Elevate the Profession Through Collaboration Brent Bauer, MD Stephen N. Blair, P.E.D.

Dale Healey, DC Adam Perlman, MD, MPH

Brent A. Bauer, MD

• Director, Complementary and Integrative Medicine – Mayo Clinic • Brief overview of work at Mayo • How massage therapy is an integral part of this work

Massage Therapy – Mayo Clinic

Pilot Trial 58 cardiac surgery patients Massage therapy vs quiet relaxation Decreased 3031090-3 Pain Anxiety Tension Cutshall, Comp. Therap.Clin. Practice, 2009

Massage Therapy after CV Surgery

Control group (n=28) Massage group (n=30)

10 10 8

V A S

6 4 2 0 Before 8 6 4 2 After 0

Anxiety Level

Before After 3031090-4

Massage Therapy after CV Surgery

Control group (n=28) Massage group (n=30)

10 10 8

V A S

6 4 2 0 Before After 8 6 4 2 0

Pain level

Before After 3031090-5

Massage Therapy – Mayo Clinic

Randomized – Controlled Trial • • • • • • 113 cardiac surgery patients MT therapy days 2,4 vs. quiet relaxation Decreased pain Decreased anxiety P<0.001

P<0.001

Decreased tension Increased relaxation P<0.001

P<0.001

Bauer, Comp. Therap. Clin. Practice, 2010 3031090-6

Massage Therapy at Mayo Clinic

Other Studies • MT for colo-rectal surgery patients 2009 • MT prior to cardiac interventions • MT for thoracic surgery patients 2009 2011 • MT for breast cancer surgery pts • MT for cardiologists and nurses • MT for cardiac ultrasonographers 2012 2010 2011 MT for in-patient nurses 2012

Massage Therapy at Mayo Clinic

The Impact • Massage therapy now routine at MC – Domino effect – Small investment > “snowball” returns • 48 hospitals in US • 7 international hospitals – Australia, Austria, China, Ireland, Switzerland, Turkey 3031090-8

Massage Therapy at Mayo Clinic

The Vision Massage therapy routinely available to

all

Hospitalized patients at Mayo Clinic Family members Staff

Continue to use the Mayo experience to transform health care in the U.S. and around the world

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Steven N. Blair, P.E.D

• Departments of Exercise Science & Epidemiology/Biostatistics Arnold School of Public Health University of South Carolina • • Physical Activity and Health How that impacts you and your practice

  

Disclosures

Medical/Scientific Advisory Boards

• • • • • •

Jenny Craig, Inc Alere Technogym Cancer Foundation for Life Santech Clarity Project Research Funding

• • • •

NIH Body Media Coca Cola Department of Defense Royalties

•

Human Kinetics

   

Non-Communicable Diseases (NCDs) Changing patterns in leisure and work have led to a health crisis NCDs cause 65% of all deaths worldwide 36.1 million deaths from CVD, Stroke, Diabetes, Cancer & Respiratory diseases. Physical inactivity causes 3.2 million deaths/year WHO. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva: World Health Organization, 2010.

Question



Rank the following exposures by the number of deaths caused worldwide.

• Tobacco use • Obesity • High blood pressure • Physical inactivity • High blood glucose

Results of Google Search February 12, 2012

       

Inactivity—3 million hits Physical inactivity—2.98 million hits Sedentary behavior—2.35 million hits Eating too much—393 million hits Obesity—90 million hits Diet and obesity—65.8 million hits Inactivity and obesity—708,000 hits Physical inactivity and obesity— 945,000 hits

L

ANCET

P

HYSICAL

A

CTIVITY

S

ERIES

More of the same is not enough

Global perspective

33 researchers, 16 countries

Findings

•

Between 6 10% of the world’s major NCDs is attributable to inactivity

•

By eliminating inactivity, >5.3 million deaths/y may be prevented

•

This leads to an increase of 0.68 years in the world’s life expectancy (For perspective: smoking causes 5 million deaths/y worldwide)

Aerobics Center Longitudinal Study

Design of the ACLS

1970 More than 80,000 patients 2005 Cooper Clinic examinations--including history and physical exam, clinical tests, body composition, EBT, and CRF Mortality surveillance to 2003 More than 4000 deaths 1982 ‘86 ‘90 ‘95 ’99 ‘04 Mail-back surveys for case finding and monitoring habits and other characteristics

All-Cause Death Rates by CRF Categories —3120 Women and 10 224 Men —ACLS

70 60 50 Women Men 40 30 20 10 0 Low Moderate High Blair SN. JAMA 1989

Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men, ACLS 60 50 40 30 20 10 0 0 Low Mod High Cardiorespiratory Fitness Groups 1 *Adjusted for age, exam year, and other risk factors # of risk factors 2 or 3 Risk Factors current smoking SBP >140 mmHg Chol >240 mg/dl Blair SN et al. JAMA 1996; 276:205-10

CRF and Other Health Outcomes

CRF and Breast Cancer Mortality

•

14,551 women, ages 20-83 years

•

Completed exam 1970-2001

•

Followed for breast cancer mortality to 12/31/2003

•

68 breast cancer deaths in average follow-up of 16 years

•

Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 Odds Ratio p for trend=0.04

Low Moderate High Sui X et al. MSSE 2009; 41:742

Activity, Fitness, and Mortality in Older Adults

Cardiorespiratory Fitness and All-Cause Mortality, Women and Men ≥60 Years of Age

   

4060 women and men ≤60 years 45 989 died during ~14 40 All-Cause death rates/1,000 PY years of follow-up 35 Low ~25% were women 30 25 Moderate High Death rates adjusted for age, sex, and exam year 20 15 10 5 0 60-69 70-79 80+ Age Groups Sui M et al. JAGS 2007.

Cardiorespiratory Fitness and Health Outcomes in Various Population Subgroups

Such as People Who Are Overweight or Obese or Those with Chronic Disease

Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in 8147 hypertensive men CVD incidence/1000 man-years 18 P <.001 P <.001 P =.048

16 14 12 CRF: Low Moderate High 10 8 6 4 2 0 Controlled HTN Stage 1 HTN Stage 2 HTN Severity of HTN Sui X et al. Am J Hyptertension. 2007

Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+ Death rate/1,000 person-years 40 30 Normal Obese 20 10 0 Deaths 151 Fit 190 29 Unfit 72 Rates adjusted for age, sex and exam year Sui M et al. JAMA 2007; 298:2507-16

2008 Physical Activity Guidelines for Americans

At-A-Glance

www.health.gov/PAGuidelines/

U.S. Department of Health and Human Services

4 Key Adult Guidelines



Avoid inactivity



Substantial health benefits from medium amounts of aerobic activity



More health benefits from high amounts of aerobic activity



Muscle-strengthening activities provide additional health benefits

 

WHO PA Recommendation

Released by WHO in December 2010 PA recommendations

• 5-17 yr—60 min MVPA/day,

vigorous intensity, including muscle and bone strengthening 3 X week

• 18-64 yr—each week accumulate

in bouts of at least 10 min, 150 min moderate intensity, 75 min vigorous intensity, or combination of both; and resistance training 2 X week

• 65 yr & older—same as 18-64 yr,

those with poor mobility should also do balance exercises, and take health conditions into account

How Can We Get Sedentary Adults to Become and Stay More Physically Active?

Track Record of Lifestyle PA Interventions



Successfully implemented in many different populations and settings

• •

Men and women of all ages African-American men and women, Hispanic women

• •

Prostate cancer survivors Worksites, YMCA’s, public heath departments, recreation facilities, senior centers, churches

Behavioral Approaches to Physical Activity Interventions

 

Theoretical foundations

•

Social Learning Theory

• •

Stages of Change Model Environmental/Ecological Model Methods

•

Problem solving

• • • • • •

Self-monitoring Goal setting Social support Cognitive restructuring Incremental changes Manipulating the environment

90% of What You Need to Know

    

about Exercise Prescription

Sitting is hazardous Some activity is better than none More activity is better than less A reasonable target is 150 minutes of moderate intensity activity/week Should be in bouts of at least 10 minutes



What Is the Best Exercise?

The one you will do regularly



No matter how excellent the exercise is or how effective the program might be, it will not produce any benefits for you if you do not do it

3031090-39

Dale Healey, DC

• • • • • Dean College of Undergraduate Health Sciences at Northwestern Health Sciences University PhD Student at the University of Minnesota – dissertation focused on the integration of CAM topics into Medical School Curriculum COMTA Commissioner ACCAHC Board Member MTF Best Practices Committee

Institute of Medicine

The U.S. health care system is in need of a fundamental change…. Health care today harms too frequently, and fails to deliver its potential benefits routinely. As medical science and technology have advanced at a rapid pace, the health care delivery system has foundered. Between the care we have and the care we could have lies not just a gap, but a wide chasm.

Crossing the quality chasm: A new health care system for the 21st century.2001

National Health Expenditures

(1)

, 1980 – 2018

(2)

$4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 80 90 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 Source: Centers for Medicare & Medicaid Services, Office of the Actuary. Data released February 23, 2009.

(1) Years 2008 – 2018 are projections.

(2) CMS completed a benchmark revision in 2006, introducing changes in methods, definitions and source data that are applied to the entire time series (back to 1960). For more information on this revision, see http://www.cms.hhs.gov/NationalHealthExpendData/downloads/benchmark.pdf.

2,900

National Supply and Demand Projections for RNs,2000 – 2020

RN FTE Demand 2,700 2,500 Shortage of over 1,000,000 nurses in 2020 2,300 2,100 1,900 1,700 1,500 RN FTE Supply 2000 2005 2010 2015 2020 Source: National Center For Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. (2004).

What Is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses?

Link: ftp://ftp.hrsa.gov/bhpr/workforce/behindshortage.pdf.

Collaboration Can Help

• • Not new idea – “Educating for the Health Team” - Institute of Medicine, 1972 More important now than ever: – Baby Boomers – Obesity epidemic – Rising costs – Provider shortages – System inefficiencies

A Role for Massage Therapy

• • • • • • • Lots of you (300,000) Positive image with the public Patients like you - helps with compliance Patients talk to you and trust you You

see

most of the patient’s body You

touch

most of the patient’s body You spend considerably more time with patients than most providers

What is Needed • • • • Education Reform A “Flexner Report” for Massage Therapy Programmatic Accreditation with supporting competencies – Interprofessional Practice Skills – Evidence Informed Practice – Expansion of Scope (e.g. health screening procedures) Participation in the conversation outside the massage therapy community

IPEC • • • Interprofessional Education Collaborative Expert Panel from the education associations of following six professions: – Nursing – Osteopathy – Pharmacy – Dentistry – – Medicine Public Health 38 Core Competencies for interprofessional collaborative practice spread over 4 domains

ASPA • • • • Association of Specialized and Professional Accreditors ASPA is working (struggling) to get interprofessional competencies into accreditation standards.

A recent meeting of the ASPA focused on how to encourage the accrediting agencies to catch up with the Interprofessional Education movement.

Education tends to lag behind practice.

CAHCIM • • • • Consortium of Academic Health Centers for Integrative Medicine Began in 1999 with 8 institutions Now consists of 51 Academic Health Centers “Core Competencies in Integrative Medicine for Medical School Curricula: A Proposal”

Academic Medicine, Vol. 79, No. 6/June, 2004

ACCAHC • • • • • Academic Consortium for Complementary and Alternative Healthcare – formed in 2004 Five licensed CAM professions plus Traditional World Medicines and Emerging Professions Center for Optimal Integration – aggregate useful information, organize activity, online courses, stimulate leadership Competencies for Optimal Practice in Integrated Environments – adopted and added to IPEC competencies Participation on IOM panels and initiatives

ACCAHC – CAHCIM teaming up • • • ACCAHC and CAHCIM have partnered on a number of initiatives and next month are sponsoring the first

“International Congress for Educators on Complementary and Integrative Medicine and Health”

Preceded by a day of Ambassador Leadership training sponsored by ACCAHC Designed to create leaders in Integrative Healthcare, capable of representing the movement, not just their own profession.

NWHSU

• Northwestern Health Sciences University • Participation with University of Minnesota NIH funded R-25 projects • Hospital Based Massage Therapy training program with clinical rotations in four local hospitals • Pillsbury House Integrated Heath Clinic – in partnership with U of M medical, nursing schools and the Adler graduate school of psychology

NWHSU

• Training of medical students and nursing students from the University of Minnesota in CAM practices • This fall, 60 Advanced Practice Nursing students will descend on Northwestern to learn about Chiropractic, Acupuncture and Massage Therapy.

• A case study will be used to guide the discussion with EIP as the nursing and CAM students explore how they could work together in the management of a complex case.

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Adam Perlman, MD, MPH, FACP

• Associate VP for Health and Wellness for the Duke University Health System • Executive Director, Duke Integrative Medicine “Thoughts derived from different settings”

New Jersey

• Siegler Center for Integrative Medicine • Services Offered • Who do you hire Clinical Research • Relationships

UMDNJ

• Research • Serving the underserved • Sustainability • Institute for Therapeutic Massage • Teach • Relationships

Duke

• Research • Shifting the model • Access • Fiscally sustainable • Forging relationship • DCI

The good, the bad, and the ugly.

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Cynthia Ribeiro

• AMTA National President • Education/Professional Experience • BS Physical Education • Surgical Nurse • Massage Educator and Massage Therapist for 25 years

University of California - Irvine

• 2004-2010: Taught 1 st year medical students as honorary clinical professor at UCI Medical School • Teach Anatomy with Medical Professors in UCI Cadaver lab • Anatomy • Functional Anatomy

University of California - Irvine Had massage therapists work on medical students so they could understand the effect of massage on their patients

Samueli Center for Integrative Medicine • • • Promote integrative medicine by: Conducting rigorous fundamental and clinical research on complementary healing practices.

Educating medical students, health professionals and the public about these practices.

Creating a model of clinical care that emphasizes healing of the whole person.

Keys to Collaboration • Create communication pathway • All healthcare professionals • Involved in the health and wellness needs of a specific patient • Includes Medical and CAM/Integrative professionals • Focus on the needs of the patient • Regular group review of patient needs and treatment plan • Ensure compliance with laws and regulations

Keys to Collaboration • Speak the same language • Medical terminology • Understand health care professionals strengths • Understand the modalities and effect of their work on the patient • Development of Inter discipinary treatment plan • Most effective and safe treatment sequence for effective healing • Appropriate documentation

Elevating the Conversation • Applies to all practice settings • Panelists have a variety of perspectives • Focus on how we make a difference in the lives of our clients • How do we apply what we’ve heard today to ensure that client is at the center of our care for them?