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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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