Alternative Medicine (cont.)

A JunkScience.com fan sent a note of inquiry about a surge in alternative medicine talk and linked me to an item on WebMD about Alternative and Complementary methods of treating pain. Actually that is one place where the placebo effect of unscientific medicine can have good effects.

Let’s consider. Medicine for pain and psych stuff should always be liberally sprinkled with placebo laced methods. They work.

Benefits from placebo effect don’t mean you’re faking, it means you are cooperating and finding some chemical neurohumeral and psychological benefits.

WebMD, a very comprehensive web site on medical matters, had an article/interview about alternative and complementary medicine as focused on pain management.

As an emergency physician I assure you anything that will control chronic pain is welcome, particularly if it reduces my risk of getting in trouble for prescribing narcotics to people seeking some opiate candy becuase their lives are focused on pain and pain meds.

This is JunkScience.com so let’s take a bite of the Alternative Medicine issue.

The inquirer sent this link to a WebMD pain management post and asked what might be the implications?

http://www.webmd.com/pain-management/guide/pain-management-alternative-therapy

Traffic is what gets a web site success, so put alternative medicine in the line up, a lot of anxious web trollers will land and look. If you equivocate you can maintain your reputation and still give the positive image of being open minded. yadayada.

From Web MD

The term ”alternative therapy” generally is used to describe any medical treatment or intervention that is used in place of conventional medicine. When alternative therapies are used in conjunction with conventional medicine, it is called complementary medicine. Alternative therapy encompasses a variety of disciplines, including acupuncture, guided imagery, chiropractic treatment, yoga, hypnosis, biofeedback, aromatherapy, relaxation, herbal remedies, massage and many others. Dunn Comment–nothing misleading there.

Dunn says–It is what they say it is, and they also explain “complementary” medicine.”

“In the past decade, strong evidence has been accumulated regarding the benefits of mind-body therapies, acupuncture, and some nutritional supplements for treating pain.”

Dunn says–In the history of medicine there is strong evidence that management of pain is benefited by improving the mind set or the attitude of the patient, again no big problem. For example hypnosis, which depends on subject suggestibility, can be effective in reducing pain.

“Other alternative therapies such as massage, chiropractic therapies, therapeutic touch, certain herbal therapies, and dietary approaches have the potential to alleviate pain in some cases. More research is needed to see how these therapies compare to conventional treatments.”

Dunn says–more research is always needed when the research shows no benefits or real efficacy from a politically popular method.


WebMD asked Eduardo Fraifeld, MD, president of the American Academy of Pain Medicine, to help readers understand acute vs. chronic pain.

Dunn–Dr. Fraifeld is in the chronic pain field–people with incurable, intractable pain–he is always willing to consider alternative approaches to reduce his need for medications that have side effects and can kill patients–why not biofeedback if the alternative is an opiate?

Mind-Body Therapies

Mind-body therapies are treatments that are meant to help the mind’s ability to affect the functions and symptoms of the body. Mind-body therapies use various approaches, including relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis. Relaxation techniques can help alleviate discomfort related to chronic pain.

Acupuncture

Although the World Health Organization currently recognizes more than 30 diseases or conditions that can be helped by acupuncture treatment, one of the main uses of acupuncture is for pain relief.

Dunn says–Nonsense–30 diseases and how much benefit? That’s where me and alternative/complementary techniques get crossways. If the techniques work then they are part of allopathic medicine, like herbs that have pharmacological effects–or physical manipulations that improve musculo skeletal conditions. Or pressure or stimulation therapy. For example we say that electrical stimulation with a TENS unit is good for severy chronic back pain, why would we disagree with an argument about acupuncture.

Acupuncture may have some pain control benefits, but if there were 30 diseases where it made a difference, other than pain control, the research would be available.

Moxibustion is piling burning mugwort on the affected area. I would add burning incense that would have a positive effect on the suggestible patient, along with some chanting and looking skyward. Why not go for the whole show, get some vestal virgins or a belly dancer. Going for a good placebo effect is an art. I am an older greying physician and a good talker–what’s the placebo effect there. Well, how about when i make the pain go away with an effective treatment, then how important is the placebo effect, like when I anesthetize a tooth ache, whichs emergency physicians do all the time at night and on the weekend. You talk about grateful patients.

Sixteenth Century Chinese doctors believed that illness was due to an imbalance of energy in the body. In acupuncture, disposable, stainless steel needles are used to stimulate the body’s 14 major meridians, or energy-carrying channels, to resist or overcome illnesses and conditions by correcting these imbalances.

Dunn says–A nice historical note, introducing but not advocating for QI, and the Meridians approach to acupuncture therapy. If Meridians exist, they are coincidentally at places where an acupuncture pin might produce an endorphin or gating effect. Nothing too bad here. However I object strongly to anyone claiming acupuncture cures non psychiatric or pain conditions. It has an effect on the nerves it pricks, but doesn’t cure Multiple Sclerosis or Parkinson’s, for example.

Acupuncture is also thought to decrease pain by increasing the release of chemicals that block pain, called endorphins. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins (morphine-like chemicals produced in our own bodies during times of pain or stress). Endorphins, along with other neurotransmitters (body chemicals that modify nerve impulses), block the message of pain from being delivered up to the brain.

The endorphin theory of how acupuncture works makes good sense. Endorphins are well understood, however there is no mention of gating, which may be another mechanism. Gating might explain pressure therapy–stimulate a nerve and it blocks another nerve impulse.

Acupuncture certainly could improve any of a number of painful conditions, headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis and myofascial pain. Why not?

Chiropractic and Massage? How could they not help some one with back pain or shoulder pain. I would add the warm baths and the curative springs.

Chiropractic and other therapies, like massage, aroma, music, how could they not have a placebo effect and how could we eliminate that placebo effect in any controlled randomized study. I would suggest that a good looking young masseuse would have an advantage in efficacy for lonely old patients.

Besides, how could Chiro not work, it takes time and time heals musculo skeletal conditions. In addition is involves stretching and massage and manipulation that might reduce stress and muscle spasm.

Therapeutic Touch and Reiki Healing

Therapeutic touch and reiki healing are thought to help. . . they do involve close physical proximity between practitioner and patient.

Touch and Reiki energy force treatment. Oral Roberts comes to mind. A caring practitioner is important to some people.

Nurse practitioners are prone to like touch therapy and Reiki and even hypnosis. Good placebo effects indeed.

And nurses would assert they care more than those physicians.

Dietary Approaches to Treating Pain other than the benefits from weight loss, anything else–placebo effect anyone? Same for veggies–they have developed a sacred place in diet therapy–but content wise they fall short of being anything really important.

Some people believe that changing dietary fat intake and/or consuming plant foods that contain anti-inflammatory agents can help ease pain by limiting inflammation.

A mostly raw vegetarian diet was found helpful for some people with fibromyalgia, but this study was not randomized and was without a control group in what i would consider a psychiatric disease. One study of women with premenstrual symptoms suggested that a low-fat vegetarian diet was associated with decreased pain intensity and duration. Weight loss achieved by a combination of dietary changes and increased physical activity has been shown to be helpful for people suffering from osteoarthritis.

Still, further research is needed to determine the effectiveness of dietary modifications as a pain treatment.
Nutritional Supplements

There is some evidence indicating that glucosamine sulfate and chondroitin sulfate may be marginally effective for knee osteoarthritis. These natural compounds were found to be well tolerated and safe. I get it. Some effect. just like all the other quakity arthritis stuff, like copper bracelets.

Now, compared to the clear cut benefits for non steroidal and steroidals for arthritis, what should we say about the equivocation on glucosamine–and chondroitin? And what did happen to copper bracelets–they were so popular at one time.

And of course never forget the element of health food stores that push brain food, and muscle food and whatever food. I believe that good health is eating the right number of calories in a balanced diet, after that–its about attitude and good genes, and being happy, which improves internal chemical environs.

There are many who patrol JunkScience.com who will bring out their anecdotes and what can I say, it’s like miracles–who am i to prove that miracles never occur. I would object to those who occasionally comment who say physicians are whores for drug companies and don’t care about good health. Such nasty negative people. In medical practice they usually sort themselves out as personality disorders–in the obnoxious groupings.

I always must consider that biology (Medicine is biology, after all) is not hard science–too many mysteries too much uncertainty. I treat a big organism that has many many small organelles that no one understands. We practice medicine in the gross, we are not cellular biologists, we treat organs and systems and a whole patient and we get a lot of help from self regulating chemical and physical activities that occur in the amazing human body. Our amazement is no more or less justified than the amazement of all biological scientists, who deal with complexity and functionality that exceed our ability to understand. A wonderful area of inquiry and I like it a lot because when I am successful and attentive I get a patient better and they like me for it.

I treated an asthmatic yesterday and her face lit up when she started feeling better–what a wonderful thing. Happens to me all the time–I am a lucky old man to be able to use my experience and expertise to help people feel better. I have no biases against complementary or alternative medicine that works, because by that time i call it the good stuff.

Too many people out their trying to sell an attitude, don’t go with traditional medicine–rebel, go back to some better place–some unscientific mythical world that doesn’t accept the authority of these physicians–after all it’s my body–I know what i need better than those authoritative doctors.

Work out your adolescent rebelions in safer ways, take your doxycycline with you when you travel to see some tropical guru so you won’t come back with malaria.

If you get sick–get some real medical person, preferrably someone with local experience if you’re in a 3rd world country where some wierd diseases are endemic.

I teach military physicians and it is difficult to think of all the things on this earth that can make you sick–Americans live in a pretty safe country, so they have the luxury and comfort of fussing about alternative and complementary medicine.

5 responses to “Alternative Medicine (cont.)

  1. Another alternative to medicine (alternative or not), is to listen to your pain and try to figure out what it means. I have just recently recovered from a condition where blocking pain was counterproductive.

    Four months of disabling pain in the wrist and elbow — does that count as chronic? It did not let me do anything useful or even sleep. None of the doctors I talked to (including myself, initially — we are all our own primary care physicians here in the Queendom) were able to diagnose it. So the next doctor up in the healthcare hierarchy prescribed codeine and physiotherapy. The physiotherapist misdiagnosed my problem as neck-related, so none of his recommendations worked. Codeine allowed me to choose between pain in the wrist and headache + nausea. When tired of one, I could go for another. To be fair, codeine gave me 2 – 3 hours of peace and quiet, followed by a day or several of headache. Addiction? What addiction? I didn’t know nausea could be addictive.

    So I staggered like that for many weeks, using codeine only when I needed to do something urgent, or else. Then, by accident, I found one configuration of my arm and shoulder that made all pain in the wrist and elbow disappear (fully abducted, with hand on the back of my neck). That was the first clue I got about the cause — brachial plexus injury — and I was even able to back-track it to the exact day and time when it occurred (it had something to do with shopping, bags, and being lazy, but I will omit the details). The diagnosis was further reinforced when I started using codeine locally, rubbing it in just below the collarbone, admixed to ibuprofen gel (Doctor: “I have never seen anybody do that, but if it helps you, here’s more codeine.”)

    Now, with the diagnosis in hand and with much, much better pain management — longer lasting effect, no headache, no nausea — it still took me another couple months to figure out that my only way out of it was to sleep with my shoulder immobilised in that one position in which I felt no pain. It was an extremely uncomfortable position to sleep in, but it let my nerve heal in just a few days. I could have done it much earlier, were I not focused on pain management instead of healing.

    Two bits of wisdom I have learnt (or rather, reinforced):

    * There is information in pain
    * That information may be misleading. To troubleshoot, check out the spot that hurts and everything upstream.

    • I do this all the time, and not to make too much of it–you don’t have a brachial plexus injury–that takes more than carrying bags.

      what you have is a flare up of a thoracic outlet problem.

      not knowing your body habitus, I will not comment.

      However, you must understand that while part of your advice is extremely important–pay attention to where it hurts, I would say you received some really primitive treatment.

      I haven’t intentionally prescribed codeine for 30 years, for many reasons. It is a shitty narcotic with a terrible side effects profile and a very limited pain management effect.

      If one would use an opiate, at least use one that is relatively free of stupid side effects and is really effective.

      So what is the proper management? First, go to a smart orthopedist or rehab physician and get examined. Have them actually find out what is wrong–trust me–you don’t have a damn brachial plexopathy, but if you do, they will find evidence of it.

      Then I would bet they find a spot of inflammation that would correspond to a tendon or bursa problem.

      get it injected with anesthetic and a little steroid–like medrol or triamcinalone.

      You could say, well how the hell can you be so confident–well it’s because I do this for a living and I am good at it.

      the reason I say you probably had a thoracic outlet problem is that it’s easy to say that, because hunching shoulder is what computer people do, and they get shoulder problems from that. also from carrying things like baggage.

      if you call me and tell me what hurts and what makes it hurt, I would be happen to refine this discussion.

      for nothin. it makes me mad when people suffer.

      John Dale Dunn MD JD Consultant Emergency Services/Peer Review Civilian Faculty, Emergency Medicine Residency Carl R. Darnall Army Med Center Fort Hood, Texas Medical Officer, Sheriff Bobby Grubbs Brown County, Texas 325 784 6697 (h) 642 5073 (c)

      • It is very kind of you, John. I wish I had had access to your wisdom while the problem was ongoing, and I am still absorbing everything you’ve written, now that I believe the problem is gone.

        It is very satisfying, given the limited spatial resolution of my uninformed poking around, to know I have arrived to within an inch from your professional conjecture and was able to fix the problem (or rather, let it fix itself) once I understood the general nature of it.

        You are right about everything: I am a computer person with hunching shoulders, and I haven’t done anything interesting with my hands in about 30 years, so now I am completely detrained. In the final analysis, it was a traction injury caused by an unusual application of load (with the shoulder abducted to about 30 degrees). The load itself wasn’t out of the ordinary. I have since carried heavier loads without problems, making sure I did not deviate from the SOP.

        • so, as my wife points out. sit up straight, and stand straight, and walk with your head up.

          keeps your shoulders back and reduces the compromise of the plexus as it comes out of the spine and goes through the shoulder girdle.

          but don’t forget supraspinatus tendinitis and subacromial bursitis, the two most common causes of shoulder pain.

          Bicipital tendinitis is a less common occurance.

          also bursitis of the rhomboids which are to the inside of the scapula on your back.

          when you find a tender spot, it means something.

          John Dale Dunn MD JD Consultant Emergency Services/Peer Review Civilian Faculty, Emergency Medicine Residency Carl R. Darnall Army Med Center Fort Hood, Texas Medical Officer, Sheriff Bobby Grubbs Brown County, Texas 325 784 6697 (h) 642 5073 (c)

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