Principles of Non-Pharmacologic

Treatment

“ Medicines will be well used when the doctor understands their

nature, what man is, what life is and 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 bcGreek-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.

PREVENTIONPreventive medicine incidence & prevalenceComponent of Prevention:1. Body Protection Injury2. Vaccination prevent Infectious diseases3. Screening programs risk factors deg. disease4. Chemoprevention farmacoTx before disease

occur e.g. lipid lowering drugs in preatherosklerosis5. Counseling Individual, family & society life styleTypes of prevention1. Primary promotive2. 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 1900–1968British 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…..

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 1881–1927US 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 EXAMPLEAX : ID : Ny. A, 45 th, BB: 85kg, TB:165 cm, BMI: 32,32. Sekretaris PMA. Jl. MTH 193, MlgKU : “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

mgTx 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 850 - 950(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 1874–1936US gynaecologistSurgery, 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