Transcript Document

Elevate the Profession
Through Collaboration
Brent Bauer, MD
Stephen N. Blair, P.E.D.
Dale Healey, DC
Adam Perlman, MD, MPH
Cynthia Ribeiro
Title by Presenter
Name
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
Pain
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Anxiety
Tension
Cutshall, Comp. Therap.Clin. Practice, 2009
Massage Therapy after CV Surgery
Control group (n=28)
V
A
S
Massage group (n=30)
10
10
8
8
6
6
4
4
2
2
0
0
Before
After
Before
Anxiety Level
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After
Massage Therapy after CV Surgery
Control group (n=28)
V
A
S
Massage group (n=30)
10
10
8
8
6
6
4
4
2
2
0
0
Before
After
Before
Pain level
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After
Massage Therapy – Mayo Clinic
Randomized – Controlled Trial
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113 cardiac surgery patients
MT therapy days 2,4 vs. quiet relaxation
Decreased pain
P<0.001
Decreased anxiety
P<0.001
Decreased tension
P<0.001
Increased relaxation
P<0.001
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Bauer, Comp. Therap. Clin. Practice, 2010
Massage Therapy at Mayo Clinic
Other Studies
• MT for colo-rectal surgery patients
2009
• MT prior to cardiac interventions
2009
• MT for thoracic surgery patients
2011
• MT for breast cancer surgery pts
2012
• MT for cardiologists and nurses
2010
• MT for cardiac ultrasonographers
2011
• MT for in-patient nurses
2012
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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
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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
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Medical/Scientific Advisory Boards
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Research Funding
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Jenny Craig, Inc
Alere
Technogym
Cancer Foundation for Life
Santech
Clarity Project
NIH
Body Media
Coca Cola
Department of Defense
Royalties
• Human Kinetics
Non-Communicable Diseases (NCDs)
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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
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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 SearchFebruary 12, 2012
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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
LANCET PHYSICAL
ACTIVITY SERIES
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
Age adj death rate/10,000
PY
70
Women
Men
60
50
40
30
20
10
0
Low
Moderate
High
Blair SN. JAMA 1989
Deaths/10,000 MY*
Cardiorespiratory Fitness, Risk
Factors and All-Cause Mortality, Men,
ACLS
60
50
40
# of risk factors
30
2 or 3
20
10
0
1
0
Risk Factors
High
Mod
Low
current smoking
Cardiorespiratory Fitness Groups
SBP >140 mmHg
*Adjusted for age, exam year, and other risk factors Chol >240 mg/dl
Blair SN et al. JAMA 1996; 276:205-10
CRF and Other Health
Outcomes
CRF and Breast
Cancer Mortality
Odds Ratio
1
0.9
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
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0.8
p for trend=0.04
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Low
Sui X et al. MSSE 2009; 41:742
Moderate
High
Activity, Fitness, and
Mortality in Older Adults
Cardiorespiratory Fitness and All-Cause
Mortality, Women and Men ≥60 Years of Age
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4060 women and men
≤60 years
989 died during ~14
years of follow-up
~25% were women
Death rates adjusted
for age, sex, and
exam year
All-Cause death rates/1,000 PY
45
40
35
Low
Moderate
High
30
25
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
CRF:
14
Low
Moderate
High
12
10
8
6
4
2
0
Controlled HTN
Stage 1 HTN
Severity of HTN
Stage 2 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
Normal
Obese
30
20
10
0
Unfit
Fit
Deaths
151
190
29
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
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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
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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
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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
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Theoretical foundations
• Social Learning Theory
• Stages of Change Model
• Environmental/Ecological Model
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Methods
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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
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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
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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
Billions
$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.
National Supply and Demand
Projections for RNs,2000 – 2020
2,900
RN FTE Demand
FTEs (Thousands)
2,700
2,500
Shortage of
over 1,000,000
nurses in 2020
2,300
2,100
1,900
1,700
RN FTE Supply
1,500
2000
2005
2010
2015
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.
2020
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
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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 1st 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?