Investigation into complementary and integrative medicine practitioners' clinical experience of intestinal permeability: A cross-sectional survey

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Abstract

Background

This study aims to explore the conditions complementary and integrative medicine (CIM) practitioners associate with increased intestinal permeability (IP) and the methods they employ to assess IP.

Methods

A cross-sectional survey of naturopaths, nutritionists and Western herbal medicine practitioners was undertaken (n = 227) through the Practitioner Research and Collaboration Initiative (PRACI) network.

Results

CIM practitioners (n = 36, response rate 15.9%) associate IP with gastrointestinal (100.0%), autoimmune (91.7%), skin (91.7%), neurological (80.6%), respiratory (55.6%) and liver-related conditions (44.4%). CIM practitioners frequently treat IP (72.7%); observing a minimum 3 months of treatment is required to resolve IP. Patient's signs and symptoms were the main reasons CIM practitioners suspected IP (94.1%).

Conclusion

CIM practitioners observe a clinical link between IP and a wide range of conditions, including those not yet recognised within the literature. The clinical experience of CIM practitioners holds substantial value to the advancement of research and the clinical management of IP.

Introduction

Complementary and integrative medicine (CIM) practitioners use the “best” available methods from conventional and complementary medicine for optimal patient care [1]. CIM practitioners such as naturopaths, nutritionists and Western herbal medicine practitioners see a large variety of health conditions in clinical practice, with over 72% reporting a clinical interest in woman's health, general health and well-being and digestive disorders [2]. CIM practitioners may view disease aetiology through a different perspective in accordance with naturopathic philosophies underpinning their clinical practice [3]. Through this clinical experience and deductive reasoning, CIM practitioners may provide insights into the understanding of disease aetiology, pathogenesis and methods to assess digestive health not yet published in the literature [4].

One aspect of digestive health is increased intestinal permeability (IP) which involves the loss of tight junction integrity between epithelium cells of the small intestine [5]. The consequence of IP in health and disease is not fully understood, however, IP has been suggested to play a role in the aetiology or pathogenesis of Crohn's disease [6], coeliac disease [7] and type 1 diabetes [7,8], and to exacerbate the pathogenesis of primary liver disease [9]. Furthermore, IP is suggested to be associated with a wide range of gastrointestinal conditions, autoimmune conditions, liver-related conditions, metabolic conditions and neurological conditions [[10], [11], [12], [13], [14]].

There is limited published literature on the clinical presentation of IP as symptoms can vary and are often non-specific [15,16]. Although the list of conditions associated with IP appears to be diverse, common symptomatology may be shared between individuals with IP. Unverified non-specific symptoms of IP may include bloating, flatulence, diarrhoea, depression and dermatitis [15,16]. Current evidence suggests that ameliorating IP corresponds with a reduction in symptoms such as abdominal pain, headaches and tiredness [17] and inducing IP may increase disease severity [[18], [19], [20]]. IP may contribute to disease exacerbation through mechanisms driven by both inflammation and dysbiosis [[21], [22], [23], [24], [25]]. The correlation between IP and disease severity may suggest that treating IP may consequently alter the presentation and progression of associated diseases.

However, the ideal treatment time to resolve IP and any corresponding symptoms remains unknown. The development and thereby the treatment of IP is suggested to be multifactorial, inflecting the time required to resolve IP [26,27]. Gene expression of tight junction proteins involved in IP is suggested to be influenced in a time-dependent manner [28]. There is no set time frame for clinical trial's investigating a treatment intervention for IP, with variation generally ranging from 4-12 weeks [29,30]. Insufficient treatment time may pose a limitation on clinical trials, as the modulation of IP appears to be time-dependent, suggesting that appropriate treatment length may coincide with a greater improvement of IP [31].

Drawing on the clinical experience of CIM practitioners who provide clinical care to individuals with IP, may offer insights to address some of the research knowledge gaps previously mentioned. Therefore, the aim of this study is to explore and describe the conditions CIM practitioners associate with IP and the methods they employ to assess IP in clinical practice.

Section snippets

Design

The study consisted of a cross-sectional electronic, self-administrated survey and was conducted with approval from the Human Research Ethics Committees (HREC) of Endeavour College of Natural Health (#20170762).

Setting

The Practitioner Research and Collaboration Initiative (PRACI) is a practice-based research network (PBRN) for CIM practitioners and is designed to facilitate collaboration between researchers and practitioners [32]. The PRACI membership provides researcher access to a national CIM

Participant characteristics

A total of 37 applicants responded to the survey with 36 meeting the eligibility criteria and completing the survey (response rate 15.9%). The majority of participants were female (n = 29, 80.6%) and worked in clinical practice in either Victoria (n = 16, 44.4%) or New South Wales (n = 11, 30.6%). Participants held a vocational (diploma/advanced diploma) (n = 15, 41.7%) or university (bachelor degree and above) (n = 21, 58.3%) qualification in naturopathy (n = 32) and/or nutrition (n = 20)

Discussion

This is the first study to explore and describe the conditions CIM practitioners associate with IP and the methods they employ to assess IP within clinical practice. Our analysis highlights a number of key findings. Firstly, the CIM practitioners observe a clinical link between IP and a wide range of conditions. The relationship between IP and some of these conditions aligns with existing epidemiological research while others have not yet been investigated at a population level (see Table 6).

Conclusion

CIM practitioners observed a clinical association between IP and a wide range of conditions, including conditions not yet recognised within the published literature. This highlights the importance of continuing to explore the conditions that may involve IP as part of their presentation. The emphasis CIM practitioners place on patient's signs and symptoms lays the foundations for the development of a validated diagnostic instrument to assess IP. The experience that CIM practitioners have

Funding

This work was supported by the Honours Funding Initiative at Endeavour College of Natural Health. The funding source had no involvement in the study design or results.

Conflicts of interest

All authors declare no conflict of interest.

Contributors

BL lead the development of the study, conducted the study and drafted the manuscript. JS and AS provided expertise on all stages of the study and revised the manuscript.

Acknowledgments

The authors would like to thank the members of PRACI who participated in this study.

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