Wellness Revolution Merging of Eastern and Western Medicine
It has begun to happen. We are presently in a wellness revolution. What had been considered Eastern philosophy has begun to merge with concepts of Western medicine. Although scientists exclaim that there is little proof that Eastern techniques “work,” the American public has begun to embrace herbs, massage therapy, acupressure, acupuncture, and meditation as accepted forms of alternative medicine.13
In a recent article by The Journal of the American Medical Association, Dr. S. Straus, the Director of the National Center for Complementary and Alternative Medicine projected that by 2020 medicine will be integrative. Dr. Straus believes rigorous scientific studies of alternative therapeutic and preventive modalities will prove some interventions to be effective, and they will be incorporated into conventional medical practice. Those that are not found to be effective will be discarded. The effectiveness of herbal and nutritional supplements will also be further researched and clarified. By 2020 the terms alternative and complementary medicine will be replaced by integrative medicine. This new field will embrace the best of Western and Eastern medicine philosophies and offer the patient a more holistic approach.14
As the mainstream medical approach becomes integrative, physical therapy practice may evolve and become more holistic. What might a holistic physical therapist be like? We know that holistic health principles focus on the interrelationships among the body, the mind, and the spirit. In addition, how different body parts react to one another is seen as an important component of the healing process.15 Envision if you will, the therapist of the future routinely using a hands-on approach to not only unlocking muscle strain but also assisting in clearing mental and spiritual stressors as well. Some therapeutic techniques that are holistic in nature are already beginning to be integrated into physical therapy practice, such as acupressure, yoga, Feldenkrais, and t'ai chi chuan. Those who currently practice craniosacral therapy, for example, know that when the body begins to unwind, emotional feelings often accompany them as well. It is possible that therapists of the future will more frequently utilize their hands-on connection with the patient to improve functional status, while contributing to a more balanced spiritual state.13,16,17
National Institute of Health Projections
The future of medical care will be characterized by dramatic change. Forecasters predict unprecedented medical innovations in the next few decades.
Dr. Claude Lenfant, NIH Director of The Heart, Lung, and Blood Institute, projects that coronary artery bypass operations will become mostly obsolete.14 He believes favorable trends in coronary risk factors should reduce the need for surgical intervention. Those who still require bypass surgery will benefit from replacement vessels that behave more like arteries than like veins. Dr. Lenfant predicts that arteries will be grown in advance of the procedure from the patient's own cells. Dr. Anthony Fauci, NIH Director of the National Institute of Allergy and Infections, believes we will find new therapies and vaccines to fight chronic as well as infectious diseases. Chronic diseases such as cardiovascular disorders will be shown to have infectious etiologies and will be treatable with inexpensive antibiotics and vaccines.14
Advances in Pulmonary Care
Large organizations are stepping to the plate to conduct research leading to improved medical management of chronic disease. The American Lung Association has a network of 20 research centers currently conducting large clinical trials focused on the direct care of those with asthma. The most current clinical trial is a study of the connection between gastro esophageal reflux (GERD) and asthma. Other leading researchers are focused on genetic and molecular-level markers in relation to asthma, and bronchial thermoplasty.
Bronchial thermoplasty is now under clinical trial for consideration as a treatment for severe asthma. The theory is that asthma is caused by an overgrowth of smooth muscle tissue in the large airways. During asthma attack, the muscle contracts and narrows the passageway making breathing more difficult. In bronchial thermoplasty, heat is applied to the smooth muscle through a flexible tube during a bronchoscopy procedure. The heat causes the muscle to relax and keeps the airway open. Bronchial thermoplasty has been effective in reducing the number of asthma attacks, and reducing the use of rescue medication in patients with severe asthma.18
Of particular interest to physical therapists is the current research on the association of weight and asthma. In an analysis of seven studies those people who were considered overweight or obese had a 51% greater chance of having asthma than a person of normal weight. Physical therapists can have direct impact on this patient population through the use of weight reduction exercise programs, and referral for nutritional counseling.18
Innovations in modern medicine in the past had taken many years of research and clinical trials before treatments were introduced to the public. Now the development cycle has been greatly decreased because of the society's demand for short-term payoff.19 In fact Cetron and Davies forecast that the first decade of the 21st century will be one of the most productive in the history of medicine.19 There will be hundreds of new treatments and diagnostic advances available to patients in the areas of gene therapy, stem cell transplants, and nanotechnology. These new treatments and devices will lead to rapid diagnosis, help predict disease, provide relief to patients with chronic respiratory ailments, repair damaged heart muscle, and treat hereditary diseases. For our purposes, we will examine those innovations that impact the field of cardiovascular and pulmonary physical therapy.
As an example of the fast-paced development cycle for clinical products, the progress in creation of ventricular assist devices (VAD) has been remarkable. Over the last few years VADs have been used experimentally as a bridge to transplantation, recovery therapy, and most recently as destination therapy. On April 22, 2008, the FDA gave approval for the use of the first compact heart assist device to support the weakened heart of a small-sized adult man or woman with heart failure awaiting heart transplant. Previous models were too large to be placed in the abdomen of the patient, and required the patient to be tethered to an external power source. The HeartMate II is a mere 3 in. in length and weighs approximately 1 lb, and can operate on two external batteries worn at the waist, allowing the patient to move freely for up to 3 hours. In a clinical study at 26 transplant centers, 57% of patients with the HeartMate II survived to receive heart transplantation. This result is comparable to those patients treated with currently approved assist devices of larger size. By the year 2020, who knows what the VAD will look like, perhaps technology will progress to the point where it will be completely internal.20
The Human Genome Project, a publicly funded, international effort, has completed one of its primary goals: to map the human genome. This represents one of the most significant medical achievements in our time, and has far-reaching potential to improve health over the next decade! Begun in 1990, the project was originally slated to last 15 years, but because of rapid technological advances, some of its goals were completed ahead of schedule. The goals of the Human Genome Project were to identify all 30,000 genes in human DNA, determine the sequences of the 3 billion chemical bases that make up DNA, and store the information on databases.21
A mutation of a single gene has been known to cause as many as 4,000 rare diseases, such as cystic fibrosis, sickle cell anemia, and Tay-Sachs disease. The causes of heart disease, diabetes, hypertension, and hypercholesterolemia, from a genetic point of view, are considered more complex. These diseases are thought to be caused by multiple gene mutations, or be the result of a combination of environmental factors, such as diet and gene mutation. Gene alteration may also influence an individual's ability to respond to viruses, bacteria, and toxins.21–23 Dr. Francis Collins, the Director of the National Human Genome Research Institute, likes to paraphrase Churchill when he says, “Sequencing the genome is not the end, or the beginning of the end, but simply the end of the beginning.”22Unlocking the genetic code is the first step in understanding the nature of disease and may lead toward more effective treatments, possible cures, or ways to prevent thousands of diseases.23
Genetic Effect on Medicine
What do scientists project will be the effect of genetics on the practice of medicine by the year 2020? A complete list of the human genome will give rise to a vast number of new medications. Drell and Adamson predict the number of new drugs tested and released for consumer use will increase sixfold from 500 new drugs in 2,000 to 3,000 in 2020.24 Consumers of health care will have a record of their genome available during routine medical visits, and it will be used to predict which medications will most closely align with their body to minimize side effects and maximize treatment. Drugs will be prescribed more accurately for each patient based on information from their genome, and from knowledge of environmental factors that may also play a role in the disease process. Knowledge of specific gene abnormalities, which predispose a person to, for example, high cholesterol, will allow that person to make lifestyle changes prior to the development of active disease. By 2020 neonatal genetic testing will be routine and single gene related disorders will be readily treated.24
At present the Food and Drug Administration (FDA) in the United States has not approved any gene therapy product for sale. Gene therapy is still considered very experimental in nature; however, gene-related research and development continues to grow at a rapid pace.25
Gene therapy works by the insertion of a normal gene into the genome to replace an abnormal disease-causing gene. To get the gene into the body, a vector molecule is used, most commonly a virus. Viruses are used because of their capacity to encapsulate a molecule and then deliver it to a targeted cell. Different types of inactive viruses are used for their ability to deliver molecules to various areas of the body. One example is the adenovirus, the virus that causes the common cold. It has been used to deliver genetically repaired cells to cardiac muscle in gene therapy studies for patients with congestive heart failure.26
In 1990, 4-year-old Ashanti DeSilva was the first recipient of gene therapy with an infusion of white blood cells carrying synthetic DNA. Ashanti suffered from severe combined immunodeficiency disorder, or SCID, which left her without a functioning immune system. Doctor W. French Anderson, formerly of the U.S. National Institutes of Health, treated Ashanti with her own genetically altered cells. They were administered through her bloodstream and produced the missing enzyme, the lack of which had caused her disease. In subsequent months she received four more cell infusions. Since then she has required booster shots but has regained her health through the use of gene therapy, and medication.19
Use of Gene Therapy in Congestive Heart Failure
Prospects for the use of gene therapy in the treatment of congestive heart failure are very real indeed. Scientists have begun basic investigative studies on rodents and on isolated cardiomyocytes from failing human hearts. The interventions that were studied focused on enhancing sarcoplasmic calcium transport, which is decreased in patients with congestive heart failure. Disturbances in calcium metabolism have been shown to contribute significantly to the contractile dysfunction observed in heart failure. In these studies the subject was “infected” with sarcoplasmic reticulum Ca2+ ATPase (SERCA2a). In other words, the SERCA2a gene was carried by an adenovirus to targeted cells in the rodent or cardiomyocyte. The results showed that gene transfer of SERCA2a improved left ventricular function. Scientists are quick to point out that these are preliminary studies, and further experimentation is needed before this form of gene therapy is ready for use in humans.27–29
First Commercial Gene Therapy Product for Humans
In October 2003, China became the first country in the world to produce a commercial gene therapy product called Gendicine for use in the treatment of head and neck squamous cell carcinoma. In 2005, a second product called Oncorine was also approved for use of head and neck cancer in China. Gendicine is delivered by an adenovector virus. Eight weeks of injections of this gene therapy product are used in conjunction with radiation treatments. After 5 years of clinical trials with Gendicine on 26 patients, 64% of late stage tumors showed regression, and 32% of tumors demonstrated partial regression. So far the only side effect seems to be self-limited fever.30 Five-year survival rates show 17 of 26 patients surviving, 16 without reoccurrence of disease. In the control group of 26 patients, 14 have survived for 5 years and 10 remained cancer-free.
In the United States and other countries around the world, an experimental sample size of 26 patients is considered too small to reach a credible level of statistical significance. In addition, the combined therapies, genetic and radiation, make it difficult to discern how much gene therapy contributed to patient improvement.31
Stem Cell Research—The Body's Self-Repair Kit
Human stem cell research, like gene therapy, is another important area in the medical field that holds great promise. Research in human developmental biology has led to the discovery of human stem cells (precursor cells that can give rise to multiple tissue types), including embryonic stem cells, embryonic germ cells, fetal stem cells, and adult stem cells. Embryonic (pluripotent) stem cells are harvested from 7-day-old embryos or aborted fetuses. These cells are used because they have the unlimited capacity to divide. In fact pluripotent stem cells can become any tissue in the body, including muscle, nerve, heart, and blood cells. Adult stem cells; however, appear to be restricted in what they can become. For example, adult stem cells in bone marrow give rise to blood cells, whereas those that are from muscle seem to create only new muscle cells. Pluripotent stem cells hold the most promise for treatment of disease but are controversial in nature due to their origin. In 2000, it was reported that scientists at the University of Wisconsin and Johns Hopkins University were able to isolate and successfully grow pluripotent human stem cells. The University of Wisconsin has been able to establish a stem cell bank so that new embryos are no longer needed, thus avoiding some of the controversy involved with this research.32,33
Scientists believe stem cells have the potential to cure disease, reverse the advance of chronic disorders, and heal injuries. These cells will be able to generate tissue for transplantation and replace damaged tissue such as myocardium. Stem cells also have the potential to assist in the way we currently develop new drugs. The drugs will be tested on stem cells first, then later on humans. Researchers project that patients with heart disease, Parkinson's disease, severe combined immunodeficiency (SCID), diabetes, and spinal cord injuries will be some of the few that may be helped with this type of treatment.32,33
Scientists have begun to study the use of stem cells for patients with congestive heart failure. Preliminary work in mice and other animals has demonstrated that healthy heart muscle cells transplanted into the heart successfully repopulate cardiac tissue, without rejection from surrounding tissue. Use of stem cell transplants has the potential to overcome the problem of tissue incompatibility and the need to use immune-suppressing drugs currently used during cardiac transplantation. The challenge now is to develop heart muscle cells from human pluripotent stem cells and transport them into failing heart muscle in order to support cardiac function.34
Telomerase Activation—The Fountain of Youth?
Telomeres form the ends of human chromosomes, like the plastic caps on the end of a shoelace. The telomeres function to maintain chromosome stability, and require a minimum length. Telomeres shorten with each round of cell division, and this mechanism limits proliferation of human cells to a finite number of cell divisions. There is growing evidence indicating that telomere shortening also limits stem cell function, regeneration, and organ maintenance during ageing. Moreover, telomere shortening during aging and disease is associated with a 3.18-fold higher mortality rate from heart disease. Telomeres have emerged as crucial cellular elements in the aging process and in various diseases including cardiovascular and chronic obstructive pulmonary disease.35
Since 1995, scientists have been working on ways to activate telomerase, which functions to repair and lengthen the telomere. They have already accomplished this in both mice and humans. T.A. Sciences Center in New York Center, New York, now offers a telomerase-activating product called TA-65, as part of a 12-month protocol. TA-65 is produced by a company called Geron and is administered in tablet form like a supplement. In clinical trials 2 to 4 daily doses of 10-mg tablets of TA-41 (a precursor to TA-65) were given to men aged 60 to 85 years for 12 weeks in a double-blind study, and the condition of their immune system, eye sight, sexual function, and skin improved dramatically. As a result of these human trials, T.A. Sciences now offers a 1-year supply of TA-65 at the low price of $25,000.00! The fountain of youth may be here, but it comes with a hefty price tag!36
Nanotechnology: The Doctor That Floats in Your Bloodstream
Molecular nanotechnology is a field of research aimed at the manipulation of atoms and molecules into nanometer size (a nanometer is 1 billionth of a meter).37 All manufactured products are made from atoms manipulated in simple ways. “Nanoscience and nanoengineering—the ability to manipulate and move matter—are leading to unprecedented understanding of the fundamental building blocks of all physical things.”38President Obama's fiscal year 2010 budget requests $7 billion for the National Science Foundation, to support scientific research in the United States. It remains to be seen what portion of that scientific funding will go toward the National Nanotechnology Initiative.39 It is expected that nanotechnology will impact the way vaccines, medical-testing devices, computers, and even automobile tires are made.
An article in The New York Times relates a futurist episode where a person has an episode of chest pressure at lunch. Instead of rushing to the emergency room, the person injects themselves with minuscule cylinders called respirocytes packed with pressurized oxygen, designed to mimic the function of red blood cells. Aboard each respirocyte is a tiny computer that gives the command to deliver oxygen when the distressed cells are reached. Instead of collapsing, the person finishes lunch and goes for a checkup with their doctor.37 Ralph Merkle, a nanotechnology engineer, foresees a time when patients with cardiac and respiratory disorders will carry respirocytes like diabetics carry insulin. This technology may be 30 years in the future, but less fantastic medical applications may be only a few years away.40
The first medical applications of nanotechnology will probably be in the field of screening and diagnostic tools. The New York Times reports that a Palo Alto–based company called Quantum Dot Corporation is developing nanoscopic crystals to be used in basic genetic screening and detection of disease. These nanosensors will greatly enhance tools such as CAT scans, MRIs, and catheter tips that will allow physicians a better view of a patient's anatomy. Within a decade we may see passive nanobots that can be inserted into the bloodstream to study internal organs. Beyond that, some predict that we will be able to create self-replicating nanobots, which will actually follow directions. They can be programmed to seek out viruses or cancer cells and destroy them before they have impact on the body.37