IBS: Non-pharmacological and integrative health treatments

More than 1/3 and up to 1/2 of IBS patients opt for the drug-free and more natural interventions provided by integrative health (IH) practitioners in the hope of relief of disabling symptoms with fewer adverse outcomes.[i] ,[ii] Some of these “alternative” treatments do appear in evidence based conventional medicine treatment guidelines.  Many more have a level of evidence that is equivalent to the evidence that supports conventional medicine treatments.  In this last blog post on IBS, we will briefly survey some of them including lifestyle and behavioral interventions, natural medicines, and physical medicine treatments. (CHP providers can find a more complete review of IH treatment of IBS, on the IBS Clinical Pathway at behind the provider log-in.)

There are many prescription and OTC drug treatments for the symptoms of irritable bowel syndrome (IBS). These were surveyed in previous posts.  They are all of variable effectiveness and each has a risk of adverse side-effects. IBS patients are generally not satisfied with the outcomes of this care.  A University at Buffalo survey of 483 IBS patients found less that 20% were “very satisfied” with their medical treatments and 40% reported their treatment to be “below average.”[iii] A 2009 survey by University of North Carolina found only about 8% of patients were “very or extremely” satisfied with care and over 1/3 were “not at all” satisfied.[iv]

There unfortunately is no “gold standard” of care. Patients and their clinicians must necessarily develop treatment plans empirically based on the clinicians’ experience and “best guess” coupled with each patient’s preferences and tolerance for risk.  “Try it and see what works.”

A critical factor in successful management of IBS is a meaningful and supportive relationship between the IBS patient and her clinician.  Many IBS patients have been dismissed by uninformed conventional medical providers as “untreatable head cases” since no objective abnormality can be identified for this “functional” illness.  A small clinical trial of empathic clinician interaction[v] shows the benefit of exploring an IBS patient’s concerns, acknowledging the impact of the symptoms on quality of life, and providing evidence-based guidance regarding medication, diet, stress reduction, and reducing avoidance behavior is well recognized as a foundation of effective IBS therapy.

Many lifestyle interventions including diet recommendations and behavioral therapies can contribute to evidence based IH treatments. A summary of evidence in Cochrane[vi] found support for “CAM” treatments including peppermint oil, probiotics, soluble fiber, and the Chinese medicine formula, Tong xie yao fang.  Hypnotherapy, mindfulness meditation, yoga, relaxation therapy, and cognitive behavioral therapy (CBT) all have been supported by randomized controlled trials[vii],[viii],[ix],[x].

IH herbal treatments, both self-administered and clinician prescribed, are used by about ½ of IBS patients.  Of these patients, about ½ report benefit from herbal preparations, both single herbs and herbal formulas. Well designed clinical trials have shown benefit from peppermint oil, turmeric, artichoke leaf extract, and certain herbal formulas from Chinese and Tibetan medicine and Traditional Chinese Medicine.[xi]

Acupuncture trials show variable outcomes. Trials that compare sham to true acupuncture show no superiority of the real thing (there are of course many concerns with the validity of sham acupuncture). However in a head-to-head comparison trial of acupuncture and antispasmodic drugs, acupuncture recipients reported greater benefit.[xii]

Physical medicine in the form of exercise, yoga, and massage has not been studied extensively, but some clinical trials have investigated specific forms of massage traditions. IBS symptom relief has been shown form physical activity.[xiii] Twice daily yoga practice in a head-to-head trial with loperamide (Imodium) found equal benefit.

Massage itself is well known to facilitate relaxation and improve mood which in turn improves functional disturbances such as IBS. Specific abdominal massage directed to the GI tract has anecdotal evidence of effectiveness. Self-massage likely improves a sense of self-efficacy among patients.

The evidence about IBS shows it to be a most troubling clinical problem. From a clinician perspective, the lack of a clearly defined pathology, or rather a very complex set of potential pathologies involving the microbe-gut-brain axis make diagnosis and treatment planning very difficult. IH approaches, with a whole-person perspective brings all of physiology, neurology, psychology, and personality into the diagnostic picture. This view can set the stage for effective treatment planning that can bring the evidence to facilitate informed patient decision making, which is clearly the goal of effective patient care.

[i] Moayyedi P, et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). Journal of the Canadian Association of Gastroenterology, 2019, XX(X), 1–24 doi: 10.1093/jcag/gwy071
[ii] Shen YH, Nahas R. Complementary and alternative medicine for treatment of irritable bowel syndrome. Can Fam Physician. 2009;55(2):143–148.
[iii] University at Buffalo. IBS patients (can’t get no) satisfaction, study finds.  MedicalXpress. https://medicalxpress.com/news/2017-05-ibs-patients-satisfaction.html
[iv] Drossman DA, Morris CB, Schneck S, et al. International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit. J Clin Gastroenterol. 2009;43(6):541–550. doi:10.1097/MCG.0b013e318189a7f9
[v] Conboy LA, Macklin E, Kelley J, et al. Which patients improve: characteristics increasing sensitivity to a supportive patient-practitioner relationship. Social Science & Medicine. 2010;70(3):479–484.
[vii] Labus J, Gupta A, Gill HK, et al. Randomised clinical trial: symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention. Alimentary Pharmacology and Therapeutics. 2013;37(3):304-315.
[viii] Gaylord SA, Palsson OS, Garland EL, et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. The American Journal of Gastroenterology. 2011;106(9):1678–1688.
[ix] Phillips-Moore JS, Talley NJ, Jones MP. The mind-body connection in irritable bowel syndrome: A randomised controlled trial of hypnotherapy as a treatment. Health Psychol Open. 2015;2(1):2055102914564583. Published 2015 Jan 28. doi:10.1177/2055102914564583
[x] Schumann D, Langhorst J, Dobbs G, Cramer H. Randomised clinical trial: yoga vs a low‐FODMAP diet in patients with irritable bowel syndrome. Alimentary Pharmacology & Therapeutics Volume 47, Issue 2.
[xi] Yoon S, Grundman O, Koepp L, Farrell L. Management of Irritable Bowel Syndrome (IBS) in Adults: Conventional and Complementary/Alternative Approaches. Alternative Medicine Review 2011 Volume 16, Number 2.
[xii] Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman BM, Lao L. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD005111. DOI: 10.1002/14651858.CD005111.pub3
[xiii] . Villoria A, Serra J, Azpiroz F, Malagelada JR. Physical activity and intestinal gas clearance in patients with bloating. Am J Gastroenterol 2006;101:2552-2557.