Hot Topics In Integrative Medicine - PowerPoint Presentation

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Hot Topics In Integrative Medicine

Jill Schneiderhan MD

October 20, 2017

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Objectives

Participants will be able to review up to date evidence based knowledge about common

integrative medicine topics

in primary care

.

Chronic Pain Management

Microbiome

Vasomotor Symptoms of Menopause

Participants will be able to review common complementary and alternative medicine techniques and what conditions they are best used to treat

.

Mindfulness

Elimination Diet

Acupuncture

Participants will be able to list where they can go to find evidence based treatment options related to Integrative Medicine.

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Integrative Medicine

Approaching each patient where they are

Combining the best of our current evidence base with whole person oriented approaches that take into account mental, physical, emotional, spiritual aspects of health and wellness

Foundation of Wellness

Activity

Diet/Nutrition

Sleep

Stress/Emotional Regulation

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Chronic Pain

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Chronic Pain

S

ignificant advances in understanding of physiology have not equaled improvement in treatments

Most treatments overall are poor to fair

Most average around 30% effective in improving pain (roughly equal to placebo)

Even if a treatment improves pain it rarely provides concomitant physical or emotional functional improvements

Turk, D. C., Wilson, H. D., &

Cahana

, A. (2011).

The Lancet, 377

(9784), 2226-2235.

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Improved Pain Experience

Activity

Sleep

Diet/Obesity

Emotion/Mood

Medications & Supplements

Body Issues

Cognitive & Stress

Social/

Relationship

Integrative Chronic Pain Management

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Physical Activity

Fear of damage from pain often leads to less activity leading to tightening of muscles and increased pain in a negative cycle

For most chronic pain conditions graded exercise programs are shown beneficial

30% improvement for low back pain

Most effective for centralized pain conditions

Cunningham, N. R., &

Kashikar-Zuck

, S. (2013).

Nonpharmacological

treatment of pain in rheumatic diseases and other musculoskeletal pain conditions.

Curr

Rheumatol

Rep, 15

(2), 306.

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Obesity and Inflammation

For many obese patients there is chronic non-resolving

inflammation

1

CRP

is an accepted marker of chronic inflammation

Elevated CRP has been shown preliminarily to increase rates of low back pain

Higher elevation in patients who are

obese

2

1.

Arranz

, L. I., et al.

Curr

Rheumatol Rep. 2014. 2. Briggs, M., et al. Arch Phys Med

Rehabil. 2012.

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Inflammation

Chronic inflammation promotes nociception

Chronic non-resolving inflammation is associated with:

Low back pain, arthritis, RA, MS, atherosclerotic disease, diabetes

1

Western diets low in fruits and vegetable (natural antioxidants) and high in red meat (generator of IL-6) promote inflammation

2

1. Seaman,

D.

Chiropractic

& Manual Therapies

,

2013. 2. Esposito, K., eta l.

Eur

Heart J,

2006.

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Diet as Treatment

Diets high in fruits, vegetables, fiber and Omega 3 Fatty Acids decrease inflammation

1

Anti-Inflammatory Diet – high in fruits, vegetables, legumes, healthy oils, omega 3

Mediterranean Diet – high in vegetables, fish, olive oil as main fat

2

1. Esposito, K., et al.

Eur

Heart J,

2006. 2. Esposito, K., et al.

JAMA,

2004.

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Supplements

Omega 3 Fatty Acids - 3 grams daily DHA/EPA

1

Vitamin D – keep level between 30-50

2

Magnesium ( Magnesium

glycinate

or chelated magnesium)

– 400mg a night and titrate to tolerance

3

Tumeric

500mg QID

4

1. Esposito, K., et al.

Eur

Heart J, 2006. 2. Esposito, K., et al. JAMA, 2004. 3. Yousef, A. A., et al. Anaesthesia

, 2013. 4. Tizabi, Y., et al. Molecules, 2014.

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The Microbiome

The microbiome consists of all the microbes that live on and in

humans

C

ontributes

99% of the genetic material in the human

body

The highest number of organisms are found inside the gastrointestinal

tract

Most

are

bacteria

90

% are anaerobic

Tsukumo DM et. Al. Archives of endocrinology and metabolism.

Apr 2015

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Functions of the Gut Flora

Role in Digestion/Nutrition

Supplying

essential nutrients through their breakdown of complex

carbohydrates

G

enerating

secondary bile acids that assist in the digestion of

fats

1

S

ynthesizing

vitamins such as Vitamins K, B12, folate, and

biotin

2Role in Immune System/Protection

Contribute to the defensive barrier in the colonstimulate mucous production, lymphatic tissue development, antibody formation

Induce protective cytokines, suppress pro-inflammatory cytokines in the mucosa of patients through the actions of Short Chain Fatty Acids (SCFA’s) 3

Interact with our systemic immune system in a way that maintains a level of homeostasisAllowing for the appropriate activationWith NO autoimmunity.

31. Conlon MA, Bird AR. Nutrients. Jan 2015. 2. Nicholson JK, et al.

Science. June 2012. 3. Zhang YJ, et al. International journal of molecular sciences. 2015.

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Functions of the Gut Flora

Role in Gut-Brain Axis

Bidirectional communication

Brain can signal enteric nervous system to speed up or slow down transit time

Neurotransmitters generated by gut bacteria can affect pathways in the CNS

Hormonal signaling

Nervous system communication

1,2

Modulate pain perception

L acidophilus induces expression of mu-opioid

and cannabinoid receptors in intestinal

epithelial cells, mediates analgesic

functions similar to morphine

3

1.

Tillisch K. Gut microbes.

May 2014. 2. Cong X, Hender et al. Advances in neonatal care : official journal of the National Association of Neonatal Nurses. Oct 2015. 3. Rousseaux

C, et al. Nat Med. Jan 2007.

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Irritable Bowel Syndrome

Probiotics associated with decreased pain, bloating, urgency

1,2

Restore more normal gut microflora, improve intestinal permeability, normalize imbalances in inflammatory cytokine ratios

Soluble fiber, commonly found to be helpful in treating

IBS,

has been shown to have profound effects on improving microbiota diversity and in shifting the composition toward less pathogenic

strains

3,4

Dosing:

VSL#3, 225 billion CFU daily-BID

Multiple strains of

Bifidobacterium

and Lactobacillus, 20-40 billion CFU, daily to BID

Recommend trial for 4-8 weeks, can then try decreasing dose

1.

Didari

T et al.

World J Gastroenterol. Mar 14 2015. 2. Ford

AC et al. Am J Gastroenterol. Oct 2014. 3. Moayyedi

P, et al. Am J Gastroenterol. Sept 2014. 4. Simpson HL, Campbell BJ. Aliment

Pharmacol Ther. Jul 2015.

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Obesity

Multifactorial process

In setting of stable energy consumption and adequate physical activity – prevalence of metabolic disorders is rising

Animal data showing that the microbiota of obese rats cause weight gain in settings of controlled calorie intake

Mechanism is thought to be through increased calorie break down and absorption

Recent Meta-analysis of 4 RCT’s showed no difference in those treated with probiotics for weight loss

2 studies not included for poor description of randomization were longer and with higher doses of probiotics showed positive results

Possible that future studies will with higher concentrations and better control for diet will show better results

Park S, Bae JH.

Nutrition research (New York, N.Y.).

Jul 2015

.

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Diabetes

Hypothesis is that dysbiosis of the gut flora

Activation of pro-inflammatory cytokines

Disruption of the intestinal mucosa

Leading to systemic inflammation and glucose dysregulation

Probiotic supplementation studies are showing largely beneficial effects on glycemic controls especially in animal studies.

The largest systematic review to date looked at 33 studies of which 5 were in humans.

All of the studies in humans showed a significant reduction in at least one parameter of glycemic control

It is still unclear which strains confer the most benefit and if those benefits are sustainable without dietary and activity changes.

Le

Barz

M, et al.

Diabetes & metabolism journal.

Aug 2015. Tarantino G,

Finelli

C.

Future microbiology.

2015

.

Samah

S, et al. Diabetes Research and Clin

Pract. Aug 2016.

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Hot Flashes – Non biological therapies

CBT

Several small RCT’s show decrease in problem rating although not in frequency

1

Yoga

Several RCT’s show improvement in hot flashes as well as insomnia, mood disturbances, irritability and anxiety

1,2

Acupuncture

Meta-analysis level data show improvement in hot flash frequency and severity as well as improvement in QOL

3

1. "

Nonhormonal

management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society."

Menopause 2015. 2. Crowe BM, et al.

Health care for women international. 2015. 3. Chiu HY, et al. Menopause. Feb 2015.

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Hot Flashes – Biological therapies

Soy

Isoflavones

Meta-analysis level data show statistically significant reduction in frequency of hot flashes but no change in the

Kupperman

Index (11 menopausal related symptoms)

1,2

60-90mg a day of

Isoflavones

(average dose studied)

S-

Equol

– intestinal bacterial metabolite of soy

30-40mg S-

Equol decreased vasomotor symptoms in small RCT3

Pycogenol – lignand from Maritime Pine PlantTwo small RCT’s show decrease in vasomotor symptoms and improvement in sleep4

Linseed/Flaxseed – Isoflavone with less estrogenic effect than soy1 g of either extract or meal shoed decrease in vasomotor symptoms in small RCT5

1. Chen MN, et al. Climacteric : the journal of the International Menopause Society. 2015. 2. Taku

K, et al. Menopause 2012. 3. Utian WH, et al. Journal of women's health. 2015. 4. Kohama

T, Negami K. Journal of Reproductive Medicine. 2013. 5. Colli MC, et al. Journal of medicinal food.

2012.

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Therapies Commonly Used in Integrative Medicine

Mindfulness

Elimination Diets

Acupuncture

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Mindfulness

Growing evidence on mindfulness impacting QOL in almost all chronic diseases

Evidence:

Improved coping with pain

Decreased anxiety/depression

Improved relapse prevention in substance abuse

Eating disorders

Improved glycemic control in diabetes

Vasomotor symptom

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Mindfulness Based Stress Reduction

8 week course

2.5 hours per week with home practice

Includes instruction on mindfulness, stress and its impact on body

Practice/teaching of mindful awareness practices, walking meditation, simply yoga postures

First developed by Jon

Kabat-Zinn

, PhD at University of Massachusetts and applied at first to patients with chronic pain

1

Now adapted into many other programs based on individual disease being treated

1.

Kabat-Zinn

J.

General hospital psychiatry.

1982.

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Elimination Diets

Removal of offending food from diet, assessment of symptoms, challenge with offending food if symptoms had improved to assess for recurrence

Theory behind causation is evolving

Foods that are not tolerated cause inflammation in the gut lining leading to gut wall breakdown and protein translocation leading to antibody development

The inflammation itself leads to dysbiosis of microbiome

Common starting point is removal of 5 most allergenic foods

Wheat/gluten, dairy, soy, corn, eggs

3-4 weeks off food

Re-introduce with assessment of symptoms

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Elimination Diet

Allergic/dermatitis

IBS/ chronic abdominal

pain

FODMAPS

Fatigue

Possibly related to improved nutrition/lower glycemic index

Chronic

Pain

Fibromyalgia

1

Migraines

Small RCT for patients with migraines and IBS

2

1. Rossi A, et al.

Clin Exp Rheumatol. 2015. 2.

Aydinlar EI, et al. Headache. 2013.

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Acupuncture

Growing evidence:

Chronic

Pain

1,2

Chronic Musculoskeletal Pain

Fibromyalgia

Osteoarthritis

Chronic Back Pain

PMS/Menopausal symptoms

3

Chronic

Fatigue

4

Fertility5

1. Vickers AJ, et al. Archives of internal medicine. 2012. 2. Manyanga

T, et al. BMC complementary and alternative medicine. 3. Chiu HY, et al. Menopause 2015. 4. Kim JE, et al. Trials. 2015. 5. Nandi A, et al.

Journal of obstetrics and gynaecology, 2014.

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Resources

Pub Med & Google Scholar

Natural Medicines & Consumer Labs

https://naturalmedicines.therapeuticresearch.com/

https://www.consumerlab.com/

University of Michigan – Educational Modules

https://sites.google.com/a/umich.edu/fammed-modules/

University of Wisconsin – Educational Modules and Patient Handouts

http://www.fammed.wisc.edu/integrative/resources/modules/

Integrative Medicine by David

Rakel

, MD