Back to Journal

Six Evidence-Based Integrative Health Practices to Manage Eight Common Chronic Conditions and Promote Self-Care: A Review with Findings Inspired by a Workplace Wellness Case Study

[ ISSN : 2573-3648 ]

Abstract Citation Purpose and Rationale The Use of IHPs in WPW Programs Methods Results Discussion References

Details

Received: 04-May-2016

Accepted: 27-Jul-2016

Published: 03-Aug-2016

Research Article | Volume 2 - Issue 2 | Article DOI :

Download PDF

Ruthann Russo¹* and Luann Drolc Fortune²

¹Berkeley Research Group, Emeryville, CA, USA
²College of Integrative Medicine and Health Services, Saybrook University, Oakland, CA, USA

Corresponding Author:

Ruthann Russo, Berkeley Research Group, Emeryville, CA, USA, Tel: 484- 357-7899; Email: rrusso@thinkbrg.com

Keywords

Affordable Care Act; Integrative Health; Mind-Body Medicine; Integrative Wellness; Preventative Healthcare; Workplace Wellness Programs

Abstract

Workplace Wellness (WPW) programs are rapidly appearing as one tactic to control healthcare costs and decrease chronic conditions. The Patient Protection and Affordable Care Act (PPACA) addresses these concerns by encouraging employers to adopt evidence-based employee WPW programs. One WPW program option focuses on Integrative Health Practices (IHPs) that have the potential to shift wellness responsibility to the individual, which may result in increased WPW effectiveness, individual self-care and overall improved health and wellness. This article presents current supporting evidence on specific IHPs for the eight most common costly and chronic conditions in the workplace. When introduced and examined via the case study method into WPW at one organization, employees reported that as a result of their participation, they were highly likely to take better care of themselves. The review portion of this research serves as the foundation for IHP selection and provides much needed evidence for employers to make more informed and inclusive decisions about WPW program content. The case study results provide a tested model for IHPs that can be integrated into existing WPW offerings. The findings of this observational study support the need for future investigative research on the use of IHPs in WPW programs

Citation

Russo R and Fortune LD. Six Evidence-Based Integrative Health Practices to Manage Eight Common Chronic Conditions and Promote Self-Care: A Review with Findings Inspired by a Workplace Wellness Case Study. SM J Community Med. 2016; 2(2): 1018.

Purpose and Rationale

Total U.S. healthcare expenditures were estimated to be $3 trillion in 2015 and are projected to soar to $3.3 trillion by the end of 2016 [1]. Workplace Wellness (WPW) programs are rapidly appearing as one tactic to control escalating costs incurred by employers in both direct expenses and lost human resources. Supporting the need for WPW programs to address chronic disease, the Centers for Disease Control approximates 83% of healthcare dollars are spent treating chronic conditions, and this figure is projected to increase 42% over the next decade [2]. The Patient Protection and Affordable Care Act (PPACA) [3] addresses these concerns by encouraging employers to adopt evidence-based employee WPW strategies. One WPW program option involves Integrative Health Practices (IHPs), such as meditation, yoga, and biofeedback, which have been shown to help manage chronic conditions. The legislative charge for WPW programs, the prevalence of chronic conditions, and evidence supporting the efficacy of IHPs to manage chronic disease provide the rationale for this research.

The use of IHPs in WPW programs may increase employee engagement in other areas related to health and wellness promotion. Individuals can perform IHPs independently after receiving adequate instruction. Regular practice of IHPs, when chosen based upon the individual’s current readiness to change, are likely to result in improved engagement [4]. Therefore, IHPs encourage employees to participate more actively in their own self-care [5]

Self-care is decision-making in response to signs and symptoms that require the individual to be aware of and assess any change, take action, and appraise the outcome [6]. Self-care behavior encompasses a range of practices that individuals perform on behalf of their own health [7] and is deemed a key strategy in chronic illness management as well as essential to the enhancement of quality of life and life expectancy [8].

IHPs have been used successfully to manage stress and prevent chronic disease [9,12,15]. Although there are evidence-based research studies that support IHPs as effective interventions for all of the eight common chronic conditions, WPW programs often associate IHPs primarily with stress management. Interestingly, many researchers have described stress as the root of chronic disease [10,11-14]. The stress response is a group of modifications in response to a stressful event that result in changes in physiology that may include an increase in heart rate, blood pressure, respiration rate, and metabolic shifts, all of which result in the release of energy from the body [11]. Over time, these symptoms lay the foundation for the development of chronic disease [10,11]. As a result, by adopting IHPs in WPW programs, employers have an opportunity to manage employees’ current and prevent the development of future chronic conditions.

IHPs can be used to alleviate the effects of the stress response and decrease the risk of chronic illness by triggering certain positive physiological responses that may involve the nervous, immune, musculoskeletal, cardiovascular, and/or endocrine systems [11].

These mechanisms of IHPs include one or more of the following:

(a) Activation of the relaxation response and decrease in stress hormones [12,16,17];

(b) Stimulation or inhibition of areas of the brain [18-20];

(d) Stimulation of the immune system [22,23] and

(e) An increase in cortical thickness and neuroplasticity of the brain [24-26]. It appears, therefore, that IHPs can be used to mitigate the effects of stress and potentially decrease the risk of chronic illness.

The purpose of this research is to highlight the evidence for and provide a model to incorporate IHPs, such as meditation and yoga, into WPW programs. Geared to cultivate increased self-awareness and self-care, these interventions have the potential to shift wellness responsibility to the individual, resulting in increased WPW effectiveness and overall improvement in the health and wellness of employee populations. The PPACA requires such programs to be evidence-based [3]. This article presents a compilation of the current research for specific IHPs matched to their evidence-based use to manage symptoms of the most common chronic conditions. Employers can use these findings to inform their WPW designs as the research provides a tested model for an IHP component that can be integrated into WPW offerings.

The six practices included in this research are acupressure, biofeedback, guided imagery, meditation, qigong, and yoga (Table 1).

Table 1: Integrative Health Practices: Definitions.

MB Practice	Definition	Source
	Based on meridian theory, application of pressure to points stimulates meridians, a network of energy
Acupressure	pathways throughout the body, to increase the flow of qi (bio-energy), subsequently altering physiological	Lee & Frazier, 2011 [44]
	states.
	Individuals are trained to change physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature as measured by precise instruments.	Association for Applied Psychophysiology and
Biofeedback		Biofeedback, 2008 [43]
Guided imagery	An instructor guide provides directions for imagined scenes intended to bring relaxation and an altered state.	Ezra & Reed, 2008 [45]
	A group of techniques, such as mantra meditation, relaxation response, mindfulness meditation, and Zen Buddhist meditation. Most types of meditation have four elements in common: a quiet location; a specific,
Meditation	comfortable posture; focused attention; and an open attitude”	NCCIH, 2014 [27]
Qi gong	A component of traditional Chinese medicine that involves movement, meditation and controlled breathing.	NCCIH, 2014 [27]
Qi gong	The intent is to improve blood flow and the flow of qi (energy).	NCCIH, 2014 [27]
Yoga	With origins in ancient Indian philosophy, a mind and body practice with various styles that combine physical	NCCIH, 2014 [27]
Yoga	postures, breathing techniques, meditation, and relaxation.	NCCIH, 2014 [27]

The National Center for Complementary and Integrative Health (NCCIH) refers to these practices as mind-body practices [27]. However, the NCCIH also stated that the phrase integrative health is used when mind-body or any other complementary practices are incorporated into mainstream healthcare [28]. Because the practices referenced here are intended to be used adjunctively and not in place of mainstream treatments, the phrase Integrative Health Practices (IHPs) is used to represent the practices investigated in this research.

This review focused on eight common chronic conditions including the seven most common chronic conditions that are linked to more than 20% of employer healthcare spending: depression, increased blood glucose, high blood pressure, obesity, tobacco use, physical inactivity, and stress [29]. Pain, the eighth chronic condition addressed in this review, also has been identified as a condition that is costly to employers. Headache, back pain, and arthritis-related pain have been found to be responsible for lost productive time, costing employers an estimated $61.2 billion per year [29]. The Center on an Aging Society found that back pain is a leading cause of work-loss days, estimating that 83 million work days are lost to back pain each year [30].

The Use of IHPs in WPW Programs

Similar to our research, WPW program research designs have incorporated multiple IHPs. It does not appear, however, that those IHPs were matched to common chronic conditions. Additionally, the rationale for the inclusion of one or more IHP interventions in prior WPW research does not appear to be tied to evidence-based support, perhaps because the evidence-based requirement did not exist prior to the PPACA. The present study involves a review of research on IHPs for each of the eight common chronic conditions and only includes evidence-based IHPs in the subsequent WPW program. The following paragraphs summarize WPW programs that have incorporated IHPs, many side-by-side with more traditional interventions.

The C. Everett Koop National Health Award recognizes exemplary WPW programs; the 2012 winners offered onsite fitness centers, walking paths, health coaching, educational and physical activity interventions and wellness coaching [31]. To complement these mainstream interventions, IHPs such as meditation and yoga were included in the educational interventions category for these WPW programs. The Cleveland Clinic offers its employees yoga classes and also offers a mindfulness-based resiliency program that its team implements for several external corporate WPW programs [32]. Aetna has offered yoga and mindfulness meditation to its employees as part of its WPW program since 2009 [33]. In 2012, Aetna employees participated in a randomized controlled trial that found improvements in perceived stress, sleep quality, and heart rhythm coherence ratio as a result of yoga and mindfulness meditation practices [34].

Johnson and Johnson’s (J&J’s) WPW program, which has been in place since 1978, includes a mental health and well-being component [35]. More recent mental health and well-being programs offered to J&J employees include resilience and stress management training, relaxation programs, yoga, and meditation [35]. J&J also offers employees a healthy nutrition program and smoking cessation in the healthy lifestyle component of its program. Although these programs employed various degrees of IHPs, they did not link IHPs to the most common chronic conditions. Further, although likely safe, not all of the interventions were evidence-based.

The Benson-Henry Institute found that a program that consists of relaxation training, enhancement of positive attitudes and beliefs, nutrition, exercise, recuperative sleep, social support and coping has improved participant symptoms including headaches and chronic low-back pain [36]. The program comprised 12weekly 2.5 hour sessions that included hatha yoga, imagery, and mindfulness meditation to complement the mainstream interventions [36]. In addition to pain improvement, the study also found statistically significant improvements in stress management and patient engagement.

Tarantino et al. tested the use of a program for stress management that included some IHPs with 84 healthcare professionals [37]. The program included Reiki, guided imagery, yoga and meditation, among others. After participants completed the 8-week course, the researchers found significantly lower levels of stress and significantly increased confidence in the ability to cope among the study participants [37].

One study used stress management programs that involved a variety of interventions [38]. These interventions included relaxation training, biofeedback, and yoga. In this case, IHPs were combined with psychosocial approaches and resulted in lower perceived stress by the study group [38]. This research provided a good example of the use of IHPs as an adjunct to conventional psychotherapy interventions. Neither it nor the previously described research examples in this section matched specific IHP interventions to chronic conditions and symptoms.

Methods

Methods are described for the two approaches addressed in this article. First, the literature review process that was used to identify research supporting the use of IHPs for common chronic conditions is described. Second, the findings from the WPW case study that applied the evidence-based IHPs from the literature review to the workplace are presented.

Identifying Evidence-Based IHPs for Chronic Conditions

Components of WPW programs that qualify for tax credits must be evidence-based, which means they must be supported by current research published in peer-reviewed journals [3] or otherwise proved on the basis of rigorous scientific research [3]. Although IHPs are one form of employee wellness that use evidence-based practices, there are few published summaries of their effective use to manage specific chronic conditions. The review portion of this research sought to fill that gap.

IHPs were researched for each of the eight common chronic conditions using both the specific IHP and the condition in each key search phrase. The databases searched were: Academic Search Premier, CINAHL Complete, Cochrane Library, Medline and PubMed. Keyword searches were performed in a pair that linked each IHP with each one of the eight common chronic conditions. For example, yoga was paired first with smoking cessation, then high blood pressure, and each of the other eight common chronic conditions. This same pairing and searching procedure was performed for each of the other six IHPs. The original search included the pairing of two additional IHPs, hypnosis and tai qi, with each of the eight common chronic conditions.

IHPs were included in the final list of evidence-based interventions in Table 2

Table 2: Integrative Health Practices for WPW Concerns.

	Smoking Cessation	High Blood Pressure		Physical Inactivity			Increased Blood Glucose
IH Practice	Smoking Cessation	High Blood Pressure	Obesity	Physical Inactivity	Stress	Depression	Increased Blood Glucose	Pain
			Darbandi et al., 2012 [47]					Chen & Wang,
		Bergmann et al.,	Kim et al., 2014 [53]					2014 [51]
		2014 [10]	Elder et al., 2013 [56]					Kober et al., 2002
	Di et al., 2014	Gao et al., 2012	He et al., 2012 [59]			Honda et al., 2012		[55]
	[46]	[48]	Hsieh et al., 2012 [60]			[49]	Bay &Bay, 2011	Lang et al., 2007 [57]
Acu-pressure	Yeh et al., A, 2014 [52]	Darbandi et al., 2012 [47]	Chien et al., 2014 [62]		Gao et al., 2012 [48] Hmwe et al., 2015 [54]	Hmwe et al., 2015 [54]	[50]	Luo et al., 2013
		Zheng et al., 2014						[61]
		[58]						Yeh et al., 2014
								[63]
		Alabdulagder,
		2012 [65]	Bozinovska et
		Lin et al., 2012	al., 2014 [66]		Danielson et al., 2014 [67]	Beckham et al.,
		[71]	Joseph et al.,		Koithan, 2009 [73] LeMaire et al., 2011 [77]	2013 [68]		Corrado et al.,
		Danielson et al.,	2014 [72]		Rotkis et al., 2014 [78]	Hammond, 2005	McGinnis et al.,	2003 [70]
	Ojedokun et al.,	2014 [67]	Koithan, 2009		Teufel et al., 2013 [82]	[74]	2005 [69]	Nestoriuc et al.,
Biofeed-back	2013 [64]	Lin et al., 2012	[73]			Rotkis et al., 2014	McGrady&	2008 [76]
		[157]	Meule et al.,			[78]	Horner, 1999 [75]	Rotkiset al., 2014
		Linden &	2012 [79]			Siepmann et al.,		[78]
		Moseley, 2006	Teufel et al.,			2008 [80]
		[81]	2013 [82]
		Patel et al., 1981
		[83]
				Duncan, et al., 2011 [87]	Koithan, 2009 [73]	Apostolo&Kolcaba, 2009 [88]		Carroll & Seers, 1998 [89]
		Jallo et al., 2013 [85]	Hamilton et al., 2013 [86]	Anderson & Moss, 2011	Gruzelier, 2002 [22]	Rees, 1995 [92]		Posadzki& Ernst, 2011 [93]
Guided Imagery	Wynd, 2005 [84]	Ko et al., 2012 [90]	Koithan, 2009	[91]	Ko et al,. 2012 [90] Trackhten-berg, 2008 [23]	Sloman, 2002 [94]		Posadzki et al.,
			[73]			Sloman, 2002 [94]		2012 [95]
		Bai et al., 2015

						D’Silva et al., 2012 [99]
						Hoffman et al., 2010 [106]
		[97]				Kenney & Williams, 2007 [111]
		Chung et al., 2012 [103]	Caldwell et al., 2012 [98]			Manocha et al., 2011 [118]		Kabat-Zinn et al.,
	Brewer et al., 2011 [96]	Goldstein et al., 2012 [108]	Dalen et al., 2010 [104]		Koithan, 2009 [73]	Ramel et al., 2004 [122]	Bay &Bay, 2011	1985 [100], 1987
	Carim-Todd et al., 2013 [102]	Devi et al., 2015 [115]	Daubenmier et al., 2011 [109]		Melville et al., 2012 [105]	Prakhinkit et al., 2014 [124]	[50]	[101]
	Elwafi et al.,	Goldstein et al., 2012 [158]	Katterman et al., 2014 [116]		Poulin et al., 2008 [110]		Herzog et al., 1991 [107]	Mehling et al., 2014 [113]
	2013 [114]	Nidich et al., 2009	Koithan, 2009		Shapiro et al., 2005 [117]		Paul-Labrador et al., 2006 [112]	Rosenzweig et al., 2010 [120]
	Tang et al., 2013 [121]	[123]	[73]				Wilson et al., 2013 [119]	Zeidan et al., 2012
Meditation								[20]
		Paul-Labrador et
		al., 2006 [112]
		Freeman et al., 2014 [125]
		Guo et al., 2008 [132]				Tsang et al., 2008 [129]	Liu et al., 2008 [130]
		Lee et al., 2004 [136]	Elder et al., 2007 [126]		Griffith et al.,	GrifFith et al., 2008 [128]	Liu et al., 2011 [134]	Lee et al., 2007 [131]
		Lee et al., 2007 [140]	Koithan, 2009		2008 [128]	Tsang et al., 2013 [137]	Tsujiuchi et al, 2002 [138]	Sawynok& Lynch, 2014 [135]
		Xiong et al., 2015 [144]	[73]		Jouper&Hasseman, 2008 [133]	Yeung et al., 2013 [142]	Xin et al., 2007 [143]	VonTrott et al., 2009 [139]
Qi Gong			Liu et al., 2011 [134]	Ho et al., 2012 [127]	Koithan, 2009 [73] Wang, et al., 2014 [141]
		Cohen et al.,	Chung et al.,					Cramer et al., 2013
		2011 [145]	2012 [103]		Chong et al., 2011 [147]			[148]
		Cohen et al., 2013 [149]	Koithan, 2009		Kim, 2014 [150]	Cramer et al., 2013 [148]	Herzog et al, 1991 [107]	Mehling et al., 2014 [113]
Yoga	Carim-Todd et al., 2013 [102]	Cade et al, 2010	[73]	Bryan et al., 2012 [146]	Koithan, 2009 [73] Melville et al., 2012 [105]	D’Silva et al., 2012	Kim, 2014 [150]	Michalsen et al.,
		[151]	Murthy et al., 2010 [152]			[99]		2005 [153]
		Hagins et al.,	Sharpe et al,					Wren et al., 2011
		2013 [154]	2007 [155]					[156]

if they were

(1) Practices that, after appropriate instruction, can be performed independently,

(2) Found in the review of literature to be effective in managing at least 6 of the 8 common chronic conditions,

(3) Contained at least two research studies published in the past f ive years with positive findings for managing at least 6 of the 8 chronic conditions. Hypnosis and tai qi were eliminated because they did not meet these criteria.

We identified a large number of evidence-based research studies that support the use of IHPs to address many chronic conditions and their symptoms, as well as behaviors that promote health and wellbeing. The number of studies that support each IHP cross referenced by common chronic condition are presented in Table 2. Based upon the criteria for inclusion used in this study, yoga addresses all eight of the eight common chronic conditions (Table 2). All of the other practices (i.e., acupressure, guided imagery, biofeedback, meditation, and qi gong) each address 7 of the 8 conditions. Only guided imagery, qi gong and yoga were found to manage physical inactivity effectively. As a result, a WPW program that includes yoga alone, or guided imagery or qi gong combined with one of the other IHPs (acupressure, biofeedback, or meditation) will address all eight of the most common chronic conditions. IHPs may be the only group of evidence-based interventions that can interchangeably be used to manage the most common chronic conditions (Table 2).

Case Study: Incorporation of IHPs into a WPW Program

The IH model used in this research was introduced in conjunction with an existing WPW program at a medium-sized organization of 175 employees located in a suburban area on the east coast of the United States. The organization was one location of a Fortune 100 firm in the technology industry. Of the 175 employees, 146 attended a pre research information session and were provided with informed consent pursuant to the Saybrook University IRB under which this research was conducted.

Employees who signed informed consents were invited to participate in an 8-week WPW program that incorporated the 6 IHPs that were found to manage the 8 most common chronic conditions. The program included an introduction to one of the following IHPs each week: meditation, guided imagery, biofeedback, yoga, qi gong, and acupressure. Because they are an inherent foundation for most IHPs [9], week one was dedicated to learning about and practicing breathing exercises. Two weeks were dedicated to learning and practicing various meditation techniques. The primary researcher for this article was also the facilitator for the IHP sessions offered as part of the organization’s WPW program.

This research used the mind-body skills group model established by the Center for Mind Body Medicine in 1996as the structure for conducting these IHP sessions [9]. The human resource managers at the organization where this research was conducted elected to name the groups Resiliency Training as they believed this term would be more well-received by employees than mind-body skills or integrative health groups. During each week of an 8-week period, one IHP topic was presented during a training session that was conducted two times a week on Tuesdays. One session was held in the morning and one was held in the afternoon to accommodate employee schedules. Each training session was approximately 45 minutes long and each was conducted in a large, private conference room at the workplace.

The sessions began with a 10-15 minute description of the IHP that included a presentation of the mechanisms of action and supporting research. This presentation was followed by an employee question-and-answer session. After employee questions were answered, employees were invited to participate in practicing the IHP for the next 15-20 minutes. At the conclusion of the practice, a few employees were asked to share their experience and comments with the group. Finally, employees were provided with a tangible tool or reference card to assist them in practicing the skill independently. At the completion of the eight training sessions, attendees were asked to complete a questionnaire.

Results

Human resources staff reported that historically, attendance at similar WPW program events in this organization was between 0 and 10%. The mean number of attendees at the training sessions was 49, which represents 28% of the total employees at this location and 34% of employees who signed informed consents. Attendance ranged from a low of 19 employees at the guided imagery session, to a high of 60 attendees at the second meditation session. At this location of the organization, 91% of staff were engineers and 8% were administrative support staff; 78% of staff were male and 22% were female. Although gender and position were not collected as data elements during the training sessions, attendance was observed as generally consistent with the overall demographics of the organization.

Forty-two individuals attended the last session and completed a post-training session survey. The survey asked participants to identify which of the common chronic conditions they had ever experienced as well as to identify the impact of the WPW training sessions they attended. Because of the use of an exploratory case study, it was not possible to calculate statistical significance of the findings.

Employees were asked whether they were currently experiencing any of the most common chronic conditions or whether they had done so in the past. Those most commonly experienced at any time were stress (57% of respondents), back pain (52%) and headache (45%), followed by being overweight (32%), physical inactivity (31%) and high blood pressure (24%). The two least commonly experienced conditions were tobacco abuse (7%) and arthritis (10%). No employees reported current tobacco use (Table 3).

Table 3: Employees who experienced the common chronic conditions

Symptom	Current (%)	Past (%)	Total Respondents Who Had Experienced this Symptom (%)
High blood pressure	14.3	9.5	23.8
Depression	5.7	11.9	17.6
Increased blood sugar	7.1	5.7	12.8
Tobacco use	0	7.11	7.1
Physical inactivity	14.3	16.7	31
Stress	33.3	23.8	57.1
Overweight	26.2	5.7	31.9
Back pain	28.6	23.8	52.4
Headache	23.8	21.4	45.2
Arthritis	7.1	2.4	9.5

When asked to rate the impact of the training sessions, overall stronger positive findings appear to be present for employees who attended at least 4 sessions. Of the 42 survey respondents who attended at least four training sessions, 95% agreed or strongly agreed that they would be more likely to take better care of themselves as a result of their participation in the training, compared with 67% of employees who attended less than 4 sessions. Of respondents who attended at least four training sessions, 90% agreed or strongly agreed that they were more aware of their actions after they had participated in the training, compared with 78% of employees who attended less than 4 sessions. Number of sessions attended did not appear to be as much of a factor for recommending the training to co-workers. Of respondents who attended 4 or more sessions, 90% agreed or strongly agreed that they would recommend the training sessions to their coworkers, compared with 89% of employees who attended less than 4 sessions.

Lowest overall scores were for employees who attended less than 4 sessions: 56% said they would share the skills with their family (compared with 63% who attended 4 or more sessions) and 56% said they would integrate the skills into their everyday life, compared with 68% who attended 4 or more sessions. When asked how likely, as a result of attending the training sessions, the employee would be to practice at least one IHP per day, of those who attended less than 4 sessions, 67% would engage in such a practice, compared with 79% of employees who attended 4 or more sessions. Results of the post training survey are provided in Table 4.

Table 4: Percentage of Employees Who Agreed or Strongly Agreed with the Statements.

As a result of my participation in resiliency training, I	All Employees	Attended>4 sessions (n	Attended <4 sessions (n
believe that I will:	(N = 28)	= 19)	= 9)
Practice at least one resiliency skill per day	75	79	67
Be more aware of my actions	86	90	78
Take better care of myself	86	95	67
Integrate the skills into my everyday life	64	68	56
Share the skills with my family	61	63	56
Recommend resiliency training to my friends	82	84	78
Recommend resiliency training to my coworkers	89	90	89

Discussion

Although this research provided important foundational evidence and tools for the use of IHPs in WPW programs, it was limited by its design as a case study, and as such, its findings represent only the location and population studied. In addition, the use of case study method is observational and exploratory in nature, which prohibits the generation of calculations that measure statistical significance. Future research could replicate this study with more participants as well as intervention and control groups to validate and generalize these findings.

Because it is important for employers to know whether the chronic condition(s) experienced by the employees are likely to improve as a result of IHPs, future research should include follow up to measure the severity of each chronic condition both before and after the intervention. Conditions such as tobacco use, which are currently identified as one of most common and costly for employers, were reported by a very small number of participants (0% currently; 7% in the past). As a result, future research also should seek to validate chronic conditions on that list.

Employers have the ability to make a substantial contribution to positive health outcomes by creating a culture of health that supports healthy lifestyles for employees [39]. Berry and Mirabito claimed that “employers are better positioned to eliminate employee-generated barriers to change than the medical community” because they have continuous access to the working population [40]. In addition, employers benefit from a WPW intervention because stress increases absenteeism and negatively impacts work performance, employee productivity, and satisfaction rates [41,42]. IHPs can be used to address these concerns

Incorporation of IHPs in a WPW program provides both choice and evidence to address those conditions that are most costly to the employer. Inclusion of yoga, or meditation and guided imagery, in the WPW program is one example of how this goal could be accomplished. Additionally, interventions in a group setting are a low cost investment for employers. When taught and practiced in a group setting, IHPs involve new learning together with respectful and nonjudgmental interactions with others [9]. Indeed, some IHPs implemented in a group format have been found to “facilitate imaginative solutions to personal and professional problems” [9]. Such practices contribute to a more productive, positive, and potentially more creative workplace and a more satisfied and engaged workforce

The inclusion of IHPs in WPW programs provides an overarching means to promote success in other behavior changes. Based on the findings from this case study, IH practices have the potential to increase individual awareness and result in improved self-care. The combination of a choice in relevant, evidence-based IHPs and training in the science and practice of each intervention, as was done during each training session in this research, may have contributed to the positive findings. Improved self-care could ultimately result in greater individual employee satisfaction and contributions. In the process, the shift to increased self-responsibility also could trigger a shift to a healthier, more empowered corporate culture.

References

1. Sisko AM, Keethan SP, Cuckler GA, Madison AJ, Smith SD, Wolfe CJ, et al. National health expenditure projections, 2013-23: faster growth expected with expanded coverage and improving economy. Health Aff (Millwood). 2014; 33: 1841-1850.

2. Centers for Disease Control. Chronic disease prevention and health promotion. 2012.

3. The Patient Protection and Affordable Care Act. Quality, Affordable Health Care For All Americans. Public Law 111-148. 2010.

4. Habib S, Morrissey S, Helmes E. Preparing for pain management: a pilot study to enhance engagement. J Pain. 2005; 6: 48-54.

5. Maizes V, Rakel D, Niemiec C. Integrative medicine and patient-centered care. Explore (NY). 2009; 5: 277-289.

6. Riegel B, Moser DK, Anker SD, Appel LJ, Dunbar SB, Grady KL, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009; 120: 1141-1163.

7. Dean K, Kickbusch I. Health related behavior in health promotion: utilizing the concept of self care. Health Promotion International. 1995; 10: 35-40.

8. Gallant MP, Spitze G, Grove JG. Chronic illness self-care and the family lives of older adults: a synthetic review across four ethnic groups. J Cross Cult Gerontol. 2010; 25: 21-43.

9. Gordon JS. Mind-body skills groups for medical students: reducing stress, enhancing commitment, and promoting patient-centered care. BMC Med Educ.2014; 14: 198.

10. Bergmann N, Ballegaard S, Bech P, Hjalmarson A, Krogh J, Gyntelberg F, et al. The Effect of Daily Self-Measurement of Pressure Pain Sensitivity Followed by Acupressure on Depression and Quality of Life versus Treatment as Usual in Ischemic Heart Disease: A Randomized Clinical Trial. PLoS One. 2014; 9: e97553.

11. Dusek JA, Benson H. Mind-body medicine: A model of the comparative clinical impact of the acute stress and relaxation responses. Minn Med. 2009; 92: 47-50.

12. Jacobs GD. Clinical applications of the relaxation response and mind-body interventions. J Altern Complement Med. 2001; 7: S93-101.

13. McEwen BS, Kalia M. The role of corticosteroids and stress in chronic pain conditions. Metabolism. 2010; 59: S9-15.

14. Selye H. Stress without distress. Philadelphia, JB Lippincott. 1974.

15. Astin, JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract. 2003; 16: 131-147.

16. Brownstone A. Therapeutic Mechanisms of Yoga Aasana. International Journal of Yoga Therapy. 2001; 11: 11-14.

17. Kamei T, Toriumi Y, Kimura H, Ohno S, Kumano H, Kimura K. Decrease in serum cortisol during yoga exercise is correlated with alpha wave activation. Percept Mot Skills. 2000; 90: 1027-1032.

18. Faymonville ME, Laureys S, Degueldre C, DelFiore G, Luxen A, Franck G, et al. Neural mechanisms of antinociceptive effects of hypnosis. Anesthesiology. 2000; 92: 1257-1267.

19. Muller K, Bacht K, Schramm S, Seitz RJ. The facilitating effect of clinical hypnosis on motor imagery: an fMRI study. Behav Brain Res. 2012; 231: 164-169.

20. Zeidan F, Grant JA, Brown CA, McHaffie JG, Coghill RC. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain. Neurosci Lett. 2012; 520: 165-173.

21. Rainville P, Hofbauer RK, Paus T, Duncan GH, Bushnell MC, Price DD. Cerebral mechanisms of hypnotic induction and suggestion. J Cogn Neurosci. 1999; 11: 110-125.

22. Gruzelier JH. A review of the impact of hypnosis, relaxation, guided imagery and individual differences on aspects of immunity and health. Stress. 2002; 5: 147-163.

23. Trakhtenberg EC. The effects of guided imagery on the immune system: a critical review. Int J Neurosci.2008; 118: 839-855.

24. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005; 16: 1893-1897.

25. Tang YY, Lu Q, Fan M, Yang Y, Posner MI. Mechanisms of white matter changes induced by meditation. Proceedings of the National Academy of Sciences of the United States of America. 2012; 109: 10570-10574.

26. Xiong GL, Doraiswamy PM. Does meditation enhance cognition and brain plasticity? Ann N Y Acad Sci. 2009; 1172: 63-69.

27. National Center for Complementary and Integrative Health. The Science of Mind and Body Therapies. 2016.

28. National Center for Complementary and Integrative Health. Complementary, Alternative, or Integrative Health: What’s In a Name? 2016.

29. Goetzel RZ, Pei X, Tabrizi MJ, Henke RM, Kowlessar N, Nelson CF, et al. Ten Modifiable Health Risk Factors Are Linked To More Than One-Fifth Of Employer-Employee Health Care Spending. Health Affairs. 2012; 31: 2474 2484.

30. Center on an Aging Society. Chronic Back Pain: A leading cause of work limitations. Georgetown University. 2003.

31. C Everett Koop National Health Awards. 2012 Koop Award Winners. 2013.

32. Cleveland Clinic. Wellness institute. 2016.

33. Little K. Severe Ski Accident Spurs Aetna CEO to Bring Yoga to Work. 2013.

34. Wolever RQ, Bobinet KJ, McCabe K, Mackenzie ER, Fekete E, Kusnick CA, et al. Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. J Occup Health Psychol. 2012; 17: 246-258.

35. Weldon WC. Fix the Health Care Crisis, One Employee at a Time. Harvard Business Review. 2011.

36. Samuelson M, Foret M, Baim M, Lerner J, Fricchione G, Benson H, et al. Exploring the effectiveness of a comprehensive mind-body intervention for medical symptom relief. J Altern Complement Med. 2010; 16: 187-192.

37. Tarantino B, Earley M, Audia D, D’Adamo C, Berman B. Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare professionals. Explore (NY). 2013; 9: 44-47.

38. Jones DL, Tanigawa T, Weiss SM. Stress management and workplace disability in the US, Europe and Japan. J Occup Health. 2003; 45: 1-7.

39. Anderko L, Roffenbender JS, Goetzel RZ, Millard F, Wildenhaus K, DeSantis Charles, et al. Promoting Prevention Through the Affordable Care Act: Workplace wellness. Centers for Disease Control and Prevention. 2012.

40. Berry LL, Mirabito AM. Partnering for Prevention With Workplace Health Promotion Programs. Mayo Clin Proc. 2011; 86: 335-337.

41. Burnard P, Edwards D, Fothergill A, Hannigan B, Coyle D. Community mental health nurses in Wales: Self-reported stressors and coping strategies. J Psychiatr Ment Health Nurs. 2000; 7: 523-528.

42. Schure MB, Christopher J, Christopher S. Mind-Body Medicine and the Art of Self-Care: Teaching Mindfulness to Counseling Students Through Yoga, Meditation, and Qi gong. Journal of Counseling and Development. 2008; 86: 47-56.

43. The Association for Applied Psychophysiology and Biofeedback. Tell Me More About Biofeedback.

44. Lee EJ, Frazier SK. The efficacy of acupressure for symptom management: A systematic review. J Pain Symptom Manage. 2011; 42: 589-603.

45. Ezra S, Reed T. Guided Imagery and Beyond. 2008.

46. Di YM, May BH, Zhang AL, Zhou IW, Worsnop C, Xue CC. A meta-analysis of ear-acupuncture, ear-acupressure and auriculotherapy for cigarette smoking cessation. Drug Alcohol Depend. 2014; 142: 14-23.

47. Darbandi M, Darbandi S, Mobarhan MG, Owji AA, Zhao B, Iraji K, et al. Effects of auricular acupressure combined with low-calorie diet on the leptin hormone in obese and overweight Iranian individuals. Acupunct Med. 2012; 30: 208-213.

48. Gao X, Wang L, Gaischek I, Michenthaler Y, Zhu B, Litscher Gerhard. Brain Modulated Effects of Auricular Acupressure on the Regulation of Autonomic Function in Healthy Volunteers. Evidence-based Complementary and Alternative Medicine. 2012.

49. Honda Y, Tsuda A, Horiuchi S. Effect of a Four-Week Self-Administered Acupressure Intervention on Perceived Stress over the Past Month. Open Journal of Medical Psychology. 2012; 1: 20-24.

50. Bay R, Bay F. Combined therapy using acupressure therapy, hypnotherapy, and transcendental meditation versus placebo in type 2 diabetes. J Acupunc Meridian Stud. 2011; 4: 183-186.

51. Chen YW, Wang HH. The effectiveness of acupressure on relieving pain: a systematic review. Pain Manag Nurs. 2014; 15: 539-550.

52. Yeh M, Wang P, Lin J, Chung M. The Effects and Measures of Auricular Acupressure and Interactive Multimedia for Smoking Cessation in College Students. Evidence-based Complementary and Alternative Medicine. 2014.

53. Kim D, Ham OK, Kang C, Jun E. Effects of auricular acupressure using Sinapsis alba seeds on obesity and self-efficacy in female college students. J Altern Complement Med. 2014; 20: 258-264.

54. Hmwe NT, Subramanian P, Tan LP, Chong WK. The effects of acupressure on depression, anxiety, and stress in patients with hemodialysis: a randomized controlled trial. Int J Nurs Stud. 2015; 52: 509-518.

55. Kober A, Scheck T, Greher M, Lieba F, Fleishhackl S, Randunsky F, et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anesth Analg. 2002; 95: 723 727.

56. Elder CR, DeBar LL, Funk KL, Vollmer WM, Lindberg NM, Ritenbaugh C, et al. Adherence to, and Satisfaction with, the self-Acupressure Intervention in the LIFE Weight-Loss Maintenance Study. Med Acupunct. 2013; 25: 43-47

57. Lang T, Hager H, Funovits V, Barker R, Steinlechner B, Hoerauf K, et al. Prehospital analgesia with acupressure at the Baihui and Hegu points in patients with radial fractures: a prospective, randomized, doubled-blind trial. Am J Emerg Med. 2007; 25: 887-893.

58. Zheng L, Chen Y, Chen F, Zhang P, Wu L. Effect of acupressure on sleep quality of middle-aged and elderly patients with hypertension. International Journal of Nursing Sciences. 2014; 1: 334-338.

59. He W, Zhou Z, Li J, Wang L, Zhu B, Litscher G. Auricular Acupressure Plus Exercise for Treating Primary Obese Women: A Randomized Controlled Clinical Trial. Medical Acupuncure. 2012; 24: 227-232.

60. Hsieh CH, Su TJ, Fang YW, Chou PH. Efficacy of two different materials used in auricular acupressure on weight reduction and abdominal obesity. Am J Chin Med. 2012; 40: 713-720.

61. Luo D, Wang X, He J. A comparison between acute pressure block of the sciatic nerve and acupressure: methodology, analgesia and mechanism involved. J Pain Res. 2013; 6: 589-593.

62. Chien LW, Chen FC, Hu HY, Liu CF. Correlation of electrical conductance in meridian and autonomic nervous activity after auricular acupressure in middle-aged women. J Altern Complement Med. 2014; 20: 635-641.

63. Yeh CH, Morone NE, Chien LC, Cao Y, Lu H, Shen J, et al. Auricular point acupressure to manage chronic low back pain in older adults: a randomized controlled pilot study. Evid Based Complement Alternat Med. 2014.

64. Ojedokun J, Keane S, O’Connor K. Lung Age Bio-feedback Using a Portable Lung Age Meter with Brief Advice During Routine Consultations Promote Smoking Cessation? Know2quit Multicenter Randomized Control Trial. Journal of General Practice. 2013.

65. Alabdulgader AA. Coherence: a novel nonpharmacological modality for lowering blood pressure in hypertensive patients. Glob Adv Health Med. 2012; 1: 56-64.

66. Bozinovska L, Majekodunmi A. Biofeedback Relaxation Techniques in Addressing Cortex-Hypothalamus Control Loop for Motivation of Obesity Avoidance. Professional Agricultural Workers Journal. 2014; 2: 1-8.

67. Danielson K, Jeffers K, Kaiser L, McKinley L, Kuhn T, Voorhies G. Sustained Hospital-based Wellness Program. Glob Adv Health Med. 2014; 3.

68. Beckham J, Greene TB, Meltzer-Brody S. A pilot study of heart rate variability biofeedback therapy in the treatment of perinatal depression on a specialized perinatal psychiatry inpatient unit. Arc Womens Ment Health. 2013; 16: 59-65.

69. McGinnis RA, McGrady A, Cox SA, Grower-Dowling KA. Biofeedback assisted relaxation in type 2 diabetes. Diabetes Care. 2005; 28: 2145-2149.

70. Corrado P, Gottlieb H, Abdelhamid MH. The effect of biofeedback and relaxation training on anxiety and somatic complaints in chronic pain patients. Am J Pain Manag. 2003; 13: 133-139.

71. Lin G, Xiang Q, Fu X, Wang S, Wang S, Chen S, et al. Heart rate variability biofeedback decreases blood pressure in prehypertensive subjects by improving autonomic function and baroreflex. J Altern Complement Med. 2012; 18: 143-152.

72. Joseph MM, McIntosh MS, Joseph CM. The Effects of Various Comfort Food on Heart Coherence in Adults. Glob Adv Health Med. 2014; 3.

73. Koithan M. Mind-Body Solutions for Obesity. J Nurse Pract. 2009; 5: 536 537.

74. Hammond DC. Neurofeedback Treatment of Depression and Anxiety. Journal of Adult Development. 2005;12.

75. 75McGrady A, Horner J. Role of mood in outcome of biofeedback assisted relaxation therapy in insulin dependent diabetes mellitus. Appl Psychophysiol Biofeedback. 1999; 24: 79-88.

76. Nestoriuc Y, Martin A, Rief W, Andrasik F. Biofeedback treatment for headache disorders: a comprehensive efficacy review. Appl Psychophysiol Biofeedback. 2008; 33: 125-140.

77. Lemaire JB, Wallace JE, Lewin AM, de Grood J, Schaefer JP. The effect of a biofeedback-based stress management tool on physician stress: a randomized controlled clinical trial. Open Med. 2011; 5: e154-163.

78. Rotkis LN, Abelon R, Breuner CC. The Effect of Biofeedback Therapy on Depression and Anxiety in the Pediatric and Adolescent When Used to Treat Migraines, Chronic Headaches and Chronic Abdominal Pain. Journal of Adolescent Health. 2014; 54: S42.

79. Meule A, Freund R, Skirde AK, Vogele C, Kubler A. Heart rate variability biofeedback reduces food cravings in high food cravers. Appl Psychophysiol Biofeedback. 2012; 37: 241-251.

80. Siepmann M, Aykac V, Unterdorfer J, Petrowski K, Mueck-Weymann M. A pilot study on the effects of heart rate variability biofeedback in patients with depression and in healthy subjects. Appl Psychophysiol Biofeedback. 2008; 33: 195-201.

81. Linden W, Moseley JV. The efficacy of behavioral treatments for hypertension. Appl Psychophysiol Biofeedback. 2006; 31: 51-63.

82. Teufel M, Stephan K, Kowalski A, Kasberger S, Enck P, Zipfel S, et al. Impact of biofeedback on self-efficacy and stress reduction in obesity: a randomized controlled pilot study. Appl Psychophysiol Biofeedback. 2013; 38: 177-184.