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Complementary medicine.

Continuing education and the APD program

This quiz is an ideal activity for APD members to include in your CPD log, where it relates to personal learning goals. Record the time taken, to the nearest hour, to complete the quiz and any associated research.

Introduction

Interest in complementary medicine (CM) has increased in the past decade, in parallel with the public's demand for more autonomy and involvement in healthcare, plus the desire to optimise health and prevent illness (1). This continuing education quiz is the first of a two-part series and covers the broader principles of CM.

It has been estimated that 50% of the Australian population use at least one non-medically prescribed complementary medicine, and 20% visit a practitioner of CM annually (2). In Australia, complementary therapies are now being prescribed in around 15% of all mainstream general practice consultations (2). Despite moves to support complementary therapies, in practice it seems that there are two distinct healthcare systems in Australia operating in parallel and without much interaction. It is estimated that of the patients who go to complementary practitioners, over 50% do not inform their doctor they are doing so (3).

Even if you do not particularly advocate CM this continuing education quiz provides dietitians with basic information on CM including the place of complementary medicine in the Australian health system. The second part of the quiz in the next issue will concentrate on the current legislation designed to maximise the appropriateness and safety of CM use, and how CM may be used to optimise the nutrition management of your patients. Those dietitians working in private practice, as well as in the hospital sector, will find the information valuable in these quizzes and particularly useful references for further reading.

1. Which statement best describes CM?

a. CM, alternative, unorthodox or unconventional medicine generally refers to the use of interventions that complement the use of drugs and surgery

b. CM is treatment based on philosophies, manual techniques, medicinal systems, mind-body techniques and bioenergetic principles

c. the major CMs used in Australia are herbal medicines, nutritional medicines, naturopathic medicines, traditional chinese medicines (TCM), homoeopathic medicines and acupuncture

d. all of the above

2. Which statement regarding the place of CM in the Australian health system is true?

a. CMs are subsidised through the Australian government Pharmaceutical Benefits Scheme

b. a goods and services tax (GST) is not charged on CMs in Australia

c. patients who have private health insurance are unlikely to receive a rebate for CM services

d. the public spending on CM is nearly four times the public contribution to the cost of pharmaceutical medicines

e. all of the above

3. In Australia, professionally trained practitioners of CM generally include chiropractors, osteopaths, herbalists, homoeopaths, naturopaths and traditional Chinese medicine practitioners. Which statement is not true?

a. they can undertake a four- to five-year full-time education program

b. their education generally has a basis in western medicine science and clinical medicine as well as extensive CM

c. education is taught in private colleges and universities throughout Australia

d. they undertake a four- to six-week education program taught in private colleges only

4. The evidence-based scientific approach has a number of limitations when used to substantiate claims for CM. Which one of the following statements is true?

a. scientific evidence can be limiting when assessing the effectiveness of the individualised therapy approach of CM

b. it is difficult to provide scientific evidence to measure a patient's transition from 'average' to 'optimal' health, which is the basis of CM

c. the lack of evidence for a particular CM effect may mean that the research has not yet been conducted

d. lack of funding and specialised resources, methodological or logistical constraints and a general lack of opportunity may limit scientific evidence

e. all of the above

5. Which CM preparation is traditionally used to relieve the symptoms of both rheumatoid and osteoarthritis?

a. St Johns Wort

b. Ginseng

c. New Zealand green-lipped mussel

d. Coenzyme 10

6. What are the useful web site links supporting conventional medicine practitioners interested in CM?

a. Australasian Integrative Medicine Association http://www.aima.net.au/

b. Complementary Medicine Evaluation Committee http://www.tga.gov.au/cm/cm.htm

c. Natural Medicines Comprehensive Database www.naturaldatabase.com/default.asp

d. Australian College and Nutritional and Environmental Medicine http://www.acnem.org/

e. all of the above

Answers

1. d.

Complementary medicine (CM), alternative, unorthodox or unconventional medicine generally refers to the use of interventions that complement the use of drugs and surgery. In Australia, the key types of CMs include herbal medicines, nutritional medicines, naturopathic medicines, naturopathic medicines, traditional Chinese medicines (TCM), homoeopathic medicines and acupuncture. The range of complementary therapies includes treatments based on philosophies, manual techniques, medicinal systems, mind-body techniques and bioenergetic principles. These therapies vary widely with respect to levels of efficacy, cost, safety and scientific validation, yet they often share common principles, including the concept of supporting the body's homeostatic systems, as well as acknowledging the role of lifestyle practices, personal creativity, group sharing, the mind-body connection and the role of spiritual practice in health (4). While the range of available therapists is vast, there is a common benchmark for all therapies including conventional and CM, which is 'reducing human suffering' (4).

2. d.

It has been estimated that in 2000, 50% of Australians took a non-medically prescribed complementary medicine and about 20% formally saw a complementary medicine practitioner (3). The public spent AUD$2.3 billion on CMs (nearly four times the public contribution to the cost of pharmaceutical medicines) (3) with the Australian government providing no formal budget allocation for research into the area, and there is no subsidy for any CMs via the Pharmaceutical Benefits Scheme (PBS). In addition, a goods and services tax is charged on these medications, unlike prescription medicines. Patients who have private health insurance with the appropriate level of cover may receive a selected rebate for CM services provided by an accredited CM practitioner. Suitably accredited medical practitioners can receive a specific Medicare rebate for the practice of acupuncture. However, most doctors offering CM within general practice do not receive a specific rebate for these services.

Despite moves to support complementary therapies, in practice it seems that there are two distinct healthcare systems in Australia operating in parallel and without much interaction. It is estimated that of the patients who go to complementary practitioners, over 50% do not inform their doctor they are doing so (3). The lack of communication about complementary medicine is potentially hazardous, as it raises the possibility of adverse treatment interactions (5).

3. d.

In Australia, professionally trained practitioners of CM include chiropractors, osteopaths, herbalists, homoeopaths, naturopaths and Traditional Chinese Medicine practitioners (4). Professional training is usually a four- to five-year full-time program that incorporates a basis in western medical sciences and clinical medicine as well as extensive CM. Teaching has been in private colleges until the last 10 years, when courses began to be established in universities. Currently about one third of all students in CMs graduate from universities (e.g. Southern Cross University, RMIT, Swinburne University, University of Western Sydney) and two thirds from private colleges (e.g. Southern School of Natural Therapy, Naturecare College, Australasian College of Natural Therapy, Australian College of Natural Medicine). The short four- to six-week introductory courses offered by some of the private colleges are generally not recognised by the professional associations regulating each of the CM practitioners. If you have further questions concerning the training of CM practitioners check with the associations listed on the next page.

Also in Australia there are no formal requirements for doctors, or any other conventional medical practitioners, to receive training in the use of CM (1). Therefore doctors tend to formulate their own methods of accessing available evidence. A recent survey showed that 15%-25% of GPs in Victoria use some form of acupuncture, hypnosis and meditation (6).

4. e.

The rational use of medicines has recently moved toward 'evidence-based care' and recognises that this relies on the conscientious, explicit and judicious use of the best available evidence in making decisions about the care of individual patients (7). An evidence-based approach recognises different levels of evidence and that the most rigorous types are not always available. As such, many clinical questions cannot be answered by reference to well conducted trials and require additional information such as that obtained from experience and historical use (4).

Randomised controlled trials (RCTs) have only been commonly performed since the 1950s and are a complex and costly process that requires large investments of time and money as well as access to specialised infrastructure and technical and clinical skills. These hurdles are often placed at even higher levels for herbs and natural supplements compared to pharmaceutical medicines, as the lack of patent protection for these products means there is little incentive. The lack of evidence for a particular effect may simply mean that the research has not yet been conducted. This may be due to a lack of funding and specialised resources, methodological or logistical constraints and a general lack of opportunity (4). Other limitations includes the application of scientific evidence when assessing the effectiveness of individualised therapy which is generally the focus of CM and the difficulty in provide scientific evidence for measures designed to move people from 'average health' toward 'enhanced' or 'optimal health'.

In summary evidence-based 'patient-centred' care, is becoming more widely adopted, the chief principles of which are in unison with the integrative medicine approach to incorporating evidence into clinical practice (4).

5. c.

A lipid extract from the New Zealand green-lipped mussel (Perna canaliculus) has been shown to reduce pain in patients with osteoarthritis (OA) of the knee, according to a double-blind RCT. Professor Chak Lau of the University of Hong Kong and researchers at the Queen Mary Hospital randomised 80 patients with knee OA to receive either two 50 mg doses of the stabilised lipid extract (commercially known as Lyprinol[R]) or placebo (olive oil) twice daily doses for two months, then half that dosage for the remaining four months of the study. Patients had also been asked to discontinue their NSAID (non-steroidal anti-inflammatory) therapy and commence 2 g paracetamol daily, with an additional 2 g/day available for break-through pain. Paracetamol use was recorded at regular visits throughout the study, when assessments were made of OA symptoms and drug safety (8).

Both groups showed improvement in almost all the OA assessment parameters studied, but there was a greater and statistically significant improvement in the perception of pain as measured by a visual analogue scale, and patients' global assessment of OA, in those who took Lyprinol[R] following adjustment for paracetamol use (8). Previous (in-vitro) studies have shown that the extract exhibits its anti-inflammatory effects through inhibition of the synthesis of inflammatory leukotrienes and possibly some prostaglandins.

As with previous trials on green-lipped mussel extract, the beneficial effects were apparent four weeks after commencement of treatment. Lyprinol[R] was also found to be well tolerated, with no significant differences in the overall incidence of adverse reactions, or dropout as a result of drug toxicity. The researchers concluded the lack of upper GI toxicity may be an advantage over NSAIDs and although no such comparison was made in this study, it should be considered in future studies (8).

6. e.

There are a number of useful web sites for complementary medicine information, which include the following:

CM information--free sites

* Medscape: www.medscape.com

* IM Gateway https://www.imgateway.net/wheel.htm

* Alternative Health News www.altmedicine.com

* Healthnotes: www.gnc.com/healthnotes

* Reuters Health Well-Connected report www.reutershealth.com/wellconnected/doc39.html

* US National Institutes of Health www.cc.nih.gov/ccc/supplements/

* Linus Pauling Institute http://lpi.oregonstate.edu/index.html

* Memorial Sloan-Kettering Cancer Centre www.mskcc.org/mskcc/html/11570.cfm

* American Botanical Council www.herbalgram.org/default.asp?c=defaulthome

* Herbmed www.herbmed.org/index.asp

* Longwood Herbal Task Force www.mcp.edu/herbal/about.htm

* The Journal of Complementary Medicine (Australian) http://www.jnlcompmed.com.au/aboutus.asp

* The practice of Chinese medicine in Australia report http://www.dhs.vic.gov.au/pdpd/chinese/report/contents.html

CM information--subscription only

* Natural Medicines Comprehensive Database www.naturadatabase.com/default.asp

CM practitioner associations

* Australasian Integrative Medicine Association http://www.aima.net.au/

* Australian Traditional Medicine Society http://www.atms.com.au/

* National Herbalists Association of Australia http://www.nhaa.org.au/

* Australian Natural Therapists Association http://www.anta.com.au/

* Australian Chinese Medicine Association http://www.acma.org.au/about.htm

CM industry associations

* Complementary Healthcare Council of Australia http://www.chc.org.au/

* Australian Self Medication Industry http://www.asmi.com.au/

Therapeutic Goods Administration (TGA)

* Complementary Medicine Evaluation Committee http://www.tga.gov.au/cm/cm.htm

Post-graduate education for conventional medicine practitioners

* RMIT http://www.rmit.edu.au/browse;ID=g8kj021rvsoq1, http://www.nutrition-education.com/100255.php

* Australian Centre of Complementary Medicine Research and Education (ACCMER) Southern Cross University & University of Queensland http://www.accmer.edu.au/

* Swinburne University of Technology http://www.swin.edu.au/gsim/gsmed_courses.html

* University of Sydney http://www.pharm.usyd.edu.au/hmrec/Herbal_Masters_Inform.doc

* Australian College and Nutritional and Environmental Medicine http://www.acnem.org/

References

1. Cohen M. Complementary therapies: Where to from here? Aust Family Physician 2000;2(6).

2. Shenfield GM, Atkin P. Kristoffersen S. Med J Aust 1997;166:516-7.

3. MacLennan AH, Wilson D, Taylor A. The escalating cost and prevalence of alternative medicine. Preventative Medicine 2002;35:166-73.

4. Pirott MV, Cohen M, Kotsirilos V, Farish S. Complementary therapies: Have they become accepted in general practice? Med J Aust 2000;172:105-9.

5. Einsenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. 1998 Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 280:1569-75.

6. Braun L, Cohen M. Herbs and natural supplements--An evidence based guide. Sydney: Elsevier Mosby; 2005.

7. Sackett DLR, Rosenberg W, Gray M, Haynes B, Richardson S. Evidence based medicine: what it is and what it isn't. BMJ 1996;312(7023):71-2.

8. Lau C. Treatment of Knew Osteoarthritis with Lyprinol lipid extract of the green lipped mussel--a double blind placebo controlled study. Progress in nutrition. 2004;6:17-23.

Sandra Murray and members of a group of dietitians interested in complementary medicine have prepared this quiz. Correspondence should be directed to Sandra Murray at sandram@uow.edu.au or Rocco Di Vincenzo at rdivincenzo@swin.edu.au
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Title Annotation:Continuing education
Author:Murray, Sandra
Publication:Nutrition & Dietetics: The Journal of the Dietitians Association of Australia
Geographic Code:8AUST
Date:Mar 1, 2005
Words:2427
Previous Article:BDA/HCA seminar on implementation of the Council of Europe recommendations on food and nutritional care in hospitals, London, 3 November 2004.
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