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Mehl A, von Laue B, Trapp B, Gerlach K, Reif M, Pretzer K, Zerm R, Berger B, Gutenbrunner C, Kröz M. The Anthroposophic Artistic Movement Assessment for Eurythmy Therapy (AART-ASSESS-EuMove). A validation study. Complement Ther Med 2023; 76:102957. [PMID: 37286140 DOI: 10.1016/j.ctim.2023.102957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVE Eurythmy Therapy (ET) is a mindfulness oriented therapy developed in the context of anthroposophic medicine. Despite commonly used in practice, it remains unclear whether active participation (Inner Correspondence) during ET can be observed in eurythmy gestures (EGest). So far, no validated peer-report instrument to evaluate EGest exists. METHOD To validate an 83-item ET peer-report scale, a nested study on a sample of n = 82 breast cancer survivors with cancer-related fatigue was conducted. EGest were evaluated twice, at baseline and at 10-week follow-up, by peer-reports from two separate therapists. Interrater-reliability (IRR) was estimated by Cohen's weighted kappa (κw) across all items. Additionally, reliability-(RA) and principal component analyses (PCA) were conducted. Patients completed two self-report scales: Satisfaction with ET (SET) and Inner Correspondence with the Movement Therapy (ICPH). RESULTS IRR was greater than or equal (κw ≥ 0.25) for 41 items (49.3%) with a mean weighted kappa of κ̅w = 0.40 (SD = 0.17, range = 0.25-0.85). RA resulted in the exclusion of 25 items with insufficient item-total correlations < 0.40. A PCA with 16 items revealed 3 subscales: 1. Mindfulness in Movement (8 items), 2. Motor Skills (5 items), 3. Walking Pattern (3items) explaining 63.86% of total variance. Internal consistency (Cronbach's alpha) was high for the sum score with α = 0.89 and for the subscales with α = 0.88, 0.86 and 0.84 respectively. Significant small to moderate subscale correlations were found ranging from r = 0.29-0.63 (all p < 0.01). Mindfulness in Movement correlated with Inner Correspondence (r = 0.32) and with Satisfaction with ET (r = - 0.25, both p < 0.05). CONCLUSIONS The new AART-ASSESS-EuMove is the first consistent and reliable peer-report instrument to evaluate EGest. It shows associations between peer-reported Mindful Movement and patients' self-reported ICPH and SET.
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Affiliation(s)
- A Mehl
- Research Institute Havelhöhe, Kladower Damm 221, 14089 Berlin, Germany.
| | - B von Laue
- AnthroMed Öschelbronn - Centre for Integrative Medicine, 75233 Niefern-Öschelbronn, Germany
| | - B Trapp
- Praxis Frauenheilkunde - Lebenswunder, Berlin-Havelhöhe, 14089 Berlin, Germany
| | - K Gerlach
- Institute for Eurythmy Therapy, Research Institute of Arts Therapy, Alanus Hochschule, Villestraße 3, 53347 Alfter, Germany
| | - M Reif
- Society for Clinical Research, Hardenbergstraße 20, 10623 Berlin, Germany
| | - K Pretzer
- Raumzeitwerker, Practice for Eurythmy Therapy, 10967 Berlin, Germany
| | - R Zerm
- Research Institute Havelhöhe, Kladower Damm 221, 14089 Berlin, Germany
| | - B Berger
- Institute for Integrative Medicine, University Witten/Herdecke, Gerhard Kienle Weg 8, 58313 Herdecke, Germany
| | - C Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - M Kröz
- Research Institute Havelhöhe, Kladower Damm 221, 14089 Berlin, Germany; Institute for Integrative Medicine, University Witten/Herdecke, Gerhard Kienle Weg 8, 58313 Herdecke, Germany; Hospital Arlesheim, Research Department, Pfeffinger Weg 1, 4144 Arlesheim, Switzerland
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Zerm R, Müller-Glinz A, Pranga D, Reif M, Bartsch C, Heckmann C, Gutenbrunner C, Kröz M. Influence of multimodal treatment on rest/activity and autonomic regulation in breast cancer patients with cancer related fatigue - results of a tri-center trial with a comprehensive cohort design. Complement Med Res 2022; 30:115-129. [PMID: 36228577 DOI: 10.1159/000527354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/29/2022] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Breast cancer patients with cancer-related fatigue (BC-CRF) often have lower physical activity. To investigate how this could be improved we evaluated a multimodal treatment (MT) and a combination of MT with aerobic training (CT) were and compared these with aerobic training (AT) regarding rest/activity rhythm and state autonomic regulation (State aR). METHODS In this pragmatic comprehensive cohort design study the explorative analysis focused on actigraphy and State aR including the rest/activity regulation subscale (State aR-R/A) which were assessed at baseline (T0), after ten weeks of intervention (T1) and State aR additionally six months later (T2). STATISTICS General linear modelling including propensity scores. RESULTS 65 BC-CRF were randomised and 61 allocated by preference to the treatment arms. 105 patients started the intervention. At T1 State aR-R/A improved the most in MT (+3.49, CI [2.42; 4.55]) compared to AT (+1.59, CI [0.13; 3.06] and CT (+1.68, CI [0.83; 2.52]) showing superiority of MT to AT (p=0.048). At T2 MT was sustainably superior to AT regarding State aR-R/A (+3.61, CI [2.38; 4.83] p<0.01) and State aR also showed superiority of MT to AT (p=0.006). AT T1 24-hour activity was higher in MT compared to AT (p=0.029). CONCLUSIONS MT was superior to AT regarding State aR total score after six months, State aR-R/A after 10 weeks and after six months. Actigraphically measured total activity also improved after 10 weeks.
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Affiliation(s)
- Roland Zerm
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Department of Internal Medicine, Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Augustina Müller-Glinz
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Institute for Integrative Medicine, University Witten/Herdecke, Herdecke, Germany
| | | | - Marcus Reif
- Society for Clinical Research, Berlin, Germany
| | - Christian Bartsch
- Interfaculty Institute of Biochemistry, University Tübingen, Tübingen, Germany
| | - Christian Heckmann
- Institute for Integrative Medicine, University Witten/Herdecke, Herdecke, Germany
| | | | - Matthias Kröz
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Institute for Integrative Medicine, University Witten/Herdecke, Herdecke, Germany
- Department of Research, Arlesheim Hospital, Arlesheim, Switzerland
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Schröder ML, Stöckigt B, Binting S, Tissen-Diabaté T, Bangemann N, Goerling U, Kröz M, Blohmer JU, Ortiz M, Brinkhaus B. Feasibility and Possible Effects of Mindful Walking and Moderate Walking in Breast Cancer Survivors: A Randomized Controlled Pilot Study With a Nested Qualitative Study Part. Integr Cancer Ther 2022; 21:15347354211066067. [PMID: 35045736 PMCID: PMC8777370 DOI: 10.1177/15347354211066067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction: Breast cancer (BC) survivors often suffer from disease- and therapy-related
long-term side-effects. The study aim was to explore the feasibility,
adherence, and individual experiences as well as possible effects of 2
different walking interventions in BC patients. Methods: This randomized controlled, pragmatic pilot trial included a qualitative
study component. BC patients were randomized to either mindful walking (MFW)
with mindfulness exercises and walking or moderate walking (MW) alone in
weekly group sessions over 8 weeks. After 8 and 16 weeks, satisfaction, and
self-perceived effectiveness as well as different health-related outcomes
including health-related (WHOQOL-BREF) and disease-specific quality of life
(FACT-G), perceived stress (PSQ) and cancer-related fatigue (CFS-D) were
assessed. ANCOVA was used to evaluate differences in study outcomes.
Qualitative data included 4 focus group interviews including 20 patients and
were analyzed using a directed qualitative content analysis approach. Results: Altogether, 51 women (mean age 55.8 years (SD 10.9)) were randomized (n = 24
MFW; n = 27 MW). Both groups would recommend the course to other BC patients
(MFW 88.9%; MW 95.2%) and showed possible improvements from baseline to week
8, without statistically significant difference between groups: WHOQOL-BREF
(MFW: adjusted mean 65.4 (95% confidence interval (CI), 57.1-73.7); MW: 61.6
(53.6-69.6)); FACT-G (MFW: 76.0 (71.5-80.5); MW: 73.0 (68.5-77.4)); PSQ
(MFW: 45.3 (40.5-50.1); MW: 45.4 (40.8-50.0)); CFS-D (MFW: 24.3 (20.8-27.8);
MW: 25.5 (22.1-28.8)). Improvements lasted until the 16-weeks follow-up. The
qualitative analysis suggested that MFW primarily promoted mindfulness,
self-care, and acceptability in BC patients, whereas MW activated and
empowered the patients as a result of the physical exercise. Conclusion: Both study interventions were positively evaluated by patients and showed
possible pre-post effects in disease-specific health-related outcomes
without differences between groups. The qualitative analysis results
indicate that different resources and coping strategies were addressed by
the 2 study interventions. Trial registration: DKRS00011521; prospectively registered 21.12.2016; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011521.
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Affiliation(s)
| | | | | | | | | | - Ute Goerling
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Kröz
- Research Institute Havelhoehe, Berlin, Germany.,University Witten/Herdecke, Witten, Germany.,Hospital Arlesheim, Switzerland
| | | | - Miriam Ortiz
- Charité - Universitätsmedizin Berlin, Berlin, Germany
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Quittel F, Zerm R, Reif M, Büssing A, Gutenbrunner C, Kröz M. Long-term effects on Quality of life of a Multimodal Therapy in Breast Cancer patients with Fatigue. Eur J Integr Med 2021. [DOI: 10.1016/j.eujim.2021.101937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Michalsen A, Jeitler M, Kessler CS, Steckhan N, Robens S, Ostermann T, Kandil FI, Stankewitz J, Berger B, Jung S, Kröz M, Büssing A. Yoga, Eurythmy Therapy and Standard Physiotherapy (YES-Trial) for Patients With Chronic Non-specific Low Back Pain: A Three-Armed Randomized Controlled Trial. J Pain 2021; 22:1233-1245. [PMID: 33892154 DOI: 10.1016/j.jpain.2021.03.154] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
We aimed to evaluate the effects of yoga and eurythmy therapy compared to conventional physiotherapy exercises in patients with chronic low back pain. In a three-armed, multicentre, randomized controlled trial, patients with chronic low back pain were treated for 8 weeks in group sessions (75 minutes once per week). Primary outcome was patients' physical disability (measured by RMDQ) from baseline to week 8. Secondary outcome variables were pain intensity and pain-related bothersomeness (VAS), health-related quality of life (SF-12) and life satisfaction (BMLSS). Outcomes were assessed at baseline, after the intervention at 8 weeks and at a 16-week follow up. Data of 274 participants were used for statistical analyses. There were no significant differences between the three groups for the primary and all secondary outcomes. In all groups, RMDQ decreased comparably at 8 weeks, but did not reach clinical meaningfulness. Pain intensity and pain-related bothersomeness decreased, while quality of life increased in all 3 groups. In explorative general linear models for the SF-12's mental health component participants in the eurythmy arm benefitted significantly more compared to physiotherapy and yoga. Furthermore, within-group analyses showed improvements of SF-12 mental score for yoga and eurythmy therapy only. All interventions were safe. Clinical Trials Register: DRKS-ID: DRKS00004651 Perspective: This article presents the results of a multicentre three-armed randomized controlled trial on the clinical effects of three 8-week programs in patients with chronic low back pain. Compared to the 'gold standard' of conventional physiotherapeutic exercises, eurythmy therapy and yoga therapy lead to comparable symptomatic improvements in patients with chronic low back pain. However, the within-group effect sizes were small to moderate and did not reach clinical meaningfulness on patients' physical disability (RMDQ).
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Affiliation(s)
- Andreas Michalsen
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; Department of Internal and Integrative Medicine, Immanuel Hospital Berlin, Germany.
| | - Michael Jeitler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; Department of Internal and Integrative Medicine, Immanuel Hospital Berlin, Germany
| | - Christian S Kessler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; Department of Internal and Integrative Medicine, Immanuel Hospital Berlin, Germany
| | - Nico Steckhan
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; Department of Internal and Integrative Medicine, Immanuel Hospital Berlin, Germany
| | - Sibylle Robens
- Department of Psychology and Psychotherapy, Witten/Herdecke University, Germany
| | - Thomas Ostermann
- Department of Psychology and Psychotherapy, Witten/Herdecke University, Germany
| | - Farid I Kandil
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | - Bettina Berger
- Institute of Integrative Medicine, Witten/Herdecke University, Germany
| | - Sonny Jung
- Institute of Integrative Medicine, Witten/Herdecke University, Germany
| | - Matthias Kröz
- Research Institute Havelhöhe (FIH), Berlin, Germany; Institute of Integrative Medicine, Witten/Herdecke University, Germany; Department of Research and Sleep Medicine Arlesheim Hospital, Arlesheim, Switzerland
| | - Arndt Büssing
- Institute of Integrative Medicine, Witten/Herdecke University, Germany
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Oei SL, Thronicke A, Kröz M, von Trott P, Schad F, Matthes H. Impact of Oncological Therapy and Viscum album L Treatment on Cancer-Related Fatigue and Internal Coherence in Nonmetastasized Breast Cancer Patients. Integr Cancer Ther 2021; 19:1534735420917211. [PMID: 32478590 PMCID: PMC7273755 DOI: 10.1177/1534735420917211] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Introduction:Viscum album L extracts (VA) are frequently used in integrative
oncology. Aim of this study was to evaluate the impact of add-on VA applications
on various patient-reported outcome measures. Methods: A
longitudinal real-world study was conducted, using data from the Network
Oncology clinical registry. Primary, nonmetastasized breast cancer patients
treated with oncological standard therapy partly combined with VA applications
were included. Internal Coherence Cancer-related Fatigue, and EORTC QLQ-C30
questionnaires were assessed at baseline and 6, 12, and 24 months later.
Results: A total of 319 patients received standard oncological
therapy and 40% of them additionally VA applications. After 6 and 12 months for
patients treated with chemotherapy (Ctx) only a significant decline of the
thermo-coherence, and worsening of fatigue was observed. For patients receiving
VA applications but no Ctx, significant beneficial effects on thermo-coherence,
fatigue, and seven EORTC QLQ-C30 scales were observed 24 months later. Adjusted
multivariable long-term subgroup (n = 106) regression analysis
revealed that Ctx, immuno-, and endocrine therapies had a worsening of 17, 17,
and 6 point changes, respectively, for EORTC QLQ-C30 fatigue (P
= .0004), while VA applications showed an improvement of 12 point change. A
similar impact of improvement (add-on VA) and worsening (standard oncological
treatment regimens) on EORTC QLQ-C30 insomnia (P = .009) and
physical functioning (P = .005) were observed.
Conclusions: In the present real-world study, add-on VA
applications had a supportive effect on cancer-related fatigue, insomnia,
physical functioning, and thermo-coherence. Thus, VA applications might be
suited to alleviate symptom burden during anticancer therapy in breast cancer
patients.
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Affiliation(s)
| | | | - Matthias Kröz
- Research Institute Havelhöhe, Berlin, Germany.,Institute for Integrative Medicine, Witten/Herdecke, Germany
| | - Philipp von Trott
- Interdisciplinary Oncology and Palliative Care, Hospital Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Friedemann Schad
- Research Institute Havelhöhe, Berlin, Germany.,Interdisciplinary Oncology and Palliative Care, Hospital Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Harald Matthes
- Research Institute Havelhöhe, Berlin, Germany.,Interdisciplinary Oncology and Palliative Care, Hospital Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany.,Medical Clinic for Gastroenterology, CBF, Charité Universitätsmedizin Berlin, Berlin, Germany
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Megas IF, Tolzmann DS, Bastiaanse J, Fuchs PC, Kim BS, Kröz M, Schad F, Matthes H, Grieb G. Integrative Medicine and Plastic Surgery: A Synergy-Not an Antonym. ACTA ACUST UNITED AC 2021; 57:medicina57040326. [PMID: 33915729 PMCID: PMC8066838 DOI: 10.3390/medicina57040326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/09/2021] [Accepted: 03/25/2021] [Indexed: 01/25/2023]
Abstract
Background: Integrative medicine focuses on the human being as a whole—on the body, mind, and spirit—to achieve optimal health and healing. As a synthesis of conventional and complementary treatment options, integrative medicine combines the pathological with the salutogenetic approach of therapy. The aim is to create a holistic system of medicine for the individual. So far, little is known about its role in plastic surgery. Hypothesis: We hypothesize that integrative medicine based on a conventional therapy with additional anthroposophic therapies is very potent and beneficial for plastic surgery patients. Evaluation and consequence of the hypothesis: Additional anthroposophic pharmacological and non-pharmacological treatments are promising for all areas of plastic surgery. We are convinced that our specific approach will induce further clinical trials to underline its therapeutic potential.
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Affiliation(s)
- Ioannis-Fivos Megas
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (I.-F.M.); (D.S.T.); (J.B.)
| | - Dascha Sophie Tolzmann
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (I.-F.M.); (D.S.T.); (J.B.)
| | - Jacqueline Bastiaanse
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (I.-F.M.); (D.S.T.); (J.B.)
| | - Paul Christian Fuchs
- Department of Plastic Surgery and Hand Surgery, Burn Center, University of Witten/Herdecke, Kliniken der Stadt Köln, Ostmerheimer Str. 200, 51109 Köln, Germany;
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland;
| | - Matthias Kröz
- Institute of Integrative Medicine, University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany;
- Research Department Klinik Arlesheim, Pfeffingerweg 1, 4144 Arlesheim, Switzerland
- Research Institute Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (F.S.); (H.M.)
| | - Friedemann Schad
- Research Institute Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (F.S.); (H.M.)
| | - Harald Matthes
- Research Institute Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (F.S.); (H.M.)
- Institute of Social Medicine, Epidemiology and Health Economics CCM, Charité University Medicine, Charitéplatz 1, 10117 Berlin, Germany
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; (I.-F.M.); (D.S.T.); (J.B.)
- Department of Plastic Surgery and Hand Surgery, Burn Center, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
- Correspondence:
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Kröz M, Reif M, Glinz A, Berger B, Nikolaou A, Zerm R, Brinkhaus B, Girke M, Büssing A, Gutenbrunner C. Correction to: Impact of a combined multimodal-aerobic and multimodal intervention compared to standard aerobic treatment in breast cancer survivors with chronic cancer-related fatigue - results of a three-armed pragmatic trial in a comprehensive cohort design. BMC Cancer 2020; 20:1174. [PMID: 33261571 PMCID: PMC7708222 DOI: 10.1186/s12885-020-07679-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- Matthias Kröz
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089, Berlin, Germany. .,Research Institute Havelhöhe, Kladower Damm 221, D-14089, Berlin, Germany. .,Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Charité CCM, 10098, Berlin, Berlin, Germany. .,nstitute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg, 58313, Herdecke, Germany.
| | - Marcus Reif
- Society for Clinical Research, Hardenbergstraße 20, 10623, Berlin, Germany
| | - Augustina Glinz
- Research Institute Havelhöhe, Kladower Damm 221, D-14089, Berlin, Germany
| | - Bettina Berger
- nstitute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg, 58313, Herdecke, Germany
| | - Andreas Nikolaou
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Roland Zerm
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089, Berlin, Germany.,Research Institute Havelhöhe, Kladower Damm 221, D-14089, Berlin, Germany
| | - Benno Brinkhaus
- Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Charité CCM, 10098, Berlin, Berlin, Germany
| | - Matthias Girke
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089, Berlin, Germany.,Research Institute Havelhöhe, Kladower Damm 221, D-14089, Berlin, Germany
| | - Arndt Büssing
- nstitute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg, 58313, Herdecke, Germany
| | - Christoph Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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Mehl A, Brauer D, Didwiszus A, Gelin-Kröz B, Pranga D, Zerm R, Gutenbrunner C, Reif M, Kröz M. The Anthroposophic Art Therapy Assessment Paint (AART-ASSESS-P): A peer-report instrument to assess patients' pictorial expression during Anthroposophic Painting Therapy. Explore (NY) 2020; 17:541-548. [PMID: 32843248 DOI: 10.1016/j.explore.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Anthroposophic painting therapy (APT) is a specific form of art therapy that aims to activate self-healing capacities through painting aquarelles. METHODS The Anthroposophic Art Therapy Assessment-Paint' (AART-ASSESS-P) was developed to measure pictorial expression and validated in the framework of a comprehensive cohort design study. The validation study examined 68 breast cancer patients with fatigue. Art therapists made pre- and post-assessments of spontaneously drawn water-color paintings with a preliminary version of the AART-ASSESS-P (58 items). Inter-rater reliability (IRR) for the items was examined with Cohen's weighted Kappa (κw). Additionally, a reliability- and factor analysis (FA) were conducted. Convergence criteria were patients' self-report measures: the Satisfaction with Painting Therapy, Inner Correspondence with Painting Therapy and the Self-Regulation Questionnaire. RESULTS IRR for the items was heterogeneous (κw= 0.09-0.89, Mean κw= 0.40, SD = 0.17). Thirty-six items were excluded due to insufficient IRR and item-total correlation (κw= < 0.30, ρitem-total< 0.30). A FA with 22 items revealed 5 subscales: Shape Development (6 items), Shape Arrangement (6 items), Order and Symmetry (5 items), Color Application (3 items), and Color Quality (2 items) explaining 61% of total variance. Psychometric properties for the AART-ASSESS-P were satisfying with Cronbach's alpha coefficients (rα = 0.60-0.81) across subscales. Due to weak inter-subscale correlations (r = 0.18-0.48, p < 0.05) and the ambiguity of face validity a sum-score was not formed. Correlations between subscales and self-reports were small (all p < 0.05). CONCLUSION The AART-ASSESS-P is the first reliable instrument to measure pictorial expression during APT.
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Affiliation(s)
- A Mehl
- Research Institute Havelhöhe, Kladower Damm 221, 14089Berlin, Germany.
| | - D Brauer
- Medical Section, School of Spiritual Science/Goetheanum, 4134Dornach, Switzerland
| | - A Didwiszus
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089Berlin, Germany
| | - B Gelin-Kröz
- Research Institute Havelhöhe, Kladower Damm 221, 14089Berlin, Germany
| | - D Pranga
- Research Institute Havelhöhe, Kladower Damm 221, 14089Berlin, Germany
| | - R Zerm
- Research Institute Havelhöhe, Kladower Damm 221, 14089Berlin, Germany; Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089Berlin, Germany
| | - C Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625Hannover, Germany
| | - M Reif
- Society for Clinical Research, Hardenbergstraße 20, 10623Berlin, Germany
| | - M Kröz
- Research Institute Havelhöhe, Kladower Damm 221, 14089Berlin, Germany; Institute for Integrative Medicine, University Witten/Herdecke, Gerhard Kienle Weg 8, 58313Herdecke, Germany; Hospital Arlesheim, Research Department, Pfeffinger Weg 1, 4144Arlesheim, Switzerland
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Mehl A, Reif M, Zerm R, Pranga D, Friemel D, Berger B, Brinkhaus B, Gutenbrunner C, Büssing A, Kröz M. Impact of a Multimodal and Combination Therapy on Self-Regulation and Internal Coherence in German Breast Cancer Survivors With Chronic Cancer-Related Fatigue: A Mixed-Method Comprehensive Cohort Design Study. Integr Cancer Ther 2020; 19:1534735420935618. [PMID: 32618207 PMCID: PMC7491213 DOI: 10.1177/1534735420935618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Recent studies have proved the relevance of salutogenetic variables for fatigue management in breast cancer survivors with cancer-related fatigue (CRF). This comprehensive cohort design study is the first to examine the impact of 2 multimodal therapies, multimodal therapy (MT) and combined therapy (CT), compared with standard aerobic training (AT) on salutogenetic variables (self-regulation and internal coherence) and distress in breast cancer survivors with CRF. Methods: A total of 105 patients started the therapies and n = 84 completed the Self-regulation Scale, the Internal Coherence Scale, the Cancer Fatigue Scale, and the Hospital Anxiety and Depression Scale at baseline, 10 weeks after treatment (T1) and n = 81 after 6 months (T2). Patient satisfaction and qualitative feedback regarding therapy quality was assessed at T1. A general linear model including allocation type, therapy arm (MT/CT/AT), and bias-adjusting propensity scores tested the superiority of both multimodal therapies versus AT for all questionnaires at T1 and T2. Results: MT and CT were superior to AT to improve self-regulation and patients' satisfaction at T1. Additionally, CT showed superiority for self-regulation at T2 (all P < .05). Compared with AT, internal coherence was significantly higher for patients in the MT arms at T2, respectively (all P < .01). Pearson's correlations between self-regulation, internal coherence, and CRF improved from baseline to T2 (Mean r = -0.60). Qualitative feedback confirmed patients' benefits in several health-related categories. Conclusions: Self-regulation and internal coherence are manipulable variables with relevant CRF associations. They can be positively affected by multimodal therapies. Alongside patients' satisfaction and qualitative feedback they help refine treatment.
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Affiliation(s)
| | - Marcus Reif
- Society for Clinical Research, Berlin, Germany
| | - Roland Zerm
- Research Institute Havelhöhe, Berlin, Germany.,Havelhöhe Hospital, Berlin, Germany
| | | | | | | | | | | | | | - Matthias Kröz
- Research Institute Havelhöhe, Berlin, Germany.,Witten/Herdecke University, Witten, Germany
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Oei SL, Thronicke A, Kröz M, Matthes H, Schad F. Use and Safety of Viscum album L Applications in Cancer Patients With Preexisting Autoimmune Diseases: Findings From the Network Oncology Study. Integr Cancer Ther 2019; 18:1534735419832367. [PMID: 30808274 PMCID: PMC6432670 DOI: 10.1177/1534735419832367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Viscum album L (VA, mistletoe) extracts are commonly used in integrative oncology. Here the clinical safety profile of additional VA-treatments to standard care in cancer patients with preexisting autoimmune diseases was analyzed. METHODS In this observational cohort study medical data and recorded adverse events (AEs) of treated patients were retrieved from the Network Oncology registry and a safety analysis was performed. RESULTS A total of 106 patients (median age 63 years) treated with add-on VA-extracts were analyzed. Most frequent autoimmune diseases were Hashimoto's thyroiditis (27%), psoriasis (19%), and ulcerative colitis (15%). Seventeen patients (16%) experienced VA-related AEs, but neither long-term side effects nor VA-therapy discontinuations were recorded. In a subgroup of 30 patients receiving long-term VA-therapy no exacerbations or flares of underlying autoimmune diseases were recorded. Additionally, a significant halving of overall AE-rates was observed during VA-treatment periods (p= 0.019). CONCLUSIONS Our findings suggest that add-on VA-therapy in cancer patients with preexisting autoimmune diseases as Hashimoto's thyroiditis, psoriasis, ulcerative colitis, Grave's disease, and some rheumatic diseases is safe. No higher rates of VA-associated AEs were observed and the overall AE-rates were significantly lowered in VA-therapy periods. However, results should be interpreted with caution in light of the study's observational character.
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Affiliation(s)
| | | | - Matthias Kröz
- 1 Research Institute Havelhöhe, Berlin, Germany.,3 Institute for Social Medicine, Charité, Berlin, Germany.,4 Institute for Integrative Medicine, Witten/Herdecke, Germany
| | - Harald Matthes
- 1 Research Institute Havelhöhe, Berlin, Germany.,3 Institute for Social Medicine, Charité, Berlin, Germany.,5 Medical Clinic for Gastroenterology, CBF, Charité, Berlin, Germany
| | - Friedemann Schad
- 1 Research Institute Havelhöhe, Berlin, Germany.,2 Oncological Centre, Hospital Havelhöhe, Berlin, Germany
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12
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Kröz M, Mehl A, Didwiszus A, Gelin-Kröz B, Reif M, Berger B, Ten Brink F, Zerm R, Girke M, Gutenbrunner C, Büssing A. Reliability and first validity of the inner correspondence questionnaire for painting therapy (ICPTh) in a sample of breast cancer patients. Complement Ther Med 2019; 42:355-360. [PMID: 30670266 DOI: 10.1016/j.ctim.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 01/31/2023] Open
Abstract
Objectives Art therapy (ArT) such as mindfulness-oriented painting therapy is increasingly used in psychosomatic, oncological integrative and rehabilitative medicine. Though it remains unknown how ArT works, we hypothesize that an engaged participation with painting ('Inner-Correspondence') contributes to improved symptom scores. In the context of a comprehensive cohort study for breast cancer survivors with cancer-related fatigue, we developed a patient-reported outcome measure to assess 'Inner Correspondence' with painting therapy and conducted a first validation study. Design A 24-item questionnaire on 'Inner Correspondence' (ICPTh) was administered after ten weeks of intervention and at six month followup together with concurrent scales (Inner Correspondence and Peaceful Harmony, Cancer Fatigue Scale, Hospital Anxiety and Depression Scale, Internal Coherence Scale). Statistical assessment included reliability- and factor analyses. Results A total of n = 68 BC (mean age, 58.2 years, SD = 8.7) participated in the preliminary validation study. Exploratory factor analysis revealed a robust 22-item scale with an unambiguous four-factor solution explaining 78% of total variance and the following subsales: 1) therapy congruence and relaxation (11 items), 2) inner development and mood (6 items), 3) artistic skill (3 items) and 4) task congruence (2 items). The 22-item ICPTh yielded high reliability (Cronbach's alpha = .966, item-total correlation = .497 - .883, test-retest reliability = .888). Conclusions We present a reliable instrument to measure 'Inner Correspondence' with painting therapy. Due to the small sample size and sample selection further validation studies are indicated.
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Affiliation(s)
- M Kröz
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089 Berlin, Germany; Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany; Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Luisenstraße 57, 10117, Berlin, Germany; Institute of Integrative Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
| | - A Mehl
- Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| | - A Didwiszus
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089 Berlin, Germany; Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| | - B Gelin-Kröz
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089 Berlin, Germany; Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| | - M Reif
- Society for Clinical Research, Hardenbergstraße 19, 10623, Berlin, Germany.
| | - B Berger
- Institute of Integrative Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
| | - F Ten Brink
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - R Zerm
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089 Berlin, Germany; Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| | - M Girke
- Department of Internal Medicine Havelhöhe Hospital, Kladower Damm 221, 14089 Berlin, Germany; Research Institute Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| | - C Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - A Büssing
- Institute of Integrative Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
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Poier D, Büssing A, Rodrigues Recchia D, Beerenbrock Y, Reif M, Nikolaou A, Zerm R, Gutenbrunner C, Kröz M. Influence of a Multimodal and Multimodal-Aerobic Therapy Concept on Health-Related Quality of Life in Breast Cancer Survivors. Integr Cancer Ther 2018; 18:1534735418820447. [PMID: 30584782 PMCID: PMC6432685 DOI: 10.1177/1534735418820447] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Context: Cancer-related fatigue (CRF) is one of the most burdensome symptoms in breast cancer survivors (BCSs), accompanied by reduced health-related quality of life (HRQOL). Objectives: This study investigated the influence of a multimodal therapy (MT; psychoeducation, eurythmy therapy, painting therapy, and sleep education/restriction), or a combination therapy (CT; MT plus aerobic training [AT]) on HRQOL in BCS with chronic CRF in comparison with AT alone. Methods: One hundred and twenty-six BCSs with CRF were included in a pragmatic comprehensive cohort study and allocated either per randomization or by preference to MT, CT, or AT. The EORTC QLQ-C30 core questionnaire was used to measure HRQOL. All analyses on HRQOL parameters were done in an explorative intention. Results: Patients were assigned to MT (n = 44), CT (n = 54), or AT (n = 28). CT was significantly superior to AT after 10 weeks of intervention (T1) in improving physical function. MT was found to have significant superiority over AT at T1 and T2 for physical functioning, emotional functioning, insomnia, and financial problems as well as role functioning, cognitive, social functioning, and fatigue 6 months later (T2). Conclusion: A multimodal approach appears to be a suitable concept for BCS with chronic CRF. A confirmatory study with larger samples should demonstrate the superiority of MT and adapted CT in HRQOL compared with the current treatment AT found in these explorative analyses.
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Affiliation(s)
| | | | | | | | - Marcus Reif
- 2 Society for Clinical Research, Berlin, Germany
| | | | - Roland Zerm
- 4 Research Institute Havelhoehe, Berlin, Germany.,5 Havelhöhe Hospital, Berlin, Germany
| | | | - Matthias Kröz
- 1 Witten/Herdecke University, Herdecke, Germany.,4 Research Institute Havelhoehe, Berlin, Germany.,6 Charité University Medical Center, Berlin, Germany
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Thronicke A, Kröz M, Merkle A, Matthes H, Herbstreit C, Schad F. Psychosocial, Cognitive, and Physical Impact of Elaborate Consultations and Life Review in Female Patients with Non-Metastasized Breast Cancer. Complement Med Res 2018; 25:92-101. [DOI: 10.1159/000486672] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Elaborate consultations and life review (ECLR) has been regularly applied in patients of various cancer entities and stages within Anthroposophic-integrative oncology concepts. However, a lack of systematic research in this field has been detected. To close this gap of knowledge, we evaluated the impact of ECLR in patients with non-metastasized breast cancer before, during, and after primary oncological treatment. Methods: Patient-reported outcome measures were evaluated by analyzing European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ-C30) in patients with non-metastasized breast cancer who had received either oncological standard therapy alone or in combination with ECLR. Results: 95 female patients were eligible for questionnaire analysis (median age 58 years). Adjusted multivariable linear regression analysis revealed that ECLR was associated with significant improvements in medium-term global health/quality of life and emotional, social, and cognitive functioning. Furthermore, ECLR was associated with significant reductions of short-term appetite loss burden, pain, and short- and medium-term financial difficulties. Subgroup analyses revealed significant improvements in pivotal quality-of-life aspects including fatigue (p = 0.002) in chemotherapy-treated patients after ECLR. Conclusions: 12 months of surveillance of breast cancer patients reveals medium-term recovery of the global health status/quality of life and cognitive and psychosocial well-being associated with ECLR. In addition, our data indicate a possible association between ECLR and reduced short-term fatigue burden, which has to be re-confirmed prospectively in a larger study cohort. As long-term cancer survivors develop psychological symptoms similar to patients with chronic diseases, prospective studies should evaluate the impact of ECLR on the psychosocial well-being in these patients.
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Thronicke A, Oei SL, Merkle A, Herbstreit C, Lemmens HP, Grah C, Kröz M, Matthes H, Schad F. Integrative cancer care in a certified Cancer Centre of a German Anthroposophic hospital. Complement Ther Med 2018; 40:151-157. [PMID: 30219441 DOI: 10.1016/j.ctim.2018.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/19/2018] [Accepted: 03/31/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The concept of integrative oncology (IO) comprising guideline-oriented standard and add-on complementary medicine has gained growing importance. The Anthroposophic-integrative Cancer Centre (CC) at the hospital Gemeinschaftskrankenhaus (GKH) in Berlin has been implementing IO concepts during recent years. Furthermore, it is a certified CC and has been annually audited by national cancer authorities since 2012. The objective of the present study was to evaluate IO concepts of the certified CC GKH. METHODS Clinical, demographic, integrative treatment and follow-up data were analyzed between 2011 and 2016. In addition, CC GKH quality measures were compared with those of nationwide benchmarking CCs. RESULTS Between 2011 and 2016, 2.382 primary cancer patients, median age 66 years, were treated at the CC GKH. 70.1% of the patients showed either Union for International Cancer Control (UICC) stage 0, I, II or III and 25.6% were in UICC stage IV. IO therapies included surgery (64.4% of patients), radiation (41.2%), and application of cytostatic drugs (53.9%), add-on mistletoe therapy (30.5%), and non-pharmacological interventions (87.3%). Regarding psycho-oncological support and quota of patient's enrollment in studies the CC GKH performs above nationwide benchmarks. Research outcomes including safety issues, clinical impact as well as patient's health-related quality of life are continuously evaluated and integrated into hospital's decision-management. CONCLUSION This analysis reveals that IO concepts are applied to a high proportion of male and female primary cancer patients of all age groups, indicating a successful implementation at the certified CC GKH. Ongoing clinical evaluations have been initiated and cost-effectiveness comparisons are under analyses.
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Affiliation(s)
| | - Shiao Li Oei
- Research Institute Havelhöhe, 14089 Berlin, Germany.
| | - Antje Merkle
- Research Institute Havelhöhe, 14089 Berlin, Germany; Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany.
| | - Cornelia Herbstreit
- Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany; Breast Cancer Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany.
| | - Hans-Peter Lemmens
- Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany; Colon and Rectum Cancer Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany.
| | - Christian Grah
- Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany; Lung Cancer Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany.
| | - Matthias Kröz
- Research Institute Havelhöhe, 14089 Berlin, Germany; Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, 10098 Berlin, Germany; Institute for Integrative Medicine, University of Witten/Herdecke, 58313 Witten, Herdecke, Germany.
| | - Harald Matthes
- Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany; Medical Department, Division of Gastroenterology, Infectiology and Rheumatology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.
| | - Friedemann Schad
- Research Institute Havelhöhe, 14089 Berlin, Germany; Oncological Centre, Hospital Gemeinschaftskrankenhaus Havelhöhe, 14089 Berlin, Germany.
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Schad F, Thronicke A, Merkle A, Steele ML, Kröz M, Herbstreit C, Matthes H. Implementation of an Integrative Oncological Concept in the Daily Care of a German Certified Breast Cancer Center. Complement Med Res 2018; 25:85-91. [PMID: 29510405 DOI: 10.1159/000478655] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In recent decades the concept of integrative medicine has attracted growing interest in patients and professionals. At the Gemeinschaftskrankenhaus Havelhöhe (GKH), a hospital specialized in anthroposophical medicine, a breast cancer center (BCC) has been successfully certified for more than 5 years. The objective of the present study was to analyze how integrative strategies were implemented in the daily care of primary breast cancer patients. METHODS Clinical, demographic, and follow-up data as well as information on non-pharmacological interventions were analyzed. In addition, BCC quality measures were compared with data of the National Breast Cancer Benchmarking Report 2016. RESULTS Between 2011 and 2016, 741 primary breast cancer patients (median age 57.4 years) were treated at the GKH BCC. 91.5% of the patients showed Union for International Cancer Control (UICC) stage 0, I, II, or III and 8.2% were in UICC stage IV. 97% of the patients underwent surgery, 53% radiation, 38% had hormone therapy, and 25% received cytostatic drugs. 96% of the patients received non-pharmacological interventions and 32% received Viscum album L. THERAPY Follow-up was performed in up to 93% of the patients 2 years after first diagnosis. Compared to nationwide benchmarking BCCs, the GKH BCC met the requirements in central items. CONCLUSIONS The results of the present study show that integrative therapies offered by the concept of anthroposophical medicine can be implemented in the daily care and treatment of a certified BCC. However, as national guidelines on integrative concepts in oncology are missing, further studies are needed for a systematic evaluation of integrative treatment and care concepts in this field.
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Büssing A, Poier D, Ostermann T, Kröz M, Michalsen A. Treatment of Chronic Lower Back Pain: Study Protocol of a Comparative Effectiveness Study on Yoga, Eurythmy Therapy, and Physiotherapeutic Exercises. Complement Med Res 2017; 25:24-29. [PMID: 28675892 DOI: 10.1159/000471801] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We aim to compare the effectiveness of 3 active interventions, i.e., yoga, eurythmy therapy, and physiotherapeutic exercise, on chronic lower back pain. METHODS In this randomized controlled trial over 16 weeks (8 weeks of intervention, 8 weeks of follow-up), data of individuals with chronic lower back pain will be analyzed. Interventions are implemented as group sessions (75 min) once per week. Participants receive a manual for home-based practice and are assessed before and at the end of the 8-week intervention period, and at the end of an 8-week follow-up period. Standardized questionnaires are: the Roland-Morris Disability Score, visual analog scales measuring intensity of pain, the Brief Multidimensional Life Satisfaction Scale, the Perceived Stress Scale, the Inner Correspondence with the Practices questionnaire, the Freiburg Mindfulness Questionnaire, the General Self-Efficacy Scale, a self-regulation questionnaire, the Internal Coherence Scale, a pain diary (registering the need of analgesic medication), and a questionnaire on the patients' expectation that the interventions will be effective in reducing pain and how strong this reduction might be (2 single items), etc. DISCUSSION This large multicenter study will provide evidence on the effectiveness of 3 contrasting movement-orientated treatments that share some similarities but differ in essential details: yoga, eurythmy therapy, and physiotherapeutic exercises. It will provide important data on non-pharmacological options to treat lower back pain in a large group of affected individuals.
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Ortiz M, Schnabel K, Teut M, Rotter G, Binting S, Cree M, Lotz F, Suhr R, Brinkhaus B, Parvizi MM, Handjani F, Zarshenas MM, Moein MR, Nimrouzi M, Hatam G, Hasanzadeh J, Hamidizadeh N, Parvizi MM, Heydari M, Namazi MR, Parvizi Z, Pasalar M, Mosaffa-Jahromi M, Bagheri-Lankarani K, Afsharypuor S, Tamaddon AM, Ostovar M, Peloni G, Bolliger I, Faria RMDC, Quadri P, Sanzeni W, Zemp D, Risvoll H, Giverhaug T, Halvorsen KH, Waaseth M, Musial F, Rossi E, Baccetti S, Picchi M, Conti T, Firenzuoli F, Guido C, Bosco F, Guido C, Rossi E, Panozzo M, Picchi M, Cervino C, Nurra L, Rossi E, Picchi M, Firenzuoli F, Traversi A, Vuono K, Sabatini F, Bellandi T, Rutert B, Eggert A, Seifert G, Stritter W, Holmberg C, Längler A, Salamonsen A, Wiesener S, Schad F, Steele M, Kröz M, Matthes H, Herbstreit C, Thronicke A, Schlingensiepen I, von Schoen-Angerer T, Schneider R, Waeber L, Vagedes J, Kaczala G, Pharisa C, Wildhaber J, Huber B, Sidorov P, Sovershaeva E, Simões-Wüst AP, Nietlispach A, Mennet M, Schnelle M, von Mandach U, Wang X, Woo HL, Lee JM, Wu Y, Cho Y, Yun Y, Kim H, Jung W, Jang BH, Ziea E, Hui H, Li M, Tsui D, Lam C, Hsieh J, Chan E, Balneaves L, Burnside S, Doyle E, Dorazio S, Chan PK, Bhagra A, Chen PH, Chung VCH, Wu JCY, Lin ZX, Wong W, Wu XY, Ho RST, Wong CHL, Chan L, Ziea ETC, Elder W, Cardarelli R, Kaspar C, Kempenich R, Kopferschmitt J, Marinko Z, Damir S, Vcev A, Monezi R, Ruggerini EM, Fuchigami IM, Mazini ACM, Monezi R, Oliveira MW, Papuga P, Schloss J, Steel A, Jacobsen MDS, Monezi R, Jacobsen MR, Mangini MT, Trapani G, Di Giampietro T, Zanino L, Ciullo L, Lanaro D, Cerritelli F, Macrì F, Tsai A, Lin C, Wu TH, D’Alessandro E, Watts S, Zhang Y, Wu X, Li X, Fei Y, Liu J, Zhao N, Jia L, Yan X, Zhen F, Liu Z, Liu J, Ahn J, Yun Y, AlEidi S, Mohamed AG, Al-Beda AM, Abutalib RA, Khalil MKM, Amri H, Badekila S, Behmanesh E, Mozaffarpour S, Behmanesh E, Mozaffarpour S, Behmanesh E, Shirooye P, Meybodi RN, Mokaberinejad R, Tansaz M, Mozaffarpour S, Chung VCH, Wu XY, Wu JCY, Daneshfard B, Hosseinkhani A, Tafazoli V, Jaladat AM, Jaladat AM, Sadeghi H, Jia L, Zhao N, Yan X, Zhou L, Zhao M, Li W, Liu J, Liu Z, Jia L, Zhao N, Yan X, Zhou L, Zhao M, Li W, Liu J, Liu Z, Larsen AL, Salamonsen A, Kristoffersen AE, Hamran T, Evjen B, Stub T, Li M, Cai J, Lu T, Yin L, Wu D, Wang L, Liew SM, Liu T, Bai C, Zheng Z, Wan Y, Xu J, Wang X, Yu H, Gu X, Liu Z, Yan X, Jia L, Zhao N, Yang G, Liu J, Mozaffarpour S, Behmanesh E, Nimrouzi M, Tafazoli V, Daneshfard B, Ostrowski D, Fox K, Pasalar M, Tabatabei F, Amini F, Sathasivampillai S, Rajamanoharan P, Munday M, Heinrich M, Scherrer YM, Heinrich M, Szuter C, Amini F, Tabatabaei F, Tavakoli A, Tavakoli F, Pasalar M, rostami M, Torri MC, Szuter C, Walach H, Warner F, Majumdar A, Serasingh P, Yan X, Jia L, Zhao N, Liu Z, Liu J, Zhao N, Zhen F, Jia L, Yan X, Liu Z, Liu J, Abbing A, Ponstein A, Baars E, Croke S, Hanser S, Heckel V, Krüerke D, Simões-Wüst AP, Weiss S, Metzner S, Lee JW, Hyun MK, Masetti M, Oepen R, Gruber H, Heusser P, Pelz H, Perlitz V, Ponstein A, Abbing A, Baars E, Robinson N, Ronan P, Mian A, Madge S, Lorenc A, Agent P, Carr S, Ronan P, Robinson N, Carr S, Mian A, Lorenc A, Agent P, Madge S, Winnubst ME, Monezi R, Abolghasemi J, Heydari M, Baccetti S, Rossi E, Fedi P, Di Stefano M, Belvedere K, Baccetti S, Rossi E, Firenzuoli F, Di Stefano M, Belvedere K, Beaven K, Rose A, Florschutz G, Phil NB, Parsons H, Stewart-Brown S, Burke K, Busch M, Heyning F, Smit J, Jeekel H, de Goeij H, Guido PC, Barraza N, Balbarrey Z, Ribas A, Jimenez B, Iachino C, Quattrone F, Gaioli M, Dell’Orso M, Villanueva S, Rocha C, Macchi A, Cai J, Chen L, Wu D, Wang S, Choi E, Go N, Lee Y, Dahal G, Frauenknecht X, Gerhardt H, Galanti M, Cerda CJ, Galanti M, Galanti M, Heckersdorf DN, Jorquera H, Saldivia MLA, Jakubonienė D, McEwen B, Melo F, Fontana FM, Valle ACV, Neres MTB, Mohagheghzadeh A, Zohalinezhad ME, Njaradi O, Dunjic M, Njaradi O, Dunjic M, Ostrowski D, Fox K, Pokladnikova J, Selke-Krulichova I, Seo J, Jang H, Simões-Wüst AP, Moltó-Puigmartí C, van Dongen M, Dagnelie P, Thijs C, Tihanyi E, Hegyi G, Zhang Y, Li X, Fei Y, Liu J, Zhang Y, Liu J, Tong X. World Congress Integrative Medicine & Health 2017: part three. Altern Ther Health Med 2017. [PMCID: PMC5499100 DOI: 10.1186/s12906-017-1784-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Estrems MS, Gómez VG, Estrems MS, Sabater MV, Ferreri R, Bernardini S, Pulcri R, Cracolici F, Rinaldi M, Porciani C, Firenzuoli F, Baccetti S, Di Stefano M, Monechi MV, Gallo E, Maggini V, Gori L, Rossi E, Fisher P, Hughes J, Mendoza A, MacPherson H, Witt C, Filshie J, Lewith G, Di Francesco A, Bernardini A, Messe M, Primitivo V, Iasella PA, Ghelman R, Taminato M, Alcantara JDC, De Oliveira KR, Rodrigues DCDA, Mumme JRC, Sunakozawa OKM, Filho VO, Seifert G, Goldenberg J, Day A, Sasagawa M, Ward L, Cooley K, Gunnarsdottir T, Hjaltadottir I. World Congress Integrative Medicine & Health 2017: part two. BMC Complement Altern Med 2017. [PMCID: PMC5498867 DOI: 10.1186/s12906-017-1783-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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FJ, Dobos G, Anheyer D, Haller H, Lauche R, Dobos G, Cramer H, Azizi H, Khadem N, Hassanzadeh M, Estiri N, Azizi H, Tavassoli F, Lotfalizadeh M, Zabihi R, Esmaily H, Azizi H, Shabestari MM, Paeizi R, Azari MA, Bahrami-Taghanaki H, Zabihi R, Azizi H, Esmaily H, Baars E, De Bruin A, Ponstein A, Baccetti S, Di Stefano M, Rossi E, Firenzuoli F, Segantini S, Monechi MV, Voller F, Barth J, Kern A, Lüthi S, Witt C, Barth J, Zieger A, Otto F, Witt C, Beccia A, Dunlap C, Courneene B, Bedregal P, Passi A, Rodríguez A, Chang M, Gutiérrez S, Beissner F, Beissner F, Preibisch C, Schweizer-Arau A, Popovici R, Meissner K, Beljanski S, Belland L, Rivera-Reyes L, Hwang U, Berger B, Sethe D, Hilgard D, Heusser P, Bishop F, Al-Abbadey M, Bradbury K, Carnes D, Dimitrov B, Fawkes C, Foster J, MacPherson H, Roberts L, Yardley L, Lewith G, Bishop F, Al-Abbadey M, Bradbury K, Carnes D, Dimitrov B, Fawkes C, Foster J, MacPherson H, Roberts L, Yardley L, Lewith G, Bishop F, Holmes M, Lewith G, Yardley L, Little P, Cooper C, Bogani P, Maggini V, Gallo E, Miceli E, Biffi S, Mengoni A, Fani R, Firenzuoli F, Brands-Guendling N, Guendling PW, Bronfort G, Evans R, Haas M, Leininger B, Schulz C, Bu X, Wang J, Fang T, Shen Z, He Y, Zhang X, Zhang Z, Wang D, Meng F, Büssing A, Baumann K, Frick E, Jacobs C, Büssing A, Grünther RA, Lötzke D, Büssing A, Jung S, Lötzke D, Recchia DR, Robens S, Ostermann T, Berger B, Stankewitz J, Kröz M, Jeitler M, Kessler C, Michalsen A, Cheon C, Jang BH, Ko SG, Huang CW, Sasaki Y, Ko Y, Cheshire A, Ridge D, Hughes J, Peters D, Panagioti M, Simon C, Lewith G, Cho HJ, Han D, Choi SJ, Jung YS, Im HB, Cooley K, Tummon-Simmons L, Cotton S, Luberto CM, Wasson R, Kraemer K, Sears R, Hueber C, Derk G, Lill JR, An R, Steinberg L, Rodriguez LD, la Fuente FGD, De la Vega M, Vargas-Román K, Fernández-Ruiz J, Cantarero-Villanueva I, Rodriguez LD, García-De la Fuente F, Jiménez-Guerrero F, Vargas-Román K, Fernández-Ruiz J, Galiano-Castillo N, Diaz-Saez G, Torres-Jimenez JI, Garcia-Gomez O, Hortal-Muñoz L, Diaz-Diez C, Dicen D, Diezel H, Adams J, Steel A, Wardle J, Diezel H, Steel A, Frawley J, Wardle J, Broom A, Adams J, Dong F, Yu H, Liu T, Ma X, Yan L, Wan Y, Zheng Z, Gu X, Dong F, Yu H, Wu L, Liu T, Ma X, Ma J, Yan L, Wan Y, Zheng Z, Zhen J, Gu X, Dubois J, Rodondi PY, Edelhäuser F, Schwartze S, Trapp B, Cysarz D. World Congress Integrative Medicine & Health 2017: Part one. Altern Ther Health Med 2017. [PMCID: PMC5498855 DOI: 10.1186/s12906-017-1782-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Kröz M, Reif M, Glinz A, Berger B, Nikolaou A, Zerm R, Brinkhaus B, Girke M, Büssing A, Gutenbrunner C. Impact of a combined multimodal-aerobic and multimodal intervention compared to standard aerobic treatment in breast cancer survivors with chronic cancer-related fatigue - results of a three-armed pragmatic trial in a comprehensive cohort design. BMC Cancer 2017; 17:166. [PMID: 28253845 PMCID: PMC5335840 DOI: 10.1186/s12885-017-3142-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cancer-related fatigue (CRF) and insomnia are major complaints in breast cancer survivors (BC). Aerobic training (AT), the standard therapy for CRF in BC, shows only minor to moderate treatment effects. Other evidence-based treatments include cognitive behavioral therapy, e.g., sleep education/restriction (SE) and mindfulness-based therapies. We investigated the effectiveness of a 10-week multimodal program (MT) consisting of SE, psycho-education, eurythmy- and painting-therapy, administered separately or in combination with AT (CT) and compared both arms to AT alone. METHODS In a pragmatic comprehensive cohort study BC with chronic CRF were allocated randomly or by patient preference to (a) MT, (b) CT (MT + AT) or (c) AT alone. Primary endpoint was a composite score of the Pittsburgh Sleep Quality Index and the Cancer Fatigue Scale after 10 weeks of intervention (T1); a second endpoint was a follow-up assessment 6 months later (T2). The primary hypothesis stated superiority of CT and non-inferiority of MT vs. AT at T1. A closed testing procedure preserved the global α-level. The intention-to-treat analysis included propensity scores for the mode of allocation and for the preferred treatment, respectively. RESULTS Altogether 126 BC were recruited: 65 were randomized and 61 allocated by preference; 105 started the intervention. Socio-demographic parameters were generally balanced at baseline. Non-inferiority of MT to AT at T1 was confirmed (p < 0.05), yet the confirmative analysis stopped as it was not possible to confirm superiority of CT vs. AT (p = 0.119). In consecutive exploratory analyses MT and CT were superior to AT at T1 and T2 (MT) or T2 alone (CT), respectively. CONCLUSIONS The multimodal CRF-therapy was found to be confirmatively non-inferior to standard therapy and even yielded exploratively sustained superiority. A randomized controlled trial including a larger sample size and a longer follow-up to evaluate multimodal CRF-therapy is highly warranted. TRIAL REGISTER DRKS-ID: DRKS00003736 . Recruitment period June 2011 to March 2013. Date of registering 19 June 2012.
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Affiliation(s)
- Matthias Kröz
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089 Berlin, Germany
- Research Institute Havelhöhe, Kladower Damm 221, Berlin, D-14089 Germany
- Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Charité CCM, Berlin, 10098 Berlin Germany
- Institute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, Herdecke, 58313 Germany
| | - Marcus Reif
- Society for Clinical Research, Hardenbergstraße 20, Berlin, 10623 Germany
| | - Augustina Glinz
- Research Institute Havelhöhe, Kladower Damm 221, Berlin, D-14089 Germany
| | - Bettina Berger
- Institute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, Herdecke, 58313 Germany
| | - Andreas Nikolaou
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, 30625 Germany
| | - Roland Zerm
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089 Berlin, Germany
- Research Institute Havelhöhe, Kladower Damm 221, Berlin, D-14089 Germany
| | - Benno Brinkhaus
- Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Charité CCM, Berlin, 10098 Berlin Germany
| | - Matthias Girke
- Department of Internal Medicine, Havelhöhe Hospital, Kladower Damm 221, D-14089 Berlin, Germany
- Research Institute Havelhöhe, Kladower Damm 221, Berlin, D-14089 Germany
| | - Arndt Büssing
- Institute for Integrative Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, Herdecke, 58313 Germany
| | - Christoph Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, 30625 Germany
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Abstract
Combination strategies involving chemotherapy and monoclonal antibodies (mAb) are
commonly used in attempts to produce better clinical outcomes. This practice has
led to new and ongoing toxicities that may lead to reductions in dose or
noncompliance, limiting the effectiveness of treatment. Viscum
album L (VA) preparations are widely used in Europe as additive
therapy and have been associated with reduced chemotherapy-related adverse
reactions and increased health-related quality of life. Concomitant VA therapy
might also reduce toxicity related to mAb. This retrospective study investigated
the safety of combined treatment with VA and mAb in cancer patients. A total of
43 patients had combined therapy (474 exposures); 12 had VA without mAb (129
exposures), and 8 had mAb without VA (68 exposures). Most patients (89.3%)
received concomitant chemotherapy or supportive therapies. A total of 34
patients (60.7%) experienced 142 adverse events (AEs). Leucopenia (14.1% of all
events), acneiform rash (8.5%), and stomatitis (6.3%) occurred most frequently.
Longitudinal logistic regression analysis suggested a nearly 5 times higher odds
of experiencing an AE following treatment with mAb compared with mAb plus VA
(95% CI = 1.53-16.14). Our results, together with theoretical consideration of
potential botanical-drug interactions, suggest that combined treatment with VA
and mAb is safe.
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Affiliation(s)
- Friedemann Schad
- 1 Research Institute Havelhoehe, Berlin, Germany.,2 Hospital Havelhoehe, Berlin, Germany
| | - Jan Axtner
- 1 Research Institute Havelhoehe, Berlin, Germany
| | - Matthias Kröz
- 1 Research Institute Havelhoehe, Berlin, Germany.,2 Hospital Havelhoehe, Berlin, Germany.,3 Charité University Medical Center, Berlin, Germany.,4 University of Witten/Herdecke, Herdecke, Germany
| | - Harald Matthes
- 1 Research Institute Havelhoehe, Berlin, Germany.,2 Hospital Havelhoehe, Berlin, Germany
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Kröz M, Reif M, Pranga D, Zerm R, Schad F, Baars EW, Girke M. The questionnaire on autonomic regulation: a useful concept for integrative medicine? J Integr Med 2016; 14:315-21. [PMID: 27641604 DOI: 10.1016/s2095-4964(16)60264-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The concept of autonomic regulation (aR) reflects the relevance of the function of different autonomic systems for health. aR can be captured by questionnaires. We differentiate between a trait or constitutional aR questionnaire version including 12 (short-version) or 18 items, respectively, with three subscales (orthostatic-circulatory, rest/activity and digestive regulation), and an 18-item state aR questionnaire on the preceding week with four subscales (rest/activity, orthostatic-circulatory, thermo- and digestive regulation). The validated questionnaires show satisfying to good reliability and robust validity with clear construct validity. In this article, we summarized the actually available literature on aR and the use of aR questionnaires in clinical and observational studies. We described the relationship of high aR with health and in case of low aR or loss of regulation with disease and functional disorder in the three (four) different subscales and functional systems, such as rest/activity, orthostatic-circulatory or digestive regulation (thermoregulation) with the consecutive therapeutic need. Finally, we gave perspectives of its further application in clinical research.
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Affiliation(s)
- Matthias Kröz
- Research Institute Havelhöhe, D-14089 Berlin, Germany
- Department of Internal Medicine, Havelhöhe Hospital, D-14089 Berlin, Germany
- Institute for Social Medicine, Epidemiology and Health Economics, D-10117 Berlin, Germany
- Institute for Integrative Medicine, University of Witten/Herdecke, D-58313 Witten/Herdecke, Germany
| | - Marcus Reif
- Society for Clinical Research, D-10623 Berlin, Germany
| | - Danilo Pranga
- Research Institute Havelhöhe, D-14089 Berlin, Germany
| | - Roland Zerm
- Research Institute Havelhöhe, D-14089 Berlin, Germany
- Department of Internal Medicine, Havelhöhe Hospital, D-14089 Berlin, Germany
| | - Friedemann Schad
- Research Institute Havelhöhe, D-14089 Berlin, Germany
- Department of Internal Medicine, Havelhöhe Hospital, D-14089 Berlin, Germany
| | - Erik Wim Baars
- Professorship Anthroposophic Healthcare, University of Applied Sciences Leiden, NL-2300 AJ Leiden, the Netherlands
| | - Matthias Girke
- Research Institute Havelhöhe, D-14089 Berlin, Germany
- Department of Internal Medicine, Havelhöhe Hospital, D-14089 Berlin, Germany
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Kröz M, Didwiszus A, Gelin-Kröz B, Pranga D, Reif M, Brink F, Zerm R, Gutenbrunner C, Büssing A. Reliability of the inner correspondence and harmony questionnaire with painting therapy (ICPTh). Eur J Integr Med 2016. [DOI: 10.1016/j.eujim.2016.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Axtner J, Steele M, Kröz M, Spahn G, Matthes H, Schad F. Health services research of integrative oncology in palliative care of patients with advanced pancreatic cancer. BMC Cancer 2016; 16:579. [PMID: 27485618 PMCID: PMC4971628 DOI: 10.1186/s12885-016-2594-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 07/21/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pancreatic cancer has a dire prognosis and is associated with a high mortality. Palliative patients have special needs and often seek help in integrative oncological concepts (IO) that combine conventional and complementary therapies. Nevertheless there are few recommendations regarding IO in current cancer guidelines. The aims of this study were to report on implementation of IO in everyday palliative care and to analyze patient survival in advanced pancreatic cancer. METHODS This multicenter observational study investigates the implementation of IO and length of survival of patients suffering from advanced pancreatic cancer (stage IV). We analyzed patient's survival by employing multivariable proportional hazard models using different parametric distribution functions and compared patients receiving chemotherapy only, a combination of chemotherapy and Viscum album (VA) treatment, and VA treatment only. RESULTS Records of 240 patients were analyzed. Complementary therapy showed high acceptance (93 %). Most frequent therapy was VA treatment (74 %) that was often administered concomitantly to chemotherapy (64 %). Both therapies had positive effects on patient survival as they had significant negative effects on the hazard in our log-normal model. A second analysis showed that patients with combined chemotherapy and VA therapy performed significantly better than patients receiving only chemotherapy (12.1 to 7.3 month). Patients receiving only VA therapy showed longer survival than those receiving neither chemotherapy nor VA therapy (5.4 to 2.5 months). Our data demonstrates that IO can be implemented in the everyday care of patients without disregarding conventional treatment. Patients combining VA with chemotherapy showed longest survival. CONCLUSIONS Our data demonstrate the importance and potential of health services research showing that IO treatment can be successfully implemented in the every-day care of patients suffering from advanced pancreatic cancer. Patients combining VA with chemotherapy showed longest survival. To address patients' needs adequately, future cancer guidelines might increasingly include comments on complementary treatment options in addition to conventional therapies. Further studies should investigate the effect of complementary treatments on survival and quality of life in more detail.
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Affiliation(s)
- Jan Axtner
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany
| | - Megan Steele
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,ihop Research Group, Queensland University of Technology, School of Public Health and Social Work, Victoria Park Road, 4059, Brisbane, Australia
| | - Matthias Kröz
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Günther Spahn
- Institut für Integrative Krebstherapie, Hans-Böckler-Str. 7, 55128, Mainz, Germany
| | - Harald Matthes
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Friedemann Schad
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany. .,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
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Kröz M, Pranga D, Zerm R, Friemel D, Reif M, Schad F, Matthes H, Girke M. Hat die Selbstregulation eine Bedeutung in der Behandlung von onkologischen Patienten? ACTA ACUST UNITED AC 2016. [DOI: 10.1055/s-0042-103522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Baars EW, Ponstein A, Kok ET, Heybroek R, Van der Veen W, Kröz M, De Bruin A. Validation of the Dutch State Version of the Autonomic Regulation (State-aR) questionnaire in a group of patients and a group of healthy persons. Eur J Integr Med 2015. [DOI: 10.1016/j.eujim.2015.09.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kröz M, Reif M, Pranga D, Berger B, Nikolaou A, Zerm R, Brinkhaus B, Heckmann C, Girke M, Bartsch C, Gutenbrunner C, Lötzke D, Büssing A. Effectiveness of a multimodal and combined therapy in breast cancer survivors with cancer-related fatigue on self-regulation and internal coherence. Eur J Integr Med 2015. [DOI: 10.1016/j.eujim.2015.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kröz M, Reif M, Glinz A, Berger B, Nikolaou A, Zerm R, Brinkhaus B, Girke M, Büssing A, Gutenbrunner C. Multimodal and combined multimodal-aerobic therapy in breast cancer survivors with cancer-related fatigue. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e20717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Marcus Reif
- Institute for Clinical Research, Berlin, Germany
| | | | | | - Andreas Nikolaou
- Clinic for Rehabilitative Medicine, Hannover Medical School, Hannover, Germany
| | - Roland Zerm
- Research Institute Havelhoehe, Berlin, Germany
| | - Benno Brinkhaus
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center Berlin, Berlin, Germany
| | - Matthias Girke
- Department of Internal Medicine Havelhoehe Hospital, Berlin, Germany
| | - Arndt Büssing
- Center of Integrative Medicine, University of Witten/ Herdecke, Herdecke, Germany
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Kröz M, Reif M, Zerm R, Winter K, Schad F, Gutenbrunner C, Girke M, Bartsch C. Do we have predictors of therapy responsiveness for a multimodal therapy concept and aerobic training in breast cancer survivors with chronic cancer-related fatigue? Eur J Cancer Care (Engl) 2015; 24:707-17. [PMID: 25602030 DOI: 10.1111/ecc.12278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
Abstract
Cancer-related fatigue (CRF) is a burdensome symptom for breast cancer (BC) patients. In this pilot study, we tested several questionnaires as predictors for treatment responsiveness, along with the implementation of a multimodal therapy concept consisting of sleep, psycho-education, eurythmy, painting therapy and standard aerobic training. At the Community Hospital Havelhöhe and the Hannover Medical School, 31 BC patients suffering from CRF could be evaluated in a 10-week intervention study. CRF was assessed by the Cancer Fatigue Scale (CFS-D). Further questionnaires were the Pittsburgh Sleep Quality Index, the autonomic regulation scale, Self-Regulation Scale (SRS), the Internal Coherence Scale (ICS) and the European Organization of Research and Treatment Health-Related Quality of Life Core Questionnaire scale. We estimated the regression coefficients of all scales on CFS-D by simple and multiple linear regression analyses and compared regression slopes and variances between the different questionnaires on CFS-D at the end of treatment. We found a significant impact of SRS and ICS at baseline on CFS-D at the end of the intervention [absolute standardised multiple regression coefficient values ranging from 0.319 (SRS) to 0.269 (ICS)] but not for the other questionnaires. In conclusion, this study supports the hypothesis that the SRS or ICS measuring adaptive capacities could be more appropriate as outcome predictors than classical questionnaire measures in complex interventions studies.
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Affiliation(s)
- M Kröz
- Research Institute Havelhöhe (FIH), Berlin, Germany.,Department of Internal Medicine, Community Hospital Havelhöhe, Berlin, Germany.,Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medicine Berlin, Berlin, Germany.,Institute of Integrative Medicine, Witten, Germany
| | - M Reif
- Institute for Clinical Research (IKF), Berlin, Germany
| | - R Zerm
- Research Institute Havelhöhe (FIH), Berlin, Germany.,Department of Internal Medicine, Community Hospital Havelhöhe, Berlin, Germany
| | - K Winter
- Clinic for Rehabilitative Medicine, Hannover Medical School, Hannover, Germany
| | - F Schad
- Research Institute Havelhöhe (FIH), Berlin, Germany.,Department of Internal Medicine, Community Hospital Havelhöhe, Berlin, Germany
| | - C Gutenbrunner
- Clinic for Rehabilitative Medicine, Hannover Medical School, Hannover, Germany
| | - M Girke
- Research Institute Havelhöhe (FIH), Berlin, Germany.,Department of Internal Medicine, Community Hospital Havelhöhe, Berlin, Germany
| | - C Bartsch
- Center for Research in Medical and Natural Sciences, University of Tübingen, Tübingen, Germany
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Steele ML, Axtner J, Happe A, Kröz M, Matthes H, Schad F. Use and Safety of Intratumoral Application of European Mistletoe (Viscum album L) Preparations in Oncology. Integr Cancer Ther 2014; 14:140-8. [DOI: 10.1177/1534735414563977] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background. Intratumoral (IT) injection of European mistletoe ( Viscum album L) preparations might induce local tumor response through combined cytotoxic and immunomodulatory actions of the preparations. Although promising in vitro and in vivo data, along with clinical case studies suggest the need for validation of this hypothesis in prospective trials, the safety of IT mistletoe injections has yet to be thoroughly assessed. Methods. The present study summarizes the practice and safety of off-label IT mistletoe therapy within the Network Oncology, a conjoint clinical registry of German hospitals and outpatients specialized in anthroposophic and integrative medicine. Demographic, diagnosis and treatment data of cancer patients who received IT mistletoe applications between 2007 and 2013 were assessed. Suspected adverse drug reactions (ADRs) were analyzed in terms of type, frequency, severity, seriousness and potential risk factors. Results. A total of 123 cancer patients received 862 IT mistletoe injections (preparations from Abnoba, Helixor and Iscucin). The most commonly applied preparations were Abnoba viscum Fraxini (71 patients) and Helixor Mali (54 patients). Of the total patients, 26 patients (21.1%) experienced 74 ADRs. All ADRs were in response to either Abnoba viscum Fraxini (25.4% of exposed patients) or Helixor Mali (18.5% of exposed patients). ADRs were mostly body temperature or immune related and of mild (83.8%) or moderate (14.9%) intensity. Only one possible ADR was described as severe (hypertension) and no serious ADRs occurred. The frequency of ADRs to IT mistletoe injections was 3 times and 5 times higher than has previously been found for subcutaneous and intravenous applications of mistletoe, respectively. Conclusion. IT injection of mistletoe preparations resulted in a relatively high frequency of ADRs. Nearly all ADRs were mild to moderate however, and no serious ADRs occurred. Furthermore, it is possible that immune-related ADRs such as pyrexia and local inflammatory reactions might be critical for tumor response. In light of these results, IT mistletoe therapy seems to be safe and prospective trials are recommended.
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Affiliation(s)
| | - Jan Axtner
- Research Institute Havelhoehe, Berlin, Germany
| | - Antje Happe
- Research Institute Havelhoehe, Berlin, Germany
| | - Matthias Kröz
- Research Institute Havelhoehe, Berlin, Germany
- Witten/Herdecke University, Herdecke, Germany
| | - Harald Matthes
- Research Institute Havelhoehe, Berlin, Germany
- Hospital Havelhoehe, Berlin, Germany
| | - Friedemann Schad
- Research Institute Havelhoehe, Berlin, Germany
- Hospital Havelhoehe, Berlin, Germany
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Heckenbach K, Ostermann T, Schad F, Kröz M, Matthes H. Medication and falls in elderly outpatients: an epidemiological study from a German Pharmacovigilance Network. Springerplus 2014; 3:483. [PMID: 25207204 PMCID: PMC4158008 DOI: 10.1186/2193-1801-3-483] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/12/2014] [Indexed: 01/07/2023]
Abstract
The aim of this study was to investigate the relationship between fall risk increasing drugs (FRIDS) and the risk of falls in regard to fall-related chronic diseases. In total, 39 primary care physicians in Germany participated in the EvaMed Pharmacovigilance Network. Antihypertensives, non-steroidal anti-inflammatory drugs, hypnotics and sedatives, antidepressants and psycholeptics were labelled as FRIDS. A fall was defined according to a diagnosis in the chapter Injury or poisoning (S00-T14 in International Statistical Classification of Diseases 10th Revision (ICD-10)). Patients older than or equal to 65 years with at least two doctor’s visits were included. FRIDS were prescribed for 1768 patients from a total of 5124 patients included in the analysis. FRIDS and seven chronic diseases were statistically significant associated with a higher risk of experiencing a fall. The risk was highest for patients with a diagnosis abnormalities of gait and mobility, vertigo, visual -impairment and weight loss, and increased by 50-90% with arthritis, diseases of arteries, arterioles and capillaries and heart failure. From patients (N = 425) with at least one diagnosis of fall, 219 patients were prescribed FRIDS. In 100 (45.7%) of cases the diagnoses for fall were made before and in 105 (47.9%) of cases at least a month after the prescription of FRIDS. 14 (6.4%) patients had a prescription of FRIDS and a diagnosis of fall within one month. Perceptual disorders, low walking speed and pain are prominent predictors for falls in the elderly. A prescription of FRIDS selects more vulnerable patients having a higher risk of falls. However, experiencing a fall is mainly due to the disease followed by treatment. Thus, not prescribing FRIDS will avoid only a small number of falls.
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Affiliation(s)
| | - Thomas Ostermann
- Institute of Integrated medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, D-58313 Herdecke, Germany
| | - Friedemann Schad
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
| | - Matthias Kröz
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
| | - Harald Matthes
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
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Zerm R, Zerm R, Lutnæs-Mast F, Mast H, Girke M, Kröz M. Effects of eurythmy therapy in the treatment of essential arterial hypertension: a pilot study. Glob Adv Health Med 2014; 2:24-30. [PMID: 24381822 PMCID: PMC3833577 DOI: 10.7453/gahmj.2013.2.1.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: Although eurythmy therapy (ET) has been used in the context of anthroposophic medicine (AM) for the treatment of, among other conditions, arterial hypertension (AH) for more than 80 years, there are as yet no studies on its effectiveness on disease entity. However, it has been shown that ET can increase heart rate variability comparably to ergometer training. Objective: To determine whether a 10-week course of ET has an impact on AH and if so, to determine the strength of the effect. The impact of ET on state-autonomic regulation, self-regulation, internal coherence, and quality of life is also explored. Methods: Consecutive inclusion of 9 subjects (6 female, 3 male, mean age of 64 years, SD 8.26) with AH diagnosed by their general practitioners. Inclusion criteria: no or unchanged antihypertensive medication from 4 weeks prior to the start of the study until the end of the study. ET was carried out with weekly instruction along with a daily, home-based program for 10 weeks with specific exercises. Twenty-four–hour blood pressure (BP) measuring was carried out, and the questionnaires were administered before and after the intervention. In addition, after a further 6 months during which 8 of the 9 patients carried on with the exercises of their own accord, the aforementioned parameters were assessed for a third time. Results: Parameters of the 24-hour BP measurements show a moderate, but not significant, improvement immediately after the intervention and 6 months after the intervention. After the 10-week intervention, we saw an improvement of the State-autonomic Regulation questionnaire, the subscale on “Rest/Activity regulation,” of the Self-regulation questionnaire, and the subscale “Initiative and Interest” of the Herdecke Quality of Life Questionnaire (HLQ) (all P < .045). After the 6-month post-study observation period, the aforementioned parameters improved further still, and an additional, significant improvement was seen for the Trait-autonomic Regulation subscale “Rest/Activity regulation,” the HLQ-sum score, and the HLQ subscales “social interaction,” “mental balance,” and “physical ability.” Conclusion: A 10-week course of ET does not result in a significant improvement in BP. The average BP measurements improved post-intervention by an absolute 3.2/2.0 mmHg and after 6 months of independent continuation of ET by 6.3/4.4 mmHg (systolic/diastolic). Despite the small group size, the regulation and quality-of-life parameters improved significantly after the intervention and further still after the 6-month observation period. The results need to be validated with larger patient collectives and control groups.
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Affiliation(s)
| | - Ronald Zerm
- Research Institute Havelhoehe Berlin, Community Hospital Havelhoehe, Berlin, Germany
| | - Froeydis Lutnæs-Mast
- Practice for Eurythmy Therapy at the Ambulatory Healthcare Centre, Zehlendorf, Berlin, Germany
| | - Heiner Mast
- Ambulatory Healthcare Centre, Zehlendorf, Berlin, Germany
| | - Matthias Girke
- Research Institute Havelhoehe Berlin, Community Hospital Havelhoehe, Berlin, Germany
| | - Matthias Kröz
- Research Institute Havelhoehe Berlin, Community Hospital Havelhoehe, Berlin, Germany
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Schad F, Atxner J, Buchwald D, Happe A, Popp S, Kröz M, Matthes H. Intratumoral Mistletoe (Viscum album L) Therapy in Patients With Unresectable Pancreas Carcinoma: A Retrospective Analysis. Integr Cancer Ther 2013; 13:332-40. [PMID: 24363283 DOI: 10.1177/1534735413513637] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic carcinoma remains one of the main causes for cancer-related death. Intratumoral application of anticancer agents is discussed as a promising method for solid tumors such as pancreatic cancer. Endoscopic ultrasound provides a good tool to examine and treat the pancreas. European mistletoe (Viscum album L) is a phytotherapeutic commonly used in integrative oncology in Central Europe. Its complementary use seeks to induce immunostimulation and antitumoral effects as well as alleviate chemotherapeutic side effects. Intratumoral mistletoe application has induced local tumor response in various cancer entities. This off-label use needs to be validated carefully in terms of safety and benefits. Here we report on 39 patients with advanced, inoperable pancreatic cancer, who received in total 223 intratumoral applications of mistletoe, endoscopic ultrasound guided or under transabdominal ultrasound control. No severe procedure-related events were reported. Adverse drug reactions were mainly increased body temperature or fever in 14% and 11% of the applications, respectively. Other adverse drug reactions, such as pain or nausea, occurred in less than 7% of the procedures. No severe adverse drug reaction was recorded. Patients received standard first- and second-line chemotherapy and underwent adequate palliative surgical interventions as well as additive subcutaneous and partly intravenous mistletoe application. A median survival of 11 months was observed for all patients, or 11.8 and 8.3 months for stages III and IV, respectively. Due to the multimodal therapeutic setting and the lack of a control group, the effect of intratumoral mistletoe administration alone remains unclear. This retrospective analysis suggests that intratumoral-applicated mistletoe might contribute to improve survival of patients with pancreatic cancer. In conclusion, the application is feasible and safe, and its efficacy should be evaluated in a randomized controlled trial.
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Affiliation(s)
- Friedemann Schad
- Hospital Havelhoehe, Berlin, Germany Research Institute Havelhoehe, Berlin, Germany
| | - Jan Atxner
- Research Institute Havelhoehe, Berlin, Germany
| | | | - Antje Happe
- Research Institute Havelhoehe, Berlin, Germany
| | | | - Matthias Kröz
- Hospital Havelhoehe, Berlin, Germany Research Institute Havelhoehe, Berlin, Germany
| | - Harald Matthes
- Hospital Havelhoehe, Berlin, Germany Research Institute Havelhoehe, Berlin, Germany
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Zerm R, Helbrecht B, Jecht M, Hein A, Millet E, Girke M, Kröz M. Oatmeal diet days may improve insulin resistance in patients with type 2 diabetes mellitus. ACTA ACUST UNITED AC 2013; 20:465-8. [PMID: 24434762 DOI: 10.1159/000357485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Roland Zerm
- Havelhoehe Hospital, Department of Internal Medicine/Diabetology, Berlin, Germany
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Kröz M, Reif M, Bartsch C, Heckmann C, Zerm R, Schad F, Girke M. Impact of autonomic and self-regulation on cancer-related fatigue and distress in breast cancer patients--a prospective observational study. J Cancer Surviv 2013; 8:319-28. [PMID: 24253954 DOI: 10.1007/s11764-013-0314-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/26/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE Cancer-related fatigue (CRF) has a major impact on the quality of life in breast cancer patients (BC). So far, only a few prospective studies have investigated the effect of adaptive salutogenic mechanisms on CRF. The aim of our study was to evaluate the possible prospective influence of autonomic Regulation (aR) and self-regulation (SR) on CRF and distress in long-term survivors. METHODS 95 BC and 80 healthy female controls (C) had been included in the observational study between 2000 and 2001 and completed the questionnaires on aR, SR and Hospital Anxiety and Depression Scale (HADS). Of these, 62 BC, and 58 C participated in the re-evaluation 6.6 years later: 16 participants were deceased (14 BC and 2 C). During follow-up, participants were requested to answer questions involving (Cancer Fatigue Scales) CFS-D, aR, SR and HADS. Multiple regression analysis was used to evaluate the influence of aR, SR, age, Charlson co-morbidity-index and diagnosis on CFS-D and HADS, and to select further potentially relevant factors. RESULTS High aR values showed significant effects, namely inverse relationships with CFS-D, cognitive fatigue, anxiety and depression. SR showed a reduced influence on anxiety and depression (all p < 0.05). CONCLUSIONS Autonomic regulation might have an independent, reductive influence on global fatigue, cognitive fatigue and--together with self-regulation--it seems to have a protective influence on anxiety and depression. The connection between these parameters is still unclear and awaits further evaluation. IMPLICATION FOR CANCER SURVIVORS AR seems to be a prognostic factor in breast cancer survivors, capable of reducing cancer-related fatigue and self-regulation distress as well. Further research is necessary in order to show how aR can be improved by therapeutic interventions.
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Affiliation(s)
- M Kröz
- Research Institute Havelhöhe (FIH), Berlin, Germany,
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Schad F, Axtner J, Happe A, Breitkreuz T, Paxino C, Gutsch J, Matthes B, Debus M, Kröz M, Spahn G, Riess H, von Laue HB, Matthes H. Network Oncology (NO)--a clinical cancer register for health services research and the evaluation of integrative therapeutic interventions in anthroposophic medicine. ACTA ACUST UNITED AC 2013; 20:353-60. [PMID: 24200825 DOI: 10.1159/000356204] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Concepts of integrative oncology (IO), as have been offered by anthroposophic medicine (AM) for decades, are gaining increasing interest and acceptance. Central aspects are multimodal therapeutic interventions, health-related quality of live, and patients' preference as well as therapeutic relationship and clinical outcome. Despite its broad application, IO lacks evaluation in clinical practice and complementary therapies are not monitored by any cancer registries. METHODS To close this gap we established 'Network Oncology' (NO), a conjoint registry of German outpatient AM practitioners and AM hospitals. In this paper we present the project and a first data overview and compare it to epidemiological registers and current literature. RESULTS NO has collected 10,405 cancer patients' records in 6 years. Compared to epidemiological registers our data show minor differences in disease entity distribution, age, and gender. There is an overproportional amount of young breast cancer patients in NO institutions indicating a demand for integrative therapies in this group. There is no difference between the UICC (Union for International Cancer Control) stages at first diagnosis and at admission to a NO facility. According to our data conventional therapies were less frequently administered after admission to a NO facility. Nevertheless, one third of the patients received their first conventional therapy in a NO facility. 80% of the patients received mistletoe preparations and 63% had nonpharmacotherapeutic, complementary interventions. CONCLUSION Integrative oncological approaches attract a great number of patients visiting AM institutions. The NO provides an infrastructure to evaluate integrative interventions in AM, allows comparison to other clinical registers, and thus can contribute to health service research in this field.
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Kröz M, Fink M, Reif M, Grobbecker S, Zerm R, Quetz M, Frühwirth M, Brinkhaus B, Bartsch C, Girke M, Gutenbrunner C. Multimodal Therapy Concept and Aerobic Training in Breast Cancer Patients With Chronic Cancer-Related Fatigue. Integr Cancer Ther 2012; 12:301-11. [DOI: 10.1177/1534735412464552] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hypothese: Cancer-related fatigue (CRF) and sleep disorders are some of the most wearing and common symptoms in disease-free breast cancer patients (BC). Aerobic training (AT) is the treatment with the best available evidence, even though it seems to be insufficient with regards to improvements in cognitive fatigue. We introduced a new multimodal therapy concept (MM) consisting of psycho-, sleep-education and new approaches based on anthroposophic medicine such as eurythmy and painting therapy. Study design: This pilot study will test the implementation of MM and yield first results of the MM and AE in our centres. Methods: 31 out of 34 patients suffering from BC and CRF were fully assessed in a ten-week intervention study. 21 patients chose MM and 10 decided on AT. CRF was measured with the help of the Cancer Fatigue Scale (CFS-D), and the global quality of sleep was measured with the Pittsburgh Sleep Quality Index (PSQI). We also captured autonomic regulation (aR) and patients’ satisfaction with questionnaires. Statistical analysis was done with SAS 9.1.3 for windows. Results: The new MM therapy can be implemented with high satisfaction among patients. Significant improvements were found in the MM group with regards to CFS-D, global quality of sleep, sleep efficiency (PSQI), aR and rest/activity regulation compared to baseline (all p<0.05). In the AT group aR orthostatic-circulatory and rest/activity regulation improved significantly (p<0.05), too. However, no improvement in cognitive fatigue was seen in either group. Conclusion: The multimodal therapy concept was feasible and improved cancer fatigue, sleep quality, autonomic and rest-/activity regulation in breast cancer patients. It may therefore constitute a valuable treatment option in addition to aerobic training for BC patients with CRF. A further study with larger sample size needs to be carried out to assess the efficacy of combined multimodal-aerobic therapy.
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Affiliation(s)
- Matthias Kröz
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Community Hospital Havelhöhe (GKH), Berlin, Germany
- Charité University Medicine, Berlin, Germany
| | | | - Marcus Reif
- Institute for Clinical Research (IKF), Berlin, Germany
| | | | - Roland Zerm
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Community Hospital Havelhöhe (GKH), Berlin, Germany
| | | | | | | | | | - Matthias Girke
- Research Institute Havelhöhe (FIH), Berlin, Germany
- Community Hospital Havelhöhe (GKH), Berlin, Germany
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Kröz M, Reif M, Büssing A, Zerm R, Feder G, Bockelbrink A, von Laue HB, Matthes H H, Willich SN, Girke M. Does self-regulation and autonomic regulation have an influence on survival in breast and colon carcinoma patients? results of a prospective outcome study. Health Qual Life Outcomes 2011; 9:85. [PMID: 21961625 PMCID: PMC3192663 DOI: 10.1186/1477-7525-9-85] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 09/30/2011] [Indexed: 12/21/2022] Open
Abstract
Background Cancer Related Fatigue (CRF) and circadian rhythm have a great impact on the quality of life (HRQL) of patients with breast (BC) and colon cancer (CRC). Other patient related outcomes in oncology are measured by new instruments focusing on adaptive characteristics such as sense of coherence or self-regulation, which could be more appropriate as a prognostic tool than classical HRQL. The aim of this study was to assess the association of autonomic regulation (aR) and self-regulation (SR) with survival. Methods 146 cancer patients and 120 healthy controls took part in an initial evaluation in 2000/2001. At a median follow up of 5.9 years later, 62 of 95 BC, 17 of 51 CRC patients, and 85 of 117 healthy controls took part in the follow-up study. 41 participants had died. For the follow-up evaluation, participants were requested to complete the standardized aR and SR questionnaires. Results On average, cancer patients had survived for 10.1 years with the disease. Using a Cox proportional hazard regression with stepwise variables such as age, diagnosis group, Charlson co-morbidity index, body mass index (BMI)) aR and SR. SR were identified as independent parameters with potential prognostic relevance on survival While aR did not significantly influence survival, SR showed a positive and independent impact on survival (OR = 0.589; 95%-CI: 0.354 - 0.979). This positive effect persisted significantly in the sensitivity analysis of the subgroup of tumour patients and in the subscale 'Achieve satisfaction and well-being' and by tendency in the UICC stages nested for the different diagnoses groups. Conclusions Self-regulation might be an independent prognostic factor for the survival of breast and colon carcinoma patients and merits further prospective studies.
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Affiliation(s)
- Matthias Kröz
- Center of Integrative Medicine, Professorship Quality of Life, Spirituality and Coping, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany
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Jeschke E, Ostermann T, Tabali M, Kröz M, Bockelbrink A, Witt CM, Willich SN, Matthes H. Anthroposophic medicine in pediatric primary care: a prospective, multicenter observational study on prescribing patterns. Altern Ther Health Med 2011; 17:18-28. [PMID: 21717821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Although the treatment of children has been a core domain ofanthroposophic medicine since its inception, a systematic analysis of anthroposophic therapies in pediatric primary care is still lacking. This study describes the spectrum of diagnoses and therapies observed in children treated in everyday anthroposophic practice. METHODS Thirty-eight primary care physicians in Germany participated in this prospective, multicenter observational study on prescribing patterns. Prescriptions and diagnoses were reported for each consecutive patient. Multiple logistic regression analysis was used to determine factors associated with anthroposophic prescriptions. RESULTS In 2005, a total of 57 893 prescriptions for 18 440 children under 12 years of age (48.1% female) were issued. In total, 50.3% of the prescriptions were classified as CAM remedies alone, 22.6% as conventional pharmaceuticals alone, and 27.1% as a combination of both. Anthroposophic remedies accounted for 41.8% of all medications prescribed. The odds ratio (OR) for receiving an anthroposophic remedy was significantly higher for the first consultation (OR= 1.19; confidence interval [CI]: 1.16-1.23). Anthroposophic remedies were prescribed most frequently for disorders of the conjunctiva (OR = 2.47; CI: 2.27-2.70), otitis media (OR = 1.50; CI: 1.43-1.59), acute upper respiratory tract infections (OR= 1.28; CI: 1.23-1.33), other respiratory diseases (OR= 1.15; CI: 1.07-1.24), digestive system and abdominal symptoms (OR= 1.39; CI: 1.28-1.51), general symptoms and signs (OR= 1.25; CI: 1.16-1.36), .and pneumonia (OR= 1.36; CI: 1.25-1.49). The likelihood of being prescribed an anthroposophic remedy decreased with patient age (OR= 0.96; CI: 0.95-0.96) and was lower in patients treated by a pediatrician (OR= 0.43; CI: 0.42-0.44). Of the 2475 therapeutic procedures prescribed (29% anthroposophic), the most frequent were physiotherapy, speech therapy, ergotherapy, and logopedics. CONCLUSION The present study is the first to provide a systematic overview of everyday anthroposophic medical practice in primary care for children. The findings show that practitioners of anthroposophic medicine take an integrative approach by combining conventional and anthroposophic treatments.
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Eisenbraun J, Scheer R, Kröz M, Schad F, Huber R. Quality of life in breast cancer patients during chemotherapy and concurrent therapy with a mistletoe extract. Phytomedicine 2011; 18:151-157. [PMID: 20724129 DOI: 10.1016/j.phymed.2010.06.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND The effects of standardized aqueous mistletoe extracts on Health Related Quality of Life (HRQoL) of tumor patients needs further evaluation. METHODS in this non-interventional, prospective clinical investigation the longitudinal course of Quality of Life of 270 breast cancer patients during adjuvant chemotherapy and mistletoe therapy with abnobaVISCUM(®) Mali was investigated. HRQoL was measured 4 times by self-assessment with the QLQ-C30 and QLQ-BR23 questionnaire of the European Organization for Research and Treatment of Cancer (EORTC): at the beginning of mistletoe- and chemotherapy, 4 weeks later, at the end of the chemotherapy and 4 weeks after finishing chemotherapy. Secondary objectives were the tolerability and safety of mistletoe therapy in combination with chemotherapy under conditions of daily practice. RESULTS after an initial deterioration the average range of all obtained QLQ-C30 function scales (n=262, 48.9-71.5) remained stable even at the last chemotherapy cycle and improved significantly (p<0.0001) to 66.9-80.7 4 weeks later, compared to the initial visit. Also the QLQ-BR23 function scales significantly improved (p<0.0001) 4 weeks later. The symptom scales of the QLQ-C30 remained stable under chemotherapy even at the final chemotherapy cycle and decreased from 16.2 to 44.1 at the initial visit to 11.2-29.9 (p<0.001) at the final visit. These results were comparable to the subgroup with initial visit before chemotherapy (n=114) in which rather stable function scales during chemotherapy (difference of the mean values: 9.6 to -3.7) and only little increase of symptoms (difference: 13.2 to -4.9) was measured. The tolerability of the therapy was judged by the physicians as good or very good for 91% of the patients and the efficacy was rated as good or very good for 94%. 89% of the patients reported about a good or very good benefit. CONCLUSION the overall results point to a relevant stabilisation of Health Related Quality of Life during various chemotherapy regimes, possibly due to a reduction of chemotherapy caused side effects with an excellent tolerability of the mistletoe therapy.
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Affiliation(s)
- J Eisenbraun
- ABNOBA GmbH, Hohenzollernstr. 16, D-75177 Pforzheim, Germany.
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Zerm R, Brauer D, Girke M, Kröz M. Daily activity, quality of sleep, autonomic regulation and self-regulation in breast cancer and insomniac patients. Eur J Integr Med 2010. [DOI: 10.1016/j.eujim.2010.09.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kröz M, Fink M, Reif M, Grobbecker S, Winter K, Zerm R, Brauer D, Candir F, Quetz M, Zastruzki S, Houben H, Gelin-Kröz B, Naghavi M, Klug P, von Laue HB, Girke M, Gutenbrunner C. Feasibility and results of a new multimodal therapy concept versus aerobic training in breast cancer patients with chronic Cancer-Related-Fatigue. Eur J Integr Med 2010. [DOI: 10.1016/j.eujim.2010.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jeschke E, Ostermann T, Tabali M, Vollmar HC, Kröz M, Bockelbrink A, Witt CM, Willich SN, Matthes H. Pharmacotherapy of elderly patients in everyday anthroposophic medical practice: a prospective, multicenter observational study. BMC Geriatr 2010; 10:48. [PMID: 20663129 PMCID: PMC2916899 DOI: 10.1186/1471-2318-10-48] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/21/2010] [Indexed: 01/12/2023] Open
Abstract
Background Pharmacotherapy in the older adult is a complex field involving several different medical professionals. The evidence base for pharmacotherapy in elderly patients in primary care relies on only a few clinical trials, thus documentation must be improved, particularly in the field of complementary and alternative medicine (CAM) like phytotherapy, homoeopathy, and anthroposophic medicine. This study describes diagnoses and therapies observed in elderly patients treated with anthroposophic medicine in usual care. Methods Twenty-nine primary care physicians in Germany participated in this prospective, multicenter observational study on prescribing patterns. Prescriptions and diagnoses were reported for each consecutive patient. Data were included if patients were at least 60 years of age. Multiple logistic regression analysis was used to determine factors associated with anthroposophic prescriptions. Results In 2005, a total of 12 314 prescriptions for 3076 patients (68.1% female) were included. The most frequent diagnoses were hypertension (11.1%), breast cancer (3.5%), and heart failure (3.0%). In total, 30.5% of the prescriptions were classified as CAM remedies alone, 54.4% as conventional pharmaceuticals alone, and 15.1% as a combination of both. CAM remedies accounted for 41.7% of all medications prescribed (35.5% anthroposophic). The adjusted odds ratio (AOR) for receiving an anthroposophic remedy was significantly higher for the first consultation (AOR = 1.65; CI: 1.52-1.79), treatment by an internist (AOR = 1.49; CI: 1.40-1.58), female patients (AOR = 1.35; CI: 1.27-1.43), cancer (AOR = 4.54; CI: 4.12-4.99), arthropathies (AOR = 1.36; CI: 1.19-1.55), or dorsopathies (AOR = 1.34; CI: 1.16-1.55) and it decreased with patient age (AOR = 0.97; CI: 0.97-0.98). The likelihood of being prescribed an anthroposophic remedy was especially low for patients with hypertensive diseases (AOR = 0.36; CI: 0.32-0.39), diabetes mellitus (AOR = 0.17; CI: 0.14-0.22), or metabolic disorders (AOR = 0.17; CI: 0.13-0.22). Conclusion The present study is the first to provide a systematic overview of everyday anthroposophic medical practice in primary care for elderly patients. Practitioners of anthroposophic medicine prescribe both conventional and complementary treatments. Our study may facilitate further CAM-research on indications of, for example, dementia or adverse drug reactions in the elderly.
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Kröz M, Linke J, Gutenbrunner CH, Girke M, Hecht K, Bockelbrink A, Dimeo F, Matthes H. Cancer Fatigue, gestörte Ruhe/Aktivitäts-Regulation und Schlafstörungen bei Patientinnen mit nicht metastasiertem Mammakarzinom – eine Pilotstudie. Phys Rehab Kur Med 2010. [DOI: 10.1055/s-0029-1241853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jeschke E, Ostermann T, Vollmar HC, Kröz M, Bockelbrink A, Witt CM, Willich SN, Matthes H. Evaluation of prescribing patterns in a German network of CAM physicians for the treatment of patients with hypertension: a prospective observational study. BMC Fam Pract 2009; 10:78. [PMID: 20003298 PMCID: PMC2804584 DOI: 10.1186/1471-2296-10-78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 12/10/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND The management of hypertension is a key challenge in modern health systems. This study aimed to investigate hypertension treatment strategies among physicians specialized in complementary and alternative medicine (CAM) in Germany by analysing prescribing patterns and comparing these to the current treatment guidelines issued by the German Hypertension Society. METHODS In this prospective, multicentre observational study, which included 25 primary care physicians specialized in CAM treatment, prescriptions and diagnoses were analysed for each consecutive hypertensive patient using routine electronic data. Data analysis was performed using univariate statistical tests (Chi square test, Cochran-Armitage trend test). Multiple logistic regression was used to determine factors associated with antihypertensive medication. RESULTS In the year 2005, 1320 patients with 3278 prescriptions were included (mean age = 64.2 years (SD = 14.5), 63.5% women). Most patients were treated with conventional antihypertensive monotherapies (n = 838, 63.5%). Beta-blockers were the most commonly prescribed monotherapy (30.7%), followed by ACE inhibitors (24.0%). Combination treatment usually consisted of two antihypertensive drugs administered either as separate agents or as a coformulation. The most common combination was a diuretic plus an ACE inhibitor (31.2% of dual therapies). Patient gender, age, and comorbidities significantly influenced which treatment was prescribed. 187 patients (14.2%) received one or more CAM remedies, most of which were administered in addition to classic monotherapies (n = 104). Men (OR = 0.66; 95% CI: 0.54-0.80) and patients with diabetes (OR = 0.55; 95% CI: 0.42-0.0.73), hypercholesterolaemia (OR = 0.59; 95% CI: 0.47-0.75), obesity (OR = 0.74; 95% CI: 0.57-0.97), stroke (OR = 0.54; 95% CI: 0.40-0.74), or prior myocardial infarction (OR = 0.37; 95% CI: 0.17-0.81) were less likely to receive CAM treatment. CONCLUSIONS The large majority of antihypertensive treatments prescribed by CAM physicians in the present study complied with the current German Hypertension Society treatment guidelines. Deviations from the guidelines were observed in one of every seven patients receiving some form of CAM treatment.
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Affiliation(s)
- Elke Jeschke
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
| | - Thomas Ostermann
- Chair for Theory of Medicine, Integrative and Anthroposophic Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany
| | - Horst C Vollmar
- Institute for General Practice and Family Medicine, University of Witten/Herdecke, Alfred-Herrhausen-Str 50, 58448 Witten, Germany
- Fraunhofer Institute for Systems and Innovation Transfer (ISI), Breslauer Str 48, 76139 Karlsruhe, Germany
| | - Matthias Kröz
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
| | - Angelina Bockelbrink
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre, 10117 Berlin, Germany
| | - Claudia M Witt
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre, 10117 Berlin, Germany
| | - Stefan N Willich
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre, 10117 Berlin, Germany
| | - Harald Matthes
- Havelhoehe Research Institute, Kladower Damm 221, 14089 Berlin, Germany
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Zerm R, Jecht M, Hein A, Millet E, Girke M, Kröz M. Treatment of severe insulin-resistance with a 2-day oat-diet in clinical routine. Eur J Integr Med 2009. [DOI: 10.1016/j.eujim.2009.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kröz M, von Laue H, Bockelbrink A, Reif M, Brauer D, Zerm R, Schad F, Feder G, Willich S, Girke M. 3055 Does self regulation and autonomic regulation have an influence on survival in breast and colon carcinoma patients? – results of a prospective study. EJC Suppl 2009. [DOI: 10.1016/s1359-6349(09)70654-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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