Title by Presenter Name
Elevate the Profession Through Collaboration
Brent Bauer, MDStephen N. Blair, P.E.D.
Dale Healey, DCAdam Perlman, MD, MPH
Cynthia Ribeiro
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
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Decreased
Massage Therapy – Mayo ClinicPilot Trial
58 cardiac surgery patients
Cutshall, Comp. Therap.Clin. Practice, 2009
Pain Anxiety Tension
Massage therapy
quiet relaxationvs
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Massage Therapy after CV Surgery
10
8
6
4
2
0
Before After
VAS
Anxiety Level
Control group (n=28)
10
8
6
4
2
0
Before After
Massage group (n=30)
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Massage Therapy after CV Surgery
10
8
6
4
2
0
Before After
VAS
Pain level
Control group (n=28)
10
8
6
4
2
0
Before After
Massage group (n=30)
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Massage Therapy – Mayo ClinicRandomized – Controlled Trial
• 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
Bauer, Comp. Therap. Clin. Practice, 2010
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Massage Therapy at Mayo ClinicOther Studies
• MT for colo-rectal surgery patients 2009
• MT prior to cardiac interventions 2009
• MT for thoracic surgery patients2011
• MT for breast cancer surgery pts2012
• MT for cardiologists and nurses 2010
• MT for cardiac ultrasonographers 2011
• MT for in-patient nurses2012
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Massage Therapy at Mayo ClinicThe 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 ClinicThe Vision
Massage therapy routinely available to all
Continue to use the Mayo experience to transform
health care in the U.S. and around the world
Hospitalized patients at Mayo Clinic
Family members
Staff
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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
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
Mortality surveillance to 2003More than 4000 deaths
Cooper Clinic examinations--includinghistory and physical exam, clinical tests,body composition, EBT, and CRF
1982 ‘86 ‘90 ‘95 ’99 ‘04Mail-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
0
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50
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70
Ag
e ad
j d
eath
rat
e/10
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P
Y
Low Moderate High
Women
Men
Blair SN. JAMA 1989
Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men,
ACLS
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60
Dea
ths/
10,0
00 M
Y*
Low Mod High
01
2 or 3
# of risk factors
Risk Factorscurrent smokingSBP >140 mmHgChol >240 mg/dl
Cardiorespiratory Fitness Groups*Adjusted for age, exam year, and other risk factors
Blair SN et al. JAMA 1996; 276:205-10
CRF and Other Health Outcomes
CRF and Breast Cancer Mortality
Low Moderate High0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
•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
Odds Ratio
p for trend=0.04
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
989 died during ~14 years of follow-up
~25% were women Death rates adjusted
for age, sex, and exam year
0
5
10
15
20
25
30
35
40
45
60-69 70-79 80+
Low
Moderate
High
All-Cause death rates/1,000 PY
Age Groups
Sui M et al. JAGS 2007.
Cardiorespiratory Fitness and Health Outcomes in Various
Population SubgroupsSuch as People Who Are Overweight or Obese or
Those with Chronic Disease
0
2
4
6
8
10
12
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18
LowModerateHigh
Controlled HTN Stage 1 HTN Stage 2 HTN
Severity of HTN
P <.001 P <.001 P =.048
CRF:
Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in
8147 hypertensive men
Sui X et al. Am J Hyptertension. 2007
CVD incidence/1000 man-years
Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+
0
10
20
30
40
Fit Unfit
Normal
Obese
Death rate/1,000 person-years
Rates adjusted for age, sex and exam year
Deaths 151 190 29 72
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
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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)
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.
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
80 90 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18
Bill
ions
National Supply and Demand Projections for RNs,2000 – 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.
RN FTE Supply
RN FTE Demand
1,500
1,700
1,900
2,100
2,300
2,500
2,700
2,900
2000 2005 2010 2015 2020
FT
Es
(Tho
usan
ds)
Shortage of over 1,000,000 nurses in 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
• 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
ClinicalResearch
• 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?
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