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

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

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

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

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

7. { 66-year old female with a one year history of back pain Sylvia

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

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

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

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

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

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

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

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 Sylvia’s exam

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

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

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

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

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

22. Sylvia’s Integrative Health Plan  Nutrition and Dietary Approaches  Botanicals and Supplements  Pharmaceuticals  MindBody and Behavioral therapies  Biomechanical therapies  Bioenergetic therapies

23. Nutrition and Dietary Approaches

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

25. “Here, take this root…………..” Glycyrrhiza labra

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

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.

28. Botanicals and Supplements  Sylvia’s 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)  Devil’s claw ( Harpagophytum procumbens)  Ginger ( Zingiber officinale)  Omega-3-fatty acids

29. Mind-Body and Behavioral Therapies  Sylvia’s 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

30. Biomechanical therapies  Sylvia’s 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

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

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

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

34. Now, for the magic word………….. RELIEVE

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

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

37.  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

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