Integrative Medicine and the Medicine of Cycling

1,058 views

Published on

Talk delivered at the Medicine of Cycling conference 8/26/12 at the US Olympic Training Center in Colorado Springs.

Published in: Health & Medicine, Education

Integrative Medicine and the Medicine of Cycling

  1. 1. Integrative Medicine Paul Abramson MD My Doctor Medical Group, San Francisco Clinical Faculty, UCSFSunday, August 26, 12
  2. 2. Acknowledgements • Arizona Center for Integrative Medicine • Andrew Weil MD • Tieraona Low Dog MD • Harmon Meyers DO • Michael Menke DCSunday, August 26, 12
  3. 3. Disclosures No conflicts of interest to discloseSunday, August 26, 12
  4. 4. Disclaimer These are just my opinions, except as notedSunday, August 26, 12
  5. 5. Objectives #1 Integrative Medicine • Understand my version of “what is integrative medicine” • Identify strengths and challenges of the integrative medicine approach • Identify desirable traits in an integrative medicine practitionerSunday, August 26, 12
  6. 6. Objectives #2 Manual Medicine • Identify types of manual medicine practitioners and their scopes of practice • Identify features of, and differences between, Osteopathic and Chiropractic medicine • Learn some ways to screen practitionersSunday, August 26, 12
  7. 7. Objectives #3 Cervical Spine Adjustment • Review some of the evidence regarding safety of high velocity, low amplitude cervical spine adjustment • Identify patients at higher risk of complicationsSunday, August 26, 12
  8. 8. “Integrative medicine combines mainstream medical therapies and alternative therapies for which there is some high-quality scientific evidence of safety and effectiveness.”Sunday, August 26, 12
  9. 9. “[integrative medicine] doesnt seem wedded to a particular dogma, Western or Eastern, only to the get-the-patient- better philosophy.” Abraham Verghese MD Professor for the Theory and Practice of Medicine Stanford University Medical SchoolSunday, August 26, 12
  10. 10. “The good physician treats the disease; the great physician treats the patient who has the disease.” Sir William Osler (1849-1919)Sunday, August 26, 12
  11. 11. Medicine: Universal Principles • History • Review of Available Data • Physical Examination • Appropriate Testing • Formulation of Diagnoses • Treatment Plan • Self Tracking and FeedbackSunday, August 26, 12
  12. 12. Definitions: Conventional Medicine • Drugs • Surgery • Ancillary Specialties - PT, OT, ST, RT • Dietary Consultation - RD • Lab testing and diagnostic imaging • Lifestyle AdviceSunday, August 26, 12
  13. 13. Definitions: Alternative Medicine • Health paradigms outside of what is accepted by “conventional medicine.” • From massage to herbs to homeopathy, plus culturally-based whole systems • Naturopathy: eclectic mix • “Alternative laboratory testing” and “functional medicine” • Issues of “scientific validation”Sunday, August 26, 12
  14. 14. Cycling: Most Common Modalities • Manual medicine - massage, chiropractic, osteopathy • Traditional Chinese Medicine, acupuncture • Alternative lab testing and dietary supplements • Mind-body medicine - guided imagery, hypnosis, meditationSunday, August 26, 12
  15. 15. Definitions: Integrative Medicine • Comprehensive: all appropriate means, all factors that includence health and disease • Quarterback - Therapeutic matchmaker • Collaborative: doctor-patient relationship • Evidence based* • Open minded yet skeptical* • Prefers more natural and less invasive*Sunday, August 26, 12
  16. 16. Components of an Integrative Plan • Conventional • Whole-systems medicine* medicine (e.g. • Nutrition TCM) • Physical activity • Manual medicine • Mind-body medicine • Energy medicine • Dietary supplements, • Spiritual botanicals counselingSunday, August 26, 12
  17. 17. Sliding Scale of Evidence • More potential for harm More Evidence • More cost Needed • Sicker patientSunday, August 26, 12
  18. 18. Why do People Seek Integrative Care* • Conventional care: • “Reductionistic, focuses on disease” • “Lacking in accessibility, guidance” • Integrative care: • “Focuses on the whole person” • “Empowers patients to care for self” *Altern Ther Health Med 2012: PMID 22875559Sunday, August 26, 12
  19. 19. Challenges for Patients • Higher out of pocket costs • Practitioners operating outside their scope of practice • Inappropriate telemedicine • Large percentage of practitioner income from sales of tests and supplements, and other undisclosed conflicts of interestSunday, August 26, 12
  20. 20. Challenges for Practitioners • Evidence base is overall low quality • Studies focus on individual agents, not systems of care • Hard to succeed financially without conflicts of interest • Good integrative care requires good self careSunday, August 26, 12
  21. 21. Desirable Traits in a Practitioner • Licensed to diagnose and treat medical conditions • Only MD/DO should order and interpret laboratory tests • Standard format for medical practice: history, physical exam, diagnosis, treatment planSunday, August 26, 12
  22. 22. Desirable Traits in a Practitioner • Full disclosure of all profits from sales of tests and treatments (and they are minimal) • Full disclosure of all other conflicts of interest (and they are minimal)Sunday, August 26, 12
  23. 23. Summary • Integrative Medicine is a philosophy and a paradigm shift, ties together fragmented care • Look for a legitimate and rigorous practitioner with a broad perspective • Look for transparency and ethical business modelsSunday, August 26, 12
  24. 24. Case Study: Gerald • 48 year old cyclist, still racing • Chronic neck pain, worse after cycling • Maintenance-type insomnia • Trouble concentrating at work, anxiety • Chronic dyspepsia, flatulenceSunday, August 26, 12
  25. 25. Gerald • History including diet, training schedule, ergonomics, psychosocial • Physical Exam: multiple tender points, not symmetric. Blood pressure 148/84. • Review previous MRI, labs, spine surgery consult, primary care notes • Determine patient’s “world view” and goals for treatmentSunday, August 26, 12
  26. 26. Gerald: Initial Considerations • Make sure conventional work up was complete, including bike-specific • Home sleep study to rule out apnea • Further exam to define myofascial dysfunction • Testing for small bowel bacterial overgrowth, celiac diseaseSunday, August 26, 12
  27. 27. Gerald: Treatment Plan • Sleep apnea: CPAP for AHI of 42 • Elimination/rechallenge diet • Valerian, hops, melatonin, self-hypnosis • Self-hypnosis for anxiety, cognitive- behavioral therapy • Osteopathy or myofascial release referralSunday, August 26, 12
  28. 28. Gerald: Results • CPAP: “Awakenings.” Cognition improved. Blood pressure normalized. • GI symptoms resolve when wheat and dairy eliminated (but not just one) • Short-term improvements from self- hypnosis CDs • Osteopath reduces neck pain 80%Sunday, August 26, 12
  29. 29. Manual Medicine “The use of hands to treat disorders of the somatic system”Sunday, August 26, 12
  30. 30. Manual Medicine: Applications • Typical: To treat headaches, muscle tension, back pain, joint pain • Outside the box: Fibromyalgia, sleep disorders, gastroesophageal reflux • Beyond: Release emotions stored in tissuesSunday, August 26, 12
  31. 31. Level 1 • Swedish massage • Reflexology • Deep tissue • Lymphatic drainageSunday, August 26, 12
  32. 32. Level 1 Scope of Practice • Relaxation, pain relief, body awareness education • Can not diagnose • Can assess soft-tissue relationships • Can suggest self care techniques • Can refer for issues outside scopeSunday, August 26, 12
  33. 33. Assessing A Massage Therapist • State and local licensing (37 states plus Washington DC regulate massage) • School certificate, AMTA membership, national certification • Experience, knowledge, communication, presence, quality of touchSunday, August 26, 12
  34. 34. Level 2 • Myofascial Release • Rolf • Structural Integration • Feldenkrais • Alexander TechniqueSunday, August 26, 12
  35. 35. Level 2 Scope of Practice • Assessing and treating specific somatic imbalances and patterns. Pain relief, postural alignment, balance improvement • More advanced assessment techniques based on theoretical frameworks • Specialty certificationsSunday, August 26, 12
  36. 36. Level 3 • Chiropractic Adjustment • Osteopathic Manipulation • (Physical Therapy) • (Trigger Point Injection by MD/DO)Sunday, August 26, 12
  37. 37. Level 3 Scope of Practice • Licensed practitioners • Can diagnose • Treat within specialty scope • Potentially more invasive, more riskSunday, August 26, 12
  38. 38. Osteopathic Medicine: Doctor of Osteopathy • Developed in 1800s by A.T. Still as a reaction to conventional medicine blood-letting - purgatives - emetics - mercury • Medical school, residency • DO has scope of practice similar to MD, plus manipulation techniquesSunday, August 26, 12
  39. 39. Osteopathic Philosophy • Unity of body’s entire structure and function • Restoring body’s natural ability to heal itself, removing impediments • Myofascial dysfunction and neural feedback loopsSunday, August 26, 12
  40. 40. Osteopathic Principles Palpation Skills Sympathetic Innervation Viscero-Somatic ReflexSunday, August 26, 12
  41. 41. Osteopathic Techniques • Muscle energy • Myofascial release • High Velocity / Low Amplitude (HVLA) adjustment • Strain / Counterstrain • Cranial OsteopathySunday, August 26, 12
  42. 42. Osteopathic Challenges • Hard to find a DO who still practices manipulation • Most DOs doing manipulation are fee for serviceSunday, August 26, 12
  43. 43. Where to Find An Osteopath • American Academy of Osteopathy: 317-879-1881, academyofosteopathy.org • Cranial Academy: 317-594-0411, cranialacademy.com • Word of mouthSunday, August 26, 12
  44. 44. Chiropractic: Doctor of Chiropractic • Developed as a reaction to the crude conventional medicine in the post-Civil War era, like osteopathy • Since early 1900s, has evolved into a broader more eclectic set of practices (“straights” vs. “mixers”) • Spinal subluxation remains the focusSunday, August 26, 12
  45. 45. Chiropractic Training • Education: Basic sciences, anatomy, physiology are similar to MD • Ambulatory-only clinical outpatient training • Clinical experience* MD/DO: 5227 hours DC: 1405 hours *Altern Ther Health Med 1998- PMID 9737032Sunday, August 26, 12
  46. 46. Chiropractic Philosophy • Spinal subluxation is the underlying cause of disease • Correct spinal misalignment to prevent and to cure diseaseSunday, August 26, 12
  47. 47. Chiropractic Assessment Palpation (static and motion) Postural observation X-raysSunday, August 26, 12
  48. 48. Chiropractic Treatment • High Velocity Low Amplitude (HVLA) • Low Velocity (pressure) • Cranial and Sacral adjustments • (Eclectic mix of other modalities)Sunday, August 26, 12
  49. 49. Chiropractic Scope: Standard • Diagnosis of musculoskeletal pain and dysfunction • Physical exam plus x-rays • Treat with spinal adjustments and other manual techniquesSunday, August 26, 12
  50. 50. Chiropractic Scope: Beyond • Other practices: • Medical diagnosis • Diagnostic testing with conventional and alternative labs • Treatment with dietary supplements • Alternative procedures • Issues of collaboration with MDsSunday, August 26, 12
  51. 51. Expectations of a Doctor of Chiropractic • Intervention limited to musculoskeletal pain & dysfunction • Assessment by physical exam • X-rays and other imaging reserved for high-risk cases • Diagnosis using standard ICD-9/10 codes, familar with medical nomenclatureSunday, August 26, 12
  52. 52. Expectations of a Doctor of Chiropractic • Clearly-explained, finite treatment plan • All conditions should respond by 50-75% within 6-8 visits • If inadequate response, refer to specialist • Discharge if endpoint reached sooner! • Willing to consult with other healthcare practitioners regarding treatmentSunday, August 26, 12
  53. 53. SMT for Low Back Pain • 41 RCTs on manipulative treatment of acute, subacute and chronic low back pain (Meeker, 2000). • 28 favored manipulation over comparison treatments in a subgroup of patients. Comparison groups varied • 13 found SMT to be equal to the other comparison treatments. J Manipulative Physiol Ther. 2000 Feb;23(2):123-6. PMID 10714541 Palmer Center for Chiropractic Research, IowaSunday, August 26, 12
  54. 54. Chiropractic for Low Back Pain • Chiropractic treatment compared to a type of physical therapy (McKenzie extension exercises) and an education booklet. • The one-dollar booklet was as effective as physical therapy and chiropractic at 12 weeks. • However, at three weeks chiropractic treatment demonstrated a greater, though non-significant clinical effect than the other two treatments. • The study had several methodological flaws and received a low quality score. N Engl J Med. 1998 Oct 8;339(15):1021-9. PMID 9761803 Department of Health Services, Univ WashingtonSunday, August 26, 12
  55. 55. SMT for Low Back Pain • Review of 36 studies found 8 of the 10 highest quality ones favored spinal manipulation for chronic LBP. Spine (Phila Pa 1976). 1996 Dec 15;21(24):2860-71; discussion 2872-3, PMID 9112710 Institute for Research in Extramural Medicine, AmsterdamSunday, August 26, 12
  56. 56. Childs Clinical Decision Rule • 4 out of 5 criteria = 92% likelihood of benefit from chiropractic adjustment • Duration of low back pain < 16 days • No pain below the knee • Fear Avoidance Beliefs Questionnaire FABQ < 19 • >= 1 hypermobile segment in the lumbar spine • >=1 hip with >35 degrees range of motion PMID 15611489Sunday, August 26, 12
  57. 57. Osteopathic Manipulation LBP • Osteopathic Manipulation vs. Standard Treatement (primary care) • No difference in outcome measures • BUT: Less medication use, less physical therapy utilization in osteopathic group. Significantly lower costs in the osteopathic group. NEJM 1999, 341:1426-31Sunday, August 26, 12
  58. 58. Beyond Manual Medicine • Level 4 - Examples • Epidural Injections • Implantable Nerve Stimulators • Spinal Surgery • Joint SurgerySunday, August 26, 12
  59. 59. Cervical Spinal ManipulationSunday, August 26, 12
  60. 60. Sunday, August 26, 12
  61. 61. Cervical Artery Dissection • Review, 2009 of hospital-based studies • One systematic review 2003: 20 case series or cohort studies • Additional 9 studies with 1033 patients found • Cervical SMT in 16-28% of cases Thromb Res. 2009 Apr;123(6):810-21. PMID 19269682 McMaster University, CanadaSunday, August 26, 12
  62. 62. Cervical Adjustment: Safety 1 • Hurwitz et al, 1996. PubMed 8855459 • Out of 10 million treatments: -- Stroke 5-10 -- Major impairment 3-6 -- Death < 3Sunday, August 26, 12
  63. 63. Cervical Adjustment: Safety 2 • Jonas 1999, Ernst, 2002- PubMed 12041633 • Published case reports from 1995-01 • 31 case reports of adverse events, 42 cases total • 18 arterial dissection and strokeSunday, August 26, 12
  64. 64. Cervical Adjustment: Safety 3 • 22 patients treated by neurosurgical group in 5-year period in Tulsa, OK • Radiculopathy 21, myelopathy 11, Brown- Séquard 2, vertebral occlusion 1 Malone, 2002 PMID 15766233 • Denmark 1978-88 • About 1 stroke per 1M rotational cervical adjustments Klougart, 1996 PMID 8864967 • France Survey • “Incidence of vertebrobasilar stroke 30x higher than published estimates” Dupeyron et al, 2003 PubMed 12657480Sunday, August 26, 12
  65. 65. Cervical Adjustments: What does UCSF Say? • Smith et al, Neurology, 2003 PubMed 12743225 • Nested case control study • “Cervical SMT is an independent risk factor for vertebral artery dissection”Sunday, August 26, 12
  66. 66. Cervical Adjustment: Risk Factors • Age • Smoking • Migraine • Diabetes • Gender (F > M) • Fibromuscular hyperplasia • Hypertension • Syphilis • Oral • Marfan’s Contraceptives SyndromeSunday, August 26, 12
  67. 67. High Risk Features for Cervical Adjustment • Pain unrelieved by • Sudden change in position and overall health status analgesics • Chest pain, dyspnea • Inability to void bowel • Palpable mass or lymph or bladder node enlargement • Suspicious skin lesions • Vascular compromise to • Bad family history of extremities risk factors • Abnormal cranial nerve • Personal risk factors exam • Unexplained weight • Focal neurologic deficits lossSunday, August 26, 12
  68. 68. Contact Information: Paul Abramson MD mydoctorsf.com @paulabramsonmd office@mydoctorsf.com 415-963-4431Sunday, August 26, 12

×