3/9/18 Integrative Medicine ´ Integrative medicine and health reaffirms and Health the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare Kimberly Washington, MD, DC professionals and disciplines to achieve optimal health and healing. Assistant Clinical Professor, Orthopaedic Surgery Osher Center for Integrative Medicine University of California, San Francisco American Board of Integrative Medicine & March 9, 2018 Academic Consortium for Integrative Medicine & Health Disclosures: None Noninvasive Treatments for Acute, Subacute, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain and Chronic Low Back Pain Clinical Practice Guidelines ACP (2017) Clinical Practice Guidelines ACP (2017) ´ Recommendation 1: Given that most patients with ´ Recommendation 2: For patients with chronic low acute or subacute low back pain improve over time back pain, clinicians and patients should initially select regardless of treatment, clinicians and patients should nonpharmacologic treatment with exercise, select nonpharmacologic treatment with superficial multidisciplinary rehabilitation, acupuncture, heat (moderate-quality evidence), massage, mindfulness-based stress reduction (moderate-quality acupuncture, or spinal manipulation (low-quality evidence), tai chi, yoga, motor control exercise, evidence). If pharmacologic treatment is desired, progressive relaxation, electromyography clinicians and patients should select nonsteroidal anti- biofeedback, low-level laser therapy, operant inflammatory drugs or skeletal muscle relaxants therapy, cognitive behavioral therapy, or spinal (moderate-quality evidence). (Grade: strong manipulation (low-quality evidence). (Grade: strong recommendation) recommendation) 1
3/9/18 ´ 2012 National Health Interview Survey ´ One-third of US adults use ´ Natural products (17.7%) ´ Yoga, Tai Chi, Qi Gong (9.5%) ´ Chiropractic and Osteopathic manipulation (8.4%) ´ Meditation (8%) ´ $30 billion out-of-pocket ´ Pain management ´ Prevention and health maintenance “Yoga teaches us how to infuse our movements with intelligence, transforming them into action.” BKS Iyengar ´ Integration of body, mind, and breath ´ various styles of yoga typically combine physical postures, breathing techniques, and meditation or relaxation ´ Current research suggests that a carefully adapted set of yoga poses may reduce low-back pain and improve function. Other studies also suggest that practicing yoga (as well as other forms of regular exercise) might improve quality of life; reduce stress; lower heart rate and blood pressure; help relieve anxiety, depression, and insomnia; and improve overall physical fitness, strength, and flexibility. 2
3/9/18 Evaluating and Treating Pain “We are the knowing, not the conditions known.” Eckhart Tolle Imperative to be aware of behavioral and functional disruption requiring more comprehensive treatment options to reduce disability. ´ Meditation is a mind and body practice that has a long history of use for increasing calmness and physical relaxation, improving psychological balance, Acute Chronic coping with illness, and enhancing overall health and well-being. ´ Usually response to noxious ´ May not be associated with ´ Quiet location event ongoing noxious event ´ Specific, comfortable posture (sitting, lying down, ´ Time limited ´ Lasts longer than typically walking, or in other positions) ´ Adaptive function expected for healing ´ Focus of attention (a specially chosen word or set of ´ Goal to remove or minimize ´ Maladaptive words, an object, or the sensations of the breath) underlying injurious process ´ More dynamic interplay of ´ Open attitude, non-reactive (letting distractions come ´ Failure to adequately treat psychologic and behavioral and go naturally without judging them) risks development of chronic mechanisms pain It’s Not Magic Dust “You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.” Hunter Doherty “Patch” Adams, MD ´ Apply foundational health principles allowing patients to re- inhabit their bodies and minds, to understand and resolve many of the distressing symptoms by addressing their sleep and rest, good nutrition, focused activity, relaxation, creativity. 3
3/9/18 NIH Pain Consortium ´ Self Management - actions taken by the patient to manage or minimize the impact of a chronic condition on everyday life ´ Treatment of the whole person ´ Empowerment of the patient ´ Active participation by the patient ´ Get back to life even while in pain ´ Pain medication management ´ Coping skills ´ Relaxation techniques ´ Problem solving ´ Enhancement of the patient’s social network ´ Goal setting ´ Managing emotions ´ Exercise 4
3/9/18 Resources ´ Academic Consortium for Integrative Medicine & Health ´ University of Wisconsin-Madison Integrative Health Program ´ National Center for Complementary and Integrative Health (NCCIH) ´ NIH Pain Consortium ´ Agency for healthcare research and quality (AHRQ) ´ PubMed 1. A maladaptive behavior observed with 2. Mind body medicine involves: chronic pain is: ´ A. Fear avoidance ´ A. Intentionally deceiving a patient ´ B. A clear understanding that mood is never ´ B. Promoting self-care practices such as exercise, influenced by pain adequate sleep, and attention to diet ´ C. Functional activity is rarely impaired ´ C. Skills that are beyond the scope of a practicing physician ´ D. Increased generosity ´ D. Using a placebo 5
3/9/18 3. Contemplative practices such as ABPM answer key meditation: ´ A. Support non-judgmental self evaluation ´ Question #1 – A. Fear avoidance is a maladaptive behavior observed in patients with chronic pain ´ B. Might encourage an attitude of approaching rather than avoiding pain ´ Question #2 – B. Mind body medicine involves promotion ´ C. Are being studied for their effects on brain activity of self care practices such as exercise, adequate sleep, in the default mode network and attention to diet. ´ D. All of the above ´ Question #3 – D. All of the above (Contemplative practices such as meditation support A. non-judgmental self evaluation, B. might encourage and attitude of approaching rather than avoiding pain, C. are being studied for their effects on brain activity in the default mode network. 6
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