Integrative Medicine Chronic Pain

1. Hot Topics In Integrative
Medicine
Jill Schneiderhan MD
October 20, 2017

2. Objectives
 Participants will be able to review up to date evidence based
knowledge about common integrative medicine topics in
primary care.
 Chronic Pain Management
 Microbiome
 Vasomotor Symptoms of Menopause
 Participants will be able to review common complementary
and alternative medicine techniques and what conditions
they are best used to treat.
 Mindfulness
 Elimination Diet
 Acupuncture
 Participants will be able to list where they can go to find
evidence based treatment options related to Integrative
Medicine.

3. Integrative Medicine
 Approaching each patient where they are
 Combining the best of our current evidence base with
whole person oriented approaches that take into account
mental, physical, emotional, spiritual aspects of health
and wellness
 Foundation of Wellness
 Activity
 Diet/Nutrition
 Sleep
 Stress/Emotional Regulation

4. Chronic Pain

5. Chronic Pain
 Significant advances in understanding of physiology
have not equaled improvement in treatments
 Most treatments overall are poor to fair
 Most average around 30% effective in improving pain
(roughly equal to placebo)
 Even if a treatment improves pain it rarely provides
concomitant physical or emotional functional
improvements
Turk, D. C., Wilson, H. D., & Cahana, A. (2011). The Lancet, 377(9784), 2226-2235.

6. Improved
Pain
Experience
Activity
Sleep
Diet/Obesity
Emotion
/Mood
Medications &
Supplements
Body
Issues
Cognitive
& Stress
Social/
Relationship
Integrative
Chronic Pain
Management

7. Physical Activity
 Fear of damage from pain often leads to less activity
leading to tightening of muscles and increased pain in a
negative cycle
 For most chronic pain conditions graded exercise
programs are shown beneficial
 30% improvement for low back pain
 Most effective for centralized pain conditions
Cunningham, N. R., & Kashikar-Zuck, S. (2013). Nonpharmacological treatment of pain in rheumatic
diseases and other musculoskeletal pain conditions. Curr Rheumatol Rep, 15(2), 306.

8. Obesity and Inflammation
 For many obese patients there is chronic non-resolving
inflammation1
 CRP is an accepted marker of chronic inflammation
 Elevated CRP has been shown preliminarily to increase
rates of low back pain
 Higher elevation in patients who are obese2
1. Arranz, L. I., et al. Curr Rheumatol Rep. 2014. 2. Briggs, M., et al. Arch Phys Med Rehabil. 2012.

9. Inflammation
 Chronic inflammation promotes nociception
 Chronic non-resolving inflammation is associated with:
 Low back pain, arthritis, RA, MS, atherosclerotic disease,
diabetes1
 Western diets low in fruits and vegetable (natural
antioxidants) and high in red meat (generator of IL-6)
promote inflammation2
1. Seaman, D. Chiropractic & Manual Therapies, 2013. 2. Esposito, K., eta l. Eur Heart J,
2006.

10. Diet as Treatment
 Diets high in fruits, vegetables, fiber and Omega 3 Fatty
Acids decrease inflammation1
 Anti-Inflammatory Diet – high in fruits, vegetables,
legumes, healthy oils, omega 3
 Mediterranean Diet – high in vegetables, fish, olive oil as
main fat2
1. Esposito, K., et al. Eur Heart J, 2006. 2. Esposito, K., et al. JAMA, 2004.

11. Supplements
 Omega 3 Fatty Acids - 3 grams daily DHA/EPA1
 Vitamin D – keep level between 30-502
 Magnesium ( Magnesium glycinate or chelated
magnesium) – 400mg a night and titrate to tolerance3
 Tumeric 500mg QID4
1. Esposito, K., et al. Eur Heart J, 2006. 2. Esposito, K., et al. JAMA, 2004. 3. Yousef, A. A., et al. Anaesthesia,
2013. 4. Tizabi, Y., et al. Molecules, 2014.

12. The Microbiome
 The microbiome consists of all the microbes that live on
and in humans
 Contributes 99% of the genetic material in the human
body
 The highest number of organisms are found inside the
gastrointestinal tract
 Most are bacteria
 90% are anaerobic
Tsukumo DM et. Al. Archives of endocrinology and metabolism. Apr 2015

13. Functions of the Gut Flora
 Role in Digestion/Nutrition
 Supplying essential nutrients through their breakdown of complex
carbohydrates
 Generating secondary bile acids that assist in the digestion of fats1
 Synthesizing vitamins such as Vitamins K, B12, folate, and biotin2
 Role in Immune System/Protection
 Contribute to the defensive barrier in the colon
 stimulate mucous production, lymphatic tissue development, antibody
formation
 Induce protective cytokines, suppress pro-inflammatory cytokines in
the mucosa of patients through the actions of Short Chain Fatty Acids
(SCFA’s) 3
 Interact with our systemic immune system in a way that
maintains a level of homeostasis
 Allowing for the appropriate activation
 With NO autoimmunity.3
1. Conlon MA, Bird AR. Nutrients. Jan 2015. 2. Nicholson JK, et al. Science. June 2012. 3. Zhang YJ, et al.
International journal of molecular sciences. 2015.

14. Functions of the Gut Flora
 Role in Gut-Brain Axis
 Bidirectional communication
Brain can signal enteric nervous system to speed up or
slow down transit time
Neurotransmitters generated by gut bacteria can affect
pathways in the CNS
 Hormonal signaling
 Nervous system communication1,2
 Modulate pain perception
 L acidophilus induces expression of mu-opioid
and cannabinoid receptors in intestinal
epithelial cells, mediates analgesic
functions similar to morphine3
1. Tillisch K. Gut microbes. May 2014. 2. Cong X, Hender et al. Advances in neonatal care :
official journal of the National Association of Neonatal Nurses. Oct 2015. 3. Rousseaux C, et al.
Nat Med. Jan 2007.

15. Irritable Bowel Syndrome
 Probiotics associated with decreased pain, bloating,
urgency 1,2
 Restore more normal gut microflora, improve intestinal
permeability, normalize imbalances in inflammatory
cytokine ratios
 Soluble fiber, commonly found to be helpful in treating IBS,
has been shown to have profound effects on improving
microbiota diversity and in shifting the composition toward
less pathogenic strains 3,4
 Dosing:
 VSL#3, 225 billion CFU daily-BID
 Multiple strains of Bifidobacterium and
Lactobacillus, 20-40 billion CFU, daily to BID
 Recommend trial for 4-8 weeks, can
then try decreasing dose
1. Didari T et al. World J Gastroenterol. Mar 14 2015. 2. Ford AC et al. Am J Gastroenterol. Oct 2014. 3. Moayyedi P, et
al. Am J Gastroenterol. Sept 2014. 4. Simpson HL, Campbell BJ. Aliment Pharmacol Ther. Jul 2015.

16. Obesity
 Multifactorial process
 In setting of stable energy consumption and adequate
physical activity – prevalence of metabolic disorders is
rising
 Animal data showing that the microbiota of obese rats
cause weight gain in settings of controlled calorie intake
 Mechanism is thought to be through increased calorie break down and
absorption
 Recent Meta-analysis of 4 RCT’s showed no difference in
those treated with probiotics for weight loss
 2 studies not included for poor description of randomization were
longer and with higher doses of probiotics showed positive results
 Possible that future studies will with higher concentrations and better
control for diet will show better results
Park S, Bae JH. Nutrition research (New York, N.Y.). Jul 2015.

17. Diabetes
 Hypothesis is that dysbiosis of the gut flora
 Activation of pro-inflammatory cytokines
 Disruption of the intestinal mucosa
 Leading to systemic inflammation and glucose dysregulation
 Probiotic supplementation studies are showing largely beneficial
effects on glycemic controls especially in animal studies.
 The largest systematic review to date looked at 33 studies of
which 5 were in humans.
 All of the studies in humans showed a significant reduction in at
least one parameter of glycemic control
 It is still unclear which strains confer the most benefit and if
those benefits are sustainable without dietary and activity
changes.
Le Barz M, et al. Diabetes & metabolism journal. Aug 2015. Tarantino G, Finelli C. Future microbiology. 2015. Samah S, et al. Diabetes Research
and Clin Pract. Aug 2016.

18. Hot Flashes – Non biological
therapies
 CBT
 Several small RCT’s show decrease in problem rating
although not in frequency1
 Yoga
 Several RCT’s show improvement in hot flashes as well as
insomnia, mood disturbances, irritability and anxiety1,2
 Acupuncture
 Meta-analysis level data show improvement in hot flash
frequency and severity as well as improvement in QOL3
1. "Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The
North American Menopause Society." Menopause 2015. 2. Crowe BM, et al. Health care for women international.
2015. 3. Chiu HY, et al. Menopause. Feb 2015.

19. Hot Flashes – Biological therapies
 Soy Isoflavones
 Meta-analysis level data show statistically significant reduction
in frequency of hot flashes but no change in the Kupperman
Index (11 menopausal related symptoms)1,2
 60-90mg a day of Isoflavones (average dose studied)
 S-Equol – intestinal bacterial metabolite of soy
 30-40mg S-Equol decreased vasomotor symptoms in small RCT3
 Pycogenol – lignand from Maritime Pine Plant
 Two small RCT’s show decrease in vasomotor symptoms and
improvement in sleep4
 Linseed/Flaxseed – Isoflavone with less estrogenic effect
than soy
 1 g of either extract or meal shoed decrease in vasomotor
symptoms in small RCT5
1. Chen MN, et al. Climacteric : the journal of the International Menopause Society. 2015. 2.
Taku K, et al. Menopause 2012. 3. Utian WH, et al. Journal of women's health. 2015. 4. Kohama
T, Negami K. Journal of Reproductive Medicine. 2013. 5. Colli MC, et al. Journal of medicinal food.
2012.

20. Therapies Commonly Used in
Integrative Medicine
 Mindfulness
 Elimination Diets
 Acupuncture

21. Mindfulness
 Growing evidence on mindfulness impacting QOL in
almost all chronic diseases
 Evidence:
 Improved coping with pain
 Decreased anxiety/depression
 Improved relapse prevention in substance abuse
 Eating disorders
 Improved glycemic control in diabetes
 Vasomotor symptom

22. Mindfulness Based Stress
Reduction
 8 week course
 2.5 hours per week with home practice
 Includes instruction on mindfulness, stress and its impact
on body
 Practice/teaching of mindful awareness practices, walking
meditation, simply yoga postures
 First developed by Jon Kabat-Zinn, PhD at University of
Massachusetts and applied at first to patients with
chronic pain1
 Now adapted into many other programs based on
individual disease being treated
1. Kabat-Zinn J. General hospital psychiatry. 1982.

23. Elimination Diets
 Removal of offending food from diet, assessment of
symptoms, challenge with offending food if symptoms
had improved to assess for recurrence
 Theory behind causation is evolving
 Foods that are not tolerated cause inflammation in the gut
lining leading to gut wall breakdown and protein
translocation leading to antibody development
 The inflammation itself leads to dysbiosis of microbiome
 Common starting point is removal of 5 most allergenic
foods
 Wheat/gluten, dairy, soy, corn, eggs
 3-4 weeks off food
 Re-introduce with assessment of symptoms

24. Elimination Diet
 Allergic/dermatitis
 IBS/ chronic abdominal pain
 FODMAPS
 Fatigue
 Possibly related to improved nutrition/lower glycemic index
 Chronic Pain
 Fibromyalgia1
 Migraines
 Small RCT for patients with migraines and IBS2
1. Rossi A, et al. Clin Exp Rheumatol. 2015. 2. Aydinlar EI, et al. Headache. 2013.

25. Acupuncture
 Growing evidence:
 Chronic Pain1,2
 Chronic Musculoskeletal Pain
 Fibromyalgia
 Osteoarthritis
 Chronic Back Pain
 PMS/Menopausal symptoms3
 Chronic Fatigue4
 Fertility5
1. Vickers AJ, et al. Archives of internal medicine. 2012. 2. Manyanga T, et al. BMC
complementary and alternative medicine. 3. Chiu HY, et al. Menopause 2015. 4. Kim JE, et al.
Trials. 2015. 5. Nandi A, et al. Journal of obstetrics and gynaecology, 2014.

26. Resources
 Pub Med & Google Scholar
 Natural Medicines & Consumer Labs
 https://naturalmedicines.therapeuticresearch.com/
 https://www.consumerlab.com/
 University of Michigan – Educational Modules
 https://sites.google.com/a/umich.edu/fammed-modules/
 University of Wisconsin – Educational Modules and Patient
Handouts
 http://www.fammed.wisc.edu/integrative/resources/modules/
 Integrative Medicine by David Rakel, MD