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Hot Topics In Integrative Medicine Jill Schneiderhan MD October 20, 2017 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. 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 Chronic Pain Chronic Pain Significant 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. Integrative Chronic Pain Management Activity Body Issues Cognitive & Stress Sleep Improved Pain Experience Diet/Obesity Emotion /Mood Social/ Relationship Medications & Supplements 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. Obesity and Inflammation For many obese patients there is chronic non-resolving inflammation1 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 obese2 1. Arranz, L. I., et al. Curr Rheumatol Rep. 2014. 2. Briggs, M., et al. Arch Phys Med Rehabil. 2012. Inflammation Chronic inflammation promotes nociception Chronic non-resolving inflammation is associated with: Low back pain, arthritis, RA, MS, atherosclerotic disease, diabetes1 Western diets low in fruits and vegetable (natural antioxidants) and high in red meat (generator of IL-6) promote inflammation2 1. Seaman, D. Chiropractic & Manual Therapies, 2013. 2. Esposito, K., eta l. Eur Heart J, 2006. Diet as Treatment Diets high in fruits, vegetables, fiber and Omega 3 Fatty Acids decrease inflammation1 Anti-Inflammatory Diet – high in fruits, vegetables, legumes, healthy oils, omega 3 Mediterranean Diet – high in vegetables, fish, olive oil as main fat2 1. Esposito, K., et al. Eur Heart J, 2006. 2. Esposito, K., et al. JAMA, 2004. Supplements Omega 3 Fatty Acids - 3 grams daily DHA/EPA1 Vitamin D – keep level between 30-502 Magnesium ( Magnesium glycinate or chelated magnesium) – 400mg a night and titrate to tolerance3 Tumeric 500mg QID4 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. The Microbiome The microbiome consists of all the microbes that live on and in humans Contributes 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 Functions of the Gut Flora Role in Digestion/Nutrition Supplying essential nutrients through their breakdown of complex carbohydrates Generating secondary bile acids that assist in the digestion of fats1 Synthesizing vitamins such as Vitamins K, B12, folate, and biotin2 Role in Immune System/Protection Contribute to the defensive barrier in the colon stimulate 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 homeostasis Allowing for the appropriate activation With NO autoimmunity.3 1. 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. 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 communication1,2 Modulate pain perception L acidophilus induces expression of mu-opioid and cannabinoid receptors in intestinal epithelial cells, mediates analgesic functions similar to morphine3 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. 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. 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. 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. Hot Flashes – Non biological therapies CBT Several small RCT’s show decrease in problem rating although not in frequency1 Yoga Several RCT’s show improvement in hot flashes as well as insomnia, mood disturbances, irritability and anxiety1,2 Acupuncture Meta-analysis level data show improvement in hot flash frequency and severity as well as improvement in QOL3 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. 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 Plant Two small RCT’s show decrease in vasomotor symptoms and improvement in sleep4 Linseed/Flaxseed – Isoflavone with less estrogenic effect than soy 1 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. Therapies Commonly Used in Integrative Medicine Mindfulness Elimination Diets Acupuncture 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 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 pain1 Now adapted into many other programs based on individual disease being treated 1. Kabat-Zinn J. General hospital psychiatry. 1982. 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 Elimination Diet Allergic/dermatitis IBS/ chronic abdominal pain FODMAPS Fatigue Possibly related to improved nutrition/lower glycemic index Chronic Pain Fibromyalgia1 Migraines Small RCT for patients with migraines and IBS2 1. Rossi A, et al. Clin Exp Rheumatol. 2015. 2. Aydinlar EI, et al. Headache. 2013. Acupuncture Growing evidence: Chronic Pain1,2 Chronic Musculoskeletal Pain Fibromyalgia Osteoarthritis Chronic Back Pain PMS/Menopausal symptoms3 Chronic Fatigue4 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. 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
