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CHS Research News
Vol 19, Issue 1, Winter 2007

Feature Article

CAM Research at CHS:
What can conventional providers learn from alternative approaches to healing?

By Katie Saunders

Complementary and Alternative (CAM) therapies such as massage, chiropractic, and acupuncture are often called “untraditional” or “unorthodox” when compared to “conventional” treatments taught in medical schools. Not only do CAM physical treatments, such as needling, stand in sharp contrast to traditional western offerings, but many CAM practitioners explicitly rely on the powerful healing properties of the patient-provider relationship. CAM therapies generally embody the “whole” person—mind, body, and spirit.

It was precisely these unique elements that appealed to CHS Investigators Dan Cherkin and Karen Sherman, collaborators for the past seven years on CAM-related research primarily related to back pain. Cherkin was initially drawn to the field because of his study in the late 1980s showing that back-pain patients were much more satisfied with care provided by chiropractors than primary care providers. This finding, coupled with the limited effectiveness of conventional treatments for back pain, pointed Cherkin in CAM’s direction. Sherman was also attracted to CAM’s mind-body approach to health and its openness to different ways of thinking about health and healing. Her curiosity made her want to evaluate treatments that might be tried by her friends.

Finding answers for back pain
The two researchers have made their mark on the field, having collaborated on nine randomized trials of CAM therapies. Results from these trials, published in high profile medical journals, indicate that massage and yoga are promising treatments for reducing symptoms and dysfunction resulting from back pain. The jury is still out on the effectiveness of acupuncture for low back pain. Cherkin and Sherman will help resolve this issue when results become available in about a year from their multi-site trial of acupuncture for low back pain. It is the largest acupuncture trial funded to date by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health. Sherman and Cherkin will also soon begin a randomized trial evaluating the effectiveness of massage for stress.

According to Cherkin, the last 10 to 15 years have presented unique opportunities for CAM researchers. Largely due to patient dissatisfaction with conventional medicine, use of CAM therapies for conditions such as back and neck pain, headache, anxiety, allergies, and menopausal symptoms has skyrocketed. For example, in 1997 almost one-third of Americans with a back problem consulted a CAM provider. In Washington state, CAM’s emergence into the mainstream was further propelled by a 1996 law requiring that major insurers provide coverage for alternative therapies such as massage, acupuncture, and naturopathic medicine.

Despite the growing acceptance of CAM, relatively little credible research has evaluated whether the treatments actually work. That’s where Sherman and Cherkin come in. Trained as epidemiologists, these two scientists bring methodologic rigor to CAM research that has sometimes been lacking. Explains Cherkin: “A lot of people view CAM therapies as inherently good or bad. To me, the important questions for both CAM and conventional treatments are: Are they safe, do they work, and, are their benefits worth their costs?”

Sherman adds: “We’re open to the tenets of CAM, while at the same time we’re aware—unlike some CAM researchers—that improvement isn’t always due to the specific treatments. Sometimes people get better on their own or because of the positive expectations they bring into treatment.”

CAM trials present challenges
Designing randomized trials that can determine a treatment’s effectiveness after taking into account factors such as patient expectations and spontaneous improvement represents the biggest challenge faced by the two researchers. “Designing the appropriate treatment protocol and selecting an appropriate control group—this is where we spend huge amounts of time,” says Cherkin.

In brief, CAM researchers are challenged to come up with standardized treatment protocols that make sense to and satisfy practitioners who, as a rule, believe that treatments must be individualized to each patient.

Regarding control groups, in many studies, Sherman and Cherkin’s aim is to try to disentangle improvements due to physiologic effects of the treatments, positive interactions with the provider, and patient expectations that the treatment is going to work.

While Cherkin’s and Sherman’s primary focus to date has been on back pain, they are branching out with an ongoing study of optimal healing in primary care. “I’m very interested in what promotes healing in primary care,” says Cherkin. “I believe that one of the most appealing, and possibly healing, characteristics of many CAM providers is that they are really glad to see you, spend time with you, listen to you, and offer you hope. These things are often in short supply in conventional medical care for chronic problems,” he continues. Cherkin chalks this up to a more biomedical emphasis in conventional medical care and an overloaded primary care system that is not always conducive to healing.

“The conditions in primary care settings, throughout the U.S. and Europe, have become very stressful in recent years,” he says. “This reality does not provide an optimal healing environment for patients.” “Before we can substantially improve patient care, we need to attend to the physicians’ and nursing staff’s own needs for healing,” he continues.

To that end, Cherkin, Sherman and colleagues developed an intervention aimed at primary care teams, figuring that this would ultimately benefit patients. The researchers trained providers and nursing staff at two Group Health clinics in mindfulness techniques to increase awareness of themselves and others, including colleagues and patients. They also learned communication skills, partly to ensure that the patients’ major underlying concerns were identified, even those that aren’t mentioned first or at all. Finally, the intervention targeted team-building.

“Typically, primary care teams have had no training or time to develop into fully effective and efficient teams,” says Cherkin. “They don’t have time to talk about how they can work together because they’re too busy trying to stay on schedule. They often are unable to benefit from the efficiencies and support that can come from a well-functioning team.” To help remedy this, the project is paying for substitute providers and nursing staff to allow team members time away from their hectic practices so they can talk, reflect, and plan together, says Cherkin.

Discussion of optimal healing eventually segued into a discussion of the future of Cherkin’s and Sherman’s research. Both think big. They don’t focus on specific CAM treatments but rather on exploring the benefits for primary care teams and patients of a more holistic mind-body-spirit approach to health care. “Health care exists within a larger cultural context. It’s hard to change any single component of a culture such as health care, unless there are broader cultural changes that will support and sustain these changes,” says Cherkin.

(For more historical information on CAM research at CHS, see Off Line Summer 2001).

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