Integrative medicine in rehab - PowerPoint Presentation

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Integrative medicine

in rehab

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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.

Alternative medical

systems

Mind-body

interventions

Biologically based

therapies

Manipulative and body-based

therapies

Energy therapies

Slide3

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.

Slide4

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.

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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

.

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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.

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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

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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.

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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.

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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

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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.

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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

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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

.

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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.

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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

.

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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.

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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)

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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.'

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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

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Camphor (

Cinnamomum

camphora

)

A topical cream containing camphor, glucosamine

sulfate, and

chondroitin

sulfate was found to provide

reduction in pain due to osteoarthritis

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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

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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.

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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

Slide23

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

.

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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

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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

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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

.

Slide27

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

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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:

there are very few high-quality studies;

there is some evidence for the effectiveness of manipulation and mobilization for neck pain;

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.

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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.

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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.

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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

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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

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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.

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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)

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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.

Slide42

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

Slide43

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).

Slide44

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.

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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.

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Slide48

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

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Slide50

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

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Slide52

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

Slide53

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.

Slide54

Masuleh-Gilan