medicina natural

#The Need for Incorporating #Emotional Intelligence and #Mindfulness Training in #Modern Medical Education

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Hakeem J Shakir; Chelsea L Recor; Daniel W Sheehan; Renée M Reynolds

Although the study of medicine and the tradition of medical students gaining clinical experience on hospital wards have not significantly changed over the years, the experience of physicians practicing in the current climate has changed dramatically. Physicians are confronted with increasing regulations aimed at improving quality of care and are often overwhelmed by their position in a tug-of-war between administrators, staff, colleagues and most importantly, patients. With more than half of the US physicians experiencing professional burnout, questions arise regarding their mental health and work-life balance. Blendon et al[1] reported an overall decline in the public’s confidence and trust in physicians, which may be explained by cultural changes as well as displeasure with medical leaders’ responses to healthcare needs. As the next generation of physicians emerges in this evolving healthcare environment, adaptation to new practices and regulations will be imperative. Emotional intelligence (EI) and mindfulness provide a possible solution to the struggles physicians will invariably face.

The term EI, which refers to a person’s ability to recognise, discriminate and label their own emotions and those of others, was coined by Salovey and Mayer and popularised by Goleman.[2,3] Mindfulness is the process by which an individual actively observes his or her thoughts and feelings without judgement.[4] With foundations in Eastern meditation, mindfulness is now an accepted method of stress reduction in Western culture.[4]

The practice and employment of synergistic EI and mindfulness is grossly lacking from medical school curricula, postgraduate training and continuing medical education (CME) programmes. The systemic deficiency of both EI and mindfulness in healthcare has become more apparent as studies have demonstrated high burnout rates,[5] increasing public mistrust in physicians[1] and disheartening data indicating that 300–400 physicians commit suicide each year; a surprising figure that equals approximately one physician per day.[6]

Identifying a patient’s primary emotion and conveying empathy in the staged, standardised patient settings found commonly in medical education are helpful but not entirely accurate tests of one’s EI and are insufficient for the modern physician. EI and mindfulness are tested most aptly during the trainwreck situations that are not uncommon in healthcare settings. These are the moments in which the patient is acutely deteriorating, the nurses and staff are overworked and unhappy and the patient’s frightened family members are gathered around the room. Here, the physician is required to both identify and adapt to the intense emotions of all parties involved and respond to these emotions in an appropriate manner. However, some may argue in favour of managing the task or crisis at hand rather than the people involved in the particular event. Effective physicians, like effective politicians, businessmen and academics, who subscribe to the notion of separating people from tasks, could perhaps be more effective if they routinely incorporate EI into problem solving. Moreover, focus should be shifted to training physicians to understand their own personalities. Personalities certainly vary among physicians, but physicians with insight into their own EI may cater their interactions to patients by acknowledging their own pre-existing personality traits. Therefore, different personality types may be able to navigate similar situations in disparate but successful fashions. A physician with EI and mindfulness training will be able to do this successfully while still acknowledging their own emotional reactions to this difficult situation.

Physician performance is influenced by interactions with the system as a whole. Therefore, medical schools, residency programmes and CME programmes should enhance existing curricula with EI courses and mindfulness training. EI combined with mindfulness must be taught from the beginning of medical school in anticipation of the realities that students will undoubtedly face as they advance to clinical years. Junior medical students are generally required to take a course that prepares them for scenarios that they may encounter in their upcoming clinical rotations and clinical medicine. As described earlier, this course usually employs actors portraying standardised patients with an illness and often an underlying emotional issue that must also be addressed. Theoretically, the concept is quite practical; however, it does not adequately prepare the student for enough aspects of clinical reality. The reality sometimes unbeknownst to new doctors can be found in, for example, the situation a new resident faces while delivering bad news to a real patient. A hysterical family member in the background or a dispute among family members about treatment options may be unaccounted for in medical school scenarios. Unlike the staged situation where predictability prevails, newly graduated doctors are often thrust into emotionally laden, high stakes interactions with patients and family members, nurses, staff and sometimes colleagues. Early immersion through shadowing and mentorship programmes could better prepare students for what lies ahead in the real clinical environment.

With the proper training, medical students could learn how to effectively deal with these challenges in an emotionally intelligent manner. Dobkin and Hutchinson[7] suggested that mindfulness training was useful for medical and dental students; however, there were many unanswered questions with respect to the timing of training in the trajectory of the physician’s career. Residency training programmes have undoubtedly changed in recent times with Accreditation Council for Graduate Medical Education regulations on work hours and an increased focus on resident health. Nevertheless, more specific strategies are required to promote mental health.

The current climate in medicine, rife with regulation and litigation, encourages physicians to behave less as healers and more as salesmen with the patients as their customers and administrators assuming the roles of bosses. Medical students and residents, immersed in the process of learning how to doctor, are sometimes naïve and unaware of the post-training responsibilities required in real-world practice. In addition to taking care of patients, physicians are required to run their practices, paying attention to billing and collections, management of staff and maintaining licensures. Although physicians contend with these responsibilities and duties mandated by the system, EI and mindfulness continue to be underemphasised.

In following the unwritten rule that the customer is always right, physicians are begrudgingly thrust into a vulnerable role. Furthermore, modern physicians in the USA find themselves pressured to comply with policies that have no evidence base as hospitals maintain accreditations or Press-Ganey scores at any cost. Simultaneously, physicians must interact with potentially unhappy colleagues, dissatisfied staff and patients who may feel they do not get enough physician contact. EI and mindfulness strategies that emphasise conflict management and self-compassion should be taught formally within leadership courses and CME offerings to support the practicing physician in navigating this difficult environment.

Ambady and Rosenthal[8] discovered that when people watched 30 s soundless clips of real physician-patient interactions, their judgements of the physician’s kindness predicted whether that physician would be sued rather than the outcome of the procedure or care. To further touch on the litigious climate of medicine, Robbennolt[9] has suggested that many physicians have not been trained effectively in communicating with patients, especially with regard to apologising after making mistakes, thus leading to potential malpractice suits. Of course, physician hubris is not the sole factor in malpractice suits and some adverse events merit litigation. Physicians still struggle though, coping with denial and having difficulty acknowledging their errors like any lay person may. A paradigm shift might better prepare the physician for some of the difficulties he or she will undoubtedly encounter. What should differentiate physicians from the public, aside from the medical knowledge they have been privileged to garner through years of schooling, is EI and the employment of mindfulness strategies. The combination of these attributes may enable physicians to better realise what factors may be in or out of their control in addition to more effectively communicating possible mistakes made. Furthermore, EI and mindfulness provide physicians with one technique, among many others, which can aid in handling truly stressful moments.

Techniques employed by physicians to contend with overwhelming feelings of anxiety are not limited to EI and mindfulness. Self-compassion and stress inoculation training are examples of two other strategies that can certainly enhance medical education. Neff[10] has described self-compassion as ‘perceiving one’s experiences as part of the larger human experience rather than seeing them as separating and isolating’. She goes on to define it as having ‘an emotionally positive self-attitude that should protect against the negative consequences of self-judgement, isolation and rumination’. Stress inoculation training is a form of cognitive behavioural therapy that can serve as a preventative strategy by preparing individuals and/or exposing them to stressful situations so that they may develop familiarity and ultimately ‘resistance’ to certain stressors.[11] In addition to both EI and mindfulness, these two methods may serve as tools in the modern physicians’ armamentarium. Physicians must understand that they assume an inherent burden that may not be entirely understood by everyone around them. Any of the potential stressors that accompany being a physician, specifically fatigue coupled with the overarching responsibility of caring for a sick human being are not experienced by all members of the healthcare team. This further highlights the need for increased EI and mindfulness training. Nurses and other hospital employees may encounter a less than approachable and short-tempered physician poorly coping with fatigue and other stressors. Adding to the workloads and stress borne by modern physicians are non-patient care tasks that are painstakingly time-consuming. In American medical practice, it has been shown that for every hour physicians provide direct clinical face-time to patients, nearly 2 additional hours are spent on documentation and desk work within the clinic day.[12] Outside actual office hours, physicians spend another 1–2 hours of personal time each night doing additional computer and other clerical work.

The importance of maintaining mindfulness while being overworked should be impressed on medical students, residents and physicians. Unfortunately, a paucity of sufficient coping mechanisms and physicians’ oblivion to their emotional states and reactions leads to tenuous relationships with peers that should be avoidable.

The physician is looked on as the leader of the healthcare team, thus making the roles of EI and mindfulness integral for his or her leadership success. As Mayer[13] points out, ‘EI, however, is not agreeableness. It is not optimism. It is not happiness. It is not calmness. It is not motivation. Such qualities, although important, have little to do with intelligence, little to do with emotions and nearly nothing to do with actual EI.’ The EI and mindfulness attributes required of a physician in a critical situation are the ability to sense the impending panic and potential fear of the other people involved and react appropriately along with recognising their own emotions. The manner in which physicians carry themselves is sensed by those around them, but more importantly should be sensed by themselves. Employment of mindfulness strategies coupled with higher EI translates to better care by a reassured team. Although learning these tools can and may occur on the job, more opportunities should be afforded to physicians in anticipation of the challenges that lie ahead. The art of medicine encompasses the ability to adeptly navigate challenging situations with emotional equanimity. Equipping next-generation and practicing physicians with tools to enhance their EI and mindfulness by providing training while they are medical students and residents as well as throughout their professional life can only improve the field of medicine.


#Meditation may lower risk of #cardiovascular disease

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The American Heart Association has issued its first scientific statement specifically on the role of meditation in the management of heart disease.
While guideline-directed cardiovascular risk reduction measures remain the gold standard for lowering the risk of cardiovascular disease, a new scientific statement from the American Heart Association (AHA) suggests that meditation also has the potential to reduce some risk factors.
The statement, which is the AHA’s first scientific statement specifically on meditation, follows a review of current high-quality scientific studies to determine what is currently known from the scientific evidence.
It found sitting meditation may be associated with decreased levels of stress, anxiety and depression, and improved quality of sleep. Additionally, it may help lower blood pressure and may support smoking cessation. Studies of meditation also suggested a possible benefit on cardiovascular risk, although the authors said the overall quality and, in some cases, quantity of study data is modest.
Writing in the Journal of the American Heart Association , the authors said, “given the low costs and low risks of this intervention, meditation may be considered as an adjunct to guideline-directed cardiovascular risk reduction by those interested in this lifestyle modification, with the understanding that the benefits of such intervention remain to be better established.”

#Taxa anual de #óbitos por histoplasmose entre portadores de #HIV na América Latina equivale a 70 acidentes aéreos

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Teresa Santos (colaborou Dra. llana Polistchuck)

O Brasil é responsável por 80% dos casos de paracoccidioidomicose que ocorrem no mundo, e a maioria dos relatos remanescentes vem de outros países da América do Sul, entre eles, Colômbia, Venezuela, Argentina e Equador[1]. Essa enfermidade é, segundo o DR. Guillermo Porras Cortés, do Hospital Vivian Pellas, da Nicarágua, uma das micoses endêmicas mais importantes para a América Latina. Outras duas doenças causadas por fungos que merecem destaque na região são a histoplasmose, especialmente na América Central e no Caribe, e a coccioidomicose, principalmente no México. A epidemiologia dessas três patologias foi discutida pelo infectologista durante um simpósio do 20º Congresso Brasileiro de Infectologia, realizado em setembro no Rio de Janeiro.


O agente etiológico da paracoccidioidomicose é o Paracoccidioides brasiliensis e a rota de contaminação é por inalação. Trabalho na agricultura, tabagismo, tuberculose, neoplasias e infecção por HIV/Aids são alguns dos fatores de risco para a doença. Além disso, segundo o Dr. Cortés, sabe-se que homens têm maior propensão, pois o estrógeno presente no organismo feminino inibe a transformação dos conídios em leveduras[1]. Há ainda aspectos genéticos que podem favorecer o desenvolvimento dessa enfermidade, por exemplo, alguns genótipos do sistema de histocompatibilidade humano-HLA (HLA-A9, HLA-813)[2]. Além disso, alguns polimorfismos em genes que codificam citocinas (IL12RB1, 641AA) também são mais frequentes em homens com a forma multifocal crônica da doença[3].


Aqui o agente etiológico é o Histoplasma capsulatum, e a forma de aquisição também é por inalação. Entre as formas clínicas da doença temos: histoplasmose pulmonar aguda, histoplasmose pulmonar cavitária crônica, granuloma mediastinal, fibrose mediastinal e histoplasmose disseminada.

De tempos em tempos surgem relatos de casos de hospedeiros não imunocomprometidos na América Central e no Caribe. A infecção desses grupos pode estar associada a surtos epidêmicos, ou representar casos isolados. O Dr. Cortés apresentou à plateia quadros ocorridos na República Dominicana e na Nicarágua. No primeiro evento, transcorrido em 2015, morcegos transmitiram a doença para 27 indivíduos que trabalhavam em túneis de uma hidrelétrica[4]. No segundo episódio, 14 turistas norte-americanos foram infectados após visitar uma caverna infestada de morcegos na Nicarágua[5].

Quando o hospedeiro é imunocomprometido, a situação pode se tornar ainda mais grave. Estima-se que a histoplasmose seja responsável anualmente pela morte de 9600 pessoas vivendo com HIV/Aids, o que, segundo pesquisa publicada na revista AIDS, equivale anualmente a 70 quedas de Boeing 737[6].


Segundo o Dr. Cortés, as espécies Coccidioides immitis e Coccidioides posadasii são endêmicas no leste e sul dos Estados Unidos, mesoamérica e América do Sul, sendo o México o país da América Latina com taxas mais altas da doença (7,6/100.000)[7].

“Cerca de 60% dos expostos geralmente permanecem assintomáticos. Mas, nos 40% sintomáticos pode ocorrer síndrome febril e primária, com infecção pulmonar geralmente autolimitada, ou evoluir para doença pulmonar mais agressiva ou extrapulmonar”, disse.

Ser do sexo masculino também é fator de risco na coccidioidomicose. Outros fatores são: gravidez, etnia africana e filipina, imunodeficiência celular, e linfadenopatia mediastinal com anormalidades hilares[8,9]. Apesar da importância das micoses endêmicas, o Dr. Cortés alertou que os dados de vigilância sistemática ainda são insuficientes na América Latina, o que dificulta o combate a estas doenças.

#Sólo con 30 minutos de #actividad física se pueden evitar una de cada 12 #muertes prematuras (Lancet)

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Andar es gratis.

Andar es gratis.

Investigadores del St. Paul’s Hospital en Canadá aseguran que practicar una actividad física cinco días a la semana durante al menos 30 minutos es suficiente para reducir significativamente el riesgo de desarrollar enfermedades cardiovasculares o el de muerte prematura, evitando al menos uno de cada 12 fallecimientos por esta causa.
Su investigación, cuyos resultados publica la revista “The Lancet”, se basó en el seguimiento de unas 130.000 personas de 17 países, de diferente nivel de ingresos, y vieron que quienes iban al gimnasio, iban andando a trabajar o simplemente llevaban a cabo tareas domésticas sencillas que les hacían estar físicamente activos, lograban mejorar su supervivencia libre de enfermedad.
Asimismo, vieron que cuantas más personas había físicamente activas mayor era el riesgo de sufrir enfermedades del corazón o acabar falleciendo.
De igual modo, el estudio no encontró ningún riesgo asociado a niveles extremadamente altos de actividad física, considerando como tal la práctica de ejercicio durante más de 2.500 minutos o 41 horas por semana.
Las enfermedades cardiovasculares son la principal causa de muerte en el mundo, con 9,48 millones de muertes a nivel mundial según datos de 2016. Y como ha reconocido Scott Lear, autor de la investigación, “sólo 30 minutos caminando todos los días puede tener un beneficio sustancial”.
Además, este experto recuerda que otras medidas para prevenir o tratar las enfermedades cardiovasculares mediante un cambio en la dieta o el uso de medicamentos no siempre es posible en los países con menos recursos. En cambio, ha apuntado, “andar es gratis”.

#Taumaturgia y # salud: un binomio imposible

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La importancia de la salud para el ser humano ha llevado a que, desde antiguo, se haya intentado estafar con tratamientos milagrosos. ¿Qué debería hacer un médico si se encuentra en la consulta ante un paciente al que le han dicho que “ha desarrollado el cáncer porque se le ha muerto el canario”?
Desde tiempos muy antiguos la salud ha sido fundamental para el ser humano; y también desde antiguo se ha intentado estafar con terapias milagro. Muchos desaprensivos han jugado a ser magos y se han aprovechado de la debilidad del enfermo, haciéndole soñar con curaciones prodigiosas. La Asociación para Proteger al Enfermo de Terapias Pseudocientíficas dispone de un amplio listado de falsas terapias y terapias pseudocientíficas, técnicas de curación que van desde el suero de anguila hasta la técnica metamórfica (un masaje suave sanador) o la terapia de vidas pasadas.
Las pseudoterapias y terapias pseudocientíficas son aquellas prácticas que ofrecen actos médicos curativos que no han demostrado científicamente su efectividad. Afirman curar enfermedades, aliviar síntomas o mejorar la salud sin que exista respaldo de la evidencia científica. Coloquialmente podríamos denominarlas “falsas terapias”. Muchas de ellas se engloban en  las terapias alternativas (a la medicina científica), complementarias (con la medicina científica) o integrativas, al considerar que la medicina convencional parcializa al ser humano. Sin embargo, no debemos meter todas las terapias incluidas en dichos epígrafes bajo el mismo paraguas. Su seriedad depende fundamentalmente de dos factores: de si quien las utiliza es un profesional formado y responsable, y de para qué se utilizan (por ejemplo, si se crean expectativas infundadas de curación).
Pero si una pseudoterapia es empleada por un desaprensivo que promete lo imposible, puede llegar a convertirse en un serio riesgo para la salud, porque un paciente puede abandonar una terapia que sí está probada científicamente por otra sin valor real curativo. A ello se añade el hecho de que muchas de estas terapias pueden no ser inocuas (muchas veces las pseudoterapias se venden como inofensivas), provocando daños orgánicos. Al final del camino, las víctimas de estos engaños y estafas se encuentran con un posible perjuicio moral y económico del que puede resultar difícil recuperarse.

Ante este panorama parece sencillo desmontar las falsas terapias, pero no resulta tan fácil. Hay muchas razones por las que se mantienen vigentes. En primer lugar, porque la llamada medicina científica no es infalible ya que, aparte de los casos que no soluciona, hay que señalar que la validez científica real de muchas terapias usadas por la medicina tradicional es dudosa. Por otro lado, hay ciudadanos que tienen prejuicios contra ella, y solo piensan en los posibles efectos secundarios de la medicina científica o que detrás de las recetas médicas hay intereses espurios.
Además de las dudas que muchas personas tienen para con la medicina científica, también hay que considerar los argumentos a favor de las falsas terapias. La primera es el lexema “-terapia”. Colocar el apellido “-terapia” a algo es sencillo: risoterapia, musicoterapia, iridoterapia, talasoterapia, etcétera. Pero ¿son realmente terapias? Si entendemos la salud como mero bienestar, muchas podrían serlo, porque pueden hacer que una persona se sienta bien. La explicación del bienestar que producen es amplia: se crea un entorno relajante y se da una atención delicada (lejos de lo que muchas veces se encuentra en un hospital o en un centro de salud), por el efecto placebo derivado de sentirse cuidado, por la confianza en la técnica o en quien la realiza, por la evolución favorable del curso natural de la enfermedad, etcétera. De ahí a postular que estas técnicas pueden curar o prevenir enfermedades, hay un trecho muy largo.
Otro motivo que anima a subirse al carro de las falsas terapias son sus dianas, muchas veces pacientes con enfermedades crónicas y muy molestas a las que la medicina convencional no termina de dar una respuesta satisfactoria, como puede ser la fibromialgia o el colon irritable; sin olvidar las enfermedades graves incurables, como un cáncer terminal. Además de aprovecharse de la vulnerabilidad y de la desesperación de las personas que padecen estas patologías, se usan técnicas comerciales como el “yo lo probé y me fue bien” y promesas de sanación que sorprenderían al más escéptico.
¿Qué debería hacer un médico si se encuentra en la consulta con un paciente al que le han dicho que “ha desarrollado el cáncer porque se le ha muerto el canario”? O que viene convencido de que la bioneuroemoción (tomar conciencia de las emociones inconscientes para auto-sanarse) tiene la misma validez científica que la oncología.
En primer lugar, hay que informar, si es que el paciente quiere ser informado. El Ministerio de Sanidad publicó en 2011 un documento que analizaba las mal llamadas terapias naturales. En el documento se utiliza la clasificación del National Center for Complementary and Alternative Medicine norteamericano: 1.- Sistemas integrales o completos (homeopatía, medicina naturista, naturopatía, medicina tradicional china, acupuntura, ayurveda); 2.- Prácticas biológicas (fitoterapia, terapia nutricional, tratamientos con suplementos nutricionales y vitaminas); 3.- Prácticas de manipulación y basadas en el cuerpo (osteopatía, quiropraxia, quiromasaje, drenaje linfático, reflexología, shiatsu, sotai, aromaterapia); 4.- Técnicas de la mente y el cuerpo (yoga, meditación, kinesiología, hipnoterapia, sofronización, musicoterapia, arteterapia y otras); 5.- Técnicas sobre la base de la energía (Qi-Gong o Chi-kung, Reiki, terapia floral, terapia biomagnética o con campos magnéticos).
Tras analizar 139 técnicas se concluye que la evidencia científica disponible sobre su eficacia es muy escasa y, si bien en la mayoría de los casos estas terapias son inocuas, no están completamente exentas de riesgos. Solo una pequeña parte tiene influencia directa sobre la salud (entendida orgánicamente) y el resto van fundamentalmente dirigidas al bienestar o confort del usuario. Para poder informar, el primero que tiene que estar informado es el médico. Hay cantidad de documentos y estudios al respecto y antes de opinar debemos saber. Sobre las técnicas mencionadas, tenemos que decir que son muy diversas y hay algunas que pueden resultar útiles en casos concretos, pero muchas son una mera estafa.

Además de informar, si nos encontramos con un caso de falsa terapia con riesgos para la salud de un paciente, habría que pasar a la denuncia. El Código de Deontología Médica señala que “La publicidad médica ha de ser objetiva, prudente y veraz, de modo que no levante falsas esperanzas o propague conceptos infundados”. Esto es aplicable a los médicos, pero debería generalizarse a cualquier individuo que trabaje con enfermos. Recientemente la Organización Médica Colegial ha creado un Observatorio contra las Pseudociencias, Pseudoterapias, Intrusismo y Sectas Sanitarias, al que nos podríamos dirigir en casos de estafa o engaño flagrante, sin olvidar la vía judicial en situaciones extremas.
La llamada medicina tradicional utiliza principios activos del reino animal, mineral y vegetal, y si una técnica nueva prueba su eficacia debería incorporarse con normalidad a la práctica clínica. De la misma manera que debemos ser críticos con nuestra práctica y que no hay que tener prejuicios ante las novedades, hay que ser firmes ante una posible estafa. La salud de nuestros pacientes es lo primero.

Expanded criteria for #PCOS may be causing harm to women, say experts

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Australian clinicians suggest symptomatic treatment without diagnosis.

Australian experts have claimed that expanded criteria for the diagnosis of polycystic ovary syndrome (PCOS) may be leading to unnecessary overdiagnosis and overtreatment of the condition.

PCOS is the most commonly diagnosed endocrine disorder affecting reproductive aged women and is associated with adverse reproductive, metabolic, and cardiovascular outcomes. First described in 1935 in a case series of seven women with amenorrhoea and infertility associated with multiple cysts in the ovaries, diagnosis rates rapidly increased following the introduction of criteria in 2003 to include sonographic presence of polycystic ovaries. In 2006 a taskforce said that clinical or biochemical evidence of hyperandrogenism was essential for diagnosis.

Writing in the BMJ , the authors pointed out that symptoms of PCOS, such as acne and oligomenorrhea, are also common to pubertal development, yet diagnostic criteria for PCOS fail to take adolescence into account.

They warned there is evidence of overdiagnosis of PCOS and said labelling healthy women with PCOS may negatively impact their psychological health and well-being, causing fear and anxiety about future fertility and long-term health. They said there is also limited evidence to support the benefits of certain pharmacological treatments.

They suggest a slower, stepped or delayed approach to diagnosis to reduce harm from labelling.

#Acupuncture and #electrotherapy reduce #opioid use after #knee replacement

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The new study has also identified poorer quality evidence for interventions such as cryotherapy.

A new analysis of drug-free interventions to reduce pain or opioid use after total knee arthroplasty (TKA) has found modest but clinically significant evidence that acupuncture and electrotherapy can potentially reduce and delay opioid use.

The findings, published in JAMA Surgery , come at a time when there is increased interest in nonpharmacological treatments to reduce pain after TKA. Despite this growing awareness, there is little consensus to support the effectiveness of these interventions.

The study, which is the first comprehensive study to examine the most frequently-used treatments, identified continuous passive motion (CPM), preoperative exercise, cryotherapy, electrotherapy, and acupuncture as the most commonly performed interventions.

The authors identified moderate-certainty evidence which showed that electrotherapy reduced the use of opioids and that acupuncture delayed opioid use, and low-certainty evidence that acupuncture improved pain. The findings also suggested electrotherapy may not only reduce early pain, but also change the long-term trajectory of recovery from pain after TKA.

There was very low-certainty evidence that cryotherapy reduced opioid consumption, and no evidence that it improved perceived pain. Low-certainty or very low-certainty evidence showed that CPM and preoperative exercise had no pain improvement and reduction in opioid consumption.