- Email: [email protected]
Case Study in Integrative Medicine: Mary S.
CASE REPORT
CASE STUDY IN INTEGRATIVE MEDICINE: MARY S. Arya Nielsen, MA, MS, LAc, FNAAOM,1 Roberta Lee, MD,1 Aurora Ocampo, MSN,1 Mary Beth Augustine, RD,1 and Benjamin Kligler, MD, MPH1# INTRODUCTION The following is the third in a series of case studies from the multidisciplinary integrative medicine practice at the Continuum Center for Health and Healing in New York City. This case of a 69-year-old woman with coronary artery disease, originally published in the text Integrative Medicine: Principles for Practice,1 illustrates some of the possibilities inherent in the integrative approach to health and illness. Our hope is that these cases will illustrate how the diverse voices of the various healing arts that comprise the integrative healthcare team can come together in a given case to offer an approach to treatment much more powerful than that which any of the disciplines can provide on their own. Of course, the manner in which these cases were handled by our team represents only one of the many ways in which these patients’ problems could have been effectively treated. Because we view the patient and/or the family as the primary decision maker on the healthcare team, our choices for therapies and approaches in these cases were guided in large measure by the patients’ previous experience, personal preferences, and intuition, as well as by our clinical experience and knowledge of the evidence. Different people presenting with these same sets of problems could very well have been treated in dramatically different ways in each of these scenarios, and still with potential benefit.
CASE STUDY 3: MARY S. M.S. is a 69-year-old woman who initially came to our practice in January 2002. She was six months status post (S/P) coronary artery bypass surgery and came to us looking for help with an integrative approach to promoting cardiovascular health and minimizing her risk of further coronary artery disease progression. Fortunately she had no history of myocardial infarction prior to her surgery; her coronary artery disease was diagnosed during a workup for new-onset angina, and she went to surgery rather than angioplasty because of significant left main coronary artery stenosis. Prior history was significant for a long history of hypertension, intermittently controlled with medications; however, because she had experienced side effects from multiple antihypertensives, there were a number of extended periods over the 15 years since her diagnosis of hypertension during which her blood
1 Department of Integrative Medicine, Beth Israel Medical Center, New York, NY # Corresponding Author. Address: Continuum Center for Health and Healing, 245 Fifth Avenue, 2nd floor, New York, NY 10016 e-mail: [email protected]
380
pressure was not well controlled. She also had a history of hyperlipidemia, for which she was at her initial visit taking Lipitor. Mary had a distant history of smoking, having stopped 10 years prior to her surgery, no history of diabetes, and no significant family history of heart disease. Her other major presenting problem was left hip pain with sciatica, as well as ongoing pain at the site of her cardiac surgery scar. At the time, she was taking Tylenol with codeine intermittently for this pain and recently had been requiring this almost daily; physical therapy (PT) had not been helpful, and she did not tolerate nonsteroidal anti-inflammatory drugs due to gastrointestinal upset. The pain was constant, though typically worse when she was stationary for a long period of time; at times the pain radiated down the posterior left leg. Medical history was otherwise significant for Hashimoto’s thyroiditis, diagnosed 30 years earlier and stable on thyroid replacement medication. M.S. is widowed, with two grown sons and three grandchildren. One son has no children and lives in the New York area; the other is in California. In the previous year, patient had been unable to travel to visit the grandchildren due to her back pain, and she experienced this as a major loss. M.S. is a retired school administrator and enjoys reading. She does have a network of friends, although three of her close friends had been ill over the past year and she had not been able to see them very often. Physical exam was remarkable for blood pressure of 140/80, a systolic murmur, and mild peripheral edema. M.S.’s mood was upbeat, though she did report a fair amount of loneliness in recent months due to her growing disability from her back pain. She also reported an ongoing sadness since the events of 9/11, with occasional bouts of significant anxiety, in which she was particularly focused on the safety of her children and grandchildren. This did not tend to occur prior to 9/11. She also reported feeling more tired than she would like to. Her cardiologist did not feel that this was cardiac in origin, as her ejection fraction and left ventricular function were normal. M.S. is followed by a cardiologist, in whom she has great confidence. Recently, though, he had been urging her to add a fourth antihypertensive medication, and she was reluctant based on her experience of adverse effects from multiple medications in the past. He was aware of her visit to the Continuum Center for Health and Healing and was supportive of her wish to pursue other approaches to blood pressure and lipid control as long as these were done cautiously and he was kept informed. Medications at the time of her initial presentation were Atenolol, Zestril, Dyazide, Lipitor, enteric-coated baby aspirin, Synthroid, and Tylenol with codeine. She takes a multivitamin. She reported that she tried to keep to a “low-fat” diet in general. Labs on initial evaluation were all normal, with total cholesterol 162, LDL 102, HDL 43, thyroid function in normal range, homocysteine 7.2.
© 2008 by Elsevier Inc. Printed in the United States. All Rights Reserved ISSN 1550-8307/08/$34.00
EXPLORE November/December 2008, Vol. 4, No. 6 doi:10.1016/j.explore.2008.09.001
INTEGRATIVE PHYSICIAN PERSPECTIVE, INITIAL EVALUATION: ROBERTA LEE, MD Integrative medicine seeks to understand the whole person, addressing the mind, body, and spirit. In order to explore this perspective with Mary, I began my 90 minute visit by asking her, “What brings you here today?” She replied that in the past six months, she had a significant event happen— coronary bypass surgery—and she was experiencing difficulty with fatigue. This fatigue was especially severe when she went to cardiac rehabilitation. Her coach was encouraging her to push herself physically to improve cardiovascular resilience but she was anxious about pushing too hard. Mary brought all of her medical records from her internist and cardiologist for me to review. She volunteered that she had recently had a “great report” from her cardiologist, and was told that she had normal left ventricular function and ejection fraction, but this knowledge did not seem to comfort her. When I asked her why, she volunteered that prior to her surgery, she had been following her primary care physician’s recommendations for hypertension, hyperlipidemia, and hypothyroidism, but the surgery made her feel like a failure. Furthermore, she felt “isolated and trapped” by her fatigue; she was afraid that every time she had shortness of breath, it represented another anginal episode. She was afraid to travel, she missed her grandchildren, and noted that she felt isolated. She felt like much of her focus these days was attending to all the doctor visits and was especially alarmed at her cardiologist’s suggestion that she add another medication to control her hypertension. With each medication that was added, she felt less in control of her health. When I asked Mary if she had anything that she enjoyed, she remarked upon her inability to concentrate on reading. Her closest friends had been ill, and this added increasing tension within, as she wanted to spend time with them but could not due to her medical conditions. Furthermore, she was not sleeping well. Her primary care physician had offered her a medication to help her sleep through the night (Ambien) but she decided that she would approach this using a more integrative approach. I asked her, based on past experiences, if she could recall how anxiety usually manifested itself. She replied that under pressured circumstances she would sleep more, but that she did not feel rested after sleep. For a number of years when she slept excessively, she would have more aches and pains, with the discomfort usually focused in her lower back. However, with her recent anxiety she would also wake up in the middle of the night. Her first thoughts on these awakenings were always to notice whether she was experiencing any difficulty with chest pressure or palpitations. Mary revealed that once she had seen a TV show explaining progressive relaxation and simple breathing techniques and found it intriguing. She was interested in exploring this. I taught her a simple breathing exercise in the first visit. I asked her to sit comfortably in the chair, focus on her breath, breathing in to a count of four through her nostrils, holding her breath to a count of seven, and exhaling through her mouth to a count of eight with her tongue on the roof of her mouth (this is a breathing technique that I learned from the University of Arizona Program in Integrative Medicine). Her instructions were to practice this breath twice a day—four breaths in the morning and four in the
Case Study in Integrative Medicine
evening. She felt this was too much for her. I asked her if there was something else she found relaxing. She remarked how much she enjoyed walking— but never seemed to have enough time to do this. We decided that rather that implementing the breathing exercises twice a day, she would walk for 20 minutes in the morning, and before retiring she would sit comfortably and practice her breathing exercise before going to sleep. I suggested that the most important aspect of these exercises was really to make them part of a daily routine. I screened for signs of depression, asking about suicidal ideation, but Mary denied any plans for action or feelings of significant despair. We acknowledged that she could be mildly depressed with anxiety present, especially in view of her recent slide downward after 9/11. A recommendation to consider psychological counseling was made during this first visit. We moved on to exploring her diet. She recently had stopped adding salt to her food, but admitted that she did not actually understand the relationship between sodium and hypertension. We explored the need to begin reading labels for sodium. I began to explain the relationship of cholesterol and coronary artery disease to omega-3 fatty acids, trans-fatty acids, and saturated fat. I suggested specific protein sources that represented sources containing less saturated fat (fish, lean chicken, and soy). We discussed the need to have five to seven servings of fruits and vegetables in her daily diet. She expressed a wish to learn more about nutrition, and so I suggested that she might benefit from nutritional consultation. We reviewed her medications, and with the exception of her antihypertension medication she had been on most of her medications for over a year. She did not take any supplements. The statin family of hypolipidemic medications have been reported to deplete CoQ10 stores in the body, so I suggested that she begin by taking 200 mg a day of this supplement. In addition, I also suggested that she take two tablespoons of flaxseed meal a day to increase fiber and omega-3 content. Garlic supplements are mildly hypolipidemic, and I recommended she add this at a dose of 1,000 mg a day (standardized to contain 6-10 mg of alliin or 2-5 mg of allicin). In addition, I suggested that she take a daily multivitamin containing the following vitamins and micronutrients, for their possible role in preventing progression of heart disease: vitamin C (500 mg), vitamin E (mixed tocopherols and tocotrienols, 800 IU), selenium (200 mcg), folic acid (400 mcg), vitamin B12 (500 mcg), vitamin B6 (50 mg), and mixed betacarotenes (25,000 IU). For prevention of osteoporosis, I also recommended adding 1,500 mg of calcium citrate and 400 mg of magnesium gluconate. Mary raised the question of what alternatives were available for treatment of pain if she did not want to take a nonsteroidal anti-inflammatory medication. I suggested either glucosamine sulfate (500 mg three times a day) with chondroitin sulfate (400 mg three times a day) or a combination of turmeric (Curcuma longa), ginger (Zingiber officinale), and boswellia (Boswellia serrata) in a blended product— botanical medicines with anti-inflammatory activity. Mary’s exercise routine to this point had been guided by her cardiac rehabilitation team. I explained that deconditioning can occur with inactivity and encouraged her to continue her rehabilitation. We explored the need to add stretch to her exercise
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regimen; balance is an aspect of physical health that is overlooked. We agreed that yoga even once a week may provide a fun way to bring this dimension to her health. I suggested that physical activities like swimming and pool walking can be incorporated in substitution for the yoga. We agreed to meet in eight weeks. A long-range goal from Mary’s perspective was to eventually reduce her antihypertensive medications. At the close of the visit together, we prioritized which interventions seemed most important and potentially meaningful to her. Anxiety seemed to be a big obstacle, and along with it her inability to relax. I therefore recommended a series of visits with Aurora Ocampo, our clinic mind/body specialist. In addition, as Mary had a desire to learn more about the applications of nutrition to her cardiovascular/hypertensive history, we agreed on a nutritional consult as part of the treatment plan. For pain relief—and a different perspective on her overall health—I also recommended acupuncture. In order to prevent “overmedicalizing” Mary’s treatment, we agreed to reevaluate each of these interventions and the treatment plan as a whole after two months.
MIND-BODY/ENERGY MEDICINE PERSPECTIVE: AURORA OCAMPO, MSN In collaboration with the patient and the physician, I chose to use the following approaches to help manage the hypertension and anxiety of this patient: biofeedback, guided imagery, Reiki, and essential oil therapy. I felt that biofeedback would work particularly well as a relaxation training strategy for this patient. This technique is particularly effective in eliciting the vasodilatation response that can help control blood pressure. She was extremely motivated to make it work. Adding to this motivation was the fact that she had experienced significant side effects from her multiple antihypertensive drugs, and her blood pressure remained uncontrolled. Biofeedback training is virtually the opposite of any drug treatment, as rather than relying on an external input (the medication) to lower blood pressure, it teaches the patient to utilize their internal resources for the same purpose. It allows the patients to remain totally in control—responsible and empowered to work it out for themselves. It is a useful tool that allows them to learn self-regulation. This can be particularly effective in a patient like Mary for whom anxiety is a significant contributor to hypertension. I learned on my first visit with her that her blood pressure control had become much worse after 9/11 due to her increased anxiety. This confirmed my belief that, especially given her high motivation level, biofeedback would be an effective approach. I also used imagery, Reiki, and essential oil therapy to complement biofeedback. My experience with these modalities with other patients has been that these additional techniques can greatly enhance the relaxation-oriented management of anxiety and hypertension. The goal of the treatment that Mary and I agreed to in our first visit was the recognition and minimizing of the stress and anxiety in her everyday life through the learning and home practice of relaxation skills, which can also reduce blood pressure.
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On the first session, the rationale of the treatment, what the feedback equipment does, how it is used, and the immediate temperature training goals were discussed. We also discussed how the mind and the body work together, and how through imagination (imagery) she could easily affect the temperature of the hands. The average person cannot tell the temperature of the hands within four to five degrees; the sensitivity of the temperature feedback machine, however, can detect and feedback to the patient subtle changes in the activity of the sympathetic nervous system as reflected in hand temperature change. This feedback signal can be used to teach the patient how to consciously control a process (vasodilatation) that is normally not controlled by the conscious mind. Because vasodilatation leads to decreased blood pressure, this approach is extremely useful in treatment of hypertension. The peripheral vascular system, which controls surface body temperature, does not have significant parasympathetic innervation. The smooth muscles of the blood vessel walls that control vasoconstriction are almost completely regulated by the level of sympathetic nervous system input. Because of this fact, blood flow in the hands and other peripheral areas is easily affected by stress. This makes hand temperature a particularly effective feedback measure as it responds so readily to changes in stress level. In the first biofeedback training session, the thermistor was attached to the index finger of the dominant hand, and I then gave instruction on breathing technique and a 15-minute autogenic session with heaviness, warmth, and inner quietness phrases. The initial hand temp (79°F) was recorded, and then the temperature was again recorded at the beginning of each phrase. At the end of the autogenic session, the patient shared the thoughts and emotions felt during the session. At the conclusion of the first session, the temp unit was turned toward the patient, and we reviewed the current temperature and the recorded temperatures during the session in the context of her inner experience of relaxation. Her hand temp ranged from 93°F to 96.1°F. Blood pressure went down to 140/70 from 160/88 at the start of the session. This was a very successful first experience, and I encouraged Mary to go forward with her home practice as instructed and to return to me in a week to continue with the training. She was instructed to use the “script” of autogenic phrases that were used during her session with me as part of the home practice. In the second session, review of the home practice experience revealed that Mary was practicing the techniques throughout the day as instructed. Her blood pressure following this second session was down to 130/70; the hand temperature during this session was maintained between 90°F to 95°F. Reiki and essential oil therapy were also used during this session to further enhance the treatment. These techniques often allow the patient to achieve an even deeper state of relaxation during the session. After two weeks of home training, the patient was instructed to discontinue the use of the autogenic phrases (script) and to replace them with her own personal visualization relating to the temperature control. She chose the image of lying on a sunny, warm beach. The transition from scripted phrases to a more personal image allows the patient to realize that the use of set phrases or listening to a recorded tape is not necessary to initiate a desirable physiological behavior. I strongly recommended to
Case Study in Integrative Medicine
Mary that regular home practice with relaxation, warmth, and breathing exercises be done until the newly developing skill at handling stress “become a way of life.” This can often take several months. On the third and final session several weeks later, the patient determined that she had the self-mastery of the techniques that she needed to continue to apply this approach to her everyday stressful life. Mary shared with me descriptions of several incidents of acute stressful situations and how she was able to cope with these by using her practice of breathing, imagery, and hand warming. I encouraged her to continue her practice and to come back as needed for refresher sessions.
EAST ASIAN MEDICINE PERSPECTIVE: ARYA NIELSEN, LAC Mary and I decided it was best for us to focus on several unresolved problem areas that were significant to her but not addressed by her cardiologist beyond ruling out disease. These problems were the pain in her chest from the surgery itself, the scar that had healed with a disturbing keloid that pulled and was sore, her general anxiety, and her hip pain. Her hip pain and sciatica were preventing her from participating fully in cardiac rehab. The anxiety she identified was both in relation to the 9/11 disaster that she witnessed, as well as to her surgery. She was still in the process of learning how to interpret sensation in her changed body. Because Mary was already taking a few medications and a number of supplements prescribed by Dr Lee, I opted to forego herbs—although there are options in the East Asian pharmacopeia specific to cardiac and hypertensive cases. We relied on acupuncture and Gua Sha to resolve the sciatica right away so she could comfortably begin exercising. Mary experienced anxiety reduction during acupuncture treatment for her heart and chest, and this worked synergistically with the skills she was learning with Aurora to reduce anxiety on her own. After the first two months of weekly treatments, her chest pain resolved completely, and she could exercise without dyspnea. As her condition improved, she began to question the need for some of her medications, feeling her blood pressure was too low. She addressed those questions to her cardiologist, who then adjusted her medication. Each time I treated Mary, I also used acupuncture to reduce the keloid scar. Our first sessions eliminated the pulling pain she suffered, breaking the adhesion of the scar tissue from deeper fascia so the skin at her chest could move. Over time, the keloid cord has become softer and smaller in width and height. The East Asian medicine perspective is that even a necessary corrective surgery still represents a trauma with all the attending forms of stasis and altering of channel pathways. The very definition of pain in East Asian medicine is that something is “stuck.” Acupuncture and Gua Sha in this case were used together to resolve the blood stasis that had resulted from her surgery and to restore proper channel function. Blood stasis at the chest is felt as oppression and heaviness. In this sense, anxiety is not considered a mind state alone. Removing the blood stasis clears the sensation of chest oppression, resolving anxiety associated with it.
Case Study in Integrative Medicine
Mary is now doing very well in cardiac rehab and is able to push herself physically; this has also greatly improved her stamina and health status while also enabling her to lose some weight. She sustained a slight shoulder injury that is common with people returning to exercise programs, and this was also easily treated.
NUTRITIONAL MEDICINE: MARY BETH AUGUSTINE, RD My primary goal on my initial visit with this patient was to develop a nutritional plan that would help her with her hypertension. I have used the Dietary Approaches to Stop Hypertension (DASH) diet extensively in this setting and fund it extremely effective in the motivated patient. I was very impressed with Mary’s motivation level and felt she was ready to make some significant changes in her diet. Her body mass index was 34 on this initial visit, which concerned me given her history of coronary disease, but I opted not to focus on weight control in our visit as I felt this was not her top priority at that time. I have also found that in certain patients, the DASH diet leads naturally to weight loss without a need to identify weight control as a specific goal. After taking the initial diet history, I made the following initial recommendations for Mary: ●
● ● ● ● ● ●
fruit at breakfast every day, at least one piece; minimize fruit juices and concentrate on whole fruits instead to help with fiber intake 1 cup of cooked or raw vegetables at both lunch and dinner every day 1 leafy green salad daily 1 yellow-orange-red colored fruit or vegetable daily 1 citrus fruit daily cruciferous vegetables every other day 1 oz nuts every other day
In addition, I recommended she eat fish at least once weekly, and ideally as often as four times per week; fish intake and omega-3 essential fatty acid intake have been shown to be effective in reducing risk of adverse cardiac events. Sardines, canned tuna, herring, and anchovies are all good options as they do not contain high levels of mercury. I also recommended a specific dish—Tuscany tuna salad, which contains tuna, white beans, olive oil, olives, vinegar, walnuts, and canned tuna. The Mediterranean diet, in which many of these ingredients play a major part, has also been shown to lower cardiac risk. Garlic and onions are also important components in this diet, and I recommended liberal consumption of these for Mary. We also discussed the possible use of hawthorn berry extract and of herbal teas and/or supplements for lipid-lowering effects, but we chose to focus on the dietary measures outlined above for this first visit and held these herbal options in reserve for possible use in the future. We also discussed weight management as a goal for future visits, as Mary’s body mass index did put her in a high-risk category for cardiovascular disease. On our follow-up visit six weeks later, I was please to find that Mary was doing quite well with the DASH diet, and that her
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blood pressure control appeared to be improving. At this point she and I decided to add weight loss as a second goal in hopes of increasing the impact of her diet on her hypertension. I also made a set of additional recommendations aimed at enhancing cardiovascular health. Our plan at this second visit was as follows: ● ●
● ●
●
●
continue DASH diet decrease/limit wheat intake; Mary reported a heavy emphasis on wheat-containing foods in her diet and moving towards a more low-glycemic index/higher protein diet seemed the best approach to weight control in this case, so I suggested substituting lentil pastas for wheat pastas, taking more brown rice as a carbohydrate source in moderate amounts, and trying other grains such as quinoa and spelt decreasing simple sugars overall, especially sorbet, which she was eating almost daily at this point increasing emphasis on allium family vegetables, including leeks, shallots, onions, and garlic to take advantage of their potential lipid-lowering effects increase red-purple-blue fruits and vegetables, including cabbage, radishes, eggplant, grapes, and berries as sources of cardioprotective flavonoids one cup daily of a “cardioprotective” tea containing hawthorn, green tea, raspberry leaf, blueberry, and elderberry, again as a good source of flavonoids
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INTEGRATIVE PHYSICIAN FOLLOW-UP: ROBERTA LEE, MD M.S. was seen eight weeks later for follow-up. She reported that she was sleeping more soundly—especially after she initiated a daily relaxation exercise and breathing exercises that Aurora and I had taught her. Furthermore, she continued her cardiac rehabilitation and now reported improved exercise tolerance. She felt “less” scared. She now had somewhat improved blood pressure readings—mostly because her anxiety was reduced—but she still clearly had hypertension. At this visit, Mary spoke of her need to look at this more in depth and now had made a commitment to undergo cognitive therapy. Because one of her major initial goals was to reduce her medication intake—and because she had shown significant improvement in her blood pressure control—we decided to eliminate one of her hypertensive medications. This was done with the caveat that she report daily blood pressure readings on a weekly basis. Parameters for unacceptably high readings were set in case she rebounded, at which point she would resume the removed medication and notify me of the change. We agreed on regular follow-up visits at intervals of six to eight weeks. Mary has continued to do well on this combination of therapeutic approaches and we anticipate being able to further reduce her antihypertensive medication.
REFERENCE 1. Kligler B, Lee R, eds. Integrative Medicine: Principles for Practice. New York, NY: McGraw-Hill; 2004.
Case Study in Integrative Medicine
CASE STUDY IN INTEGRATIVE MEDICINE: MARY S. Arya Nielsen, MA, MS, LAc, FNAAOM,1 Roberta Lee, MD,1 Aurora Ocampo, MSN,1 Mary Beth Augustine, RD,1 and Benjamin Kligler, MD, MPH1# INTRODUCTION The following is the third in a series of case studies from the multidisciplinary integrative medicine practice at the Continuum Center for Health and Healing in New York City. This case of a 69-year-old woman with coronary artery disease, originally published in the text Integrative Medicine: Principles for Practice,1 illustrates some of the possibilities inherent in the integrative approach to health and illness. Our hope is that these cases will illustrate how the diverse voices of the various healing arts that comprise the integrative healthcare team can come together in a given case to offer an approach to treatment much more powerful than that which any of the disciplines can provide on their own. Of course, the manner in which these cases were handled by our team represents only one of the many ways in which these patients’ problems could have been effectively treated. Because we view the patient and/or the family as the primary decision maker on the healthcare team, our choices for therapies and approaches in these cases were guided in large measure by the patients’ previous experience, personal preferences, and intuition, as well as by our clinical experience and knowledge of the evidence. Different people presenting with these same sets of problems could very well have been treated in dramatically different ways in each of these scenarios, and still with potential benefit.
CASE STUDY 3: MARY S. M.S. is a 69-year-old woman who initially came to our practice in January 2002. She was six months status post (S/P) coronary artery bypass surgery and came to us looking for help with an integrative approach to promoting cardiovascular health and minimizing her risk of further coronary artery disease progression. Fortunately she had no history of myocardial infarction prior to her surgery; her coronary artery disease was diagnosed during a workup for new-onset angina, and she went to surgery rather than angioplasty because of significant left main coronary artery stenosis. Prior history was significant for a long history of hypertension, intermittently controlled with medications; however, because she had experienced side effects from multiple antihypertensives, there were a number of extended periods over the 15 years since her diagnosis of hypertension during which her blood
1 Department of Integrative Medicine, Beth Israel Medical Center, New York, NY # Corresponding Author. Address: Continuum Center for Health and Healing, 245 Fifth Avenue, 2nd floor, New York, NY 10016 e-mail: [email protected]
380
pressure was not well controlled. She also had a history of hyperlipidemia, for which she was at her initial visit taking Lipitor. Mary had a distant history of smoking, having stopped 10 years prior to her surgery, no history of diabetes, and no significant family history of heart disease. Her other major presenting problem was left hip pain with sciatica, as well as ongoing pain at the site of her cardiac surgery scar. At the time, she was taking Tylenol with codeine intermittently for this pain and recently had been requiring this almost daily; physical therapy (PT) had not been helpful, and she did not tolerate nonsteroidal anti-inflammatory drugs due to gastrointestinal upset. The pain was constant, though typically worse when she was stationary for a long period of time; at times the pain radiated down the posterior left leg. Medical history was otherwise significant for Hashimoto’s thyroiditis, diagnosed 30 years earlier and stable on thyroid replacement medication. M.S. is widowed, with two grown sons and three grandchildren. One son has no children and lives in the New York area; the other is in California. In the previous year, patient had been unable to travel to visit the grandchildren due to her back pain, and she experienced this as a major loss. M.S. is a retired school administrator and enjoys reading. She does have a network of friends, although three of her close friends had been ill over the past year and she had not been able to see them very often. Physical exam was remarkable for blood pressure of 140/80, a systolic murmur, and mild peripheral edema. M.S.’s mood was upbeat, though she did report a fair amount of loneliness in recent months due to her growing disability from her back pain. She also reported an ongoing sadness since the events of 9/11, with occasional bouts of significant anxiety, in which she was particularly focused on the safety of her children and grandchildren. This did not tend to occur prior to 9/11. She also reported feeling more tired than she would like to. Her cardiologist did not feel that this was cardiac in origin, as her ejection fraction and left ventricular function were normal. M.S. is followed by a cardiologist, in whom she has great confidence. Recently, though, he had been urging her to add a fourth antihypertensive medication, and she was reluctant based on her experience of adverse effects from multiple medications in the past. He was aware of her visit to the Continuum Center for Health and Healing and was supportive of her wish to pursue other approaches to blood pressure and lipid control as long as these were done cautiously and he was kept informed. Medications at the time of her initial presentation were Atenolol, Zestril, Dyazide, Lipitor, enteric-coated baby aspirin, Synthroid, and Tylenol with codeine. She takes a multivitamin. She reported that she tried to keep to a “low-fat” diet in general. Labs on initial evaluation were all normal, with total cholesterol 162, LDL 102, HDL 43, thyroid function in normal range, homocysteine 7.2.
© 2008 by Elsevier Inc. Printed in the United States. All Rights Reserved ISSN 1550-8307/08/$34.00
EXPLORE November/December 2008, Vol. 4, No. 6 doi:10.1016/j.explore.2008.09.001
INTEGRATIVE PHYSICIAN PERSPECTIVE, INITIAL EVALUATION: ROBERTA LEE, MD Integrative medicine seeks to understand the whole person, addressing the mind, body, and spirit. In order to explore this perspective with Mary, I began my 90 minute visit by asking her, “What brings you here today?” She replied that in the past six months, she had a significant event happen— coronary bypass surgery—and she was experiencing difficulty with fatigue. This fatigue was especially severe when she went to cardiac rehabilitation. Her coach was encouraging her to push herself physically to improve cardiovascular resilience but she was anxious about pushing too hard. Mary brought all of her medical records from her internist and cardiologist for me to review. She volunteered that she had recently had a “great report” from her cardiologist, and was told that she had normal left ventricular function and ejection fraction, but this knowledge did not seem to comfort her. When I asked her why, she volunteered that prior to her surgery, she had been following her primary care physician’s recommendations for hypertension, hyperlipidemia, and hypothyroidism, but the surgery made her feel like a failure. Furthermore, she felt “isolated and trapped” by her fatigue; she was afraid that every time she had shortness of breath, it represented another anginal episode. She was afraid to travel, she missed her grandchildren, and noted that she felt isolated. She felt like much of her focus these days was attending to all the doctor visits and was especially alarmed at her cardiologist’s suggestion that she add another medication to control her hypertension. With each medication that was added, she felt less in control of her health. When I asked Mary if she had anything that she enjoyed, she remarked upon her inability to concentrate on reading. Her closest friends had been ill, and this added increasing tension within, as she wanted to spend time with them but could not due to her medical conditions. Furthermore, she was not sleeping well. Her primary care physician had offered her a medication to help her sleep through the night (Ambien) but she decided that she would approach this using a more integrative approach. I asked her, based on past experiences, if she could recall how anxiety usually manifested itself. She replied that under pressured circumstances she would sleep more, but that she did not feel rested after sleep. For a number of years when she slept excessively, she would have more aches and pains, with the discomfort usually focused in her lower back. However, with her recent anxiety she would also wake up in the middle of the night. Her first thoughts on these awakenings were always to notice whether she was experiencing any difficulty with chest pressure or palpitations. Mary revealed that once she had seen a TV show explaining progressive relaxation and simple breathing techniques and found it intriguing. She was interested in exploring this. I taught her a simple breathing exercise in the first visit. I asked her to sit comfortably in the chair, focus on her breath, breathing in to a count of four through her nostrils, holding her breath to a count of seven, and exhaling through her mouth to a count of eight with her tongue on the roof of her mouth (this is a breathing technique that I learned from the University of Arizona Program in Integrative Medicine). Her instructions were to practice this breath twice a day—four breaths in the morning and four in the
Case Study in Integrative Medicine
evening. She felt this was too much for her. I asked her if there was something else she found relaxing. She remarked how much she enjoyed walking— but never seemed to have enough time to do this. We decided that rather that implementing the breathing exercises twice a day, she would walk for 20 minutes in the morning, and before retiring she would sit comfortably and practice her breathing exercise before going to sleep. I suggested that the most important aspect of these exercises was really to make them part of a daily routine. I screened for signs of depression, asking about suicidal ideation, but Mary denied any plans for action or feelings of significant despair. We acknowledged that she could be mildly depressed with anxiety present, especially in view of her recent slide downward after 9/11. A recommendation to consider psychological counseling was made during this first visit. We moved on to exploring her diet. She recently had stopped adding salt to her food, but admitted that she did not actually understand the relationship between sodium and hypertension. We explored the need to begin reading labels for sodium. I began to explain the relationship of cholesterol and coronary artery disease to omega-3 fatty acids, trans-fatty acids, and saturated fat. I suggested specific protein sources that represented sources containing less saturated fat (fish, lean chicken, and soy). We discussed the need to have five to seven servings of fruits and vegetables in her daily diet. She expressed a wish to learn more about nutrition, and so I suggested that she might benefit from nutritional consultation. We reviewed her medications, and with the exception of her antihypertension medication she had been on most of her medications for over a year. She did not take any supplements. The statin family of hypolipidemic medications have been reported to deplete CoQ10 stores in the body, so I suggested that she begin by taking 200 mg a day of this supplement. In addition, I also suggested that she take two tablespoons of flaxseed meal a day to increase fiber and omega-3 content. Garlic supplements are mildly hypolipidemic, and I recommended she add this at a dose of 1,000 mg a day (standardized to contain 6-10 mg of alliin or 2-5 mg of allicin). In addition, I suggested that she take a daily multivitamin containing the following vitamins and micronutrients, for their possible role in preventing progression of heart disease: vitamin C (500 mg), vitamin E (mixed tocopherols and tocotrienols, 800 IU), selenium (200 mcg), folic acid (400 mcg), vitamin B12 (500 mcg), vitamin B6 (50 mg), and mixed betacarotenes (25,000 IU). For prevention of osteoporosis, I also recommended adding 1,500 mg of calcium citrate and 400 mg of magnesium gluconate. Mary raised the question of what alternatives were available for treatment of pain if she did not want to take a nonsteroidal anti-inflammatory medication. I suggested either glucosamine sulfate (500 mg three times a day) with chondroitin sulfate (400 mg three times a day) or a combination of turmeric (Curcuma longa), ginger (Zingiber officinale), and boswellia (Boswellia serrata) in a blended product— botanical medicines with anti-inflammatory activity. Mary’s exercise routine to this point had been guided by her cardiac rehabilitation team. I explained that deconditioning can occur with inactivity and encouraged her to continue her rehabilitation. We explored the need to add stretch to her exercise
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regimen; balance is an aspect of physical health that is overlooked. We agreed that yoga even once a week may provide a fun way to bring this dimension to her health. I suggested that physical activities like swimming and pool walking can be incorporated in substitution for the yoga. We agreed to meet in eight weeks. A long-range goal from Mary’s perspective was to eventually reduce her antihypertensive medications. At the close of the visit together, we prioritized which interventions seemed most important and potentially meaningful to her. Anxiety seemed to be a big obstacle, and along with it her inability to relax. I therefore recommended a series of visits with Aurora Ocampo, our clinic mind/body specialist. In addition, as Mary had a desire to learn more about the applications of nutrition to her cardiovascular/hypertensive history, we agreed on a nutritional consult as part of the treatment plan. For pain relief—and a different perspective on her overall health—I also recommended acupuncture. In order to prevent “overmedicalizing” Mary’s treatment, we agreed to reevaluate each of these interventions and the treatment plan as a whole after two months.
MIND-BODY/ENERGY MEDICINE PERSPECTIVE: AURORA OCAMPO, MSN In collaboration with the patient and the physician, I chose to use the following approaches to help manage the hypertension and anxiety of this patient: biofeedback, guided imagery, Reiki, and essential oil therapy. I felt that biofeedback would work particularly well as a relaxation training strategy for this patient. This technique is particularly effective in eliciting the vasodilatation response that can help control blood pressure. She was extremely motivated to make it work. Adding to this motivation was the fact that she had experienced significant side effects from her multiple antihypertensive drugs, and her blood pressure remained uncontrolled. Biofeedback training is virtually the opposite of any drug treatment, as rather than relying on an external input (the medication) to lower blood pressure, it teaches the patient to utilize their internal resources for the same purpose. It allows the patients to remain totally in control—responsible and empowered to work it out for themselves. It is a useful tool that allows them to learn self-regulation. This can be particularly effective in a patient like Mary for whom anxiety is a significant contributor to hypertension. I learned on my first visit with her that her blood pressure control had become much worse after 9/11 due to her increased anxiety. This confirmed my belief that, especially given her high motivation level, biofeedback would be an effective approach. I also used imagery, Reiki, and essential oil therapy to complement biofeedback. My experience with these modalities with other patients has been that these additional techniques can greatly enhance the relaxation-oriented management of anxiety and hypertension. The goal of the treatment that Mary and I agreed to in our first visit was the recognition and minimizing of the stress and anxiety in her everyday life through the learning and home practice of relaxation skills, which can also reduce blood pressure.
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On the first session, the rationale of the treatment, what the feedback equipment does, how it is used, and the immediate temperature training goals were discussed. We also discussed how the mind and the body work together, and how through imagination (imagery) she could easily affect the temperature of the hands. The average person cannot tell the temperature of the hands within four to five degrees; the sensitivity of the temperature feedback machine, however, can detect and feedback to the patient subtle changes in the activity of the sympathetic nervous system as reflected in hand temperature change. This feedback signal can be used to teach the patient how to consciously control a process (vasodilatation) that is normally not controlled by the conscious mind. Because vasodilatation leads to decreased blood pressure, this approach is extremely useful in treatment of hypertension. The peripheral vascular system, which controls surface body temperature, does not have significant parasympathetic innervation. The smooth muscles of the blood vessel walls that control vasoconstriction are almost completely regulated by the level of sympathetic nervous system input. Because of this fact, blood flow in the hands and other peripheral areas is easily affected by stress. This makes hand temperature a particularly effective feedback measure as it responds so readily to changes in stress level. In the first biofeedback training session, the thermistor was attached to the index finger of the dominant hand, and I then gave instruction on breathing technique and a 15-minute autogenic session with heaviness, warmth, and inner quietness phrases. The initial hand temp (79°F) was recorded, and then the temperature was again recorded at the beginning of each phrase. At the end of the autogenic session, the patient shared the thoughts and emotions felt during the session. At the conclusion of the first session, the temp unit was turned toward the patient, and we reviewed the current temperature and the recorded temperatures during the session in the context of her inner experience of relaxation. Her hand temp ranged from 93°F to 96.1°F. Blood pressure went down to 140/70 from 160/88 at the start of the session. This was a very successful first experience, and I encouraged Mary to go forward with her home practice as instructed and to return to me in a week to continue with the training. She was instructed to use the “script” of autogenic phrases that were used during her session with me as part of the home practice. In the second session, review of the home practice experience revealed that Mary was practicing the techniques throughout the day as instructed. Her blood pressure following this second session was down to 130/70; the hand temperature during this session was maintained between 90°F to 95°F. Reiki and essential oil therapy were also used during this session to further enhance the treatment. These techniques often allow the patient to achieve an even deeper state of relaxation during the session. After two weeks of home training, the patient was instructed to discontinue the use of the autogenic phrases (script) and to replace them with her own personal visualization relating to the temperature control. She chose the image of lying on a sunny, warm beach. The transition from scripted phrases to a more personal image allows the patient to realize that the use of set phrases or listening to a recorded tape is not necessary to initiate a desirable physiological behavior. I strongly recommended to
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Mary that regular home practice with relaxation, warmth, and breathing exercises be done until the newly developing skill at handling stress “become a way of life.” This can often take several months. On the third and final session several weeks later, the patient determined that she had the self-mastery of the techniques that she needed to continue to apply this approach to her everyday stressful life. Mary shared with me descriptions of several incidents of acute stressful situations and how she was able to cope with these by using her practice of breathing, imagery, and hand warming. I encouraged her to continue her practice and to come back as needed for refresher sessions.
EAST ASIAN MEDICINE PERSPECTIVE: ARYA NIELSEN, LAC Mary and I decided it was best for us to focus on several unresolved problem areas that were significant to her but not addressed by her cardiologist beyond ruling out disease. These problems were the pain in her chest from the surgery itself, the scar that had healed with a disturbing keloid that pulled and was sore, her general anxiety, and her hip pain. Her hip pain and sciatica were preventing her from participating fully in cardiac rehab. The anxiety she identified was both in relation to the 9/11 disaster that she witnessed, as well as to her surgery. She was still in the process of learning how to interpret sensation in her changed body. Because Mary was already taking a few medications and a number of supplements prescribed by Dr Lee, I opted to forego herbs—although there are options in the East Asian pharmacopeia specific to cardiac and hypertensive cases. We relied on acupuncture and Gua Sha to resolve the sciatica right away so she could comfortably begin exercising. Mary experienced anxiety reduction during acupuncture treatment for her heart and chest, and this worked synergistically with the skills she was learning with Aurora to reduce anxiety on her own. After the first two months of weekly treatments, her chest pain resolved completely, and she could exercise without dyspnea. As her condition improved, she began to question the need for some of her medications, feeling her blood pressure was too low. She addressed those questions to her cardiologist, who then adjusted her medication. Each time I treated Mary, I also used acupuncture to reduce the keloid scar. Our first sessions eliminated the pulling pain she suffered, breaking the adhesion of the scar tissue from deeper fascia so the skin at her chest could move. Over time, the keloid cord has become softer and smaller in width and height. The East Asian medicine perspective is that even a necessary corrective surgery still represents a trauma with all the attending forms of stasis and altering of channel pathways. The very definition of pain in East Asian medicine is that something is “stuck.” Acupuncture and Gua Sha in this case were used together to resolve the blood stasis that had resulted from her surgery and to restore proper channel function. Blood stasis at the chest is felt as oppression and heaviness. In this sense, anxiety is not considered a mind state alone. Removing the blood stasis clears the sensation of chest oppression, resolving anxiety associated with it.
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Mary is now doing very well in cardiac rehab and is able to push herself physically; this has also greatly improved her stamina and health status while also enabling her to lose some weight. She sustained a slight shoulder injury that is common with people returning to exercise programs, and this was also easily treated.
NUTRITIONAL MEDICINE: MARY BETH AUGUSTINE, RD My primary goal on my initial visit with this patient was to develop a nutritional plan that would help her with her hypertension. I have used the Dietary Approaches to Stop Hypertension (DASH) diet extensively in this setting and fund it extremely effective in the motivated patient. I was very impressed with Mary’s motivation level and felt she was ready to make some significant changes in her diet. Her body mass index was 34 on this initial visit, which concerned me given her history of coronary disease, but I opted not to focus on weight control in our visit as I felt this was not her top priority at that time. I have also found that in certain patients, the DASH diet leads naturally to weight loss without a need to identify weight control as a specific goal. After taking the initial diet history, I made the following initial recommendations for Mary: ●
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fruit at breakfast every day, at least one piece; minimize fruit juices and concentrate on whole fruits instead to help with fiber intake 1 cup of cooked or raw vegetables at both lunch and dinner every day 1 leafy green salad daily 1 yellow-orange-red colored fruit or vegetable daily 1 citrus fruit daily cruciferous vegetables every other day 1 oz nuts every other day
In addition, I recommended she eat fish at least once weekly, and ideally as often as four times per week; fish intake and omega-3 essential fatty acid intake have been shown to be effective in reducing risk of adverse cardiac events. Sardines, canned tuna, herring, and anchovies are all good options as they do not contain high levels of mercury. I also recommended a specific dish—Tuscany tuna salad, which contains tuna, white beans, olive oil, olives, vinegar, walnuts, and canned tuna. The Mediterranean diet, in which many of these ingredients play a major part, has also been shown to lower cardiac risk. Garlic and onions are also important components in this diet, and I recommended liberal consumption of these for Mary. We also discussed the possible use of hawthorn berry extract and of herbal teas and/or supplements for lipid-lowering effects, but we chose to focus on the dietary measures outlined above for this first visit and held these herbal options in reserve for possible use in the future. We also discussed weight management as a goal for future visits, as Mary’s body mass index did put her in a high-risk category for cardiovascular disease. On our follow-up visit six weeks later, I was please to find that Mary was doing quite well with the DASH diet, and that her
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blood pressure control appeared to be improving. At this point she and I decided to add weight loss as a second goal in hopes of increasing the impact of her diet on her hypertension. I also made a set of additional recommendations aimed at enhancing cardiovascular health. Our plan at this second visit was as follows: ● ●
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continue DASH diet decrease/limit wheat intake; Mary reported a heavy emphasis on wheat-containing foods in her diet and moving towards a more low-glycemic index/higher protein diet seemed the best approach to weight control in this case, so I suggested substituting lentil pastas for wheat pastas, taking more brown rice as a carbohydrate source in moderate amounts, and trying other grains such as quinoa and spelt decreasing simple sugars overall, especially sorbet, which she was eating almost daily at this point increasing emphasis on allium family vegetables, including leeks, shallots, onions, and garlic to take advantage of their potential lipid-lowering effects increase red-purple-blue fruits and vegetables, including cabbage, radishes, eggplant, grapes, and berries as sources of cardioprotective flavonoids one cup daily of a “cardioprotective” tea containing hawthorn, green tea, raspberry leaf, blueberry, and elderberry, again as a good source of flavonoids
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INTEGRATIVE PHYSICIAN FOLLOW-UP: ROBERTA LEE, MD M.S. was seen eight weeks later for follow-up. She reported that she was sleeping more soundly—especially after she initiated a daily relaxation exercise and breathing exercises that Aurora and I had taught her. Furthermore, she continued her cardiac rehabilitation and now reported improved exercise tolerance. She felt “less” scared. She now had somewhat improved blood pressure readings—mostly because her anxiety was reduced—but she still clearly had hypertension. At this visit, Mary spoke of her need to look at this more in depth and now had made a commitment to undergo cognitive therapy. Because one of her major initial goals was to reduce her medication intake—and because she had shown significant improvement in her blood pressure control—we decided to eliminate one of her hypertensive medications. This was done with the caveat that she report daily blood pressure readings on a weekly basis. Parameters for unacceptably high readings were set in case she rebounded, at which point she would resume the removed medication and notify me of the change. We agreed on regular follow-up visits at intervals of six to eight weeks. Mary has continued to do well on this combination of therapeutic approaches and we anticipate being able to further reduce her antihypertensive medication.
REFERENCE 1. Kligler B, Lee R, eds. Integrative Medicine: Principles for Practice. New York, NY: McGraw-Hill; 2004.
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