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Ask Stanford Med, Health and Fitness

Director of Stanford Runner’s Injury Clinic discusses treating and preventing common injuries

Director of Stanford Runner's Injury Clinic discusses treating and preventing common injuries

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It may surprise you to learn that past studies show that runners have a 50 percent chance of sustaining an injury that disrupts their training, and those that compete in marathons have an incidence rate as high as 90 percent. But don’t hang up your sneakers just yet. Many common aches and pains that nag runners can easily be treated or avoided.

On Thursday, Michael Fredericson, MD, who is director of the Stanford Runner’s Injury Clinic and has been head team physician with the Stanford Sports Medicine Program since 1992, will talk about the latest running prevention and treatment methods during a Stanford Health Library lecture. (For those unable to attend the event in person, you can watch the live webcast starting at 7 PM Pacifiic time.) To kick off the conversation, I reached out to Fredericson to discuss some of the topics of his upcoming talk, including the harms of overstriding, the benefits of cross-training, and remedies for prevalent joint problems. He and Adam Tenforde, MD, a sports medicine fellow at Stanford, responded to my questions.

How can overstriding lead to injury?

The term “overstriding” refers to running with the foot striking the ground too far forward from normal stride length. This results in heel strike pattern that may increase stress in the hip and knee joints. Research has shown that forefoot strike patterns tend to reduce stress on the knees and hips, although this may lead to greater stress on the foot and ankle. We conduct a clinic called RunSafe, where we evaluate gait of runners using video and markers. More efficient stride frequency is 90 strides per leg per minute. When a runner overstrides, this may result in a lower stride rate and an inefficient gait. We evaluate for the causes of overstriding, including poor hip extensor strength (weak gluteal muscles), decreased flexibility and technique and encourage correction of these biomechanical contributors. Also, we may suggest shoes with reduced weight, such as ‘minimalist shoes’ as these tend to encourage a runner to run with a more mid-foot strike pattern. However, we caution any changes in shoe type or technique be introduced gradually to decrease risk of developing an injury from changes in gait pattern that stress the body in a new way.

Why is it important for runners to cross-train?

Cross-training refers to forms of aerobic exercise that do not involve running. Doing exercises that do not involve the repetitive ground-impact experienced during running help to rest tired muscles and decrease stress on bones, assisting in recovery while building aerobic capacity. There are no established forms of cross-training to prevent injuries, but performing exercises that do not involve impact loading through the legs, such as elliptical trainer, cycling or deep water running may be helpful.

Many runners select shoes that compensate for how their foot pronates. But recent research shows that pronating too much or too little may not actually increase a runner’s risk of injury. How important is pronation and foot type in preventing injuries?

We evaluate foot type and pronation during our RunSafe clinics. Pronation is a normal motion that helps to distribute forces while landing through the foot and ankle, reducing stresses through the lower extremities. If the foot abruptly stops moving from too much or too little pronation, the other joints and lower limbs may absorb these forces and can become injured. Foot type (having too high an arch or too flat a foot) may also result in higher forces in the legs and joints through associated biomechanics. Foot type and concerns of pronation need to be put into context of prior injury history, as recent research has suggested that foot type and pronation do not necessarily predict future injury risk.

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Ask Stanford Med, In the News, Infectious Disease, Public Health, Stanford News

A conversation on West Nile virus and its recent California surge

A conversation on West Nile virus and its recent California surge

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Ebola isn’t the only virus commanding media attention: West Nile virus, now in its 15th year in the United States, may be surging to unprecedented levels in California, fueled in part by the state’s earth-parching drought.

It’s a big deal elsewhere as well, with parts of Texas, Louisiana and Midwestern states like Nebraska are also being hit. But California – and its 237 cases as reported by the CDC –  has taken the lead, in part because the drought brings birds and mosquito together at the scarce sources of water, according to reports by the Wall Street Journal and San Francisco’s NPR-affiliate KQED. Some regions, including a few communities close to Stanford, are now spraying for the mosquitoes.

I recently chatted with infectious disease expert Lucy Tompkins, MD, PhD, about the disease and how to prevent it. (Tompkins, a fly fisherwoman, knows quite a bit about mosquitoes).

What are the symptoms of West Nile?

The majority of people who get bitten don’t have any symptoms. About 20 percent of those bitten develop what is called West Nile fever with a fever, aches, fatigue, maybe a headache and sometimes a rash. It was previously felt this was completely benign but there may be long-term effects. Less than one percent are  the serious  cases with involvement of the brain and nervous system, which has a high mortality rate. That’s particularly common in people who are immunosuppressed due to transplants or high use of prednisone or even to those over 50 years. It can be a very disabling infection.

What can people do to protect themselves?

Reduce standing water such as in bird baths and wear protective clothing with long sleeves, long pants and socks covering your pants. Use insect repellents containing DEET - not low-potency insecticides. If possible, avoid being out during the times of day mosquitoes are active such as early in the morning and at sunset. It’s all about prevention.

Why isn’t there a vaccine for West Nile?

The chances of any one person getting West Nile are pretty remote. There’s no market, honestly. There’s a much bigger demand in the veterinary market for a vaccine like this. There is a vaccine for horses – West Nile can be fatal in horses. It also affects dogs and cats. There are some experimental treatments – last year at Stanford we gave a patient an experimental treatment and he awoke from a coma.

Do you expect the virus to continue spreading?

It’s hard to predict from year to year what communities will be affected. It all depends on what happens in the environment. The best information is available at the CDC.

Becky Bach is a former park ranger who now spends her time writing about science or practicing yoga. She is a science-writing intern in the Office of Communications and Public Affairs.

Previously: Should local residents be worried about West Nile virus?, Image of the Week: West Nile virus and Close encounters: How we’re rubbing up against pathogen-packing pests
Photo by: CulexNil

Ask Stanford Med, Chronic Disease, Grand Roundup, Stanford News

Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing world

Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing world

Basu and RosenkranzThere’s a new health policy challenge in developing countries. Though many see chronic conditions like type-2 diabetes and heart disease as problems plaguing the wealthiest nations, “Nearly 80 percent of the deaths worldwide from these two diseases are coming from the developing world,” says Sanjay Basu, MD, PhD, an assistant professor of medicine at the Stanford Prevention Research Center.

But Basu is working to change this statistic, and his efforts just won him the $100,000 George Rosenkranz Prize for Health Care Research in Developing Countries. Administered by Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research at the Freeman Spogli Institute for International Studies, the award will help fund Basu’s large-scale data collection project in India. With a data set from over 65,000 people, Basu hopes to improve type-2 diabetes screening in the country, leading to better treatment and detection of the disease.

A researcher focused primarily on global development and human health, Basu is also an internal medicine physician with a master’s in medical anthropology and a doctorate in epidemiology. In the following Q&A, he discusses his current research interests and plans for the future.

How did you first become interested in global health policy and the developing world?

As a child, our family went back and forth between the United States and India, and the contrasts in daily life were striking and overwhelming. There is a sense in many parts of India that life is a privilege, and a constant struggle to maintain.

Your research in India will involve data collection and mathematical modeling, which sounds rather abstract. How does this work translate into real-world improvements in people’s health?

Our research serves as a bridge between the clinical science of how to prevent and treat disease, and the detailed operations of how to actually deliver better prevention and treatment in the real world. What we specifically do is combine biological and clinical data with data on program reach, budgets, and operations. In other words, we might learn how to build a car in a textbook, but our models look at how to make the car factory operate optimally so that the product, in the end, is drivable. We’ve worked closely with both government agencies and non-governmental groups to deliver programs in real-world populations, and to continuously improve those programs over time. For example, our work on how to introduce better tobacco control programs in India has actually resulted in recent legislation that has lowered tobacco use in some critical parts of the population.

What’s different about approaching chronic disease prevention in India versus in the United States?

The sheer size and diversity of the population is one big difference. India is four times the size of the United States, and far more diverse. There is simultaneously malnutrition and obesity, starvation and type-2 diabetes, vitamin deficiency and heart attacks – often in the same city. That means designing programs for a country – or a province, or even a city – requires a lot of attention to complicated perverse outcomes that may happen. For example, we’ve looked into reducing sodium intake as a strategy to lower hypertension and cardiovascular disease. But we also have to make sure that we don’t generate iodine deficiency since salt is the major delivery strategy for iodine and, unlike the United States, iodine deficiency is a serious concern in India.

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Ask Stanford Med, Chronic Disease, Clinical Trials, Patient Care

Ask Stanford Med: A focus on scleroderma

Ask Stanford Med: A focus on scleroderma

Melissa Warde’s life was forever changed 21 years ago when, at the age of 15, she was diagnosed with scleroderma. At the time, little was known about the chronic connective tissue disease, which involves the hardening and tightening of the skin and fibers that provide the framework and support for the body. “I knew from that day forward, I could sit back and wait for the disease to progress or I could, to the best of my ability, work to control the disease within myself,” Warde said during an Ask Stanford Med Google+ Hangout last week. “I knew I had to have a cheerful disposition, despite the tragedy that I was dealt, and of course having a positive attitude really helped me to focus on the winnings of life.”

During the live conversation, Warde was joined by Lorinda Chung, MD, director of the Scleroderma Center and co-director of the Multidisciplinary Rheumatologic Dermatology Clinic at Stanford, and Karen Gottesman, patient services director for the Scleroderma Foundation of Southern California, for a panel on scleroderma research and progress being made to enhance patients’ quality of life.

Chung opened the discussion with an overview of recent modifications to the disease criteria used in diagnosing scleroderma. Since no two cases of scleroderma are alike, the disease can often be difficult to diagnosis. However, early detection (.pdf) is critical for improving patient outcomes. Under the new criteria, physicians are directed to look for symptoms such as puffy fingers, capillary changes in the nail folds or Raynaud’s disease, which is present in 90 percent of patients with systemic sclerosis. Chung said:

Previously, patients really had to have significant, pretty obvious, skin tightening in order to meet the classification criteria. Or have interstitial lung disease or pulmonary fibrosis, which is scarring in the basis of the lungs, in order to meet the criteria.

These new classification criteria will enable rheumatologists, who may be less experienced in scleroderma, to detect early signs and then refer [patients] appropriately for an accurate diagnosis.

Following Chung’s update on the modifications to the disease criteria, Gottesman spoke about how patients can mange stress related to learning they have a rare, incurable disease and continue living life to the fullest. She advised:

Really learn to be your own advocate. Part of that means educating yourself, not only on all the different aspects of the disease, but also on what type of scleroderma you have so you are aware of possible symptoms that come up.

I think what scares a lot of patients and is really stressful is when you hear of a disease that doesn’t have a cure. But you have to keep in mind that there are hundreds of diseases without cures and we have a lot of treatments in the toolbox to treat the symptoms. At the end of the day you have to learn to co-exist with the disease and that process is really different for every single patient.

Being a proactive patient, Gottesman said, also means being a compliant patient and following through on properly taking any prescribed medications, completing physician recommended tests and other instructions from health-care providers. She said, “If you have a different game plan in mind, then you really need to be upfront [with your doctor] about what it is you need and what you think you want to do, so that you can communicate. That will help you in the long run.”

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Ask Stanford Med, Autoimmune Disease, Chronic Disease

Join Ask Stanford Med for a live discussion about scleroderma on Wednesday

Join Ask Stanford Med for a live discussion about scleroderma on Wednesday

hands_laptop_033114Although scleroderma is derived from the Greek words meaning “hardness” and “skin,” its symptoms affect far more than patients’ epidermis. The complex, rare disease can cause damage to the vascular system, lungs, kidneys and gastrointestinal tract with potentially life-threatening consequences.

On Wednesday at 4:30 PM Pacific time, we’ll be hosting an Ask Stanford Med Google+ Hangout about scleroderma research and progress being made to enhance patients’ quality of life. The live video discussion was organized in partnership with the Scleroderma Foundation and Inspire, a company that builds and manages online support communities for patients and caregivers.

Our panel of special guests includes Lorinda Chung, MD, director of the Scleroderma Center and co-director of the Multidisciplinary Rheumatologic Dermatology Clinic at Stanford; Karen Gottesman, patient services director for the Scleroderma Foundation of Southern California; and Melissa Warde, who was diagnosed with scleroderma at age 15 and has lived with the disease for more than two decades.

Panelist will address a range of topics, including:

  • Recent modifications to the disease criteria used in diagnosing scleroderma
  • The importance of patients being screened for pulmonary hypertension
  • The use of rating skin-thickness progression to help determine prognosis
  • A patient’s perspective on participating in a clinical trial
  • Efforts to develop online tools that enhance quality of life
  • Tips on how patients can live life to the fullest despite this debilitating disease

To participate in the discussion, watch the broadcast on the Stanford Medicine YouTube channel. A link to the hangout will also be tweeted on the @SUMedicine feed and posted on the School of Medicine’s Facebook page once the broadcast begins. Only panelists will be featured on screen, so audience members don’t need to be camera ready to join the conversation.

The public is welcome to submit questions for panelists in advance of the discussion by posting them in the comments section below before 3 PM Pacific time tomorrow (Tuesday). Questions can also be submitted during the live video discussion via Twitter using the hashtag #AskSUMed.

Previously: Save the date: Ask Stanford Med Google+ Hangout on Scleroderma April 2Another piece of the pulmonary-hypertension puzzle gets plugged into place, Patients with rare diseases share their extraordinary stories and Restoring hand function with surgery 
Photo by Judit Klein

Ask Stanford Med, Autoimmune Disease, Chronic Disease

Save the date: Ask Stanford Med Google+ Hangout on Scleroderma April 2

Save the date: Ask Stanford Med Google+ Hangout on Scleroderma April 2

Updated 03-25-14: Readers are welcome to submit questions for our panelists in the comments section below. We’ll collect questions until 3 PM Pacific time on April 2. A selection of the questions will be answered during the live video conversation, which will be broadcast on the Stanford Medicine YouTube channel starting at 4:30 PM Pacific time. A future blog entry will provide details on how to watch the Google+ Hangout.

***

3-17-14: An estimated 300,000 Americans are living with scleroderma, a chronic connective tissue disease that is generally classified as one of the autoimmune rheumatic diseases. While hardening of the skin is the most visible manifestation of scleroderma, symptoms of the disease vary greatly among patients and the effects range from mild to life-threatening. Researchers are still working to determine the cause of scleroderma, and currently there is no cure for the disorder.

To foster conversation about this complex, rare disease, we’re partnering with the Scleroderma Foundation and Inspire, a company that builds and manages online support communities for patients and caregivers, for a Google+ Hangout about scleroderma research and progress being made to enhance patients’ quality of life. Among the panel of special guests are:

  • Lorinda Chung, MD, director of the Scleroderma Center and co-director of the Multidisciplinary Rheumatologic Dermatology Clinic at Stanford. Chung is actively involved in clinical, translational, and epidemiologic research on systemic sclerosis and related connective tissue disease, and she’s the principal investigator on a number of clinical trials of new potential therapies for scleroderma patients.
  • Karen Gottesman, patient services director for the Scleroderma Foundation of Southern California. Both a patient and a long-standing patient advocate, she is author of The First Year – Scleroderma, An Essential Guide for the Newly Diagnosed. Gottesman is also a member of the Scleroderma Patient-centred Intervention Network (SPIN), an international consortium of scientific researchers and clinicians organized to develop, test and disseminate psychosocial interventions to improve the quality of life for scleroderma patients worldwide.

Audience members are welcome to submit questions during the live video discussion via Twitter using the hashtag #AskSUMed. Please save the date and join us on April 2 at 4:30 PM Pacific Time.

Previously: Another piece of the pulmonary-hypertension puzzle gets plugged into place, Rules for living with a chronic illness, Patients with rare diseases share their extraordinary stories and Restoring hand function with surgery

Ask Stanford Med, Autoimmune Disease

A closer look at the autoimmune disease vasculitis

When various forms of news media last week reported the cause of death of Harold Ramis, the writer/director/actor, as complications from the “rare autoimmune disorder vasculitis,” I can promise you there were many people who read that and said, “Huh?” for very personal reasons. These are people who, like me, knew that these reports weren’t quite right. Vasculitis is actually a family of at least 15 forms of this disease group and one not so rare when all those who have some form (perhaps as many as 3 million) are added together.

Research and clinical trials on vasculitis have been carried on in a handful of centers around the world. One long-time investigator in this area, also a teacher and clinician, is here at Stanford: Cornelia Weyand, MD, PhD, division chief of immunology and rheumatology. Wayand’s e-mail box was flooded last week, so we asked her to answer some basic questions here about the vasculitis family.

I understand the vasculitides are a family of diseases. Is there something all forms have in common?

A diagnosis of vasculitis means that there is inflammatory disease in the blood vessels.

All organ systems in the body have blood vessels. Therefore, all organ systems can be affected by vasculitis. Blood vessels provide oxygen and nutrients to the tissues. Inflamed blood vessels have a tendency to become blocked. In that case, the tissues do not get blood supply anymore, causing serious complications. In some cases, the inflamed blood vessel bursts, causing life-threatening bleeding. This complication is particularly serious if the body’s largest blood vessel, the aorta, is affected. A leak in the aorta is incompatible with life.

What insights into vasculitis have we gotten from research?

My research team has been involved in vasculitis research for the last decade. We have been trying to find answers to the questions most patients ask at one point in the course of their disease:

A. Why did I get this disease?

Vasculitis results from a faulty immune response. Cells of the immune system attack the blood vessel and cause tissue injury. The blood vessel responds to the attack by either closing up or by rupturing. We have been able to identify the immune cells that initiate and sustain vasculitis. Remarkably, cells that induce disease are identical to cells that protect the body. We have also learned that blood vessels have specialized sensor cells in them that keep a dialogue with the immune system and start the inflammation.

B. How can my disease be treated or prevented?

We cannot prevent vasculitis, but since the disease takes a course of flares and remission, we may be able to prevent the next disease flare.

Vasculitis is treated by suppressing the immune system. One of the most effective drugs is cortisone. Some patients need it in large doses and we are very cognizant of side effects.

We have devoted our research effort to develop new means of therapy. To accomplish that goal, we have developed a system in which we can induce vasculitis and then test new therapies. This system involves the transplantation of human blood vessels into mice. If such mice are supplied with immune cells from our patients, vasculitis develops in the engrafted blood vessel. We can treat that inflammation in the mice and can easily take a biopsy from the blood vessel to check what we have achieved and how therapy actually works.

C. How do you know whether my disease is active or not?

This is one of our greatest challenges as we take care of our patients. We cannot just go and take a tissue biopsy of our patients every time they come and see us. We have a research project in place which is aimed at developing biomarkers of vasculitis in a blood sample. We isolate out the immune cells of the patient and, by applying cutting edge technology, we assess these immune cells to get information how likely or unlikely these cells would cause inflammation.

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Ask Stanford Med, Health and Fitness

When it comes to holiday exercise, “something is better than nothing”

When it comes to holiday exercise, "something is better than nothing"

snowy run

Worried about maintaining your work-out routine during this busy holiday season? In a 2011 Scope Q&A, Joyce Hanna, associate director of Stanford’s Health Improvement Program, offered some tips on how to stay fit and active this time of year. When asked for suggestions on how to squeeze in a work-out amongst travel and festivities, she had this to say:

Chances are you’ll find that in spite of your good intentions there are times when you just won’t have time to do your planned exercise program. The most important thing to remember is that something is better than nothing. A study done at Stanford showed that breaking up a 30 minute exercise time into three shorter ten-minute segments produced significant health benefits.

I suggest to friends and family a “talk while we walk” date instead of a coffee or lunch date. Take advantage of the walking you’re doing while shopping. Walk briskly! Take the stairs, park far away, schedule meetings outside the office, walk down the hall to deliver a message instead of sending an e-mail, set a timer every 30 minutes to stand up and move. If you resist having an all-or-nothing attitude toward exercise, you’ll find that you can maintain your fitness level over the holidays.

Previously: A full workout in just seven minutes? Science says so!, Boosting willpower and breaking bad habits, Stanford nutritionist offers tips for eating healthy during the holidays, How to stay fit and active this holiday season and What you can do in thirty minutes a day
Photo by michael_bielecki

Ask Stanford Med, Medical Education, Patient Care, Research, Stanford News, Technology

Clinical informatics gains recognition as new medical sub-specialty

Clinical informatics gains recognition as new medical sub-specialty

diversityClinical informatics, a field at the intersection of clinical medicine and information technology, has reached a new milestone: Physicians can now become board-certified in this medical sub-specialty. Christopher Longhurst, MD, who is the chief medical information officer at Lucile Packard Children’s Hospital Stanford and the leader of a new Stanford clinical informatics fellowship training program for physicians, talked with Scope about where this field has been and where it’s going.

First off, what exactly is clinical informatics?

In clinical informatics, we leverage information technology to improve outcomes for patients. Research has been done in this area since 1960s and 70s, but what’s different now is the ubiquitous nature of computing devices. Everybody has access to information and communications technologies. The majority of U.S. hospitals are implementing an electronic health record.

And yet electronic health records are not something most front-line doctors are really excited about – they can be seen as disruptive to the patient-care process. I really think we have yet to deliver on the promise of electronic health records. There’s a tremendous opportunity to use data in those records to build a health care system that can make personalized care recommendations and automatically learn from patients.

How is clinical informatics changing the way that medical discoveries are made?

The idea when I was in grad school was that randomized trials were the gold standard for medical evidence. But, increasingly, people are recognizing that this “level A” evidence is cost-prohibitive to generate. And the subjects are so narrowly selected that the results are not always generalizable. I know what medication to give a white male in his 50s because of high blood pressure, but what if I have a different kind of patient?

So a lot of people are advocating for a shift away from traditional trials, toward using enormous, anonymized data sets gleaned from existing electronic medical records. The idea is that you can make valid conclusions based on retrospective research if the data set is large enough.

That’s why we want to create a “patients like mine” button in every electronic health record that would essentially allow real-time comparative effectiveness studies. Then, if you’re treating a 40-year-old, half-Vietnamese, half-black woman for high blood pressure, you can instantly generate a similar cohort and see which medications have provided the best outcomes for those patients.

A “patients like mine” button would also help us start to understand what questions doctors ask. Today, we don’t always know what physicians’ information needs are. If we start to collect this meta-data, we can better focus randomized controlled trials so that they match doctors’ biggest questions.

How does Stanford lead the field?

Stanford is often considered the place where clinical informatics all started. The father of this field, Ted Shortliffe, MD, PhD, was a graduate student at Stanford when, in the 1970s, he wrote a software program called MYCIN to make decisions about prescribing antibiotics. MYCIN performed better at those decisions than your average internist. Shortliffe came back to Stanford in the early 80s and founded the division of medical informatics, now the Stanford Center for Biomedical Informatics Research, starting the Masters and PhD programs.

More recently, we have a really solid history of finding unique ways to use and study electronic medical records: For instance, we’ve provided automatic daily updates to parents whose infants are hospitalized in our neonatal intensive care unit, reduced unnecessary use of blood transfusions, assisted in selecting the appropriate IV fluid to give to kids and more, all under this one umbrella.

We have nine physicians who received the new board certification, placing us among the largest programs in the country.

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Ask Stanford Med, Complementary Medicine, Nutrition, Pain

Ask Stanford Med: Pain expert responds to questions on integrative medicine

Ask Stanford Med: Pain expert responds to questions on integrative medicine

rolfing2Sometimes the best medicine is staying healthy. As more Americans look for ways to improve their health, prevent disease and manage pain, the subject of complementary practices may enter more conversations between patients and physicians. So for this installment of Ask Stanford Med, we asked Emily Ratner, MD, clinical professor of anesthesiology, perioperative and pain medicine and co-director of medical acupuncture and the resident wellness program at Stanford, to respond to questions on integrative medicine. Her answers appear below.

As a reminder, these answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

Mary says: Please speak about the efficacy of integrative medicine to alleviate multi-point pain from a variety of causes (ITP, OA, aging). A relative has doctor fatigue as well, and is not interested in anything else.

Integrative Medicine (IM) may be defined as the combination of conventional and nonconventional modalities chosen by a patient and physician in a patient-centered decision-making process in order to achieve the best outcome for an individual. Patients often seek nonconventional modalities when conventional medicine techniques are unable to achieve a particular goal, often pain relief or pain management. As a general rule, multi- and inter-disciplinary measures are often most helpful in relieving suffering from pain. These may include five general categories of nonconventional modalities, although there is overlap amongst the different types:

  • Mind-body medicine: meditation, hypnosis, biofeedback, guided imagery, yoga
  • Biologically based practices: uses substances found in nature – herbs, foods, vitamins, supplements
  • Manipulative/Body-based practices – massage, chiropractic/osteopathic manipulation
  • Whole medical systems: Traditional Chinese Medicine (includes acupuncture), Ayurveda, naturopathy
  • Energy Medicine – Reiki, Healing/Therapeutic touch, Qi Gong, acupuncture, yoga

Depending on patient preference, available resources in the community and other factors, a decision is made where to begin. I often recommend acupuncture as a place to start, closely followed by a mind-body medicine technique, as my experience is that stress plays a large role in either pain or the perception of pain. However, it largely depends on the individual’s needs and preferences.

Scope Editor asks: A recent study of herbal products found that most of those examined contained contaminants, substitutions and unlisted fillers among their ingredients. What are the implications of these findings, and how can consumers protect themselves when buying supplements?

This is a significant issue that highlights the need for increased supplement regulation, although the study to which you refer has been criticized for some of its conclusions. While FDA regulations for supplements are a bit stricter than for foods, the regulations are far less comprehensive than those for pharmaceutical agents.

That being said, product contamination with heavy metals, undisclosed pharmaceutical agents (especially in products from outside the U.S.), and inaccurate product ingredient amounts plague this field.

Until improved regulatory procedures are instituted, I suggest looking at a reputable database that independently tests these products, such as ConsumerLab.com. This and other independent organizations add their seal of approval to product labels that have tested either the products or the manufacturing practice involved in production of the substance. Look for the Consumer Lab seal or other seals: cGMP (current Good Manufacturing Practice), USP (United States Pharmacopeia), or NSF (another independent lab).

Some experts note that specific stores have strict quality control for their products – like Sam’s Club, Costco, Whole Foods – but I typically look up each individual product on a database (I use consumerlab.com) prior to recommending it.

Another option is to consult with a trained Integrative Medicine practitioner who has access to these databases and is knowledgeable about these products.

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