Complementary and alternative medicine - Wiley Online Library

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GUEST EDITORIAL

Complementary and Alternative Medicine: An Overlooked Adjunct for the Care of Patients with Kidney Disease Mariana S. Markell, MD The author is Associate Professor of Medicine with SUNY Downstate Medical Center, Brooklyn, New York, and Director, Office of Complementary and Alternative Medicine, North Shore–LIJ Health System, Manhasset, New York. She is also a member of D&T’s Editorial Advisory Board.

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f you do a PubMed search for complementary and alternative medicine (CAM) and kidney disease you will, for the most part, retrieve articles warning of their dangers—but very few articles examining their potential benefits. Evidence is accumulating, however, that CAM therapies can help to forestall the development of cardiovascular disease,1 alter pain perception,2 and improve symptoms of anxiety and depression.3 The following CAM therapies, for which there is evidence of efficacy in other disease states, should be considered for patients with kidney disease: . . . . . .

guided and integrative imagery massage reflexology acupuncture Qi Gong, yoga, and Tai Qi meditation

Guided and Integrative Imagery Guided imagery is the use of a script to lead a patient through a series of relaxing images or progressive muscle relaxation. Relaxing music is usually played in the background. Guided imagery tapes and CDs are commercially available and can be played through headphones while patients are being dialyzed. The images can be tailored to the

disease or procedure specific to the patient. For patients who are hearing impaired, the script can be flashed across a screen of relaxing images. The North Shore-LIJ Health System in Manhasset, New York, has created a series of programs that play continuously on the patient care channel and can be used by patients at will. Integrative imagery requires oneon-one interaction. A trained nurse or other professional uses a loosely scripted scenario that allows the patient to build his or her own images. The images are then discussed and expanded on to create a ‘‘safe place’’ for the patient to visualize when stressed or anxious. There is a great deal of data showing that imagery decreases stress and anxiety, improves depression, and may lower blood pressure and improve blood glucose levels if practiced regularly. North Shore University Hospital (Manhasset, New York) has a program that offers guided imagery sessions to hospitalized patients provided by a nurse-practitioner. The procedure essentially has no downside except for requiring a trained nurse or the purchase of a tape or CD. Massage Most patients with kidney disease have musculoskeletal pain, which arises from osteodystrophy, hyper-

parathyroidism, neuropathic conditions, and concomitant diseases such as diabetes. When a patient develops a localized pain, he or she will compensate by altering gait or favoring the area, putting stress on the contralateral muscles. The result is muscle spasm and increased pain. Furthermore, amyloid deposition can alter range of motion, leading to other kinesthetic abnormalities. Massage fosters relaxation of muscle spasm and relief from the inflammation that may be contributing to pain. It also activates the parasympathetic nervous system and may reset the imbalance between sympathetic and parasympathetic tone that occurs in a stressed situation. The end result is lower blood pressure, decreased inflammatory markers, and improved mood. All these findings and improvement in natural killer cell function have been demonstrated in published studies published, although none have studied patients with kidney disease. The feasibility of intradialytic massage was investigated at SUNY Downstate in Brooklyn, New York. Avoiding the first hour of dialysis, limited full-body massage was performed without untoward hypotension or interference with the dialytic process.

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GUEST EDITORIAL Some patients are uncomfortable with full-body massage and may be better served by reflexology treatments (see below). Massage is within the purview of the nursing license, and many nurses have already taken courses. Infected areas and access arms must be avoided and massage may not be appropriate for patients with hypotension, as blood pressure may fall during the procedure as vagal tone improves. Reflexology Reflexology, an ancient technique that originated in Asia, concentrates on the hands and feet. In traditional reflexology, areas of the hands and feet correspond to parts of the body, and appropriate areas are pressed and massaged, depending on a patient’s condition. In modern times, a simple hand or foot massage is sometimes referred to as ‘‘reflexology.’’ Reflexology is well tolerated and accepted by most patients, even those resistant to being touched. Training is widely available, and the therapy works well in a hospital setting. The program at North Shore University Hospital has treated intubated patients in the ICU, and could easily be used in the dialysis unit. As is true of massage, hypotension may occur in patients with previously low blood pressure. Thus, situations that might exacerbate this effect should be avoided. Infected areas also should be avoided. Acupuncture Acupuncture is an ancient Chinese technique in which fine needles are placed along channels according to diagnoses that may have nothing to do with the Western diagnoses. It is probably the most extensively studied of the CAM modalities, showing benefit in pain conditions, including arthritis and neuropathy. An acupuncturist undergoes extensive training in diagnosis and needle placement, and many phys-

icians are attending courses in medical acupuncture. An acupuncturist can be brought in to perform treatments in a clinic setting. The North Shore University Hospital has such a setting in its HIV clinics, and a similar arrangement could be established in a dialysis unit or a kidney disease clinic, sparing patients the expense of traveling to the acupuncturist. Acupuncture treatment is one of the few CAM therapies reimbursed by Medicaid in New York State and many other states as long as it is performed at a Medicaid selected site.

Meditative breathing is helpful during stressful procedures, such as dialysis cannulation, and can help to lower blood pressure. It can also assist weight loss and improve glucose control.

The few caveats about acupuncture are that it should not be performed in patients on full-dose anticoagulation, sterile technique should be observed, and the needles must be disposed of in appropriate sharps containers. The hypotensive effects observed during massage and reflexology are less problematic in acupuncture therapy. Movement Therapies: Qi Gong, Yoga, and Tai Qi Qi Gong and Tai Qi are movement therapies that originated in China developing out of the martial arts. Yoga is a movement therapy that originated in ancient India. All three can be adapted for patients in any condition and focus on slow breathing, linking it to movement. They

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also strengthen the ‘‘core muscles’’ that support the trunk and have been repeatedly demonstrated to decrease the fall rate of frail elderly patients. Yoga can be performed in a chair or on the floor if patients cannot support themselves in an upright position. The movements of all 3 disciplines are slow and controlled and do not place undue stress on the cardiovascular system. Potential benefits from the movement therapies include improved blood pressure and blood glucose control, improved balance, decreased pain (especially in the lower back), decreased anxiety, and improved well-being. Two examples of patients who benefited from Qi Gong are from my own practice. One is blind with type 1 diabetes and has had three kidney transplants. He has severe osteodystrophy and has suffered two spontaneous leg fractures, rendering him wheelchair bound for several months. After his casts were removed, he began doing a very simple Qi Gong workout. His wife placed his limbs in the appropriate positions. After several months he was noticeably calmer and happier, and he has had no further recurrence of fractures. A second patient was a severely hypertensive man who had suffered a stroke and was depressed and withdrawn. He was persuaded to purchase a Qi Gong tape and began practicing it daily. After three months he returned, walking erect, smiling, and commenting ‘‘I don’t understand it, but something is happening in my body.’’ The former is an ItalianAmerican from Brooklyn, the latter a Haitian immigrant, attesting to the cross-cultural appeal of these modalities. Meditation Meditation techniques have similarities to movement therapies and guided imagery, in that they focus on breathing exercises that activate

GUEST EDITORIAL the parasympathetic nervous system and decrease stress hormone levels. Techniques can involve focusing on the breath, on being present (mindfulness meditation), on sending loving feelings (loving kindness meditation), and many others. Meditative breathing is helpful during stressful procedures, such as dialysis cannulation, and can help to lower blood pressure. It can also assist weight loss and improve glucose control. There are no contraindications to meditation practices except for those with certain anxiety disorders with ruminative features that could be worsened. Other Benefits The techniques mentioned above are helpful not only for patients, but for staff as well. We observed a tremendous increase in morale

when massage was offered not only to the patients, but also to the staff at a busy inner-city dialysis unit. Patients who are less stressed and generally more relaxed do not make as many demands on staff and make for a more pleasant healing environment. Although it is probably impractical both physically and financially for most practices to hire outside CAM practitioners, and reimbursement for these procedures is spotty at best, training in basic CAM techniques is available for nurses and physicians and can be delivered at the bedside, in a dialysis unit, or in a clinic setting without imposing a tremendous burden of time or manpower. The focus of CAM techniques is a holistic approach to patient care, with an emphasis on compassion and healing, rather than on simply treating

a condition. In this day of decreasing reimbursement and increasing patient load, it is sometimes difficult to remember why we decided to pursue a career in health care. Approaching a patient with a CAM perspective can bring us back to our original intent. References 1. Paul-Labrador M, Polk D, Dwyer JH, et al. Effects of a randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. Arch Intern Med. 2006;166:1218–1224. 2. Ernst E, Pittler MH, Wider B, et al. Complementary therapies for back pain: is the evidence getting stronger? Clin Rheumatol. 2006; [Epub ahead of print]. 3. Markell M. Potential benefits of complementary medicine modalities in patients with chronic kidney disease. Adv Chronic Kidney Dis. 2005;12:292–299. Review

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