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Non-Medica1onTreatmentandManagementofPainGregoryW.Coppola,DO,FAOASM
LECOMLifestyleandIntegra1veMedicineLECOMCMEToronto2016
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LECOMIntegra1veMedicine
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LECOMLifestyleandIntegra1veMedicine
• OsteopathicManualMedicine• Cupping/GuaSha• MedicalAcupuncture• AquaHealing• Prolotherapy• Regenera1veInjec1on
Therapies• YogaforChronicPain• PhysicianGuidedMedita1on
Programs• Nutri1on/DietarySupplements
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Integra1veMedicine• Integra1vemedicine(IM)
ashealing-orientedmedicinethattakesaccountofthewholeperson,includingallaspectsoflifestyle.Itemphasizesthetherapeu1crela1onshipbetweenprac11onerandpa1ent,isinformedbyevidence,andmakesuseofallappropriatetherapies.(UniversityofArizona)
Integra1veMedicine• Anon-pharmacologicand
non-surgicalfocusforpa1entswhoaremo1vatedtohelpthemselveswithanemphasisonempoweringthepa1entswiththerapeu1cchoices.
• Whichtherapeu1cop1on(s)resonatesmostwiththepa1ent’sbeliefsystem?
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Theprinciplesofintegra1vemedicine:
• Apartnershipbetweenpa1entandprac11onerinthehealingprocess.
• Appropriateuseofconven1onalandalterna1vemethodstofacilitatethebody'sinnatehealingresponse.
• Considera1onofallfactorsthatinfluencehealth,wellnessanddisease,includingmind,spiritandcommunityaswellasbody.
• Aphilosophythatneitherrejectsconven1onalmedicinenoracceptsalterna1vetherapiesuncri1cally.
Theprinciplesofintegra1vemedicine:
• Recogni1onthatgoodmedicineshouldbebasedingoodscience,beinquirydriven,andbeopentonewparadigms.
• Useofnatural,effec1ve,less-invasiveinterven1onswheneverpossible.
• Useofthebroaderconceptsofpromo1onofhealthandthepreven1onofillnessaswellasthetreatmentofdisease.
• Trainingofprac11onerstobemodelsofhealthandhealing,commicedtotheprocessofself-explora1onandself-development.
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UniversityofNorthCarolina FellowshipinResearchinIntegra1veMedicine
OhioStateUniversity Integra1veMedicineFellowshipProgram
DukeUniversity FellowshipinIntegra1veHealth&Medicine
LakeErieCollegeofOsteopathicMedicineIntegra?ve&LifestyleMedicine
GraduateTrainingPrograminIntegra1veMedicine
SwedishCherryHill Integra1veMedicineFellowshipUniversityofWisconsin,DepartmentofFamilyMedicine
AcademicIntegra1veMedicineFellowship
TheGeorgeWashingtonUniversity Integra1veGeriatricFellowship
Integra1veMedicineFellowships
Integra1veMedicineFellowshipsUniversityofKansas
Integra1veMedicineFellowship
MaineMedicalCenterFamilyMedicineResidencyProgram(MMCFMRP)
Integra1veFamilyMedicine(IFM)ProgramandFellowship
HarvardMedicalSchool ResearchFellowshipinIntegra1veMedicine
GreaterLawrenceFamilyHealthCenter
HIPFellowship
UniversityofMichigan Integra1veMedicineFellowshipMayoClinic(Minnesota)AlbertEinsteinCollegeofMedicine/BethIsraelMedicalCenter
AcademicIntegra1veMedicineFellowship
WeillCornellMedicalCollege FellowshipPrograminComplementaryandIntegra1veMedicine
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UniversityofArizona/ArizonaCenterforIntegra?veMedicine
FellowshipinIntegra1veMedicine;BravewellFellowshipProgram
UniversityofCaliforniaLosAngelesCenterforEast-WestMedicine
FellowshipinIntegra1veMedicine
SantaRosaFamilyMedicineResidency
Integra1veFamilyMedicineFellowship
UCSFOsherCenterforIntegra?veMedicine
TraininginResearchforIntegra1veMedicine(TRIM)
ScrippsCenterforIntegra?veMedicine
Integra1veCardiology
MiddlesexHospitalCancerCenter Integra1veMedicineFellowshipProgram
StamfordHospital,anaffiliateofColumbiaUniversity
Integra1veMedicineFellowship
GeorgeWashingtonUniversityandtheJesseBrownVAMedicalCenter
Integra1veMedicineEmployeeEduca1on/FellowshipPilot
Integra1veMedicineFellowships
FutureFellowshipDesign• Mee1ngtheneedsofphysicians
whowantto“reinvent”themselveswithinmedicineinsteadofleavingmedicine.
• TheACGMErealitywillmeanmoreMD’swanttolearnaboutandprac1ceOsteopathy.AlsomoreDO’swhowantto“relearn”theirOMMtechniquesandprac1cedifferently.
• Expandingthephysician’sskillsetsmaydecreasetheneedforprescribingmedica1onsandincreaseoveralljobsa1sfac1on(andtheirtelomerelength!)
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Objec1ves:
• ReviewtheCDC’s2016guidelinesonnarco1cuse.
• Provideabackgroundunderstandingaboutlifestyleandintegra1vemedicine.
• Createaframeworkofunderstandingaboutchronicpain.
• Describecommonclinicalpainscenariosandsomeoftheintegra1vestrategiesu1lizedtoreducepain.
ThePainEpidemic• AccordingtotheWorldHealthOrganiza1on(WHO)overone-fimh
oftheworldpopula1onhasexperiencedsometypeofchronicpain.• TheNa1onalCenterforHealthSta1s1cses1matesthatnearly35
percentoftheU.S.generalpopula1onhaspersistentorchronicpainsymptoms.
• Ofpa1entsdiagnosedwithchronicpainandtreatedbyafamilyphysician,64percentreportpersistentpaintwoyearsamertreatmentini1a1on.
• Morethan40Americansdiedailyfrompainkilleroverdoses.• 50%ofpa1entswhotookpainkillersfor3monthss1lltookthem5
yearslater.• Studiesrevealthatmostprimarycareprovidersarenot
comfortablewithchronicpainmanagement.
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PainCategories• Twomajorcategoriesofpainarenocicep1veandneuropathic(a
thirdispsychogenic).• Nocicep1onisanormalphysiologicresponsetos1muliini1atedby
nociceptors,whichdetectmechanical,thermal,orchemicalchanges.
• Nocicep1vepainmaybedividedintothreesubtypes:superficialsoma1cpainfromcutaneousnociceptorsontheskinorsuperficial1ssues;deepsoma1cpainfromsoma1cnociceptorsonligaments,bones,bloodvessels,andmuscles;andvisceralpainfromvisceralnociceptorswithinbodyorgans.
• Soma1cpainistypicallylocalizedandisdescribedasthrobbing,aching,orsharp/gnawing;visceralpainisgenerallydifficulttolocalizeandisdescribedascramping,achy,squeezing,ordragging.
Reali1esofPainManagement
CentersforDiseaseControlandPreven1onNa1onalCenterforInjuryPreven1onandControlDivisionofUninten1onalInjuryPreven1onMarch2016
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PainfulReali1es
• CentersforDiseaseControlandPreven1onNa1onalCenterforInjuryPreven1onandControlDivisionofUninten1onalInjuryPreven1onMarch2016
Reali1esofPainMedicine
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Reali1esofPain
WhatistheCDCGuideline’sFocus?• Theguidelinehelpsprovidersmakeinformeddecisionsaboutpaintreatmentforpa1ents18andolderinprimarycareseqngs.Therecommenda1onsfocusontheuseofopioidsintrea1ngchronicpain—painlas1nglongerthanthreemonthsorpastthe1meofnormal1ssuehealing.Theguidelineisnotintendedforpa1entswhoareinac1vecancertreatment,pallia1vecare,orend-of-lifecare.
• Opioidsposearisktoallpa1ents.Theguidelineencouragesproviderstoimplementbestprac1cesforresponsibleprescribing.
• Usenonopioidtherapies
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WhatistheCDCGuideline’sAim?• Startlowandgoslow• Whenopioidsareused,prescribethelowestpossibleeffec1vedosageandstartwithimmediate-releaseopioidsinsteadofextended-release/long-ac1ngopioids.Onlyprovidethequan1tyneededfortheexpecteddura1onofpain.
• Follow-up• Regularlymonitorpa1entstomakesureopioidsareimprovingpainandfunc1onwithoutcausingharm.Ifbenefitsdonotoutweighharms,op1mizeothertherapiesandworkwithpa1entstotaperordiscon1nueopioids,ifneeded.
WhatistheCDCGuideline’sAim?
• Usenonpharmacologictherapies(suchasexerciseandcogni1vebehavioraltherapy)andnonopioidpharmacologictherapies(suchasan1-inflammatories)forchronicpain.
• Don’tuseopioidsrou1nelyforchronicpain.Whenopioidsareused,combinethemwithnonpharmacologicornonopioidpharmacologictherapy,asappropriate,toprovidegreaterbenefits.
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TiersofNon-SurgicalTreatment1.Conserva1vemanagement
– LifestyleModifica1ons– OsteopathicManualMedicine/PhysicalTherapy/HomeExercises– Nutri1on/Supplements(VitaminD3/Omega-3facyacids/An1-inflammatory
foods&spices)– Acupuncture&Dryneedling– Injec1onTherapies– PsychologicalCounseling
2.Viscosupplementa1on(HyaluronicAcid)3.Prolotherapy4.Peri-neuralSubcutaneousInjec1ons(PSI)4.Alkalinizingsolu1ons5.Autologousbloodinjec1on(ABI)5.Plateletrichplasma(PRP)6.Bonemarrowaspirateconcentrate(BMAC)7.Adipocytes8.Amnion
OsteopathicMedicine• Thebodyisaunit.• Thebodypossessesself
regulatorymechanisms.• Structureandfunc1onare
reciprocallyinterrelated.• Ra1onaltherapyisbased
uponanunderstandingofbodyunity,selfregulatorymechanisms,andtheinter-rela1onshipofstructureandfunc1on.
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AutonomicNervousSystem
ImpactofConcussions:
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SignificanceoftheJugularForamen
WhyAcupuncture?
• >100,000Americansdieeachyearfromdrugrelatedissues.
• Mostpa1entswantnon-medica1onandnonsurgicalop1ons.
• InfluencestheANS• Costeffec1ve• Minimalsideeffects• Professionallyrewarding
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BaclefieldAcupuncture
• DevelopedbyRichardNiemtzow,MDin2001• Treatmentforpain• Acupoints:– Cingulategyrus– Thalamus– Omega2– PointZero– Shenmen
www.nyacuhealth.com
GuaSha&Cupping
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PainGenerators
GluteusMinimusTriggerPoints
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SacroiliacJointandLigaments
Painbeyondthephysical…….
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LECOMSportsandOrthopedicMedicine
Reali1esofExerciseandMovement
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SagicalPlane
FrontalPlane
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TransversePlane
MeniscalInjuries
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Sodium 73 mg
Sodium 131 mg
Sodium 242 mg
Sodium 100 mg
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An1-inflammatoryFoodPyramid
An1-inflammatoryAgents:• Lowprotein-plantbased
diet• OrganicTartCherryJuice• UnsweetenedCocoa
Powder• HealthySpices:
cinnamon,turmeric,garlicandginger
• VitaminDandOmega3facyacids
• Ice
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AutonomicNervousSystem
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JointHealthConsidera1ons:• OsteopathicStructuralEvalua1on• Op1miza1onofNutri1on• WeightManagement• StretchingandStrengthening
exercises• Aerobicexercise/Aqua1ctherapy• Suppor1veShoewear• Considera1onofsupplements:• Glucosamine(1500mg/D)and
Chondroi1n(1200mg/D)• Omega-3FacyAcids(2-4grams/D)• VitaminD3(2,000IUsD3/D)• Zyflamend(BotanicalCOX-2inhibitor)• SAMe(400mg/D)
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KneePain
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Whatisthemainpaingenerator?
FundamentalsofLigaments
• Allarerichlyinnervated(Paciniancorpuscles,musclespindleappara1,Golgitendonorgans.)
• Formconnec1onsbetweenvertebralbodies,facets,mul1fidi,sacrumtopelvis-sacroiliacjoints,sacrumtoposteriorpelvisandcoccyxtopelvisandsacrum.
• Propriocep1veinputfromligaments,followedbyCNSprocessing,regulatestone,posture,firingpacernsofaxialandappendicularmusculature.
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ImportantGrowthFactorsinPRP
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Infrapatellartendinosis
Results
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PlantarFascii1s
RunningShoes
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LumbosacralPain
CommonPainPacerns
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ImportanceofPosture
BasalJointArthri1s
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ExpandingTherapeu1cOp1ons
Regenera1veBiomedicine
Tradi1onal
OMT&Exercise
RX
Supp
lemen
ts
Tradi1onalMedicine
Integra1veMedicine
TakeHomePoints• Rememberthatenthesopathiesdonotrespondwelltochronic
steroidinjec1onsorlongtermuseofan1-inflammatories.Differenttypeofregenera1veinjec1onsmaybehelpfulforarthri1c,tendonandligamentpain.
• Considersomeintegra1vetherapiesforyourselflikemedita1on,OMT,oracupuncturetofurtheryourownunderstandingandhelpyourownhealth.
• Exploredifferentwaystobroadenyourownskillsetasitrelatestothetreatmentofpain-liketakinganinjec1oncourseoracupuncturetraining.
• Considersupplements(VitaminD32,000IUs/D,Omega-3facyacids,healthyspices)whichmayprovidehealthierwaystoreduceinflamma1ontoweanpa1entsofftheuseoflongterman1-inflammatories.
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DangerofOMT
References:• 1.IsaacsERandBookhoutMR.Bourdillon’sSpinalManipula1on,6thEdi1on.BucerworthandHeinemann.Boston.2002.p
38.2.DvorakJ,DvorakV,GilliarW,SchneiderW,SpringH,andTritschlerT.MusculoskeletalMedicine:DiagnosisandTreatment.Thieme.2007.pp145-147.
• 3.Ibidref2.Dvoraketal;pp1-2.• 4.DvorakJ,DvorakV,andSchneiderW.(eds).ManualMedicine.SpringerVerlag.1984.• 5.NelsonKEandGlonekT.(eds).Soma1cDysfunc1oninOsteopathicFamilyMedicine.LippincocWilliamsandWilkins.
2007.pv.• 6.Ibidref5.NelsonandGlonekT;p1.• 7.KoesBW,vanTulderMW,andThomasS.Diagnosisandtreatmentoflowbackpain.BMJ.2006.332:1430-1434.• 8.CypressBK.Characteris1csofPhysicianVisitsforBackSymptoms:ANa1onalPerspec1ve.AmJPublicHealth.1983.pp
389-395.• 9.AnderssonGBJ,LucenteT,DavisAM,etal.AComparisonofOsteopathicSpinalManipula1onwithStandardCarefor
Pa1entswithLowBackPain.TheNewEnglandJournalofMedicine.November1999.Vol.341:1426-1431.• 10.CherkinDC,DeyoRA,WheelerK,andCiolM.Physicianvaria1onindiagnos1ctes1ngforlowbackpain:whoyouseeis
whatyouget.Arthri1sRheum.1994.37:15-22.• 11.CherkinDC,DeyoRA,LoeserJD,BushT,andWaddellG.Anninterna1onalcomparisonofbacksurgeryrates.Spine.
1994.19:1201-1206.• 12.DvorakJ,DvorakV,GilliarW,SchneiderW,SpringH,TritschlerT.MusculoskeletalMedicine:DiagnosisandTreatment.
Thieme.2008.pp131-135.• 13.GilliarWGandAndersonW.NormalandAbnormalVertebralMo1on:APrac1calApproach.PhysicalMedicineand
Rehabilita1on:StateoftheArtReviews.1998.14(1):5-25.• 14.GilliarWG,KucheraM,andGiulianeqD.NeurologicBasisofManualMedicine.PhysicalMedicineandRehabilita1on
ClinicsofNorthAmerica.1996.7(4):693-714• 15.DegenhardtBF,DarmaniNA,andJohnsonJC.RoleofOsteopathicManipula1veTreatmentinalteringpainbiomarkers:
apilotstudy.JAOA.2007.107:387-400.• 16.Teodorcyk-InjeyanJA,InjeyanHS,andRueggR.Spinalmanipula1vetherapyreducesinflammatorycytokinesbutnot
stubstancePproduc1oninnormalsubjects.JManipula1vePhysiolTher.2006.29(1):14-21.
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References:• 17.SalamonE,ZhuW,andStefanoGB.NitricOxideasaPossibleMechanismforunderstandingthe
therapeu1ceffectsofOsteopathicManipula1veMedicine.IntJMolMed.Sept2004.14(3):443-449.• 18.TraceyKJ.Physiologyandimmunologyofthecholinergican1-inflammatorypathway.JClinInvest.
2007.117:289-296.• 19.Ibidref2.Dvoraketal;pp81-98.• 20.KoesBW,vanTulderMW,andThomasS.Diagnosisandtreatmentoflowbackpain.BMJ.2006.332:
1430-1434.• 21.Ibidref2.Dvoraketal;pp167-168.• 22.LicciardoneJC,BrimhallAK,andKingLN.OsteopathicManipula1veTreatmentforLowBackPain:A
Systema1cReviewandMeta-AnalysisofRandomizedControlledTrials.BMCMusculoskeletalDisorders.2005.6:43.
• 23.LicciardoneJC,KingHH,HenselKL,andWilliamsDG.OsteopathicHealthOutcomesinChronicLowBackPain:theOsteopathicTrial.OsteopathicMedicineandPrimaryCare.2008.Availableatwww.om-pc.com/content/2/15/Accessed8/25/2008.
• 24.UKBackpainExerciseandManipula1on(UKBEAM)trial–na1onalrandomisedtrialofphysicaltreatmentsforbackpaininprimarycare:objec1ves,designandinterven1ons[ISRCTN32683578].BMCHealthServRes.PublishedonlineAugust2003.Availableat:www.pubmedcentral.nih.gov/ar1clerender.fcgi?ar1d=194218.Accessed8/20/08.
• 25.Ibidref12.Dvoraketal.2008.• 26.MeinE.LowBackPainandManualMedicine–AlookattheLiterature.PhysicalMedicineand
Rehabilita1onClinicsofNorthAmerica.7(4)Nov.1996.715-729
“Whenitcomestohealingpa1entswhoaresuffering,wedrama1callyunderu1lizeourpowerifweonlyapplythegeniusofourtechnology.Whatmodernmedicinedoesbestistreatacutediseaseandtrauma;whatitdoesleastwellistreatchronicdiseases.Todealwithchronicdiseaseyouhavetotouchpa1entswithmorethanjustinstruments-youmusttouchthemwithyourheart.” --CarlHammerschlag,MD
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