Integrative Medicine at the Hospital for Special Surgery

Complementary and alternative medicine, now frequently known as CAM, is the term to describe an array of medical practices and beliefs that vary widely. By default, they have been defined mainly by their exclusion or alienation from the dominant (conventional) forms of Western medicine. Various forces, however, are beginning to erode this alienation, and CAM - as a unique domain of medical practice - is becoming increasingly accepted in conventional medical circles.

The Integrative Care Center at the Hospital for Special Surgery is a new institutional endeavor. Its mission is to add CAM to the range of services offered at our hospital. It mirrors the development of similar programs at other hospitals across the country. Interestingly, the stimulus for this change has not been by the usual route for the development of new fields in medicine. Historically, innovations in medicine have resulted from an endorsement by the hierarchy of medicine, i.e. from the top down. In CAM, the very opposite has occurred. In a bottom-up fashion - through patients expressing interest in the field - conventional medicine has indeed responded to the public's growing demand for alternative forms and styles of medicine.

Major surveys have shown how substantial the interest in CAM is: from 1990 to 1997, the reported utilization of CAM grew from 25% to 42% in the U.S. Herbal remedy use increased by 380%; high dose vitamin use increased by 130%; and visits to CAM providers actually exceeded the number of visits to primary care physicians. (Unfortunately, most people surveyed had not shared this information with their physicians, nor had their physicians asked about CAM use) Thus, the medical profession is gradually getting the message that there is something here that merits our attention.

As a further index of the acceptance and recognition of CAM, approximately 75% of medical schools offer courses, often mandatory, on its principles. There are a few advanced programs, such as Dr. Andrew Weil's center in Arizona, where a physician trainee can elect to become a CAM medical specialist. Such educational developments will have an important role in inculcating these concepts in the next generation of physicians, many of whom already have more open minds about these therapies.

Why the great interest from patients? Certainly, there has been some dissatisfaction with traditional medicine. On some levels, the advances of traditional medicine have been extraordinary, but the one-to-one style of CAM practice is a throwback to an era that is longed for by many people - an approach that is slower, more thoughtful, more preventive in its focus. There has been dismay that high tech medicine brings into your life a cast of professionals who do not have the degree of investment in you that your physician has, thereby making your care very impersonal. Thus, traditional physicians may have a lot to learn from the style of CAM

However, as we go forth, the scientific rigor that has defined the development of new therapies in traditional medicine is going to be brought to bear on the unconventional healing practices of CAM. This involves evidence-based medicine for physicians, in which we seek to document with evidence both the effectiveness and the safety of these therapies. Such scientific literature already exists for some, such as acupuncture, but much more needs to be done in the study of these unconventional therapies.

What Constitutes CAM?

Several broad categories of medical practice constitute unconventional medicine of CAM. The greatest public interest is in the well-recognized professional CAM systems, which include such fields as Chiropractic Medicine, Acupuncture, Massage Therapy, Homeopathy, and Naturopathy. In addition, there is the domain referred to as "popular health reform," which revolves around lifestyle and dietary considerations. So-called "New Age" healing and mind-body medicine includes such techniques as relaxation therapy and biofeedback.

In fact, mind-body medicine is one of the better studied areas and has considerable literature supporting its usefulness in treating people with arthritis and pain syndromes. Thus, there is a quasi-scientific foundation for its usefulness based on medicine suggesting that these psychological approaches, acting in concert interact with the immune system, may alter the immune response - and, in so doing, modify the inflammatory response mediating such conditions as rheumatoid arthritis.

Here's a brief look at the professional systems.

• Chiropractic Medicine has been kept outside of hospitals for many years, largely because of fears by physicians about the danger of one particular practice - manipulation of the spine. However, public support for this profession is testament to the benefits of this therapy.
  
  
• Acupuncture uses fine needles or simply pressure applied to points on the body that were mapped thousands of years ago. This is believed to promote health and treat pain. We have three acupuncturists at the Integrated Care Center - two of whom are also board certified in internal medicine.
  
  
• Homeopathy, founded in the 19th century, employs the principle of "like cures like" in which a substance that produces a set of symptoms in a healthy person is used to treat the same symptoms in a sick person. However, the remedies used are highly diluted - so much so that when they have been analyzed for the presence of the active ingredient, it is often not found. Traditional physicians have the most difficult time with this form of alternative medicine because it is totally contrary to conventional pharmacological principles. In order to embrace this, a physician would have to abandon the rational principles of medical training.
  
  
• Naturopathy focuses on herbal therapy, nutritional supplements, dietary manipulation, and lifestyle advice. What is now called herbal medicine may be the largest of all the fields of CAM, if you consider how many dollars are spent on vitamin and dietary supplements.
  
  
• Massage is fairly self-explanatory. It is one of the manipulative types of professions, somewhat like chiropractic medicine and what osteopathy may have been like years ago. It also overlaps in some ways with traditional physical therapy, such as the Feldenkrais and Alexander methods.

The following comments were in response to questions from the audience.

• Fasting - The few studies that have been done about fasting have shown it not to be as effective as original anecdotal reports suggested. When scrutinized scientifically, the suggestion that a fasting diet has any long-term effect does not hold up, although there do seem to be some short-term improvements in symptoms. Of course, it has a practical problem because you cannot fast long term. Further, people with chronic inflammatory diseases like rheumatoid arthritis actually have enhanced nutritional requirements. A persistent inflammatory process tends to utilize nutrients and, in order to optimize healing of inflammation, one needs to have reasonable nutritional balance. I would be uneasy about recommending fasting to treat a potentially debilitating chronic disease.
  
  
• Multiple Modalities - Another feature of CAM, and a more challenging perceptual aspect, is the concept of bringing multiple modalities to bear on a problem. When you go to an alternative medicine center, you usually experience multiple approaches. For example, you may be put on a fasting diet, but you also may be given education about your disease, massage or physical therapy, and herbal treatments. Discerning what in that array of therapies actually provides the benefits you may experience is hard to tell.

That brings up a problem with the traditional medical approach to investigation, which is to reduce it to its most basic set of choices - such as new drug vs. no drug or new drug vs. old drug - since, in fact, that is not the way people operate in the real world nor the way traditional medicine operates. A problem might be sequentially treated with an oral medicine as well as physical therapy and massage. When benefit occurs, the person may think it's the last modality that did it - but it may actually be due to an interaction of different modalities

For example, at the Integrative Care Center, we have found, in patients with shoulder problems, that those who had received a massage prior to standard physical therapy were better primed to receive and benefit from physical therapy. They had a more supple joint, achieved a great deal more in the session, and needed fewer sessions. So we are interested in studying the interaction of multiple modalities. Indeed, we call it the Integrative Care Center because we want to see how these therapies interact with each other and with traditional medicine - and how that might lead to faster resolution of problems.

• The Integrative Care Center - People can come to us on their own or by referral from their healthcare provider. While most come to a specific practitioner, such as a massage or physical therapist, others are referred to me or to Dr. Charis Meng - both board-certified rheumatologists - for an assessment. Then, we discuss with the person what services might be appropriate.
  
  
• Insurance coverage of CAM is still very thin, although a few companies such as Oxford offer some coverage. Insurance companies have discovered that, on balance, people who use CAM are healthier than the rest of the population and, in the end, those patients cost them less. The reason such individuals are healthier probably goes beyond whether they use alternative medicine and is most likely due to the fact that they are oriented to good health.
  
  
• Herbal Risks - As alternative medicines become more widely used, we learn more about them. On a cautionary note, we have increasingly learned that herbal therapies have adverse effects just as traditional medicines do. For example, a striking condition known as eosinophilic fasciitis was discovered to be a consequence of L-tryptophan when it became very popular, and it had to be taken off the market. A number of other herbs have been shown to have adverse effects. Further, just as traditional drugs may have negative interactions with each other, herbs may interact with drugs as well as each other. Thus, there is an increasing realization that herbs also have problems with them, just as traditional drugs do.
  
  
• Glucosamine and chondroitin - There has been considerable misunderstanding about these dietary supplements. Glucosamine is a sugar that is a constituent of connective tissue, which is the main tissue that makes up joints. It is a natural substance that gets incorporated into cells and stimulates the synthesis of proteins that make up cartilage. However, it is not useful in inflammatory arthritis, such as rheumatoid arthritis. All the studies that have been done are in osteoarthritis, and there has never been ever any suggestion that it might be useful in RA. Indeed, the NIH now has a large center devoted to alternative and complementary therapies, and glucosamine is one of the entities under study for - although only for osteoarthritis.

Chondroitin is added to some glucosamine preparations. Chondroitin exists in joints naturally. It is thought to draw fluid into the joint and hydrate it to make the tissue a little more pliable and slow its breakdown. It's not clear that chondroitin adds anything to glucosamine's potential benefits, although conceptually it seems to be a good idea. But, again, it is of no benefit in rheumatoid arthritis.

• SAM-e is a naturally occurring amino acid called methionine. It is believed to improve joint mobility and pain via a complicated mechanism that has been looked at scientifically
  
  
• but only in osteoarthritis. It does not have a role in rheumatoid disease.

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