You may raise an eyebrow upon hearing about the use of comple- mentary alternative (CAMs) in the OR. You may ask, “What are some CAMs that have been used in the OR?” or “How can a practitioner who performs YCAMs be permitted in the OR, when in the past only the surgical team involved in the procedure was permitted in the OR?” There’s a common misconcep- tion that “CAM” and “alternative ” are the same; in fact, you may hear the terms used syn- onymously. According to the National Center for Complement- ary and , however, CAMs are used together with conventional medi- cine.1 For example, music Complementing traditional surgery Jeanne Hately, RN, MSN, PhD

delivered through earphones to lessen a patient’s discomfort during and following surgery. Originating in China more than 2,000 years ago, acu- Alternative medicine is used in place of conven- puncture is one of the oldest, most commonly used tional medicine. For example, a special diet to treat therapies in the world. Acupuncture uses thin needles cancer rather than undergoing surgery, radiation, or to stimulate anatomical points on the body. The practi- .1 tioner inserts the needles and either a manual or elec- trical technique is used in key areas. Key areas are Various CAMs often determined according to symptoms described by CAMs include a long list of therapies or modalities, the patient.3 such as acupuncture, , guided imagery, herbalism, homeopathy, hypnosis, , music, Aromatherapy Qigong, Reiki, and therapeutic touch (TT). Many Aromatherapy is the practice of using volatile plant CAMs are natural modalities that were commonly oils, including essential oils, for psychological and used for hundreds of years but were discontinued with physical well-being. Essential oils are the pure essence the development of antibiotics and other medications.2 of a plant, not to be confused with perfumed oils,

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and have been found to provide both Essential oils and effects psychological and physical benefits Essential oil Effect when used correctly.4 (See Essential Basil Uplifting, refreshing, clarifying, aids oils and effects.) concentration Bergamot Refreshing, uplifting Guided imagery Chamomile Refreshing, relaxing, calming, soothing, Guided imagery is an effective visualiza- balancing Cedarwood Sedating, calming, soothing, strengthening tion technique sometimes referred to as Clary sage Warming, relaxing, uplifting, calming, a focused daydream. This method helps causes euphoria patients to focus on positive images to Cypress Relaxing, refreshing, provides astringent heal their bodies. Guided imagery prac- qualities titioners instruct patients in general Eucalyptus Head clearing, provides antiseptic and relaxation exercises and help patients decongestant properties, invigorating create detailed images in their minds. Fennel Provides carminative properties, eases A commonly used method of guided indigestion imagery is the Simonton Method, devel- Frankincense Relaxing, rejuvenating, eases breathing, oped by oncologist Dr. O. Carl Simon- dispels fears ton. The Simonton Method was devised Geranium Refreshing, relaxing, balancing Hyssop Provides decongestant properties to help patients undergoing cancer treat- Jasmine Relaxing, soothing, builds confidence ments to imagine their immune system Juniper Refreshing, stimulating, relaxing, promotes eating up and destroying cancer cells diuresis during treatment, thus freeing them of Lavender Refreshing, relaxing, provides therapeutic cancer.5 qualities, calming, soothing Lemon Refreshing, stimulating, uplifting, motivating Herbalism Lemongrass Toning, refreshing, fortifying Herbalism is the practice of prescribing Marjoram Warming, fortifying, sedating or making herbs for certain medical Melissa Uplifting, refreshing conditions, such as recommending black Myrrh Toning, strengthening, rejuvenating, cohosh for the treatment of hot flashes. provides expectorant properties Neroli Relaxing, dispels fears Many herbalists revert only to herbs for Orange Refreshing, relaxing the treatment of all conditions. Some Patchouli Relaxing, enhances sensuality caution must be used as individuals may Peppermint Cooling, refreshing, head clearing misuse and overdose or have sensitivi- Petigrain Refreshing, relaxing ties to an herb or compound.6 Pine Refreshing, provides antiseptic properties, invigorating, stimulating Homeopathy Rose Relaxing, soothing, enhances sensuality, A German physician in the late 18th builds confidence century, Samuel Hahnemann, is the Rosemary Invigorating, refreshing, stimulating, founder of homeopathy. Hahnemann clarifying worked on the premise of treating “like Sandalwood Relaxing, warming, builds confidence, grounding with like.” He studied patient symptoms Tea tree Acts as an antiseptic, strengthens immune and determined that symptoms were the system body’s way of fighting disease. Homeo- Thyme Acts as an antiseptic, refreshing, pathy practitioners encourage the symp- strengthens immune system toms seen and prescribe a remedy in Ylang ylang Relaxing, soothing, enhances sensuality small doses that in larger doses would produce the same symptoms displayed

Source: Thomas DV. Aromatherapy: Mythical, Magical, or Medicinal? Holist Nurs in the patient. According to homeopa- Pract. 2002; 17(1): 10. thy, this method stimulates the immune system to help cure the illness.7

40 OR Nurse2008 July/August www.ORNurseJournal.com Hypnosis eratively report a decrease in stress and pain postop- Clinical hypnosis is a technique used by a qualified eratively.11 health professional or therapist who give patients carefully worded instructions intended to guide the Reiki patient into a state of deep relaxation. In this relaxed Reiki is based on the belief that when energy is chan- state, the patient is aware of everything that’s occur- neled through a Reiki practitioner, the patient’s spirit is ring but, at the same time, becomes increasingly healed, which in turn heals the body and contributes absorbed in using her imagination as directed by the to an overall feeling of well-being.12 Reiki is practiced clinician. The clinician monitors the patient through- by placing the hands on or above the patient in vari- out the session and is able to reverse the hypnotic ous positions. A state of deep relaxation and a general state.8 feeling of well-being is usually one of the most imme- diate effects of the treatment. Reiki practice is based Massage on the concept that an unseen life force energy flows Massage is the manipulation of through all people. If one’s life connective tissues and muscles force energy is low, that person to stimulate circulation and is more likely to get sick or feel enhance the function of those stress; if the life force energy is tissues to promote relaxation high, that person is more capa- and well-being. Massage thera- ble of being happy and py can be highly effective for healthy.13 reducing the symptoms of arthritis, back pain, carpal tun- has been Therapeutic touch nel syndrome, and other disor- used in the OR to Reiki and TT are often con- ders of the muscles and ner- decrease postoperative fused, but in essence work on vous system.9 the same principles. TT is a rel- pain and anxiety. atively modern therapy with Music therapy origins in ancient healing prac- According to the American Music Therapy tices, and is a technique used to balance and restore Association, “Music therapy is the clinical and evi- the flow of human energy.14 TT was developed in dence-based use of music interventions to accom- the early 1970s by Dora Kunz, a natural healer, and plish individualized goals within a therapeutic rela- Dolores Krieger, RN, PhD, Professor Emerita of tionship by a credentialed professional who has com- Nursing at New York University and author of sever- pleted an approved music therapy program.”10 Music al books on the topic. therapy is designed to uplift physical and emotional health through the use of music. It’s often used in CAMs at work in the OR stress management programs or in conjunction with Some anesthesia providers use aromatherapy in the exercise. Music therapy is used in a variety of health- form of essential oils in the OR to promote relax- care settings with positive results in both short-term ation (lavender) and reduce nausea or perceptions of and more serious long-term conditions.10 smell (peppermint). Dr. Mehmet Oz, in his book Healing from the Heart, Qigong discussed his belief in the value of aromatherapy. He Qigong, similar to Tai Chi is an energy-producing stated that when patients were given a whiff of a Chinese movement technique that many healthcare flowery scent, their pain was lessened compared with providers now recommend for relaxation, stress when they sniffed spices, which made the patient reduction, and an overall feeling of well-being. more sensitive to pain. Dr. Oz also suspected that Qigong combines focused concentration with move- aromatherapy could be used to help surgical patients ments and balanced breathing in a controlled way. by inducing a relaxation response. Dr. Oz stated that The movements are simple, making the technique aromatherapy is very appealing because the emotion- easy to learn and easy to perform for most patients. al center of the brain is profoundly affected by Many patients who practice this technique preop- smell.15 www.ORNurseJournal.com July/August OR Nurse2008 41 Complementing traditional surgery

Hypnosis has been used for some time in the pre- tions found that there were significant decreases in operative area and has now extended into the OR. the intensity of pain in patients who experienced Mind-body methods for surgical application date music therapy during procedures compared with back to ancient Egypt. Noteworthy is the use of hyp- those who didn’t. The patients in this study had nosis in the 1840s by the Scottish surgeon, Dr. lower systolic BP and heart rate readings and took James Esdaile, who practiced in India and used hyp- fewer oral analgesics for pain.18 In another study by nosis as the anesthetic for eye surgery to limb ampu- Cooke et al., patients who listened to music during tations. During Dr. Esdaile’s era, standard surgical their preoperative period had significantly lower lev- mortality was 40% while Dr. Esdaile’s surgical mor- els of anxiety than patients who received routine tality was 5%.16 care without music.19 While under hypnosis, patients can be taught to Finally, a study on the effects of music therapy on alter psychophysiological functions. Research has the physiologic and psychological outcomes in shown that hypnosis is beneficial in reducing anxiety, patients who underwent cardiac surgery showed evi- decreasing blood loss and dence that patients who listened postoperative nausea and to music during surgery had a vomiting, lowering the per- significant reduction in pain and ception of pain, accelerating anxiety postoperatively.20 wound healing, lowering Reiki has been used success- complication rates, and short- fully as an adjunct to surgery.21 ening hospital length of stay.16 Reiki practitioners can be in the The patient benefits and cost OR at the patient’s request as savings make hypnosis both Some anesthesia pro- long as the risks are reviewed an accessible and feasible viders use aromatherapy with the patient and practitioner option for patients who want to promote relaxation and and both sign the required to use CAM methods to waivers. increase their healing and sat- reduce nausea or Reiki induces relaxation, isfaction with the overall peri- perceptions of smell. relieves stress, and can lower operative experience. the patient’s BP and heart rate. Hypnosis can be used with or without an experi- Because Reiki is noninvasive, it’s often referred to as enced professional.16 a hands-on healing technique. Acting through the It would be difficult to perform massage therapy autonomic nervous system to lower BP and heart during a surgical procedure, but there are benefits of rate, it can relieve anxiety and stress. It’s believed that massage in the preoperative and postoperative areas. this technique encourages a feeling of well-being, Dr. Phil Barr of Longmont, Colorado, is an advocate assisting the immune system in defending against of bodywork and prescribes massage for all of his bacteria and viruses. This feeling of well-being stimu- hospitalized patients. Longmont United Hospital is lates the production of endorphins in the brain, based on the Planetree model, which provides a thereby decreasing the brain’s perception of pain.21 humanized and personalized atmosphere that Operatively, the Reiki practitioner stands at the attends to the heart and spirit of the patient. Many head of the OR table, or wherever appropriate, and preoperative and postoperative patients at this facility uses light touch to channel energy to the patient. This are offered massage for relaxation and to reduce is coordinated with the circulating nurse, anesthesia anxiety before and after their procedures. Studies provider, and surgeon before the case begins to indicate that this trend is catching on throughout the avoid any confusion or stressful situation in the OR. United States.17 Some patients request a Reiki session with their prac- Music therapy in the OR has been used to titioner immediately before surgery, which reportedly decrease postoperative pain and anxiety. It’s well- has the same benefits as stated above for patients known that high levels of postoperative pain can lead during and after surgery.22 to adverse reactions, including extended hospitaliza- TT can be used in the preoperative and postopera- tion and longer recovery times. tive areas. The practitioner uses her hands to facilitate A study by Tse et al. of postoperative pain percep- the healing process by the exchange of energy. TT

42 OR Nurse2008 July/August www.ORNurseJournal.com Guides. 2002. Available at: http://www.abc.net.au/health/ repatterns the body’s energy field so that the patient’s consumerguides/stories/2002/08/22/1836994.htm. Accessed May 28, own natural healing can begin. Hartford Hospital in 2008. Connecticut provides patients with TT to help the 3. National Center for Complementary and Alternative Medicine. National Institutes of Health. Definition of Acupuncture. Available at: healing process. TT has been reported to create a http://www.nccam.nih.gov/health/acupuncture. Accessed April 23, relaxation response, alleviate anxiety and tension, 2008. alter the perception of pain and discomfort, and 4. AromaWeb.com. Definition of Aromatherapy. Available at: http:// www.aromaweb.com. Accessed April 23, 2008. noticeably enhance the body’s natural healing 5. University of California, San Diego Medical Center. Moores Cancer 23 process. It may also help accelerate healing of Center. Definition of Guided Imagery. Available at: http://cancer. wounds, fractures, and infections.23 ucsd.edu/Outreach/PublicEducation/CAMs/guidedimagery.asp. Accessed April 23, 2008. 6. MedicineNet.com. Definition of Herbalism. Available at: http:// Future research www.medterms.com/script/main/art.asp?articlekey=11465. Accessed Future research may explore other CAMs that can be April 23, 2008. 7. MedicineNet.com. Definition of Homeopathy. Available at: http:// used in the OR to benefit the patient without compro- www.medterms.com/script/main/art.asp?articlekey=3775. Accessed April mising the integrity of the sterile field or surgical site. 23, 2008. CAMs have been identified as the third way to cut 8. MedicineNet.com. Definition of Hypnosis. Available at: http:// www.medterms.com/script/main/art.asp?articlekey=10809. Accessed healthcare costs; the first two are cutting benefits and April 23, 2008. raising taxes. Ruggie stated that alternative medicine 9. MedicineNet.com. Massage therapy: what massage therapy is. Avail- promises an inclusive, innovative, and fiscally respon- able at: http://www.medicinenet.com/massage_therapy/page2. htm. Accessed April 23, 2008. 24 sible solution to helping cut healthcare costs. It’s 10. American Music Therapy Association. Definition of Music Therapy. incumbent upon surgeons and perioperative nurses 2005. Available at: http://www.musictherapy.org. Accessed April 23, to familiarize themselves with the psychological and 2008. 11. Qigong Energy Healing. Definition of Qigong Energy Healing. Avail- physiologic effects of surgery on the patient and with able at: http://www.qigongenergyhealing.com/. Accessed April 23, 2008. the literature on CAMs. This information is useful in 12. MedicineNet.com. Definition of Reiki. Available at: http://www. modifying the adverse reactions of surgery, as well as medterms.com/script/main/art.asp?articlekey=31106. Accessed April 23, 2008. improving outcome measures to offer patients the 13. The International Center for Reiki Training. Available at: http:// maximum benefit from surgery. www.reiki.org. Accessed April 23, 2008. Improvement in surgical outcomes measures using 14. Therapeutic touch. Available at: http://www.therapeutictouch.org/. CAMs, including monitoring anxiety, blood loss, post- Accessed May 22, 2008. 15. Oz M. Healing from the heart: a leading surgeon combines eastern and operative pain levels, pain medication requirements, western traditions to create the medicine of the future. New York: Putnam postoperative nausea and vomiting, recovery of bowel Penguin; 1999: 110-11. function, length of hospital stay, cost of care, and 16. Gurgevich S. Clinical hypnosis and surgery. Alt Med Alert. 2003; 6(10):115-20. patient satisfaction, have been documented in various 17. Vanderbilt S. A day in the life. The many faces of Hospital-based studies. CAMs have been noted to be highly beneficial massage and bodywork. Massage and Bodywork. 2002. Available at: in improving preoperative, intraoperative, and postop- http://www.massageandbodywork.com/Articles/JuneJuly2000/aday. html. Accessed May 28, 2008. erative patient outcomes. Although there are studies 18. Tse M, Chan M, Benzie I. The effect of music therapy on postopera- available, there’s a need for further research and docu- tive pain, heart rate, systolic blood pressures and analgesic use following mentation by and for perioperative nurses. nasal surgery. J Pain Pharmacother. 2005;19(3):21-29. 19. Cooke M, Capboyer W, Schluter P, Hiratos M. The effect of music As more is learned about the effects of CAM ther- on preoperative anxiety in day surgery. J Adv Nurs. 2005;Oct;52(1):47- apies, these specific effects can be integrated into and 55. used with other more traditional pain treatments as a 20. Sendelbach S, Halm M, Doran K et al. Effects of music therapy on physiological and psychological outcomes for patients undergoing means to maximize overall efficacy of pain treatment cardiac surgery. J Cardiovasc Nurs. 2006 May-Jun;21(3):194-200. and perception. In this way, nurses can seek to ensure 21. Sawyer J. The first Reiki practitioner in our OR. AORN J. 1998 that the greatest number of patients obtain the great- Mar;67(3):674-76. OR 22. McMillen M. Light touch in the operating room. Special to the est benefit from the care offered. Washington Post. 2005 (July). 23. Hartford Hospital. Therapeutic Touch. Available at: http://www. REFERENCES harthosp.org/integrativemed/Therapies/TherapeuticTouch/default. aspx?sitesearch=true. Accessed May 28, 2008. 1. National Center for Complementary and Alternative Medicine, National Institutes of Health. Definition of Complementary and Alter- 24. Ruggie MA. ‘Third way’ to cut healthcare costs. Christian Science native Medicine. Available at: http://nccam.nih.gov/health/whatiscam. Monitor. June 30, 2004. Accessed April 23, 2008. Jeanne Hately is the regional nursing director at Corinthian Colleges, Inc., 2. Head J. Alternative therapies. ABC Health and Wellbeing. Consumer Santa Ana, Calif.

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