lifestyle medicine

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A peer-reviewed journal • nov/dec 2009 • VOL. 15, NO. 6 • $6.95
YOGA FOR CHRONIC LOW BACK PAIN • LOMI LOMI: A MASSAGE WITH MOVEMENTS
CAM WORKSHOP FOR MEDICAL STUDENTS • TREATING THE CAUSES OF DISEASE
PUTTING HEALING INTO HEALTHCARE REFORM • YEAR-END INDEX
ANTHROPOSOPHIC MEDICINE • CONVERSATIONS/BENJAMIN KLIGLER, MD
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nov/dec 2009, VOL. 15, NO. 6
TABLE OF CONTENTS
perspectives
8
Putting Healing Into Healthcare Reform: Will Physicians and Healthcare
Practitioners Lead?
Wayne B. Jonas, MD; David P. Rakel, MD
12
Lifestyle Medicine: Treating the Causes of Disease
Mark A. Hyman, MD; Dean Ornish, MD; Michael Roizen, MD
ORIGINAL RESEARCH
18
Yoga for Chronic Low Back Pain in a Predominantly Minority Population: A Pilot
Randomized Controlled Trial
Robert B. Saper, MD, MPH; Karen J. Sherman, PhD, MPH; Diana Cullum-Dugan, RD, LDN, RYT;
Roger B. Davis, ScD; Russell S. Phillips, MD; Larry Culpepper, MD, MPH
30
A Complementary and Alternative Medicine Workshop Using Standardized Patients
Improves Knowledge and Clinical Skills of Medical Students
Andrew R. Hoellein, MD, MS; Charles H. Griffith, III, MD, MSPH; Michelle J. Lineberry, MA, CCRP;
John F. Wilson, PhD; Steven A. Haist, MD, MS
narrative reviews
38
Temporal Bone Motion Asymmetry as a Cause of Vertigo: The Craniosacral Model
Dave Christine, CST
44
Lomi Lomi as a Massage With Movements: A Conceptual Synthesis?
Paul Posadzki, PhD; Toby O. Smith, MSc; Pawel Lizis, PhD
hypothesis
52
2
Clinical Research in Anthroposophic Medicine
Harald Johan Hamre, Dr med; Helmut Kiene, Dr med; Gunver Sophia Kienle, Dr med
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Table of Contents
conversations
58
Benjamin Kligler, MD: Advancing the Cause of Healing-oriented Medicine
departments
14
70
78
78
78
80
Errata
Author and Subject Index: Volume 15, 2009
Classifieds
Conference Calendar
Advertisers Index
Resources
in future issues
• Efficacy of Black Cohosh–containing Preparations on Menopausal Symptoms: A Meta-analysis
• The Effect of a Contemplative Self-healing Program on Quality of Life in Women With Breast Cancer
and Other Gynecologic Cancer
• Acupuncture for Essential Hypertension: A Meta-analysis
• Acupoint Electrical Stimulation Reduces Acute Postoperative Pain in Surgical Patients With Patientcontrolled Analgesia
• Therapeutic Value of Laughter in Medicine
• Homeopathy in Cancer Care
• Wet Cupping Therapy for Treatment of Herpes Zoster: A Systematic Review of Randomized
Controlled Trials
about
the
cover
Fertility dolls, known as akuabas, stand side by side in this charming painting by Godwin Atta Geoman. Childless
women hold great faith in their powers and often carry a doll with them until they become pregnant. The akuaba
is also a symbol of beauty and wisdom. “They sing in rhythm,” the artist says.
Rhythms. Acrylic on canvas, 27.6" x 39.8", Godwin Atta Geoman. Godwin’s paintings can be viewed at www.novica.com.
ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE (ISSN 1078-6791) is published bimonthly (January, March, May, July, September, November) by InnoVision
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Table of Contents
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EDITOR in chief
David Riley, MD
EDITORs
Christine L. Girard, ND • Jason Hao, DOM • Michele Mittelman, RN, MPH
CONTRIBUTING EDITORs
Michael Balick, PhD
Jeffrey Bland, PhD
Marc David
Mark A. Hyman, MD
Roberta Lee, MD
Melvyn R. Werbach, MD
Editorial Board
Sidney MacDonald Baker, MD
Co-Chairman of the DAN!
Advisory Board
Elizabeth Ann Manhart Barrett, RN, PhD, FAAN
Hunter College of CUNY
Ellen Kamhi, PhD, RN
Stony Brook University
Ted Kaptchuk, OMD
Harvard Medical School
Brent A. Bauer, MD
Mayo Clinic
Stanley Krippner, PhD
Saybrook Graduate School and
Research Center
Harriet Beinfield, LAc
Chinese Medicine Works
George Lewith, MD, FRCP
University of Southampton
William Benda, MD
University of California
San Francisco
Peter Libby, MD
Brigham and Women’s Hospital
Harvard Medical School
Mark Blumenthal
American Botanical Council
Tieraona Low Dog, MD
University of Arizona
Ian Coulter, PhD
RAND; UCLA; Samueli Institute;
Southern University of Health Sciences
Victoria Maizes, MD
University of Arizona
Joel S. Edman, DSc, FACN
Jefferson-Myrna Brind Center of
Integrative Medicine
Harley Goldberg, DO
Kaiser Permanente
Pamela Miles, Reiki master
Institute for the Advancement of Complementary
Therapies (I*ACT)
Dean Ornish, MD
Preventive Medicine Research Institute,
University of California, San Francisco
Joseph E. Pizzorno, ND
President Emeritus, Bastyr University and
President, SaluGenecists, Inc
Anthony L. Rosner, PhD, LLD (Hon)
Parker College of Chiropractic
Robert B. Saper, MD, MPH
Boston University Medical Center
Betsy B. Singh, PhD
Medicus Research, LLC
Leanna Standish, ND, PhD, LAc
Bastyr University
Bill Manahan, MD
American Holistic Medical Association
Woodson C. Merrell, MD
Continuum Center for Health and Healing,
Beth Israel Medical Center
Eugene Taylor, PhD
Saybrook Graduate School
Harvard University
Roeland van Wijk, PhD
International Institute of Biophysics, Germany
Managing Editor, SUZANNE SNYDER • Creative Director, LEE DIXSON • Circulation Director, NICK COLLATOS • Editorial Coordinator, ANNE LANCTÔT
E-mail: [email protected] • Web: www.alternative-therapies.com
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perspectives on healthcare reform
PUTTING HEALING INTO HEALTHCARE REFORM:
WILL PHYSICIANS AND HEALTHCARE
PRACTITIONERS
LEAD?
Wayne B. Jonas, ; David P. Rakel,
MD
Wayne B. Jonas, MD, is president and chief executive officer of
Samueli Institute, Alexandria, Virginia, and professor of family
medicine, Georgetown University, Washington, DC. David P.
Rakel, MD, is director of the University of Wisconsin Integrative
Medicine and assistant professor, Department of Family
Medicine, University of Wisconsin School of Medicine and
Public Health, Madison. (Altern Ther Health Med. 2009;15(6):8-9.)
illiam James, founder of modern psychology, was one of the most brilliant scientific
thinkers of the last century. As professor of
Psychology at Harvard University, he continuously showed both the curiosity and the
courage to evaluate new and emerging concepts and discern
their importance. A favorite quote from James comes from 100
years ago:
W
Round about the accredited and orderly facts of every science
there ever floats a sort of dust-cloud of exceptional observations, of occurrences minute and irregular and seldom met
with, which it always proves more easy to ignore than to attend
to. . . . Anyone will renovate his science who will steadily look
after the irregular phenomena, and when science is renewed, its
new formulas often have more of the voice of the exceptions in
them than of what were supposed to be the rules.
To modern-day biomedicine, the importance of “healing” and
“caring” have remained in Dr James’s dust cloud. Is it possible that
“healing” and “caring” could emerge from that cloud and sow the
seeds of true healthcare reform? Could they become the rules?
So far, the parameters of healthcare reform discussions
revolve around insurance coverage and access to our current system. As exciting as this opportunity is and as notable as these
efforts are, they will not be able to accomplish the central goals of
healthcare delivery—the creation of health and the delivery of
care. That is because the core requirements for creating health and
delivering care are largely absent from the discussion. They have
been left on the periphery.
Healthcare reform is currently “medical treatment system
reform” of a system that does not deliver health, especially for
what it costs. The facts are well known and no longer debated. In
8
MD
the United States, we pay almost twice as much for healthcare as
any other country in the world and yet by almost all indices lag far
behind in health. And our system is not producing health compared to other countries that spend much less.1 Thus, it’s not a
health system. The creation of health and the management of disease are both important, but currently the disease-focused model
attracts the majority of healthcare funding.
Recently, a coalition of insurers, physicians, pharmaceutical
companies, and others who are at the heart of our medical treatment system have vowed to cut costs and improve quality. Though
the quality issues are a bit vague, the cost cutting is said to be the
equivalent of a 1.5% reduction in the growth rate in healthcare
costs.2 Increased efficiency in system management has been tried
before. A reduction in the margin of cost increase—that is, a
slightly flatter rise in the cost increase slope—does not promote a
transformation nor will it produce the 2 core elements that we are
seeking: health and care.
The irony is that the pillars of human flourishing are already
well known and grounded in good science and evidence. These are
social integration, stress management, a balance of exercise and
rest, and appropriate exposure to a clean environment including
no smoking, no or moderate alcohol consumption, and not being
exposed to toxic chemicals or a poor diet. We now know that these
four pillars—the social, psychological, physical, and environmental factors—are major contributors in up to 70% of chronic diseases.3 Thus, they form the foundation for both prevention of chronic
disease and its management once it is developed. If the health
reformers are looking to get the biggest “bang for their buck” both
in the prevention and management of chronic disease, they need
look no further than delivering these 4 pillars.
In addition, we do not have a care system. While individual
practitioners are often compassionate and kind, the system itself
treats patients like a commodity. Patient needs are no longer front
and center in healthcare. As with health, we already know how to
create a system that cares for suffering people. Since Florence
Nightingale, nurses have developed detailed models of caringbased medicine accompanied by not only theories, but a science
and a practice.4 These principles, too, have largely sat on the sidelines of biomedicine and are not part of the current healthcare
reform debate.
Of course, the key to effective healthcare delivery is in the
term delivery. To bring healing back into healthcare, we must
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Putting Healing Into Healthcare Reform
have a system that provides the tools and practices necessary to
make healing happen. Right now it does not do this effectively. If
you look at the top 5 health-producing behaviors (not smoking,
adequate exercise, a healthy diet, stress management, and early
disease detection) only 2% to 4% of the population engages in all
of them.5 The issue is not about science. It is not about the facts
of what we need to do to reduce costs and improve health; it is
about the delivery. We need a system, a culture, and an industry
that can create healing, that has salutogenesis as its primary
focus and wellness as its primary goal. We need “A Wellness
Initiative for the Nation.”6
As in all such cultural change movements, leadership is crucial. We need the innovators who will reach out and grab the concepts of health and caring that are now sitting out in the periphery
and bring them into the mainstream. We need the advocates—
the ones who are passionate enough about the creation of health
and care to make it a part of their daily practice—both personally
and professionally. We need the “avatars”—the information systems that incorporate what we already know about health creation into a format and process that shows us how. We need the
industry—producing the tools and technologies for a wellness
system as powerful and as vast as the disease treatment system we
currently have. Imagine a system that has expertise in the creation
of health. What would it look like, and what kind of professionals
would be needed for it to succeed?
Our question to physicians and healthcare practitioners is
this: Will we be the leaders that put healing into healthcare
reform? We can do this if we are willing to create integrated models of quality and low-cost healing within the mainstream. We
must go beyond the promotion of our professions and join others
who share the common values of health, healing, wellness, and
caring; to become the leaders of a true healthcare reform—in our
practice, in our research, in our teaching, in our community, and
in local and national governments. The time has come for physicians and healthcare practitioners to cultivate paradigms and
practices that will allow healing to reemerge from Dr James’s “dust
cloud of exceptional observations” and become new rules of our
healthcare system for the 21st century.
Acknowledgments
Thanks to the leaders in healthcare who have started and
who hold and deliver the core values of medicine and healing
every day.
REFERENCES
1. World Health Organization. The World Health Report 2000: Health Systems: Improving
Performance. Geneva, Switzerland: World Health Organization; 2000.
2. Executive Office of the President Council of Economic Advisors. The Economic Case for
Health Care Reform: Executive Summary. Available at: http://www.whitehouse.gov/assets/
documents/CEA_Health_Care_Report.pdf. Accessed July 12, 2009.
3. McGinnis JM, Russo P, Knickman J. The case for more active policy attention. Health Affairs.
2002;21(2):78-93.
4. Watson J. Nursing the Philosophy and Science of Caring. Revised New Edition. Boulder, CO:
University Press; 2008.
5. Reeves MJ, Rafferty AP. Healthy lifestyle characteristics among adults in the United States,
2000. Arch Intern Med. 2005;165(8):854-857.
6. The Samueli Institute. The Wellness Initiative for the Nation. Available at; http://www.siib.
org/news/news-home/press-releases/112-SIIB.html. Accessed April 20, 2009.
Putting Healing Into Healthcare Reform
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NUTRIENTS
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perspectives on healthcare reform
LIFESTYLE MEDICINE: TREATING THE
CAUSES OF DISEASE
Mark A. Hyman, ; Dean Ornish, ; Michael Roizen,
MD
Mark A. Hyman, MD, is a contributing editor of Alternative
Therapies in Health and Medicine. He recently launched the
Functional Medicine Foundation, based in New York, New
York, to promote awareness of, fund research on, and educate
the public about functional medicine. Dean Ornish, MD, is
clinical professor of medicine at the University of California,
San Francisco. Michael Roizen, MD, is chief wellness officer
and chair of the Wellness Institute at Cleveland Clinic, Ohio.
(Altern Ther Health Med. 2009;15(6):12-14.)
ecently, at a small gathering in Martha’s Vineyard
in support of the Robert F. Kennedy Center for
Justice and Human Rights, Larry Summers, PhD,
economist and director of the White House’s
National Economic Council, spoke about our narrow escape from economic depression. Dr Summers also
addressed the even larger impending risks to our economy if the
costs of healthcare are not successfully addressed now. He was
asked how we could control these costs without tackling the
root causes of the problem, the fact that most of the chronic diseases that affect 160 million Americans and account for 78% of
our healthcare costs are caused by lifestyle and environmental
factors—namely our diet, sedentary lifestyle, smoking, chronic
stress, and environmental toxins.
But most believe that doctors don’t “do” lifestyle. Dr
Summers dismissed “lifestyle” as a community and public health
issue that was already included in the current plan. He didn’t
understand that physicians can and must practice clinical lifestyle medicine to effectively treat disease and dramatically reduce
healthcare costs. Lifestyle factors leading to chronic diseases such
as heart disease, diabetes, obesity, and cancer are the domain of
doctors and not merely a “public health problem.”
Lifestyle is not only a public health issue; it is also a medical
and clinical care issue. Lifestyle medicine is not just about preventing chronic disease but also about treating it, often more
effectively and less expensively than relying only on drugs and
surgery. Nearly all the major medical societies recently joined in
publishing a review of the scientific evidence for lifestyle medicine both for the prevention and treatment of chronic disease.1
There is strong evidence that this approach works and saves
money. Unfortunately, insurance doesn’t usually pay for it. No
one profits from lifestyle medicine, so it is not part of medical
R
12
MD
MD
education or practice. It should be the foundation of our healthcare system.
For example, the recent “EPIC” study published in the
Archives of Internal Medicine studied 23 000 people’s adherence to
4 simple behaviors (not smoking, exercising 3.5 hours a week,
eating a healthy diet [fruits, vegetables, beans, whole grains,
nuts, seeds, and limited amounts of meat], and maintaining a
healthy weight [BMI <30]). In those adhering to these behaviors,
93% of diabetes, 81% of heart attacks, 50% of strokes, and 36% of
all cancers were prevented.2
This study is only one among a large evidence base documenting how lifestyle intervention is often more effective in
reducing cardiovascular disease, hypertension, heart failure,
stroke, cancer, diabetes, and all-cause mortality than almost any
other medical intervention.1 It is because lifestyle addresses not
only risk factor modification or reduction. Our lifestyle and environment influence the fundamental biological mechanisms leading to disease: changes in gene expression, which modulate
inflammation, oxidative stress, and metabolic dysfunction.
The distinction between risk factors and causes is an important one. 3 High blood pressure, dyslipidemia, and elevated
C-reactive protein or glucose are not in and of themselves the real
causes of chronic disease but simply surrogate markers that are
the effects of environmental toxins, what we eat, how much we
exercise, and how we respond to stress.
The future of medical care must be to transform the general
lifestyle guidance (eat a healthy diet, exercise regularly) that many
physicians try to provide to their patients in individually tailored
lifestyle prescriptions for both prevention and treatment of chronic diseases. Lifestyle is the best medicine when applied correctly.
“Prevention” therapies as written into current healthcare
bills are public health– and community-based wellness initiatives
or payment for early detection of disease with mammograms,
colonoscopies, and other screening tests. As the Congressional
Budget Office recently indicated, early detection without treating
the major underlying causes of chronic diseases—our lifestyle
choices—may actually add to costs.
For example, a mammogram does not prevent breast cancer; it may find it sooner, when it is more easily treated, but hundreds or thousands of women must be tested to find 1 incidence
of cancer. The argument for this type of “prevention” is necessary
and moral but not economic.
Health insurance reform is important, but it is insufficient.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Lifestyle Medicine: Treating the Causes of Disease
We need healthcare reform. We need to change the content and
not just the financing and coverage of healthcare. We must change
not only the way we do medicine, but the medicine we do.
The center of the healthcare debate must change to what is
covered, not just who is covered, if we are to make current treatments more effective and less costly.
The lifestyle factors leading to chronic disease are the
domain of doctors and not just a “public health problem.”
Doctors must “do” lifestyle medicine and receive adequate reimbursement; otherwise, the cost of chronic disease will bankrupt
Medicare by 2017.4
TREATING CAUSES RATHER THAN RISK FACTORS
Let’s circle back to the flaw in treatment of risk factors and
not causes. Typically doctors treat “risk factors” for disease such
as giving a lifetime’s worth of medications to lower high blood
pressure, elevated blood sugar, and high cholesterol. These, however, do not treat the underlying causes of those risk factors:
what and how much we eat, whether we smoke, how often we
exercise, how we manage stress, and the effects of environmental
toxins. Disregarding the underlying causes and treating only risk
factors is somewhat like mopping up the floor around an overflowing sink instead of turning off the faucet, which is why medications usually have to be taken for a lifetime. When the
underlying lifestyle causes are addressed, patients often are able
to stop taking medication (under their doctor’s supervision, of
course). Likewise, they often can avoid surgery as well.
Presently, according to the American Heart Association, 1.3
million coronary angioplasty and 448 000 coronary bypass operations are performed annually at a cost of more than $100 billion. 5 Despite these costs, many studies, including one last
month in The New England Journal of Medicine, reveal that angioplasties and stents do not prolong life or even prevent heart
attacks in stable patients (ie, 95% of those who receive them6).
Coronary bypass surgery prolongs life in less than 2% to 3% of
patients who receive it.7
In contrast, the INTERHEART study, published in The
Lancet in 2004, followed 30 000 people and found that changing
lifestyle could prevent at least 90% of all heart disease.8
Think about it. Heart disease accounts for more premature
deaths and costs Americans more than any other illness and is
almost completely preventable simply by changing diet and lifestyle. The same lifestyle changes that can prevent or even reverse
heart disease can prevent or reverse many other chronic diseases
as well.
Medicare and insurance companies currently pay billions of
dollars every year for surgical procedures such as angioplasties and
bypass surgeries. These are high-risk, invasive, expensive procedures fraught with complications, and they are largely ineffective.
In the large ACCORD study of more than 10 000 diabetics,
aggressive blood sugar lowering with medication actually caused
deaths.9 High blood sugar is a side effect of poor lifestyle choices. The treatment isn’t insulin to lower blood glucose, but healthy
dietary choices, exercise, stress management, and not smoking.
Lifestyle Medicine: Treating the Causes of Disease
The Diabetes Prevention Program Research Group study showed
that lifestyle changes are even more effective than diabetes drugs
such as metformin in reducing the incidence of diabetes in people at high risk, with lower costs and fewer side effects.10
Lifestyle medical treatment, including personalized, sciencebased prescriptions for diet, exercise, and stress management,
however, are not reimbursed or are only partially reimbursed.
These therapies are low-risk and effective in reversing and preventing chronic diseases.
If we train and pay for doctors to learn how to help patients
address the real causes of disease with lifestyle medicine and not
just treat disease risk factors (simply the effects of poor lifestyle
choices) with medications or surgery, we can save almost $1.9
trillion over 10 years for just 5 major diseases: heart disease, diabetes, “pre-diabetes” or metabolic syndrome, and prostate and
breast cancer.*
Our nation is actively debating whether we can provide
access to healthcare for all Americans and reduce costs at the
same time. We cannot do either if we continue to provide the
same type of healthcare based primarily on treating disease with
medications and surgery rather than lifestyle medicine. Giving
47 million more people access to our current methods of treatment for chronic disease will surely cost more and offer less.
Many, including the head of the American Medical
Association, argue that lifestyle medicine is a social, community,
and public health issue, not a medical care issue. Real doctors
don’t “treat” patients with lifestyle medicine. While community
wellness programs and public health education do work (tobacco
use decreased by two-thirds since the 1950s; Americans reduced
dietary fat by 4% and increased carbohydrate consumption by 6%
on the urging of the misguided US Dietary guidelines of 1977;
and more people use seatbelts, sunscreen, and helmets),11 they
only go part way. Doctors need to go the rest of the way.
DOCTORS MUST LEARN AND PRACTICE LIFESTYLE
MEDICINE
The fundamental flaw in thinking in healthcare right now is
that doctors don’t “do” lifestyle medicine and that people don’t
change. In part that is true. Only 50% of patients take the drugs
their doctors recommend. The food and drug industry, however,
has been very successful in changing our habits for the worse.
The typical American now eats 680 more calories per day than
30 years ago, and 81% of the adult population takes at least 1
medication.12 Established financial interests drive research and
delivery of care based on medication and surgery. There are no
incentives to drive doctors to treat disease with lifestyle medicine. Changes in policy, reimbursement, research, education, and
clinical care encouraging doctors to “do” lifestyle medicine must
take center stage in healthcare reform.
You might argue that doing this for everyone may cost
*According to Cleveland Clinic estimates for the Take Back Your Health Act of
2009. Data were prepared by the clinic and presented to Congress by Drs Mark
Hyman, Dean Ornish, and Michael Roizen.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
13
more (and it might), so let’s begin with those who already have
chronic disease. Integrated healthcare teams led by physicians
practicing lifestyle medicine can save our healthcare system.
Presently, however, physicians lack training and financial incentives to help people learn how to eat a healthy diet, exercise, stop
smoking, manage their weight, or address the effects of environmental toxins. So they continue to do what they know how to do:
prescribe medication and perform surgery.
Personalized lifestyle medicine is a high-science, hightouch, low-tech, low-cost treatment that is more effective for the
top 5 chronic diseases than our current approaches. Yet is it not
taught in medical schools, practiced by physicians, or delivered
in hospitals or healthcare settings. In fact, this treatment, if
applied to all the patients with cardiovascular disease, diabetes,
metabolic syndrome (obesity), prostate cancer, and breast cancer
could reduce net health care expenditures $930 billion over 5
years and result in dramatically better health and quality of life.*
OPPORTUNITIES FOR CHANGE
On August 6, 2009, Senator Ron Wyden (D, Oregon) introduced new legislation, the Take Back Your Health Act (S. 1640)
that includes payment for intensive lifestyle medicine as treatments, not just prevention. This legislation has bipartisan cosponsorship by Senators John Cornyn (R, Texas) and Tom Harkin
(D, Iowa). We worked closely with these senators to help craft
this initiative. This pending legislation, or changes in Medicare
policy, can make it feasible for intensive lifestyle treatments to
take hold in medical care. It will reinvigorate primary care medicine and drive the transformation of existing healthcare institutions, medical schools, postgraduate education, and insurers to
meet the demand for interventional lifestyle treatment of chronic
disease. It will induce doctors to learn and practice lifestyle medicine both because it works better for their patients and physicians will be paid to do it. It will support the development of a
wellness- and health-based economy rather than one based on
sickness and chronic disease.
If lifestyle medicine becomes central to the practice of medicine,
our sick care system will be transformed into a healthcare system.
REFERENCES
1. American College of Preventive Medicine. Lifestyle Medicine—Evidence Review. June 30,
2009. Available at: http://www.acpm.org/LifestyleMedicine.htm. Accessed September
18, 2009.
2. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into
Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169(15):1355-1362.
3. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors:
lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031-3038.
4. Samuelson RJ. Let them go bankrupt, soon. Solving Social Security and Medicare.
Newsweek. 2009 Jun 1;153(22):23. Available at: http://www.newsweek.com/id/199167.
Accessed September 23, 2009.
5. Ornish D. Intensive lifestyle changes and health reform. Lancet Oncol. 2009;10(7):638-639.
6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Investigators. Impact of optimal medical therapy with or without percutaneous coronary intervention on long-term
cardiovascular end points in patients with stable coronary artery disease (from the
COURAGE Trial). Am J Cardiol. 2009;104(1):1-4.
7. Morrison DA, Sacks J. Balancing benefit against risk in the choice of therapy for coronary artery disease. Lesson from prospective, randomized, clinical trials of percutaneous coronary intervention and coronary artery bypass graft surgery. Minerva
Cardioangiol. 2003;51(5):585-597.
8. Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the
INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952
9. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller
ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J
Med. 2008;358(24):2545-2559
10. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program
Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
11. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors:
lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031-3038.
12. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of
medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287(3):337-344.
ERRATA
North American Research Conference Abstracts
In each of the following abstracts that were published in
our May/Jun issue in partnership with the Consortium of
Academic Health Centers for Integrative Medicine
(CAHCIM), an author was mistakenly excluded from the listing. The corrected listings appear below.
3156
Poznanski A, Lapides J, Hsu M, Gracely R, Clauw D, Harris R.
Differences in central neural pain processing following acupuncture and sham acupuncture therapy in fibromyalgia (FM).
University of Michigan Medical School, 24 Frank Lloyd
Wright Drive, Ann Arbor, MI 48106
[email protected]
Altern Ther Health Med. 2009;15(3):S120.
2975
Shin S, Tsutomo K, Sei S.
Anti-obesity effect by a newly developed Chinese Qi-gong
meridian therapy.
Japan Chinese Medical Qigong Diet Association, Tokyo
150-0002, Japan
[email protected]
Altern Ther Health Med. 2009;15(3):S122.
CAHCIM regrets the errors.
Probiotics for Preventing Necrotizing Enterocolitis
The byline for the article, “The effect of probiotics on
preventing necrotizing enterocolitis in premature babies,”
which appeared on page 18 of our Jul/Aug issue (Altern Ther
Health Med. 2009;15(4):18-20) should have read “Eric
Manheimer, MS; Brian Berman, MD; Gunn Vist, PhD; Claire
Glenton, PhD.”
*According to Cleveland Clinic estimates for the Take Back Your Health Act of
2009. Data were prepared by the clinic and presented to Congress by Drs Mark
Hyman, Dean Ornish, and Michael Roizen.
14
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
The authors regret the oversight.
Lifestyle Medicine: Treating the Causes of Disease
AVIPAXIN
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Changes in mood and mental health are frequently associated with proinflammatory cytokines that trigger imbalances in certain neurotransmitters.
How Does Avipaxin Work?
Neuro-EndoImmune
Modulator
Avipaxin supports normal brain function by utilizing acetylcholine to
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binds to activated white blood cells, attenuating their pro-inflammatory
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* Percent Daily Values (DV%) are based on a 2,000
calorie diet.
† Daily Value (DV) not established.
Other Ingredients: Magnesium Stearate and Vegetable Cellulose
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Does not contain wheat, corn, salt, sucrose, starch, yeast,
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Contains Lecithin from soy.
Avipaxin contains:
• Huperzine A, a potent inhibitor of acetylcholinesterase, the enzyme
that metabolizes acetylcholine
• -Glyceryl Phosphoryl Choline ( -GPC) which supplies
choline for acetylcholine synthesis
• Acetyl-L-Carnitine which supplies an acetyl group for
acetylcholine synthesis
Avipaxin supports acetylcholine levels, leading to
a down-regulation of pro-inflammatory cytokines
and a subsequent improvement of neurotransmitter
concentrations2.*
1. Pavlov V, Tracey K et al., Molecular Medicine 2003;9:125-134.
2. Thayer J, Fischer J. J Intern Med 2009;265:439-447.
For more information on Avipaxin,
visit www.avipaxin.com
or call 888-342-7272.
Improving Health Through The Nervous System
*These statements have not been evaluated by the Food and Drug Administration.
This product is not intended to diagnose, treat, cure, or prevent any disease.
THANK YOU
Alternative Therapies in Health and Medicine is recognized as the premier journal in the field of complementary and alternative medicine. In 2006, 2007, and 2008, ATHM had the highest impact factor ranking of any independently published peer-reviewed CAM journal in the United States—meaning that its research articles were cited more frequently than any other journal’s in the field. These
achievements are due in large part to the dedication and hard work of our peer reviewers. Thank you to all of the peer reviewers who
reviewed articles that were published in 2009.
Lise Alschuler, ND, FABNO
Midwestern Regional Medical Center,
Cancer Treatment Centers of America
Carol Ardman
New York, New York
Harriet Beinfield, LAc
Chinese Medicine Works
Mark Blumenthal
American Botanical Council
Lisa Conboy, MA, MS, ScD
Osher Institute,
Harvard Medical School
Paula Gardiner, MD, PhD
Boston University
Mary Jane Hanson, PhD, CRNP, RN, CS
University of Scranton
Cheryl Hawk, DC, PhD
Cleveland Chiropractic College
Randy A. Jones, PhD
University of Virginia School of Nursing
Ellen Kamhi, PhD, RN
Stony Brook University
16
Kathy Kapps, CMT, Dipl AB
Berkeley, California
Satya P. Rao, PhD, CHES
New Mexico State University
Kathi Kemper, MD, MPH
Wake Forest University School of Medicine
Lawrence D. Rosen, MD
Oradell, New Jersey
Karen Lawson, MD
University of Minnesota
Anthony L. Rosner, PhD, LLD (Hon)
Parker College of Chiropractic
DeAnn Liska, PhD
Kellogg Company
Alexander G. Schauss, PhD
AIBMR Life Sciences, Inc
Andrew F. Long, MPhil, MSc
University of Leeds
Mark A. Schroll, PhD
Beatrice, Nebraska
Tieraona Low Dog, MD
University of Arizona
Betsy B. Singh, PhD
Medicus Research, LLC
Holly Lucille, ND, RN
Beverly Hills, California
Suzanne Steinbaum, MD
Lenox Hill Hospital
Deanna Minich, PhD, CN
Metagenics
Melvyn R. Werbach, MD
Tarzana, California
Lakshmi Mishra, PhD
National Institute of Ayurveda
Kristine Westrom, MD
Northwestern Health Sciences University
Stephen Perlstein, DC
Santa Fe, New Mexico
Joanne L. Perron, MD, FACOG
Pebble Beach, California
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Thank you
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original research
YOGA FOR CHRONIC LOW BACK PAIN IN A
PREDOMINANTLY MINORITY POPULATION:
ARobert
PILOT
RANDOMIZED
CONTROLLED
TRIAL
B. Saper, ,
; Karen J. Sherman,
,
; Diana Cullum-Dugan, ,
, ; Roger B. Davis, ;
MD MPH
PhD MPH
RD LDN RYT
ScD
Russell S. Phillips, MD; Larry Culpepper, MD, MPH
Background • Several studies suggest yoga may be effective for
chronic low back pain; however, trials targeting minorities have
not been conducted.
Primary Study Objectives • Assess the feasibility of studying yoga
in a predominantly minority population with chronic low back
pain. Collect preliminary data to plan a larger powered study.
Study Design • Pilot randomized controlled trial.
Setting • Two community health centers in a racially diverse
neighborhood of Boston, Massachusetts.
Participants • Thirty English-speaking adults (mean age 44 years,
83% female, 83% racial/ethnic minorities; 48% with incomes
≤$30 000) with moderate-to-severe chronic low back pain.
Interventions • Standardized series of weekly hatha yoga classes
for 12 weeks compared to a waitlist usual care control.
Outcome Measures • Feasibility measured by time to complete
enrollment, proportion of racial/ethnic minorities enrolled,
retention rates, and adverse events. Primary efficacy outcomes
were changes from baseline to 12 weeks in pain score (0=no pain
Robert B. Saper, MD, MPH, is an assistant professor and director
of integrative medicine in the Department of Family Medicine,
Boston University School of Medicine and Boston Medical Center,
Massachusetts. Karen J. Sherman, PhD, MPH, is senior scientific
investigator at the Center for Health Studies, Group Health
Cooperative, Seattle, Washington. Diana Cullum-Dugan, RD,
LDN, RYT, is a yoga teacher in private practice in Watertown,
Massachusetts. Roger B. Davis, ScD, is associate professor in the
Division of General Internal Medicine and Primary Care, Beth
Israel Deaconess Medical Center, Boston, and director of biostatistics in the Division for Research and Education in
Complementary and Integrative Medical Therapies, Osher
Research Center, Harvard Medical School, Boston. Russell S.
Phillips, MD, is chief of the Division of General Internal Medicine
and Primary Care, Beth Israel Deaconess Medical Center, and
director of fellowship training in the Division for Research and
Education in Complementary and Integrative Medical Therapies,
Osher Research Center. Larry Culpepper, MD, MPH, is a professor
in and chairman of the Department of Family Medicine, Boston
University School of Medicine and Boston Medical Center.
18
to 10=worst possible pain) and back-related function using the
modified Roland-Morris Disability Questionnaire (0-23 point scale,
higher scores reflect poorer function). Secondary efficacy outcomes
were analgesic use, global improvement, and quality of life (SF-36).
Results • Recruitment took 2 months. Retention rates were 97% at
12 weeks and 77% at 26 weeks. Mean pain scores for yoga decreased
from baseline to 12 weeks (6.7 to 4.4) compared to usual care,
which decreased from 7.5 to 7.1 (P=.02). Mean Roland scores for
yoga decreased from 14.5 to 8.2 compared to usual care, which
decreased from 16.1 to 12.5 (P=.28). At 12 weeks, yoga compared
to usual care participants reported less analgesic use (13% vs 73%,
P=.003), less opiate use (0% vs 33%, P=.04), and greater overall
improvement (73% vs 27%, P=.03). There were no differences in
SF-36 scores and no serious adverse events.
Conclusion • A yoga study intervention in a predominantly minority population with chronic low back pain was moderately feasible
and may be more effective than usual care for reducing pain and
pain medication use. (Altern Ther Health Med. 2009;15(6):18-27.)
ow back pain is the most common cause of pain in the
United States1,2 resulting in substantial morbidity,3
disability,4,5 and cost to society.6,7 An estimated 5% to
10% of US adults experience chronic low back pain
(CLBP).1,2,5 Individuals from low-income minority
backgrounds with CLBP may be disproportionately affected due
to disparities in access to treatment. For example, minorities
have less access to analgesic prescriptions,8 surgery,9 and intensive rehabilitation.10
Many CLBP patients seek relief using complementary therapies such as yoga.11,12 Yoga originated over 2000 years ago in India
as a system of physical, moral, and spiritual practices.13 Hatha
yoga is one branch of yoga consisting of physical postures (asanas), breathing techniques (pranayama), and meditation.
Although yoga use by adults in the United States increased to
more than 6% in 2007,12,14,15 it is less common among minorities
and individuals with lower incomes or education.12,14 Several
studies of yoga for CLBP in predominantly white middle-class
populations suggest it may be effective for reducing pain and
improving function.16-20 A practice guideline from the American
L
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Yoga for Chronic Low Back Pain
College of Physicians and American Pain Society lists a specific
style of hatha yoga called Viniyoga as having fair evidence for a
moderate benefit for CLBP.21 The feasibility and effectiveness of
offering any style of yoga intervention in minority populations
with chronic low back pain has not been assessed, however. Our
objective, therefore, was to assess the feasibility of offering a
hatha yoga intervention for a predominantly minority population with CLBP and collect preliminary data in order to plan a
future adequately powered trial.
METHODS
Study Design and Setting
We conducted a pilot randomized controlled trial for adults
with chronic low back pain recruited from 2 community health
centers (CHCs) that serve a racially diverse, low-income neighborhood of Boston, Massachusetts. Participants were randomly
assigned to a standardized 12-week protocol of hatha yoga classes
or a usual care waitlist control group. We used computer-generated
permuted block randomization. Treatment assignments were
placed in opaque, sequentially numbered envelopes prepared by a
biostatistician (RBD) who had no contact with participants. The
study was approved by the Boston University Medical Center
Institutional Review Board and the CHCs’ research committees.
Study Participants
To recruit our target of 30 participants for this pilot study, we
posted flyers in exam rooms and waiting room areas in the CHCs
and surrounding community. A community newspaper and radio
station carried study advertisements. We informed providers and
staff members about the trial through presentations and e-mails.
Using the CHCs’ electronic medical records, we identified patients
seen in the last 2 years with a low back pain diagnosis and generated
recruitment letters for their providers to sign and send.
Participants needed to be 18 to 64 years old and have current
low back pain persisting ≥12 weeks. Mean pain intensity for the 2
weeks prior to enrollment needed to be ≥4 on a numerical rating
scale of 0 to 10. Sufficient understanding of English to follow class
instructions and complete surveys was required. Exclusion criteria included yoga use in the previous year; new pain medicine or
other low back pain treatments started within the previous month
or anticipated to begin in the next 6 months; pregnancy; back surgery in the previous 3 years; nonmuscular pathologies (eg, spinal
canal stenosis, spondylolisthesis, infection, malignancy, fracture);
severe or progressive neurological deficits; sciatica pain equal to
or greater than back pain; active substance or alcohol abuse; serious systemic disease, medical, or psychiatric comorbidities precluding yoga practice; active or planned worker’s compensation,
disability, or personal injury claims; and inability to attend classes
at the times and location offered.
Interested individuals were initially screened for eligibility
by telephone after oral informed consent was obtained. If individuals appeared eligible, they were invited to meet with research
staff. At the first meeting, we obtained written informed consent
to verify eligibility criteria and asked them to record their daily
Yoga for Chronic Low Back Pain
pain intensity for 2 weeks on an 11-point numerical rating scale.
Two weeks later at the second meeting, we confirmed their average weekly pain intensity was ≥4, collected baseline data, and
randomized them.
Yoga Intervention
We developed a reproducible standardized hatha yoga intervention for CLBP intended for individuals with little or no yoga
experience. We searched Medline, Alt HealthWatch, and
Cochrane for papers on yoga and low back pain. Non–peer
reviewed books, periodicals, and videos on yoga for low back
pain were identified through searching an online bookstore
(Amazon.com), an annotated bibliography,22 and websites on the
first 2 pages of a Google Internet search using keywords “yoga”
and “back pain.” We collected and distributed these materials to
an expert panel consisting of 2 national yoga experts, a yoga
instructor for the study (DCD), and the principal investigator
(RBS). Panel members had expertise in several popular styles of
hatha yoga including Anusara, Ashtanga, Iyengar, and Kripalu.
One member had special expertise in yoga programs for minority
women. Panel members reviewed the information before meeting in March 2006. At the meeting, they synthesized information
from the literature with their experience to draft a protocol that
was subsequently refined iteratively through discussion, consensus, and use in nonstudy yoga classes.
The final protocol consisted of 12 weekly 75-minute yoga
classes divided into four 3-week segments (Appendix Table and
Figure). Each segment was given a theme, such as “Listening to
the Wisdom of the Body” and “Engaging Your Power.” Each class
began and ended with Svasana, a relaxation exercise. Classes
included postures and breathing techniques. Each segment built
upon the previous segment. The protocol provided variations
and used various aids (eg, chair, strap, block) to accommodate
different abilities. A variety of world music was used during the
classes. Classes were limited to 8 participants, occurred at one
CHC, and were taught by a team of 2 female yoga instructors, 1
white and 1 African American. Both were registered yoga teachers with Yoga Alliance, and each had approximately 4 years of
teaching experience. Home practice for 30 minutes daily was
strongly encouraged. We provided participants with an audio CD
of the protocol; a portable CD player; a handbook describing and
depicting the exercises; and a yoga mat, strap, and block. The 2
national yoga experts from the panel observed several classes in
person to provide feedback to the instructors on accurate, effective, and safe protocol delivery.
Usual Care Control Group
Both groups continued to receive their routine medical care
and medications. The usual care control participants were
offered the yoga intervention after 26 weeks. Both groups
received an educational book used in previous low back pain
studies23 that describes self-care management strategies for low
back pain. Both groups were discouraged from starting any new
back pain treatments during the study.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
19
20
RESULTS
Feasibility Outcomes
Patient Recruitment and Retention
We received more than 200 inquiries about the study from
February to March 2007 (Figure 1). Over 2 months, we needed to
Enrollment:
Patients
Inquiries about study
(n=234)
Assessed for potential
eligibility (n=66)
Allocation:
Patients
Excluded (n=36)
Did not meet inclusion
criteria (n=33)*
Declined to participate (n=3)
Allocated to yoga (n=15)
Attended any classes (n=14)
Received self-care book (n=15)
Allocation:
Care providers
Randomized
(n=30)
Recruitment ended before
eligibility determined (n=168)
Centers (n=1) and yoga teachers (n=2)
performing the intervention
Number of patients treated by both
yoga teachers (n=14)
Not applicable
Follow-up:
Patients
Data Analysis
Baseline data for the 2 groups were compared using Student’s
t-test for continuous variables, Fisher’s exact test for dichotomous
variables, and chi-square test of independence for categorical variables. Feasibility outcomes were summarized with descriptive statistics. For the primary efficacy outcomes pain and function, we
calculated change scores by subtracting 12-week data from baseline. Change scores for each group had a non-normal distribution
and were therefore compared using the Wilcoxon Rank Sum test.
We also completed a post-hoc analysis of the proportion of individuals experiencing a minimal clinically significant decrease in the
primary outcomes at 12 weeks (≥2 points for pain28 and ≥30%
decrease from baseline for the Roland29) using Fisher’s exact test.
For the secondary efficacy outcomes, we compared change in
pain medication use between groups at 6 and 12 weeks using exact
logistic regression. Medication use was the dependent variable,
and baseline medication use and group assignment were the independent variables. Global improvement at 12 weeks was dichotomized into improved vs no change or worse. Proportions of
improved participants in the 2 groups were compared with Fisher’s
exact test. Change scores for the SF-36 physical and mental health
components were also compared with Wilcoxon Rank Sum.
All analyses used an intention-to-treat approach and a 2-sided
P criteria of <.05 for statistical significance. Missing data were
imputed using the last-value-carried-forward approach. We used
LogXact software (Cytel, Cambridge, Massachusetts) for logistic
regression analyses and SAS version 9.1 (SAS Institute, Cary, North
Carolina) for all others.
Lost to follow-up
12 weeks (n=0)
26 weeks (n=7)
Did not return calls or letters (n=4)
No phone (n=1)
Refused (n=1)
Moved (n=1)
Lost to follow-up
12 weeks (n=1)
26 weeks (n=0)
Analysis:
Patients
Data Collection
We collected baseline sociodemographic data and back pain
history including duration, sciatica, and previous treatments such
as physical therapy, epidural steroid injections, and CAM.
Outcome data were collected at 6, 12, and 26 weeks.
Feasibility outcomes related to recruitment (time to complete
enrollment, proportion of racial and ethnic minorities enrolled),
participant retention, adherence to treatment allocation (class
attendance, home practice, use of nonstudy treatments), and safety
were measured through weekly adverse event logs.
There were 2 primary outcomes of efficacy measured at 12
weeks: (1) average pain level for the previous week using an
11-point numerical rating scale (0=no pain to 10=worst possible
pain);24,25 and (2) back-related function using the modified RolandMorris Disability Questionnaire,26 a 23-item reliable validated
instrument measuring the number of activities of daily living limited due to back pain. Scores can range from 0 to 23 with higher
scores reflecting poorer back-related function.
Secondary efficacy outcomes included use of pain medication
during the preceding week; global improvement using a 7-point
Likert scale (0=extremely worsened to 6=extremely improved);
and health-related quality of life using the SF-36.27
Participants and yoga teachers could not be blinded to treatment allocation. All study participants met in person with unblinded research staff members to complete paper questionnaires at
baseline, 6, and 12 weeks. We also attempted to collect follow-up
data at 26 weeks. After completing each survey, participants
received honoraria for study participation and defraying transportation costs: $25 at baseline, $25 at 6 weeks, $50 at 12 weeks, and
$25 at 26 weeks. Blinded data-entry staff used double entry verification to minimize error.
Sample for analysis
6 weeks (n=14)
12 weeks (n=15)
26 weeks (n=8)
Sample for analysis
6 weeks (n=13)
12 weeks (n=14)
26 weeks (n=15)
Allocated to usual care waitlist
control (n=15)
Received self-care book (n=15)
*Reasons for exclusion were as follows: Low back pain (LBP) score <4 on a
0-10 numerical rating scale (n=9); sciatica pain equal to or greater than LBP
(n=8); age >65 years (n=4); yoga use in previous year (n=4); schedule conflicts (n=3); spinal canal stenosis (n=2); unwillingness to be randomized
(n=2); and pregnancy (n=1).
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
FIGURE 1 Participant Flow Diagram
Yoga for Chronic Low Back Pain
screen 66 individuals in the order they contacted us to enroll 30
participants. The most common reasons for exclusion were severe
sciatica and insufficient severity of low back pain. The Table
describes baseline sociodemographic and clinical characteristics of
the participants. Eighty-three percent were racial or ethnic minorities. A majority were female, unemployed, or working part-time.
Almost half had annual household incomes ≤$30 000 and publicfunded health insurance coverage. Previous practice of yoga was
rare. Mean pain and Roland scores for the study sample were high
and consistent with moderate-to-severe chronic low back pain.
Comorbidities such as osteoarthritis, obesity, diabetes, and depression were common (data not shown). No statistically significant
differences between groups at baseline were observed. Participant
retention was 97% at 12 weeks and 77% at 26 weeks. We were
unable to collect 26-week data from 7 members of the yoga group.
Treatment Adherence
Yoga participants attended a median of 8 classes (range 0-12),
and 13 practiced at least once at home. One participant was not
willing to attend any classes because of discomfort with groups but
agreed to practice at home. Another individual avoided the
Svasana component of the protocol due to a perceived conflict with
his religion (Jehovah’s Witness). Thirteen yoga participants completed a mean of 6 home practice logs showing on average 4 days
of home practice per week for 24 minutes per practice session. This
was similar to what they reported on the 12-week questionnaire: 4
days per week and 38 minutes per session.
During the 12-week intervention period, use of any nonstudy
treatments by yoga and control participants was 27% and 40%,
respectively (P=.70) and included mostly physical therapy and
acupuncture. Although no control group individuals reported
yoga use during the 12-week intervention period, 5 reported starting yoga during the follow-up period. Use of any nonstudy treatments during the 12-to-26-week follow-up period increased to
100% for the 7 yoga participants and 87% for the usual care participants, respectively, and included new medications, physical therapy, epidural steroid injections, acupuncture, and chiropractic.
Safety
One yoga participant reported transient worsening of low
back pain that improved after discontinuing yoga. No other significant adverse events were reported.
Primary Outcomes
Mean pain scores for yoga participants decreased 2.3 points
(SD 2.1) from baseline to 12 weeks compared to the control group,
which decreased 0.4 points (SD 1.8, P=.02, Figure 2). Mean Roland
scores for yoga participants decreased 6.3 points (SD 6.9) from
baseline to 12 weeks compared to the control group, which
decreased 3.7 points (SD 4.9, P=.28, Figure 3). The proportion of
yoga participants experiencing a minimal clinically significant
decrease in pain at 12 weeks was 67% vs 13% of control participants (OR 5.0, 95% CI 1.3-19.1, P=.008). For the Roland disability
measure, 67% of yoga participants vs 40% of the control group had
Yoga for Chronic Low Back Pain
TABLE Baseline Characteristics of 30 Individuals With Chronic Low
Back Pain Randomized to 12 Weeks of Yoga Classes or a Usual Care
Waitlist Control Group
Characteristic
Treatment Group
Yoga
(n=15)
Sociodemographics
Mean age (SD), years
Women, no. (%)
Highest level of education, no. (%)
High school graduate or less
Some college
College graduate
Race, no. (%)
White
Black*
Asian†
Native American
Hispanic, no. (%)
Non-white and/or Hispanic, no. (%)
Born outside United States, no. (%)
Annual household income, no. (%)
≤$10,000
$10 001-$30 000
$30 001-$50 000
>$50 000
Unknown
Employment, no. (%)
Full-time
Part-time
Unemployed due to back pain
Unemployed due to other causes
Health insurance, no. (%)
Private (HMO, PPO)
Public
Medicaid
“Free Care”‡
Medicare
None
Religious preference, no. (%)
Protestant§
Roman Catholic
Muslim
Santeria
Jehovah’s Witness
None or unknown
Total
(n=30)
Usual
Care
(n=15)
44 (13)
11 (73)
44 (11)
14 (93)
44 (12)
25 (83)
4 (27)
4 (27)
7 (46)
6 (40)
9 (60)
0
10 (33)
13 (43)
7 (24)
3 (20)
11 (73)
1 (7)
0
2 (13)
13 (87)
7 (47)
4 (27)
10 (66)
0
1 (7)
2 (13)
12 (80)
2 (13)
7 (24)
21 (70)
1 (3)
1 (3)
4 (13)
25 (83)
9 (30)
2 (13)
2 (13)
5 (33)
3 (20)
3 (20)
6 (40)
3 (20)
3 (20)
3 (20)
0
8 (27)
5 (17)
8 (27)
6 (20)
3 (10)
6 (40)
4 (27)
3 (20)
2 (13)
6 (40)
5 (33)
3 (20)
1 (7)
12 (40)
9 (30)
6 (20)
3 (10)
8 (53)
7 (47)
15 (50)
2 (13)
4 (27)
1 (7)
0
5 (33)
2 (13)
0
1 (7)
7 (23)
6 (20)
1 (3)
1 (3)
7 (47)
2 (13)
1 (7)
0
1 (7)
4 (26)
6 (40)
4 (27)
0
1 (7)
0
4 (26)
13 (44)
6 (20)
1 (3)
1 (3)
1 (3)
8 (26)
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
21
Yoga
(n=15)
Back Pain History
Initial onset >1 year ago, no. (%)
15 (100)
Current episode began >1 year ago, no. (%) 13 (87)
Pain radiates below knee, no. (%)
5 (33)
>45 days pain in past 3 months, no. (%)
13 (87)
>1 day of lost work in past month, no. (%)
4 (27)
>7 days of restricted activity in past
month, no. (%)
11 (73)
Back pain treatments previously used, no. (%)
Physical therapy
10 (67)
Exercise
10 (67)
Epidural steroid injections
2 (13)
Back surgery
0
Massage
10 (67)
Chiropractic
6 (40)
Acupuncture
3 (20)
Yoga
3 (20)
Baseline Outcome Measures
Mean pain score during past week
(11-point scale) (SD)
6.7 (1.9)
Mean Roland disability score
(23-point scale) (SD)
14.5 (5.0)
Use of pain medication in past week, no. (%)
Any pain medication
Nonsteroidal antiinflammatory drugs
Acetaminophen
Opiates
Muscle relaxants
Other pain medication
Mean SF-36 physical component
score (SD)
Mean SF-36 mental health component
score (SD)
Total
(n=30)
Usual
Care
(n=15)
6
4
2
15 (100)
11 (73)
7 (47)
8 (53)
3 (20)
30 (100)
24 (80)
12 (40)
21 (70)
7 (23)
9 (60)
20 (67)
12 (80)
14 (93)
5 (33)
2 (13)
10 (67)
6 (40)
5 (33)
1 (7)
22 (73)
24 (80)
7 (23)
2 (7)
20 (67)
12 (40)
8 (27)
4 (13)
0
0
6
12
Week
FIGURE 2 The x-axis is time from initiation of yoga classes. The y-axis is
the mean low back pain intensity in the previous week on an 11-point
numerical rating scale. The yoga group received hatha yoga classes weekly for 12 weeks. Both groups received an educational book on self-care
management of low back pain and continued their usual medical care. P
values for any difference in mean pain scores between groups (calculated
by comparing mean pain change scores from baseline using the
Wilcoxon rank sum test) are .25 and .02 at 6 and 12 weeks, respectively.
Yoga group
Usual care
20
16
12
7.5 (1.3) 7.1 (1.7)
16.1 (4.0) 15.3 (4.5)
10 (67)
4 (27)
3 (20)
2 (13)
1 (7)
2 (13)
11 (73)
5 (33)
4 (27)
2 (13)
3 (20)
3 (20)
21 (70)
9 (30)
7 (23)
4 (13)
4 (13)
5 (17)
40 (8)
34 (7)
37 (8)
47 (11)
45 (11)
46 (11)
There were no statistically significant differences (P<.05) between baseline
characteristics of the yoga and usual care waitlist control groups. SD indicates
standard deviation; SF-36, Short-form 36 Health Survey.
*The 21 black individuals in the sample included 15 African Americans and 6
Afro-Carribbeans (2 Jamaicans, 2 Haitians, 1 Barbadian, and 1 Trinidadian).
†Bangladeshi.
‡Funded by the Commonwealth of Massachusetts, Free Care is a managed
health plan that provided basic health insurance to uninsured low-income residents not meeting criteria for Medicaid.
§Protestant religions included Baptist, Episcopalian, Presbyterian, United
Methodist, and born-again Christian.
22
Yoga group
Usual care
8
Roland Disability Scale Score
Characteristic
Treatment
Group
10
Pain Score
TABLE Baseline Characteristics of 30 Individuals With Chronic Low
Back Pain Randomized to 12 Weeks of Yoga Classes or a Usual Care
Waitlist Control Group, continued
8
4
0
0
6
Week
12
FIGURE 3 The x-axis is time from initiation of yoga classes. The
y-axis is the modified 23-point Roland Disability Scale mean score.
Higher scores reflect worse back pain–related function. The yoga
group received hatha yoga classes weekly for the first 12 weeks of
the study. Both groups received an educational book on self-care
management of low back pain and continued their usual medical
care. P values for any difference in mean Roland Disability scores
between groups (calculated by comparing mean Roland change
scores from baseline using the Wilcoxon rank sum test) are .29 and
.28 at 6 and 12 weeks, respectively.
a minimal clinically significant decrease (OR 1.7, 95% CI 0.8-3.4,
P=.27). None of our results changed significantly when outcomes
were reanalyzed without imputing missing data.
Secondary Outcomes
Use of any pain medicines during the previous week by yoga
participants decreased from 67% to 13%, whereas use by usual
care participants did not change (P=.003, Figure 4). Whereas
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Yoga for Chronic Low Back Pain
70
Yoga
Percentage
60
50
40
*
30
20
†
10
*
*
*
0
Any pain medicine
NSAIDs
Acetaminophen
70
Muscle relaxants
Other
Opiates
Muscle relaxants
Other
Usual Care
60
Percentage
Opiates
50
40
30
20
10
0
Any pain medicine
NSAIDs
*P value <.05 for comparison between groups
†P value <.01 for comparison between groups
Acetaminophen
Baseline
6 Weeks
12 Weeks
FIGURE 4 The top and bottom panels show pain medication use by the yoga and usual care groups, respectively. For each medication category, use at baseline, 6, and 12 weeks is displayed. Bar heights reflect the percentage of participants reporting any use within the previous week. Pain medication use was compared between groups at 6 and 12 weeks using exact logistic regression with 6-week or 12-week medication use as the dependent variable and baseline medication use and group assignment as the independent variables. Examples of “other” types of pain medicine included tramadol, gabapentin, and amitryptiline.
opiate analgesic use by control participants during the 12th week
increased to 33%, it decreased to zero for yoga participants
(P=.04). Use of nonsteroidal antiinflammatory drugs and muscle
relaxants showed similar patterns. At week 12, 73% of the yoga
group compared to 27% of control participants reported global
improvement in back pain (P=.03). SF-36 scores at 12 weeks did
not differ significantly between groups.
Long-term Follow-up
The mean pain and Roland scores at 26 weeks for the 8 yoga
individuals we had data for were 3.9 (SD 0.6) and 6.6 (SD 2.6),
respectively. We were able to collect data at 26 weeks from all 15
usual care participants. Compared to their 12-week data, their
26-week mean pain and Roland scores decreased to 4.5 (SD 1.2)
and 8.3 (SD 2.9), respectively.
DISCUSSION
We found it was feasible to recruit and retain for 12 weeks a
sample of predominantly minority adults for a pilot randomized
controlled trial of a standardized hatha yoga intervention for
chronic low back pain. Adherence to treatment assignment dur-
Yoga for Chronic Low Back Pain
ing the 12-week intervention period was good, with no serious
adverse events. Yoga participants had statistically significant
greater reduction in pain intensity and pain medication use at 12
weeks compared to individuals receiving usual care only. Beyond
the 12-week intervention period, however, participant retention
was poor and use of nonstudy treatments was high.
Although several studies3,6,8,9,30 have demonstrated racial and
socioeconomic disparities in low back pain treatment and outcomes, few intervention studies for CLBP have targeted underserved populations. Our feasibility data illustrate some of the
opportunities and challenges of such studies. The large number
of respondents to our recruitment effort may reflect a significant
interest in and unmet need for low back pain treatment among
people living in these communities. This need may have contributed to impatience among the usual care group for their waitlist
yoga classes to start and thereby led to high use of nonstudy
treatments during the follow-up period. Basing the study in community health centers that were familiar and convenient to participants also may have facilitated recruitment. Obtaining
long-term follow-up data of almost half of the yoga group was not
possible, however, and may reflect loss of the regular structure
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
23
and social support provided by the yoga classes.
Our preliminary efficacy results are consistent with previous
yoga studies showing improvement of CLBP.16-20 Like our study,
most trials were randomized16-18,20; included usual care and/or
education controls16-18; employed a waitlist control design16,20; and
measured standard back pain research outcomes such as pain17-20
and function.16-18,20 An important difference between our trial and
prior studies is that our study included a more racially diverse
patient population with lower incomes and less education.
Furthermore, our participants reported considerably greater
pain and worse function than individuals in other trials. For
example, the largest study to date by Sherman et al enrolled a
predominantly white college-educated middle-class sample with
a mean baseline Roland score 7.2 points less than in our sample.17
Lastly, although prior yoga studies for CLBP also used a standardized yoga sequence, most used a specific yoga style such as
Viniyoga,17 Iyengar,12 or Anusara19 rather than the more generic
hatha yoga we employed. To date, no research suggests one yoga
protocol or style is superior to another for low back pain.
There are multiple limitations to our study. The usual care
group did not control for the increased attention and group support yoga participants may have received. These nonspecific
aspects may have played a significant role in yoga’s effect. Lack of
blinding and use of self-report measures may have further contributed to bias. The small sample size associated with our pilot
design limits our statistical power. Nonrandom distribution of
participant characteristics can also occur in small pilot trials.
Furthermore, the impact of honoraria payments on recruitment,
retention, and potential subject bias is uncertain. Regarding generalizability, it is unknown whether our findings can be replicated in other minority groups, multiple locations, nonresearch
yoga programs, and with different yoga teachers. In addition, our
findings apply only to patients with nonspecific CLBP as opposed
to excluded conditions such as sciatica or spinal canal stenosis.
Lastly, substantial loss to long-term follow-up in the yoga group
and use of many nonstudy treatments including yoga by the control group preclude any meaningful conclusions from the
26-week data. Strengths of our study, however, include the randomized design, standardized reproducible yoga intervention,
standard enrollment criteria and outcome measures used in
other CLBP trials,31 community-based setting, and recruitment of
a racial and socioeconomic diverse population with moderate-tosevere CLBP.
In summary, conducting a 12-week pilot randomized controlled trial of hatha yoga compared to usual care for an urban
English-speaking predominantly minority sample with CLBP was
moderately feasible. However, long-term retention and adherence
to treatment assignment was poor. Yoga was more effective than
usual care at least in the short term for reducing pain and pain
medication use. Opportunities for future yoga and low back pain
research in minorities include larger trials testing new strategies
for improving long-term retention, adherence, and outcomes;
comparing effectiveness and cost of yoga to other common back
pain treatments; and targeting non-English speakers.
24
Acknowledgments
The authors gratefully acknowledge the study participants; Deborah Neubauer, RYT, and Maya
Breuer, RYT, for assistance in designing the yoga protocol; Anna Dunwell, MFA, RYT, for helping
teach the yoga classes; Nadia Khouri, MPH, Florence Uzogara, MA, Surya Karri, MBBS, MPH,
Sasha Yakhkind, and Julia Keosaian for research assistance; and Stephen Tringale, MD, Tom
Powers, and the providers and staff of Codman Square Health Center and Dorchester House
Multiservice Center.
Support and Role of Sponsor
Dr Saper is supported by a Career Development Award (K07 AT002915-04) from the National
Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health
(NIH), Bethesda, Maryland. Dr Phillips is supported by a Mid-career Investigator Award
(5K24AT000589-08) from NCCAM, NIH. NCCAM had no role in the design and conduct of
the study; collection, management, analysis, and interpretation of the data; or preparation,
review, or approval of the manuscript for submission.
Data Access and Responsibility
Dr Saper had full access to all the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
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APPENDIX TABLE 12-week Standardized Hatha Yoga Protocol for the Treatment of Chronic Low Back Pain
Yoga Posture (Asana)
Total Classes
Incorporating Posture
Classes Incorporating Posture by Segment
Segment 1
Weeks 1-3
Segment 2
Weeks 4-6
Segment 3
Weeks 7-9
Segment 4
Weeks 10-12
Opening to
Something Greater
Listening to the
Wisdom of the Body
Engaging
Your Power
Bringing it
Home
Svasana relaxation and breathing exercises*
Yes
Yes
Yes
Yes
12
Knee to chest*
Yes
Yes
Yes
Yes
12
Knee to chest with twist*
Yes
Yes
Yes
Yes
12
Pelvic clocks*
Yes
Yes
Yes
Yes
12
Cat and dog pose (and modifications)*
Yes
Yes
Yes
Yes
12
Chair pose (and modified)*
Yes
Yes
Yes
Yes
12
Mountain pose*
Yes
Yes
Yes
Yes
12
Shoulder opener*
Yes
Yes
Yes
Yes
12
Half moon*
Yes
Yes
Yes
Yes
12
Child’s pose*
Yes
Yes
Yes
9
Cobra (original and modified)*
Yes
Yes
Yes
Yes
12
Bridge pose*
Yes
Yes
Yes
Reclining cobbler*
Yes
Yes
Yes
9
9
Downward-facing dog (and modified at wall)*
Yes
Yes
6
Triangle pose at wall
Yes
3
Locust pose
Yes
3
Reclining big toe pose
Yes
Yes
6
Warrior I pose
Yes
Yes
6
Yes
3
Downward-facing dog
Lunge with wall assist
Yes
6
Standing squat with half forward bend
Yes
3
Baby dancer pose
Yes
3
Deep lunge
Yes
3
Spinal rolls
Yes
3
Yes
12
Svasana relaxation and breathing exercises*
Yes
Yes
Yes
Yes
The hatha yoga protocol developed for chronic low back pain patients consisted of 12 weekly 75-minute yoga classes divided into four 3-week segments. Each segment
was given a theme. The exercises for each segment are indicated in the Table. The sequence of exercises for each segment follows the order provided in the Table. Each
class began and ended with Svasana, a relaxation exercise. The protocol provided for variations of poses to accommodate different abilities.
*Exercises included on the audio CD provided to participants for home practice.
TK for Chronic Low Back Pain
Yoga
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
25
Knee to chest
Chair pose
Half moon (crescent)
Bridge pose
Knee to chest with twist
Chair pose modified
Cat and dog pose
Mountain pose
Child’s pose
Cat and dog pose variation
Shoulder opener
Cobra and variation
Table top leg extension
APPENDIX FIGURE The yoga postures (asanas) shown were part of a standardized hatha yoga protocol developed for chronic low back pain in
individuals with little or no yoga experience. To design the protocol, we performed a systematic search of the peer-reviewed and lay literature on
yoga for low back pain. We collected and distributed this literature to an expert panel with a broad range of experience in different yoga styles.
After reviewing the literature, the panel met and synthesized information from the literature with their professional experience to draft a protocol that was subsequently refined iteratively through discussion, consensus, and use in nonstudy yoga classes.
26
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Yoga for Chronic Low Back Pain
Triangle at wall
Lunge with wall assist
Spinal rolls
Reclining big toe pose variation
Locust
Warrior I
Standing squat with half
forward bend
Deep lunge with variation
Reclining cobbler
Downward-facing dog
Baby dancer pose
Reclining big toe pose
Svasana
APPENDIX FIGURE, continued
Yoga for Chronic Low Back Pain
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
27
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original research
A COMPLEMENTARY AND ALTERNATIVE
MEDICINE WORKSHOP USING STANDARDIZED
PATIENTS IMPROVES KNOWLEDGE AND CLINICAL
SKILLS OF MEDICAL
STUDENTS
Andrew R. Hoellein, , ; Charles H. Griffith, III, ,
; Michelle J. Lineberry, ,
; John F. Wilson, ; Steven A. Haist, ,
MD MS
MD MSPH
Objectives • As the use of complementary and alternative
medicine (CAM) has increased in the general population, so has
the interest in CAM education among medical students and
medical educators. The purpose of this study is to determine the
impact of a CAM workshop using standardized patients (SP) on
knowledge and clinical skills of third-year medical students.
Design • A 4-hour CAM workshop was developed as part of a
new curriculum for a required third-year 4-week primary care
internal medicine clerkship. The CAM workshop and 3 other
novel workshops were randomized for delivery to half of the
rotational groups. The CAM workshop incorporates 4 SP cases
representing different clinical challenges. All students in every
rotation group are assigned CAM readings. At the end of the
rotation, all students take a 100-item written exam (7 CAM
items) and 9-station SP exam (1 CAM station) including a post–
SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended
Andrew R. Hoellein, MD, MS, is the clerkship director and an
assistant professor of medicine, Charles H. Griffith, III, MD,
MSPH, is the director of the internal medicine program and
professor of medicine, and Michelle J. Lineberry, MA, CCRP,
is the research coordinator for General Internal Medicine, all
in the Department of Internal Medicine, University of
Kentucky, Lexington. John F. Wilson, PhD, is a professor of
behavioral science in the Department of Behavioral Science,
University of Kentucky. Steven A. Haist, MD, MS, is the associate vice president for test development for the National
Board of Medical Examiners, Philadelphia, Pennsylvania.
omplementary and Alternative Medicine (CAM) is
defined as “a group of diverse medical and health care
systems, practices, and products that are not presently considered to be part of conventional medicine.”1
At least 300 distinct therapies are classified as CAM,2
and about 20 000 herbal products are available.3 CAM use is com-
C
30
MA CCRP
PhD
MD MS
written exercise of workshop participants and nonparticipants
were analyzed with simple means, standard deviations, and
multiple regression approaches.
Results • The CAM workshop was delivered to 12 of the 24
rotation groups during the 2004-2005 and 2005-2006 academic
years. Ninety-two students participated in the workshop, and
94 did not. Workshop participants performed significantly better than nonparticipants on the CAM-specific SP checklist
items (58 vs 36.6%, P<.0001), post-SP encounter written exercise (76.9 vs 63.3%, P<.0001), and 7 CAM written exam items
(84.8 vs 76.3%, P<.0001).
Conclusions • Students participating in a 4-hour SP workshop
exhibit superior CAM knowledge as assessed by SP checklist,
open-ended exercises, and multiple choice items. It appears
that practice with SPs assists in acqusition and application of
CAM knowledge and deferential counseling skills. (Altern Ther
Health Med. 2009;15(6):30-34.)
mon and gaining popularity, with 36% of US adults reporting use
in 2002 and 38% in 2007.4 Such wide use of CAM indicates that
patients value CAM approaches5; however, practicing physicians
are perceived as, and often are, reluctant to refer their patients for
CAM.6 Many physicians neglect to ask specifically about CAM use
or are so uncomfortable with their instruction in CAM, they limit
their ability to assist patients.7,8 Therefore, most CAM use remains
unsupervised, and only a minority of patients report it to their
physicians.6,9 This lack of communication between physician and
patient can have dire consequences for the patient, as some CAM
therapies, especially herbs, have potentially dangerous interactions
or adverse effects. Thus, it is imperative that physicians are both
knowledgeable about CAM and routinely inquire about their
patients’ CAM use. Medical school curricula are already tightly
packed into 4 years, so any additional instruction must be proven
effective to justify its inclusion. The aim of this study was to evaluate the efficacy of a new CAM curriculum integrated into the
required primary care internal medicine clerkship at the University
of Kentucky College of Medicine, Lexington.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
A CAM Workshop Using Standardized Patients
MATERIALS AND METHODS
A 4-hour CAM workshop was developed as part of a new
curriculum for a required third-year 4-week primary care internal
medicine clerkship. The clerkship began with a general orientation about the goals and objectives for the rotation. All students
participated in a Preventive Medicine and Routine Screening
workshop, previously validated Intimate Partner Violence10 and
Sexual History-taking/HIV Risk Reduction Counseling11 workshops, and 2 of 4 newly developed standardized patient (SP)
workshops (Adolescent Medicine, Geriatric Medicine,
Complementary and Alternative Medicine, and Nutrition and
Physical Well-being). Students were then released to clinical
activities with general internists on campus or designated area
health education centers. On the last day of the clerkship, all students were given a 100-item written examination and 9-station
SP-based clinical examination with a post-SP encounter openended written exercise.
Grounded in theories of adult learning, the workshops
were designed to employ cognitivist and social learning with
interactive practice, feedback, and reflection.12 At the University
of Kentucky College of Medicine, SPs have been employed to
teach history-taking and physical examination skills since the
early 1990s. SPs are laypeople trained to reliably respond to specific questions and display certain emotions to teach as well as
evaluate trainees. Our SPs are recruited predominantly from the
local theater community and organized, trained, and compensated by the office of the dean. More recently at our institution,
SP workshops have been implemented to teach advanced history taking and counseling. Specifically, our workshops on intimate partner violence 10 and sexual history and HIV risk
reduction11 were shown to significantly increase students’ acquisition and retention of knowledge and skills. We hoped to continue this tradition with the development of 4 novel workshops:
CAM, Adolescent Medicine, Nutrition and Physical Well-being,
and Geriatric Medicine.
The format of the CAM workshop was modeled after our
previously implemented workshops. After a brief introduction of
the topic, 4 SPs introduced different realms of CAM history taking and counseling through various clinical scenarios. Students
interviewed the SPs in front of a small group of their peers, and
all students were expected to be active participants in feedback
and discussion facilitated by a faculty preceptor. The specific SP
encounters were with (1) a 45-year-old man with back pain who
raised a question about chiropractic and acupuncuture, (2) a
49-year-old female yoga enthusiast taking several herbal supplements and requesting a cardiac evaluation, (3) a 57-year-old man
who had trouble urinating, and (4) a 21-year-old woman with frequent colds. The latter 2 SP cases were designed to continue discussion of herbal supplements.
The CAM workshop and the 3 other novel workshops were
randomized for delivery to one-half of the rotational groups.
Twelve of the 24 rotational groups received the CAM workshop
in the academic years 2004 to 2005 and 2005 to 2006. All students had an equal chance of participating in the CAM workshop
A CAM Workshop Using Standardized Patients
or any of the other 3 novel workshops. Participating students
were given a 44-page CAM reference. All students in every rotational group had assigned CAM readings; therefore, all students
were provided with the same basic information about CAM. The
CAM workshop served as a unique vehicle for the delivery of that
information while promoting skill acquisition through role play
with SPs. All students participated in 2 of the novel SP workshops and had the same opportunity to practice general communication skills with SPs; therefore, differences in scores between
CAM workshop participants and nonparticipants were the result
of the CAM workshop rather than specific CAM information or
practice of general skills with SPs.
The end-of-clerkship written examination contained 7 CAM
questions (Figure 1), and 1 of the 9 stations in the clinical exam
was CAM-based. The end-of-clerkship CAM SP portrayed a
47-year-old woman who presented with complaints of being “tired
and forgetful recently.” If specifically asked about herbs or alternative therapies, the SP disclosed that she had been considering
ginkgo and ginseng to treat her symptoms. If not specifically
asked about CAM use, the SP would wait until near the end of the
encounter to ask the student if ginseng might increase her energy
or if ginkgo might improve her memory. The checklist for the
CAM station consisted of 68 total items. There were 27 CAMspecific items: 14 on history taking and 13 on counseling subscales (Table 1). Immediately after the SP encounter, while the
student completed the open-ended written exercise, the SP would
mark “yes” or “no” for each item on the checklist depending on
the student’s achievement of the corresponding target behavior.
The SPs were rigorously trained to portray the CAM-interested
patient. This training included reliability testing to ensure at least
90% agreement between the trainer and SP following mock testing encounters where the SP trainer role played with the student.
FIGURE 1 Example CAM Item on End-of-clerkship Written
Examination and Results of Participants vs Nonparticipants
A 47-year-old woman with a history of breast cancer inquires about
using ginkgo biloba to help her memory. She is on no medications
other than an occasional aspirin. She is 6 years post-lumpectomy,
-chemotherapy, and –radiation therapy. Her family history is significant only for her father having a stroke at age 62. Her exam is unremarkable. Regarding her use of this herbal therapy, your response
should include the following:
A. “It has no known side effects.”
B. “It is contraindicated in people with a history of cancer.”
C. “It is safe to combine with aspirin.”
D. “It may accelerate atherosclerosis and with your family history
of stroke, put you at increased risk.”
E. “It may be helpful in people with Alzheimer’s disease but there is
no evidence for benefit in normal patients.”
(Correct answer: E.)
Participants, 98%; Nonparticipants, 87% ; F=4.2 ; P=.042, Effect Size=0.40 SD
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
31
TABLE 1 Sample Checklist Items From CAM Standardized Patient Station and Scores of CAM Workshop Participants vs Nonparticipants
Participants %
Nonparticipants %
F
P
Effect Size (SD)
Student inquires about use of herbal medications
77
49
17.8
<.001
0.58
Student inquires about your attitude toward herbs
54
24
19.3
<.001
0.61
Student explains importance of telling physician about
complementary and alternative therapies
62
43
7.2
.008
0.39
Student explains that herbs are considered dietary
supplements and not medications
62
53
1.3
.257
0.18
Student explains lack of FDA or other agency oversight
about ingredients, safety, and efficacy
89
68
12.8
<.001
0.51
Student explains that there is no guarantee that the herb is
in the pill, is safe, or will work
95
67
24.9
<.001
0.70
Student counsels that, if using herbs, note botanical name,
part of plant, lot number, expiration date, and manufacturer
53
19
27.1
<.001
0.71
Student explains danger of bleeding on ginseng and ginkgo,
especially if also on ibuprofen or other like drug
85
39
49.0
<.001
0.93
Student explains ginseng has never been proven to boost
energy or protect from infection
66
47
6.8
.010
0.39
Student explains ginkgo can be helpful for mild-to-moderate
dementia but not for normal persons
43
39
0.3
.580
0.08
Student recommends that safety and efficacy be reevaluated
with physician on a regular basis
54
34
9.9
.002
0.41
Student discusses complementary and alternative medicine
in a nonjudgmental way
97
95
0.6
.449
0.10
Checklist item
The open-ended written exercise asked students to name 5 CAM
therapies and the conditions for which adequate evidence exists
for benefit/noninferiority and poses little risk. Standards were set
for student scores on the SP checklist and open-ended written
exercise using the modified Angoff technique.13
Performance on the written exam CAM items, CAM SP
checklist, and CAM open-ended written exercise of workshop
participants and nonparticipants were analyzed with simple
means, standard deviations, and analysis of variance. Multiple
regression approaches using the general linear model were completed with participation or nonparticipation in the CAM workshop as independent variables. The regression analyses were
adjusted for prior academic performance by controlling the SP
checklist scores with checklist scores from a preventive medicine
station, and the written items and open-ended exercise were
adjusted for performance on US Medical Licensing Examination
(USMLE) Step 1. Cohen’s d was used to calculate effect size.
Students were also asked to evaluate the workshop. All data were
analyzed with SPSS Version 11.5 (2001; Chicago, Illinois). The
project was approved by the Institutional Review Board at the
University of Kentucky.
students participated in the CAM workshop, and 94 students
did not. Students who participated in the workshop scored significantly higher (P<.001) on all outcomes of interest (Table 2).
Note that Table 2 describes results for 91 nonparticipants rather
than 94. This difference is due to missing USMLE Step 1 data,
which we used to control for prior academic performance, for 3
nonparticipants.
CAM workshop participants scored 84.8% on the CAMspecific written exam items, and nonparticipants scored 76.3%.
In the CAM SP exam station, workshop participants achieved
54.3% of target history-taking items and 61.5% of target counseling items vs 32.9% and 40.8% for those students not participating
in the CAM workshop. Table 1 shows group differences on a sampling of individual SP checklist items. Of note, CAM workshop
participants were more likely than nonparticipants to initiate a
discussion of CAM use (77% vs 49%, respectively). In addition,
CAM workshop participants scored 76.8% on the CAM openended written exercise vs the 63.3% scored by nonparticipants.
Finally, students’ overall evaluation of the workshop on a
10-point, Likert-type scale (1=poor, 10=excellent) was quite
favorable: 7.9±1.6.
RESULTS
For the academic years 2004 to 2005 and 2005 to 2006, 92
DISCUSSION
The results of this study indicate that our new CAM workshop
32
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
A CAM Workshop Using Standardized Patients
TABLE 2 CAM Workshop Participant vs Nonparticipant Score Analysis
Outcome (n)
Participants, %
(n=92)
Nonparticipants, %
(n=91)
F-value
P value
Effect Size
Written items (7)
84.8
76.3
18.6
<.001
.602
Checklist total (68)
58.0
36.6
36.7
<.001
.817
History (14)
54.3
32.9
20.8
<.001
.625
Counseling (13)
61.5
40.8
42.3
<.001
.844
Open-ended (10)
76.8
63.3
14.3
<.001
.502
increases the CAM knowledge and counseling skills of third-year
medical students. With about one-third of US adults using some
type of CAM therapy 4,14 and speculation that CAM use will
increase along with the rise in healthcare costs and chronic diseases,15 physicians recognize the need to assimilate CAM knowledge and skills into their everyday practice. The consequences of
being unaware of patients’ CAM use can have serious consequences and potentially lead to death. Given these harsh realities, the incorporation of CAM curriculum into undergraduate
medical education is crucial.
Medical education innovations, while common and increasing, often suffer from significant and well-publicized flaws due
primarily to lack of methodological and theoretical rigor.16,17 We
present a rare experiment in medical education: a randomized,
controlled trial based on a validated teaching pedagogy. The
SP-based small group format seems to be an efficient method to
improve knowledge and skills and perhaps alter attitudes.
According to Ericsson’s theory of deliberate practice, the acquisition and maintenance of expert performance requires time commitment, immediate feedback, and reflection,18 notions fostered
in our small group SP approach.
CAM education appears to be especially idyllic in this setting. The SP encounters were modeled after actual patient experiences in which CAM overtly or subtly arises, reinforcing the
importance of acquiring some basic CAM clinical skills and critically evaluating relevant literature. The group learning experience
encourages sharing of personal experiences, anecdotes, and even
expertise with CAM modalities. In fact, other CAM medical student curricula have as one of their goals advancement of student
self-awareness and mindfulness.19 Further, CAM education in supportive learning climates such as this may promote relationshipcentered approaches by students to their future patients.20
Our study has several limitations to consider in the interpretations of the findings. The single-institution nature of our study
might limit the generalizability with other schools that might
have more or less formal CAM curricula. Additionally, our students’ personal or actual clinical experiences with CAM or even
their clinical preceptors’ interest with CAM were not measured.
In fact, during the period of this study, our colleagues in family
medicine were incorporating CAM curricula into all years of
training, possibly influencing our findings.21 If there were such an
effect, we would have expected it to decrease the difference
A CAM Workshop Using Standardized Patients
between the students who participated in the workshop and
those who did not participate. Also, we could not control for dissemination of workshop information to nonparticipants, but we
would expect dilution of findings if this occurred as well. Finally,
we do not have measures of actual practice of graduates regarding their CAM knowledge and skills, which would be the ultimate
measure of a successful intervention.
CONCLUSIONS
Despite these limitations, we conclude that our SP-based
CAM workshop meets rigorous evaluation criteria for retention
in an already crowded health professions curriculum.22 Our findings suggest that focused instruction using SPs results in better
clinical skills and greater knowledge. Third-year medical students who received a 4-hour, interactive, SP-based workshop on
CAM scored significantly higher on end-of-clerkship CAMspecific written examination items, an SP clinical exam CAM station, and a post–SP encounter open-ended written exercise than
students who did not participate in the workshop. It appears that
practice with SPs assists in acquisition and application of CAM
knowledge and solidifies CAM attitudinal and deferential counseling skills. Perhaps it is through promotion of students’ selfawareness, review of current evidence, and the opportunity to
practice in a low-stakes clinical setting that we found objective
evidence to support that such an intervention is beneficial to student learning. Though students’ positive ratings of new curricula
are desirable, established efficacy is essential. Our CAM workshop successfully achieved both student satisfaction and empirical support for the curriculum.
Future studies should evaluate the effectiveness of SP workshops in increasing CAM knowledge and skills in graduate medical education and through continuing education opportunities
for physicians. Integration of such a curriculum into medical
school is necessary to prepare future physicians, and we must
not neglect the training of practicing physicians whose current
patients use CAM and for many of whom training in CAM was
inadequate. Our patients request and deserve physicians who are
sensitive to societal desires for CAM.
Acknowledgment
This project was supported in part by a Predoctoral Primary Care Internal Medicine Training
Grant funded by the Health Resources Services Administration (#D56HP00038).
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
33
The authors will provide the standardized patient materials (cases and checklists) and the
Complementary and Alternative Medicine Student and Instructor References to any clerkship or residency program director requesting the materials. These can be requested from Dr
Hoellstein at [email protected].
REFERENCES
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8. Xu S, Levine M. Medical residents’ and students’ attitudes toward herbal medicine: a
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11. Haist SA, Lineberry MJ, Griffith CH, Hoellein AR, Talente GM, Wilson JF. Sexual history inquiry and HIV counseling: improving clinical skills and medical knowledge
through an interactive workshop utilizing standardized patients. Adv Health Sci Educ
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13. Talente G, Haist SA, Wilson JF. A model for setting performance standards for standardized patient examinations. Eval Health Prof. 2003;26(4):427-446.
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N Engl J Med. 1993:328(4):246-252.
15. Faass N, ed. Integrating Complementary Medicine into Health Systems. Gaithersberg, MD:
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18. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 Suppl):S70-S81.
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ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
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narrative review
TEMPORAL BONE MISALIGNMENT AND
MOTION ASYMMETRY AS A CAUSE OF VERTIGO:
THE CRANIOSACRAL
MODEL
David C. Christine,
CST
Objective • To describe dysfunction of the craniosacral system,
particularly temporal bone motion asymmetry, as a cause of
vertigo and to suggest a new perspective on research, diagnosis,
and treatment.
Data sources • A database search was conducted using
MEDLINE, CINHAL; Health Sources: Nursing/Academic
Edition; and the Internet. Keywords: vertigo diagnosis and
treatment, craniosacral therapy, temporal bones, cranial bone
mobility, Upledger, and temporomandibular disorders.
Study selection • Articles that most clearly described a relationship between cranial bone misalignment and vertigo were selected for review.
David Christine, CST, works on a therapeutic team at Essential
Therapeutics and Wellness, Stroudsburg, Pennsylvania.
he term dizziness is nonspecific but may refer to vertigo, lightheadedness, presyncope, disequilibrium,
or other dizziness.1 Vertigo is a type of dizziness
characterized by sensations of movement (usually
spinning) felt inside a person’s head or perceived as
the environment moving. Many conditions involving dizziness
have overlapping symptoms; therefore, diagnosis with certainty
is often difficult.1-3 Diagnoses in clinical practice are based mainly
on patient history and symptoms, and patients are often vague
or contradictory in describing their symptoms.2 Agreement as to
diagnostic terminology for various dizziness disorders varies.1-3
Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge.
Most of those with chronic symptoms are not relieved by
medical treatment.4 Undetermined and ill-defined causes of vertigo such as vasovagal syncope, hyperventilation syndrome, posttraumatic vertigo, and nonspecific dizziness are the most common
single “cause” of dizziness reported.5 Many patients for whom the
diagnostic process has failed may be erroneously diagnosed with
a psychiatric problem.5
The lack of specific therapies for many types of dizziness has
been called one of the “Achilles’ heels in our ability to confidently
ascribe etiologic labels.”6 Likewise, establishing a cause of dizzi-
T
38
Conclusion • Clinical experience suggests that craniosacral
therapy is a powerful evaluative and treatment modality for vertigo patients who have not found relief from medical treatments.
A narrative review of the literature describes and supports a theoretical link between dysfunction of the craniosacral system and
vertigo. Dysfunction of the craniosacral system may include
osseous, dural membrane, and fascial restrictions leading to
asymmetric temporal bone movement and hence vertigo. Clinical
trials are necessary not only to verify that craniosacral therapy is
an effective treatment but also to determine the full range of
symptoms and medical diagnoses for which craniosacral therapy
is beneficial. (Altern Ther Health Med. 2009;15(6):38-42.)
ness is most useful when it leads to a specific therapy.7 Calls have
been made for new approaches to diagnosis,1-3 and investigation of
alternative therapies for chronic and recurrent dizziness has been
advocated.1 Patients, hospital-based physicians, and practitioners
in primary care and medical subspecialties felt that they were not
adequately informed about alternative treatments.8,9 Increased
referral to alternative healthcare providers may require both
ongoing peer-reviewed studies of efficacy and increased physician
access to information concerning therapies that have undergone
definitive study.9
The objective of this paper is to describe dysfunction of the
craniosacral system,10-12 particularly temporal bone misalignment,10,13-15 as a cause of vertigo and to suggest a new perspective
on research, diagnosis, and treatment. The hypothesis presented
here is that patients with asymmetrical temporal bone movement
are likely to have some form of vertigo, dizziness, or imbalance,
and there is a high likelihood that craniosacral treatment will
relieve the symptoms if a temporal bone restriction is present. In
this author’s craniosacral practice, asymmetrical temporal bone
motion has been found across a spectrum of dizziness patients
who have not responded well to traditional medical treatments.
Among the treatments that have not worked for these patients are
meclizine, Vertigoheel (a homeopathic betahistine equivalent)16
prednisone, allergy treatment, Epley maneuver,17 physical therapy,
vestibular rehabilitation, and chiropractic. The symptoms that
have been resolved with the craniosacral technique include episodic spinning vertigo lasting hours, fluctuating hearing loss,
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Temporal Bone Misalignment and Vertigo
tinnitus, aural pressure, headaches, cyclical vomiting, motion
intolerance, imbalance, positional vertigo, and autonomic symptoms associated with vertigo.
Dizziness patients, particularly those with spinning sensations accompanied by moderate-to-severe temporal bone asymmetry, generally find relief in a short time, usually within a few
sessions. Successfully treated patients do not need medication,
lifestyle changes, dietary restrictions, or vestibular rehabilitation.
At this writing, no clinical trials have been performed to verify
these claims; therefore, a review of literature was conducted to
determine if there is evidence to support a theoretical foundation
for craniosacral dysfunction as a cause of vertigo and perhaps to
help bring some clarity to this often puzzling arena at least
among a certain class of identifiable patients.
A database search was conducted using MEDLINE,
CINHAL; Health Sources: Nursing/Academic Edition; and the
Internet. Keywords used included vertigo diagnosis and treatment,
craniosacral therapy, temporal bones, cranial bone mobility, Upledger,
and temporomandibular disorders. Articles that most clearly
described a relationship between cranial bone misalignment and
vertigo were selected for review.
DISCUSSION
The craniosacral model10-12 proposes a new way of evaluating
and treating vertigo symptoms with the observation that the
bones of the skull move in response to rhythmic pressure changes within the membranes surrounding the brain and spinal
canal. Mobility restrictions or misalignments along the cranial
sutures are said to have adverse effects on health that can be corrected through gentle manipulation of the cranial bones, sacrum,
and the connecting membranes enclosing the brain and spinal
cord. These structures also may be influenced through release of
connective tissue tension anywhere in the body.
Proper functioning of the craniosacral system is evaluated
through palpation of the craniosacral rhythm, the regular wave
of fluid-pressure changes within the system, about 6 to 12 cycles
per minute. The production phase of the cycle is termed “flexion”
or filling cycle. The resorption phase is termed “extension” or
draining cycle.
The craniosacral rhythm is transmitted to the sacrum via
the dural tube and throughout the entire body via osseous connections, dural spinal sleeves, and the motor division of the nervous system. During flexion, the entire body externally rotates
slightly; during extension, the body internally rotates. The craniosacral rhythm, therefore, may be palpated anywhere in the
body. Restrictions in the body fascia can result from a variety of
internal and external causes. These restrictions cause interruptions of the craniosacral rhythm, thereby revealing the location
of the problem. The entire system constitutes a delicate and subtle pattern of energy ebb and flow that is responsive to gentle
touch but resists heavy or intrusive touch.
Temporal Bone Motion and Dural Attachments
The 2 adherent layers of the dural membrane within the cra-
Temporal Bone Misalignment and Vertigo
nium separate to form a horizontal leaf (the tentorium cerebelli)
and a vertical leaf (the falx cerebri), thus dividing the brain into
quadrants. When the system is filling during flexion, the skull
widens and shortens. When the system is draining during extension, the skull narrows and lengthens.
The temporal bones are connected bilaterally along a roughly horizontal plane by attachments of the tentorium cerebelli.
They move in tandem about diagonal axes roughly along the
lines of the auditory canals. During flexion (Figure 1) the
squamous portion of the temporal bones arc forward and lateral,
increasing the distance between them. At the same time, the
zygomatic processes move inferior. The mastoid tips move posteriorally, superiorally, and closer together. This movement is
known as external rotation and causes the anterior borders of the
tentorium cerebelli to move slightly anterior. The effect is to
tighten the membrane, which acts as a diaphragm influencing
the fluctuation of cerebrospinal fluid. During extension, cerebrospinal fluid-pressure decreases and the movements of the temporal bones reverse along the same axes. Thus, the general
movement of the paired bones is forward and backward in an
arc. But because the axis of rotation is along a diagonal axis, they
also move inward and outward, something like a casement window swinging externally above and internally below its horizontal axis. This complex motion has frequently been compared to a
wheel wobbling around a bent axle.
Axis of
rotation
Left temporal bone
Right temporal bone
FIGURE 1 Normal Temporal Bone Motion
Left and right temporal bones move in sync. No effect on semicircular canals.
(Flexion shown. Extension is the reverse.) Lateral view of right temporal bone
(unshaded) is shown superimposed on medial view of the left temporal bone
(shaded). Unshaded arrowheads show the movement of right temporal.
Shaded arrowheads show the movement of left temporal as if looking through
the head to see both bones at once. Illustration by D. Christine.
Dysfunctional Temporal Bone Movement
Impediments to normal temporal bone motion can occur
anywhere along the arc of its normal motion. These impediments
could stop motion completely at a certain point, disallowing
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
39
completion of the motion cycle in that direction, then return
under normal rate and amplitude. Alternately, the impediment
may simply cause a drag at that point that slows the motion but
that is gradually overcome as the momentum carries the bone
beyond the point of restriction. Such restrictions also may cause
a jerky stop-start motion of the bones that could adversely influence inner ear fluid dynamics. Osseous compression of 1 or both
temporal bones could result in little or no motion. Torsion in the
dural membrane could cause a variety of abnormal wavy or wobbly motions.
If the movement of the temporal bones contradicts or overaccentuates fluid movement in the semicircular canals, the
resulting sensory conflict may lead to the classic symptoms of
motion sickness: pallor, sweating, hypersalivation, disorientation, nausea, drowsiness, and vomiting.18 One temporal bone
moving anterior and lateral while the other moves posterior and
medial (Figure 2) would produce not only asymmetrical neural
inputs, inducing vestibular symptoms, but also could create the
illusion of self-rotation with or without actual body movement.19
Spinning vertigo, in contrast to more vague sensations of dizziness, may thus be a result of the opposite motions of the bones
on 2 sides of the head as if, in fact, the head were spinning.
Axis of
rotation
Left temporal bone
Right temporal bone
FIGURE 2 Dysfunctional Temporal Bone Motion
Bones move in opposite directions, theoretically causing contradictory neural
inputs to semicircular canals. Lateral view of right temporal bone (unshaded)
is shown superimposed on medial view of the left temporal bone (shaded).
Unshaded arrowheads show the movement of right temporal. Shaded arrowheads show the movement of left temporal as if looking through the head to
see both bones at once. Illustration by D. Christine.
Supporting Evidence
In the 1930s, osteopathic physician William Garner
Sutherland, DO, observed that the spheno-temporal suture was
beveled liked the gills of a fish and appeared to be designed for
movement.13 Skulls with patent sutures have been described as
complexes of independent units or functional components rather
than isolated single structures.20,21 Slight movement has been
40
measured between the cranial sutures.22-29 The cranial sutures are
innervated and highly vascularized but are not rigidly fused.30,31
Mechanical restriction of cranial bone movement causes measurable physiological responses, which abate when constriction is
removed.23 Cranial bones of rats transplanted to a new location
changed the morphology of the suture (eg, butt-end to beveled
overlapping)32 consistent with the functional demand of the new
location for growth and movement.20,31,32 There is evidence that
sutures are patent throughout life.34-36 Dural membranes can
elongate upon application of traction of the cranial bones on an
embalmed cadaver.37 Dissection studies of fresh cadavers38,39 suggest that the dural membranes are capable of manipulation with
light traction via osseous “handles.” Changes in cranial bone
positions after cranial manipulation were measured in degrees
using x-rays (Dental Orthogonal Radiographic Analysis). 40
Degree of change of the atlas, mastoid, zyogomatic, sphenoid,
and temporal ranged from 0 o to 8 o. 40 The average degree of
change for the mastoid was 1.66 (range 0-6).40 The average degree
of change for the temporal was 1.75 (range 0-5).40 Measurements
of strain on the skull using laser holography show strain patterns
with as little as the weight of a penny.41 Distinct swirling patterns
appear upon compression of the temporal bones with a pair of
tongs.41 This pattern is consistent with reported palpated motion
of the temporal bones classically described as a wobbly wheel.
Sources of Craniosacral Restriction
Clinical experience suggests that spinning vertigo, in contrast to the more vague complaints of dizziness and unease, is
more likely to occur the more diametrically opposed the temporal bones move in relation to one another (Figure 2). Hearing
loss, nausea, vomiting, and/or other autonomic symptoms with
or without vertigo are more likely to occur when one or both
temporal bones are compressed or moving sluggishly. Because
the temporal bones have articulations with the sphenoid,
occiput, parietals, and zygoma, misalignment of any of these
bones could affect the entire cranium, causing any number of
nerve entrapment pathologies, vascular occlusion, and interference with lymphatic channels.13,14,33,42
This author has seen a patient who, in a single session, was
completely relieved of episodic vertigo and hearing loss, tinnitus,
and aural pressure along with nausea, pain in the left cheek,
excess saliva, difficulty swallowing, and a bitter taste in the
mouth by a craniosacral release of a compression at the left jugular foramen. Table 1 lists the nerves and blood vessels passing
through the temporal bone, suggesting possible causes for these
symptoms if the temporal bones are compressed or misaligned.
Temporal bone problems may result directly from osseous
impaction or from dural tension on the bones that can be transmitted from anywhere in the body. The intracranial dural membranes are connected with the cervical fascia and so with much of
the rest of the body.33 For example, there is a direct continuity of
fascia from the apex of the diaphragm to the base of the skull
extending to the outer surface of the sphenoid, occipital, and temporal foramina. The fascia continues through the foramina at the
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Temporal Bone Misalignment and Vertigo
TABLE 1 Nerves and Blood Vessels Running Through the Temporal Bones
Acoustic
Internal carotid artery
Chorda tympani
Stylomastoid artery
Facial (C.N. VII)
Internal jugular vein
Greater petrosal
Occipital artery
Sympathetic plexus of internal carotid
Inferior petrosal sinus
Semilunar gaglion of trigeminal (C.N. V)
Middle meningeal vessels
Tympanic branch of glossopharyngeal (C.N. IX)
Tympanic branch of maxillary artery
Auricular branch of vagus (C.N. X)
Internal auditory branch of basilar artery
Internal cochlear branches of jugular
base of the skull around the vessels and nerves to join the intracranial dura.33 Extradural restrictions may arise from muscle or visceral fascia envelopes from superficial fascias just deep to the skin
or from any of the other fascial layers.43 Quite often, abnormal
tension from peripheral fascias enters via the dural sleeves that
accompany spinal nerve roots from or to the spinal cord and to or
from the transverse foramina of the vertebral spine.43
The exact pathway to dural membrane tension and temporal bone restriction may vary considerably. Common restrictions
include direct osseous impaction at the temporo-occipital suture
or tension on muscles crossing the suture, thoracic inlet tension,
respiratory diaphragm tension, strain on the sphenoid, and compression of the occipital condyles into the transverse process of
the atlas.
Other restrictions found by this author to cause asymmetric
temporal bone movement include a restriction of the hyoid bone
with tight muscle connections to the mastoid process; compression of the vomer into the rostrum of the sphenoid; dural twisting
at the thoracic-lumbar area transmitted into the tentorial membrane, producing a rhythmic torsion and side bending of the temporal bones; pyloric spasms apparently due to anxiety, which
pulled the temporal bones out of sync; and a radical hysterectomy
transmitting pelvic diaphragm tension into the cranium.
The value of craniosacral therapy is that it can identify
seemingly esoteric and unsuspected structural abnormalities
that can lead to vertigo with no apparent cause under traditional
diagnostic techniques. It is usually easy for a skilled therapist to
locate and release structural restrictions in the body once asymmetrical temporal motion has been found. Upledger once
relieved a case of vertigo by tracing the cause of a jammed left
temporal bone from an old knee and ankle injury through the
pelvis and spine and into the cranium.44
Since connective tissue restrictions from various places in the
body can be transmitted into the dural tube, external or internal
stressors can cause variable tension on the dura, locally or from a
distance. Once a critical structural imbalance has been created,
any one of these stressors (such as venous pressure changes, muscle tension, organic dysfunction, menstruation, allergies, or emotional disturbance) may trigger acute symptoms.
Temporal Bone Misalignment and Vertigo
CONCLUSION
Clinical experience suggests that craniosacral therapy is
a powerful evaluative and treatment modality for vertigo
patients who have not found relief from medical treatments.
A narrative review of literature describes and supports a theoretical link between dysfunction of the craniosacral system
and vertigo. Dysfunction of the craniosacral system may
include osseous, dural membrane, and fascial restrictions
leading to asymmetric temporal bone movement and hence
vertigo. Clinical trials are necessary not only to verify that
craniosacral therapy is an effective treatment but also to
determine the full range of symptoms and medical diagnoses
for which craniosacral therapy is beneficial. These studies
ought to be performed at vestibular rehabilitation or hearing
and balance centers that see large numbers of patients with a
variety of symptoms and established medical diagnoses.
Initially, all patients with any kind of non–life-threatening
dizziness or vertigo should be tested for temporal bone asymmetry. Nonspecific dizziness and vertigo, posttraumatic vertigo, positional vertigo, recurrent benign vestibulopathy,
migraine vertigo, and Ménière’s disease are among the diagnoses that could be evaluated for temporal bone misalignment. Results of craniosacral therapy on appropriate patients
could then be evaluated and tested against standard rehabilitation techniques and controls.
Care must be taken in selecting a craniosacral therapist
who has the sufficient level of skill to accurately assess and treat
temporal bone misalignment, including the ability to palpate
dural membrane and fascial restrictions, which may affect the
temporal bones from anywhere in the body. The presence of
temporal bone motion asymmetry provides a specific structural
marker that is both predictive of vertigo and indicative of a
positive prognosis; therefore, craniosacral therapy could reduce
the amount of laboratory testing, neuroimaging, and other
low-yield tests without adversely affecting patient outcome.6
Because of its efficiency in skilled hands, craniosacral therapy
has the potential to greatly reduce the amount of time, money,
and misery that vertigo often involves, at least among this class
of identifiable patients.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
41
Acknowledgments
I would like to thank Gene Miller, CST-D, for critical feedback and unending support and
encouragement; Ellen McKay for invaluable critique and proofreading; and Penny Rhodes,
CST-D, for insightful commentary.
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narrative review
LOMI LOMI AS A MASSAGE WITH MOVEMENTS:
A CONCEPTUAL
SYNTHESIS?
Paul Posadzki,
; Toby O. Smith,
; Pawel Lizis,
PhD
This article narratively reviews the evidence of 2 therapeutic
modalities, massage and passive movement. The authors suggest that these 2 treatment techniques may be combined as 1
treatment to be used in a variety of clinical settings. We present
the rationale through which the concept of massage with movement (MWM) has been developed and constructed from the
principles of passive movements with gentle massage during
Paul Posadzki, PhD, is an honorary researcher and lecturer in
physiotherapy at the University of East Anglia School of
Medicine, Health Policy and Practice, Norwich, Norfolk,
United Kingdom. Toby O. Smith, MSc, is a research physiotherapist in orthopedics at the Institute of Orthopaedics,
Norfolk and Norwich University Hospital, United Kingdom.
Pawel Lizis, PhD, is an associate professor in physiotherapy
at the Swietokrzyska Vocational School in Kielce, Poland.
assage therapy is a manual therapeutic
approach used to facilitate healing and health.
It is used by various healthcare professions
such as physiotherapists, occupational therapists, manual and massage therapists, and
nurses in a wide variety of clinical settings.1 Massage has a long
history within orthodox medicine and has been adopted as a
therapeutic modality in all cultures since early civilization.2,3 This
treatment also has been cited as having social, educational, cultural, and humanitarian importance by addressing patients’ need
for human contact.4,5 Massage has recently re-emerged as a complementary therapy, requiring a full re-evaluation and audit of its
clinical application and therapeutic outcomes.3 Recently, studies
have evaluated the effectiveness of Swedish massage techniques
as well as massage through reflexology, acupressure, and aromatherapeutic massage.6 It is worth emphasising, however, that
in such studies, the location to which massage was undertaken
and the frequency and duration of treatment varied considerably. Such methodological “challenges” can cause difficulties in
drawing scientifically valid conclusions.7 Nevertheless, the preliminary evidence provides some support for massage with
regard to clinical and cost effectiveness.8-10 Although the literature
has concluded that massage appears to be a safe, noninvasive,
M
44
MSc
PhD
Lomi Lomi massage. It is hypothesized that through further
investigation and empirical studies, this concept may allow
bodywork and movement therapists, nurses, physiotherapists,
and occupational therapists to combine the positive effects of
passive movements with those of massage for patients’ health
benefits, most notably through enhanced relaxation. (Altern
Ther Health Med. 2009;15(6):44-49.)
therapeutic modality that can provide a high patient satisfaction
rate and be integrated as an adjunct for a number of different
health conditions such as cancer, back pain, knee osteoarthritis,
anxiety, dementia, insomnia, and lowered self-esteem, the evidence for its effectiveness in managing these health conditions
remains weak, and future research has been recommended.4,11-13
Passive movements are a treatment technique that is performed by another person or machine, thereby not requiring voluntary activity from the patient’s own muscles.14 Physiotherapists,
manual therapists, massage therapists, and other appropriately
trained personnel frequently perform these movements as a
treatment modality and as an assessment tool to provide sensory
information on the quality of joint range of motion. It has been
recommended that passive movements as a treatment to stretch
soft tissues and joints should be performed slowly and carefully,
with a gradual increase in range of motion within the movement
segment.15 The rationale for performing passive movements is to
prevent soft-tissue immobility, to encourage the development or
establishment of correct movements, to maintain the integrity
and elasticity of joints and soft tissues, to sustain or improve
existing range of motion, to enhance joint nutrition, and to assist
circulation by stimulating the muscle pump concept.15,16 Passive
movements also have been associated with the inhibition of pain
to promote local and general relaxation and to enhance a positive
psychological state and healing processes.17-21
Within the scope of this article, Lomi Lomi massage is a
technique that combines passive movements and massage.
From the Lomi Lomi perspective, this article offers a new way of
using massage and passive movements. The theoretical foundations that underpin both modalities, their clinical applications,
and an examination of their biopsychosocial and spiritual
effects will be undertaken in a narrative manner. Finally, the
article will present an argument for why combining massage
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Lomi Lomi as a Massage With Movements
and passive movements may have beneficial therapeutic effects
to enhance the work of physiotherapists, massage therapists,
bodywork and movement therapists, and nurses. The qualitative
convergence and conceptual development of this combined
treatment approach, massage with movements (MWM), will be
explored and explained.
BENEFICIAL EFFECTS OF MASSAGE
The objective of the following sections is to discuss the purported physiological effects of massage and passive movement.
Then the authors will identify the hypothetical clinical benefits
that these 2 treatments may provide when combined.
A number of reviews have attributed numerous positive
clinical outcomes to massage. These have included improvements in the quality of patients’ relaxation, sleep, and immune
system responses, in addition to the relief of fatigue. 4,6,22-24
Massage also has been proposed to have an influence at a cellular
level through an increase in lymphocytes.25 As a result of this,
previous authors have suggested that massage may be efficacious
for patients with profound immune suppression.4,6,23,26,27
Clinical trials evaluating massage have reported significant
improvements in anxiety and depression and perception of tension and stress as measured by cortisol levels.6,23,24,26,28 Calenda
attributed these “calming” effects and emotional wellness to an
increased level of dopamine.25 Massage therapy also may have a
role in the management of patients with behavioral conditions.29
Massage has been used clinically as an adjunct to other modalities in the management of musculoskeletal pain, particularly in
the treatment of nonspecific low-back pain.8,23,30-33 Similarly, massage has been regarded as an established therapy for the relief of
swelling, muscle spasms, and restricted range of motion.34,35 It is
hypothesized that through mechanical pressure, massage can
increase muscle compliance to facilitate increased range of joint
motion while decreasing passive and active stiffness of the soft
tissues and joints.24
Results from clinical trials have indicated that massage may
provide several additional benefits to the body. These include an
increase in neurological excitability, hemodynamics, or muscle
temperature in addition to a reduction of blood and muscle tension.24 It is theorized that through these physiological effects,
massage has been subjectively associated with an increase in
well-being and perceived general health in adult24,34,36,37 and childhood populations.5,38,39
This brief overview of massage and its holistic benefits on
patient well-being has indicated that this therapeutic modality
may be used by therapists to enhance patients’ homeostasis.
These findings can provide further support for the value of massage to optimize the body’s structure and function.
BENEFITS OF PASSIVE MOVEMENT
Recent research has indicated that passive movements may
provide positive effects in rehabilitation processes.40 More specifically, passive movement treatments have been shown to influence the excitability of the corticomotor pathway.41 Macé et al
Lomi Lomi as a Massage With Movements
suggested that the prolonged proprioceptive stimulation, which
passive movements facilitate, may induce a delayed increase in
corticospinal excitability of the targeted muscles.42 Through this
mechanism, cortical reorganization may occur.42 Passive movements also may elicit additional activation of cortical regions
outside the contralateral primary somatosensory cortex, also
influencing the bilateral perisylvian and contralateral cingulate
gyrus regions.43
A 2002 study reported that passive movement therapy may
increase metabolism, blood flow velocity, and cerebral hemodynamics, which are associated with autoregulative mechanisms.44
Additionally, Hellsten et al demonstrated that passive lower limb
movements can enhance interstitial concentrations of vascular
endothelial growth factor (VEGF) and endothelial nitric oxide
synthase (eNOS) in muscle tissue, factors which are involved in
capillary growth in human muscle.45 Such a treatment may exert
an anti-inflammatory effect on chondrocytes, downregulating
the quantity of inducible nitric oxide synthase (iNOS)–positive
cells.46 Nitric oxide acts as an intracellular, transcellular, and
cytotoxic molecule; therefore, passive movements may be important for the correction of posttraumatic and postoperative joint
function and as an adjunct to inflammatory drug therapy in musculoskeletal disorders.46 Similarly, passive movements have been
used to assist in the prevention of soft tissue adhesion formation
and adaptive tissue shortening and in the improvement of movement memory and kinesthetic/proprioceptive sense.47 Passive
movements also have been associated with an enhanced venous
and lymphatic return rate through mechanical pressure and
stretching of vessels that pass over a joint as it is moved.47 Further
physiological effects attributed to passive movements have
included an increase in mean breathing frequency, tidal volume,
and ventilation.48 Chang et al suggested that passive movements
may improve short-term ventilatory function in the management
of high-dependency neurological patients.49
Some authors have suggested that fluent and gentle passive
movements may, on the premise of neuroplasticity, promote
organizational changes within the brain and assist in limiting
degenerative changes to the musculoskeletal system.41-43 This
brief analysis of the literature would suggest that passive movements may act to resonate with the body’s “internal intelligence”
and lead to an accelerated rehabilitation process.
LOMI LOMI
Lomi Lomi has its roots in ancient Hawaiian philosophy,
religion, and culture.50 The treatment originates from a Maori
massage technique.50 It has been developed over centuries and
therefore offers profound heritage and richness for contemporary therapists. The essence of this approach is founded upon the
“wisdom about life” and was developed through knowledge of
holistic health.51 Lomi Lomi has been described as a treatment
for “tired bodies.”51 It has been defined as a body massage that is
applied through the forearms using long flowing strokes and
rhythmic patterns.52,53 It has been suggested that this technique
can reduce soft tissue stiffness and soreness while encouraging
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
45
sleep and relaxation.54 This technique also has been described as
tai chi on the body (Trybulski, personal communication, March
2006). There is, however, a paucity of research specifically assessing the outcomes of this massage technique.
LOMI LOMI: A MASSAGE WITH MOVEMENT
Through the lens of Lomi Lomi massage, the synthesis of
massage and passive movements on both a conceptual and
pragmatic level will be discussed within this section of the article. It is possible to make a number of deductions about the
fusion of massage and passive movements. First and theoretically, the combination of massage with passive movements may
provide a number of therapeutic benefits. Both treatments are
performed manually and are therefore viewed as treatments of
“therapeutic touch,” which are cited as a means of enhancing
healing.4,11-13,17-21 Second, both techniques aim to increase blood
flow, stimulate exteroceptors, and maximize flexibility and joint
range of motion. Third, both modalities enhance relaxation and
promote well-being. Consequently, if a clinician is able to concentrate his or her attention on both passive movements and
effleurage techniques simultaneously, therapeutic benefits may
be optimized through MWM. Through this technique, the clinician may combine different movement patterns, such as shoulder extension and external rotation and/or adduction, while
performing simultaneous effleurage massage to the upper limb
(Figures 1 through 4). Similar patterns can be applied to the
lower extremity, such as hip adduction, rotation, or knee flexion, with simultaneous efflourage to the whole lower extremity
(Figures 5 and 6). However, therapists should also consider work
ergonomics, especially when performing MWMs on lower limbs
among patients who are overweight or obese. MWM patterns
also may be performed to more distal joints, such as the knee
and the ankle and the elbow and the wrist. In these joints, flexion and rotation, adduction or abduction, in addition to gentle
massage of the posterior aspect of a patient’s thigh and lower
leg, may have therapeutic benefits. Other MWM characteristics
could include the addition of smooth, rhythmical movements,
performed at a slow tempo, using a relatively wide contact surface area provided through the therapist’s forearms and hands.
Such movements can be performed imperceptibly and progressively slower as the patient relaxes.17 Therapists may also consider other factors such as the patient’s position, which may
influence the forces placed upon the joints and surrounding soft
tissues.55 It is recommended that MWM only be commenced
once the patient feels secure and the therapist has a comfortable, but gentle, grasp of the limb, exerting slight traction at the
beginning of each movement. This may also help to decrease
pain and muscle spasm.56
The duration of the MWM session may be tailored to the
individual patient. As with both principle techniques, the indications and contraindicators for massage and passive movements
should be considered during the clinical decision-making process
for this treatment technique. If suitable, MWM may provide a
number of therapeutic benefits, which are hypothesized here.
46
FIGURE 1 illustrates a combination of abduction/adduction with
the therapist’s supportive forearm (left hand) while effleurage along
the long axis of the patient’s upper limb is performed.
FIGURE 2 illustrates a combination of flexion, abduction, and
internal rotation of the gleno-humeral joint by the therapist’s right
hand while gentle effleurage strokes are performed using the therapist’s prone and/or supine forearm. External rotation with abduction of the patient’s shoulder is performed while the upper hand
glides on the anterior surface of the upper limb.
Psychologically, MWM may enhance an individual’s
sense of coherence, level of optimism, self-esteem, emotional
awareness, and cognitive processes. This may lead to more
positive mind states, including empathy, happiness, joy,
serenity, and calmness.
MWM may augment and encourage deeper relaxation,
enhancing bodily structure and function, by maintaining or
increasing tissue mobility and flexibility and decreasing pain.
A combination of extraception (gentle effleurage) and proprioception (limbs’ position in space during passive movements) could develop the patients’ self-consciousness through
increased self-perception of their bodies within the here and
now (actual reality).
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Lomi Lomi as a Massage With Movements
FIGURE 3 illustrates proximally directed effleurage stroke on
the medial surface of the arm with simultaneous abduction and
external rotation.
FIGURE 5 illustrates a combination of abduction/external rotation
in the hip joint and flexion in the hip and knee joint, combined with
effleurage on the anterior thigh muscles (quadriceps femoris).
FIGURE 4 illustrates horizontal flexion and traction of the
gleno-humeral joint while the therapist’s supportive hand glides
laterally and medially, proximally and distally.
FIGURE 6 illustrates a combination of adduction and internal
rotation of the hip joint and flexion in the hip and knee joint,
accompanied by axial effleurage in distal direction.
Spiritual transformation during MWM practices may facilitate personal growth and fulfillment through a cycle of awareness
and fuller integration of spiritual self.
Joint range of motion, ligament, tendon, and fascia elasticity
and resistance may be improved through enhanced tissues oxygenation and metabolism. This may optimize movement coordination and fluency.
The autonomic nervous system, through skin-visceral reflexes, may be stimulated during MWM. This may promote optimal
functioning of cardiorespiratory, endocrine, immune, digestive,
or reproductive systems and ultimately result in optimal health,
better quality of life, and overall well-being. Through improved
circulation, tissue nutrition may be enhanced and metabolic
waste may be optimally expelled.
MWM may mobilize nerve tracks, correct existing misalignments, and deactivate trigger point activity via increased oxygenation.
INDICATIONS AND CONTRAINDICATIONS
As with both principle techniques, the indications and contraindicators for massage and passive movements are dependent
upon the patient’s medical history and through the clinical decisionmaking process.
Lomi Lomi as a Massage With Movements
Indications
Indications to MWM may include psychosocial conditions
such as stress, anxiety, and depression. MWM may be useful for
patients with low quality of life, self-esteem, and level of optimism.
Furthermore, immobilized patients and those with neurological or
orthopedic disorders may benefit from MWM interventions due
to the proposed biopsychosocial benefits previously discussed.
Contraindications
All the contraindications concerning massage and passive
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
47
movements should be considered before applying this manual
procedure. Contraindications may include musculoskeletal
inflammatory processes, viral infections, and changes in the tissues continuity. Acute injuries that may be aggravated through
the use of massage or passive motions should be avoided. The
cases of patients with psychiatric conditions such as phobias,
panic attacks, or schizophrenia should be carefully considered
prior to MWM.
DISCUSSION
Massage is regarded as a therapy that harmonizes the wellbeing and general health of an individual. These effects can be
attributed to increased relaxation; enhanced mood and emotional
wellness; and improved immune and nervous system reactivity,
blood flow, and muscle temperature. Massage also decreases joint
stiffness, swelling, and muscle spasm.54,57,58 Alternatively, passive
movements are cited as being able to enhance the activation of cortical regions, improve cardiorespiratory parameters, and limit joint
adhesions and adaptive tissue shortening.14,41,47,48
The purpose of this article is to investigate the underlying
principles and the concepts of massage and passive movements and
to assess whether these modalities could be combined through a
coherent and rational construct of MWM under the Lomi Lomi
umbrella. The main principles of MWM consist of elements of passive movement to the extremities along with gentle massage. It also
has been suggested that positive effects of this treatment may optimize therapeutic outcomes among various groups of patients. The
concepts of this treatment would suggest that MWM might be beneficial through its “mobilization” of various bodily systems such as
the immunological, cardiorespiratory, nervous, and musculoskeletal systems to improve joint range of motion, tissue elasticity and
flexibility, and cardiovascular capacity. Finally, psychosocial and
spiritual health also may be positively influenced. Future research is
recommended to quantify the possible effects of MWM’s influence
on various body systems. Assessment of the individual effects of
passive movements, massage, and MWM will provide a trustworthy indication for the establishment, or questioning, of this proposed MWM concept on a biopsychosociospiritual level.
The clinical application of the MWM model, if verified by
future research, may promote a change in current practice. A wide
variety of therapists may take inspiration from such synthesis for
their patients’ optimal health. Researchers can obtain valuable and
additional arguments through such cross-fertilization of ideas,
which may be united under the MWM concept. Furthermore, the
discussion regarding the concept itself is open, and the authors
appreciate others’ thoughts and insights that might help in modifying and developing the presented concept.
Although this article describes only MWM techniques performed in supine, these may also be administered with the patient
prone. While performing MWM, the therapist may concentrate on
the precision of each passive movement and effleurage technique
simultaneously. Although many aspects of this treatment are inherent in the teaching and development of future therapists, it is
strongly recommended that MWM practitioners acquire additional
48
training to improve the delivery and execution of this therapeutic
technique. It is recommended that if shown to be efficacious,
MWM be implemented into healthcare professionals’ academic
curriculums as a clinical technique.
In any review article, it is prudent to consider the strengths
and weakness of the presented argument. The inherent limitations
of a narrative review include the potential for bias both on study
selection and on representing both methodologically strong and
weak literature equally in order to discuss a topic. Nevertheless, the
purpose of this article was to introduce the MWM concept from the
Lomi-Lomi perspective. A paucity of literature was identified, so we
were not able to segregate literature and used all pertinent available
literature to substantiate the statements made. As the evidence base
in this field develops, further reviews using systematic strategies
and meta-analysis approaches may be indicated.
It is important to emphasize that the level of abstraction presented within the scope of this article is grounded in qualitative
approaches. It has been suggested that this approach offers a range
of epistemological, theoretical, and methodological possibilities for
knowledge building that can be unique in content, focus, and
form.59 During this qualitative analysis and synthesis, therefore,
some information regarding passive movement and massage’s
essence was derived from the presented data to reveal the underlying core principles of both practices.
CONCLUSION
Massage and passive movements are established treatments
used by a variety of healthcare professionals. This article suggests a
conceptual synthesis of these techniques by combining their essence
under the guise of Lomi Lomi. This article opens the discussion
about this potential therapeutic technique, as further theoretical
work is required to develop and establish this present concept.
Furthermore, qualitative, quantitative, or mixed method designs
may be indicated in order to develop our knowledge about MWM.
This is essential to enlarge an evidence base for these techniques
and their applications before MWM can be adopted into broader
clinical settings. If verified, the construct of MWM may be a useful
adjunct for physiotherapists, occupational therapists, massage
practitioners, or nurses who might consider expanding their “therapeutic toolkit” by using MWM. The concept presented in this article may expand the existing paradigm in which massage and passive
movements are embedded.
FUTURE RESEARCH
To the authors’ knowledge, no empirical research has been
published investigating the efficacy of Lomi Lomi as a combined
MWM treatment. The authors therefore suggest that future
research be directed toward a better understanding of the clinical
effects of MWM in different patient groups.
Future research might concentrate on patients’ experiences,
including their perception/reception of MWM. Qualitative research
methods may be indicated to investigate patients’ feelings, emotions, and perceptions using Interpretive Phenomenological
Analysis or Grounded Theory approaches to provide a deeper
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Lomi Lomi as a Massage With Movements
insight into this therapeutic modality. Similarly, quantitative
research methods may be advocated to assess the physiological
effects of this treatment, particularly with respect to endorphin or
serotonin levels among depressive or stressed patients or those with
chronic pain. Ideally, in future pragmatic randomized controlled
trials, mixed method approaches incorporating qualitative methodologies will be employed. As a result, more plausible conclusions
about this technique’s efficacy and effectiveness can be drawn.
31.
32.
33.
34.
35.
36.
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Chang A, Paratz J, Rollston J. Ventilatory effects of neurophysiological facilitation and
passive movement in patients with neurological injury. Aust J Physiother.
2002;48(4):305-310.
Miller L. Beauty Up: Exploring Contemporary Japanese Body Aesthetics. Berkeley, CA:
University of California Press; 2006.
Stewart N. The Complete Body Massage Course: An Introduction to the Most Popular
Massage Therapies. London, England: Collins & Brown; 2006.
Calvert RN. The History of Massage: An Illustrated Survey From Around the World.
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Fritz S. Mosby’s Fundamentals of Therapeutic Massage. London, England: Mosby; 2000.
Huber FE. Therapeutic Exercise: Treatment Planning for Progression. St Louis, MO:
Saunders Elsevier; 2006.
Kaltenborn FM. Manual Mobilization of the Extremity Joints: Basic Examination and
Treatment techniques. Oslo, Norway: Olaf Norlis; 1989.
Kolster BC. Massage: Klassische Massage, Querfriktionen, Funktionsmassage. Berlin,
Germany: Springer; 2003.
Premkumar K. The Massage Connection: Anatomy and Physiology. Philadelphia, PA:
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Hesse-Biber SN, Leavy P. The Practice of Qualitative Research. London, England: Sage
Publishing; 2005.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
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hypothesis
CLINICAL RESEARCH IN
ANTHROPOSOPHIC
MEDICINE
Harald Johan Hamre,
; Helmut Kiene,
; Gunver Sophia Kienle,
Dr med
Anthroposophic medicine includes special medications and
special artistic and physical therapies. More than 200 clinical
studies of varying design and quality have been conducted on
anthroposophic treatment. Half of these studies concern
anthroposophic mistletoe therapy for cancer. Clinical effects of
mistletoe products include improvement of quality of life,
reduction of side effects from chemotherapy and radiation, and
possibly increased survival.
Apart from cancer therapy, the largest studies of anthroposophic treatment have been 2 naturalistic system evaluations: In
Harald Johan Hamre, Dr med, and Gunver Sophia Kienle, Dr
med, are senior research scientists at and Helmut Kiene, Dr med,
is the director of the Institute for Applied Epistemology and
Medical Methodology, Freiburg, Germany.
nthroposophic medicine (AM) is a complementary
therapy system founded in the 1920s by Rudolf
Steiner and Ita Wegman1 and provided by specially
trained physicians in 56 countries worldwide.2 AM
acknowledges a spiritual-existential dimension in
humanity, which is assumed to interact with psychological and
somatic levels in health and disease. AM therapy includes special
treatment modalities (eurythmy movement exercises, art therapy, rhythmical massage therapy) and special medications.3,4
Eurythmy therapy is an artistic exercise therapy involving
cognitive, emotional, and volitional elements. In eurythmy
therapy sessions, patients are instructed to exercise specific
movements with the hands, the feet, or the whole body.
Eurythmy movements are related to the sounds of vowels and
consonants, to music intervals, or to affective gestures (eg,
sympathy-antipathy). In AM art therapy, patients engage in
painting, drawing, clay modeling, music, or speech exercises.
Rhythmical massage therapy was developed from Swedish massage; special techniques include lifting movements, rhythmically undulating gliding movements, and complex movement
patterns like lemniscates. AM medications are prepared from
minerals, plants, animals, and chemically defined substances.
AM medications can be prepared in concentrated form or in
homeopathic potencies and are administered in various ways
A
52
Dr med
Dr med
German outpatients with mental, musculoskeletal, respiratory,
and other chronic conditions, anthroposophic treatment was followed by sustained improvements of symptoms and quality of life.
In primary care patients from 4 European countries and the
United States treated for acute respiratory and ear infections by
anthroposophic or conventional physicians, anthroposophic treatment was associated with reduced use of antibiotics and antipyretics, quicker recovery, and fewer adverse reactions; these differences
remained after adjustment for relevant baseline differences. (Altern
Ther Health Med. 2009;15(6):52-55.)
(oral, rectal, vaginal, conjunctival, nasal, or percutaneous application or by subcutaneous, intracutaneous, or intravenous
injection). AM medication therapy can be standardized (1
product for a given indication) or individualized (involving 1
or several AM medications and sometimes nonmedication AM
therapies). AM treatments can be administered alone or combined with conventional medical therapy as needed.3,4
HISTORY
AM was developed in the 1920s and early 1930s as a
research-based therapy system. In this period, laboratory and
clinical studies were conducted according to contemporary standards. After World War II, when AM was reestablished in
Europe, the focus was on founding practices, clinics, and hospitals rather than on research. In the 1970s and 1980s, research
was performed but also restrained by the predominant paradigm
of the double-blind randomized trial, which was difficult to
implement in AM settings. In recent times, research activities
have grown strongly with experimental and observational studies, with work on methodology, and with researchers catching up
with current technical standards.4
CHALLENGES AND SOLUTIONS, STRENGTHS AND
LIMITATIONS
Research into AM poses several challenges. Randomized
allocation of patients into therapy and control groups is often
rejected by AM physicians and their patients, chiefly because the
physician-patient relationship is disturbed by randomization and
because of strong therapy preferences.5,6 Randomization refusal
and other obstacles have led to severe recruitment problems and
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Clinical Research in Anthroposophic Medicine
premature termination of a number of randomized trials of AM
medications.6 Some forms of AM therapy can be evaluated in
non-AM settings without unduly distorting the treatment, however, and for these treatments, randomized studies are possible
and have been conducted.4
Blinding of patients is often unmasked because of properties of the AM treatment such as local reactions to injections.7
Blinding can also induce a subtle form of bias, when patients
willing to participate in double-blind trials have worse outcomes
of AM therapy than patients who reject being blinded. 8
Nevertheless, for some AM medications, double-blind trials are
possible and have been successfully conducted.9-12
Another challenge is the very large number of AM therapy
options; approximately 1700 AM medications are manufactured,
and most are sold in very small quantities (personal communication, Agnes Mitzakoff, February 23, 2009; e-mail communication, Peter Vögele, March 1, 2009). Moreover, AM therapy is
often individualized, involving several AM medications sometimes combined with artistic or physical therapies, and as a
result, the number of AM therapy options is further increased.
Consequently, there is not enough money or manpower to conduct individual studies for each AM therapy option. A solution
to this challenge is to evaluate AM therapy as a whole system.13
Whole-system evaluations of AM treatment have been performed with acute infections,5 cancer,14-18 and other chronic indications.4,19 A strength of these system evaluations is their high
practice relevance, with clinically relevant settings, range of
patients, therapy administration, and outcomes.4 Whole-system
evaluations can be supplemented by analyses of major components of the AM therapy system.20-24
PREVENTION
Research into preventive effects of AM has focused on allergic diseases, which affect up to one-third of children in many
countries.25,26 Related to the AM approach is an educational philosophy implemented in more than 3000 Waldorf schools, kindergartens, and curative education centers worldwide. 27,28 In
well-controlled epidemiological studies, Waldorf school attendance was associated with a reduced risk for atopic disease,29,30
possibly mediated by effects on the intestinal bacterial flora from
restrictive use of antibiotics and antipyretics in childhood infectious disease30 or from a diet containing fermented vegetables.31
Antibiotic and antipyretic use in early childhood is a risk factor
for allergic diseases.32-34 In a naturalistic study of primary care
patients treated for acute respiratory or ear infections, the use of
antibiotics and antipyretics could be reduced to a minimum in
AM settings (antibiotics: 5% vs 34% of patients treated by AM or
conventional physicians, respectively; antipyretics: 3% vs 22%,
respectively) without detrimental effects.5
CLINICAL EFFECTIVENESS
The most complete systematic review of clinical effectiveness of AM treatment identified 195 studies, 18 of which were
randomized trials.4 Of the studies, 186 (including 15 of the 18
Clinical Research in Anthroposophic Medicine
randomized trials) had positive results for AM treatment, 8 studies had no benefit, and 1 study had a negative trend. Study quality was variable: some studies had serious deficiencies, but there
were also a number of very carefully conducted and well
described studies.4 One possible explanation for the deficiencies
is that many studies were performed by enthusiastic AM practitioners who did not have formal training in clinical research.
Half of the studies concerned AM mistletoe therapy for
cancer; other frequent indications were acute infections, pain
syndromes, and hepatitis.4 AM mistletoe products are widely
used in Central Europe. In Germany, 9.2 million defined daily
doses of AM mistletoe products were sold in 2007, amounting
to 23% of all chemotherapy agents sold.35 A large number of laboratory studies have shown that mistletoe extracts inhibit the
growth of cancer cells, modulate the immune system favorably,
and stabilize DNA in noncancerous cells.36,37 Moreover, numerous animal experiments show a reduction of tumor growth and
metastasis after mistletoe application.36,37 The most complete
systematic review of clinical effectiveness of AM mistletoe products comprised 37 studies, of which 16 were randomized trials.38
The best documented clinical effects of AM mistletoe therapy
are improvement of quality of life and reduction of side effects
from chemotherapy and radiation. A survival benefit also has
been shown but not beyond critique. Tumor remissions have
been described following local or high-dose applications of AM
mistletoe products.38
Apart from cancer therapy, the largest and most detailed
clinical studies of AM therapy have been 2 system evaluations,
together comprising more than 2700 patients. The
Anthroposophic Medicine Outcomes Study (AMOS) is a naturalistic cohort study of German outpatients treated for mental, musculoskeletal, respiratory, and other chronic conditions. 39
One-fourth of all qualified AM physicians and therapists in
Germany participated in AMOS, and the participating physicians
and dentists resembled eligible but not participating physicians
and therapists with respect to age, gender, the number of years in
practice, and the proportion working in primary care.20-23 These
features suggest that the AMOS study to a high degree mirrors
contemporary AM use in outpatient settings. Following AM treatment (art therapy, rhythmical massage, eurythmy, physicianprovided counseling, AM medications), substantial and sustained
improvements of disease symptoms and quality of life were
observed.39 These improvements were found in adults and children,39,40 in all therapy modality groups,20-24 and in all evaluable
diagnosis groups.41-44 The improvements in quality of life were at
least of the same order of magnitude as improvements following
other (non-AM) treatments.45 Some of the improvement may have
other causes than the AM therapy, such as other treatments; however, patients not using conventional therapies for their main disorder (two-thirds of patients) had a similar improvement.24 A
more detailed analysis of 4 possible causes of the improvement
showed that conventional therapies together with patient dropout, natural recovery, and regression to the mean together
explained a maximum of 37% of the improvement.46
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
53
The International Integrative Primary Care Outcomes
Study–Anthroposophy study was a naturalistic comparison of
primary care patients from 4 European countries and the United
States who were treated by AM or conventional physicians for
acute respiratory and ear infections.5 Compared to conventional
therapy, AM treatment was associated with reduced use of antibiotics and antipyretics, quicker recovery, fewer adverse reactions, and greater therapy satisfaction. These differences
remained after adjustment for country, age, gender, and 4 markers of baseline severity.5
SAFETY
In safety studies, AM treatment is generally well tolerated.
Adverse reactions are infrequent and mostly mild to moderate in
severity. Three types of adverse reactions to AM medications are
commonly described: local reactions from topical application,
systemic hypersensitivity including very rare cases of anaphylactic reactions, and aggravation of preexisting symptoms in sensitive patients.4,47,48 In a detailed safety analysis from the AMOS
study, the incidence of confirmed adverse reactions to AM medications was 3% of users and 2% of the medications used. No serious adverse reactions were found.48 An innovative electronic
pharmacovigilance system has been established in a network of
AM practices.49
Theoretically, avoidance of necessary conventional treatment
in AM settings might pose a risk,50 but no evidence has been found
for this.4 In comparative studies, AM treatment had similar42 or
lower5,19,51 rates of adverse reactions than conventional treatment.
COST
The most detailed cost analysis of AM treatment was performed in the AMOS study.52 The analysis included costs of AM
and conventional therapies, inpatient hospital and rehabilitation
treatment, and sick leave. Total costs in the first study year did not
differ significantly from costs in the pre-study year, although the
patients were starting new AM therapy, whereas in the second
year, costs were significantly reduced by 13%. The cost reduction
was due to a reduction of inpatient hospitalization that could not
be explained by secular trends during the study period.52 Other,
less detailed evaluations also indicate similar or lower costs in AM
therapy settings compared to conventional settings.4
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
CONCLUSION
It is difficult to conduct randomized trials for each AM therapy option because of therapy preferences and because of the
very large number of AM medications used. More than 200 studies are now available, 90% of them observational and of varying
quality. The studies predominantly show good clinical outcomes,
few side effects, high patient satisfaction, and possibly slightly
less cost, but there is a need for more studies of high quality.
24.
25.
26.
27.
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CONVERSATIONS
BENJAMIN KLIGLER, MD: ADVANCING THE
CAUSEInterview
OFbyHEALING-ORIENTED
MEDICINE
Frank Lampe and Suzanne Snyder • Photography by Doreen Birdsell
Benjamin Kligler, MD, is vice chair of the Department of Integrative
Medicine, Beth Israel Medical Center, New York. He is associate professor of family and social medicine at Albert Einstein College of
Medicine and research director of the Continuum Center for Health
and Healing, an integrative medicine practice that opened in May
2000. Additionally, Dr Kligler is codirector of the Beth Israel Fellowship
Program in Integrative Medicine, which accepted its first fellows for
training in January 2002, and teaches in the Beth Israel Residency
Program in Urban Family Practice. Dr Kligler is the author of
Curriculum in Complementary Therapies: A Guide for the
Medical Educator, a monograph distributed by the Society of
Teachers of Family Medicine, and coeditor of Integrative Medicine:
Principles for Practice (McGraw-Hill, 2004). He is also coeditor in
chief of the peer-reviewed journal Explore: The Journal of Science
and Healing. Dr Kligler is certified in Ericksonian hypnotherapy and
acupuncture and incorporates these and the use of botanical medicines
into his primary care practice at the Center for Health and Healing.
would be the place where it would be easiest to bring in a wider
point of view of what constituted healing and the things people
might want to do to improve their health.
That was all paralleled by, in my own life, using more herbal
medicines, using massage, seeing acupuncturists, etc. When I
had my own children, I used more of the same sort of therapies
in dealing with their health. So my professional life paralleled my
own path in terms of how I was looking at health. Conventional
medicine has an important role to play in keeping people healthy
and making them well when they’re sick, but I think it’s a foregone conclusion that it makes sense to broaden the range of
options that you have to be well.
Alternative Therapies in Health and Medicine (ATHM): What
were the influences in your life that led you to medicine and, specifically, to integrative medicine?
ATHM: Where did you do your undergraduate work?
Dr Kligler: Medicine in general was more or less ordained for
me. My dad was a pediatrician. He had an office in our basement
at home, and I grew up watching him take care of kids and families. I had periods when I thought that wasn’t what I would I do,
but I know it was in my mind from when I was young.
I was a botany major in college, mostly because I had a love
of doing things outdoors. I became interested in the ways in
which different cultures use plants for healing and for medicine—
Chinese medicine in particular. That steered me toward exploring all different kinds of therapies other than conventional
healing strategies and approaches.
When I graduated from college, I had the idea that I would
become an acupuncturist or pursue some other healing art
besides medicine, and I pondered that for a couple years and
worked in various jobs. And then I realized that it made sense to
go into medicine, but I knew that I would hold onto my interest
in the other healing arts.
So I went to medical school and then I chose family medicine as a specialty, partly because it has the most holistic philosophy of all the different medical disciplines, and I thought it
58
ATHM: Where did you grow up?
Dr Kligler: I grew up in White Plains, New York, in Westchester.
I actually have a couple of adult patients now who were my
father’s patients when they were kids.
Dr Kligler: I went to Harvard for undergraduate studies and to
Boston University for medical school. I did 1 year of medical
school at University of Vermont and then transferred to Boston
University for relationship and marriage reasons. I did my residency at Montefiore in the Bronx in family practice. That is when
I came back to New York.
ATHM: One of the things that it is very clear in looking at your
career is that you have a real focus on practitioner education,
teaching, and training. How did that evolve over the course of
your education and your experience? What were the influences
that led to that area?
Dr Kligler: A lot of it came from being in medical school as
someone who already had an interest in some of the other
approaches to healing outside of conventional medicine. I was
Opposite: Shown here at the Continuum Center for Health and
Healing, Benjamin Kligler, MD, believes that every physician can and
should incorporate into his or her way of thinking and practicing medicine the idea that patients have an intrinsic capacity to heal.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, MD
Conversations: Benjamin Kligler, MD
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
59
dismayed by the fact that these approaches were not a part of
physicians’ education.
Based on my orientation and experiences that I’d had so far,
it seemed really silly to me that all these other healing arts were
out there in the world and accessible for our patients and we as
doctors-in-training were moving through our education with
nobody teaching us about them.
Before I was even in residency, it was clear to me that there
was a need for doctors to teach each other, and I was involved with
some efforts in med school, lunches where we had practitioners in
to talk about things—very modest efforts to try to help my fellow
medical students get educated.
As a resident, you get to
teach medical students, and
when you’re a senior resident,
you teach more junior residents. I discovered that I really
loved teaching—and having
already had a sense that there
was a glaring deficiency in
medical education, it seemed
fairly clear to me that education should be part of my
focus. I saw that I could do my
individual work with patients
around helping them think
about how natural medicines
could help them be more
healthy, but as far as impacting the field of medicine goes,
doctors as a whole had to be
more aware.
It was fortunate for me
that this took place in the early
’90s, when David Eisenberg’s
first study was coming out.
There was a lot of attention
both in the public press and in
the medical literature about the
magnitude, the scope of
patients’ use of unconventional
medicines and the communication gap between practitioners and
patients. That was emerging as a theme right at the time that I was
becoming a doctor. There was a need within medical education
that people suddenly had become aware of that fit in nicely with
what I liked to do and what I felt was important.
As time has gone by, I have continued to find my work more
and more rewarding. I feel that integrative medicine, philosophically, has an important message to bring to physicians that, in
large part, is missing from conventional medical education. It
has to do with orienting oneself toward the healing potential of
every patient and making that the guiding principle of your
work, as opposed to breaking down each patient into a set of diseases or organs or conditions that you treat individually.
T
Family medicine has done a pretty good job of bringing a
whole-person view back into medical education and has made
great strides. But I think it can be taken a step further in terms of
bringing the notion of healing-oriented medicine back into the
heart of medical practice.
My passion for it and the reason I have wanted to keep doing
it is not about, “Oh, the doctors must know about 10 specific herbal medicines,” or, “They must know exactly what an acupuncturist
does or what a chiropractor does.” It’s much more about helping
doctors—whether they are interested in other healing arts or
not—to see that there’s a different way to look at patients than the
way we’ve been taught, which
focuses on treating diseases as
opposed to treating the person.
Integrative medicine has been a
really good vehicle for me to
help get that message across.
Integrative medicine is a
natural fit with family medicine as a model. Family medicine, philosophically, was born
in the ’70s as a recommitment
of physicians to view the whole
person. It has the concept of
the biopsychosocial model: it’s
not just about the biology of
the person or the disease. It is
about his or her psychology,
emotional life, spiritual life,
social setting, community, and
family. You contribute to people’s health by having a wholeperson view.
The combination of the
family medicine point of view
and the integrative medicine
point of view really suited me
and so I want everybody to
know about it. I want every person who is becoming a doctor
to know that this is potentially
one of the ways you can look at people and go about your work.
HERE’S A
TREMENDOUS
MOVEMENT IN
THE DIRECTION IN
MEDICAL EDUCATION
OF WHAT’S BEING
CALLED “PROFESSIONALISM,” WHICH HAS TO
DO WITH THE MORE
IMPORTANT QUESTION
OF “WHAT IS BEING A
DOCTOR REALLY ABOUT?”
60
ATHM: You have been trying to influence curriculum and the
academic side for close to 20 years now?
Dr Kligler: Yes. I started when I was a resident, in 1991.
ATHM: With regard to the progress that’s being made on the curriculum side, where do you think academics in the medical
schools are in embracing the concepts you just spoke about?
Dr Kligler: They’re making great progress. Not so much with
the focus on the modalities, such as learning about acupuncture
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, TK
MD
or learning about chiropractic. There is a fair amount of that
going on. But there’s a tremendous movement in the direction
in medical education of what’s being called “professionalism,”
which has to do with the more important question of “What is
being a doctor really about?” It is not just about knowing about
diseases. It is about how you speak to your patients, how you
view your patients. It’s about learning how to reflect on your
own beliefs and your own approach to things and how they
impact patients.
Every school around the country now is required by the
Liasion Committee on Medical Education (LCME) to have a professionalism curriculum. That
doesn’t sound on the surface
like it has anything to do with
integrative medicine, but the
fact is a lot of the principles
that we’re talking about, which
have to do with doctors relating to patients in a humanistic
fashion as opposed to in an
impersonal, completely reductionistic fashion, are at the core
of professionalism.
This is a new thing in medical education—it was not there
15 years ago. Many medical
schools now have very highly
evolved courses in doctor-patient
communication. There has been
tremendous progress. That’s not
something that integrative medicine has much to do with or can
take credit for, it’s more a
response to changes in our society and what our society is
demanding of doctors.
On the other hand, there
has not been such great progress in the part of medical education
that happens in the hospital. The first 2 years of medical education
happen in the classroom, where you can have a fair amount of
impact as an educator. Then in the third and fourth years, the students go to the hospital for their on-the-job training as physicians.
The hospital environment and the way doctors treat patients in
hospitals haven’t evolved all that much in terms of interpersonal
dimensions. We lose some ground during the third and fourth
years of medical school in terms of trying to turn out doctors who
are holistic and humanistic in their point of view.
In the hospital environment, students are working with tremendously overworked and sleep-deprived residents as their
immediate supervisors, and it’s hard to get things done.
Hospitals have a lot of problems in terms of how they are run,
and that’s where a lot of the education happens in the latter part
of med school. Hospitals are working on that and trying different
strategies, but it is a challenge.
M
ATHM: Are today’s medical students learning about some of the
alternative therapies that we think are important?
Dr Kligler: The majority of schools now have at least elective
courses, and a lot of schools have some required courses where
students are learning about the basics of herbal medicine or
mind-body therapies or what people from other healing professions actually do. There has been pretty good progress in that
area, too.
We have a long way to go. I’m involved with the Consortium of
Academic Health Centers for Integrative Medicine, a group of 44
US and Canadian medical
schools working together to
move this field forward within
academic medicine. The LCME
is responsible for credentialing
and regulating medical schools.
We put forward from the
Consortium a proposal to the
LCME that education in integrative medicine become a
required part of medical school
and that this become one of the
standards that they use when
they go out to evaluate medical
schools to accredit them.
They were very friendly,
and they engaged with us in
the conversation. They came
back with an acknowledgement of this as an area that
should be considered in medical education but not as something that they were going to
require every school to do. It
went onto a list of topics
about which schools had to
indicate whether they were or weren’t doing anything. It was a
very small move in the direction that we’re trying to go. We still
have a long way to go in terms of pushing this into medical education in the way it needs to be there. But I’m very optimistic.
At the residency level, the postgraduate level, there has been
tremendous progress. In some ways, that’s a much easier front
because the programs are smaller; they’re not quite as bureaucratic as the medical schools are. There are less conservative forces at play sometimes in residency programs. Especially in family
medicine in postgraduate education and at the residency level,
we have made fantastic progress.
AYBE SOMEDAY
THE WINDS OF
POLITICS AND
SOCIAL CHANGE WILL
BLOW IN SUCH A WAY
THAT PEOPLE FEEL THAT
INTEGRATIVE MEDICINE
SHOULD BECOME PART
OF THE REQUIRED
CURRICULUM.
Conversations: Benjamin Kligler, MD
ATHM: It sounds as though one of the big challenges is integrating
the education component into the actual practice component.
Dr Kligler: Exactly. For example, at Einstein, the medical school
where I teach, we just started a wellness curriculum in which the
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
61
first week the students arrive, they complete a survey looking at
their own dietary practices, their own stress management, their
exercise practices, how they take care of themselves. Then they
repeat this a couple of times throughout their 4 years of medical
school. We’re using this to help them develop an awareness of
how they make choices about their own health practices and how
hard it is to change, what’s involved in changing, and what happens to you when you go through stressful periods. This will help
them become more healthy physicians in the long run and also
will help them understand their patients better.
In the third year, we send them to their surgery rotation
where, for instance, their surgery resident is still working 24 and
30 and 36 hours straight and feeling pretty put upon and not too
empathetic toward their patients or toward anybody. And suddenly, you’re in an environment that just by its nature is entirely
opposed to the idea of your wellness.
That’s hard. It’s easier when they train in outpatient environments. The inpatient training environment is the next thing
we have to try to figure out how to tackle. That’s more difficult
because hospitals are not necessarily about education; they’re
about patient care. The rituals of hospital care are very
entrenched, and they don’t change easily. In the next 10 to 20
years, medical schools are going to have to deal with the fact that
the third and fourth years of medical training need to be
rethought in order to for us to become more effective in accomplishing some of the goals we’re after.
“Unless we can have people get to know each other early in the course of their
forming their health professional identity, it’s going to be hard to have a real
impact on their ability to collaborate.”
“Part of the reason we have all these professionalism curricula is that the
public was fed up. They were fed up with not having doctors who would listen to them. ”
62
ATHM: Do you see any geographic trends in terms of where some
of these programs are becoming more widely implemented?
Dr Kligler: I don’t see that so much. It’s actually more about
individual schools and individual programs, people with passion
and interest popping up in particular places. I don’t think it’s so
much about East Coast vs West Coast. One could say the West
Coast is always a little ahead, but on the other hand, there are
plenty of extremely conservative schools on the West Coast that
are still doing nothing in this area.
We all owe a tremendous amount to Andy Weil’s leadership
in the sense that he conceived this idea in the early ’90s. He used
his clout as a public opinion maker around health and walked
into the medical school and refused to go away. He provided a
tremendous amount of leadership around integrative medicine.
And he and Victoria Maizes (MD, Arizona Center of Integrative
Medicine), who has helped him grow the program there, have
step by step built a tremendous program there that I think is the
standard setter for medical education in this area.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, MD
The Consortium has come to be an important force in moving the effort of integrative medicine forward in all the domains,
but tremendously in education. I think that the consortium has
been an important focal point for some of the conversations
about how to get medical education moving in the direction we
want it to move.
ATHM: Can you tell us a little bit about how residency programs
have evolved to incorporate integrative medicine training?
Dr Kligler: Going back to the mid ’90s, as the awareness grew
that integrative medicine had to be part of medical education,
people at the residency level also started to see it, as well as people at the medical school level—especially in family medicine
training. So starting in the mid- to late ’90s, a lot of residency
programs started trying to figure out how to incorporate integrative medicine—it wasn’t even called integrative medicine yet—
into their curricula.
In 1995, I came to Beth Israel, and one of my mandates
from the chairman was, “We want to make complementary/
alternative medicine education a required part of our residency
curriculum.” We were one of the first programs in the country to
do that. That was the beginning of what has been a fairly consis-
“If we don’t regulate what pharmaceutical companies can charge for their
drugs and what doctors can charge for procedures, improved access is not
going to solve our problem.”
Conversations: Benjamin Kligler, MD
tent growth, at least in family practice residencies, in the commitment that every doctor has to learn something about this.
Maybe it will be some lectures; maybe it will be an elective. It’s
still not a required part of family medicine training, but I think
it’s safe to say that probably a majority of programs in family
medicine residency are incorporating this. It has been a little bit
slower to spread to other disciplines. Pediatrics is starting to
move along, internal medicine, some programs are moving along
a little. Family medicine has led the way. It is gradually seeping
out to other programs at the residency level.
The movement to have fellowships started around the same
time, obviously partly because a lot of people who had finished
training nevertheless had an interest in learning more about integrative medicine. The Arizona folks started their fellowship in
1996 or so. We started a fellowship program in 2001. Subsequently,
a lot of programs have popped up around the country.
The fellowship level education has pros and cons. At any
one site, you can train only a couple of fellows, maybe 4 at the
most. It works well on the one hand because people can get really
in-depth training. But on the other hand, the impact on the field
at large is small because it’s a small number of people. So
although fellowship training plays an important part in this
whole picture, it plays only one part because the scale is small.
Different programs have responded to that in different
ways. The way Arizona has responded to that is by saying, “We’re
going to take our fellowship and move it out onto the Internet,
so that our reach becomes much wider.” They moved from a
focus on a residential fellowship where they had 4 fellows per
year who were located in Tucson, and they expanded to an online
fellowship where they now train hundreds of people a year by
offering it as a distance learning model. That is a tremendously
successful strategy for expanding the reach of the fellowship-level
curriculum. Others of us have tried to produce models at the residency level that can be replicated and spread throughout residency programs because in a residency, you’re talking about 8 or
10 people every year.
Then in 2003, a program was started called the Integrative
Family Medicine Program. Integrative Family Medicine was an
idea that basically added 1 year onto a family practice residency
and made it a 4-year program. In the fourth year, the students
were integrative medicine fellows. That program was a joint program that Arizona developed with 6 different residency sites
around the country, including Beth Israel. It was a model for how
fellows could be housed within a family practice department, the
idea being, “We’re only training 1 or 2 people, but because it’s
happening in a department with other residents around, we’re
going to have an influence. It’s going to spill over to the rest of
the program.” That program was originally funded by a US
Department of Education grant.
It was a very successful program for learning about how to
integrate this training inside of established family medicine departments, as opposed to students having to go to a freestanding fellowship. This was getting it a home inside of an existing department in
the conventional medical center. And that program is still going.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
63
Out of that was born the Integrative Medicine in Residency
Program (IMR). The idea of the IMR is that we now have a
required curriculum in integrative medicine for not just 1 resident
per year but for all the residents in a residency program. It’s now
not just 1 person or 2 people in a given residency class who
decide, “I’m going to study integrative medicine”; everybody in a
given residency program gets a strong basis in integrative medicine. In every residency program
that participates in the IMR program, everybody, every single resident, is going to get that training.
At Beth Israel, for example,
we are turning out 8 residents per
year who, in addition to being
well-qualified, trained, boardcertified family docs, have had a
very strong background and education in integrative medicine as
well. Now, hopefully, we’re developing a model for how this
becomes a required part of graduate medical education, not an
optional part only for those who
are interested.
In the initial pilot phase,
which started last year, this is happening in 8 programs around the
country, again with Arizona as the
lead in terms of developing the curriculum. The model is a web-based,
250-hour curriculum over the 3
years of residency training that all
the residents go through that gives
them background and basic skills
in integrative medicine. This is
complemented by other teaching
and activities at their home site,
but all residents at these 8 programs are doing the same webbased program.
Somewhere between 60 and
80 residents per year at the 8 sites go through this program. We’re
now in the second year, so we have about 130 people enrolled at
these 8 sites, since some of them are second-years and some of
them are first-years. Next year, when we move into the third year,
we will have almost 200 residents in the program. It will stay at
that number for a couple of years because this is a pilot phase of
the IMR program. It is a 5-year pilot to develop the curriculum,
test it out, evaluate it, and determine whether we’re having the
impact on the residents’ education and practice patterns that we
want to have. We’ll see where we can take it from there.
The long-term goal is that at some point, the residency
review committee in family medicine, the governing body of family medicine residency training, will decide this is a core compo-
T
nent of family medicine board certification, that every program
should offer something like this. Ultimately, the IMR program or
something like it would become incorporated into every one of
the 400 or so programs there are in the country. That is not likely
to happen quickly. But the program has already gotten quite a lot
of attention in family medicine education circles so hopefully
what will happen is we will continue to demonstrate how effective it is, people will hear about it,
other programs will want to join
in, and more and more programs
will begin to offer this. One of the
things we’re looking at is whether
a residency program that offers
integrative medicine is more successful in recruiting high-quality
residents than a program that
doesn’t. In other words, is this a
way to get good residents into my
program? That is very important
for program directors.
From all different angles we
are trying to describe and quantify the potential benefits that this
program provides to residencies
so that after the initial pilot
phase, suddenly we’ve got 10 or
20 or 30 more programs that
want to join in and offer this as
part of what is available to their
residents. That is the cutting edge
of where we’re going with integrative medicine education at the
postgraduate level.
Other disciplines outside of
family medicine are starting to do
things, and it’s a little bit of a
slower process. There are much
stronger conservative forces at
work in some of the other specialties. Family medicine, since its
birth, has been quite a socially
progressive and open-minded specialty. We’ve really found a
good home there for developing a model for how this happens. I
think the day when this is part of every internal medicine program and every pediatrics program and every psychiatry program is a little bit farther off.
In those disciplines, we’re still looking for the pioneer programs that are going to step forward and try it out. My hope and I
think all of our hope is that, in a couple of years, it will not only be
family medicine programs but there will be 1 or 2 pediatrics programs and 1 or 2 medicine programs trying this type of implementation out in the different disciplines to see how it works.
Again, most of the leadership for this program has been
Victoria Maizes at Arizona, and Patricia Lebensohn, who works
o be a more
healingoriented or
holistic doctor,
it’s not just the
knowledge base, it
is an attitude, and
that attitude has
to extend to your
awareness of yourself and your own
health. That’s a
very challenging
thing to teach.
64
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, MD
with Victoria and who is the director of the Integrative Medicine
in Residency Program. They are both tremendous in their vision
of what this can be and their efforts to make it happen.
ATHM: Have you received feedback about the programs so far?
Dr Kligler: We’re in the second year of the program, and the feedback we get from the residents in
the programs that are involved is
tremendously positive. People are
grateful that we’re offering this, and
they feel the material is very strong.
We’re getting a lot of feedback that
people are specifically choosing to
visit and interview at the Integrative
Medicine in Residency Programs
because they’re interested in this.
It is clearly attracting applicants to these programs, which is
huge. You may know that in family
medicine, because it’s not the most
glamorous career choice and it’s
also not the highest-paying specialty, programs have struggled to
recruit enough high-quality medical school graduates. To have a new
offering or a new type of curriculum that is successful in drawing
high-quality candidates into the
field is very important for the field
at large.
I
the Consortium’s embrace or support of this kind of program,
since it represents 44 schools, is meaningful.
I can go to my dean and say, “Look, this organization of 44
medical schools is backing this program. Do we want to be in the
forefront of this new field? Or do we want to be the last ones to get
on board?” In that regard, the Consortium can have a big impact.
It doesn’t have the power to mandate or legislate anything. It’s
more about strength in numbers.
T’S EASY TO FALL
INTO THE
ASSUMPTION
THAT INTEGRATIVE
MEDICINE TRAINING
IS JUST ABOUT A NEW
KNOWLEDGE BASE. IF
YOU DO THAT, YOU
LOSE TOUCH WITH
THE ATTITUDES THAT
UNDERLIE IT.
ATHM: You mentioned that 8
schools are currently involved.
What are they?
Dr Kligler: These are really residencies, so not all of them are
medical school–affiliated. University of Arizona; Hennepin
County, in Minneapolis; University of Texas Medical Branch in
Galveston; Carolina’s Health System in North Carolina; Beth
Israel in New York; Maine Medical Center in Portland; MaineDartmouth, in Augusta, Maine; and University of Connecticut.
ATHM: Can an organization like the Consortium of Academic
Health Centers for Integrative Medicine help drive this program
to all of its member schools, which would then help it propagate
out to some of these other disciplines eventually?
Dr Kligler: It can help publicize it. It can’t help drive it because
the Consortium doesn’t have any regulatory power. But the publicity can have an impact: medical schools look at each other and
say, “Ooh, what are they doing? What are they doing?” And, “Is
that going to make them popular? Is that going to attract them
good candidates? Is it going to bring them grant funding?” So
Conversations: Benjamin Kligler, MD
ATHM: Is there any other regulatory body that could drive this?
Dr Kligler: The other one that
we’ve worked with very closely over
the last 4 or 5 years is called the
RRC, or Residency Revie w
Committee. Every specialty in medicine has its own RRC. That committee has credentialing and
regulatory power over the residency programs. Just like the LCME
accredits medical schools, the
RRCs in the different specialties
accredit the residency programs.
One of the goals of the
Integrative Family Medicine
Program was to involve the RRC in
family practice in overseeing some
of the efforts to incorporate this
kind of material into family medicine education. We corresponded
with them, and they gave us permission to proceed with this project. We’re in the process now of
putting together the 5-year followup report for the family medicine RRC. My impression is that
we’ve been successful in helping them become more aware of the
level of interest and the priority that people are putting on education in integrative medicine.
Maybe someday the winds of politics and social change will
blow in such a way that people feel that integrative medicine
should become part of the required curriculum. We’re making
steps in that direction, but we’ve got a lot of steps left.
Each specialty has its own RRC, so even once we have the
family medicine RRC saying, “This should be part of family medicine education nationally,” that doesn’t have any impact on, for
example, an internal medicine residency program. Or a pediatric
residency program.
Medicine is very medieval. It’s a collection of different little
kingdoms, specialties being the kingdoms. And yes, they have
alliances, and they have certain interests in common, but each is
very committed to preserving the integrity and the territory of its
kingdom. They don’t always work together. There are many steps
left in terms of expanding this to a larger audience.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
65
ATHM: Appreciating that you’re only in the second year of a
5-year program and it’s, as you admitted, too early to assess the
success of the program, other than some of the feedback that
you’re getting, are there any metrics that you’re able to look at
and say, “This is working,” or “We need to change X about the
Integrative Medicine in Residency Program”?
Dr Kligler: There’s a very detailed evaluation plan in place for
the IMR because, obviously, a big priority of this is not only
doing it but demonstrating that it works because the ability to
disseminate it in a larger way rests in
having strong evidence that it works.
One of the things that we’re
looking at that we will have data on
in the short-term are the recruiting
trends and how well these 8 programs do in filling their slots with
high-quality applicants. Every year
adds to those data. That’s one metric
that we’re looking at.
One of the big challenges with
every educational program, not just
in integrative medicine but across
the board, is determining how well
the student will put what he’s
learned to work. You can train people to do something. You can give
them a test and have them show that
they know how to do something.
You can even set up a simulated
patient encounter with a patient-actor where they have to show
that they know how to do that certain something, such as teach
a relaxation exercise. But you still don’t know if, in the end when
they’re in the room with patients, they are doing it correctly.
That ends up being the most important way to evaluate any educational program: how does the physician act when he or she is
in the room with a patient?
There’s something called direct observation that’s part of
residency training, and every single resident in this IMR program
is having 2 direct observations a year in which a faculty person
sits in the room and observes to what degree the resident brings
this new knowledge into his or her encounter with a patient. This
is another case in which the data will accrue each year as we go
through the program. Direct observation is not perfect either
because it’s influenced by the presence of the observer.
A more rigorous metric in the long run, which we’re just
starting to work on, would be for us to look at the charts in each
of the programs—or at least in a subset of the programs—and
extract from the charts information indicating whether new residents are having discussions with larger numbers of patients
about integrative approaches. That’s just getting off the ground. It
will be a year or 2 before we get anything out of that.
One other metric that we’re using is a “burnout scale” and
some other standardized stress measures with all the residents in
I
these programs. We also have a set of control programs. Eight
teaching programs are doing the IMR, and we have 5 or 6 control
programs where the residents are not involved with IMR. They
are using the same data-gathering tools that we’re using with the
IMR residents. We’re going to be able to compare, for example,
how the burnout level or stress level of residents at a control site
changes over the course of residency and how that compares
with burnout and stress levels of residents at the IMR site. Will
we see a difference?
There are a lot of different avenues that we’re going down in
trying to evaluate the impact of the
program. Much of the data are going
to take 2 to 3 years to emerge. The
short-term feedback is that the residents love it; the faculty love it.
That’s great. But data from the other
metrics will take a while. Residency
is 3 years long, and we have to look
at the whole process and see how
people come out at the end in order
to be able to determine about how
well it’s working. It will be a couple
of years before we have much to say
that can be backed up with serious
evaluation data.
NTEGRATIVE
MEDICINE
TOTALLY TRANSCENDS ANYTHING
PERTAINING TO A
SPECIFIC THERAPY
OR APPROACH.
66
ATHM: Are there any other aspects
about the residency program that
you feel make it unique?
Dr Kligler: There is a whole self-care component in the IMR curriculum for the residents, encouraging them to become aware of
their own health and how they’re managing it. It is like what I
was describing with our medical students before. All the residents in the program will get reminders in their electronic inboxes to look again at how are they doing.
They have a standardized tool that they use to track their
health practices on their own. It’s a very important part of the
model. To be a more healing-oriented or holistic doctor, it’s not
just the knowledge base, it is an attitude, and that attitude has to
extend to your awareness of yourself and your own health. That’s
a very challenging thing to teach, but we’re really making an
effort to teach it.
ATHM: How did that component of the program develop?
Dr Kligler: From the beginning, we have talked about the idea
that there’s a contradiction between the spoken commitment to
care of the whole person that we want to promote with our
patients and the workaholic, sleep-deprived, unhealthy, pressured physician or resident trainee. It’s easy to fall into the
assumption that integrative medicine training is just about a new
knowledge base. If you do that, you lose touch with the attitudes
that underlie it.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, MD
One of the first things we did with the Consortium was develop a set of educational guidelines for undergraduate medical education that a group of the schools worked together on. That was
published in Academic Medicine in 2004. Even then, the idea that
self-care had to be part of medical education was a core concept.
The great thing about the IMR program is now we have the
electronic tool. We have a way to keep putting self-care back into
people’s awareness.
ATHM: Is there a core group of professionals who have been driving the residency program to bring it to implementation?
Dr Kligler: Yes, a lot of individuals have been involved. It’s important to acknowledge Victoria Maizes and Patricia Lebensohn at
Arizona, as well as Andy Weil. Their leadership has been tremendous. There are educators all over the country who are committed
to this. For example, in the Society of Teachers of Family
Medicine, which is a professional group that I’m involved with,
we have a whole working group. There are many people around
the country who work on this. It is a very widespread movement
at this point in medical education, which is very encouraging.
ATHM: Please tell us about the article you wrote with Mary Jo
Kreitzer for the Institute of Medicine (IOM) meeting.
Dr Kligler: Mary Jo Kreitzer and I coauthored an article with
William Meeker called “Health Professions Education and
Integrated Healthcare,” which appears in the July issue of Explore:
The Journal of Science and Healing. Mary Jo Kreitzer is another
person who is tremendously influential in this area. (Editor’s note:
Mary Jo Kreitzer, PhD, RN, was featured in the Conversations column
of ATHM’s May/Jun 2009 issue.) One major focus of the article
was on the importance of cross-discipline education. We haven’t
emphasized enough the fact that part of being able to provide
more whole-person care is knowing how to work in a team that
involves people from different healing arts, whether it’s nursing,
physical therapy, chiropractic, acupuncture, psychotherapy—
whatever it might be. Another big priority in this movement to
develop doctors who are more educated about integrative medicine is to have them exposed early on in their training and then,
throughout their training, to share and work with practitioners
from other healing arts. Unless we can have people get to know
each other early in the course of their forming their health professional identity, it’s going to be hard to have a real impact on
their ability to collaborate.
That was an important point in that article in terms of
where we need to go. We need to continue to push to find ways
for schools from the different healing arts to have student
exchanges and have students teaching each other and have faculty coming and lecturing.
We have a new program at Einstein now where a group of
30 first-year students from the medical school gets to go to one of
the local acupuncture schools and observe the acupuncture students treating patients in their clinic. Later in the year, a group of
Conversations: Benjamin Kligler, MD
30 acupuncture students comes over and gets to go into the anatomy lab with the medical students and do some dissection. They
don’t get to do that as part of their education, and this allows
them to see that part of the medical education.
That seems small, and it’s just a pilot program, but you’ve
got this group of 30 medical students and 30 acupuncturists who
are getting to know each other right at the beginning of their
medical training and getting to develop a respect and an understanding of different ways to look at the human body and different ways to look at human health.
Hopefully, that is a seed that you plant early on that grows
into something later that allows people to have a more wide open
view of what their patients might want to try. That’s another area
that has huge potential and doesn’t necessarily have costs associated with it. There’s only benefit to be had from that kind of crossdisciplinary, cross-cultural exchange. But it doesn’t seem to be
seen as much of a priority. It would be great if we could get more
schools to start trying things like that and see how that works.
ATHM: What recommendations did you make in the report to
the IOM? Do you have any indication of how it was received?
Dr Kligler: The report was generated to stimulate discussion at
the meeting in February. Plenty of the speakers at the meeting
referred to it and commented on some of the points, so it’s clear
that they read it, and hopefully it’s influencing their thoughts.
Based on conversations I’ve had with people who were in the
meeting, there was a lot of positive feedback and agreement on
some of the goals that we had spelled out.
One of the main recommendations was that the government empower and fund a group of representatives from a wide
array of healing disciplines to define the basic competencies or
the basic elements that we all share around what we need our
practitioners to know about taking good care of patients. What
are these competencies that go across all the disciplines, including all the CAM disciplines? We need to have a well-informed,
follow-through conversation about that. And then we need to
move that all the health professions make those basic competencies a required part of training and licensure in their discipline. That was one recommendation. Another was that
creating more opportunities for interdisciplinary education
needs to be a priority. A third recommendation was that teaching about self-care become a required part of the curriculum in
all the healthcare disciplines.
The biggest challenge will be the process of defining what
we think everybody who is delivering healthcare to patients in
this country should have in common in terms of understanding,
attitudes, and basic knowledge, and then determining how we go
about delivering that. How can we get ourselves together as educators and students to deliver that effectively? And then, how do
we measure whether we did deliver it? That is a big challenge. I
would get that started at a level that included representatives
from the accrediting bodies. You’d have to also have people from
LCME, the body that regulates nursing schools, the body that
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
67
regulates acupuncture, the American Medical Association, and
the Academy of Family Physicians.
ATHM: What would you say is the biggest problem with the current healthcare system?
ATHM: What you’re speaking about is the breaking down of the
hierarchy with the medical doctor at the top. It sounds like this
also needs to be addressed from a cultural standpoint. How
would that approach influence the collaboration?
Dr Kligler: I think the biggest problem with the healthcare system is that there are no cost controls. Access is a tremendous
problem, but we can give everybody access, and if we don’t have
cost controls, if we don’t regulate what pharmaceutical companies can charge for their drugs and what doctors can charge for
procedures, improved access is not going to solve our problem.
Dr Kligler: That cultural shift is already happening. For 20 years
already that concept of the all-powerful, white coat, “Trust me,
I’m a doctor,” mentality has been fading out. The social change
around that is already happening in the sense of people’s view of
doctors and how doctors do or don’t fit in and people’s understanding that doctors need to learn how to work in teams and
need to be team players. It’s not just about, “Because I’m the doctor and I say so.”
It is a slow change, but it is inevitable. Part of the reason we
have all these professionalism curricula is that the public was fed
up. They were fed up with not having doctors who would listen
to them. That started years ago with healthcare advocacy and a
public demand for a different kind of healthcare.
What I think helped to change the landscape was all the
news in the late 1990s about medical errors and the magnitude of
them—how many people die from them every year. There was an
IOM report about this in 1999 that really changed the landscape.
That was what eventually led to mandatory work hour limits, for
example, for residents, which are now law around the country.
Another example of how things are changing is the recent
news about the influence of pharmaceutical companies in doctors’ prescribing practices. Public awareness is going to lead to
more potent regulations around doctors’ interactions with pharmaceutical companies. That is inevitable.
There are very conservative forces still at play. But doctors
are coming down off their pedestals little by little. This is painful
for doctors, but the good news is that as they come down off
their pedestals, suddenly it’s not going to be so lonely because of
all these other health professions they will get to work with.
What I love about my experience of being a doctor in my
practice is that not only do I have great physician colleagues to
work with, but I also have great acupuncturists and great nurses
and great chiropractors. When I’m stuck, I’ve got 15 other people
to ask for a point of view or an opinion. Yes, I have to give up the
idea that I absolutely know the most and I’m always right, but it’s
a lot more fun.
In the long run, people will get used to that because it’s a better system. There will be a whole different model 50 years from
now of how the doctor fits into the healthcare picture. It’s going to
be much more about teams, with doctors as part of the lead of the
team, not necessarily always the lead. As doctors, we have a lot of
education and training. We have a lot of responsibility, so I don’t
think it’s likely that doctors will entirely abdicate leadership over
healthcare decision making, but the idea that we’re going to share
it is a social change that is already happening.
68
ATHM: What about your work excites you?
Dr Kligler: What has been so great for me about the opportunity to
be involved in this work around integrative medicine is that it totally transcends anything pertaining to a specific therapy or approach.
Yes, it’s important to teach about acupuncture; it’s important to teach about herbs. But the great thing about it is that
every single physician, even the most conservative allopathically
minded physicians who aren’t really interested in prescribing an
herb or sending a patient to an acupuncturist, can incorporate
into their thinking and their way of working with their patients
the idea that patients have an intrinsic capacity to heal. Part of
the physician’s way of approaching problems can be helping to
mobilize that, helping patients to access that.
That is a concept that physicians can’t really argue with. It’s
clear-cut that it exists. There are millions of examples. When you
present it to physicians and ask the question, “Why wouldn’t we
want to use this?,” there’s really nothing but positive response.
The idea that learning about some of these other healing arts
has brought us back to a concept that’s a critical, informing concept of how everybody should practice medicine is very exciting.
The need for physicans to know at least something about complementary and alternative medicine got us in the door, and now we
get to talk to everybody about the idea of healing—which is what
the other healing arts have really brought to the discussion.
What matters is that physicians become willing to think
about the idea of healing-oriented medicine and about patients
as having intrinsic potential for healing. That is a concept that
can radically change medicine if we can continue to get it across
to people. That’s where it’s exciting and where I don’t want to
stop. I just want to keep going. There is endless potential there.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Conversations: Benjamin Kligler, TK
MD
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author and subject index: volume 15, 2009
AUTHOR INDEX
Agarwal T (see Sharma S et al) 2009;15(1):44-47.
Agin MC (see Morris CR et al) 2009;15(4):34-43.
Allen B (see Rayburn K et al) 2009;15(4):60-61.
Anastasi JK, Currie LM, Kim GH. Understanding diagnostic
reasoning in TCM practice: tongue diagnosis. 2009;15(3):18-28.
[Erratum: 2009;15(4):10.]
Anderson RA (see Ivker RS et al) 2009;15(1):36-43.
Artmann C (see Liu Z et al) 2009;15(2):42-46.
Bacharach G (see Feldman M et al) 2009;15(2):32-38.
Beck S (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Berger DL, Silver EJ, Stein REK. Effects of yoga on inner-city
children’s well-being: a pilot study. 2009;15(5):36-42.
Berman B (see Manheimer E et al) 2009;15(4):18-20.
Blalock SJ, Gregory PJ, Patel RA, Norton LL, Callahan LF,
Jordan JM. Factors associated with potential medicationherb/natural product interactions in a rural community.
2009;15(5):26-34.
Bland JS. Autism: asking the right questions to find the right
answers. 2008;14(6):20-21. [Erratum: 2009;15(1):14.]
Blaylock RL. A possible central mechanism in autism spectrum
disorders, part 2: immunoexcitotoxicity. 2009;15(1):60-67.
Blaylock RL. A possible central mechanism in autism spectrum
disorders, part 3: the role of excitotoxin food additives and
the synergistic effects of other environmental toxins.
2009;15(2):56-60.
Blumenthal M. Systematic reviews and meta-analyses support
the efficacy of numerous popular herbs and phytomedicines.
2009;15(2):14-15.
Bosch PR, Traustadóttir T, Howard P, Matt KS. Functional
and physiological effects of yoga in women with rheumatoid
arthritis: a pilot study. 2009;15(4):24-31.
Bralley JA (see Morrison J et al) 2009;15(2):52-53.
Bralley JA (see Nelson-Dooley C et al) 2009;15(5):56-60.
Bush T (see Rayburn K et al) 2009;15(4):60-61.
Callahan LF (see Blalock SJ et al) 2009;15(5):26-34.
Case EA (see Stone JAM et al) 2009;15(1):50-52.
Christine D. Temporal bone motion asymmetry as a cause of
vertigo: the craniosacral model. 2009;15(6):38-42.
Coletto J (see Lasater K et al) 2009;15(4):46-54.
Cuellar NG, Ratcliffe SJ. Does valerian improve sleepiness and
symptom severity in people with restless legs syndrome?
2009;15(2):22-28.
Cullum-Dugan D (see Saper RB et al) 2009;15(6):18-27.
Culpepper L (see Saper RB et al) 2009;15(6):18-27.
Currie LM (see Anastasi JK et al) 2009;15(3):18-28.
Davis AM (see Davis MA et al) 2009;15(3):36-40.
Davis MA, Davis AM, Luan J, Weeks WB. The supply and
demand of chiropractors in the United States from 1996 to
2005. 2009;15(3):36-40.
70
Davis RB (see Saper RB et al) 2009;15(6):18-27.
Edelman S (see Lichtenberg P et al) 2009;15(5):44-46.
Feldman M, Weiss E, Shemesh M, Ofek I, Bacharach G, Rozen
R, Steinberg D. Cranberry constituents affect fructosyltransferase expression in Streptoccous mutans. 2009;15(2):32-38.
Field T. Pregnancy and labor alternative therapy research.
2008;14(5):28-34. [Letter to the editor: 2009;15(1):14.]
Firenzuoli F (see Vannaci A et al) 2009;15(3):62-63.
Fleischbein E (see Rayburn K et al) 2009;15(4):60-61.
Fleishman S (see Lasater K et al) 2009;15(4):46-54.
Gallo E (see Vannaci A et al) 2009;15(3):62-63.
Geller SE. Improving the science for botanical and dietary supplements. 2009;15(1):16.
Glassey D (see Whedon JM et al) 2009;15(1):54-60.
Glenton C (see Manheimer E et al) 2009;15(4):18-20.
Gregory PJ (see Blalock SJ et al) 2009;15(5):26-34.
Griffith CH (see Hoellein AR et al) 2009;15(6):30-34.
Haist SA (see Hoellein AR et al) 2009;15(6):30-34.
Hammerschlag R (see Lasater K et al) 2009;15(4):46-54.
Hamre HJ, Kiene H, Kienle GS. Clinical research in anthroposophic medicine. 2009;15(6):52-55.
Hasper I (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Heger PW (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Heresco-Levy U (see Lichtenberg P et al) 2009;15(5):44-46.
Hoellein AR, Griffith CH, Lineberry MJ, Wilson JF, Haist
SA. A complementary and alternative medicine workshop
using standardized patients improves knowledge and clinical
skills of medical students. 2009;15(6):30-34.
Howard P (see Bosch PR et al) 2009;15(4):24-31.
Hyman MA. Autism: is it all in the head? 2008;14(6):12-15.)
[Letter to the editor: 2009;15(2):8.]
Hyman MA. The ecology of eating: the power of the fork.
2009;15(4):14-15.
Hyman MA. Finding the money for healthcare reform.
2009;15(5):20-23.
Hyman MA. The map: integrating integrative medicine.
2009;15(1):20-21.
Hyman MA. The medicine we do: real reform of healthcare.
2009;15(3):12-14.
Hyman MA. The right order of things: peeling the onion of
chronic disease. 2009;15(2):18-20.
Hyman MA, Ornish D, Roizen M. Lifestyle medicine: treating
the causes of disease. 2009;15(6):12-14.
Ivker RS, Silvers WS, Anderson RA. Clinical observations
and seven-and-one-half-year follow-up of patients using an
integrative holistic approach for treating chronic sinusitis.
2009;15(1):36-43.
Jin H (see Lasater K et al) 2009;15(4):46-54.
Jonas W. Snake Oil Science: The Truth About Complementary and
Alternative Medicine [book review]. 2009;15(2):76.
Jonas WB, Rakel DP. Putting healing into healthcare reform: will
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Author/Subject Index 2009
physicians and healthcare practitioners lead? 2009;15(6):8-9.
Jordan JM (see Blalock SJ et al) 2009;15(5):26-34.
Kaplan S (see Nelson-Dooley C et al) 2009;15(5):56-60.
Kaszkin-Bettag M, Ventskovskiy BM, Solskyy S, Beck S,
Hasper I, Kravchenko A, Rettenberger R, Richardson A,
Heger PW. Confirmation of the efficacy of ERr 731 in perimenopausal women with menopausal symptoms.
2009;15(1):24-34.
Kiene H (see Hamre HJ et al) 2009;15(6):52-55.
Kienle GS (see Hamre HJ et al) 2009;15(6):52-55.
Kim GH (see Anastasi JK et al) 2009;15(3):18-28.
Kravchenko A (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Kundert M (see Rayburn K et al) 2009;15(4):60-61.
Lampe F, Snyder S. Benjamin Kligler, MD: advancing the cause
of healing-oriented medicine. 2009;15(6):58-68.
Lampe F, Snyder S. Frank Lipman, MD: where Eastern medicine meets Western medicine. 2009;15(1):68-76.
Lampe F, Snyder S. Jason Hao, DOM: pioneering the use of
scalp acupuncture to transform healing. 2009;15(2):62-71.
Lampe F, Snyder S. Susan Frampton, PhD: expanding the reach
of patient-centered care. 2009;15(5):66-76.
Lampe F, Snyder S. Timothy Birdsall, ND: facilitating hope in
integrative cancer treatment. 2009;15(4):64-74.
Lapi F (see Vannaci A et al) 2009;15(3):62-63.
Lasater K, Salanti S, Fleishman S, Coletto J, Jin H, Lore R,
Hammerschlag R. Learning activities to enhance research literacy in a CAM college curriculum. 2009;15(4):46-54.
Lawson K. Could health coaching build a bridge to a new system
of healthcare? 2009;15(5):16-18.
Leiter C (see Rayburn K et al) 2009;15(4):60-61.
Lichtenberg P, Vass A, Ptaya H, Edelman S, Heresco-Levy U.
Shiatsu as an adjuvant therapy for schizophrenia: an openlabel pilot study. 2009;15(5):44-46.
Lineberry MJ (see Hoellein AR et al) 2009;15(6):30-34.
Liu Z, Artmann C. Relative bioavailability comparison of different coenzyme Q10 formulations with a novel delivery system.
2009;15(2):42-46.
Lizis P (see Posadzki P et al) 2009;15(6):44-49.
Lord RS (see Morrison J et al) 2009;15(2):52-53.
Lore R (see Lasater K et al) 2009;15(4):46-54.
Low Dog T. The use of botanicals during pregnancy and lactation. 2009;15(1):54-58.
Luan J (see Davis MA et al) 2009;15(3):36-40.
Manheimer E, Berman B, Vist G, Glenton C. The effect of
probiotics on preventing necrotizing enterocolitis in premature babies. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Matt KS (see Bosch PR et al) 2009;15(4):24-31.
Meland B. Effect of Reiki on pain and anxiety in the elderly diagnosed with dementia: a series of case reports. 2009;15(4):56-57.
Menniti-Ippolito F (see Vannaci A et al) 2009;15(3):62-63.
Mittelman M, Snyder S. Mary Jo Kreitzer, PhD, RN: inspiring
whole-person care through integrative models of research,
education, and clinical practice. 2009;15(3):66-75.
Morris CR, Agin MC. Syndrome of allergy, apraxia and malab-
Author/Subject Index 2009
sorption: characterization of a neurodevelopmental phenotype that responds to omega 3 and vitamin E supplementation.
2009;15(4):34-43.
Morrison J, Mutell D, Pollock TA, Redmond E, Bralley JA,
Lord RS. Effects of dried cruciferous powder on raising 2/16
hydroxyestrogen ratios in premenopausal women.
2009;15(2):52-53.
Mugelli A (see Vannaci A et al) 2009;15(3):62-63.
Mutell D (see Morrison J et al) 2009;15(2):52-53.
Nelson-Dooley C, Kaplan S, Bralley JA. Migraines and mood
disorders: nutritional and dietary intervention based on laboratory testing. 2009;15(5):56-60.
Norton LL (see Blalock SJ et al) 2009;15(5):26-34.
Ofek I (see Feldman M et al) 2009;15(2):32-38.
Ornish D (see Hyman MA et al) 2009;15(6):12-14.
Patel RA (see Blalock SJ et al) 2009;15(5):26-34.
Phillips RS (see Saper RB et al) 2009;15(6):18-27.
Pollock TA (see Morrison J et al) 2009;15(2):52-53.
Posadzki P, Smith TO, Lizis P. Lomi lomi as a massage with
movements: a conceptual synthesis? 2009;15(6):44-49.
Ptaya H (see Lichtenberg P et al) 2009;15(5):44-46.
Puri S (see Sharma S et al) 2009;15(1):44-47.
Rakel DP (see Jonas WB et al) 2009;15(6):8-9.
Raschetti R (see Vannaci A et al) 2009;15(3):62-63.
Ratcliffe SJ (see Cuellar NG et al) 2009;15(2):22-28.
Rayburn K, Fleischbein E, Song J, Allen B, Kundert M,
Leiter C, Bush T. Stinging nettle cream for osteoarthritis.
2009;15(4):60-61.
Redmond E (see Morrison J et al) 2009;15(2):52-53.
Rettenberger R (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Richardson A (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Riley D. Challenges in healthcare reform. 2009;15(4):8-9.
Riley D. Change. 2009;15(1):10-11.
Riley D. The doctor’s dilemma: healthcare reform and integrative medicine. 2009;15(2):10-11. [Letter to the editor:
2009;15(4):10.]
Riley D. Healthcare reform. 2009;15(5):8.
Riley D, Snyder S. Abstracts. 2009;15(2):72-73.
Roizen M (see Hyman MA et al) 2009;15(6):12-14.
Rosen LD. Integrative pediatrics: the future is now. 2009;15(5):12-14.
Rozen R (see Feldman M et al) 2009;15(2):32-38.
Salanti S (see Lasater K et al) 2009;15(4):46-54.
Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB, Phillips
RS, Culpepper L. Yoga for chronic low back pain in a predominantly minority population. 2009;15(6):18-27.
Shannon S. Integrative approaches to pediatric mood disorders.
2009;15(5):48-53.
Sharma S, Puri S, Agarwal T, Sharma V. Diets based on
Ayurvedic constitution—potential for weight management.
2009;15(1):44-47.
Sharma V (see Sharma S et al) 2009;15(1):44-47.
Shealy CN (see Tsubono K et al) 2009;15(3):30-34.
Shemesh M (see Feldman M et al) 2009;15(2):32-38.
Sherman KJ (see Saper RB et al) 2009;15(6):18-27.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
71
Sierpina VS. The North American Research Conference on
Complementary & Integrative Medicine. 2009;15(3):8-9.
Silver EJ (see Berger DL et al) 2009;15(5):36-42.
Silvers WS (see Ivker RS et al) 2009;15(1):36-43.
Sinatra ST. Metabolic cardiology: an integrative strategy in the
treatment of congestive heart failure. 2009;15(3):44-52.
Sinatra ST. Metabolic cardiology: the missing link in cardiovascular disease. 2009;15(2):48-50.
Smith TO (see Posadzki P et al) 2009;15(6):44-49.
Snyder S (see Lampe F et al) 2009;15(1):68-76, 2009;15(2):62-71,
2009;15(4):64-74, 2009;15(5):66-76, 2009;15(6):58-68. (see
Mittelman M et al) 2009;15(3):66-75. (see Riley D et al)
2009;15(2):72-73.
Solskyy S (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Song J (see Rayburn K et al) 2009;15(4):60-61.
Stanford R. Recurrent miscarriage syndrome treated with acupuncture and an allergy elimination/desensitization technique. 2009;15(5):62-63.
Stein REK (see Berger DL et al) 2009;15(5):36-42.
Steinberg D (see Feldman M et al) 2009;15(2):32-38.
Stone JAM, Yoder KK, Case EA. Delivery of a full-term pregnancy after TCM treatment in a previously infertile patient
diagnosed with polycystic ovary syndrome. 2009;15(1):50-52.
Thomlinson P (see Tsubono K et al) 2009;15(3):30-34.
Toti M (see Vannaci A et al) 2009;15(3):62-63.
Traustadóttir T (see Bosch PR et al) 2009;15(4):24-31.
Tsubono K, Thomlinson P, Shealy CN. The effects of distant
healing performed by a spiritual healer on chronic pain: a randomized controlled trial. 2009;15(3):30-34.
Vannaci A, Lapi F, Gallo E, Vietri M, Toti M, MennitiIppolito F, Raschetti R, Firenzuoli F, Mugelli A. A case of
hepatitis associated with long-term use of Cimicifuga racemosa.
2009;15(3):62-63.
Various authors. Abstracts From The North American Research
Conference on Complementary and Integrative Medicine.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
Vass A (see Lichtenberg P et al) 2009;15(5):44-46.
Ventskovskiy BM (see Kaszkin-Bettag M et al) 2009;15(1):24-34.
Vietri M (see Vannaci A et al) 2009;15(3):62-63.
Vist G (see Manheimer E et al) 2009;15(4):18-20.
Weeks WB (see Davis MA et al) 2009;15(3):36-40.
Weiss E (see Feldman M et al) 2009;15(2):32-38.
Whedon JM, Glassey D. Cerebrospinal fluid stasis and its clinical significance. 2009;15(1):54-60.
Wilson JF (see Hoellein AR et al) 2009;15(6):30-34.
Yoder KK (see Stone JAM et al) 2009;15(1):50-52.
SUBJECT INDEX
Abstracts.
Abstracts From The North American Research Conference on
Complementary and Integrative Medicine. Various authors.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
Abstracts. Compiled by Riley D, Snyder S. 2009;15(2):72-73.
72
Acupuncture.
Jason Hao, DOM: pioneering the use of scalp acupuncture to
transform healing. 2009;15(2):62-71.
Recurrent miscarriage syndrome treated with acupuncture and
an allergy elimination/desensitization technique. Stanford R.
2009;15(5):62-63.
Allergies.
Recurrent miscarriage syndrome treated with acupuncture and
an allergy elimination/desensitization technique. Stanford R.
2009;15(5):62-63.
Syndrome of allergy, apraxia and malabsorption: characterization of a neurodevelopmental phenotype that responds to
omega 3 and vitamin E supplementation. Morris CR, Agin
MC. 2009;15(4):34-43.
Alternative medicine. See Complementary and alternative
medicine.
Anthroposophic medicine.
Clinical research in anthroposophic medicine. Hamre HJ, Kiene
H, Kienle GS. 2009;15(6):52-55.
Apraxia.
Syndrome of allergy, apraxia and malabsorption: characterization of a neurodevelopmental phenotype that responds to
omega 3 and vitamin E supplementation. Morris CR, Agin
MC. 2009;15(4):34-43.
Arthritis.
Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study. Bosch PR, Traustadóttir T,
Howard P, Matt KS. 2009;15(4):24-31.
Stinging nettle cream for osteoarthritis. Rayburn K, Fleischbein E,
Song J, Allen B, Kundert M, Leiter C, Bush T. 2009;15(4):60-61.
Autism.
Autism: asking the right questions to find the right answers.
Bland JS. 2008;14(6);20-21. [Erratum: 2009;15(1):14.]
Autism: is it all in the head? 2008;14(6):12-15. [Letter to the editor: 2009;15(2):8.]
A possible central mechanism in autism spectrum disorders,
part 2: immunoexcitotoxicity. Blaylock R. 2009;15(1):60-67.
A possible central mechanism in autism spectrum disorders, part 3:
the role of excitotoxin food additives and the synergistic effects of
other environmental toxins. Blaylock R. 2009;15(2):56-60.
Ayurvedic medicine.
Diets based on Ayurvedic constitution—potential for weight management. Sharma S, Puri S, Agarwal T, Sharma V. 2009;15(1):44-47.
Back pain.
Yoga for chronic low back pain in a predominantly minority population. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB,
Phillips RS, Culpepper L. 2009;15(6):18-27.
Birdsall, Timothy.
Timothy Birdsall, ND: facilitating hope in integrative cancer
treatment. Lampe F, Snyder S. 2009;15(4):64-74.
Black cohosh.
A case of hepatitis associated with long-term use of Cimicifuga racemosa. Vannaci A, Lapi F, Gallo E, Vietri M, Toti M, Menniti-Ippolito F,
Raschetti R, Firenzuoli F, Mugelli A. 2009;15(3):62-63.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Author/Subject Index 2009
Book reviews.
Snake Oil Science: The Truth About Complementary and Alternative
Medicine [book review]. Jonas W. 2009;15(2):76.
Botanical supplements. See Herbs.
Bowel disease.
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Cancer.
Timothy Birdsall, ND: facilitating hope in integrative cancer
treatment. Lampe F, Snyder S. 2009;15(4):64-74.
Cardiovascular system.
Metabolic cardiology: an integrative strategy in the treatment of
congestive heart failure. Sinatra ST. 2009;15(3):44-52.
Metabolic cardiology: the missing link in cardiovascular disease.
Sinatra ST. 2009;15(2):48-50.
Cerebrospinal fluid.
Cerebrospinal fluid stasis and its clinical significance. Whedon
JM, Glassey D. 2009;15(3):54-60.
Child health. See Pediatric health.
Chinese medicine. See Traditional Chinese medicine.
Chiropractic.
The supply and demand of chiropractors in the United States
from 1996 to 2005. Davis MA, Davis AM, Luan J, Weeks WB.
2009;15(3):36-40.
Chronic disease.
Clinical observations and seven-and-one-half-year follow-up of
patients using an integrative holistic approach for treating chronic
sinusitis. Ivker RS, Silvers WS, Anderson RA. 2009;15(1):36-43.
The ecology of eating: the power of the fork. Hyman MA.
2009;15(4):14-15.
Lifestyle medicine: treating the causes of disease. Hyman MA,
Ornish D, Roizen M. 2009;15(6):12-14.
The right order of things: peeling the onion of chronic disease.
Hyman MA. 2009;15(2):18-20.
Chronic pain.
The effects of distant healing performed by a spiritual healer on
chronic pain: a randomized controlled trial. Tsubono K,
Thomlinson P, Shealy CN. 2009;15(3):30-34.
Yoga for chronic low back pain in a predominantly minority population. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB,
Phillips RS, Culpepper L. 2009;15(6):18-27.
Coaching.
Could health coaching build a bridge to a new system of healthcare? Lawson K. 2009;15(5):16-18.
Coenzyme Q10.
Relative bioavailability comparison of different coenzyme Q10
formulations with a novel delivery system. Liu Z, Artmann C.
2009;15(2):42-46.
Columns.
The ecology of eating: the power of the fork. Hyman MA.
2009;15(4):14-15.
Finding the money for healthcare reform. Hyman MA.
2009;15(5):20-23.
Author/Subject Index 2009
The map: integrating integrative medicine. Hyman MA.
2009;15(1):20-21.
The medicine we do: real reform of healthcare. Hyman MA.
2009;15(3):12-14.
The right order of things: peeling the onion of chronic disease.
Hyman MA. 2009;15(2):18-20.
Complementary and alternative medicine.
Abstracts From The North American Research Conference on
Complementary and Integrative Medicine. Various authors.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
A complementary and alternative medicine workshop using
standardized patients improves knowledge and clinical skills
of medical students. Hoellein AR, Griffith CH, Lineberry MJ,
Wilson JF, Haist SA. 2009;15(6):30-34.
Learning activities to enhance research literacy in a CAM college
curriculum. Lasater K, Salanti S, Fleishman S, Coletto J, Jin H,
Lore R, Hammerschlag R. 2009;15(4):46-54.
The map: integrating integrative medicine. Hyman MA.
2009;15(1):20-21.
The medicine we do: real reform of healthcare. Hyman MA.
2009;15(3):12-14.
The North American Research Conference on Complementary &
Integrative Medicine. Sierpina VS. 2009;15(3):8-9.
Conferences.
Abstracts From The North American Research Conference on
Complementary and Integrative Medicine Various authors.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
The North American Research Conference on Complementary &
Integrative Medicine. Sierpina VS. 2009;15(3):8-9.
Conversations.
Benjamin Kligler, MD: advancing the cause of healing-oriented
medicine. Lampe F, Snyder S. 2009;15(6):58-68.
Frank Lipman, MD: where Eastern medicine meets Western
medicine. Lampe F, Snyder S. 2009;15(1):68-76.
Jason Hao, DOM: pioneering the use of scalp acupuncture to
transform healing. 2009;15(2):62-71.
Mary Jo Kreitzer, PhD, RN: inspiring whole-person care through
integrative models of research, education, and clinical practice. Mittelman M, Snyder S. 2009;15(3):66-75.
Susan Frampton, PhD: expanding the reach of patient-centered
care. Lampe F, Snyder S. 2009;15(5):66-76.
Timothy Birdsall, ND: facilitating hope in integrative cancer
treatment. Lampe F, Snyder S. 2009;15(4):64-74.
Corrections. See Errata.
Cranberry.
Cranberry constituents affect fructosyltransferase expression in
Streptoccous mutans. Feldman M, Weiss E, Shemesh M, Ofek I,
Bacharach G, Rozen R, Steinberg D. 2009;15(2):32-38.
Craniosacral therapy.
Temporal bone motion asymmetry as a cause of vertigo: the
craniosacral model. Christine D. 2009;15(6):38-42.
Dementia.
Effect of Reiki on pain and anxiety in the elderly diagnosed with
dementia: a series of case reports. Meland B. 2009;15(4):56-57.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
73
Diagnostic methods.
Understanding diagnostic reasoning in TCM practice: tongue
diagnosis. Anastasi JK, Currie LM, Kim GH. 2009;15(3):18-28.
[Erratum: 2009;15(4):10.]
Diet.
Diets based on Ayurvedic constitution—potential for weight
management. Sharma S, Puri S, Agarwal T, Sharma V.
2009;15(1):44-47.
The ecology of eating: the power of the fork. Hyman MA.
2009;15(4):14-15.
Dietary supplements.
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Effects of dried cruciferous powder on raising 2/16 hydroxyestrogen ratios in premenopausal women. Morrison J, Mutell D,
Pollock TA, Redmond E, Bralley JA, Lord RS. 2009;15(2):52-53.
Improving the science for botanical and dietary supplements.
Geller SE. 2009;15(1):16.
Migraines and mood disorders: nutritional and dietary intervention based on laboratory testing. Nelson-Dooley C, Kaplan S,
Bralley JA. 2009;15(5):56-60.
Relative bioavailability comparison of different coenzyme Q10
formulations with a novel delivery system. Liu Z, Artmann C.
2009;15(2):42-46.
Syndrome of allergy, apraxia and malabsorption: characterization of a neurodevelopmental phenotype that responds to
omega 3 and vitamin E supplementation. Morris CR, Agin
MC. 2009;15(4):34-43.
Drugs.
Factors associated with potential medication-herb/natural product
interactions in a rural community. Blalock SJ, Gregory PJ, Patel
RA, Norton LL, Callahan LF, Jordan JM. 2009;15(5):26-34.
Editorials.
Challenges in healthcare reform. Riley D. 2009;15(4):8-9.
Change. Riley D. 2009;15(1):10-11.
The doctor’s dilemma: healthcare reform and integrative medicine. Riley D. 2009;15(2):10-11.
Healthcare reform. Riley D. 2009;15(5):8.
Editorials, Guest.
Could health coaching build a bridge to a new system of healthcare? Lawson K. 2009;15(5):16-18.
Integrative pediatrics: the future is now. Rosen LD. 2009;15(5):12-14.
The North American Research Conference on Complementary &
Integrative Medicine. Sierpina VS. 2009;15(3):8-9.
Education, Medical.
Benjamin Kligler, MD: advancing the cause of healing-oriented
medicine. Lampe F, Snyder S. 2009;15(6):58-68.
A complementary and alternative medicine workshop using
standardized patients improves knowledge and clinical skills
of medical students. Hoellein AR, Griffith CH, Lineberry MJ,
Wilson JF, Haist SA. 2009;15(6):30-34.
Learning activities to enhance research literacy in a CAM college
curriculum. Lasater K, Salanti S, Fleishman S, Coletto J, Jin H,
74
Lore R, Hammerschlag R. 2009;15(4):46-54.
Lifestyle medicine: treating the causes of disease. Hyman MA,
Ornish D, Roizen M. 2009;15(6):12-14.
Energy healing.
Effect of Reiki on pain and anxiety in the elderly diagnosed with
dementia: a series of case repor ts. Meland B.
2009;15(4):56-57.
Temporal bone motion asymmetry as a cause of vertigo: the
craniosacral model. Christine D. 2009;15(6):38-42.
Errata.
Abstracts From The North American Research Conference on
Complementary and Integrative Medicine Various authors.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
Autism: asking the right questions to find the right answers.
Bland JS. 2008;14(6):20-21. [Erratum: 2009;15(1):14.]
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Understanding diagnostic reasoning in TCM practice: tongue
diagnosis. Anastasi JK, Currie LM, Kim GH. 2009;15(3):18-28.
[Erratum: 2009;15(4):10.]
Estrogen receptors.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
Improving the science for botanical and dietary supplements.
Geller SE. 2009;15(1):16.
Fertility.
Delivery of a full-term pregnancy after TCM treatment in a previously infertile patient diagnosed with polycystic ovary syndrome. Stone JAM, Yoder KK, Case EA. 2009;15(1):50-52.
Finance.
Finding the money for healthcare reform. Hyman MA.
2009;15(5):20-23.
Food. See Diet.
Frampton, Susan.
Susan Frampton, PhD: expanding the reach of patient-centered
care. Lampe F, Snyder S. 2009;15(5):66-76.
Gastrointestinal medicine.
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Syndrome of allergy, apraxia and malabsorption: characterization of a neurodevelopmental phenotype that responds to
omega 3 and vitamin E supplementation. Morris CR, Agin
MC. 2009;15(4):34-43.
Hao, Jason.
Jason Hao, DOM: pioneering the use of scalp acupuncture to
transform healing. 2009;15(2):62-71.
Headaches.
Migraines and mood disorders: nutritional and dietary intervention based on laboratory testing. Nelson-Dooley C, Kaplan S,
Bralley JA. 2009;15(5):56-60.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Author/Subject Index 2009
Healthcare.
Challenges in healthcare reform. Riley D. 2009;15(4):8-9.
Change. Riley D. 2009;15(1):10-11.
Could health coaching build a bridge to a new system of healthcare? Lawson K. 2009;15(5):16-18.
The doctor’s dilemma: healthcare reform and integrative medicine.
Riley D. 2009;15(2):10-11. [Letter to the editor: 2009;15(4):10.]
Finding the money for healthcare reform. Hyman MA.
2009;15(5):20-23.
Healthcare reform. Riley D. 2009;15(5):8.
The medicine we do: real reform of healthcare. Hyman MA.
2009;15(3):12-14.
Putting healing into healthcare reform: will physicians and
healthcare practitioners lead? Jonas WB, Rakel DP.
2009;15(6):8-9.
Heart. See Cardiovascular system.
Hepatitis.
A case of hepatitis associated with long-term use of Cimicifuga
racemosa. Vannaci A, Lapi F, Gallo E, Vietri M, Toti M,
Menniti-Ippolito F, Raschetti R, Firenzuoli F, Mugelli A.
2009;15(3):62-63.
Herbs.
A case of hepatitis associated with long-term use of Cimicifuga
racemosa. Vannaci A, Lapi F, Gallo E, Vietri M, Toti M,
Menniti-Ippolito F, Raschetti R, Firenzuoli F, Mugelli A.
2009;15(3):62-63.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
Does valerian improve sleepiness and symptom severity in people with restless legs syndrome? Cuellar NG, Ratcliffe SJ.
2009;15(2):22-28.
Factors associated with potential medication-herb/natural product
interactions in a rural community. Blalock SJ, Gregory PJ, Patel
RA, Norton LL, Callahan LF, Jordan JM. 2009;15(5):26-34.
Improving the science for botanical and dietary supplements.
Geller SE. 2009;15(1):16.
Stinging nettle cream for osteoarthritis. Rayburn K, Fleischbein E,
Song J, Allen B, Kundert M, Leiter C, Bush T. 2009;15(4):60-61.
Systematic reviews and meta-analyses support the efficacy of
numerous popular herbs and phytomedicines. Blumenthal M.
2009;15(2):14-15.
The use of botanicals during pregnancy and lactation. Low Dog
T. 2009;15(1):54-58.
Holistic medicine. See Integrative medicine.
Hormones.
A possible central mechanism in autism spectrum disorders,
part 2: immunoexcitotoxicity. Blaylock R. 2009;15(1):60-67.
Infertility. See Fertility.
Integrative medicine.
Benjamin Kligler, MD: advancing the cause of healing-oriented
medicine. Lampe F, Snyder S. 2009;15(6):58-68.
Change. Riley D. 2009;15(1):10-11.
Author/Subject Index 2009
Clinical observations and seven-and-one-half-year follow-up of
patients using an integrative holistic approach for treating
chronic sinusitis. Ivker RS, Silvers WS, Anderson RA.
2009;15(1):36-43.
The doctor’s dilemma: healthcare reform and integrative medicine. Riley D. 2009;15(2):10-11.
Frank Lipman, MD: where Eastern medicine meets Western
medicine. Lampe F, Snyder S. 2009;15(1):68-76.
Integrative approaches to pediatric mood disorders. Shannon S.
2009;15(5):48-53.
Integrative pediatrics: the future is now. Rosen LD.
2009;15(5):12-14.
The map: integrating integrative medicine. Hyman MA.
2009;15(1):20-21.
Mary Jo Kreitzer, PhD, RN: inspiring whole-person care through
integrative models of research, education, and clinical practice. Mittelman M, Snyder S. 2009;15(3):66-75.
Susan Frampton, PhD: expanding the reach of patient-centered
care. Lampe F, Snyder S. 2009;15(5):66-76.
Timothy Birdsall, ND: facilitating hope in integrative cancer
treatment. Lampe F, Snyder S. 2009;15(4):64-74.
Interviews. See Conversations.
Kligler, Benjamin.
Benjamin Kligler, MD: advancing the cause of healing-oriented
medicine. Lampe F, Snyder S. 2009;15(6):58-68.
Kreitzer, Mary Jo.
Mary Jo Kreitzer, PhD, RN: inspiring whole-person care through
integrative models of research, education, and clinical practice. Mittelman M, Snyder S. 2009;15(3):66-75.
Lactation.
The use of botanicals during pregnancy and lactation. Low Dog
T. 2009;15(1):54-58.
Lifestyle medicine.
Lifestyle medicine: treating the causes of disease. Hyman MA,
Ornish D, Roizen M. 2009;15(6):12-14.
Lipman, Frank.
Frank Lipman, MD: where Eastern medicine meets Western
medicine. Lampe F, Snyder S. 2009;15(1):68-76.
Massage.
Lomi lomi as a massage with movements: a conceptual synthesis? Posadzki P, Smith TO, Lizis P. 2009;15(6):44-49.
Menopause.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
Effects of dried cruciferous powder on raising 2/16 hydroxyestrogen ratios in premenopausal women. Morrison J, Mutell D,
Pollock TA, Redmond E, Bralley JA, Lord RS. 2009;15(2):52-53.
Improving the science for botanical and dietary supplements.
Geller SE. 2009;15(1):16.
Mental health.
Integrative approaches to pediatric mood disorders. Shannon S.
2009;15(5):48-53.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
75
Migraines and mood disorders: nutritional and dietary intervention based on laboratory testing. Nelson-Dooley C, Kaplan S,
Bralley JA. 2009;15(5):56-60.
Shiatsu as an adjuvant therapy for schizophrenia: an open-label
pilot study. Lichtenberg P, Vass A, Ptaya H, Edelman S,
Heresco-Levy U. 2009;15(5):44-46.
Mercury.
A possible central mechanism in autism spectrum disorders,
part 2: immunoexcitotoxicity. Blaylock R. 2009;15(1):60-67.
Metabolic therapies.
Metabolic cardiology: an integrative strategy in the treatment of
congestive heart failure. Sinatra ST. 2009;15(3):44-52.
Metabolic cardiology: the missing link in cardiovascular disease.
Sinatra ST. 2009;15(2):48-50.
Moods. See Mental health.
North American Research Conference on Complementary
& Integrative Medicine.
Abstracts From The North American Research Conference on
Complementary and Integrative Medicine. Various authors.
2009;15(3):S78-S186. [Errata: 2009;15(6):14.]
The North American Research Conference on Complementary &
Integrative Medicine. Sierpina VS. 2009;15(3):8-9.
Nutrition. See Dietary supplements.
Pain relief.
Effect of Reiki on pain and anxiety in the elderly diagnosed with
dementia: a series of case reports. Meland B. 2009;15(4):56-57.
Pediatric health. See also Autism.
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Effects of yoga on inner-city children’s well-being: a pilot study.
Berger DL, Silver EJ, Stein REK. 2009;15(5):36-42.
Integrative approaches to pediatric mood disorders. Shannon S.
2009;15(5):48-53.
Integrative pediatrics: the future is now. Rosen LD. 2009;15(5):12-14.
Syndrome of allergy, apraxia and malabsorption: characterization of a neurodevelopmental phenotype that responds to
omega 3 and vitamin E supplementation. Morris CR, Agin
MC. 2009;15(4):34-43.
Perspectives.
Lifestyle medicine: treating the causes of disease. Hyman MA,
Ornish D, Roizen M. 2009;15(6):12-14.
Putting healing into healthcare reform: will physicians and healthcare practitioners lead? Jonas WB, Rakel DP. 2009;15(6):8-9.
Phytomedicines. See Herbs.
Polycystic ovary syndrome.
Delivery of a full-term pregnancy after TCM treatment in a previously infertile patient diagnosed with polycystic ovary syndrome. Stone JAM, Yoder KK, Case EA. 2009;15(1):50-52.
Pregnancy.
Delivery of a full-term pregnancy after TCM treatment in a previously infertile patient diagnosed with polycystic ovary syndrome. Stone JAM, Yoder KK, Case EA. 2009;15(1):50-52.
Pregnancy and labor alternative therapy research. 2008;14(5):28-34.
76
[Letter to the editor: 2009;15(1):14.]
Recurrent miscarriage syndrome treated with acupuncture and
an allergy elimination/desensitization technique. Stanford R.
2009;15(5):62-63.
The use of botanicals during pregnancy and lactation. Low Dog
T. 2009;15(1):54-58.
Probiotics.
The effect of probiotics on preventing necrotizing enterocolitis in
premature babies. Manheimer E, Berman B, Vist G, Glenton
C. 2009;15(4):18-20. [Erratum: 2009;15(6):14.]
Reiki.
Effect of Reiki on pain and anxiety in the elderly diagnosed with
dementia: a series of case reports. Meland B. 2009;15(4):56-57.
Research.
Clinical research in anthroposophic medicine. Hamre HJ, Kiene
H, Kienle GS. 2009;15(6):52-55.
A complementary and alternative medicine workshop using
standardized patients improves knowledge and clinical skills
of medical students. Hoellein AR, Griffith CH, Lineberry MJ,
Wilson JF, Haist SA. 2009;15(6):30-34.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
The effects of distant healing performed by a spiritual healer on
chronic pain: a randomized controlled trial. Tsubono K,
Thomlinson P, Shealy CN. 2009;15(3):30-34.
Effects of dried cruciferous powder on raising 2/16 hydroxyestrogen ratios in premenopausal women. Morrison J, Mutell D,
Pollock TA, Redmond E, Bralley JA, Lord RS. 2009;15(2):52-53.
Effects of yoga on inner-city children’s well-being: a pilot study.
Berger DL, Silver EJ, Stein REK. 2009;15(5):36-42.
Factors associated with potential medication-herb/natural product
interactions in a rural community. Blalock SJ, Gregory PJ, Patel
RA, Norton LL, Callahan LF, Jordan JM. 2009;15(5):26-34.
Metabolic cardiology: the missing link in cardiovascular disease.
Sinatra ST. 2009;15(2):48-50.
Relative bioavailability comparison of different coenzyme Q10
formulations with a novel delivery system. Liu Z, Artmann C.
2009;15(2):42-46.
Shiatsu as an adjuvant therapy for schizophrenia: an open-label
pilot study. Lichtenberg P, Vass A, Ptaya H, Edelman S,
Heresco-Levy U. 2009;15(5):44-46.
Systematic reviews and meta-analyses support the efficacy of
numerous popular herbs and phytomedicines. Blumenthal M.
2009;15(2):14-15.
Yoga for chronic low back pain in a predominantly minority population. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB,
Phillips RS, Culpepper L. 2009;15(6):18-27.
Research methods.
Clinical observations and seven-and-one-half-year follow-up of
patients using an integrative holistic approach for treating
chronic sinusitis. Ivker RS, Silvers WS, Anderson RA.
2009;15(1):36-43.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Author/Subject Index 2009
Improving the science for botanical and dietary supplements.
Geller SE. 2009;15(1):16.
Learning activities to enhance research literacy in a CAM college
curriculum. Lasater K, Salanti S, Fleishman S, Coletto J, Jin H,
Lore R, Hammerschlag R. 2009;15(4):46-54.
Restless legs syndrome.
Does valerian improve sleepiness and symptom severity in people with restless legs syndrome? Cuellar NG, Ratcliffe SJ.
2009;15(2):22-28.
Rhubarb.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
Schizophrenia.
Shiatsu as an adjuvant therapy for schizophrenia: an open-label
pilot study. Lichtenberg P, Vass A, Ptaya H, Edelman S,
Heresco-Levy U. 2009;15(5):44-46.
Shiatsu.
Shiatsu as an adjuvant therapy for schizophrenia: an open-label
pilot study. Lichtenberg P, Vass A, Ptaya H, Edelman S,
Heresco-Levy U. 2009;15(5):44-46.
Sinusitis.
Clinical observations and seven-and-one-half-year follow-up of
patients using an integrative holistic approach for treating chronic
sinusitis. Ivker RS, Silvers WS, Anderson RA. 2009;15(1):36-43.
Sleep.
Does valerian improve sleepiness and symptom severity in people with restless legs syndrome? Cuellar NG, Ratcliffe SJ.
2009;15(2):22-28.
South Africa.
Frank Lipman, MD: where Eastern medicine meets Western
medicine. Lampe F, Snyder S. 2009;15(1):68-76.
Spiritual healing.
The effects of distant healing performed by a spiritual healer on
chronic pain: a randomized controlled trial. Tsubono K,
Thomlinson P, Shealy CN. 2009;15(3):30-34.
St John’s wort.
Abstracts. Riley D, Snyder S. 2009;15(2):72-73.
Streptoccous mutans.
Cranberry constituents affect fructosyltransferase expression in
Streptoccous mutans. Feldman M, Weiss E, Shemesh M, Ofek I,
Bacharach G, Rozen R, Steinberg D. 2009;15(2):32-38.
TCM. See Traditional Chinese medicine.
Toxicants.
A possible central mechanism in autism spectrum disorders,
part 2: immunoexcitotoxicity. Blaylock R. 2009;15(1):60-67.
A possible central mechanism in autism spectrum disorders,
part 3: the role of excitotoxin food additives and the synergistic effects of other environmental toxins. Blaylock R.
2009;15(2):56-60.
Traditional Chinese medicine.
Delivery of a full-term pregnancy after TCM treatment in a previously infertile patient diagnosed with polycystic ovary syn-
Author/Subject Index 2009
drome. Stone JAM, Yoder KK, Case EA. 2009;15(1):50-52.
Understanding diagnostic reasoning in TCM practice: tongue
diagnosis. Anastasi JK, Currie LM, Kim GH. 2009;15(3):18-28.
[Erratum: 2009;15(4):10.]
Valerian.
Does valerian improve sleepiness and symptom severity in people with restless legs syndrome? Cuellar NG, Ratcliffe SJ.
2009;15(2):22-28.
Vertigo.
Temporal bone motion asymmetry as a cause of vertigo: the
craniosacral model. Christine D. 2009;15(6):38-42.
Weight management.
Diets based on Ayurvedic constitution—potential for weight
management. Sharma S, Puri S, Agarwal T, Sharma V.
2009;15(1):44-47.
Women’s health.
Confirmation of the efficacy of ERr 731 in perimenopausal
women with menopausal symptoms. Kaszkin-Bettag M,
Ventskovskiy BM, Solskyy S, Beck S, Hasper I, Kravchenko A,
Rettenberger R, Richardson A, Heger PW. 2009;15(1):24-34.
Effects of dried cruciferous powder on raising 2/16 hydroxyestrogen ratios in premenopausal women. Morrison J, Mutell D,
Pollock TA, Redmond E, Bralley JA, Lord RS.
2009;15(2):52-53.
Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study. Bosch PR, Traustadóttir T,
Howard P, Matt KS. 2009;15(4):24-31.
Yoga.
Effects of yoga on inner-city children’s well-being: a pilot study.
Berger DL, Silver EJ, Stein REK. 2009;15(5):36-42.
Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study. Bosch PR, Traustadóttir T,
Howard P, Matt KS. 2009;15(4):24-31.
Yoga for chronic low back pain in a predominantly minority population. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB,
Phillips RS, Culpepper L. 2009;15(6):18-27.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
77
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2009-2010 conference calendar
AHMA 2009 Conference: The Future of Holistic Medicine
November 5-7, 2009—Renaissance Hotel, Cleveland, Ohio
Confirmed keynote speakers include Leland Kaiser, healthcare futurist and
acknowledged authority on the changing American healthcare system;
Ben Kligler, cofounder and one of the directors of the Continuum Center
for Health and Healing; Larry Rosen, cofounder of the IPC and one of the
leading voices for holistic pediatric care; and Tieraona Low Dog, the director of education for the Program in Integrative Medicine at the University
of Arizona and inspiring public speaker. Other highlights include a pediatric track based on the highly successful Pangea conferences on pediatric
integrative medicine, most recently held in November 2008 in New York
City. We have assembled a diverse group of leaders who have created successful holistic and integrative practices to offer insights and advice on
how these practices can be started and maintained. The nurses from the
Integrated Therapies Committee of MetroHealth Hospital in Cleveland,
Ohio, in collaboration with the AHMA will be offering an exciting half-day
pre-conference on November 5 that will focus on CAM therapies and wellness approaches for both adults and seniors, followed by an evening public forum. For more information, visit www.holisticmedicine.org.
6th International Conference of the Society for Integrative
Oncology: Revitalizing Health Care: Comprehensive
Interdisciplinary Programs and Whole Systems Research
November 12-13, 2009—New York Academy of Medicine, New
York, New York
Original research, education, clinical practice, workshops, and more for
physicians, nurses, social workers, naturopaths, psychologists, psychiatrists, palliative care, acupuncturists, massage therapists, music therapists,
TCM practitioners, traditional healthcare practitioners, nutritionists, exercise and lifestyle coaches, pharmacists, herbalists, scientists, and administrators. CME certification provided through Columbia University. Plenary
speaker: Dean Ornish, MD. For more information, call (212) 305-3334,
e-mail [email protected], or visit http://www.columbiacme.org/
Ped-43-09/Ped-43-09.html.
Institute for Functional Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Metametrix Clinical Laboratory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
National Cancer Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
NeuroScience, Inc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
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Researched Nutritionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Saybrook Graduate School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Scripps Center for Integrative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . .36
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78
Ontario Association of Naturopathic Doctors Convention 2009:
Revolutionizing Medicine: The Connection Between the
Environment and Health
November 13-15, 2009—Toronto, Ontario
The OAND Convention is Canada’s largest annual naturopathic medicine
event. There are 5 keynote presentations throughout the weekend by
William J. Rea, MD; Lyn Patrick, ND; Angela Hywood, ND; David
Waltner-Toews, DVM, PhD; and Devra Davis, PhD, MPH. There are 15
presentations to choose from in 3 breakout sessions. This year, you can
earn up to 12 CE credits in 1 weekend, beginning Saturday morning and
ending Sunday afternoon. For more information, call (877) 628-7284 or
visit www.oand.org.
Homeopathy for Health Care Professionals
November 14-15, 2009—Rockville, Maryland
Sponsored by Alternative Medicine Seminars, this event offers 16
NCCAOM credit hours. For more information, call (301) 251-2335, e-mail
[email protected], or visit http://web.mac.com/nadersolimanmd.
Micronutrients for Mental Health Conference
December 4-5, 2009—Hotel Monaco, San Francisco, California
This is the first conference of its kind, where you will be able to hear some
of the world’s leading experts, clinicians, and researchers share their
knowledge on the role of vitamins, minerals, amino acids, and essential
fatty acids in mental health. There will be many opportunities to ask questions, share experiences, and connect with others who have similar interests. For more information or to register, visit www.mmhforum.org.
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
Classifieds/Advertisers Index/Conference Calendar
Third Annual Evidence-based Complementary and Alternative
Cancer Therapies Conference
January 7-9, 2010—West Palm Beach, Florida
Join us for great speakers, organic food, and networking. Check the website for updates: http://annieappleseedproject.stores.yahoo.
net/3rdanevcoca.html. Early registration began in August 2009.
Natural Supplements: An Evidence-Based Update
January 21-24, 2010—Paradise Point Resort, San Diego, California
During this informative and comprehensive CME conference, renowned
faculty will present a concise, clinically relevant overview of the latest
information on natural supplements and nutritional medicine with an
emphasis on disease states. This course provides practical information for
health care professionals who make nutritional recommendations or manage dietary supplement use. For more information, e-mail med.edu@
scrippshealth.org or visit http://www.scripps.org/events/natural-supplements-an-evidence-based-update.
Integrative Healthcare Symposium
February 25-27, 2010—Hilton New York, New York
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ihsymposium.com/09/public/Content.aspx?ID=16403.
Society for Acupuncture Research 2010 International Conference
Translational Research In Acupuncture: Bridging Science, Practice
& Community
March 19-21, 2010—Sheraton Hotel, Chapel Hill, North Carolina
This conference will explore effective strategies for advancing translational
research as it applies to acupuncture and will focus on addressing paradoxes emerging from the research evidence in this field to date. For further
details and to view the call for abstracts, go to www.acupunctureresearch.
org/index.php?option=com_content&view=article&id=63:2010conferenc
e&catid=36:events&Itemid=57.
Highlighting Massage Therapy in CIM Research
May 13-15, 2010—Red Lion Hotel, Seattle, Washington
The Massage Therapy Foundation is pleased to present its second conference. This 3-day event brings together massage and manual therapy practitioners, educators, CIM researchers, allied health professionals, and others interested in massage research. Abstract submissions are due October
15, 2009. For more information, visit www.massagetherapyfoundation.
org/researchconference2010.html.
International Congress on Complementary Medicine Research:
Relevant Research for the Chronically Ill
May 19-21, 2010—Tromsø, Norway
The local host of the congress is NAFKAM (National Research Center in
Complementary and Alternative Medicine) in conjunction with ISCMR.
Researchers from around the world will have a chance to both share
research findings and (re)establish important personal connections with
others working in the same field. For more information, visit the conference website, www.iccmr2010.com.
For more conference calendar listings, please visit our website:
www.alterative-therapies.com. Under “Resources & Content,” click
on “Conferences/Events.”
Conference Calendar
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80
ALTERNATIVE THERAPIES, nov/dec 2009, VOL. 15, NO. 6
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boxes
www.EssentialFormulas.com
Essential Formulas Incorporated • P.O. Box 166139 • Irving, TX 75016-6139
(972) 255-3918 (phone) • (972) 255-6648 (fax) • [email protected]
Are Your
Patients Living
on the Edge?
Clinical Trial
Available Now!
A
Go to www.douglaslabs.com/cardio-edge
to see the results for yourself.
Cardio-Edge™ can help.
Now your patients can take the EDGE off their
cholesterol—with Cardio-Edge, exclusively
from Douglas Laboratories. Each daily dose
of Cardio-Edge contains 300 mg of Sytrinol,
a patented citrus-based extract clinically
proven to support cardiovascular health.†
† These statements have not been evaluated by the Food and
Drug Administration. This product is not intended to diagnose,
treat, cure, or prevent any disease.
Call today 1-888-DOUGLAB (1-888-368-4522) or 1-800-245-4440
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