A Replicable and Sustainable Whole Person Care Model for Chronic Pain.

BACKGROUND: Integrative health is an expanding field that is increasingly called upon by conventional medicine to provide care for patients with chronic pain and disease. Although evidence has mounted for delivering integrative therapies individually, there is little consensus on how best to deliver these therapies in tandem as part of whole person care. While many models exist, few are financially sustainable. METHODS AND RESULTS: This article describes a conceptual and logistical model for providing integrative outpatient health care within an academic medical center or hospital system to patients with chronic pain and disease. In hopes that the model will be replicated, administrative details are provided to explain how the model operates and has been maintained over nine years. The details include the intentional building of a particular work culture. CONCLUSION: This whole person care model that addresses chronic pain and disease in an outpatient integrative clinic has been successful, sustainable and can be replicated in other academic medical centers or hospital clinics.

The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S).

Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as 'Female Athlete Triad'. The term 'Relative Energy Deficiency in Sport' (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a 'triad' of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The 'Sport Risk Assessment and Return to Play Model' categorises the syndrome into three groups and translates these classifications into clinical recommendations.

A randomized controlled trial to evaluate the effects of high-dose versus low-dose of arginine therapy on hepatic function tests in argininosuccinic aciduria.

OBJECTIVE: To compare the effects of combinatorial therapy with low-dose arginine and a nitrogen scavenging agent (sodium phenylbutyrate) vs. monotherapy with high-dose arginine on liver function tests in patients with argininosuccinic aciduria (ASA). STUDY DESIGN: Twelve patients with ASA were enrolled in a double-blind, placebo-controlled, cross-over study design. Subjects were randomized to receive either a low-dose of arginine therapy (100 mg · kg(-1) · d(-1)) combined with sodium phenylbutyrate (500 mg · kg(-1) · d(-1)) (LDA arm) or a high-dose of arginine alone (500 mg · kg(-1) · d(-1)) (HDA arm) for one week. At the end of one week of therapy, liver function tests were assessed and metabolite fluxes were measured using a multi-tracer stable isotope protocol. RESULTS: Plasma aspartate aminotransferase (AST), alanine aminotransferase (ALT), and measures of synthetic functions of the liver were the primary outcomes. Subjects had significantly increased levels of argininosuccinate (P<0.03) and AST levels (P<0.01) after treatment with high-dose arginine. In the subset of subjects with elevated AST or ALT, treatment with high-dose of arginine was associated with further increases in plasma levels of both aminotransferases. Whereas subjects had increased arginine and citrulline flux with high-dose arginine therapy, the glutamine flux was not different between the two treatment arms. The synthetic liver functions as assessed by prothrombin time, INR, and coagulation factor levels were not different between the HDA and LDA arms. CONCLUSIONS: Administering higher doses of arginine in subjects with ASA results in increases in AST and ALT levels, especially in the subset of patients with elevated baseline aminotransferases. Hence, low-dose arginine sufficient to normalize arginine levels in plasma combined with nitrogen scavenging therapy should be considered as a therapeutic option for treatment of ASA in patients with elevations of hepatic aminotransferases.

Hyperbaric oxygen therapy as a sole agent is not immunosuppressant in a highly immunogenic mouse model.

Background. Hyperbaric oxygen (HBO) therapy, which is used for many conditions, may also have immunosuppressive effects and could be used for prevention or treatment of graft-versus-host disease (GvHD). If HBO is immunosuppressant, then we hypothesize that HBO therapy will delay the T-cell mediated skin graft rejection. Methods. C57/BL6 black-coated (H2B) mice received skin graft from CBA (H2D) white-coated mice. Mice were treated with either 19 session of 240 kpa oxygen or 29 session of 300 kpa oxygen, for 90 minutes. Mice were housed either 4 per cage or separately, to prevent friction and mechanical factors that may affect graft survival. Skin grafts were assessed daily. Results. There was no difference in length of graft survival between mice that received either regimens of HBO therapy and mice that did not receive HBO therapy. Conclusions. HBO therapy, as a sole agent, did not delay skin graft rejection in a highly immunogenic mouse model.

Generalized metabolic bone disease in Neurofibromatosis type I.

Skeletal abnormalities are a recognized component of Neurofibromatosis type I (NF1) but a generalized metabolic bone defect in NF1 has not been fully characterized thus far. The purpose of this study was to characterize at the densitometric, biochemical and pathological level the bone involvement in NF1 patients. Using dual energy X-ray absorptiometry (DXA) we analyzed bone status in 73 unselected NF1 subjects, 26 males and 47 females, mainly children and adolescents (mean age: 16.6 years). In a subgroup of subjects with low bone mass, we measured indices of calcium-phosphate metabolism, bone turnover, and bone density before and after vitamin D and calcium treatment. We found statistically significant and generalized reduction in bone mass with the mean lumbar bone mineral density (BMD) z-score being -1.38+/-1.05 (CI 95% -1.62 to -1.13), and whole body bone mineral content (BMC) z-score -0.61+/-1.19 (CI 95% -0.94 to -0.29), both significantly reduced compared to normal controls (p<.001). PTH was moderately elevated and after 4 months of supplemental therapy with calcium and vitamin D, it decreased to the normal range. However, BMD z-scores did not significantly improve after 2 years of follow-up. Histological analysis of bone samples from NF1 patients revealed substantial alteration of bone microarchitecture due mainly to reduced trabecular bone. Our observations are consistent with a generalized bone metabolic defect due to loss of the function of neurofibromin. Early identification of patients with osteoporosis may permit more timely and aggressive treatments to prevent the likely substantial morbidity associated with increased fracture risk later in life.

Exercise training manages cardiopulmonary function and fatigue during and following cancer treatment in male cancer survivors.

This investigation determined the cardiopulmonary function and fatigue alterations in male cancer survivors during treatment as well as following treatment utilizing similar exercise assessment protocols and individualized, prescriptive exercise interventions. The study included 45 male cancer survivors that were referred by local oncologists. Following a comprehensive screening and physical examination, cardiovascular endurance, pulmonary function, and fatigue were assessed leading to the development of 12-week individualized exercise prescriptions and exercise interventions. The cancer survivors were divided into during treatment (DTm) and following treatment (FTm) groups. Repeated-measures analysis of variance and analyses of covariance were used to compare pre- versus postintervention and between groups. Cardiopulmonary function was maintained in the DTm, whereas the FTm showed significant reductions in resting heart rate (P < .05) with concurrent increases in predicted VO2max and time on treadmill ( P < .05) postexercise intervention. Fatigue levels did not increase in the DTm group, whereas the FTm group showed significant reductions in behavioral fatigue, affective fatigue, sensory fatigue, cognitive/mood fatigue, and total fatigue (P < .05) after the exercise intervention. The results of the current study suggest that moderate intensity, individualized, prescriptive exercise intervention maintains or improves cardiovascular and pulmonary function with concomitant reductions in fatigue in cancer survivors during and following cancer treatment. Exercise appears to be a safe, efficacious strategy for improving physical fitness in cancer survivors during and following treatment.

The effects of walking poles on shoulder function in breast cancer survivors.

Breast cancer treatment often results in impaired shoulder function, in particular, decrements in muscular endurance and range of motion, which may lead to decreased quality of life. The purpose of this investigation was to determine the effects of walking pole use on shoulder function in female breast cancer survivors. Participants had previously been treated with 1 or a combination of the following: mastectomy, breast conservation therapy, axillary lymph node dissection, chemotherapy, or radiation. Participants were randomly placed in experimental (n = 6) and control (n = 6) groups and met with a cancer exercise specialist 2 times each week for 8 weeks. The experimental group used walking poles during the 20-minute aerobic portion of their workout, whereas the control group did not use walking poles but performed 20 minutes of aerobic exercise per workout session. Both groups participated in similar resistance training programs. Testing was done pre- and postexercise intervention to determine upper body muscular endurance and active range of motion at the glenohumeral joint. Repeated-measures analysis of variance (ANOVA) revealed significant improvements in muscular endurance as measured by the bench press (P = .046) and lat pull down (P = .013) in the walking pole group. No within-group improvements were found in the group that did not use walking poles. The data suggest that using a walking pole exercise routine for 8 weeks significantly improved muscular endurance of the upper body, which would clearly be beneficial in helping breast cancer survivors perform activities of daily living and regain an independent lifestyle.

A case study: prescriptive exercise intervention after bilateral mastectomies.

Exercise for cancer patients is gaining support. In the current case study, a female breast cancer patient was diagnosed with breast cancer at the age of 29 years; she underwent a left modified radical mastectomy. She developed cancer again in the opposite breast at the age of 57 years and had a right modified radical mastectomy. After the second mastectomy (the right breast), the patient received chemotherapy and radiation. Following her cancer treatments, she participated in an exercise intervention for 6 months at the University of Northern Colorado's Rocky Mountain Cancer Rehabilitation Institute. A 6-month reassessment showed that she increased her muscular strength and cardiovascular function in addition to attenuating her cancer-related fatigue and depression. It is recommended that health professionals work together to ensure that a collaborative effort is undertaken to increase functional work capacity that will significantly improve patients' quality of life.

A model program: exercise intervention for cancer rehabilitation.

Recent advances in cancer detection and treatment have resulted in an increase in the survival rate of individuals diagnosed with cancer. The increased survival rate brings new challenges for increasing the quality of life for cancer survivors. Debilitating side effects can result from the cancer itself and the cancer treatment. The negative effects lead to decreased functional (work) capacity, increased fatigue, and debilitating muscular weakness. There have been very positive benefits seen from the use of individualized prescriptive exercise intervention in alleviating these cancer treatment related symptoms. The role of exercise intervention as a complementary therapy is just emerging. Studies have shown that exercise decreases the amount of fatigue, improves functional capacity, increases immune function, and leads to improved quality of life. The effects of cancer and cancer treatments require that an exercise intervention program be well based in sound scientific principles. The exercise intervention needs to be carefully structured and controlled. All patients should be assessed and reassessed to evaluate progress. A cancer exercise specialist should closely monitor the exercise regime. Exercise should involve a whole-body approach that emphasizes all areas of fitness. Exercise therapy for cancer patients is a new and exciting area that will continue to grow as medical professionals realize the necessity for post-cancer treatment intervention to improve quality of life.