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{{POV|date=February 2011}}
{{Merge to |Alternative medicine |discuss=Talk:Alternative medicine#Merge from Integrative medicine |date=February 2011}}
{{see also|Alternative medicine}}

Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health. Many of integrative medicine’s individual elements — such as interventions addressing the psychological and environmental influences on health — have been researched and applied for decades.
Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health. Many of integrative medicine’s individual elements — such as interventions addressing the psychological and environmental influences on health — have been researched and applied for decades.


Revision as of 18:08, 22 February 2011

See also: Alternative medicine

Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health. Many of integrative medicine’s individual elements — such as interventions addressing the psychological and environmental influences on health — have been researched and applied for decades.

Easily incorporated by all medical specialties, professional disciplines and health care systems, important areas where an integrative approach has demonstrated efficacy include prevention and wellness, obstetrics, pediatrics, primary care, acute and chronic care, pain management, cancer care, cardiac care and palliative care.


Integrative Medicine Purpose

Through personalizing care, integrative medicine goes beyond the treatment of symptoms to address all the causes of an illness. In doing so, the patient’s immediate health needs as well as the effects of the long-term and complex interplay between biological, behavioral, psychosocial and environmental influences are taken into account.[1]

History

Fueled by a nationwide survey published in 1993 by Dr. David Eisenberg, which revealed that in 1990 approximately 60 million Americans had used one or more complementary or alternative therapies to address health issues,[2] A study published in the November 11, 1998 issue of The Journal of the American Medical Association reported that 42% of Americans had used complementary and alternative therapies, up from 34% in 1990.[3] However, despite the growth in patient demand for complementary medicine, most of the early alternative/complementary medical centers failed.[4]

Foundational Science

Prevention

Main article: Preventive medicine

The importance of prevention lies in the fact that the majority of our health care dollars are currently spent after a person is in crisis, when it costs the most to intervene and when the possibilities for full recovery are the slimmest.[5] Chronic diseases—such as asthma, heart disease, diabetes, some cancers, hypertension, stroke and obesity—account for more than half of all health care costs and more than 70% of deaths. Yet many chronic conditions are largely preventable and even reversible by making positive changes in personal behaviors. The Centers for Disease Control and Prevention (CDC) state that “four modifiable health risk behaviors—lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption—are responsible for much of the illness, suffering and early death related to chronic diseases.”[6]

Because changing one’s lifestyle is not always easy, integrative medicine health care providers have developed interventions that help people make the needed changes. In addition to formal lifestyle change programs such as those developed by Dean Ornish, Founder and President of the Preventive Medicine Research Institute,[7] or the Healing Hearts Program at Scripps Center for Integrative Medicine,[8] integrative health coaching is also proving to be a successful strategy. According to Duke Integrative Medicine, “Health coaches create dynamic partnerships with people who wish to adopt lifestyle changes that will help them reach their short- and long-term goals for satisfying and healthful lives.” Integrative health coaches help people clarify their health goals, and implement and sustain behaviors, lifestyles and attitudes that are conducive to optimal health. They also guide people in their personal care and health maintenance activities and assist them in reducing the negative impact made on their lives by chronic conditions such as cardiovascular disease, cancer and diabetes.[9] or the Healing Hearts Program at Scripps Center for Integrative Medicine,[10] integrative health coaching is also proving to be a successful strategy. According to Duke Integrative Medicine, “Health coaches create dynamic partnerships with people who wish to adopt lifestyle changes that will help them reach their short- and long-term goals for satisfying and healthful lives.” Integrative health coaches help people clarify their health goals, and implement and sustain behaviors, lifestyles and attitudes that are conducive to optimal health. They also guide people in their personal care and health maintenance activities and assist them in reducing the negative impact made on their lives by chronic conditions such as cardiovascular disease, cancer and diabetes.[11]

Patient-Centered Care

Studied and embraced by many leading health care organizations, such as the Institute for Healthcare Improvement,[12] being “patient-centered” means considering patients’ cultural traditions, personal preferences and values, social circumstances and lifestyles.

A 2001 Institute of Medicine report identified a focus on patient-centered care as one of six interrelated factors constituting high-quality health care.[13]

Clinical Research

Demonstrated Benefits Throughout the Lifespan

Pediatrics

  • Playing outdoors instead of sitting around and playing videogames is part of a lifestyle that will help reduce childhood obesity.
  • Mind-body techniques, specifically relaxation mental imagery, have been shown to be successful in helping children who experience pain.[14][15]
  • Touch therapy has been shown to improve health status in preterm and neonatal babies.[16]
  • Natural products that regulate metabolic processes have been shown effective in preventing and reducing obesity in children.[17]
  • Amusement parks - Reduction of stress has been found to have positive effects on the immune system. Going to amusement parks is a way of reducing stress in children.

Primary Care

Pain Management

See also: Pain management
  • Morphine is one of the strongest pain relievers known, and is used by integrative medicine docors in hospitals around the world.
  • Hydrocodone is one of the most widely prescribed pain relievers for lower back pain, is far more effective than acupuncture, and is prescribed by integrative medicine doctors around the world.
  • The combination of exercise, massage and acupuncture is a useful intervention for the care for low back pain.[20]
  • Effective integrative approaches to pain management use a combination of dietary modifications, herbs and supplements, manual medicine, acupuncture, yoga and mind-body therapies.[21]
  • A meta-analysis of mindfulness-based stress reduction programs involving pain, cancer, heart disease, depression and anxiety patients demonstrated that mindfulness practice can significantly improve both health and mental health states.[22]

Cancer Care

  • Stopping smoking has been shown to be a lifestyle change that reduces lung cancer, and is recommended by the integrative medicine practitioners.
  • The June 2008 Proceedings of the United Sates National Academy of Sciences published Ornish’s more recent work in prostate cancer, which demonstrated that lifestyle change can affect gene expression. The researchers found that improved nutrition, stress management, walking and psychosocial support changed the expression of over 500 genes in men with early-stage prostate cancer. They also discovered that oncogenes associated with breast cancer and prostate cancer, as well as genes that cause heart disease, oxidative stress, and inflammation were downregulated or “turned off,” whereas protective genes were unregulated or “turned on,” by lifestyle change.[23]
  • Outpatient acupuncture for advanced cancer patients produces a measurable benefit.[24]
  • Integrative care for cancer patients includes therapeutic interventions in diet, lifestyle, exercise, stress care and nutritional supplements, as well as experimental vaccines, chrono-chemotherapy and other advanced treatments.[25]

Cardiac Care

  • Integrative medicine uses prayer as an adjunct to interventional cardiac care.[26]
  • Integrative medicine doctors recommend exercise and weight loss to help reduce the risk of cardiovascular disease.[27]
  • In addition to the studies listed under lifestyle change programs above, which demonstrated improvements in cardiac disease, stress management and dietary changes have been proven effective in the treatment of ischemic heart disease.[28]
  • Research indicates that many integrative therapies are cost-effective and well-tolerated alternatives to current allopathic remedies for cardiovascular disease, which includes coronary artery disease, peripheral vascular disease, congestive heart failure, dyslipidemias and hypertension.[29]
  • Research indicates that smoking tobacco is an unhealthy lifestyle that can lead to heart disease, and integrative medicine practitioners recommend to stop smoking.
  • The INTERHEART study, published in September 2004 in The Lancet, followed 30,000 men and women on six continents and found that changing lifestyle could prevent at least 90% of all heart disease.[30]
  • The Preventive Medicine Research Institute conducted a demonstration project in collaboration with eight hospitals to determine if comprehensive lifestyle changes could be a safe and effective alternative to bypass surgery or angioplasty. After one year, almost 80% of participants were able to safely avoid heart surgery or angioplasty and Mutual of Omaha calculated saving almost $30,000 per patient in the first year.[31]
  • A meta-analysis looking at stress reduction and blood pressure concluded that Transcendental Meditation alone was able to reduce both systolic and diastolic high blood pressure in a significant number of the subjects.[32]
  • Drinking sugar filled drinks like sodas has been shown to increase obesity, which leads to obesity and heart disease, so inetgrative medicine recommends drinking healthy natural drinks with less sugar.

Palliative Care

See also: Palliative care
  • Prayer used as an adjunct to interventional care in integrative medicine.[33]
  • Addressing spirituality in palliative care settings helps patients transcend their daily experience and achieve a sense of peace even when confronting death. 47[34]
  • Going to church builds a sense of belonging and purpose, and helps patients transcend their daily experience and achieve a sense of peace even when confronting death.
  • Music-thanatology, a sub-specialty of palliative care, successfully unites music and medicine in end of life care. The music-thanatologist utilizes harp and voice at the bedside to serve the physical, emotional and spiritual needs of the dying and their loved ones with prescriptive music.[35]
  • Listening to Mozart has been shown to increase intelligence testing scores in children.

Summit on Integrative Medicine and the Health of the Public

On February 25-27, 2009, the Institute of Medicine convened the "Summit on Integrative Medicine and the Health of the Public", in Washington, DC, to advance the field of integrative medicine. The Summit brought together leaders from multiple sectors to present the vision, challenges, evidence base and opportunities for integrative medicine to improve health care in the United States.

The summit concluded that the “disease-driven approach to care has resulted in spiraling costs as well as a fragmented health system that is reactive and episodic as well as inefficient and impersonal.” As a result, summit faculty urged that “the first priority for any health care system using an integrative approach is to ensure that the full spectrum of preventive opportunities—clinical, behavioral, social, spiritual and environmental—are included in the care and delivery process.” They further advised that care “should account for the differences in individual conditions, needs and circumstances, and engage the patient as a partner in addressing all the factors that shape wellness, illness and restoration of health. The care should be a team activity with the patient as the central member and there should be seamless integration across caregivers and institutions for the achievement and maintenance of optimal health throughout the patient’s lifespan.”

Integrative Medicine in Academia

The Consortium of Academic Health Centers for Integrative Medicine

The Consortium of Academic Health Centers for Integrative Medicine—a group of acclaimed medical schools—was formed to make a qualitative difference in people's health by advocating an integrative model of health care. The Consortium helps transform medicine by promoting rigorous scientific studies, creating new models of clinical care and evolving innovative educational programs that integrate the principles of biomedicine, the complexity of human beings, the intrinsic nature of healing and the rich diversity of therapeutic systems. As of early 2011, the Consortium had 46 member schools.

Consortium Members in the United States and Canada <http://www.imconsortium.org/members/home.html>

Bravewell Clinical Network

Established by The Bravewell Collaborative in 2004, the Bravewell Clinical Network comprises nine leading clinical centers of integrative medicine. The Network was organized with the goal of developing successful clinical and business practices that could then serve as models for change in the larger health care delivery system. Members of the Clinical Network collectively see more than 18,000 patients per month; conduct joint research through BraveNet, a practice-based research network; and oversee a clinical rotation for Bravewell Fellows. In addition, successful clinical protocols are presented through the Bravewell Best Practices project.[4]

The nine centers in the Bravewell Clinical Network are:

  • Scripps Center for Integrative Medicine, Scripps Health, La Jolla, California
  • The Continuum Center for Health and Healing, New York, New York
  • Duke Integrative Medicine, Duke University, Durham, North Carolina
  • Jefferson-Myrna Brind Center of Integrative Medicine, Thomas Jefferson Medical College, Philadelphia, Pennsylvania
  • Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
  • Osher Center for Integrative Medicine, University of California, San Francisco, San Francisco, California
  • Alliance Institute for Integrative Medicine, Cincinnati, Ohio
  • Penny George Institute for Health and Healing, Allina Hospitals & Clinics, Minneapolis, Minnesota
  • Simms-Mann Health and Wellness Center at Venice Family Clinic, Los Angeles, California

Best Practices in Integrative Medicine

The Institute for Integrative Health

Founded in 2009, The Institute for Integrative Health seeks to catalyze new ideas in health care. The Institute is committed to advancing science with expanded research methods, linking experts across disciplines to generate new ideas, mentoring the leaders of today and tomorrow, exploring new models of health and discovering fresh ways to engage the public in its pursuit of health. The Institute has a scholars program, offers training in aspects of integrative medicine and conducts professional forums. <http://tiih.org>

Research Organizations

Corporate Health Improvement Program

Founded in 1984 at the University of California School of Medicine in San Francisco, the Corporate Health Improvement Program (CHIP) develops and evaluates innovative preventive health and medical interventions for clinical and cost effectiveness. Due to the growing interest in and success of integrative medicine, in 2004, CHIP moved to the Integrative Medicine Program at the University of Arizona. The member companies participating in CHIP include Fortune 500 corporations such as Dow, Mercer, Thomson-Reuters, American Specialty Health, Ford, Prudential, IBM, Pfizer, Corning, Pepsi and Nestle.

BraveNet

Under the guidance of the Duke Clinical Research Institute, which serves as the Coordinating Center, BraveNet is the nation’s first practice-based research network in integrative medicine. It currently consists of the nine member clinics of the Bravewell Clinical Network—Alliance Institute for Integrative Medicine; Continuum Center for Health and Healing; Duke Integrative Medicine; Penny George Institute for Health and Healing; Jefferson-Myrna Brind Center of Integrative Medicine; Scripps Center for Integrative Medicine; UCSF Osher Center for Integrative Medicine; University of Maryland Center for Integrative Medicine; and the Integrative Medicine Program at the Simms Health and Wellness Center at the Venice Clinic. (https://bravenet.dcri.duke.edu/)

Samueli Institute

The Samueli Institute is a non-profit research organization supporting the scientific investigation of healing and its role in medicine and health care. Founded in 2001, the Institute's focus includes complementary, alternative and integrative medicine; optimal healing environments; relationship-centered care; the role of the mind and lifestyle in healing; health care policy research; and military and veterans health research. Current areas of research include Integrative Medicine; Optimal Healing Environments (OHE); Military Medical Research Program and Brain-Mind & Healing. <http://www.siib.org>

Cost Effectiveness

In 2009, the United States federal, state and local governments; corporations and individuals, together spent $2.5 trillion ($8,047 per person) on health care. This amount represented 17.3% of the GDP, up from 16.2% in 2008.[36] The majority of these dollars were spent on medical care to treat diseases after they had already occurred. Through its emphasis on prevention and wellness, its focus on patient empowerment and its mandate to treat causes not just symptoms, integrative medicine holds the promise of helping to curtail these costs.

Clinical Settings

Cost savings through integrative approaches in clinical settings are achieved through lower utilization of expensive medical interventions, fewer complications and related diseases and preventive measures that keep people healthier longer. Additionally, many of these integrative interventions, such as Mindfulness Based Stress Reduction (MBSR) and mind-body skills training are taught in groups, reducing per-patient provider time.

A trial conducted in 2010 at Allina Hospitals & Clinics evaluated the use of resilience training for reducing symptoms of depression and presenteeism (when employees are present but their illness has a negative repercussion on business performance) in hospital employees. This training focused on mind-body skills development, exercise and nutritional approaches. More than 60% of the employees achieved sustained remission of their depression without the aid of medications, a cost savings in and of itself. However, in addition to lowered stress and anxiety levels, the researchers also found that “Work Productivity and Activity Impairment” scores suggested a presenteeism cost savings of $2,181 per employee per year.[37]

Two randomized controlled pilot studies conducted at Duke University in 2010 in conjunction with Aetna looked at integrative stress-reduction programs. Both studies showed significant reductions in stress as compared to the control group. Aetna’s review of medical claims’ data also showed a positive correlation between costs and study participants’ stress levels, suggesting potential health care costs savings could be realized by reducing stress.[38]

Corporate Programs

Corporate wellness programs or workplace wellness focusing on prevention and wellness, two key components of integrative medicine, are resulting in improved employee health and reduced costs. A review of these programs offered by employers as one approach to curtailing health care costs showed that in 2005, employers experienced an average 26% reduction in health care costs and an average $5.81 returned for every dollar invested in worksite health promotion initiatives.52[39] In addition to good program design and a robust engagement strategy, the best of these programs included having a strong culture of health, which includes environmental interventions such as modifications to cafeteria and vending machine options. In addition, many corporations enhanced the physical environment to promote exercise and created quiet areas for relaxation and stress reduction.

A 2009 study conducted in two diverse workplace settings used a series of interventions consisting of worksite health education, nutritional counseling, smoking cessation counseling, physical activity promotion, selected physician referral and other health counseling. Significant improvements were demonstrated in quality of life scores, depression and anxiety. Body fat, high-density lipoprotein cholesterol, diastolic blood pressure, health habits and total health risk scores all improved. In addition, average employee annual claim cost decreased 48% for the 12 months after the intervention, creating a sixfold return on investment.[40]

A review of the long-term impact of Johnson & Johnson’s health and wellness program indicated a reduction in medical expenditures ($224.66 per employee per year) over a four-year period with fewer outpatient and mental health visits.[41] A study assessing the impact of Highmark Inc.’s employee wellness program found that both health care expenses and inpatient expenses were reduced and that the program yielded a return on investment of $1.65 for every dollar invested.[42]

In more targeted studies, a trial at the Ford Motor Company Assembly Plant, which tested an integrative medicine intervention for lower back pain (acupuncture and mind-body practices for stress reduction), found a significant reduction in prescription pain medication intake, suggesting a potential long-term economic benefit to the company.[43] Another employee health program study reported in Preventive Cardiology looked at the impact of health education, smoking cessation programs, stress management, weight management, membership in a health club and other strategies. The researchers found that medical costs decreased for the employees in the program by $1,539 annually and that every dollar invested in worksite interventions resulted in $6.00 in health care savings.[40]

Future of Integrative Medicine

The practices and principles of integrative medicine have the potential to transform health care, improve the health care system, reduce costs and produce a much healthier nation better able to meet the challenges of the 21st century.

Because of the growing evidence base, insurance companies are now beginning to conduct their own research. Aetna, Duke Integrative Medicine, eMindful Inc. and American Viniyoga Institute are conducting randomized controlled studies on the potential of therapeutic yoga and meditation to reduce stress and improve health. Early results from the pilot studies of two stress-reduction programs showed significant reductions in stress as compared to the control group. Aetna’s review of medical claims’ data showed a positive correlation between costs and study participants’ stress levels, suggesting potential health care costs savings could be realized by reducing stress.[44]

Criticism of Integrative medicine

Because the nature of integrative medicine is to attempt to merge mainstream practice with alternative medicine techniques, as well as partially focusing treatment on the "spiritual", it is not without controversy and regarded by many medical experts as pseudoscience. Accordingly, it falls into the same category of criticisms as much of alternative medicine does. [45][46]

"There really is no such thing as alternative medicine--only medicine that has been proved to work and medicine that has not." Dr. Arnold Relman, editor in chief emeritus of The New England Journal of Medicine.[47] Speaking of government funding studies of integrating alternative medicine techniques into the mainstream, Dr. Steven Novella, a neurologist at Yale School of Medicine wrote that it "is used to lend an appearance of legitimacy to treatments that are not legitimate." Dr. Marcia Angell, executive editor of The New England Journal of Medicine says, "It's a new name for snake oil." [48]

See also

References

  1. ^ Vicki Weisfeld. (2009). Summit on Integrative Medicine & The Health of the Public: Issue Background and Overview. Washington, DC: Institute of Medicine. Retrieval 2011-1-18. http://www.bravewell.org/integrative_medicine/
  2. ^ Eisenberg, DM, et al. (1993). “Unconventional Medicine in the United States – Prevalence, Costs, and Patterns of Use.” JAMA: 328:246-252.
  3. ^ Eisenberg DM, Davis RB, Ettner SL, et al. 1998. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1;280 (18):1569-75.
  4. ^ a b Best Practices in Integrative Medicine: A Report from the Bravewell Clinical Network. Published 2007. The Bravewell Collaborative. Page 4.
  5. ^ Oz, MD, Mehmet. (2009). Real Health Care Reform: What’s Next. http://www.huffingtonpost.com/dr-mehmet-oz/real-health-care-reform-w_b_356123.html. Retrieval 2011-1-18.
  6. ^ National Centers for Disease Control and Prevention. (2010). “Chronic Disease Prevention and Health Promotion.” Centers for Disease Control and Prevention. http://www.cdc.gov/chronicdisease/overview/index.htm.
  7. ^ "Preventive Medicine Research Institute".
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  9. ^ "www.prmi.org".
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  11. ^ http://www.dukeintegrativehealthcoach.org/. {{cite web}}: Missing or empty |title= (help)
  12. ^ Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/
  13. ^ Institute on Medicine. Century.aspx "Crossing the Quality Chasm: A New Health System for the 21st Century". Retrieved 2 February 2011. {{cite web}}: Check |url= value (help)
  14. ^ Zeltzer, L, Lebaron, S. (1982). “Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer.” J Pediatr, 101:1032-1035.
  15. ^ Kohen,DP, Olness, KN. (1984). “The use of relaxation-mental imagery (self-hypnosis) in the management of 505 pediatric behavioral encounters.” J Dev Behav Pediatr, 5:21-25.
  16. ^ Field, TM, Schanberg SM, Scafidi F, et al. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics;77:654-658.
  17. ^ Jin-Taek Hwang, Dae Young Kwon, Joohun Ha. (2011) “Prevention of childhood obesity with use of natural products.” Global Perspectives on Childhood Obesity;443-452.
  18. ^ PubMed http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&term=vitamin%20d%20deficiency
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  21. ^ Raymond Y. Teets, Stephen Dahmer, Emilie Scott. (2010) “Integrative Medicine Approach to Chronic Pain.” Primary Care: Clinics in Office Practice, 37(2); 407-421
  22. ^ Paul Grossmana, Ludger Niemann, Stefan Schmidt, Harald Walach. (2004)Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of Psychosomatic Research. 57(1):35-43.
  23. ^ Dean Ornish, et.al. (2008)Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proceedings of the National Academy of Sciences. June 2008. http://www.pnas.org/content/105/24/8369.full.
  24. ^ Dean-Clower, E, Doherty-Gilman, AM, Keshaviah, A, Baker, F, Kaw, C, Lu, W, et.al.(2010) “Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients.” Integr Cancer Ther. 9(2):158-67.
  25. ^ "www.sagepub.com/journals/Journal201510".
  26. ^ Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study, The Lancet, Volume 366, Issue 9481, Pages 211-217, M. Krucoff, S. Crater, D. Gallup, J. Blankenship, M. Cuffe, M. Guarneri, R. Krieger, V. Kshettry, K. Morris, M. Oz
  27. ^ Journal of General Internal Medicine, Volume 21, Number 7, 728-734, DOI: 10.1111/j.1525-1497.2006.00495.x, A multidimensional integrative medicine intervention to improve cardiovascular risk, David Edelman, Eugene Z. Oddone, Richard S. Liebowitz, William S. Yancy, Maren K. Olsen, Amy S. Jeffreys, Samuel D. Moon, Amy C. Harris, Linda L. Smith and Ruth E. Quillian-Wolever, et al., [1]
  28. ^ Dean Ornish, et.al. (1982) “Effects of stress management training and dietary changes in treating ischemic heart disease.” The American Journal of Cardiology, 49 (4); 1008.
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  30. ^ Salim Yusuf, Steven Hawken, et.al. (2004), “Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-Control study,” The Lancet 364. 937–952.
  31. ^ Dean Ornish, et.al. (1990) “The Lifestyle Heart Trial.” The Lancet. 336(8708):129-33.
  32. ^ (2007)“Stress reduction programs in patients with elevated blood pressure: A systematic review and meta-analysis.” Current Hypertension Reports, 9:520-528.
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  34. ^ David Aldridge (1995) “Spirituality, hope and music therapy in palliative care,” The Arts in Psychotherapy, 22(2):103-109.
  35. ^ International Association of Music Thanatology. http://www.mtai.org/index.php/what_is.
  36. ^ Brent Jones (2010-02-04). Medical expenses have 'very steep rate of growth.' USA Today. http://www.usatoday.com/news/health/2010-02-04-health-care-costs_N.htm.
  37. ^ Private Communication April 24, 2010. Dr. Jeffrey Dusek, Research Director, The Penny George Institute for Health and Healing at Allina Hospitals.
  38. ^ "insurancenewsnet.com/article.aspx?id=242978".
  39. ^ (2009) “Do employee health management programs work?” American Journal of Health Promotion. 2009 Mar-Apr; 23(4):1-8.
  40. ^ a b Richard V. Milani, MD, Carl J. Lavie, MD (2009) Impact of Worksite Wellness Intervention on Cardiac Risk Factors and One-Year Health Care Costs. Preventive Cardiology. 104 (10),(15):1389-1392.
  41. ^ RJ Ozminkowski, et.al.(2002)Long-term impact of Johnson & John son’s Health And Wellness Program on Health Care Utilization and Expenditures. Journal of Occupational and Environmental Medicine. 44(1): 21-29.
  42. ^ BL Naydeck (2008) “The impact of the Highmark employee wellness programs on 4-year health costs.” Journal of Occupational and Environmental Medicine. 50 (2):146-56.
  43. ^ E. Kimbrough(2010) An Integrative Medicine Intervention in a Ford Motor Company Assembly Plant. Journal of Occupational and Environmental Medicine. 52 (3):256-257.
  44. ^ Aetna (January 13, 2011). "Aetna Building a Case for a "Mind-Body" Approach to Stress Management". Business Wire. Retrieved 4 February 2011.
  45. ^ http://scienceblogs.com/insolence/2011/01/the_integration_of_pseudoscience_into_me.php
  46. ^ http://www.washingtonpost.com/wp-dyn/content/article/2009/03/16/AR2009031602139.html
  47. ^ The New England Journal of Medicine, July 1995.
  48. ^ http://www.washingtonpost.com/wp-dyn/content/article/2009/03/16/AR2009031602139.html
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