Teaching evidence-based complementary and alternative medicine: 3. Asking the questions and identifying the information

Practicing evidence-based complementary and alternative medicine (EBCAM) requires skills in accessing current valid literature on clinical queries. This requires searching a variety of sources within a broad scope of scientific disciplines. This daunting task requires effective skills for accessing information from both print and electronic sources. This paper identifies the progression from question formulation through to searching and acquiring the valid information. In the evolving information age, complementary and alternative medicine (CAM) practitioners require informational databases and knowledge of search terminology. This paper suggests practical strategies for successful database searches in support of EBCAM.

Teaching evidence-based complementary and alternative medicine: 2. A conceptual approach to causation-part 1

One of the most common questions that arise in clinical practice is whether a causal relationship exists between two factors. In order to answer this question three steps need to be taken: First an association needs to be demonstrated between treatment/exposure and effect. Next, the possibility of this association being the result of error needs to be determined. Finally additional evidence to support a cause-and-effect relationship needs to be identified. Part 1 of this two-part paper describes how a complementary and alternative medicine provider goes through the first two steps when confronted with the question of whether silicone breast implants cause arthritis to develop. Also covered are the need for a control group when attempting to establish whether an association exists, the potential for systematic error (bias) or unsystematic error (chance) to distort an association, and the susceptibility of different study designs to systematic error.

Teaching evidence-based complementary and alternative medicine: 2. A conceptual approach to causation-part 2

As noted in Part 1, of this two-part paper, one of the most common questions that arise in clinical practice is whether a causal relationship exists between two factors. In order to answer this question we noted in Part 1 that three steps need to be taken: First an association needs to be demonstrated between treatment/exposure and effect. Next, the possibility of this association being the result of error needs to be determined. Finally, additional evidence to support a cause-and-effect relationship needs to be identified. Part 1 covered the first two steps and now Part 2 describes how a complementary and alternative medicine provider goes through the last step of this process when confronted with the question of whether silicone breast implants cause the development of arthritis. Part 3 examines the importance of answering the following questions: Did the cause precede the effect? How strong was the association observed? Is increasing exposure more likely to lead to disease? Is there evidence from several different studies showing the same association? Does withdrawal of the cause result in loss of the effect? Is there a biologic model that can explain the causal relationship?

Teaching evidence-based complementary and alternative medicine: 1. A learning structure for clinical decision changes

Complementary and alternative medicine (CAM) education is at a crossroads and has been an area of increasing debate. Public use of CAM has risen dramatically since 1997, with initial reports ranging from 30% to a possible 60% in the United States. Much attention has been directed to the education of the public regarding CAM, with respect to efficacy, potential harm, and integration. Far less attention has been paid to the education of CAM practitioners. In the current climate of integrative health settings, CAM practitioners should be trained to interact with conventional physicians, the public, and policy makers in an evidence-based format. In order to create communication effectively, an evidence-based approach may provide the common ground required for all schools of thought.

In vivo and in vitro measurement of tendon strain in the horse

Strains gauges were applied to the superficial flexor tendon, deep flexor tendon, and suspensory ligament of sound adult horses. Maximum tendon strain occurred during full weight bearing while walking, when the forelimb was perpendicular to the group surface. There was decrease in tendon strain with increase in hoof angle for the deep digital flexor, but no change in tendon strain for the superficial digital flexor and suspensory ligament with changing hoof angle. At physiologic rates of strain, tendons were able to withstand large loads without yielding. Load strain curves developed in vitro indicated that during walking, the deep digital flexor was calculated to load to 416.8 kg; the superficial flexor tendon to 362.9 kg; and the suspensory ligament to 172.4 kg. This study shows that in the horse, strain in flexor tendons during walking was in excess of 5%, indicating strains within the visco-elastic range.

In vivo measurement of bone strain in the horse

Strain gauges were successfully bonded in vivo to the cranial, caudal, medial, and lateral aspects of the equine radium and tibia and to the dorsal, palmar, or plantar, medial, the lateral aspects of the metacarpus and metatarsus--all in the mid-diaphyseal region. Various activities were investigated, including walking, trotting or pacing, and standing up from anesthesia. The strain patterns showed that each stride produced a characteristic deformation cycle. The strains were measured and the axial loads were calculated as the horse performed certain activities. The tension band side of each bone was predicted from the results. The tension band sides of the metacarpus and metatarsus were the dorsomedial and dorsolateral aspects; for the radius and tibia, the tension band sides were the cranial and craniolateral aspects, respectively.