Models for the Study of Whole Systems

The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles

RATIONALE

Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two.

METHOD

Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools.

RESULTS

Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients.

CONCLUSIONS

Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine.

Primary health care case management through the lens of complexity: an exploratory study of naturopathic practice using complexity science principles

Background

Advances in systems science creates an opportunity to bring a complexity perspective to health care practices and research. While medical knowledge has greatly progressed using a reductionist and mechanistic philosophy, this approach may be limited in its capacity to manage chronic and complex illness. With its holistic foundation, naturopathy is a primary health profession with a purported alignment with a complexity perspective. As such this pilot study aimed to investigate the application of complexity science principles, strategies, and tools to primary health care using naturopathy as a case study.

Methods

A network mapping and analysis of the naturopathic case management process was conducted. Mind maps were created by naturopathic practitioners to reflect their clinical conceptualisation of a common paper clinical case. These mind maps were inputed into Gephi, a network mapping, exploration, and analysis software. Various layouts of the data were produced, and these were analysed using exploratory data analysis and computational network analysis.

Results

Seven naturopathic practitioners participated in the study. In the combined network mapping, 133 unique elements and 399 links were identified. Obesity, the presenting issue in the case, was centrally located. Along with obesity, other keystone elements included: systemic inflammation, dysbiosis, diet, the liver, and mood. Each element was connected on average to 3.05 other elements, with a degree variation between one and 36. Six communities within the dataset were identified, comprising: the nervous system and mood, gastroinstetinal and dietary factors, systemic inflammation and obesity, the endocrine system and metabolism.

Conclusions

This pilot study demonstrates that it is feasible to apply a complexity science perspective to investigating primary health care case management. This supports a shift to viewing the human organism as a complex adaptive system within primary health care settings, with implications for health care practices that are more cognisant with the treatment of chronic and complex conditions and research opportunities to capture the complex clinical reasoning processes of practitioners.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03585-2.

The Intersection Between Models of Health and How Healing Transpires: A Metaethnographic Synthesis of Complementary Medicine Practitioners' Perceptions

Introduction: This metaethnography provides an interpretative synthesis of complementary medicine (CM) practitioners' perceptions toward their health model and the healing process. CM is commonly described on the basis of its distinction from biomedicine with limited research available on CM practitioners' understanding of what the essence of their practice is and how healing transpires as a result. This is despite the significant patronage of CM and high rates of couse with biomedical services. Materials and Methods: An extensive and systematic search of the literature was conducted across seven databases (AMED, SINAHL, Medline, PsycINFO, PUBMED, Science Direct, and Scopus) with no date, language, or region restrictions applied. The basis for the search was MeSH terms and keywords relating to (1) CM practitioners, (2) perceptions, and (3) healing. A screening process was conducted and articles were identified for inclusion based on their addressing the research question. These articles were then quality appraised. A seven-stage metaethnographic framework was utilized to assist with identifying and interpreting the themes within the data. Results: Following the screening process, merely 10 qualitative studies were identified, which represented practitioner views across 22 CM professions. CM practitioners believe they provide a distinct model of care informed by a traditional shared holistic and vitalistic philosophy. Nonspecific factors, such as an augmented therapeutic relationship, empathy, and patient empowerment, are actively and deliberately incorporated into the treatment process alongside specific interventions and afforded equal valued. Conclusions: This metaethnographic synthesis brings together the perceptions of CM practitioners on how healing transpires within the CM clinical setting. In a context of medical pluralism and aspirational integrative health care, this synthesis highlights the understanding and approach CM practitioners bring to health management and may assist in further defining CM philosophy and practice, and the positioning of CM in the contemporary health care landscape.

Clinician perspectives and understanding of the adaptogenic concept: A focus group study with Naturopaths and Western Herbalists

Background

Herbal adaptogens are plant medicines which have traditional associations with herbal ‘tonics’ and promote homeostasis and non-specifically increase resistance to stress. Current definitions of adaptogens have been derived from extensive laboratory research, however there has not been sufficient clinical data for the concept to be standardised by regulatory bodies in Europe or Australia, nor is there clarity around how adaptogens are used and understood by herbalist clinicians themselves. This study aimed to identify how Australian Naturopaths measure adaptogenic activity relative to the clinical outcomes they aim to achieve.

Methods

A qualitative methodology was implemented using focus groups and thematic analysis.

Results

Three focus groups were conducted with a total of 17 Naturopaths with a Bachelor degree or higher qualification and over five years clinical experience. Three core themes were identified: ambiguous cultural origins with divergent perceptions on sources of knowledge about adaptogens; raising vitality and having a restorative effect, and intersystem activity. Within these three central themes, a number of sub-themes were identified.

Conclusions

Naturopathic clinicians utilise both subjective and objective measures of vitalistic signs across multiple body systems; however, the current available research may not accurately reflect expert clinician understanding and use of adaptogens. The study opens pathways to developing novel approaches to measuring adaptogenic activity which may facilitate the process of international standardisation of the adaptogenic concept for the development of well-designed clinical studies.

Experimental Studies of Inter-Rater Agreement in Traditional Chinese Medicine: A Systematic Review

Objectives: It has been recommended that clinical trials of Traditional Chinese Medicine (TCM) would be more ecologically valid if its characteristic mode of diagnostic reasoning were integrated into their design. In that context, however, it is also widely held that demonstrating a high level of agreement on initial TCM diagnoses is necessary for the replicability that the biomedical paradigm requires for the conclusions from such trials. Our aim was to review, summarize, and critique quantitative experimental studies of inter-rater agreement in TCM, and some of their underlying assumptions. Design: Systematic electronic searches were conducted for articles that reported a quantitative measure of inter-rater agreement across a number of rating choices based on examinations of human subjects in person by TCM practitioners, and published in English language peer-reviewed journals. Publications in languages other than English were not included, nor those appearing in other than peer-reviewed journals. Predefined categories of information were extracted from full texts by two investigators working independently. Each article was scored for methodological quality. Outcome measures: Design features across all studies and levels of inter-rater agreement across studies that reported the same type of outcome statistic were compared. Results: Twenty-one articles met inclusion criteria. Fourteen assessed inter-rater agreement on TCM diagnoses, two on diagnostic signs found upon traditional TCM examination, and five on novel rating schemes derived from TCM theory and practice. Raters were students of TCM colleges or graduates of TCM training programs with 3 or more years experience and licensure. Type of outcome statistic varied. Mean rates of pairwise agreement averaged 57% (median 65, range 19-96) across the 9 studies reporting them. Mean Cohen's kappa averaged 0.34 (median 0.34, range 0.07-0.59) across the seven studies reporting them. Meta-analysis was not possible due to variations in study design and outcome statistics. High risks of bias and confounding, and deficits in statistical reporting were common. Conclusions: With a few exceptions, the levels of agreement were low to moderate. Most studies had significant deficits of both methodology and reporting. Results overall suggest a few design features that might contribute to higher levels of agreement. These should be studied further with better experimental controls and more thorough reporting of outcomes. In addition, methods of complex systems analysis should be explored to more adequately model the relationship between clinical outcomes, and the series of diagnoses and treatments that are the norm in actual TCM practice.

Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain

OBJECTIVES

The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings.

DESIGN

Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment.

METHODS

Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas.

RESULTS

Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks.

CONCLUSIONS

In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.

Whole Systems Research Methods in Health Care: A Scoping Review

Objectives: This scoping review evaluates two decades of methodological advances made by “whole systems research” (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of “model validity,” representing a “fit” between research design and therapeutic paradigm.

Design: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment.

Results: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to “dual” (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with “usual care” comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre–post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes.

Conclusions: Aligned with trends emphasizing “fit-for-purpose” research designs to study the “real-world” effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.

Treating the patient not the symptoms: Acupuncture to improve overall health - Evidence, acceptance and strategies

Documented mechanisms of acupuncture suggest the possibility of whole body effects in addition to local and regional effects. Traditional theories of acupuncture predict whole body effects. Does this permit the possibility of applying treatment to target overall health improvement of the patient rather than the symptom? After introducing the term 'health improvement' this paper explores situations where it might be advantageous to do this, giving examples of how health authorities in some countries have proposed broader treatment approaches that focus on health improvement. It also discusses cases where acupuncture has been recommended as a treatment method in a number of these proposals and gives some clinical examples of this kind of whole body 'health improvement' targeted treatment effects. Given that health authorities have already recognised this potential for the application of acupuncture the author then explores evidence of more whole-body 'health improvement' effects from systematic reviews and examples of health experts recommending acupuncture to take advantage of them. Research strategies and foci are then proposed and explored to develop this evidence. What are the best treatment approaches to create these effects? By what mechanisms can 'health improvement' be produced? How can one measure these effects? It is likely that treatments based on 'pattern identification' (PI) may provide the best strategies for producing 'health improvement', thus PI-based acupuncture treatments are likely to be the best strategy for clinical research investigating these effects.

Lessons from Outside and Within: Exploring Advancements in Methodology for Naturopathic Medicine Clinical Research

INTRODUCTION

Naturopathy is a mixture of both traditional and complementary medicine. It incorporates a broad set of health care practices that may or may not be traditional to that country or conventional medicine and are not fully integrated into the dominant health care system. Research required to evaluate or substantiate naturopathic medicine may not fall under the testing of randomized clinical trials, which opens up discussions on what is the best practice for research in naturopathic medicine.

DISCUSSION

Not only do advances in health research methodology offer important opportunities to progress naturopathic research, there are also areas where the unique characteristics of naturopathic philosophy and practice can impact other areas of health research. Some of the new advances in health research methodology involve whole-system research, pragmatic trials, template for intervention description and replication protocols for complex interventions, patient-centered care models, and the pragmatic-explanatory continuum indicator summary tool for designing pragmatic trials. Discussion and critique of these health-related methodologies shows that these research methods are more suited for the philosophy and treatment options that naturopathy is based on.

CONCLUSIONS

Successful implementation of naturopathic research methodologies, and translation and dissemination of research will require a substantial paradigm shift in which naturopathic practitioners adopt a greater level of responsibility for developing an evidence base for naturopathic medicine.

Research methods in complementary and alternative medicine: an integrative review

The scientific literature presents a modest amount of evidence in the use of complementary and alternative medicine (CAM). On the other hand, in practice, relevant results are common. The debates among CAM practitioners about the quality and execution of scientific research are important. Therefore, the aim of this review is to gather, synthesize and describe the differentiated methodological models that encompass the complexity of therapeutic interventions. The process of bringing evidence-based medicine into clinical practice in CAM is essential for the growth and strengthening of complementary medicines worldwide.

Measuring patient reported outcomes of acupuncture treatment on pain patients' health status

OBJECTIVES

The primary aim of this observational multicenter case series study was to assess patient reported outcome measures of health status following routine acupuncture treatment.

DESIGN

Via the patient reported 'MYMOP2-online' questionnaire 110 pain patients reported three times (baseline, after four weeks, after sixteen weeks) whether changes in health status occurred following un-standardized routine acupuncture treatment.

RESULTS

ANOVA for repeated measures showed that primary pain (-38.8%), secondary pain (-38.4%), limitation to daily functioning (-33.2%), subjective well-being (24.2%), and health status (34.0%) significantly improved between zero and four weeks (p < 0.001). The achieved health benefits persisted over the long term (sixteen weeks). Pain medication usage decreased by 44.5% in four weeks. The changes in health status could not be related to specific aspects of acupuncture treatment.

CONCLUSION

In this observational study pain patients self-reported a statistically significant and clinically relevant long-term improvement in health status following acupuncture treatments in routine practice.

Whole Medical Systems versus the System of Conventional Biomedicine: A Critical, Narrative Review of Similarities, Differences, and Factors That Promote the Integration Process

BACKGROUND

There is an increasing need for a worldwide professional integration of conventional medicine and traditional/complementary whole medical systems (WMSs). However, the integration is perceived by conventional medicine as problematic or unacceptable, because of a supposed lack of evidence for specific effects of WMSs therapies and supposed prescientific or unscientific paradigms of WMSs.

OBJECTIVES

To review the literature on the features of WMSs, similarities and differences between conventional medicine and WMSs, and scientific and clinical practice issues that should be dealt with in order to promote the integration process.

METHODS

A critical, narrative review of the literature on six WMSs.

RESULTS AND CONCLUSIONS

Key factors for the integration of WMSs and conventional medicine are as follows: legal frameworks, quality standards, high-quality research on safety and efficacy of WMS interventions, infrastructure, and financial resources. For scientific assessment of WMSs, there are unresolved ontological, epistemological, and methodological issues and issues of diagnostics, therapy delivery, and outcome assessment in clinical practice. Future research not only should be directed at quality assurance and generating the necessary data on safety and efficacy/effectiveness but also should address more fundamental (ontological, epistemological, and methodological) issues, in order to overcome the differences between WMSs and conventional medicine.

An Object-Oriented Regression for Building Disease Predictive Models with Multiallelic HLA Genes

Recent genome-wide association studies confirm that human leukocyte antigen (HLA) genes have the strongest associations with several autoimmune diseases, including type 1 diabetes (T1D), providing an impetus to reduce this genetic association to practice through an HLA-based disease predictive model. However, conventional model-building methods tend to be suboptimal when predictors are highly polymorphic with many rare alleles combined with complex patterns of sequence homology within and between genes. To circumvent this challenge, we describe an alternative methodology; treating complex genotypes of HLA genes as "objects" or "exemplars," one focuses on systemic associations of disease phenotype with "objects" via similarity measurements. Conceptually, this approach assigns disease risks base on complex genotype profiles instead of specific disease-associated genotypes or alleles. Effectively, it transforms large, discrete, and sparse HLA genotypes into a matrix of similarity-based covariates. By the Kernel representative theorem and machine learning techniques, it uses a penalized likelihood method to select disease-associated exemplars in building predictive models. To illustrate this methodology, we apply it to a T1D study with eight HLA genes (HLA-DRB1, HLA-DRB3, HLA-DRB4, HLA-DRB5, HLA-DQA1, HLA-DQB1, HLA-DPA1, and HLA-DPB1) to build a predictive model. The resulted predictive model has an area under curve of 0.92 in the training set, and 0.89 in the validating set, indicating that this methodology is useful to build predictive models with complex HLA genotypes.

Employing observational method for prospective data collection: A case study for analyzing diagnostic process and evaluating efficacy of TCM treatments for diabetes mellitus

ETHNOPHARMACOLOGICAL RELEVANCE

With the mounting pandemic of glucose metabolism dysregulation and type 2 Diabetes Mellitus (T2DM), traditional medicine such as traditional Chinese medicine (TCM) recipes has been widely adopted as a part of therapeutic approach, especially in Asian countries.

AIM OF THE STUDY

A novel approach, which is adopted from cohort studies from epidemiology has been applied to explore the clinical efficacy, as well as the herbal component selection of a variety of TCM formulations against T2DM.

MATERIALS AND METHODS

In the current study, 98 newly diagnosed T2DM patients were recruited in two hospitals. Over a span of 4 weeks, the patients were treated by prescriptions of their individual TCM physicians. General TCM symptoms, blood glucose parameters, as well as general metabolic health biomarkers were evaluated over the therapy period. The pattern of which herbs were used, together with association between blood glucose level change and the use of herbs, were analyzed.

RESULTS

TCM diabetic syndrome diagnosis was made by physicians based on symptoms, who prescribed herbal TCM medication afterwards for individual subjects. The results showed significant reduction in fasting and postmeal glucose levels, as well as insulin after the TCM treatment regimen as compared to baseline. As secondary endpoint, total triglyceride level decreased over the period of study as well. Kudzuvine root, Rhemannia root, Figwoot root, and Mulberry leaf were the top herbs associated with pronounced glucose reduction.

CONCLUSIONS

In conclusion, an observational study on a cohort of patients receiving TCM therapy has shown good clinical outcome for T2DM patients receiving TCM treatments. Association analysis on herbal usage and clinical outcome suggested opportunity in constructing optimized formulation for superior efficacy with future studies at a larger scale.

The effectiveness of ayurvedic oil-based nasal instillation (Nasya) medicines in the treatment of facial paralysis (Ardita): a systematic review

BACKGROUND

Ardita (facial paralysis) is a medical condition that disfigures or distorts the facial appearance of the sufferer causing facial asymmetry and malfunction. Ardita patients may benefit from considering alternative treatments such as Ayurveda, including Taila Nasya (nasal instillation of medicated oil).

OBJECTIVES

To synthesize the best available evidence on the effectiveness of different Nasya oils in the treatment of Ardita.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Studies conducted on adult sufferers (18-70 years) of Ardita (chronic or acute) in any setting were considered. Studies including participants who were pregnant or suffered allergic rhinitis, fever, intracranial tumor/hemorrhage and bilateral facial palsy were excluded.

INTERVENTION(S)/COMPARATOR(S)

Standalone treatment of Nasya (at all dosages and frequencies) compared to Nasya in combination with other Ayurvedic treatments was considered. Comparisons between different interventions including Taila Nasya alone, Taila Nasya in combination with other Ayurvedic interventions and Ayurvedic interventions that did not include Taila Nasya were also considered.

OUTCOMES AND MEASURES

Changes in Ardita symptoms, including facial distortion, speech disorders and facial pain, were measured.

TYPES OF STUDIES

All quantitative study designs (experimental, quasi-experimental and observational) were considered.

SEARCH STRATEGY

Relevant studies were identified following a comprehensive literature search. References provided within these key studies identified additional resources. Indian universities were also contacted for results of Ardita studies undertaken in their institutions.A three-step search strategy aimed to find studies of published and unpublished studies was undertaken. Studies published in the English language were considered for inclusion, irrespective of publication date/year. Following an initial limited search of MEDLINE and CINAHL, the text words contained in the title and abstract, and of the index terms used to describe each articles were analyzed. From the identified keywords and index terms, searches were undertaken across all relevant databases such as PubMed, CINHAL, Cochrane (CENTRAL), Scopus, Centre for Review and Dissemination databases, Turning Research into Practice (TRIP), EMBASE, EBM Reviews, DHARA, Google Scholar, MedNar and ProQuest Dissertations. Finally, reference lists of identified theses and articles were searched for additional studies. Universities and website operators related to Ayurvedic research in India were contacted, including the National Institute of Ayurveda for relevant studies. Besides this, the University of Adelaide librarian was contacted to retrieve those studies identified in the reference lists of theses and articles.

METHODOLOGICAL QUALITY

Studies were critically assessed by the review author and a secondary reviewer prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute.

DATA EXTRACTION

Data was extracted by the primary reviewer using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

Different interventions and comparators across studies precluded meta-analysis. Narrative synthesis was performed.

RESULTS

Only two pseudo randomized studies with a small number of participants met inclusion criteria and were included in the review. One study with 20 participants, divided equally into two groups compared the effectiveness of two nasal instillations in alleviating four Ardita symptoms. The second study of 15 participants each in two groups compared the effectiveness of nasal instillation with placement of medicated oil on the head on seven Ardita symptoms. Observational measurements of Ardita symptoms were graded as Mild, Moderate or Marked at baseline and after one month. The study conducted on 30 participants using Nasya intervention showed participants had better relief from the symptoms of facial pain, speech disorder and earache within the range of 78.2% to 90.9%, graded as Marked. Along with statistical data available in the studies, this review found low levels of evidence favoring Taila Nasya intervention. The review did not include any studies examining effectiveness of Nasya compared to conventional treatment for Ardita.

CONCLUSIONS

This review presents extremely limited evidence from only two small experimental studies that administration of Nasya oil alone may provide some relief from Ardita symptoms of facial distortion, speech disorder, inability to shut eyelids/upward eye rolling and dribbling of saliva in adult patients. No strong conclusions may be drawn from the evidence included in the review due to the limited number of studies, limited number of participants and poor quality of studies.

IMPLICATIONS FOR PRACTICE

Practitioners should advice Ardita patients that there is extremely limited evidence suggesting the potential effectiveness of Nasya oils alone or Nasya in conjunction with other Ayurvedic treatments in managing symptoms. However, given the absence of a strong evidence base, practitioners should be guided by clinical wisdom and patient preference.

IMPLICATIONS FOR RESEARCH

Well controlled clinical trials comparing standalone Nasya therapy to other Ayurvedic treatments and/or conventional medicine for Ardita symptoms need to be conducted to examine the relative effectiveness of different Nasya oils in treating Ardita.

Patients' Experiences and Perceptions of a Consultative Model Integrative Medicine Clinic: A Qualitative Study

Objective: A common theme in integrative medicine (IM) is patient-centered partnering in care between patients and providers. Despite the stated ideals, few studies have assessed patients' perspectives on their actual experience in the context of a specific care model. The purpose of the present study was to retrospectively explore and compare experiences of cancer and noncancer patients under care in a consultative IM outpatient teaching clinic in the south-western United States. Design: Qualitative study using inductive content analysis of focus group interview transcripts (2 groups of adult patients with cancers of various types and 1 group of chronically ill noncancer patients with mixed diagnoses). Method: Participants were recruited by random selection from a pool of eligible patients. Groups were conducted with patients who had completed their initial conventional cancer treatment and were at least 6 months postconsultation with an IM clinic physician. Transcripts of the audiotaped focus groups were analyzed. Results: Cancer patients (n = 15) and noncancer patients (n = 6) (mean age, 60 years; 77% women) expressed overall satisfaction with IM, emphasizing (1) expansion of treatment options with lower perceived toxicity than conventional therapies, (2) positive experiences of the IM physician as caring and taking time to listen, and (3) improved self-care skills and sense of empowerment. Cancer patients noted positive relationships with their conventional MDs more than did noncancer patients, although both groups appreciated the IM physicians' communication styles. Conclusion: Patients experience a consultative integrative clinic model overall as favorable. The impact on outcomes, costs, and long-term quality of life requires additional study.

Low protein diets in patients with chronic kidney disease: a bridge between mainstream and complementary-alternative medicines?

Dietary therapy represents an important tool in the management of chronic kidney disease (CKD), mainly through a balanced reduction of protein intake aimed at giving the remnant nephrons in damaged kidneys a "functional rest". While dialysis, transplantation, and pharmacological therapies are usually seen as "high tech" medicine, non pharmacological interventions, including diets, are frequently considered lifestyle-complementary treatments. Diet is one of the oldest CKD treatments, and it is usually considered a part of "mainstream" management. In this narrative review we discuss how the lessons of complementary alternative medicines (CAMs) can be useful for the implementation and study of low-protein diets in CKD. While high tech medicine is mainly prescriptive, prescribing a "good" life-style change is usually not enough and comprehensive counselling is required; the empathic educational approach, on which CAMs are mainly, though not exclusively based, may support a successful personalized nutritional intervention.There is no gold-standard, low-protein diet for all CKD patients: from among a relatively vast choice, the best compliance is probably obtained by personalization. This approach interferes with the traditional RCT-based analyses which are grounded upon an assumption of equal preference of treatments (ideally blinded). Whole system approaches and narrative medicine, that are widely used in the study of CAMs, may offer ways to integrate EBM and personalised medicine in the search for innovative solutions respecting individualization, but gaining sound data, such as with partially-randomised patient preference trials.

The Effect of a Complex Multi-modality Ayurvedic Treatment in a Case of Unknown Female Infertility

BACKGROUND

Treatment of female infertility has been growing globally in recent years. In spite of improvements in medical strategies and the improved outcomes for infertile couples, treatment attempts remain largely unsuccessful. A growing number of patients pursue complementary and alternative medicine treatment options like Ayurveda that offers a variety of inpatient and outpatient treatments for infertility.

CASE REPORT

A case of a 38 year-old woman with infertility of unknown origin is presented. She received 18 conventional fertility treatments in 5 different fertility centers and 3 different countries. After several complications, the patient quitted conventional treatment and admitted to an Ayurvedic outpatient clinic where she received a complex Ayurvedic treatment, which included botanicals, dietary and lifestyle advice, manual therapy, yoga, and spiritual elements. The patient then became pregnant and gave birth to a healthy boy in 2012.

CONCLUSIONS

Ayurveda may be a useful complementary option in the case of futile conventional treatment attempts in female infertility. Nevertheless, the evidence base for Ayurvedic interventions remains weak and requires well-designed clinical trials. This case raises some questions, such as whether the exposure to a large number of assisted reproduction procedures can lead to more health problems than health benefits. The Ayurvedic approach to fertility strives first to improve the health of the patient leading to a higher likelihood of pregnancy. As this is a case report, we are not able to exclude temporal factors stimulating the pregnancy. However, the chronology suggests that this approach might have been an important factor in the eventual pregnancy.

Can Yin-Yang Guide Chinese Indigenous Management Research?

In this article, I argue that it is misleading to dichotomize the West as being either/or and the East as being both/and. The West has thought dialectically since ancient Greece. I offer a typology to compare and contrast three dialectical or non-either/or logical systems or ways of thinking: Chinese Yin-Yang philosophy, Hegel's dialectic, and Niels Bohr's complementarity principle, as well as Aristotle's formal (either/or) logic. I show that the four logical systems have differences and similarities and show that Westerners can and do think dialectically. I also argue that Chinese Yin-Yang philosophy, while useful and powerful in some situations, is not always superior to the other logical systems and philosophies. My purpose is to alert Chinese management scholars to the dangers of overconfidence and to stimulate discussion and debate on the true value of Yin-Yang in particular and the promotion of Chinese indigenous management research in general. To that end, I present my opinion on the merits and drawbacks of Yin-Yang and posit that it may inspire but cannot guide Chinese indigenous management research because Chinese philosophy lacks a well-defined methodology and operationalizable methods.

Homeopathic medications as clinical alternatives for symptomatic care of acute otitis media and upper respiratory infections in children

The public health and individual risks of inappropriate antibiotic prescribing and conventional over-the-counter symptomatic drugs in pediatric treatment of acute otitis media (AOM) and upper respiratory infections (URIs) are significant. Clinical research suggests that over-the-counter homeopathic medicines offer pragmatic treatment alternatives to conventional drugs for symptom relief in children with uncomplicated AOM or URIs. Homeopathy is a controversial but demonstrably safe and effective 200-year-old whole system of complementary and alternative medicine used worldwide. Numerous clinical studies demonstrate that homeopathy accelerates early symptom relief in acute illnesses at much lower risk than conventional drug approaches. Evidence-based advantages for homeopathy include lower antibiotic fill rates during watchful waiting in otitis media, fewer and less serious side effects, absence of drug-drug interactions, and reduced parental sick leave from work. Emerging evidence from basic and preclinical science research counter the skeptics' claims that homeopathic remedies are biologically inert placebos. Consumers already accept and use homeopathic medicines for self care, as evidenced by annual US consumer expenditures of $2.9 billion on homeopathic remedies. Homeopathy appears equivalent to and safer than conventional standard care in comparative effectiveness trials, but additional well-designed efficacy trials are indicated. Nonetheless, the existing research evidence on safety supports pragmatic use of homeopathy in order to “first do no harm” in the early symptom management of otherwise uncomplicated AOM and URIs in children.

Ayurveda: between religion, spirituality, and medicine

Ayurveda is playing a growing part in Europe. Questions regarding the role of religion and spirituality within Ayurveda are discussed widely. Yet, there is little data on the influence of religious and spiritual aspects on its European diffusion. Methods. A survey was conducted with a new questionnaire. It was analysed by calculating frequency variables and testing differences in distributions with the χ (2)-Test. Principal Component Analyses with Varimax Rotation were performed. Results. 140 questionnaires were analysed. Researchers found that individual religious and spiritual backgrounds influence attitudes and expectations towards Ayurveda. Statistical relationships were found between religious/spiritual backgrounds and decisions to offer/access Ayurveda. Accessing Ayurveda did not exclude the simultaneous use of modern medicine and CAM. From the majority's perspective Ayurveda is simultaneously a science, medicine, and a spiritual approach. Conclusion. Ayurveda seems to be able to satisfy the individual needs of therapists and patients, despite worldview differences. Ayurvedic concepts are based on anthropologic assumptions including different levels of existence in healing approaches. Thereby, Ayurveda can be seen in accordance with the prerequisites for a Whole Medical System. As a result of this, intimate and individual therapist-patient relationships can emerge. Larger surveys involving bigger participant numbers with fully validated questionnaires are warranted to support these results.

When a whole practice model is the intervention: developing fidelity evaluation components using program theory-driven science for an integrative medicine primary care clinic

Integrative medicine (IM) is a clinical paradigm of whole person healthcare that combines appropriate conventional and complementary medicine (CM) treatments. Studies of integrative healthcare systems and theory-driven evaluations of IM practice models need to be undertaken. Two health services research methods can strengthen the validity of IM healthcare studies, practice theory, and fidelity evaluation. The University of Arizona Integrative Health Center (UAIHC) is a membership-supported integrative primary care clinic in Phoenix, AZ. A comparative effectiveness evaluation is being conducted to assess its clinical and cost outcomes. A process evaluation of the clinic's practice theory components assesses model fidelity for four purposes: (1) as a measure of intervention integrity to determine whether the practice model was delivered as intended; (2) to describe an integrative primary care clinic model as it is being developed and refined; (3) as potential covariates in the outcomes analyses, to assist in interpretation of findings, and for external validity and replication; and (4) to provide feedback for needed corrections and improvements of clinic operations over time. This paper provides a rationale for the use of practice theory and fidelity evaluation in studies of integrative practices and describes the approach and protocol used in fidelity evaluation of the UAIHC.

Testing the nanoparticle-allostatic cross-adaptation-sensitization model for homeopathic remedy effects

Key concepts of the Nanoparticle-Allostatic Cross-Adaptation-Sensitization (NPCAS) Model for the action of homeopathic remedies in living systems include source nanoparticles as low level environmental stressors, heterotypic hormesis, cross-adaptation, allostasis (stress response network), time-dependent sensitization with endogenous amplification and bidirectional change, and self-organizing complex adaptive systems. The model accommodates the requirement for measurable physical agents in the remedy (source nanoparticles and/or source adsorbed to silica nanoparticles). Hormetic adaptive responses in the organism, triggered by nanoparticles; bipolar, metaplastic change, dependent on the history of the organism. Clinical matching of the patient's symptom picture, including modalities, to the symptom pattern that the source material can cause (cross-adaptation and cross-sensitization). Evidence for nanoparticle-related quantum macro-entanglement in homeopathic pathogenetic trials. This paper examines research implications of the model, discussing the following hypotheses: Variability in nanoparticle size, morphology, and aggregation affects remedy properties and reproducibility of findings. Homeopathic remedies modulate adaptive allostatic responses, with multiple dynamic short- and long-term effects. Simillimum remedy nanoparticles, as novel mild stressors corresponding to the organism's dysfunction initiate time-dependent cross-sensitization, reversing the direction of dysfunctional reactivity to environmental stressors. The NPCAS model suggests a way forward for systematic research on homeopathy. The central proposition is that homeopathic treatment is a form of nanomedicine acting by modulation of endogenous adaptation and metaplastic amplification processes in the organism to enhance long-term systemic resilience and health.

Yoga experience as a predictor of psychological wellness in women over 45 years

BACKGROUND

Although high levels of subjective well-being (SWB) are common in old age, a subset of older individuals is disproportionately vulnerable to negative affect. Yoga has been shown to have many short-term benefits, but researchers have not determined whether a long-term or frequent yoga practice increasingly protects older women from low levels of psychological well-being.

AIMS

The purpose of this study was to examine the extent to which psychological attitudes, transcendence, mental mastery, and subjective vitality in a sample of female yoga practitioners over 45 years varied according to the length and frequency of yoga practice.

MATERIALS AND METHODS

We administered online surveys to a non-probability sample of 211 female yoga practitioners 45 to 80. We used weighted least squares regression analyses to evaluate the relationship of extent of yoga experience to the outcome variables after accounting for age and lifestyle factors.

RESULTS

Participants had practiced yoga for as long as 50 years and for up to 28 h per week. There were significant positive relationships between yoga experience and all outcome variables. These significant relationships remained after accounting for age and lifestyle factors. When we computed yoga experience in terms of total calendar years, without accounting for hours of practice, significant relationships did not remain. Transcendence of the ordinary was the most strongly associated with current yoga practice frequency, and positive psychological attitudes were the most strongly associated with total lifetime hours of practice.

CONCLUSIONS

Among a non-probability sample of female yoga practitioners between 45 and 80 years, increased yoga experience predicted increased levels of psychological well-being. Results showed a dose-response effect, with yoga experience exercising an increasingly protective effect against low levels of SWB and vitality.

Nonlinear dynamical systems effects of homeopathic remedies on multiscale entropy and correlation dimension of slow wave sleep EEG in young adults with histories of coffee-induced insomnia

BACKGROUND

Investigators of homeopathy have proposed that nonlinear dynamical systems (NDS) and complex systems science offer conceptual and analytic tools for evaluating homeopathic remedy effects. Previous animal studies demonstrate that homeopathic medicines alter delta electroencephalographic (EEG) slow wave sleep. The present study extended findings of remedy-related sleep stage alterations in human subjects by testing the feasibility of using two different NDS analytic approaches to assess remedy effects on human slow wave sleep EEG.

METHODS

Subjects (N=54) were young adult male and female college students with a history of coffee-related insomnia who participated in a larger 4-week study of the polysomnographic effects of homeopathic medicines on home-based all-night sleep recordings. Subjects took one bedtime dose of a homeopathic remedy (Coffea cruda or Nux vomica 30c). We computed multiscale entropy (MSE) and the correlation dimension (Mekler-D2) for stages 3 and 4 slow wave sleep EEG sampled in artifact-free 2-min segments during the first two rapid-eye-movement (REM) cycles for remedy and post-remedy nights, controlling for placebo and post-placebo night effects.

RESULTS

MSE results indicate significant, remedy-specific directional effects, especially later in the night (REM cycle 2) (CC: remedy night increases and post-remedy night decreases in MSE at multiple sites for both stages 3 and 4 in both REM cycles; NV: remedy night decreases and post-remedy night increases, mainly in stage 3 REM cycle 2 MSE). D2 analyses yielded more sporadic and inconsistent findings.

CONCLUSIONS

Homeopathic medicines Coffea cruda and Nux vomica in 30c potencies alter short-term nonlinear dynamic parameters of slow wave sleep EEG in healthy young adults. MSE may provide a more sensitive NDS analytic method than D2 for evaluating homeopathic remedy effects on human sleep EEG patterns.

A complex, nonlinear dynamic systems perspective on Ayurveda and Ayurvedic research

The fields of complexity theory and nonlinear dynamic systems (NDS) are relevant for analyzing the theory and practice of Ayurvedic medicine from a Western scientific perspective. Ayurvedic definitions of health map clearly onto the tenets of both systems and complexity theory and focus primarily on the preservation of organismic equanimity. Health care research informed by NDS and complexity theory would prioritize (1) ascertaining patterns reflected in whole systems as opposed to isolating components; (2) relationships and dynamic interaction rather than static end-points; (3) transitions, change and cumulative effects, consistent with delivery of therapeutic packages in the reality of the clinical setting; and (4) simultaneously exploring both local and global levels of healing phenomena. NDS and complexity theory are useful in examining nonlinear transitions between states of health and illness; the qualitative nature of shifts in health status; and looking at emergent properties and behaviors stemming from interactions between organismic and environmental systems. Complexity and NDS theory also demonstrate promise for enhancing the suitability of research strategies applied to Ayurvedic medicine through utilizing core concepts such as initial conditions, emergent properties, fractal patterns, and critical fluctuations. In the Ayurvedic paradigm, multiple scales and their interactions are addressed simultaneously, necessitating data collection on change patterns that occur on continuums of both time and space, and are viewed as complementary rather than isolated and discrete. Serious consideration of Ayurvedic clinical understandings will necessitate new measurement options that can account for the relevance of both context and environmental factors, in terms of local biology and the processual features of the clinical encounter. Relevant research design issues will need to address clinical tailoring strategies and provide mechanisms for mapping patterns of change that account for the contiguous, self-replicating, cumulative, and synergistic theories associated with successful Ayurvedic treatment approaches.

A model for homeopathic remedy effects: low dose nanoparticles, allostatic cross-adaptation, and time-dependent sensitization in a complex adaptive system

Background

This paper proposes a novel model for homeopathic remedy action on living systems. Research indicates that homeopathic remedies (a) contain measurable source and silica nanoparticles heterogeneously dispersed in colloidal solution; (b) act by modulating biological function of the allostatic stress response network (c) evoke biphasic actions on living systems via organism-dependent adaptive and endogenously amplified effects; (d) improve systemic resilience.

Discussion

The proposed active components of homeopathic remedies are nanoparticles of source substance in water-based colloidal solution, not bulk-form drugs. Nanoparticles have unique biological and physico-chemical properties, including increased catalytic reactivity, protein and DNA adsorption, bioavailability, dose-sparing, electromagnetic, and quantum effects different from bulk-form materials. Trituration and/or liquid succussions during classical remedy preparation create “top-down” nanostructures. Plants can biosynthesize remedy-templated silica nanostructures. Nanoparticles stimulate hormesis, a beneficial low-dose adaptive response. Homeopathic remedies prescribed in low doses spaced intermittently over time act as biological signals that stimulate the organism’s allostatic biological stress response network, evoking nonlinear modulatory, self-organizing change. Potential mechanisms include time-dependent sensitization (TDS), a type of adaptive plasticity/metaplasticity involving progressive amplification of host responses, which reverse direction and oscillate at physiological limits. To mobilize hormesis and TDS, the remedy must be appraised as a salient, but low level, novel threat, stressor, or homeostatic disruption for the whole organism. Silica nanoparticles adsorb remedy source and amplify effects. Properly-timed remedy dosing elicits disease-primed compensatory reversal in direction of maladaptive dynamics of the allostatic network, thus promoting resilience and recovery from disease.

Summary

Homeopathic remedies are proposed as source nanoparticles that mobilize hormesis and time-dependent sensitization via non-pharmacological effects on specific biological adaptive and amplification mechanisms. The nanoparticle nature of remedies would distinguish them from conventional bulk drugs in structure, morphology, and functional properties. Outcomes would depend upon the ability of the organism to respond to the remedy as a novel stressor or heterotypic biological threat, initiating reversals of cumulative, cross-adapted biological maladaptations underlying disease in the allostatic stress response network. Systemic resilience would improve. This model provides a foundation for theory-driven research on the role of nanomaterials in living systems, mechanisms of homeopathic remedy actions and translational uses in nanomedicine.

Multiweek resting EEG cordance change patterns from repeated olfactory activation with two constitutionally salient homeopathic remedies in healthy young adults

OBJECTIVES

Electroencephalography (EEG) offers psychophysiologic tools to improve sensitivity for detecting objective effects in complementary and alternative medicine. This current investigation extended prior clinical research studies to evaluate effects of one of two different homeopathic remedies on resting EEG cordance after an olfactory activation protocol on healthy young adults with remedy-relevant, self-perceived characteristics.

METHODS

Ninety-seven (7) young adults (N=97, mean age 19 years, 55% women) with good self-rated global health and screened for homeopathic constitutional types consistent with one of two remedies (either Sulphur or Pulsatilla) underwent three weekly laboratory sessions. At each visit, subjects had 5-minute resting, eyes-closed EEG recordings before and after a placebo-controlled olfactory activation task with their constitutionally relevant verum remedy. One remedy potency (6c, 12c, or 30c) used per week, was presented in a randomized order over the 3 sessions. Prefrontal resting EEG cordance values at Fp1 and Fp2 were computed from artifact-free 2-minute EEG samples from the presniffing and postsniffing rest periods. Cordance derives from an algorithm that incorporates absolute and relative EEG values.

RESULTS

The data showed significant two-way oscillatory interactions of remedy by time for ß, α, θ, and δ cordance, controlling for gender and chemical sensitivity.

CONCLUSIONS

EEG cordance provided a minimally invasive technique for assessing objective nonlinear physiologic effects of two different homeopathic remedies salient to the individuals who received them. Time factors modulated the direction of effects. Given previous evidence of correlations between cordance and single-photon emission computed tomography, these findings encourage additional neuroimaging research on nonlinear psychophysiologic effects of specific homeopathic remedies.

The healing experience-how can we capture it?

BACKGROUND

The Integrative Medicine (I-MED) Index, designed to be a universal instrument to assess the 5 levels of healing (physical, energetic, emotional, subconscious, spiritual) among individuals who use complementary therapies, is based on the hypothesis of healing (HH), which considers healing as a dynamic process towards wholeness generally following the same steps. When we pilot-tested the instrument, it became clear that the way participants experience healing in their lives was not as the HH suggested. This led us to ask how patients experience healing and what outcomes they identify as key to their journey.

METHODS

In-depth, semistructured interviews were conducted with 35 individuals with previous healing experiences at 2 wellness centers in Vancouver, BC. Qualitative content analysis and thematic coding were used to analyze the data.

ANALYSIS AND RESULTS

Four themes emerged from participants' stories; they suggested that healing is (1) a personal and subjective experience, (2) a return to wholeness, (3) self-directed and requiring positive intention and (4) experienced in varying degrees. Symptom resolution, goal attainment, changes in social support, mental outlook, and the subtle but significant changes like engaging in life differently were important healing outcomes. Contrary to the assumptions of the HH, healing is an individualized process that does not follow a uniform pattern.

CONCLUSIONS

A lack of consensus on the key concepts of healing has hindered efforts to evaluate the effects of complementary therapies and outcome. The results from this study provide the basis for an instrument to assess individuals' healing experiences in a more dynamic manner.

The Peter Brojde lung cancer centre: a model of integrative practice

BACKGROUND

The generally poor prognosis and poor quality of life for lung cancer patients have highlighted the need for a conceptual model of integrative practice. Although the philosophy of integrative oncology is well described, conceptual models that could guide the implementation and scientific evaluation of integrative practice are lacking.

PURPOSE

The present paper describes a conceptual model of integrative practice in which the philosophical underpinnings derive mainly from integrative oncology, with important contributions from Traditional Chinese Medicine (TCM) and the discipline of nursing. The conceptual model is described in terms of its purpose, values, concepts, dynamic components, scientific evidence, clinical approach, and theoretical underpinnings. The model argues that these components delineate the initial scope and orientation of integrative practice. They serve as the needed context for evaluating and interpreting the effectiveness of clinical interventions in enhancing patient outcomes in lung cancer at various phases of the illness. Furthermore, the development of relevant and effective integrative clinical interventions requires new research methods based on whole-systems research. An initial focus would be the identification of interrelationship patterns among variables that influence clinical interventions and their targeted patient outcomes.

A complex systems science perspective for whole systems of complementary and alternative medicine research

Whole systems complementary and alternative medicine (WS-CAM) approaches share a basic worldview that embraces interconnectedness; emergent, non-linear outcomes to treatment that include both local and global changes in the human condition; a contextual view of human beings that are inseparable from and responsive to their environments; and interventions that are complex, synergistic, and interdependent. These fundamental beliefs and principles run counter to the assumptions of reductionism and conventional biomedical research methods that presuppose unidimensional simple causes and thus dismantle and individually test various interventions that comprise only single aspects of the WSCAM system. This paper will demonstrate the superior fit and practical advantages of using complex adaptive systems (CAS) and related modeling approaches to develop the scientific basis for WS-CAM. Furthermore, the details of these CAS models will be used to provide working hypotheses to explain clinical phenomena such as (a) persistence of changes for weeks to months between treatments and/or after cessation of treatment, (b) nonlocal and whole systems changes resulting from therapy, (c) Hering's law, and (d) healing crises. Finally, complex systems science will be used to offer an alternative perspective on cause, beyond the simple reductionism of mainstream mechanistic ontology and more parsimonious than the historical vitalism of WS-CAM. Rather, complex systems science provides a scientifically rigorous, yet essentially holistic ontological perspective with which to conceptualize and empirically explore the development of disease and illness experiences, as well as experiences of healing and wellness.

Methodological implications of nonlinear dynamical systems models for whole systems of complementary and alternative medicine

This paper focuses on the worldview hypotheses and research design approaches from nonlinear dynamical complex systems (NDS) science that can inform future studies of whole systems of complementary and alternative medicine (WS-CAM), e.g., Ayurveda, traditional Chinese medicine, and homeopathy. The worldview hypotheses that underlie NDS and WS-CAM (contextual, organismic, interactive-integrative - Pepper, 1942) overlap with each other, but differ fundamentally from those of biomedicine (formistic, mechanistic). Differing views on the nature of causality itself lead to different types of study designs. Biomedical efficacy studies assume a simple direct mechanistic cause-effect relationship between a specific intervention and a specific bodily outcome, an assumption less relevant to WS-CAM outcomes. WS-CAM practitioners do not necessarily treat a symptom directly. Rather, they intervene to modulate an intrinsic central imbalance of the person as a system and to create a more favorable environmental context for the emergence of health, e.g., with dietary changes compatible with the constitutional type. The rebalancing of the system thereby fosters the emergence of indirect, diffuse, complex effects throughout the person and the person's interactions with his/her environment. NDS theory-driven study designs thus have the potential for greater external and model validity than biomedically driven efficacy studies (e.g., clinical trials) for evaluating the indirect effects of WS-CAM practices. Potential applications of NDS analytic techniques to WS-CAM include characterizing different constitutional types and documenting the evolution and dynamics of whole-person healing and well-being over time. Furthermore, NDS provides models and methods for examining interactions across organizational scales, from genomic/proteomic/metabolomic networks to individuals and social groups.

State-space grid analysis: applications for clinical whole systems complementary and alternative medicine research

This paper presents state space grids (SSGs) as a mathematically less intensive methodology for process-oriented research beyond traditional qualitative and quantitative approaches in whole systems of complementary and alternative medicine (WS-CAM). SSGs, originally applied in developmental psychology research, offer a logical, flexible, and accessible tool for capturing emergent changes in the temporal dynamics of patient behaviors, manifestations of resilience, and outcomes. The SSG method generates a two-dimensional visualization and quantification of the inter-relationships between variables on a moment-to-moment basis. SSGs can describe dyadic interactive behavior in real time and, followed longitudinally, allow evaluation of how change occurs over extended time periods. Practice theories of WS-CAM encompass the holistic health concept of whole-person outcomes, including nonlinear pathways to complex, multidimensional changes. Understanding how the patient as a living system arrives at these outcomes requires studying the process of healing, e.g., sudden abrupt worsening and/or improvements, 'healing crises', and 'unstuckness', from which the multiple inter-personal and intra-personal outcomes emerge. SSGs can document the indirect, emergent dynamic effects of interventions, transitional phases, and the mutual interaction of patient and environment that underlie the healing process. Two WS-CAM research exemplars are provided to demonstrate the feasibility of using SSGs in both dyadic and within-patient contexts, and to illustrate the possibilities for clinically relevant, process-focused hypotheses. This type of research has the potential to help clinicians select, modify and optimize treatment plans earlier in the course of care and produce more successful outcomes for more patients.

Whole complementary and alternative medical systems and complexity: creating collaborative relationships

In recent years, investigators have discovered significant limitations in applying biomedical cause-effect assumptions and using conventional efficacy study designs to assess the clinical outcomes of whole systems of complementary and alternative medicine (WS-CAM). A group of WS-CAM researchers has been working collaboratively since 2001 to address the limitations of studies evaluating WS-CAM and discern ways to conduct research that would capture the complexity of such systems and the synergistic effects between the various elements of the system and would take into account treatment individualization and/or the patient-centered nature of treatment systems. In 2009, 14 complexity scientists from systems biology, psychology and the social sciences were invited to attend a workshop with these CAM scientists to (a) identify and discuss analytical techniques that can be used to study phenomena from a complex/nonlinear dynamical sciences perspective, (b) establish working relationships with these researchers, and (c) develop working research projects/ protocols to collaboratively study patient-centered responses to CAM treatments. This paper provides an overview of the workshop goals and outcomes, introducing this special issue of Forschende Komplementärmedizin.

Short-term effects of repeated olfactory administration of homeopathic sulphur or pulsatilla on electroencephalographic alpha power in healthy young adults

INTRODUCTION

Homeopathic pathogenetic trials usually rely on symptom self report measures. Adding objective biomarkers could enhance detection of subtle initial remedy effects. The present feasibility study examined electroencephalographic (EEG) effects of repeated olfactory administration of two polycrest remedies.

METHODS

College student volunteers (ages 18-30, both sexes) from an introductory psychology course were screened for good health and relatively elevated Sulphur or Pulsatilla symptom scores on the Homeopathic Constitutional Type Questionnaire (CTQ). Subjects underwent a series of 3 once-weekly double-blind sessions during which they repeatedly sniffed the remedy matched to their CTQ type and solvent controls. Each remedy was given in a 6c, 12c, and 30c potency, one potency per week, in randomly assigned order. Solvent controls included both plain distilled water and a water-ethanol (95%) solution. All sniff test solutions were further diluted just prior to laboratory sessions (0.5 ml test solution in 150 ml distilled water). Within a session, remedies and control solvents were administered via 2-s sniffs (8 sniffs of each of 4 different succussion levels for the potency in randomized order). Primary outcome variable was relative EEG power (alpha 1 8-10 Hz; alpha 2 10-12 Hz) averaged over 19 electrode sites, including all succussions for a given potency.

RESULTS

Mixed-effect models revealed significant main effects for remedy type (Sulphur >Pulsatilla) in both alpha bands, controlling for gender, baseline resting EEG alpha, and solvent control responses. Additional analyses showed significant nonlinear interactions between dilution and time (weekly session) in alpha 2 for both remedies and alpha 1 for Sulphur.

CONCLUSION

EEG alpha offers an objective biomarker of remedy effects for future studies and potential method for distinguishing time-dependent effects of specific remedies and remedy potencies from one another.

Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

How do we evaluate outcome in an integrative oncology program?

Integrative oncology focuses on the roles of complementary therapies to increase the effectiveness of conventional cancer treatment programs by improving defined outcomes such as symptom control, quality of life, rehabilitation, and prevention of recurrence. Implementation of integrative oncology programs should be based on the best evidence and must continually be evaluated to ensure quality, optimization of techniques, collection of new data, and cost-effectiveness. Useful domains that can be evaluated include symptom control, adherence to treatment protocols, quality of life, individual outcomes, prevention, rehabilitation, potential advantages of a whole-systems health approach, and economics of health services.

Increased Hatha yoga experience predicts lower body mass index and reduced medication use in women over 45 years

BACKGROUND

Yoga has been shown to have many short-term health benefits, but little is known about the extent to which these benefits accrue over a long time frame or with frequent practice.

AIMS

The purpose of this study was to examine the extent to which body mass index (BMI) and medication use in a sample of female yoga practitioners over 45 years varied according to the length and frequency of yoga practice.

MATERIALS AND METHODS

We administered online surveys to 211 female yoga practitioners aged 45 to 80 years. We used regression analyses to evaluate the relationship of extent of yoga experience to both BMI and medication use after accounting for age and lifestyle factors. We also conducted comparisons with 182 matched controls.

RESULTS

Participants had practiced yoga for as long as 50 years and for up to 28 hours per week. There were significant inverse relationships between yoga experience and both BMI and medication load. These significant relationships remained after accounting for age and lifestyle factors. When we computed yoga experience in terms of total calendar years, without accounting for hours of practice, significant relationships did not remain. However, there was no obesity in the 49 participants with more than 25 years of yoga practice. Yoga practitioners were less likely than non-practitioners to use medication for metabolic syndrome, mood disorders, inflammation, and pain.

CONCLUSIONS

A long-term yoga practice was associated with little or no obesity in a non-probability sample of women over 45 years. Relationships showed a dose-response effect, with increased yoga experience predicting lower BMI and reduced medication use.

Exploring measures of whole person wellness: integrative well-being and psychological flourishing

OBJECTIVES

Whole systems of complementary and alternative medicine (WSCAM) emphasize positive emergent outcomes for the patient, for example, a sense of well-being. This paper presents a questionnaire-based study in healthy young adults for the purpose of exploring individual differences that contribute to the sense of well-being and to identify characteristics of flourishing versus nonflourishing individuals in terms of nonlinear dynamical systems concepts.

METHODS

Young adult college students (N = 856) completed questionnaires assessing global well-being (Arizona Integrative Outcomes Scale [AIOS]), global physical health, positive and negative mood (Positive and Negative Affect Schedule [PANAS]), resilience (Connor- Davidson Resilience Scale), and repressive defensiveness. Next, subjects were divided into flourisher/languisher groups by a previously determined ratio of positive/negative scores established by a study using complex systems methods.

RESULTS

Positive-to-negative affect (P:N) ratio accounted for more variance in AIOS (R(2) = 0.19; P < .001) than did separate positive or negative PANAS scores or physical health. Flourishers (14.5% of the sample) were significantly higher than languishers in defensiveness and resilience.

CONCLUSIONS

Positive-to-negative affect explains a substantial portion of the variance in well-being of healthy young adults. The low percentage of flourishers in this nonclinical sample is consistent with previous population-based studies and suggests that flourishers are a minority, even in nonclinical settings. Positive-to-negative affect may be a useful variable for subsequent prospective studies of applied WSCAM treatments and in well and clinical populations. The well-being measure used in this study is easy to complete, sensitive, and may be a useful clinical measure to track change with treatment over time.

Research on integrative healthcare: context and priorities

It is important that integrative healthcare research be conducted to optimize the effectiveness, safety, costs, and social and economic impact of prospective, personalized, patient-centered, comprehensive, and holistic healthcare that focuses on well-being as well as disease management, and that the research itself be well understood. The scope of this research extends beyond evaluation of specific therapies, to include evaluations of multimodality whole system intervention, practitioner-patient relationships, patient goals and priorities, promoting self-care and resilience, personalized diagnostic and therapeutic measures, practitioner well-being, the comparative effectiveness of different educational and outreach strategies in improving health and healthcare, and the environmental/social causes and consequence of health and healthcare. In this paper, we describe the state of the science of research on integrative healthcare, research needs, and opportunities offered by cutting-edge research tools. We propose a framework for setting priorities in integrative health research, list areas for discussion, and pose a few questions on a future research agenda.

Effects of homeopathic medicines on polysomnographic sleep of young adults with histories of coffee-related insomnia

BACKGROUND

Homeopathy, a common form of alternative medicine worldwide, relies on subjective patient reports for diagnosis and treatment. Polysomnography offers a modern methodology for evaluating the objective effects of taking homeopathic remedies that clinicians claim exert effects on sleep quality in susceptible individuals. Animal studies have previously shown changes in non rapid eye movement sleep with certain homeopathic remedies.

METHODS

Young adults of both sexes (ages 18-31) with above-average scores on standardized personality scales for either cynical hostility or anxiety sensitivity (but not both) and a history of coffee-induced insomnia participated in the month-long study. At-home polysomnographic recordings were obtained on successive pairs of nights once per week for a total of eight recordings (nights 1, 2, 8, 9, 15, 16, 22, 23). Subjects (N=54) received placebo pellets on night 8 (single-blind) and verum pellets on night 22 (double-blind) in 30c doses of one of two homeopathic remedies, Nux Vomica or Coffea Cruda. Subjects completed daily morning sleep diaries and weekly Pittsburgh sleep quality index scales, as well as profile of mood states scales at bedtime on polysomnography nights.

RESULTS

Verum remedies significantly increased PSG total sleep time and NREM, as well as awakenings and stage changes. Changes in actigraphic and self-rated scale effects were not significant.

CONCLUSIONS

The study demonstrated the feasibility of using in-home, all-night sleep recordings to study homeopathic remedy effects. Findings are similar though not identical to those reported in animals with the same remedies. Possible mechanisms include initial disruption of the nonlinear dynamics of sleep patterns by the verum remedies.

The use of mixed methods for therapeutic massage research

Mixed methods research is the integration of quantitative and qualitative components in a research project. Whether you are reading or designing a mixed methods research project, it is important to be familiar with both qualitative and quantitative research methods and the specific purposes for which they are brought together in a study: triangulation, complementarity, expansion, initiation, or development. In addition, decisions need to be made about the sequencing and the priority or importance of each qualitative and quantitative component relative to the other components, and the point or points at which the various qualitative and quantitative components will be integrated.

Mixed methods research is increasingly being recognized for its ability to bring multiple points of view to a research project, taking advantage of the strengths of each of the quantitative and qualitative components to explain or resolve complex phenomena or results. This ability becomes critical when complex healing systems such as therapeutic massage are being studied. Complex healing systems may have multiple physiologic effects, often reflected in changes throughout the patient’s body. Additionally, the patient’s experience of the treatment may be an important outcome.