UnCAMventional treatment: do complementary/alternative medicines have a place in your facility? (CAM).

UNTIL RECENTLY, HEALTH CARE FACILITIES, CLINICIANS, AND insurers in this country were quick to ignore the benefits derived from offering complementary! alternative medicines (CAM) in conjunction with traditional therapies, but times are changing. In the past few years interest has skyrocketed in unconventional treatments designed to help manage chronic medical conditions; cut back on drug use and surgeries; and strengthen the mind, body, spirit connection.

Considering the multi-faceted benefits associated with what experts now term integrative therapies (i.e., an alternative-complementary combo), these health care tools appear to be tailor-made for our elderly population. From sick care for acute physical ailments to well care enhancing stability, mobility, and proper body mechanics, chiropractic promotes autonomy. Select herbal medications are safe and effective treatments for osteoarthritis. (1) T'ai chi, an ancient Chinese martial art akin to slow-motion kung fu, improves balance and coordination, lessening the likelihood of falls. (2) (See "A hearty menu of healthy choices," below left, for a general breakdown of CAM options.)

Despite the potential of CAM to improve seniors' overall well-being, these practices remain largely unattainable to long term care residents. How important are integrative therapies for facilities? Why are services such as chiropractic and acupuncture scarce within these settings? How might the tables be turned? Answers to these and related questions follow.

Healing alternatives

According to Faith T. Hemsey, DC, a practicing physician in Little Falls, NJ., while chiropractic has become widely accepted into mainstream medicine, it remains obscure for the average long term care resident. 'Seniors have shoulder, hip, knee, and back problems. Many have difficulty getting out of bed or have such stiffness in the spine and extremities that walking unassisted is difficult," she says. "They sit for long periods of time, increasing loss of muscle tone and decreasing flexibility of the joints." She adds: "Chiropractic care not only increases range of motion of the spine and reduces pain but also offers hands-on therapy via rehabilitative care that in-house exercise classes can't provide."

Robert Decker, LAC, a licensed acupuncturist with Mind, Body, Spirit Clinic, a complementary-medicine clinic affiliate of Fairview University Systems in the Twin Cities, Minneapolis, believes acupuncture can offer remedies for an assortment of conditions common among the elderly (see "Common conditions amenable to acupuncture," page 23).

Among his regular clients are patients at Redeemer Residence, a 147-bed skilled nursing facility in Minneapolis. "Whether I'm treating post-stroke or osteoarthritis pain, managing anxiety, depression, or insomnia, residents and staff there respond positively to my services." And like other CAM, he emphasizes, acupuncture offers the opportunity for reduced drug use.

Massage therapies are ideal for long term care, asserts Charlotte Eliopoulos, RNC, MPH, PhD, a specialist in holistic and long term chronic care, in Glen Arm, Md. Therapeutic massage stimulates circulation, relieves stress, and relaxes the body physically and emotionally, she says. "Simple comfort measures such as back rubs and foot and hand massage allow nurses to connect with residents in a more holistic fashion while helping to curtail resident complaints and attention-getting behaviors."

Mary E. Lindenmuth, RNC, director of nursing at Levindale Hebrew Geriatric Center and Hospital, a 288-bed nursing home hospital facility in Baltimore, Md., says residents at her facility look forward to treatments such as massage therapy, aroma therapy, and music therapy. 'These activities have a particularly potent stress-reducing effect on dementia patients," she says, "and can improve the effectiveness of medications."

The laying on of hands 

Long term care facilities are just beginning to recognize the healing properties of reiki, reports Michael William Smith, a reiki master who teaches this practice to health care facilities around the Baltimore area. Reiki involves a practitioner holding his or her hands over parts of a patient's body to release and channel energy, "which helps treat physical, mental, and emotional disease," says Smith.

Smith recalls a particularly successful reilti encounter with an Alzheimer's patient during a visit to a nursing home in Maryland: "Nurses asked me to comfort an agitated woman who was hearing voices foreboding her impending death. She wouldn't eat and had isolated herself in a comer, refusing care." After just one session, he says, "she calmed down, ordered lunch, and let a nurse fix her hair."

T'ai chi is another practice showing great potential for older adults. According to Robert Levine, director of the Balance Institute (a Baltimore training facility for PTs, OTs, and CRTs), "This martial arts activity, based on softness and balance rather than strength, speed, and endurance, teaches people how to maintain balance, observe what's going on around them, and avoid impending danger."

Because t'ai chi takes years to master, Levine developed PsychoPhysical Balance Therapy (PPBTh therapeutic skills based on t'ai chi principles that can be taught in a weekend workshop. He then collaborated with Keswick Multi-Care Center (a CCRC) and Sheppard-Pratt Hospital Center (both in Baltimore) on a yearlong research project to demonstrate (1) health professionals with no t'ai chi expertise can learn and apply PPBT effectively, and (2) PPBT is a potent restorative activity for people with equilibrium difficulties.

Results were positive on both fronts. "Participants from Keswick increased their ability to be mobile, stay mobile, and know when they were losing balance and likely to fall. Some residents also reported increased relaxation and ease in falling asleep without medication."

Use of herbal remedies has increased by as much as 380 percent since 1990. (3) "Typically, these therapies are much less costly than prescription drugs and trigger fewer side effects," notes Eliopoulos. "A few facilities are starting to stock herbs and homeopathic remedies in their pharmacies and to develop formulary systems for them."

Residents of The Paims of Largo, a 96-acre, intergenerational CCRC campus in Largo, Fla., benefit from a mixed bag of alternative therapies, notes John Goodman, chairman of The Goodman Group (Chaska, Minn.), builder of this and other multifamily and health care facilities for seniors and children. Besides regular therapies such as chiropractic, massage therapy, meditation, yoga, and t'ai chi, Goodman says seniors at The Palms experience remarkable health benefits from reflexology and watsu (a warm-water therapy designed to improve range-of-motion and energy levels).

Stumbling blocks

Insufficient Medicare reimbursement remains the biggest obstacle preventing increased integration of CAM into long term care, according to experts. Time limitations and fear of the unknown are among other stumbling blocks noted.

Hemsey notes the current fee structure for chiropractic discourages colleagues from servicing long term care organizations. "Medicare pays chiropractors for only a set number of spinal manipulations per patient and offers no reimbursement for exams, spinal x-rays, and the time needed for 'rehab,'" she explains. For now, she adds, only chiropractors and physical therapists who work under the guidance of a corporation headed up by a medical doctor receive fair-rate reimbursement.

According to Mary Jo Kreitzer, PhD, RN, director of the Center for Spirituality and Healing, Academic Health Center, at the University of Minnesota, Minneapolis, future reimbursement for alternative therapies hinges on upcoming scientific evidence. "As researchers continue to announce the safety and efficacy of certain therapies, more third-party payers will be inclined to reimburse for them."

Some long term care personnel note lack of time as a common impediment to progress, says Eliopoulos. "Many integrative therapies can be offered along with basic nursing care, however." She suggests initiating therapeutic stretches while walking with residents. "Music- and aromatherapy require little more than getting residents comfortable in a quiet area and pushing a button or lighting a match," she adds.

"There's a definite gray area where specific CAM guidelines are concerned," Eliopoulos asserts. "Which activities can staff conduct on their own and which require contractual agreements with outside practitioners? How do facilities ensure they're developing the right policies and procedures? What risks are associated with individual therapies?"

For instance, according to the literature, acupuncture can cause weakness and dizziness, increasing risk for falls. Massage can induce an anticoagulant effect, and its tendency to increase the flow of body fluids can enhance the flow of toxins, placing added stress on the liver and kidneys. Certain herbal remedies are associated with adverse effects, too.(4) Researchers believe some 3 million Americans age 65 and older are at risk for potential drug/herb interactions.(3)

"We must view integrative therapies as consultative therapies," Eliopoulos advises. "Call state health departments to learn what to do to guarantee resident safety." She reminds readers the licensure requirements for certain practitioners, such as massage therapists and acupuncturists, vary from state to state.

Not just a 'blip'

"With proper nutrition and the right mix of alternative therapies, people are growing younger and enjoying their lives more than ever before," Goodman contends. He believes the key is to keep introducing new health care techniques into the communities and combining customary and unconventional medicine.

"When you look closely at the needs of long term care residents, it's evident these facilities can't afford not to incorporate integrative therapies into standard protocols of care," Eliopoulos asserts. "CAM helps our elderly manage the overwhelming stress associated with chronic illness and living in an institutional setting. It also brings out the healer instinct in personnel," she says, "many of whom get excited about assuming responsibility beyond traditional physical tasks and following doctors' orders. Implementing CAM spells better staff recruitment and retention, and improved health for all involved."

If life-altering initiatives such as t'ai chi enable even a few residents to stand with confidence, take baths without assistance, or walk to the lunchroom alone, then the money spent for staff training is money well spent, says Levine.

Kreitzer feels alternative medicine is much more than just "a blip on the screen. It's here to stay," she says. "Our country, therefore, needs to produce graduates more attentive to holistic care." Her university, in fact, has received a $1.6 million, 5-year grant from the National Institutes of Health to integrate content on complementary, cross-cultural, and spiritual care into the curriculum for the medical school, college of pharmacy, and school of nursing.

Fortunately, says Kreitzer, "our country's health care system is shifting from managed care to personal medical savings accounts, which will give consumers the freedom to spend a portion of their health care dollars on complementary approaches to healing, if they choose. I'm hopeful this realignment in the system will be a step in the right direction for our elderly."

References

(1.) Long L., Soeken K, Ernst E. Herbal medicines for the treatment of osteoarthritis: a systematic review. Rheumatology (Oxford). 2001;40(7):779-793.

(2.) Chen KM. Snyder M. A research-based use OF t'ai chi/movement therapy as a nursing intervention. J Holist Nurs. 1999;17(3):267-279.

(3.) Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998;280(18):1569-1575.

(4.) Eliopoulos C. Using complementary and alternative therapies wisely. Geriatr Nurs. 1999;20(3):139-142.

RELATED ARTICLE: A hearty menu of healthy choices

The term complementary and alternative medicine (CAM) was developed by the National Institutes of Health to represent a wide range of healing philosophies and therapies generally not taught in medical schools, not administered in hospitals, and not reimbursed by insurance. Some therapies are considered holistic. Many also are considered preventive medicine.

According to the National Center for Complementary and Alternative Medicine, CAM practices can be grouped within five major domains:

Alternative medical systems

These therapies include complete systems of theory and practice that have evolved independent of conventional biomedical approaches. They include acupuncture, herbal medicines, and t'ai chi.

Mind-body interventions

These techniques help the mind influence bodily function and symptoms; however, only a subset of these interventions (such as meditation, music and art therapy, certain uses of hypnosis) are considered CAM.

Biological-based therapies

This category includes natural and biologically based interventions and products. Many overlap with conventional medicine's use of dietary supplements. They include herbal and orthomolecular therapies.

Manipulative and body-based methods

These therapies include methods based on manipulation of the body. Chiropractors, for instance, focus on the relationship between structure and function and how that relationship preserves and restores health. Massage therapy manipulates soft tissues of the body for increased health.

Energy therapies

These therapies focus on energy fields from within the body or external sources. Examples of the former category include reiki and therapeutic touch. The latter category involves the use of electromagnetic fields to manage pain and treat certain conditions.

SOURCE: <HTTP://NCCAM.NIH.GOV/FCP/CLASSIFY/>. ACCESSED AUGUST 2001

Digestive

Common conditions amenable to acupuncture

* Abdominal pain

* Constipation

* Diarrhea

* Hyperacidity 

* Indigestion

Emotional

* Anxiety

* Depression

* Insomnia

Eyes

* Cataracts

* Poor vision

Musculoskeletal 

* Arthritis

* Back pain

* Muscle cramping/pain/weakness

* Neck pain

Neurological

* Headaches

* Migraines

* Neurogenic bladder dysfunction

* Parkinson's disease

* Postoperative pain

* Stroke

Respiratory

* Asthma

* Bronchitis

* Common cold

* Sinusitis 

Other

* Chronic fatigue

* High/low blood pressure

* Stress

Nancy E. Trotto, a freelance writer based in Totowa, NJ, is a regular contributor to CLTC.