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AAOS Now

Published 3/1/2017
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Eeric Truumees, MD

Do You Believe in Integrative Medicine?

In January, Daniel Neides, MD, medical director and chief operating officer of the Cleveland Clinic Wellness Institute, posted a column widely viewed as anti-vaccine on a local news site. A mild media circus erupted. Soon after, Dr. Neides issued an apology, and the hospital system—whose name and logo were included in his byline—disavowed the column, promising that “appropriate disciplinary action would be taken” against Dr. Neides.

Having done my residency at Cleveland Clinic, I read all this with interest—in particular, the subsequent commentary addressing the role of complementary and alternative medicine (CAM) centers and wellness centers in major health systems. The episode has prompted the Cleveland Clinic to reevaluate its Wellness Institute because “the institute’s focus has grown too unwieldy and less connected to the clinic’s broader mission of providing the best, evidence-based medicine and services to patients,” according to Eileen Sheil, Cleveland Clinic’s executive director of corporate communications.

All of this got me thinking about the extent to which we, as orthopaedic surgeons, address integrative medicine within our stated framework of evidence-based treatment. Integrative medicine modalities such as prolotherapy are frequently used in orthopaedic care to treat injuries, while other methods such as deep breathing, guided imagery, and meditation may be used to help with symptoms stemming from injuries. So, the question is this: “Is our desire for patient-centered care expanding our armamentarium in difficult clinical situations, or is it simply giving people what they want, even when it runs against the evidence?”

What is integrative medicine?
There are seemingly dozens of ways to define “integrative medicine,” including some that are vague or clearly self-serving. Commonly, these complementary approaches are considered healthcare modalities that fall outside of conventional, allopathic medicine. They are commonly said to “re-affirm the importance of the relationship between practitioner and patient” and “focus on the whole person.” The National Institutes of Health defines integrative medicine as utilization of one or more of these techniques in conjunction with more typical, allopathic care. Alternative medicine, on the other hand, seeks to use these techniques to the exclusion of conventional care.

Where to draw the borders around these treatment types is difficult. They represent ancient practices—such as yoga, tai chi, Ayurvedic medicine, and traditional Chinese medicine—and more recently developed treatments, such as chelation therapy, colon cleansing, and ozone therapy. Some, such as faith healing, Reiki, and Qi Gong, are based on external healing powers, while others, such as craniosacral therapy, homeopathy, and reflexology, attempt to use a different model of disease to address the affliction. Some treatments have at least some supporting evidence—chiropractic, osteopathic manipulations, and nutritional supplements would fall into this category—while others seem to have none. Some proponents consider only one or two of these approaches valid, while others see them as part of a large folio of options.

In 2011, Forbes published a piece on integrative medicine by University of Maryland Professor Steven Salzberg, who calls it “just the latest buzzword for a collection of superstitions, myths, and pseudoscience.” The collection of practices has changed slightly over time, he notes, with new modalities added to much older practices such as acupuncture. He details the gradual loss of favor of the previous names (holistic medicine, alternative medicine, and CAM) leading to the newest iteration: integrative medicine.

Amusingly, he deconstructs the “science” behind homeopathy, saying that, beyond the fact that there is no evidence that “like cures like,” the dilutions recommended in homeopathy render less “active ingredient” than one molecule immersed on “a sphere of water the size of the whole planet.” Yet, he is astounded that academic institutions, such as his own and the Cleveland Clinic, sell this “water dropped on a sugar pill.”

I became interested in Dr. Salzberg’s work in 2010 when he deconstructed a New England Journal of Medicine article recommending acupuncture for low back pain patients. The trial showed acupuncture was as effective as sham acupuncture, which was toothpicks placed without regard to the “meridians”—thus demonstrating the power of the placebo effect. The study authors and lay media, however, had a different take on the study, asserting that its results support the benefits of acupuncture for back pain.

But before any of us gets too far into criticizing CAM therapies, we should acknowledge limitations in the orthopaedic literature. Even when strong evidence is thought to exist, we orthopaedists do not always rapidly incorporate that evidence into our treatment protocols. For example, as a spine surgeon, I still “believe” in the power of vertebral body augmentation procedures like kyphoplasty to improve fragility fracture–related pain. Is it merely confirmation bias that reassures me when new studies point to the efficacy of these procedures?

Regenerative medicine
And what of regenerative medicine, which has received favorable coverage by public figures such as Oprah, Dr. Oz, and “the Doctors”? We find that, too often, real scientific progress in this area—such as a heart valve grown in a Wake Forest Institute for Regenerative Medicine laboratory—is conflated with much less rigorous injection techniques.

In Texas, as many patients ask me about stem cell injections as about laser surgery. This relates to Texas Gov. Rick Perry’s 2011 lumbar spine fusion using adipose-derived stem cells. Some patients come with stacks of “peer-reviewed” articles from obscure journals. Given that I do not have much to offer some of these patients with severe, diffuse low back pain, I want to believe; however, my understanding of the harsh environment of the lumbar disk space and its limited vascularity makes it difficult for me to recommend a cash-only, $5000 injection of marrow aspirate into the disk. I firmly believe, on the other hand, that a combination of scaffold, cells, and signaling proteins may someday provide these patients with relief.

To stay current in my discussions with these patients, I update my literature search on this topic every year or two. In December, Regenerative Medicine published a special issue celebrating its 10th anniversary that explored the history and current state of regenerative medicine, including issues such as nanotechnology scaffolds and development of pluripotent human stem cells. Missing was any mention of the current use of “regenerative medicine” in clinics around the world. In fact, Robert Lanza, MD, the special issue’s editor, said the following in his introduction: “Significant progress has been made in the development of potential regenerative cell-based therapies, especially [for] neurodegenerative diseases, such as Parkinson’s disease, which are poised to enter the clinic in the next few years.”

But, the reality is that more than 500 stem cell clinics have opened across the United States. There are surely an equal number abroad, most of which are operated legally under the proviso that homologous stem cells can be re-injected into the patient without U.S. Food and Drug Administration (FDA) approval or oversight as long as they are “minimally manipulated.” Some of these clinics have very slick websites touting the allopathic credentials of stem cell treatments. Most start with a claim, in large font: “Stem Cell and Platelet-Rich Plasma Therapy Offers 82 Percent Excellent Results. Regenerate...DON’T OPERATE!” Then comes the disclaimer in tiny font: “Our affiliated clinics are not offering stem cell therapy as a cure for any medical condition. No statements or treatments on this site have been evaluated or approved by the FDA. This site contains no medical advice. All statements and opinions on this site are provided for educational and informational purposes only.” Interestingly, these clinics’ offerings are rarely part of a spectrum of care. Instead, other treatment options are often denigrated with statements such as “refuse to fuse.” 

In September 2016, the FDA held public hearings around its plans to crack down on what the publication STAT calls “scores of clinics across the United States that offer pricey stem cell therapies for conditions ranging from autism to multiple sclerosis to erectile dysfunction without any scientific evidence that they work.” In the article, University of Minnesota bioethicist Leigh Turner, PhD, MA, said he has been amazed that regulators have allowed the industry to grow so rapidly. “If it’s not safe and it’s not going to help patients,” Dr. Turner said, “it’s just predatory behavior.”

How do we respond?
Although science should not have a “dogma,” we know that it does. Some new ideas spread rapidly, while others require a generational change before widespread acceptance. Most of us are familiar with the years it took British surgeon Joseph Lister’s ideas about antiseptic surgery to become widely accepted in medicine. In The New Yorker magazine, surgeon, writer, and public health researcher Atul Gawande, MD, MPH, points out that, in the nineteenth century, some clergymen opposed anesthesia in childbirth because it represented “a frustration of the Almighty’s designs” that the process be painful.

For some, CAM therapies are part of a larger belief system. As such, the discussion around CAM therapies has become political or divisive. These belief systems do not favor one or the other side of the political spectrum. For every “climate-denier” on the right, there seems to be an “anti-vaxxer” on the left.

For a fascinating look at how differently patients and physicians view allopathic versus integrative medicine, read the comments section of any article on integrative techniques. The responses range from scorn (eg, “on a related note, 37 percent of Americans believe in haunted houses”) to aggressive defenses incorporating harsh criticisms of allopathic medicine (eg, “Oh, the arrogance of medical doctors. Why can’t they embrace other healing methods and work toward integrating other time-honored methods of healing?? Is it because all they are trained to do is CUT and push DRUGS? Is it because ‘quacks’ are cutting into their profits?”)

You may say, aren’t these treatments benign? I guess that depends on the type of treatment and the definition of benign. Most subject patients to little morbidity or risk, but there are countless stories of children dying when traditional or faith-based healing practices were favored over modern medicine. In January, the FDA warned that certain homeopathic teething products pose a risk to infants because they contain the toxic chemical belladonna.

Then, there are the costs. The most recent data readily available suggest that, in 2007, the U.S. population spent $33.9 billion on CAM practitioners and products.

My biggest concern lies in the steady assault allopathic care receives from purveyors of alternative medicine. While conspiracy theories about greedy surgeons and hospitals are irritating when they come from fringe websites, attacks on allopathic treatment recommendations are more dangerous when they come from MDs and respected healthcare institutions. 

Keeping an open mind
Integrative medicine is not going anywhere: Clearly, our patients sometimes want more than what allopathic medicine can offer. Therefore, it would behoove orthopaedic surgeons to have a basic understanding of these different modalities. Some orthopaedists may even find that incorporating elements of integrative medicine into their practices benefits patients by increasing their sense of engagement and responsibility for their own health.

Any formal incorporation of integrative medicine into our practices, hospital systems, and medical schools must be done judiciously, with clear demarcations between scientific medicine and these alternative modalities. Orthopaedic practices and hospital systems want to capture ancillaries to better enable streamlined, coordinated care—and to enhance revenue streams—but it seems wise for us, as orthopaedists, to limit our offerings to practices that are based on reasonable principles of medicine and to favor those with the strongest evidence base.

Clearly, we orthopaedists have no basis for arrogance, since our own evidence base remains limited and our treatments do not help everyone. We need to listen to patients with an open mind. It may not be useful to try to talk them out of therapies that do not interfere with the care we provide.

Eeric Truumees, MD, is the editor-in-chief of AAOS Now.

References:
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