Category Archives: Integrative medicine

Chronic Low Back Pain: Regular Massage Actually Helps

Back pain is one of the most common medical complaints in the world, and too often it is very difficult for us family doctors to find the best treatment. We will take the occasional x-ray which never shows anything; prescribe pain pills we hope won’t over-sedate them, and pray that their body’s natural healing process kicks in. Unfortunately, a small percentage’s pain never completely goes away, and back pain becomes an irritating/debilitating part of their life. It’s frustrating for patients and their doctors.

Perhaps there’s a very simple answer to every doctor’s treatment plans: massage! This may seem obvious to many people, but most docs thought that massage’s effects were very short-lived. Now, I’m happy to report that perhaps massage does have long-lasting effects on people with chronic back pains. This is due to a new study, just published in the Annals of Internal Medicine, which studied three groups: a control group; one group getting relaxing massage; and a third getting more aggressive “structural massage”. The NY Times Health Section, as usual, does such a good job that I’ll just quote them:

Those who received massage scored significantly better on both symptom and function tests, and they spent less time in bed, used less medicine and were more satisfied with their current level of back pain.

At 26 weeks after treatment, those in the usual care group continued to function less well than those who had gotten massage. But there were no significant differences in the pain scores in the three groups, either at 26 or at 52 weeks.

Daniel C. Cherkin, the lead author and an epidemiologist with the Group Health Research Institute in Seattle, mentioned some of the study’s considerable strengths. It had a randomized design, a high follow-up rate, good adherence to the treatment and a large sample size. Still, he said, the study was done on a mostly white, middle-class population in otherwise good health, which may limit its applicability to other groups. The study appeared online Monday in Annals of Internal Medicine.

It is unclear how massage eases back pain, but the researchers suggest it may stimulate tissue locally or cause a more generalized central nervous system response. It is also possible that just spending time in a relaxing environment or being touched and cared for by a sympathetic therapist could have led to improvement. Also, those in the control group knew that the other groups were getting massage, and the knowledge that others were getting the treatment while they got none may have led them to underestimate their own progress.

Still, the researchers conclude that massage has few adverse effects and is a reasonable treatment for low back pain. There is no evidence, though, that it lowers the cost of health services related to back pain.

“We tested this on people who had not been getting better from the usual medical approaches, Dr. Cherkin said. “If you’ve tried other things and you’re not getting adequate relief, then massage is a reasonable thing to try.”

So there you have it; a simple massage once a week can help your overall quality of life with chronic back pain. Note how while there was no major difference in pain levels, the patient’s satisfaction rates were higher — as well as medication use.

Another good take-home message is that a more aggressive, Chinese-style massage was as effective as the more sleepy, Swedish-oil relaxation style massage. I vastly prefer the invigorating Chinese massages but actually wasn’t sure if it would make back pains worse or better — and now I know.

In my practice, I will no longer be hesitant when recommending massage to my back pain patients. Such is the power of good studies; they can quickly change medical practice.

Naturopathic Medicine: A Holistic View of Health

I’m happy to announce that naturopathic doctor Melissa Rodriguez is now offering her services here at the International Medical Center. What is naturopathic medicine, you may ask? Here’s Melissa’s excellent review:

These days many people know about the availability of natural medicines like herbal remedies, homeopathy, and the use of vitamins and minerals to treat and prevent disease. However, not many people are aware that there is a profession that is highly specialized in the use and prescription of natural medicines. A naturopathic doctor (N.D.), or naturopath, is very well educated when it comes to the appropriate use of nutritional supplements, herbal remedies, and other alternative treatments. Naturopaths are also knowledgeable about interactions between drugs and natural medicines. You might be asking yourself, what exactly is naturopathic medicine? How do I recognize a formally trained, licensed naturopath? And what can naturopathic medicine do for me? Let’s begin with a brief synopsis about the origins of naturopathic medicine.

History

Naturopathic medicine has been around in its primitive form since pre-historic times. In those days there was likely a “healer” in the village or a wise elder who knew what herbs and plants were useful for what condition. They were also aware of which foods were beneficial for which maladies; and what foods to avoid when ill. All ancient cultures have their traditional healing wisdom, the Persians, Native Americans, East Indians, Chinese… The list goes on and on. Hippocrates, a Greek physician who is considered by many to be the father of modern medicine, described the concept of “the healing power of nature” almost 2500 years ago.

Naturopathic medicine as it is known today developed in Europe in the late 1800’s before coming to North America. Dr. Benedict Lust popularized the term “naturopathy” and used it to describe a medical practice using herbal remedies, homeopathy, acupuncture, nutrition, lifestyle counseling and manipulative therapy. In the early 1900’s he opened many naturopathic colleges and healing centers in the United States. Naturopathic medicine flourished in North America until antibiotics and surgery took centre stage during the 1930’s and 40’s. This trend continued until the last few decades, when people began to look for alternatives to conventional medical treatments.

Philosophy

Treating the root cause of disease is the fundamental purpose of naturopathic medicine. A visit with a naturopathic doctor takes a long time, because many aspects of a person must be studied, their diet, lifestyle, medical history… Everything must be considered in order to understand the underlying cause of disease. The goal is not to treat the symptoms, although at times the symptoms must be alleviated. The goal is to find out the why, not just the what. Like a detective, a naturopathic doctor must put all the clues together to discover the cause. For example, why does this individual suffer from migraines? Could it be a reaction to stress? Perhaps a trigger in the environment, or maybe an unknown food sensitivity? While relieving the pain is important, to treat the cause is imperative in order to prevent further migraines from occurring. Thus the cause and therefore the prescription will be unique to each individual.

One of the most important principles of naturopathic medicine is that the body has the innate ability to heal itself. We see this phenomenon in everyday situations, if we get a cut or a cold, our body will naturally heal the wound and eventually cure the cold. This is true for most people and in most situations. A naturopathic doctor uses natural medicines to help the body heal itself. Naturopathic treatments can give the body that extra boost it needs to heal faster and more efficiently. For example, if a person’s body is too weak to handle a simple cold, complications can arise such as secondary bacterial infections. These become harder for the body to treat by itself. If natural medicines that support the immune system are given, we can potentially avoid complications like bronchitis or pneumonia. There are also extreme situations in which the body is struggling to heal itself, for example when someone has a disease like cancer. In this case, natural medicine can help strengthen the body and counteract the side effects of conventional therapies like radiation or chemotherapy.

Education

To become a licensed naturopathic doctor one must go through a long and rigorous process that is both challenging and extremely rewarding.

Naturopaths must first receive a university Bachelor degree and complete certain pre-requisites such as biochemistry, anatomy and physiology. Then they apply to a naturopathic college that is accredited by whatever organization is responsible for that country. In Canada it is the Council on Naturopathic Medical Education (CNME), which is recognized by the US Department of Education. The naturopathic program is 4 years and is very intense. Courses include histology, embryology, and immunology, as well as pharmacology and other medical sciences. The naturopathic component includes botanical medicine, nutrition, traditional Chinese medicine, and homeopathy. There is also one year of clinical experience. By the time someone graduates from a naturopathic college they would have completed over 4200 hours of classroom and clinical training.

The next step to become a licensed N.D. is to successfully complete the licensing exams. In the US and Canada these are administered by the Naturopathic Physicians Licensing Examinations (NPLEX). After this process is complete, an ND must continue learning in order to maintain their license. The science of natural medicine is constantly being developed, so continuing education is critical to stay current and well informed.

The Naturopathic Advantage

Naturopathic doctors are trained primary care providers who can help a person optimize their health through diet and nutritional supplements. They empower and educate their patients, helping them make healthier choices. They can also treat disease, from acute conditions like ear infections to chronic conditions like Alzheimer’s. The methods they use are gentle and many have stood the test of time, some still being used after thousands of years. Naturopaths are also trained to recognize when to refer a patient. This is important because there are times when the perspective of a different professional is needed, when further investigations are warranted, or when natural medicines are not enough. A naturopathic doctor is your best resource to find a healthy balance between natural and modern medicine.

Traditional Chinese Medicine For Dummies

Many of you may share my interest in traditional Chinese medicine (TCM) but, like me, have trouble finding good resources to educate ourselves. I just finished a new illustrated book which makes learning about Chinese medicine almost fun. Almost. It’s called The Illustrated Book of Traditional Chinese Cultivation of Health. I recommend it as good starter material for anyone interested in TCM. Here’s the publisher blurb:

This is the first illustrated book ever published in English about the basic theories of traditional Chinese medicine (TCM).
It is concise, yet vivid, and easy to comprehend. Filled with hundreds of lively illustrations, Zhou Chuncai introdues the subject systematically, comprehensively and enjoyable, guiding the reader step by step through the enigmatic world of TCM.

The book covers:

  • Theories of Yin-Yang and Five Elements, the Basic Theories of TCM
  • Doctrine of Visceral Manifestions
  • The Basic concepts of Qi, Blood and Body Fluid
  • Pathogenic Factors in TCM
  • Treatment based on syndrome differentation
  • Eight Therapeutic methods in Chinese medicine

It’s As Easy As It’s Going To Get…

Readers are probably familiar with the Dummies series of books which for two decades have provided simple how-to guides for hundreds of topics. So you can consider this book as a “Dummies Guide to TCM”. It covers all the basic theory, as well as more practical issues of which famous medicines work for what diseases. The very cute illustrations make this far more readable than any other text I’ve seen on TCM, and studying TCM literally probably can’t get any easier than this. But honestly that isn’t such high praise, as it’s still very difficult reading, and understanding TCM is never easy.

After finishing this book, I must confess that I still have almost no deep grasp of TCM theories. The illustrations help a lot, but the underlying structure remains completely obscure to me. More importantly for me, I am less inclined than before to think of TCM as a serious approach to health. It’s elegant and poetic and provides nice basic instructions on good health, but the underlying scientific basis for almost any of it remains unproven. After reading this, I feel fairly done with my attempts to understand TCM. I’ve tried, and I’ve researched, and I am more comfortable than ever that TCM has little to add to my medical practice. I still will continue my attempts to find herbs that work.

Where To Buy

It’s only available in China now, but you can order it for $10 plus international shipping from the English language site Mandarinbooks.com.

Acupuncture: What’s It Good For — Or Not?

One of my continuing goals while working as a doctor in China is to find traditional Chinese medicines and practices that I can integrate into my Western, allopathic-style family practice. As I’ve reported a few times, I’ve been struggling to find Chinese herbal medicines that I am comfortable prescribing, usually due to lack of evidence for a clear benefit.

As for acupuncture, there are actually a lot more well-designed studies done on this field when compared to Chinese herbs, mostly because Europe and the West have become very interested over the last couple decades and are funding better clinical trials. The evidence trail is building, which is great for everyone. So, what works, and what doesn’t?

The New York Times has a very readable article last month which covers this issue. The gist of the article discusses the most recent, well-designed studies on back pains and other disorders; the studies usually show no difference between acupuncture and placebo (usually a “sham” needle that doesn’t penetrate the skin). In other words, the best studies lately are usually showing that most of the perceived effect from acupuncture is simply a placebo effect.

These recent findings are by no means surprising, as most of the best studies have been reporting similar conclusions for many years. The best collection of acupuncture research is from the Cochrane Review Group, which performs the world’s most rigorous reviews of all treatments, including alternative medicines. They have an outstanding collection of the best literature on acupuncture which details the best evidence regarding a number of acupuncture treatments. Unfortunately, as many other researchers have noted, the only treatments for which acupuncture is even mildly effective are for musculoskeletal problems and nausea. There is some evidence of effectiveness for treatments for IVF, as well as insomnia. But many well-designed studies have specifically shown no benefit over placebo for a host of other treatments. The Cochrane group also commonly finds that the quality of studies is very poor and cannot recommend either for or against.

Readers should be aware that this is not simply a Western bias against alternative medicines; in April a group from Beijing Hospital published in a  Chinese journal a similar literature review of acupuncture for insomnia, and couldn’t even make a conclusion because the studies were so poor:

Regarding the assessment of the therapeutic effect, measuring scales are often adopted in overseas studies, while in domestic researches, self-drawn standards are frequently used. In conclusion, there have had no high-quality clinical trails about acupuncture treatment of primary insomnia in China at the present, and the related evaluating methods could not definitely confirm the efficacy of acupuncture in relieving insomnia. Therefore, a strict and scientific clinical trail scheme being in line with evidence-based medicine is urgently needed in the coming studies on acupuncture treatment of primary insomnia.

The Cochrane’s reports cover a lot of therapies that I’m sure many readers have tried. Here’s an example of Cochrane’s findings on the most common acupuncture treatment — low back pain:

Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and “alternative” treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.

For depression:

“…Thirty trials, and 2812 participants were included in the review and meta-analysis, however there was insufficient evidence that acupuncture can assist with the management of depression.”

For migraines:

In the four trials in which acupuncture was compared to a proven prophylactic drug treatment, patients receiving acupuncture tended to report more improvement and fewer side effects. Collectively, the studies suggest that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists.

For insomnia:

Seven studies were eligible for inclusion in the review, involving 590 participants. The studies were of low methodological quality and were diverse in the types of participant, acupuncture treatments and sleep outcome measures used, which limited the ability to pool the findings and draw conclusions. Currently there is a lack of high quality clinical evidence supporting the treatment of people with insomnia using acupuncture. More rigorous studies are needed to assess the efficacy and safety of various forms of acupuncture for treating people with insomnia.

Other reputable sources of evidence include the National Center for Complementary and Alternative Medicine. Also, the excellent evidence-based blog The C.A.M. Report has a section on acupuncture studies. Another blog, Science-Based Medicine, has a section on acupuncture. And I’ve started to read a couple of recently published books which also take a rigorous, evidence-based review of alternative medicines, and I recommend them to my readers. One is called Trick or Treatment: The Undeniable Facts About Alternative Medicine; the other is called Snake Oil Science: The Truth About Complementary and Alternative Medicine. Both can be downloaded via Amazon.com as an e-book. The New England Journal of Medicine has a book review of Trick or Treatment.

Does It Even Matter What The Science Shows?

Many readers may remark that complementary medicine, even if it is just a placebo effect, is still better than nothing. And I think that’s partly true; the placebo effect is simply a person believing and hoping they will get better. It’s an amazing and profoundly humbling revelation that simply believing in healing can set off a biochemical cascade which can boost your immune system and help your body to heal itself. The placebo effect is proven time and again in every study ever done. It’s called faith, and it’s crucial in any illness and is crucial just for living. Here’s a nice quote from the New York Times article:

…acupuncture believers say it doesn’t really matter whether Western scientific studies find that the treatment has a strong placebo effect. After all, the goal of what they call integrative medicine, which combines conventional and alternative treatments like acupuncture, is to harness the body’s power to heal itself. It doesn’t matter whether that power is stimulated by a placebo effect or by skillful placement of needles.

“In general in integrative medicine, when patients are involved in their healing process, they have a tendency to do better,” said Angela Johnson, a practitioner of Chinese medicine at Rush Children’s Hospital in Chicago who is conducting a pilot study of acupuncture to relieve pain in children. “I believe that’s part of the reason why they get better.”…

But one of the problems of relying on alternative medicines (which probably are a placebo effect) would be that you are losing valuable time in getting proper, effective treatment for something which may be serious. Also, you will potentially be spending a lot of your personal money for treatments no better than a placebo.

My Bottom Line

I personally feel that if a patient wants to try acupuncture for musculoskeletal problems like back pains, then they are welcome to try. It’s usually very safe, and sometimes can help; it’s also an interesting experience to do at least once. For almost all other treatments, I would try to pull up Cochrane Database evidence for such treatment and show my patients, and let them make their own decisions.

Hopefully by now, my long-term readers are convinced that evidence-based medicine is the most proper method of testing therapies, and that all treatments of any culture’s medical systems should be tested and proven with rigorous clinical trials. So, I hope we are all open-minded enough to believe that when the best trials show no benefit for a specific treatment — whether mainstream or alternative — then doctors shouldn’t recommend that, and consumers should think twice before wasting their money on it. On the flip side, doctors such as myself should be open-minded and recommend alternative treatments that are proven to work. There just aren’t that many…yet?

Complementary Medicine: Here's How To Find The Best Data

There are so many complementary treatments out there, it’s simply impossible to keep up. As an allopathic, Western-trained doctor, I have enough trouble keeping on top of my family medicine literature, so I have even less time to learn about other types of medicine. So, I’ve developed my own screening techniques to weed out good from bad. I’ve mentioned this subject before, but I’d like to mention a nice summary from the good consumer website, Mayoclinic.com. They have a nice review article that helps consumers fine-tune some critical analysis (Alternative medicine: Evaluate claims of treatment success). One crucial element is trying to see through a website’s promotions to find real evidence of effectiveness. There are a lot of red flags: big promises; guarantees and money-back offers; and my favorite red flag, testimonials:

Testimonials. Anecdotes from individuals who have used the product are no substitute for scientific proof. If the product’s claims were backed up with hard evidence, the manufacturer would say so.

So, if you see any website with big top banners linking to testimonials andnot to research/evidence, then forget about that product. A testimonial is scientifically worthless; that patient could simply be one of the ~30% of people who benefit from the placebo effect of any pill.

As for my favorite websites, I like:

Detoxify Your Body: The Basics

The following article is written by guest author Dr. Melissa Rodriguez, N.D. Her website address is www.drmelissarodriguez.com

For many expats, living in a busy metropolitan city has many advantages. Benefits include exposure to a different language and culture, a plethora of delicious foods to excite the palate, and the chance to live unique, life altering experiences. However, there is also one major disadvantage, namely our exposure to pollution and toxins. Thankfully our bodies can deal with these unwanted substances through a process called detoxification.

Modern World, Modern Issues

It seems that “detox” is quickly becoming one of today’s top health related buzz words, but the fact that our bodies are capable of cleansing our system of toxic materials is nothing new. We have 5 organs of detoxification: our skin, our liver, our kidneys, our bowels, and our lungs. These organs not only help our body dispose of metabolic wastes -for example the bi-products of cellular respiration- but also rid the body of toxins that are harmful to our system.

What is new, however, is the vast amount of synthetic chemicals that have been created in recent history and that are now floating around our planet. On a daily basis we come in contact with tens of thousands of man-made chemicals; in our personal care products, our cleaning supplies, and even the food we eat. Greenpeace estimates that approximately 100,000 new synthetic chemicals are produced in the world every year. Most of these chemicals do not have any long term studies related to safety. We have no knowledge of how these chemicals -specifically their molecules- interact with the cellular components of our bodies; much less how they interact with each other. Recently it was discovered that Bisphenol-A (BPA), a chemical found in many plastics -including baby bottles- is a hormone disrupter and can potentially cause a multitude of problems in the body. Bisphenol-A easily leaches into water or food that has been heated in plastics containing BPA. It is then ingested, by adults and infants alike. Thankfully, BPA has been legally banned in Canada and other countries are following suit.  Harmful chemicals like heavy metals can accumulate in various tissues, including fat, blood,  lymph, and even hair.  These aren’t the only chemicals that can be found in the human body. Some studies have found over 200 chemicals in the umbilical cord blood of newborns, including chemicals used in flame retardants and industrial lubricants. Particularly alarming is the fact that the short and long-term effects of having these chemicals in our systems are not fully understood.

Detoxification Simplified

From a naturopathic point of view the concept of detoxification is quite straightforward. By using techniques that support and enhance the work of the organs of elimination, we can help our bodies speed up, or make the process of releasing unwanted toxins more effective. This is commonly referred to as doing a detox.

For example a light detox can be done by eating organic whole foods and avoiding common allergens like dairy, wheat and gluten. Consuming organic products decreases the toxic burden on our bodies. During a detox avoiding processed foods, like frozen dinners, soft drinks and luncheon meats, decreases our exposure to food additives and preservatives. These provide no nutrition and instead add more unwanted chemicals to our system. Usually when following this type of diet weight loss occurs. Many toxins are stored in fat and are thus released when the fat stores are utilized.

Fasting for Health

A fast is another, more powerful, method of detoxification that should only be done under the supervision of a licensed naturopathic doctor. When people hear the word fast, they often think of a water fast. This type of a fast involves drinking only water for 24 hours or more. It is best to avoid water fasts as they can be debilitating and can also cause detoxification to happen too quickly, leading to more intense side effects. Juice fasts are a great alternative that provide a source of energy, as well as valuable vitamins, minerals and enzymes. During a fast the amount of chemicals consumed is greatly decreased. Its benefits are like those of a detox diet only more intense. The importance of drinking clean, pure water during a fast cannot be underscored enough. Keeping hydrated is essential to our health. During a detox the organs of elimination are kept busy releasing all of the unwanted substances, therefore making sure we have enough water and fluids to “flush” out toxins is vital.

Saunas: A Tool for Detoxificiation

Saunas are often used in conjunction with dietary modifications in a detox protocol. The best saunas for this purpose are called far infrared saunas. These saunas emit a form of heat energy that gently raises body temperature, thus increasing the rate of metabolic reactions in the cells. This causes a higher release of waste products. Fat stores are mobilized, sweat production is increased and thus toxins -along with water and other minerals- are released through our skin.

More Research is Needed

The process of detoxification is an area of medicine that has not yet fully been explored. There are many questions that need to be studied further, including the clinical applications of detoxification. Recent studies have shown promising results with the use of infrared saunas in the treatment of fibromyalgia and Chronic Fatigue Syndrome.  Both of these conditions are a medical mystery, the exact cause of which is still unknown. Could these conditions be caused by a buildup of toxins in the body? With the ever increasing rates of cancers, should we not ask ourselves if this has something to do with the massive amount of chemicals that we are exposed to? Reproductive disorders are also on the rise.  Could these man-made chemicals be to blame?

Small Steps Make a Difference

A visit to a naturopathic doctor can assist you in making changes that can contribute to a healthier lifestyle. Naturopathic doctors are trained to help their patients create a customized detoxification plan. In lieu of your own personal detox protocol, try having a “detox day” once a week or even once a month. Keep your diet clean by avoiding as much pesticides, artificial colours and flavours, preservatives, and food additives as possible. Eat as much raw fruits and vegetables as you can, and avoid fried or BBQ’d foods. On your “detox day” drink plenty of pure filtered water, herbal teas, as well as freshly squeezed fruit and vegetable juices. The effects of our contact with toxins are often cumulative, so every little reduction in exposure helps.