12/6/2017

1

Increasing Resilience with

Diet and Lifestyle

Loch S. Chandler, ND, MPA:HA, MSOM, LAc

Providence Integrative Medicine

December 8, 2017

Patient Case

• 67 yo male PTC with complaints of RA

• Hands/fingers—red, swollen

• Has been on Methotrexate for 2 years

• Options?

Question….The Island Where

People Forget To Die

Ikaria’s Secrets?

• Nutrition

• Exercise

• Social Support

• Sun

• Herbal tea

• Wine

• Other…”Silver buckshot.”

What is Health?

• Is it the absence of disease OR the presence

of wellness?

• Etymology: health (n.) O.E. hælþ "wholeness, a

being whole, sound or well," from P.Gmc. *hailitho, from

PIE *kailo- "whole, uninjured, of good omen" (cf. O.E. hal

"hale, whole;" O.N. heill "healthy;" O.E. halig, O.N. helge

"holy, sacred;" O.E. hælan "to heal"). Of physical health

in Middle English, but also "prosperity, happiness,

welfare; preservation, safety."

12/6/2017

2

Zhong daoBalance

=

Health

Chinese

Medicine Pain

• Americans are in more pain than any other population

in the world—consume 80% of world opioid supply– Pain…Acute and Chronic (intermittant, incident or

breakthrough)

• Pain drugs are the 2nd largest pharmaceutical class

globally (cancer medications #1)

• 300 million prescriptions were written in 2015

(up from 259 million in 2012)

o As a narcotic, hydrocodone relieves pain by binding to opioid (mu) receptors in the brain and spinal cord

o The chief side effects of pain medications are: nausea, vomiting and constipation

(4/27/16, cnbc.com, “Americans consume vast majority of the world’s opioids”)

Pain

•Patient Barriers to optimal pain control:

•Reluctance to report

•Reluctance to follow recommendations

•Fear of addiction

•Worries about side effects (nausea, vomiting and constipation, sedation)

•Cicely Saunders (Founder of the modern hospice

movement) talked about “Total Pain”

•Involved: physical pain, psychological pain,

emotional pain, and spiritual pain

“Every practitioner of medicine was to be skilled in

Nature and must strive to know what man is in

relation to food, drink, occupation, and what effect

these have on him. Moreover, the physician should

never forget that disturbances in any organ

correspond to a disturbance of the whole person

and that to heal even an eye, one must heal the head

and even the whole body”

Hippocrates

(460-377 BCE)

Team Medicine

The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM):

“Integrative medicine makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing.”

=Multidisciplinary approach= “Silver Buckshot”

Pain and Stress

12/6/2017

3

Total

Stress

Chronic sinusitis

BPH

Mental/Emotional

(family, job, self)

Environment

(weather,

pollution, EMR…

Causes of Cancer

• Genetics: 5-10%

• Diet/nutrition: 30-35%

• Exercise/activity (obesity): 10-20%

• Alcohol: 4-6%

• Smoking: 25-30% (173,200 deaths annually)

• Infections: 15-20% (certain viruses, bacteria)

• Environment: ???% (sunlight, radiation, certain

hormones)

• Other (chemicals, etc.): 10-15%

Pain

Cause = Cure

Inflammation and

Disease Today’s Topics

•Ways to Increasing Overall Resilience (e.g. Health), reduce “stress” and Decrease Pain:

•Integrative Medicine, Pain and Inflammation, Diet, Nutrition and Supplements

•Massage

•Acupuncture….all can help reduce INFLAMMATION!!!

•Other considerations, not included today:

•Placebo

•Homeopathy

•Botanical Medicine (herbs)

•Mind-Body, Guided Imagery, Hypnotherapy

•Qi Gong, Tai chi

•Hydrotherapy

•Aromatherapy, Therapeutic touch, Prolotherapy…

What is Integrative

Medicine?• Combines the best of non-traditional care

with mainstream conventional therapies

• Uses: unconventional interventions with

evidence for benefit, reasonable cost, and

safety

• Focuses on: the whole person,

accessibility, more time and touch, and

greater patient involvement in decision

making

Pain and Stress

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4

How Integrative Medicine

Can Help Increase

Resilience

• PAIN

• Peripheral neuropathy

• Mucositis/stomatitis

• Cachexia

• Nausea/Vomiting

• Diarrhea, Constipation

• Fatigue, sedation

• Depression, anxiety**

• Addressing possible

nutrient deficiencies

• Helping NON-pain

related symptoms

• Improving tolerance,

reducing need, of

conventional therapies

• Minimizing medications

used to treat side effects

•Using food, supplements, acupuncture and massage to help address patient concerns such as:

Therapeutic Order

Causes of Cancer &

Inflammation

Infections

(15-20%)

Genetics

(5-10%)

(Diet/Lifestyle/Exercis

e/Weight; 40-55%)

(4-6%)

(20-30%)(??%)

Pain

Nutrition

Mediterranean Diet

Two studies (each for 4 years):

– Lyon Heart: Randomized prospective controlled study. deLorgeril, Arch Int Med, 1998;158:1181-87

– Greek Epic: Observational, Trichopoulou, et al. (2003). NEJM, 348:2599-608. (n=22,043 people)

– Both: 60-70% reduction in cancer deaths, heart disease and diabetes

– More: vegetables, carrots, tomatoes, fruit, legumes, grains, fish, olive oil, canola oil, less red meat (particularly preserved meats), more white meat, dairy (cheese, yogurt), butter, moderate alcohol OK, sageFortes, C., et al. (2003). Nutr Cancer, 46(1):30-7.

Mediterranean Diet

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Mediterranean Diet and

Pain• (n=60) RA patients, did anti-inflam diet (AA< 90

mg/day) or standard western diet

– Randomized to receive fish oil (30 mg/kg body

wt)

– Less tender/swollen/painful joints, less inflamm

PGs, leukotrienes: AI diet + fish oil>AI diet

Adam, et al. (2003). Rheum Int, 23(1):27-36.

• Mediterranean Diet reduces disease activity, pain

and stiffness in patients with inflammatory arthritis.

– Due in part to oleic acid, phenolic

compounds olecanthol, which has anti-

inflammatory properties (both in olive oil).

– Sales, C, et al. (2009). Rheumatism,

61(1):10-4.

Mediterranean Diet and

Pain• Measured adherence to the Mediterranean Diet

• 4470 participants (2605 women, mean age 61.3 y)

• Measured: QOL, disability, pain, stiffness, and

depressive symptoms

• Conclusion:

– Higher adherence to the Mediterranean Diet

was associated with:

• Better QOL

• Decreased pain and disability

• Less depression

Veronese, N., et al. (2016). Am J Clin Nutr, 104(5):1403-1409.

• Better health-related QOL with MD adherence

Henriquez, SP, et al. (2012). Eur J Clin Nutrition; 66(3):360-8.

Mediterranean Diet and

Pain• Benefits of the Mediterranean Diet related to:

– Exerts anti-inflammatory effects by affecting the

arachidonic acid (AA) cascade

– Reducing the expression of pro-inflammatory

genes

– Affecting the activity of immune cells.

– Benefit for patient’s with arthritis

Oliviero, F, et al. (2015). Swiss Med Wkly,

145:w14190.

Mediterranean Diet and

Pain

• Decreases stress and inflammation by:

– Lowers Arachidonic Acid (AA)

– Decreases Prostaglandins E2 (PGE2),

Thromboxane-A2 (TXA-2), & Leukotrienes-4

series (LTB-4)

– Lowers CRP levels

– Decreases inflammatory cytokines (IL-6)Shanmugan, et al. (2011). Nutrition and Cancer; 63(2):161-173.

– Decreases glycemic load

– Decreases insulin resistance

– Decreases oxidative stress markers

– Increases serum antioxidant capacity

Olive OilDiet and ANTI-

inflammation• EPA:

– Increases: Leukotriene-B5 series (LTB-5)

• Relaxes blood vessels

• Increases circulation

• Relaxes airways

• Promotes anti-inflammatory response

– Increases: Prostaglandin-E3 (PGE-3)

• Improves circulation

• Decreases sensitivity to pain

• Relaxes blood vessels

• Promotes anti-inflammatory response

• GLA:

– Increases: Prostaglandin-E1 (PGE-1)

• Relaxes muscle spasms

• Reduces blood clotting

• Increases protective stomach secretions

• Improves circulation

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PRO-Pain Dietary

Choices

• Avoid:– Refined grains (white flour), sugar

– Fried, fatty, processed/cured meats (bacon,

ham, lunchmeats), preserved food

• Associated with more cancer, heart disease and diabetes. Willett, JAMA, 2005;293:233-4.

– Soda, High Fructose Corn Syrup (HFCS),

artificial sweeteners, hydrogenated

fats

Pro-Inflammatory

Foods• Arachidonic Acid:

– Increases: Leukotriene-B4 series (LTB-4)• Promotes inflammation

• Constricts airways

• Prolongs duration of inflammation

– Increases: Thromboxane-A2 (TXA-2)• Constricts blood vessels

• Constricts airways

• Increases blood clotting

• Reduces circulation

– Increases: Prostaglandins-E2 (PGE-2)• Increases sensitivity to pain

• Increases swelling

• Induces fever

• Constricts blood vessels

Arachidonic Acid (AA)

& Pain

An unsaturated fatty acid, C20H32O2, found in

animal fats, that is essential in human nutrition

and is a precursor in the biosynthesis of some

prostaglandins.

Arachidonic Acid (AA)

Linus Pauling Institute, Oregon State University

http://lpi.oregonstate.edu/mic/other-nutrients/essential-fatty-acids

Nightshades?

• Plants in the family, Solanaceae (nightshades) are a potential causative factor in arthritis in sensitive people—key here = sensitive people

– This family includes potato (Solanum tuberosum L.), tomato (Lycopersicon esculentum L.), eggplant (Solanum melongena L.), tobacco (Nicotiana tabacum L.), and peppers (Capsicum sp.) of all kinds except the black pepper (family, Piperaceae)

– Trial of avoidance—Elimination and Reintroduction?

Patient Case (cont’d)

• 67 yo male PTC with complaints of RA

• Hands/fingers—red, swollen

• Has been on Methotrexate for 2 years

• Options?

• Symptoms worse last 2-3 months

• Retired 3 months earlier

• What changed?

12/6/2017

7

Nutrition, Gut Health &

Inflammation Overview

A

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P

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Symptom Management

Pain Reduction

Increase Resilience

Cachexia

• Indirect Rx: Treat PAIN, anxiety, GI problems,

depression, nutritional deficiency, constipation

• Conventional: Megace, other hormones,

dronabinol, NSAIDS

• Factors impacting cachexia:

– Inflammation secondary to pro-inflammatory-

cytokines (TNF-alpha, IL-6…)

– Decreased insulin responses

Cachexia and Fish Oil

• Omega-3 fats: appear beneficial for cancer

cachexia:

– 2-6 gm EPA daily reversed weight loss in

patients with pancreatic cancer. Wigmore, et al. (2000). Nutrition and Cancer,

36:177-84. (n=26).

2 gm/d appears sufficient.

Barber, et al. (2001) Nutrition and Cancer, 40:118-

24. (n=20)

– 18 gm/day fish oil significantly improved mean survival in both well-nourished and malnourished patients with generalized malignancy.

• RCT vs placebo, Gogos, et al. (1998). Cancer, 82:395-402. (n=60)

Cachexia and

Glutamine

• Glutamine: A non-essential amino acid which becomes essential under states of stress

• 1 heaped Tbsp per day (about 15 gms) appears to help cachexia

– Added arginine may enhance effects

Attenuates loss of muscle in animal models.

Yoshida, S, et al. (2001). Nutrition;

17:766-8.

• Taken: mixed in juice or smoothie,

with fiber drinks, or soup (fairly

tasteless)

Mucositis and

Glutamine• Glutamine:

– 30 gm per day (about 3 Tbsp per day) reduced

‘leaky gut’ during radiationYoshida, S, et al. (2001). Nutrition;17:766-8.

– 16 gm per day in patients receiving mouth

radiation had significantly less mucositis• 4 gm in 240 ml water, swish & spit 4x per day.

Huang, EY, et al. (2000). Int J Rad Onc, Biol, Phys;

46(3):535-39.

– Prevents chemotherapy induced stomatitis• About 8 gm per day.

Skubitz, KM, et al. (1996). J Lab Clin Med, 127:223-228.

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Diarrhea and

Glutamine

• Glutamine: up to 10 gm 3 times per day

– Fewer stools, shorter period of diarrhea, less

use of anti-diarrheal medications Daniele, B, et al. (2001). Gut;48:28-33.

Savarese, DM, et al. (2003). Cancer Treat Rev;29:501-13

• Also helps radiation-induced diarrhea

• At very high doses may lead to constipation

• Also helps viral diarrheaYalcin, SS, et al. (2004). J Ped Gastro & Nutr; 38(5):494-501.

Diarrhea and

Glutamine

Prevention of Chronic

Radiation Enteropathy

by Dietary Glutamine.

Jensen, J.C., et al.

(1994). Annals of Surg

Oncolgy, 1(2):157-163.

Diarrhea and

Glutamine

Prevention of Chronic Radiation Enteropathy

by Dietary Glutamine. Jensen, J.C., et al.

(1994). Annals of Surg Oncolgy, 1(2):157-163.

Fish Oil and Pain• Fish oil and inflammation:

– 2,400 mg EFAs per day X2wks, then 1,200 mg/day after

• 59% stopped NSAIDS, 60% pain reduced,

• 60% joint pain decreased. No controls.

Maroon, et al. (2006). Surg Neur, 65(4):326-31. (n=250; time=3 months).

– Patients with RA, random, 3 groups: placebo (soy oil), fish oil (3 g/d), fish oil (3 g/d) + olive oil (9.6 ml).

• Decreased pain/stiffness: fish oil + olive>fish oil>placebo

Berbert, et al. (2005). Nutrition, 21(2):131-6. (n=43)

Fish Oil and Pain

– Systematic Review and Meta-Analysis of Randomized Trials

– Marine oils in regards to patients with arthritis

– 42 trials included

– Standardized mean difference suggested a favorable effect

– Significant effect found in patients with RA—reduce joint swelling and pain, less morning stiffness, less NSAID use..

Senftleber, NK, et al. (2017). Nutrients, 9(1).

Fish Oil and Pain

Senftleber, NK, et al. (2017). Nutrients, 9(1).

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Fish Oil

• Reasonable dose: 1 Tbsp per day

• High-dose omega-3 fats have significant anti-depressant value

Nemets, et al. (2002). Am J Psychiatry;159:477-9.

• Helps rheumatoid arthritis, in addition to inflammatory bowel disease, asthma, heart disease, etc…

• Possible enhanced benefit when omega-6 fats (vegetable oils) are minimized

Probiotics

• Probiotics (e.g. lactobacilli, intestinal

“gut bugs”):

– Multiple effects: • Improves mucosal barrier and immune response

• Decreases inflammation

• Improve synthesis and absorption of nutrients

• Reduces antibiotic-associated diarrhea by average of 60%

– Various supplements; Nancy’s plain yogurt Guarner, F., et al. (2002). BMJ, 324:1361-66. Meta-analysis of 9 RCT.

Probiotics and

Pain• Balanced microflora has been shown

to:

– Reduce intestinal inflammation (decreases antigen load and pro-inflamm cytokines)

– Reduce abdominal pain and discomfort

– Decrease frequency of colds and flu

– Decrease allergy signs and symptoms

– Found to induce the expression of mu-opioid and cannabinoid receptors in the intestinal epithelial cells (similar to the effects of morphine)

Probiotics and

Fatigue• 46 men given probiotic supplements over a

6-month period

• Assessed with stress questionnaire

• 40.7% improvement in stress was noted (17.4% improvement of positive conditions and 23.3% improvement of negative conditions)

• Also noted 29% decrease in frequency of infections and 91% improvement of GI complaints

Gruenwald, J., et al. (2002). Advances in Therapy,

19(3):141-50.

Probiotic Mechanism

of ActionConstipation

Things to consider for treatment:

– Ground Flax seed

– Probiotics (“gut bugs”)

– Dried plums, prune juice

– Magnesium

– Hydrotherapy (Epsom salt baths), Massage

– Senna tea (“Smooth Move” by

Traditional Medicincals teas)

– Chinese medicine: 2-4 whole figs/prunes, and cup of

warm water with 1-2 Tbsp honey a.m. before food

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Vitamin D and Chronic

LBP• N=145, 35-65 yo

• Classified into 3 Groups:

– Normal Vitamin D levels (>30 ng/mL)

– Insufficient Vitamin D levels (21-29 ng/mL)

– Deficient Vitamin D levels (<20 ng/mL)

• Found:

– Chronic LBP functional capacity significantly lower in

Vitamin D deficiency vs. other 2 groups

Calik, Y., et al. (2017). Acta Orthop Traumatol Turc,

S1017-995X(17)30177-3.

• Supplementation of Vitamin D in deficient CLBP

patients can reduce pain intensity and improve

functional ability

Ghai, B., et al. (2017). Pain Physician, 20(1):E99-E105.

Vitamin D and Lupus

• Systematic Review and Meta-Analysis

• Identified 9 RCTs using Vitamin D

supplementation for rheumatic diseases

• At least 3 months

• Found:

– RA recurrence decreased but not significant

(p=0.05)

– No significant difference in the VAS (p=0.24)

– Regarding systemic lupus erythematosus, anti-

dsDNA positivity was significantly reduced

(p=0.005)…further studies needed

Franco, AS, et al. (2017). Medicine (Baltimore);

96(23):e7024.

Vitamin D

• Vitamin D deficiency can cause aches and

pains and decreased muscle strength

• Focus on adequate sun exposure and

adequate dietary intake with

supplementation if necessary

• Magnesium?

• Supplementation: 2,000 i.u. per day

• Goal: 40-60 ng/mL in blood serum

Garland, CF, et al. (2009). Ann Epidemiol, 19:468-483.

Shinchuk, L, et al. (2007). Nut Clin Pract, 22(3):297-

304.

Lifestyle Effects on

Inflammation

Magnesium and

Fatigue

• Plays a role in all major metabolisms (ox-red, ionic regulation, etc.)

• Normal concentrations of extracellular magnesium and calcium are crucial for normal neuromuscular activity

• Intracellular Mg forms a key complex with ATP

• Important cofactor: for wide range of enzymes, transporters and nucleic acids required for normal cellular function, replication and energy metabolism

Magnesium and

Fatigue

• A study of 93 patients with unexplained

fatigue found:

• 47% were Mg deficient, and had

lower total antioxidant capacity in

plasma

• These patients had persistently

lower blood glutathione levels

Keenoy, M., et al. (2000). J Am College of

Nutrition, 19(3):374-382.

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Magnesium

• Intestinal absorption is stimulated by 1,25(OH)2D (Vitamin D)

• Deficiency can cause: muscle weakness, apathy/fatigue, depression, irritability…

• Found in: fish, almonds, nuts, soybeans, spinach, potatoes, legumes, avocadoes, bananas, raisins…

• Dose Recommendation: 6 mg/kg/day (i.e. 150 lbs= 400 mg per day)

Peripheral Neuropathy

and Glutamine

• Glutamine: 10 gm three times daily after paclitaxelsignificantly reduced severity of neuropathy (66)

• RCT, metastatic colorectal cancer:

– oxaliplatin + 5-FU,

– glutamine group (n=42) 15 grams 2X/day for 2 wks from chemo start, control (n=44) no glutamine

– Glutamine group: • lower Grade 1-2 PN vs control (16.7% vs 38.6%) post 2

cycles

• Lower Grade 3-4 PN vs control (4.8% vs 18.2%) post 4 cycles and (11.9% vs 31.8%) post 6 cycles

• Interference with ADL decreased (16.7% vs 40.9%)

• Need for oxaliplatin dose reduction less (7.1% vs 27.3%)

Wang, WS, et al, The Oncologist, 2007;12:312-319.

•

Peripheral Neuropathy

and Vitamin B6

• Vitamin B6 (Pyridoxine): 50 mg 3 times per day– ASCO 2009 Annual Meeting, Verschraegen, CF, et

al, J Clin Oncol, 2009.

– 3 cohorts: Taxane (n=49), Vincristine or Vinblastine (n=7), and Platinum (n=25)

– Taxane cohort reported:• Randomized to:

– 1/6 of 100% DRD multivitamin (placebo; n=22)

– Same + B6 at 50 mg tid + B12 1 mg/3-4 wks (n=24)

• Assessed over 4 cycles of chemotherapy

• No other supplements allowed

– Placebo group significantly worsened, especially in cold sensation (p=0.0097)

Green Tea (Camellia

sinensis)

• Protective effects from oxidative

stress (anti-oxidant polyphenols)

• Same plant for: Green, Black, &

White teas

• Also contains 1/3 caffeine as

coffee

• Numerous health benefits from

cancer-protective to blood sugar

balancing to pain reduction

Green Tea

(Camellia sinensis)• RCT, n=50 adults with knee OA

• Groups: Green tea + diclofenac (intervention group), diclofenac alone (control group)

• Time: 4 weeks (assessed week 1, week 4)

• Significant reduction in pain in intervention group vs. control group

Hashempur, MH, et al., (2016). Clin Nutr, SO261-

5614(16)31345-0.

• Caffeinated appears MORE beneficial

Recommendation:

• Aim for 3-12 cups (20 - 72 ounces)/day

Curcumin

• May act by inhibiting cyclooxygenase-2

(COX-2) isoenzyme and inhibit

prostaglandin E2. Lev-Ari. (2006). J Soc Integ Onc, 4(1):21-6.

– In other words, anti-inflammatory

• When given with ECGC decreased

effect; when given sequentially--

increased response!

• Recommended dose: 500 mg three

times per day

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Curcumin

• Systematic Review (pain)

• 13 studies, n=1101 total

• Some of the studies showed benefit with: reduction

in musculoskeletal pain, improved pain reduction

when combined with ibuprofenGaffey, A., et al. (2017). JBI Database System Rev Implement

Rep. 15(2):486-516.

• Systematic Review and Meta-Analysis of RCTs

(arthritis symptoms)

• Benefit with turmeric in the treatment of arthritis

(1000 mg per day)Daily, JW, et al. (2016). J Med Food, 19(8):717-29.

Radiation and Curcumin

• RDBPCT

• n = 30 breast cancer patients

• Prescribed radiotherapy without concurrent

chemotherapy

• Dose: 2 grams curcumin or placebo orally three

times per day throughout radiation

• Curcumin reduced severity of radiation dermatitis

(p=0.008)

• Product: Curcumin (Curcumin C3 Complex) and placebo

capsules, >95% curcuminoids, approx 390 mg curcumin, 75 mg

demethoxycurcumin.

Ryan, J.L., et al. (2013). Radiation Research, 180:34-43.

Inflammation

Kim, Y.S., et al. (2009). Cancer Prev Res; 2(3):200-208.

Massage

Sloan-Kettering Massage

Study for Cancer Patients• n=1290 patients with cancer; out- & in-patient

• Statistically significant (50%) reductions in:

– Pain

– Fatigue

– Nausea

– Anxiety and Depression

• Outpatients had slightly more benefit than inpatients, benefits persisted at least 48 hours

• No side effects, greatly appreciated by recipients

Cassileth, B, et al. (2004). J Pain Symptom Manage;28(3):244-9.

Massage and Post-op

Ileus Pain• Post-op colon surgery patients, n=50 (38 colon ca)

• Two groups: massage and control (25 each)

• Daily: 30 min abdominal massage for 7 days

• Analgesic use Day 3 : Decreased 50% vs 25% con

• Pain intensity (0-7 pain scale) Day 3: 74 in

massage group vs 76 in control

• Ileus average duration – 1.8 days vs 3.6 days in

control

Le Blanc-Louvry, I, et al. (2002). J Gastrointest Surg;6(1):43-9.

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Massage and Peripheral

Neuropathy (PN)• HIV+ patients with painful PN and little/no

improvement with narcotic analgesics, tricyclic

antidepressants and/or SSRIs

– 5 of 7 patients reported a mean decrease in

pain of 3.2 on a 0-7 point scaleAcosta, AM, et al. (1998). Int Conf AIDS; 12:849. (n=7)

• Diabetic patients with lower extremity (PN)

– 56% (n=14) “Good response”; 32% (n=8)

“improvement”; 12% (n=3) “no effect”

Ezzo, J, et al. (2001). Diabetes Spectrum; 14:218-24. (n=25)

Chinese Medicine &

Acupuncture

Acupuncture

• Involves placing thin surgical stainless

steel needles into the skin to

promote health

• Practiced for 3,000-5,000 years

• President Nixon’s trip to China in the

early 1971 helped it grow in the U.S.

• Used worldwide

• Tremendous growth in research in the last

20 years

Acupuncture and Pain

•Research Supports Use With:

Facial pain, trigeminal neuralgia, shingles pain

Dental pain

Headache, migraines

Neck and back pain

Tennis or golfer’s elbow

Labor pain, menses pain

Osteoarthritic pain

Endoscopy-associated pain

Myalgia and fibromyalgic pain

Kidney stone-associated pain

How Does Acupuncture

Work?• Conventional medicine:

– Increased secretion of the endogenous opioids(beta-endorphins, enkephalin and dynorphin, endomorphin)…major role (antagonized by opioid receptor antagonist naloxone) and target mu opioid receptors on presynaptic sensory cells

– Affects polymodal receptors (PMRs)

– Affects release of bradykinin, histamine, prostaglandins, serotonin, dopamine

– Affects the release of neuropeptides such as: substance P, calcitonin generated peptide, somatostatin, and vasoactive intestinal peptide

How Does Acupuncture

Work?• Chinese medicine: restoring balance

harmony = health

• Optimizing the flow of Qi and Blood

• Research is difficult!!

-Hard to blind or control studies; difficult to

use “sham” treatments

-Difficult to create standard methodologyDerry, CJ, et al, Clin Med, 2006, 6(4):381-386.

-Minimal acupuncture points also result in

physiological changes

Lund, I, et al, Foundation for Acupuncture and Alternative

Biological Treatment Methods, 2008

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Research is difficult!

Zyloney, C.E., et al. (2010). Molecular Pain, 6:80.

http://www.molecularpain/content/6/1/80.

Sham Genuine

Acupuncture and Pain

• Recent Meta-analysis of RCTs

• Found 29 RCTs, involving 17,922 pts

• Assessed four chronic pain conditions:

– Back and neck pain

– Osteoarthritis

– Chronic headache

– Shoulder pain

• Found: acupuncture > sham and no acupuncture controls

• Summary: patients receiving acupuncture reported less pain

Vickers, A.J., et al. (2012). Arch Intern Med, 172(19):1444-1453.

Patient Case (cont’d)

• 67 yo male PTC with complaints of RA

• Hands/fingers—red, swollen

• Has been on Methotrexate for 2 years

• Symptoms worse last 2-3 months

• Retired 3 months earlier

• Doing more bellpeppers—2-3/day.

• Suggested stop bellpeppers, gave probiotics,

fish oil and gave acupuncture

• Comes back in 2 weeks—redness/swelling

gone

Acupuncture and

Nausea• Looked at 2,302 research articles on acupuncture

(all research from January, 1970 – October, 1997)

• Found useful for chemotherapy-associated nausea and vomiting

• Difficult to have appropriate controls, placebos, and sham acupunctureNIH Consensus Statement. (1997). November 3-5;15(5):1-34.

• Results consistent between different investigators, different patient groups and different forms of point stimulation -Vickers, A.J. (1996). J R Soc Med;89(6):303-11.

-JAMA, (1998, Nov); 4;280(17):1518-24.

-Ezzo, et al. (2005). J Clin Oncol, 23:7188-7198.

-Ezzo, et al. (2006). Cochrane Database Syst Rev; 19;(2):CD002285. (n= 1247)

-Konno, R. (2010). Cancer Nurs; 33(6):479-80. Cochrane review .

Acupressure and

Nausea• Acupressure wristbands reduced

chemotherapy-induced nausea

• Three groups (n=86):

– one used PC-6 (46% nauseous)

– one used a “sham” point on opposite side (68%)

– one received no treatment (standard care) (73%)

• Acupressure wristband group reported less nausea and took less anti-nausea medications

-Roscoe, J.A. (2006). J. Soc Int Onc; 4(1); 16-20.

-Roscoe, J.A., et al. (2002). Am J Obstet Gynecol;186:S244-7.

-Lee, E.J., et al. (2011). Systematic Review. J Pain Symptom Manag, 42(4):589-603.

-Song, H.J., et al. (2015 Feb). Complement Ther Med; 23(1) 68-78. Effect of self-acupressure for symptom management: a systematic

review.

Pericardium-6 (PC-6)

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Ginger and

Nausea/Vomiting• As effective as metoclopramide for post-op

nausea and vomiting, but not if narcotic-induced

• Improves: chemotherapy-induced nausea and vomiting:

– Typical dose: 2 - 4 gm per day

– Lower doses may be ineffective

I J Gyn Ca, 2004;14:1063-9.

– Powder in capsules used most commonly

– Also ginger soda, tea, candied ginger…

Ernst, Br J Anaesth, 2000;84:367-71.

Ginger and Pain

• Hip/Knee Osteoarthritis RCT:

– Similar results between 400 mg ibuprofen to 170 mg

ginger extract (both more effective than placebo).

Bliddal H, et al. RCT, Osteoarthritis Cartilage, 2000, 8(1):9-

12 (n=75).

• Rheumatoid Arthritis and Musculoskeletal Issues:

– Gave 0.5-1 tsp powdered ginger (approx. 1-2 gms)

– Found 75% had pain relief and swelling reduction

Srivastava KC, et al, Medical Hypotheses, 1992, 39(4):342-

348 (n=56; RA=28, OA=18, myalgia=10).

Acupuncture and

Fatigue

• Study of 31 patients at Memorial Sloan Kettering Cancer Center in New York

• Participants had completed chemo an average of 2 years previously

• Two Groups:– 2 treatments per week for 4 weeks

– 1 treatment per week for 6 weeks

• Average improvement was 31%

J Clin Oncol, 2004, May 1;22(9):1731-5 [n=31].

Acupuncture and

Radiation-Fatigue

• Acupuncture feasibility trial for patients (n=16) during

radiation therapy regarding fatigue

• 12 acupuncture treatments over the course of their

Radiation Therapy

• Lee Fatigue Scale used: pre, middle and end

• 50% (n=8) reported fatigue static during and after

• 37% (n=6) reported energy as improved

• Researchers: results need to be confirmed with RCT

Mao, J.J., et al. (2009). J Society for Integrative Oncology, 7(2):52-58.

BRCT Acupuncture and

Aromatase Inhibitor-

Associated Myalgia

-True (n=20; full body/auricular and 3 joint specific

points) vs. Sham acupuncture (n=18; superficial

needling at nonacupoint locations)

-Treatments: 2X/wk for 6 wks, in postmenopausal

women with Stage I-III, ER/PR+ breast cancer

-All had self-reported musculoskeletal pain related

to Aromatase Inhibitors

-Allowed to take nonnarcotic and nonsteroidal pain

medications as needed

Crew, K, et al, J Clin Onc, March 2010, 28(7):1154-1160.

-Assessed: baseline, 3 & 6 weeks

-TA group: lower Worst pain scores (3.0 v 5.5;

p<0.001), pain severity (2.6 v 4.5; p=0.003) and

pain related interference (2.5 v 4.5, p=0.002)

-TA group: physical well-being improved (19.8 v

15.4, p=0.03), 5/25 participants taking

acetaminophen or NSAIDs for pain relief

discontinued after 6 weeks

-No adverse events reported

Crew, K, et al, J Clin Onc, March 2010, 28(7):1154-1160.

BRCT Acupuncture and

Aromatase Inhibitor-

Associated Myalgia

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-Assessed: 8-week trial

-All were on AIs and experiencing joint pain

-Groups: Randomized--True-EA group, sham group

(placebo needle—non-insertion) and control (usual care)

-T-EA group: less joint pain, fatigue, less anxiety, less

depression, better sleep.

-Sham: no change to anxiety, but also had less

depression.

-Effects: maintained through week 12.

Mao, J., et al. (2014, July). Cancer. (ASCO Post, posted 7/30/14)

Acupuncture and Aromatase

Inhibitor-Associated Myalgia

& QOL

Neck Dissection Post-

Operative Pain• RCT, n=70 head and neck cancer patients

• Randomized to usual care (included PT, medications) or acupuncture

• Been at least 3 months from surgery and radiation

• Treatment group received 4 txs over 4 weeks

• Pain/mobility improved 39% (vs. 7% usual care), added benefit of decreased xerostomia

Results presented at the American Society for Clinical Oncology annual meeting May 31, 2008 by Dr. David Pfister, Memorial Sloan-Kettering Cancer Center.

Case Study: Pain

• 69 year old female in-patient with

metastatic lung cancer

• Pathological leg fracture

• Had also received radiation

• Treatment: Electro-acupuncture given

in-patient

• Could roll onto affected side (“a first”),

slept better, more restful, less anxiety

Hot Flashes and

Breast Cancer

• 72 women with breast cancer, RCT

• 3+ hot flashes per day

• Randomized: true vs. sham acup

• Treatments: 2X/wk for 4 weeks

• Hot flash frequency: baseline, 6 weeks, 6 months

• Mean number hot flashes acup group: 8.76.2/d, 10.07.6 in sham group

• Reduction in both, not statistically significant (sham point 3 cm away)

Deng, G, et al. J Clin Oncol, 2007 Dec, 25(35):5546-5547.

Hot Flashes and Breast

Cancer

• 50 women randomly assigned to receive: 12 weeks acupuncture (n=25) ORVenlafaxine (Effexor) (n=25)

• Both groups found: decrease in hot flashes, depressive symptoms and improvement in quality of life and mental health

• Similar results in both groups

• Summary: acupuncture was as effective as Venlafaxine

• 2 weeks post-treatment: Venlafaxine group had increase in hot flashes, acupuncture group didn’t

Walker, E.M., et al. (2010). J Clin Oncol;28(4):634-640.

Acupuncture and

Peripheral Neuropathy

• Pilot study

• n=6 in treatment group, n=5 in control

• Examined by Nerve Conduction Study (NCS)

• Mean of 10.3 months post chemo (2-21 mos)

• Performed: before tx, and 3 mos post study

• Results:

• NCS improved post acupuncture treatment

• Acupuncture should be considered for CIPN• Often used: ST-34, Qi duan, Ba feng (20 needles per session)

Schroeder, S., et al. (2012). Acupunct Med, 30:4-7.

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Acupuncture and

Insomnia• Systematic review of RCTs of acupuncture

vs. placebo, Western Rx or controls

• 20 RCTs identified

• Concluded acupuncture more effective than:

– Benzodiazepines: mean effective rates of 91% and 75% respectively

– more than sham acupuncture or sleep hygiene counseling

• Methodological shortcomings, better studies needed

Yeung, W.F., et al. (2009). Sleep Medicine; 10(7):694-704.

Acupuncture and

Weight Loss•n=60 (Simple obesity=30, perimenopausal

obesity=30), non-randomized observational Pilot Study

•Given 5 Electro-acupuncture & Ear seed treatments 3 times (total of 15 treatments; 1 week of treatment, 3 weeks off)

•Measured: body weight, BMI, obesity degree, & waist/hip ratios

•Obesity indexes reduced in group with simple obesity (reduced: body weight, BMI, obesity degree, & waist/hip ratio)

•Perimenopausal obesity= no change round 1, decreased in 2nd and 3rd. Changed, but slower.

•Points: EA to St36, Sp6, Cv10, weight loss point ½ between Cv8 and LEFT ASIS, Cv6 and R weight loss point; St25, Sp15, Gb25, Gb26, Bl13, Bl17, Bl20, Bl21. Ear: Shen men, Central rim, Spleen, Stomach, Large Intestine, Triple Energizer and Hunger point.

Wang, et al. (2012). Am J Chin Med, 40(60):1157-1166.

Providence’s Infusion

Acupuncture Study

• We recently started a program to support our patients getting infusions

• Partnering with NCNM Chinese Medicine students

• There is no charge for patients

• We’re collecting data/surveys

to better assess value

Safety and Side Effects

• Safe when conducted by a trained professional

• Study of 574 British acupuncturists and involved 34,407 treatments

• Concluded: Acupuncture is safe!

• Risks: infection, bleeding, pneumothorax, nerve damage and allergic reactions (rare!)

Alternative Therapies, 2003;9(1):72-83

Acupuncture in Medicine, 2001;19(2):93-102

• Of 97,733 patient acupuncture visits in Germany, only 6 potentially serious adverse events were reported

Melchart, D, et al, Arch Int Med, 2004, 164:104-105.

When to Consider An

Integrated Approach• For any patient with acute and/or chronic pain

• Could potentially reduce pain responses and

support the step-wise approach that could make

non-opioid analgesics more effective OR reduce

the amount of opioid analgesics needed

• To help reduce side effects of prescribed

medications

– such as nausea and vomiting, constipation,

and fatigue/sedation

• To speed recovery and improve quality of life

Providence Integrative

Medicine• Services provided:

– Acupuncture

– Naturopathic Medicine• Nutrition – diet counseling, therapeutic foods,

nutritional supplements

– Massage

– Chiropractic

– Public lectures on Integrative Medicine

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Summary

• Treating Pain with Integrated Medicine:– Treat the whole person

• Improve Overall Health and Decrease Inflammation Using:– Diet and Nutrition

– Supplements

– Acupuncture

– Massage

• Consider Integrative Medicine as a part of the multidisciplinary pain management health care team

Question….

Thank you! Questions??

Providence Integrative

Medicine ClinicsStaff:

Loch S. Chandler, ND, MPA:HA, MSOM, LAc, Medical Director

Jennifer Crisp, Manager

Clinical Staff:

Loch Chandler, ND, MPA:HA, MSOM, LAc

Ken Weizer, ND

Malea MacOdrum, ND, MSOM, LAc

Nicci Lambert, ND, MAc, LAc

Tzumin Weng, ND, LAc

Laura Martell, ND, LAc

Anthony Marrone, DC

Anthony Marrone, DC

Polonca Marx, LMT

Tina Russell, LMT

Providence Integrative

Medicine Clinics

Westside

9135 S.W. Barnes Rd.,

Suite 261

Portland, OR 97225

Phone: 503-216-0246

• Located in the East

Pavillion (Medical

Office Building) next

to St. Vincent

Hospital

Eastside

4805 N.E. Glisan St., 1st

Floor North Tower

Portland, OR 97213

Phone: 503-215-3219

• Located on the first

floor of the cancer

tower near the

elevators and the

fountain