We really appreciate you coming out today. My name is Saloni Sharma, and I'm the session director for this. I just want to do a super quick intro, but I want to get right into it to make this very valuable. So our first speaker is Dr. Jeremy Simon. He is the chief of PM&R at Rothman Orthopedics affiliated with Jefferson. And he's going to talk about the traditional approach to low back pain. And then we'll talk about the lifestyle medicine integrative approach, and really how they're complementary. And it's not about excluding one type. It's about blending them to optimize care. So with no further ado, Dr. Simon. Thank you, Saloni, and thanks for everybody for coming. So I just want to start out by saying Saloni has done a fantastic job at our group. We're with a very large orthopedic group. For those of you who don't know Rothman, we're expanding everywhere. And we're in a group of people who are, it's an evidence-based practice. So whenever we are presenting any kind of idea, we always want to make sure we have evidence to support it, or sort of presenting some value to it. So to start a de novo project on something like integrative medicine, which I don't think they even know that term. I think when we were talking about it, you had to kind of explain what that was. So she's been doing a great job. So just as a brief overview, it's a very large topic. How do we treat back pain traditionally? This is, so some of it I'll briefly talk about. Structural causes, medication, some of the fluoroscopic injections that could be considered. And later, I'll summarize it, but then later we'll have questions and answers. So I would just start out by saying, you know, what I was taught by when I was a fellow, and Mike Furman's here, was my fellowship director. We look for what's, quote, the pain generator. And that's not always obvious, as a lot of us know. And there was a recent article where they looked at sort of what patients want with back pain. I presented it at Journal Club. And so what does the ACTS patient with back pain want? And more than imaging, which maybe in Philadelphia a lot of people do seem to want imaging, but they wanna know why they have back pain. And they actually were not satisfied with the diagnosis of nonspecific low back pain, which of course we're all taught is the most common cause of low back pain. So one of the things, I think this population kind of screams for a different approach. And I'm gonna show you just briefly just with some of the references. A lot of these things that we do for axial back pain, there's really not great evidence for it. And a lot of them don't work very well. And I think we've all had that experience. So I'm very excited about the integrative approach that we have at Rothman to try and help look at the patient kind of in a lot of different ways. So of course, from an anatomic standpoint, we all know there's a lot of musculature in there that can get sprained, strained. You can get trigger points. I'm not gonna get into detail about this, but the back has a lot of musculature that can get injured. There's of course lots of different structures in the spine itself that could be a source of back pain. Traditionally we think about the zygapophyseal joints or facet joints. The disc is a potential pain generator. Various ligaments. And then recently there was a talk, which a lot of people are kind of getting on board, a lot of excitement about what they consider to be the anterior column or vertebrogenic back pain. And of course sacroiliac joints are a potential cause of back pain as well. Sorry. So in terms of treatment, the treatment for back pain, we often are asked what kind of medicines can I take or what should I take. Tylenol, one of the things that I got kind of ticked off about was some years ago when they talked about how, quote, Tylenol doesn't help back pain. And I sometimes will get patients that come and say, well I'm not gonna take that because Tylenol doesn't help. Interestingly there's a reference, I put it in here, where they compared Tylenol for acute back pain to NSAIDs. And of course Tylenol has a much safer side effect profile than a lot of the NSAIDs. You don't worry about GI bleeding and the kidney stuff as much, hypertension. For chronic back pain it hasn't been shown to be as effective as NSAIDs. But I still tell patients, I think it's worth trying it because you're not as concerned about having someone have an untoward outcome. It's recommended if a patient's gonna do it on their own and a physician's not checking their labs or kind of following along that you don't go beyond 3.25 grams a day. Four grams a day with supervision. I tend to stay kind of more in the three gram a day range. But there is data for this. And of course in people with liver impairment you wanna be even more judicious about it. NSAIDs, I think when I first started I was prescribing this a lot. You know, take some ibuprofen. I told my in-laws to do that, my parents to take NSAIDs. But the longer I'm at it the less juiced I am about writing this because there's really evidence that it's not that great. There is evidence that it shows NSAIDs have some relief over placebo. In a JAMA review the evidence was kind of low quality for how much it actually helps. And actually the American College of Physicians, the American Pain Society really tell you try to limit this stuff. Because it hasn't really been shown to be all that great and you could have some bad outcomes. Again, no superiority between the different types of NSAIDs, a lot of times people will say, and we practice things, we try to be in an evidence-based way. But should I take diclofenac as opposed to meloxicam? There's not fantastic evidence that switching from one to another one is really gonna do much. And again, kind of circling back to the business of what we're here with the integrative program. They're really not shown to be, you could look at it the other way. You could say manipulation is equal to NSAIDs, but NSAIDs are kind of equal to manipulation, PT and also relative rest. I put a bubble burst here because a lot of times, and we see we have some urgent cares and it seems like a lot of times when people come into the urgent care they get the mandatory MedDRAL dose pack. There's really no evidence that this works any better than placebo for axial back pain. I think it's simple for people to use and a lot of people feel kind of good and activated on steroids but it doesn't really show that it's gonna, evidence doesn't really show it's gonna help. Muscle relaxers have been shown to be superior to placebo for acute low back pain. There is also no evidence that one is better than the other. So again, when we go through this stuff you say, well is tizanidine better than cyclobenzaprine? Really there's not evidence to support that and you have to watch out. There are some common side effects such as drowsiness, dizziness, and nausea. Antidepressants, I rarely use these. I have to make sure that if I'm gonna use an antidepressant on somebody I really took the time to see if they have depression or are at risk. It's been shown that ones that have norepinephrine uptake are better than those that don't and they're considered a second line treatment. Opioids, that's everybody's hot potato. We do not like to write opioids and I don't really believe in, I'm sure most of us don't prescribe them much anymore. There is some data of course that the high potency opioids may have a small benefit in pain and function but actually no good evidence for long acting opioids. So writing fentanyl patches for someone with chronic low back pain isn't supported by the literature. Tramadol, I put that in kind of separately. It's still in the opioid class but short term benefit, modest improvement. And benzodiazepines, it seems that if someone's really in a lot of pain and ends up in the emergency room this is often their go to. This also doesn't show any significant benefit for axial back pain or improvement when people have herniated discs in function versus placebo. Sorry. I put this picture up. This was a patient that came in. It gets a little bit cut off and it says all next to it. So the all is referring to what symptoms are you feeling? Like is it burning? Is it spasm? And it's all. And you see that she actually I think interestingly did color in her head too. And I think that, I don't say that purely as a joke but I think that we have to look at kind of what this person is experiencing. They're experiencing this pain. And this is something that when we start talking about doing fluoroscopy, I had asked Mike Furman for permission to say this but I'll call him out. He would say, he called it the modified prayer for the interventional physician. So grant me the courage to treat those patients with these procedures if you will or aggressively treat those people. I believe that can help the serenity to be conservative with those that I cannot and the wisdom to know the difference. So one of the things about this patient is that where do you begin? The whole back is lit up. Am I gonna do facet injections of the entire back? So patient selection is very important when you're doing this and when you're doing procedures and expectations to be set. I'll briefly go through these slides. These are some common procedures that are done with some of the evidence to support or refute them. Interlaminar epidurals, just to review, those are the epidural steroid injections where you place a needle through the ligamentum flavum, use a loss of resistance technique and the medicine flows kind of diffusely. This is a couple pictures, the AP and contralateral oblique picture. You can see the straight line showing that it's in the epidural space between the ligamentum flavum and the fecal sac. Sorry, there it goes. There have been studies, these have been around for a very long time that showed that there's some statistical improvement for axial pain at a year in the VAS and ODI. This was a study in 2016. A very small study of low quality evidence showed some evidence for some improvement in low back pain. Interestingly, Manchikanti back in 2013 did a study and looked whether or not you use steroid and showed if you just use lidocaine versus using steroid and showed that there was greater than 50% relief in about 72% of patients. I would say that I tend to use this as a second, third line sort of treatment in patients with back pain. Usually they have to have had physical therapy and failed it or really be miserable and then I try to set expectations that this is not a panacea. Transfer abnormal injections, this is placing the needle inside the foramen. Forgive me if this is basic, but what we're doing is placing the medication closer to the ventral epidural space which is closer to the disc. So in theory, if there's a problem with the posterior part of the disc, you may be getting the medicine kind of closer to that region. This was interesting. For those of you who don't know, I put the reference for the PROMIS scores. PROMIS is the Patient Reported Outcome Measurement Information System and it's used for a lot of studies. We did a study at Rothman using PROMIS scores for carpal tunnel and they did show that there was an improvement in axial back pain in this recent study from Michael Lick, I might be pronouncing his name wrong, in people who have axial back pain with discogenic cause. Caudal epidurals, these are the oldest types. The 1901, it's always funny to hear the history of this, cocaine was used to try and treat sciatica. That was the common anesthetic used at that time. Didn't help much, might have felt good for a little while. The first reported steroid use was described by Levra in 1953. This article was actually in French. I had to get a translation to see it, but they used a steroid via caudal approach. Important things to note, this is just, sometimes this comes up in test situations, but you don't want to advance the needle beyond S3 because the fecal sac ends at S2 in most people. The medicine is nonspecific, so it kind of goes to multiple places. There's a statistical improvement shown in one study, again a small study of 68 patients in axial back pain for central disc herniations, short and long term for discogenic low back pain, and a study again, these are small studies, but 72 patients with stenosis had some meaningful relief. That's just a picture of a AP view of a caudal injection. Sacroiliac injections, I think these, it's interesting, I sometimes have patients that come to see me from a rheumatologist. There may be people here that do this too, but it's been shown that if you do blind SI joint injections, so without guidance, ultrasound, or fluoroscopy, you miss it 78% of the time. So only 22% of the time are you actually intra-articular. So I think it's a little much to bill that as an SI injection as opposed to a trigger point if you're not using guidance. Diagnosing sacroiliac joint pain can be challenging. Patients typically have buttock axial pain that may radiate around to the hip or groin. Sometimes it can radiate down the leg. Typically you want to check to make sure they don't have a hip that's mimicking it, hip pathology. And they usually, studies have shown that you need at least three positive SI maneuvers. I have a picture here of an SI joint injection. And then these are some of the more common maneuvers, sorry, that you do. So distraction, thigh thrust, there's SI thrust where you press on the SI joint while they're prone. Faber, compression, Gainsland's, and Yeoman's tests. This is in the slides if you need it. Sorry. Intraarticular injections have been used for a long time but the data really doesn't support them very well. There's been some conflicting data and it's actually hard to get these things approved by insurance companies. That's putting cortisone and an anesthetic into the joint. Some of that may be that the joint's just not big enough to hold a meaningful amount of steroid or that sometimes it's loculated, the medicine doesn't get throughout the entire joint. We tend not to do them too much. This is a picture I dug up of a intraarticular injection so you could see the line of contrast going into the Z joint there. Medial branch blocks. These are done for facetogenic pain and are more commonly used. There are two branches that supply each joint, the superior and inferior articular process. You put a small aliquot of a concentrated anesthetic and patients are given a pain diary. This is always fun to interpret because sometimes I think we want it to be positive and sometimes you'll get someone who said, well it helped for the first two hours, then it stopped helping and then it came back again or it helped the next day. Those are not considered positive pain diaries so they should have a meaningful decrease in their pain and it should last the duration of the anesthetic. Insurance companies like this and we practice this way. You have to have two positive blocks before proceeding to a radiofrequency ablation which would be to ablate those nerves using heat energy. I'll talk about that in a minute because there's a placebo, a study from Schwarzer was showed that there was a placebo response in over 50% of people if they didn't have two blocks. So if someone gets one block and it's positive and then they get a second block and it's negative, you don't proceed with ablation. That's just a picture of where you place it at the junction of superior articular process and transverse process is where we go. Sorry. Ablation uses thermal energy to interrupt pain transmission. The needle tip gets to about 80 to 85 degrees Celsius which is kind of hot. Selection criteria varies. The data, most people use 80%. There have been studies that show people are happy with 50%. I know that in Australia they like 100%. The relief that you get from an ablation, we usually tell patients it could be anywhere from six to 18 months because the nerves can regenerate. And this is just a picture of ablation. The reported complications, they're rare but you can get a hematoma around where you were placing the needles. Neuritis meaning kind of inflammation of the nerves in that area where possibly if you're close you can get some lumbar radiculitis. Neuroma, localized numbness, infection. Sometimes people report itching in their back and then, I've never had this, but needle breakage. That's bad. Last thing I'm gonna go through, and again there's a whole, this is emerging literature but I just wanted to mention it. Basal vertebral nerve ablation for what's called anterior column pain or vertebrogenic pain. People who have what are called modic end plate changes which are, depending on what literature you ascribe to, but degenerative end plate changes that you can see where they are signs of disc degeneration. Type I are bright on T2 images and dark on T1 and type II are bright on both. The basal vertebral nerve carries a pain transmission from the vertebral end plates. So what is done, we have a doctor who's piloting this at our group. The early data's been kind of promising. There haven't been any major adverse events but this is something that's sort of an emerging treatment. That's just a picture of the basal vertebral nerve. You go through the pedicle and you place a catheter that's kind of through that area that has a J curve to it to heat up and destroy those nerve endings. So in summary, I'm doing a whirlwind tour through here but there's really not a magic bullet for back pain. I think we'd all agree with that. I've been tasked to talk about how we treat it and there's a lot of things out there but really a multidisciplinary approach with these people and integrative approach is really, I believe, and I think it's getting more and more supported by literature, meditative strategies, other things that you do would better suit these patients than always trying to identify a pain generator. My references are here and thank you. Thank you. I'm in private practice in a big orthopedic group in Austin, Texas. I'm one of three physiatrists in the group and there's like, I think, 36 physicians. The rest of them are orthopedic surgeons and a couple of rheumatologists. So I'm kind of coming at it more from a private practice perspective. I am not, I take insurance, you know, I'm not cash based. I'm not necessarily, you know, billing myself as an integrative medicine physician, but I've kind of incorporated a lot of the integrative approaches and being able to talk about lifestyle with my patients really have been beneficial, especially, you know, given that I'm in Austin and we have a lot of the keep Austin weird and, you know, just kind of, you know, people who are really seeking more active role in their health and pain. So that's kind of how I started really integrating a lot of this into my practice. My talk is going to be mostly about nutrition and supplements for pain. There's not really a lot of supplements specifically for back pain because obviously you're taking it internally and it's going to go everywhere. So I kind of talk about nutrition and supplements to people who are interested with any pain. Let me see if I can, there we go. So why the sudden interest, I guess, in nutrition? So I remember when I was training, you know, they used to have, you know, they used to label a lot of things, complimentary alternative medicine, that this was an alternative to traditional medicine. And you know, there were some more traditional physicians that kind of poo-pooed, you know, anything that was outside of what you learned in medical school. But then, you know, more recently we've kind of seen a shift in that mentality and more focus on just wellness in general and really looking at ways to promote, you know, more health and wellness in our patients and more preventative care, that kind of stuff. We've seen a rise in the cost of pain care. We also have a crisis in terms of addiction, opioid, you know, diversion, overdose. And there's been a lot of pressure placed on us as physicians to really try to shift away from our traditional approach of giving medications, whether it's opioids or non-opioids, surgery, procedures, and really trying to figure out a way to make these patients better without those things. Overdose has been an issue even before the pandemic. The pandemic, I think, has accelerated a lot of these addiction and overdose issues. And we've seen a lot of media coverage recently of fentanyl overdoses, especially in the teens and the young adults. So even in my own community, we've had, you know, several overdose deaths of teenagers and it's been heartbreaking just to see what's going on in the community. So you can kind of see, just in terms of the overdose, what it's been doing since the onset of the pandemic in 2020. You can see that the angle of increase has shifted. And then the more synthetic opioids are becoming a bigger issue than, you know, in the past. Sorry. And then the impact of COVID on pain. So, you know, we have a white paper out just in terms of how we approach pain patients during the COVID pandemic. And we've seen that there's an increase of pain, but then related to that, a lot of psychosocial issues, as well as mood, catastrophizing, you know, decreased resilience, and there's a lot of social isolation and increased conflicts within our families. And I'm sure many of you have seen an increase just in general of anxiety and frustration in our patients. You know, a lot of patients have pretty short fuses now. So, you know, it's not uncommon for me to have to get involved with an angry patient about something really small like an appointment or whatever. They had to wait longer than they expected or they couldn't make the appointment that they wanted online and they got frustrated. And so as physicians, we've kind of been burdened with dealing with a lot of the untreated anxiety and frustration and depression that's kind of accumulated over the time that we've been more socially isolated. So nutrition, supplements, and pain. So, you know, nutrition has been a pretty big industry globally as well as in the US and obviously it's worth billions of dollars. And in 2020, and probably as a result of a lot of the media attention on supplements to treat COVID, we've seen an increase in, you know, supplement sales. And so you can see there's, you know, the references talking about the increase in sales in that 2020, April of 2020 is kind of when we think that the United States has really entered that pandemic peak at the beginning when we started shutting down and stuff. So people are going online to buy supplements to try to protect themselves from COVID and using a lot of the immune, you know, modulatory supplements to try to treat COVID and prevent COVID. But in terms of pain, you know, these are some of the supplements that I usually cover during clinic visits if patients are asking about it. My orthopedic colleagues, you know, will usually poo-poo, you know, glucosamine and chondroitin because there have been a lot of studies that show that it may not be as efficacious in certain subgroups. But from most of the research that I've read, it looks like there's some weak evidence that it does help. And, you know, these are all about level B evidence, but then it becomes a risk benefit calculation. So what are, you know, what's the risk of taking it? And so what I usually tell patients to do, especially with those with Neo A or Hippo A, is they can try taking it for maybe three months and they can see if that helps. And if it doesn't help, maybe they stop it for after that three month period and see if they notice a difference when they stop it because sometimes the effects are pretty subtle and they don't really recognize it as helping. But then when they stop, they realize, oh, maybe it was doing something, you know, after all. So I usually do tell them to try that. I don't think there's anything to lose by doing that and there's not too many side effects or issues that have been reported with glucosamine and chondroitin. There was a 2018 meta-analysis looking at supplements for OA. And I usually will apply a lot of the OA data to lumbar pain, chronic lumbar pain, because a lot of that is facet pain and degenerative spine pain. And so I figure degeneration in other parts of the body will also affect the spine as well. So these are the supplements that they saw. Some clinically important effects of pain reduction they looked at it short term. Collagen, passion fruit peel extract, turmeric curcumin, which is the same as turmeric but a slightly different formulation. Boswellia, I'm not sure if I spelled that right, pycnogenol, I'm not sure what that is, and then l-carnitine. And of those, primarily I've been recommending turmeric because those are more readily available and that seems to be kind of the more popular supplement because you can go to a cafe and get golden milk and it tastes good too. So fish oil has always been shown to have some anti-inflammatory effect. And it's been studied in a lot of different pain conditions. Omega-3, so I do get some vegans and plant-based patients who ask about whether they can take flaxseed or an alternative because they don't eat fish. And unfortunately it doesn't seem that flaxseed-based omega-3 has the same effect as the fish-based omega-3. I have been more recently recommending more algae-based omega-3 because I think at least there's some correlation that that may be a little bit closer to fish omega-3 than flaxseed. So bottom line in terms of what I recommend my patients in clinic when they start asking about, well, what supplement should I be taking? I'll usually recommend vitamin D supplement even though I'm in Austin. When I used to check a lot of vitamin D levels before I started getting pushback from the insurance companies about paying for it, I've noticed that even during the summer, vitamin D levels were pretty low in most of my patients. And I've never had anyone overdose from vitamin D supplementation. So I usually will tell them to take vitamin D3. The traditional supplements, the multivitamins have 400 units and that's usually not enough. So I usually will recommend anywhere between 1,500 to 2,500. If they have a document in vitamin D deficiency or I'm able to check the level and it's pretty low, then I'll actually prescribe the prescription strength to vitamin D to 50,000 units. And depending on the level, if it's single digit, I'll have them take that twice a week for six weeks. And then once a week for another six weeks and then recheck at that three month mark to see if their level has risen. If the level is not rising, then I will sometimes refer to see if there's a fat absorption issue. So usually it's either a primary care doctor or a GI doctor that will check fecal fat and stuff like that to see if there's a problem with absorption. I will talk about glucosamine like I said. And then we'll talk about curcumin. I also will recommend magnesium, especially for those that seem to have a component of central sensitization. A lot of them will also report sleep disturbance and magnesium can be very helpful with that. And so in whatever form they can get, I know there's several different forms of magnesium. The ones that seem to be more readily available at most supermarkets is called Calm and it's a powder. And I just have them take a half a scoop or a scoop in water at night and usually it'll help them get some rest. I do caution them that it can be a laxative. So just to kind of slowly titrate up the dose. But that can help with myofascial pain as well as sleep. There's evidence of efficacy of capsaicin, but as you know from some of the products that are out there, even the topical capsaicin and stuff, that can be very difficult to handle. And so that's not usually something that I recommend, although if they're already using it, then I'm not gonna stop them from taking it. And then there's some evidence that vitamin B12 may be helpful for back pain. And I'll usually recommend the whole vitamin B complex instead of just the B12. So I'll tell them to just take the B6, 9, and 12. And if there's any component of nerve, neuropathic pain or anything like that, that can help support that as well. In terms of just nutrition, so not just supplements, but in terms of diet, that's been a pretty big focus of integrative medicine physicians talking about nutritional interventions. And it's a little bit hard for me to do an appropriate nutritional intervention in my practice because obviously I'm in a fairly traditional orthopedic private practice, so I have maybe 15 minutes, 20 minutes for an appointment. But I'll usually start planting the seed, especially if the patient's ready to hear it. And I do find that the patients who ask about diet tend to be ready to make that mindset change from the passive mindset of give me a pill that's gonna help me, or do a procedure on me to what can I do to make myself better? So can I change my diet? Can I go to physical therapy and learn what I can do? Can I make some ergonomic changes at work or at home? And so it's really part of that whole conversation that I'll bring in the nutrition conversation. And there's been plenty of studies showing that you can significantly reduce pain in patients by altering their diet. And most of the studies have looked at the anti-inflammatory diet. Sorry. This is a white paper. I'm gonna speed through some of the slides just in the interest of time. But all these slides are available in the slide deck in your app, so you can read through some of the papers later. But I thought these were pretty interesting papers. For the anti-inflammatory diet, we usually talk about whole foods, avoiding processed foods, avoiding trans fats, and then really trying to be a little bit more plant-based if possible, looking at utilizing some of the things that we talked about in the supplement lecture about turmeric and ginger and spices and stuff like that to help. And then again, a lot of these supplements in terms of micronutrient deficiency that really may not have shown up on lab work that the primary care doctor may have ordered, but really trying to encourage incorporation of foods that contain these nutrients as well. So the polyphenols, the fruits and vegetables, I usually talk about that. There's a pretty good handout for patients on that IASP website. So a lot of times when I don't have the time to get into the nitty gritty details of their daily diet, I'll usually recommend books and websites that are reputable. So this is one of them where they kind of talk about practical tips to try to increase the fruit and vegetable consumption, even economically considering that it might be more expensive to get organic and fresh fruits and vegetables, encouraging the use of frozen vegetables versus canned, that kind of stuff. And then cheaper oily fish like sardines even or salmon. And then oils that they use for cooking and eating and covering those kinds of things. And then talking about water intake and then sugar intake. So a lot of, some patients are not aware that sugar is not just sugar sweet, right? You have the simple carbs that just basically turn into sugar in your body. So a lot of times it's just raising awareness of what are you eating for breakfast and lunch and if they say, well I'll have a pancake and some coffee with creamer and sugar. And it's like, well, that may not really last you that long after you eat that. So having some practical advice to give them and trying to incorporate it into your own lifestyle is helpful just to kind of be able to talk to them about that. So I think, I usually like to talk about this in a lecture like this because I don't know how many of you are practicing specifically integrative medicine practices. I know there are some out there. And a lot of those practices are cash based because it's really hard to work within the paradigm of insurance company payments and stuff to be able to squeeze in to a 15, 20 minute visit a full comprehensive evaluation of lifestyle and diet and nutrition and lifestyle sleep and all those things. And so there are physiatrists that are venturing into that. A lot of them will kind of start slow where they might maybe start integrating some cash based practices and find that patients are willing to pay for your time. But also taking insurance so that you can kind of do both for a while. I have tried to do things that are kind of time effective where I have handouts and I also tell them about books. Saloni's book has been really helpful just because I have kind of a one stop shop, I guess, for being able to tell them to just go get that. That'll help you with the mindset part and really kind of start your journey in terms of trying to use some of these lifestyle approaches to help your pain. I also, there's a book called The Anti-Inflammatory Diet. That one also has a lot of science behind it. It's a PhD. I think she's a biochemist that wrote it. So it actually gets into the nitty gritty details of why some of these dietary changes help you. And then most communities actually have a network of dieticians and nutritionists and integrative medicine doctors and holistic primary care doctors and holistic pharmacies. In Austin we have People's Pharmacy. There's an online Facebook group of like-minded practitioners and stuff and there are physicians on there. Sometimes I read the post and I'm like, I'm not sure about that. But you can kind of get involved in that community and kind of see what's out there in terms of who you would be able to send your patients to to kind of co-treat. And that can actually help your referral base as well. And that kind of changes the types of patients that come into your practice because these patients are paying to go see these practitioners because they hold that belief that that's what they want to do. And then you get those patients into your practice which can be a little bit more satisfying to treat than having clinic after clinic of chronic pain patients that just want their opioid refill and that kind of stuff. So from my perspective it's actually helped me in terms of my own burnout because I feel like I'm conversing with the patients about something meaningful. And so this is kind of what I just talked about. And you can kind of go from anywhere from zero to 100 in terms of how much of this you want to incorporate into your practice. And I don't think I'm ever going to get to that point where I want to go full time, just integrative. And cash is just not something that I can do within my own practice setting. But there's room to be able to incorporate a lot of these strategies. And I think as physiatrists we're uniquely positioned to talk about these things because our training is more about quality of life and function and lifestyle. And what do you want to be able to do that the pain stops you from doing kind of question versus what nerve innervates that area so I can block it. So there's definitely a role for procedures. I'm not poo-pooing procedures because I obviously perform those procedures. But I have something to be able to offer those patients that I know that a procedure is not going to help. So I think that's that part. If you want to. Hi, I'm Eric Ensrud. I'm from the University of Missouri. And I was happy when Sloney asked me to come and speak with you all. They're just getting my slides up. But to talk about exercise and sleep and the effects on low back pain. Because I think they both actually have pretty profound effects. And part of this kind of army of complimentary things we can do with patients, they can be very helpful. So I think when I'm in a setting talking to physiatrists, I always feel like I have to frame shift everybody as to what is exercise. Because this is a very fit group. And we need to kind of think about what might be exercise for our patients rather than the average physiatrist. So instead of thinking about things like the Peloton bike or we've got a triathlete here on the right, very fit. You know and this is an audience that would probably score very well if we gave you a quiz on what does H-I-I-T mean or Tabata and those type of things. But really when we're working with our patients who have low back pain, I mean it's really helpful to think about gentler types of exercise. Water exercise of course is great with people with axial back pain. And think about settings like a Y or a community center or a JCC, ways that we can help our patients access the forms of exercise that can be helpful for them. I have a father who's 96 and a stepmother who's 95 and I've moved back to the Midwest to spend more time with them. So I've spent a lot of time actually at a senior apartment building in Minneapolis that's full of elderly people and they have exercise classes sitting in a chair. Now I know while we're speaking about spine, this is axial loading and everything but just the exercise itself can be helpful. So there are all sorts of forms that can be helpful. You know low intensity and when we're talking about you know if we've got patients who can tolerate more aerobic exercise, what tends to be really helpful is if you mention to them the talk test and that's actually very specific for getting patients at about a VO2 max of 65 where they can get a real benefit from that and that's telling the patients that you should be exerting yourself at a level where you can hold a conversation. I had to be careful because I was telling patients exert yourself at a level where you can hold a conversation and they were coming back and saying, it's going really well but people are getting tired of talking to me. It's just you feel you could hold a conversation is the talk test and that actually correlates very well with the VO2 max of 65%. Oh and back here, you know and then again with our more elderly or more mobility impaired patients, thinking about different forms of exercise, I as part of my role as a helicopter child put a Fitbit on my dad and occasionally he would get this great step count and I'm like, what the hell is going on? And he was going to Super Target and walking around. If you think about somebody who's got pain and mobility impaired, you've got a cart to hold on to. There are lots of interesting things to look at. It's a huge store so you get lost. So instead of the frustration that we feel going into a place like that, the surface is level, it's temperature controlled. So I actually frequently recommend to patients that they go to big box stores and walk around. It's not gonna work as well as like a Whole Foods or a Trader Joe's where people are battling with those mini carts and all stressed out. I don't know if you've ever seen that video, it's getting real in the Whole Foods parking lot. If you haven't, I highly recommend it, it's very funny. So there are systematic reviews on exercise and low back pain as part of a plan and this one I really liked. It actually has a physiatrist, Jana Freedly, who's our editor of PM&R was on this. Non-pharmacologic therapies for low back pain, a systematic review. This was in the Annals of Internal Medicine about five years ago. And some interesting things I pulled out of that, that there was newer evidence that Tai Chi provided some evidence for low back pain and strengthened previous findings as well regarding the effectiveness as yoga and so overall the evidence continued to support the effectiveness of exercise. And you know what, best moderate. But it looked good and just in comparison, the same group did a pharmacologic therapies review the same year, the same group of authors, same journal. And for opioids, the evidence remained limited to short-term trials and again modest or moderate effects. So when we think about it not giving much effect, I mean it's similar to other things for chronic low back pain. Now we do have, just last year, a more recent systematic review and meta-analysis from the British Journal of Sports Medicine. And they looked at 27 published reports of 25 different studies. And you know, big grouping, lots of patients, over 8,000. And they found moderate quality evidence with about 600 participants that an exercise program can prevent future low back pain intensity with a mean difference of negative 4.5. And then with about close to 500 participants they found that exercise and education can prevent future disability due to low back pain with a mean difference of 6.25. So I thought, well that's great, it sounds pretty big but what does the mean difference mean? Well when you look at the paper here, the mean difference, that scale where they're reporting those they converted the outcomes to a zero to 100 scale. So we're thinking about five to six out of 100. So not very big, but again we're thinking about putting it together with supplements, putting it together with nutrition and other things. You add enough sixes together, pretty soon you're talking real numbers, right? And if anybody in the audience, like if your practice said we're gonna give you a $6,000 bonus, everybody put their hands up who would say no? So there is some meaningful evidence, adding it together. So there's actually a Cochran review, there's a Cochran review on everything. I was thinking before this talk, I wonder if there's a Cochran review or like a systematic review on systematic reviews. Gotta look for that sometime. But a yoga treatment for chronic nonspecific low back pain and they did find low to moderate evidence and Cochran is very stingy, those reviews. So this is good that yoga compared to non-exercise controls did recommend, did result in small to moderate improvements in back related function at both three and six months. So that's certainly something that you can recommend to your patient, it's something they can do now, you know, post COVID at home via Zoom or do, you know, in a class setting and enjoy that camaraderie. And then something that, another form of exercise, isolated lumbar resistance, extension resistance training. This is from our journal PM&R in 2015, did a review on that and if you'll remember that Cybex machines I think were actually invented by a physiatrist and these results suggested that isolated lumbar extension resistance training produces significant and meaningful improvements in perceived pain, disability, and global perceived outcomes. And what was interesting about that is that a low frequency yet high intensity of effort just once a week seemed to be enough to provide sufficient for meaningful outcomes. And this of course is a machine like this and it could be done on a Cybex type machine like this or it could be done on a Roman chair, which is a inverted back extension type thing. The problem with this is how many of our patients actually have, you know, access to this? And so I'm always thinking, you know, I have a lot of patients where I could tell them to like exercise in the street, but the street they live on isn't a place of safety. You know what I mean? So they need to be inside and what can they be doing? And you know, you can have patients lie prone like this and hyperextend, lift their arms off. They lift their feet off too, I'd do that, but I'd fall down. But that's not so great for low back pain, of course, because that's going to load the facets, narrow the nerve root frame. Hyperextending is not good. So this, you know, is a little bit limited, but for selected patients can be very helpful. I found this very interesting. You know, we think about exercise as being, you know, more maybe it affects your brain, endorphins, but there actually are some papers on real musculoskeletal effects of exercise. This was a great one, that running exercise strengthens the intervertebral disc from just a few years back. And here's their kind of summary graph here. And on the left side, they're looking at the T2 signal, you know, related to better hydration of the disc. And on the right, they're looking at the height of the disc related to the height of the vertebral body. In the groups, the red is 20 to 40 kilometers total running per week, and the black is 50 kilometers per week. But you know, the signal of the hydration of the disc was actually significantly better in both the lower distance and higher distance group. And then the width of the disc compared to the vertebral body was significantly different in the higher distance group. So there really are some musculoskeletal effects as well. So cost considerations, you know, what if insurance paid for two 30-minute personal training sessions per week? Well, as part of this helicopter child thing, I did look up the, you know, got my dad engaged with the YMCA across the street and eight 30-minute personal training sessions for one month for $340. And just think about how many of our treatments cost $340 a month. I mean, it's really kind of a societal decision we've made that we don't value providing exercise for patients the way we do drugs. I mean, it kind of blows my mind as part of my work with muscular dystrophy patients. I have a patient who's on a drug that's $2 million a year, just that drug. So exercise is certainly a reasonable addition to consider in a low back pain treatment plan. And this, I have found time in time-limited appointments to ask patients about their exercise and what they're doing and, you know, are they walking the dog and so on. It seems to work well and can be incorporated. It's part of my templates. And then really, finally, maybe the biggest effect over musculoskeletal endorphins with exercise is really when patients suffer from pain, they're really experiencing an external locus of control. You know, why bother? There's nothing I can do about my future. This is something that happens to them and we all know that's highly correlated with depressive symptoms. And getting the patients to engage in some level of exercise, even if it's going to the super target a couple times a week and walking around, is, you know, I'm doing something, bringing that locus of control inside, lowers depressive symptoms. Look what I can do, I can affect my future. And this is, it's really a profound effect. And so Saloni also asked me to talk about sleep and low back pain. And that's really a can of worms, kind of a gruesome twosome. Think about it as like two monsters dancing with each other. So there actually is something that, there's a paper that proves that we of course, everyone knows, on the bidirectional relationship between pain intensity and sleep disturbance or quality in patients with low back pain. And they of course showed, you know, they use sleep monitors and also a sleep diary that a night of poor sleep quality, you have difficulty falling asleep, you woke up after sleep bomb set, or you have low sleep efficiency, will follow with a day, it's statistically correlated with a day of higher pain intensity. And then the converse is true. If you have a day of higher pain intensity, then you have a decrease in the subsequent night's sleep quality and increase in sleep latency, waking up after sleep onset and low sleep efficiency. So asking about sleep is just difficult and difficult to contain to an appointment. But I'm gonna propose something different for you here and something that I've used actually quite a bit is asking patients about their mattress. And there actually is a review of literature about mattresses in low back pain. And this is from last year and they looked at 39 articles on mattresses for patients with low back pain. And the results of their review showed that a medium firm mattress promotes comfort, sleep quality, and rachis or low back alignment. So kind of thinking about that, kind of before this came out separately, you know if we think about most patients end up sleeping on their back and that induces a lateral bend in the lumbosacral area. And that of course is going to load the facet joints. So this is something that how many people have ever slept on like a poor quality mattress, a very soft mattress, and you will almost inevitably wake up with low back pain even if you didn't have it when you went to sleep, right? So if anyone here has lived in New England maybe 10 to 15 years ago, you might recognize these two brothers, Barry and Elliot Tatelman. They are actually the brothers who started this furniture store, Jordan's Furniture, or at least blew it up. And one of the main things they did, they had very entertaining commercials on TV so they were fun to watch, the two brothers. But instead of the standard, you know, coiled spring mattresses, they realized that you could do a mattress with a pillow top. And this is kind of an interesting thing. And so you have half the mattress surfaces, right? Because you can't flip a pillow top mattress. And also this cushion that helps with a firm mattress wears out because it's compressed a lot. So the mattresses don't last as long. So you're selling a lot of mattresses and new mattresses to people. And Jordan's did extremely well. In fact, so well it was purchased by Warren Buffett and is now, and became part of Berkshire Hathaway. So they did very well, but you know, this is a little more expensive. So I have a little bit different approach. I have patients try and find an extra firm, just standard spring mattress. And these are actually not easy to find now because the entire mattress industry loves the whole pillow top concept because the mattresses wear out faster. But so what's the problem with an extra firm mattress is then you get pressure points when you're sidelined like most people on your shoulder and your hip, and it's too firm. But that thing that wears out, that softly compressive thing, you can just have them get, you know, at Costco or at Target anywhere, we'll have these, you know, kind of Tempur-Pedic foam tops or an egg crate top, and then put a couple mattress pads on top of that. So you're trying to get the spine aligned better with the extra firm mattress and then cushion the pressure points with that soft top. And as that wears out, that can just be replaced and they can flip the mattress. So I actually have spent quite a bit of time talking with patients about mattresses. So just in summary, you know, exercise can be helpful as part of our group of therapies that we use along with your RFA, again, and your nutrition. And, you know, really helps, I think, primarily, or the greatest effect is bringing in that internal locus of control. And then try and avoid that vicious sleep, low back pain circle, and consider mentioning mattresses to your patients. Thanks. Thank you. All right, well, I know everyone's getting tired, and thank you for still being here Saturday morning. So I'm so grateful to have amazing colleagues who are up here with me, who went through all the data, and we can try to piece it together now, and really take an integrative and lifestyle approach together. So, here we go. That's me. I'll move on from that. I'm going to sort of kind of buzz ahead in the interest of time, but when I was a resident, I was taught five ways to treat pain, back pain, neck pain, joint pain, right? And Jeremy and other people are familiar with this. The number one was lifestyle, but in my teaching, that was weight loss. That's all lifestyle meant. And it meant maybe tobacco cessation, and it was something we glossed over in favor of all the other things, right? So it's lifestyle, PT, medications, therapy, injections, surgery, you know, those sort of like the big boxes. But at this point, we're sort of pausing, taking a look back, and saying, well, why are we skipping over lifestyle, right? So that's really what I want to delve into. These are the components of lifestyle medicine that address back pain, and guess what? They're the components that address all conditions. So I think wherever you are in practice, if you're an SCI practice, if you are, even if you're an internist, lifestyle medicine applies, and it reduces inflammation and disease. You just have to spin it for your group and your C-suite in a way that matches with their motives. So these are integrative treatments, and my concept is really to put them together. And the reason we have to put them together is because this is the biopsychosocial model of pain, right? It's so complicated. There's so much going on. You can't just address it with one or the other. You really want to take the best of lifestyle medicine and integrative medicine and make it your own. So I think we know that, you know, back pain's a big issue, right? So these are the global burden of disease. These are the top four causes of disability. You can see that back pain's number one. And then MSK, neck pain, and depression, that's often fed by pain as well. So why do we even want to have this approach, right? And my colleagues have gone over this. We have a pain crisis. We have an opioid crisis. We have a medical system that saves lives, not quality of lives. And we're really not about building health and prevention, and we want to live better, and our patients want to live better. So it's really combining the evidence of things they can do themselves to empower themselves. I'm trying to get my clicker to work. There we go. Okay. So this is a concept of orthopedic integrative health. So if you look at sort of the ring picture, it's conventional medicine, it's integrative medicine, and it's a marriage of integrative and lifestyle. And that's why it's not integrative medicine, it's integrative health, because it's really marrying the two together to optimize typical care. And again, it's not exclusionary, it's inclusive, and it's taking the best of all the worlds that's evidence-based. And I think that's key. We're not talking about standing your head for 10 minutes and hoping that you're going to cure your back pain, right? And maybe there's some merit to that, I don't know, but that's not what we're talking about. We're talking about evidence-based medicine and really using the best of all of our data. And these are the factors that affect inflammation pain. They're similar to lifestyle factors, right? So it's food, movement, sleep, stress, relief, really, and relationships. So this is actually a picture I show patients who I see in the Orthopedic Integrative Health Center, which is a program that started at Rothman Orthopedics. And we talk about, you really have to be upstream on the left. So on the right is the pain dysfunction. It's fed by inflammation. But you have to make these lifestyle changes. And so I really like them to have this visual, because it's like, well, why are you talking about diet? Why are you talking about exercise? And it's like, this feeds that inflammation. This feeds disease. This feeds pain. So I think that education piece, which some of my colleagues mentioned, is so critical. If they don't understand why you're talking about this, then it's not going to be meaningful to them. Oops. I was supposed to talk about whole body approaches. I think everyone in this room knows that there is data, varying data, but there is data for acupuncture, tai chi, yoga. These are some of the VA recommendations. I was at another great lifestyle talk another day, and they talked about the VA's whole health approach, which is actually kind of similar to this approach. It's marrying integrative and lifestyle medicine, evidence-based way. And they definitely support acupuncture, CBT, and some of the integrative type treatments that we use. This is the data, like I said. I'm just going to skim through this. It's all in this slide deck. We know there's data for acupuncture. I really want to get to this. This is sort of how my program's built. And I think this is something, again, trying to be practical, that you can do at your own institution and make your own version of this. I call it the 5R program. So it's based on nutrition, exercise, sleep, stress relief, and relationships. And it sounds cheesy, but that's what patients like. That's what people like. They like mnemonics. They like things that are easy to remember. So this is my relief 5R program. It starts out with nutrition, which Dr. McKay did a wonderful job of covering. I just like this picture because it shows the value meal in the corner, and right how that goes to the pain, the spinal cord, and so feeds inflammation. So I think that's an important way to look at it is, you know, it matters. A standard American diet is sad. It feeds inflammation. It feeds pain. It increases pain. It increases pain flare-ups. It slows down recoveries. It affects your lean body mass and your fat mass. And the American Heart Association has shown that 90% of Americans sort of match up to the sad diet. So there aren't enough vegetables, not enough fruits, and a lot of processed foods. This is the data. Actually, this is a study about knee pain specifically, but like Dr. McKay said, you can extrapolate a lot from joint pain to back pain, too. It's a lot of degenerative overlap. But they found that polyphenols actually help slow down oxidative damage and arthritic degeneration. So I think there's data there, and we just have to learn how to present it to our patients the best way. This is actually this ISAP study that Dr. McKay mentioned. I just took that right from her slide deck. But on the right is the anti-inflammatory pyramid. That's Dr. Weil's pyramid. And it's pretty simple, right? It's fruits and vegetables. People want visuals. So I think making handouts, when we get to the practical part, I think that's the easiest way to incorporate this into your practice is to have handouts and visuals. And so you can just say, stay at the bottom. And they try to call meats, like meats and treats are in the top. So they're sort of not something you necessarily do every day, but that you can participate in. And the plant-based diet, there's a lot of good data on that, but no one has to be vegan or vegetarian. If you're going to eat meat, it should just be two or three times a week in high-quality meat. So no one's saying you have to do this, right? It's saying, eat the way you want to eat in terms of the types of food, but have the best quality food and the best sources that are possible. This is another good resource. This is MyPlate.gov. So I'm going to show my age, but when I was in high school, we had the horrible black pyramid of 1992, right? It's all the carbs and processed food on the bottom. It's like, eat all this, right? So now they change it to a plate, thankfully. And this is a clickable thing. You can go to their website, and your patients go to their website and actually use this. So you could have that last pyramid plus this on a handout, and you could already be helping your patients and empowering them. And it makes a difference. When a physician says nutrition matters, that makes a difference. When you don't just say, refer a dietitian, refer a dietitian, which I think is a really valuable resource. I think it has to come from you first, and that makes a big difference for patients. So we're just moving along. We had a great talk about exercise, right? So we're just putting it together. So we talk about exercise is a secret sauce, and that's sort of in the top of this graphic. It releases natural endorphins, right, pain killers. It activates your endocannabinoid system. It improves mood through serotonin. And through myokines, it actually helps inflammation. So I think if you can frame it like that to your patients, that these are natural ways to activate all these great systems without taking pills, and there's evidence behind it, I think that can be helpful. This is a study that came out last month. Oh, my screen went blank. This is a study that came out last month in the Sports Medicine Journal. And there we go. And it basically said that if you can do some light exercise after eating, even just for five minutes within an hour of eating, you can help with your insulin and glucose spike. And we all know that that helps with inflammation. So I think a lot of this can translate to pain. Again, it's lifestyle medicine, but we can sort of niche it down to whatever area we focus on. I'm now going into the sleep. And my clicker is so fussy. There we go. So this is sort of basic sleep hygiene stuff that hopefully most of you are familiar with. And again, you might not be able to talk about all this stuff with your patients, but if you have handouts, I think that's really the best way. This is sort of a typical sleep hygiene thing, like no screens 30 minutes before bed, have a relaxation routine, that kind of thing. And then if you throw the integrative piece on top, then you can sort of even empower them even more with mindfulness, meditation, you can talk about breathing, body scan. I'm not a big supplement person, I'm more of a food first person. But patients want to know about supplements, so I think you need to know about that. But instead of taking melatonin, you could try to change your diet to have melatonin rich foods. And the same with magnesium. Like I said, it was sort of buzz through. If anyone in this room doesn't know there's data behind mindfulness, then you've sort of been living under a rock, right? So there's a lot of good data. We know it helps people. It's just how to make it accessible for people. And I think a lot of the free apps are a nice way. And sometimes we'll have people like download the app while they're in the room. I think that can be empowering. I think showing them how to use it can be empowering. And just, again, having a list of recommendations. Because if you're new to this, and you just go onto, you know, like the App Store or whatever device you have, it's really overwhelming. So saying, look, this is the one I use at home. Oh, I use 10% Happier. Oh, I use Headspace. And there's a free version. You can just do it five minutes a day. That's how a lot of my patients and colleagues, when you're in the parking lot before you leave work, it's five minutes there, right? Because a lot of people don't have time for this. But they really need to shift from work person to home person. And if they don't do that, then the stress and inflammation and then the pain, it's all cyclical. So I think really making it practical for people is part of devising your own system. This is just another graphic about how we know mindfulness and meditation is so great. And some people, I've had patients who are sort of turned off by the term meditation, which is unfortunate. So mindfulness seems to have less of a religious or cultural connotation. So you may want to just spin it that way, even though there's a lot of overlap. So this is a huge, like a whole topic on its own, talking about relationships, family support, and how things impact pain. There's a reason that social isolation or solitary is the worst punishment in jail. It's because it's bad for you. It's bad for your mind. It's bad for your body. And we've all experienced this with the pandemic and social distancing. But if you have a lot of pain and you're by yourself, you tend to perseverate on it. And it's cyclical. You tend to have less human connection. It actually makes your pain worse. So I think mentioning that it's a factor for pain is important. And as an aside, like Jeremy mentioned, I'm part of a large orthopedic group. And AAOS, the American Academy of Orthopedic Surgeons, their surgical toolkit actually mentions all these factors. It mentions optimizing this for better surgical outcomes. So the data's there. And our surgical colleagues, if you work with them in a large group, they're aware of it. It's more making it doable and showing them the benefits. And that goes back to some of our other talks we've had other days, which is don't get mad, don't get upset, get data. Right? And that's our big problem. In physiatry, to some degrees, we don't have enough data. So there's a lot of ways that we can make programs like this or similar to this and just track it with the PROMIS scores, which are really easy to implement. So Dr. McKay did a great job talking about different ways to add this to your practice. So I will not dwell on that. I still think handouts are the way to go if you don't have time or the ability to sort of make your own program. These are some of their resources. And again, it's all in there. I want to talk about the lifestyle medicine free resources. So this is their picture. This is a little screenshot of their nutrition handout. This is a screenshot, a couple clicks, come on, baby, let's see, of activity. And so it defines the moderate activity versus vigorous activity. These are all free resources. So this is not anything you actually need to even be a member of, although it could be helpful. Stress reduction, things to do it, how to make it easy. Sleep hygiene. And then also touches on social connection, which I call relationships in mind. So these are just free handouts, and the website's right at the top there. There's so many resources and ways to incorporate this, but again, it has to come from the physician. I think if you just send someone, say, oh, yeah, go talk to the dietician, go talk to the physical therapist, that doesn't have the same impact as saying, this is important, I want you to do this, and here's a script for therapy, and here's a referral to a dietician. So having that extra minute can really impact the patient and how invested they are. And that's pretty much it. There's lots of resources. I'm happy to talk with anyone afterwards. I know it was kind of like a whirlwind, but we definitely have time for questions. So feel free to use the microphone, or apparently there's some app stuff and live streams I'm supposed to look at, too. Yeah. I'm actually, I'm going to represent the people, the virtual people. There's a question about, can you comment on artificial sweeteners from the virtual community? They're bad. Let's just say that. So sugar is terrible, but artificial sweeteners can be just as disastrous. There's a lot of studies about increased weight gain as well as kidney disease perpetuated by artificial sweeteners. If you want to do sweeteners, you want to go as natural as possible. There's things about honey and agave and things like that, which are nice, but I think it's just natural sugars. If you want to have, you can really retrain your taste buds. So there's been studies about this, and I've written about this in my book, too. You can take two groups of people and have them have a low sugar, meaning not artificial sweeteners, just low sugar without artificial sweeteners diet, and your sense of taste actually changes. So if you can slowly wean the sugar out of your, the added sugar, let me be clear, the added sugar out of your diet, I think that's a better way to go. Natural sugars like fruits and vegetables, those are fine. You never want to just have a glass of orange juice. You would rather have the orange with the fiber to slow down the sugar spike. So I think counseling people, counseling people and stuff like that, like you can still have treats, but in the natural way. I think that answered the question. Yeah. Yeah, and then another question is vitamin D needs liver function to convert to active form. Do you have a strategy for your patients maybe with liver disease? Yeah, the patients with significant medical comorbidities, I usually like to get the primary care doctor involved just because, you know, obviously I get patients on dialysis and stuff like that. So I usually don't go into the supplement conversation with the fairly medically complex patients. I'll talk to the primary care doctors. There are a more kind of integrative or holistic primary care doctors in the area. And I've noticed that a lot of them, you know, because I get their notes will incorporate some nutritional information in there. So usually I'll defer to the primary care doctor if there's significant concern about liver function or kidney function or even, you know, heart issues and things like that. Hi Esther. Hi, great talk. Something I'm very passionate about as you guys know. I'm in Austin as well. So yeah, I get patients that already have an acupuncturist, have a massage therapist, have an energy healer or whatever it is. But my question is, I guess for I, I have a lot of patients asking me about intermittent fasting. It's a, you know, that's like everyone's all about that. And so I've done my own research on it and read books and stuff like that. There's all, there's 12-8, there's 18-4, whatever, you know. But it has shown to reduce inflammation, specifically insulin growth factor. Have there been any studies correlating that, expanding that to pain that you're aware of? That I know of, no. I didn't specifically see that, but it kind of makes sense, mechanic, just mechanically speaking. So I do talk about intermittent fasting with my patients, especially if they're at that point. You know, you kind of have to gauge the audience, right? And so if a patient is eating a standard American diet, from going from there to fasting and plant-based, it's going to be a pretty big distance. But if they are curious about it and they're asking about it, I will, you know, talk to them about Jason Fung's book. I also practice intermittent fasting personally, so I'm able to talk about it kind of more personally. And then, and then, you know, kind of going back to talking about weaning, you know, from sugars and stuff, you know, because with intermittent fasting, you can't, you really don't want to be adding sugar or fat to any drinks, even your morning coffee. You know, I've kind of gone to black coffee, right? So I can kind of talk about my own journey, which usually will get more buy-in from the patients. So I do talk about intermittent fasting as a way, especially in those who will say, you know, that they were told that they had borderline diabetes from their primary care doctor, or, you know, I'm now probably officially middle-aged. And so I can have those conversations with the people who are starting to feel old. So a lot of them, you know, a lot of patients who have back pain, they, you know, may not have gone to a primary care doctor. They may not even have a primary care doctor. They've never had health issues. They're coming in. They're already feeling kind of old because they're like, am I getting old, you know? And so it's that part of that conversation about, you know, longevity and health and wellness that I will usually incorporate talking about intermittent fasting because it's kind of the buzz thing. Yeah. Well, hopefully there'll be some studies that will happen in the future. Thank you. Yeah, just to piggyback on that, I think it goes back to the positive again. So I call it circadian eating. And so trying to do like the daylight hours, in theory, obviously there's daylight saving times and things like that, but not so much focusing on what you're deprived of, but when you're eating, what your eating window is. And I think that's been kind of helped some people. And I also talked to patients about closing your kitchen, like your kitchen closes at 7, like a restaurant, you know, it's just done. And so I think having that cut off, and that can be harsh for some people, but you know, so maybe it's like 8 depending on your sleep schedule. But I like work my patients up who I see in the integrated program. So you really want to not eat based on sleep size, so last three hours before bedtime. That helps your body go into auto aging and clean out cell debris and helps with inflammation. So however we can work our patients there, but I think really talking about, you know, eat when it's daylight hours. Eat really what you can do, not what you can't. I think there's like a subtle difference. One other question from online. Do you have any advice on specific product sources for supplements? Yeah, that's kind of a difficult topic. There are, I think, I don't, usually Consumer Reports magazine actually does do supplement reviews to look at reputable sources for supplements. And, you know, a lot of times it's, I'm Asian and I'm female, which is the key demographic for Costco. But Costco actually has some pretty high quality supplements and it comes in a big bottle. So when I tell them to try the glucosamine chondroitin for three months, I mean, usually it's like a three month supply that you can get at Costco. So I do talk about Costco. You know, obviously there are concerns about contaminants and stuff like that. And actually there are supplement companies that do market to physicians to do kind of more like an affiliate marketing or purchase through your office some of the pharmaceutical grade supplements and stuff like that. And there are physicians that do incorporate that into their practice. I haven't, but I know plenty of physicians that have. I mean, it can be an income stream for, you know, for your practice as well. Just to pay back on that too, there is a website called Consumer Labs. I believe it's a membership one, but they actually do independent reviews of supplements. So yeah, that's a good one. And a lot of the Kirkland brands are on there. Yeah. I have a comment and a question. The comment is, it's kind of funny that you bring up mattresses because I've had patients that literally have asked me what's better in orthopedic or chiropractic mattress. So I just thought it was funny. So now I have a physiatric mattress finally. So that's really helpful. I really was wanting to find that. So thank you. What's hard to wrap around is the fact that we're trying to do this lifestyle medicine for all our patients. But the challenge we have, and there's no way to sort this out, is how do you sort out that patient who's going to really respond well to it, to that chronic pain or, as we said, that is not going to. And I don't know, you know, there are, I have other people would say you could give them some functional instrument to sort out who's going to do well with cognitive behavioral therapy. It'd be great if we had this magical back box instrument that we can give them that says you're going to do great with lifestyle, you need a procedure, and you need cognitive behavioral therapy. And I don't really have the answer to that. But I don't know if any of you guys have struggled with that, trying to sort these people into these different, but they're all going to do well with what you're talking about. Don't get me wrong. But some may do better than others. I just wanted to know if you had any comment on that. kind of sometimes leads them to other conversations to change their lifestyle. Two things. Can I make a comment on that? I believe, is this Dr. Fuhrman over there? I can't see very well because I'm as old as you are now, and we started out together here. But that's been my biggest issue is to try to figure out who's right for treatment, right? So we're actually doing a study now looking at the pain stages of change questionnaire that was originally adopted in the VA system, and we're looking at who's pre-contemplative and who's contemplative. There are actually four of those stages, but if I could just subset out the pre-contemplatives and the contemplatives. The pre-contemplatives, no matter what I give them, no matter what I say, they're probably not going to do it. They want the quick fix. They are not going to change their lifestyle. So how much energy should I spend on them, right? It's not that I give up on them, but maybe we should be doing cognitive behavioral therapy, changing their paradigm so that they're more receptive to being a participant in their overall integrative health, etc. So that's kind of the approach I use, and we're looking at that now for low back pain. We're doing an ongoing study. I have over 200 patients enrolled in that, so more to follow, but thanks for bringing up that point, Mike. Great. I think the other thing, just to finish that out, is if you are doing an out-of-pocket anything, like a membership or just an out-of-pocket program, those patients self-select, right? So it's like if you join a gym, then you're more likely to work out because you put that money out there. So when they're invested financially in their health, it makes a difference, and that's unfortunate, but that's sort of human nature. It's something to think about if you do a program, if it's something, and it doesn't have to be crazy expensive, but you will self-select. They will self-select, people who are motivated, and they have some skin in the game, and so then they're more likely to do things and advocate for themselves and be part of their health care. You're going to do a rough paper, so you want to go? Hi. My name is Kevin Panetta. I'm a PGY-4 Rutgers NGMS counselor. Thanks a lot for the presentation. There are two comments I wanted to make. The first was the question about is there, like, an outcomes or, like, questionnaire that can help predict which patients on the trans-theoretical model are ready to make changes. Last year in AAPMNR, there was an MSK Lifestyle Lecture that actually discussed the model. I think Dr. Heidi Prather from HSS discussed it, how they were able to kind of sort out which patients were better for CBT, which patients were better for more, like, nutritional things, and they've showed data that their model worked and they had good outcomes in determining which patients are eligible for that. The second thing I wanted to mention, this was also discussed in a Lifestyle Medicine talk yesterday with Dr. Beth Fradies, that the White House has an initiative basically to educate physicians, and they put out basically a big grant for a $220 course originally about the essentials of lifestyle medicine and nutrition. So it's actually free if you look in the American College of Lifestyle Medicine website. There's, like, a promo code. You just sign up for it. So it's a 5.5-hour CME course that you can get accreditation and stuff. So I think that would be useful for us as physicians to know how we talk about this for nutrition, especially in food to our patients. Thank you. Okay. Hi, good morning. I'm Elver. I'm a third-year med student from SUNY Downstate New York, and thank you for the great talk. And I was just wondering, since low back pain can be caused by many etiologies, such as sickle cell disease, DDD, or disc herniation, how can we sort of cater or develop the integrative therapies you've introduced to us to cater to that specific pain etiology for low back pain? So I think it goes back to the one figure I had, which is those are all inflammatory-based conditions, right? So, you know, someone has arthritis. I use this example with my patients. Someone has arthritis to their knee. It's not always swollen. It's not always inflamed, but they still have degenerative changes, right? So if your food, sleep, stress, and other factors are contributing to more whole-body inflammation, you're going to have more pain and more painful flares. So I think that's the connection. To your point, you know, we still want to do the treatments that Jeremy talked about, too. You know, it doesn't mean that that person doesn't get therapy directed at their disc herniation and customized to that. It doesn't mean epidurals indicate if they have a redic that you don't do the epidural. We're not saying, you know, poo-poo to everything else. We're saying let's make it better. Let's make it work. Let's make it last longer. Let's have less side effects with medications. And maybe we might do a few less procedures because they don't need it. Hopefully that answers. Yeah. Okay, cool. Great. Thank you. Sure. Hi. Thank you all so much for the insightful talk. I've read that glyphosate-containing foods such as gluten or a lot of other commodity crops can be inflammatory in a lot of populations and disrupt the microbiome. So I was just wondering if any of you have done research regarding this or have seen anecdotally in your practices if gluten-free diets can impact low back pain? So I'll let Dr. McKay comment as well because I think she has something in mind too. But I think it's really working with a good dietician and then seeing if an elimination diet is indicated. For some people it can be inflammatory and not for everyone. But it's really the processed food that's pretty much inflammatory for everyone. You want to get down to gluten because then you can get down to dairy, which can also cause inflammation for people. So it's really having a good dietician. And if all else fails, having to do an elimination diet safely with a dietician, including a gluten-free trial, and then slowly reintroducing foods back in. That would be my take. But you really have to have good resources. It's not something that I would have time to direct in the way my practice is set up. It would really be through a dietician. I think they do cover some of that in the anti-inflammatory diet book, just in terms of common intolerances that some people have. And then some of the intermittent fasting authors, more in the realm of longevity, will kind of talk about ancestral foods and stuff like that, just from your background and stuff like that. So there's not really a one-size-fits-all, like everyone should cut out gluten. But I do kind of talk about what you could do is maybe keep a little diary for a little bit to see, okay, when you do have pain, how was your sleep? What did you eat? All that stuff to kind of get some correlation going. And then if they're motivated, and it is pretty difficult to do true elimination diets, but if they want to do that, they can certainly do that. But that's usually what I go to and what I talk to about. Thank you. Okay. Hi. So I really appreciate the talk. I think it's very obvious this could be its own conference maybe. My question was, I was hoping you could expand or the panel could expand. Dr. Mukai had a slide on financial and practical considerations. You know, to me it's pretty clear it doesn't really fit, like you said, maybe the length of time that you have with a patient in certain types of structures, like an RVU structure for some of the physicians who practice that way. And then, you know, on the flip side, a cash-based private practice, right, may conflict with contractual obligations, may conflict with, you know, conflict of interest, et cetera. So, you know, before we toe that line, do you have any advice to how to fit it into, like, a more academic health system-based format? Or, you know, is it really something that, as many of my colleagues have done in the tri-state areas, just kind of go private and do their own thing? I'm trying to kind of... I'm trying to understand your question. So, are you specifically talking about your setting or how to integrate this into academic practice? Before jumping to private, because, you know, cash-based... Oh, you mean private cash pay? Yeah. Okay. So before doing that, is there anything you would, like, explore within a health system before branching out? Yeah, so I don't do private pay. Like, I don't take cash from patients. I work within the insurance and Medicare and whatever else. So that is kind of my limitation, is that I don't have the time to spend to do the, you know, the entire conversation that we just had, right, because this would take a long time to get all those things. It depends on... I mean, it really depends on the patient, you know, whether they have the means to do that. A lot of them, like Esther said, sometimes they have a team already, or they might come from a concierge primary care doctor that's already, you know, doing a lot of those things, and so I'm just speaking the same lingo and just, you know, reinforcing some of those things. Right. If you're in an academic setting, you know, you can kind of take what Saloni has done, you know, even at the Rothman Institute in terms of showing, you know, some cost-effectiveness and success, you know, in terms of just outcomes and stuff like that, and especially in an orthopedic group, the orthopedic complication rates and stuff. So you can kind of put it... You can come up with programs and paradigms, you know, for example, maybe, you know, you could do a total joint population, because, you know, now there's all these recommendations about not performing total joint surgeries on certain BMIs and up, or if they smoke, or if they, you know... So you can maybe try to integrate that into that kind of program where it is of use to the key decision-makers, so you could do it that way. Academically, you can integrate it into, you know, research and outcomes measures and stuff like that if you wanted to do more research-type things, and there are grants and stuff that you can get as well. Is that kind of what you were thinking, or were you thinking more... Yeah, definitely. I appreciate those insights. I think as far as billing and coding, like, you know, maybe adding staff that can do some of the counseling under a practice, right, that's something that I've thought about, but, you know, any practical... Are you in a private practice setting right now? No, I'm with Northwell. It's a health system in New York. Okay. Yeah, I mean, sometimes it's also about finding some like-minded, you know, healthcare people in your community. It doesn't necessarily have to be other physicians, but, you know, just kind of having a team that I can refer to. Like, for example, you know, if I have a patient who's really interested in yoga, you know, I know I can send those patients to Dr. Yaniv, and I'll say she's a physician, she understands the spine and what you're going through, and I'm going to send her my notes so she knows what's going on with your spine, and so she's going to be able to understand what's safe for you to do right now, because not all yoga positions are going to be helpful. If you're doing deep flexion and twisting without any core strength, that's going to make your disc herniation worse. And so having, you know, building that network can be helpful, because I know my limitation in terms of what I'm able to offer and cover in a clinic visit. And then sometimes with the chronic pain patients, you kind of have to bring them back several times to cover small little bits and make small changes that you can measure over years, really, even. So I have long-term patients that have come a long way from when we first started, and it just takes that little, you know, small building blocks, too. I think one other addition would be the shared medical appointment is a way to do that, where you see five to eight patients over an hour together. You have to have a structure set up. Cleveland Clinic has a nice model for this. They published on it. The American College of Lifestyle Medicine, the lifestyle medicine group with the website that we showed, they also have some articles and data on that, too, and some of the billing codes for that. There's a way to do it where you have to have, like, five minutes with each patient individually and get, like, a history, but then you do the counseling piece together, and then, like, an MA gets the vitals and so on. You know, it's a team approach, but it can be cost-effective and just bill through insurance. I've been trying to talk to my group about it for a while. I'm hitting a little wall. But I think that's some of the future of medicine is, I mean, how many times can I talk about plant-based diet over and over again? It's just not as effective. And there's a lot of data that those patients form a community, and they actually form, like, a support group for each other. And so it's sort of like your buddies who cheer you on. So there's multiple layers to it. But, yeah, shared medical appointments is a great way to do it. That's a great idea. Yeah, and integrated practice units, too, is also another buzzword that gets used around. So, like, at our local medical school, they have a spine IPU clinic. And so that brings in a physiatrist at the helm, but there's also a McKinsey-Method-certified chiropractor, dietician, cognitive behavioral therapist. So it's all kind of incorporated into that IPU clinic. So you can do that in an academic setting, and they do take insurance and workers' comp and all those payers as well. So sometimes they'll send patients who really need that more kind of comprehensive, intense program to that program as well. Thank you. Thank you all so much. Thank you. We appreciate it.

low back pain

traditional approach

integrative approach

exercise

nutrition

water exercise

chair-based exercises

walking

benefits of exercise

lifestyle medicine

mindfulness

social connections

patient motivation