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

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6

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Before After

Massage group (n=30)

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Massage Therapy after CV Surgery

10

8

6

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Before After

VAS

Pain level

Control group (n=28)10

8

6

4

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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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Age

adj

dea

th ra

te/1

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Low Moderate High

WomenMen

Blair SN. JAMA 1989

Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men,

ACLS

0102030405060

Dea

ths/

10,0

00 M

Y*

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12 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

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•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

05

1015202530354045

60-69 70-79 80+

LowModerateHigh

All-Cause death rates/1,000 PY

Age GroupsSui 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

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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

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Fit Unfit

NormalObese

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

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$3,000

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$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

FTE

s (T

hous

ands

)

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?