asthma medications are safe for children

>> welcome everyone to ouryour child's health university presentation this evening. i'm nancy sanchez from communityhealth education programs and it's my great pleasure topresent our speaker this evening who is doctor john mark. he's going to be speaking withus on integrative medicine and children, a fascinatingsubject. a little bit about dr. mark -- dr. mark received his medicaldegree from the university

of kansas and he completeda residency in pediatrics at children's mercy, universityof missouri in kansas city. he continued his training in pediatric pulmonarymedicine during his fellowship at the university ofrochester, rochester, new york. and then in 1999, he wentto the university of arizona to complete the first fellowship in pediatric integrativemedicine and that was funded by the national instituteof health.

he's now on the faculty at lucile packardchildren's hospital since 2005 and he's been utilizingdifferent complementary and alternative health carepractices with his patients with chronic pulmonaryillnesses, asthma, cystic fibrosis. his interest is in nutrition,mind body approach to healing and trying to minimizemedication and emphasis on such things as exercise.

very fascinating subjectand we thank you dr. mark for being here this evening. when i first got intoacademic medicine after i left my fellowship atthe university of rochester, i came out to californiaand took a position at u.c. davis in sacramento. and after about twoyears of being in academic medicinei discovered that it wasn't really for me.

i mean it was likeresearch and it wasn't like very holisticand not very caring. and plus i'd met my now-wife whowanted to live in santa cruz. so i left academic medicineand moved to santa cruz. and for the next 15 years ilearned mostly about how to care for children throughnon-conventional ways because about everybody in the central coast useseverything but medicine. they'd only cometo see the doctor

if their acupuncture didn't workor their homeopathy didn't work, if their mind-bodystuff didn't work. and so they were teaching mereally over those next 15 years. and so in 1999, i wasfortunate to find an offer for a fellowship at theuniversity of arizona. they got what wascalled a center grant where for the next five years,they were actually going to study alternativetherapies in children. and so i applied just on kindof a whim and i got accepted

to be a fellow down there. and what was really nice isthat many of you may have heard of andrew weil whois kind of the guru in integrative medicine. he was at the universityof arizona for a long time and he had an on-going programthat was a clinical program, what they call aresidential fellowship but there was nopediatric part of it. and so we went downthinking i'd be down there

for two years just doingresearch but actually they kind of adopted us into theprogram so that we got to hang out with doctor weil and all hisgroup for the next two years. and you know we would spendthe day with deepak chopra or the day with patch adams and we would learn allthese different therapies and we really got to know alot about the different types of alternative therapies. plus i was doing research too.

a couple of topics that i lookedat was the use of echinacea in children one to five yearsof age who had recurrent or persistent otitis media. and we also looked atmind-body relaxation in children with recurrent abdominal pain. and we also lookedat chamomile tea with kids with abdominal pain. and one of the interestingones that we did is we looked at acupuncture andmassage therapy in children

with cerebral palsy to see if we could actuallydecrease their spasticity. so we were doing all thisresearch and at the same time, we got to be part of all theintegrative therapies and go to all the clinics and listen to all the lectureson those things. i thought, "well, after twoyears of being in the university of arizona, that's why istill have the u of a up there because i would comeback down to santa cruz

and i would neverhave to practice in academic centers again." but then i kind of got luredback into academics when i was at the u of a because as manyof you know, the university of arizona has a long history of having an excellentrespiratory therapy and respiratory bothpediatrics and adult medicine. so i started hangingout with those guys and when i finished myfellowship they asked me

if i wanted to be one oftheir staff, on the faculty. so i went back toacademic medicine after being goneall those 15 years and started being a practicingpediatric pulmonary person again and using all thesealternative therapies integrated into conventional therapies, theso-called integrative medicine. and after being down therefor another four years, i wanted to come backto the central coast because that's reallywhere i wanted to be

and i came back tostanford in 2005. so that's kind ofmy long journey. actually i was out of academicmedicine and then i kind of got into it by actually goingback in and learning about alternative therapiesand complementary medicine which we now callintegrative medicine. and so that's kind of how igot interested in it and so since being back here, i've beentrying to use it more and more in the patients that i see,

especially with chronicillnesses and we'll talk about that in a minute. and i was just telling nancythat i just came from a meeting where we're actuallytrying to set up an outpatient integrativemedicine service here at packard. and we're trying to workon that for the next, hopefully for thenext fiscal year which starts this september,

where we'll actuallyhave outpatient clinics in rheumatology, gi,infectious disease, pulmonary, and pain all kind of workingtogether in different ways, not just using conventionaltherapies. that's kind of thebackground for tonight so i think we're moving along. it's taken me a whilebut if you know stanford or packard very well,everything takes a long time. you just have to be reallypersistent which i am

and so we are just kindof working this along. so you might ask about what iscam, what sometime people refer to complementary andalternative medicine? and what is the prevalence? in 2007, you could see adultsspent almost $34 billion -- billion dollars out ofpocket to visit practitioners and purchase thedifferent products. so it's huge; it's ahuge industry out there. if you've ever walkedinto a health food store

and you're saying, "like iheard echinacea helps you when you get a cold tohelp decrease the severity and duration." walk into it and try to figureout what echinacea to take. there's a whole wallof echinacea. you know, how doyou have any idea? it's such a big thingand such a big industry? nearly two-thirds of thetotal out of pocket costs by adults were forself-care products

and so people are reallytrying to stay healthy. they're actually trying todo things to avoid going to physicians and going toemergency rooms and going to urgent care and what can i do to help promote myown self-care. and despite the emphasison self-care therapies, there's still 38.1million adults who made over 350 millionvisits to practitioners of alternative medicine.

so that's your acupunctures, that's your homeopathicphysicians, that's your osteopathic personwho does therapeutic massage. you have all thesedifferent people who are doing all thesedifferent techniques. so this just gives you an idea, this is from an nihreport trying to show you what the cam use is. you can see that in the unitedstates, this is the percent

of the population, about42% of the population -- it's not as high as some placelike canada which is up to 70% which is really amazing. and in the developing worldreally, we always talk about conventional medicinereally is the alternative medicine in mostconventional countries, in non-industrial ones becausereally this is what they practice and will onlyuse conventional medicine on the side.

but you can see likein ethiopia and stuff, it's up to almost 90%. and then i put thislittle figure in here because even though peoplethink they want to do self-care, you know, it's a lot harderto really do good nutrition. and it's hard to do lifestyles. it's hard to do exercise. it's easier to just take a pill. so if you can go to the healthfood store and just take a pill,

it's more conventional,it's more natural, it's dietary supplementswhich is one of the things i actually amgoing to talk about tonight. it's actually the mostconventional-like. so it's one of the thingsthat kind of bothers me about "alternative medicine" becausea lot of people really rely on dietary supplements and it'sactually my least favorite thing to talk about because it's theone that's most conventional. if you get my drift.

instead of trying to be healthy, it's like i'll justgo get another bottle and even though it'ssupposed to be natural, i'll just take this medication. and again, this one youcould see cam use by adults and children and in 2007, itwas -- this is all children. so this is not just childrenwith chronic diseases because if you look atchildren with chronic diseases, it actually goes up to 50%, 60%and even 80% in some studies.

in over-all children,it's still about 12%. and then one of thethings you can see here is that $14.8 billionwere in non-vitamin, non-mineral natural products. so there's your dietarysupplements -- - huge, huge industries. so really dietary supplements and natural productsare still the thing that people use the most.

you can see there's a littlebit of what we're going to talk about is, there's almost$3 billion in homeopathic. you can see, theycall it yoga here and then there's all thepractitioners' costs. and you can see thatonly about $.2 billion in relaxation techniques andactually relaxation techniques and mind-body therapieswhich we'll talk about are actually oneof the leading causes that actually showed there'ssome evidence behind it.

yes? so nutritionactually doesn't really, they didn't really countthat as being alternative and that's why itdidn't really fit in. there is, i mean what is reallyalternative medicine in a way? if you take 250 milligramsof vitamin c, that's consideredto be the standard. how about if you takea gram of vitamin c? well, that's a little bit more. how about if you take sixgrams every day of vitamin c?

well then all of a sudden you're into complementaryalternative medicine and dietary supplements. so it's a fine line. so what is diet? i mean you see a lot of childrenwho have chronic illnesses. they do a lot ofdifferent types of diets. so when do you make it soit's not really just nutrition and when is it really a typeof alternative therapies?

so it's hard to really sort out. so that's why thesestudies are hard to do. if you look at ethnicity, you can see thatactually native american and alaskan nativesare actually over 50%. and as you go down, the hispanic and actually afro-americansare the two lowest. and asians. but again, a lot of thesestudies depend on what they ask.

you know, what do they meanby alternative therapies? so really how about in children? so about 8 million individualsyounger than 18 years of age according to thispediatric article that just came out now two years ago, usealternative medicine in 2007. adolescents and children livingin the west like california, those with parents with12 years of education and prescription medication usewere independently associated with overall increase cam use.

so the more educatedthey were and the more that the parents usedalternative therapies, the more the kidstend to use it too. common medical conditionsincluded gi problems, anxiety/stress, skinissues, insomnia, musculoskeletal conditions,especially fatigue, sinusitis were increasedwith cam use. parental cam use was a strongcorrelative of child cam use and many studies have found

that the higher thecam use among children with chronic conditionslike asthma, adhd, autism, food allergies, arthritis,type 1 diabetes and sickle cell wereactually the highest. so the more chronic you got,the more it tended to go up. so why do people use these? i mean why don't theyjust go to the doctor and get their normal care? well therapies areconsistent with the patients'

and families' values which isyou know, what they believe in. so that's really whatthey want to use. and a lot of times it has to dowith what your grandmother used, your auntie used,what was traditional in your family and lifestyle. and it's really natural,ecological and maybe empowering because you're decidingwhat you're going to take. it's not just when you goto the doctor or you go to your physician or you goto your health care clinic

where they'll say,"take this medicine. take this medicine. take this medicine." it's like i'm tryingto make a decision as to what makes the bestdecisions for myself. the cam providers are feltto be more patient-centered. so we talk about beinghigh touch, low tech. because you know whenyou go to see physicians, a lot of times theyonly spend like 30,

it seems like 30seconds with you. they listen one, two andthen they're out the door. they charge you a lot of money. if you actually go into analternative medicine practice, sometimes it's an hour,hour and a half, two hours. they really get adetailed history and maybe hands-on therapyif you're doing massage, your osteopathic manipulationor even a chiropractor and it's all very kind ofhigh touch which people feel

at times very soothingand actually very healing. and it is for a lot of families. it makes a tremendousdifference. so it tends to be muchmore patient-centered. conventional therapies areperceived to be emotionally or spiritually without benefit. that sounds funnybut it's really true. i mean if you go and just getanother pill or another inhaler or whatever kind of therapy youget, it's not very spiritual

and it doesn't feel like thatthere's much that you are going to get out of it emotionally. and conventional therapy isassociated with side effects and significant risksin some conditions. so even the medicines i use forcommon asthma, we always talk about all the risks thatare involved with it. and if you see the ones ontv like for advair or one of those combinations, they'resaying, "oh yeah, you can play. you can run.

you can do things." and then they have alittle disclaimer thing where they talk reallyfast where they say, "of course there's anincreased number of deaths, an increased numberof side effects, etc." oh, okay, yeah, did theysay something about death? and so it's like why would iwant to ever take this medicine that has an increased riskof death with this condition? and it's also a circularprocess.

and this is really, reallyimportant in california. if there's a lot of alternativepractitioners then there's a lot of alternative practice use. and they did a nicestudy in england where they had one children'shospital that had a lot of practitioners around thatdid alternative therapies and another one thatdidn't have very much and where they didn't have verymany, they didn't use very much. where they had alot, they used a lot.

so again, it tendsto be more circular. so if you have people available,you tend to use it more often. and then you cansay, "what is -- " i keep mentioning theseback and forth because i want to make the distinctionabout what is cam or complementaryalternative medicine and what's integrative medicine. so really complementaryalternative medicine according to the nih, the nationalcenter for complementary

and alternative medicine, isa group of diverse products and health care systems,practices and products notconsidered to be part of the conventional medicine. which is kind of interestingbecause over the last 10, 15, 20 years, things that wereone time not considered to be conventionalnow are conventional. so now they're nolonger cam any more. they're like, "ohyeah, we do that.

oh yeah, that's okayto take certain things if you have diabetes. it's okay if youtake certain things if you have heart disease." but even 15, 20 yearsago it was considered to be the alternative. some scientific evidenceexists regarding cam therapies for some. for most, actuallythere's still a lot

of questions regardingsafety and efficacy because they haven't gone through randomizedcontrolled trials. they're not quoteevidence-based. and i'll mention that alittle bit later because a lot of things we do inconventional medicine aren't too evidence-based either. but since we're taughtabout them in medical school and that's what's practicedin our lives, they're okay.

but what tends to be nottaught in medical schools, they're not what'staught to us tends to be kind of more alternative. integrative medicine actuallyis what we try to practice and what i was promotingwhen i was at the university of arizona. it really combinesmainstream medical therapies and these different types of complementaryalternative therapies

for which there is some highquality scientific evidence of safety and effectiveness. so you try to take the best ofboth worlds and try to make it. so if i have a child thathas asthma, i'll say, "i'm going to give you thismedicine and this medicine." i'm going to try to getthe cat out of the house, try to get the dad toquit smoking in the house. i'm going to do all theseenvironmental things and then over the next 6 or 12 months,

i'm going to improveyour nutrition. i'm going to helpyour lifestyle. i'm going to get youto exercise again. maybe we're going to start youon some dietary supplements that have been shownto be more effective and not have the sideeffects that some of the medicine you're taking. and try to do a mixand try to -- how can you get the besttherapies with the least amount

of medications and it reallychanges the whole patient's and the family's life. so a couple of jokesjust to break it up here, you can see 100% naturalremedies, pure snake oil and i think that's the onething i'll keep mentioning over and over again is that dietarysupplements aren't regulated very well. we have really a --you don't know what's in almost any product thatyou pick up on the shelf,

unless you have areally good seal of approval so you don't know. this is herbal remediesversus verbal remedies. i kind of liked this because itkind of fits in my talk tonight which is dietary supplementsversus mind-body, right? so sometimes i thinkthe mind-body, the verbal remediesare actually better. "snap out of it." and you can see here, "the truthis, doctor, i've lost faith

in western medicine"which is appropriate for being in california. so what are the majorclasses of cam with complementaryalternative medicine? again i use this becausethis is what the nih uses, the national institutesof health. so they have a national center for complementaryalternative medicine. they broke it, kind of a littlebit spuriously but they broke it

into five categories whichmakes it easier to talk about. the first one whichi'm not going to talk about in detail is alternativemedical systems: homeopathy, naturopathic, andtraditional chinese, and ayurvedic treatments. these are systems thatare completely different than conventional therapies. this is not -- you're notgoing to just take a medicine because you havean ear infection.

so you take 10 days ofantibiotics and you get over it. this is actually approachingmedicine in a different way and i'll mention why that is. it has to do more withkeeping your life in balance and not going aftera specific symptom. the one that we aregoing to talk about is mind-body intervention which is actuallymy favorite one because i think there'svery little side effects

in using the personto really think about how they cancontrol their illness, how they can controltheir chronic conditions and even their acute conditions. and we'll talk a little bit moreabout that as the night goes on but it enhances themind's capacity to affect bodilyfunctions and symptoms. i just talked to one of mynurses today and she thought -- she goes, "you know i'mgoing to sound crazy."

i said, "what do you mean?" she goes, "i'm going togo to a hypnotic practice where they're going todo virtual lap bands." so instead of gettingfor obesity -- instead of gettingyour stomach banded, she's going to actuallygo to get hypnosis to get virtual bands placed so she'll feel full beforeshe actually is full. so then she won't eatand she doesn't have

to go through the surgery. and it sounds -- she goes,"you think that sounds crazy?" i said, "no, it soundsperfectly logical to me because you can dothat type of thing." you can really get your mind tochange your way that you think about how you feel and thatactually can promote health more than actually havingthat actual surgery. so -- but you have to be theright person, you have to have that kind of mind-setto be able to do that.

you have to be kindof accepting. the mind's capacity and it'sactually almost not even considered to be alternativemedicine anymore because really, the most of the researchthat's been done over the last 50 yearshas been in this area. it's almost all beenvery positive. the one i'm reluctantto talk about but i have to because you saw how manypeople spent all these billions of dollars using arebiologically-based therapies --

- the dietary supplements, theherbs, the foods, the vitamins, the natural substancesand again, this is kind of a big quagmire of everything. and we'll talk about some thatare very recently thought out, some actually have some verygood scientific evidence behind it and i'll mention acouple of those studies and some are just peoplethat are just nuts trying to make a lot of money. so it has a full rangebut when you talk

about dietary supplements. the last one -- i mean thefourth one is manipulative body-based therapieslike chiropractic, osteopathy, and massage. and we'll talk a littlebit more about that. again massage is anotherone that's been a lot of press lately and thenational institutes of health and national center for complementaryalternative medicine now --

have now over $2 and a halfmillion in studies just based on massage right nowin the united states. and the last one is the onethat's a little bit further out there just like it iswith alternative medicine. these are all theenergy therapies. this is the biofield therapies, the bioelectromagnetictherapies. so you think about you know,this goes all the way back to the 1700s wherepeople tried to say,

"if you could just figureout your magnetic waves, you could reallymake people better". and if you think about it, youhave emgs that do your muscles, you have ekgs that doyour heart, you have eogs that do your eyes, you haveeegs, you have all these things. all your body is justreally electric all the time so it seems like ifyou could just try to coordinate all thiselectricity and all that stuff to kind of flow inthe right way,

it would make a big difference. mesmer was this guy backin the 1700s in france. you know he used to putpeople in bathtubs surrounded with magnets and you know, hewore this big hat with a cone on it you know, heactually tried to -- they tried to ostracize him andthen ben franklin was brought from the united states overthere to put him on trial and say he was a quack. and they had all thesethings about having sap go

up in trees and hecould feel it. and it was really, this goesback hundreds and hundreds of years now, this wholethought about trying to really do magnetic therapy. when you think aboutit, you still see it, you still see people whoput magnets in their shoes and magnets in theirbeds and try to hit their back painand their arthritis. there's all these things thatgo along with magnet therapy.

and so again, there'sa lot to do with that but as you can imagine, itwould be very hard to study. so what are a couple of examplesof alternative medical systems? well there's homeopathicmedicine. this is the beliefthat likes cure likes which is very differentfrom what we do. we give aspirin for a fever, tylenol for a feverto bring it down. but if you're inhomeopathic medicine,

you'd actually give somethingthat would cause the fever but you're just giving thema very, very small amount. that's where you get theidea that likes cure likes and the law of similars. so they actually wentthrough thousands or hundreds of thousands of differentremedies to find out what caused certainconditions and then they just give youvery small amounts of it and that's what willmake it better.

so it's very different -- that'swhy it's called alternative. it's like very hard forpeople to kind of grasp it. that's why people always say,"you give such a small amount. oh, don't worry about it. it's a homeopathic dose,it's so tiny of a dose." and they're all giving --if you're giving the higher, more concentrated dose, itactually causes those symptoms. so the notation, if you'veever seen a homeopathic, i'll show it to you.

6x means that theactive substance -- - so say we take somethinglike sulphur and we have a 6x after it, that means thatit's been diluted 1:10 in a water-alcoholmixture and succussed which is shook -- shaken. and this procedure of diluting and succussing is repeatedsequentially six times so that you have onepart in a million for the notation of times six.

so that's why people arelike saying, "oh don't worry about it, it's homeopathic," because there's hardlyanything in there. the thing you haveto remember though about homeopathic is it'snot the law of similars but also the least concentratedit is where it's to the point that it's not evenone molecule in there. that's actually the strongest. so that's the law of dilutions.

that's why people really thinkits nonsense because if it's so diluted, how could itactually have anything in there? and that's where it kindof switches over to kind of more energy medicine becausethere's a memory in the water that when you did thatshaking, that somehow that thing got memory intothe water that you're taking. and when you take that pillor you take that little thing under your tongue, thatactually is very effective. and the more diluted itis, the stronger it is.

so you could see that people, especially when conventionallytrained to think like homeopathy, that's crazy. there's naturopathicmedicine or naturopathy and there's actually threeor four different schools in the united statesthat actually put out naturopathic physicians. and this is a great groupof people if you ever run into a really good naturopathbecause you can see here,

they believe in thepower of the body that maintains andrestores health. they use nutrition, lifestylecounseling, supplements, homeopathy, and chinesemedicine. they kind of practice everything that allopathic medicinedoesn't do. so if you ever hook upwith a good naturopath and you're the conventionallytrained doctor, you have the balanceof almost everything.

so they're actually canbe very good counterparts. and bastyr is kind of thething, this university and they have a lotof collaboration with the university ofwashington in seattle. bastyr? b-a-s-t-y-r. and then there'straditional chinese medicine and again i just want toshow you what these different alternative medicines are. we're not going totalk about them.

these are all lectures inthemselves as you can imagine. that's the belief inunseen vital energy that effects the health and howthis energy or qi kind of flows up and down your body. and that's what acupuncture,acupressure does. the thing you have to remember about traditional chinesemedicine is it's not just acupressure or acupuncture. it also has to dowith herbal remedies.

it has to do with nutrition. it has to do with martial arts. it has to do with fivedifferent things really. they really all work together. so people think abouttraditional chinese medicine as just being acupuncture,but it's actually acupuncture and a lot of other things. and actually the herbal remedies in chinese medicine arewhat's getting a lot

of press right now. and last week there was a big --the allergy meetings in florida, the aaaai, they call them. and there was a lotof reporting on some of the chinese herbal mixturesshowing that they really work and they're very effectivein different animal models for allergies and eczema. and so it looks like there's alot of the immuno-modularly type of things that workwith chinese medicine.

we'll talk a little bitmore about it when we get to the herbal remediesand dietary supplements. but they don't just use oneherb, they usually use five or 10 herbs and they havethem mixed in a certain grade. they have gradations withone that's very strong and one that's very weakand they kind of have like little soldiers like theyall kind of march together. so here's an example of one thati like that's called flu-plus. this is one that -- "hmm, iwonder what you use this for?"

so this is the, you knowyou're supposed to be, in dietary supplementsyou're supposed to not say that you cure or treat anythingbut you always enhance health. well this one enhancesyou not to have the flu. and so you can seethat it has four times and now you all knowwhat that 4x means now, it's been succussedtimes four, 1:10. this one you can seeis one to a million. actually that's ipecac.

you all know what ipecac is. it makes you vomitif you take a poison. pulsatilla, here's a littlemercury, a little phosphorus, here's a little sulphur, here's a little last year'sinfluenza, that's 12 times. so that's like one in a billionpieces so i'm not too worried about you're going toget too sick from that. one in a billion which is morethan even one molecule would be in the fluid and you cansee here's my favorite.

bushmaster's snake venom,there it is right there. it's also is one to 12times x. so you can see that this is a mixtureof what they call more clinical homeopathy. if you actually went to aclassical homeopathic physician, they would nevergive you this mixture because this is a whole bunch ofstuff they just throw together. they would actually getyour symptom, your flu and they really try tocountegorize it to the one thing

that would work the most. and they would give you one,at the most maybe two remedies. and they would actually giveyou a not too diluted one because rememberthat's too strong. and as you got better, they would give you morediluted ones which are stronger. so again, it's an interestingway of approaching things. but this is what most peopletend to buy in the stores now which is a mixture of all thesedifferent homeopathic remedies.

how about energy therapies? they involve energy fieldsor usually two types. the biofield therapiesare intended to affect energy fields. this is like qi-gong, reiki. a lot of nurses use this. you think about therapeutictouch or a natural touch. and this is trying to again,trying to get your energy in the right way to open upyour chakras, to get your things

to flow up and downto really improve. if you've ever seena good qi-gong or reiki therapist,it's pretty amazing. i mean i've watched somebodyactually make somebody's migraine headache go awayright in front of me. she went from being nauseated,in sunglasses to being able to have a full meal right there within ten minutesin front of us. again, that's just one womanjust standing over her,

never touched her,but just trying to move her energy around. so it's -- yeah shedid the reiki method. bioelectromagneticenergy is what i talked about a little bit earlier. electromagnetic fields such aspulse fields, magnetic fields or alternating currentor direct current fields. and again, this is all this idea that you have all thisenergy running through you.

and if you just try to figureout how to get your ekgs, your emgs, your eegsall to work together, you can imagine youshould feel a lot better because there should besome kind of disconnect if you're not doing well. so let's go on to -- thelast one is manipulative and body-based therapies. and most people think aboutchiropractic as being one which is it focuseson the relationship

between bodily structure orthe spine and the function. that's for the kind of highvelocity, low amplitude. that's when you getcracked, right? and that's why youusually do a lot of different therapies for that. osteopathic manipulationactually emphasizes diseases rising from the musculoskeletalsystem. the body systems work together and the disturbancesin one system.

people don't realize this butthere's six major categories of osteopathic manipulation withover 100 different techniques. so in the '60s and '70s, mostosteopaths kind of quit learning about osteopathic manipulation. they kind of became morequote conventional doctors. now it's making a big comebackand even in the santa cruz, monterey, salinas areas,there's osteopathic physicians who don't do anyconventional therapies. all they do is manipulation.

and they do cranio-sacral; they do the high velocitylow amplitude ones like the cracking the back. they do different typesof lymphatic drainage. they do musculoskeletal;they do pressure points. they have all thesedifferent ones they do. and some of these places, like when i was givinga talk last year at the barbara bushchildren's hospital in portland,

they had a lot of osteopathicmanipulations going right on in their inpatient,even in the ed. so they, some hospitalsespecially in the midwest and the east coast havereally embraced osteopathic manipulation as beingacute therapies. and massage therapistsmanipulate muscles and connective tissue to enhancefunction of those tissues to promote relaxationand well-being. and there's been quite a fewstudies actually supporting the

use of that as well. so now let's move to research. there's been multiple studiesshowing the most popular treatments are dietarysupplements, much to my chagrin. there's evidence lacking even for the most popularones, even in adults. and the institute of medicinesaying that "the same principles and standards of evidence oftreatment effectiveness apply to all treatmentswhether currently labeled

as conventional medicineor cam." so really if you'regoing to use something, you really should have some typeof evidence to support its use. and maybe it doesn't have to belarge, randomized control trial like you do for drugs, but ithas to be some type of evidence where you actually tryto study it and show. and sometimes itcould be historical; sometimes it couldbe traditional. but most of the time theinstitutes of medicine would

like to have sometype of research. and there's very few studiesthat are done very well in part because they're notvery well-funded which is another whole story. so funding in researchis growing but is still relativelysmall for totals. so if you look at some ofthe studies that you look at that have shown to beeffective, here are the ones. this is from the archives ofdisease in childhood article

about six years ago and theythought this was well-documented now that biofeedback forconstipation and headache, hypnotherapy for headacheand irritable bowel syndrome. so you can see mind-bodiesare really embraced and they are reallyfelt to be part of almost standardprotocols now. lemon balm for herpes simplex,massage for constipation, these are all ones thathave enough studies that people now cansay these really work.

these are uncertain, maybeacupuncture for asthma, acupuncture for hay fever,for rheumatoid arthritis. chromium for diabetes was abig one in the '60s and '70s and even up into the '90s. it's just like, if you justgive enough chromium a lot of diabetes will get better. now cinnamon is one that's takenover for a lot of diabetes. echinacea for the commoncold, evening primrose. and unlikely is some foracupuncture that you could see

over there for smoking,for weight reduction. flower remedies for anxiety,homeopathy for anxiety. again these are veryhard studies. you can imagine now justafter i give you my talk about what these are, howcould you really study these in a large group of patients because everybody'sso individualized? so again, this is what they felt to be effective andnot effective.

how about the useof supplements? well alternativehealth supplements in the 2002 nationalhealth interview data on ten common herbs: of30,000 adults, 19% used herbs in the past 12 months. and in 57% of those, 20% whichis a large amount used them for a specific condition. what was interesting isthat approximately two out of three used herbs exceptfor echinacea was not even

in accordance ofevidence-based indications. so they were goingto health food stores and they were buying thesedifferent herbal remedies and they were using them for different indications noteven what was on the bottle in the health food stores. so again, even thoughit's really used and is really used commonlyby a lot of adults especially, they don't even use it forwhat's commonly practiced

in the health food store. so again, it's kindof a really mixed bag. you can see why alot of families and children don't reallyhave a lot of direction because there's nobody reallytelling them what to do. it's usually what your neighbortold you, your auntie told you, your grandmother told you. and you might try it justbased on what you saw even in a newspaper or ina magazine article.

so how about studies supportingconventional medicine? i always like to throwthis slide in here just to remind people that there wasthis nice article in archives of disease of childrenway back in 1999 where they did 240 consults and 1149 clinicalactions were performed. good evidence was found bya randomized control trial or other appropriate study foronly 40% of the 629 actions. so of all those ones in ahospital, there were only 40%

that were evidence-based. so that's why when people say, "oh you can't usethese herbal remedies. you can't use thismind-body stuff. you can't use these energymedicines, alternative therapies because there's noevidence behind it." i can tell you that 40% ofthe time that what you do in the hospital doesn't haveany evidence behind it either. and you can even seenon-experimental is 7%,

inconclusive for 25%. there's actually evidenceof ineffectiveness for .2% and no evidence at all foralmost a third of them. so you can see thepeople are just like, "oh, it makes sense to me. i'll just try it." and since i'm a doctor,there's evidence. so it just shows you how thewhole kind of mindset kind of happens especially inthe medical community.

there was one even lookingat surgery interventions in a regional pediatricsurgical unit. this is about as old. of 281 patient interventions,11% were based on controlled trials, and66 were on non-convincing, non-experimental evidence. if you think about surgery, that's kind of howsurgery developed. it's like, "i don't know ifthat kidney transplant's going

to work. let's just throw one inthere and see what happens." and then after --after a few, five, 10, 15 years they actually startedto work because it's very hard to do a randomized control trial for something that,like a surgery. i mean you can't say, "well,i'm only going to take out half the appendix." usually you're goingto take it out

or you're not goingto take it out. so again, it's very hard todo these types of trials. but people give youall types of grief for not having good evidencefor doing alternative medicine when a lot of things that we do in conventional medicine doesn'thave much evidence behind it either. so really what youwant to do is you want to figure out the parts.

so there's all thisalternative medicine, there's all thisconventional western medicine. and integrative medicineis trying to take the best of both parts. you want to use conventionalwestern medicine that has the leastamount of side effects, that's most effective, thathas the best safety profile and you want to take alternativetherapies that have shown to be clinically effectiveto be safe and you want

to marriage those two together. that's really the mostimportant thing to do. and really, you have tobring in the patient's values because what they -- you cansay acupuncture, acupuncture, acupuncture and if theperson does not want needles, it's not going to work. i'm sorry; it's not goingto make a difference. so you really have to bringin what they think too. you have to look at theresearch, you have to look

at the clinical data,and hopefully you'll come up with the optimaldecision by trying to marry all thosethree together. so how about biologicallybased therapies? well biologicallybased therapies or dietary supplements are usedin herbs, foods, and vitamins. they include all the dietarysupplements and herbal products that are used inso-called natural therapies. the dietary supplement healthand education act, the dshea act

of 1994, this is what kind ofthrew everything into chaos. there was a tom harkin whowas a senator from iowa and i just blanked his name --what's the senator from utah? orin hatch. now you think that thoseguys don't have anything in common, right? one's very republicanand very right wing and one's very liberaland very democrat. but they got together andthey wrote the dshea act

because in iowa and utahare two of the hotbeds of dietary supplements,where they're made. and they were saying, like,"we don't want the fda to regulate this stuff. these are really justnatural substances. they're like foods. they should be regulatedlike foods." and so they wrotethe dshea act in 1994 which acknowledges thepotential health benefits

of dietary supplements whichmust contain vitamins, minerals, herbs or botanicals, amino acidsor any combination of these and may affect the structureor function of the body. so that flu-plus isnot a very good name. i mean they couldactually get into trouble for calling it flu-plus. but like if you have jointpain, you have to have something like joint-health, youcan't say arthritis. if you have some type likeliver, you can say liver-health;

you can't say hepatitis. you can say anythingto promote the health, but you can't say it willactually treat a disease. so that's where youmake the distinction. so when you look at a dietarysupplement, you should look and if it makes a claimthat it's going to treat or cure something,that's actually a red flag that maybe that's nota very good product. because really, whatthey're supposed to do -- -

the ones that reallyfollow the law are the ones that enhance thehealth in that area. it cannot claim to cureor treat a disease. that way they don't need anynew drug application process which is millions and millionsof dollars, all that safety, all that animal data, all thatlab data, all those trial one, two, three, all thosehave to do that. all you have to do is justput it in a pill and put it in a bottle and put it on themarket and you're good to go.

there's no quality control, there's no good manufacturingstandards enforced and no oversight by the fda. they actually changedthat in 2007 but the fda was never fundedto actually make a difference. so actually it'sstill not regulated. so you know there's -- - i'lltalk about it in a minute, but there's things youcan do to try and figure out which ones are safeand which ones aren't safe.

but right now, it'skind of chaos. the herbal industry at firstdidn't really care about this because they were sellingeverything off the shelves. in the late 1990s andearly 2000s, they started to have more problems like youmight remember the kava-kava causes some typeof liver problem. there was this that saint john'swart causes problems with people who had aids who weretaking hiv medications. so then they thought,"oh my gosh".

people were reallystarting to -- all their sales startedto drop off. so now they're actuallytrying to, actually try to policethemselves. so certain groups areactually trying to make some of their products much moresafe and much more reliable. here's the different approaches. i think this is actually oneof my more important slides that i talk aboutdietary supplements.

there's traditional use,like the western approach. these are the folkmedicinal traditions. these are like your teas, yourtinctures, your poultices. this is what your grandmamight have taught you. this is what your curanderomight have taught you. this might be what youraunt or uncles used to take when they were in the oldcountry whatever that is. this is all the kindof the western approach for folk medicine andthese don't have a lot

of studies behind them butthey have thousands or hundreds of years of traditionbehind them. so a lot of times these on onesthat have been very effective. there's indigenous use, nativeamerican, polynesian and a lot of times, these aredrinks or even smoking of certain substances. there's chinese andayurvedic and again, i mentioned earlier theseare using multiple herbs. they give it to you in apaper sack, you go home

and you make it intoa concoction or a tea. usually they really smellawful, they really taste bad and they give you a bellyacheand kids really hate them. but these are actuallysome of the ones that have the mostresearch behind that shows them tobe most effective. but they're hard for pediatrics because they don'ttaste very good. and there's homeopathy i talkedabout which are tiny doses

of mineral, plants oreven animal products like snake venom. then over here is thenon-traditional use and this is based on theory. like glutathioneis an antioxidant. so these guys thought, "well youneed antioxidants in your lungs, so let's just nebulizesome to your lungs and let's treat cysticfibrosis with it". and they must makethis whole thing up

and people just started usingit all across the country. it was written up in oneof the women's articles, women's magazines and prettysoon everybody was using it. in fact to the point that thecystic fibrosis foundation had to come out witha policy statement because everybody just startedusing inhaled glutathione based on nothing exceptthat the theory that if you could take itorally, it must be good if you take it nebulized.

combination therapieswhich i think is one that really drives me crazy isthat you'll find if you pick up a bottle of dietarysupplements, you'll say, "there's a chinese herb. there's an ayurvedic herb. there's a western herb. there's a mineral. there's a vitamin." they just mix everything inthere so if you have something

to do with joint pain,they'll take every tradition, and they'll take a littlebit of that herb and put it in one capsule and chargeyou a lot of money for it and say that it works. it makes no sense. why would it work? you don't know whatthe interactions are. you don't know howthey're all going to do. so i always tellfamilies and patients

that if you see somethingthat has like lots of different things init that come from lots of different backgrounds, that's not usually a very gooddietary supplement to take. yeah so vitaminsare another one. you know again, vitaminsare like i said earlier, that if you take a low-dose,it's supposed to be okay but if you take higherdoses and you mix them in with a lot of things.

so with vitamins,no one really knows. the thing you have to beworried about vitamins is that sometimes you'll betaking one say that has so many international units ofvitamin a. then another one has so many units of vitamin a.it's kind of like acetominophen. pretty soon you'regetting toxic on vitamin a because you're taking allthese different herbal remedies that have all that in them. so you really have to lookat everything very carefully.

here's one i justlike on garlic. you can see here,depending on the intended use by the manufacturer, garlicproducts are classified for regulatory purposes inone of eight categories: conventional food,dietary supplement, food for special dietary uses,biological, drug medical device, cosmetic, or food additive. so you can take garlicfor about anything. you can say that it helps allthese different areas depending

on how you take it. so garlic is one of these things that traditionally have beenused for a very long time to help you withall kinds of things. it kind of dependson how it's marketed. you could see how it's eitherregulated or not regulated. so these are things that youthink and again i was going to mention this earlierthat anybody wants any of these slides, you can justask nancy or felice there

at the end and they'llhave email addresses. they can send you all the talk; some of these arevery nice to have. here's the national center of complementaryalternative medicine. it's become a verygood website in a lot of ways, for definitions. it has some herbal remediesthat you can look up and it has some monographs.

the office of dietarysupplements, medwatch, cam which has todo with research and the canadianhealth directorate. but the best oneprobably in this slide for government sitesis the national center for alternative medicine. there are academic sites. there's the boston-longwoodherbal task force. this is actually a great one.

this one has to, ifyou look up echinacea, it has all the animalstudies, all the human studies. it has a monograph. it has one that you couldhand out to parents, a one-page like this worksand this doesn't work. so this is one that was done upat boston children's years ago. university of pittsburg,beth israel, columbia and even berkeley still hastheir good old wellness letter which is still veryeffective and very nice

and they really tryto keep it up to date. there's herbs andcourses you can take like the dietarysupplements by wake forest. and this is one of myfavorite ones i'll talk about which is consumerlabs.com and this is one that you actuallyhave to subscribe to. and what it does, every monthit takes a commonly used dietary supplement and it takeslike 15 to 20 popular brands and it actually looksto see what's in them.

so they're not paid by anybody. so you go look and see. and what you do, when youcan start looking at it, you can start getting the ideas. "well this company seemsto be always spot on. this company seemsto be always way off. so maybe i should startbuying my herbal remedies from this company." so i can't really tellpeople what to buy anywhere

because it's all sorichly different. i mean it's evendifferent in santa cruz than it is in palo alto. so again, every onedepends on what you have but this is actuallya very good website. the natural medicines and comprehensive databaseis also a very good one. this is one especiallyfor medical types. this one really tells youabout all the, it's like a pda

for herbal remedies anddietary supplements. so this tells you allthe up-to-date studies that have ever been done onthese different medication. and the same way for nutritionand dietary supplements. so if you go to the nccamwebsite, here's like this, i just took one of their pagesand just put it on this paper. you can see like here's allthese things you can click on to learn about; all thesedifferent ones you can see. so if you hit on dietarysupplements, here's all the e's

and the g's and the h's. you can see there's theintroduction to naturopathy, you can see grape seedextract, you can see what's new, past highlights, andthen you can subscribe to their newsletterand their e-bulletin which is also very good. so when you do a resourceevaluation, say you're going to a website and you'retrying to figure out, "is this a good website?

is this not a good website?" i always tell people,what's the introduction? who runs the site? who pays for the site? i mean they're askingyou for information. they ask you for acredit card number. they ask you whatyour address is. does your computer pick upspyware when you go there? i mean these are all thingsyou want to know about.

what's the purpose of the site? does it actually help you ordoes it try to sell something to you and how muchadvertising is there? where does the informationcome from? what's the basis oftheir information? sometimes they'll say'references' and you go look at the references, they'reall like in 1966 and they're in china and they allhave to do with dogs. so that's probably not thebest references for somebody.

some of them are very good. some are right up to date. some have been done locally. some have been done atsome of the osteopathic or naturopathic colleges. how is the information selected? how current is it? where does the site choosethe links to other sites? you know, where doesit kind of link you to?

and what information about youdoes the site collect and why? so this is all fromnccam as to kind of how to resource whether asite is any good or not. and how does the site manageinteractions with visitors? so this consumer labs imentioned, this is a nice one. it's a provider of independenttest results and information to evaluate health, wellness,and nutrition products. they get about 2.5million visits per year and has a certification.

and actually you can on thebottles, you can get the cl. they've actuallybeen tested by cl. sort of like the goodhousekeeping seal of approval. it enables companiesof all sizes to have their productsvoluntarily tested and that way theyget the cl seal. in the past seven years, they'vetested more than 1,800 products, representing 350 differentbrands and supplements. a one-year, 12-monthsubscription is only $27

so really it's veryinexpensive and if you're into dietary supplements,especially if you have families and patients coming to seeyou, this is a very nice one because you could lookit up very easily. natural products encyclopediaand there's a free newsletter. another one i like is thenatural medicine database. this again has a search method and again this one alsocosts about $30 a year. and you enter the naturalproduct names like echinacea

or you can enter a diseaselike migraine headaches or you can do a condition likefibromyalgia or a drug name. it gives you objectionalproduct information, effectiveness ratings andpotential interactions even with conventional medicines. so this is a very nice one. you can actually searchin a lot of different ways to give you a lotof good information. the natural producteffectiveness checker tells you

the level of effectivenessfor natural products. so it has a gradiationfrom 'a' to 'd'. this one's an 'a' -- it hasa lot of history behind it. it has a lot of researchbehind it. it looks to be very safe andvery efficacious all the way to 'd', maybe it'snot even that safe. and then 'c' with a lot ofmiddle like in the middle, we don't have much about it. it has a natural productdrug interaction checker.

it tells you potentialinteraction between any natural product andany drug which is very important because people always mixand match all this stuff, and you have no ideawhat's going to interact or not interact. the disease medicalcondition search which shows you medicalcondition. it allows you to see which natural productsmight be effective.

so you can see, it'll actuallyshow you: here's a western one, here's an ayurvedic one,here's a mix of chinese ones from traditionalchinese medicines. so you can kind of get a mix as to all the different ways youcan approach a certain condition by looking at dietarysupplements. you actually can searchcolleague interaction. it shows you questions,answers, and comments posted by other health professionals.

so you can say like, "itried this on my patient and they had thiskind of reaction." and colloidal silver isone of my favorite ones. colloidal silver is thisthing that people considered to be a natural antibiotic and you can actuallymake it yourself. and if you take itit's supposed to cure, i think the last timei looked it up online, it can cure like 1,000different diseases.

the thing is if you take it toolong or you take too much of it, it actually causes you tohave permanent discoloration of your hands and your skin. it actually, the silvergets out into your hands and into your skinso it's always there. and there's some families insome parts of the united states where everybody lookskind of blue because they all have thiscolloidal silver that's into their bodies andnever can go out of them.

so again, it can be -- and wehad written up a case a couple of years ago in a cysticfibrosis patient in denver who thought that wouldreally be the new approach to treating theirchronic lung infection. and they got all thiscolloidal silver involvement. there are also supplementsand books out there. the abc clinical guideto herbs by blumenthal. again, it's a very good book. blumenthal's kind of 'the'name in natural products.

contraindication and druginteractions by frances brinker. he's at the universityof arizona. he's a naturopath;he's very good. integrative medicine by daverakel, integrative pediatrics by tim culbert and olness. she's in cleveland and timculbert is in minnesota. then there's the journalsof herbal pharmacology, the journal of alternativeand complementary medicine, alternative therapiesin health and medicine,

and evidence based complementaryand alternative medicine. these are all verynice journals. and we can get almostall of these now on lane here at stanford. so i'm just going to give youa quick example of a couple of things we might see. for cystic fibrosis, theseare all just a smidgeon of all the ones i've heardabout in the last five years. and again you can see thatpeople use probiotics,

b complex, all thedifferent vitamins and again, vitamins is like a funny mix. it's like, it could be just finebut if you're taking high doses of vitamins like mega-vitaminsthen it becomes a little bit different. all these different ginko,garlic, ginger, echinacea, essential oils inhalation. we sometimes find inhalation of different essentialoils can be very powerful.

lipoic acid, especially for cystic fibrosis-relateddiabetes. and actually lipoic acidis actually used by a lot of endocrinologists rightnow for even standard, especially if you have any type of neurological sideeffects from your diabetes. milk thistle to helpprotect your liver. grapefruit seed extract, baker'syeast, green tea, airborne. everybody knows aboutairborne, right?

you get that before youget on the airplane. it's all, it's a mixture,it's not just homeopathic. it's got some homeopathic; it'sgot some chinese medicines; it's got ayurvedic medicines;it's got some vitamins in it. and people will swearby airborne. you know, "i get airborne and inever get sick on an airplane." coenzyme q-10 which again, forcardiology, for heart strength, that's one that's almost notconsidered alternative any more. a lot of cardiologists nowuse it for their patients.

and then all these ones,or most of these have to do with a very strong antioxidants. gingseng, licorice, boswellia. these are ones that are fromfrom the ayurvedic and india. and pycnogenol -- - therewas just a cochrane review on pycnogenol because it'sreally promoted for asthma and all kinds ofchronic conditions. so it's one that's been verypopular and it actually has to do with frenchwhite pine bark,

is where pycnogenol comes from. i just wanted toput the one study that was done just two yearsago on pulmonology looking at probiotics andcystic fibrosis. and we found out that studies offecal calprotectin concentration and rectal nitric oxidehave found to be increased, suggesting a constantintestinal inflammatory. so your gut is really fullof a lot of inflammation. so people feel like if you couldjust decrease the inflammation

in your gut, you can actuallypromote health elsewhere including your lungs. and so probiotics have livebacteria you give orally. it's to decrease theseverity of gastroenteritis and prevent atopicdiseases in children. and the mechanism maybe through improvement of intestinal barrier function and through modificationof immune responses. so we know that children whoare born by cesarean section,

they don't get that samevaginal flora, they sometimes, or they have a lotof antibiotics in their first year of life. those children sometimes goon to have more lung problems. so this whole idea ofreally getting the right, proper type of bugs in yourgut from the very early on can actually bevery powerful. so they did 10 cf patients withmild to moderate lung disease and pseudomonas colonizationwere treated

with lactobacillusgg which is one of the most commonprobiotics that are used. and the pfts didn't change andthere wasn't really a change in sputum but theydid find a reduction of pulmonary exacerbation rates. and then they got sickless often and had to come into the hospital. this is just a cartoon to showyou about what people think. you have all these pathogens,

allergens cominginto your lungs. and if you have all this stuffin your gut, it helps you. with this probiotic itactually blocks all these inflammatory responses. so again, this is fromchest which is one of the more traditionalconventional therapy journals for pulmonary physiciansand they have a whole thing, a whole article just onprobiotics and lung health. and then here's some dietarysupplements for asthma

and allergies you can see. again, here's butterbur,pycnogenol, vitamin c, magnesium and the ones that arein blue are all the ones that actually havehad some studies. ma huang or ephedra is onethat's been off the market now for the last few yearsalthough you can still get it on the internet. that's because people weremixing it with caffeine and other dietary supplements.

and that's when all theseathletes were having all these seizures and heart disease because they were takinghigh doses and going out and trying to over-exercise. but it used to be, it was a veryeasy one to use for children with very mild bronchospasm. and they had one that'scalled breathe easy tea that we used to use a lot. and it was for children thatjust got a little bit of wheeze

when they had a littlebit of viral illness. and people wouldreally overuse it so they took it off the market. so here's just some otherones too for allergies. you can see that there's allthese different ones out there and every day peoplewill ask me about one that i've never heard of. so there's so many dietarysupplements out there. so let's move into the nextgroup which i like the most.

which is kind of your mind-body. so these guys areall meditating. you can see this guy -- he'sgot the legs going here. so mind-body therapies area cognitive behavior therapy that encompasses severalapproaches: relaxation, breathing, biofeedback,hypnosis, and guided imagery. in fact, these are ones thatare almost considered to be, have so much evidence behindthem anymore they're almost not considered to becomplementary alternative.

although there'restill people who feel like they just makeyou feel better but they don't reallydo anything for you. they just make you feellike you don't have disease or they make you feel likeyou don't have lung problems, but actually there are somestudies now showing they actually decrease theinflammatory response in all different types of situations includinginflammatory bowel disease,

arthritis and even asthma. but theories based on decreasingthe inflammatory process that can be triggered byautonomic nervous system through strong emotions. and if you think about it,asthma back in the '60s and '50s used to be consideredto be a psychiatric disease. because kids would get soanxious and adults would get so anxious, they actually usedto treat them with phenobarbital to try to sedate people.

they found that they got better. that's probably becausethey reduced the anxiety, there was a very strongautonomic component to it and actually it wouldenhance bronchial dilatation. so i'm not saying you shouldsedate your patients with asthma when they're having a reactionor having an asthma attack. but again, if youcan calm them down and you can havethem do relaxation, you can have themdoing belly breathing,

you can actuallybreak a lot of people who have respiratory issues. stress has been associatedwith higher morbidity and cytokine levels attributedto airway inflammation. and now they're even doingstudies in pre-term babies and mothers and looking attheir stress level and find that the kids that have, the mothers that have evenmore stress prenatally and postnatally, theirchildren have more problems

with inflammatory diseases. in addition to anxiety,stress is shown to influence the immune response and prevent increasedsympathetic activity, promote airway inflammationwithout overt symptoms. and the way i remember thatis that they had a group of patients with moderate asthmawho were college students. and they did inducedsputums on them. and even though they werehaving normal lung functions,

they were havingno symptoms at all on their induced sputums duringtimes of finals and midterms, they actually showed theyhad an inflammatory response in their sputum. even just the stress showedthey had more inflammation in the lungs even whenthey had no overt signs. their lung functiondidn't changed at all and they had no wheezingor cough. so self hypnosis, breathingexercises including yoga,

relaxation with or withoutguided imagery have all been studied. and imagery and selfhypnosis have been shown to decrease shortness of breathin asthma and abdominal pain in children withrecurrent abdominal pain. and often these services areavailable in most communities. actually anybody in this roomcan be taught how to do imagery, taught how to do hypnosis, taught about howto do relaxation.

they're very easy to do. in some services, it'sthe social workers, sometimes it's the nurse,sometimes it's the doctor, sometimes it's the mas, sometimes the respiratorytherapist. almost anybody in a medicalsituation can be taught how to do some of these mind-bodyrelaxation techniques. and breathing exercises may alsohelp, especially deep breathing and yoga and martial artsand that's one of the ones i

like to use for littleboys especially. they all want to takekung-fu or karate and it's actuallyvery good for them because it really teachesthem control and really how to use all their lungs and ittends to be very disciplined. so there is a pilot study ofmind-body changes in adults with asthma who practice mentalimagery, that was in 2004. there's effect of self-hypnosison hay fever symptoms in 2005; hypnosis and asthma: acritical review in 2000.

again, these are allpositive studies showing that all these work in all thesedifferent areas of lung disease. biofeedback -- -interventions where you look at heart rate variabilityand abdominal breathing. and heart rate variabilityalone, placebo eeg feedback, and wait control in 94adults with stable asthma. medications were titratedfollowing the symptoms, lung function and peakflow meters were monitored. and the ones that had the heartrate variability groups were

given less medication,decrease in severity, improved lung function. and they all got betterjust using biofeedback. so it's a very powerfulone for children and adults who have respiratory symptoms. so behavioral interventionsin asthma such as biofeedback, overall the evidence wasas an objective treatment in asthma is meager but theyonly reviewed 12 studies. so what is progressiverelaxation and guided imageries?

so i'll just kind of walk youthrough what i use with my kids when i did a study down atthe university of arizona. we took children who hadmild to moderate asthma. they were on medications. they were stable. they had normal lungfunction tests. and we introduced thegoals and techniques, discussed the importanceof practicing, modeled the practice techniques.

we identified theirsensations with relaxation such as warmth andtingly feelings. we identified relaxationas a positive feeling and we introduced this to guidetheir asthma reduction imagery. so what you do is -- has anybodyever done a guided imagery or relaxation? so again, you can see that youtell a child that it's going to consist of learning to tense and relax variousgroups of the body.

so they tense them upand they relax them. you can move top to bottom. you can do it alldifferent ways. usually you start at the topand you move all the way down. and you go through while at thesame time you pay very close and careful attention tothe feelings associated with both tensionand relaxation. because when they get an asthmaattack or they have some type of problem with their breathingor pain, you want to associate

that with a certain feeling. sometimes that'sthat tense feeling. so they get an image of whatthat seems like when they have that tense feeling andthen when they relax it, they get another image of what that image is whenthey relax it. so it's very, andthe kids are great. if i had to do it foryou guys in this room, i'd have to turndown the lights.

i'd have to have you all sit up. you'd all have to you know,close your eyes and put you to start taking deep, nicebreaths and start to think about and try to clear your mind of all the other crapthat's going on there. but for kids you can say,"okay, i want you to relax." "okay." "i want youto have an image when you think about something." "okay." i mean they'rejust like right there.

they can go just right there. you can just do imageryso fast with children because their mindis already there. we beat it out of them, wesay, "quit daydreaming," you know, "pay attention." "get back here." but you know we kind of beatit out of kids by the time that they get to be in juniorhigh or high school or college. but little kids especially8, 9, 10, 12 year olds,

they can go rightthere, right away. they're just like,"okay, i'm right there." and you start off by runningthrough each muscle group and modeling for each childhow to tense and relax. and you practice thistensing and releasing twice. after each tensionand relaxation, you ask the child what it feelslike and it's important for them to tell you what they feel like. you don't want to put toomany images in their mind.

you don't want to tellthem, "oh you feel like it's something -- ". they may not like that image. so you want to be very carefulwhen you try to do imagery. you want to make sure you usethe image of what the child or the young adult is using. and then you wantto know what that's like when they're relaxing. and then you tell the child thatwhile his body remains relaxed

that you're going to askhim to do some imaging. and you ask him that when wasthe last time they had a tickle in their throat or felt like they were havingtrouble breathing and try to imagine what thatwould look like. you get all kinds of ideaswhat they might come up with. i mean it's really amazingwhat they'll come up with. and sometimes it'sstuff that makes sense, sometimes it makes no senseat all, but it doesn't matter

because that's their imagefor whatever they're having. then you ask the child todescribe what it's like. is it tight? is it heavy? is it cold? does it tickle? you really try to get themto use all their senses. do they feel somethingon their face? do they feel somethingon their skin?

do they smell something? do they hear something? you really try touse all their senses. and they really get into it. they really say, "ohyeah, i do this," and they're reallytelling you all this stuff. and i had this littlegirl that had migraines. and she was telling mehow it was like a rose and she could smell it andthe smell would go away

and it would get really right. and it would really likeclose up all the way. and she would -- andthorns would get bigger. i mean she really gotinto this whole thing about what the rose was doing when she had thismigraine headache of hers. then you have to imagine whatthe discomfort would look like or come up with a mental pictureof what the pain could be like. if they're having difficultybreathing, you can give examples

like a block of ice in thethroat but i don't even like to do that with them. i like to just let themdo their own imagery. and then you reinforcethe description and encourage thechild to elaborate on details and clarify. like i said, the colors,the sounds, the involvement. you really try to getthem to go for it. then you tell the child thatthe clearer the image is,

the more powerful thepain reliever will be. so really when theyget it specific, then when you make itbetter, it's much better. so you want to make it reallyspecific and then you want to make what makes itbetter very specific too. and when the child has aclear image of the discomfort, you ask them, "wellget rid of the image." and you can image like theblock of ice or for the rose or whatever you canimagine, the kids will come

up with somethingvery quickly with how to make that much better. and you guide the child to describe the second imageincluding how the second image may make the pain disappear. and you ask the child toimagine the second image to make the firstimage disappear and you notice thegood feeling that comes with the less discomfort.

so you have them go throughthe whole thing again. how do they feel, whatdoes it smell like, is it cold, is it warm? what's the air like? you know, how are they feeling with all these differentthings you try to put together. and then you do thispost-session reinforcement where you reinforcethe effort of success. you describe thepractice, you tell the child

to practice at leasttwice a day. they should use theirrescue inhaler if they have asthma beforepracticing techniques because if the child hasbreathing difficulties because you don't want to putthem into an asthma attack by having the badfeeling about it, right? you don't want to sayi want you to practice when you can't breathe. so when they need to, youhave them actually take their

albuterol inhaler or oneof the rescuers prior to doing their relaxationtechniques. do not tell the child tostop using medications if they need them,especially with the exercises. and when you developa plan with the child about practicingthese techniques. and he or she shouldbe in quiet place with privacy when practicing. and ask the child where andwhen they might practice

because they'll come up withall kinds of crazy ideas about when they'regoing to do it and how they're going to do it. and so some of the images thatcame up -- - you can imagine, this is a little childthat was having problems with the breathing, it waslike a fish out of water. i think it was either anadvertisement i think i saw on tv last night where theyhave a fish that's like flopping around on the ground

and it shows you like,they can't breathe. and they give him the medicationof course and throw it back in the water and itswims away, you know. but you could see ifyou just do that image without the medication, itcould also be very effective. you can have flowersopening up and closing. these are ones thatpeople have told me about. we had a big fire intucson when i was there. and the whole catalinamountains were

on fire for about two months. so one person was tellingme about their asthma, it felt like their whole life, like their wholechest was burning up. and so that was onething which they gave. this is like a fireworks displayabout trying to open up things and it gets much better. you can see an ice pick in thethroat is always a popular one. darth vader was very popularfor a while [raspy noises].

the elephant that pusheson your chest, the giant, the giraffe withthe very long neck, these are all very powerfulimages that kids came up with while i wastalking to them. and so that's kind of my talk. this is one that i actuallyused to put in as a joke. but actually, havepeople seen this? this is not a joke. this is one that just came out.

it just came out on themarket just about a month ago. it's aeroshot. you can see it hereit says "pure energy. dry energy shot dietarysupplement. breathable energyanytime, anyplace." it's actually caffeinethat you [sucking noise]. it's about the sizeof a lipstick. and so the fda did not letthis one get past them. they saw this one.

now they're saying, "wellyou're really not supposed to inhale it." but this is after it justcame out on the market, just in the last couple weeks. and so it's beingstopped by the fda. so this is one that people cameup with the idea, it's like, "well you don't wantto drink your caffeine, we'll just give it toyou in an inhaler." [sound] take a shotand it's about the same

as a strong cup of coffee. so thanks and if you haveany questions let me know. applause.