Issues in the use of complementary/alternative medical therapies for low back pain

Unfortunately, current conventional medical treatments for low back pain are not managing the problem effectively. Standard approaches to treatment, particularly surgery, may even be exacerbating the problem and causing additional pain and suffering. In this context, it is understandable that LBP patients often go outside of the conventional medical system seeking other treatment options. Conventional medical physicians who treat low back pain patients, therefore, need to become more aware of the fact that their patients may be using complementary/alternative medical therapies.

Alternative medicine instruction in medical schools and family practice residency programs

BACKGROUND AND OBJECTIVES

The use of medical therapies outside of mainstream Western medicine, referred to as complementary medicine or alternative medicine (CAM), is rapidly increasing in the United States. Despite evidence of physician interest and willingness to refer to CAM providers, there is currently little information regarding medical education in these practices. This survey assessed the frequency and nature of alternative medicine instruction in US medical schools and family practice residency programs.

METHODS

Society of Teachers of Family Medicine staff mailed a 16-question survey to all US medical school family medicine department chairs and non-university-based family practice residency program directors about existing instruction in alternative medicine, planned instruction, and educational programs under consideration.

RESULTS

The overall response rate was 77.9% (364/467), with 29.7% (108/364) of all respondents currently teaching, 6.0% (22/364) starting to teach, and 6.3% (23/364) considering teaching some form of alternative medicine. CAM instruction is most common in the Northeast and Rocky Mountain regions. The instruction is predominantly elective (72.2%). Instructional content and methodologies vary widely.

CONCLUSIONS

Alternative medicine has begun to establish a presence in US medical schools and family practice residency programs. Offerings in this diverse subject vary widely in content and format.

How should we research unconventional therapies? A panel report from the Conference on Complementary and Alternative Medicine Research Methodology, National Institutes of Health

Research in unconventional medicine requires a number of different questions to build up a "mosaic" of evidence. Choice of research design depends on the question being asked and is independent of the therapy under investigation. Despite the doubts of some practitioners, randomized trials are of value for determining certain questions in alternative medicine.

Supravital staining of eosinophils

Live eosinophils when mixed with Acridine Orange solution and viewed microscopically using u.v. light show very intense colours of their granules (yellow, orange and red) and green nuclear staining. Their active movement, translocation of granules and degranulation can be observed in vitro. Using this method, live eosinophils can be easily differentiated and enumerated.

Drug-abbreviated infections and development of immunity against Trichostrongylus colubriformis in sheep

A protective immune response without liveweight loss can be induced in sheep against T. colubriformis but results depend on the anthelmintic used and duration of immunizing infections. More than 90% protection was achieved in sheep immunized by three 15- or 7-day oxfendazole abbreviated infections or three 21-day nonabbreviated infections. Only 41% protection was induced by 3-day oxfendazole abbreviated infections. Significantly higher worm burden and faecal egg counts were present after challenge in sheep immunized by 7-day levamizole abbreviated infections compared to 7-day oxfendazole abbreviated infection. Liveweight gains of sheep immunized by 15- and 7-day abbreviated infections were not significantly different than non infected controls. Liveweight loss seemed to be associated with high activity of mucus peroxidase and high numbers of eosinophils in the intestinal lumen. High parasite numbers seemed to be associated with low activity of alkaline phosphatase in mucus. Mucus peroxidase, arylsulphatase, larval migration inhibition of mucus, mucus or serum antibody against L3 excretory/secretory antigen or somatic L3, L4 and adult antigen were not associated with protection.

Immune responsiveness of Romney sheep selected for resistance or susceptibility to gastrointestinal nematodes: field studies

Long-term selection of sheep for resistance to parasite infections may be jeopardized if animals do not retain their normal ability to respond to non-parasite antigens. Therefore the antibody responses to ovalbumin (OVA) and human red blood cells (HRBC), and kinetics of peripheral blood lymphocyte phenotypes were examined in mature grazing sheep, genetically resistant or susceptible to gastrointestinal nematodes. In both lines the HRBC antibody response peaked 2 weeks after the primary injection, 1 week after the second injection and 3 weeks after the second OVA injection. The antibody titres of the resistant line sheep decreased sooner after both primary and secondary injections. The resistant line sheep had higher percentages of CD5+ and CD4+ cells than the susceptible sheep. Two injections of OVA and HRBC did not result in significant alterations in percentages of CD5+, CD4+, CD8+ and CD45R+ lymphocytes in either line. In both lines, the control groups showed a steady increase of 0.29% per week in percentages of T19+ (gamma delta) T cells which was significantly higher than in the antigen injected sheep.

Patent infections of Ascaris suum in pigs: effect of previous exposure to multiple, high doses of eggs and various treatment regimes

Fifty-four crossbred, 4-week-old pigs divided into nine equal groups were used to test whether multiple inoculations with high numbers of A. suum eggs with or without anthelmintic would result in patent infections. All pigs exposed to multiple prechallenge inoculations of 500, 1000, 2000, 5000, 10,000 and 20,000 and challenged orally 2 weeks later with 10,000 eggs harboured adult worms. When prechallenge infections were removed by pyrantel tartrate treatment the animals were more susceptible to challenge than controls not previously exposed to infections. The same drug used from 2 days before until 10 days after the last prechallenge infection eliminated that effect. Pigs subjected to the same multiple egg dosing regimen but given feed containing fenbendazole immediately before, during and for 10 days after multiple dosing developed significantly more adult intestinal worms after challenge than any other group. These worms were, however, significantly shorter than those that developed in any group of pigs. Adult worms from all these groups produced eggs that after embryonation were infective to mice.

Effect of age on homovanillic and 4-hydroxy-3-methoxymandelic acid levels in plasma

The plasma levels of homovanillic and 4-hydroxy-3-methoxymandelic acids have been determined in 524 normal subjects ranging from birth to 49 years of age using a mass fragmentographic method. The mean concentration of homovanillic acid in plasma declines exponentially from the age of 1 day (X = 2342.0 nmol/l, 426.6 ng/ml) to adulthood (X = 60 nmol/l, 10.9 ng/ml). 4-Hydroxy-3-methoxymandelic acid behaves in a similar although not so extreme manner (392 nmol/l, 77.6 ng/ml-50 nmol/l, 10 ng/ml).

Variations in sheep serum conglutinating and haemolytic activity for sheep erythrocytes sensitized by rabbit antibody

Based on conglutinating and haemolytic reactions with sheep erythrocytes (E) sensitized by rabbit antibody (A), three types of sheep sera were encountered. Type 1 sera do not conglutinate or haemolyse sheep E-rabbit A. Type 2 sera failed to conglutinate or haemolytically active. Type 3 sera have both activities. Serum from one type 1 sheep still failed to conglutinate 5 days after venepuncture but was not haemolytically active (i.e., type 2). Some sheep that initially had type 2 sera had, five days after an intraperitoneal injection of yeast cells, sera with conglutinating activity (type 3 sera). Type 1, 2 and 3 sera all had haemolytic activity with human E-sheep A indicator cells. Pooled type 3 sera have the highest conglutinating titres with sheep E-rabbit A after 10 min incubation at 39 degrees C. At this stage, the haemolytic titres were very low. From 10 min, the conglutinating titres decreased whereas the haemolytic titres gradually increased until 80 min. Optimal conglutinating activity required less rabbit A to sensitize sheep E than did haemolytic activity.

Inhibitory activity of heated ewe serum for ewe and ram serum complement

In the presence of an indicator antigen-antibody complex, the complement (C) activity in ewe and ram serum was reduced or abolished by addition of ewe serum that had been heated at 56 degrees C for 10 minutes. Pre-incubation of heated ewe serum at 39 degrees C for 30 minutes with the C source prior to addition of the indicator system or addition at the same time caused similar reductions in C activity. Results from the haemolytic, conglutinating and haemagglutinating activities studied indicate that the ewe serum inhibitor(s) reacts with activated classical or alternative activating pathway components and/or the third component of C (C3). The presence of a potent C inhibitor(s) in ewe serum probably accounts for the low sheep C titres with some assay systems. As the heated ewe serum did not appear to activate ewe or ram C per se, it is more appropriate to regard it as 'inhibitory' rather than 'anticomplementary'.

Conglutination and haemolysis of unsensitized human erythrocytes by bovine serum complement

Unsensitized human erythrocytes (E) were haemolyzed by bovine serum to a titre of 1:16-1:32. In the single dilution beyond the haemolytic endpoint, the cells were conglutinated. In dilutions in which haemolysis occurred, cells were conglutinated before being lyzed. With no or minimal haemolysis, conglutination to 1:32-1:64 occurred in tests using insulin-absorbed serum, serum heated at 50 degrees C for 30 min and in tests incubated at 4 degrees C for 30 min. In two-stage tests, EDTA and Mg2+-EGTA prevented bovine C sensitization of human E for conglutination by bovine serum heated at 56 degrees C for 30 min. EDTA prevented haemolysis, but haemolysis to 1:16-1:32 occurred with serum dilutions containing Mg2+-EGTA. Haemolytic activity was restored to serum heated at 50 degrees C by a factor B-containing fraction. Conglutination and haemolysis were blocked by heating serum at 56 degrees C for 30 min and were reduced to low titres by absorbing serum with zymosan. These results strongly suggest that the conglutination reaction involved the classical activation pathway whereas the haemolytic reaction involved the alternative activation pathway. Thus, with dilutions of untreated or treated bovine serum, two C-dependent reactions and the pathways involved can be demonstrated by using unsensitized human E as an indicator system.

Alternative pathway activation of complement in fetal lamb serum by Trichostrongylus vitrinus larvae

Fetal lamb serum (FLS) complement activated by incubation with Trichostrongylus vitrinus larvae was deposited on the larval surface and its presence was demonstrated by leucocyte and erythrocyte adherence reactions and by analysis of antisera from guinea-pig immunized with the larvae. The complement activation proceeded in the apparent absence of antibody and in the presence of ethylene glycol tetracetic acid (EGTA) or Mg++-EGTA but not ethylenediamine tetracetic acid (EDTA). FLS heated to 50 degrees C for 30 min was inactive, but activity was restored by addition of FLS factor B alone or factor B plus Mg++-EGTA. FLS treated with zymosan or inulin was inactive. These results suggest that this non-immune activation of sheep complement by T. vitrinus takes place via the alternative pathway.

Haemolysis of human erythrocytes heavily sensitized with sheep amboceptor by sheep complement chelated with EGTA or Mg2+-EGTA

Human erythrocytes sensitized with an agglutinating dose of either sheep anti-human erythrocyte antiserum, IgM, slow or fast gamma-globulin antibody are haemolysed by foetal lamb or sheep serum complement (C) in the presence of ethyleneglycoltetraacetic acid (EGTA) or Mg2+-EGTA but not ethylenediaminetetraacetic acid (EDTA) or triethylenetetraminehexaacetic acid (TTHA). Dialysis of the C source against phosphate buffered saline rendered it inactive, but addition of Mg2+ or Mg2+-EGTA restored haemolytic activity. Haemolysis of sensitized erythrocytes took place more rapidly in buffer containing Ca2+ and Mg2+ than in EGTA or Mg2+-EGTA. Heating the C source at 50 degrees C for 30 min or 56 degree C for 3 min abolished haemolytic activity. In the presence of EGTA or Mg2+-EGTA, haemolytic activity was restored to 50 degrees C-heated serum by a CM-cellulose fraction that contained sheep factor B. These results show that sheep C, in the presence of EGTA or Mg2+-EGTA will haemolyse human erythrocytes heavily sensitized with sheep amboceptor. The alternative pathway of sheep C is thought to be involved.

[Reduction in cardiotoxicity of ionic contrast media used in coronary angiography by added calcium--Clinical study (author's transl)]

In 16 patients with CAD, hemodynamic and electrophysiologic side effects were examined following selective coronary artery injections with Urografin 76%, a commonly used ionic contrast medium. A Millar transducer tipped catheter was placed in the left ventricle for continuous pressure recording also during injections. The unmodified contrast medium decreases peak left ventricular pressure (-22 +/- 8%) and dp/dt max (-27 +/- 13%) markedly at injection. With added calcium (22.5 mEq/l) this cardiodepressive reaction becomes diminished to -15 +/- 7% and -13 +/- 8% respectively with high significance (p < 0.001). This positive effect is even more marked using higher volumes of contrast material for injection. In contrast to animal experiments, calcium did not completely compensate the negative inotropic reaction even in higher concentration (33.75 mEq/l). The marked sinus slowing (-29 +/- 14%)--observed in patients and not influenced by the calcium addition--has an additional effect in the sense of a "negative frequency-inotropism" and is responsible for the residual cardiodepressive reaction. An influence on electrophysiologic side reactions can also be observed with added calcium but only in injections with higher volumes of contrast medium. QT-elongation, T-wave changes are reduced significantly. We did not see any unfavorable reactions caused by added calcium. The cardiodepressive side effects on the contractile force by commonly used ionic contrast media can be reduced by adding calcium in the above-mentioned concentration. This may be helpful when studying high risk patients and using high injection volumes.