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Integrative Medicine: What
the Health?
Lisa W. Corbin, MD, FACPMedical Director, Integrative Medicine
University of Colorado Hospital and Health Sciences Center
Associate Professor, Rehabilitation and Internal Medicine
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ObjectivesAfter this talk, you should be able to:
– Define “CAM”, “Integrative Medicine”– Discuss the basic background, risks, and
benefits* of some common CAM therapies– Discuss CAM with your doctor / patient– Identify qualified CAM practitioners – List resources for finding more information– Describe the Integrative Medicine program at
UCDHSC
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What is Integrative Medicine?
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What is Integrative Medicine?
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Real Definitions Please…• CAM
– Complementary / Alternative Medicine– Therapies not usually associated with
hospitals or medical schools• Acupuncture, Massage Therapy, Chiropractic…
• Integrative Medicine – CAM therapies coordinated with conventional
medical treatments
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Integrative Medicine
• Reaffirms patient / practitioner relationships
• Considers the “whole” person
• Is informed by evidence
• Considers all appropriate therapies, practitioners, and disciplines
• Promotes “optimal wellness”From Consortium of Academic Health Centers for Integrative Medicine(www.imconsortium.org)
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Who Uses CAM Therapies?
Barnes PM. www.cdc.gov/nchs/data/ad/ad343.pdf
Adults, 2002 incidence of CAM use:
•Over 80% also using conventional medicine•Less than 35% discuss with physician – why?
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CAM: Potential Risks
• Directly harmful treatment• Indirectly harmful treatment
– Reducing efficacy of conventional treatment
– Replacing curative conventional care
• Cost
CAM: Potential Benefits
• Symptom control– Reduce use of medications
with side effects – Better tolerance of curative
conventional care
• Empowering to patient• Less cost• Less risk
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Balancing Risks and Benefits• Discuss CAM openly
– Enhance doc / patient relationship– Improve health
• Dissuade from harmful practice
• Encourage beneficial treatments
• Integrate care with all providers– Take ownership of your health and health care
• Be informed about specific risks and benefits
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CAM Considerations
• Avoid harmful practices
• Use evidence-based, safe therapies
• Consider plausible, safe modalities
Sugarman J, Burk L. Physicians’ ethical obligations regarding alternative medicine. JAMA 1998;280(18):1623-1625.
Hippocrates : “First, do no harm”
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Harmful CAM Therapies• Colonic enemas• Chelation therapy• IV therapies• Restrictive diets• Megavitamins• Some herbs / supplements
– Direct toxicity– Indirect: drug interactions– Stimulate tumor growth, immune system
• Anything used IN PLACE OF proven, curative, conventional treatments
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Therapies to Highlight
• Mind / body techniques– Sleep– Exercise
• Acupuncture
• Massage
• Chiropractic
• Herbs and supplements
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Why Mind-body?• Perception of pain requires processing by the
mind; mind-body therapies can alter perception• Stress / anxiety perceived as a threat,
processed by the mind as equivalent to pain• Insomnia worsens pain• Mind-body therapies are generally safe
– Caution with “blame the victim”
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Mind-body Therapies• Cognitive Behavioral Tx• Relaxation techniques• Breathing techniques• Stress management• Biofeedback / heart math• Art, music, pet therapy• Mindfulness / Meditation• Imagery / visualization• Yoga / tai chi• Hypnosis
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Mind-body Details• Typically meet with therapist 5 – 10 visits
• Patient needs to practice at home
• Not all therapists comfortable with all methods
• Often covered by insurance• Workbook:
– Caudill, Margaret. Managing Pain Before It Manages You, Revised Edition (Paperback)
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Mind-body: Highlighted Uses• Stress reduction
• Anxiety, depression, insomnia
• Grieving / acceptance
• Behavior change
• Symptom management– Pain (FM, muscle pain, HA)– Dyspnea (COPD, VCD)– Nausea
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Get Some Sleep!• Restorative sleep improves pain, fatigue, and mood• Sleep deprived “normals” develop chronic pain• Links: breast cancer, weight gain• Behavioral approaches:
– Don’t eat, drink, exercise just before bed– Avoid late day caffeine , too much alcohol– Get consistent exercise earlier in the day– Pay attention to room environment– Establish consistent sleep times– Get out of bed if not tired– Don’t nap
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Exercise: Highlighted Uses• Improves sleep, depression, anxiety -
improving overall health• Duh – cholesterol, weight, BP, DM• Wow!
– Decreased pain in arthritis– Decreased hot flashes– Improvement in BMD– One of the cornerstone treatments for
fibromyalgia and chronic fatigue– Dramatic reduction of breast CA recurrence– Improvement in immune function
• Too much – decreased immunity
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Exercise Instruction: FIT• F requency
– Exercise every day
• I ntensity– Break a sweat; increase difficulty of exercise
• T ime– Start with 5 minutes daily, increase by 1 minute
daily each week; goal 30 minutes / day
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AcupunctureChinese Medicine Background
– Health = balance of yin and yang– Qi = energy force created by interaction
of yin and yang– Meridians = channels that carry qi throughout the body;
each corresponds with a specific organ– Excess, deficiency, or stagnant flow of qi results in
disease– Examples of TCM diagnoses:
• Yin deficiency and yang predominance with reduced kidney qi• Stomach qi rebelling
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AcupunctureWestern Medicine Background
– Osler, 19th century “best treatment for lumbago”
– James Reston, China, 1971 – Biological effects
• Local nerve activation• Endorphins, ACTH, endogenous opiods (reversal of
analgesia with naloxone)– SPECT scanning: increased activity and reversal of
asymmetry in chronic pain patients in thalamic and prefrontal cortex during acupuncture over baseline
Han JS. Neurosci Lett 2004;361(1-3):258-61.
Newberg AB et al. J Neuroimaging 2005;15(1):43-9
Mayer (1977) Brain Res
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General Advice: Acupuncture• Acupuncture is generally safe
– Adverse events: minor or rare (pain, bleeding, fatigue)– Disposable needles, alcohol wipes to avoid infection
• Practitioners – State to state variability (www.acupuncture.com/statelaws)– TCM: National Certification Commission for Acupuncture and Oriental
Medicine (www.nccaom.org)– MD: American Academy of Medical Acupuncture
(www.medicalacupuncture.org)• Costs
– Initial / follow up: $80 (MD $175) / $55 (MD $100)– Covered by some insurances
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Acupuncture: Highlighted Uses• WHO - Chronic pain of any etiology
– Fibromyalgia / myofascial pain – Low back, neck pain– Headaches– Carpal tunnel – Osteoarthritis
• IBS• Depression / anxiety • Fertility / menstrual irregularity• Nausea (chemo, pregnancy, post op)
Acupuncture. NIH consensus statement 1997;15(5):1-34.
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Massage Therapy• Developed by almost
all cultures• Many different forms• Emphasis on
improving circulation, releasing muscle tension, calming and relaxing patient
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General Advice: Massage• Generally safe. Use caution with:
– Congestive heart failure– Infections– Blood clots / bleeding disorders– Osteoporosis or bone metastases– Pregnancy
• A license is NOT required in Colorado– Look for “CMT” or “LMT”– Look for involvement in AMTA (www.massagetherapy.org)
• $60+++ / hour, occasionally covered
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Massage Therapy: Highlighted Uses
• Relaxation, improved QOL
• Post-operative wound healing
• Lymphedema treatment
• Pain management– Musculoskeletal complaints– Tension headaches– Fibromyalgia
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Chiropractic• “Manipulation” referenced by
Hippocrates; Galen• Daniel David Palmer, 1895
– “Normalization of the nervous system” is key to health
• CAM vs. subspecialty
•Manipulation; often exercises, fitness, general health advice; acupressure, supplements•Practice styles, practice philosophies vary
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Chiropractic: General Advice• Safety
– Generally safe– Local discomfort, headache, fatigue– Excessive xrays from some DCs– Stroke, dislocation, fracture rare but possible
• Risk of serious complication estimated at 6.39 per 10 million cervical manipulations (3.2 per 1000 for NSAIDS)
• Avoid high velocity neck manipulation
– Caution: cerebrovascular disease, osteoporosis, rheumatoid arthritis, metastatic cancer, bleeding disorders
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Chiropractic: General Advice• Practitioners
– 4 year accredited school– Philosophies and styles vary widely – Licensing required in 50 states; scope of practice
variable
• Costs / reimbursement– Initial / follow-up $35 - 150 / $25 - 50– OMT usually covered; chiropractic often covered
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Chiropractic: Highlighted Uses
• Back pain
• Neck pain
• Headaches
• Other msk complaints
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Herbs and Supplements• Three types of medicines:
– Prescription (Rx)– Over-the-counter (OTC)– Dietary Supplements
• Unlike Rx and OTC, supplements:– Are not required to prove safety or efficacy
• Burden of proof on FDA to show unsafe
– Are not required to enforce quality control• GMP to be required by 2008
– Can vary in concentration of ingredients
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• Natural safe
• Use extra caution when taking prescriptions– Herb / drug interactions may be dangerous
• Use trustworthy resources for information
• If you choose to take or recommend supplements:– Look for well-labeled brands– Avoid combination products, MLM sales products– Tell your health care providers / ask your patients
General Advice: Supplements
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Supplements to Avoid
• Vitamin E– No proof of benefit, meta-analysis with concerns of
toxicity
• St. John’s wort– Too many drug interactions, ? DNA damage
• Pre-op– Blanket statement – stop all products 2 weeks
prior to surgery / upon hospital admit• Beware of metabolic / pharmacokinetic implications
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Supplements to Consider• Multivitamin
– But latest data doubts benefit; good diet better
• Calcium (women)– 1500 mg / day total
• Vitamin D– Most Americans deficient– Cancer prevention, muscle pain
• Fish oil (Omega 3 FA)– Heart disease, TG, HTN, HA, weight
loss, depression, cancer prevention
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Supplements to Consider• Probiotics
– Infectious diarrhea, IBD, IBS, antibiotic associated diarrhea
• Coenyme Q10– Deficiencies: beta blockers,
statins, CHF– Helps statin-associated muscle
pain, reduces doxirubicin cardiac toxicity
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Finding a Good Practitioner
• Training and licensure
• Experience with symptom
• Risks
• Costs / reimbursement
• Time frame / progress assessment
• Ability to work with conventional physicians
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What the Health!• Integrative medicine coordinates CAM
with conventional care
• Don’t use harmful CAM therapies
• Use beneficial, safe therapies
• Consider TCFIM at the University of Colorado Hospital as a resource
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University of Colorado Hospital Anschutz Medical Campus• 720-848-1090• www.uch.edu/integrativemed
The Center for Integrative Medicine
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Conception • Group of interested faculty presented
proposal to UCH/HSC administration, late 1990’s
• Administrator hired March, 2001• Steering committee drawn from all 4
UCHSC schools• “Clinical first, then education / research”• First clinical services December, 2001
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General Assessment / Oversight• Lisa Corbin, MD
Traditional Chinese Medicine• Daisy Dong, L.Ac • Mel Drisko, L.Ac
Massage therapy• Rose Patch, CMT• Molly Monahan, CMT• Ann Mathews, CMT
Nutritional Counseling• Colleen Gill, RD• Pamela Ham, RD
Pharmaceutical / Herbal Consults• Susan Paulsen, Pharm D
Chiropractic• Brian Enebo, DC
Behavioral Medicine / Biofeedback• Bennett Leslie, PsyD• Denise McGuire, PhD
Clinical Care
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Access to Services• Referrals
– Self referred– UCH physician or provider referred– Outside physician or provider referred
• Insurance / authorizations checked• Visits scheduled
– With specific practitioner, and / or– With Medical Director to explore all options and
make a personalized plan
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Integration of Care
• Notes for each visit available in EMR
• Referral letter written to physicians, other providers, and patient
• Formal case reviews– Integrates the care from within TCFIM– Further integration with other care providers
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• www.imconsortium.org
• 39 member schools in US, Canada
• Collaboratively working to promote Integrative Medicine care, education, and research
• Resource to learn from each other
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Education: UCHSC• Resident elective (est. 1999)• Medical student elective (2003)• Medical student required lectures
– Herbal pharmacology / small groups– Chiropractic theory and practice– Advising patients on use of CAM
• Formal classroom teaching in PT and Pharmacy Schools (required courses)
• Lectures in CHA/PA training
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Education
• Other medical professionals / CME
• Public education – support groups
• School of Nursing, Metro – separate courses
• Half-day shadowing experiences
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Research
• CAMPUS group
• REST study
• Demographic descriptive articles
• Reviews
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Clinical Care• Expand outpatient services• Develop satellite programs
Education• CME conferences, lectures• Hands-on time
Future directionsResearch• Participate in campus-
wide projects• Fund small grants• Follow treatment-
specific clinical outcomes data