Cognitive behaviour therapy has a sound evidence base for a range of chronic pain conditions, 38 including chronic back pain 39 and fibromyalgia, 40 and has been shown to be associated with fewer days of work missed due to pain related disability. A review of 46 RCTs of various aspects of delivering psychosocial interventions for chronic pain found that group-delivered courses that had healthcare professional input showed more beneficial effects. Group-delivered psychosocial interventions for chronic pain aim to provide patients with greater self-efficacy through skills that they can apply at home and work.
The aim is self-sufficiency and not dependency on a therapist, but in order to do this a patient needs to be assisted through the sometimes difficult early stages of learning these skills. A supportive, experienced practitioner and a group working toward the same end help enormously. The facilitator therefore needs skills in the mind-body therapy being used, group facilitation skills and motivational skills see Resources. Groups are also useful for breaking down isolation, enhancing motivation and providing the benefits of learning from the insights and experiences of other group members.
Some mind-body therapies lend themselves more easily to use in general practice. For example, skills in relaxation techniques are a good starting point. More extensive training is needed to apply approaches such as mindfulness, hypnosis, imagery and CBT, but they are eminently adaptable to the general practice setting if adequate time is taken for their implementation. Yoga and biofeedback will generally require referral.
Importantly, GPs are well placed to recommend or learn and provide a range of mind-body approaches to improve outcomes for patients with chronic pain. Competing interests: None. Provenance and peer review: Commissioned; externally peer reviewed. To open click on the link, your computer or device will try and open the file using compatible software.
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To view these documents you will need software that can read Microsoft Word format. If you don't have anything you can download the MS Word Viewer free of charge. Opioid use in chronic non-cancer pain Part 1 Known knowns and known unknowns. Opioid use in chronic non-cancer pain Part 2 Prescribing issues and alternatives. Chronic itch on the back associated with disc hernia A case study. Appointments How to shape a more effective appointment system. Requests for permission to reprint articles must be sent to permissions racgp. The views expressed by the authors of articles in Australian Family Physician are their own and not necessarily those of the publisher or the editorial staff, and must not be quoted as such.
What is integrative health? Treating more than an illness - Sanford Health News
Focus Pain. Mind-body therapies Use in chronic pain management Volume 42, No. Article Download article Download Citations. Craig Hassed Background Chronic pain is a common presentation to general practice. Discussion The mind, emotions and attention play an important role in the experience of pain.
Downloads Help with downloads. Mind-body therapies — use in chronic pain management pdf KB. Opening or saving files Files on the website can be opened or downloaded and saved to your computer or device. MP3 Most web browsers will play the MP3 audio within the browser. No competing interests:. I declare the following competing interests:. Yes No. Confirm E-mail:. Add Another Author. Competing Interests:. Even among the troubled. Letters to the editor. Neuropathic pain A management update. Mind-body therapies Use in chronic pain management. Macroscopic haematuria A urological approach. Wet combing for the eradication of head lice.
Childhood headache and H. Chronic refractory dyspnoea Evidence based management. Shared learning in general practice Facilitators and barriers. Clinical challenge. Psychological factors that may affect pain outcomes are not routinely assessed by many treating clinicians. Better methods of screening and early intervention are needed to improve feasibility and utility in usual care settings.
Persistent pain naturally leads to emotional and behavioural consequences for the majority of individuals. Psychological concepts of learning can be useful to provide empathy and support without reinforcing pain behaviour. Clients who are depressed or have a history of depression may have more difficulty dealing with pain. A brief assessment of mood symptoms should be part of routine screening and intake procedures for pain conditions. Persistent pain problems can lead to hypervigilance and avoidance, but simple distraction techniques are not enough to counter these behaviours.
Clinicians should avoid inadvertent messages that escape or avoidance from pain is necessary in order to preserve function. Individuals hold very different attitudes and beliefs about the origins of pain, the seriousness of pain, and how to react to pain. Assessment and treatment planning should take into account individual differences in pain beliefs and attitudes. Personal expectations about the course of pain recovery and treatment benefits are associated with pain outcomes. Research has suggested numerous cancers to be primarily nutrition-responsive and preventable by dietary [ 96 , 97 ] and lifestyle changes [ 98 , 99 ].
The mechanism responsible may be by aliment-induced reversible epigenetic modification or the protective effects conferred by a diet high in fiber and antioxidants [ 20 , , ]. Establishing healthy habits in children to focus on healthy nutrition, mind—body interventions for stress reduction, quality sleep, and generous physical activity may be paramount in decreasing overall risk of some cancers colon, lung, breast, and prostate in later life [ ].
Pediatric asthma is another area where an integrative approach may provide benefit. Elimination diets and those emphasizing core facets of the Mediterranean diet high in fruits, vegetables, and legumes have been shown to protect children from asthma and allergies [ , , ]. A systematic review and meta-analysis by Cramer et al. Mark describes a multitude of integrative therapies as effective for pediatric asthma, including: 1 mind—body therapies to reduce anxiety and stress, lowering immune response and sympathetic activity; 2 proper prenatal and childhood nutrition that is high in fruits and vegetables; and 3 exercise and yoga to improve regimen adherence and decrease anxiety [ , ].
There is a role for an integrative approach within many subspecialties. We know, for instance, that diet and exercise management can halt or reverse cardiovascular disease, diabetes, and obesity [ 10 , 13 , 23 , , , ]. Integrative cardiology targets high body mass index BMI and poor nutrition using mind—body therapies to influence caloric consumption, sedentary or stressful lifestyles, and depression-associated symptoms [ ]. Cognitive behavioral therapy has been used as an adjuvant in pediatric obesity management [ ].
Mindfulness-based cognitive therapy has shown preliminary efficacy in youths with anxiety disorder and mindfulness based stress reduction programs in urban youth have improved psychological functioning and decreased negative effects of stress [ 33 , ]. Furthermore, a recent study has proposed mechanistic pathways of action of acupuncture in alleviating cardiovascular disease [ , , , ]. As the evidence base to support the use of integrative approaches in each pediatric subspecialty grows, the use of CAM in pediatrics will increase.
In light of this, clinical practices and academic centers are starting to integrate CAM modalities. Existing models of care can provide a foundation for future growth and utilization of integrative approaches for children. Families travel from 50 states and 40 countries for care. The program was developed in recognition of the growing interests of patients and their families in the use, benefits, and potential complications of complementary therapies.
Reasons for wanting further education included: 1 a desire to learn more about different CAM therapies to better advise their patients and families about safety and efficacy of supplements and mind—body approaches which they were already using ; and 2 a need to knowledgably introduce evidence-based pediatric IM practices into patient care. The business plan included: proposed faculty, support staff allocation 0. Rather than creating a separate PIM clinic, the four faculty members centered the integrative clinics within four established specialty clinics: pain, gastroenterology GI , pulmonary, and rheumatology.
This model aimed to decrease overhead cost space, staff, supplies and make PIM clinics easily accessible. This model was fiscally sustainable as it allowed continued financial support of the faculty for conventional work in their respective subspecialty in addition to the subspecialty PIM clinics. The anecdotal response to this model by patients, families, and institutional leadership was positive. Patients and families expressed satisfaction e. As the program grew, institutional leadership and division chiefs continued to support the program, allowing the IM faculty to shift more time toward integrative clinics.
Community providers were welcomed to educational sessions offered by the program leaders and began incorporating evidence-based IM practices into their own specialties. Program accomplishments. The four subspecialty integrative clinics staffed by four IM-trained faculties in the pulmonary, rheumatology, pain medicine, and gastroenterology fields , continue to grow. Clinical volume has increased significantly since inception in In , there were visits for integrative medicine, and by that number had nearly doubled to over annual visits. The greatest growth was noted in integrative pain and gastroenterology clinics.
Referrals have come from community alternative care providers e. Prior to an initial visit with a PIM provider, insurance authorization is obtained.
If the visit is with an acupuncture provider, patients interested in acupuncture are given current procedure terminology CPT codes and instructed to determine insurance benefits and out-of-pocket costs. Many insurances in California do cover acupuncture services for certain indications. Authorization is also required for pain psychology services through the IM pain clinic. An insurance authorization team is available to assist in this process. Each subspecialty clinic has a slightly different staffing structure. The integrative pain clinic includes a comprehensive initial pain evaluation for each new patient with the pain physician, nurse practitioner NP , and pain psychologist.
Pain clinic NPs are also medical acupuncture-trained and therefore can continue treatment plans started by the acupuncture-trained physician. New patient visits in IM GI, pulmonary, and rheumatology clinics are for 90 min with an IM physician and follow-up visits are for 45 min. After a through intake evaluation, a comprehensive treatment plan is developed.
The modalities offered depend largely on the individual training of the providers. The range of integrative treatment modalities include: nutrition recommendations, mind—body interventions, acupuncture, botanical or supplement review, and recommendations. The integrative GI clinic and integrative pulmonary clinic both have access to a registered dietician and social worker directly within the clinic. Pediatric IM providers will often refer to Stanford colleagues in the fields of nutrition, occupational therapy, psychiatry, child and pain psychology, and physical therapy.
Frequency of referral to these services depends somewhat on the subspecialty, but the highest utilized services include psychology and occupational therapy for biofeedback. Further, the IM faculty will refer to community providers outside of the institution in acupuncture, massage, physical therapy, biofeedback, clinical hypnosis, mindfulness, and yoga. Community referrals are especially common when a patient lives a far distance from the Stanford campus and needs a particular therapy frequently for example, weekly acupuncture for a patient who lives three hours away.
In the inpatient setting, a few IM modalities are available to inpatients through existing clinical departments. For example, the inpatient pain service provides acupressure and acupuncture. The child life department provides mind—body therapies, including guided imagery and virtual reality. The child psychology service provides clinical hypnosis as one of their treatment interventions.
At this point there is not a dedicated PIM inpatient service but rather a meshwork of services offered by individual departments. For the future, an inpatient IM consultation service is a planned area for program expansion. Research for many integrative modalities is lacking, especially for pediatric patients. The Stanford faculties have produced a variety of publications including narrative reviews, book chapters, prospective pilot studies, retrospective studies of clinic outcomes, and position statements.
Three faculty members are in the clinician educator track which does not afford protected research time. One faculty member is in the physician scientist track and has a dedicated 0. Several generous foundation grants Lawlor Foundation and Mayday Foundation have allowed for support of the faculty and research assistants. A recent study found immersive virtual reality safe and effective for treating complex regional pain syndrome [ 80 , ]. This has prompted further research on using virtual reality for other types of chronic, acute, and procedural pain.
Intraoperative acupuncture for patients undergoing tonsillectomy and adenoidectomy was found to be feasible, decreased postoperative pain, and increased return of diet [ 77 ]. A pilot study on yoga for adolescents with inflammatory bowel disease found yoga to be widely acceptable, feasible, and safe [ ]. For further details and a summary on research productivity and ongoing projects please see Table 1. Challenges to studying the PIM program as a whole is that program providers often recommend a comprehensive treatment plan instead of a single intervention.
This mirrors the wide array of interventions offered at other programs around the country particularly for pain clinics [ 69 , ]. Therefore, developing research techniques to study multimodal interventions is needed to adequately study the integrative medicine approach as a whole [ ]. This may include examining cost effectiveness and resource utilization emergency visits, urgent care visits, and hospitalizations in patients seen in a PIM program versus standard care. In addition to providing a foundation in PIM knowledge, the curriculum enabled residents to improve their own lifestyle and wellness behaviors during the pilot [ ].
To supplement the online curriculum offered by PIMR, the faculty developed a pediatric integrative medicine and wellness elective for pediatric residents who wanted in-depth exposure to integrative medicine in practice. The elective is currently offered as either a two-week or four-week in-person rotation. Residents taking the elective participate in the subspecialty PIM clinics average four to five half-day clinic sessions per two-week rotation. Required readings and hands-on didactic sessions average 4 h per two-week rotation include lectures about plant-based nutrition and mind—body medicine.
A field trip to a natural foods store provides the venue for a hands-on discussion of herbs and supplements. Residents are also asked to choose one integrative modality to experience for themselves to improve their own health. Meditation, massage, acupuncture, and yoga have been the most popular modalities that residents explore. Residents enrolled in the four-week elective are required to complete the h PIMR online curriculum in addition to the above activities. The Fellowship WellBeing Program FWP focuses on fatigue mitigation, self-care, resiliency, and stress mitigation for over pediatric fellows.
This seven-hour curriculum emphasizes the use of breathing, movement, mindfulness and nutrition to help physician trainees find and maintain wellness. The PIM fellowship includes partnership with the University of Arizona Fellowship in Integrative Medicine, a h, two-year distance learning program with three, week-long, hands-on training sessions.
The fellow has a dedicated general pediatrics IM clinic precepted by the PIM faculty average two half-day clinics per week and also works alongside faculty members in their respective subspecialty PIM clinics average two half-day clinics per week. Curriculum intensives—one to three-week mini courses—were developed by the PIM and adjunct faculty members to cover the important PIM topics of nutrition, mind—body medicine, botanical medicine, and inpatient consultation. The fellow may also work with non-Stanford affiliated community integrative medicine pediatric providers on an elective basis for niche skill development and clinical exposure.
The fellow is also required to teach pediatric residents formally in several conferences per year and informally when residents are on the PIM elective. The conferences are attended by community integrative medicine general pediatricians, PIM subspecialty providers GI, pulmonary, pain, rheumatology , massage therapists, acupuncturists, psychologists, mind—body intervention providers, and nutritionists.
After each case presentation, attendees offer their treatment recommendations from their own unique perspectives , and these recommendations are provided to the patient at clinic follow-up. A year-old girl presented to the outpatient pediatric integrative medicine clinic with chief complaint of abdominal pain for three years which had been diagnosed as abdominal migraines.
A comprehensive history was taken regarding her pain including an evaluation of life stressors, a detailed diet history, and her extensive medication list. Pertinent findings included a past medical history of anxiety and release of a tethered cord at nine months of age. Her prescription medications included duloxetine, cariprazine, amitriptyline, topiramate, polyethylene glycol, and a combined estrogen—progesterone oral contraceptive pill daily. She took clonazepam, ondansetron, sumatriptan, cyproheptadine, and simethicone on an as-needed basis for symptoms related to abdominal migraine.
She did not find any of these as needed medications particularly helpful in treating her abdominal migraine episodes. Supplements included melatonin nightly and peppermint oil by mouth as needed for abdominal pain. She was an only child of her mother and father. She was starting the 10th grade and achieved good grades. Her bedtime was h nightly and she fell asleep easily.
She reported occasional overnight awakenings and feeling tired on waking at h daily. She described herself as a worrier but also as willful and ambitious.
Her favorite color was teal, and her favorite season was winter. She preferred salty foods. Her self-reported personal strength was relating to other people, including classmates. She stated she was weak in mathematics. Her physical activity included biking to school or walking to the school bus stop. She was planning to join the school speech and debate team at the time of the visit. On physical exam her weight was in the 73rd percentile and her height was in the 38th percentile. Her body mass index was She was talkative and engaged. Abdominal exam was significant for hyperesthesia with light touch of all abdominal quadrants with significant epigastric tenderness.
There was no palpable stool burden. The remainder of her physical exam was normal. Prior negative workup for her abdominal pain included infectious stool studies, Helicobacter pylori , fecal calprotectin, complete blood count with differential, and a comprehensive metabolic panel including liver function testing, amylase, lipase, sedimentation rate, lipids, tissue transglutaminase immunoglobulin A, ceruloplasmin, and thyroid stimulation hormone.
The results of these studies were normal. Mind—body therapies were discussed, and the patient elected to start attending a free yoga class at her primary medical center. She continued to see her outpatient psychiatrist for weekly psychotherapy including cognitive behavioral therapy. From a lifestyle perspective, she was recommended to increase physical activity and offered that she would start walking a few evenings per week with her mother. A therapy plan for acute abdominal discomfort was formulated, and, in addition to her current pharmaceutical regimen, included: acupressure massage, enteric coated peppermint oil, and aromatherapy.
At her first follow-up the patient reported acupressure massage helpful, and she and the family asked for further instruction on in-home use of acupressure massage. At the third visit, approximately six weeks later, the patient emphatically reported she had aborted two abdominal migraines using acupressure beads with massage—something she had never achieved before. She started receiving biweekly acupuncture.
She continued yoga once per week. She also found benefit from using a mind—body application on her mobile phone for daily meditation to augment anxiety treatment. She weaned off amitriptyline and topiramate without incident and reserved only ondansetron and clonazepam on an as needed basis for acute discomfort. In the first three months of treatment the patient aborted abdominal migraines twice and experienced only two breakthrough episodes.
Additionally, she missed fewer days of school due to abdominal pain. She continues to follow-up in the integrative medicine clinic every two—three weeks for acupuncture treatments. Pediatric Integrative Medicine is an emerging subspecialty that provides the foundation for whole-patient and whole-child preventative care and lifestyle medicine [ 44 ]. According to a national survey performed by the Centers for Disease Control, in , These children often have multiple subspecialties involved in their care and their subsequent care coordination and communication between multiple consultants can be challenging.
Specialists tend to focus on their organ system of interest, and the holistic approach to the care and healing of the child may be overlooked. Integrative medicine may help bring together all aspects of care since PIM is a blend of mainstream therapies with the other aspects of wellness.
Further, our PIM faculty members are trained in both a pediatric subspecialty and integrative medicine. This affords a unique opportunity for specialized clinical care, education, and research in these integrative pediatric subspecialties. In addition, recruiting and collaborating with the well-respected existing faculty within the institution to provide consultations rather than hiring or contracting with external providers established trust, garnered respect for the program, and continued collegiality amongst providers.
This mirrors an important key to success among other established non-pediatric integrative medicine centers around the world [ 44 , ]. Given that integrative medicine at times can include treatment modalities that may not be well known to mainstream medicine, the faculty group also emphasizes evidence-informed treatment modalities to the extent available and emphasizes patient safety. Lifestyle recommendations that have minimal side effects such as good nutrition, sleep hygiene, physical activity, and mind—body modalities are often cornerstones of each treatment plan. When research on treatment efficacy in a pediatric population may not be available, providers extrapolate data from adult populations and utilize shared-decision making with families, and use the safety-effectiveness rubric to discuss and document efficacy [ ].
Every effort is made to utilize available resources to ensure the safety of a treatment recommendation, especially in regard to botanicals or supplements. Further, pharmacy consultations are sometimes required in patients who have significant polypharmacy. The elective also increased resident exposure and engagement with the integrative medicine faculty, which led to several resident-initiated scholarly works [ , ]. The novel conception of the pediatric integrative medicine fellowship has additionally increased clinical services and education efforts.
The weekly didactic conference available in person and by webinar had the unanticipated benefit of bringing together PIM providers within Stanford and the larger community. Continuing education courses for the pediatric community also stimulated community building and aided in patient referrals. Therefore, medical education and teaching are important keys to success. Finally, the educational and research programs would not exist without generous philanthropic support—both in the form of private donations and research grants.
The program has faced several challenges. From a financial standpoint, integrative medicine bills using time-based evaluation and management codes, behavioral health codes, and acupuncture CPT codes. Although we have not had significant challenges having physician billing codes covered, preventative services in the current fee-for-service model do not reimburse equally when more time is spent with the patient compared to seeing several patients in the same time period. Currently, the PIM faculty members work in their respective pediatric subspecialties to offset some of the costs of the PIM clinic.
A separate bill center was created to track financial progress and will add insight to this challenge. As newer models of care such as accountable care organizations ACOs are adopted in adult primary care fields [ ], this will hopefully translate to novel prevention models for pediatrics. While children from underserved populations are still able to be seen by PIM providers at our institution, additional services such as acupuncture, biofeedback, psychology, and nutrition may not be as readily covered. Further, these patients may not be able to afford additional supplements and suggested dietary changes.
This continues to pose a significant challenge for our underserved population and deserves significant and sustained advocacy and philanthropy. While the newly developed PIM fellowship currently has institutional and philanthropic support, the sustainability of this training program is uncertain. Given that it is a completely new fellowship program, accreditation by the ACGME is likely years away. Currently, a two-year pilot by the hospital and Pediatrics Department is currently funding the fellow salary, program director effort, and coordinator time; philanthropy is funding the educational programming for the fellow.
Lastly, the concept of an integrative approach is, at times, a difficult philosophical mindset for patients and families. Behavior, lifestyle, and diet changes are frequently more challenging to implement than taking medications. These changes also take time. While evidence on integrative modalities is emerging in pediatrics, colleagues often remain skeptical and have reservations on the value of integrative therapies. The PIM program at Stanford hopes to increase clinical services, education efforts, and research productivity. Clinically, a pilot inpatient integrative medicine consultation service is planned for Spring Discussions are underway to integrate mind—body and acupuncture treatment modalities to perioperative and postoperative treatment protocols.
The program also needs to formally survey patients and families on patient satisfaction of its current programs. On a national level, the faculty aims to collaborate with national organizations such as the American Academy of Pediatrics and other pediatric subspecialty organizations to have a broader reach for educational efforts. Several faculties have participated in discussions about developing an integrative medicine core competency requirement for all pediatric residents.
Additionally, our program leadership advocates for other academic centers to establish pediatric integrative medicine clinical training fellowships. Continued research is needed to establish evidenced-based safety and efficacy data for integrative therapies in pediatrics.
Specific ongoing projects at our center include examining acupuncture for patients undergoing craniotomy, mind—body interventions for pediatric inflammatory bowel disease, and utilizing virtual reality for procedural pain and anxiety. Our program would be open to collaborating with other centers to develop the recently proposed multi-center PIM research network [ ]. Continued growth in these areas will require ongoing institutional support for faculty time, resource allocation, and financial support.
Evidence of safety and efficacy of pediatric integrative treatment modalities within pediatric subspecialties continues to grow. The establishment of a pediatric integrative medicine program within an academic setting is feasible. It requires sufficient institutional support, funding, and adequately trained physician faculty and staff. We acknowledge Leland Lei for assistance with pulling financial details for integrative clinics.
We thank Ellen Gomes for technical editing, language editing, and proofreading. We would also like to thank Sudha K. Conceptualization, A. National Center for Biotechnology Information , U. Journal List Children Basel v. Children Basel. Published online Dec Author information Article notes Copyright and License information Disclaimer. Received Sep 18; Accepted Nov Abstract Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States.
Keywords: pediatric, integrative medicine, academic medicine. Background Integrative medicine IM is a patient-centric, evidence-based, therapeutic paradigm that coordinates the integration of all pertinent conventional and complementary approaches to achieve patient health. Pediatric Integrative Subspecialties in Academia Academic medical centers are often the hub where education, research, and clinical care meet innovation to improve medical care. Asthma and Allergy Pediatric asthma is another area where an integrative approach may provide benefit. Other Subspecialties There is a role for an integrative approach within many subspecialties.
Open in a separate window. Figure 1. Clinical Work The four subspecialty integrative clinics staffed by four IM-trained faculties in the pulmonary, rheumatology, pain medicine, and gastroenterology fields , continue to grow. Research Research for many integrative modalities is lacking, especially for pediatric patients. Massage decreased anxiety scores and lowered exposure to benzodiazepines. Sample Case Presentation Identifying Details Changed for Patient Privacy A year-old girl presented to the outpatient pediatric integrative medicine clinic with chief complaint of abdominal pain for three years which had been diagnosed as abdominal migraines.
Discussion 4. Pediatric Integrative Medicine in Academia Pediatric Integrative Medicine is an emerging subspecialty that provides the foundation for whole-patient and whole-child preventative care and lifestyle medicine [ 44 ]. Challenges and Financial Considerations The program has faced several challenges.
Future Directions The PIM program at Stanford hopes to increase clinical services, education efforts, and research productivity. Conclusions Evidence of safety and efficacy of pediatric integrative treatment modalities within pediatric subspecialties continues to grow. Author Contributions Conceptualization, A. Funding This research received no external funding. Conflicts of Interest The authors declare no conflict of interest.
References 1. Misra S. Kemper K. McClafferty H. Pediatric Integrative Medicine. Black L. Health Stat. Clarke T. Trends in the use of complementary health approaches among adults: United States, — McCann L. Survey of paediatric complementary and alternative medicine use in health and chronic illness. Eisenberg D. Taw M. Integrative medicine, or not integrative medicine: That is the question.
Herman P. Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. BMJ Open. Ali A. Vohra S. Comparative effectiveness of pediatric integrative medicine as an adjunct to usual care for pediatric inpatients of a North American tertiary care centre: A study protocol for a pragmatic cluster controlled trial. Trials Commun. Cooney G. Exercise for Depression. Ornish D. Knowler W. Loef M. The combined effects of healthy lifestyle behaviors on all cause mortality: A systematic review and meta-analysis.
Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncol. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Cancer Investig. Supic G. Patel V.
Penny George Institute for Health and Healing
Nutrition and prostate cancer: An overview. Expert Rev. Anticancer Ther. Riccio P. Nutrition Facts in Multiple Sclerosis. ASN Neuro.
Gustafson D. Kawicka A. How nutritional status, diet and dietary supplements can affect autism.
A review. Eilat-Adar S. Nutritional Recommendations for Cardiovascular Disease Prevention. Rodriguez-Leyva D. Chen T. Cancer Prev. Zeidan F. Jacob J. Cherkin D. Nidich S. Davidson R. Cotton S. Mindfulness-based cognitive therapy for youth with anxiety disorders at risk for bipolar disorder: A pilot trial. Early Interv. Spigelblatt L. The Use of Alternative Medicine by Children. Sawni-Sikand A. Sibinga E. Pappas S. Complementary and alternative medicine: The importance of doctor-patient communication.
Perlman A. Talking with Patients about Alternative and Complementary Medicine.