Adam Perlman

Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial.

Background In a previous trial of massage for osteoarthritis (OA) of the knee, we demonstrated feasibility, safety and possible efficacy, with benefits that persisted at least 8 weeks beyond treatment termination. Methods We performed a RCT to identify the optimal dose of massage within an 8-week treatment regimen and to further examine durability of response. Participants were 125 adults with OA of the knee, randomized to one of four 8-week regimens of a standardized Swedish massage regimen (30 or 60 min weekly or biweekly) or to a Usual Care control. Outcomes included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analog pain scale, range of motion, and time to walk 50 feet, assessed at baseline, 8-, 16-, and 24-weeks. Results WOMAC Global scores improved significantly (24.0 points, 95% CI ranged from 15.3–32.7) in the 60-minute massage groups compared to Usual Care (6.3 points, 95% CI 0.1–12.8) at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analog pain scale also demonstrated significant improvements in the 60-minute doses compared to usual care. No significant differences were seen in range of motion at 8-weeks, and no significant effects were seen in any outcome measure at 24-weeks compared to usual care. A dose-response curve based on WOMAC Global scores shows increasing effect with greater total time of massage, but with a plateau at the 60-minute/week dose. Conclusion Given the superior convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, establishing a standard for future trials. Trial Registration ClinicalTrials.gov NCT00970008

Integrative Health Coach Training: A Model for Shifting the Paradigm Toward Patient-centricity and Meeting New National Prevention Goals

Objective: To describe the evolution, training, and results of an emerging allied health profession skilled in eliciting sustainable health-related behavior change and charged with improving patient engagement. Methods: Through techniques sourced from humanistic and positive psychology, solution-focused and mindfulness-based therapies, and leadership coaching, Integrative Health Coaching (IHC) provides a mechanism to empower patients through various stages of learning and change. IHC also provides a method for the creation and implementation of forward-focused personalized health plans. Results: Clinical studies employing Duke University Integrative Medicines model of IHC have demonstrated improvements in measures of diabetes and diabetes risk, weight management, and risk for cardiovascular disease and stroke. By supporting and enabling individuals in making major lifestyle changes for the improvement of their health, IHC carries the potential to reduce rates and morbidity of chronic disease and impact myriad aspects of healthcare. Conclusion: As a model of educational and clinical innovation aimed at patient empowerment and lifestyle modification, IHC is aligned well with the tenets and goals of recently sanctioned federal healthcare reform, specifically the creation of the first National Prevention and Health Promotion Strategy. Practice Implications: IHC may allow greater patient-centricity while targeting the lifestyle-related chronic disease that lies at the heart of the current healthcare crisis.

Evidence and Potential Mechanisms for Mindfulness Practices and Energy Psychology for Obesity and Binge-Eating Disorder

Obesity is a growing epidemic. Chronic stress produces endocrine and immune factors that are contributors to obesitys etiology. These biochemicals also can affect appetite and eating behaviors that can lead to binge-eating disorder. The inadequacies of standard care and the problem of patient noncompliance have inspired a search for alternative treatments. Proposals in the literature have called for combination therapies involving behavioral or new biological therapies. This manuscript suggests that mind-body interventions would be ideal for such combinations. Two mind-body modalities, energy psychology and mindfulness meditation, are reviewed for their potential in treating weight loss, stress, and behavior modification related to binge-eating disorder. Whereas mindfulness meditation and practices show more compelling evidence, energy psychology, in the infancy stages of elucidation, exhibits initially promising outcomes but requires further evidence-based trials.

Psychosocial benefits of cardiac rehabilitation among women compared with men.

PURPOSE: Cardiac rehabilitation (CR) has been shown to reduce cardiac risk and improve the psychosocial functioning of participants. This study examines gender differences on several psychosocial indicators across the course of CR. METHODS: Patients (N = 380; 67.9% men and 32.1% women) referred from local inpatient and outpatient settings at a southeastern US academic medical facility were assessed on reported levels of depression, anxiety, panic, anger, and relationship satisfaction, using the Burns Brief Mood Survey, at the start and conclusion of a CR program. Medical variables were also assessed but are not the focus of this report. Statistical analyses included 1-way, Kruskal-Wallis, and repeated-measures analysis of variance procedures, as well as &khgr;2 analyses. RESULTS: Women reported more psychosocial symptoms at pre-CR than men, and overall, both groups improved across CR. Women with significant depression, anxiety, and panic experienced clinically significant benefit across CR. Although the percentage of men reporting clinically significant levels of anger decreased significantly across CR, clinically significant levels of anger did not significantly change among women. In addition, women did not report benefits in relationship dissatisfaction. CONCLUSION: This study provides further evidence that CR offers psychosocial benefit for women, as has been reported in several small clinical samples. Some notable gender differences on anger and relationship satisfaction were observed. Clinical attention may be warranted to facilitate improvement for symptoms of anger and relationship concerns among selected women who participate in CR.

Multivitamin/Mineral supplementation does not affect standardized assessment of academic performance in elementary school children.

Limited research suggests that micronutrient supplementation may have a positive effect on the academic performance and behavior of school-aged children. To determine the effect of multivitamin/mineral supplementation on academic performance, students in grades three through six (approximate age range=8 to 12 years old) were recruited from 37 parochial schools in northern New Jersey to participate in a double-blind, placebo-controlled clinical trial conducted during the 2004-2005 academic school year. Participants were randomized to receive either a standard childrens multivitamin/mineral supplement (MVM) or a placebo. MVM or placebo was administered in school only during lunch or snack period by a teacher or study personnel who were blinded to group assignment. The main outcome measured was change in scores on Terra Nova, a standardized achievement test administered by the State of New Jersey, at the beginning of March 2005 compared to March 2004. Compared with placebo, participants receiving MVM supplements showed no statistically significant improvement for Terra Nova National Percentile total scores by treatment assignment or for any of the subject area scores using repeated measures analysis of variance. No significant improvements were observed in secondary end points: number of days absent from school, tardiness, or grade point average. In conclusion, the in-school daily consumption of an MVM supplement by third- through sixth-grade inner-city children did not lead to improved school performance based upon standardized testing, grade point average, and absenteeism.

Integrative Medicine Patients Have High Stress, Pain, and Psychological Symptoms

CONTEXT Integrative medicine (IM) is a rapidly growing field whose providers report clinical success in treating significant stress, chronic pain, and depressive and anxiety symptoms. While IM therapies have demonstrated efficacy for numerous medical conditions, IM for psychological symptoms has been slower to gain recognition in the medical community. OBJECTIVE AND DESIGN This large, cross-sectional study is the first of its kind to document the psychosocial profiles of 4182 patients at 9 IM clinics that form the BraveNet Practice-Based Research Network (PBRN). RESULTS IM patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics. Those with high stress, psychological conditions, and pain were most frequently treated with acupuncture, IM physician consultation, exercise, chiropractic services, diet/nutrition counseling, and massage. CONCLUSION With baseline information on clinical presentation and service utilization, future PBRN studies can examine promising interventions delivered at the clinic to treat stress and psychological conditions.

Developing a Complementary, Alternative, and Integrative Medicine Course: One Medical School's Experience

BACKGROUND There is significant overlap with many concepts emphasized in integrative medicine and current educational priorities within medical school education such as cultural sensitivity, doctor-patient relationship, and physician self-care. Although the concept of Integrative Medicine is just beginning to gain recognition in academic medical institutions, the recognition of Complementary and Alternative Medicines (CAM) growing popularity has led to increased incorporation of CAM content into U.S. medical school education. AIM The present article describes the evolution of a complementary, alternative, and integrative medicine course within the New Jersey Medical School at the University of Medicine and Dentistry over the last 3 years, and critically evaluates its successes and challenges.

Development of a manualized protocol of massage therapy for clinical trials in osteoarthritis

BackgroundClinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials.MethodsThe manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists’ clinical judgment and maintaining consistency with a prior pilot study.ResultsThe manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated.ConclusionsThe massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings.Trial registrationClinicaltrials.gov NCT00970008 (18 August 2009)

Perspectives about complementary and alternative medicine in rheumatology.

Complementary and alternative medical (CAM) treatments are considered nonmainstream therapies. The popularity and widespread usage of CAM reflects the inadequacies of the current understanding and management of rheumatic and musculoskeletal (and other) diseases despite significant progress. Better science in the future will relegate certain CAM therapies to the margins of medicine or to history and perhaps see the adoption of others into mainstream medicine. Despite the recent increased interest in CAM, particularly for rheumatic diseases, few clinically important contributions have emerged thus far.

P05.31. Development of a manualized protocol of massage therapy for clinical trials in osteoarthritis

Background: Clinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials. Methods: The manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists’ clinical judgment and maintaining consistency with a prior pilot study. Results: The manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated. Conclusions: The massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings. Trial registration: Clinicaltrials.gov NCT00970008 (18 August 2009)