Transformation in Periop, Integrative Therapies for Healing the Whole Patient

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Transformation in Periop, Integrative Therapies
for Healing the Whole Patient
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Whats in a name?

• Alternative Medicine- unorthodox
• WHolistic Medicine- mind-body-spirit
• Complementary Medicine (or CAM)
• Denotes modalities
• Integrative Medicine
• A philosophy of care

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Philosophy of Integrative Medicine

• WHAT?
• Goal is optimal functioning, not simply absence
  of disease
• WHO?
• Care of the whole person not disease in
  isolation
• WHY?
• Interconnection of mind, body, and spirit is
  relevant to health
• HOW?
• Use the best of conventional and complementary
  therapies
• Use evidence to inform treatment decisions
  (balance risk/benefit)
• Recognize importance of relationships,
  diagnostically therapeutically

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Your Patients Are Using CAM

• 1990-1997 42 of surveyed Americans used CAM
  (Eisenberg 1998, JAMA)
• 2002 62 of surveyed Americans used CAM (Barnes
  2004)
• 2007 38 of Americans use some form of CAM (CDC
  National Health Statistics Report 2007)

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Decrease Your Frustration With Patients Who Have

• Chronic digestive problems
• Chronic fatigue
• Sleep disorders
• Chronic pain
• Chronic headaches
• Irritable Bowel Syndrome
• Anxiety-related symptoms
• Non-adherence / hostility toward your
  suggestions

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Integrative Health Evidence Sample

• RCT showing relaxation training/guided imagery
  improved NK and T-helper cell activity in cancer
  pts undergoing chemo/rads (Eremin Breast 2009)
• Tai Chi improved fibromyalgia (Wang NEJM 2010),
  QOL/mood in CHF patients (Yeh Arch Intern Med
  2011)
• RCT showing mindfulness training improved IBS
  (Gaylord Am J Gastroenterol 2011)
• Acupuncture improves pain function in knee DJD
  (Berman Ann Intern Med 2004)

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NCCAM Classification of CAM Therapies

• Natural Products
• Herbs, supplements, probiotics
• Mind-Based Mind-body Practices
• Meditation, guided imagery, yoga, tai chi, qi
  gong
• Body-Based Mind-body Practices
• Spinal and soft tissue manipulation, massage,
  biofield methods (Reiki, healing touch),
  acupuncture, acupressure, somatic education
• Traditional and Alternative Aystems
• Traditional East Asian Medicine, Homeopathy,
  Ayurveda, Naturopathy

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Most Prevalent CAM Practices among US Adults- 2007
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Mind and Body
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Mindful Awareness-Based Therapies

• Meditation
• Guided imagery
• Tai Chi/Qi Gong
• Cognitive behavioral therapy
• Biofeedback
• Hypnosis
• Prayer
• Other (art therapy, music therapy, pet therapy)

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Proprioceptive/KinestheticBody-Based Physical
Methods

• Profession-related
• Chiropractic manipulation
• Osteopathic manipulation
• Therapeutic Massage
• Acupuncture

Bronfort, et al. Effectiveness of Manual
Therapies, The UK Evidence Report, Chiropractic
and Osteopathy. 2010. 18, 3

• Approach Related
• Biofield Reiki, Healing Touch
• Neurologic learning Feldenkrais, Alexander,
  PNF, Sensory integration
• Fascia biomechanics Rolfing Structural
  Integration, MFR, Craniosacral

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Alternative Medical Systems

• Homeopathy
• Philosophy like cures like,something that
  provokes symptoms can help body heal itself of
  those symptoms use the minimum dosage that
  provokes a healing response
• Naturopathy
• Philosophy the body can heal itself, work with
  the bodys physiologic properties first do no
  harm
• 4 year training is important, licensing issues
• Traditional Chinese Medicine
• Philosophy disruption of the dynamic balance of
  vital forces and physical substances that sustain
  life. Chi and Blood, characterized by yin /yang
  balance of internal and external natural forces
• Acupuncture, Chinese herbs, Qi Gong, Tui-na,
  Seasonal diet, etc

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OKbut whats the evidence base??

• Yes, but
• Increasing number of well done studies in
  respected journals (NEJM, Annals of Intern Med,
  JAMA etc)
• Many poor quality studies (no control, small
  sample etc)
• NIH NCCAM (National Center for Complementary and
  Alternative Medicine) budget was 122 million in
  2006
• Many studies underway
• Conventional medicine is not always
  evidence-based
• E.g. HRT ? Womens Health Study

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What supplements should I use?

• Use anti oxidant supplements only before and
  after chemo and radiation, not during
• Food (e.g. berries) tea (e.g. green tea) is OK
• Acupuncture for chemo nausea
• Guided imagery pre/post-op to facilitate recovery
• Mind-body therapies for stress reduction

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How to Learn More

• Websites
• http//nccam.nih.gov/
• http//www.naturalstandard.com/
• http//naturaldatabase.therapeuticresearch.com
• http//www.drweil.com/
• http//www.wholehealthmd.com

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UMB SOM Resources

• Center for Integrative Medicine
• Integrative Medicine Clinic UMORI (Kernan) 2200
  Kernan Drive, 2nd Floor, Baltimore, MD 21207,
  410-448-6361
• Little Green Book community integrative
  practices
• Integrative Care Team- UMMC

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The Integrative Care Team

• Dr. John Reed, Medical Director of Inpatient
  Services
• Donna Audia, RN
• Lolly Forsythe-Chisolm, Integrative Care
  Specialist
• Carol Joy Loeb, RN
• Matthew Peroutka, Certified Music Practitioner
• Terry Fevang, Certified Music Practitioner

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Relaxation Response
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Relaxation Response
Stress Relaxation
Increased heart rate Decreased heart rate
Increased Respiratory rate Decreased Respiratory rate
Increased Muscle tone/ tension Decreased Muscle tone/ tension
Increased Metabolic rate Decreased Metabolic rate
Increased Stress hormones (cortisol) Decreased Stress hormones (cortisol)
Decreased Immune function Increased Immune function
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Reiki
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Sound Therapy
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Acupressure/Acupuncture
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Auriculotherapy
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Art for Compassion
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Guided Imagery
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Therapeutic Music
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Yoga Breath Work
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Integrative Medicine Wheel
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Healing Presence
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ICT Inpatient Service Levels -1

• Integrative Medicine Consult (Attending to ICT
  MD) Evaluation by MD and RN for complex mind-body
  challenged patients and families, and adapting
  natural healing beliefs to hospital
  environment. Results in adjunctive management
  recommendations, and team interventions if
  requested.
• Acupuncture Treatment Referral (Pain Management,
  Attending to ICT MD) for supportive/adjunctive
  pain, stress, PONV, chemotherapy nausea, delayed
  wound healing. Acupuncture will be
• initiated unless contraindicated.
• Additional ICT services will be
• offered as appropriate.
• All referrals will be subject to
• ICT review and case supervision.

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ICT Inpatient Service Levels-2

• Pain and Stress IC Team Referral (Attending to
  Integrative Care Team) for open-ended team
  consult. Supportive care plan developed and
  delivered in conjunction with patient preferences
  and goals. Full range of service options,
  follow-up during hospital stay, interaction with
  unit management and other specialty teams ( pain
  management, palliative care, social work,
  therapy, etc)
• Comfort and Support Referral (Nurse unit manager
  to Integrative Care Team) for short-term
  supportive presence for stressful transitions
  (ending life support, adverse med/surgical
  outcomes, uncontrolled anxiety). Will typically
  involve therapeutic sound/music and simple
  relaxation methods, one or two visits only.
  Additional requests will trigger level 1-3
  interventions
• All referral patients will be subject to ICT case
  review and supervision.

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Do Something for Yourself!

• Pain problems
• Acupuncture
• Manual therapies
• Biofield/ Reiki
• Sleep and energy issues
• Elimination diet (excess carbs,
• definitely reduce caffeine!)
• Consider supplements (Magnesium, Theanine,
  ashwaganda, Siberian ginseng)
• Stress
• Mind-Body Techniques Meditation, yoga, Guided
  imagery, biofeedback, hypnosis