ICL 10.6: Behavioral and Complimentary Interventions

Question 1

what is the mission of the national center for complementary and integrative health?

Answer 1

the mission of NCCIH is to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health andhealthcare

this used to be called the alternative medicine center!

Question 2

what are the different domains of complimentary and integrative health practices?

Answer 2

1. biologically based = herbs, diets, vitamins
2. energy = use of energy fields
3. manipulative = body movements by others like massage therapy
4. mind-body = mind effects on body functions
5. whole medical systems = complete theory and practice like acupuncture

Question 3

in which conditions is complimentary and integrative heath most commonly used?

Answer 3

(most common)
1. chronic back pain

2. head cold
3. chronic neck pain
4. joint pain; arhtritis
5. anxiety/depression
6. chronic GI problems
7. acute headaches
   (least common)

a lot of these are chronic so it makes sense these patients want to seek complimentary treatment! also, these things don’t have cures! plus a lot of these problems have a lot of important comorbidities. so patients will probably be reaching out to their physician when deciding which therapies to chose

Question 4

how frequently do people use complimentary and integrative heath therapies?

Answer 4

1. mind body medicine (52%)

emphasis on mindfulness, relaxation therapy, guided imagery etc.

2. biologically based practices (22%)
3. manipulative and body based practices (11%)
4. whole medical systems (3%)
5. energy medicine (.5%)

Question 5

what practices are mind-body interventions?

Answer 5

1. relaxation
2. biofeedback
3. meditation

Question 6

what are relaxation therapies?

Answer 6

a group of behavioral therapeutic approaches whose primary objective is the achievement of physical and mental relaxation –> this is a type of mind-body intervention

two common components are:
1. repetitive focus on a word, sound, phrase, or body sensation (breath)

2. a passive attitude toward intruding thoughts
   ex. mindful breathing, progressive relaxation, passive relaxation

Question 7

what is passive relaxation?

Answer 7

repeat relaxing words that convey mental and physical relaxation to reduce arousal and pain

1. the words usually mention heaviness which is associated with muscular relaxation
2. warmth of the hands and feet; use mental techniques to warm the hands/feed
3. saying words like calm, peaceful, quiet

a type of relaxation therapy which is a type of mind-body intervention

Question 8

what is progressive relaxation?

Answer 8

muscles are alternately tensed and relaxed to identify the difference between tension and relaxation and produce relaxation voluntarily

you’re trying to help people who have pain but don’t realize that their muscles are tight

a type of relaxation therapy which is a type of mind-body intervention

Question 9

what is biofeedback therapy?

Answer 9

an active therapeutic technique, based on operant conditioning by which a person learns awareness and control of a physiological function (self regulation) and then is able to apply that to whatever their personal goal is –> this is a type of mind-body intervention

it involves some kind of instrument or measuring device! eventually after the person has been trained, they will no longer need the instrument

ex. biofeedback device that measures the temperature of the skin; the person would have this attached to their finger and the person is guided through a relaxation therapy talking about how to get your hands to warm and as your hands warm, the noise from the device will decrease – so the feedback is in the form of the sound decreasing and patients can also watch the temperature too in live time – through training the patient will help identify their internal state and they’re able to generate the relaxation response without the deivce

Question 10

what are the types of biofeedback in clinical use?

Answer 10

1. EMG = electromyograph measures skeletal muscle motor unit potentials
2. thermal = measures the temperature of the skin
3. heart rate variability = measures the change in heart rate during inhalation and exhalation
4. EEG = electroencephalography measures brain wave activity –> doesn’t work as well because it’s hard for patients to identify when they’re at a good brain wave activity and replicate that without the machine

Question 11

which disorders are treated with biofeedback alone?

Answer 11

pediatric ADHD

Question 12

how id pediatric ADHD treated?

Answer 12

biofeedback therapy! specifically EEG feedback which provides information about brain wave patterns

the goal is to learn to generate brain waves associated with concentration and attention (decrease theta/beta ratio) – > multiple sessions are required (30)

controlled study showed improvement in attention and executive function

metanalysis rated EEG as “probably efficacious” so the risk is low and the benefits can be pretty high for some kids if they’re able to stick with it

Question 13

how are tension-type headaches treated with complimentary and integrative heath treatments?

Answer 13

biofeedback + relaxation therapy

sensors on the forehead (back of neck, jaw) connect to an EMG which provides information about muscle tension –> relaxation is used to relieve tension in face, neck and shoulder muscles

protocol: approximately 10 sessions and home practice of relaxation = progressive/passive relaxation or breathing

there is a documented decrease in frequency and intensity of muscle tension headache!

Question 14

how does cognitive behavioral therapy vs. relaxation help with chronic back pain treatment?

Answer 14

CBT: evidence is good; benefit is moderate

progressive relaxation: evidence is fair; benefit is substantial!!

since most pain over time becomes comorbid with a mood or anxiety disorder, you should recommend CBT in addition to progressive relaxation!

Question 15

how are anxiety disorders treated with complimentary and integrative heath treatments?

Answer 15

biofeedback + relaxation + psychotherapy

1. thoughts and beliefs related to anxiety responses are explored through psychotherapy, usually CBT
2. biofeedback promotes mastery of stress related physiological responses (ex. heart rate variability or thermal biofeedback of fingers would be great; fingers get cold and heart rate goes up during stress)
3. passive relaxation and slow breathing are practiced to generalize the relaxation response

Question 16

what is meditation? what are the 2 types of meditation?

Answer 16

focusing your attention on a mantra (a word or words), an object or the breath, or the moment

1. transcendental meditation (TM)
2. mindfulness meditation

Question 17

what is transcendental meditation?

Answer 17

uses a mantra to quiet the mind

the mantra is usually a word; so it’s a repetition of this mantra

practice 2x a day for 20 minutes

Question 18

what is mindfulness meditation?

Answer 18

non-judgmental awareness of and acceptance of the present moment

can be practiced formally or informally

formal would be taking time specifically to meditate and be in the moment, focus on the full experience of that moment

informal meditation would be focusing on eating; eating meditation would be paying attention specifically to what you’re eating and the entire experience of that – walking meditation would be paying attention to walking, the sensation of your feet on the ground, the breeze, your heart rate; everything about that specific experience

Question 19

what are the effects of transcendental meditation on metabolic syndrome? what is metabolic syndrome?

Answer 19

metabolic syndrome = high BP, DM2, hyperlipidemia

TM decreased BP, decreased insulin resistance and improved the lipoprotein profile as long as TM practices were continued!

for people with pain and anxiety conditions, once they learn the process of relaxation, they can cut back relaxation to 2-3 times a week but people with physical conditions like high BP have to do the meditation every day

Question 20

what are the physical effects of mindfulness meditation on the body?

Answer 20

changes were observed in brain regions associated with attention, emotional balance and self regulation!

patients were less reactive to stress, better able to concentrate and less reactivity to anxiety, anger, etc.

this includes regions such as anterior cingulate cortex, prefrontal cortex and striatum, limbic areas, insula, medial prefrontal cortex

these results suggest neuroplasticity

Question 21

what does MBSR stand for?

Answer 21

MBSR = mindfulness-based stress reduction

Question 22

which psychiatric conditions is MBSR used to treat?

Answer 22

1. depression: significant increase in positive emotions and ability to find pleasure in day to day activities
2. bipolar disorder: significant decrease in anxiety and fewer depressive symptoms

MBSR = mindfulness-based stress reduction

Question 23

how does mindfulness meditation effect sleep?

Answer 23

a study compared sleep hygiene with mindfulness

results showed mindfulness meditation had:
1. shorter time to get to sleep; decrease onset insomnia

2. fewer awakenings
3. sense of restorative sleep upon awakening

Question 24

what is medical acupuncture?

Answer 24

acupuncture involves the insertion of thin metal needles at precise points and applying heat or electrical stimulation.

in Ohio, it’s provided by physicians who have a valid medical license and who have completed 300 hours of acupuncture training

non-physician providers must file with the state medical board and be recognized by the National Certification Commission for Acupuncture and Oriental Medicine

Question 25

what is the theory of acupuncture?

Answer 25

origin: There are patterns of energy flow (Qi) through the body (meridians) that are essential for health

disruptions in this flow are believed to be responsible for disease

learning where the sites are that are connected to a certain part of the body is what acupuncture is all about – for example, if someone was having neck problems, the physician would know the specific part of the ear to put the needles to effect the neck

acupuncture is provided as part of Traditional Chinese Medicine or alone

Question 26

how is acupuncture used to psychiatric conditions?

Answer 26

1. depression in adults –> significant decreases in depression scores in counseling and acupuncture groups at 3 and 12 months compared to usual care (education) – so this is a long term benefit from 10 sessions of acupuncture!
2. depressed pregnant women –> results showed most benefit for acupuncture specific for depression vs. massages/control acupuncture

this is great because pregnant women are limited in the anti-depressants that they can take so it’s good to have options

Question 27

what are herbs and supplements?

Answer 27

herbals have been used in non -Western cultures and other systems of medicine for centuries

currently, herbs and supplements are not regulated by FDA but change is coming because the FDA decided since they’re so widely used, people need better guidance in what should be recommended

currently, labeling of products is restricted to structure and function claims like “improve well being”, not medical or psychiatric claims –> they can’t say that they lower BP or help with anxiety/PTSD because they haven’t been tested rigorously enough to back that claim

Question 28

what are the challenges seen with herbs and supplements?

Answer 28

it’s super hard to study the effects of herbs and supplements…

Scholey et al 2010 showed short term improvements in working memory with ginseng

the problem is “American ginseng (Panax quinquetolius) has a distinct chemical profile from Asian ginseng (Panax ginseng)..” and getting a standardized extract of ginseng is very variable because it depends on where the plant was grown and which portion of the plant was used! so this is why it’s difficult in assessing the effects of herbs

Question 29

what is the physicians role in complementary and integrative health?

Answer 29

be knowledgable!

mind-body therapies and acupuncture are important and you need to follow the literature on these! you should follow herbal literature so you can answer patient questions

rely on the national center for complimentary and integrative help (NCCIH) because they’re doing studies and metaanalysis

Question 30

when should physicians recommend complementary and integrative health therapies?

Answer 30

1. if the evidence supports safety and effectiveness then recommend and monitor
2. if the evidence supports safely but inconclusive on effectiveness then tolerate and monitor
3. if the evidence supports effectiveness but inconclusive on safety (so there may be risks) then have caution, educate patient and closely monitor
4. if the evidence does not support either then actively discourage

Question 31

which therapies are behavioral therapies?

Answer 31

1. biofeedback
2. relaxation
3. meditation
4. hypnosis
5. imagery

Question 32

which therapies are complementary therapies?

Answer 32

1. acupuncture
2. yoga
3. herbal therapy

Question 33

meg is a 20 year old student with tension type headaches. headaches occur weekly and some are so severe that she misses class. the muscles of her face, neck and shoulders feel tense. she is anxious and sometimes hyperventilates. she worries that if she gets a headache around final exam time she won’t be able to study or concentrate and will fail her exams. she doesn’t meet criteria for anxiety disorder?

what would you recommend to meg?

Answer 33

relaxation and biofeedback

she has tension, is worried and anxious but no anxiety disorder; if she had an anxiety disorder she would also need psychotherapy

Question 34

which disorder can be successful treated with biofeedback alone?

Answer 34

ADHD

EEG biofeedback can be used by itself to treat ADHD! they work with a computer screen where there’s immediate feedback and reinforcement so it’s good for ADHD patients that can’t concentrate for long periods of time

Question 35

what is the least likely reason for a patient to seek complementary medicine?

Answer 35

obtain a cure for a chronic illness

people might seek CAM for help with a chronic illness, to combine CAM with standard treatments for chronic pain, mistrust of allopathic medicine or because they want to be actively involved in their care