Friday, February 27, 2009

CAM Paper Part IV: Osteopathy

Osteopathy is now regarded as a part of conventional medicine. Osteopathic physicians, who make up approximately 5.5% of American physicians, are fully licensed in all 50 states and have the same scope of practice as allopathic physicians. In addition, there is no longer a significant difference between allopathic and osteopathic medical school curriculums, and osteopathic principles like holistic medicine have been adopted by allopathic physicians.(9) However, since osteopathy arose as a competitor to allopathic medicine in response to the inadequacies of allopathic medicine of that time, a discussion of osteopathy is still appropriate here.

Andrew Taylor Still, the founder of osteopathy, was deeply affected by the inability of allopathic medicine to save his children from dying of meningitis. He became a harsh critic of many then common medical practices like blood-letting and purging, which he felt did more harm than good. Several of the principles advocated by Still continue to form the philosophical basis of osteopathic medicine today. These include focusing on health rather than disease, treatment of the entire patient rather than a reductionist approach, and relating the structure of the body to its function.(9,10) In the early days of osteopathy, practitioners treated patients with musculoskeletal manipulation (osteopathic manipulative treatment, or OMT) in order to restore their structural integrity and thereby their health. Still and other early osteopaths were opposed to the use of drugs, although osteopaths later acknowledged the importance of teaching pharmacology to their students and noted that drugs were useful and even necessary in some situations.(9)

Osteopathic principles and practice are heavily intertwined with competing medical systems. For example, although allopathic medicine is widely considered as following in the tradition of Hippocrates, the reductionist perspective that has historically characterized allopathic medicine was actually espoused by a second school of medicine that was the rival of Hippocrates. In contrast, the osteopathic principle of restoring the natural condition of the body to promote health is more in keeping with the ideas espoused by Hippocrates.(9) Second, many of the ideas held by Still were also held by Palmer, the founder of chiropractic, including an aversion to the use of drugs, rejection of the microbial theory of disease, and the belief that manipulation could be used to treat all human diseases.(7,9) In fact, some evidence suggests that Palmer learned his manipulation techniques from Still.(7) In spite of these similarities, osteopathy, unlike chiropractic, evolved over time to become part of conventional medicine.

In modern osteopathic practice, there continues to be overlap between osteopathy and these two other medical systems. An osteopathic physician’s office and practice are indistinguishable from any allopathic physician’s office and practice. Patients come in with the same complaints of sore throats and back pain. However, there is potentially some difference in how osteopathic and allopathic physicians treat patients who present with musculoskeletal pain. This is because an osteopathic physician may choose to use OMT along with or instead of muscle relaxing-drugs.

Upon observing an osteopathic physician perform OMT, I was struck by how similar it is to chiropractic musculoskeletal manipulation. In addition, the osteopathic physician and chiropractor used the same accessory modalities to treat patients with musculoskeletal pain, including heat, cold, and ultrasound. However, this osteopathic physician rarely performs OMT in his practice, in keeping with published reports that only a minority of osteopaths commonly treat their patients with OMT.(10) He pointed out that the current health care system often makes it financially and temporally impractical to perform OMT even when it would be helpful. For example, he is not able to bill many HMOs for OMT. Also, he does not have time to perform OMT when he must book patients every 15 minutes in order to keep his practice solvent.

Thursday, February 26, 2009

CAM Paper Part III: Chiropractic

Chiropractic was defined by Daniel Palmer, its founder, as “a science of healing without drugs.” However, the underpinnings of chiropractic are not rooted in science. In fact, Palmer himself noted that chiropractic ideas could not be researched or subjected to experiments, and he considered chiropractic to be akin to a religion.(7)

The theory behind chiropractic is that disease is caused by spinal subluxations.(7) In medicine, subluxation is the term for a partial joint dislocation. However, this word is used differently in chiropractic, where a subluxation is a more abstract construct that refers to functional or structural changes in the musculoskeletal system. These changes are thought to compromise the integrity of the nervous system, thereby affecting the patient’s organs and health.(8) Palmer furthermore wrote of what he called innate intelligence, which is related to the body’s ability to heal itself. This innate intelligence cannot function properly in the presence of subluxations. Thus, the goal of chiropractic is to detect and correct subluxations via spinal manipulation in order to allow innate intelligence to flow freely throughout the nervous system.(7,8)

Currently, there are two basic camps of chiropractors, the so-called “straights” and the “mixers.” Straights continue to accept the ideas of Palmer, including his theories of innate intelligence, subluxation as the cause of all disease, and spinal manipulation as the cure for all disease. Thus, the straights use only spinal manipulation to treat their patients, and they do not work with conventional physicians. In contrast, mixers view themselves as more of musculoskeletal pain specialists, especially for the treatment of back pain. They use other forms of treatment along with spinal manipulation, and they are more likely to work with the medical establishment. Early in the history of chiropractic, Palmer claimed that mixers were essentially defiling its tenets, but today, mixers comprise the majority of chiropractors.(7)

Spinal manipulation, also called adjustment, is performed by applying a force to a specific joint with the intention of moving vertebrae beyond the normal range of motion, but not far enough to cause damage. These manipulations are believed to break down adhesions in joints, affect mechanoreceptors in the joints, inhibit C-fiber-mediated perception of pain, and/or modulate function of the central nervous system.(7) A clicking sound often occurs during an adjustment as the stuck joint is released.(8)

Most patients who visit chiropractors are self-referred, and many of them come to chiropractors due to the inability of conventional medicine to adequately treat their pain. Chiropractors who are mixers mainly treat chronic pain caused by musculoskeletal problems, especially back and neck pain. Along with spinal manipulation, they may also use heat, cold, electrotherapy, herbal remedies, nutritional supplements, massage, meditation, and other non-pharmaceutical therapies. Mixers may also use conventional diagnostic tools such as radiographs and blood or urine analysis. Compared to straights, mixers are more willing to acknowledge that part or even most of the effect of chiropractic is due to the placebo effect. Unlike straights, mixers are also more willing to accept the idea that immunization is beneficial.(7)

The chiropractor with whom I worked was easily identifiable as a mixer. Along with spinal manipulation, he made use of heat and cold, massage, ultrasound, electrotherapy, and herbal remedies. For example, he recommended echinacea and high dose vitamin C to one patient with bronchitis. In addition, he openly acknowledged that certain conditions were better treated by allopathic or osteopathic physicians, and noted that pharmaceuticals were necessary in some circumstances. In keeping with his general open-mindedness toward conventional medicine, he presented himself as a chiropractic physician, and even stated that he considered chiropractic to be mainstream rather than alternative medicine. Finally, he described the science coursework he had taken in great detail to one of his patients and me, particularly emphasizing his training in physics and biomechanics. If he believed in Palmer’s ideas about subluxations or innate intelligence, he did not at any point indicate that.

The patients whom this chiropractor treated were mainly chronic pain patients. At the beginning of a session, he would test each patient’s range of motion and ask the patient to rate his or her pain level on a scale of 0-10. Next, he would palpate the patient’s vertebrae one by one, asking the patient if there was any pain at each level. Then he would begin adjusting the patient’s spine. Several patients were elderly and had arthritis, especially back and joint pain. These patients were treated with a mixture of lumbar spinal manipulation, heat, cold, ultrasound, and massage. There were also a few patients who had been rear-ended in car accidents and were suffering from whiplash. The treatment for whiplash was similar, except that the chiropractor focused more on manipulating the cervical spine rather than the lumbar spine. At the end of each session, the chiropractor would again ask the patients to rate their pain on a scale of 0-10. In every case, the patient’s pain had diminished, sometimes all the way down to the zero level. The patients generally agreed that the treatments were helpful.

Wednesday, February 25, 2009

CAM Paper Part II: Massage Therapy

Massage therapy (MT) is defined by the American Massage Therapy Association as including manual soft tissue manipulation that can involve holding, causation of movement, and/or application of pressure to the patient’s body; these manipulations must be done for the purpose of improving the health and well-being of the patient. MT can have many forms, with wide variations in duration of treatment, types of touch, apparatus used, and body sites treated. In addition, MT has been studied as treatment for a large number of illnesses and symptoms, including anxiety, depression, pain, rheumatologic diseases, asthma, migraine headaches, MS, PTSD, diabetes, cancer, and even HIV.(6)

Several theories have been proposed to explain why and how MT provides benefit to patients. The most commonly cited hypothesis is the gate control theory of pain reduction, which suggests that the more quickly transmitted pressure stimulus interferes with the slower pain stimulus, thereby decreasing pain reception by the brain. This could explain why MT improves subjective perception of pain. Another common idea is that MT may shift the autonomic system from a predominantly sympathetic state to a predominantly parasympathetic state. Effects of MT like slower heart rate, reduction of stress hormones, and a feeling of calmness could be explained by this theory. Other proposed explanations for the mechanism of MT include increases in serotonin levels, mechanical effects that reduce adhesions and fibrosis, indirect effects via improvement of sleep, and the one-on-one personal attention that occurs during a MT session. This last hypothesis is particularly interesting because it may also explain the efficacy of psychotherapy in improving many of the same symptoms.(6)

Anecdotally, the patients whom I observed having MT were very enthusiastic about its benefits. One patient came to the massage therapist because of a sinus headache. She stated that the treatment improved her symptoms of sinus pain and pressure, as well as decreasing the bags under her eyes. The therapist treated her by applying deep pressure with a circular motion over the patient’s ethmoid, maxillary, and frontal sinuses. She also manipulated the patient’s facial skin by using shallower touch and applying a cream. Throughout the treatment, the therapist spoke with the patient, explaining what she was doing and even telling us about her personal theories concerning how MT works. Furthermore, the atmosphere in the room promoted relaxation with soft lighting, plants and pictures suggestive of a natural setting, a warm massage table, and aromatherapy.

Tuesday, February 24, 2009

CAM Paper Part I: Introduction

Complementary and alternative medicine (CAM) can be defined as a diverse group of therapies and products that are not considered to be part of conventional medicine. Patients may use CAM to treat a wide variety of conditions, including back problems, colds, neck problems, joint pain, anxiety, depression, rheumatologic problems, digestive problems, chronic pain, insomnia, and other chronic conditions.(1)

Currently, CAM is very popular with patients. A national health interview survey found that in 2002, 36% of American adults had used some form of CAM within the previous 12 months, not including prayer. According to the survey, the most common non-prayer CAM modalities used by patients included natural products, deep breathing exercises, meditation, chiropractic, yoga, massage, and nutritional therapies. Interestingly, prayer for improved health, performed either by the patient or by others on behalf of the patient, was by far the most commonly used form of CAM. Inclusion of prayer as a CAM modality increased the percentage of adults using CAM in the past 12 months to 62%, and the percentage using CAM at any point in their lives to 75%. The popularity of CAM may stem at least in part from patient dissatisfaction with conventional treatments for chronic conditions such as pain.(1)

Multiple surveys suggest that physicians, medical students, and other healthcare providers have limited knowledge about CAM, although some studies have found that physicians would like to learn more about CAM.(2-4) In addition, physicians tend to have more negative attitudes about CAM compared with other healthcare providers like nurses and pharmacists.(3) There is some evidence that the attitudes of medical students toward CAM tend to become less positive as they get further along in medical school and become more entrenched in the conventional medicine model.(5) This may help explain why only about one quarter of surveyed patients reported that they had tried CAM because their physician had suggested that they try it.(1)

Unfortunately, patients themselves are often misinformed about CAM.(1) The rise of the internet has generated a confusing information overload, much of which can mislead patients and possibly even harm their health.(2) Patients commonly self-medicate with CAM and often do not tell their doctors or pharmacists about the nutritional supplements and herbal remedies they are taking.(1-3) Furthermore, physicians opposed to CAM may overstate the case that all CAM is useless, while practitioners of CAM may overstate the curative powers of CAM or claim that the medical establishment wants to suppress CAM.(2)

As a result of the proliferation of misinformation and lack of reliable information about CAM, patients often hold misguided beliefs about CAM therapies.(2) For example, many patients believe that “natural” equates with “safe.” However, herbal remedies and other natural products may interact with prescription drugs, as well as have toxic effects of their own.(2,3) In addition, many patients believe that using CAM therapies will save money. However, the few studies done on this subject suggest the opposite, namely that use of CAM increases costs for healthcare compared to conventional healthcare alone.(2)

This paper will review some of the more popular forms of CAM, including both the theory and practice of these therapies. It will not be possible to cover every form of CAM that patients might discuss with their physicians. However, my hope is that this paper will be a good starting point to help educate current and future healthcare providers about CAM. Although prayer for improved health is the most common form of CAM, it will not be covered here in order to focus in greater detail on several of the physical and chemical CAM modalities that are popular among patients.

Monday, February 23, 2009

Complementary and Alternative Medicine

This week, I started an unlisted elective in complementary and alternative medicine (CAM). An unlisted elective is one that is not listed in the Case elective course catalog. With the school's permission, you create it yourself. The impetus for me to want to study CAM was that I have had multiple patients in clinic asking me about herbal remedies, acupuncture, and the like. I have to admit that I am woefully ignorant about these subjects, and so were many of my attendings. Even though some doctors think that alternative medicine is bunk, my experience is that a lot of patients believe in it, so I thought I should at least understand a little about it.

For the elective, I am reading a book about herbal remedies used for various purposes and some articles about the history of alternative medical systems like osteopathy and chiropractic. I am also spending some time shadowing an osteopathic physician (to see manipulation), a chiropractor, an acupuncturist, a massage therapist, and an herbalist. At the end, I will write a ten-page paper about all of these alternative therapies. Since so many people are interested in CAM, starting tomorrow, I will post each section of the paper online, including my references.

For those of you who want to learn more about CAM, please keep in mind that there is a lot of biased and self-serving misinformation about CAM out there on the internet. (Actually, there is plenty of misinformation about medical topics in general, but it's especially problematic for CAM.) If you would like to consider using CAM therapies for your own health care needs, I recommend that you discuss CAM with your physician. In addition, you should educate yourself about CAM by only visiting websites that provide reliable, evidence-based information for consumers.

One of the best sites I've seen is hosted by the National Institutes of Health (NIH). NIH is a government research organization that funds much of the medical research done in the United States, including clinical trials. You can find a great deal of reliable information about many types of CAM by visiting the NIH's National Center for Complementary and Alternative Medicine webpage.

Friday, February 20, 2009

Done with Preventive Medicine

After a small snafu with getting my answers uploaded, I was done with the online test by Monday night. It's pretty much all about hypertension. My advice for other Case students taking this elective is to only read the module on hypertension and then do the test. The other modules are not very helpful for answering the test questions. It's also not necessary to read all of the linked additional readings.

I hope it doesn't sound like I think this elective is fluff just because it wasn't organized the most efficiently. Actually, it helped reinforce some things I had learned in my medicine rotations, which is good because preventive medicine is covered on Step 2. Plus, I learned a few new things too, the most surprising of which is that there is conflicting evidence about the utility of restricting salt intake in hypertensive patients.

Even if the effect of restricting salt intake on blood pressure is small, it's probably still a good idea to encourage people to eat less salt, because American diets are ridiculously high in sodium. But getting patients to restrict their salt intake is very difficult, because there is a lot of salt in just about every processed food in existence. Try looking at some nutritional labelings on the packages even for sweet things like tomato sauce and cookies the next time you're in the supermarket, and you'll see what I mean. It doesn't help that food without salt tastes bland to most people, either.

Friday, February 13, 2009

Phlebotomy and Online Preventive Medicine

On Tuesday, I took an optional day-long course at CCF to learn how to draw blood. It was free, and phlebotomy seems like a useful skill to have, so I figured why not. There were four of us who did it. First, we were shown the different types of needles and tubes for collecting blood. Then we each went out with a phlebotomist to draw blood on actual patients. Each time you draw blood, it is called a "stick." We had to get eight sticks to be certified. My phlebotomist didn't have very many patients on his list, but two of them let me draw their blood and I got them both on the first try. Then I got my last six sticks on some of the other phlebotomists who were coming in to change shifts. There was one I couldn't get, but I thought getting 7 out of 8 sticks was pretty good for a novice like me!

I'm doing an online elective this week and next week so that I could go out of town. It's on preventive medicine, and there are a bunch of modules we are supposed to read, followed by an online test that we have to take. The online test has 31 questions, which looked pretty scary until I realized that the first 15 are in groups of five that go together, and the last 16 are in pairs with one multiple choice and one essay. It's going pretty fast. I already am pretty much done with the whole test. The modules are another story. They are really long, and they have different reports and articles linked to them. It would take a lot longer than two weeks to read them all, so I decided to start working on the test and then just read the relevant parts of the modules as I went along. That made things a lot more efficient.

We had an afternoon seminar today on biomarkers, which I missed since I'm not there. I can't say I'm terribly broken up about this. :-)

Friday, February 06, 2009

Last Week of Toxicology

This was my last week of toxicology. We each had to give a 40-minute presentation today. Mine was on alcohol withdrawal. It turned out to be a really good topic, since I had at least one alcoholic patient on my medicine rotation who we thought might be having withdrawal. The problem with hospitalizing alcoholic patients is that since they can't get a drink in the hospital, they can start going through withdrawal a day or two after they get admitted. Alcohol withdrawal is a serious problem, and it can kill the patient. The worst symptoms come with delirium tremens and include seizures, delirium, hallucinations, nervous system dysfunction, and electrolyte disturbances. Of course, fortunately not all patients get delirium tremens. But the ones who do need supportive care.

I also gave a brief presentation yesterday about absinthe, which is a drink made from wormwood extract. It is said that the artist Vincent Van Gogh was under the influence of absinthe when he cut off his ear. There are several alkaloids (chemicals) in wormwood that could cause the symptoms of "absinthism" (seizures, hallucinations, problems walking). But it turns out that the major ingredient in absinthe is alcohol! No wonder these people were stumbling around like drunks and hallucinating. They were alcoholics! It is still not legal to make absinthe in the United States, but they do have it in Europe.

Next on the agenda is preventive medicine, which is an online elective that is really an excuse for me to get out of Cleveland for a couple of weeks.

Wednesday, February 04, 2009

An Artificial Asthma Attack

Over the last couple of weeks, I've been getting increasingly short of breath while walking. Now granted, I'm not currently in nearly as good of shape as I was before med school, but I'm still in good enough shape that I should be able to walk a mile without getting short of breath!

So I went to the doctor, and I ended up getting some lab work, a chest x-ray, an echo, an albuterol inhaler, and an appointment for lung function tests. These tests measure how much air you can inhale and exhale by having you breathe a full breath of air in and out of a machine with your nose pinched shut. The machine measures the speed and amount of air you're moving.

Today was the day that I took the lung function tests. One of these tests is called a methacholine challenge, and its purpose is to see if the patient has asthma. How, you may ask, is the test performed? Well, the patient inhales a drug (methacholine) in periodically increasing amounts. After each dose, they have to keep inhaling and exhaling air into the machine to measure their lung function. Meanwhile, the tech administering the test watches to see if the patient's airways close up enough to diagnose them with asthma.

When I tried it, the first few doses weren't that bad. By the fourth dose, my chest was starting to feel a little tight. The fifth dose was absolute agony. The woman giving me the test asked if I thought I could still hang on long enough to inhale and exhale into the machine. I felt like I was seeing stars a little, but I nodded and did what I could. She then gave me albuterol, which is a medication that opens the patient's airways again. If they have asthma, this should lead to a recovery of lung function to the level it was at before starting the methacholine challenge.

Inhaling that albuterol helped me tremendously. It also made my heart start pounding (side effect), but being able to move air in and out of my lungs freely was more than worth a few palpitations. When the entire test was over, the tech showed me the graph of my lung function test, which was textbook beautiful for asthma.

Now that I've been officially diagnosed with asthma, I have to start using an inhaled steroid and taking a pill, both for prophylaxis. In other words, these medications won't stop an asthma attack that is already taking place, but they will prevent future attacks. I'll still have the albuterol inhaler to use in case I have more attacks.

The most indelible impression that this test made on me is that I will never order a methacholine challenge for a patient unless I think it's absolutely necessary. Feeling like you can't breathe is extremely unpleasant.