E-Pub Ahead of Print

From David Riley, MD, editor in chief:
We are publishing this editorial electronically ahead of the Nov/Dec issue of Alternative Therapies in Health and Medicine because the struggle over healthcare reform is reaching a climax. The visible and invisible struggles are immense, and powerful lobbies that have an interest influencing the outcome have much at stake. This editorial, from 3 of the leaders in healthcare reform, offers a solution for changing the the medical care we offer, as well as who is covered.

Mark A. Hyman, MD, is a contributing editor of Alternative Therapies in Health and Medicine. He recently launched the Functional Medicine Foundation, based in New York, New York, to promote awareness of, fund research on, and educate the public about functional medicine. Dean Ornish, MD, is clinical professor of medicine at the University of California, San Francisco. Michael Roizen, MD, is chief wellness officer and chair of the Wellness Institute at Cleveland Clinic, Ohio.  (Altern Ther Health Med. 2009;15(6):12-14.)

For more information on these types of approaches, go to: www.functionalmedicine.org, www.pmri.org, or http://my.clevelandclinic.org/wellness/default.aspx

LIFESTYLE MEDICINE: TREATING THE CAUSES OF DISEASE
Mark A. Hyman, MD; Dean Ornish, MD; Michael Roizen, MD

Recently, at a small gathering in Martha’s Vineyard in support of the Robert F. Kennedy Center for Justice and Human Rights, Larry Summers, PhD, economist and director of the White House’s National Economic Council, spoke about our narrow escape from economic depression. Dr Summers also addressed the even larger impending risks to our economy if the costs of healthcare are not successfully addressed now. He was asked how we could control these costs without tackling the root causes of the problem, the fact that most of the chronic diseases that affect 160 million Americans and account for 78% of our healthcare costs are caused by lifestyle and environmental factors—namely our diet, sedentary lifestyle, smoking, chronic stress, and environmental toxins.

But most believe that doctors don’t “do” lifestyle. Dr Summers dismissed “lifestyle” as a community and public health issue that was already included in the current plan. He didn’t understand that physicians can and must practice clinical lifestyle medicine to effectively treat disease and dramatically reduce healthcare costs. Lifestyle factors leading to chronic diseases such as heart disease, diabetes, obesity, and cancer are the domain of doctors and not merely a “public health problem.”

Lifestyle is not only a public health issue; it is also a medical and clinical care issue. Lifestyle medicine is not just about preventing chronic disease but also about treating it, often more effectively and less expensively than relying only on drugs and surgery. Nearly all the major medical societies recently joined in publishing a review of the scientific evidence for lifestyle medicine both for the prevention and treatment of chronic disease.1 There is strong evidence that this approach works and saves money. Unfortunately, insurance doesn’t usually pay for it. No one profits from lifestyle medicine, so it is not part of medical education or practice. It should be the foundation of our healthcare system.

For example, the recent “EPIC” study published in the Archives of Internal Medicine studied 23 000 people’s adherence to 4 simple behaviors (not smoking, exercising 3.5 hours a week, eating a healthy diet [fruits, vegetables, beans, whole grains, nuts, seeds, and limited amounts of meat], and maintaining a healthy weight [BMI <30]). In those adhering to these behaviors, 93% of diabetes, 81% of heart attacks, 50% of strokes, and 36% of all cancers were prevented.2

This study is only one among a large evidence base documenting how lifestyle intervention is often more effective in reducing cardiovascular disease, hypertension, heart failure, stroke, cancer, diabetes, and all-cause mortality than almost any other medical intervention.1 It is because lifestyle addresses not only risk factor modification or reduction. Our lifestyle and environment influence the fundamental biological mechanisms leading to disease: changes in gene expression, which modulate inflammation, oxidative stress, and metabolic dysfunction.

The distinction between risk factors and causes is an important one.3 High blood pressure, dyslipidemia, and elevated C-reactive protein or glucose are not in and of themselves the real causes of chronic disease but simply surrogate markers that are the effects of environmental toxins, what we eat, how much we exercise, and how we respond to stress.

The future of medical care must be to transform the general lifestyle guidance (eat a healthy diet, exercise regularly) that many physicians try to provide to their patients in individually tailored lifestyle prescriptions for both prevention and treatment of chronic diseases. Lifestyle is the best medicine when applied correctly.

“Prevention” therapies as written into current healthcare bills are public health– and community-based wellness initiatives or payment for early detection of disease with mammograms, colonoscopies, and other screening tests. As the Congressional Budget Office recently indicated, early detection without treating the major underlying causes of chronic diseases—our lifestyle choices—may actually add to costs.

For example, a mammogram does not prevent breast cancer; it may find it sooner, when it is more easily treated, but hundreds or thousands of women must be tested to find 1 incidence of cancer. The argument for this type of “prevention” is necessary and moral but not economic.

Health insurance reform is important, but it is insufficient. We need healthcare reform. We need to change the content and not just the financing and coverage of healthcare. We must change not only the way we do medicine, but the medicine we do.

The center of the healthcare debate must change to what is covered, not just who is covered, if we are to make current treatments more effective and less costly.

The lifestyle factors leading to chronic disease are the domain of doctors and not just a “public health problem.” Doctors must “do” lifestyle medicine and receive adequate reimbursement; otherwise, the cost of chronic disease will bankrupt Medicare by 2017.4

Treating Causes Rather than Risk Factors
Let’s circle back to the flaw in treatment of risk factors and not causes. Typically doctors treat “risk factors” for disease such as giving a lifetime’s worth of medications to lower high blood pressure, elevated blood sugar, and high cholesterol. These, however, do not treat the underlying causes of those risk factors: what and how much we eat, whether we smoke, how often we exercise, how we manage stress, and the effects of environmental toxins. Disregarding the underlying causes and treating only risk factors is somewhat like mopping up the floor around an overflowing sink instead of turning off the faucet, which is why medications usually have to be taken for a lifetime. When the underlying lifestyle causes are addressed, patients often are able to stop taking medication (under their doctor’s supervision, of course). Likewise, they often can avoid surgery as well.

Presently, according to the American Heart Association, 1.3 million coronary angioplasty and 448 000 coronary bypass operations are performed annually at a cost of more than $100 billion.5 Despite these costs, many studies, including one last month in The New England Journal of Medicine, reveal that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (ie, 95% of those who receive them6). Coronary bypass surgery prolongs life in less than 2% to 3% of patients who receive it.7

In contrast, the INTERHEART study, published in The Lancet in 2004, followed 30 000 people and found that changing lifestyle could prevent at least 90% of all heart disease.8

Think about it. Heart disease accounts for more premature deaths and costs Americans more than any other illness and is almost completely preventable simply by changing diet and lifestyle. The same lifestyle changes that can prevent or even reverse heart disease can prevent or reverse many other chronic diseases as well.

Medicare and insurance companies currently pay billions of dollars every year for surgical procedures such as angioplasties and bypass surgeries. These are high-risk, invasive, expensive procedures fraught with complications, and they are largely ineffective.

In the large ACCORD study of more than 10 000 diabetics, aggressive blood sugar lowering with medication actually caused deaths.9 High blood sugar is a side effect of poor lifestyle choices. The treatment isn’t insulin to lower blood glucose, but healthy dietary choices, exercise, stress management, and not smoking. The Diabetes Prevention Program Research Group study showed that lifestyle changes are even more effective than diabetes drugs such as metformin in reducing the incidence of diabetes in people at high risk, with lower costs and fewer side effects.10

Lifestyle medical treatment, including personalized, science-based prescriptions for diet, exercise, and stress management, however, are not reimbursed or are only partially reimbursed. These therapies are low-risk and effective in reversing and preventing chronic diseases.

If we train and pay for doctors to learn how to help patients address the real causes of disease with lifestyle medicine and not just treat disease risk factors (simply the effects of poor lifestyle choices) with medications or surgery, we can save almost $1.9 trillion over 10 years for just 5 major diseases: heart disease, diabetes, “pre-diabetes” or metabolic syndrome, and prostate and breast cancer.*

Our nation is actively debating whether we can provide access to healthcare for all Americans and reduce costs at the same time. We cannot do either if we continue to provide the same type of healthcare based primarily on treating disease with medications and surgery rather than lifestyle medicine. Giving 47 million more people access to our current methods of treatment for chronic disease will surely cost more and offer less.

Many, including the head of the American Medical Association, argue that lifestyle medicine is a social, community, and public health issue, not a medical care issue. Real doctors don’t “treat” patients with lifestyle medicine. While community wellness programs and public health education do work (tobacco use decreased by two-thirds since the 1950s; Americans reduced dietary fat by 4% and increased carbohydrate consumption by 6% on the urging of the misguided US Dietary guidelines of 1977; and more people use seatbelts, sunscreen, and helmets),11 they only go part way. Doctors need to go the rest of the way.

Doctors Must Learn and Practice Lifestyle Medicine
The fundamental flaw in thinking in healthcare right now is that doctors don’t “do” lifestyle medicine and that people don’t change. In part that is true. Only 50% of patients take the drugs their doctors recommend. The food and drug industry, however, has been very successful in changing our habits for the worse. The typical American now eats 680 more calories per day than 30 years ago, and 81% of the adult population takes at least 1 medication.12 Established financial interests drive research and delivery of care based on medication and surgery. There are no incentives to drive doctors to treat disease with lifestyle medicine. Changes in policy, reimbursement, research, education, and clinical care encouraging doctors to “do” lifestyle medicine must take center stage in healthcare reform.

You might argue that doing this for everyone may cost more (and it might), so let’s begin with those who already have chronic disease. Integrated healthcare teams led by physicians practicing lifestyle medicine can save our healthcare system. Presently, however, physicians lack training and financial incentives to help people learn how to eat a healthy diet, exercise, stop smoking, manage their weight, or address the effects of environmental toxins. So they continue to do what they know how to do: prescribe medication and perform surgery.

Personalized lifestyle medicine is a high-science, high-touch, low-tech, low-cost treatment that is more effective for the top 5 chronic diseases than our current approaches. Yet is it not taught in medical schools, practiced by physicians, or delivered in hospitals or healthcare settings. In fact, this treatment, if applied to all the patients with cardiovascular disease, diabetes, metabolic syndrome (obesity), prostate cancer, and breast cancer could reduce net health care expenditures $930 billion over 5 years and result in dramatically better health and quality of life.*

Opportunities for Change
On August 6, 2009, Senator Ron Wyden (D, Oregon) introduced new legislation, theTake Back Your Health Act (S. 1640) that includes payment for intensive lifestyle medicine as treatments, not just prevention. This legislation has bipartisan co-sponsorship by Senators John Cornyn (R, Texas) and Tom Harkin (D, Iowa). We worked closely with these senators to help craft this initiative. This pending legislation, or changes in Medicare policy, can make it feasible for intensive lifestyle treatments to take hold in medical care. It will reinvigorate primary care medicine and drive the transformation of existing healthcare institutions, medical schools, postgraduate education, and insurers to meet the demand for interventional lifestyle treatment of chronic disease. It will induce doctors to learn and practice lifestyle medicine both because it works better for their patients and physicians will be paid to do it. It will support the development of a wellness- and health-based economy rather than one based on sickness and chronic disease.

If lifestyle medicine becomes central to the practice of medicine, our sick care system will be transformed into a healthcare system.

References
1. American College of Preventive Medicine. Lifestyle Medicine—Evidence Review. June 30, 2009. Available at: http://www.acpm.org/LifestyleMedicine.htm. Accessed September 18, 2009.
2. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169(15):1355-1362.
3. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031-3038.
4.Samuelson RJ. Let them go bankrupt, soon. Solving Social Security and Medicare. Newsweek. 2009 Jun 1;153(22):23. Available at: http://www.newsweek.com/id/199167. Accessed September 23, 2009.
5. Ornish D. Intensive lifestyle changes and health reform. Lancet Oncol. 2009;10(7):638-639.
6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Investigators. Impact of optimal medical therapy with or without percutaneous coronary intervention on long-term cardiovascular end points in patients with stable coronary artery disease (from the COURAGE Trial). Am J Cardiol.
7. Morrison DA, Sacks J. Balancing benefit against risk in the choice of therapy for coronary artery disease. Lesson from prospective, randomized, clinical trials of percutaneous coronary intervention and coronary artery bypass graft surgery. Minerva Cardioangiol. 2003;51(5):585-597.
8. Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet.
9. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559
10. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
11. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation.
12. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287(3):337-344. 2009;104(1):1-4. 2008;117(23):3031-3038. 2004;364(9438):937-952

CLINICAL RESEARCH IN ANTHROPOSOPHIC MEDICINE

Harald Johan Hamre, Dr med; Helmut Kiene, Dr med; Gunver Sophia Kienle, Dr med

Harald Johan Hamre, Dr med, and Gunver Sophia Kienle, Dr med, are senior research scientists at and Helmut Kiene, Dr med, is the director of the Institute for Applied Epistemology and Medical Methodology, Freiburg, Germany.

Abstract
Anthroposophic medicine includes special medications and special artistic and physical therapies. More than 200 clinical studies of varying design and quality have been conducted on anthroposophic treatment. Half of these studies concern anthroposophic mistletoe therapy for cancer. Clinical effects of mistletoe products include improvement of quality of life, reduction of side effects from chemotherapy and radiation, and possibly increased survival.

Apart from cancer therapy, the largest studies of anthroposophic treatment have been 2 naturalistic system evaluations: In German outpatients with mental, musculoskeletal, respiratory, and other chronic conditions, anthroposophic treatment was followed by sustained improvements of symptoms and quality of life. In primary care patients from 4 European countries and the United States treated for acute respiratory and ear infections by anthroposophic or conventional physicians, anthroposophic treatment was associated with reduced use of antibiotics and antipyretics, quicker recovery, and fewer adverse reactions; these differences remained after adjustment for relevant baseline differences. (Altern Ther Health Med. 2009;15(6):52-55.)

Anthroposophic medicine (AM) is a complementary therapy system founded in the 1920s by Rudolf Steiner and Ita Wegman1 and provided by specially trained physicians in 56 countries worldwide.2 AM acknowledges a spiritual-existential dimension in humanity, which is assumed to interact with psychological and somatic levels in health and disease. AM therapy includes special treatment modalities (eurythmy movement exercises, art therapy, rhythmical massage therapy) and special medications.3,4

Eurythmy therapy is an artistic exercise therapy involving cognitive, emotional, and volitional elements. In eurythmy therapy sessions, patients are instructed to exercise specific movements with the hands, the feet, or the whole body. Eurythmy movements are related to the sounds of vowels and consonants, to music intervals, or to affective gestures (eg, sympathy-antipathy). In AM art therapy, patients engage in painting, drawing, clay modeling, music, or speech exercises. Rhythmical massage therapy was developed from Swedish massage; special techniques include lifting movements, rhythmically undulating gliding movements, and complex movement patterns like lemniscates. AM medications are prepared from minerals, plants, animals, and chemically defined substances. AM medications can be prepared in concentrated form or in homeopathic potencies and are administered in various ways (oral, rectal, vaginal, conjunctival, nasal, or percutaneous application or by subcutaneous, intracutaneous, or intravenous injection). AM medication therapy can be standardized (1 product for a given indication) or individualized (involving 1 or several AM medications and sometimes nonmedication AM therapies). AM treatments can be administered alone or combined with conventional medical therapy as needed.3,4

History
AM was developed in the 1920s and early 1930s as a research-based therapy system. In this period, laboratory and clinical studies were conducted according to contemporary standards. After World War II, when AM was reestablished in Europe, the focus was on founding practices, clinics, and hospitals rather than on research. In the 1970s and 1980s, research was performed but also restrained by the predominant paradigm of the double-blind randomized trial, which was difficult to implement in AM settings. In recent times, research activities have grown strongly with experimental and observational studies, with work on methodology, and with researchers catching up with current technical standards.4

Challenges and solutions, strengths and limitations
Research into AM poses several challenges. Randomized allocation of patients into therapy and control groups is often rejected by AM physicians and their patients, chiefly because the physician-patient relationship is disturbed by randomization and because of strong therapy preferences.5,6 Randomization refusal and other obstacles have led to severe recruitment problems and premature termination of a number of randomized trials of AM medications.6 Some forms of AM therapy can be evaluated in non-AM settings without unduly distorting the treatment, however, and for these treatments, randomized studies are possible and have been conducted.4

Blinding of patients is often unmasked because of properties of the AM treatment such as local reactions to injections.7 Blinding can also induce a subtle form of bias, when patients willing to participate in double-blind trials have worse outcomes of AM therapy than patients who reject being blinded.8 Nevertheless, for some AM medications, double-blind trials are possible and have been successfully conducted.9-12

Another challenge is the very large number of AM therapy options; approximately 1700 AM medications are manufactured, and most are sold in very small quantities (personal communication, Agnes Mitzakoff, February 23, 2009; e-mail communication, Peter Vögele, March 1, 2009). Moreover, AM therapy is often individualized, involving several AM medications sometimes combined with artistic or physical therapies, and as a result, the number of AM therapy options is further increased.

Consequently, there is not enough money or manpower to conduct individual studies for each AM therapy option. A solution to this challenge is to evaluate AM therapy as a whole system.13 Whole-system evaluations of AM treatment have been performed with acute infections,5 cancer,14-18 and other chronic indications.4,19 A strength of these system evaluations is their high practice relevance, with clinically relevant settings, range of patients, therapy administration, and outcomes.4 Whole-system evaluations can be supplemented by analyses of major components of the AM therapy system.20-24

Prevention
Research into preventive effects of AM has focused on allergic diseases, which affect up to one-third of children in many countries.25,26 Related to the AM approach is an educational philosophy implemented in more than 3000 Waldorf schools, kindergartens, and curative education centers worldwide.27,28 In well-controlled epidemiological studies, Waldorf school attendance was associated with a reduced risk for atopic disease,29,30 possibly mediated by effects on the intestinal bacterial flora from restrictive use of antibiotics and antipyretics in childhood infectious disease30 or from a diet containing fermented vegetables.31 Antibiotic and antipyretic use in early childhood is a risk factor for allergic diseases.32-34 In a naturalistic study of primary care patients treated for acute respiratory or ear infections, the use of antibiotics and antipyretics could be reduced to a minimum in AM settings (antibiotics: 5% vs 34% of patients treated by AM or conventional physicians, respectively; antipyretics: 3% vs 22%, respectively) without detrimental effects.5

Clinical effectiveness
The most complete systematic review of clinical effectiveness of AM treatment identified 195 studies, 18 of which were randomized trials.4 Of the studies, 186 (including 15 of the 18 randomized trials) had positive results for AM treatment, 8 studies had no benefit, and 1 study had a negative trend. Study quality was variable: some studies had serious deficiencies, but there were also a number of very carefully conducted and well described studies.4 One possible explanation for the deficiencies is that many studies were performed by enthusiastic AM practitioners who did not have formal training in clinical research.

Half of the studies concerned AM mistletoe therapy for cancer; other frequent indications were acute infections, pain syndromes, and hepatitis.4 AM mistletoe products are widely used in Central Europe. In Germany, 9.2 million defined daily doses of AM mistletoe products were sold in 2007, amounting to 23% of all chemotherapy agents sold.35 A large number of laboratory studies have shown that mistletoe extracts inhibit the growth of cancer cells, modulate the immune system favorably, and stabilize DNA in noncancerous cells.36,37 Moreover, numerous animal experiments show a reduction of tumor growth and metastasis after mistletoe application.36,37 The most complete systematic review of clinical effectiveness of AM mistletoe products comprised 37 studies, of which 16 were randomized trials.38 The best documented clinical effects of AM mistletoe therapy are improvement of quality of life and reduction of side effects from chemotherapy and radiation. A survival benefit also has been shown but not beyond critique. Tumor remissions have been described following local or high-dose applications of AM mistletoe products.38

Apart from cancer therapy, the largest and most detailed clinical studies of AM therapy have been 2 system evaluations, together comprising more than 2700 patients. The Anthroposophic Medicine Outcomes Study (AMOS) is a naturalistic cohort study of German outpatients treated for mental, musculoskeletal, respiratory, and other chronic conditions.39 One-fourth of all qualified AM physicians and therapists in Germany participated in AMOS, and the participating physicians and dentists resembled eligible but not participating physicians and therapists with respect to age, gender, the number of years in practice, and the proportion working in primary care.20-23 These features suggest that the AMOS study to a high degree mirrors contemporary AM use in outpatient settings. Following AM treatment (art therapy, rhythmical massage, eurythmy, physician-provided counseling, AM medications), substantial and sustained improvements of disease symptoms and quality of life were observed.39 These improvements were found in adults and children,39,40 in all therapy modality groups,20-24 and in all evaluable diagnosis groups.41-44 The improvements in quality of life were at least of the same order of magnitude as improvements following other (non-AM) treatments.45 Some of the improvement may have other causes than the AM therapy, such as other treatments; however, patients not using conventional therapies for their main disorder (two-thirds of patients) had a similar improvement.24 A more detailed analysis of 4 possible causes of the improvement showed that conventional therapies together with patient dropout, natural recovery, and regression to the mean together explained a maximum of 37% of the improvement.46

The International Integrative Primary Care Outcomes Study–Anthroposophy study was a naturalistic comparison of primary care patients from 4 European countries and the United States who were treated by AM or conventional physicians for acute respiratory and ear infections.5 Compared to conventional therapy, AM treatment was associated with reduced use of antibiotics and antipyretics, quicker recovery, fewer adverse reactions, and greater therapy satisfaction. These differences remained after adjustment for country, age, gender, and 4 markers of baseline severity.5

Safety
In safety studies, AM treatment is generally well tolerated. Adverse reactions are infrequent and mostly mild to moderate in severity. Three types of adverse reactions to AM medications are commonly described: local reactions from topical application, systemic hypersensitivity including very rare cases of anaphylactic reactions, and aggravation of preexisting symptoms in sensitive patients.4,47,48 In a detailed safety analysis from the AMOS study, the incidence of confirmed adverse reactions to AM medications was 3% of users and 2% of the medications used. No serious adverse reactions were found.48 An innovative electronic pharmacovigilance system has been established in a network of AM practices.49

Theoretically, avoidance of necessary conventional treatment in AM settings might pose a risk,50 but no evidence has been found for this.4 In comparative studies, AM treatment had similar42 or lower5,19,51 rates of adverse reactions than conventional treatment.

Cost
The most detailed cost analysis of AM treatment was performed in the AMOS study.52 The analysis included costs of AM and conventional therapies, inpatient hospital and rehabilitation treatment, and sick leave. Total costs in the first study year did not differ significantly from costs in the pre-study year, although the patients were starting new AM therapy, whereas in the second year, costs were significantly reduced by 13%. The cost reduction was due to a reduction of inpatient hospitalization that could not be explained by secular trends during the study period.52 Other, less detailed evaluations also indicate similar or lower costs in AM therapy settings compared to conventional settings.4

Conclusion
It is difficult to conduct randomized trials for each AM therapy option because of therapy preferences and because of the very large number of AM medications used. More than 200 studies are now available, 90% of them observational and of varying quality. The studies predominantly show good clinical outcomes, few side effects, high patient satisfaction, and possibly slightly less cost, but there is a need for more studies of high quality.

References
1. Steiner R, Wegman I. Extending Practical Medicine: Fundamental Principles Based on the Science of the Spirit. [First published 1925]. Bristol: Rudolf Steiner Press; 2000.
2. Derzeitige Ausbreitung der Anthroposophisch-Medizinischen Bewegung [Current dissemination of the anthroposophic medical movement]. 1924-2004 Sektion für Anthroposophische Medizin. Standortbestimmung / Arbeitsperspektiven. [1924-2004 Section for Anthroposophic Medicine. Current status and future perspectives]. Dornach: Free Academy of Spiritual Science; 2004:7-9.
3. Ritchie J, Wilkinson J, Gantley M, Feder G, Carter Y, Formby J. A Model of Integrated Primary Care: Anthroposophic Medicine. London: Department of General Practice and Primary Care, St Bartholomew’s and the Royal London School of Medicine, Queen Mary, University of London; 2001.
4. Kienle GS, Kiene H, Albonico HU. Anthroposophic Medicine: Effectiveness, Utility, Costs, Safety. Stuttgart, Germany; New York, NY: Schattauer Verlag; 2006.
5. Hamre HJ, Fischer M, Heger M, et al. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wien Klin Wochenschr. 2005;117(7-8):256-268.
6. Ziegler R. Mistletoe preparation Iscador: are there methodological concerns with respect to controlled clinical trials? Evid Based Complement Alternat Med. 2009;6(1):19-30. Epub 2007 Oct 4.
7. Rostock M, Huber R. Randomized and double-blind studies—demands and reality as demonstrated by two examples of mistletoe research. Forsch Komplementarmed Klass Naturheilkd. 2004;11 Suppl 1:18-22.
8. Grossarth-Maticek R, Kiene H, Baumgartner SM, Ziegler R. Use of Iscador, an extract of European mistletoe (Viscum album), in cancer treatment: prospective nonrandomized and randomized matched-pair studies nested within a cohort study. Altern Ther Health Med. 2001;7(3):57-66, 68-72, 74-6 passim.
9. Cysarz D, Schürholz T, Bettermann H, Kümmell HC. Evaluation of modulations in heart rate variability caused by a composition of herbal extracts. Arzneimittelforschung. 2000;50(5):420-424.
10. Cysarz D, Heckmann C, Bettermann H, Kümmell HC. Effects of an anthroposophical remedy on cardiorespiratory regulation. Altern Ther Health Med. 2002;8(6):78-83.
11. Jeffrey SL, Belcher HJ. Use of Arnica to relieve pain after carpal-tunnel release surgery. Altern Ther Health Med. 2002;8(2):66-68.
12. Karow JH, Abt HP, Fröhling M, Ackermann H. Efficacy of Arnica montana D4 for healing of wounds after Hallux valgus surgery compared to diclofenac. J Altern Complement Med. 2008;14(1):17-25.
13. Boon H, MacPherson H, Fleishman S, et al. Evaluating complex healthcare systems: a critique of four approaches. Evid Based Complement Alternat Med. 2007;4(3):279-285.
14. Arman M, Rehnsfeldt A, Carlsson M, Hamrin E. Indications of change in life perspective among women with breast cancer admitted to complementary care. Eur J Cancer Care (Engl). 2001;10(3):192-200.
15. Carlsson M, Arman M, Backman M, Flatters U, Hatschek T, Hamrin E. Evaluation of quality of life/life satisfaction in women with breast cancer in complementary and conventional care. Acta Oncol. 2004;43(1):27-34.
16. Arman M, Backman M. A longitudinal study on women’s experiences of life with breast cancer in anthroposophical (complementary) and conventional care. Eur J Cancer Care (Engl). 2007;16(5):444-450.
17. Heusser P, Braun SB, Ziegler R, et al. Palliative in-patient cancer treatment in an anthroposophic hospital: I. Treatment patterns and compliance with anthroposophic medicine. Forsch Komplementarmed. 2006;13(2):94-100.
18. Heusser P, Braun SB, Bertschy M et al. Palliative in-patient cancer treatment in an anthroposophic hospital: II. Quality of life during and after stationary treatment, and subjective treatment benefits. Forsch Komplementarmed. 2006;13(3):156-166.
19. Esch BM, Marian F, Busato A, Heusser P. Patient satisfaction with primary care: an observational study comparing anthroposophic and conventional care. Health Qual Life Outcomes. 2008 Sep 30;6:74.
20. Hamre HJ, Witt CM, Glockmann A, Ziegler R, Willich SN, Kiene H. Eurythmy therapy in chronic disease: a four-year prospective cohort study. BMC Public Health. 2007 Apr 23;7:61.
21. Hamre HJ, Witt CM, Glockmann A, Ziegler R, Willich SN, Kiene H. Anthroposophic art therapy in chronic disease: a four-year prospective cohort study. Explore (NY). 2007;3(4):365-371.
22. Hamre HJ, Witt CM, Glockmann A, Ziegler R, Willich SN, Kiene H. Rhythmical massage therapy in chronic disease: a 4-year prospective cohort study. J Altern Complement Med. 2007;13(6):635-642.
23. Hamre HJ, Witt CM, Glockmann A, Ziegler R, Willich SN, Kiene H. Anthroposophic medical therapy in chronic disease: a four-year prospective cohort study. BMC Complement Altern Med. 2007 Apr 23;7:10.
24. Hamre HJ, Witt CM, Glockmann A, et al. Outcome of anthroposophic medication therapy in chronic disease: a 12-month prospective cohort study. Drug Design Devel Ther. 2008;2:25-37.
25. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet. 1998;351(9111):1225-1232.
26. Asher MI, Montefort S, Björkstén B, et al; ISAAC Phase Three Study Group. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys. Lancet.
27. No authors listed. List of centers. KHS: Council for Curative Education and Social Therapy. Available at:http://www.khsdornach.org/en/evz/. Accessed July 6, 2009.
28. No authors listed. Waldorfschulen weltweit. Bund der Freien Waldorfschulen. Available at: http://www.waldorfschule.info/de/schulen/index.html. Accessed July 6, 2009.
29. Alm JS, Swartz J, Lilja G, Scheynius A, Pershagen G. Atopy in children of families with an anthroposophic lifestyle. Lancet.
30. Flöistrup H, Swartz J, Bergström A, et al. Allergic disease and sensitization in Steiner school children. J Allergy Clin Immunol. 2006;117(1):59-66.
31. Alm JS, Swartz J, Björksten B, et al. An anthroposophic lifestyle and intestinal microflora in infancy. Pediatr Allergy Immunol. 2002;13(6):402-411.
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