VetInfo Digest                     November 2007

Table of Contents:

Defining Practice Philosophies

My definition of Holistic

New Stuff

This Month’s Note:

I tried this month to come up with some definitions and descriptions of types of medicine that are lumped under various names, such as holistic, alternative, complementary, allopathic, conventional, traditional, homeopathic, chiropractic, etc.  I know from my clients that many people have no idea what these terms actually describe and I think they are confusing to veterinarians sometimes, as well. 

Ultimately, I think the most important thing is for your veterinarian to do a good job of examining your pet and communicating with you, regardless of practice philosophy. 

What do all these terms mean?

Last month I mentioned that I had attended a meeting on holistic medicine in September.  The seminar really made me think about the way that terms like this are used in medicine, particularly veterinary medicine.  To me, the term holistic simply means making the effort to view the entire patient and to keep the overall welfare of the patient in mind when making diagnostic and treatment decisions.  This isn’t how most people seem to view the term, though. 

The speaker seemed to think that subscribing to any of the “alternative” forms of medication was sufficient to make the claim of being a holistic practitioner while using standard therapies didn’t qualify.  If practitioners of any of the alternative modalities confined themselves to one of the modalities and used it without regard to the overall patient’s health and well being, would that still be “holistic”?  This question was kind of important to me as the talk went on because in the sections of the talk devoted to acupuncture and traditional Chinese medicine the speaker stated that it wasn’t necessary to know anything more than one symptom and it was possible to treat the patient. To quote one example, he said it didn’t matter whether a dog had hip dysplasia or a spinal disc problem because the acupuncture therapy had one protocol for “hind end weakness”.   I have a hard time accepting that holistic means ignoring the underlying conditions that might be contributing to a problem or to the understanding of that problem.

This is what really got me thinking about what all the terms that get thrown about in describing approaches to medicine might mean.  The most common ones that I hear are “conventional” medicine, “alternative medicine”, “complementary medicine”, “homeopathic” medicine and “holistic medicine”.  Sometimes I hear references to “Western” medicine and “Eastern” medicine.  The term “allopathic” medicine seems to be used by practitioners of homeopathic medicine to describe everyone else (with an emphasis on people who use other pharmaceuticals). There are also descriptive names for particular techniques that sometimes come close to being an entirely different philosophy of medicine, such as acupuncture and chiropractic.

The simplest explanation for the differences between “conventional” medicine and “alternative” medicine is the difference in believing that diseases have an external cause (conventional medicine) or that they have an internal cause (alternative medicine).  In this way of looking at the terms the conventional medicine practitioner tries to find a bacterium, virus, parasite, toxin or other cause for the body’s problem and treats it.  The alternative practitioner tries to identify why the body’s own defenses have become compromised and allowed disease to happen.  I think that it is clear that most conventional practitioners are fully aware of the possibility that disease might be caused by disorders within the body and that most alternative practitioners recognize that it is a good idea to avoid contact with say, Ebola virus.

It is extraordinarily hard to define the term “conventional medicine” and then apply it according to the definition. I think that ideally the definition would be something like “medicine based on scientific evidence that a diagnostic test works, a treatment is effective, a particular organism or toxin causes disease” and so on. However, there is a pitifully small amount of information in veterinary medicine that is based in well proven science. A great deal of the “conventional” therapy is really pharmaceutical therapy passed on from one veterinarian to another.  If a practitioner who views herself as conventional uses a pill for an unapproved use because Dr. X down  the road says that it works even though there is no evidence at all other than his testimony, is the practitioner truly practicing conventional medicine? At best I’d have to say they were practicing experimental medicine using your pet as a guinea pig. You should at least be informed that is the case.

On the other hand, if the term conventional medicine refers to scientifically based medicine then it should include any of the current therapies viewed as “alternative” that can be shown to work using scientific studies.  One caveat to this that I think is really important is that the treatments, diagnostics or other procedures should be shown to be clinically significant, not just statistically significant.  It isn’t important to a clinician if a patient lives 5 additional days on the average with an alternative therapy for cancer, for instance – but this could be declared statistically significant and evidence for some benefit of the therapy even though it  isn’t of much significance to the patient.  

If the term conventional medicine is used to describe only pharmaceutically and surgically based treatments and diagnostic tests that can be shown to be accurate and reproducible then it has an entirely different meaning.  In this case the better description might be something like “evidence based medicine” as opposed to “traditional Chinese medicine” or traditional homeopathic medicine.  Lots of things that practitioners who favor using pharmaceuticals do have not been proven scientifically but have been passed down from practitioner to practitioner.  To me, this makes “traditional Western medicine” a better description than “conventional” Western medicine.

At the present time the term alternative medicine seems to encompass everything that is different in any way from conventional or traditional Western medicine.  Some people use the term “complementary medicine” instead of alternative medicine.  I think that they do that so they can include things that most people would think of as conventional or traditional Western medicine except that they are being used in different ways, as well as to cover a large group of practitioners who use pharmaceuticals as well as other treatment modalities.  An example of this is laser therapy.  For some reason “alternative” or “complementary” veterinarians are latching onto laser therapy for lots of things other than the traditional surgical uses, such as pain control. Low level laser therapy has been used for some time in attempts to control pain and there is some evidence that this is successful according to Dr. Narda Robinson in “Veterinary Practice News, Oct. 2007). However, it is usually lumped into the “complementary medicine” category because it is unclear (or has been unclear) why it might work.  Most of the folks in my practice area who think of themselves as alternative medicine types aren’t thinking about laser therapy, though.  On the other hand, people who like the term complementary medicine might. A laser seems like a scientific tool even when it isn’t being used in a scientific manner.  Another example of this is the increased use of rehabilitative therapy techniques in veterinary medicine. These are probably considered traditional medicine in humans now but are still new enough for dogs that they are often lumped into the area that the term complementary medicine is supposed to cover.

The general terms alternative and complementary do not really do justice to all of the modalities that people might include under these terms.  For many of these, it is best to look at the particular type of medicinal practice or philosophy and to try to understand it on its own merits. There are a number of fields to consider, including chiropractic, acupuncture, herbalism, homeopathy, massage therapy (numerous subgroups here), traditional Chinese medicine (herbalism with a different mindset than many Western herbalists)

Homeopathy is a particularly bothersome treatment modality for most veterinarians who try to practice evidence based medicine.  The original hypotheses are extremely difficult to ignore, especially the one in which Dr. Hahneman, who invented homeopathy states that it is a waste of time to look for a cause for disease since the only thing wrong with patients is loss of regulation of their body’s systems and that can be cured by giving medications that would induce similar symptoms to whatever is currently wrong with the body.  For those that accept that concept as reasonable, there is the added impediment that homeopathic preparations are dilutions of these medications. In many cases they are so dilute that there probably isn’t any actual medication in them. This can be a very good thing when dealing with homeopathic medicines, since several of them are quite toxic in normal strength doses.  Realistically, though, even most of modern medicine’s detractors have to admit that the search for causes of diseases has progressed remarkably since Dr. Hahneman wrote his book in 1730 and it is possible to say unequivocally that there are diseases caused by specific organisms and that elimination of these organisms does provide a complete cure in most instances.  If you reject the basic premises of the founder of homeopathy does it make sense to continue to use the therapies?  I believe that homeopathy is simply a way to do nothing while waiting for the patient to heal. In Dr. Hahenman’s day, when giving arsenic  and blood –letting were common treatments,  his therapies probably did save lives if for no other reason than they didn’t make sick people even weaker.  At the present time the only justification that I can see for homeopathy is that it is way to do nothing while giving clients can’t stand idly by and wait something to do.

I can’t resist one a little more commentary on homeopathy.  Many of the people who come to our practice and discuss homeopathy are dead set against the use of pharmaceuticals.  They frequently state something like “Western medicine only treats symptoms and homeopathy treats the whole patient.”  I often wonder if they think about the fact that homeopathic medicines are man made preparations just like pharmaceuticals and that their homeopathic practitioner looks up a set of symptoms and matches them to the observed effects of the treatment.   This treatment is aimed directly at treating symptoms with no regard for treating causes. In fact, Dr. Hahneman specifically rejected the idea that it was necessary to look for causes of diseases or disorders.  It is a treatment modality built entirely on treating symptoms. 

It is obvious that some herbs have medicinal value. Many of our current pharmaceuticals are derived directly from medicinal uses of herbs in the past.  There are lots of questions about herbal medicine that need to be answered as time goes on, though.  In some instances herbal sources of medicine will only work well if they are used as part of the plant.  One notable example of this that some folks might identify with is marijuana. Only the d-isomer of tetrahydrocannabinal (THC) is active in humans. The l-isomer has no effect.  In manufactured THC the l and d isomers almost always coexist in about equal amounts. In marijuana plants the d isomer is predominant and is at least 90% of the form of THC found. This makes a significant difference in the effect of similar quantities of THC from the plant or from a manufacturer.  In many other instances the opposite effect is true – the plant may contain only small amounts of the active ingredient where it may be pure when manufactured.  There is also a possibility that some of the identified active ingredients need other ingredients in the plant to work properly or most effectively.  In this case giving a pharmaceutical may not be as effective as using the herbal form.  As long as there is evidence to show that herbs work well for a particular disease or set of disease symptoms it seems reasonable to use them as an alternative. On the other hand, when the active ingredient is well known and the effects can be documented it doesn’t seem unreasonable to want to use standardized quantities with known purity in pharmaceutical preparations.

Traditional Chinese medicine, or Chinese herbalism, is a little more difficult to evaluate. Most of the Chinese herbal treatments consist of multiple herbs and most are in small quantities.  The recipes are often based on a particular herbalist’s accumulated knowledge rather than well documented studies. This causes problems because the ingredients aren’t standard from one preparation to the next and some ingredients aren’t identified.  Chinese herbal preparations frequently do not stick to strong standards for accuracy of the ingredients in them or the quantities of those ingredients.  It is almost impossible to do good scientific studies of this group of medicines that is meaningful because of the variations in preparations from one practitioner to another in China. Even if it is proven that one preparation works well there will be no guarantee that the next practitioner would use it or make it the same way as the studied version.   This introduces an element of uncertainty that makes it nearly impossible to do well controlled studies.  Most of the practitioners who favor Chinese herbalism seem to think that this isn’t a big deal because the whole system of determining how to administer therapies is radically different from the Western medicine concept of identifying a disorder and treating it, making the system one that operates more on tradition and individual practitioner experience than on science, anyway.  While that does seem to be true it also makes it very hard to prove or disprove the actual effectiveness of therapy.  

There is good evidence that acupuncture therapy helps some patients.  In the most rigorous of studies it seems to make a difference in 25% to 47% of patients when compared to control methods (the control methods have varied in the studies as it is hard to figure out a way to pretend to place needles in the skin).   A number of theories have been advanced concerning how acupuncture might work but at present there is not adequate proof to validate any particular theory.  It seems to work best for conditions in which chronic pain is a factor.  I think that this is perhaps the alternative treatment modality that is most accepted by practitioners of science based medicine, simply because it does seem to produce statistically significant results in some controlled studies. It should be noted that in at least one study in which the needles were placed randomly in comparison with traditional sites the random placement did just as well. That doesn’t disprove the impact of acupuncture, it just raises questions about how technique affects results.

I am assuming that most people have some understanding of chiropractic manipulation. The underlying theory of chiropractic is that subluxations (incomplete dislocations) of spinal vertebrae lead to pressure on the spinal nerves and that this interferes with the body’s ability to function, causing disease.  Chiropractic treatment of veterinary patients has not been proven to be effective based on scientifically controlled studies, as far as I can tell, to date.  There is a problem with chiropractic treatment of pets in that most veterinarians have no knowledge of chiropractic manipulation and most chiropractors know very little about veterinary medicine.  So most of the people offering chiropractic services are somewhat deficient in one field or the other, although there are some practitioners with degrees in both fields.  I do not know what the future will bring as far as research into chiropractic veterinary applications goes.  There are a few studies but they have concentrated on demonstrating that chiropractic manipulation actually has a physical effect on the spine. It is necessary to consider this and so it is a good first step in evaluating chiropractic manipulation of pets but it will eventually be necessary to show that it does have benefits for specific conditions in pets.

Dietary treatment/supplementation theories are also common in veterinary medicine. There are many variations on this from special diets that simulate natural diets to supplements that may or may not be naturally occurring substances.   I can’t bear to go back the controversy over dietary philosophies so I am just going to discuss supplements that seem to have some scientific validity at this time. The best of these is probably omega3 fatty acid supplements, particularly fish oil. It does seem to help with immune mediated problems such as allergies and with chronic inflammatory diseases such as arthritis. Glucosamine and chondroitin are commonly used either alone or together. The data is confusing, still, on these supplements but there are small statistically valid benefits in some patients in studies and they appear to be very safe, so they are fairly widely accepted at this time.  L-lysine supplementation seems to be helpful for patients with chronic herpesvirus problems.   These are the supplements that have the best data backing up their use, as far as I can tell. There are lots of other supplements. The claims made for them may or may not be true. 

Veterinarians and pet owners have lots of choices in how they approach health care for pets. The experiences that people have with different forms of medicine will influence their opinions. While this is inevitable it is more rational to look for objective data about the medicine or medical philosophy being considered.   The experiences of a larger group are just more meaningful than the experiences of a single individual.

So how should a veterinarian approach treating the whole patient?  The first and most important thing in my mind is to do a thorough physical examination on every patient.  I try very hard to do this. If a patient comes in with ear problems I go ahead and check all of the things that I would if they came in for a yearly physical examination.   At least I try to – there are busy or frustrating days in every practice and on some of those days I do shortened examinations.  It is not uncommon for a client to bring a pet in with a complaint like ear pain and to find a generalized allergy problem or to find that there is more than one possible cause for the pain, such as a tooth abscess on the same side.  If we don’t look, we don’t find these things and the patient is not well served.

What “Holistic” Means to Me

This is my outline for practicing holistically:

 

1) Take the time to look at the whole patient on each office visit. An office for an ear infection shouldn't be confined to a quick look in the ears; it should include a physical examination for other signs of infection or inflammation and a general evaluation of the patient's health, for instance.

 

2) Know what the pet is being fed. While I do not believe that diet plays as large a role in many illnesses as proponents of various dietary philosophies do, I think that it is best if the veterinarian is aware of the pet's diet.  This is particularly true for chronic conditions such as allergic skin disease, immune mediated disease, cancer and kidney or liver disease. When dietary adjustments seem necessary make sure recommendations are based on scientifically valid facts whenever it is possible to do so.

 

3) Evaluate each individual pet's need for preventative care measures and try to assess the risks being taken as well as expected benefits of a procedure. While it is easy to make a case for spaying female dogs as a health benefit there are some risks and there is a select group of patients where the risks outweigh the benefits. This is true for just about every medical or surgical procedure -- there are risks and benefits that apply uniquely to each patient and it is therefore necessary to consider the patient rather than to have one size fits all policies.

 

4) Try to use only diagnostic procedures, treatment procedures and surgical procedures that have been proven to be more beneficial than doing nothing in scientific studies whenever possible. When more than one treatment or surgical procedure exists use the one with the best chance of success in the patient that is being treated, not just the one the veterinarian is most familiar with. This may involve referral to a specialist or to another practitioner who is more familiar with a particular procedure. There is nothing wrong with referral when it is appropriate.

 

5) Make treatment recommendations the pet's owners can actually handle. There is no point in dispensing pills for patients when the pet's owners can't give them. The difficulty in keeping a 2 year old Labrador retriever inactive for six weeks has to be factored into the decision to consider tibial plateau leveling osteotomy (TPLO) surgery for cruciate ligament surgery.

 

6) Take risks when it is appropriate to do so. It is necessary to keep a patient being treated for heartworm disease as inactive as possible for approximately 2 months. This can be quite difficult and for some dogs it is really impossible as they will pace or struggle frantically when confined. Being active increases the risk of therapy dramatically, causing complications in perhaps as many as 5 to 10% of patients, including death. On the other hand, heartworm disease causes death over time in at least 50% of patients and it causes disability in almost all the rest of them. In this case even though the risk of treatment is increased by the dog's personality the overall difference in risk still favors heartworm treatment.

 

7) When it seems best to do nothing, do nothing. Don't send home remedies that have no purpose but to occupy the owner's time. Almost any remedy (with the possible exception of true homeopathic medicines and a few pharmaceuticals that truly appear non-harmful to mammals) comes with some risk. Why take any risk unnecessarily when the intent is to do nothing?

 

8) Keep up with the literature.  Some "alternative" therapies turn out to be very successful and many "conventional" therapies are proven to be ineffective over time. It is extremely frustrating for clients when therapies that seem to work are eventually proven to be ineffective but that really is the way science is supposed to work. It can take years and many studies to pinpoint when a medication is effective and when it is not. The continual revision of the evidence is a good thing, not a bad thing. It does mean that sometimes you have to look back at something you tried with the knowledge you actually made the situation worse but it is still better to know that than to keep on using the outdated treatment.

 

9) Your veterinarian should know about your pet's lifestyle. What percentage of the time is your pet allowed to be outside unsupervised? How many other pets are there in the family? How many family members have some responsibility for your pet's care? Is your pet taken to shows or obedience competitions?  Is your dog a therapy dog? A police dog? Do you take family trips that include the pets? Do you live half the year in Florida or Arizona?  Any lifestyle factors that might impact the health care of your pet should be known to your veterinarian.

 

10) Your vet should ask about any medications or supplements your pet may be getting.  If you are using any of these products that you did not get from your veterinarian it is best to tell him or her about them, especially if your veterinarian is planning on putting your pet on a new medication.

 

New stuff

Stem cell treatment for arthritis is available for dogs through the efforts of Vet-Stem Inc.  Their web site is www.vet-stem.com  .  At the present time they restrict the use of this technology to veterinarians certified through their company but it may be a viable option for some of you already and is likely to become more widely available as time goes on if it lives up to its promise.

Vectra 3D ™ is  another new flea and tick medication that became available this month.  The active ingredient is dinotefuran, a new insecticide that is a relative of imidocloprid and fipronil, the ingredients in Advantage ™ and Frontline Topspot ™.   It also contains permethrin to kill ticks.  In our past experiences with permethrin it has not provided good tick control for more than 2 weeks or so but for many pets with low risk of tick exposure this should be OK.

Hills produces a hypoallergenic treat for both dogs and cats now.  This is a nice option for folks with food allergic pets so they can have treats, too.

Bayer Profender Topical Solution ™ contains a new compound, emodepside, to kill hookworms and roundworms.  It also contains praziquantel to kill tapeworms.  The main advantage of this product, though, is that it can be applied topically to cats, making it unnecessary to give a pill or liquid orally.

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