Transformation in Periop, Integrative Therapies for Healing the Whole Patient

What’s in a name?

• Alternative Medicine- “unorthodox”

• [W]Holistic Medicine- “mind-body-spirit”

• Complementary Medicine (or CAM)– Denotes modalities

• Integrative Medicine– A philosophy of care

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

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)

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

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)

NCCAM Classification of CAM Therapies

Natural ProductsHerbs, supplements, probiotics

Mind-Based Mind-body PracticesMeditation, guided imagery, yoga, tai chi, qi gong

Body-Based Mind-body PracticesSpinal and soft tissue manipulation, massage, biofield

methods (Reiki, healing touch), acupuncture, acupressure, somatic education

Traditional and Alternative AystemsTraditional East Asian Medicine, Homeopathy,

Ayurveda, Naturopathy

Most Prevalent CAM Practices among US Adults- 2007

Mind and Body

Mindful Awareness-Based Therapies

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

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

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 body’s 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

OK…but what’s 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 Women’s Health Study

“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

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

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

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

Relaxation Response

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

Reiki

Sound Therapy

Acupressure/Acupuncture

Auriculotherapy

Art for Compassion

Guided Imagery

Therapeutic Music

Yoga Breath Work

Integrative Medicine Wheel

Healing Presence

ICT Inpatient Service Levels -1

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.

2. 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.

ICT Inpatient Service Levels-2

3. 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)

4. 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.

Do Something for Yourself!

Pain problems:• Acupuncture• Manual therapies• Biofield/ ReikiSleep 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