Addressing Complementary and Alternative Medicine Use Among Individuals With Cancer: An Integrative Review and Clinical Practice Guideline.

Complementary and alternative medicine (CAM) use is common among individuals with cancer, but many choose not to discuss CAM with health-care providers (HCPs). Moreover, there is variability in the provision of evidence-informed decision making about CAM use. A clinical practice guideline was developed to standardize how oncology HCPs address CAM use as well as to inform how individuals with cancer can be supported in making evidence-informed decisions about CAM. An integrative review of the literature, from inception to December 31, 2018, was conducted in MEDLINE, EMBASE, PsychINFO, CINAHL, and AMED databases. Eligible articles included oncology HCPs' practice related to discussing, assessing, documenting, providing decision support, or offering information about CAM. Two authors independently searched the literature, and selected articles were summarized. Recommendations for clinical practice were formulated from the appraised evidence and clinical experiences of the research team. An expert panel reviewed the guideline for usability and appropriateness and recommendations were finalized. The majority of the 30 studies eligible for inclusion were either observational or qualitative, with only 3 being reviews and 3 being experimental. From the literature, 7 practice recommendations were formulated for oncology HCPs regarding how to address CAM use by individuals with cancer, including communicating, assessing, educating, decision coaching, documenting, active monitoring, and adverse event reporting. It is imperative for safe and comprehensive care that oncology HCPs address CAM use as part of standard practice. This clinical practice guideline offers directions on how to support evidence-informed decision making about CAM among individuals with cancer.

The Effect of a Complementary Therapy Education Seminar on Support Persons of Individuals with Cancer.

Objectives: Complementary therapy (CT) use is prevalent among individuals living with cancer, who often consult family and friends (i.e., support persons) in making decisions about CT. This study examines the effect of an education seminar for adult cancer patients and support persons on the support persons' use, knowledge, and decision-making processes related to CT. Design: A patient education seminar that included support persons was developed and evaluated as part of a CT decision support research program. Survey data were collected before and after the education seminar to examine its impact on support persons' knowledge and use of CT, as well as their engagement in the CT decision-making process. Setting: The study was conducted in Western Canada. Subjects: 62 adult support persons. Interventions: Participants attended a 4-h CT education seminar at one in four provincial cancer centers. The seminar provided recommendations regarding how to make informed decisions about CT, where to find credible information, and key issues to consider to avoid potential risks of CT use. The evidence related to popular CT was also reviewed. Outcome Measures: The primary outcome was support persons' CT knowledge. Secondary outcomes included CT use, information-seeking behavior, decision self-efficacy, decision conflict, and distress. Results: A significant increase in support persons' CT knowledge was observed, as well as improved confidence in CT decision making. There was no significant difference in participants' CT use following the education seminar. Most indicated they would continue to locate information about CT using the Internet. A significant decrease in support persons' decisional conflict was reported; however, there were no significant change in distress related to CT decision making. Conclusions: This study demonstrates the importance of including support persons in patient education related to CT and the positive impact on their knowledge and treatment decision-making processes. No significant change in CT use, information seeking behavior and distress related to CT decisions, however, was observed in the study.

Pediatric natural health products recommended by chiropractic and naturopathic doctors in Canada.

OBJECTIVES: To assess chiropractic (DC) and naturopathic doctors' (ND) pediatric care natural health product (NHP) recommendations. DESIGN: Surveys were developed in collaboration with DC and ND educators, and delivered as an on-line national survey. NHP dose, form of delivery, and indications across pediatric age ranges (from newborn to 16 years) for each practitioner's top five NHPs were assessed. Data were analyzed using descriptive statistics, t-tests, and non-parametric tests. RESULTS: Of the 421 respondents seeing one or more pediatric patients per week, 172 (41%, 107 DCs, 65 NDs) provided 440 NHP recommendations, categorized as: vitamins and minerals (89 practitioners, 127 recommendations), probiotics (110 practitioners, 110 recommendations), essential fatty acids (EFAs: 72 practitioners, 72 recommendations), homeopathics (56 practitioners, 66 recommendations), botanicals (29 practitioners, 31 recommendations), and other NHPs (33 practitioners, 34 recommendations). Indications for the NHP recommendations were tabulated for NHPs with 10 or more recommendations in any age category: 596 total indications for probiotics, 318 indications for essential fatty acids, 138 indications for vitamin D, and 71 indications for multi-vitamins. CONCLUSIONS: This is the first study documenting the pediatric NHP recommendations of two popular complementary medicine professions. Common NHPs at standard doses are the most frequently recommended products, with use and doses adjusted according to age. High-quality evidence regarding the efficacy, safety, and dosing for NHP use in children is scarce; development of evidence-informed pediatric guidelines is recommended, particularly for the most commonly used and recommended NHPs.

Pediatric training and practice of Canadian chiropractic and naturopathic doctors: a 2004-2014 comparative study.

BACKGROUND: To assess chiropractic (DC) and naturopathic doctors' (ND) knowledge, attitudes, and behaviour with respect to the pediatric patients in their practice. METHODS: Cross-sectional surveys were developed in collaboration with DC and ND educators. Surveys were sent to randomly selected DCs and NDs in Ontario, Canada in 2004, and a national online survey was conducted in 2014. Data were analyzed using descriptive statistics, t-tests, non-parametric tests, and linear regression. RESULTS: Response rates for DCs were n = 172 (34%) in 2004, n = 553 (15.5%) in 2014, and for NDs, n = 171 (36%) in 2004, n = 162 (7%) in 2014. In 2014, 366 (78.4%) of DCs and 83 (61%) of NDs saw one or more pediatric patients per week. Pediatric training was rated as inadequate by most respondents in both 2004 and 2014, with most respondents (n = 643, 89.9%) seeking post-graduate training by 2014. Respondents' comfort in treating children and youth is based on experience and post-graduate training. Both DCs and NDs that see children and youth in their practices address a broad array of pediatric health concerns, from well child care and preventative health, to mild and serious illness. CONCLUSIONS: Although the response rate in 2014 is low, the concerns identified a decade earlier remain. The majority of responding DCs and NDs see infants, children, and youth for a variety of health conditions and issues, but self-assess their undergraduate pediatric training as inadequate. We encourage augmented pediatric educational content be included as core curriculum for DCs and NDs and suggest collaboration with institutions/organizations with expertise in pediatric education to facilitate curriculum development, especially in areas that affect patient safety.

Qualitative assessment of information and decision support needs for managing menopausal symptoms after breast cancer.

PURPOSE: For breast cancer (BrCa) survivors, premature menopause can result from conventional cancer treatment. Due to limited treatment options, survivors often turn to complementary therapies (CTs), but struggle to make informed decisions. In this study, we identified BrCa survivors' CT and general information and decision-making needs related to menopausal symptoms. METHODS: The needs assessment was informed by interpretive descriptive methodology. Focus groups with survivors (n = 22) and interviews with conventional (n = 12) and CT (n = 5) healthcare professionals (HCPs) were conducted at two Canadian urban cancer centers. Thematic, inductive analysis was conducted on the data. RESULTS: Menopausal symptoms have significant negative impact on BrCa survivors. Close to 70 % of the sample were currently using CTs, including mind-body therapies (45.5 %), natural health products (NHPs) and dietary therapies (31.8 %), and lifestyle interventions (36.4 %). However, BrCa survivors reported inadequate access to information on the safety and efficacy of CT options. Survivors also struggled in their efforts to discuss CT with HCPs, who had limited time and information to support women in their CT decisions. Concise and credible information about CTs was required by BrCa survivors to support them in making informed and safe decisions about using CTs for menopausal symptom management. CONCLUSIONS: High quality research is needed on the efficacy and safety of CTs in managing menopausal symptoms following BrCa treatment. Decision support strategies, such as patient decision aids (DAs), may help synthesize and translate evidence on CTs and promote shared decision-making between BrCa survivors and HCPs about the role of CTs in coping with menopause following cancer treatment.

Negotiating consent: exploring ethical issues when therapeutic massage bodywork practitioners are trained in multiple therapies.

INTRODUCTION: Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both. METHODS: As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies. RESULTS: Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent. CONCLUSIONS: An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.

Introducing IJTMB's Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators.

The International Journal of Therapeutic Massage and Bodywork (IJTMB) has as its core a key interest in and mission to develop the practice of therapeutic massage and bodywork by contributing to the field's body of knowledge. The IJTMB Editorial Board understands that one's daily practice provides the initial testing ground for the development of practice-based knowledge and, ultimately, expertise. Consequently, this practice-based knowledge and experience provides fertile ground for research ideas that further refine our understanding and come full circle to enhance clinical efficacy. Ultimately, without discourse and knowledge transference, the possibility of growing the body of knowledge for therapeutic massage and bodywork or stimulating research in the field is lost. To facilitate discourse and transference of knowledge within the field of therapeutic massage and bodywork, the IJTMB is launching a new journal component entitled Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators. The purpose of IJTMB's Trigger Points is to "trigger" the sharing and discussion of knowledge and expertise among therapeutic massage and bodywork practitioners, educators, and researchers about different approaches to treating specific conditions or addressing specific population issues. Each IJTMB issue, starting with this issue, will include a call for responses to the next Trigger Points topic. Publication of the results for each topic will be in the second issue after the initial call for submissions. With your participation, these IJTMB Trigger Points columns will spark dynamic dialogue, perhaps even collaborations, in the therapeutic massage and bodywork field across practitioners, educators, and researchers.

Advancing the Therapeutic Massage Research Agenda(s).

Therapeutic massage and bodywork (TMB) is now an established field of research with dedicated funding, researchers, and many venues and channels for dissemination of TMB research. Research agendas are a way for a profession to focus the development and funding of research on facets of TMB practice and education that are most needed at a given point of time to best move forward the practice and professionalization of TMB. Of the two TMB research agendas, one is currently being updated, the other is newly developed. Because of the impact on the development of the profession, gaps in research agendas also need to be carefully considered. Three areas that could use further consideration or support within the current agendas include education, methods and methodologies, and underlying assumptions. TMB researchers need to engage with and support the current agendas, and participate in their evolution.

Exploring the nature of therapeutic massage bodywork practice.

BACKGROUND: Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice. PURPOSE: This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research. PARTICIPANTS SETTING: 19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada. RESEARCH DESIGN: Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice. RESULTS: TWO BROAD THEMES EMERGED FROM THE DATA: (1) every treatment is individualized, and (2) each practitioner's practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned. CONCLUSIONS: There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.

Identifying conflicts of interest in therapeutic massage and bodywork research.

Identifying and addressing forms of bias in research are critical to the integrity and value of research. Conflicts of interest are an important aspect of research that must be addressed equally to any other form of research bias. Conflicts of interest occur when the judgment of a party involved in the research, either a researcher or a treatment provider, may be compromised by more than one interest relative to the research. As therapeutic massage and bodywork (TMB) is a younger field of research, some forms or aspects of conflicts of interest may not be understood. This editorial explores the meaning of conflicts of interest, how to increase awareness of them, and facets of research specific to TMB that may create such conflicts. Full disclosure in grant applications and manuscripts is critical to ensure that grantors, reviewers, and users of research are better informed of potential conflicts of interest, can understand the steps taken to manage the conflicts, and ultimately can better assess the research integrity and value.

Complementary and alternative medicine (CAM) use in advanced cancer: a systematic review.

This systematic review synthesizes knowledge about the use of complementary and alternative medicine (CAM) among advanced cancer patients. EBSCO and Ovid databases were searched using core concepts, including advanced cancer, CAM, integrative medicine, and decision-making. Articles included in the final review were analyzed using narrative synthesis methods, including thematic analysis, concept mapping, and critical reflection on the synthesis process. Results demonstrate that advanced cancer patients who are younger, female, more educated, have longer duration of disease, and have previously used CAM are more likely to use CAM during this stage of illness. Key themes identified include patterns of and reasons for use; and barriers and facilitators to informed CAM decision-making. Knowledge regarding the use of CAM in advanced cancer remains in its nascent stages. Findings suggest a need for more research on understanding the dynamic process of CAM decision-making in the advanced cancer population from the patients' perspective.

The Complementary Medicine Education and Outcomes (CAMEO) program: a foundation for patient and health professional education and decision support programs.

OBJECTIVE: This paper describes the background, design and evaluation of a theory-informed education and decision support program for cancer patients considering complementary medicine (CM). METHODS: The program was informed by the Shared Decision Making theory, the Ottawa Decision Support Framework and the Supportive Care Framework. Previous empirical evidence and baseline research were used to identify patients' and health professionals' (HPs) information and decision support needs related to CM. RESULTS: To address the continuum of CM needs, a variety of education and decision support interventions were developed, including basic CM information and resources for patients and HPs, a group education program and one-on-one decision support coaching for patients, and an on-line education module for HPs. Evaluation of the program and individual interventions is underway. CONCLUSIONS: This education and decision support program addresses a significant gap in care and offers an evidence-informed framework in which to translate CM evidence to conventional care settings and promote communication about CM. PRACTICE IMPLICATIONS: Evidence-informed CM education and decision support interventions are needed to shift the culture around CM within conventional care settings and promote open communication that will lead to CM therapies being safely integrated into care.

The Greater Value of the CONSORT Statement Guidelines: Guideposts for Designing and Reporting all TMB Research.

The IJTMB recommends the use of the CONSORT Statement (Consolidated Standards of Reporting Trials) guidelines for the reporting of randomized, controlled clinical trials (RCTs). A careful review of the guidelines shows important applications of these guidelines to all types of research reporting and design, not just RCTs. There is an Extension to these guidelines specific to nonpharmacologic interventions, including manually applied therapies and complementary medicine, and thus therapeutic massage and bodywork (TMB). Components of the Extension are thus relevant to publication in the IJTMB and should be considered part of standard reporting. As well, while the goals of the CONSORT Statement guidelines are to improve reporting of RCTs, the issues raised in the guidelines and explanatory document are relevant to all forms of TMB research and should be considered in all TMB research manuscripts. Finally, while not their purpose, the guidelines could also be used as an informal checklist when developing robust TMB research.

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

BACKGROUND: Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. METHODS: Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. RESULTS: Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. CONCLUSIONS: The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

Use of complementary and alternative medicine by patients with inflammatory bowel disease.

In this review article we provide a broad overview of complementary and alternative medicine (CAM) use in inflammatory bowel diseases (IBDs), including prevalence of use, common therapies used, and reasons for and factors associated with CAM use. CAM is commonly used by those suffering from IBD. Multiple forms of CAM are used to treat IBD, and often patients use multiple CAM therapies and continue to use conventional medical therapies. Patients using CAM report benefits that extend beyond simply improved disease control. Using CAM allows patients to exert a greater degree of control over their disease and its management than they are afforded by conventional medicine. There is limited evidence on the efficacy of CAM therapies in IBD. It is important for physicians caring for those with IBD to be familiar with common forms of CAM and to be able to provide general counseling to their patients about CAM use.

Changing the global health care landscape-proceedings of a "glocal" symposium.

BACKGROUND: This glocal (global knowledge with local action) symposium was convened by a professional therapeutic massage bodywork professional organization to bring together the fields of economics, politics, and traditional and complementary and alternative medicine (TCAM) to begin development of effective TCAM advocacy worldwide. The symposium addressed the core question, "What information will be needed to address issues that will arise as TCAM practitioners advocate for a respectful and equalfooting access to health care provision, public and private, worldwide?" PARTICIPANTS AND SETTING: The 35 international participants convened in a Victoria, Canada hotel. They were selectively invited to provide expertise in: advocacy, politics, public policy, economics, TCAM practice, integrative practice, sociology and TCAM research, education, media and language framing, psychology, and mediation. METHODS: The two-day symposium used a facilitated dialogue and knowledge-sharing design process geared to achieving group-supported recommendations. Invited panelists discussed each agenda topic, followed by facilitated discussion with the entire group. RESULTS: In general, participants agreed that advocacy from a TCAM perspective is needed. Additionally, more research should use methods with more relevance to everyday health care provision and health care costs such as effectiveness comparative trials and cost effectiveness studies. A number of specific advocacy steps were recommended. Most focused on developing local support for better access and equity regarding TCAM within local health care systems and advocacy work, which needs to both understand and engage the local TCAM practitioners and those using the TCAM services. CONCLUSIONS: The increasing awareness of TCAM and advancement toward integrative medicine-including traditional medicines and perspectives-are themes currently in development worldwide. Now is a good time for TCAM practitioners to open dialogue to develop better partnerships in health care. Such dialogue is facilitated when diverse people at the health care table understand each other's perspectives. More discussions like this, with diverse people across more disciplines, need to occur worldwide.

The use of mixed methods for therapeutic massage research.

Mixed methods research is the integration of quantitative and qualitative components in a research project. Whether you are reading or designing a mixed methods research project, it is important to be familiar with both qualitative and quantitative research methods and the specific purposes for which they are brought together in a study: triangulation, complementarity, expansion, initiation, or development. In addition, decisions need to be made about the sequencing and the priority or importance of each qualitative and quantitative component relative to the other components, and the point or points at which the various qualitative and quantitative components will be integrated.Mixed methods research is increasingly being recognized for its ability to bring multiple points of view to a research project, taking advantage of the strengths of each of the quantitative and qualitative components to explain or resolve complex phenomena or results. This ability becomes critical when complex healing systems such as therapeutic massage are being studied. Complex healing systems may have multiple physiologic effects, often reflected in changes throughout the patient's body. Additionally, the patient's experience of the treatment may be an important outcome.

The integrated taxonomy of health care: classifying both complementary and biomedical practices using a uniform classification protocol.

BACKGROUND: Since the late 1980s, several taxonomies have been developed to help map and describe the interrelationships of complementary and alternative medicine (CAM) modalities. In these taxonomies, several issues are often incompletely addressed: A simple categorization process that clearly isolates a modality to a single conceptual categoryClear delineation of verticality-that is, a differentiation of scale being observed from individually applied techniques, through modalities (therapies), to whole medical systemsRecognition of CAM as part of the general field of health care METHODS: DEVELOPMENT OF THE INTEGRATED TAXONOMY OF HEALTH CARE (ITHC) INVOLVED THREE STAGES: Development of a precise, uniform health glossaryAnalysis of the extant taxonomiesUse of an iterative process of classifying modalities and medical systems into categories until a failure to singularly classify a modality occurred, requiring a return to the glossary and adjustment of the classifying protocol RESULTS: A full vertical taxonomy was developed that includes and clearly differentiates between techniques, modalities, domains (clusters of similar modalities), systems of health care (coordinated care system involving multiple modalities), and integrative health care. Domains are the classical primary focus of taxonomies. The ITHC has eleven domains: chemical/substance-based work, device-based work, soft tissue-focused manipulation, skeletal manipulation, fitness/movement instruction, mind-body integration/classical somatics work, mental/emotional-based work, bio-energy work based on physical manipulation, bio-energy modulation, spiritual-based work, unique assessments. Modalities are assigned to the domains based on the primary mode of interaction with the client, according the literature of the practitioners. CONCLUSIONS: THE ITHC HAS SEVERAL STRENGTHS: little interpretation is used while successfully assigning modalities to single domains; the issue of taxonomic verticality is fully resolved; and the design fully integrates the complementary health care fields of biomedicine and CAM.

Value of qualitative research in the study of massage therapy.

Qualitative inquiry is increasingly used in health research because it is particularly suited to the study of complex topics or issues about which little is known and concerning which quantification cannot easily create or effectively convey understanding. By exploring the lived experience of people providing and receiving massage therapy and the meaning that those people ascribe to those experiences, in-depth understanding of the nature of massage therapy and of how it affects people's lives is possible. Qualitative research may also provide insights into the outcomes, process and context of massage therapy that cannot be fully achieved through quantification alone.The purpose of the present article is to describe qualitative research and to discuss its value to the massage therapy profession. The target audience is massage therapists who want to be able to better understand the research literature, novice massage therapy researchers who are unfamiliar with qualitative research, and teachers of research methods courses in massage therapy training programs who want to include qualitative research methods in their curriculum.