Whole Health is part of collaborative effort by the Pacific Institute for Research and Evaluation, VA Office of Patient Care and Cultural Transformation, and University of Wisconsin Integrative Health Program to transform healthcare and help people live healthier, happier lives, and more purpose-driven lives.
Learn more: https://wholehealth.wisc.edu/courses-training/whole-health-for-pain-and-suffering/
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
Whole Health for Pain and Suffering Day 1/2
1. Whole Health for Pain
and Suffering
An Integrative Approach
Day 1
Welcome!
2. Whole Health for Pain and Suffering
1. New Perspectives on
Pain and Suffering
3. Veterans Health Administration
Office of Patient Centered Care & Cultural
Transformation (OPCC&CT)
Pacific Institute for Research
and Evaluation (PIRE)
University of Wisconsin-Madison
Family Medicine and Community Health
Integrative Health
This course was created by:
4. Module 1
• Outline course structure and goals
• Whole Health in the VA: Where are we?
• Chronic pain: scope of the problem
• Whole Health Introduction
• How does WH relate to CIH?
• Whole Health Resources
• Local Resources
5. Course Manual
• Created by OPCC&CT
• Whole Health training began in
2013
• 200+ Whole Health courses
• Over 13,000 VHA employees
have trained in Whole Health
• Tied with Comprehensive
Addiction and Recovery Act
6. Comprehensive Addiction and Recovery Act (CARA) 2016
• Section 931 – Expansion of Research and Education on and
Delivery of Complementary and Integrative Health to Veterans
• H.R. 4063, as reported, establishes a Commission to examine the
evidence-based therapy treatment model used by VA for
treating mental health conditions of Veterans and the potential
benefits of incorporating complementary and integrative health
as standard practice throughout the Department.
• Section 932 – Pilot Program on Integration of Complementary
and Integrative Health and Related Issues for Veterans and
Family Members of Veterans
• The provision requires that the Secretary, informed by the
Commission’s findings, commence a pilot program to assess the
feasibility and advisability of using wellness-based programs to
complement pain management and related health care services.
7. About This Course
What are we trying to accomplish?
1. Untangle the web of chronic pain
2. Use the Whole Health model to individualize the
pain and suffering experience
3. Gain exposure to non-pharmacologic approaches
to pain care using Whole Health
4. Develop a common language in caring for
Veterans with chronic pain and suffering
5. Network: employ the wisdom of the group
8. About This Course
What are YOU trying to accomplish?
1. Are you hoping to learn what Whole Health means?
2. Are you trying to experience some of the self-care
approaches that are mentioned in Whole Health?
3. Do you find it difficult to sit with a patient that is
suffering?
4. Are you an expert in this field? How can we build
better bridges? Are there aspects of the Whole
Health Approach that you could do better? How can
you lead the way at your site?
9. Setting Intentions
GOOD: Understand the concepts of Whole Health and
Complementary & Integrative Health for Pain and
Suffering
BETTER: ...learn skills to use right away
EVEN BETTER: ...implement Whole Health approaches
on your team at a team, facility, and/or system level
BEST: ...apply them to your own life!
10. For Our 2 Days Together
• 14 modules with themes for each half day
– Beginning at the Center of the Circle of Health
– Walking the Green Circles, Self-Care, Self-Management
– Integrative Health: Expanding Possibilities
– Whole Health in Your Practice: Moving Your Team Forward
• Interludes to highlight local resources
11. Community Agreements
• Be Present – minimize technology
• Be Curious…and strategic
• Be Silent (with experiential sessions)
• Be Respectful – set pagers and phones to stun
• Be Healthy – okay to stand/move
• Be Punctual – we will get you out on time
• Be Honest – give feedback
• Have Fun!
12. Whole Health for Pain and Suffering
Introductions
Photo credit: rockindave1 via Foter.com
13. Small Group Introductions
1. Name
2. Role in the VA
3. What is one thing you
are hoping to take
away from this course?
4. An interest, hobby, or
favorite past time
~20 seconds!
Pinterest.com
16. Greater Los
Angeles
San
Francisco
Portland
North Texas -
Plano
St. Louis
Columbia
Minneapolis
Tomah
Central
Arkansas
Jesse
Brown
Salisbury
Washington DC
Baltimore
Boston
Biloxi
Durham
Iowa City
Hudson Valley
= FY16 Whole Health Facilities = FY17 Whole Health Facilities
Whole Health 2016-17
Greater Los
Angeles
San
Francisco
Portland
North Texas -
Plano
St. Louis
Columbia
Minneapolis
Tomah
Central
Arkansas
Jesse
Brown
Salisbury
Washington DC
Baltimore
Boston
Biloxi
Durham
Iowa City
Hudson Valley
17. Whole Health Design Sites, 2018
Fresno
Syracuse
Kansas City
Fargo
Madison
Cincinnati
Manchester
Mountain Home, TN
Bedford
Birmingham
West Palm Beach
Sioux Falls
Detroit
FY18 Design Sites
18. And it will keep
happening! VISN’s have
designated flagship sites
for 2018
19. Whole Health Flagship and Design Sites
Key
Flagship Sites (18)
FY16 Original Design Sites (18)
FY17 Additional Design Sites (18)
FY18 Additional Design Sites (13)
VSN, Name
20-
Portland
19-
Salt Lake
21-
Palo Alto 23-
Omaha
7-Atlanta
17-San
Antonio
16-Little
Rock
15-St. Louis
6-Salisbury
5-Beckley
4-Erie
2-NJ
1-Boston12-Tomah 10-
Saginaw
9- TN
Valley
22-
Tucson
8-Tampa
21. The VA health care
system is leading the
change towards a better
approach to pain care
22. Pain and Suffering: A Serious Problem
American Acadamy Pain Med,
http://www.painmed.org/patientcenter/facts_on_pain.
aspxToblin et al. JAMA Intern Med, 2014;174(8):1400-1.
Publications.mcgill.ca
• Pain affects more people than
diabetes, heart disease, and
cancer combined
• 100 million in U.S. have chronic pain
• 1.5 billion worldwide
• Higher rate in Veterans
• Sample of 2,597 Afghanistan
Veterans
• 44% had chronic pain
• 15% used opioids
• 26% and 4% in civilian population
• Costs U.S. over $600 billion yearly
23. Pain Versus Suffering
• Pain is a signal
• Suffering is the response
to the signal
What happens if we focus
on suffering, in addition
to pain?
24. The Unfortunate Reality…
• Pain and suffering are a serious problem
• They are complex
• Treating them is also complex
• The “conventional” approach has
limitations
• Opioids, in particular, are problematic
25. Increases in Drug and Opioid Overdose Deaths —
United States, 2000–2014
January 1, 2016 / 64(50);1378-82
26. Pain is Complex
• It travels in a pack with other problems
– Depression -PTSD
– Addiction -Anxiety
– Fatigue -Insomnia
– Obesity -Inactivity
– Isolation -Medication problems
– Stalled-out personal growth
• It changes us at the cellular level
Watercolor by Marion Bologna, pinterest.com
28. Treatment is Also Complex
Schoolhouse Rock, The Nervous System, on YouTube.com
http://www.va.gov/PAINMANAGEMENT/Chronic_Pain_Primer.asp
• Chronic and acute pain are
different
• Low correspondence between
symptoms and imaging (40-60%)
• Neuroplasticity and new-found
mechanisms
• Many risk factors – not just
demographics
• Psychosocial
• Mood and coping skills
• Diet and neurotransmitters
• Informed by past experiences
29. Abnormal MRI in Asymptomatic Adults
Boden SD et al., J Bone Joint Surg Am 1990;72.
30. Opioids Are Problematic: Some Numbers
Brady et al, Am J Psychiatry, 2016;173(1):18-26.
Dowell D et al, JAMA, 2016;315(15):1624-45.
Sharonmunday70.wordpress.com
• 1.9 million Americans initiated into
prescription opioid use yearly
• 12.5 million Americans abusing
opioids in 2012 (from 4.9 million,
1992)
• 259 million - number of Americans
and number of opioid prescriptions
in 2012
• 165,000 - US deaths from
prescription opioid OD’s, 1999-2014
• 83% - percentage of world’s
population without access to
opioids
31. Danish Health & Morbidity Survey of 10,066 people
Assessed chronic opioid use for non-cancer pain
Chronic opioid therapy did not meet any of the KEY
outcome opioid treatment goals:
• Pain relief
• Improved quality of life
• Improved functional capacity
Eriksen J, et al. Pain 2006;125:172-9.
32. Other Medications Also Raise Concerns
• Acetaminophen taken by ¼ of US
adults weekly
• 2015 study: Blunts reactions to positive
and negative emotional stimuli
• 2016: Seems to reduce empathy
response to pain in others
Durso GRO, Psychol Sci, 2015;26(6):750-8.
Mischkowski D, Soc Cogn Affective Neurosci, 2016;1345-53.
33. NSAIDS: COX1 and COX 2 inhibitors
• 20-30% adults take daily
• 20,000 deaths and 100,000 hospitalizations per year1
• ^ risk GI bleed-only 1/5 have warning2
• ^ cardiovascular risk stroke and MI3
• ^ progression of osteoarthritis4
• ^ leaky gut with ^ inflammation (pain)5
1. Am J Med, 1998;105:31S-38S, as referenced in New England Journal of Medicine, 1999;340:1888-1899)
2. Gastroenterology, 2007;132:498-506
3. JAMA, 2006;296:1633-1644
4. Arthritis and Rheumatism, 2000;9:S220; Lancet, 1985;2:11-14
5. Gut, 1986;27:1292-1297; Gut, 1991;32:66-69
34. We are often told what not to do.
But what do we do instead?
35. What Else Might Help?
What happens if we re-frame “pain?”
– A ‘verb’
– Not so much a disease as a state
– A disorder of The Whole Person
Pinterest.com
37. Defining Whole Health
• Personalized, Proactive, Patient-driven Care
• An approach to health care that empowers and equips people
to take charge of their health and well-being and to live their
life to the fullest.
• The Whole Health System includes conventional treatment, but
also focuses on self-empowerment, self-healing, and self-care.
40. Ten Reasons to Practice Whole Health
1. You get to know your patients better.
2. Your work feels more fulfilling.
3. It helps cultivate mindful awareness.
4. You are reminded of the “Power of You.”
5. It makes your patients more satisfied with their care.
6. It is more empowering for patients.
7. Patients do better.
8. It works well for teams.
9. It has the potential to save resources.
10. It saves time.
42. Whole Health is inclusive of
conventional clinical
treatment and prevention,
self-care strategies, and
complementary practices.
43.
44. 2015 HAIG Report
Complementary and Integrative Health
Healthcare Analysis & Information Group (HAIG)
A Field Unit of the Office of Strategic Planning & Analysis
within the Office of the ADUSH for Policy and Planning
45. What about CIH at the VA?
2015 HAIG Report
More VA facilities are offering more CIH
approaches
Table 5.
2002
n=111
2011
n=125
2015
n=131
Provides 1-5 Modalities 70 34 17
Provides 6-10 Modalities 39 59 40
Provides 11-15 Modalities 2 25 50
Provides 16-20 Modalities 0 6 19
Provides 21-26 Modalities 0 0 5
Referred all to non-VA provider 0 1 0
46. What about CIH at the VA?
Top 10 Integrative Health Services :
1. Stress Management Relaxation Therapy (SMRT)
2. Mindfulness
3. Guided Imagery
4. Yoga
5. Progressive Muscle Relaxation Therapy (PMRT)
6. Art Therapy
7. Acupuncture
8. Music Therapy
9. Biofeedback
10. Animal Assisted Therapy
2015 HAIG Report
47. What CIH Approach is Most Commonly Used in VA?
• Mind-Body Medicine
• Biologically Based Practices
• Manipulative Body-Based Practices
• Energy Medicine
• Whole Body Systems
HAIG Report 2011
http://www.research.va.gov/research_topics/
2011CAM_FinalReport.pdf
48. The five most common conditions
treated at the VA:
» Stress Management
» Anxiety
» PTSD
» Depression
» Pain
49. CIH and Pain – General Evaluation
Approach OA Fibro Back Neck Headache
Acupuncture +/- +/- +/-
Massage + + +
Relaxation +/- +
Spinal
Manipulation
+ + +
Osteopathy +/-
Tai Chi + +
Yoga + +
Nahin RL, Mayo Clin Proc, 2016;91(9):1292-
130.
53. Integrative Health Coordinating Center
• VHA established the Integrative Health Coordinating Center (IHCC)
within the Office of Patient Centered Care and Cultural
Transformation (OPCC&CT) in 2013
• The IHCC is charged with developing and implementing CIH
strategies in clinical activities, education, and research across the
system.
• Its two major functions are:
(1) to identify and address barriers to providing CIH across the
VHA system
(2) to serve as a resource and subject matter experts for clinical
practices and education for both Veterans, clinicians, and
leadership.
54. Integrative Health Coordinating Center
• Addressing barriers in business infrastructure
– Stop Codes, CHAR4 codes
• New occupations and position descriptions created
• Advocating for nutraceuticals on formularies
• Supporting research on multiple fronts
55. Ongoing Efforts
• Office of Community Care
• Telehealth
• Volunteer Services
• Position Descriptions
– Acupuncturist, GS-9/13
– Whole Health Program Manager, GS-11
– Health Coach, GS-7/9
– Whole Health Partner Supervisor, GS-8
– Whole Health Program Assistant, GS-7
– Whole Health Partner, GS-6
– Yoga Instructor GS-6
– Tai Chi/Qi Gong Instructor, GS-6
56. Connect!
• IHCC Email
– vhaopcctintegrativehealth@va.gov
• FIT CIH Specialty Team Email
-- VHAOPCCCTCIHSpecialtyTeam@va.gov
• Whole Health System Tracking Team Email
-- VHAOPCCCTWHSTrackingTeam@va.gov
• IHCC SharePoint
– http://vaww.infoshare.va.gov/sites/OPCC/sitePages/IHCC-
home.aspx
57. THE PATHWAY
(Empower)
Partners with Veterans
to discover their mission, aspiration,
and purpose and begins to create an
overarching personal health plan
Personal
Health
Plan
WHOLE HEALTH
CLINICAL CARE
(Treat)
Outpatient & Inpatient
Health & Disease Management
within a Whole Health Paradigm
(i.e., Personal Health Planning,
CIH, Health Coaching)
WELL-BEING
PROGRAMS
(Equip)
Self-Care/Skill Building and
Support
Complementary &
Integrative Health (CIH)
Health Coaching &
Health Partner Support
Whole Health System
61. Three Key Whole Health Websites:
1. VA Patient-Centered Care
• External: OPCC&CT resources for Veterans & family
http://www.va.gov/patientcenteredcare/
67. Three Key Whole Health Websites:
3. Whole Health Library Website
• External: resources for clinicians & Veterans
http://projects.hsl.wisc.edu/SERVICE/
• Can also Google “Whole Health Library”
68. Whole Health Library Website
http://projects.hsl.wisc.edu/SERVICE/
Can also Google “Whole Health Library”
72
69. Whole Health Library
• Grounded in the Whole Health Approach
• Structured around the “Circle of Health”
• Case-based
• Mindful awareness moments
• 25 Subject matter experts
• 35 Educational Overviews – 5 pain-focused (recently updated)
• 200 + “Point of Care” Clinical Tools
• Evidence-informed
• Peer-reviewed
• 600,000+ words
82. A Key Point
• Your presence, in and of itself, is an important nonspecific
variable.
• Use all of these elements to enhance what you can do:
– Relationship
– Empathy
– Listening
– Insight
– Expectation
– Values
– Empowerment
83. What Is a “Good Back Consult?”
• Patients emphasized the importance of:
– An explanation what was being done and found
– Understandable information on the cause
– Receiving reassurance
– Discussing psychosocial issues
– Discussing what can be done
• Most important part of "Good Back Consult”
The specialist took the patient seriously
• Conclusion: The findings may represent an important potential for
enhancing clinical communication with patients.
Laerum E et al. J Rehabil Med. 2006 Jul;38(4):255-62.
84. McKay KM, Imel ZE, Wampold BE.. J Affect. Disord. 2006;92:287-90.
Practitioner Effects
For Depression: Good Therapist + Placebo > Poor Therapist + Imipramine
85. Empathy
Definition:
• A clinician can resonate with
the:
– Situation
– Perspective
– Feelings of another person
• They can verify
• They can act on this
understanding
Pinterest.com
86. Empathy Research
2013 systematic review
• 7 studies
• Over 3,000 patients and 225
physicians
• Conclusions
“There is a relationship between
empathy in patient–physician
communication and patient
satisfaction and adherence,
patients’ anxiety and distress,
better diagnostic and clinical
outcomes, and strengthening of
patients’ enablement.”
Pinterest.com
Derksen F et al. Br J Gen Pract, 2013;Jan:376-84.
87. We have two ears and one mouth so we can
listen twice as much as we speak. -Epictetus
• 1984 study: The average doc
interrupts after 18 seconds
• 2002: 23 seconds
• How long will patients talk with
no interruption?
– Mean: 92 seconds
– Median: 59 seconds
– In all 335 sessions, the info was
rated as ‘useful.’ 1ohww.org
Beckman et al, Ann Intern Med 1984;101:692-6.
Langewitz et al. BMJ 2002;325:682-3.
91. “Positive expectations (i.e., expectations for
decreased pain) produce a reduction in
perceived pain (28.4%) that rivals the effects of
a clearly analgesic dose of morphine (0.08
mg/kg, an ~ 25% reduction in pain).”
Koyama T et al, Proc Natl Acad Sci USA. 2005;102:12950-5.
92. “Difficult” Patients
• Patients who are
– Complex
– In chronic pain
– Have psychosocial issues
– Abuse substances
– Have unmet expectations
– High users of medical resources
• Being seen by clinicians who are
– Working long hours
– Stressed
– Have psychosocial issues
Medscape.com
93. “BREATHE OUT”
A Mindful Awareness Approach
• University of Wisconsin study
• 57 clinicians, 112 visits
• Team huddled to id. difficult
patients
• Answered a pre- and post-visit
questionnaire
• Self-reflective process
• Findings:
– BREATHE OUT Protocol increased
clinician satisfaction with difficult
patient visits
• Physician Satisfaction Scale
– Helped attending docs and residents
alike
Edgoose J et al. J Am Board Fam Med 2015;28:13–20.
Menshealth.com
94. 1. List at least one Bias/assumption you
have about the patient
2. REflect on why you identify this
patient as difficult
3. List one thing you’d like to
Accomplish today
4. THink about one question you’d like
to express today that would enable
you to explore your assumptions
5. Take 3 deep breaths before you
Enter the room
Activateyourthirdeye.com
“BREATHE OUT”
A Mindful Awareness Approach
96. To Sum Up
• Your presence, in and of itself, is an important nonspecific
variable.
• Use all of these elements to enhance what you can do!
– Relationship Know their story.
– Empathy Humanize the person.
– Listening Don’t interrupt. Listen deeply.
– Insight Take time to reflect.
– Expectation Consider agendas.
– Values Explore what really matters.
– Empowerment Help them drive their care.
98. What are the root causes
of the pain and suffering?
99. Looking at the Circle of Health, what might be the
cause of pain and suffering?
page 5
100. Potential Causes – A Circle Perspective
Realms of Health – the inner green circles
• Food & Drink
– Pro-inflammatory diet
– Food intolerance
– Disordered microbiome
– Missing nutrient (D, Mg)
– Dehydrated
• Recharge
– Not enough
– Poor sleep environment
• Working Your Body
– Inactive
– Over-exercising
• Personal Development
– No outlets, no fun
• Family, Friends & Coworkers
– Abusive relationship
– Isolation
• Surroundings
– Toxins
– Temperature
– Ergonomics
• Power of the Mind
– Stress, muscle tension
– Addiction
– Fear of pain
• Spirit & Soul
– Moral injury
– Trauma
Root cause?
101. What can you do
about it?
(Now, we can start
talking about the plan!)
102. “Increasingly, chronic pain research points out that
what kind of pain (the location or other descriptors…)
may not be as important as who is in pain and how that
pain is being experienced.”
-Bonakdar RA, Integrative Pain Management
103. A Shift in Perspective
From…
What’s the matter with you?
To…
What really matters to you?
105. Elena
• 55 y.o. Army Veteran
• Recent neck and knee pain
• Negative imaging
• PT, OTC’s not helpful
• Started on opioids
– Pain: helpful
– Function: not helpful
– You are very aware of national
policies on prescribing
• Worsening depression
• Weight gain
page 17
106. Going More In-Depth: The PHI
• Find a partner
• Take a few minutes to read
Elena’s PHI
• Discuss with your partner:
– How helpful was the PHI?
– How did your understanding
of Elena change?
– Have you identified any
potential reversible causes of
pain?
– How does the PHI guide you
to start a plan?
110. Why Shared Goals Are Important
• We often have goals (agendas) in mind for our patients
• Clinician and patient goals don’t always overlap
• Patients are more likely to have success with goals that
they set for themselves (adherence and engagement)
• Ultimately, this personalizes care and centers it on them
(is more patient centered)
111. How to Get to Shared Goals
• Use the PHI and other assessments as a guide
• Consider your patient’s responses to The Big Questions
• Be clear about your agenda. Do you have major concerns
that need to be addressed?
• What does the patient want to do?
• Support the patient’s choice of a goal
112. Plan Writing Tips and Tricks
The next 11 modules are about
co-creating the plan
– Tools
– Skills
– We’ll go over Elena’s PHP
(manual page 23)
– We’ll discuss key tips for writing
them
113. Potential Elements of a Health Plan:
Self-Care
• Food & Drink
– Anti-inflammatory diet
– Elimination diet
– Probiotics
– Nutrients, supplements
– Hydrate
• Sleep
– Sleep Hygiene
• Working the Body
– Exercise prescription
– Yoga? Tai Chi?
• Personal Development
– Hobby, creativity, learning
• Family, Friends & Coworkers
– Building connections
– Support groups
– Volunteering
• Surroundings
– Altering work or home spaces
– Tie in nature
• Power of the Mind
– Mind-body techniques
– Fear of pain
• Spirit & Soul
– Explore forgiveness
– Explore values, gratitude,
aspirations
114. Elena’s Plan
• It comes down to what she
wants to do!
• She will be more adherent if
you build on what matters to
her (connections)
• This plan more elaborate than
most would be
• Has clear goals outlined
• Designates her care team
• Includes follow up
Page 23
115. The Big Questions
Page 23
• What REALLY matters to you in your life?
• What do you want your health for?
• What brings you a sense of joy and happiness?
• What gets you up in the morning?
117. Mindful Awareness
“From the brain alone
arise our pleasures,
laughter, and jests, as
well as our sorrows,
pain, and griefs.”
—Hippocrates
118. Mindful Awareness Is…
Noticing and gaining insight into your thoughts, sensations, and
feelings as they arise in the present.
“Mindfulness means paying attention in a particular way; on purpose,
in the present moment, and [doing so] non-judgmentally.”
– Jon Kabat-Zinn, PhD
Founding Executive Director of the Center for Mindfulness in Medicine,
Health Care, and Society at the University of Massachusetts Medical School
119. What Mindfulness is NOT
• A relaxation exercise
• Progressive muscle relaxation
• Guided imagery
• The Relaxation Response
• An “intervention”
120. Mindful Awareness to Ease Suffering
PAIN is inevitable,
SUFFERING is optional.
Loeser’s model of pain
http://practicalpainmanagement.com
124. fMRI
-Brefczynski-Lewis, et al. PNAS, 2007;104(27):11483-8
Expert meditators “had less brain activation in regions related to discursive
thoughts and emotions and more activation in regions related to response
inhibition and attention.”
125. Prefrontal Cortex Activated
People have MORE
• Vigor
• Optimism
• Enthusiasm
• Buoyancy
• Meditators also have a better
response (antibody titer) to the flu
vaccine
Davidson RJ et al. Psychosom Med, 2003;65(4):564-70.
126. Right Prefrontal Cortex Less Activated
• People have LESS
– Anger
– Fear
– Anxiety
– Depression
Davidson RJ et al. Psychosom Med, 2003;65(4):564-70.
127. QUERI Evidence Map for
Mindfulness
• 81 systematic reviews, up to Feb
2014
• Y axis = size of the literature
• X axis = efficacy
• Size of circle = number of reviews
• Color represents the type of
mindfulness studied:
– Green a mix
– Pink is Mindfulness Based Stress
Reduction (MBSR)
– Purple is Mindfulness Based
Cognitive Therapy (MBCT)
– Blue is a combo of MBSR and
MBCT
is for “unique interventions”
http://www.hsrd.research.va.gov/publications/esp/cam_
mindfulness-REPORT.pdf
128. Highlights
• Remember, mindfulness is not
a ‘therapy’ per se
• Especially responsive:
– Chronic stress
– Depression
– Somatization
– Cancer related depression and
anxiety
– Pain
– Anxiety
– Psychosis
Photo credit: mangloard via Foter.com
129. Mindful Awareness and Veteran Mental Health
• MBSR program at VA Greater Los Angeles HCS
• Naturalistic population – “Take all comers”
• Includes Veterans with active substance use disorders,
suicidal ideation, active psychosis, and severe
personality disorders as well as homelessness
• n = 78
• Significant reduction in anxiety, depression and suicidal
ideation with improvement in Mental Health Composite
scores
Serpa, et al. Medical Care, 2014;52(12 Suppl 5):S19-24.
130. Mindful Awareness and Veteran Mental Health
Baseline
(Mean[SD])
Post-test
(Mean[SD])
Mindfulness
(FFMQ) 120.71 (20.84) 131.44 (19.48) t = 5.64 p < 0.0001
Pain 4.21 (2.63) 4.01 (2.74) t = -0.73 p = 0.47
Depression
(PHQ9) 11.85 (6.13) 8.13 (4.78) t = -7.11 p < 0.0001
Anxiety (GAD7) 10.06 (5.46) 6.67 (4.44) t = -6.06 p < 0.0001
Mental Health
(SF12 MCS) 36.81 (9.66) 43.94 (8.76) t = 7.72 p < 0.0001
Physical Health
(SF12 PCS) 46.55 (11.62) 45.81 (11.95) t = -1.78 p = 0.08
Suicidal Ideation
(PHQ9) 19/24.05% 10/12.66% X2 = 4.26 p < 0.05
Serpa et al., Med Care. 2014 Dec;52(12 Suppl 5):S19-24.
n = 78
131. Mindful Awareness and Veteran Mental Health
Baseline
(Mean[SD])
Post-test
(Mean[SD])
Pain 4.21 (2.63) 4.01 (2.74) t = -0.73 p = 0.47
Pain >= 6/10
n=23 7.00 (1.00) 6.00 (1.76) p < 0.05
Serpa et al., Med Care. 2014 Dec;52(12 Suppl 5):S19-24.
132. Drop beneath your mind’s thoughts and observe
Thoughts Judgment Emotions
Awareness
133. Drop beneath your mind’s thoughts and observe
Thoughts Judgment Emotions
Awareness
I find, by experience, that the mind and the body are more than married, for they are most
intimately united; and when one suffers, the other sympathizes.
-Lord Chesterfield-
135. Reflections from Mindful Eating Exercise
• What did you notice?
-Thoughts
-Sensations
-Emotions
• How does this compare to the way you normally eat?
• How can you use this experience in your daily life?
• How can you use Mindful Eating with Veterans?
Notice and be
present with the
texture, taste,
feel, look, smell,
and sounds.
136. Mindful Eating: Benefits of Awareness
• Become aware of the interconnection of earth, living beings, and
cultural and spiritual practices and the impact of food choices.
• Choosing to eat food that is both pleasing to you and nourishing
to your body by using all your senses to explore, savor and taste.
• Acknowledging responses to food (likes, neutral or dislikes)
without judgment.
• Learning to be aware of physical hunger and satiety cues to guide
your decision to begin eating and to stop eating.
138. How can your clinical stool or chair become your
meditation cushion?
How might you integrate mindful
awareness in your daily life?
139. Starting Your Own Practice
• Try a few minutes a day, perhaps with a recording
(see Resources, p. 61 in Passport)
• Join a class, like MBSR, or a meditation group
• Introduce informal practices into your life, including
in your clinical work
140. Mindfulness in Clinical Practice
Auscultation:
“There are not many instances in busy medical
environments for a doctor to sit still and silent, with
their attention focused solely in one direction, yet this
is the cornerstone of mindful practice.”
(Lovell, 2016, Learning to Listen and Mindful Practice)
141. Mindfulness Practice:
Pause, Presence, Proceed: Paying Attention to What Really Matters
Pause
• Stop what you’re doing. Take
just a moment. Where is your
mind?
Presence
• Gather your attention and
sense your body. What is this
situation asking of you?
Proceed
• Use mindful speech, action,
positive intention. Bring all
yourself into the encounter
Photo credit: fueg0 via Foter.com / CC BY-NC
142. A Few Ideas for Your Patients
• Upon awakening or before going to sleep (transitions)
– Mini-Meditation, mindfully observe five breaths
• During the day being aware of
– How body and mind feel when moving
– Areas of tightness, release tension on out-breath
– Unhelpful patterns of thinking and coping
• Waiting in line
– Notice breathing, posture and connection to ground
• Daily activities
– Brushing teeth, washing dishes, putting on shoes, driving
Adapted from Segal et al. 2002. New York: Guilford.
145. Whole Health for Pain and Suffering
4. Self-Care and Pain:
An Overview
146. 7
Self-Care and Pain
It is much more important to know what sort
of a patient has a disease than what sort of a
disease a patient has.
- William Osler
147. The Pain Cycle
Promoting self-management of
pain empowers patients to
proactively address their pain
and shifts how patients and
clinicians relate to one another.
148. Victorious
Cycle
Vicious
Cycle
Adapted for a pain population from: Randal P, Stewart M,
Proverbs D, Lampshire D, Symes J, Hamer H. “The Re-covery
Model:” An integrative developmental stress – vulnerability-
strengths approach to mental health. Psychosis: vol 1, 2009 Issue
2. 122-133.
Make new social
connections
Increase
functioning
Enhance
coping
Approach
activities
Build
strength
Improve
mood
Social isolation
Decrease in
functioning
Lower mood
Pain with progressively less activity
Muscles weakened
by lack of activity
Fear of pain/damage
(activities avoided)
PAIN
Victorious & Vicious Pain Cycles
149. Promote Self-Management of Chronic Pain
• Use “Third Person Statements” to discuss a self-management plan -
(e.g.,“Many people with chronic pain feel...”)
• Validate the experience of chronic pain, including the many losses
• Understand the mindset of many individuals with pain
• Educate about the limitations of pain medications
• Encourage patients with pain to move
• Provide positive feedback for any reported attempts at self-management
• Involve significant others to encourage self-management behaviors
150. Self-Management Action Plan
• Exercise
Relaxation/meditation/quieting
response
• Social support/social activity
• Meaningful life activities
• Pleasurable activities
• Attitude/mood/thinking
• Sleep Hygiene
• Activity Pacing
• Self Management of Flare-ups
152. Developing Personal Resilience: Your PHI
• Take a few minutes to complete a
PHI for yourself
• Find a partner
• Discuss with your partner:
– Do you have a personal
mission?
– Is there an aspect of your
health you would like to
commit to work on?
153. Care for the Caregiver
• It is challenging to work in modern health care.
• It is tough to bear witness to other people’s suffering.
• It is especially hard to work with people in chronic pain.
154. Burnout Check-In
1. I feel emotionally burned out or emotionally depleted from
my work.
2. I have become more callous toward people since I took this
job—treating patients and colleagues as objects instead of
humans.
Reference: West et al. (2009) adaptation of Maslach Burnout Inventory
155. What Are Some of the Causes of
Burnout?
theravenwing@wordpress.com
What Are Some of the
Causes of Burnout?
158. Burnout in Pain Clinicians
207 Pain Specialists surveyed for 3 elements of burnout
– Emotional exhaustion high in 60%
– Depersonalization 36%
– Low sense of personal
accomplishment 19%
#1 contributor:
Job dissatisfaction
Kroll et al. Pain Physician 2016;19(5):E-689-96
159. What Contributes to Burnout?
1. Perfectionism
2. Lack of coping skills for stress
3. Personal bad habits (smoking,
recreational drug use)
4. Lack of control over office
processes
5. Lack of control over schedule
6. Poor relationships with
colleagues
7. Lack of time for self-care
8. Difficult and complicated
patients
9. Not enough time in the day
10. Excessive paperwork
11. Regret over chosen career
Eckleberry-Hunt et al, Acad Med 2009; 84:269-277.
Amazon.com
160. • What is going well in your practice of providing pain care to
Veterans?
• What are the challenges of providing pain care to Veterans?
Where do you struggle?
• How do you feel you are doing at this time with respect to
burnout? How does this compare with other times?
• What areas of self-care would most contribute to building and
maintaining your resilience?
What Does Resilience Mean to You?
161. Resilience Can Be Learned!
1. Positive attitude
2. Cognitive flexibility
3. Moral compass
4. Role model
5. Face fears
6. Develop active coping skills
7. Social support
8. Physical well-being
9. Train regularly
10. Recognize and foster signature strengths
162.
163. -Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated Mindfulness Intervention for Job Satisfaction,
Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med. 11(5); 412-420. 2013
Significant Improvements with Maslach Burnout Inventory
164. -Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated Mindfulness Intervention for Job Satisfaction,
Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med. 11(5); 412-420. 2013
Significant Improvements with Depression, Anxiety and Stress
166. Body Scan
• What was your experience?
• Could you sense/feel your body?
• Were there areas that were easier/harder to access?
• Could you notice how thoughts arose and left?
• Did you have insights about where you carry stress?
• How could you use this practice as a way to reframe stress?
Practice for
a short time,
multiple times
during your day.
167. Whole Health for Pain and Suffering
4. Self-Care and Pain I:
Nutrition and Exercise
168. Nutrition and Movement: Questions to Consider
Does nutrition impact pain?
What are different dietary
intervention options?
What are some nutrition
resources?
My patient has pain. What
are some exercise options
they may not have
considered?
169. Frank
• 53 y.o. Gulf War Veteran (Army)
• Osteoarthritis (OA) – knees, hands
• Given oxycodone
– Hates how it makes him feel
– Fatigue an issue
• Offered injections
• Comorbidities: HTN, obesity, GERD
• Job in construction he can’t do much
longer
page 33
170. OA: Not-so-fun Facts
• By 2030, ¼ of Americans will have
OA
• Complex – not just ‘wear and tear’
– Physiological pathways go awry
– Chondrocytes, osteoblasts
– Microfracture – callus –
microfracture
– Interleukins and cytokines
– Soft tissues get involved
• Options can seem limited
– Pills
– Procedures (surgery, injections)
Osteoarthritis, in Rakel D (ed) Integrative Med 3rd ed, Philadelphia: Elsevier, 2012
Photo: Rakel, Integrative Med, 3rd ed
173. Frank asks you a
question:
Does how I eat
influence my pain?
174. Food & Drink: Does Nutrition Influence Pain
page 34
• Modulates inflammation
• Influences hormones
• Influences vitamin and mineral deficiencies
• Food intolerances can trigger pain symptoms
• Modulates multiple systems
• Affects overall function (sleep, mood)
• Influences obesity
175. Nutrition & Inflammation: It’s Complicated…
page 34
Inflammation Pain
• Ways that diet alters inflammation:
– Processed foods altering insulin response
– Influence on obesity
– vitamin and mineral deficiency
– Microbiome disruption and immune dysfunction
176. Nutrition and Obesity in OA
• OA is made worse by excess weight
• 10 pounds of weight loss...
...Led to a 28% increase in function
• N=80, intervention a low
energy diet
• NNT to improve WOMAC
scores by >50% was 3.4
...Led to noticeable pathological
changes
• Decreased joint compression
• Altered hamstring firing
-Christensen R et al., Osteoarthritis Cartilage, 2005;13:20-7.
-Messier SP et al. Osteoarthritis Cartilage, 2010;19:272-80.
totalbodycoach.tumblr.com
177. Pain influencing food: It goes the other way too!
• Chronic pain linked to dietary shifts
– More overeating, reduced satiety
– Altered palatability of food
– Ventral striatum and prefrontal cortex changes
– Changes regardless of obesity
Geha P et al, Pain 2014;155(4):712-22.
182. AID – Highlights
• What affects inflammation?
-The fats we eat
-Omega-3’s and 6’s (ratio
matters)
-Anti-oxidant foods
-Glycemic index and load
-The microbiome
The Anti-inflammatory Food Pyramid.
Drweil.com
183. 14 Ways to Eat Toward an AID
1. Keep non-fish animal fats
intake low
2. Eat more fish
3. Limit omega-6 fats
4. Eat more omega-3’s
5. Keep vegetable and fruit
intake high
6. Eat whole grains
7. Eat dietary fiber
8. Eat legumes
9. Eating nuts and seeds
10. Eat anti-inflammatory
herbs and spices
11. Don’t char food
12. Pay attention to glycemic
load
13. Avoid obesity
14. Ensure adequate
magnesium intake
184. Elimination Diets
• Types of Elimination Diets
– Junk Food Elimination
– Common Trigger Elimination
– Classic Elimination
185. Elimination Diets
• Junk Food
– Low hanging fruit
– Typically easier to find a dietary smart goal—many nutrition goals to
choose from
– Often a good place to start in patients who haven’t considered dietary
changes
– Many Resources Available (Passport pg 137)
• Common Trigger Elimination
– Eliminates foods that have high suspicion (dairy, gluten, etc)
– Good if there is a high index of suspicion
186. • Classic Elimination Diets (Online library, module 18)
– Several variations, but eliminate multiple foods at once
– Higher chance of success initially at identifying triggers
• Simple: wheat, dairy, eggs
• More Restrictive: again, several variations.
– Wheat, dairy, eggs, soy, corn, tomatoes, shellfish,
peanuts, grapefruit, caffeine, additives, high sugar
foods
– FODMaP
• Foods avoided for 3 weeks
• Reintroduced 1 food at a time, every 3 days. Most suspicious foods first.
Elimination Diets
187. Supporting the Microbiome
• Diets high in fruits, vegetables and fiber
• Avoiding highly sugared and processed foods
• Including probiotic foods: yougurt, kombucha, sauerkraut,
many others
• Consider probiotic supplements
188. Dietary Supplements
The “Dietary Supplements for
Pain: A Clinician’s Guide”
on Whole Health Library
website
Passport Chapter 15
Photo by Adam Rindfleisch
190. Avoiding Death by PowerPoint…
Let’s Practice!
• Your task: create a dietary
plan or goal for Frank
• Work together at your table
• Get a better dietary history
from Frank (Passport, pg 118)
• Come up with initial
recommendations: AID,
elimination, or smart-goal
based (Be specific!)
191. OA and Activity
• Recommended in all guidelines
• Best support for knee OA
– Hip generally favorable
– Hands by consensus opinion
• Types: aerobic, resistance and flexibility
– Aquatic exercises have moderate quality
evidence of benefit
• How much: start 20’ three times weekly
– Shoot for 180’
– Lessen if pain not returning to baseline a few hours after activity
• Studies support individualizing activity by
preference (class, with trainer, at home)
K.L. Bennell et al, Best Pract Res Clin Rheumatol 2014;28:93–117
192. De-Mythologizing
Exercise Does NOT Tend to Worsen OA
2014 review of reviews
– No association of leisure activity
and incident knee OA
– Moderate and vigorous activities
don’t wear out joints
– Odds ratio with walking and knee
OA was 0.8 in one study
– Hip studies show the same
– Work-related joint use (heavy
lifting, heavy tools) seems to be the
biggest contributor
• Not sports so much
Fransen M et al. Best Pract Res Clin Rheumatol, 2014;28:435-60
Cartoonstock.com
193. OA and Activity: The FAST Trial
• 365 seniors with knee OA
exercised for 18 months
• Aerobic exercise improved
function by 10%, pain by
12%
• Resistance training
improved function by 8%,
pain by 8%
Ettinger WH Jr et al, JAMA 1997;277(1)25-31.
194. Tai Chi and Qi Gong
Photo: VA.Reno.gov
Photo credit: Elvert Barnes via Foter.com
195. Tai Chi for Chronic Pain
• QUERI Evidence Map
• Note locations for “Pain” and
“Osteoarthritis”
• Reviews have found benefit for
OA, back pain, fibromyalgia
– More study needed
– Not as much for RA or headache
-Vincent A et al. Am J Chin Med, 2010;38(4):695-703
page 39
196. Tai Chi and OA
• 2014 review – 6 studies
– “…effective way of relieving pain and
improving physical function”
– OA of knee
• 2013 systematic review found support
for Tai Chi in OA of knee
– Moderate quality
• Pain
• Physical function
• Stiffness
-Lauche R et al, Complement Ther Med, 2013;21(4):396-406.
Pinterest.com
-Ye J et al, J Phys Ther Sci, 2014;26(7):1133-7.
197. Yoga and Pain
A 2013 Review and Meta-Analysis
“Evidence suggests that yoga is an acceptable
and safe intervention, which may result in
clinically relevant improvements in pain and
functional outcomes associated with a range
of musculoskeletal conditions.”
• 17 studies (12 good
quality), n=1626
• Moderate overall effect
for function and pain
– Pain in OA, RA, LBP
– Function in LBP and
fibromyalgia
http://www.hsrd.research.va.gov/publications/esp/yoga-EXEC.pdf
198. Frank’s Personal Health Plan
• Focus on Food & Drink
– Consider role of inflammation
– Smart Goal focused on adding fruits and Vegetables
• Focus on Working the Body
– Exercise prescription that works for him
– Array of activities (and tai chi, yoga, etc. worth considering)
– Tie in his love of the outdoors (Surroundings)
• Other self-care areas
• Professional care
– Consider acupuncture
– Consider massage
– PT a given
Page 36
201. Whole Health for Pain and Suffering
6. Self-Care and Pain II:
Recharge and Reconnect
202. Jennifer
Subjective: 37 yo female diagnosed with fibromyalgia seven years ago, approximately six
months after returning from an Air Force deployment to Afghanistan.
Developed neck, back and leg pain on deployment which persisted. Ongoing fatigue. Non-
restorative sleep.
Past Medical History: Mild depression, that resolved w/o meds. Frequent migraine
headaches.
Meds: Gabapentin, amitriptyline, nonsteroidal anti-inflammatory drugs (NSAIDs), Tylenol,
and intermittent short-acting opioids.
Social History: Divorced, two children. Medically retired from the Air Force five years ago
and unable to keep her job as an air traffic controller. No tobacco. Limited exercise, fair
nutrition.
page 41
203. Jennifer Completes the PHI
• What REALLY matters to you in your life?
My two kids and parents are important to me.
• What brings you a sense of joy and happiness?
Spending time with my two kids, swimming, solving problems.
• What brings you a sense of sadness or sorrow?
Since leaving my job, my life does not have much purpose. I wish I
could return to work.
• What do you want your health for?
Being a good role model for my kids. I feel great whenever I’m
spending time with them.
page 43
204. What else are you curious about?
Jennifer’s PHI
• Take 3 minutes to
discuss Jennifer’s PHI
with your table
206. Potential Causes – A Circle Perspective
Green Circle
• Food & Drink
– Pro-inflammatory diet
– Food intolerance
– Disordered microbiome
– Missing nutrient (D, Mg)
– Dehydrated
• Recharge
– Not enough
– Poor sleep environment
• Working Your Body
– Hormone balance
– Inactive
– Over-exercising
• Personal Development
– No outlets, no fun
• Family, Friends & Coworkers
– Abusive relationship
– Isolation
• Surroundings
– Toxins
– Temperature
– Ergonomics
• Power of the Mind
– Stress, muscle tension
– Addiction
– Fear of pain
– Neurotransmitter balance
• Spirit & Soul
– Moral injury
– Trauma Root cause?
207. Recharge: Sleep to reduce pain!
-Wilkie R.. Rheumatology (Oxford). 2015;54(2):248-256.
-Aili K et al.,. Eur J Pain. 2015;19(3):341-349.
• Sleep and pain are bidirectional.
With more pain, sleep quality
suffers. As sleep quality suffers,
people often experience more
pain.
• Improving sleep quality may also
be associated with long term
improvements in pain.
Wallpaperswala.com
208. Recharge: Tips for the Patient
-Wilkie R.. Rheumatology (Oxford). 2015;54(2):248-256.
-Aili K et al.,. Eur J Pain. 2015;19(3):341-349.
Wallpaperswala.com
• Recommend:
– Cognitive-behavioral training
– Exercise
– Relaxation training (e.g., PMR)
– Create a bedroom sanctuary
– Blue filters on electronics
– Melatonin and Valerian
209. Family, Friends & Coworkers
Connection = Life
• 2015 meta-analysis of 70 studies
– Social isolation led to a 29% higher likelihood of dying
– Loneliness = 26% higher likelihood
– Living alone = 32%
– Results “…consistent across gender, length of follow-up, and world region…”
Holt-Lunstad, et al., Perspectives Psychol Sci, 10(2):227-37, 2015
• 2014 summary: Interviews with 23 Veterans who had attempted suicide
Two things would have helped most:
– Social support
– More compassion and empathy from care providers
Montross, et al. Crisis. 2014;35(3):161-167.
• Loneliness and poor social connection cause inflammation and chronic
disease Fagundes CP, et al, Soc Personal Psychol Compass, 5(11):891-903, 2011
210. Social Environment and Stress
The same stressor that, when given to an animal who is
alone increases plasma cortisol by 50%, does not
increase the cortisol level at all when the animal is
surrounded by familiar companions.
http://petoftheday.com
Levine S., Lysons DM, Schatzberg AF. Ann NY ACAD Sci. 1997; 807:210-218
211. How do we help Jennifer connect?
• Support groups
• Hobbies with others
• Pain management group
• Volunteering
• Ask social workers for help
• Involve family and friends (including visits)
• Encourage regular contact with social network
213. Spirit & Soul
Aspects of Spirituality
• Religious
• Humanistic
• Nature
• Experiential
• Cosmos
• Mystery
214. Spirit & Soul: Growing and Connecting
Spiritual practices can improve a person’s sense of control,
enhance coping skills, decrease the impact of stress, provide a
network of social support, contribute to a sense of purpose or
connectedness and can improve a person’s pain experience.
Ask your patients:
• What gives you a sense of meaning or purpose?
• What is it that makes you feel a part of something bigger
than yourself?
215. Spirituality and Health
• Lowers systolic and diastolic BP
• Greater compliance with medication
• Exercise more
• Eat healthier
• Quit smoking more readily
.
-Mueller, PS et al, Mayo Clinic Proc.2001;76:1225-35
216. Religion and Health
• Lowers mortality, especially in women
• Predicts social connections, better mental health
• 19x higher risk of death from all causes if no service versus
weekly services over 8 years
– And 7.5 longer life expectancy
• Lower stress hormones and lipids
-Mallin R, Prim Care Clin Office Pract 2008; 35:857-66.
217. Power of the Mind
A Spectrum of Techniques
A spectrum of techniques
• Biofeedback
• Progressive muscle relaxation
• Meditation
• Breathing exercises
• Cognitive behavioral therapy
• Eye movement desensitization
and reprocessing
• Therapeutic disclosure
• Hypnosis
…and many others
218. Psychotherapies
• A meta-analysis of psychological interventions was supportive
of cognitive-behavioral therapy for pain reduction in
fibromyalgia, with a moderate effect noted.
• Controlled trials of mindfulness-based stress reduction have
shown improvements in quality of life, coping skills, and
depressive symptoms, although the trial results have been
mixed.
-Glombiewski JA, et. al., Pain. 2010;151(2):280-295.
-Grossman P, et. al., Psychother Psychosom. 2007;76(4):226-233.
-Sephton SE, et. al., Arthritis Rheum. 2007;57(1):77-85.
-Schmidt S, et. Al., Pain. 2011;152(2):361-369.
219. Small incremental
benefit over control
interventions in reducing
pain, negative mood and
disability at the end of
treatment and at long-
term follow-up.
Cognitive Behavioral
Therapies for
Fibromyalgia
220. Pain Symptoms and Abuse History
Green CR et al, J Pain Symptom Manage, 1999;18(6):420-6.
221. Emotional Trauma
• Significant physical or emotional stressors such as physical trauma or
deployment have been implicated as potential syndrome triggers along
with other types of trauma.
• Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have
been found to produce clinically significant improvement in PTSD
symptoms in multiple randomized controlled trials.
• Although these treatments share many common factors, the focus of CPT
is on changing maladaptive thoughts while the main mechanism of PE is
exposure exercises.
-Resick, P. Journal of Consulting and Clinical Psychology. 2002. 70(4), 867-879.
-Powers M. Clinical Psychology Review. 2010. 30 (6). 635-641.
kemidanowolabi.wordpress.com
222. Some suggestions for Jennifer:
• Walking five minutes per day
• Referral to an acupuncturist for further treatment
• Took a class on mindfulness meditation
• Join a fibromyalgia support group
• Started on vitamin D and magnesium supplements
• Scheduled time with her children in the mornings when her
energy level was better.
page 48
223. For Tomorrow…
• Consider a principle of PHP you would like to try with a
patient
• How about an area to work on yourself?
• Consider how you can take implementation to the next phase
Jragsdale.wordpress.com
