The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease. —Thomas Edison

How often does your doctor ask you about stressors in your life and how they influence your breathing? When was the last time you were prescribed a meditation routine? Likely rarely, if ever. But more patients use Complementary and Alternative Medicine (CAM), and doctors are increasingly integrating CAM with traditional practices.

CAM is, by definition, distinct from conventional medical practice. Acupuncture, yoga, meditation, Ayurveda, hypnosis, Reiki, herbal medicine, and nutrition are all examples of healing arts categorized as CAM and not included in traditional medical training. These practices have historically been separated from the allopathic tradition by a lack of scientifically rigorous evidence for their effectiveness. Many treatments are individualized and vary based on the practitioner, and randomized control trials rely upon standardization of practice.

In conducting CAM research, challenging questions arise, such as: How can we standardize meditation? What does the control group in the study do? How can we make the study blinded, such that participants don’t know if they’re in the control or treatment group? In the absence of research, Integrative Medicine doctors with knowledge of meditation and yogic breathing can teach their patients to practice these techniques on faith, but they aren’t reimbursed for their time. Other doctors may be comfortable allowing interested patients to pursue CAM, especially those for whom other options have been exhausted, knowing little harm can come from trying many of these treatments. Only recently has the medical community begun to consider CAM effective.

Proposed models and research findings on the effects of CAM point to their ability to influence the mind. In a trial of women undergoing In Vitro Fertilization (IVF), those who received an acupuncture regimen had lower perceived stress before and after embryo transfer, and decreased stress from baseline was associated with higher pregnancy rates compared to those without a decrease. The authors suggest that the relaxation response may lead to vasodilation, improving pregnancy rates by increasing uterine perfusion. A particularly compelling theory offered in this Medical Hypotheses journal article suggests that yogic breathing may reverse the body’s stress response by stimulating the vagus nerve, the parasympathetic nervous system’s main conduit from the brain to the heart. Proponents of this model explain that breath is influenced by emotional state, and emotional state is influenced by breath:

The fact that breathing is the only autonomic function that can easily be voluntarily controlled provides a portal through which specific selected breathing patterns can be used to send messages… to affect how the brain perceives, interprets, and responds to stress or threat. (Streeter et al.)

Decreasing stress in the body involves a change in both an emotional and physiological state, with implications for perceived health and medical outcomes. Acupuncture and yoga are two techniques that may decrease the body’s stress response; there are many others activities that may have a similar impact. Both papers mentioned above describe the value of incorporating stress reduction techniques into clinical care, noting that successful treatment of certain cases of stress-related disorders requires correction of nervous system activity, which may be done using CAM.

More than proving the effectiveness of specific CAM therapies, CAM research is providing insights into how the mind influences physical health and the role of physicians as healers. The mind-body connection is described by Dr. Bernard Lown in The Lost Art of Healing: Practicing Compassion in Medicine. While practicing cardiology at what was then the Peter Bent Brigham Hospital in Boston, Lown noticed first-hand how his patients’ levels of stress influenced their clinical outcomes. Inspired by these observations, he embarked on a clinical research trial of nervous activity and ventricular fibrillation. Using dogs as subjects, Lown placed one group in a calm setting and another in a stressful setting, which induced rapid heart rate, high blood pressure, and restlessness. He writes, “These findings demonstrated for the first time that psychological stress can substantially increase the cardiac susceptibility to potentially malignant cardiac arrhythmias.”

Lown went on to study the role of the parasympathetic nervous system and the vagus nerve during psychological stress. After five years of study he concluded that “vagus activity diminishes or entirely annuls sympathetic, neurally mediated emotional arousal, thereby protecting against sudden cardiac death.” The concept that the mind-body could provoke cardiac malfunctioning in the absence of structural abnormalities—and that this could lead to death— was revolutionary. Still, for practitioners, the art of lessening potentially negative nervous activity in the presence of stressors remains a challenge.

Lown’s findings corroborated his own clinical experiences with patients at the Brigham, where he had learned that healing required listening to patients—seeing in their words and body language the true source of their problems. They also provided scientific evidence for a belief stated four centuries prior by Dr. William Harvey, the discoverer of blood circulation. In 1628 Harvey stated:

Every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart.

This is a statement cardiologists continue to refer to today.

Further research followed Dr. Lown’s: behavioral cardiologists have identified the biobehavioral pathways leading from chronic psychological stressors to cardiovascular disease; depression, anxiety, and hopelessness are together now considered risk factors for cardiovascular disease. We also know now that chronic stress influences the physiology of the whole body; a chronic stress response promotes systemic inflammation and coagulation, along with poor lifestyle habits (like nutrient-poor diet and smoking) that lead to further bodily harm. What remains uncertain is how to decrease stress—and perceived distress—in patients. If we focus just on treating the symptoms, we miss the root cause. But the pathophysiology is considered easier to see and make sense of: cardiovascular disease can be observed, measured, and treated; a stressful job and home life goes beyond the doctor’s expertise.

Many CAM treatments come from traditions that view patients holistically as body, mind, and spirit, and respond to patients’ health complaints with treatments that address each of these aspects of a person. Practitioners speak a different language and have a different set of tools for responding to physical ailments. Chinese medicine describes how life-energy or “qi” flows through the body on a path called the meridian system. Physical complaints are due to blockages in these pathways, which can be released through physical touch at particular points along the path, reestablishing flow. Practices like acupuncture and Jin Shin Jyutsu are based in this conception of the body. These treatments vary based on the practitioner; they involve human touch, conversations with the patient beforehand, listening to pulses, and the careful laying on of hands; they require the patient to pause and rest. Piecing apart the role of each component in influencing patient health remains a challenge.

As we begin to adopt CAM practices in Western medicine, we are finding ways of translating their language and traditions into our own. We are still treating the patient’s body, but may realize that effective treatment of the body requires paying attention to mental health. We may recommend standard deep breathing exercises for stress relief as we understand that it stimulates the vagus nerve and the parasympathetic nervous system. Many of the medications we prescribe are derived from Chinese herbs, as those cited in this Dana Farber Cancer Institute post, which we have tested and standardized in laboratories. We call hypnosis “guided imagery” and may use it to focus patients’ minds elsewhere when they are experiencing pain. Treatments that are cost-effective and have minimal to no side effects are not “complementary” or “alternative”—they’re simply powerful treatments.

With further research, skeptics note that some CAM practices may be found to lack physiological underpinnings and may be equivalent to the placebo effect—which is still healing, but not up to the standard that the allopathic tradition holds itself to. Despite this, it’s worth examining the fact that over the years, many standard practices in medicine have similarly been found not to be scientifically sound. In a review of original articles published from 2001 to 2010 in the widely-respected medical journal The Mayo Clinic Proceedings, researchers found that of those articles testing standard of care, 40.2% reversed that practice. Further on the subject of medical reversals, in “Reversals of Established Medical Practices: Evidence to Abandon Ship” (in The Journal of the American Medical Association), doctors Vinay Prasad, Adam Cifu, and John PA Ioannidis write:

How many established standards of medical care are wrong? It is not known. Medical practice has evolved out of centuries of theorizing, personal experiences, bits of evidence, expert consensus, and diverse conflicts and biases. Rigorous questioning of long-established practices is difficult. There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence.

The authors site vertebroplasty as an example of unnecessary medical care:

 Vertebroplasty—the injection of polymethylmethacrylate cement into fractured bone—gained popularity in the early 2000s for the treatment of osteoporotic fractures. Initial studies addressed the pathophysiology of this therapy, delineated the technical skills required to optimally perform the procedure, and furthered the discussion about the benefits of vertebroplasty. Claims of benefit were strongly contradicted in two randomized trials that included a sham procedure, which alone might have been responsible for pain relief… it is difficult to justify performing invasive, expensive operations simply to obtain placebo effects.

As cited in these studies, effective treatments and sham procedures can be found in Eastern and Western healing traditions; there is an art and a science to both traditions.

The truth of the matter is there isn’t solid evidence for much of what we do in medicine, and we mostly treat symptoms rather than the causes of disease. We say, “You are sad because you are depressed,” or “you feel sick because you have cancer”— but depression and cancer define a set of symptoms, they don’t give a cause. To rigorously treat the causes of disease requires looking deeper into the sources and mediators of physiological stressors, understanding patients as part of complex systems.

Further Reading:

Image credit: Thunderchild7 via flickr