty of Vermont University of Calgary University of Wisconsin University of Haw University of Was! 

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The Future of Integrative Medicine * Definition of Integrative Medicine From the CAHCIM “Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches to achieve optimal health and healing.” 

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The Future of Integrative Medicine * The Term “Integrative Medicine” Will Die — Our Patients Will Demand Integrative Medicine From All of Us —Training Will Be Demanded by Medical Students —Training Will Be Demanded by Residents 

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The Future of Integrative Medicine * Integrative Medicine Will Be A Skill Set Added on Just Like: — Electronic Health Records —New Medications — New Procedures 

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Real Patient 54 year-old female presents with peripheral neuropathy, shoulder tendonitis, and carpal tunnel syndrome about 15 months after completin: 3 for breast cancer. She is believed to be in complete remission currently. She states that she is exercising, doing physica therapy, taking a multi-vitamin and following all of the recommendations of her physicians, but feels like she could be doing more for her issues. What more do you want to know? What options would come to mind for you? How would you find information about those options? 

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Integrative Medicine requires a paradigm shift from the disease-centered approach of conventional biomedicine to an approach in which patient values and participation of patients are central. Maizes 1999 

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Integrative Medicine * Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. * It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative. www.integrativemedicine.ariazona.edu PIM - U of Arizona 

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The Future of Integrative Medicine Epocrates Rx Pro Micromedex Commission E Plus Many Other Databases 

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Resources ٠ Commission E — Germany — Ranks Quality of Evidence — Evaluates Benefits and Risks 

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NATIONAL CENTER FOR COMPLEMENTAR’ AND ALTERNATIVE MEDICINE http://nccam.nih.gov/ 

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] To identify the best quality health ond ‘hutrition products through independent testing ) لمم ‎Latest Result:‏ ‎amet‏ ی مد سوه هت ‘Some Zinc supplements Found Low in Ingredient and Many Lack Anstructions for Proper Use Tost results posted for zinc lozenges and supplements Many Echinacea Supplements Don't Meet Quality Standards tn Latest resting Results posted for 11 products ~ 5 fail ocalls and warnings strat and Lutein Supplements (for Eve Health) Vary Widely in strength but Most Meet Ingredient Claims | ERA ig Test Results for 19 Litein ond Lanes Zeaxanthin Supplements Pasted. | Glidance Given an Produce and Decage. | Ts the headin ‏سه‎ ا 11 | ‎meet‏ مه موم مود تس ‎Label Claim‏ ‎{inet Cautoned a check rand;‏ ‘52 Products Tested Natural Products Encyclopedia: 8 ae Arthritis Supplements for People and Pets 7 Larue roview of glucosami ‏ف‎ chondroitin, and 5M supplements ince op nei cordon ‏زپ‎ Hecker: 

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Integrative Medicine 2 * Donald Novey, Complemen M.D. - Lutheran (ores General Hospital CI — Evidence Based Review of Each Modality 

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Integrative Medicine * David Rakel, M.D., University of Wisconsin — Instructions on how to put CAM into your own medical practice 

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NATURAL MEDICINES cE 2 VE DAT Co ee out the Database Sipe aan about sy reaentor brand narra credue, Cea Natal Prowl Eecthonoss chiockot tlc yu to eel orators Tonnlutal raauale veeetarvariaue model cordon See aSomnle dal Dest Dra aati Checkley scan itracto tutoon aye sualrodue 6 any dug Aubenatiea chock insracons vi EACH INGREDIENT ofeacn paul 1 apecMe nation a eH 002 00 0 errs ‘Search Calenauea ieract-showsyou questens, snower3, and a ‏مر‎ | كع صصص سدس 1 تست ‎Cottages Inte‏ تسس هب ‎hange Your Profile or Address‏ مس مه ستاه سیگ اه ‎‘senna peta‏ ‎Mia ou enti‏ مها ‎Eerste‏ ‎Book Version PDA Version 

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Resources » National Center for Complementary and Alternative Medicine —http://nccam.nih.gov/ * Agency for Healthcare Research and Quality —http://www.ahrq.gov/clinic/epcindex.htm 

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Resources * American Academy of Medical Acupuncture —www.medicalacupuncture.org * Online Resource — http://www.altmedicine.com 

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Where Should We Go for Information? Product claims — www.quackwatch.com — www.snopes.com Product quality assurance — www.consumerlab.com Product ingredients — Natural Medicines Database www.naturaldatabase.com Product safety and efficacy — www.cfsan.fda.gov/~dms/ds-ind.html — www.naturaldatabase.com — The Natural Pharmacist www.iherb.com or www.consumerlab.com 

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Dr. Clairborne began her journey at Emory University completing her BA in Psychology then went on to complete her medical degree at Morehouse School of Medicine. Finishing her Family Medicine Residency at Florida Hospital in Orlando, FL., she ventured on to complete pose graduate trainings in acupuncture with The Academy 

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“PROGRESSIVE MEDICAL CENTERS OF AMERICA This is your life. Live it well." 

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