Manual medicine diversity: research pitfalls and the emerging medical paradigm

              Mein et al • Special communications JAOA • Vol 101 • No 8 • August 2001 • 441
Manual medicine covers a broad
spectrum of techniques, including
soft tissue treatment and high-velocity
low-amplitude (HVLA) thrusting. In
osteopathic terminology, these and many
other manual medicine techniques as a
whole are commonly referred to as osteo-pathic
manipulative treatment (OMT).1
Although many osteopathic physicians
take the variety of techniques for granted
because of the rich heritage of their pro-fession,
there remains ignorance of man-ual
medicine diversity in the healthcare
community at large, and this has led to
serious shortcomings in current research
methodology with regard to manipula-tion.
Consequently, the role of manual
medicine in the emerging medical
paradigm is uncertain.
Healthcare services that use manual
medicine include osteopathic medicine,
chiropractic, physical therapy, and mas-sage
therapy. Specific types of practi-tioners
often rely more often on certain
techniques or sets of techniques than do
other practitioners (for example, long-lever
techniques with osteopathic physi-cians,
HVLA adjustments with chiro-practors),
but there remains considerable
diversity within manual medicine–ori-ented
professions and significant overlap
between them. However, the research lit-erature
often fails to reflect this diversity.
For example, one recent study of treat-ments
for low back pain refers simply to
“chiropractic” in the abstract and
throughout most of the article, as if a
general set of modalities were being
applied (the article only noted briefly that
side-posture, HVLA adjustments were
the only chiropractic modality used).2
Early osteopathic physicians used a
variety of articular and nonarticular
approaches to achieve their goal of nor-malizing
blood flow. They used general
mobilizations (the osteopathic “general
treatment”), long- and short-lever manip-ulations
of the entire musculoskeletal sys-tem,
strain-counterstrain, and specific
pressures (“stimulation” and “inhibi-tion”)
to influence and regulate sympa-thetic
nervous system functions. Also,
drainage techniques were part of com-monly
accepted practice.3
Early chiropractors, with the goal of
normalizing nerve function by reducing
the vertebral subluxation, were some-what
more limited in their approach, rely-ing
primarily on HVLA thrusts. As time
has passed, chiropractors have added con-siderably
to their body of therapeutic
applications, broadening their range of
manual articular techniques; adding man-ual
reflex and muscle relaxation tech-niques;
and incorporating nonmanual
therapeutic modalities, such as electrical
and thermal modes of therapy, bracing,
casts, support, traction, and nutritional
counseling—all of which have been ben-eficial.
However, in their research
approach to demonstrate the validity of
manual medicine, chiropractors have
focused almost entirely on the HVLA
spinal adjustment, ignoring the diversity
of other manual techniques with claims of
effectiveness.4
Problematic research
methodology
Two well-publicized studies reported in
leading medical journals illustrate the
potential methodologic problems associ-
Dr Mein is medical director at Meridian Institute,
Virginia Beach, Virginia, where Mr McMillin is
program director, Dr Richards is director of
research, and Dr Nelson is a clinical
researcher. Dr Greenman is professor emer-itus
at Michigan State University College of
Osteopathic Medicine, East Lansing, Mich.
Correspondence to Eric A. Mein, MD,
Meridian Institute, 1853 Old Donation Park-way,
Suite 1, Virginia Beach, VA 23454.
E-mail: meridian@meridianinstitute.com
Manual medicine diversity: research
pitfalls and the emerging medical
paradigm
ERIC A. MEIN, MD; PHILIP E. GREENMAN, DO; DAVID L. MCMILLIN, MA;
DOUGLAS G. RICHARDS, PhD; CARL D. NELSON, DC
Special communications
Recent studies published in leading medical journals have concluded that chiropractic
treatment is not particularly helpful for relieving asthma and migraine symptoms
because even though study participants showed notable improvement in symptoms,
those subjects who received sham manual medicine treatments also showed
improvement. Yet the sham treatment received by control groups in these studies
is reminiscent in many ways of traditional osteopathic manipulation. This seems
to represent not only a failure to recognize the value of many manual medicine tech-niques
but also an ignorance of the broad spectrum of manual medicine tech-niques
used by various practitioners, from osteopathic physicians to chiropractors
to physical therapists. Such blind spots compromise research methodology with
regard to manual medicine studies, which could, in turn, diminish the role of
manual medicine in clinical practice. Osteopathic manipulative treatment pro-vides
an excellent model for recognizing and integrating the full range of manual
medicine techniques into research and clinical applications because of the wide range
of techniques employed. The potential exists for these techniques to contribute much
to medical research and clinical practice—provided that osteopathic physicians and
other manual medicine practitioners work to alleviate ignorance about the effica-cy
of various forms of manipulation.
(Key words: osteopathic manipulative treatment, chiropractic, research
design, alternative medicine)
ated with manual medicine diversity. One
such example is a study that compared
“active” and “simulated” chiropractic
manipulation as adjunctive treatment for
childhood asthma, conducted by Balon
and others.5
The active treatment consisted of
“manual contact with spinal or pelvic
joints followed by high-velocity low-amplitude
directional push often associ-ated
with joint opening, creating a cavi-tation,
or ‘pop.’” This treatment is a
standard HVLA technique used by a wide
variety of practitioners, such as osteo-pathic
physicians, chiropractors, and phys-ical
therapists.
The simulated treatment involved the
following parameters: (1) providing “soft-tissue
massage and gentle palpation” to
the spine, paraspinal muscles, and shoul-ders;
(2) “turning the subject’s head from
one side to the other”; (3) providing “a
nondirectional push, or impulse” to the
gluteal area with the subject lying on one
side and then the other; (4) placing the
subject in a prone position so that “a
similar impulse was applied bilaterally to
the scapulae”; (5) putting the subject in a
supine position “with the head rotated
slightly to each side, and an impulse
applied to the external occipital protu-berance”;
and (6) applying low-ampli-tude,
low-velocity impulses “in all these
nontherapeutic contacts, with adequate
joint slack so that no joint opening or
cavitation occurred.”
Jongeward6 and Rossner7 have ques-tioned
the appropriateness of such simu-lated
treatment, noting that standard chi-ropractic
practice can include soft tissue
work. Another problem is that the simu-lated
treatment bears a marked similari-ty
to a traditional general osteopathic
treatment.8,9,10(pp85-86)
Balon and colleagues5 summarized the
simulated treatment by stating, “Hence,
the comparison of treatments was
between active spinal manipulation as
routinely performed by chiropractors and
hands-on procedures without adjustments
or manipulation.” Based on the conclu-sions
of the researchers, it would seem
they were unaware of the early osteo-pathic
works addressing asthma8-10 and
the more recent literature on OMT for
respiratory conditions, particularly by
Kuchera and Kuchera.11 The method-ologic
limitations of the study by Balon
and others with regard to manual
medicine diversity have been noted.12
Balon and coworkers responded that they
were unconvinced by the evidence sup-porting
the efficacy of their “simulated
treatment.”13
The results as reported by the re-searchers
were “Symptoms of asthma
and use of  -agonists decreased and the
quality of life increased in both groups,
with no significant differences between
the groups.” The conclusion was that
“the addition of chiropractic spinal
manipulation to usual medical care pro-vided
no benefit.”5
Thus, the conclusion suggests an
apparent failure of chiropractic to address
systemic dysfunction, such as asthma.
Although technically this conclusion is
limited to HVLA spinal adjustments, the
fallout will, for all practical purpose, prob-ably
affect attitudes toward all types of
manual medicine and manual medicine
practitioners. The problem is that while
the study is widely perceived as indicating
a failure of manual medicine for the treat-ment
of systemic dysfunction, it may
instead be indicative that the subjects in
both groups benefited—but from two
distinct forms of manual medicine. Igno-rance
(whether by lack of knowledge or
by the choice to ignore the available infor-mation)
has severely distorted the findings
of this widely publicized study.
This study is not the only example of
such confusion. A similar study14 demon-strates
a comparable ignorance of manual
medicine diversity, duplicating the
methodologic flaws, favorable outcomes,
and unfounded conclusions of the study
by Balon and others. The researchers in
this study compared two forms of man-ual
therapy for the treatment of tension
headache. The experimental treatment
consisted of standard HVLA chiropractic
treatment and deep friction massage, plus
trigger point therapy if indicated. The
subjects receiving this intervention were
designated as the “manipulation” group.
The control group received deep friction
massage plus low-power laser light (con-sidered
not to be efficacious for tension
headache). Thus, essentially, one form of
manual medicine is again compared to
another. The researchers observed that
“by week 7, each group experienced sig-nificant
reductions in mean daily headache
hours...and mean number of analgesics
per day.”14 Because both groups bene-fited
equally, the authors concluded that
“As an isolated intervention, spinal
manipulation does not seem to have a
positive effect on episodic tension-type
headaches.”14
Both studies were reported in the mass
media with the simplistic conclusion that
chiropractic does not work for such con-ditions
as childhood asthma and tension
headache. The design and outcome of
the studies do not allow us to draw such
conclusions, however. Perhaps a more
accurate conclusion should have been
that we do not know if HVLA adjust-ments
are specifically helpful or not.
Although the favorable outcomes could
have resulted from chance or placebo
effects, a reasonable person might also
justifiably conclude that various forms
of manual medicine can be helpful for
these conditions. Kuchera15 recently dis-cussed
in detail the mechanisms by which
OMT could be used in treatment of
headaches of various types. Ignorance of
the diversity and validity of the full spec-trum
of manual therapy applications con-founds
the issue. More research is des-perately
needed—research which seriously
considers the full spectrum of manual
medicine options from a variety of health-care
professions.
Developing an appropriate research
methodology is a challenge. Consideration
must be given not only to the diversity of
potentially effective manual techniques,
but to the difficulty of identifying a sim-ulated
treatment with no physical effects.
Even light stroking of the skin may have
significant effects on physiology.16 In con-trast
to randomized clinical trials of drugs,
double-blind methodology is not possible
with manual medicine research; the ther-apist
is always aware of the technique
being applied. Even blinding patients is
problematic, particularly if they have pre-vious
exposure to manual techniques.
Rather than a treatment/placebo com-parison,
perhaps the only possible com-
442 • JAOA • Vol 101 • No 8 • August 2001 Mein et al • Special communications
parison will be between active treatment
methods. This then raises the problem of
individualization of treatment; even the
study by Balon and others5 acknowledges
that the therapists tailored their treat-ments
to the needs of the individual
patients. A wider discussion of the
methodologic issues inherent in the study
of manual therapy is necessary to counter
the application of overly simplistic and
inappropriate methodologies in studies
of manual medicine and in the media
coverage of such studies.
Manual medicine and the
emerging medical paradigm
So what does this have to do with osteo-pathic
medicine? It would seem that chi-ropractors
and many members of the
medical establishment involved in report-ing
these studies are simply ignorant of the
osteopathic medical perspective. While
this type of misunderstanding is neither
new nor surprising, it has tremendous
implications for the future.
We are in the midst of a medical rev-olution,
and in this revolution, many
questions are being asked about manual
medicine and other techniques that are
sometimes referred to as “alternative”
medicine. What is the role of manual
medicine in the emerging medical
paradigm? Will manual medicine be lim-ited
to relieving musculoskeletal pain?
Will osteopathic manipulative treatment
remain a self-contained system of healing?
Is there a legitimate role for the full spec-trum
of manipulative techniques in the
treatment of systemic dysfunction?
Osteopathic medicine has a great deal
to offer. Because of its rich heritage of
philosophy, research, and clinical tech-niques,
the profession can influence the
direction of healthcare in a positive man-ner.
Osteopathic medicine has integrated
the diversity of manual medicine tech-niques
into its own system in the form
of OMT. Thus, osteopathic medicine is
the single best representative of manual
medicine diversity currently available to
researchers and clinicians.
Another primary factor driving the
current changes in healthcare is eco-nomics.
Not only must treatment options
be safe and efficacious, they must be cost-effective.
The diversity of manual medicine
techniques provides a variety of approach-es
that could have significant cost-saving
potential. This is particularly true for sim-ple
regulatory techniques, as contrasted
with corrective techniques. For example,
inhibitive pressure and thoracic lymphatic
pump applications can be easily adapted
for application by lay persons and thera-pists.
In a study on labor pain during con-tractions
of gravid uterus at term, lumbar
inhibitory pressure was shown to be effec-tive
in reducing pain in a group of 175
women. This simple technique was
applied by husbands and other family
members, as well as by nurses and physi-cians.
“Since back pressure in a high per-centage
of cases was administered by the
husband, this suggests that training of
husbands in the proper technique would
minimize staff time required in labor and
delivery, as well as the need for medica-tion.”
17
Also, thoracic lymphatic pumping
(TLP) has been shown to be at least as
effective as incentive spirometry in pre-venting
atelectasis in patients who have
undergone cholecystectomy. In addition
to its treatment efficacy, the authors noted
that TLP costs were lower than those for
incentive spirometry and that “the TLP
treatment costs could be further reduced
by training a respiratory therapist to
administer the treatment.”18
There is historical precedent for involv-ing
lay persons and therapists in the less
technical manual therapy applications.
The early osteopathic physicians recog-nized
a hierarchy of expertise with regard
to technique. One early osteopathic text-book
was specifically written with the
lower end of this hierarchy in mind. In the
preface to the second edition of his book,
Eduard Goetz acknowledged the accessi-bility
of simple manual medicine appli-cations
when he wrote, “The mere read-ing
of the book cannot possibly result in
one’s becoming a full fledged osteopath.
The intention is simply to impart sufficient
knowledge of the mode of procedure to
enable the careful reader to apply the
treatment in his home in case of emer-gency
and until such a time as a regular
practicing osteopath can be called in
should that be found necessary.”10 (For
those interested in the work of Goetz and
other early osteopathic physicians, some
of their texts are now available on the
Early American Manual Therapy Web
site at www.meridianinstitute.com.)
When considering the relatively low
level of expertise required to perform
deep friction massage and soft-tissue tech-niques,
such as those used as control treat-ments
in the previously discussed asth-ma
and tension headache studies, one
wonders if there might be a role for fam-ily
members or massage therapists in treat-ing
conditions like asthma and headache.
Theoretically, the physician could become
an educator, trainer, and supervisor of
the treatment regimen for certain condi-tions.
With the increased emphasis on
home health and cost-effectiveness, this
could be a workable model in the new
medical paradigm—so long as issues of
training and safety are addressed.
Osteopathic medicine is now pre-sented
with the opportunity to contribute
to the broader emerging medical
paradigm with regard to research into
manual medicine and clinical applica-tions
of manual techniques. Osteopath-ic
physicians are in an excellent position
to shape the new paradigm, but they also
face the danger of sitting quietly on the
sidelines while others determine the role
of manual medicine in the evolving health-care
system.
References
1. Glossary of Osteopathic Terminology.
Kirksville, Mo: Kirksville College of Osteopath-ic
Medicine; 1990.
2. Cherkin DC, Deyo RA, Battie M, Street J,
Barlow W. A comparison of physical therapy,
chiropractic manipulation, and provision of an
educational booklet for the treatment of patients
with low-back pain. N Engl J Med
1998;339:1021-1029.
3. Mein EA, Richards DG, McMillin DL, McPart-land
JM, Nelson CD. Physiologic regulation
through manual therapy. Phys Med Rehab
2000;14:27-42.
4. Nelson CD, McMillin DL, Richards DG, Mein
EA, Redwood D. Manual healing diversity and
other challenges to chiropractic integration. J
Manipulative Physiol Ther 2000;23:202-207.
Mein et al • Special communications JAOA • Vol 101 • No 8 • August 2001 • 443
5. Balon J, Aker PD, Crowther ER, Danielson
C, Cox PG, O’Shaughnessy D, et al. A com-parison
of active and simulated chiropractic
manipulation as adjunctive treatment for child-hood
asthma. N Engl J Med 1998;339:1013-
1020.
6. Jongeward BV. Chiropractic manipulation
for childhood asthma. N Engl J Med 1999; 340:
391-392.
7. Rossner A. Scratching where it itches: core
issues in chiropractic research. Dynamic Chi-ropractic
1999;17:16,22.
8. Hazzard C. The Practice and Applied Ther-apeutics
of Osteopathy. 3rd ed. Kirksville, Mo:
Journal Printing Company; 1905: 75-80.
9. Barber ED. Osteopathy Complete. 4th ed.
Kansas City, Mo: Hudson-Kimberly Publish-ing
Co; 1898:60-68.
10. Goetz EW. A Manual of Osteopathy. 2nd
ed. Cincinnati, Ohio: Nature’s Cure Co; 1909:
85-86.
11. Kuchera M, Kuchera WA. Osteopathic
Considerations in Systemic Dysfunction.
Kirksville, Mo: Kirksville College of Osteopath-ic
Medicine; 1991.
12. Richards DG, Mein EA, Nelson CD. Chi-ropractic
manipulation for childhood asthma.
N Engl J Med 1999;340:391-392.
13. Balon J, Crowther ER, Sears MR. Chiro-practic
manipulation for childhood asthma. N
Engl J Med 1999;340:392.
14. Bove G, Nilsson N. Spinal manipulation in
the treatment of episodic tension-type
headache. JAMA 1998;280:1576-1579.
15. Kuchera ML. Osteopathic principles and
practice/osteopathic manipulative treatment
considerations in cephalgia. JAOA
1998;98(suppl):514-519.
16. Kurz I. Textbook of Dr. Vodder’s Manual
Lymph Drainage. Vol 2. Brussels, Belgium:
Haug International; 1986.
17. Guthrie RA. Lumbar inhibitory pressure for
lumbar myalgia during contractions of the gravid
uterus at term. JAOA 1980;80:264-266.
18. Sleszynski SL, Kelso AF. Comparison of
thoracic manipulation with incentive spirometry
in preventing postoperative atelectasis. JAOA
1993;93:834-845.
444 • JAOA • Vol 101 • No 8 • August 2001 Mein et al • Special communications/Scheinost • Case report
Use of herbs as dietary supplements
has become common in the United
States. According to a 1997 survey,
12.1% of the households interviewed
were using herbal medicines.1 The out-of-pocket
expense for these medicines was
estimated at $5.1 billion. Unfortunately,
many people do not know the possible
side effects of these treatments. Too often,
patients perceive that because herbal med-ications
are “natural,” they are therefore
safe to take without fear of side effects.
This case presents an otherwise healthy
young female who was taking an herbal
supplement for emotional stress. She came
to the emergency department because of
chest pain, and subsequently became
bradycardic and hypotensive. The patient
was then found to have an elevated digox-in
level.
Report of case
A 26-year-old woman presented to the
emergency department via ambulance
with chest pain of approximately 7 hours’
duration. The patient was a topless dancer
who started having the chest pain while
at work. The pain was described as a
shooting pain that was “in her ribs” on
the left side. She went home after work
and continued to have pain, and it even-tually
became severe enough that she
decided to visit the hospital.
She had no known drug allergies. The
patient’s only medication was birth con-trol
pills. Her past medical history was
negative, and her past surgical history
was negative. The social history was sig-nificant
in that the patient reported tobac-co
use (1 pack/day) and reported that she
had ingested four alcoholic drinks over the
course of her shift at work. The patient
denied use of illicit drugs. Review of sys-tems
was noncontributory.
Physical examination was significant
only for chest pain, which was repro-ducible
to palpation over the left chest,
superior to the breast, and approaching
the left sternal border. The patient’s heart
exhibited regular rate and rhythm with-out
murmur. Her lungs were clear to aus-cultation.
Vital signs included tempera-ture,
98.6 F; respirations, 16 breaths/min;
heart rate, 76 beats/min; and blood pres-sure,
112/59 mm Hg. The rest of the
examination was unremarkable.
In the emergency department, the
patient was given oxygen via nasal can-nula,
and she was placed on a cardiac
monitor—according to standard chest
pain protocol. During the course of mon-itoring,
her heart rate dropped to 39
beats/min and her blood pressure dropped
Dr Scheinost is in private practice in Hender-son,
Kentucky.
Correspondence to Michael E. Scheinost,
DO, PhD, Family Health Center, 110 Third
Street, Suite 370, Henderson, KY 42420.
E-mail: mikescheinost@pol.net
Digoxin toxicity in a 26-year-old woman
taking a herbal dietary supplement
MICHAEL E. SCHEINOST, DO, PhD
Case report
Herbal dietary supplements are often considered by patients to be safe and free from
side effects. The case described here shows digoxin toxicity in a patient taking a
dietary supplement not normally considered to contain digoxin. In addition to
highlighting the risks of herbal supplements, this case also demonstrates the con-cept
that digoxin equivalents are not picked up by the standard digoxin assay.
(Key words: digoxin, dietary supplements)
to 59/36 mm Hg. The monitor showed an
absence of P waves (Figure 1). The patient
was placed in Trendelenburg’s position
and infused with normal saline. Before a
12-lead EKG could be obtained, the
patient’s heart rate and blood pressure
returned to original baseline. Cardiac lab-oratory
results and urine drug screen
results were normal with the exception of
a digoxin level of 0.9 ng/mL (normal ther-apeutic
range, 0.5 to 2.0 ng/mL).
Further discussion with the patient
revealed that she had been under a great
deal of stress recently and that she had
been taking an herbal dietary supplement
that contained skullcap herb (Scutellaria
lateriflora), wood betony herb (Pedicularis
canadensis), black cohosh root (Cimi-cifuga
racemosa), hops flowers (Humulus
lupulus), valerian root (Valeriana offici-nalis),
and cayenne pepper fruit (Cap-sicum
annuum). She denied taking any
more than the indicated dosage of one
to two capsules three times a day. Poison
control center personnel suggested that
the herbs in the patient’s supplement could
cause bradycardia and hypotension. The
recommendation was to observe the
patient, provide supportive care, and to
instruct her to stop taking the medica-tion.
The patient was admitted to teleme-try
for 24-hour observation. She was dis-charged
in normal sinus rhythm and was
lost to subsequent follow-up after this
time.
Comments
Use of herbal dietary supplements in the
United States has become a multibillion
dollar industry.1 Because many of these
products are listed as dietary supplements,
no US Food and Drug Administration
controls are exerted over the quality or
quantity of herbs in any given product.
Patients tend to see such products as
harmless supplements and therefore rarely
inform their physicians of herbal supple-ment
use, unless specifically asked about
such use. In this case, the patient was tak-ing
an herbal supplement to help relieve
her stress—as the product name suggest-ed
the supplement would do. The only
warning on the product label was one
Scheinost • Case report JAOA • Vol 101 • No 8 • August 2001 • 445
Table
Digoxin-like “Factors” in Selected Herbs
 g Digoxin equivalents per
200 mL cup of tea
Herb NKA* RIA†
Cayenne 4.85 0.004
Hops 2.51 0.013
Skullcap 1.84 0.014
Wood Betony 0.656 0.008
Valerian 0.579 0.006
Black Cohosh 0.555 0.013
*NKA = inhibition of Na, K-ATPase ouabain binding.
†RIA = cross-reactivity to digoxin antibody in radioimmunoassay.
Adapted from Longerich et al2
Figure 1.
Emergen-cy
room
monitor
strips.
that stated, “Do not drive or operate
machinery while using this product, as
drowsiness may result.”
Longerich and colleagues2 showed that
many of the herbs used in teas contain
digoxin-like “factors.” Like digoxin, these
“factors” are cardioglycoside compounds,
and they exert the same effect on the
myocardium as does digoxin. Table 1
lists the digoxin activity equivalents for the
herbs in the supplement described in this
case study. Note that there is a difference
between the amounts of digoxin-like “fac-tors”
measured by the two methods. This
suggests that while the measured amount
of “digoxin” in this patient was 0.9
ng/mL, the effective amount of digoxin-like
“factors” in the blood may have been
much higher.
Digoxin antibody immunoassays only
detect those digoxin-like compounds with
a chemical structure similar enough to
digoxin to bind to the antibody. Such
tests do not detect compounds with
enough difference in the structure to avoid
binding, but which still exhibit signifi-cant
cardioglycoside activity. This activ-ity
is measured by the ouabain Na,K-ATPase
binding assay that detects those
compounds, which will exert an effect
on the digoxin receptor on the myocardi-um.
The assay works by detecting the
ability of compounds to displace radio-labeled
ouabain from Na,K-ATPase and
comparing it to the ability of digoxin to
displace the ouabain from the Na,K-ATPase
(the site of action for digoxin in
the body). While the patient denied tak-ing
any more pills than was suggested on
the label, actual amounts consumed can-not
be verified.
The product the patient had taken
was not available for further analysis.
Therefore, we could evaluate neither the
precise amounts of the specified herbs
nor contamination of the product with
other herbs. Over the past several years,
some herbal supplements have come
under increased scrutiny as a result of
patient illnesses. A recent report describes
digoxin toxicity in two patients taking
an herbal supplement for cleansing of the
bowel.3 The shipment of plantain used
in the supplement was shown to be con-taminated
with Digitalis lanata. A num-ber
of other plants, including oleander
(Nerium oleander, a cause of accidental
poisoning in children), have been shown
to contain cardiac glycosides.4 Further-more,
an analysis of traditional Chinese
medicines in California showed that 32%
contained undeclared compounds.5
This case serves to remind us, as physi-cians,
of the importance of discussing
alternative medicines with patients. Our
patients take a wide variety of herbal
medications, including saw palmetto
(Serenoa repens or Sabal serrulata) for
prostate problems, ginkgo (Ginkgo bilo-ba)
for dementia and memory problems,
echinacea (Echinacea purpurea or Echi-nacea
angustifolia) for immunostimula-tion,
pleurisy root (Asclepias tuberosa,
which also contains high quantities of
digoxin-like compounds) for asthma, and
so on. Furthermore, many patients take
combination products that contain several
different herbal compounds. All of these
kinds of herbal supplements can poten-tially
interact with medications that
patients may be taking.
Depending on the reliability of the
source of the herbs, these supplements
also may be contaminated with other
plants that are not intended to be in the
product. Such contamination can signif-icantly
interfere with treatments we may
be giving outpatients. Such contamina-tion
also means the patient may be
unknowingly receiving medicinal sub-stances
that they do not need or want,
such as digoxin or digoxin-like factors.
We must remember to ask our patients
not just what medicines they are taking,
but also what dietary supplements they
may be using.
References
1. Eisenberg DM, Davis RB, Ettner SL, et al.
Trends in alternative medicine use in the Unit-ed
States, 1990-1997: results of a follow-up
national survey. JAMA 1998;280:1569-1575.
2. Longerich L, Johnson E, Gault MH. Digox-in-
like factors in herbal teas. Clin Invest Med
1993;16:210-218.
3. Slifman NR, Obermeyer WR, Aloi BK, et al.
Contamination of botanical dietary supplements
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446 • JAOA • Vol 101 • No 8 • August 2001 Scheinost • Case report