Principles of Non-Pharmacologic Treatment

“ Medicines w ill be well used when the doctor understands their nature, what man is, what life is a nd what constitution and health are. Know these well and you will know their opposites; you will then know well how to devise a remedy." Leonardo da Vinci

A Knowledge Of The Specific Element In Disease Is The Key Of Medicine. Armand Trousseau 1810–1867 (French physician) (Clinical Medicine Vol. I, Introduction)

MUST KNOW! Normal Body Structure & Functions Pathophysiologic principles Methods of therapy appropriate to each diseases Evaluation of the diseases to which the system is prey Based on the most recent evidence  evidence- based medicine Cooperate with the Law of Nature

PURPOSE Non pharmacological treatment in medicine are aimed to…. Increase health status (Individual, Family & Society)  Self reliance Control Risk Factors Diseases Management & Control Increase Quality of Life Life Completion  death & dying

Asclepiades 1st century bc Greek-born Roman physician Attributed To cure safely, swiftly and pleasantly.

Non-Pharmacologic Tx Treatment WO Drugs &/ Chemical Substance (herbs/herbalism & naturopathy), &/ combination of chemical subtance (jamu/unani/ homeopathy) & body substance e.g. transplant (cell or organ), blood, imunoglobulin, etc Divided into Preventive (prevent diseases)  increase health, control risk factors Curative (treat disease) Rehabilitative (post disease incidents)

Based on Primum non nocere Done Separately, in sequence &/ simultaneusly when treating a patient Depend on disease What is necessary for patient clinical condition Principles

Sylvius (François De La Bois) 8th century (French Professor of Anatomy, Paris) Praxeos medicae idia nova (1671) The aim of treatment must be to maintain the energies of the organism to drive away the illness, to remove the causes and to mitigate the symptoms.

PREVENTION Preventive medicine   incidence & prevalence Component of Prevention: 1. Body Protection  Injury 2. Vaccination  prevent Infectious diseases 3. Screening programs  risk factors  deg. disease 4. Chemoprevention  farmacoTx before disease occur e.g. lipid lowering drugs in preatherosklerosis 5. Counseling  Individual, family & society  life style Types of prevention 1. Primary  promotive 2. Secondary  detect & treated early 3. Tertiary  prevent fx loss/death, ↑ quality of live

RISK FACTORS CONTROL Factors involve in disease/s development Not Modifiable Risk Factors Age, Sex, Race Family history  genetics Immune system  immunity Modifiable Risk Factors Smoking, Drugs & Alcohol Weight & Diet Physical environment & risk prevention Social environment (stress, mental health & social setting) Vaccination

Patients may recover in spite of drugs or because of them. J. H. Gaddum 1900–1968 British professor of physiology Pharmacology by D. R. Laurence, Churchill Livingstone, Edinburgh (1973), Frontispiece

MANAGEMENT W.O DRUGS Information & education to patient/s, family & society Life style changes Eating & drinking (nutrition/dietary treatment) Smoking cessation Daily routine (Sleep & Wake Cycle) Physical stress (Work load & activity) Exercises & physical fitness

Enviromental changes Emotional stress  Individual Coping mechanism Support groub Family counseling & treatment Social Function & changes Economy Public Health & Epidemiology  diseases incidence, prevalence & mode of transfer Continued…..

Radiologic tx  Radiotherapy  Cancer Patient Care  nursing skills Alternative Medicine Acupuncture Mind-Body Technique  Meditation, Relaxation, Guided Imaginary, Hypnotherapy, Biofeedback Body-based therapy  Chiropractic, massage, rolfing, reflexiology, postural reeducation, Osteopathy Energy Therapies  Bioelectromagnetic based therapy, reiki, therapetic touch.

REHABILITATION Temperature mediated  Heat  Superficial (hot packs, warm water, etc), deep (Short Wave Diatermy & Long Wave Diatermy), Cold  Superficial cold (ice packs, etyl chloride, cold water), deep cold is rarely use Electrical simulation  Transcutaneus Electrical Simulation Traction & Massage Physical Therapy  Exercise  ROM, Muscle Strengthening, coordination, ambulatory, general conditioning Tilt table & tranfer training

C I E Comunication Good dr-patient relationship, family & society relation Information - Information on the disease for patients (family & society if allowed by the patients) Education - Education (to patients, family & society in written & oral methods)

Francis Weld Peabody 1881–1927 US pathologist, haematologist, and author The Care of the Patient The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.

CASE EXAMPLE AX : ID : Ny. A, 45 th, BB: 85kg, TB:165 cm, BMI: 32,32. Sekretaris PMA. Jl. MTH 193, Mlg KU : “Nyeri Dada, terasa terbakar.” RPS: Nyeri dada dirasakan 7 hari yang lalu, memberat dengan aktifitas, menghilang dengan istirahat. Nyeri dada dirasakan di daerah ulu hati, menjalar ke lengan kiri kadang ke rahang. BAB & BAK dbN. Riwayat trauma (-), Riwayat alergi (-), dan Riwayat operasi (-). Ayah & ibunya meninggal o.k hipertensi. Ny. A sering minum kopi, sering bergadang, sering stress karena pekerjaan dan jarang berolahraga. Ia tidak pernah minum alkohol, jamu, dan hanya minum obat2 yang diresepkan dokter. RPD: Hipertensi (150/90 tertinggi 170/100, tidak minum obat HT khusus

Continued… PMX FISIK KU : Sadar, dapat duduk tegak, memegangi dada o.k. nyeri VS : T: 160/95 mmHg; N: 100 x/min, reg; RR 20x/min; Tax 37°C Kulit : Rash (-), Kuku baik, clubbing (-) cyanosis (-) Kepala: Ukuran normal, jejas/trauma (-) Mata : Visus O.D & O.S t.a.a. Telinga: Luar t.a.a. Kanal paten, membrana tymphani t.a.a. Mulut : Mukosa pink; gigi baik, pharynx t.a.a Leher : Supple, pembesaran tyroid (-), Pembesaran KGB (-) Thorax : Symmetric, Diameter AP normal Paru : Inspeksi & perkusi Normal. Suara vesikuler paru normal, wheezing (-), rhonchi (-) Jantung: JVP + 2 cm, Denyut karotis regular, tanpa bruits S1, S2 tunggal; S3-S4 N. Gallop – Bising - Abdomen: Flat, Supple, Hepar/Lien ttb. Bising usus N ↑ Extremitas sup : Edema - / -, motorik +5/+5, sensorik N/N Extremitas Inf : Edema - / -, motorik +5/+5, sensorik N/N

QUESTIONS 1. What is your most likely diagnosis? 2. What is the best “prescribed” non pharmacological treatment for this patient?

JAWAB: 1. Wdx. Angina Pectoris Unstable + Hipertensi esensial Tx u/ Angina : ISDN 2 x 5mg, Aspirin 1 x 80 – 160 mg Tx u/Hipertensi : Anti Hipertensi (β Blocker/CCB/ACEI/ARB). Masalah kesehatan lain: - Hipertensi - Overweight - Sedentary life style/kurang olahraga - Stress pekerjaan tinggi 2. Mrs. A. Non Pharmacological Tx? Lets Follow These Procedures… Shall We?

Isaac Judaeus c. ad (Baghdad physician) Attributed Most illnesses are cured without the physician’s help through the aid of Nature. If you can cure the patient by dietary means, do not turn to drugs.

DIETARY/NUTRITION TREATMENT Balance diet  calories (40kal/kgBB in male & 35 in female with normal condition, add/substract 5/kgBB in weight for gain/loss weight diet), types of food. Consist of Macronutrients  fat, carbs, protein, & fiber Micronutrients +  vit., minerals, trace elements Serving  Portions & Methods Food/drink to avoid &/ consumed Weight loss diet  High-prot-low carbs diet, low-fat diet, High-fiber diet, fruit diet, atkins diet, liquid diet, food-combining & food cycling diet Weight Gain diet  gradual high calories diet

Mrs A. Dietary/Nutrition Tx Diet  35 kal x BB Ideal (70kg) = 2450 kal/hari Jenis  Weight loss diet  high-protein-low carbs diet, low-fat diet, High-Fiber diet Micro nutrients  Buah, sayur & susu, rendah garam (tanpa garam) Serving  dibagi dalam 3 x makan, 2 x snack. Food/drink to avoid : Nangka, Tewel, Santan, minyak goreng kelapa sawit, Jerohan, daging “serat putih/ tetelan”, ikan asin, makanan kaleng Food/drink to consumed : Apel, pisang, mentimun, protein nabati dll

EXERCISE Daily work IS NOT ALWAYS exercise Exercise  Physical activity performed repeatedly to achieve & maintain fitness Fitness  capacity to performed physical activity Regular Exercise  Part of Prevention & Disease management Exercise Intensity  hard/soft exercise depend on condition. ↑ 20% in HR or 75%-80% from max human HR (220) with heavy breathing, & profuse sweating = HARD intensity exercise Prevent injury  Warming up, stretching, choose the rite exercise, wear protective measures, cooling down Types of Exercise  Aerobic (Jumping, Running, biking, swimming, skating) & Non Aerobic (Weight lift)

Continued… Duration  short or long periods  few min then grew longer (30 – 60 min) Frequency  Every 2 days or 3 – 4 x a week depend on Px condition Prescribe exercise for the patient above

Mrs A. EXERCISE RECEPY Tipe  Low impact Aerobic (biking, swimming, fast walking, senam pernafasan, senam taichi dll) & Non Aerobic (angkat beban boleh, asal ringan ) Intensitas  Soft exercise (o.k. obese dg low physical fitness & HT) s.d tercapai HR maksimal 20% dari Normal (100 – 120x/min) Durasi & frekuensi  pendek dulu (20 min/x 3 x seminggu) s.d. 40 min/kali 2 hari sekali. Dimulai dari yang ringan, sebentar  perlahan2 meningkat seiring peningkatan kemampuan fisik Upaya pencegahan “injury” o.k. olahraga  Pemantauan keluhan Pemanasan, memakai pelindung & cooling down

C. Jeff Miller 1874–1936 US gynaecologist Surgery, Gynaecology and Obstetrics 52: 488 (1931) Body and soul cannot be separated for purposes of treatment, for they are one and indivisible. Sick minds must be healed as well as sick bodies.

SLEEP & WAKE CYCLE BODY FUCTION HAVE CIRCARDIAN CYCLE Daily routine  Wake time & sleep time Sleep intensity  deep & undisturbed sleep  enough REM (dream state, give fresh feeling) & good Non REM sleep (non-dream state, muscle resting) Duration  at least 5 – 8 hours in normal, increase in bedridden individual Frequency  Daily Wake cycle  Not more than 19 hours Prescribe routine cycle for the patient above

Mrs. A SLEEP & WAKE CYCLE Kebiasaan  Tidur -jaga yg teratur dalam 1 atau 2 sesi. Intensitas  tidur nyenyak > baik, teratur jam-jam tertentu. Durasi/frekuensi  min 5 jam maks 8 jam/hari Jaga  Tidak lebih dari 18 jam

SUBSTANCE CONSUMPTION Drugs  Drugs with addiction side effects Nicotine  Tobbacco & smoke Cafein  Coffee, tea, coke Food additives Food preservatives Alcohol & its derivatives  beer, vodca etc Trans Fatty Acids  fried fast food High calori, high fat, high salt diet Others  Toxic substance, depend on condition Prescribe substance/food avoidance for the patient above

Mrs. A. SUBSTANCE CONSUMPTION Drugs  sesuai dg resep dokter Cafein  m-<< minum kopi, teh ringan, coke tdk boleh, minuman berkafein lain tidak boleh. Food additives & preservatives : Sebaiknya makan dr bahan segar (natural homemade food) krn pengawet dan bahan tambahan makanan biasanya mengandung natrium. Alcohol & its derivatives  Pertahankan tidak konsumsi alkohol/turunannya Trans Fatty Acids  dilarang, tidak menggunakan minyak goreng shg masakan dibakar, dipanggang atau direbus/dikukus

ENVIRONMENT CHANGES INDIVIDUAL Emotional stress  Coping mechanism  positive thinking & attitude Personality  open mind & attitude  ppl Support &/ suppport groub Personal problem/s Job & work (salary & economy) FAMILY Family counseling & treatment Building Family support groub Economy SOCIETY Social Function & changes  person’s task & role in society Prevent diseases incidence & prevalence by preventing mode of transfer  e.g avian flu Economy

Mrs. A ENVIRONMENTAL CHANGES INDIVIDUAL  Stress emosi +, Kepribadian, Masalah individual, masalah kerja DLL  jika ada diperbaiki, bila perlu konsultasi dg psikolog/psikiater atau bergabung dg Support groub (spt AA (alcoholic anonymous), Fight Fat (obese ppl), QS (quit smoking), Gerakan Anti Narkoba FAMILY  jika ada masalah keluarga  Family counseling dg psikolog/psikiater/bergabung dg support groub SOCIETY  perubahan fungsi sosial bila diperlukan  ganti pekerjaan, pensiun dini. Pertimbangkan posisi Ny. A. dalam komunitas.

Sir Thomas Browne 1605 ‒ 82 (English physician, writer and rhetorician) Religio Medici ii, Sect. II (1643) We all labour against our own cure, for death is the cure of all diseases.

DEATH & DYING NOT PART OF A TREATMENT BUT a Completion of live Making health care choise  doctor, system care, treatment option, organ donation Financial concern Legal & ethical concern (advance directives/will/wasiat & suicide/euthanasia) Coming to term with death  when it is near & when it is occur  individual & family

Mrs. A DEATH & DYING Mungkin belum perlu untuk kasus ini karena tidak ada perubahan jantung yang bermakna, prognosis relatif baik  angka kematian kecil tapi angka kesakitan tinggi (dapat menjadi serangan jantung). Penting dipertimbangkan dalam upaya penentuan terapi operatif B/P  dokter, RS pilihan, opsi pilihan dll Pertimbangan dalam hal/masalah keuangan  Asuransi, biaya sendiri, dibiayai perusahaan, loan/pinjaman dll