Integrative Medicine and the Medicine of Cycling

Integrative MedicinePaul Abramson MD

My Doctor Medical Group, San FranciscoClinical Faculty, UCSF

Sunday, August 26, 12

Acknowledgements

• Arizona Center for Integrative Medicine

• Andrew Weil MD• Tieraona Low Dog MD• Harmon Meyers DO• Michael Menke DC


Disclosures

No conflicts of interest to disclose


Disclaimer

These are just my opinions, except as noted


Objectives #1Integrative 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 practitioner


Objectives #2Manual 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 practitioners


Objectives #3Cervical Spine Adjustment

• Review some of the evidence regarding safety of high velocity, low amplitude cervical spine adjustment

• Identify patients at higher risk of complications


“Integrative medicine combines mainstream medical therapies and alternative therapies for which there is some high-quality scientific evidence of safety and effectiveness.”


“[integrative medicine] doesn't seem wedded to a particular dogma, Western or Eastern, only to the get-the-patient-better philosophy.”

Professor for the Theory and Practice of Medicine Stanford University Medical School

Abraham Verghese MD


“The good physician treats the disease; the great physician treats the patient who

has the disease.”

Sir William Osler (1849-1919)


Medicine:Universal Principles

• History• Review of Available Data• Physical Examination• Appropriate Testing• Formulation of Diagnoses• Treatment Plan• Self Tracking and Feedback


Definitions:Conventional Medicine

• Drugs• Surgery• Ancillary Specialties - PT, OT, ST, RT• Dietary Consultation - RD• Lab testing and diagnostic imaging • Lifestyle Advice


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”


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, meditation


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*


Components of anIntegrative Plan

• Conventional medicine*

• Nutrition• Physical activity• Mind-body medicine• Dietary supplements,

botanicals

• Whole-systems medicine (e.g. TCM)

• Manual medicine• Energy medicine• Spiritual

counseling


Sliding Scale of Evidence

• More potential for harm

• More cost• Sicker patient

More Evidence Needed


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

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 interest


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

care


Desirable Traitsin 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 plan


Desirable Traitsin 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)


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 models


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, flatulence


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 treatment


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 disease


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

referral


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%


Manual Medicine“The use of hands to treat disorders

of the somatic system”


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 tissues


Level 1

• Swedish massage• Reflexology• Deep tissue• Lymphatic drainage


Level 1Scope 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 scope


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 touch


Level 2

• Myofascial Release• Rolf• Structural Integration• Feldenkrais• Alexander Technique



• Assessing and treating specific somatic imbalances and patterns. Pain relief, postural alignment, balance improvement

• More advanced assessment techniques based on theoretical frameworks

• Specialty certifications


Level 3

• Chiropractic Adjustment• Osteopathic Manipulation• (Physical Therapy)• (Trigger Point Injection

by MD/DO)



• Licensed practitioners• Can diagnose• Treat within specialty scope• Potentially more invasive, more risk


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 techniques


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 loops


Osteopathic Principles

Viscero-Somatic Reflex

Sympathetic Innervation

Palpation Skills


Osteopathic Techniques

• Muscle energy• Myofascial release• High Velocity / Low Amplitude

(HVLA) adjustment• Strain / Counterstrain• Cranial Osteopathy


Osteopathic Challenges

• Hard to find a DO who still practices manipulation

• Most DOs doing manipulation are fee for service


Where to FindAn Osteopath

• American Academy of Osteopathy: 317-879-1881, academyofosteopathy.org

• Cranial Academy: 317-594-0411, cranialacademy.com

• Word of mouth


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 focus


Chiropractic Training

• Education: Basic sciences, anatomy, physiology are similar to MD

• Ambulatory-only clinical outpatient training

• Clinical experience* MD/DO: 5227 hoursDC: 1405 hours

*Altern Ther Health Med 1998- PMID 9737032


Chiropractic Philosophy

• Spinal subluxation is the underlying cause of disease

• Correct spinal misalignment to prevent and to cure disease


Chiropractic Assessment

Postural observation

Palpation (static and motion)

X-raysSunday, August 26, 12

Chiropractic Treatment

• High Velocity Low Amplitude (HVLA) • Low Velocity (pressure)• Cranial and Sacral adjustments• (Eclectic mix of other modalities)


Chiropractic Scope:Standard

• Diagnosis of musculoskeletal pain and dysfunction

• Physical exam plus x-rays• Treat with spinal adjustments and other

manual techniques


Chiropractic Scope:Beyond

• Other practices:• Medical diagnosis• Diagnostic testing with conventional

and alternative labs• Treatment with dietary supplements• Alternative procedures

• Issues of collaboration with MDs


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 nomenclature


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 treatment


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 10714541Palmer Center for Chiropractic Research, Iowa


http://www.ncbi.nlm.nih.gov/pubmed/10714541#


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 9761803Department of Health Services, Univ Washington




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 9112710Institute for Research in Extramural Medicine, Amsterdam




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

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, 341:1426-31


Beyond Manual Medicine

• Level 4 - Examples• Epidural Injections • Implantable Nerve

Stimulators• Spinal Surgery• Joint Surgery


Cervical Spinal Manipulation



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 19269682McMaster University, Canada




Cervical Adjustment:Safety 1

• Hurwitz et al, 1996. PubMed 8855459• Out of 10 million treatments:

-- Stroke 5-10-- Major impairment 3-6-- Death < 3



• 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 stroke



• 22 patients treated by neurosurgical group in 5-year period in Tulsa, OK

• Radiculopathy 21, myelopathy 11, Brown-Séquard 2, vertebral occlusion 1

• Denmark 1978-88• About 1 stroke per 1M rotational cervical

adjustments• France Survey

• “Incidence of vertebrobasilar stroke 30x higher than published estimates”

Malone, 2002PMID 15766233

Klougart, 1996PMID 8864967

Dupeyron et al, 2003PubMed 12657480


Cervical Adjustments:What does UCSF Say?

• Smith et al, Neurology, 2003PubMed 12743225

• Nested case control study

• “Cervical SMT is an independent risk factor for vertebral artery dissection”


Cervical Adjustment:Risk Factors

• Age• Migraine• Gender (F > M)• Hypertension• Oral

Contraceptives

• Smoking

• Diabetes

• Fibromuscular hyperplasia

• Syphilis

• Marfan’s Syndrome


High Risk Features for Cervical Adjustment

• Pain unrelieved by position and analgesics

• Inability to void bowel or bladder

• Suspicious skin lesions• Bad family history of

risk factors• Personal risk factors• Unexplained weight

loss

• Sudden change in overall health status

• Chest pain, dyspnea• Palpable mass or lymph

node enlargement• Vascular compromise to

extremities• Abnormal cranial nerve

exam• Focal neurologic deficits


Contact Information:Paul Abramson MD

mydoctorsf.com@paulabramsonmd

[email protected]


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Integrative Medicine and the Medicine of Cycling

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