Integrative Medicine: Information for Cystic Fibrosis and COVID-19 (Part 1)

It is of utmost importance to consult with your healthcare team if you have any symptoms of COVID-19 (refers to the disease, SARS-CoV-2 refers to the virus itself see here), it is also as important during this time to ensure you take all medications prescribed, do your air-way clearance and exercise, get a good nights sleep, eat well and reduce stress, the TLT4CF will be doing blogs on some of the aforementioned topics to help.

If you are feeling sick call your healthcare team immediately and/or HSE helpline on 1850 24 1850. Updated Government guild-lines please see here and for the most up-to-date information from the HSE see here

Please support our work on integrative medicine and help  us to continue to provide information and evidence-based research for those with CF, you can do this virtually donating via text Support Integrative Medicine or donating via our Just Giving page

Professor Brian Harvey Emeritus Professor of Molecular Medicine, RCSI, Dublin, Ireland has this advice:

The pandemic situation and in Ireland is evolving rapidly towards increased numbers of infections and spreading of the virus and could be several weeks away from peaking and months away from declining. I would emphasise the HSE advice to limit social contacts to an absolute necessity and wash hands thoroughly every hour or so especially after touching surfaces like door handles and always before food preparation and meals. It is very important that Cystic Fibrosis (CF) patients keep taking their usual medication and be on the alert for symptoms of a combination of fever and dry cough with breathing difficulties and contact their GP to arrange testing or hospitalisation on the appearance of these symptoms.

What is Integrative Medicine?

According to Dr. Andrew Weil a leading integrative medical physician the core principles of Integrative medicine are:

• A partnership between patient and practitioner in the healing process
• Appropriate use of conventional and alternative methods to facilitate the body’s innate healing response
• Consideration of all factors that influence health, wellness and disease, including mind, spirit and community as well as body
• A philosophy that neither rejects conventional medicine nor accepts alternative therapies uncritically
• Recognition that good medicine should be based in good science, be inquiry driven, and be open to new paradigms
• Use of natural, effective, less-invasive interventions whenever possible
• Use of the broader concepts of promotion of health and the prevention of illness as well as the treatment of disease
• Training of practitioners to be models of health and healing, committed to the process of self-exploration and self-development.

How can it help?

Integrative medicine may help ease the burden or help with coping with a chronic illness. It is not a replacement of prescribed medication and should never interfere with your current healthcare management, however it can aid with many mental and physical aspects of CF. In this post we will look at meditative movement and the evidence for Cystic Fibrosis and some treatments that are been used in CF care.

In a prospective pilot study (n=11  range 12-15 years) of yoga for CF, patients who engaged in a session twice weekly for 50 minutes over 8 weeks, of standardised yoga. Yoga was found to be safe and well tolerated in those with mild to moderate lung disease (>40% FEV1).¹ In another study in children with CF (n=20, range 7-20 years, over 10-weeks) yoga was shown to immediately decrease anxiety and joint pain.²
It must be noted that these are very small studies over a short period of time however they show some promise in CF but there may be some issue with certain yoga procedures such as two reported events of calf and headache pain², more research is needed before any firm conclusion can be drawn.

Tai chi when learned correctly in some populations has been shown to:

• Decrease stress, anxiety and depression
• Increase energy and stamina,
• Improve mood,
• Improve flexibility, balance and agility,
• Improve aerobic capacity. ³

A more indepth presentation on a holistic approach in 2015 was provided at the Cystic Fibrosis Research Inc.talk by Professor John D. Mark, MD, possibly the world’s leading pulmonologist of integrative medicine in Cystic Fibrosis at Lucile Packard Children’s Hospital Stanford, USA, see video below, (please note the video is now 5 years old).

How can  I reduce stress and improve my mental help while at home?

As mentioned above during these unprecedented times and with the necessity to stay indoors it is extremely important to keep taking your prescribed medication consistently and continue your standard care regime.

Learn a new skill try Tai Chi (TC) for CF (see below) or yoga (see above). Clinical studies into Tai Chi show similar benefits to that of mindfulness meditation, randomised control trials and meta-analysis also confirm beneficial effects in reducing symptoms of anxiety and depression.⁴ It is theorised that the slow movement and breathing methods together enables attenuation of stress related to the HPA axis and may cause functional changes within certain pathways in the brain or in the expression of inflammatory genes.⁴

Evidence from TLT4CF funded studies into Tai Chi for CF

In studies funded by Tracie Lawlor Trust foundation (TLT4CF), on the use of Tai Chi in complementing the health of those at all stages of CF, Children and Adults Tai Chi Study (CF-CATS), lead researcher(s) Professor Nicola Robinson the editor in chief of the European Journal of Integrative Medicine and Patricia Ronan PhD. of LSBU Department of Allied Health  Sciences suggests:

1. 1. 1. Even 5-10 minutes practice of basic Tai Chi movements can make a big difference to respiration and general fitness that will count when you are really unwell and help you recover more quickly.
   
   
   1. 1. 1. Doing some tai chi just before your normal physio can help bring up more phlegm -make sure you have tissues handy.
         
         
         1. 1. I think self isolate is the key message and avoid contact with friends and restrict activities to the household or over the internet-it makes it more fun and helps with motivation. (Studies were conducted via skype).
            
            
            1. 1. Tune into when is best for you – Some people need a good start in the morning and Tai Chi can help then, others need something to help them relax at night and these movements can really aid sleep.
               
               
               1. 1. Good mental health is protective against physical illness. Make sure you have people who care for you in regular contact and use exercise to keep your endorphins working well for as long as possible.

In the first phase of studies conducted by researchers, a feasibility study of using Tai Chi (TC) in CF (n=11 FEV1 26% – 74%) participants were taught at home for 5 weeks and then continued for another 5 weeks with a DVD (available online free in the coming days) with a significant improvement in CFQ-R from the mean suggesting that TC may improve sleep, self-efficacy and improve respiratory symptoms⁵

In the next phase using a RCT to test the feasibility of TC and CF comparing TC taught to an individual CF via online platform or face-to-face and to that of standard care (n=40, range 6.1–51.5 years), which was also co-funded by CF Trust UK. Tai Chi was found to be safe and well tolerated and there was significant improvements in self reported sleep, cough (both day and night-time) stomach pain and breathing.⁷ However the study was small and possibly too short a duration to draw definitive data. There was no change in lung function, QofL, sleep or mindfulness after completing the lessons and a further larger study is required.⁷ Overall the studies seem to show an internet-based intervention is safe and economical.

Broken down:⁷

• 23 received face-to-face (8 lessons over 3 months)
• 17 used video-call training including 8 lessons over 3 months
• 58% said their breathing improved after the course (mainly in face-to-face group).
• 35% of internet participants reported increased sputum production when TC was done before airway clearance.
• 85% reported feeling less stressed when doing Tai Chi
• Reported less chance of infection due to training at home and no embarrassment from coughing during a class.
• Self-reported improvements on deeper breaths, better breathing at night and ability to use Tai Chi learned to relax and destress.

What about other treatments?

Currently there is no treatments available for COVID-19, trials are underway for a vaccine and more recently an anti-viral drug remdesivir . A Vitamin C trail is also been conducted but as of yet there is no evidence. There is no human evidence as of yet for integrative medical treatments.

However Professor John Mark paediatric pulmonary specialist in CF at Stanford suggests:

The usual stay away from crowds etc and eat healthy, get good sleep and basically try to keep clear of any ill.

I have been using Elderberry syrup for my patients even before COVID-19. It (and zinc) have been shown to hep with viral infections.

The elderberry syrup is usually better than capsules or gummies because it is a stronger concentration.

Is there any evidence?

Please see part 2 document here released from Centre for Integrative Medicine Arizona USA.

How to reduce risk

Follow HSE guild lines (check for updates) and always keep taking your prescribed medication, exercise, do meditative movement such as Tai Chi, do your airway clearance, get a good nights sleep, eat a balanced healthy diet, as stated above we will be providing extra information on some of these topics over the next few days to help you along your way. Also please take breaks from social media and give your mind a rest.

Please note nothing in the above is to be taken as medical advise always consult your healthcare providers before making any changes to your healthcare regime, see disclaimer.

References:

1. Ruddy J, Emerson J, McNamara S, et al. Yoga as a Therapy for Adolescents and Young Adults With Cystic Fibrosis: A Pilot Study. Glob Adv Health Med. 2015;4(6):32–36. doi:10.7453/gahmj.2015.061
2. McNamara, Christopher & Johnson, Mahrya & Read, Lisa & Velden, Heidi & Thygeson, Megan & Liu, Meixia & Gandrud, Laura & Mcnamara, John. (2016). Yoga Therapy in Children with Cystic Fibrosis Decreases Immediate Anxiety and Joint Pain. Evidence-Based Complementary and Alternative Medicine. 2016. 1-10. 10.1155/2016/9429504.
3. Mayo Clinic, (2018). Tai chi: A gentle way to fight stress https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/tai-chi/art-20045184 Accessed 18 March 2020
4. Yeung A, Chan JSM, Cheung JC, Zou L. Qigong and Tai-Chi for Mood Regulation. Focus (Am Psychiatr Publ). 2018;16(1):40–47. doi:10.1176/appi.focus.20170042
5. Ava Lorenc, Awais Mian, Susan Madge, Siobhán B. Carr, Nicola Robinson,CF-CATS: An uncontrolled feasibility study of using tai chi for adults with cystic fibrosis,European Journal of Integrative Medicine,Volume 5, Issue 6, 2013,Pages 476-486,
   https://doi.org/10.1016/j.eujim.2013.09.003.
6. Lorenc, A., Ronan, P., Mian, A. et al. Cystic fibrosis—Children and adults Tai Chi study (CF CATS2): Can Tai Chi improve symptoms and quality of life for people with cystic fibrosis? Second phase study protocol. Chin. J. Integr. Med. (2015). https://doi.org/10.1007/s11655-015-2150-1
7. Carr SB, Ronan P, Lorenc A, Mian A, Madge SL, Robinson N. Children and Adults Tai Chi Study (CF-CATS2): a randomised controlled feasibility study comparing internet-delivered with face-to-face Tai Chi lessons in cystic fibrosis. ERJ Open Res. 2018;4(4):00042-2018. Published 2018 Dec 14. doi:10.1183/23120541.00042-2018