Integrative Medicine and Children

Integrative Medicine and Children


>>Welcome everyone to our
Your Child’s Health University presentation this evening. I’m Nancy Sanchez from Community
Health Education Programs and it’s my great pleasure to
present our speaker this evening who is Doctor John Mark. He’s going to be speaking with
us on Integrative Medicine and Children, a fascinating
subject. A little bit about Dr. Mark — Dr. Mark received his medical
degree from the University of Kansas and he completed
a residency in pediatrics at Children’s Mercy, University
of Missouri in Kansas City. He continued his training in Pediatric Pulmonary
Medicine during his fellowship at the University of
Rochester, Rochester, New York. And then in 1999, he went
to the University of Arizona to complete the first fellowship in Pediatric Integrative
Medicine and that was funded by the National Institute
of Health. He’s now on the faculty at Lucile Packard
Children’s Hospital since 2005 and he’s been utilizing
different complementary and alternative health care
practices with his patients with chronic pulmonary
illnesses, asthma, cystic fibrosis. His interest is in nutrition,
mind body approach to healing and trying to minimize
medication and emphasis on such things as exercise. Very fascinating subject
and we thank you Dr. Mark for being here this evening. When I first got into
academic medicine after I left my fellowship at
the University of Rochester, I came out to California
and took a position at U.C. Davis in Sacramento. And after about two
years of being in academic medicine
I discovered that it wasn’t really for me. I mean it was like
research and it wasn’t like very holistic
and not very caring. And plus I’d met my now-wife who
wanted to live in Santa Cruz. So I left academic medicine
and moved to Santa Cruz. And for the next 15 years I
learned mostly about how to care for children through
non-conventional ways because about everybody in the central coast uses
everything but medicine. They’d only come
to see the doctor if their acupuncture didn’t work
or their homeopathy didn’t work, if their mind-body
stuff didn’t work. And so they were teaching me
really over those next 15 years. And so in 1999, I was
fortunate to find an offer for a fellowship at the
University of Arizona. They got what was
called a center grant where for the next five years,
they were actually going to study alternative
therapies in children. And so I applied just on kind
of a whim and I got accepted to be a fellow down there. And what was really nice is
that many of you may have heard of Andrew Weil who
is kind of the guru in Integrative Medicine. He was at the University
of Arizona for a long time and he had an on-going program
that was a clinical program, what they call a
residential fellowship but there was no
pediatric part of it. And so we went down
thinking I’d be down there for two years just doing
research but actually they kind of adopted us into the
program so that we got to hang out with Doctor Weil and all his
group for the next two years. And you know we would spend
the day with Deepak Chopra or the day with Patch Adams and we would learn all
these different therapies and we really got to know a
lot about the different types of alternative therapies. Plus I was doing research too. A couple of topics that I looked
at was the use of Echinacea in children one to five years
of age who had recurrent or persistent Otitis Media. And we also looked at
mind-body relaxation in children with recurrent abdominal pain. And we also looked
at chamomile tea with kids with abdominal pain. And one of the interesting
ones that we did is we looked at acupuncture and
massage therapy in children with cerebral palsy to see if we could actually
decrease their spasticity. So we were doing all this
research and at the same time, we got to be part of all the
integrative therapies and go to all the clinics and listen to all the lectures
on those things. I thought, “Well, after two
years of being in the University of Arizona, that’s why I
still have the U of A up there because I would come
back down to Santa Cruz and I would never
have to practice in academic centers again.” But then I kind of got lured
back into academics when I was at the U of A because as many
of you know, the University of Arizona has a long history of having an excellent
respiratory therapy and respiratory both
Pediatrics and Adult Medicine. So I started hanging
out with those guys and when I finished my
fellowship they asked me if I wanted to be one of
their staff, on the faculty. So I went back to
academic medicine after being gone
all those 15 years and started being a practicing
pediatric pulmonary person again and using all these
alternative therapies integrated into conventional therapies, the
so-called Integrative Medicine. And after being down there
for another four years, I wanted to come back
to the central coast because that’s really
where I wanted to be and I came back to
Stanford in 2005. So that’s kind of
my long journey. Actually I was out of academic
medicine and then I kind of got into it by actually going
back in and learning about alternative therapies
and complementary medicine which we now call
Integrative Medicine. And so that’s kind of how I
got interested in it and so since being back here, I’ve been
trying to use it more and more in the patients that I see, especially with chronic
illnesses and we’ll talk about that in a minute. And I was just telling Nancy
that I just came from a meeting where we’re actually
trying to set up an outpatient Integrative
Medicine Service here at Packard. And we’re trying to work
on that for the next, hopefully for the
next fiscal year which starts this September, where we’ll actually
have outpatient clinics in Rheumatology, GI,
Infectious Disease, Pulmonary, and Pain all kind of working
together in different ways, not just using conventional
therapies. That’s kind of the
background for tonight so I think we’re moving along. It’s taken me a while
but if you know Stanford or Packard very well,
everything takes a long time. You just have to be really
persistent which I am and so we are just kind
of working this along. So you might ask about what is
CAM, what sometime people refer to Complementary and
Alternative Medicine? And what is the prevalence? In 2007, you could see adults
spent almost $34 billion — billion dollars out of
pocket to visit practitioners and purchase the
different products. So it’s huge; it’s a
huge industry out there. If you’ve ever walked
into a health food store and you’re saying, “Like I
heard Echinacea helps you when you get a cold to
help decrease the severity and duration.” Walk into it and try to figure
out what Echinacea to take. There’s a whole wall
of Echinacea. You know, how do
you have any idea? It’s such a big thing
and such a big industry? Nearly two-thirds of the
total out of pocket costs by adults were for
self-care products and so people are really
trying to stay healthy. They’re actually trying to
do things to avoid going to physicians and going to
Emergency Rooms and going to Urgent Care and what can I do to help promote my
own self-care. And despite the emphasis
on self-care therapies, there’s still 38.1
million adults who made over 350 million
visits to practitioners of alternative medicine. So that’s your acupunctures, that’s your homeopathic
physicians, that’s your osteopathic person
who does therapeutic massage. You have all these
different people who are doing all these
different techniques. So this just gives you an idea, this is from an NIH
report trying to show you what the CAM use is. You can see that in the United
States, this is the percent of the population, about
42% of the population — it’s not as high as some place
like Canada which is up to 70% which is really amazing. And in the developing world
really, we always talk about conventional medicine
really is the alternative medicine in most
conventional countries, in non-industrial ones because
really this is what they practice and will only
use conventional medicine on the side. But you can see like
in Ethiopia and stuff, it’s up to almost 90%. And then I put this
little figure in here because even though people
think they want to do self-care, you know, it’s a lot harder
to really do good nutrition. And it’s hard to do lifestyles. It’s hard to do exercise. It’s easier to just take a pill. So if you can go to the health
food store and just take a pill, it’s more conventional,
it’s more natural, it’s dietary supplements
which is one of the things I actually am
going to talk about tonight. It’s actually the most
conventional-like. So it’s one of the things
that kind of bothers me about “alternative medicine” because
a lot of people really rely on dietary supplements and it’s
actually my least favorite thing to talk about because it’s the
one that’s most conventional. If you get my drift. Instead of trying to be healthy, it’s like I’ll just
go get another bottle and even though it’s
supposed to be natural, I’ll just take this medication. And again, this one you
could see CAM use by adults and children and in 2007, it
was — this is all children. So this is not just children
with chronic diseases because if you look at
children with chronic diseases, it actually goes up to 50%, 60%
and even 80% in some studies. In over-all children,
it’s still about 12%. And then one of the
things you can see here is that $14.8 billion
were in non-vitamin, non-mineral natural products. So there’s your dietary
supplements — – huge, huge industries. So really dietary supplements and natural products
are still the thing that people use the most. You can see there’s a little
bit of what we’re going to talk about is, there’s almost
$3 billion in homeopathic. You can see, they
call it Yoga here and then there’s all the
practitioners’ costs. And you can see that
only about $.2 billion in relaxation techniques and
actually relaxation techniques and mind-body therapies
which we’ll talk about are actually one
of the leading causes that actually showed there’s
some evidence behind it. Yes? So nutrition
actually doesn’t really, they didn’t really count
that as being alternative and that’s why it
didn’t really fit in. There is, I mean what is really
alternative medicine in a way? If you take 250 milligrams
of Vitamin C, that’s considered
to be the standard. How about if you take
a gram of Vitamin C? Well, that’s a little bit more. How about if you take six
grams every day of Vitamin C? Well then all of a sudden you’re into Complementary
Alternative Medicine and Dietary Supplements. So it’s a fine line. So what is diet? I mean you see a lot of children
who have chronic illnesses. They do a lot of
different types of diets. So when do you make it so
it’s not really just nutrition and when is it really a type
of alternative therapies? So it’s hard to really sort out. So that’s why these
studies are hard to do. If you look at ethnicity, you can see that
actually Native American and Alaskan Natives
are actually over 50%. And as you go down, the Hispanic and actually Afro-Americans
are the two lowest. And Asians. But again, a lot of these
studies depend on what they ask. You know, what do they mean
by alternative therapies? So really how about in children? So about 8 million individuals
younger than 18 years of age according to this
pediatric article that just came out now two years ago, use
alternative medicine in 2007. Adolescents and children living
in the West like California, those with parents with
12 years of education and prescription medication use
were independently associated with overall increase CAM use. So the more educated
they were and the more that the parents used
alternative therapies, the more the kids
tend to use it too. Common medical conditions
included GI problems, anxiety/stress, skin
issues, insomnia, musculoskeletal conditions,
especially fatigue, sinusitis were increased
with CAM use. Parental CAM use was a strong
correlative of child CAM use and many studies have found that the higher the
CAM use among children with chronic conditions
like asthma, ADHD, autism, food allergies, arthritis,
type 1 diabetes and sickle cell were
actually the highest. So the more chronic you got,
the more it tended to go up. So why do people use these? I mean why don’t they
just go to the doctor and get their normal care? Well therapies are
consistent with the patients’ and families’ values which is
you know, what they believe in. So that’s really what
they want to use. And a lot of times it has to do
with what your grandmother used, your auntie used,
what was traditional in your family and lifestyle. And it’s really natural,
ecological and maybe empowering because you’re deciding
what you’re going to take. It’s not just when you go
to the doctor or you go to your physician or you go
to your health care clinic where they’ll say,
“Take this medicine. Take this medicine. Take this medicine.” It’s like I’m trying
to make a decision as to what makes the best
decisions for myself. The CAM providers are felt
to be more patient-centered. So we talk about being
high touch, low tech. Because you know when
you go to see physicians, a lot of times they
only spend like 30, it seems like 30
seconds with you. They listen one, two and
then they’re out the door. They charge you a lot of money. If you actually go into an
alternative medicine practice, sometimes it’s an hour,
hour and a half, two hours. They really get a
detailed history and maybe hands-on therapy
if you’re doing massage, your osteopathic manipulation
or even a chiropractor and it’s all very kind of
high touch which people feel at times very soothing
and actually very healing. And it is for a lot of families. It makes a tremendous
difference. So it tends to be much
more patient-centered. Conventional therapies are
perceived to be emotionally or spiritually without benefit. That sounds funny
but it’s really true. I mean if you go and just get
another pill or another inhaler or whatever kind of therapy you
get, it’s not very spiritual and it doesn’t feel like that
there’s much that you are going to get out of it emotionally. And conventional therapy is
associated with side effects and significant risks
in some conditions. So even the medicines I use for
common asthma, we always talk about all the risks that
are involved with it. And if you see the ones on
TV like for Advair or one of those combinations, they’re
saying, “Oh yeah, you can play. You can run. You can do things.” And then they have a
little disclaimer thing where they talk really
fast where they say, “Of course there’s an
increased number of deaths, an increased number
of side effects, etc.” Oh, okay, yeah, did they
say something about death? And so it’s like why would I
want to ever take this medicine that has an increased risk
of death with this condition? And it’s also a circular
process. And this is really, really
important in California. If there’s a lot of alternative
practitioners then there’s a lot of alternative practice use. And they did a nice
study in England where they had one children’s
hospital that had a lot of practitioners around that
did alternative therapies and another one that
didn’t have very much and where they didn’t have very
many, they didn’t use very much. Where they had a
lot, they used a lot. So again, it tends
to be more circular. So if you have people available,
you tend to use it more often. And then you can
say, “What is — ” I keep mentioning these
back and forth because I want to make the distinction
about what is CAM or Complementary
Alternative Medicine and what’s Integrative Medicine. So really Complementary
Alternative Medicine according to the NIH, the National
Center for Complementary and Alternative Medicine, is
a group of diverse products and health care systems,
practices and products not
considered to be part of the conventional medicine. Which is kind of interesting
because over the last 10, 15, 20 years, things that were
one time not considered to be conventional
now are conventional. So now they’re no
longer CAM any more. They’re like, “Oh
yeah, we do that. Oh yeah, that’s okay
to take certain things if you have diabetes. It’s okay if you
take certain things if you have heart disease.” But even 15, 20 years
ago it was considered to be the alternative. Some scientific evidence
exists regarding CAM therapies for some. For most, actually
there’s still a lot of questions regarding
safety and efficacy because they haven’t gone through randomized
controlled trials. They’re not quote
evidence-based. And I’ll mention that a
little bit later because a lot of things we do in
conventional medicine aren’t too evidence-based either. But since we’re taught
about them in medical school and that’s what’s practiced
in our lives, they’re okay. But what tends to be not
taught in medical schools, they’re not what’s
taught to us tends to be kind of more alternative. Integrative Medicine actually
is what we try to practice and what I was promoting
when I was at the University of Arizona. It really combines
mainstream medical therapies and these different types of complementary
alternative therapies for which there is some high
quality scientific evidence of safety and effectiveness. So you try to take the best of
both worlds and try to make it. So if I have a child that
has asthma, I’ll say, “I’m going to give you this
medicine and this medicine.” I’m going to try to get
the cat out of the house, try to get the dad to
quit smoking in the house. I’m going to do all these
environmental things and then over the next 6 or 12 months, I’m going to improve
your nutrition. I’m going to help
your lifestyle. I’m going to get you
to exercise again. Maybe we’re going to start you
on some dietary supplements that have been shown
to be more effective and not have the side
effects that some of the medicine you’re taking. And try to do a mix
and try to — how can you get the best
therapies with the least amount of medications and it really
changes the whole patient’s and the family’s life. So a couple of jokes
just to break it up here, you can see 100% natural
remedies, pure snake oil and I think that’s the one
thing I’ll keep mentioning over and over again is that dietary
supplements aren’t regulated very well. We have really a —
you don’t know what’s in almost any product that
you pick up on the shelf, unless you have a
really good seal of approval so you don’t know. This is herbal remedies
versus verbal remedies. I kind of liked this because it
kind of fits in my talk tonight which is dietary supplements
versus mind-body, right? So sometimes I think
the mind-body, the verbal remedies
are actually better. “Snap out of it.” And you can see here, “The truth
is, Doctor, I’ve lost faith in Western Medicine”
which is appropriate for being in California. So what are the major
classes of CAM with Complementary
Alternative Medicine? Again I use this because
this is what the NIH uses, the National Institutes
of Health. So they have a National Center for Complementary
Alternative Medicine. They broke it, kind of a little
bit spuriously but they broke it into five categories which
makes it easier to talk about. The first one which
I’m not going to talk about in detail is Alternative
Medical Systems: homeopathy, naturopathic, and
traditional Chinese, and Ayurvedic treatments. These are systems that
are completely different than conventional therapies. This is not — you’re not
going to just take a medicine because you have
an ear infection. So you take 10 days of
antibiotics and you get over it. This is actually approaching
medicine in a different way and I’ll mention why that is. It has to do more with
keeping your life in balance and not going after
a specific symptom. The one that we are
going to talk about is Mind-Body Intervention which is actually
my favorite one because I think there’s
very little side effects in using the person
to really think about how they can
control their illness, how they can control
their chronic conditions and even their acute conditions. And we’ll talk a little bit more
about that as the night goes on but it enhances the
mind’s capacity to affect bodily
functions and symptoms. I just talked to one of my
nurses today and she thought — she goes, “You know I’m
going to sound crazy.” I said, “What do you mean?” She goes, “I’m going to
go to a hypnotic practice where they’re going to
do virtual lap bands.” So instead of getting
for obesity — instead of getting
your stomach banded, she’s going to actually
go to get hypnosis to get virtual bands placed so she’ll feel full before
she actually is full. So then she won’t eat
and she doesn’t have to go through the surgery. And it sounds — she goes,
“You think that sounds crazy?” I said, “No, it sounds
perfectly logical to me because you can do
that type of thing.” You can really get your mind to
change your way that you think about how you feel and that
actually can promote health more than actually having
that actual surgery. So — but you have to be the
right person, you have to have that kind of mind-set
to be able to do that. You have to be kind
of accepting. The mind’s capacity and it’s
actually almost not even considered to be alternative
medicine anymore because really, the most of the research
that’s been done over the last 50 years
has been in this area. It’s almost all been
very positive. The one I’m reluctant
to talk about but I have to because you saw how many
people spent all these billions of dollars using are
biologically-based therapies — – the dietary supplements, the
herbs, the foods, the vitamins, the natural substances
and again, this is kind of a big quagmire of everything. And we’ll talk about some that
are very recently thought out, some actually have some very
good scientific evidence behind it and I’ll mention a
couple of those studies and some are just people
that are just nuts trying to make a lot of money. So it has a full range
but when you talk about dietary supplements. The last one — I mean the
fourth one is manipulative body-based therapies
like chiropractic, osteopathy, and massage. And we’ll talk a little
bit more about that. Again massage is another
one that’s been a lot of press lately and the
National Institutes of Health and National Center for Complementary
Alternative Medicine now — have now over $2 and a half
million in studies just based on massage right now
in the United States. And the last one is the one
that’s a little bit further out there just like it is
with Alternative Medicine. These are all the
energy therapies. This is the biofield therapies, the bioelectromagnetic
therapies. So you think about you know,
this goes all the way back to the 1700s where
people tried to say, “If you could just figure
out your magnetic waves, you could really
make people better”. And if you think about it, you
have EMGs that do your muscles, you have EKGs that do
your heart, you have EOGs that do your eyes, you have
EEGs, you have all these things. All your body is just
really electric all the time so it seems like if
you could just try to coordinate all this
electricity and all that stuff to kind of flow in
the right way, it would make a big difference. Mesmer was this guy back
in the 1700s in France. You know he used to put
people in bathtubs surrounded with magnets and you know, he
wore this big hat with a cone on it you know, he
actually tried to — they tried to ostracize him and
then Ben Franklin was brought from the United States over
there to put him on trial and say he was a quack. And they had all these
things about having sap go up in trees and he
could feel it. And it was really, this goes
back hundreds and hundreds of years now, this whole
thought about trying to really do magnetic therapy. When you think about
it, you still see it, you still see people who
put magnets in their shoes and magnets in their
beds and try to hit their back pain
and their arthritis. There’s all these things that
go along with magnet therapy. And so again, there’s
a lot to do with that but as you can imagine, it
would be very hard to study. So what are a couple of examples
of Alternative Medical Systems? Well there’s homeopathic
medicine. This is the belief
that likes cure likes which is very different
from what we do. We give aspirin for a fever, Tylenol for a fever
to bring it down. But if you’re in
homeopathic medicine, you’d actually give something
that would cause the fever but you’re just giving them
a very, very small amount. That’s where you get the
idea that likes cure likes and the Law of Similars. So they actually went
through thousands or hundreds of thousands of different
remedies to find out what caused certain
conditions and then they just give you
very small amounts of it and that’s what will
make it better. So it’s very different — that’s
why it’s called Alternative. It’s like very hard for
people to kind of grasp it. That’s why people always say,
“You give such a small amount. Oh, don’t worry about it. It’s a homeopathic dose,
it’s so tiny of a dose.” And they’re all giving —
if you’re giving the higher, more concentrated dose, it
actually causes those symptoms. So the notation, if you’ve
ever seen a homeopathic, I’ll show it to you. 6X means that the
active substance — – so say we take something
like sulphur and we have a 6X after it, that means that
it’s been diluted 1:10 in a water-alcohol
mixture and succussed which is shook — shaken. And this procedure of diluting and succussing is repeated
sequentially six times so that you have one
part in a million for the notation of times six. So that’s why people are
like saying, “Oh don’t worry about it, it’s homeopathic,” because there’s hardly
anything in there. The thing you have
to remember though about homeopathic is it’s
not the Law of Similars but also the least concentrated
it is where it’s to the point that it’s not even
one molecule in there. That’s actually the strongest. So that’s the Law of Dilutions. That’s why people really think
its nonsense because if it’s so diluted, how could it
actually have anything in there? And that’s where it kind
of switches over to kind of more energy medicine because
there’s a memory in the water that when you did that
shaking, that somehow that thing got memory into
the water that you’re taking. And when you take that pill
or you take that little thing under your tongue, that
actually is very effective. And the more diluted it
is, the stronger it is. So you could see that people, especially when conventionally
trained to think like homeopathy, that’s crazy. There’s naturopathic
medicine or naturopathy and there’s actually three
or four different schools in the United States
that actually put out naturopathic physicians. And this is a great group
of people if you ever run into a really good naturopath
because you can see here, they believe in the
power of the body that maintains and
restores health. They use nutrition, lifestyle
counseling, supplements, homeopathy, and Chinese
Medicine. They kind of practice everything that allopathic medicine
doesn’t do. So if you ever hook up
with a good naturopath and you’re the conventionally
trained doctor, you have the balance
of almost everything. So they’re actually can
be very good counterparts. And Bastyr is kind of the
thing, this University and they have a lot
of collaboration with the University of
Washington in Seattle. Bastyr? B-A-S-T-Y-R. And then there’s
Traditional Chinese Medicine and again I just want to
show you what these different alternative medicines are. We’re not going to
talk about them. These are all lectures in
themselves as you can imagine. That’s the belief in
unseen vital energy that effects the health and how
this energy or qi kind of flows up and down your body. And that’s what acupuncture,
acupressure does. The thing you have to remember about Traditional Chinese
Medicine is it’s not just acupressure or acupuncture. It also has to do
with herbal remedies. It has to do with nutrition. It has to do with martial arts. It has to do with five
different things really. They really all work together. So people think about
Traditional Chinese Medicine as just being acupuncture,
but it’s actually acupuncture and a lot of other things. And actually the herbal remedies in Chinese Medicine are
what’s getting a lot of press right now. And last week there was a big —
the allergy meetings in Florida, the AAAAI, they call them. And there was a lot
of reporting on some of the Chinese herbal mixtures
showing that they really work and they’re very effective
in different animal models for allergies and eczema. And so it looks like there’s a
lot of the immuno-modularly type of things that work
with Chinese Medicine. We’ll talk a little bit
more about it when we get to the herbal remedies
and dietary supplements. But they don’t just use one
herb, they usually use five or 10 herbs and they have
them mixed in a certain grade. They have gradations with
one that’s very strong and one that’s very weak
and they kind of have like little soldiers like they
all kind of march together. So here’s an example of one that
I like that’s called Flu-Plus. This is one that — “Hmm, I
wonder what you use this for?” So this is the, you know
you’re supposed to be, in dietary supplements
you’re supposed to not say that you cure or treat anything
but you always enhance health. Well this one enhances
you not to have the flu. And so you can see
that it has four times and now you all know
what that 4X means now, it’s been succussed
times four, 1:10. This one you can see
is one to a million. Actually that’s ipecac. You all know what ipecac is. It makes you vomit
if you take a poison. Pulsatilla, here’s a little
mercury, a little phosphorus, here’s a little sulphur, here’s a little last year’s
influenza, that’s 12 times. So that’s like one in a billion
pieces so I’m not too worried about you’re going to
get too sick from that. One in a billion which is more
than even one molecule would be in the fluid and you can
see here’s my favorite. Bushmaster’s Snake Venom,
there it is right there. It’s also is one to 12
times X. So you can see that this is a mixture
of what they call more clinical homeopathy. If you actually went to a
classical homeopathic physician, they would never
give you this mixture because this is a whole bunch of
stuff they just throw together. They would actually get
your symptom, your flu and they really try to
countegorize it to the one thing that would work the most. And they would give you one,
at the most maybe two remedies. And they would actually give
you a not too diluted one because remember
that’s too strong. And as you got better, they would give you more
diluted ones which are stronger. So again, it’s an interesting
way of approaching things. But this is what most people
tend to buy in the stores now which is a mixture of all these
different homeopathic remedies. How about energy therapies? They involve energy fields
or usually two types. The biofield therapies
are intended to affect energy fields. This is like Qi-Gong, Reiki. A lot of nurses use this. You think about therapeutic
touch or a natural touch. And this is trying to again,
trying to get your energy in the right way to open up
your chakras, to get your things to flow up and down
to really improve. If you’ve ever seen
a good Qi-Gong or Reiki therapist,
it’s pretty amazing. I mean I’ve watched somebody
actually make somebody’s migraine headache go away
right in front of me. She went from being nauseated,
in sunglasses to being able to have a full meal right there within ten minutes
in front of us. Again, that’s just one woman
just standing over her, never touched her,
but just trying to move her energy around. So it’s — yeah she
did the Reiki method. Bioelectromagnetic
energy is what I talked about a little bit earlier. Electromagnetic fields such as
pulse fields, magnetic fields or alternating current
or direct current fields. And again, this is all this idea that you have all this
energy running through you. And if you just try to figure
out how to get your EKGs, your EMGs, your EEGs
all to work together, you can imagine you
should feel a lot better because there should be
some kind of disconnect if you’re not doing well. So let’s go on to — the
last one is manipulative and body-based therapies. And most people think about
chiropractic as being one which is it focuses
on the relationship between bodily structure or
the spine and the function. That’s for the kind of high
velocity, low amplitude. That’s when you get
cracked, right? And that’s why you
usually do a lot of different therapies for that. Osteopathic manipulation
actually emphasizes diseases rising from the musculoskeletal
system. The body systems work together and the disturbances
in one system. People don’t realize this but
there’s six major categories of osteopathic manipulation with
over 100 different techniques. So in the ’60s and ’70s, most
osteopaths kind of quit learning about osteopathic manipulation. They kind of became more
quote conventional doctors. Now it’s making a big comeback
and even in the Santa Cruz, Monterey, Salinas areas,
there’s osteopathic physicians who don’t do any
conventional therapies. All they do is manipulation. And they do cranio-sacral; they do the high velocity
low amplitude ones like the cracking the back. They do different types
of lymphatic drainage. They do musculoskeletal;
they do pressure points. They have all these
different ones they do. And some of these places, like when I was giving
a talk last year at the Barbara Bush
Children’s Hospital in Portland, they had a lot of osteopathic
manipulations going right on in their inpatient,
even in the ED. So they, some hospitals
especially in the Midwest and the East Coast have
really embraced osteopathic manipulation as being
acute therapies. And massage therapists
manipulate muscles and connective tissue to enhance
function of those tissues to promote relaxation
and well-being. And there’s been quite a few
studies actually supporting the use of that as well. So now let’s move to research. There’s been multiple studies
showing the most popular treatments are dietary
supplements, much to my chagrin. There’s evidence lacking even for the most popular
ones, even in adults. And the Institute of Medicine
saying that “the same principles and standards of evidence of
treatment effectiveness apply to all treatments
whether currently labeled as conventional medicine
or CAM.” So really if you’re
going to use something, you really should have some type
of evidence to support its use. And maybe it doesn’t have to be
large, randomized control trial like you do for drugs, but it
has to be some type of evidence where you actually try
to study it and show. And sometimes it
could be historical; sometimes it could
be traditional. But most of the time the
Institutes of Medicine would like to have some
type of research. And there’s very few studies
that are done very well in part because they’re not
very well-funded which is another whole story. So funding in research
is growing but is still relatively
small for totals. So if you look at some of
the studies that you look at that have shown to be
effective, here are the ones. This is from the Archives of
Disease in Childhood article about six years ago and they
thought this was well-documented now that biofeedback for
constipation and headache, hypnotherapy for headache
and irritable bowel syndrome. So you can see Mind-Bodies
are really embraced and they are really
felt to be part of almost standard
protocols now. Lemon balm for herpes simplex,
massage for constipation, these are all ones that
have enough studies that people now can
say these really work. These are uncertain, maybe
acupuncture for asthma, acupuncture for hay fever,
for rheumatoid arthritis. Chromium for diabetes was a
big one in the ’60s and ’70s and even up into the ’90s. It’s just like, if you just
give enough chromium a lot of diabetes will get better. Now cinnamon is one that’s taken
over for a lot of diabetes. Echinacea for the common
cold, Evening Primrose. And unlikely is some for
acupuncture that you could see over there for smoking,
for weight reduction. Flower remedies for anxiety,
homeopathy for anxiety. Again these are very
hard studies. You can imagine now just
after I give you my talk about what these are, how
could you really study these in a large group of patients because everybody’s
so individualized? So again, this is what they felt to be effective and
not effective. How about the use
of supplements? Well alternative
health supplements in the 2002 National
Health Interview data on ten common herbs: Of
30,000 adults, 19% used herbs in the past 12 months. And in 57% of those, 20% which
is a large amount used them for a specific condition. What was interesting is
that approximately two out of three used herbs except
for Echinacea was not even in accordance of
evidence-based indications. So they were going
to health food stores and they were buying these
different herbal remedies and they were using them for different indications not
even what was on the bottle in the health food stores. So again, even though
it’s really used and is really used commonly
by a lot of adults especially, they don’t even use it for
what’s commonly practiced in the health food store. So again, it’s kind
of a really mixed bag. You can see why a
lot of families and children don’t really
have a lot of direction because there’s nobody really
telling them what to do. It’s usually what your neighbor
told you, your auntie told you, your grandmother told you. And you might try it just
based on what you saw even in a newspaper or in
a magazine article. So how about studies supporting
conventional medicine? I always like to throw
this slide in here just to remind people that there was
this nice article in Archives of Disease of Children
way back in 1999 where they did 240 consults and 1149 clinical
actions were performed. Good evidence was found by
a randomized control trial or other appropriate study for
only 40% of the 629 actions. So of all those ones in a
hospital, there were only 40% that were evidence-based. So that’s why when people say, “Oh you can’t use
these herbal remedies. You can’t use this
Mind-Body stuff. You can’t use these energy
medicines, alternative therapies because there’s no
evidence behind it.” I can tell you that 40% of
the time that what you do in the hospital doesn’t have
any evidence behind it either. And you can even see
non-experimental is 7%, inconclusive for 25%. There’s actually evidence
of ineffectiveness for .2% and no evidence at all for
almost a third of them. So you can see the
people are just like, “Oh, it makes sense to me. I’ll just try it.” And since I’m a doctor,
there’s evidence. So it just shows you how the
whole kind of mindset kind of happens especially in
the medical community. There was one even looking
at surgery interventions in a regional pediatric
surgical unit. This is about as old. Of 281 patient interventions,
11% were based on controlled trials, and
66 were on non-convincing, non-experimental evidence. If you think about surgery, that’s kind of how
surgery developed. It’s like, “I don’t know if
that kidney transplant’s going to work. Let’s just throw one in
there and see what happens.” And then after —
after a few, five, 10, 15 years they actually started
to work because it’s very hard to do a randomized control trial for something that,
like a surgery. I mean you can’t say, “Well,
I’m only going to take out half the appendix.” Usually you’re going
to take it out or you’re not going
to take it out. So again, it’s very hard to
do these types of trials. But people give you
all types of grief for not having good evidence
for doing alternative medicine when a lot of things that we do in conventional medicine doesn’t
have much evidence behind it either. So really what you
want to do is you want to figure out the parts. So there’s all this
Alternative Medicine, there’s all this
conventional Western Medicine. And Integrative Medicine
is trying to take the best of both parts. You want to use conventional
Western Medicine that has the least
amount of side effects, that’s most effective, that
has the best safety profile and you want to take Alternative
Therapies that have shown to be clinically effective
to be safe and you want to marriage those two together. That’s really the most
important thing to do. And really, you have to
bring in the patient’s values because what they — you can
say acupuncture, acupuncture, acupuncture and if the
person does not want needles, it’s not going to work. I’m sorry; it’s not going
to make a difference. So you really have to bring
in what they think too. You have to look at the
research, you have to look at the clinical data,
and hopefully you’ll come up with the optimal
decision by trying to marry all those
three together. So how about biologically
based therapies? Well biologically
based therapies or dietary supplements are used
in herbs, foods, and vitamins. They include all the dietary
supplements and herbal products that are used in
so-called natural therapies. The Dietary Supplement Health
and Education Act, the DSHEA Act of 1994, this is what kind of
threw everything into chaos. There was a Tom Harkin who
was a Senator from Iowa and I just blanked his name —
what’s the Senator from Utah? Orin Hatch. Now you think that those
guys don’t have anything in common, right? One’s very Republican
and very right wing and one’s very liberal
and very Democrat. But they got together and
they wrote the DSHEA Act because in Iowa and Utah
are two of the hotbeds of dietary supplements,
where they’re made. And they were saying, like,
“We don’t want the FDA to regulate this stuff. These are really just
natural substances. They’re like foods. They should be regulated
like foods.” And so they wrote
the DSHEA Act in 1994 which acknowledges the
potential health benefits of dietary supplements which
must contain vitamins, minerals, herbs or botanicals, amino acids
or any combination of these and may affect the structure
or function of the body. So that Flu-Plus is
not a very good name. I mean they could
actually get into trouble for calling it Flu-Plus. But like if you have joint
pain, you have to have something like Joint-Health, you
can’t say arthritis. If you have some type like
liver, you can say Liver-Health; you can’t say Hepatitis. You can say anything
to promote the health, but you can’t say it will
actually treat a disease. So that’s where you
make the distinction. So when you look at a dietary
supplement, you should look and if it makes a claim
that it’s going to treat or cure something,
that’s actually a red flag that maybe that’s not
a very good product. Because really, what
they’re supposed to do — – the ones that really
follow the law are the ones that enhance the
health in that area. It cannot claim to cure
or treat a disease. That way they don’t need any
new drug application process which is millions and millions
of dollars, all that safety, all that animal data, all that
lab data, all those trial one, two, three, all those
have to do that. All you have to do is just
put it in a pill and put it in a bottle and put it on the
market and you’re good to go. There’s no quality control, there’s no good manufacturing
standards enforced and no oversight by the FDA. They actually changed
that in 2007 but the FDA was never funded
to actually make a difference. So actually it’s
still not regulated. So you know there’s — – I’ll
talk about it in a minute, but there’s things you
can do to try and figure out which ones are safe
and which ones aren’t safe. But right now, it’s
kind of chaos. The herbal industry at first
didn’t really care about this because they were selling
everything off the shelves. In the late 1990s and
early 2000s, they started to have more problems like you
might remember the Kava-Kava causes some type
of liver problem. There was this that Saint John’s
Wart causes problems with people who had AIDS who were
taking HIV medications. So then they thought,
“Oh my gosh”. People were really
starting to — all their sales started
to drop off. So now they’re actually
trying to, actually try to police
themselves. So certain groups are
actually trying to make some of their products much more
safe and much more reliable. Here’s the different approaches. I think this is actually one
of my more important slides that I talk about
dietary supplements. There’s traditional use,
like the Western approach. These are the folk
medicinal traditions. These are like your teas, your
tinctures, your poultices. This is what your grandma
might have taught you. This is what your curandero
might have taught you. This might be what your
aunt or uncles used to take when they were in the old
country whatever that is. This is all the kind
of the Western approach for folk medicine and
these don’t have a lot of studies behind them but
they have thousands or hundreds of years of tradition
behind them. So a lot of times these on ones
that have been very effective. There’s indigenous use, Native
American, Polynesian and a lot of times, these are
drinks or even smoking of certain substances. There’s Chinese and
Ayurvedic and again, I mentioned earlier these
are using multiple herbs. They give it to you in a
paper sack, you go home and you make it into
a concoction or a tea. Usually they really smell
awful, they really taste bad and they give you a bellyache
and kids really hate them. But these are actually
some of the ones that have the most
research behind that shows them to
be most effective. But they’re hard for Pediatrics because they don’t
taste very good. And there’s homeopathy I talked
about which are tiny doses of mineral, plants or
even animal products like snake venom. Then over here is the
non-traditional use and this is based on theory. Like glutathione
is an antioxidant. So these guys thought, “Well you
need antioxidants in your lungs, so let’s just nebulize
some to your lungs and let’s treat cystic
fibrosis with it”. And they must make
this whole thing up and people just started using
it all across the country. It was written up in one
of the women’s articles, women’s magazines and pretty
soon everybody was using it. In fact to the point that the
Cystic Fibrosis Foundation had to come out with
a policy statement because everybody just started
using inhaled glutathione based on nothing except
that the theory that if you could take it
orally, it must be good if you take it nebulized. Combination therapies
which I think is one that really drives me crazy is
that you’ll find if you pick up a bottle of dietary
supplements, you’ll say, “There’s a Chinese herb. There’s an Ayurvedic herb. There’s a Western herb. There’s a mineral. There’s a vitamin.” They just mix everything in
there so if you have something to do with joint pain,
they’ll take every tradition, and they’ll take a little
bit of that herb and put it in one capsule and charge
you a lot of money for it and say that it works. It makes no sense. Why would it work? You don’t know what
the interactions are. You don’t know how
they’re all going to do. So I always tell
families and patients that if you see something
that has like lots of different things in
it that come from lots of different backgrounds, that’s not usually a very good
dietary supplement to take. Yeah so vitamins
are another one. You know again, vitamins
are like I said earlier, that if you take a low-dose,
it’s supposed to be okay but if you take higher
doses and you mix them in with a lot of things. So with vitamins,
no one really knows. The thing you have to be
worried about vitamins is that sometimes you’ll be
taking one say that has so many international units of
Vitamin A. Then another one has so many international units of
Vitamin A. Then another one has so many international units of
Vitamin A. Then another one has so many units of Vitamin A.
It’s kind of like acetominophen. Pretty soon you’re
getting toxic on Vitamin A because you’re taking all
these different herbal remedies that have all that in them. So you really have to look
at everything very carefully. Here’s one I just
like on garlic. You can see here,
depending on the intended use by the manufacturer, garlic
products are classified for regulatory purposes in
one of eight categories: conventional food,
dietary supplement, food for special dietary uses,
biological, drug medical device, cosmetic, or food additive. So you can take garlic
for about anything. You can say that it helps all
these different areas depending on how you take it. So garlic is one of these things that traditionally have been
used for a very long time to help you with
all kinds of things. It kind of depends
on how it’s marketed. You could see how it’s either
regulated or not regulated. So these are things that you
think and again I was going to mention this earlier
that anybody wants any of these slides, you can just
ask Nancy or Felice there at the end and they’ll
have email addresses. They can send you all the talk; some of these are
very nice to have. Here’s the National Center of Complementary
Alternative Medicine. It’s become a very
good website in a lot of ways, for definitions. It has some herbal remedies
that you can look up and it has some monographs. The Office of Dietary
Supplements, MedWatch, CAM which has to
do with research and the Canadian
Health Directorate. But the best one
probably in this slide for government sites
is the National Center for Alternative Medicine. There are academic sites. There’s the Boston-Longwood
Herbal Task Force. This is actually a great one. This one has to, if
you look up Echinacea, it has all the animal
studies, all the human studies. It has a monograph. It has one that you could
hand out to parents, a one-page like this works
and this doesn’t work. So this is one that was done up
at Boston Children’s years ago. University of Pittsburg,
Beth Israel, Columbia and even Berkeley still has
their good old Wellness Letter which is still very
effective and very nice and they really try
to keep it up to date. There’s herbs and
courses you can take like the Dietary
Supplements by Wake Forest. And this is one of my
favorite ones I’ll talk about which is Consumer
Labs.com and this is one that you actually
have to subscribe to. And what it does, every month
it takes a commonly used dietary supplement and it takes
like 15 to 20 popular brands and it actually looks
to see what’s in them. So they’re not paid by anybody. So you go look and see. And what you do, when you
can start looking at it, you can start getting the ideas. “Well this company seems
to be always spot on. This company seems
to be always way off. So maybe I should start
buying my herbal remedies from this company.” So I can’t really tell
people what to buy anywhere because it’s all so
richly different. I mean it’s even
different in Santa Cruz than it is in Palo Alto. So again, every one
depends on what you have but this is actually
a very good website. The Natural Medicines and Comprehensive Database
is also a very good one. This is one especially
for medical types. This one really tells you
about all the, it’s like a PDA for herbal remedies and
dietary supplements. So this tells you all
the up-to-date studies that have ever been done on
these different medication. And the same way for nutrition
and dietary supplements. So if you go to the NCCAM
website, here’s like this, I just took one of their pages
and just put it on this paper. You can see like here’s all
these things you can click on to learn about; all these
different ones you can see. So if you hit on dietary
supplements, here’s all the E’s and the G’s and the H’s. You can see there’s the
introduction to naturopathy, you can see grape seed
extract, you can see what’s new, past highlights, and
then you can subscribe to their newsletter
and their E-Bulletin which is also very good. So when you do a resource
evaluation, say you’re going to a website and you’re
trying to figure out, “Is this a good website? Is this not a good website?” I always tell people,
what’s the introduction? Who runs the site? Who pays for the site? I mean they’re asking
you for information. They ask you for a
credit card number. They ask you what
your address is. Does your computer pick up
spyware when you go there? I mean these are all things
you want to know about. What’s the purpose of the site? Does it actually help you or
does it try to sell something to you and how much
advertising is there? Where does the information
come from? What’s the basis of
their information? Sometimes they’ll say
‘References’ and you go look at the references, they’re
all like in 1966 and they’re in China and they all
have to do with dogs. So that’s probably not the
best references for somebody. Some of them are very good. Some are right up to date. Some have been done locally. Some have been done at
some of the osteopathic or naturopathic colleges. How is the information selected? How current is it? Where does the site choose
the links to other sites? You know, where does
it kind of link you to? And what information about you
does the site collect and why? So this is all from
NCCAM as to kind of how to resource whether a
site is any good or not. And how does the site manage
interactions with visitors? So this Consumer Labs I
mentioned, this is a nice one. It’s a provider of independent
test results and information to evaluate health, wellness,
and nutrition products. They get about 2.5
million visits per year and has a certification. And actually you can on the
bottles, you can get the CL. They’ve actually
been tested by CL. Sort of like the Good
Housekeeping Seal of Approval. It enables companies
of all sizes to have their products
voluntarily tested and that way they
get the CL seal. In the past seven years, they’ve
tested more than 1,800 products, representing 350 different
brands and supplements. A one-year, 12-month
subscription is only $27 so really it’s very
inexpensive and if you’re into dietary supplements,
especially if you have families and patients coming to see
you, this is a very nice one because you could look
it up very easily. Natural Products Encyclopedia
and there’s a free newsletter. Another one I like is the
Natural Medicine Database. This again has a search method and again this one also
costs about $30 a year. And you enter the natural
product names like Echinacea or you can enter a disease
like migraine headaches or you can do a condition like
fibromyalgia or a drug name. It gives you objectional
product information, effectiveness ratings and
potential interactions even with conventional medicines. So this is a very nice one. You can actually search
in a lot of different ways to give you a lot
of good information. The Natural Product
Effectiveness Checker tells you the level of effectiveness
for natural products. So it has a gradiation
from ‘A’ to ‘D’. This one’s an ‘A’ — it has
a lot of history behind it. It has a lot of research
behind it. It looks to be very safe and
very efficacious all the way to ‘D’, maybe it’s
not even that safe. And then ‘C’ with a lot of
middle like in the middle, we don’t have much about it. It has a natural product
drug interaction checker. It tells you potential
interaction between any natural product and
any drug which is very important because people always mix
and match all this stuff, and you have no idea
what’s going to interact or not interact. The Disease Medical
Condition Search which shows you medical
condition. It allows you to see which natural products
might be effective. So you can see, it’ll actually
show you: here’s a Western one, here’s an Ayurvedic one,
here’s a mix of Chinese ones from traditional
Chinese Medicines. So you can kind of get a mix as to all the different ways you
can approach a certain condition by looking at dietary
supplements. You actually can search
colleague interaction. It shows you questions,
answers, and comments posted by other health professionals. So you can say like, “I
tried this on my patient and they had this
kind of reaction.” And colloidal silver is
one of my favorite ones. Colloidal silver is this
thing that people considered to be a natural antibiotic and you can actually
make it yourself. And if you take it
it’s supposed to cure, I think the last time
I looked it up online, it can cure like 1,000
different diseases. The thing is if you take it too
long or you take too much of it, it actually causes you to
have permanent discoloration of your hands and your skin. It actually, the silver
gets out into your hands and into your skin
so it’s always there. And there’s some families in
some parts of the United States where everybody looks
kind of blue because they all have this
colloidal silver that’s into their bodies and
never can go out of them. So again, it can be — and we
had written up a case a couple of years ago in a cystic
fibrosis patient in Denver who thought that would
really be the new approach to treating their
chronic lung infection. And they got all this
colloidal silver involvement. There are also supplements
and books out there. The ABC Clinical Guide
to Herbs by Blumenthal. Again, it’s a very good book. Blumenthal’s kind of ‘the’
name in natural products. Contraindication and Drug
Interactions by Frances Brinker. He’s at the University
of Arizona. He’s a naturopath;
he’s very good. Integrative Medicine by Dave
Rakel, Integrative Pediatrics by Tim Culbert and Olness. She’s in Cleveland and Tim
Culbert is in Minnesota. Then there’s The Journals
of Herbal Pharmacology, The Journal of Alternative
and Complementary Medicine, Alternative Therapies
in Health and Medicine, and Evidence Based Complementary
and Alternative Medicine. These are all very
nice journals. And we can get almost
all of these now on Lane here at Stanford. So I’m just going to give you
a quick example of a couple of things we might see. For cystic fibrosis, these
are all just a smidgeon of all the ones I’ve heard
about in the last five years. And again you can see that
people use probiotics, B Complex, all the
different vitamins and again, vitamins is like a funny mix. It’s like, it could be just fine
but if you’re taking high doses of vitamins like Mega-Vitamins
then it becomes a little bit different. All these different ginko,
garlic, ginger, echinacea, essential oils inhalation. We sometimes find inhalation of different essential
oils can be very powerful. Lipoic Acid, especially for cystic fibrosis-related
diabetes. And actually Lipoic Acid
is actually used by a lot of endocrinologists right
now for even standard, especially if you have any type of neurological side
effects from your diabetes. Milk thistle to help
protect your liver. Grapefruit seed extract, Baker’s
yeast, green tea, Airborne. Everybody knows about
Airborne, right? You get that before you
get on the airplane. It’s all, it’s a mixture,
it’s not just homeopathic. It’s got some homeopathic; it’s
got some Chinese Medicines; it’s got Ayurvedic Medicines;
it’s got some vitamins in it. And people will swear
by Airborne. You know, “I get Airborne and I
never get sick on an airplane.” Coenzyme Q-10 which again, for
cardiology, for heart strength, that’s one that’s almost not
considered alternative any more. A lot of cardiologists now
use it for their patients. And then all these ones,
or most of these have to do with a very strong antioxidants. Gingseng, licorice, boswellia. These are ones that are from
from the Ayurvedic and India. And Pycnogenol — – there
was just a Cochrane Review on Pycnogenol because it’s
really promoted for asthma and all kinds of
chronic conditions. So it’s one that’s been very
popular and it actually has to do with French
white pine bark, is where Pycnogenol comes from. I just wanted to
put the one study that was done just two years
ago on pulmonology looking at probiotics and
cystic fibrosis. And we found out that studies of
fecal calprotectin concentration and rectal nitric oxide
have found to be increased, suggesting a constant
intestinal inflammatory. So your gut is really full
of a lot of inflammation. So people feel like if you could
just decrease the inflammation in your gut, you can actually
promote health elsewhere including your lungs. And so probiotics have live
bacteria you give orally. It’s to decrease the
severity of gastroenteritis and prevent atopic
diseases in children. And the mechanism may
be through improvement of intestinal barrier function and through modification
of immune responses. So we know that children who
are born by cesarean section, they don’t get that same
vaginal flora, they sometimes, or they have a lot
of antibiotics in their first year of life. Those children sometimes go
on to have more lung problems. So this whole idea of
really getting the right, proper type of bugs in your
gut from the very early on can actually be
very powerful. So they did 10 CF patients with
mild to moderate lung disease and pseudomonas colonization
were treated with Lactobacillus
GG which is one of the most common
probiotics that are used. And the PFTs didn’t change and
there wasn’t really a change in sputum but they
did find a reduction of pulmonary exacerbation rates. And then they got sick
less often and had to come into the hospital. This is just a cartoon to show
you about what people think. You have all these pathogens, allergens coming
into your lungs. And if you have all this stuff
in your gut, it helps you. With this probiotic it
actually blocks all these inflammatory responses. So again, this is from
CHEST which is one of the more traditional
conventional therapy journals for pulmonary physicians
and they have a whole thing, a whole article just on
probiotics and lung health. And then here’s some dietary
supplements for asthma and allergies you can see. Again, here’s Butterbur,
Pycnogenol, Vitamin C, Magnesium and the ones that are
in blue are all the ones that actually have
had some studies. Ma Huang or Ephedra is one
that’s been off the market now for the last few years
although you can still get it on the internet. That’s because people were
mixing it with caffeine and other dietary supplements. And that’s when all these
athletes were having all these seizures and heart disease because they were taking
high doses and going out and trying to over-exercise. But it used to be, it was a very
easy one to use for children with very mild bronchospasm. And they had one that’s
called Breathe Easy Tea that we used to use a lot. And it was for children that
just got a little bit of wheeze when they had a little
bit of viral illness. And people would
really overuse it so they took it off the market. So here’s just some other
ones too for allergies. You can see that there’s all
these different ones out there and every day people
will ask me about one that I’ve never heard of. So there’s so many dietary
supplements out there. So let’s move into the next
group which I like the most. Which is kind of your Mind-Body. So these guys are
all meditating. You can see this guy — he’s
got the legs going here. So Mind-Body Therapies are
a cognitive behavior therapy that encompasses several
approaches: relaxation, breathing, biofeedback,
hypnosis, and guided imagery. In fact, these are ones that
are almost considered to be, have so much evidence behind
them anymore they’re almost not considered to be
Complementary Alternative. Although there’re
still people who feel like they just make
you feel better but they don’t really
do anything for you. They just make you feel
like you don’t have disease or they make you feel like
you don’t have lung problems, but actually there are some
studies now showing they actually decrease the
inflammatory response in all different types of situations including
inflammatory bowel disease, arthritis and even asthma. But theories based on decreasing
the inflammatory process that can be triggered by
autonomic nervous system through strong emotions. And if you think about it,
asthma back in the ’60s and ’50s used to be considered
to be a psychiatric disease. Because kids would get so
anxious and adults would get so anxious, they actually used
to treat them with Phenobarbital to try to sedate people. They found that they got better. That’s probably because
they reduced the anxiety, there was a very strong
autonomic component to it and actually it would
enhance bronchial dilatation. So I’m not saying you should
sedate your patients with asthma when they’re having a reaction
or having an asthma attack. But again, if you
can calm them down and you can have
them do relaxation, you can have them
doing belly breathing, you can actually
break a lot of people who have respiratory issues. Stress has been associated
with higher morbidity and cytokine levels attributed
to airway inflammation. And now they’re even doing
studies in pre-term babies and mothers and looking at
their stress level and find that the kids that have, the mothers that have even
more stress prenatally and postnatally, their
children have more problems with inflammatory diseases. In addition to anxiety,
stress is shown to influence the immune response and prevent increased
sympathetic activity, promote airway inflammation
without overt symptoms. And the way I remember that
is that they had a group of patients with moderate asthma
who were college students. And they did induced
sputums on them. And even though they were
having normal lung functions, they were having
no symptoms at all on their induced sputums during
times of finals and midterms, they actually showed they
had an inflammatory response in their sputum. Even just the stress showed
they had more inflammation in the lungs even when
they had no overt signs. Their lung function
didn’t changed at all and they had no wheezing
or cough. So self hypnosis, breathing
exercises including yoga, relaxation with or without
guided imagery have all been studied. And imagery and self
hypnosis have been shown to decrease shortness of breath
in asthma and abdominal pain in children with
recurrent abdominal pain. And often these services are
available in most communities. Actually anybody in this room
can be taught how to do imagery, taught how to do hypnosis, taught about how
to do relaxation. They’re very easy to do. In some services, it’s
the social workers, sometimes it’s the nurse,
sometimes it’s the doctor, sometimes it’s the MAs, sometimes the respiratory
therapist. Almost anybody in a medical
situation can be taught how to do some of these Mind-Body
relaxation techniques. And breathing exercises may also
help, especially deep breathing and yoga and martial arts
and that’s one of the ones I like to use for little
boys especially. They all want to take
Kung-Fu or Karate and it’s actually
very good for them because it really teaches
them control and really how to use all their lungs and it
tends to be very disciplined. So there is a pilot study of
mind-body changes in adults with asthma who practice mental
imagery, that was in 2004. There’s Effect of self-hypnosis
on hay fever symptoms in 2005; Hypnosis and asthma: a
critical review in 2000. Again, these are all
positive studies showing that all these work in all these
different areas of lung disease. Biofeedback — –
interventions where you look at heart rate variability
and abdominal breathing. And heart rate variability
alone, placebo EEG feedback, and wait control in 94
adults with stable asthma. Medications were titrated
following the symptoms, lung function and peak
flow meters were monitored. And the ones that had the heart
rate variability groups were given less medication,
decrease in severity, improved lung function. And they all got better
just using biofeedback. So it’s a very powerful
one for children and adults who have respiratory symptoms. So behavioral interventions
in asthma such as biofeedback, overall the evidence was
as an objective treatment in asthma is meager but they
only reviewed 12 studies. So what is progressive
relaxation and guided imageries? So I’ll just kind of walk you
through what I use with my kids when I did a study down at
the University of Arizona. We took children who had
mild to moderate asthma. They were on medications. They were stable. They had normal lung
function tests. And we introduced the
goals and techniques, discussed the importance
of practicing, modeled the practice techniques. We identified their
sensations with relaxation such as warmth and
tingly feelings. We identified relaxation
as a positive feeling and we introduced this to guide
their asthma reduction imagery. So what you do is — has anybody
ever done a guided imagery or relaxation? So again, you can see that you
tell a child that it’s going to consist of learning to tense and relax various
groups of the body. So they tense them up
and they relax them. You can move top to bottom. You can do it all
different ways. Usually you start at the top
and you move all the way down. And you go through while at the
same time you pay very close and careful attention to
the feelings associated with both tension
and relaxation. Because when they get an asthma
attack or they have some type of problem with their breathing
or pain, you want to associate that with a certain feeling. Sometimes that’s
that tense feeling. So they get an image of what
that seems like when they have that tense feeling and
then when they relax it, they get another image of what that image is when
they relax it. So it’s very, and
the kids are great. If I had to do it for
you guys in this room, I’d have to turn
down the lights. I’d have to have you all sit up. You’d all have to you know,
close your eyes and put you to start taking deep, nice
breaths and start to think about and try to clear your mind of all the other crap
that’s going on there. But for kids you can say,
“Okay, I want you to relax.” “Okay.” “I want you
to have an image when you think about something.” “Okay.” I mean they’re
just like right there. They can go just right there. You can just do imagery
so fast with children because their mind
is already there. We beat it out of them, we
say, “Quit daydreaming,” you know, “Pay attention.” “Get back here.” But you know we kind of beat
it out of kids by the time that they get to be in junior
high or high school or college. But little kids especially
8, 9, 10, 12 year olds, they can go right
there, right away. They’re just like,
“Okay, I’m right there.” And you start off by running
through each muscle group and modeling for each child
how to tense and relax. And you practice this
tensing and releasing twice. After each tension
and relaxation, you ask the child what it feels
like and it’s important for them to tell you what they feel like. You don’t want to put too
many images in their mind. You don’t want to tell
them, “Oh you feel like it’s something — “. They may not like that image. So you want to be very careful
when you try to do imagery. You want to make sure you use
the image of what the child or the young adult is using. And then you want
to know what that’s like when they’re relaxing. And then you tell the child that
while his body remains relaxed that you’re going to ask
him to do some imaging. And you ask him that when was
the last time they had a tickle in their throat or felt like they were having
trouble breathing and try to imagine what that
would look like. You get all kinds of ideas
what they might come up with. I mean it’s really amazing
what they’ll come up with. And sometimes it’s
stuff that makes sense, sometimes it makes no sense
at all, but it doesn’t matter because that’s their image
for whatever they’re having. Then you ask the child to
describe what it’s like. Is it tight? Is it heavy? Is it cold? Does it tickle? You really try to get them
to use all their senses. Do they feel something
on their face? Do they feel something
on their skin? Do they smell something? Do they hear something? You really try to
use all their senses. And they really get into it. They really say, “Oh
yeah, I do this,” and they’re really
telling you all this stuff. And I had this little
girl that had migraines. And she was telling me
how it was like a rose and she could smell it and
the smell would go away and it would get really right. And it would really like
close up all the way. And she would — and
thorns would get bigger. I mean she really got
into this whole thing about what the rose was doing when she had this
migraine headache of hers. Then you have to imagine what
the discomfort would look like or come up with a mental picture
of what the pain could be like. If they’re having difficulty
breathing, you can give examples like a block of ice in the
throat but I don’t even like to do that with them. I like to just let them
do their own imagery. And then you reinforce
the description and encourage the
child to elaborate on details and clarify. Like I said, the colors,
the sounds, the involvement. You really try to get
them to go for it. Then you tell the child that
the clearer the image is, the more powerful the
pain reliever will be. So really when they
get it specific, then when you make it
better, it’s much better. So you want to make it really
specific and then you want to make what makes it
better very specific too. And when the child has a
clear image of the discomfort, you ask them, “Well
get rid of the image.” And you can image like the
block of ice or for the rose or whatever you can
imagine, the kids will come up with something
very quickly with how to make that much better. And you guide the child to describe the second image
including how the second image may make the pain disappear. And you ask the child to
imagine the second image to make the first
image disappear and you notice the
good feeling that comes with the less discomfort. So you have them go through
the whole thing again. How do they feel, what
does it smell like, is it cold, is it warm? What’s the air like? You know, how are they feeling with all these different
things you try to put together. And then you do this
post-session reinforcement where you reinforce
the effort of success. You describe the
practice, you tell the child to practice at least
twice a day. They should use their
rescue inhaler if they have asthma before
practicing techniques because if the child has
breathing difficulties because you don’t want to put
them into an asthma attack by having the bad
feeling about it, right? You don’t want to say
I want you to practice when you can’t breathe. So when they need to, you
have them actually take their Albuterol inhaler or one
of the rescuers prior to doing their relaxation
techniques. Do not tell the child to
stop using medications if they need them,
especially with the exercises. And when you develop
a plan with the child about practicing
these techniques. And he or she should
be in quiet place with privacy when practicing. And ask the child where and
when they might practice because they’ll come up with
all kinds of crazy ideas about when they’re
going to do it and how they’re going to do it. And so some of the images that
came up — – you can imagine, this is a little child
that was having problems with the breathing, it was
like a fish out of water. I think it was either an
advertisement I think I saw on TV last night where they
have a fish that’s like flopping around on the ground and it shows you like,
they can’t breathe. And they give him the medication
of course and throw it back in the water and it
swims away, you know. But you could see if
you just do that image without the medication, it
could also be very effective. You can have flowers
opening up and closing. These are ones that
people have told me about. We had a big fire in
Tucson when I was there. And the whole Catalina
Mountains were on fire for about two months. So one person was telling
me about their asthma, it felt like their whole life, like their whole
chest was burning up. And so that was one
thing which they gave. This is like a fireworks display
about trying to open up things and it gets much better. You can see an ice pick in the
throat is always a popular one. Darth Vader was very popular
for a while [raspy noises]. The elephant that pushes
on your chest, the giant, the giraffe with
the very long neck, these are all very powerful
images that kids came up with while I was
talking to them. And so that’s kind of my talk. This is one that I actually
used to put in as a joke. But actually, have
people seen this? This is not a joke. This is one that just came out. It just came out on the
market just about a month ago. It’s Aeroshot. You can see it here
it says “Pure energy. Dry energy shot dietary
supplement. Breathable energy
anytime, anyplace.” It’s actually caffeine
that you [sucking noise]. It’s about the size
of a lipstick. And so the FDA did not let
this one get past them. They saw this one. Now they’re saying, “Well
you’re really not supposed to inhale it.” But this is after it just
came out on the market, just in the last couple weeks. And so it’s being
stopped by the FDA. So this is one that people came
up with the idea, it’s like, “Well you don’t want
to drink your caffeine, we’ll just give it to
you in an inhaler.” [Sound] Take a shot
and it’s about the same as a strong cup of coffee. So thanks and if you have
any questions let me know. Applause.

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