It’s Time for an OT Education Standard on Integrative Health
By Emmy Vadnais, OTR/L
Originally published on ADVANCE Magazine on September 2, 2016
An OT education standard is needed on complementary and integrative health (CIH) — what has been commonly referred to as complementary/alternative medicine (CAM), because CAM is becoming more utilized by OTs and other health care professionals, and the public is seeking these services. OT practitioners and students need to have foundational knowledge about how they can utilize these approaches as part of a comprehensive OT treatment plan to improve occupations.
Standardization of required CAM content would prepare more versatile occupational therapy practitioners, benefitting occupational therapy practitioners themselves and their clients. This would also support new occupational therapy practitioners to stay current in an evolving health care system.1
Complementary and Integrative Health Growth
According to the National Center for Complementary and Integrative Health (NCCIH), the use of an integrative approach for health and wellness has grown within care settings across the United States, including hospitals, hospices, and military health facilities since its inception 16 years ago.
The NCCIH is the federal government’s lead agency for scientific research on the diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. It defines “complementary” as a non-mainstream practice used together with conventional medicine. If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.”
“Integrative health” care is a comprehensive, often used as an interdisciplinary, approach to treatment, prevention and health promotion that brings together complementary and conventional therapies. NCCIH uses the term “integrative health” to describe incorporating complementary approaches into mainstream health care, and will use the term “complementary health approaches” when they share information about practices and products of non-mainstream origin.2
In 2014, the NCCIH removed the word “alternative” from its title “National Center for Complementary and Alternative Medicine” (NCCAM), because large population-based surveys found that the use of alternative medicine is rare. Integrative health care is used more frequently.3
Health, Wellness, and Prevention
Health and Wellness is one of the six key OT practice areas, and are outcomes that may occur from OT intervention. CIH could fall within this area to support occupations and to promote health, wellness, and disease prevention across all areas of OT for children and adults. The United States health care system has primarily functioned as “sick care” that addresses disease and illness rather than promoting health or prevention of disease, but this may be changing as more people desire to stay well and prevent disease. OTs can be leaders in prevention and wellness.4
CIH approaches may improve health, wellness, and prevention.5 It may likely lower healthcare costs, as an estimated 75% of illnesses and chronic conditions may be prevented through lifestyle changes.6 Comprehensive lifestyle changes can often reverse their progression.7
Health for groups and populations includes these individual aspects but also includes social responsibility of members to the group or population as a whole. Health is a state of physical, mental, and social well-being, as well as a positive concept emphasizing social and personal resources and physical capacities.8
Wellness is “an active process through which individuals [or groups or populations] become aware of and make choices toward a more successful existence.” Wellness is more than a lack of disease symptoms; it is a state of mental and physical balance and fitness.8
Prevention is education or health promotion efforts designed to identify, reduce, or prevent the onset and reduce the incidence of unhealthy conditions, risk factors, diseases, or injuries. Occupational therapy promotes a healthy lifestyle at the individual, group, community (societal), and governmental or policy level.8-9
In 2011, the AOTA Ad Hoc Committee on Health Care Reform formed by the Prevention and Wellness group found progress in the areas of fall prevention, ergonomics, anti-bullying initiatives, and aging-in-place supports. The group highlights the good fit between occupational therapy and prevention, but demonstrates that more work is needed with transitioning prevention practice opportunities into realities.10 CIH could further support OT with health, wellness and prevention.
AOTA Asserts that CAM May Be Used in OT Practice
The American Occupational Therapy Association (AOTA) states in their CAM Position Paper from 2011 that CAM may be used responsibly by occupational therapists and occupational therapy assistants as part of a comprehensive approach to enhance engagement in occupation by people, organizations, and populations to promote their health and participation in life.9
It is estimated by the National Center for Complementary and Integrative Health that 34% of adults and 12% of children use these approaches, and they are more frequently used by individuals with chronic conditions and functional limitations.11 This position paper outlines the appropriate use of CAM by occupational therapy practitioners.12
For years, CAM approaches have been utilized in occupational therapy, including guided imagery, massage, myofascial release, meditation, and behavioral relaxation training.13-16 Yoga postures also have been used to reduce reliance on pain medication, promote relaxation for restorative sleep, and improve ADL performance.14
Recent studies have indicated that yoga intervention can reduce anxiety among children and adolescents,17 and preliminary evidence has found that an individualized 8-week yoga intervention may improve emotional regulation and quality of life after a traumatic brain injury.18
Including CIH in OT Education
Now is the time to include CIH as a standard in OT education. For OTs to understand the best approaches available, and to be able to communicate with other health care professionals and clients, it’s important to have a foundational knowledge. Several health care professions are preparing their students by currently teaching these approaches in their programs.
Over half of medical schools in the United States now offer at least one course about CAM, and there are 60 medical institutions that are members of the Academic Consortium for Integrative Medicine and Health.19-20 In addition, the nursing profession developed an Integrative Nursing theoretical framework and the Holistic Nursing specialty certification.21-22
The inclusion of CAM in professional healthcare educational programs began in the late 20th century. This was in response to consumer trends in the United States.23-25 Curricular inclusion of CAM was found in literature of allied health professionals such as physical therapists,26 nurses,27 nurse practitioners,28 and physician assistants,29 but not in occupational therapy.30
Including CAM in occupational therapy practice for the promotion of occupational participation is a natural progression given the common holistic philosophical roots shared by occupational therapy and CAM practitioners.14,31-33
Majority of OTs Include CAM in their Curriculum
Many occupational therapy educators are teaching CAM in response to the demands of a more integrative healthcare system. A paper by Michelle Bradshaw, DC, OTR/L, presents an overview of current curricular inclusion of CAM by occupational therapy educators in the United States. The study explored the extent to which CAM was included, what factors impacted the inclusion, topics and student learning outcomes covered, who taught the material, and what sources were used to prepare for delivering course content.
A majority of responding OT educators reported curricular inclusion of CAM (79%), with independent learning opportunities (35%) as the most frequent method of education. Other methods of teaching CAM included required courses (20%), other (14%), elective courses (10%), and no inclusion (22%).
A majority of respondents’ comments supported curricular inclusion in occupational therapy education for the following reasons: 1) expose students to CAM practices supported by evidence, 2) develop clinical reasoning skills for collaboration with and referrals to appropriate CAM practitioners, and 3) exposure to CAM within a cultural context, while some suggested that students would benefit from experiential training in CAM and exposure to billing related CAM.
Those responding OT educators who had additional training in CAM felt more comfortable teaching general content and CAM for use as occupational therapy interventions. Some educators reported that some CAM content was taught by multiple educators representing occupational therapy, CAM practitioners, guest speakers and care recipients.
OT educators without additional CAM training felt inadequately prepared to teach general content, and a handful felt they had the skills to instruct students to incorporate CAM as an occupational therapy intervention. However, over half stated they were teaching CAM content. While this study does not represent all OT programs, the significant inclusion of CAM may indicate that OT educators recognize and value the importance of teaching CAM as part of a comprehensive OT curriculum education.
“If the OT profession resolves ethical and pragmatic issues, provides faculty developmental opportunities, and standardized student learning outcomes, this would align stakeholders and mitigate ambiguities that currently exist surrounding the inclusion of CAM in occupational therapy education. Without an ACOTE standard requiring inclusion of CAM in occupational therapy curricula, there would be a shortage of trained occupational therapy faculty members, and the educators may be teaching biased or incomplete information.”1
Knowledge and Use of CAM Among OT Practitioners
Do you practice complementary and integrative health with your clients or for your own self-care? Johnson (2011) found as many as 76 percent of healthcare providers used at least one form of CAM, and concluded that personal use of CAM by healthcare providers may influence the integration of CAM with conventional medicine.34 Several studies have shown a link between knowledge, attitudes and perceived usefulness of CAM.35-38 With a greater knowledge of CAM comes a more positive attitude about it and its perceived usefulness.36
Herold (2009) conducted a multistate study of occupational therapists that found 93% of respondents thought OT practitioners ought to be aware of CAM, while only 34% actually received education about it. In addition, 72% would be interested in CAM education. Participants showed an overall positive attitude toward CAM, a high level of knowledge regarding CAM, and an increased level of usefulness concerning CAM.39 This study supports findings made by other researchers that CAM knowledge is important for occupational therapy professionals.35-36
It is imperative that an ACOTE standard be established in OT education on CIH for OTs to be relevant and current with healthcare trends and best practices. This will enable OTs to optimally support their clients’ occupations, have knowledgeable conversations with other healthcare practitioners, and know when to refer to CIH practitioners.
Moreover, the occupational therapy profession, with its holistic perspective that addresses the mind, the body, and spirit — from person to the environment — is uniquely able to embrace and administer these perspectives. This will further strengthen the OT profession now and in the future.
Emmy Vadnais, OTR/L, BCTMB, ARCB, is a teacher, health writer, and consultant. She is certified in a variety of complementary and integrative healthcare approaches, and provides holistic health, wellness, and prevention services and education to children, adults, and healthcare practitioners. Contact: firstname.lastname@example.org.
1. Bradshaw, M.L. (2016). Curricular inclusion of complementary and alternative medicine content in occupational therapy education in the United States. Occupational Therapy Health Care, June 22:1- 15 [Epub ahead of print]
2. Complementary, Alternative, or Integrative Health: What’s in a Name? Retrieved from https://nccih.nih.gov/health/integrative-health
3. NIH complementary and integrative health agency gets new name: The National Center for Complementary and Alternative Medicine is now the National Center for Complementary and Integrative Health. Retrieved from https://www.nih.gov/news-events/news-releases/nih-complementary-integrative-health-agency-gets-new-name
4. Vadnais, E. (2015). OTs as Leaders in Prevention and Wellness: Identifying barriers and helping patients make choices for healthy living. ADVANCE Magazine for OT Practitioners. Retrieved from http://occupational-therapy.advanceweb.com/Columns/Holistic-OT/OTs-as-Leaders-in-Prevention-and-Wellness.aspx
5. Hawk, C., Adams, J., Hartvigsen, J. (2015). The Role of CAM in Public Health, Disease Prevention, and Health Promotion. Evidence-Based Complementary and Alternative Medicine Volume 2015, Article ID 528487, 2 pages http://dx.doi.org/10.1155/2015/528487
6. Chronic Disease Prevention and Health Promotion. Retrieved from www.cdc.gov/chronicdisease/
7. Change Your Lifestyle, Reverse Your Diseases. Retrieved from www.cnn.com/2013/03/16/opinion/ornish-health-lifystyle/
8. American Occupational Therapy Association. (2014). Occupational Therapy Practice framework: Domain and process (3rd Ed.). American Journal of Occupational Therapy, 68(139). doi:10.5014/ajot.2014.682005
9. American Occupational Therapy Association. (2011). Complementary and alternative medicine. American Journal of Occupational Therapy, 65, (Suppl.), S26-S31. doi: 10.5014/ajot.2011.65S26
10. Hildenbrand. W. & Lamb, A. (2013). Occupational Therapy in Prevention & Wellness: Retaining Relevance in a New Health Care World. American Journal of Occupational Therapy, 67, 266-271. doi: http://ajot.aota.org/Article.aspx?articleid=1851676
11. Statistics From the National Health Interview Survey. Retrieved from https://nccih.nih.gov/research/statistics/NHIS
12. Complementary and Alternative Medicine. American Journal of Occupational Therapy, November/December 2011, Vol. 65, S26-S31. doi:10.5014/ajot.2011.65S26
13. American Occupational Therapy Association. (1998). OT perspective: Complementary care survey results. OT Week, 12(48), 4
14. Brachtesende A. (2005). Using complementary and alternative medicine in occupational therapy. OT Practice, 10, 9-13.
15. Lindsay, W. R., Fee, M., Michie, A., & Heap, I. (1994). The effects of cue control relaxation on adults with severe mental retardation. Research in Developmental Disabilities, 15, 425-437.
16. Scott, A. H. (1999). Wellness works: Community service health promotion groups led by occupational therapy students. American Journal of Occupational Therapy, 53, 566-574.
17. Weaver, L. L. & Darragh, A. R. (2015). Systematic Review of Yoga Interventions for Anxiety Reduction Among Children and Adolescents. American Journal of Occupational Therapy, 69, 6906180070p1-6906180070p9. doi:10.5014/ajot.2015.020115
18. Montgomery, L., Schmid, A. A. , Davis, T. L., Mitchell, J. E., Short, E. R., & Miller, K. K. (2015). Changes in Emotional Regulation and Quality of Life After Therapeutic Yoga for Individuals With Traumatic Brain Injury. American Journal of Occupational Therapy, 69, 6911515229p1. doi:10.5014/ajot.2015.69S1-PO6079
19. Academic Consortium for Integrative Health. (2015). Consortium fact sheet. Retrieved August 10, 2015, http://www.from imconsortium.org/docs-public/Consortium_Fact_Sheet-June10_2015.pdf
20. Cowen, VS & Cyr V. (2015). Complementary and alternative medicine in the US medical schools. Advances in Medical Education and Practice, (6), 113 – 117.
21. American Holistic Nurses Association. (2015). What is holistic nursing practice? Retrieved from http://www.ahncc.org/images/AHNCC_FAQ-revised_2.25.2014.pdf
22. Kreitzer MJ. (2015). Integrative Nursing: Application of principles across clinical settings. Ramban Maimonides Medical Journal, 6(2), 1-8.
23. Hart J. (2009). CAM and medical education. Alternative and Complementary Therapies, 15(6), 287- 291.
24. Pearson, NJ, & Chesney MA. (2007). The CAM education program of the national center for complementary and alternative medicine: An overview. Academic Medicine, 82(10), 921 – 926. Doi: 10.1097/ACM/0b013c31814a5014
25. Wiese M, Oster C, & Pincombe J. (2010). Understanding the emerging relationships between complementary medicine and mainstream healthcare: A review of the literature. Health, 14(3), 326-342.
26. Geigle PR, & Galantino ML. (2009). Complementary and alternative medicine inclusion in physical therapist education in the United States. Physiotherapy Research International, (14), 224 – 233.
27. Richardson, S. (2003). Complementary health and healing in nursing education. Journal of Holistic Nursing, 21, 20-35.
28. Nottingham, E. N. (2006). Complementary and alternative medicine: nurse practitioner education and practice. Holistic Nurse Practitioner, 20(5):242-6.
29. Lloyd LF, Simon B, Dunn LR, & Isberner F. (2007) The status of complementary and alternative medicine education in the U.S. physician assistant programs. Teaching and Learning in Medicine, 19(2), 174 – 179. Doi: 10/1080/10401330701333498
30. Bradshaw, M.L. (2014) Knowledge, attitudes, and personal use of complementary and alternative medicine among occupational therapy educators in the United States. Occupational Therapy Health Care, 30(1): 80-94 doi: 3109/07380577.2014.982315.
31. American Occupational Therapy Association. (2015b). Wellness and prevention. Occupational Therapy’s opportunity in the era of health care reform. Retrieved from http.//www.aota.org/About-Occupational-Therapy/Professionals/HCR.aspx
32. Barrett B, Marchand L, Scheder J, Plane MB, Maberry R, Applebaum D, . Rabago D. (2003). Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine. Journal of Alternative and Complementary Medicine, 9(6), 937-947.
33. Bradshaw, M., Worthley, H., Martin, K., Conley, S., Jacobs, B., Mazzamaro, L., & Welch, E. (2015). A Preliminary Look at Knowledge, Attitudes, and Personal Use of Complementary/Alternative Medicine (CAM) Among Occupational Therapy Practitioners. American Journal of Occupational Therapy, 69, 6911505018p1. doi:10.5014/ajot.2015.69S1-PO1093
34. Johnson P, et al “Personal use of complementary and alternative medicine (CAM) by U.S. healthcare workers”Health Serv Res 2011; HSR-10-0587.
35. Baugniet, J., Boon, H., & Ostbye, T. (2000). Complementary/Alternative medicine: Comparing the views of medical students with students in other health care professions. Family Medicine, 32(3), 178-184.
36. Anderson, K., & Kopp Miller, B. (2009). Attitudes and knowledge of occupational therapy professional of complementary and alternative medicine. Unpublished scholarly project, The University of Toledo, Health Science Campus, Toledo, OH.
37. Rosenbaum, M. E., Nisly, N. L., Ferguson, K. J., and Klingman, E. W. (2002). Academic physicians and alternative medicine: An institutional survey. American Journal of Medical Quality, 17(1), 3-9.
38. Lee M. Y. , Benn R., Wimsatt L., Cornman J., Hedgecock, J., Gerik S, . Haramati A. (2007). Integrating Complementary and alternative medicine instruction into health professions education: Organizational and instructional strategies. Academic Medicine, 82(10), 939-945. Doi:10.1097?ACM0b013e318149ebf8
39. Herold, Jennifer M., “Attitudes and knowledge of occupational therapy professionals in a multi-state survey on complementary and alternative medicine” (2009). Master’s and Doctoral Projects. Paper 188. http://utdr.utoledo.edu/graduate-projects/188