{ Integrative Medicine: Magic or Medicine? Irene M. Estores, MD
Medical Director UF Health Integrative Medicine Program
[email protected]
Slide 2
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
Slide 3
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
Slide 4
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
Slide 5
Slide 6
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
Slide 7
{ 66-year old female with a one year history of back pain
Sylvia
Slide 8
{{ 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
Slide 9
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
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
Smoked for 20 years, quit for past 2 years Drinks wine socially
No history of illicit drug use Habits
Slide 14
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
Slide 15
{{ 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
Slide 16
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
Slide 17
Physical therapy Psychotherapy No previous experience with
complementary medicine modalities( acupuncture, massage,
botanicals, supplements) Other therapies received
Slide 18
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
Slide 19
Slide 20
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
Slide 21
Consider the evidence, risk, benefit Consider provider
experience and preference Intuition Initial integrative health
plan
Slide 22
Sylvias Integrative Health Plan Nutrition and Dietary
Approaches Botanicals and Supplements Pharmaceuticals MindBody and
Behavioral therapies Biomechanical therapies Bioenergetic
therapies
Slide 23
Nutrition and Dietary Approaches
Slide 24
{{ 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
Slide 25
Here, take this root.. Glycyrrhiza labra
Slide 26
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
Slide 27
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.
Slide 28
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
Slide 29
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
Slide 30
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
Slide 31
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
Slide 32
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
Slide 33
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
Slide 34
Now, for the magic word.. RELIEVE
Slide 35
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
Slide 36
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