Hi, everyone, how are you doing? This is Danielle Zelnick, and I'm happy to present our community session today. So I'm just going to start with everybody introducing themselves. But before we do that, I just want everyone to take a nice deep breath, inhale and exhale, and get yourself centered and ready to hear some great presentations. So I'm going to start by introducing myself. My name is Dr. Danielle Zelnick, and I'm the Center Medical Director at Concentra Occupational Health in Southwest Oklahoma City. And before that, I was an integrative musculoskeletal and pain management physician in various practice settings. So I'm going to go ahead and introduce the rest of my panelists, or they'll introduce themselves basically. I'm Devon Checkman. I am one of the pain and physical medicine and rehab doctors at the Ann Arbor VA in Ann Arbor, Michigan. My background is obviously in physical medicine and rehab with an interest in women's health and pelvic pain. And currently, I serve as the Assistant Program Director for the Michigan Medicine Pain Fellowship. Dr. Yu? Hi, I'm Dr. Jianqing Yu. I'm a physiatrist in Taiwan. I finished my physiatry training there, and I'm also a chiropractor in the States. I got my PhD degree in Portland, Oregon. Thank you. Thank you, everyone. I'm really excited to start. So I will be warming up the chat room, so to speak. So hold on tight. I'm going to get my presentation loaded up. All right, let's get started. So my presentation is why teen physiatry should join the integrative pain movement. And I really hope I don't have to sell you too hard on this idea. So I'm going to be covering two concepts summarizing these quotes. And the first is attributed to Malcolm X. And the second is attributed to Bill O'Brien, who was the former CEO of Hanover Insurance Company, and has also been quoted multiple times by MIT professor Otto Scharmer, who is the creator of Theory U, which is a leadership program. So who decides the future of chronic pain management? And as you see, I drew a stakeholder map showing that there are many players involved. So if you ask somebody exactly who is the main factor here, you will see that there are many influencers. And so if you ask some people, they may say that there are too many variables and players. And you can ask some other people, and they may be more optimistic. And they'll say, well, it's what we do as practitioners and care teams that decides the future. And you may ask the patients, and they'll say, well, we have some stake in this as well. So my viewpoint on this whole thing is that it takes a village to shape the future together. And we have to do this in collaboration. It does start with the patient and the patient's medical provider, and of course, the care team members. And of course, as mentioned, or actually shown here in this stakeholder map, there are internal and external factors. So over the years, I've spoken to many physiatrists and many high-performing pain management practices, and the It can set the bias of pain. And what this really means is we're using rebuild therapy to maximize physical function and performing or referring for intentional procedures or judiciously using medication to improve. On the psychological side, we're using cognitive behavioral therapy for coping skills to overcome psychological barriers and we're screening and treating coexisting mental health and substance use disorders. On the social side, we are doing reintegration into the community workplace, and we're getting the friends and family of the patient involved. So you'll see here in this diagram that I didn't fully include complementary and alternative medicine. Yes, some but not all physiatrists practice complementary and alternative medicine. And by complementary, I don't necessarily mean free. I mean therapies used together with the usual standard of care for pain. So I did do a ask in the forum with our members to see which therapies they used in practice. And the overwhelming majority of people that I've spoken to have said that acupuncture in various forms is used in their practice. There's also referrals to outside community members for treatments such as manual therapy, chiropractic medicine, meditation, biofeedback, and other types of treatments. So if you ask the integrative pain medicine practitioners, which is mostly primary care, what are they recommending? Well, there are definitely some similarities between what us physiatrists are doing and what the integrative pain medicine doctors are doing, who are mostly primary care. They're considering the body, mind, and spirit, similar to this biopsychosocial approach. They're maximizing movement. This is similar to what we're doing in physical medicine and rehabilitation, but they may be using different movement therapies besides physical and occupational therapy. They may be doing things such as yoga therapy and lesser known movement therapies such as the Alexander technique and Feldekrais movement techniques. There's also a subset of integrative medicine called functional medicine, and many people may be aware of this, that addresses the root cause and any underlying nutritional biochemical factors. And so that is another way to view inflammation in the body and the causal factors for developing chronic pain. In addition, the integrative pain medicine practitioners focus on managing chronic health conditions. For example, diabetes can predispose to neuropathy, and worsening diabetic control can lead to worsening neuropathy symptoms and progression of the disease. So it's so important to manage these chronic health conditions and promote healthy lifestyles. Integrative pain medicine physicians believe in food as medicine, healthy eating habits. They also believe in teaching patients and providers self-care. It's so important for us as medical providers, pain management providers, to take good care of ourselves as well as take good care of our patients. And of course, they do similar things to what we do in our biopsychosocial model, involving close family, loved ones, and the community. Another thing that I've mentioned here, and I've added into the diagram here, is the focus on life's purpose, focusing on goals and what gives life meaning. That is something that can't be understated when treating chronic pain. And the utilization of complementary therapies. So you see here that we're all in here with the utilization of complementary and alternative medicine. And of course, minimizing the use of medication. Some integrative practitioners will use supplements. So what are the patients recommending? Well, they're not necessarily recommending anything specific or fancy. Some of them may not even know what integrative medicine or integrative pain care is. Basically, they're asking for us to do the fundamental aspects of care and form a genuine connection with them. They want a two-way trust with their provider. And if they're using unconventional treatments or alternative medicine, they want to discuss this with us without any type of fear of judgment. So why not join the integrative pain movement if there's so many similarities between what we do as physiatrists and what integrative trained pain practitioners are doing? Well, there are definitely some barriers. The first barrier is that some people believe that this is a little bit too out there for them, too woo-woo. Others may believe that there's not enough scientific evidence to integrate these therapies into their practice. Others may say it's too expensive. The insurance company is not going to cover it, so why even do it? And of course, the most common thing we definitely see in our practice is that there's no buy-in from the higher-level executives, the administration, and even the patients sometimes. It can be too time-consuming for providers and patients, especially if you're in a care model that is based on productivity or fee-for-service. So what are the solutions? Obviously, I don't have all the solutions, but here's some ideas. We can promote healthy lifestyles. That's not woo-woo. That's actually very basic. Food is medicine. Exercise. Connection to a higher meaning or life's purpose. These are definitely things that we can do in our practice. We don't have to go out there on a limb and integrate a therapy into our practice that we're not familiar with or comfortable with. We can just focus on the basics. What about not enough scientific evidence? Well, you can do your own research. You can draw your own conclusions. You could do your own pilot project in your practice and see how it goes. See if your patient's outcomes do improve with using integrative or complementary therapies. And it brings me back again to value-based care and bundle payment options. If we're going to continue to use the fee-for-service model or the volume-based model, productivity model, integrative pain medicine is really not going to fit very well into that model. So if your practice or your administration is moving more toward a value-based care system, this would be the time to bring this up to them and to get some advice. Obviously, the bottom line is money. So conversations with the CFO or somebody who knows what they're doing with the finances and the budget can go a long way. And of course, you can just do it. Design thinking. Just design and implement a rapid prototype. Work it. Get feedback. And reiterate it. Improve upon it step by step. And it doesn't have to be anything fancy or complicated. It can just be one measure that you're implementing into your practice. And of course, networking. That is the key to success. External and internal providers in your practice. You may want somebody to distribute your caseload so you can focus more on these types of programs and projects. What were the game changers? What is pushing this movement forward? I didn't mention the Affordable Care Act. There are some controversies about that, but I will say one thing. Value-based care is, I believe, is the way to go in the future. And it was a game changer, in my opinion, for integrative health and integrative health care. Also, we see the 2016 Comprehensive Addiction and Recovery Act. That paved the way for the VA Whole Health System, which you'll be hearing about a little bit later with Dr. Schuchman's presentation. Of course, the CDC guidelines for prescribing opioids for chronic pain. Again, controversial in many circles, but it mentioned norm pharmacologic therapies, non-opioid pharmacologic therapies. So that's a start for this movement. How about this year, 2020? The CMS decision memo for acupuncture for chronic low back pain. This is also a game changer. They're covering acupuncture for chronic low back pain. That is great. So who are the players? Who is the we of integrative pain medicine? And of course, we acknowledge that the evidence-based gold standard for managing complex chronic pain conditions is the Interdisciplinary Intensive Outpatient Program. Obviously, we can't all do it in our practices. So what are other ways that we can go about doing this? Thinking of our pain management practice as a team-based effort. And I got this diagram here where you see these circles. I adapted that from some research I did on high-functioning primary care teams. And I found in these high-functioning primary care teams, and there's plenty of literature on this if you want to go look this up, that there's a core team, an expanded care team, and community resources. So if you have a relatively small practice, you can just have a provider and a medical support staff member as the core team. In the periphery here, in the expanded care team, you can have a behavioral health specialist or somebody who does mind-body therapies. You can have a dietician or other complementary health practitioners in the community or as part of your organization. And of course, it goes without saying that peer support is very important for changing lifestyle and behavior and promoting a positive outlook on pain and helping people who are struggling to cope better. So what are the actual interventions? There are many, but I'm going to focus on the ones that we see the most. These are very basic, and they fall under lifestyle medicine, which is more accepted, has more evidence behind it. And some integrative health practitioners are actually more in the lifestyle medicine group. Physical activity, cardiovascular exercise, sleep hygiene, food as medicine, cessation of unhelpful habits, screening for and addressing substance abuse disorders, promoting and connecting with others. Functional medicine, again, as I mentioned, focuses on root cause, biochemistry in the body, environmental factors, nutritional disorders, and of course, the gut. Complementary therapies, as we know, most of us, or I don't personally do it, but most of the physiatrists that I have interviewed or asked, they perform acupuncture in some form or another. Manual medicine, chiropractic medicine would fall under this. Osteopathic manual medicine would also fall under this. Mind-body medicine, yoga, biofeedback, guided imagery, hypnosis, progressive muscle relaxation, many, many ways to go about this. Even the heart math equipment for heart rate variability, there was a great presentation last year on that at AAPMNR as well. So what about self-management, stress management? There is an evidence-based program out of UMass, the Mindfulness-Based Stress Reduction Program, which has shown some benefit for certain chronic pain conditions. Peer-led programs, there's an evidence-based program that was once out of Stanford, it's now called the Self-Management Resource Center, and it teaches patients to cope with chronic pain, and it's conducted by peers in the community. And of course, cognitive behavioral therapy, plenty of evidence for that. What about the intervener? I think I have to do this presentation and mention that this is a really important factor when managing chronic pain. We really have to look within. As you're aware, there's high burnout rates for pain practitioners in the United States and probably elsewhere. We really do have to look within, we have to focus on personal development, and we have to go even deeper in the way that we interact with our team and with our patients. We have to examine our biases. What false narratives and stories do we need to let go of about our patients, about our care team, about our organization that's holding us back from succeeding in our pain practice and producing very positive outcomes for our patients? Then there's a cognitive bias of Maslow's hammer. If you have a hammer, everything you're gonna see is a nail. So if we're trained in a specific complementary therapy or we're trained in a specific pain intervention, sometimes when we see a patient, all we want to do is do what we were trained to do. We really have to look beyond that, and I feel that the team-based way to manage chronic pain will allow for that, because you'll get perspectives from the other team members, and you don't have to do this on your own. Maybe there's something that is best for the patient that you haven't even thought of yet. With your team, you can come up with a better treatment plan than you would have alone. And you always have to consider the patient's perspectives and needs. One thing I would suggest is if you are interested in doing a integrative pain program is do a needs assessment with your patients. Find out what they want, because if you like acupuncture and your patients aren't interested in it, it's of no use to anybody. You have to be the steward of the team. I have learned this with personal experience. I've been in leadership positions and I have failed. And a lot of times I've succeeded. So you have to learn. You have to be the steward. You have to hold the space for your medical team. You have to hold the space for your patients to heal. And you have to care for and support one another because it is a very stressful thing being a pain management doctor. And of course, avoiding therapy overload. They're using this very sexy term, multimodal now. And you can say, oh, I use a lot of multimodal therapies and blah, blah, blah. But adding on more therapies does not necessarily lead to improved outcomes. So you have to specialize it and individualize it for the patient and what their needs are. And of course, integrity. Don't do stuff you're not comfortable with or that's in conflict with your values. And then ask yourself the deeper meaning questions. What is the deeper purpose that led you to practice pain medicine? What gives you the most joy in your practice? If you cannot cure the pain or fix the problem, what can you do? What is that one thing you can do to put a smile on your patient's face when they come in to see you every day? How can you facilitate your patients finding inner meaning and inner peace through their struggle? These are the intervener questions you'll ask yourself when being an integrative pain medicine doctor. And of course, let's see if we can do something to change this. If you're interested in integrative pain medicine or you're already practicing it and you wanna get involved at a deeper level, we really have to be heard. Like I mentioned before, a lot of the people making up the recommendations are primary care. And I think they would like to hear a little bit from us about what our thoughts are on best managing chronic pain and doing it in a holistic manner. So I'm urging you guys to connect with members of the Alliance to Advance Integrative Pain Management. They currently do not have a physiatry liaison. Ask yourself the deeper meaning questions. Think of how you can launch your own integrative pain program in your practice. And it doesn't have to be fancy. It can be just something very simple. And you're gonna explore the aspects of integrative pain movement that appeal to you. Like I mentioned, not everything may be appealing and you may have your own thoughts and opinions about it. And of course, as a team, build up your team, listen to your team, hold a retreat and connect with local CAM practitioners in your community or integrative health practitioners in your community. And Dr. Yu will be talking a little bit more about that when he does his presentation. And of course, speaking of deeper meaning, life's purpose, we have Dr. Schuchman talking today about the VA Whole Health Program, which I'm really, really excited to hear her talk about. So I'm gonna just shut it down and I'm gonna let her take over from here. Thank you, Dr. Zelnick. Let me get started with that. And here. All right. So that was a perfect handoff. Dr. Zelnick shared a whole lot of background information for those of you that have been practicing in physical medicine and rehab. Physical medicine and rehab and overlapping pain medicine. Many of you may have been in the same position that I'd been when taking care of patients in really challenging situations. When you finally get to the point where there really isn't another intervention or medication therapy that you can find that will really make a difference for this patient sitting in front of you, you really ask yourself, what are we trying to achieve? Are we trying to achieve an improved pain score? And usually that answer is no. We're trying to improve their function, their experience and make things better from day to day, having more good days than bad days. So really reflecting on this, I've really understood my shift in the last many years of my early career is really moving towards this integrative model of pain medicine. So I do practice at the Ann Arbor VA Healthcare System in Ann Arbor, Michigan. I have no disclosures to share. The whole purpose of my section of our community session is to really appreciate the complex history of pain care for veterans. Just to get started, I was gonna ask this in a little bit, but we have a poll question that we can share with everybody that's joined us today. If you've ever worked during your training or your current position at a VA health system, most of us have, I see those numbers flying in. This is faster than election numbers. So that's really great. So an overwhelming majority of you, very clearly have had some exposure to the VA. What I'd like to highlight is that experience should really shape how you look at your care of patients, whether you're in a VA health system setting or out in the community. But I'm gonna highlight some of the differences in those two populations today, as well as to become familiar with the VA data for opioid safety and risk mitigation tools. This was the basis for why we've really opened our eyes to some alternative and integrative medicine strategies for pain management. And then to understand the role of the whole health initiative and the whole health program in veteran pain management plans. I don't have to go through the history, but obviously the opioid epidemic was an impetus for a lot of changes. And what's lovely about medications and prescriptions is that we can really track data. We can track numbers of prescriptions and unfortunate adverse effects and deaths related to those prescriptions and track what other risk mitigation tools we can use and that have been helpful to reduce the risk for these populations. In the veterans alone, we know that there are very specific risks, but pain affects more people than diabetes, heart disease and cancer combined. We know that chronic pain is a problem in almost every day we go to work. We are encountering someone with chronic pain. This number is higher in veterans. This is a sample study of combat veterans from Afghanistan. Almost a half of them had chronic pain. 15% had the used opioids. And these are young men and women in that combat situation compared to the civilian population groups that had 26 and 4% for those chronic pain and opioid use. Rates and the cost is not insignificant over 600 billion yearly. So really boiling it down to not just chronic pain, but pain in recent months, severe pain, pain in the younger age group, 18 to 39. When you're comparing all of these categories of drill down pain experiences, the veteran population seems to have a very consistent higher rate of pain reported. And these two studies actually all in combat veterans also demonstrated the overlapping pain conditions, PTSD, TBIs with chronic pain, as well as persistent post-concussive symptoms and chronic pain. These are all not making pain management easier. So these are things that the VA population has been in tune with and aware of so that we can better care for our veterans. This is that broad timeline, this stroke of history, really starting in the late 80s when we maybe errantly started identifying pain as a fifth vital sign, but it focused our attention on pain and the pain experience and good, bad, or ugly, we developed an appreciation for not just the physical manifestations of pain, but the psychological components of pain and that pain experience. The VA and Department of Defense developed this National Pain Office and Pain Directive, as well as the Opioid Safety Initiative in the 2011 timeframe. We started really focusing on opioid therapy risk reduction in 2013, and really joined the rest of the healthcare system in this stepped care model of escalating with lower risk interventions and active treatments earlier in the process for pain care when it comes to the 2014 timeframe. The STORM tool for risk mitigation is really an opioid risk stratification tool that I'll go into in a little bit, but the VA had its own model and data dived to come up with risk mitigation and risk increasing components to a patient's medical history, and use that to score and intervene where we could to reduce adverse events and outcomes. And then later with the VA DOD pain guidelines to come from that. What are the VA best practices? This is from very early on. It's a stepped care model, and already number two on the list is treatments with alternatives and complimentary care. Ongoing monitoring, practice guidelines, prescription monitoring, academic detailing. So for those of you that are not familiar with the VA health model, academic detailing is when we have clinical pharmacists placed into physician provider models where they are working directly with physicians and physician extenders and nurse practitioners and PAs throughout the VA healthcare system to give guidance to the providers as well as to the patients on improvements in prescribing strategies. Informed consent for all of the opioid prescriptions and controlled substances as well as the naloxone distribution plan. And what did we look at when we looked at the data to drive how we can improve pain care? Well, reducing risk was huge. So we looked at the number of unique patients with opioid prescriptions, the number of combined medication prescriptions of benzodiazepines and opioids, and those with high dose, the over 100 morphine daily equivalents. And I'll go through these quickly because this really doesn't give you anything you probably haven't heard of, but I want to highlight here that the trend of opioid prescriptions really does arc at the point with which we intervened with some of the safety initiatives. And same here goes with the attention to multi-drug therapies with opioid and benzo prescriptions decreasing on a drastic scale. This is from 2013 to 2019. That's not as insignificant drop at 82%. And the same thing goes for those greater than or equal to 100 milligrams of morphine daily equivalents. That storm tool that I mentioned is something that if you are familiar with, it's something that we have access to as VA providers. Every patient you click one button and it comes up with this predictive risk model based information. And this was a model from a population of 100 million, sorry, 1 million veterans that were prescribed opioids and the related overdose and suicide related events in that population. Based on clinical informatics, I know there are some of you that are much smarter than me and into the clinical informatics side of medicine, but this was a really, really cool data dive to identify those strategies to intervene at the granular level for risk mitigation. And this is the tool that comes up for the providers. On the left, you see some of the patient information if this was a real patient and how at risk they are, whether it's very high, high, moderate, or low, some of the contributing factors being substance use disorder, mental health diagnoses, other medical comorbidities and current prescriptions. And then to the right, you start to see the risk mitigation tools and strategies and a temperature monitor here really showing you where you can intervene and some check boxes. So for example, this is somebody that has a lower than 90 morphine milligram daily equivalent dosing. So that's checked. It was only 15 milligrams for this patient, but they don't have a naloxone kit. So this is a prompt for the provider to make sure that they get some of the intervening risk mitigation strategies initiated right at that moment of time. So on the far right would be your care team and follow up who is involved. And you can see that it's primary care providers, upcoming appointments. If they've got, this is if they have a chiropractic appointment, it would be listed if they are engaged with physical therapy, if they are working with occupational therapy. Other active therapies are the CIH complementary and integrative health care therapy. And so it is already identified as one of the tools to intervene and reduce risk in this population. Like I said, these coded diagnoses, the demographics, pharmacy data and healthcare utilization, all those appointments come up with your risk score. But really the core is to intervene in a way that can reduce that risk and improve outcomes for your patient. What makes the VA special? I could go on for days. I came to the VA because it's a wonderful place to work with great colleagues and a team-based environment. But what does it really do? It is this example of do what's best for the patient without an intervening insurance company to tell you what's approved, what's not approved, what's worth it. What's really fantastic when it comes to integrative and alternative pain care is that we are able to introduce that battlefield acupuncture. We are able to introduce the massage therapy or chiropractic care. And we do it at the local level in a way that works for our patients. Because for some patients, giving them all of the passive treatments of massage therapy and acupuncture and chiropractic care will make them feel good in the moment. But what do we know to be best for the patient in the long-term is those active treatments. But using these passive treatments and interventions to help them get over the hurdle and help them get engaged in those active treatments, that's what we're trying to do and individualize. So risk mitigation is great, but what are you doing for the pain care? What are the strategies that you're using to reduce those opioids because you have to offer something when you're trying to take something else away. The VA is the largest integrated healthcare system in the world. It's pretty mind-blowing to see that we are a small part of it, but you have all, for the most part, had your foot in the door. You know what this experience is like. The red tape with us is just different red tape, but it's a pretty comfortable one for those of us that are really engaging in integrative medicine. It focuses on innovations and pilots and research, and it has an infrastructure to support those culture and system changes. And early on, through the Office of Patient-Centered Care and Cultural Transformation, using some of the financial model that the VA has in place, they instituted the Whole Health Program. And that was really a guide to flip this script. You know, we practice medicine really based off of all these negatives, the deficit model, the chief complaint. What is the problem that the patient's complaining of? What's wrong? What are the labels that I can put on them? And they say what they can't do. And then our job is to really turn that around and focus on that life model of what's, what are the patient's priorities? What are the tools that we have to support the patient? What's working well for this particular person in front of us? What self-management strategies have they engaged in and what can we encourage or add to the list? And what can they do? Our goals may be very different from the patient's goals. You know, if you're a primary care doctor, your goal for an A1C is very specific. The patient may have a different goal. They may not understand why that goal is important. Our purpose is to participate in those shared goals and making those goals together very clear. And when they are clear and they are shared and that A1C isn't just a number, the improved healthcare outcomes come along with it, along with the ownership, both of the provider, as well as the patient when it comes to the outcomes. Behavior change is hard. There's a whole institute. I believe it's University of Pennsylvania, but don't quote me on that. But they have a whole institute for behavioral change because we had to figure out and we have to still figure out how do we get someone to change their behavior even when the outcome is very clearly going to be positive. That behavior change is hard. So shared goals is one way to get there. And patient satisfaction is much easier to achieve when your goals are aligning with your patients. Whole health, and I'll go into more details as we dive into this, is personalized, it's proactive, and it's patient-driven. Values and aspirations are used along with the health and well-being of the patient. We don't ignore conventional medical care. This is just to add to the standard of care that we know to be effective. But it focuses on the self, the self-care, the self-empowerment, and the self-healing. And it uses those complementary therapies that we know have low risk and high reward for those that want to and are willing to engage in those. And when it comes to that scientific evidence, the reason why we should be using them, Dr. Zelnick mentioned there are studies and you can do them on your own for your own practice, but this is a big hurdle. It's a big hurdle to get it approved for your patients, but the VA did some of the dirty work for us and approved through their own literature review and research review that these strategies, the yoga, tai chi, guided imagery, and meditation are approved complementary and integrative approaches for well-being. And those that were approved for a complementary integrative approaches for treatment include acupuncture, biofeedback, clinical hypnosis, and massage therapy. This is just one example of their promotional strategy. This is really just to highlight how we align with team physiatry and the goals of physical medicine and rehabilitation. Our goal is to improve the health and lives and participation in life for our patient. That is physiatry. That is what we are here to do. And Whole Health really did open the door for non-PM&R providers to enter our world of function. So Dr. Zelnick also had that model that she showed earlier with the patient at the middle and the providers, the core group of providers in the middle of that circle, and then the community of providers outside as you expand that circle. And this is the same thing with the Whole Health model. At the center is the patient. The patient is responsible for their outcomes just as much as we are, but their important focus is on a few of the things that they can manage, the self-management tools, the outer layers of the community, the prevention and treatment, conventional and complementary approaches. And to look at the more detailed version of the Whole Health model, it does go into a lot of those relationships and support tools, the recharge, how they refresh, how they sleep, what they're nourishing their body with, food and drink, what they're doing for their personal development, whether it's personal or work development, their surroundings, both physical and emotional, and how are they moving their body? How are they getting energy and improving strength and flexibility? And what are their connections, growing spiritually and what's important to their soul? This is a video. Hopefully this comes through for you. What matters to me? That's a tough one. I haven't thought about that since I served. My doctor's never asked me that before. I guess I'm looking for purpose. To be more present. To discover what matters. Whole Health is about treating you, the person. It's a conversation with your doctor or peer, talking about what you want out of your life. We focus on what matters to you. Not what's the matter with you. Instead, helping you reach goals, like being there. Or my kids. Rediscovering my drive to compete. Finding my center. Giving back to my fellow veterans. And I'm not doing it alone. I've got a team. I've got a plan. I've got support. What matters to you? So that was the Whole Health model in a 30-second bit that they're promoting. There's all kinds of tools on the VA website that are open for your use, and I would encourage you to do so. One of the ones that I use often is what Dr. Zelnick had really hinted at and encouraged you to use. And that's that personal health inventory. What that is is really a detailed dive for the patient to reflect on what's important to them. What do they do with their time? What do they want to do with their time? The pandemic has certainly made that conversation easier for me as an individual provider in pain care, because it really has forced us all to reflect on what's important to us. What are we missing? What are we missing out on that we want to get back to first? And that personal health inventory helps start that conversation. So even filling that out with your patient is an easy way to start that and to start getting towards those shared goals. The personal health plan is just the next step of that. So I gave you the example of the A1C. Yes, our goal is to get to an A1C of X, but the purpose is to really keep those neuropathy symptoms at bay. We want to be able to use steroid for that shoulder pain, and we really don't want to risk increasing those blood sugar levels in the coming months. So those are conversations that are better understood by all of those participants when we have that conversation about the shared goals first. The patient work was also including peer facilitators, and these are our peer veterans that may not have the same diagnoses or concerns, but do have training in helping guide the personal health inventory discussion and personalized health plan discussions. On our side, on the provider side of the physician's work, we need to listen. We need to know what's important to our patient. We need to understand why it's important and how our goals may not be what the patient's goals are, and if they're not, then let's figure out what we do share as our goals. Let's get to that compromise. We're all talking about compromise and finding common ground. We need to do the same with our patients, and this is just one of the steps. I know we all strive to do it, but it takes a little bit more time, and it takes some effort, but we can do it. In summary, I hope you got a little taste of what the VA can provide to our veteran population, but it's not only something that we can do for veterans that carry a lot of complex medical comorbidities, but we can use this model for our civilians as well. Those risk mitigation tools are just an example of how we can reduce risk and reduce numbers and improve our data and prove our worth, but it carries the other side of that is that our patients do better. Our patients have improved outcomes when we use those tools and add other things to improve pain care, and the VA Whole Health Program is a mechanism to allow physicians and veterans to align our goals and keeping our veterans and our veterans' priorities at the center of that. So with that, I thank you. I'll stop my sharing and hand that back over to Dr. Zelnick and Dr. Yu. Thank you so much. As of now, we don't have any specific questions in the Q&A, but if the viewers want to put some questions in there, we would love that, and we can get to them later in the community session. So Dr. Yu, you're up. Thank you, Dr. Zelnick and Dr. Sherman. Hello, everyone. I'm sorry about that. Stop there. We can now move. Okay. Hello, everyone. I'm Dr. Yu. I'm a physiatrist in Taiwan and also a chiropractor in the States, and as a solo integrative pain practitioner, I would like to share my experience providing team-based care in the community in patients with temporomandibular disorders. So, first of all, I have no financial disclosure or complaint of interest with the presented material in this presentation. There are three parts of my presentation. The first part of my presentation is the current evidence to support a multidisciplinary approach to a patient with temporomandibular disorders. I searched on Mainline, PubMed, Gocain, Google Scholar, and there is one review, one RCT, and two test reports in recent 10 years. There is not enough strong evidence to support a multidisciplinary approach to patients with temporomandibular disorders. These two slide summary are the above researches about a multidisciplinary approach to a patient with temporomandibular disorder. And however, when I search the patient with temporomandibular disorders and spinal issues, like neck pain, there is more and more evidence to reveal a strong relationship between the temporomandibular disorders and spinal issues. The below five slides summary are researches. For the second part of my presentations, because today I don't have much time, so the second part is a brief summary of a temporomandibular disorder, and this part is for your information. I still would like to talk a little bit about using the musculoskeletal ultrasound to evaluate the disc displacement of the TMJ. So in this slide, we can use the musculoskeletal ultrasound to evaluate the disc of a temporomandibular joint, like in the image A, the number one is mandibular condyle, the number two is articular disc, and number three is articular amyloid. So under the ultrasound, we can evaluate the disc displacement, and is the disc with or without a reduction. And why I use the ultrasound? Because the ultrasound is not so expensive, and it's real time, I can do the ultrasound and also explain my patients of what I found under the ultrasound. And now I would like to share my experience providing a team-based care for patients with temporomandibular disorders as an alternative medicine provider. So how to find your community? Using social media is a good way to letting people to know who you are and your professional background. I have a personal page on Facebook. I frequently post some articles about health issues. I also share this post to some Taiwanese group on Facebook. And why we need a team? Diagnosing a disease like brain pustule gain, as we know, temporomandibular disorder, is a multifactorial disease. We only have a piece of a pustules of this disease based on our professional background. And a good strategy is using team-based care to treat patient with temporomandibular disorders. We can give our patient more comprehensive treatment. And how to find your team? I need to say I'm very lucky. When I post an article about temporomandibular disorders on Facebook, there was a dentist that contacted me. She noticed that her patients with TMDs always had poor posture and posture. So she asked me to help her find her team. She always had poor posture or other spinal issues, such as test neck, upper cross syndrome, or lower cross syndrome. She was looking for a chiropractor to treat patients with temporomandibular disorders together. And why would a chiropractor help patients with temporomandibular disorders? Let me use these two pictures to explain. Poor postures not just only causes the upper cross syndrome or lower cross syndrome. It also imbalances the overall muscles and misalign the temporomandibular joint. I noticed that my patients with temporomandibular disorders usually have tight oral and neck muscles. And my patients with neck pains also have a great chance to temporomandibular disorders. Back to our previous slide, there is more and more evidence to support the relationship between the temporomandibular disorders and spinal issue. And this slide is the flowchart on how we treat patients with temporomandibular disorder in two different clinics. So when I have a patient with temporomandibular disorders, I do the history checking, fecal elimination, and sometimes I will use musculoskeletal artery ultrasound to evaluate my patient if they have any displacement. And then I will fill out a referral form and on the Google Drive and share with my team partner. And after I start my treatment, I will do the chiropractic adjustment, soft tissue work and fecal modalities and teach my patient what kinds of exercise they can do at home. And after eight to 12 treatments, I will write a report and share with my team members and discuss with my team members. This is a referral form I use to share with my team members. I will evaluate patients' spinal issues, evaluate their neck conditions, lower back conditions, and also the temporomandibular joint. And then I will send to my team members. And that's what I did with my team members to treat our patients with temporomandibular joint. Thank you for your listening. Thank you so much, Dr. Yu. That was great. I do have some questions for both of you. Well, one of them actually was brought up in the chat for Dr. Schuckman. Where can a participant find the personal health inventory? The lovely Assistant Google. If you Google personal health inventory, VA, or personal health inventory, Whole Health, you'll see a 12-page PDF link under some of the va.gov websites. And that's full access. You can use that as a tool for yourself. I didn't write it, so I'm not taking credit for it, but it is a tool that the VA has published online. Thank you. Now I have a question for the audience. I don't know if the moderators can put up the poll. I had meant to put it out in the beginning, but I did not. So yeah. How familiar are you with integrative medicine? To the viewers. This is like a post-test, right? Yes, exactly. Okay, so we have a good mix from everybody. Okay. Some people who are very familiar probably do it in their own practice. Some people who are familiar read about it. Some people who are somewhat familiar maybe heard about it once. And then a few people who have not ever heard of integrative medicine. So integrative medicine is healing-oriented medicine that takes into account all aspects of the patient's health, physical, emotional, spiritual, and uses complementary therapies that are usually evidence-based. So that's what we would promote in addition to usual standard medical care. So I'm gonna share the results with the audience. Okay. All right, I have a question for Dr. Yu. How do we connect using Facebook to find outside providers in our community that we can establish referral relationships with? Okay, good question. When I post the article on Facebook, I don't have any prediction I can contact other medical profession. But on the Facebook, you don't know everyone's background. But it's a good chance you can contact every different people, many different people. Like, we don't know other people on Facebook. Maybe they are physical therapists or maybe they are dentists. But I will say it's a good chance, use the Facebook or other social media to contact different people. And it's also a good chance to let people know who, what physiatrist can do and what is alternative medicine. Yeah. Did I answer your question? Yeah, very good. I have another question for Dr. Shukman. In the VA system, if you're a VA provider, how do you refer somebody to the Whole Health Program? Oh, excellent question. So not every VA has a up and running Whole Health Program. We have components available throughout the VA healthcare system. But there are sites that have really well advanced teams for Whole Health. And as an example, we've been aware in incorporating Whole Health into the Ann Arbor VA, but we don't have all of the components. So it is a consult based referral, but even now with a lot of the Whole Health Programs and our general healthcare being transitioned to telehealth as much as possible, a lot of those services can be utilized within a region or a vision to take advantage of those sites that are a little bit more established. So to answer your question, it is a little bit complicated. It's not the same thing at every site, but every vision or region of VA healthcare will have some core sites that have those resources available. Yes, thank you for that. And yes, I hope that the VA will continue to develop this program. It looks like it has great outcomes and it may be a game changer when it comes to managing chronic pain. The moderator has posted a link to getting the personal health inventory in the chat space. So if you're interested, any of the viewers, they can click on that and you can get that information. We have a Q&A in the box. Do any of you know any way to find a cognitive behavioral therapy trained or PIP, which I'm not too familiar with, physical therapist? Like you can easily find MDT trained physical therapists. Thanks. I'm thinking the American Physical Therapy Association may be a good resource. I don't know specifically psychologically informed practice, PIP. Thank you, I learned something. I would second using the APTA as a resource when it comes to those that are certified to deliver very specific or advanced level PT care. All right, if anyone else does not have any more questions, we're gonna close it down, but we're gonna continue the discussion. And oh, yep, they're saying that the APTA doesn't collect info on their members. Darn it. To be continued. Oh, wait, wait, like there's some more. Many patients with chronic pain frequently present with their personal goal of a definitive diagnosis and cure. What are your strategies for engaging patients in an integrative care plan? What timeframe do you expect to see changes? Can I speak? Yeah, go ahead. That's kind of my everyday and I have failed at it many times, probably many more times than I have succeeded. I usually, you know, we'll get that, I wanna be out of pain, I want this cured. And I think that validating those wishes is a place to start. We can all agree that we would want that too. And then coming to, well, you know, what would you do if you had a day where you woke up and you didn't have this pain? What would you do with that day? And that starts my conversation at least with, you know, really digging into how I'm gonna get to something that this person really wants to get towards. Because if I can't get there and I don't push it for that first visit, if they don't have an answer for me, that's okay. Think about it, come back and we'll talk about it some more. But I really want you to think about if you woke up tomorrow and didn't have pain, what would you do? So that's my approach to getting to that shared goal. But yeah, most of our patients are gonna wanna cure. And usually my needles aren't gonna fix anything, but they're gonna get them closer to having better days or more good days than bad days. Hopefully that answered your question. And it is about setting expectations early on in the provider-patient relationship. I'm sure a lot of times when people came to see me, they had seen the top experts in the country and they're coming to me and they have all their paperwork and maybe there's a large stack of it. And I go over everything with them and we go over everything that's been done already. And then I look to see if there's anything that I need to do further for the workup. But if the workup's already been done, we kind of establish the expectations that this is going to be to enrich their life and to help them manage their pain better. And the goal setting is definitely the key piece with that. Like Dr. Shuckman mentioned, just getting that conversation started about what their goals is, what is the most significant thing to them. And it may not be medical. I was working at a tribal health center and the most significant thing to my patient was to be able to participate in his tribal dances. So yeah, it may not even have anything to do with about managing their A1C or controlling their chronic health conditions or their pain. It may be more about life goals and connecting with their family and loved ones. And the timeframe, it's a long timeframe to do goals, but to have them written out, making them specific, actionable, it goes a long way. And you can review your progress at every visit and see how close you're coming to meeting those goals. We have some more questions here. Let me see here. I don't know if I have every... Is there an association or academy that helps connect practitioners from various disciplines who are interested in providing care through an integrative care model? Or is this pretty specific to your market or region? There's the Academy of Integrative Health and Medicine, the AIHM that you can go to. And also on my slide, there's also the Alliance to Advance Integrative Pain Management. So there's definitely other pain management friendly resources. I'm kind of losing my... I thank you for bringing up the slideshow. Hold on a second here. And while you pull that up, go ahead. You typically screen for yellow flags in these patients. I think PTs are more likely to, but I think it'd be really useful for us to do in our interaction with patients. Do you want to take that Dr. Zelnick? I don't think she's present. Do you screen for yellow flags? Yes, definitely. And Dr. Shukman explained that in her presentation that there is a screening process in the beginning of the doctor-patient relationship where you have to look for pre-existing disorders that may predispose to worse outcomes like depression, anxiety, history of trauma, et cetera. Would you say TMD is secondary to neck pain, posture problems, or does TMD cause neck pain or posture problems? Which is first? Thank you for Dr. Yu. It's very hard to say which one is first, but I would say neck pain, neck muscle imbalance, maybe have additional bad effects on patient with temporal manipulative disorder. Yeah, it's very hard to say which one is first. But if you have a patient with a temporal manipulative disorder, maybe you have a TMJ problem, but you don't care your posture, and then your TMD will get worse. Not that for sure. All right, great. If anyone else doesn't have any further questions, we're going to close down this session. Thank you everyone for attending. We really appreciate your presence here today with us, and we hope you have a wonderful week with AAPMNR 2020. Thanks. Bye.

integrative pain management

multidisciplinary approach

VA Whole Health program

temporomandibular disorders

team-based approach

engaging patients

integrative care plans

goal setting

healing-oriented care

AAPMNR 2020