Critique each article using the appropriate appraisal form· Sys

Critique each article using the appropriate appraisal form:
· Systematic or Integrative Review Download Systematic or
Integrative Review
Use the information below to help you know which section of
the article to use to answer questions in the template:
· Introduction and its subsections have the purpose
or WHY study done.
· Methods section and its subsections contains HOW the study
was done.
· Results, Discussion and Conclusions section will
have WHAT was found.
1/26/2017 PlayPosit
Name: Date:
Mary Jackson
Career and Technology Education - Accounting I
1. This video shows a high school Career and Technology
teacher teaching a lesson in an Accounting I class. The students
are juniors and seniors. The lesson is on 'making adjustments' to
an accounting balance sheet. Listen to the first part of the
lesson when she states the objective and listen for how she
'hooks' students into the lesson.
2. Did you hear the teacher state the objective? What did the
teacher do to get the students 'hooked' into the lesson objective

and to understand what is meant by 'making adjustments?
Reflect.
3. The teacher used examples from real life to help students
connect to the objective - making adjustments to a balance
sheet. She continued to give more real life examples as she
transitioned to the direct instruction portion of the lesson.
Now continue to watch the lesson. Reflect on these questions as
you watch for the next several minutes:
1. Does the teacher relate to prior knowledge?
2. What form of instruction is used?
3. Is there a tone of respect on the part of the teacher to her
students? And students to teacher?
4. Did you hear the teacher relate to prior knowledge and
previously taught concepts and terms? Did you hear her relate
to her students in a very respectful manner? And so far in the
lesson she is using direct instruction to review previously
learned concepts and terms and begin to move on to the
objective of the day.
Now continue to watch as the teacher moves to the next phase
of the lesson. Does she intentionally do more to engage
students in the lesson? If so, what does she do?
https://www.playposit.com/printable/507186
1/2

1/26/2017 PlayPosit
5. Did you see how the teacher used a matching activity to get
students more engaged in the lesson? She also began to call on
students randomly to check for understanding.
Now watch how the teacher transitions to the next activity and
look for what she asks students to do. Watch and listen to the
students during the activity.
6. Effective teachers always reflect on the lesson, and lesson
outcomes. Listen as the teacher reflects on this lesson, and
compare it to the responses you have written on the observation
worksheet. Use both the teacher’s reflections and your own
observation when writing your overall observational reflection.
7. (44:47) What did the teacher ask of the students? Would you
consider this part of the lesson guided practice? Did you notice
that some students were having difficulty with the activity -
specifically using an Excel spreadsheet?
CLASSROOM OBSERVATION:
Mary Jackson uses direct instruction in teaching a lesson in her
Accounting I class. Throughout the lesson, she engages
students with questions and analysis. She also recognizes that
her students were not as familiar with spreadsheets as she
initially thought. Her reflection at the end of the lesson is
particularly insightful.
TASK- View video and complete observation reflection

Effective teachers always reflect on the lesson, and lesson
outcomes. Listen as the teacher reflects on this lesson, and
compare it to the responses you have written on the observation
worksheet. Use both the teacher’s reflections and your own
observation when writing your overall observational reflection.
*****RECORD YOUR ANSWERS ON THE ATTACHED
DOCUMENT – OBSERVATIONAL REFLECTION
>>>>> VIEW VIDEO HERE
World Journal of
Meta-Analysis
World J Meta-Anal 2019 November 28; 7(9): 406-435
ISSN 2308-3840 (online)
Published by Baishideng Publishing Group Inc
W J M A
World Journal of
Meta-Analysis
Contents Irregular Volume 7 Number 9 November 28, 2019
REVIEW
406 Treatment of early stage (T1) esophageal adenocarcinoma:
Personalizing the best therapy choice
Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C

MINIREVIEWS
418 Mechanisms of action of aqueous extract from the Hunteria
umbellata seed and metformin in diabetes
Ejelonu OC
423 Fecal microbiota transplantation: Historical review and
current perspective
Leung PC, Cheng KF
META-ANALYSIS
428 Use of music during colonoscopy: An updated meta-
analysis of randomized controlled trials
Heath RD, Parsa N, Matteson-Kome ML, Buescher V, Samiullah
S, Nguyen DL, Tahan V, Ghouri YA, Puli SR, Bechtold ML
WJMA https://www.wjgnet.com November 28, 2019 Volume 7
Issue 9I
https://www.wjgnet.com
Contents
World Journal of Meta-Analysis
Volume 7 Number 9 November 28, 2019
ABOUT COVER Editorial Board Member of World Journal of
Meta-Analysis, Xiangchun Shen,
PhD, Director, Postdoc, Professor, Teacher, School of
Pharmaceutical
Sciences, State Key Laboratory of Functions and Applications
of Medicinal
Plants, Guizhou Medical University, Guian New District
550025, Guizhou

Province, China
AIMS AND SCOPE The primary aim of World Journal of Meta-
Analysis (WJMA, World J Meta-
Anal) is to provide scholars and readers from various fields of
clinical
medicine with a platform to publish high-quality meta-analysis
and
systematic review articles and communicate their research
findings online.
WJMA mainly publishes articles reporting research results and
findings
obtained through meta-analysis and systematic review in a wide
range of
areas, including medicine, pharmacy, preventive medicine,
stomatology,
nursing, medical imaging, and laboratory medicine.
INDEXING/ABSTRACTING The WJMA is now abstracted and
indexed in China National Knowledge
Infrastructure (CNKI), China Science and Technology Journal
Database (CSTJ), and
Superstar Journals Database
RESPONSIBLE EDITORS FOR
THIS ISSUE
Responsible Electronic Editor: Yan-Xia Xing
Proofing Production Department Director: Yun-Xiaojian Wu
NAME OF JOURNAL
World Journal of Meta-Analysis
ISSN

ISSN 2308-3840 (online)
LAUNCH DATE
May 26, 2013
FREQUENCY
Irregular
EDITORS-IN-CHIEF
Giuseppe Biondi-Zoccai
EDITORIAL BOARD MEMBERS
https://www.wjgnet.com/2308-3840/editorialboard.htm
EDITORIAL OFFICE
Jin-Lei Wang, Director
PUBLICATION DATE
November 28, 2019
COPYRIGHT
© 2019 Baishideng Publishing Group Inc
INSTRUCTIONS TO AUTHORS
https://www.wjgnet.com/bpg/gerinfo/204
GUIDELINES FOR ETHICS DOCUMENTS
https://www.wjgnet.com/bpg/GerInfo/287
GUIDELINES FOR NON-NATIVE SPEAKERS OF ENGLISH
PUBLICATION MISCONDUCT
ARTICLE PROCESSING CHARGE

STEPS FOR SUBMITTING MANUSCRIPTS
https://www.wjgnet.com/bpg/GerInfo/239
ONLINE SUBMISSION
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© 2019 Baishideng Publishing Group Inc. All rights reserved.
7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566,
USA
E-mail: [email protected] https://www.wjgnet.com
Issue 9II
mailto:[email protected]
W J M A
World Journal of
Meta-Analysis
Submit a Manuscript: https://www.f6publishing.com World J
Meta-Anal 2019 November 28; 7(9): 428-435
DOI: 10.13105/wjma.v7.i9.428 ISSN 2308-3840 (online)
META-ANALYSIS
Use of music during colonoscopy: An updated meta-analysis of
randomized controlled trials
Ryan D Heath, Nasim Parsa, Michelle L Matteson-Kome,
Victoria Buescher, Sami Samiullah,

Douglas L Nguyen, Veysel Tahan, Yezaz A Ghouri, Srinivas R
Puli, Matthew L Bechtold
ORCID number: Ryan D Heath
(0000-0002-2072-4028); Nasim Parsa
(0000-0003-3882-266X); Michelle L
Matteson-Kome
(0000-0001-8575-1943); Victoria
Buescher (0000-0002-9841-4193);
Sami Samiullah
(0000-0002-1498-0527); Douglas L
Nguyen (0000-0003-3804-0385);
Veysel Tahan (0000-0001-6796-9359);
Yezaz A Ghouri
(0000-0002-8677-1871); Srinivas R
Puli (0000-0001-7650-6938); Matthew
L Bechtold (0000-0002-0205-3400).
Author contributions: Heath RD
and Parsa N contributed equally to
this work; Heath RD, Bechtold ML,
and Parsa N designed research;
Heath RD, Parsa N, Matteson-
Kome ML, Buescher V, and
Bechtold ML performed research;
Matteson-Kome ML, Nguyen DL,
and Puli SR contributed new
reagents/analytic tools; Tahan V,
Ghouri YA, Samiullah S, and
Bechtold ML analyzed data; and
Heath RD, Parsa N, Nguyen DL,
Tahan V, Ghouri YA, Puli SR, and
Bechtold ML wrote the paper.
Conflict-of-interest statement: The
authors deny any conflict of

interest.
Open-Access: This article is an
open-access article which was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution Non
Commercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
Ryan D Heath, Nasim Parsa, Michelle L Matteson-Kome,
Victoria Buescher, Sami Samiullah,
Veysel Tahan, Yezaz A Ghouri, Matthew L Bechtold, Division
of Gastroenterology, University of
Missouri School of Medicine, Columbia, MO 65212, United
States
Douglas L Nguyen, Division of Gastroenterology, Heart of the
Rockies Regional Medical
Center, Colorado Springs, CO 80907, United States
Srinivas R Puli, Division of Gastroenterology, University of
Illinois–Peoria, Peoria, IL 61604,
United States
Corresponding author: Matthew L Bechtold, AGAF, FACG,
FACP, FASGE, MD, Professor,
Division of Gastroenterology and Hepatology, Department of
Medicine, University Hospital
and Clinics CE405, 5 Hospital Drive, Columbia, MO 65212,
United States.
[email protected]

Telephone: +1-573-8821013
Fax: +1-573-8844595
Abstract
BACKGROUND
Music seems to be beneficial in multiple clinical areas.
Colonoscopy is a stressful
event for patients, especially with conscious sedation. Music
during colonoscopy
has been evaluated in multiple randomized controlled trials
(RCTs) with varied
results. Even meta-analyses on the subject over the years have
yielded
inconsistent conclusions. Therefore, we conducted an up-to-date
meta-analysis
regarding music during colonoscopy.
AIM
To assess the effects of music played during colonoscopy on
patients’
perspectives and sedation requirements.
METHODS
Multiple large databases were aggressively searched (November
2018). RCTs
comparing music to without music during colonoscopy on adult
patients were
included. Pooled estimates were calculated for sedative
medication doses, total
procedure time, and patients’ experience, willingness to repeat
procedure, and
pain scores using odds ratio (OR) and mean difference (MD)
with random effects
model.
RESULTS

Eleven studies (n = 988) were included. Music during
colonoscopy showed a
Issue 9428
https://dx.doi.org/10.13105/wjma.v7.i9.428
http://orcid.org/0000-0002-2072-4028
http://orcid.org/0000-0003-3882-266X
http://orcid.org/0000-0001-8575-1943
http://orcid.org/0000-0002-9841-4193
http://orcid.org/0000-0002-1498-0527
http://orcid.org/0000-0003-3804-0385
http://orcid.org/0000-0001-6796-9359
http://orcid.org/0000-0002-8677-1871
http://orcid.org/0000-0001-7650-6938
http://orcid.org/0000-0002-0205-3400
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See:
http://creativecommons.org/licen
ses/by-nc/4.0/
Manuscript source: Unsolicited
manuscript
Received: October 2, 2019
Peer-review started: October 2,
2019
First decision: October 23, 2019
Revised: October 26, 2019

Accepted: November 15, 2019
Article in press: November 15, 2019
Published online: November 28,
2019
P-Reviewer: Cremers I
S-Editor: Zhang L
L-Editor: A
E-Editor: Xing YX
statistically significant reduction in procedure times (MD: -2.3
min; 95%CI: -4.13
to -0.47; P = 0.01) and patients’ pain (MD: -1.26; 95%CI: -2.28
to -0.24; P = 0.02)
while improving patients’ experience (MD: -1.11; 95%CI: -1.7
to -0.53; P < 0.01) as
compared to no music. No statistically significant differences
were observed
between music and no music during colonoscopy for midazolam
(MD: -0.4 mg;
95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg;
95%CI: -10.79 to 4.67; P =
0.44), or patients’ willingness to repeat the colonoscopy (OR:
3.89; 95%CI: 0.76 to
19.97; P = 0.1).
CONCLUSION
Music appears to improve overall patient experience while
reducing procedure
times and patient pain. Therefore, music, being a non-invasive
intervention,
should be strongly considered during colonoscopy.
Key words: Colonoscopy; Music; Relaxation; Meta-analysis
©The Author(s) 2019. Published by Baishideng Publishing

Group Inc. All rights reserved.
Core tip: Music during stressful events has been shown to
improve patient experience.
Colonoscopy is a stressful event for many patients. Music
during colonoscopy has been
studied by many randomized controlled trials and meta-analyses
with varying results.
Therefore, given new studies available for analysis, we
performed an updated meta-
analysis. This meta-analysis demonstrated that music during
colonoscopy reduces
patients’ pain while improving patients’ experience and
procedure times. With these
results and extremely limited adverse effects of music, music
should be strongly
considered during colonoscopy.
Citation: Heath RD, Parsa N, Matteson-Kome ML, Buescher V,
Samiullah S, Nguyen DL,
Tahan V, Ghouri YA, Puli SR, Bechtold ML. Use of music
during colonoscopy: An updated
meta-analysis of randomized controlled trials. World J Meta-
Anal 2019; 7(9): 428-435
URL: https://www.wjgnet.com/2308-3840/full/v7/i9/428.htm
DOI: https://dx.doi.org/10.13105/wjma.v7.i9.428
INTRODUCTION
Colonoscopy is an important procedure with screening,
diagnostic, and therapeutic
indications, but it is associated with significant patient anxiety.
Stress and discomfort
encountered both pre- and intra-operatively are associated with
delays in proceeding
with screening colonoscopy, increased medication use
during the procedure,

decreased patient satisfaction, and increased patient refusal to
repeat colonoscopy[1-3].
Utilization of music during gastrointestinal procedures is a
common approach to
reduce patient anxiety, as it has been in many fields of
medicine, including radiology,
gynecology, urology, and pulmonology[4-11]. Multiple
randomized control trials (RCTs)
have attempted to quantify the effects of music on various
aspects of undergoing
colonoscopy. A previous meta-analysis of RCTs
demonstrated increased patient
willingness to repeat the procedure when music was utilized in
the endoscopy suite;
however, no significant differences in levels of dosage of
administered sedative,
patient reported pain level, nor procedure time[12]. Other
meta-analyses have also
come to differing conclusions regarding the utility of music
during colonoscopy[13-15].
Over time, many other RCTs have been undertaken,
demonstrating variable findings
in regards to significant differences in these aforementioned
parameters. Some studies
demonstrate reduced anxiety scores and improved
satisfaction[16-25]. Some studies
showed reduced pain scores[19,26-27] and reduced sedative
requirements[18-19,28-30].
Furthermore, some studies demonstrated little significant
difference amongst anxiety
levels nor sedation requirements, though variable improvements
in patient experience
and willingness to repeat the procedure[31-35]. Given this
variation in results and
sedative medication utilized, this meta-analysis sought to

include novel data points
by selecting only studies using moderate sedation to
ascertain any significant
differences in patient reported pain, satisfaction, procedure
time, sedating medication
requirements, and patient willingness to repeat exam when
music is utilized in the
endoscopy suite.
Issue 9
Heath RD et al. Impact of music during colonoscopy
429
http://creativecommons.org/licenses/by-nc/4.0/
http://creativecommons.org/licenses/by-nc/4.0/
MATERIALS AND METHODS
Data acquisition
Medline, PubMed, Scopus, Cumulative Index for Nursing
and Allied Health
Literature, Cochrane Central Register of Controlled trials, and
Embase were searched
for articles (search date November 2018) using “music” and
“colonoscopy”. Studies
included were RCTs with adult subjects (age ≥ 18 years)
comparing music vs no music
during colonoscopy and only moderate sedation. Two
independent reviewers
extracted data using standard forms. Pooled estimates were
calculated for the effects
of music for dose of sedative medications (midazolam and

meperidine), total
procedure time, and patient’s self-reported pain scores,
experience, and willingness to
repeat the same procedure using odds ratio (OR) and
mean difference (MD) with
random effects model.
Statistics
The impact of music on patients having colonoscopy was
analyzed by calculating
pooled estimates of sedative medication doses (meperidine and
midazolam), total
procedure time, and patients’ pain scores, experience, and
willingness to repeat the
colonoscopy using OR and MD. A random effects model was
utilized to calculate the
summary estimate with significance was indicated by P-value <
0.05. I2 measure of
inconsistency was used to assess heterogeneity.
Quality assessment of studies
The Cochrane’s Collaboration Risk of Bias Tool was used
to assess the quality of
included studies[36]. In this tool, each outcome was given a
GRADE (very low, low,
moderate, or high) based on the quality of evidence. The
parameters evaluated in each
study were as follows: Precision, consistency of results,
effect magnitude, and
potential bias (publication and other forms)[37].
RESULTS
The initial search identified 177 articles. Figure 1 of these
articles, 11 RCTs (n = 988)
met the inclusion criteria[18,19,25,26,28,29,32,33,35,38,39].
Table 1 all RCTs were published from

2002-2016. Studies were global, including many countries
(United States, Germany,
Spain, Japan, Italy, China, Turkey, India, Australia, and
Sri Lanka). Most of the
studies were deemed high quality studies based on the
Cochrane’s Collaboration Risk
of Bias Tool (Table 2).
Procedure times were evaluated in nine
studies[19,25,26,28,29,32,35,38,39]. Music during
colonoscopy demonstrated a statistically significant
reduction in procedure times
(MD: -2.3 min; 95%CI: -4.13 to -0.47; P = 0.01). Figure
2 Patient pain scores were
evaluated in six studies[18,19,28,29,33,35]. The use of
music during colonoscopy showed
statistically significant decrease in patient pain levels as
compared to no music (MD: -
1.26; 95%CI: -2.28 to -0.24; P = 0.02). Figure 3 Furthermore,
patient experience was
improved using music as compared to no music (MD: -1.11;
95%CI: -1.7 to -0.53; P <
0.01) in four studies[18,28,29,35]. Figure 4 No statistically
significant differences were
observed between music and no music during colonoscopy for
midazolam (MD: -0.4
mg; 95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg;
95%CI: -10.79 to 4.67; P =
0.44), or patients’ willingness to repeat the procedure (OR:
3.89; 95%CI: 0.76 to 19.97; P
= 0.1).
DISCUSSION
Undergoing colonoscopy is a stressful experience for many
patients. The ease of
introducing music into the endoscopy suite makes its use an

attractive modality to
enhance the patient experience. Multiple studies demonstrate
that use of music not
only subjectively improves patient experience during
medical procedures, but
improves objective measures of patient stress including heart
rate, blood pressure,
and measured levels of salivary cortisol[16,27,39,40]. As noted
above, multiple RCTs have
attempted to demonstrate possible benefits of music during
colonoscopy with
variable results. Ten years ago, many authors of this study
conducted a meta-analysis
yielding the observation that while music does increase patient
willingness to repeat
the procedure, it did not necessarily reduce need for
sedating medication, reduce
patient reported pain score, nor reduce procedure time[12].
However, many RCTs
conducted over the ensuing decade supplied new data
points which suggest the
benefits of music during colonoscopy may be greater than
previously observed, with
Issue 9
430
Table 1 Description of studies included in the meta-analysis
Ref. Publication year Number of patients Type of study Type of

music
De silva et al[26] 2016 118 RCT Variety per patient
Martindale et al[33] 2013 119 RCT Classical
Costa et al[19] 2010 110 RCT Variety per patient
Bechtold et al[35] 2006 29 RCT Watermark by Enya
Ovayolu et al[18] 2006 32 RCT Turkish classical
Harikumar et al[28] 2006 166 RCT Choice of 6 styles
(headphones)
Uedo et al[39] 2004 60 RCT Easy-listening
López-Cepero Andrada et al[25] 2004 78 RCT Classical
Smolen et al[32] 2002 34 RCT Variety per patient
Schiemann et al[38] 2002 133 RCT Variety radio station
Lee et al[29] 2002 109 RCT Variety per patient
RCT: Randomized controlled trial.
possible statistically significant reduced procedure times,
patient reported pain scores,
and enhanced overall patient experience.
This meta-analysis concludes that music played during
colonoscopy improved
patient experience and procedure times while reducing
patient pain. This meta-
analysis is unique from the others given the use of the newest

RCTs and minimizing
confounding variables by only using moderate sedation rather
than moderate and
deep sedation.
This updated meta-analysis has many strengths. This meta-
analysis includes only
RCTs to limit selection and observation bias, more patients than
prior meta-analyses,
and global studies. This meta-analysis also focused on
only one type of sedation.
However, all meta-analyses have limitations as well. First,
music was initiated at
different times during the procedure process, in some
studies initiated pre-
procedurally while initiated later in others. Second, the delivery
method also differed
amongst studies, with some patients receiving music via
headphones and others via a
radio in the room. Third, the genre of music varied widely
amongst these studies with
some studies utilized classical or easy listening selections,
while other studies allowed
patients to select their own music. The inevitable variation of
any given individual
patient’s response to different music selections, particularly
when considering
cultural and generational preferences as well as response to
stressful stimuli, must be
considered when translating these results into one’s own
clinical practice. Naturally,
music selection likely also alters the behavior of the performing
endoscopist with new
evidence that selection of music can affect adenoma detection
rate[41].

In conclusion, given the low cost and relative ease of
introducing music during
colonoscopy, these results suggest it is reasonable to include
music to both improve
patient pain and experience as well as possibly productivity
given reduced procedure
times.
Issue 9
431
Table 2 Quality assessment summary of all included studies
Ref.
Study
design
Random
sequence
generation
Allocation
con-
cealment
Blinding
Blinding
outcome
assessment

Incomplete
outcome
data
Selective
reporting
Other bias
Quality
assessment
De silva et
al[26], 2016
RCT Adequate Adequate Double-
blinded
Adequate None None None High
Martindale
et al[33], 2013
blinded
Costa et
al[19], 2010
RCT Adequate Inadequate Single-
blinded
Adequate None None None Moderate
Bechtold et

al[35], 2006
RCT Adequate Not described None Inadequate None None None
Low
Ovayolu et
al[18], 2006
blinded
Harikumar
et al[28], 2006
RCT Adequate Adequate Single-
blinded
Uedo et al[39],
2004
RCT Not described Not described Double-
blinded
Adequate None None None Low
López-
Cepero
Andrada et
al[25], 2004
RCT Not described Adequate Double-
blinded

Smolen et
al[32], 2002
blinded
Schiemann
et al[38], 2002
blinded
Lee et al[29],
2002
blinded
RCT: Randomized controlled trial.
Figure 1
Figure 1 Details of search algorithm.
Issue 9

432
Figure 2
Figure 2 Forest plot showing comparison between music and no
music during colonoscopy for procedure time.
Figure 3
music during colonoscopy for patients’ pain.
Figure 4
music during colonoscopy for patients’ experience.
ARTICLE HIGHLIGHTS
Research background
Music during colonoscopy has been a controversy subject
despite multiple randomized
controlled trials and meta-analyses. Studies vary from music
during colonoscopy helping reduce
need for sedative medications and enhancing patient experience
to offering little to no benefit.
Given this variability, we conducted this meta-analysis to
include all studies to-date and limiting
them to only conscious sedation.
Research motivation
To determine if music is beneficial to patients undergoing
colonoscopy. If beneficial, music

would be a very low-cost intervention to improve patients’
experience and pain during a very
stressful procedure.
Research objectives
The objectives of this research were to fully assess the
effects of music during colonoscopy
sedative medication doses (meperidine and midazolam), total
procedure time, and patients’ pain
scores, experience, and willingness to repeat the colonoscopy.
Research methods
Issue 9
433
A meta-analysis was performed by calculating pooled estimates
of sedative medication doses
(meperidine and midazolam), total procedure time, and patients’
pain scores, experience, and
willingness to repeat the colonoscopy using odds ratio and mean
difference using a random
effects model.
Research results
This research showed that music during colonoscopy
improved patient experience and
procedure times while reducing patient pain.
Research conclusions

Music is a benefit to patients undergoing the stressful procedure
of colonoscopy. Music during
colonoscopy improves the patient experience while reducing
pain. In addition, procedure times
are improved with music playing during colonoscopy. Music is
a low-cost intervention that
shows significant benefit and should strongly be considered in
endoscopy suites. In the future,
more endoscopy suites should be equipped with music.
Research perspectives
This meta-analysis shows that music has a role in the endoscopy
suite. Also, this meta-analysis
demonstrates that with more studies, the results of any
meta-analysis may be significantly
altered as these results differ from some prior meta-analyses.
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OMD, LAc, reports royalties from Health Concerns Inc, outside
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Heather Greenlee, ND, PhD, MPH, Melissa J. DuPont-Reyes,
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INC.194 VOLUME 67 | NUMBER 3 | MAY/JUNE 2017
1. Highlight current practice guidelines on the use of integrative
therapies during and after breast cancer treatment.
2. Apply evidence-based gradings of the efficacy of integrative
treatment modalities that balance potential benefits and harms
in formulating treatment decisions
and referrals for addressing the symptoms and side effects of
breast cancer therapy.
3. Acknowledge the strengths and limitations of integrative
therapies for treating breast cancer-related symptoms and side
effects and future research needs in this area.
Clinical Practice Guidelines on the Evidence-Based Use of
Integrative Therapies During and After Breast Cancer
Treatment
Heather Greenlee, ND, PhD, MPH
1,2
; Melissa J. DuPont-Reyes, MPH, MPhil
3
; Lynda G. Balneaves, RN, PhD
4
;
Linda E. Carlson, PhD
5
; Misha R. Cohen, OMD, LAc
6,7
; Gary Deng, MD, PhD

8
; Jillian A. Johnson, PhD
9
; Matthew Mumber, MD
10
;
Dugald Seely, ND, MSc
11,12
; Suzanna M. Zick, ND, MPH
13,14
; Lindsay M. Boyce, MLIS
15
; Debu Tripathy, MD
16
Abstract: Patients with breast cancer commonly use
complementary and integrative thera-
pies as supportive care during cancer treatment and to manage
treatment-related side
effects. However, evidence supporting the use of such therapies
in the oncology setting is
limited. This report provides updated clinical practice
guidelines from the Society for Integra-
tive Oncology on the use of integrative therapies for specific
clinical indications during and
after breast cancer treatment, including anxiety/stress,
depression/mood disorders, fatigue,
quality of life/physical functioning, chemotherapy-induced
nausea and vomiting, lymphede-

ma, chemotherapy-induced peripheral neuropathy, pain, and
sleep disturbance. Clinical prac-
tice guidelines are based on a systematic literature review from
1990 through 2015. Music
therapy, meditation, stress management, and yoga are
recommended for anxiety/stress
reduction. Meditation, relaxation, yoga, massage, and music
therapy are recommended for
depression/mood disorders. Meditation and yoga are
recommended to improve quality of
life. Acupressure and acupuncture are recommended for
reducing chemotherapy-induced
nausea and vomiting. Acetyl-L-carnitine is not recommended to
prevent chemotherapy-
induced peripheral neuropathy due to a possibility of harm. No
strong evidence supports the
use of ingested dietary supplements to manage breast cancer
treatment-related side effects.
In summary, there is a growing body of evidence supporting the
use of integrative therapies,
especially mind-body therapies, as effective supportive care
strategies during breast cancer
treatment. Many integrative practices, however, remain
understudied, with insufficient evi-
dence to be definitively recommended or avoided. CA Cancer J
Clin 2017;67:194-232.
VC 2017 American Cancer Society.
Keywords: acupressure, acupuncture, breast cancer,
complementary therapies, integrative
medicine, integrative oncology, massage, meditation, music
therapy, stress management, yoga
Practical Implications for Continuing Education
> To make informed decisions on the use of integrative

therapies in the oncology
setting, clinicians and patients should understand the level of
evidence of
associated benefits and harms for each therapy.
> Based on a systematic review of the literature, the Society for
Integrative
Oncology makes the following recommendations:
– Use of music therapy, meditation, stress management and
yoga for anxiety/
stress reduction.
– Use of meditation, relaxation, yoga, massage and music
therapy for
depression/mood disorders.
– Use of meditation and yoga to improve quality of life.
– Use of acupressure and acupuncture for reducing CINV.
– There is a lack of strong evidence supporting the use of
ingested dietary
supplements or botanical agents as supportive care and/or to
manage breast
cancer treatment-related side effects.
> Implementing integrative therapies in a clinical setting
requires a coordinated
team approach with well-trained providers. Training and
credentialing for many
integrative providers varies by jurisdictions. Best practices
suggest that
providers be trained to the highest standard of their profession
and educated in
other relevant disciplines.

1
Assistant Professor, Department of
Epidemiology, Mailman School of Public
Health, Columbia University, New York, NY;
2
Member, Herbert Irving Comprehensive
Cancer Center, Columbia University, New
York, NY;
3
Doctoral Fellow, Department of
Epidemiology, Mailman School of Public
Health, Columbia University, New York, NY;
4
Associate Professor, College of Nursing,
Rady Faculty of Health Sciences, Winnipeg,
MB, Canada;
5
Professor, Department of
Oncology, University of Calgary, Calgary, AB,
Canada;
6
Adjunct Professor, American
College of Traditional Chinese Medicine at
California Institute of Integral Studies, San
Francisco, CA;

7
Clinic Director, Chicken Soup
Chinese Medicine, San Francisco, CA;
8
Medical Director, Integrative Oncology,
Memorial Sloan Kettering Cancer Center,
New York, NY;
9
Post-Doctoral Scholar,
Department of Biobehavioral Health, The
Pennsylvania State University, University
Park, PA;
10
Radiation Oncologist, Harbin
Clinic, Rome, GA;
11
Executive Director,
Ottawa Integrative Cancer Center, Ottawa,
ON, Canada;
12
Executive Director of
Research, Canadian College of Naturopathic
Medicine, Toronto, ON, Canada;
13
Research

Associate Professor, Department of Family
Medicine, Michigan Medicine, University of
Michigan, Ann Arbor, MI;
14
Research
Associate Professor, Department of
Nutritional Sciences, School of Public Health,
University of Michigan, Ann Arbor, MI;
15
Research Informationist, Memorial Sloan
Kettering Library, Memorial Sloan Kettering
Cancer Center, New York, NY;
16
Professor,
Department of Breast Medical Oncology, The
University of Texas MD Anderson Cancer
Center, Houston, TX.
Additional supporting information may be
found in the online version of this article.
Corresponding author: Heather Greenlee, ND,
PhD, MPH, Department of Epidemiology, Mailman
School of Public Health, Columbia University, 722
West 168th St, Seventh Fl, New York, NY 10032;
[email protected]
DISCLOSURES: Linda E. Carlson reports book
royalties from New Harbinger and the American
Psychological Association. Misha R. Cohen
reports royalties from Health Concerns Inc.,
outside the submitted work. Matthew Mumber

owns stock in I Thrive. All remaining authors
report no conflicts of interest.
doi: 10.3322/caac.21397. Available online
at cacancerjournal.com
VOLUME 67 _ NUMBER 3 _ MAY/JUNE 2017 195
CA CANCER J CLIN 2017;67:194–232
https://www.wileyhealthlearning.com/acs.aspx
https://www.wileyhealthlearning.com/acs.aspx
http://cacancerjournal.com
Introduction
Patients with breast cancer and breast cancer survivors are
frequent users of complementary and integrative therapies,
and there are growing numbers of formal, integrative oncol -
ogy programs within cancer centers.
1-6
Various terms are
used to describe such therapies, and it is helpful at the outset
to define terms. Complementary and alternative therapies are
generally defined as any medical system, practice, or product
that is not part of conventional medical care.7,8 Other rele-

vant terminology includes complementary medicine, which
comprises therapies used as a complement alongside
conventional medicine; alternative medicine, which com-
prises therapies used in place of conventional medicine; and
integrative medicine, which is the coordinated use of
evidence-based complementary practices and conventional
care. Integrative oncology refers to the use of complementary
and integrative therapies in collaboration with conventional
oncology care. In oncology, individuals use complementary
and integrative therapies with the intent of enhancing
wellness, improving quality of life (QOL), and relieving
symptoms of disease and side effects of conventional treat-
ments. However, the evidence supporting the use of
complementary and integrative therapies in the oncology
setting is limited.
In November 2014, the Society for Integrative Oncology
(SIO) published clinical practice guidelines to inform both
clinicians and patients on the use of integrative therapies

during breast cancer treatment and to treat breast cancer
treatment-related symptoms.9 The SIO adapted methods
established by the US Preventive Services Task Force10 to
develop graded recommendations on the use of specific inte-
grative therapies for defined clinical indications based on
the strength of available evidence concerning associated
benefits and harms. The 2014 clinical practice guidelines
were derived from a systematic review of randomized clini -
cal trials published between 1990 and 2013 and organized
by specific clinical conditions (eg, anxiety/stress, fatigue).
This review provides an updated set of clinical practice
guidelines based on a current, systematic literature review of
randomized controlled trials (RCTs) published through
December 2015 along with detailed definitions of integra-
tive therapies and clinical outcomes of interest, a detailed
summary of the literature upon which the clinical practice
guidelines are based, and suggestions for how appropriate
therapies may be integrated into clinical practice.

Of note, it is important to define the use of the term rec-
ommendation in these clinical practice guidelines. In many
settings, a clinical guideline recommendation suggests that it
should be used as the standard of care and is favorable or
equal compared with all other options based on best clinical
evidence for benefit/risk ratio. Here, in the setting of inte-
grative oncology, we use the term recommendation to
conclude that the therapy should be considered as a viable
but not singular option for the management of a specific
symptom or side effect. Few studies have conducted a head-
to-head comparison of a given integrative therapy against a
conventional treatment, and most integrative therapies are
used in conjunction with standard therapy and have been
studied in this manner. Moreover, combination-based
approaches and the interactions of the numerous permuta-
tions of integrative and conventional treatments have not
been formally investigated, such that recommendations must
account for this limitation of our knowledge. Despite these

limitations to evaluating the use of integrative therapies in
the oncology setting, there is a body of well conducted trials
of specific therapies for specific conditions that provides suf-
ficient evidence to warrant recommendations on the thera-
pies as viable options for treating specific conditions.
In this review, we provide clinicians and patients with
updated SIO clinical practice guidelines on the use of inte-
grative therapies to manage symptoms and side effects during
and after breast cancer treatment. The clinical practice guide-
lines do not address breast cancer recurrence or survival end-
points, because very few adequately powered RCTs have
examined the effect of integrative therapies on these out-
comes. We also provide a definition for each integrative ther -
apy that had a sufficiently large body of evidence to formulate
a specific recommendation. Information is also provided on
how to implement the recommendations into the clinical set-
ting, with caveats for specific clinical situations. In addition,
this review summarizes pertinent meta-analyses and identifies

promising areas for future investigation. The information
that arose from other published reviews and meta-analyses
did not change the interpretation of the findings or the quali -
ty of specific trials, but the information was used to influence
the establishment of specific recommendation grades based
on consistency, reproducibility, and assessment of potential
harms and benefits. The goal of this current review is to pro-
vide clinicians and patients with practical information and
tools to evaluate whether there is an evidence base to support
the use of a defined integrative therapy for a specific clinical
application in the context of breast cancer.
Methods
Systematic Review Methodology
To update the previously published clinical practice guide-
lines, which were based on a systematic review of the litera-
ture from January 1, 1990 through December 31, 2013,
9
we
conducted a systematic review of published RCTs from Jan-

uary 1, 2014 through December 31, 2015, using the same
search criteria and process. The process followed the meth-
ods set forth by the Institute of Medicine on clinical guide-
line development.
11
The following databases were searched:
Embase, MEDLINE, PsychINFO, and CINAHL.
Integrative Therapies During and After Breast Cancer Treatment
196 CA: A Cancer Journal for Clinicians
As previously reported,9 trials were selected for inclusion in
the systematic review if they met the following criteria:
1) peer-reviewed, published RCT; 2) available in English;
3) included �50% patients with breast cancer and/or
reported results separately for patients with breast cancer;
4) used an integrative therapy as an intervention during stan-
dard treatment with surgery, chemotherapy, radiation thera-
py, and/or hormonal therapy or addressed symptoms and
side effects resulting from diagnosis and/or treatment; and

5) addressed an endpoint of clinical relevance to patients
with breast cancer and breast cancer survivors (see Support-
ing Information Table 1).9 Several lifestyle and psychological
interventions were excluded from current as well as previous
guidelines, because they have already been well summarized
by other groups (eg, diet
12,13
and physical activity
12-14
rec-
ommendations for cancer survivors) and/or because they
have a strong evidence base and are often considered to be
mainstream rather than integrative or complementary (eg,
cognitive-behavioral therapy,
15
psychoeducation,
16
counsel-
ing,
17

and support groups
16
). Other interventions that were
excluded were in early or pilot stages of research (eg,
attention-restoration therapy) or were not considered to be
an integrative oncology therapy for the purposes of the SIO
guidelines (eg, prayer, spirituality). Each article was scored
according to the quality of design and reporting based on the
Jadad scoring scale and a modified scale adapted from the
Delphi scoring system.18,19 Finally, grades of evidence were
determined for each therapy as applied to a specific clinical
outcome using a modified version of the US Preventive Serv-
ices Task Force grading system.
10
Grades were based on
strength of evidence, determined by the number of trials,
quality of trials, magnitude of effect, statistical significance,
sample size, consistency of results across studies, and whether
the outcomes were primary or secondary. The highest grades

(A and B) indicate that a specific therapy is recommended for
a particular clinical indication. Grade A indicates there is
high certainty that the net benefit is substantial, while grade
B indicates there is high certainty that the net benefit is mod-
erate or there is moderate certainty that the net benefit is
moderate to substantial. Grade C indicates that the evidence
is equivocal or that there is at least moderate certainty that
the net benefit is small. The lowest grades (D, H, and I) i ndi-
cate no demonstrated effect, suggest harm, or indicate that
the current evidence is inconclusive, respectively.
According to the clinical guideline development process
outlined by the Institute of Medicine,11 drafts prepared by
the SIO Guideline Working Group were distributed to an
interdisciplinary group of SIO internal and external reviewers.
Reviewer comments, suggestions, and critiques were incorpo-
rated into the final version of these guidelines.
It is important to note that, as we reviewed the literature,
we recognized the difference between statistical and

clinical significance. The graded recommendations reflect
our assessment of the clinical significance based on our
assessment of the body of literature, including the impor-
tance of statistical significance with respect to the primary
endpoint. We did not report on specific magnitudes of
effect because of the range of outcome measures and statisti -
cal methods used across the trials, which made it difficult to
describe detailed data on effect sizes across all trials.
Although some of the trials with small sample sizes (n <
100) may have been methodologically sound, we down-
played their contribution to the graded recommendation,
because larger trials provided more information on general-
izability of results to larger populations. Because of space
limitations, P values are reported and citations are provided
to reference the primary reports for additional details.
Definitions of Complementary and Integrative
Therapies
Below are definitions listed alphabetically for each of the
complementary and integrative therapies that received

a grade of A, B, C, D, or H in the updated clinical
practice guidelines.20,21 Table 1 displays the graded rec-
ommendations.
10,22-151
Table 2 provides background
information on the specific training, licensure, and profes-
sional organizations associated with each therapy.152 If a
therapy is known to have a specific contraindication or
caution, it is noted in the description. The descriptions
include statements on how the therapies are often used by
patients with cancer and by survivors but do not indicate
the level of evidence supporting such use. The guideline
recommendations provide a summary of the evidence on
the use for specific conditions. In addition to the informa-
tion provided below, there are continuously updated, well
referenced websites that can provide additional details on
the range of therapies, including Natural Medicines (nat-
uralmedicines.therapeuticresearch.com), Memorial Sloan

Kettering Cancer Center’s About Herbs website (mskcc.org/
cancer-care/treatments/symptom-management/integrative-
medicine/herbs), and the National Cancer Institute (NCI)
Office of Cancer Complementary and Alternative Medicine
Therapies: A-Z website (cam.cancer.gov/health_informa-
tion/cam_therapies_a-z.htm).
Acetyl-L-carnitine
Acetyl-L-carnitine is a dietary supplement that some
patients use to treat cancer-related fatigue by enhancing
energy and lowering inflammation in the body.
153
It has
demonstrated effectiveness in preventing and treating dia-
betic neuropathy and thus was of interest to examine in the
context of chemotherapy-induced peripheral neuropathy
(CIPN). It is a substance made in muscle and liver tissue
and is found in foods, including meats, poultry, fish, and
some dairy products.

http://naturalmedicines.therapeuticresearch.com
http://naturalmedicines.therapeuticresearch.com
http://mskcc.org/cancer-care/treatments/symptom-
management/integrative-medicine/herbs
http://cam.cancer.gov/health_information/cam_therapies_a-
z.htm
http://cam.cancer.gov/health_information/cam_therapies_a-
z.htm
TABLE 1. Graded Integrative Therapies for Use in Patients
With Breast Cancer According to Clinical Outcomes
a
CLINICAL
OUTCOMES RECOMMENDED THERAPY
STRENGTH OF
EVIDENCE GRADEb
Acute radiation
skin reaction
Aloe vera22,23 and hyaluronic acid cream24,25 should not be
recommended for improving acute
radiation skin reaction.
D

Anxiety/stress reduction Meditation is recommended for
reducing anxiety.26-30 A
Music therapy is recommended for reducing anxiety.31-35 B
Stress management is recommended for reducing anxiety during
treatment, but longer group
programs are likely better than self-administered home
programs or shorter programs.36-39
B
Yoga is recommended for reducing anxiety.40-48 B
Acupuncture,49-51 massage,52-55 and relaxation56-60 can be
considered for reducing anxiety. C
Chemotherapy-induced
nausea and vomiting
Acupressure can be considered as an addition to antiemeti cs
drugs to control nausea and
vomiting during chemotherapy.61-63
B
Electroacupuncture can be considered as an addition to
antiemetics drugs to control vomiting
during chemotherapy.64,65
B
Ginger66-68 and relaxation59,69 can be considered as additions
to antiemetic drugs to control
nausea and vomiting during chemotherapy.

C
Glutamine70,71 should not be recommended for improving
nausea and vomiting during
chemotherapy.
D
Depression/mood
disturbance
Meditation, particularly MBSR, is recommended for treating
mood disturbance and depressive
symptoms.26-30,72-76
A
Relaxation is recommended for improving mood disturbance and
depressive
symptoms.56,59,60,69,77,78
A
Yoga is recommended for improving mood and depressive
symptoms.40-43,45-48,79-85 B
Massage is recommended for improving mood disturbance.53-
55,86-88 B
Music therapy is recommended for improving mood.33,35,89,90
B
Acupuncture,49-51,91,92 healing touch,93,94 and stress
management36-38,95,96 can be considered
for improving mood disturbance and depressive symptoms.

C
Fatigue Hypnosis97,98 and ginseng99,100 can be considered for
improving fatigue during treatment. C
Acupuncture51,101-103 and yoga45,80,84,104-106 can be
considered for improving post-treatment
fatigue.
C
Acetyl-L-carnitine107 and guarana108,109 should not be
recommended for improving fatigue
during treatment.
D
Lymphedema Low-level laser therapy,110,111 manual
lymphatic drainage,112-118 and compression bandag-
ing114-116 can be considered for improving lymphedema.
C
Neuropathy Acetyl-L-carnitine is not recommended for the
prevention of chemotherapy-induced peripheral
neuropathy in patients with BC due to potential harm.107
H
Pain Acupuncture,119-124 healing touch,93 hypnosis,125,126
and music therapy31,34 can be considered
for the management of pain.
C
Quality of life Meditation is recommended for improving

quality of life.27-29,73-75,127 A
Yoga is recommended for improving quality of life.43,46-48,82-
85,104-106,128 B
Acupuncture,49,51,102,129,130 mistletoe,131-134
qigong,135,136 reflexology,137-139 and stress
management36-38,95,96,140,141 can be considered for
improving quality of life.
C
Sleep disturbance Gentle yoga45,48,79,84,142 can be
considered for improving sleep. C
Vasomotor/hot flashes Acupuncture49,91,92,1 43-148 can be
considered for improving hot flashes. C
Soy149-151 is not recommended for hot flashes in patients with
BC due to lack of effect. D
Abbreviations: BC, breast cancer; MBSR, mindfulness-based
stress reduction.
a
The clinical population is patients with BC during treatment,
including surgery,
chemotherapy, hormonal/biological therapy, and radiation
therapy. The clinical question is “What integrative therapies can
be used to prevent, treat and man-
age symptoms and side effects encountered during breast cancer
treatment?”
b
Definitions of the grade of recommendations are as follows

10
: Grade A recom-
mends the modality (there is high certainty that the net benefit
is substantial: offer/provide this modality). Grade B
recommends the modality (there is high
certainty that the net benefit is moderate, or there is moderate
certainty that the net benefit is moderate to substantial:
offer/provide this modality). Grade C
recommends selectively offering or providing this service to
individual patients based on professional judgment and patient
preferences (there is at least mod-
erate certainty that the net benefit is small: offer/provide this
modality for selected patients, depending on individual
circumstances). Grade D recommends
against the service (there is moderate or high certainty that the
modality has no net benefit: discourage the use of this
modality). Grade H recommends
against the service (there is moderate or high certainty that the
harms outweigh the benefits: discourage the use of this
modality).
T
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H
P)
,
nl
ch
p.
ca
/
H
yp
no
si
s
M
en
ta
l
he
al
th
an
d
m

ed
ic
al
pr
o
fe
ss
io
na
ls
ty
pi
ca
lly
pr
ac
ti
ce
hy
pn
o
si
s
as

a
sp
ec
ia
lt
y
o
r
su
bs
pe
ci
al
ty
.
C
er
ti
fi
ed
hy
pn
o
-

th
er
ap
is
ts
,
in
ge
ne
ra
l,
ho
ld
a
gr
ad
ua
te
-l
ev
el
o
r
ba
ch

el
o
r’
s-
le
ve
l
de
gr
ee
in
a
br
o
ad
ra
ng
e
o
f
sp
ec
ia
lt

ie
s,
in
cl
ud
in
g
M
D
,
re
gi
st
er
ed
nu
rs
e,
de
nt
is
t,
so
ci

al
w
o
rk
er
,
lic
en
se
d
co
un
se
lo
r
o
r
ps
yc
ho
lo
gi
st
.
pa

st
o
ra
l
co
un
se
lo
r,
o
rd
ai
ne
d
m
in
is
te
r,
an
d
ch
ir
o

pr
ac
to
r,
am
o
ng
m
an
y
o
th
er
s,
pr
io
r
to
o
bt
ai
ni
ng
tr

ai
ni
ng
in
hy
pn
o
si
s.
C
ur
re
nt
ly
,
th
er
e
ar
e
no
ac
cr
ed

it
ed
sc
ho
o
ls
o
ff
er
in
g
st
an
da
rd
co
lle
ge
o
r
un
iv
er
si

ty
de
gr
ee
s
in
hy
pn
o
si
s;
th
er
ef
o
re
,
tr
ai
ni
ng
in
o
ne

o
f
th
e
ab
o
ve
pr
o
fe
ss
io
ns
is
ty
pi
ca
lly
re
qu
ir
ed
be
fo
re

ac
ce
pt
an
ce
in
to
o
ne
o
f
m
an
y
tr
ai
ni
ng
o
r
ce
rt
if
ic

at
io
n
pr
o
gr
am
s.
Th
es
e
pr
o
gr
am
s
ha
ve
a
w
id
e
ra
ng

e
o
f
tr
ai
ni
ng
re
qu
ir
em
en
ts
bu
t
in
ge
ne
ra
l
re
qu
ir
e
an

yw
he
re
fr
o
m
5
0
to
2
0
0
h
o
f
cl
as
sr
o
o
m
an
d
cl
in

ic
al
tr
ai
ni
ng
be
fo
re
ce
rt
if
ic
at
io
n.
U
N
IT
ED
ST
A
TE
S:

To
be
ce
rt
if
ie
d
as
a
cl
in
ic
al
hy
pn
o
th
er
ap
is
t,
ap
pl
ic

an
ts
ty
pi
ca
lly
re
qu
ir
e
an
yw
he
re
fr
o
m
5
0
to
2
0
0
h

o
f
tr
ai
ni
ng
an
d
o
ft
en
y
o
f
ex
pe
ri
en
ce
.
Th
er
e
ar

e
a
nu
m
be
r
o
f
ce
rt
if
ic
at
io
n
pr
o
gr
am
s
w
it
h
a

ra
ng
e
o
f
re
qu
ir
em
en
ts
(s
ee
lin
ks
).
R
eg
ul
at
io
ns
fo
r
th

e
pr
ac
ti
ce
o
f
hy
pn
o
si
s
va
ry
o
n
a
st
at
e-
by
-s
ta
te

ba
si
s
(a
ih
cp
.o
rg
/h
yp
no
si
s-
re
gu
la
ti
o
n.
ht
m
).
Ty
pi
ca

lly
,
cl
in
ic
al
hy
pn
o
th
er
ap
is
ts
m
us
t
re
ne
w
th
ei
r
ce

rt
if
ic
at
io
n
ev
er
y
2
to
4
y
an
d
m
us
t
ha
ve
co
m
pl
et

ed
2
0
1
h
o
f
ap
pr
o
ve
d
tr
ai
ni
ng
du
ri
ng
th
at
ti
m
e.

C
A
N
A
D
A
:
C
er
ti
fi
ca
ti
o
n
is
si
m
ila
r
to
th
e
U
ni

te
d
St
at
es
;
ho
w
ev
er
,
re
qu
ir
em
en
ts
ar
e
m
uc
h
hi
gh

er
,
be
tw
ee
n
2
2
5
an
d
1
1
0
0
h
(a
rc
hc
a-
na
da
.c
a/

).
Th
e
C
o
un
ci
l
o
f
Pr
o
fe
ss
io
na
l
H
yp
no
si
s
en
co

m
pa
ss
es
m
an
y
pr
o
fe
s-
si
o
na
l
so
ci
et
ie
s
an
d
o
rg

an
iz
at
io
ns
lis
te
d
(c
o
ph
o
.c
o
m
/o
rg
.h
tm
).
A
ss
o
ci

at
io
n
o
f
R
eg
is
te
re
d
C
lin
ic
al
H
yp
no
th
er
ap
is
ts
(A
R

C
H
),
ar
ch
-
ca
na
da
.c
a/
;
A
m
er
ic
an
C
o
lle
ge
o
f
H

yp
no
th
er
ap
y
at
th
e
A
m
er
ic
an
In
st
itu
te
of
H
ea
lth
C
ar

e
Pr
of
es
si
on
al
s,
ai
hc
p.
ne
t/
am
er
ic
an
-c
ol
le
ge
-o
f-
hy

pn
ot
he
ra
py
/;
A
m
er
ic
an
So
ci
et
y
of
C
lin
ic
al
H
yp
no
si

s
(A
SC
H
),
as
ch
.
ne
t/
;
H
yp
no
si
s
M
ot
iv
at
io
n
In
st

it
ut
e
(H
M
I),
hy
pn
os
is
.e
du
;
N
at
io
na
l
B
oa
rd
fo
r
C

er
tif
ie
d
C
lin
ic
al
H
yp
no
th
er
ap
is
ts
(N
B
C
C
H
),
na
tb

oa
rd
.
co
m
;
Th
e
In
te
rn
at
io
na
l
So
ci
et
y
of
H
yp
no
si

s
(IS
H
),
is
hh
yp
no
si
s.
or
g/
;
So
ci
et
y
fo
r
C
lin
ic
al
an

d
Ex
pe
rim
en
ta
l
H
yp
no
si
s
(S
C
EH
),
sc
eh
.u
s/
;
Th
e
M

ilt
on
H
.
Er
ic
ks
on
Fo
un
da
tio
n,
er
ic
ks
on
-f
ou
nd
at
io
n.
or

g/
M
as
sa
ge
A
ss
o
ci
at
ed
B
o
dy
w
o
rk
an
d
M
as
sa
ge
Pr
o

fe
ss
io
na
l
(A
B
M
P)
m
em
be
rs
at
th
e
ce
rt
if
ie
d
o
r
pr
o

fe
ss
io
na
l
le
ve
ls
m
us
t
po
ss
es
s
a
va
lid
m
as
-
sa
ge
lic

en
se
fr
o
m
a
re
gu
la
te
d
st
at
e/
pr
o
vi
nc
e/
te
rr
it
o
ry

,
m
us
t
ha
ve
co
m
pl
et
ed
5
0
0
ap
pr
o
ve
d
ed
uc
at
io
na

l
h
o
r
be
ce
rt
if
ie
d
th
ro
ug
h
th
e
N
at
io
na
l
C
er
ti
fi

ca
ti
o
n
B
o
ar
d
fo
r
Th
er
ap
eu
ti
c
M
as
sa
ge
an
d
B
o
dy

w
o
rk
(N
C
TM
B
).
Li
ce
ns
ed
nu
rs
e
an
d
ph
ys
ic
al
th
er
ap

is
ts
m
ay
qu
al
if
y
fo
r
m
em
be
rs
hi
p
at
ei
th
er
th
e
ce
rt

if
ie
d
o
r
pr
o
fe
ss
io
na
l
le
ve
l
w
it
h
a
m
in
im
um
o
f

5
0
h
o
f
ad
di
ti
o
na
l
m
as
sa
ge
th
er
ap
y
tr
ai
ni
ng
.
B

o
ar
d
ce
rt
if
ic
at
io
n
is
th
e
hi
gh
es
t
vo
lu
nt
ar
y
cr
ed
en

ti
al
at
ta
in
ab
le
to
m
as
sa
ge
th
er
ap
is
ts
an
d
bo
dy
w
or
ke

rs
in
th
e
pr
o
fe
ss
io
n
to
da
y
(f
o
r
th
e
re
qu
ir
em
en
ts

o
f
bo
ar
d
ce
rt
if
ic
at
io
n,
se
e
nc
bt
m
b.
o
rg
/
bo
ar
d-
ce

rt
if
ic
at
io
n)
.
U
N
IT
ED
ST
A
TE
S:
M
as
sa
ge
th
er
ap
y
is

re
gu
la
te
d
by
so
m
e
U
S
st
at
es
.
Se
e
lin
k
fo
r
st
at
e-

by
-s
ta
te
m
as
sa
ge
lic
en
su
re
in
fo
rm
at
io
n
(m
as
sa
ge
th
er

ap
y.
co
m
/c
ar
ee
rs
/s
ta
te
bo
ar
ds
.p
hp
).
C
A
N
A
D
A
:

M
as
sa
ge
th
er
ap
is
ts
ca
n
o
nl
y
be
re
gi
st
er
ed
,
no
t
lic

en
se
d,
in
C
an
ad
a.
C
ur
re
nt
ly
,
o
nl
y
4
pr
o
vi
nc
es
re
gu

la
te
m
as
sa
ge
th
er
ap
is
ts
:
O
nt
ar
io
,
B
ri
ti
sh
C
o
lu

m
bi
a,
N
ew
B
ru
ns
w
ic
k,
an
d
N
ew
fo
un
dl
an
d.
Th
e
W
eb

si
te
fo
r
th
e
O
nt
ar
io
M
as
sa
ge
Th
er
ap
is
ts
ha
s
lin
ks
to

th
e
4
pr
o
vi
nc
es
’
re
gi
st
ra
ti
o
n
pr
o
ce
du
re
s
an
d

lin
ks
to
o
th
er
pr
o
vi
nc
ia
l
m
as
sa
ge
o
rg
an
iz
at
io
ns
.

A
m
er
ic
an
M
as
sa
ge
Th
er
ap
y
A
ss
o
ci
at
io
n,
am
ta
m
as
sa

ge
.o
rg
;
A
B
M
P,
ab
m
p.
co
m
;
N
C
TM
B
,
nc
bt
m
b.
o

rg
/;
So
ci
et
y
fo
r
O
nc
o
lo
gy
M
as
sa
ge
,
s4
o
m
.o
rg
/

M
as
sa
ge
Th
er
ap
is
ts
’
A
ss
o
ci
at
io
n
o
f
O
nt
ar
io
,
se

cu
re
.r
m
ta
o
.c
o
m
/
m
as
sa
ge
_
th
er
ap
y/
re
gu
la
tio
n_

of
_
m
t/
m
as
sa
ge
_
th
er
ap
y_
in
_
ca
na
da
.
ht
m

http://acaom.org
http://mx.nccaom.org
http://ctcma.bc.ca
https://www.ctcmpao.on.ca/
http://acupuncturealberta.ca/
http://acupuncture-quebec.com/en/home.html
http://acupuncture-quebec.com/en/home.html
http://nlchp.ca/
http://aihcp.org/hypnosis-regulation.htm
http://archcanada.ca/
http://copho.com/org.htm
http://aihcp.net/american-college-of-hypnotherapy/
http://aihcp.net/american-college-of-hypnotherapy/
http://hypnosis.edu/
http://natboard.com
http://natboard.com
http://ishhypnosis.org/
http://sceh.us/
http://erickson-foundation.org/
http://ncbtmb.org/board-certification
http://ncbtmb.org/board-certification
http://massagetherapy.com/careers/stateboards.php
http://amtamassage.org
http://abmp.com
http://ncbtmb.org/
http://s4om.org/
http://secure.rmtao.com/massage_therapy/regulation_of_mt/mas
sage_therapy_in_canada.htm

T
A
B
L
E
2
.
C
o
n
ti
n
u
e
d
M
O
D
A
LI
T
Y
O
R

T
H
E
R
A
P
Y
T
R
A
IN
IN
G
LI
C
E
N
S
U
R
E
A
N
D
R

E
G
U
LA
T
IO
N
P
R
O
FE
S
S
IO
N
A
L
S
O
C
IE
T
IE
S
A

N
D
O
R
G
A
N
IZ
A
T
IO
N
S
M
ed
it
at
io
n
M
in
df
ul
ne

ss
-B
as
ed
St
re
ss
R
ed
uc
ti
o
n:
Th
e
C
en
te
r
fo
r
M
in
df

ul
ne
ss
in
M
as
sa
ch
us
et
ts
pr
o
vi
de
s
m
ed
it
at
io
n
sp
ec

ia
lis
t
tr
ai
ni
ng
(u
m
as
sm
ed
.e
du
/c
fm
/t
ra
in
in
g/
de
ta
ile

d-
tr
ai
ni
ng
-i
nf
o
rm
at
io
n/
te
ac
he
r-
ce
rt
if
ic
at
io
n-
re
vi

ew
/)
.
In
bo
th
th
e
U
ni
te
d
St
at
es
an
d
C
an
ad
a,
bo
ar
d

ce
rt
if
ic
at
io
n
is
th
e
hi
gh
es
t
cr
ed
en
ti
al
at
ta
in
ab
le

fo
r
m
ed
it
at
io
n
te
ac
he
rs
in
th
e
he
al
th
ca
re
pr
o
fe
ss
io

n
to
da
y.
Th
er
e
is
no
re
gi
st
ra
ti
o
n
o
r
lic
en
su
re
cu
rr

en
tl
y
av
ai
la
bl
e.
A
m
er
ic
an
M
in
df
ul
ne
ss
R
es
ea
rc
h

A
ss
o
ci
at
io
n,
go
am
ra
.o
rg
/
Th
e
U
ni
ve
rs
it
y
o
f

C
al
if
o
rn
ia
at
Sa
n
D
ie
go
C
en
te
r
fo
r
M
in
df
ul
ne
ss
pr

o
vi
de
s
ex
te
ns
iv
e
tr
ai
ni
ng
(m
bp
ti
.o
rg
/)
.
Th
e
U
ni

ve
rs
it
y
o
f
B
an
go
r
in
W
al
es
aw
ar
ds
a
M
as
te
rs
in
M

in
df
ul
-
ne
ss
an
d
al
so
ha
s
a
ra
ng
e
o
f
te
ac
he
r
tr
ai

ni
ng
pr
o
gr
am
s
(b
an
go
r.
ac
.u
k/
m
in
df
ul
ne
ss
/c
o
ur
se

s.
ph
p.
en
)
Th
e
C
en
tr
e
fo
r
M
in
df
ul
ne
ss
St
ud
ie
s
in

To
ro
nt
o
,
O
nt
ar
io
,
C
an
ad
a,
o
ff
er
s
1
-d
w
o
rk
sh
o

ps
as
w
el
l
as
in
te
ns
iv
e
pr
o
fe
ss
io
na
l
tr
ai
ni
ng
in
M

in
df
ul
ne
ss
-B
as
ed
C
o
gn
it
iv
e
Th
er
ap
y
(m
in
df
ul
ne
ss
st

ud
ie
s.
co
m
/)
.
C
o
m
pl
et
in
g
m
in
df
ul
ne
ss
te
ac
he
r

tr
ai
ni
ng
co
ur
se
s
at
o
ne
o
f
th
e
re
co
gn
iz
ed
tr
ai
ni
ng

pr
o
gr
am
s,
in
ad
di
ti
o
n
to
pr
o
fe
ss
io
na
l
ce
rt
if
ic
at

io
n,
w
o
ul
d
be
th
e
o
pt
im
al
le
ve
l
o
f
tr
ai
ni
ng
fo
r

pr
o
vi
di
ng
th
es
e
in
te
rv
en
ti
o
ns
.
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ca
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st
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en
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cr

it
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ga
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ru
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ns
ha
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o
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qu
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em
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.
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ns
ha
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it
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pl
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ga
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r.
”
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ar
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sp
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if
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yo
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vi
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ha
ve
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de
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gn
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rt
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ie

d
yo
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th
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ni
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St
at
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th
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Y
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lli
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_
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/
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de

nt
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re
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nt
ia
ls
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rS
ch
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,
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d
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gi

ca
lli
an
ce
.
co
m
).
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er
e
ar
e
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rr
en
tl
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no
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at
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o
r

C
an
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n
pr
o
vi
nc
es
/t
er
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to
ri
es
th
at
re
gu
la
te
o
r

lic
en
se
yo
ga
.
M
o
st
st
at
es
an
d
pr
o
vi
nc
es
ha
ve
a
pr
o

fe
ss
io
na
l
as
so
ci
at
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n
(o
r
m
o
re
th
an
o
ne
)
fo
r
ce

rt
if
ie
d
yo
ga
in
st
ru
ct
o
rs
.
http://umassmed.edu/cfm/training/detailed-training-
information/teacher-certification-review/
http://umassmed.edu/cfm/training/detailed-training-
information/teacher-certification-review/
http://goamra.org/
http://mbpti.org/
http://bangor.ac.uk/mindfulness/courses.php.en
http://bangor.ac.uk/mindfulness/courses.php.en
http://mindfulnessstudies.com/
http://cbmt.org/examination/state-licensure/
http://cbmt.org/
http://musictherapy.ca/
http://musictherapy.ca/

http://apa.org/
http://cpa.ca
http://yogaalliance.org/Credentialing/Credentials_for_Teachers
http://yogaalliance.org/Credentialing/Credentials_for_Teachers
http://yogaalliance.org/Credentialing/CredentialsforSchools
http://yogaalliance.org/Credentialing/CredentialsforSchools
http://canadianyogicalliance.com
http://canadianyogicalliance.com
Acupuncture
Acupuncture involves the stimulation of specific points, (ie,
acupoints) by penetrating the skin with thin, solid, metallic
needles.154,155 A variation of acupuncture includes electro-
acupuncture, in which a small electric current is passed
along acupuncture needles to provide a stronger stimulus
than acupuncture alone, with distinct effects suggested by
functional magnetic resonance imaging.156,157 Acupuncture
has been practiced in Asia for thousands of years as a com-
ponent of traditional medicine systems (eg, traditional forms
of Chinese, Japanese, and Korean medicine) and is thought
to stimulate the flow of a form of energy called qi (chee)
throughout the body. Traditional Chinese acupuncture,

which is commonly used in North America, requires needle
manipulation to produce a de qi sensation (a soreness, full -
ness, heaviness, or local area distension157,158), along with a
period of rest with the needles in place.
159
It is posited that
this removes energetic blockages, thus reestablishing
homeostasis. The mechanisms for acupuncture’s effects are
not well understood but are thought to function in part
through modulation of specific neuronal/cortical path-
ways.
160
Acupuncture practice typically requires formal edu-
cation through schools, training programs, and certifications
(Table 2). Acupuncture is often used in the oncology setting
for chemotherapy-induced nausea/vomiting (CINV), pain
management, musculoskeletal complaints, hot flashes,
fatigue, stress, anxiety, and sleep disorders. The practice of
acupuncture in North America is regulated by some US

states and Canadian provinces and territories (Table 2).
Acupressure
Acupressure draws on the same knowledge and philosophi-
cal system as acupuncture. A trained therapist or the patient
uses his/her hands and fingers, or possibly a device, to apply
pressure to specific points on the body (acupoints), in con-
trast to metallic needles.161 Practices can range from stimu-
lating a single point or a combination of points to achieve
the intended outcome. In the oncology setting, acupressure
is often used for CINV pain, stress management, and
fatigue.
Aloe vera
Aloe vera gel is derived from the leaves of the perennial suc -
culent plant, Aloe vera (Liliaceae). Typically, it is applied
topically or ingested in the form of a clear, thick gel.153
Aloe vera gel is found in multiple skin products, such as
lotions, creams, and sunblock, and is used as a topical oint-
ment to heal wounds, sunburn, insect bites, and skin condi-

tions, including psoriasis and frostbite.162 In oncology, it is
typically used with the goal of healing surgical wounds or
preventing or treating radiation-induced dermatitis.
Ginger
Ginger (Zingiber officianale) comes from the rhizome or
root of a tropical plant with green-purple flowers and an
aromatic stem.153,163 Ginger can be used as a food in cook-
ing and for medicinal purposes. In Asian medicine, ginger is
used to treat stomach aches, nausea, and diarrhea. For
patients with cancer, it has been studied for the treatment
of CINV. Ginger is available in capsule form, fresh as a
root, as a tea, as a candy, or at highly diluted quantities in
ginger ale. Ginger supplementation should not be used in
perioperative settings or in patients with bleeding disorders
due to a potential risk of increased bleeding.
162
Ginseng
Ginseng is derived from a plant root and has been used to
treat certain medical problems.

153
Two common types of
ginseng are used: Asian ginseng (Panax ginseng) and Ameri-
can ginseng (Panax quinquefolius). Another herb called
Siberian ginseng or eleuthero is not a true ginseng.162 Asian
and American ginsengs are used to boost the immune sys-
tem and promote well being and stamina. Ginseng comes in
capsule form made of ground ginseng, extracts, and teas and
in creams and other products for topical use. Taken as an
herbal supplement, ginseng is often used to treat cancer-
related fatigue.162 Side effects of taking ginseng may include
headaches, breast tenderness and menstrual irregularities,
sleep problems, restlessness, rapid heart rate, low blood sug-
ar, allergic reactions, and gastrointestinal problems.162
Glutamine
Glutamine is a nonessential amino acid used in the biosyn-
thesis of proteins and is primarily synthesized in skeletal
muscle.162 Most of the glutamine synthesized in the body is

used by the intestinal tract. Glutamine has numerous bio-
logic functions, including protein and lipid synthesis and
the regulation of acid-base balance in the kidney, and it is
an important mitochondrial cellular energy source. Normal -
ly, the body can synthesize its own glutamine; however, dur-
ing a critical illness like cancer, not enough glutamine is
made, leading to problems such as fatigue and muscle wast-
ing. Glutamine has been used as an oral supplement in
patients with cancer to reverse cachexia in those who have
advanced disease. It has also been used for CINV in patients
with cancer. Glutamine can be obtained from food or sup-
plements, and important food sources include beef, pork,
chicken, fish, eggs, milk, dairy products, wheat, cabbage,
beets, beans, spinach, and parsley.
162
Guarana
Guarana is an herbal supplement from the guarana plant
(Paullinia cupana), which is native to the Amazon basin.162
Guarana supplements contain various phytochemicals,

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