sign in sign up
<<
Home , Parapsychology

1/21/14

Integrative Oncology: Understanding the Practice and the Evidence

Presenters Judi Fouladbakhsh, PhD, RN Lynda Balneaves, PhD, RN Associate Professor Associate Professor and Wayne State University Associate Director College of Nursing Research University of Detroit, Michigan British Columbia School of Nursing Complementary Therapies in Vancouver, British Columbia Healthcare Program Director Principal Investigator Principal Investigator CAMEO Project for Lung Cancer Patients AHN-BC, CHTP, Master, Reflexologist

Conflicts of Interest

Dr. Fouladbakhsh and Dr. Balneaves have

nothing to disclose.

1

1/21/14

Permissions All patients, clients, and practitioners appearing in the photos that follow have given permission for their images to be used

in this presentation

Learning Objectives 1. Understand the complementary and (CAM) therapies most frequently used among patients with cancer. 2. Learn about the use of therapies in reducing the side effects associated with cancer therapies. 3. Become knowledgeable on the current evidence for use of integrative oncology treatments. 4. Recognize the role of the advanced practitioner in

integrative nursing/health care practice.

Understanding CAM, Integrative

Health Care, and Our Patients

2

1/21/14

What Is CAM and Integrative Care?

Complementary and alternative medicine (CAM) includes thousands of diverse medical and health care treatments, products, and practices that are not considered part of conventional biomedicine.

Many CAM therapies:

• Have existed for millennia within alternative systems of care, such as Traditional Chinese Medicine and . Others are newly emerging. • Are increasingly being integrated into conventional health

care as evidence of effectiveness emerges

What Is CAM?*

“A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine…”

• Body-based *National Center for Complementary and Alternative Medicine (NCCAM) • -body • Biologically based • Energy

• Whole systems

CAM Terminology

Complementary medicine Used together with conventional medicine Alternative medicine Used in place of conventional medicine Integrative medicine Combines treatments from conventional medicine and CAM for which there is evidence of safety and effectiveness; also called

integrated medicine

3

1/21/14

Are you currently using some form of CAM therapy in your practice?

A. Yes

B. No

Why It’s Important to Know About CAM

• Estimates of CAM use in the US range from 34% to 76%, depending on the therapies included and populations studied. • 44% of all cancer survivors use CAM therapies. Prevalence is increasing.

• Use of special diets, herbs, and supplements is significantly higher among those with cancer (5%, 23%, and 67%, respectively).

Fouladbakhsh, J. M., et al. (2008). J Comp Int Med, article 19, 1-25; Fouladbakhsh, J. M. (2010). Comparative analysis of CAM use among the

U.S. cancer and noncancer populations, 5th International Congress on Complementary Medicine Research; Barnes, P. M., et al. (2004). Adv Data, 2004(343), 1-19; Barnes, P. M., et al. (2008). Natl Health Stat Report, 12, 1-23.

Prevalence of CAM Use

CAM USE CANCER POP NONCANCER POP (past 12 mo) % 95% CI % 95% CI p VALUE* At least 1 therapy 76.4 74-78.7 62.7 61-63.7 .0001* excl. At least 1 therapy 43.8 41-46.6 37.1 36-38.2 .001* excl. prayer, vitamins Providers only 18 15.8-20 16.1 15.4-17 .09 Practices only 22.2 20-24.6 20.2 19.5-21 .09 Products only 69.7 67-72.3 56.1 55-57.1 .001* CAM combinations 27.4 24.9-30 23.6 22.8-24.5 .005* Prayer 62 59-64.8 46.9 45-48 .001*

*Pearson Chi2 p < .05 Based on NHIS 2007 analysis

4

1/21/14

Use of CAM Providers CANCER POP NONCANCER POP THERAPY % 95% CI % 95% CI p VALUE* 1.6 0.98-2.6 1.4 1.2-1.6 .58

Ayurveda 0.1 0.01-0.78 0.1 0.04-0.19 .89

Biofeedback 0.6 0.19-0.19 0.1 0.07-0.22 .008*

Chelation 0.02 0.003-0.2 0.05 0.02-0.12 .42

Chiropractic/osteopathic 9.8 8.19-11.6 8.3 7.7 -8.8 .07

Energy healer 1.0 0.5-1.88 0.5 0.4-0.63 .02*

Hypnosis 0.4 0.1-1.1 0.2 0.17-0.34 .54

Massage 8.7 7.1-10.6 8.1 7.5-8.6 .44

Naturopathy 0.3 0.1-0.67 0.3 0.25-0.4 .67

Indigenous healer 0.2 0.04-1.1 0.4 0.26-0.5 .54

Movement therapies 0.6 0.2-1.3 1.5 1.3-1.7 .02*

Homeopathy provider 0.4 0.1-0.93 0.4 0.2-0.5 .87

*Pearson Chi2 p < .05

Use of CAM Practices & Products CANCER POP NONCANCER POP PRACTICE % 95% CI % 95% CI p VALUE* Special diets 4.6 3.4-6.0 3.5 3.1-3.8 .05 South Beach Diet 1.7 1.0-2.7 1.0 0.8-1.2 .03 Yoga 4.9 3.8-6.4 6.0 5.5-6.4 .17 0.9 0.5-1.5 1.0 0.8-1.2 .75 0.2 0.06-0.5 0.3 0.2-0.4 .41 9.7 8.3-11.4 9.2 8.6-9.8 .5 Guided imagery 2.8 2.0-3.7 2.1 1.8-2.5 .1 Progressive relaxation 2.9 2.0-4.0 2.9 2.6-3.2 .9 Deep breathing 14.1 12.4-16 12.3 11.7-13 .05 Herbs 22.7 20.5-25 17 16.2-18 .001 Homeopathic products 1.4 0.8-2.3 1.8 1.6-2.0 .38 Vitamins 66.6 63.7-70 53.5 52.4-55 .001

2 *Pearson Chi p < .05

What Does the Popularity of CAM Mean for Advanced Practioners? • CAM is a of cancer care • Potential harms and benefits must be addressed in the context of conventional treatments • Consideration of role of APNs in addressing CAM and integrative oncology

q Support informed decisions q Provide evidence and/or therapies

q Referrals

5

1/21/14

What percentage of your oncology patients do you estimate are using CAM therapies?

A. 100% B. 75% C. 50% D. 25%

E. Less than 25%

So why do we use CAM therapies,

and how does this affect our health?

Reasons for CAM Use

• Quality of life • Desire for control • Seeking • Prior use of CAM • Health beliefs • Natural treatment option • Culture Shirodhara • Availability of CAM

• Dissatisfaction with conventional care

6

1/21/14

On the plus side….

• Potential for positive health benefits • Improved health and healing, health promotion, and wellness • Enhanced quality of life • Management of symptoms such as pain, insomnia, depression, and anxiety, which are more prevalent among cancer survivors

* What’s needed…Strong research to establish the evidence that varies by therapy

Fouladbakhsh , J. M., et al. (2008). J Comp Int Med, article 19, 1-25; Fouladbakhsh, J. M. (2010). Lotus flower

Comparative analysis of CAM use among the U.S. cancer and noncancer populations, 5th International Congress on Complementary Medicine Research.

Wide World of CAM • Estimated there are over 4,000 CAM therapies • Many come from alternative medical systems q Traditional Chinese medicine q Ayurvedic medicine q Homeopathic medicine • How do we classify these therapies and understand their benefits and risks?

• How do we evaluate those who provide them?

Energy Therapies

• Approach to working with the body’s system of energies for promoting health • Energy body is a subtle part of the physical body l Meridians are energy pathways l are energy centers in the body

Hover-Kramer, D. (2002). Healing touch: A guidebook for practitioners. Albany, NY: Delmar; Oschman, J. L. (2000). . NY: Churchill Livingstone; Rand, W. (2011). Reiki: The healing touch. Southfield, MI: Vision Publications.

7

1/21/14

Philosophy and Concepts • Biofield • Electromagnetic field, biophotons* • Chakras, meridians, universal • Energy grids and interconnectedness • Do these explain effects of energy therapies, intercessory and distant healing, and prayer?

*Photons/second: Intensity level of emission of electromagnetic radiation. Human tissue radiates in ultraviolet region of light spectrum.

Hover-Kramer, D. (2002). Healing touch: A guidebook for practitioners. Albany, NY: Delmar; Oschman, J. L. (2000). Energy medicine. NY: Churchill Livingstone; Joines, W. T., et al. (2004), Parapsychol Assoc Conv , 445-447; Joines, W. T., et al. (2012). J Parapsychol, 76(2).

Energetic Images

Aura - Biofield

Energy Grid

Nonlocal Consciousness Chakras

Energy Therapies

Practitioners assist with energy balancing

• Healing touch • Open the chakras • • Balance energy flow • Reiki • Smooth energy field • Acupuncture • Open energy blockages • at meridian points • Qigong • Moving and still

• Tai chi/yoga meditation

8

1/21/14

Energy Therapies

• Use light touch on and above the body • Techniques direct healing energy to specific sites • Can be used for self-care: Relaxation and pain relief

Healing Touch 6 levels, certification takes 2-3 yr Reiki 3 levels and Reiki Master (teacher) Therapeutic Touch Beginning, intermediate, advanced

www.healingtouchinternational.org www.reiki.org www.therapeutic-touch.org

Potential Benefits and Risks

• Reduce pain • Alleviate depression • Wound healing • Reduce fatigue • Decrease anxiety • Assist with grieving • Ease transition during • Decrease stress dying process • Promote comfort

Risks: Limited information is available Hover-Kramer, D. (2002). Healing touch: A guidebook for practitioners. Albany, NY: Delmar.

Chakra Assessment

Mind Clearing

Healing Touch Photo courtesy of Healing Touch Center, Farmington Hills, MI

9

1/21/14

Relaxation and Balancing Energy

Hands placed on patient’s chakras

Pain Drain

Practitioner serves as channel to balance energy flow

Pain Management: Healing Touch

Purpose: Identify outcomes of HT for chronic and acute pain in non-hospitalized clients.

Research questions • What percentage of patients seek HT for pain management? • Is there a significant difference in self-reported

pain intensity pre- and post-HT?

10

1/21/14

Study Results: Demographics

Number of clients treated N = 342

Total number of treatments completed N = 939

Gender: Female 79% (270) Male 21% (72)

Age: Mean 48 (Range) (3-87 yr)

Marital Status: Married 53% (182) Single/widowed 47% (161)

Referral Source: Another person 98%

Hospital, MD 2%

Results: Pain Relief • 72% (247 clients) complained of pain • 64% of HT treatments (541) for pain management

Pain Intensity Scores Pre-treatment: Mean 4.68, SD 2.41 Post-treatment: Mean 1.81, SD 1.94

GEE Model Analysis • Significant pain improvement following HT

intervention

Understanding Reiki

Reiki International Center for

Reiki Training Rand, W. (2011). Reiki: The healing touch. Southfield, MI: Vision Publications.

11

1/21/14

Reiki

• REI = Universal spiritual • KI = Life force energy

q Non-physical energy that animates all living things • Based on the teachings by Mikao Usui of Japan in the 1800s, brought to the west by one of his students, Mrs. Takata • Reiki levels: I & II, ART & Master, Karuna Reiki

Rand, W. (2011). Reiki: The healing touch. Southfield, MI: Vision Publications.

International Center for Reiki Training (ICRT)

ICRT Website (info and slide presentation) www.reiki.org

Reiki Free Newsletter www.reiki.org/NewsletterPage/newsletter.html

Reiki Research Summary www.centerforreikiresearch.org

Acupuncture Acupuncture may include: • Needling • Pressure • : Burning of herb called mugwort at needle site • Series of treatments (~10)

• Covered by some insurances

12

1/21/14

Acupuncture Image courtesy Beaumont Integrative Medicine Center, Royal Oak, MI

Children and Acupuncture

Columbia-Presbyterian, NYC Acupuncture for Children with Cancer

PEDsCAM

Acupressure and

Reflexology research: Teens with recurrent headaches Fouladbakhsh, J. M., et al. (2013). J Adv Pract Oncol, 4(5), 289-306.

13

1/21/14

Symptom Management Techniques

Nausea Stress & Anxiety

Pain

Integrative Oncology: UnderstandingWhat does the Evidencethe Evidence tell us about Integrative

Oncology (IO)?

What Do We Mean by Evidence? © Balneaves/CAMEO

14

1/21/14

Synthesis of IO Evidence • The Society for Integrative Oncology (SIO) q Integrative Oncology Practice Guidelines (2009) www.integrativeonc.org • World Cancer Research Fund and American Institute for Cancer Research (WCRF and AICR)

q Synthesis of Food, Nutrition, & Physical Activity Research in the Prevention of Cancer (2007)

o Designed to help reduce risk of cancer worldwide o Suitable for all societies

o http://www.dietandcancerreport.org/ © Balneaves/CAMEO

The SIO Guidelines* recommend that all patients should:

• Be asked about the use of patient-centered manner by qualified personnel • Be advised to avoid therapies promoted as “alternatives” to care

Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

Body-Based “Touch” Therapies

Recommended • Massage therapy for anxiety and pain • Manual lymph drainage with compression bandaging for lymphedema Caution • Massaging on or near radiation treatment field • Excessive rocking motions for patients with nausea Not Recommended: Deep or intense pressure: • Near lesions; enlarged lymph nodes, radiation field sites, medical devices, or surgery sites

• In patients with a bleeding tendency Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

15

1/21/14

Mind-Body Therapies

Recommended • Mind-body therapies practiced over time can reduce anxiety, mood disturbance, chronic pain, and stress and improve quality of life and sleep • For nausea and vomiting: Visualization, meditation, relaxation, biofeedback, prayer Caution • may cause dizziness, nausea, or headache when being brought out of a trance by an inexperienced hypnotherapist Not Recommended • Hypnosis on individuals with psychosis or certain personality

disorders Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

Mindfulness-Based Stress Reduction (MBSR)

WHAT IS IT? • A structured psychological and educational therapy that combines mindfulness meditation with hatha yoga, administered over 8 wk • “Moment-to-moment, non-judgmental ”

WHAT DOES THE EVIDENCE SAY? • Clinical trials have shown improvements in mood and sleep quality and reductions in stress • Beginning evidence of positive impact on immune system • Further clinical trials are recommended

Kabat-Zinn, J., et al. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Random House. © Balneaves/CAMEO

Yoga

WHAT IS IT? • Combines physical movement, breath control, and meditation WHAT DOES THE EVIDENCE SAY? • Favorable outcomes for… q Improved sleep quality q Overall quality of life q Social and emotional well-being • Study: Yoga group vs. supportive counseling q Decreased nausea following 4 chemo cycles q Better quality of life and mood

q Higher natural killer cell percentages © Balneaves/CAMEO

16

1/21/14

Energy Therapies

Recommended • Reiki and therapeutic touch are safe and may reduce stress and enhance quality of life Caution • Limited evidence as to efficacy for symptom management, including reducing pain and fatigue Not Recommended • Bio-electromagnetically based therapies, due to concern over toxicity and increased cancer risk; no controlled trials showing

effectiveness for cancer treatment or symptom control Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

Acupuncture

Recommended • Poorly controlled pain, nausea with chemo or surgery • Acupressure wristbands on day of chemo for nausea and vomiting • Hot flashes not amenable to drugs; radiation-induced dry mouth

Caution (More clinical studies needed) • Shortness of breath or fatigue or neuropathy Not Recommended • Pregnancy, low platelets or white blood cells, severe thrombocytopenia, bleeding problems, or neutropenia • AVOID acupuncture at tumor and metastasis site, limbs with

lymphedema, and surgery sites Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

Biologically Based Diet

Recommended • Learn about proper nutrition to promote basic health • Select a wide variety of foods including vegetables, fruits, whole grains, and beans • See a nutritionist for evaluation of deficits. For older cancer survivors, nutritional supplementation may be required. • Be as lean as possible without becoming underweight

Caution: Limit using the following foods: • High sugar, high salt, low fiber, high fat foods; red meat • Alcohol to 2 (men) or 1 (women) drinks/day, if consumed at all • Salty foods Not Recommended • Processed meats and foods

AICR/WCRF (2007). Food, nutrition, physical activity, and the prevention of cancer. http://www.aicr.org/research/research_science_expert_report.html © Balneaves/CAMEO

17

1/21/14

Foods to Eat on a Daily Basis • Berries • Legumes • Brazil nuts • Tea • Citrus • Tomatoes • Cruciferous vegetables • Yogurt • Fish and flax • Vegetables: dark,

orange, red, green © Balneaves/CAMEO

Natural Health Products (NHPs)

Recommended • Evaluate use of NHPs prior to the start of cancer treatment • Canadian Cancer Society recommends Canadians use 1,000 IU of vitamin D during winter months for cancer prevention • Ginger supplements for nausea and vomiting (but consult health professional) Caution • Consult a trained heath-care provider if using NHP for anti-tumor effects • Use only NHPs within the context of clinical trials, recognized nutritional guidelines, and under close evaluation and monitoring of risks and benefits, by trained health-care providers Not Recommended

• Dietary supplements usually unnecessary Deng, G., et al. (2009). J Soc Integr Oncol, 7(3), 85-120. © Balneaves/CAMEO

An Exception: Vitamin D

• Canadian Cancer Society 2007 recommendation: Adult Canadians should

use 1,000 IU of vitamin D3 during fall/winter months for cancer prevention

• Additional research needed to define the amount that will maximize health benefits

• Role of vitamin D in other chronic diseases

q Cardiovascular, rheumatoid arthritis, MS © Balneaves/CAMEO

18

1/21/14

Vitamins and Minerals: How Much Do I Need? • A balanced diet rich in fruits and vegetables requires little supplementation • Dietary recommended intake (DRI) = Recommended level of vitamin and mineral intake for overall health • Find at Office of Dietary Supplements

website: ods.od.nih.gov © Balneaves/CAMEO

But…is integrative oncology part of my

scope of practice?

Do you see CAM therapies as something you should address as part of your role in oncology care?

A. Yes B. No

C. Unsure

19

1/21/14

YES!! • Support access to evidence-based knowledge to ensure informed decisions • Provide select CAM therapies IF trained/certified (e.g., acupuncture) • Communicate and consult with team re: patient’s CAM use to ensure safe care • Monitor and evaluate outcomes/side effects

• Document care provided © Balneaves/CAMEO

When CAM Is Not Addressed… • Safety Issues q Concurrent use of CAM with conventional tx q Harmful CAM therapies q Financial harm • Communication Issues q Shuts the door to future dialogue about CAM q Impacts communication re: other sensitive issues • Potential Benefits q Supportive care and symptom management

q Preservation of hope q Placebo effect © Balneaves/CAMEO

Ethics and CAM Decisions • Principles q Autonomy/self-determination q Beneficence q Do no harm • Special context of pediatric oncology and CAM

Patients have a right to make what we

may see as the “wrong” decision! © Balneaves/CAMEO

20

1/21/14

Shared Decision-Making

An integrative process between client and health professionals that: • Engages the client in decision-making • Provides client with information about treatment options • Facilitates the incorporation of client preferences and values into the plan of care

© Balneaves/CAMEO

Open the Dialogue • Understand patients’ goals, beliefs, and values related to CAM use • Review diet and exercise status • Determine patient preferences re: decision-making • Culturally sensitive language needed q Avoid “CAM” q Provide examples q Normalize CAM use

• Revisit throughout cancer journey © Balneaves/CAMEO

Locating and Communicating Evidence-Based Information

• Unbiased and non-judgmental approach • Look for both efficacy and safety information • Avoid confusing ‘no evidence’ with ‘no efficacy’ • Empower patients to select therapies that meet their goals • Recommending therapies vs. translating evidence • Consider appropriate referrals

© Balneaves/CAMEO

21

1/21/14

Cancer and CAM Websites

• Memorial Sloan-Kettering Herbs & Botanical Database www.mskcc.org/mskcc/html/11570.cfm • National Cancer Institute − OCCAM cam.cancer.gov • CAM-CANCER

www.cam-cancer.org © Balneaves/CAMEO

General NHP Websites

• Natural Medicines Comprehensive Database Summaries of NHPs, requires a subscription www.naturaldatabase.com • Natural Standard Summaries of NHPs, access via CAMEO website www.naturalstandard.com • NIH Office of Dietary Supplements Dietary Supplement Fact Sheets

ods.od.nih.gov © Balneaves/CAMEO

www.bccancer.bc.ca/cameo Balneaves et al. (2012)

22

1/21/14

Working Through the Decision

SCOPED* Situation Choices Objectives People Evaluation Decision

*Jeff Belkora, PhD, www.scoped.org © Balneaves/CAMEO

Monitoring the Decision • Assist in development of a monitoring plan

q How will they know a therapy is working? Key outcomes? How long before they see the outcomes? How can the outcomes be measured?

q How will they know it’s hurting? What are the potential side effects, including interactions, that may occur?

q When should the decision be re-evaluated? • Consider own role re: follow-up, documentation, and

additional decision support © Balneaves/CAMEO

Tips for Monitoring CAM Use • Expected and unexpected side effects

q Adverse events reporting FDA MedWatch Program (1-800-FDA-1088) • For how long and how often should the therapy be evaluated?

q Role of CAM practitioners and standard tests q CAM use diary • Caution re: using too many

new therapies at one time © Balneaves/CAMEO

23

1/21/14

Evaluating the Decision Assist Patients in Weighing Pros and Cons

• What is patient’s overall objective? • Potential benefits vs. risks • What is unknown about a therapy? Impact on quality of life, relationships, family dynamics, hope, and overall health Ability to commit to a therapy or practice • Time, cost, energy, etc.

© Balneaves/CAMEO

And Finally… Document, document, document! Key Points • Discussion focus: CAM therapy, efficacy, safety • Information provided and referrals • Assessment of patients’ understanding of risks and benefits • CAM decision made, with follow-up plan q Type/brand name with dosage q CAM practitioner name and contact information q Monitoring and evaluation plan

© Balneaves/CAMEO

The Bottom Line

• CAM research is at a beginning stage and is always changing…patients and survivors need to stay current! • You and your organizations have a role in helping patients make safe and informed CAM decisions • Patients have the right to make what others may consider to be the wrong decision!

• Respectful communication is key

24

1/21/14

THANK YOU! Questions or Comments?

[email protected] [email protected]

Bibliography and References

Balneaves, L. G., Truant, T. L. O., Verhoef, M., Porcino, A., Ross, B., Wong, M., & Brazier, A. S. (2012). The Complementary Medicine Education and Outcomes Program (CAMEO) Program: A Foundation for Patient and Health Professional Education and Decision Support Programs. Special edition on Complementary Medicine for Patient Education & Counseling, 89(3), 461–466. Barnes, P. et al, Barnes PM, et al. (2008). Complementary and alternative medicine use among adults and children: , 2007. Natl Health Stat Report, 12,1–23. Barnes P. M., et al. (2004). Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004(343), 1–19. Braden, G. (2007). The Divine Matrix. New York: , Inc. Deng, G., et al. (2009). Evidence-based clinical practice guidelines for integrative oncology: Complementary therapies and botanicals. Journal of the Society for Integrative Oncology, 7(3), 85–120. Fouladbakhsh, J. M., & Szczesny, S. M. (2014). Integrative nursing in community health. In M. J. Kreitzer & M. Koithan (Eds.), Integrative

nursing. Weil Integrative Medicine Library. Oxford Press.

25

1/21/14

Fouladbakhsh, J. M., Balneaves, L. G., & Jenuwine, L. (2013). Understanding CAM natural health products: Implications of use among cancer patients and survivors. Journal of the Advanced Practitioner in Oncology, 4(5), 289–306. Fouladbakhsh, J. M., Davis, J. A., & Yarandi, H. (2013). Using a standardized Viniyoga protocol for lung cancer survivors: A pilot study examining effects on breathing ease. Journal of Complementary & Integrative Medicine, Jun 26, issue 10. Fouladbakhsh, J. M. (2011). Yoga and Cancer. ONCOLOGY Nurse Edition, 25(2), 40–45. Fouladbakhsh, J. M. (2010). Comparative analysis of CAM use among the U.S. cancer and noncancer populations. Paper presented at the 5th International Congress on Complementary Medicine Research, Trumso, Norway. Fouladbakhsh, J. M., & Stommel, M. (2008). Comparative analysis of CAM use in the U.S. cancer and noncancer populations. Journal of Complementary & Integrative Medicine, 5(1), Article 19, 1–25.

Fouladbakhsh , J. M., & Stommel, M. (2007). Using the Behavioral Model for complementary and alternative medicine: The CAM Healthcare Model. Journal of Complementary & Integrative Medicine, 4(1), Article 11, 1–21. Hover-Kramer, D. (2002). Healing Touch: A Guidebook for Practitioners. Albany, NY: Delmar Publishers. Joines, W.T., Baumann, S. B. & Kruth, J. G. (2012). Electromagnetic emission from during focused intent. Journal of Parapsychology, 76(2). Joines, W.T., Baumann, S. B., Kim, J., Zile, J. M., & Simmons, C. (2004). The measurement & characterization of charge accumulation & electromagnetic emissions from bioenergy healers. The Parapsychological Association Convention, 445–447. Oschman, J. L. (2000). Energy Medicine. New York: Churchill Livingstone. Rand, W. (2011). Reiki: The Healing Touch. Southfield, MI: Vision Publications. Sagar, S. M. (2006). Integrative oncology in North America. Journal of the

Society for Integrative Oncology, 4(1), 27–39.

26