Does your practice offer holistic services? Answer the opinion poll on our homepage.
The notion that we can influence health with our minds is an appealing concept. But Western medicine often leaves little room for this abstraction-focusing solely on drugs and sharp surgical instruments to cast away illness.
This trend may be changing, however, as techniques, such as acupuncture, homeopathy and guided imagery, become more closely studied. In fact, more controlled studies point to the tangible benefits, including reductions in nausea, pain and length of hospital stays, of these nontraditional approaches. This is not to mention how these techniques can improve coping skills and anxiety.
I offer several complementary medical therapies to my surgical patients, including acupuncture, homeopathy, Thai massage, aromatherapy-guided imagery and reflexology.
Having no shortage of these complementary therapy providers, it's my job as a plastic surgeon to weed through these approaches to determine which "whole body" approaches deliver the greatest proven benefits for my patients.
Holistic Advice for Surgery Preparation
To understand the use of whole-body approaches in practice, we must first distinguish between alternative and complementary therapies. Alternative therapies are used instead of conventional therapy, whereas complementary or adjunctive therapies are used in addition to conventional therapy. Thus, I encourage the use of complementary therapies to relieve stress and enhance well-being while receiving a conventional surgical treatment, such as a face lift, breast reduction or abdominoplasty.
Luckily, the quantity and quality of research on nontraditional practices has increased with the holistic movement's growing popularity. Published high quality systematic reviews of complementary medicine have provided a reliable basis for incorporating holistic support before surgery.
High quality research has made it possible for conventional medical bodies to publish guidelines and consensus statements. For example, The National Institutes of Health has issued consensus statements supporting the use of hypnosis for pain related to cancer and the use of acupuncture for pain and nausea. In addition, acupuncture, hypnosis, and relaxation techniques are included in guidelines on the management of pain associated with cancer that have been published by the United States National Comprehensive Cancer Network.1-4
Acupuncture
Of all the nontraditional approaches, acupuncture enjoys the most credibility with a large body of laboratory physiologic data. Acupuncture is the insertion of fine needles into specific points on the body's surface to manipulate the flow of energy (Qi) within the body. Pain and illness represent an obstruction in the normal flow of Qi; acupuncture restores free flow. My patients receive one to three treatments before their surgeries, and many continue afterwards.
Evidence suggests acupuncture inhibits several key steps in the inflammatory response (early-phase vascular permeability and leukocyte adherence to vascular endothelium) to a degree equivalent to aspirin and indomethacin. Acupuncture may also stimulate the gene expression of neuropeptides.5-7
Imaging studies have demonstrated remarkable findings related to acupuncture. For example, a functional MRI study found that a specific "vision" acupuncture point in the foot activated the same region in the occipital lobe that was activated by direct light. In fact, stimulation of nearby sham points did not result in similar activation.
Other imaging studies show that specific acupuncture points, but not controls, activate pathways that diminish pain signals and also deactivate multiple areas within the brain that participate in pain processing.8-10 Acupuncture has been said to have anesthesia-like qualities, which could be beneficial to surgery.
Likely, acupuncture stimulates high-threshold, small-diameter nerves that send signals via the spinal cord to the periaqueductal gray area of the brainstem. The hypothalamus triggers the release of endogenous opioids. Interestingly, studies indicate measurable changes in plasma and corticospinal fluid levels of endorphins, enkephalins, and stress-related hormones. In fact, some studies have shown that acupuncture analgesia can be reversed with naloxone (an endorphin antagonist) in a dose-dependent manner.11-16
Clinical studies show this same effect. In fact, 39 patients undergoing oral surgery were randomly assigned to receive either real acupuncture or placebo acupuncture before surgery. Patients in the acupuncture group were pain-free nearly twice as long as those in the placebo group. When post-operative pain occurred, the acupuncture group required two-thirds the amount of medication as the placebo group.17
Another study analyzed 80 patients who underwent mastectomy and axillary dissection. Forty-eight patients were treated with acupuncture on the fifth and seventh days after surgery. Thirty-two patients with the same operation did not receive acupuncture. The acupuncture group had significantly less pain according to standard pain measurement scales and greater arm abduction.18
Another study evaluated 40 patients undergoing knee arthroscopy, and who were randomized to receive either acupressure or placebo stimulation after awakening from anesthesia. Pain scores were lower in the acupressure group.19 In addition, the combination of acupuncture and massage decreased pain and depression following cancer surgery in a randomized controlled pilot study of 138 patients.20
There have been several well-designed studies reported to date on post-operative nausea and vomiting. In a study of 220 patients, vomiting was reduced from 39.6 percent to 26.8 percent of patients who underwent either gynecological or breast surgery and who were randomly assigned to receive either acupuncture or placebo acupuncture.21
A third double-blind, randomized study evaluated acupressure in 94 patients who had spinal anesthesia for a Caesarian section: acupressure reduced the incidence of nausea or vomiting from 53 percent to 36 percent compared with placebo when administered during the operation and from 66 percent to 36 percent after the operation. The same group of researchers reported a double blind, randomized study that compared acupressure to placebo in 104 patients undergoing laparoscopy: acupressure reduced nausea and vomiting from 42 percent to 19 percent compared with placebo within the first 24 hours after the procedure.22,23 Although the decrease in the incidence of nausea was significant, the overall incidence of nausea in this study was higher than that reported in other studies. Possibly, the criteria for inclusion were overly broad.
Preoperative acupuncture has been shown to reduce the pain of surgery. It also increases the flow of "energy" into the areas that will be operated upon, and I assume this leads to better wound healing.
Homeopathic Medicine
Most physicians have a difficult time accepting homeopathic medicine as a legitimate practice of medicine because it is totally contrary to conventional pharmacological principles.
One of homeopathy's main principles asserts that if a natural substance can cause symptoms in a healthy person, then this substance, in a diluted form, can stimulate self-healing of similar symptoms in a sick person. For example, if a person has seasonal allergies to juniper, then a diluted extract of the plant can decrease the allergic symptoms.
Homeopathic remedies are made from plant, mineral and animal extracts and diluted to varying degrees. The process of producing remedies is precise, with every major homeopathic company or pharmacy around the world following the same protocol.
Homeopathic solutions can be diluted to the extent that literally no molecules of the original substance remain; yet according to homeopathic philosophy, the more diluted a remedy is, the greater its potency.
Different homeopathic remedies are tailored to the various phases of the surgery, starting from before the surgery and ending several weeks to months afterwards. In the language of the discipline, the remedies used early in the treatment course help to decrease the "trauma" of the surgery and remedies used after the surgery help to minimize and "detoxify" the after effects of anesthesia. In my practice, I use a licensed Doctor of Oriental Medicine (DOM) to oversee these treatment regimens and to modify them on an individual basis.
Scientific studies are lacking to prove the efficacy of this approach, and I do not believe they are medically necessary. I have found anecdotally that patients are comforted by the regimens, which I have found to be quite safe.
Aromatherapy-guided Imagery
Research has already explored the effects of a positive mental attitude before surgery on better outcomes. We make a point to create a comfortable and relaxing mental state using the aroma of essential oils. These oils can be administered through massage, inhalation (our technique), compresses and baths. While commonly associated with pleasant applications for beauty and general relaxation, essential oils have complex chemical components-just as herbs have medicinal properties that affect the body in a variety of ways.
Understanding these uses requires training in the appropriate selection, preparation and application of these oils as well as knowledge of their toxicities, side effects and interactions with pharmaceutical drugs. Some oils can actually interfere with wound healing.
I use a practitioner trained in the Healing Touch Therapy Program, a hands-on system used in many hospitals throughout the country.
Our particular technique is a meditative/counseling session rather than a hands-on, massage type technique: the patient chooses and takes home a vial of their favorite aroma, which is linked to the calming images and feelings experienced during the session. Before and after surgery, the patient uses the essential oil to recall the imagery and soothing feelings of the session.
The Power of Touch
We also incorporate massage and reflexology into our practice. Thai massage, known as the "lazy man's yoga", combines massage, acupressure, energy work, yoga and relaxation. The patient receives a 60-minute treatment just before surgery to relieve stress and, from an Eastern perspective, to decrease congestion in muscles, joints, the lymphatic system and connective tissue by opening lines of energy into the affected areas. For example, many of our breast surgery patients undergo breast massage to stimulate the flow of lymph and energy in the breast before and after surgery.
We also incorporate reflexology, which is the physical act of applying pressure to the feet and hands with specific techniques. It is based on a system that reflects an image of the entire body onto the feet and hands; foot massage effects a physical change in the corresponding body part. In addition to increasing the flow of energy into the affected area, the practice provides relief from tension, stress and anxiety.
One randomized controlled trial of 100 patients undergoing cardiac surgery studied the effect of foot massage with neroli (orange blossom) oil on the first post-operative day. Patients showed a statistically significant improvement in the respiratory rate and a reduction of anxiety and tension one hour to several days after surgery.24
In addition, 104 patients undergoing open heart surgery were randomized to receive either standard care or preoperative guided imagery with light massage. Pain and tension scores decreased significantly in the complementary group in the first two days after surgery. Similar results were reported in a group undergoing elective colorectal surgery, and additionally there was a decrease in the use of narcotics and the time to the first bowel movement.25
My patients undergo a reflexology treatment several days after surgery, when they are still in the uncomfortable early post-operative phase. In addition to increasing the flow of energy into the affected area, the practice provides relief from tension, stress and anxiety.
What I do
As a plastic surgeon who embraces nontraditional approaches, I have three goals. I want to improve patient comfort, both preoperatively and postoperatively. I also want to decrease postoperative swelling and bruising. Most importantly, my approach aims to teach patients how to take care of themselves and their health. I also, for example, incorporate nutrition counseling, though this is hardly considered holistic. A proper diet around the time of surgery can provide the body with the building blocks needed to heal surgical wounds.
The Integrative Medicine program is not for everyone, and not everyone benefits from the program. I caution my patients that the degree to which they can influence the course of their recovery through mental or emotional work is highly variable, and that their efforts may not make a difference. I do not want them to feel guilty or inadequate if their recovery is difficult despite their best efforts. Some patients ask that I operate on them without holistic support before surgery. However, most of my patients are enthusiastic about the program, and many refer to it as the "whole being plan."
Although the scientific evidence for these therapies is still growing, their long term use in many parts of the world demonstrates their inherent safety. Evidence-based medical research has demonstrated that scientific evidence is important in clinical judgment, but clinical experience and expertise also play a vital role in patient care. The lack of evidence from randomized clinical trials does not necessarily imply lack of patient benefit. (Click Page 2 for References.)
Daniel N. Ronel, MD, is a board-certified plastic surgeon with offices in Santa Fe and Albuquerque, N.M. Educated and trained at Princeton, University of Pennsylvania, Columbia, Cornell, and Harvard universities, he is the only surgeon in the United States who is board certified in both plastic surgery and pediatrics. Dr. Ronel was named one of America's Top Plastic Surgeons by the Consumer's Research Council of America. Dr. Ronel is one of 13 national experts who sits on an advisory panel for silicone breast implants. He's a member of the National Radiesse Medical Education Facility and was voted Albuquerque's Plastic Surgeon of the Year in 2007 by readers of The Herald. He was also named one of Albuquerque's 2007 "Top Docs" by Albuquerque the Magazine.
|