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Collaboration for a Cause
The Patient Protection and Affordable Care Act strongly encourages the formation of multidisciplinary practitioner teams called Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).
News in Brief
Hamm Elected New President of the ACA; WFC / ACC 2014 Education Conference: Call for Papers; F4CP Recognizes Standard Process as $1 Million Supporter; Texas Chiro. College Begins Search for New President; League of Chiropractic Women Hosts Women's Success Summit.
AAAOM – The Beginning of the End (Part II)
In 2012, the AAAOM board members met in Chicago for their annual meeting. The goal was to come to a consensus on a long list of issues the AAAOM needed to work on including a functional board and budget.
Monoculture of the Mind: Part II
Cases are built within boundaries. Such bounds may be a program, event, activity or individuals. In this instance, a medical case has boundaries that include clinical interactions that are comprised of history, signs, symptoms, diagnoses, treatment plans and treatments.
The Healing Properties of Light: An Interview With Researcher Anna Cocliovo
This interview is with Anna Cocliovo, a light researcher and Acupuncturist in Arizona. During my own research in light, I came across the article she published for the American Journal of Acupuncture and sought her out as a result.
Leaving a Lasting Legacy: Donna Liewer
For the past 31 years, Donna Liewer has been on a personal mission "to comfort the afflicted and afflict the comfortable." In her role as executive director of the Federation of Chiropractic Licensing Boards, Liewer has accomplished that and much, much more.
Chiropractic Prevents ADHD? Research Shows...
Now that I have your attention, let me tell you what the latest study actually states. As you may have noticed, research over the past few years has begun to reveal that acetaminophen (the primary ingredient in Tylenol) is not as safe as once thought.
Flexion-Intolerant Lower Back Pain (Pt. 3): Mobilization & Soft-Tissue Treatment
What is the biggest challenge to the chiropractor in treating discogenic pain? You have to completely reframe the purpose of your manipulation. It is rarely about unlocking a stuck segment at the disc involvement level; it is not about putting a joint back in alignment.
Resilience is the New Longevity
Sometimes we must enter a room through one door and not another, even though they both lead into the same space. I am talking now of the recent cachet with the concept of "resilience" regarding health, chronic pain and longevity.
Are You Guilty of Paternalism in Your Approach to Patient Care?
Einstein is purported to have said, "When a man sits with a pretty girl for an hour, it seems like a minute. But let him sit on a hot stove for a minute and it's longer than any hour. That's relativity." In some way, everything is relative to one's point of view.
AAAOM – Making Promises They Can't Keep
When the AAAOM first formed in 2007, their mission was clear: to support the profession through education, resources and legislative advocacy. The first years of the organization were filled with promise and hope.
Risk Factors for Heel Problems
Heel pain and gait disability are common occurrences in adults, often the result of thinning heel pads and a lifetime of exposure to heel-strike shock. One condition experienced by many people is plantar fasciitis.
Successful Strategies in Integrating Acupuncture and Shiatsu in a Hospital Oncology Program
Colleagues from the Network of Researchers in Public Health in CAM recently published an article of interest to our Traditional Asian Medicine community.
Get That Shoulder to Move: Restoring Internal Rotation
How many times have you mobilized, performed ART, Graston, FAKTR and PIR, and stripped a patient's posterior capsule, yet on re-exam, discovered it was still blocked?
Creating Child-Friendly Clinics with ABT
The Zurich Dojo was scattered with toy ducks, dolls, trains, exercise balls and teddy bears during my recent pediatric workshop.
Green Tea Catechins Lower PSA, Other Biomarkers in Men With Localized Prostate Cancer
A 2006 study (Cancer Research) was the first human investigation to show that green tea catechins (GTC) are highly effective in reversing premalignant prostate lesions (high-grade prostate intra-epithelial neoplasia), an established precursor to prostate cancer.
What is a Discipline in Medicine?
In my now prolonged dialogue with physicians, one question emerges with enough regularity to deserve mention and naming: what is a discipline?
One and Done: Keeping Patients From Vanishing After Just One Appointment
What happened to my 3:30 p.m. ROF? They may have rescheduled, but there are two common answers no one wants to hear: 1) "She called to cancel. I tried to get her to reschedule, but she refused." 2) "She no-showed.
Steven Rosenblatt: Birthing A Cross-Cultural Acupuncture Profession
The existence of a cross-cultural acupuncture profession in the United States, one that is legalized, licensed, supported by formalized, academic training and inclusive of non-Asian practitioners, is an important part of the medical landscape in this country and is responsible for improving the lives of hundreds of thousands of Americans.
Why DCs Need to Understand the Principles of "Inclusive Design"
In the past few columns, I've written about the negative effects of prolonged sitting at work. I've attempted to make the point that prolonged sitting (or prolonged standing) takes a toll on workers. Now let's discuss a related issue: the concept of "inclusive design."
Epigenetics: The Western Science Supporting Essence
Since the days of Darwin, western medicine has touted that our genes were set in stone, that our genetics were our destiny. We were told that the diseases that ran in our family were likely coming to us as well.
What Does an Evidence-Based Practice Look Like?
We hear a lot these days about evidence-based practice (EBP). As massage therapy becomes more accepted as an allied health profession, I think it's important that we continue to build an evidence-based case for why massage works. So, what makes a practice evidenced-based? I hope to give you a basic understanding of EBP and offer examples from my own work elders in long-term care facilities.
Definitions of EBP vary somewhat but they all seem to agree that EBP is a combination of:
The desired outcome of EBP is optimal service to each client/patient on a case-by-case basis. I've paraphrased the steps presented by Duke University Medical School to determine if an approach, modality or method is indeed evidence-based. What we are really trying to find out is whether the methods or techniques we use really are effective to meet the client's need and why or why not? Then we can be confident in the actions we take in caring for our client and also when we articulate the benefits of our services.
Start with the client's clinical problem or a question which arises from the care of the client. Identify the need or problem of the individual client. What's the reason you are seeing this client? Generally, the reason for referral or the client's stated goal is a good place to start.
For example, I have a client who has Alzheimer's disease who is cared for in a memory support unit of an assisted living facility. She becomes increasingly physically agitated (rummaging through other elder's things and grabbing people's arms as they walk by her) and disoriented (going into other people's rooms) in the afternoons, disturbing those who also live there. She has been referred in hopes of calming her and easing the agitated, restless behavior.
Construct a well-built clinical question derived from this client's problem. The question must be phrased in such a way as to facilitate finding an answer when you look for relevant research. The question should include: 1. The key problem of the patient; 2. What treatment, method or modalities are you are considering using; and 3. The desired outcome.
In the case of my client, I might ask this question: "In people with Alzheimer's disease, is hand massage and/or back massage effective in reducing physical agitation or restlessness?"
Select the appropriate resource(s) and conduct a search. The type of question we ask can help lead us to the best type of study or research to look for. Massage therapy questions often center on how to select treatments that do more good than harm and that are worth the efforts and costs of using them. We're told by the Duke team that randomized controlled trials are best to look for when asking a therapy or treatment question. They offer this explanation of this kind of study: "Randomized controlled clinical trials are carefully planned experiments that introduce a treatment or exposure to study its effect on real patients. They include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control (no intervention) groups. A randomized controlled trial is a planned experiment and can provide sound evidence of cause and effect."
It's important to understand that just searching the internet for articles isn't enough. We must be careful about the source. The quip, "if it's written on the Web, it must be so," does not apply here! So, where should we look? One recommended source is PubMed/MEDLINE, a respected database of literature. It's beyond the scope of this article to explain how to go about a search in PubMed, however there are tutorials on that website. Since my question is a therapy question, I set out to find studies that used randomized controlled trials about hand and/or back massage to decrease agitation in people with dementia. I found a number of studies exploring massage in dementia care. Several abstracts of the articles report that hand or slow-stroke back massage reduced anxiety, restlessness and other forms of agitation. My next task is to review the articles to see if the methods used for the study meet criteria for valid research.
Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice). Fortunately, there are guides to help with this process. We are looking to answer three basic questions:
In the end, we want to have confidence in the research we cite. One example from my search is a 2008 study, Favorite Music and Hand Massage: Two Interventions to Decrease Agitation in Residents with Dementia. In my best judgment, this study holds up to the criteria for validity. It compares the effectiveness of favorite music (FM) and hand massage (HM) in reducing agitated behaviors. Researchers found that following ten minute sessions of FM and HM individually and combined significantly decreased agitation for up to an hour following the session.
Apply the results to your client. Integrate that evidence with clinical expertise, patient preferences and apply it to practice. So, back to my client. Because the afternoon is the time when she becomes more restless, I schedule sessions for mid-afternoon twice a week. Sessions consists of hand massage, slow-stroke back massage and focused one-to-one attention. I also do staff education, teaching them how to do a simple five minute hand massage and focused touch.
Evaluate client's response to treatment. What result do you see in the individual client? Were they similar or different from results you found in the research? Do you need to make adjustments to your approach? In the case of my client, she was receptive to receiving hand and back massage and she tolerated a thirty minute session without distraction when the session was carried out in a quiet room. She was talkative during the hand massage and often fell asleep during the back massage. At the end of the session, she remained in a calm, quiet state from thirty minutes to an hour. The care staff reported that they noticed a decrease in the restless behaviors, especially her tendency to grab people's arms. The staff used the simple hand massage protocol in the late afternoon and reported it seemed to also help relax her and that she enjoyed the interaction and smiled.
Where does my clinical experience fit in to all this? I've had hundreds of sessions with elders living with Alzheimer's disease and related dementia, many of whom have some degree of agitated behavior, anxiety and restlessness. It's been my experience that human touch, massage and compassionate presence ease these issues and have a profound effect on enhancing quality of life. I've also witnessed the effect of shared human touch on the ability of a person with advanced dementia to engage in relationship.
And last, but certainly not least, what about my client's needs, preferences, expectations? It's a little tricky sometimes to determine what my client might want or need when she can't state them clearly because of dementia. It falls to me to tune in to the non-verbal cues. People with dementia tell us a lot about their inner world and needs through behavior. My client's restless behaviors that annoyed others are her way of communicating a need in the moment. Perhaps she's lonely or is disoriented and thinks she needs to get home to take care of her kids. I also always know that one universal expectation of each client is to have basic human needs met and to be treated with respect.
Taking all this into account, can I state with confidence that my approach is evidence-based? I believe that, yes, I can. I hope this has helped you understand what evidence-based practice is all about so you can perhaps apply it to your own work.