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{ Integrative Medicine: Magic or Medicine? Irene M. Estores, MD Medical Director UF Health Integrative Medicine Program irene.estores@medicine.ufl.edu

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Disclosures I have no relevant financial relationships with a commercial organization that produces, markets, re- sells or distributes the products mentioned in this presentation I do not receive any financial or material support from any of the above mentioned organizations I will refer to commercial products using generic names

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Learning Objectives Define the philosophy and practice of Integrative Medicine Apply an evidence-based approach in formulating an integrative health plan Select safe and effective botanicals, dietary supplements, mind-body therapies, biomechanical and bioenergetic modalities in a treatment plan for chronic low back pain

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When religion was strong and medicine weak, men mistook magic for medicine; Now, when science is strong and religion weak, men mistake medicine for magic. Thomas Szasz, The Second Sin

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An illustrative case of chronic back pain A description of an integrative health plan that includes the following modalities: Nutrition and dietary approaches Botanicals and supplements Mind-body therapies Biomechanical therapies Bioenergetic Therapies

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{ 66-year old female with a one year history of back pain Sylvia

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{{ Present Illness Slipped and fell at her apartment complex Sustained a pelvic, thoracic ( T4) and rib fractures, managed conservatively, received PT Current pain: 6-7/10 at best, 8/10 at worst R side of body and on thoracic spine, worse with movement, relieved by cold, NSAID, acetaminophen, occasional tramadol Past History Depression Hypertension History of a TIA History of migraine Unclear diagnosis of rheumatoid arthritis Osteoporosis Dyslipidemia Medical History

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Alendronate Aspirin-dipyridamole Escitalopram Meloxicam Rosuvastatin Valsartan Calcium 1.2 gm/day Vitamin D 1,000 IU/day Topical proprietary blend of menthol, arnica, boswellia, camphor, lemon balm, calendula, ilex Medical History

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Cultural and Family background: Immigrated to the US from Eastern Europe, divorced, with two adult children who are successful professionals Raised in a family with many health professionals but also exposed to folk healing traditions Education and Work History No college education, worked in medical offices part- time, now retired and bored Personal Strengths: Considers herself to be creative and empathic, altruistic and having a young spirit Psychosocial summary

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Stressors: relocation to a different city, life transitions Practices to reduce stress: walking, praying, art Relationships: good relationships with children, misses friends from previous city Psychosocial summary

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Typical daily meals: likes cheese, fruits and vegetables, eats bread sparingly enjoys nuts olive oil, and occasional red wine Food person: she shops and prepares food her herself; daughter eats most of her meals at work Family dynamic: eats most of her meals alone, takes small, frequent meals Strengths: fair information about healthy food choices Obstacles: does not track actual food intake Nutritional history

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Smoked for 20 years, quit for past 2 years Drinks wine socially No history of illicit drug use Habits

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Typical daily activity: walking her dog, swimming Exercise: walking, home PT program Sleep pattern: sleeps 5-6 hours/night, has difficulty falling asleep due to pain Physical Function, Movement and Rest

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{{ Vitals BP: 156/98 HR: 68 T: 36.8 BMI: 31 Physical Exam Diffuse tenderness over the lateral and posterior thoracic region from R lower rib cage to the thoracic vertebrae Moderate muscle spasm No erythema, no heat Sylvias exam

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Plain radiograph of thoracic spine: healing minimally displaced fractures of the right 9 th -12 th ribs, generalized osteopenia DEXA: L fem neck : T- score: -2.0 Lumbar spine: T-score -1.7 Normal thyroid studies Normal Vitamin D levels Normal BMP, CBC Labs and Imaging

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Physical therapy Psychotherapy No previous experience with complementary medicine modalities( acupuncture, massage, botanicals, supplements) Other therapies received

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66 female with osteoporosis, healing fractures, chronic myofascial pain, with secondary fear avoidance behavior, slight physical deconditioning and concomitant depression that contributes to perpetuation of pain. Depression is worsened by limited social contacts, life transitions Has good inner resources (creativity, young and altruistic spirit), has some financial resources Open-minded about using non-conventional modalities Initial assessment

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Reassurance and encouragement Address fear avoidance behavior Identify pro-inflammatory triggers Consider patient preferences, previous experience, interest and access in selection of modalities Initial integrative health plan

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Consider the evidence, risk, benefit Consider provider experience and preference Intuition Initial integrative health plan

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Sylvias Integrative Health Plan Nutrition and Dietary Approaches Botanicals and Supplements Pharmaceuticals MindBody and Behavioral therapies Biomechanical therapies Bioenergetic therapies

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Nutrition and Dietary Approaches

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{{ Pro-inflammatory triggers Dietary imbalance Food intolerance or sensitivity Intestinal dysbiosis Infections Physical stress Psychological stress Oxidative Stress Anti-inflammatory strategies Anti-inflammatory and anti-oxidant food Low- glycemic index food Elimination or rotation diets Essential fatty acids Probiotics Nutrition and Dietary Approaches

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Here, take this root.. Glycyrrhiza labra

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Cell Membrane Phospholipase A2 Arachidonic Acid Cortisone Drug Modulation of Arachidonic Acid Cascade cyclooxygenaselipooxygenase 2 Series Prostaglandins Thromboxane A2 Leukotrienes SRS-A Colchicine Sulfasalazine (topically) Indomethacin Aspirin Ibuprofen Acetaminophen (weak) Sulfasalazine (topically) x x x x Courtesy of Dr. Ben Kligler, MDCourtesy of Dr. Ben Kligler, MD

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Cell Membrane Phospholipase A2 Arachidonic Acid Glycyrrhiza labra Quercitin Botanical Modulation of Arachidonic Acid Cascade cyclooxygenase lipooxygenase Prostaglandins 2 Series Thromboxane A2 Leukotrienes SRS-A Quercitin Allium cepa Allium sativuru Curcumin longa Boswellia serrata (specific for 5- lipoxygenase) Zingiber officinale Curcumin longa Quercitin (weak) Bromelain White Willow Bark Gaultheria procumbens x x x Potentiates cortisol: Glycyrrhiza labra Curcumin longa xx Other Anti-Inflammatory Botanicals Ananas Comosus - fibrinolysis, inhibits bradkinin, increase Series I Prostaglandins; Tanacetum parthenium - inhibits platlet aggragation; Scutellaria baicalensis - stabilize mast cell membranes; Quercitin - stabilize mast cell membranes; Amni Visnaga - stablize mast cell membranes; Capsaicin Mununm - depletes substance P; Matricaria chamomilla - unknown.

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Botanicals and Supplements Sylvias Integrative Health Plan Magnesium Muscle relaxation Vasodilator Promotes sleep Magnesium glycinate, chelate or aspartate Check renal function RDA: 300 mg/day Typical dose: 400- 800/day Other supplements to consider: Curcumin (curcuma longa) Boswellic acid ( Boswellia serrata) Willow bark (Salix sp) Devils claw ( Harpagophytum procumbens) Ginger ( Zingiber officinale) Omega-3-fatty acids

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Mind-Body and Behavioral Therapies Sylvias Integrative Health Plan Guided Imagery Psychotherapy Introduction to local arts and gardening groups Breathwork Other practices to consider: Yoga Meditation Cognitive behavioral therapy Multidisciplinary functional restoration programs Expressive and therapeutic writing, using affirmative scripts

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Biomechanical therapies Sylvias Integrative Health Plan: Therapeutic exercise Daily walking program Other therapies to Consider Spinal Manipulation Short-term use of massage Physical modalities (TENS, LLLT, heat, cryotherapy, etc) Postural therapies

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Bioenergetic therapies The cell is a machine driven by energy. It can thus be approached by studying matter, or by studying energy. In every culture and in every medical tradition before ours, healing was accomplished by moving energy. Albert Szent-Gyorgyi, Nobel Laureate in Medicine Therapies to consider: Acupuncture QiGong Energy Psychology

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Sylvia, 65 year female with chronic back pain Integrative health plan that : Provided her with reassurance and encouragement addressed her fear avoidance behavior, underlying depression and limited social connection considered her preferences, previous experience, access and personal strengths Review

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Modalities included: Nutrition and dietary approaches ( anti- inflammatory and low-glycemic diet) Supplements ( magnesium) Mindbody and behavioral therapies (guided imagery, psychotherapy, art) Pharmaceuticals ( escitalopram, BP medication) Biomechanical therapies ( therapeutic exercise, daily walking) Review

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Now, for the magic word.. RELIEVE

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Relationship-centered care built on Empathy and trust creates a positive environment where the clinician can Listen to a complicated story that creates Insight into a problem that results in an Explanation that is consistent with the patient's Values leading to Empowerment and action towards health. RELIEVE Used with permission from the University of Wisconsin School of Medicine and Public Health

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The Practice of Integrative Medicine Patient and relationship- centered Addresses the whole person Evidence-informed Uses safe and effective modalities Utilizes all appropriate healthcare professionals and disciplines Health and well-being The Practice of Medicine

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Useful Websites www.naturalstandard.com www.naturalstandard.com http://lpi.oregonstate.edu http://www.consumerlab.com http://www.consumerlab.com www.nccam.nih.gov www.nccam.nih.gov http://medlineplus.gov http://medlineplus.gov www.naturaldatabase.com https://www.fammed.wisc.edu/integrative www.azcim.org www.azcim.org Textbook reference : Rakel, D. Integrative Medicine, 3 rd ed, 2012, Elsevier Saunders Resources

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UFHealth Integrative Medicine Program Supporting people in the journey to realizing wholeness www.ufhealth.org/integrative-medicine