The role of emotional processing in art therapy (REPAT) for breast cancer patients.

Emotional awareness and acceptance of emotion are associated with improved health in breast cancer (BC) patients. Art therapy (AT) uses visual art-making for expression and communication and has been shown to reduce psychological and physical symptoms in individuals with cancer. A major objective of AT is to encourage increases in emotion processing; however, few studies examine these changes. Purpose: To examine the effect of an eight-week AT group on emotion processing as a mechanism of symptom reduction in women with BC. Design: Randomized clinical trial. Sample: Twenty women diagnosed with breast cancer whom had completed primary treatment. Methods: Participants were randomized to participate in eight-weeks of AT or sham AT, which was a mandala coloring group. Participants answered questionnaires before and after the intervention. We used a Cohen's D calculator for effect sizes and a t-test to examine group differences. Findings: Statistically significant between-group differences in emotional awareness and acceptance of emotion were found after the intervention. We found large effect sizes between groups and over time in acceptance of emotion, emotional awareness and depressive symptoms. Conclusions: We conclude that emotion processing in AT may be a potential mechanism reducing depression and somatic symptoms in cancer patients. Implications for Psychosocial Providers: Art Therapy is a feasible intervention to increase emotional processing. A larger study is required to further examine its effect on psychological and physical symptoms in breast cancer patients.

Integrative Oncology in Supportive Cancer Care in Israel.

PURPOSE: Integrative oncology (IO) services provide complementary/integrative medicine (CIM) therapies to patients as part of their supportive cancer care. In this study, we examine and compare the structural, operational, financial and academic/research-related aspects of IO services in Israeli oncology centers. METHODS: The medical directors of seven Israeli IO programs completed questionnaires which explored the objectives and organizational features of their service within the context of supportive cancer care. RESULTS: All participating IO services addressed patient-reported concerns related to quality of life and function, within the context of conventional supportive cancer care. The centers shared similar characteristics regarding the procedure of referral to their service and emphasized research and teaching initiatives within an academic framework, as part of their clinical practice. A number of obstacles to integration were identified, primarily those related to financial considerations, such as the need for patients to carry the cost of the CIM treatments. CONCLUSIONS: IO services situated within conventional oncology departments in Israel share a number of characteristics, as well as obstacles to their incorporation into standard care. All participating centers described both clinical and academic activities, including research initiatives and the promotion of CIM in an academic setting. Further research is needed in order to better understand the place of CIM in the oncology setting and prioritize the allocation of resources in order to advance the inclusion of CIM in standard supportive cancer care.

[Do's and don'ts in the establishment of an integrative medicine service in the public health care system--challenges and insights].

Although gratifying, it is somewhat misleading to describe the progress made in recent years in the field of integrative medicine just by counting the number of new programs established. This count, albeit ever-increasing, represents only one facet of the complex challenge that should concern us all--the development of a better healthcare system. In the real field, other rules apply. It is not sufficient for new integrative medicine services to survive or even to thrive if this is done in parallel to, or worse off in disconnect from, conventional medicine. The two systems, complementary and alternative medicine (CAM) and allopathic medicine, must collaborate in harmony for the sake of synergy. In order for that to happen, careful prior planning that addresses the multiple interests of the various stakeholders is warranted. This paper describes five key challenges and insights [institutional acceptance, Leadership support, the day after, the human factor, and program evaluation) gained from establishing an integrative oncology section within a tertiary academic medical center in Israel. It includes practical advice and useful tips in the form of do's and don'ts with the hope that these pearls would help others to estabLish and develop their own integrative medicine programs within the unique context of their hospitals and healthcare systems.

[Traditional immunosuppression--Lei Gong Teng in modern medicine].

Although the origin of many common modern medicines that are routinely being used nowadays in healthcare is in medicinal plants and fungi, herbal medicine as a standalone profession is no longer included in the curricula of most Western medical schools. The medicinal plant Lei Gong Teng [also known as Thunder God Vine, Tripterygium Wilfordii Hook f., that is core to traditional Chinese herbal medicine, was praised for its possible anti-inflammatory properties in ancient traditional scripts that date back thousands of years. Yet, modern interest in its proven immune-modulatory properties serves as a vivid example to the bridge that is being built, gradually but constantly, between the tradition of healing arts and the world of modern therapeutics. In this review we summarize the main findings from an increasing number of clinical and laboratory studies published in top peer-reviewed medical journals that verify the traditional indications for which Lei Gong Teng was used medicinally. Based on these findings, and the risk-benefit profile of the plant's debarked root, we conclude that Lei Gong Teng and its active metabolites should be included in the Israeli herbal pharmacopeia.

Evaluating intense rehabilitative therapies with and without acupuncture for children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To compare the outcomes of conventional therapies (physical, occupational, and hydrotherapies) plus acupuncture with those without acupuncture when administered intensely in the management of children with spastic cerebral palsy (CP). DESIGN: Evaluation-blind, prospective randomized controlled trial. SETTING: Therapies and video-recorded assessments at a children's hospital in Beijing, China, and blind scoring and data analyses at a university in the United States. PARTICIPANTS: Children (N=75), 12 to 72 months of age, with spastic CP. INTERVENTIONS: Intensely administered (5 times per week for 12wk) physical therapy, occupational therapy, and hydrotherapy either with acupuncture (group 1) or without acupuncture (group 2). To satisfy standard of care, group 2 subsequently received acupuncture (weeks 16-28). MAIN OUTCOME MEASURES: The Gross Motor Function Measure (GMFM)-66 and the Pediatric Evaluation of Disability Inventory (PEDI) assessments at 0, 4, 8, 12, 16, and 28 weeks. RESULTS: At the end of 12 weeks, there was no statistically significant difference between the 2 groups, but when group 2 received acupuncture (16-28wk) there was a shift toward improvement in the GMFM-66 and the PEDI-Functional Skills Self-Care and Mobility domain. When groups were combined, statistically significant improvements after intense therapies occurred from baseline to 12 weeks for each outcome measure at each Gross Motor Function Classification System (GMFCS) level. After adjusting for expected normative maturational gains based on age, the GMFM gains for children with GMFCS II level was statistically significant (P<.05) with a mean gain of 6.5 versus a predicted gain of 3.4. CONCLUSIONS: Intense early administered rehabilitation improves function in children with spastic CP. The contribution from acupuncture was unclear. Children's response varied widely, suggesting the importance of defining clinical profiles that identify which children might benefit most. Further research should explore how this approach might apply in the U.S.

Informed consent in complementary and alternative medicine.

The objective of this study was to examine complementary and alternative medicine (CAM) practitioners' (i) attitudes toward informed consent and (ii) to assess whether standards of practice exist with respect to informed consent, and what these standards look like. The design and setting of the study constituted face-to-face qualitative interviews with 28 non-MD, community-based providers representing 11 different CAM therapeutic modalities. It was found that there is great deal of variability with respect to the informed consent process in CAM across providers and modalities. No unique profession-based patterns were identified. The content analysis yielded five major categories related to (i) general attitude towards the informed consent process, (ii) type and amount of information exchange during that process, (iii) disclosure of risks, (iv) discussions of alternatives, and (v) potential benefits. There is a widespread lack of standards with respect to the practice of informed consent across a broad range of CAM modalities. Addressing this problem requires concerted and systematic educational, ethical and judicial remedial actions. Informed consent, which is often viewed as a pervasive obligation is medicine, must be reshaped to have therapeutic value. Acknowledging current conceptions and misconception surrounding the practice of informed consent may help to bring about this change. More translational research is needed to guide this process.

Functional magnetic resonance imaging activation of the brain in children: real acupoint versus sham acupoint.

The purpose was to examine the brain activation patterns with acupuncture using real acupoint (Liv3) versus sham acupoint in healthy, sedated children using functional magnetic resonance imaging (fMRI). Functional magnetic resonance imaging scans of the brain for 10 healthy, sedated children were taken during stimulation of real acupoint (Liv3 [Taichong]) and a nearby sham acupoint in a randomized order, employing twisting and nontwisting methods using a blocked paradigm using a 2.0-T scanner. The functional data were analyzed by using SPM 99. Various regions of the brain were activated in 2 acupoints. However, the pattern was different for the 2 acupoints. We suggest specific cerebral activation patterns with acupuncture might explain some of its therapeutic effect.

When science meets medical tradition: what is needed for a dialogue on integrative medicine?

It has been more than a decade since the release of the National Institutes of Health (NIH) and Food and Drug Administration (FDA) consensus statement declaring that acupuncture is not an experimental therapy but a sound medical technique comparable in effectiveness to common conventional medical treatments for certain clinical conditions, such as nausea and pain. For the first time in the history of modern medicine, a traditional medical system gained legitimacy in the Western medical establishment. Yet, it remains unclear whether the motivation behind this endorsement represents a unity of conceptualization regarding the desired structure of the health care system and the nature of the integration of conventional and complementary and alternative medicine (CAM). Two (2) doctors, each representing a different paradigm, met in order to discuss and elucidate issues that relate to the nature of the proposed integration between allopathy and CAM. Their responses to key questions prompted by the 1997 NIH/FDA consensus statement create a platform for a unified "contract" that represents their vision regarding the essence of collaboration between the two systems of medicine. Based on the richness of their discussion, it is recommended that other medical centers engage in similar dialogues in order to establish their own contracts. It is hoped that this will pave the way toward mutual acceptance, both conceptually and strategically, of a pluralistic health care system.

Effect of acupuncture on the brain in children with spastic cerebral palsy using functional neuroimaging (FMRI).

We study the effect of acupuncture on brain activation patterns in children with cerebral palsy using functional magnetic resonance imaging (fMRI). fMRI of the whole brain was performed in 11 children with cerebral palsy and 10 healthy children during stimulation of a common acupoint in Traditional Medicine [Liv3 (Taichong)] on the left foot. We use both twisting and nontwisting methods with a blocked paradigm on a 2.0 Tesla MRI scanner. Functional data were analyzed by using Statistical Parametric Mapping software (SPM 99). Both signal increase and decrease in various regions of the brain were found in both groups of children. However, the pattern was different for the 2 groups, especially with decreases in signal regions. We suggest that the observed differences between children with cerebral palsy and healthy children with the stimulation of acupoint Liv3 might be due to blockage of the liver meridian in children with cerebral palsy.

Randomized controlled trial of traditional Chinese medicine (acupuncture and tuina) in cerebral palsy: part 1--any increase in seizure in integrated acupuncture and rehabilitation group versus rehabilitation group?

OBJECTIVE: The objective of this study was to observe for any change in baseline seizure frequency with acupuncture in children with cerebral palsy. METHODS: A randomized controlled study was conducted: Group I consisted of integrated acupuncture, tuina, and rehabilitation (physiotherapy, occupational therapy, and hydrotherapy) for 12 weeks; and Group II consisted of rehabilitation (physiotherapy, occupational therapy, and hydrotherapy) for 12 weeks. After a washout period of 4 weeks, Group II then received acupuncture and tuina for 12 weeks. Each subject received 5 daily acupuncture sessions per week for 12 weeks (total = 60 sessions). All children were assessed for any change in seizure frequency during treatment. RESULTS: One hundred and sixteen (116) children were recruited and randomized into Group I (N = 58) and Group II (N = 58). Thirty-three (33) children withdrew (9 from Group I and 24 from Group II). Of the remaining 83 children, Group I consisted of 49 and Group II of 34 children. For baseline, 5 children (6%; 5/83) had seizures. During phase 1 (12 weeks) of integrative treatment and subsequent 4-week follow-up, 3 children in Group I had seizures. Among those 3 children with seizures, 1 child with prior history of recurrent febrile seizure had 3 more recurrent febrile seizures during acupuncture treatment and 2 children without any prior history of seizures had new-onset seizures (1 with 3 recurrent febrile seizures and 1 with afebrile seizure). For Group I, 2 children with epilepsy had no increase in seizure frequency during acupuncture treatment. For Group II during the phase 2 acupuncture period, none had increase in seizure frequency. In both groups, 4 of 5 children (80%; 2 in Group I and 2 in Group II) with seizures had no increase in seizure frequency during acupuncture treatment and follow-up. CONCLUSIONS: The risk of increasing seizure is not increased with acupuncture treatment for cerebral palsy.

[Touching cancer: shiatsu as complementary treatment to support cancer patients].

In recent years there has been an increase in the interest of cancer patients in receiving complementary medicine therapies as supportive measures to cure the disease. In response, medical units that combine conventional and complementary medicine (integrative medicine) have been established in leading cancer centers worldwide. In Israel, a special integrative medicine unit that combines mind-body, Chinese medicine, nutrition, herbs, supplements, and manual therapies (such as shiatsu) before, during and after conventional anti-cancer therapies has been established as an integral part of the Davidoff Comprehensive Cancer Center in 2006. Shiatsu represents a group of manual therapeutic techniques, including acupressure. Shiatsu offers cancer patients a non-pharmacologic method to relieve symptoms and improve quality of life throughout the course of illness. Research indicates that acupressure is relatively effective and safe for common cancer-related symptoms such as nausea, vomiting and insomnia. In our experience, shiatsu is also relatively effective and safe for other common symptoms such as fatigue, muscular pain and body image dissatisfaction. Yet, insufficient evidence exists to delineate the best means by which shiatsu and other manual therapies could or should be integrated into routine cancer care. The purpose of the present paper is to describe what is currently known about this topic in order to support decision-making that is based on facts, rather than on myths and misconceptions. We call for more research that examines the effectiveness and safety of shiatsu and other manual therapies in the care of cancer patients.

Patients' experiences and perceptions of a consultative model integrative medicine clinic: a qualitative study.

OBJECTIVE: A common theme in integrative medicine (IM) is patient-centered partnering in care between patients and providers. Despite the stated ideals, few studies have assessed patients' perspectives on their actual experience in the context of a specific care model. The purpose of the present study was to retrospectively explore and compare experiences of cancer and noncancer patients under care in a consultative IM outpatient teaching clinic in the south-western United States. DESIGN: Qualitative study using inductive content analysis of focus group interview transcripts (2 groups of adult patients with cancers of various types and 1 group of chronically ill noncancer patients with mixed diagnoses). METHOD: Participants were recruited by random selection from a pool of eligible patients. Groups were conducted with patients who had completed their initial conventional cancer treatment and were at least 6 months postconsultation with an IM clinic physician. Transcripts of the audiotaped focus groups were analyzed. RESULTS: Cancer patients (n = 15) and noncancer patients (n = 6) (mean age, 60 years; 77% women) expressed overall satisfaction with IM, emphasizing (1) expansion of treatment options with lower perceived toxicity than conventional therapies, (2) positive experiences of the IM physician as caring and taking time to listen, and (3) improved self-care skills and sense of empowerment. Cancer patients noted positive relationships with their conventional MDs more than did noncancer patients, although both groups appreciated the IM physicians' communication styles. CONCLUSION: Patients experience a consultative integrative clinic model overall as favorable. The impact on outcomes, costs, and long-term quality of life requires additional study.

Potential synergism between hypnosis and acupuncture­is the whole more than the sum of its parts?

Both hypnosis and acupuncture have gained credibility over the years in their effectiveness for treating various health conditions. Currently, each of these treatments is administered in distinct settings and separate times. That is, even if patients receive both treatments as part of a multidimensional therapeutic program, they would typically receive them separately rather than simultaneously at the same session. This separation however might be undesirable since, at least theoretically, hypnosis and acupuncture could potentially augment each other if administered concomitantly. In this article we outline the rationale for this hypothesis and discuss the potential ramifications of its implementation.

Methodological challenges in meditation research.

Like other complex, multifaceted interventions in medicine, meditation represents a mixture of specific and not-so-specific elements of therapy. However, meditation is somewhat unique in that it is difficult to standardize, quantify, and authenticate for a given sample of research subjects. Thus, it is often challenging to discern its specific effects in order to satisfy the scientific method of causal inferences that underlies evidence-based medicine. Therefore, it is important to consider the key methodological challenges that affect both the design and analysis of meditation research. The goal of this paper is to review those challenges and to offer some practical solutions. Among the challenges discussed are the mismatches between questions and designs, the variability in meditation types, problems associated with meditation implementation, individual differences across meditators, and the impossibility of double-blind, placebo-controlled meditation studies. Among the design solutions offered are aptitude x treatment interaction (ATI) research, mixed quantitative-qualitative methods, and practical (pragmatic) clinical trials. Similar issues and solutions can be applied more generally to the entire domain of mind-body therapies.

Lack of standards in informed consent in complementary and alternative medicine.

OBJECTIVES: To examine whether U.S.-based professional complementary and alternative medicine (CAM) organizations have explicit informed consent policies. DESIGN AND SETTING: Phone survey conducted in July-August 2003. RESULTS: Data were obtained from 37 out of a total of 39 eligible and accessible organizations representing 19 commonly used provider-administered CAM techniques (95% response rate.) Only 21 organizations (57%) had any informed consent policy and standards, whilst only six (16%) mandate their clinician members to routinely obtain an informed consent. CONCLUSIONS: We found no consistent standards with respect to the practice of informed consent across a broad range of CAM practices. CAM information that is not communicated appropriately or is otherwise unavailable to patients during the decision-making process may increase the potential for healthcare oversights and adversity.

Is complementary and alternative medicine (CAM) cost-effective? A systematic review.

BACKGROUND: Out-of-pocket expenditures of over 34 billion dollars per year in the US are an apparent testament to a widely held belief that complementary and alternative medicine (CAM) therapies have benefits that outweigh their costs. However, regardless of public opinion, there is often little more than anecdotal evidence on the health and economic implications of CAM therapies. The objectives of this study are to present an overview of economic evaluation and to expand upon a previous review to examine the current scope and quality of CAM economic evaluations. METHODS: The data sources used were Medline, AMED, Alt-HealthWatch, and the Complementary and Alternative Medicine Citation Index; January 1999 to October 2004. Papers that reported original data on specific CAM therapies from any form of standard economic analysis were included. Full economic evaluations were subjected to two types of quality review. The first was a 35-item checklist for reporting quality, and the second was a set of four criteria for study quality (randomization, prospective collection of economic data, comparison to usual care, and no blinding). RESULTS: A total of 56 economic evaluations (39 full evaluations) of CAM were found covering a range of therapies applied to a variety of conditions. The reporting quality of the full evaluations was poor for certain items, but was comparable to the quality found by systematic reviews of economic evaluations in conventional medicine. Regarding study quality, 14 (36%) studies were found to meet all four criteria. These exemplary studies indicate CAM therapies that may be considered cost-effective compared to usual care for various conditions: acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson's, self-administered stress management for cancer patients undergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with "functional" disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients. CONCLUSION: Whereas the number and quality of economic evaluations of CAM have increased in recent years and more CAM therapies have been shown to be of good value, the majority of CAM therapies still remain to be evaluated.

Methodological challenges in meditation research.

Like other complex, multifaceted interventions in medicine, meditation represents a mixture of specific and not-so-specific elements of therapy. However, meditation is somewhat unique in that it is difficult to standardize, quantify, and authenticate for a given sample of research subjects. Thus, it is often challenging to discern its specific effects in order to satisfy the scientific method of causal inferences that underlies evidence-based medicine. Therefore, it is important to consider the key methodological challenges that affect both the design and analysis of meditation research. The goal of this paper is to review those challenges and to offer some practical solutions. Among the challenges discussed are the mismatches between questions and designs, the variability in meditation types, problems associated with meditation implementation, individual differences across meditators, and the impossibility of double-blind, placebo-controlled meditation studies. Among the design solutions offered are aptitude x treatment interaction (ATI) research, mixed quantitative-qualitative methods, and practical (pragmatic) clinical trials. Similar issues and solutions can be applied more generally to the entire domain of mind-body therapies.

One size does not fit all: aptitude chi treatment interaction (ATI) as a conceptual framework for complementary and alternative medicine outcome research. Part II--research designs and their applications.

When multiple treatment choices are available, the question is not just "which treatment is the best?" but more importantly "best or better for whom, when, and why?" Aptitude (or attribute) by treatment interaction (ATI) is a research paradigm that attempts to examine exactly that--how outcome depends on the match or mismatch between patients' specific characteristics and the treatments they receive. The purpose of this two-part paper is to introduce ATI methods as a conceptual framework into complementary and Alternative medicine/integrative medicine (CAM/IM) outcome research. Part I presented key concepts in ATI research. Part II presents ATI research designs and discusses their applications to the examination of the relationships between individuals and therapies, and the illumination of the mechanisms that make therapies differentially effective. Based on this examination, we conclude that ATI research offers invaluable insights into the multifaceted package of care typically delivered in contemporary medicine and therefore should be included in the portfolio of all CAM/IM outcome research.