Hello, welcome to our session. We're talking about clinical pearls, practical ways to add integrative and lifestyle medicine to your practice. And we are very lucky to have some awesome people on our panel today. So just a minute about myself, my name is Saloni Sharma, I am the medical director and founder of the Integrative Health Center at Rothman Orthopedics. And it incorporates a lot of things we're gonna be talking about today. So involves exercise, sleep, stress, nutrition, and we'll kind of dive into some of this. Our first speaker today is Dr. Ayman Khay, we actually went to medical school a long time ago together. And she's now at Texas Orthopedics, and she's gonna talk to us about nutrition. We have Dr. Deepa Singh, and she is at SpineOptions in a multi-specialty practice, and she'll talk to us about exercise therapy. We have Dr. Esther Yanni, and she's going to talk to us about mindfulness, and she actually has her own practice with integrative approach to pain. So I think we're lucky to have her today. And we have my colleague, Dr. Ari Grice, and he actually founded the Cannabis Program at Rothman Orthopedics. So he'll kind of give us the nitty gritty on how to do that, and kind of some ups and downs with that. One quick slide before we get started, I think you can see my cursor, but if you go to the left, those are sort of some of the lifestyle interventions that we're gonna talk about today. And we know that these can affect inflammation and pain levels. So we're gonna focus on the diet, the sedentary lifestyle, stress, and then we'll have to sort of add on the cannabis that's not there. So with no further ado, I'd like to introduce Dr. Ayman Khay, who'll talk to us about nutrition therapy. Thank you. Okay, so let me get started. So my part of the talk is about nutrition. So I'm in a private orthopedic group practice. I don't necessarily advertise as an integrative medicine doctor or anything like that, but being in Austin, Texas, we have a lot of kind of young, educated patient population. We also jokingly say, keep Austin weird. So we have a lot of patients who are interested in complementary medicine techniques, a lot of acupuncturists in a couple of Eastern medicine schools and stuff in the city as well. So I do field a lot of questions about options other than just the standard pharmacological medications and interventions and stuff like that. So in terms of nutrition, so why nutrition? So we know just over the decades that we've seen an increasing cost in just pain care, and that's not just economically, but also socially. So we've seen an increase in addiction, the opioid crisis, diversion, overdose. We've seen the pendulum swing from one end to another. You know, when I was in medical school, I think they started talking about pain as the next vital sign, and we were really trying to almost over-treat pain with opioids. And now we're seeing the effects of that, where we see more addiction, diversion, overdose. And we know that the federal government is also very concerned about those issues as well. And it's put a lot of pressure on us as physicians to shift away from opioids, surgeries, and procedures. And that's naturally increased the interest in non-opioid, non-surgical, non-procedural techniques to help manage and treat pain, such as acupuncture and manual therapy, mindfulness, mind-body behavioral therapy, et cetera. Dr. Saloni also had another course that's pre-recorded talking about the COVID pandemic and its impact on the opioid epidemic. And we've actually seen that in 2020, we saw the biggest increase ever in overdoses in the United States. So in 2020, 93,000 people died of overdose versus 72,000 in 2019. And that's up 30% from 2019. And we were already seeing an increase in trends. So we understand that opioid addiction is a pretty big issue. In terms of nutrition and supplements, we have given talks before about supplements because we do have patients that ask a lot about supplements. And we know that it's a pretty big multi-billion dollar industry. And as physicians, we're going to have to be prepared to field those questions and understand which supplements may have a little bit more evidence behind it, looking at a safety profile and being able to give the recommendation and advice that's safe and hopefully evidence driven. So I have a couple of, I have a study here just talking about supplement use in patients with osteoarthritis. About a third of the patients will have, you know, tried a supplement to try to help with their osteoarthritis pain. There's Dr. Heather Tick, who's a professor of integrative pain medicine at University of Washington, who has published a lot on the topic of nutrition and pain. And she wrote in one of the papers in the KMNR clinic journal that appropriate nutritional interventions may be one of the most useful tools doctors have to improve overall health outcomes in their patients and specifically reduce inflammation. Whether doctors choose to do this themselves or collaborate with other professionals trained in nutritional coaching, the benefits of attending to nutritional status can enhance outcomes of other therapies. We're really just talking about the holistic approach to our patients with pain. She actually was the lead author of a white paper that was published in 2018 called Evidence Based Non-pharmacologic Strategies for Comprehensive Pain Care, led by a consortium pain task force and really looked at nutrition and we consider nutrition to be more of an active act of self care versus passive. And as physiatrists, we're very aware of the difference between passive modalities, for example, in physical therapy, heat, ice, that kind of stuff versus the active exercises and stretches and self care. And we think that active is better because it involves the patients and it also gives them ownership of the parts that they can control to help with their pain. The effect of nutrition on overall inflammation and body has been well known and studied for many years. I remember one of my co-residents, Dr. Chris Ramston, who is now at the NIH National Institute of Aging, doing a lot of research on lipids and lipid mediators in inflammation, aging, pain. So it's really been on the radar of those of us in the pain world for many, many years. And the most commonly recommended type of diet for our pain patients is the anti-inflammatory diet. And that's characterized by a diet that's high in non-starchy vegetables. So a lot of fruits and legumes and nuts and seeds, looking at healthy oils, whole grains with low animal protein consumption. It's thought to help with mitochondrial dysfunction, which is recognized as a possible cause of many illnesses, not just pain, but also just anything that has to do with degeneration and aging, a lot of the illnesses that we see over time. So digging a little bit more into the anti-inflammatory diet, there are a few herbs and spices and stuff that they recommend. The two biggest ones that have a lot of evidence behind it are turmeric and ginger. It's studied both in food and supplement form. We hear a lot about curcumin and we see that being sold in a lot of different retailers. And they've done studies to show that it's actually equal to NSAIDs in terms of pain improvement without the risk of NSAIDs. And we all have patients who can't take NSAIDs for one reason or another, whether they're on blood thinners or we're worried about their kidney function. So this is a really good alternative to recommend to them and pretty well tolerated, especially in foods and a lot of coffee shops now have turmeric lattes and stuff like that. So it's kind of a trendy thing as well. We also know that as we've seen an increase in highly processed foods, that there's a lot of micronutrient deficiencies in the U.S. The most common being vitamin D and that's actually been associated with pain and delayed healing. Magnesium deficiency has an impact on muscle spasms, systemic inflammation, hypertension, neuropathic pain, and diabetes. And we use magnesium infusions therapeutically for things like migraines. And studies have shown that it may have NMDA receptor blocking properties, which might help with pain. We also know that the ratio of omega-3 to 6 is off in the U.S. The omega-6 is thought to be pro-inflammatory. We get a lot more omega-6 than omega-3. And so we really want to try to shift that ratio by hopefully eating more seafood and fish and getting the omega-3 in that form, but also considering supplements and really trying to look at the daily intake of omega-3 fish oil. There's some research that looks at the other plant-based form of omega-3s, but most of the research looking at the anti-inflammatory effects is looked at more the fish oil form of omega-3. And then vitamin B12, we've all studied vitamin B12 deficiencies in medical school, but we understand that when it's low, it can cause a neuropathy and likely some neuropathic pain conditions might be kind of subclinical deficiency in vitamin B12. The IASB, the International Association for the Study of Pain, has a fact sheet on nutrition that was just published in July. And I put the website there. They did a systematic review of 73 studies investigating nutrition interventions and looking at its effect on self-reported pain intensity. And then what they did was they published kind of a list of recommendations and then how to give that practical advice to our patients. So for example, to reduce inflammation, recommending polyphenols, so fruits and vegetables. A practical advice might be to include more variety, maybe use some frozen vegetables or canned vegetables without all the additive and salt and preservatives because those are more shelf stable. It's a little bit easier to keep on hand. And then really just rule of thumb, aiming for half of your plate covered in some kind of fruit or vegetable. And then really trying to look at the quality of the fat you're taking in. So omega-3, we already talked about, but also looking at olive oil, trying to include more oily fish into your diet, like salmon and sardines, and then limiting the process and hydrogenated oils, you know, like the trans fats and margarine and stuff like that. And then, you know, in terms of the studies, they have looked at fish oil supplements, about 3,000 milligrams daily for over three months helped reduce pain. And you want an EPA to DHA ratio of greater than 1.5. And you can usually see that breakdown on the bottle of the supplement. Vitamin and mineral deficiency prevention. So kind of going with the same theme as the last study, looking at vitamin D, B12 and magnesium. Practical advice is to eat a wide range of foods and considering dietitian consult to assess the daily intake of those nutrients. These are actually all supplements that I recommend to most of my patients as well. When they ask me about diet and nutrition that, you know, they should consider taking these and then hydration. So water intake, dehydration can increase pain sensitivity and cause constipation, delayed wound healing. So, you know, practical advice is to aim for two to three liters per day and eat foods with higher water content, like, like watermelon and fruits and vegetables and stuff like that. And then looking at increasing fiber intake prevents constipation. And we've all seen the, mostly the elderly population struggle with constipation as they get older and their, you know, their, their bowels are just not as irregular as they used to be. So, so being able to give that practical advice, you know, and, and helping with their constipation and pain is good. And then looking at the sugar intake, limiting the ultra processed foods and sugar in general can, can increase inflammation. So we really want to try to limit the sugars. And, and, and if you are going to have sugar, you want to have the unprocessed form in more pure form. The practical advice that the IASB recommended was to tell our patients to swap sugary drinks, like sodas for water or mineral water and to limit takeout because there's a lot of hidden sugars in a lot of our takeout foods. This is one of the, the kind of the conclusion slide from the supplement talk that we gave in 2020, basically the conclusion for the supplement talk for pain was to recommend in terms of supplementing vitamin D, omega-3, and then glucosamine also has a good amount of evidence behind it. At that time in 2020, there was already emerging evidence about curcumin being effective. There's been a few more studies since then to show the effectiveness of curcumin or turmeric consider magnesium supplementation for central sensitization of myofascial pain. I routinely recommend magnesium supplements. Usually I, I like the powdered magnesium. I feel like it's just harder for some patients to swallow a whole bunch of pills. So the powdered form is nice because it dissolves in water. You can drink it at night. It helps with sleep. Sometimes it's a little bit too much of a laxative. So I caution patients about that. There are topical forms of magnesium available, but I think that the oral form works a little bit better, especially for the myofascial pain case. Um, and then at the time we looked at devil's claw and capsaicin, but there were concerns about side effects with those. And obviously handling capsaicin is not, you know, um, something that, that, that you want to recommend to someone who might not be able to, to do that, um, in a safe way. And then there was actually some studies that showed that vitamin B12 might actually be effective for back pain as well, um, which, you know, we usually think about neuropathic pain responding to vitamin B12 supplementation, but, but there, there were a couple of studies that showed that it might be helpful for back pain back then. Um, so, you know, I'm in private practice and, and so it's, it is hard to find that time to be able to have that, that prolonged conversation about lifestyle change, um, and diet and nutrition and stuff. Um, and so, so, you know, practically speaking, the, a few things you can consider doing. I, I know my community pretty well. Um, I'm part of a social media group within the Austin community, um, called like some kind of wellness group where we can, we have access to all the, the kind of complimentary practitioners like dietitians and nutritionists and, and integrative medicine doctors, holistic primary care doctors, holistic pharmacies and pharmacists, so that we have resources that we can direct our patients who really want to do a deeper dive to. Um, for example, I refer a lot of my patients to Dr. Yaniv actually here in Austin, um, who, who wants to, to, um, explore yoga and pain coaching and stuff like that. So I know that in my practice, I may not have the time to be able to sit there and have that full on conversation, but at least I have the resources that I can direct them to. And I feel pretty comfortable having a fairly short conversations, but to the point, um, and directing them to, to books and resources, um, and having them Google anti-inflammatory diet, the arthritis foundation has some good resources like a while also has some resources. So, and a lot of the, the, uh, major academic medical centers also have, um, handouts and stuff that you can look into like the Mayo clinic, Cleveland clinic, et cetera. Um, if you're really interested and you want to really get into there, we have a few people on the panel that have, um, kind of opened up more of a cash-based practice. Um, and, and some of them offer nutrition screening labs, medical grade supplements that they sell within their practice. So, so you can, you know, um, make this financially feasible if you want to pursue that as a big part of your practice. Um, and then we've also started looking at Amazon lists. So, so recommending supplements as well as actually some DMEs, I guess, I belts and stuff that, that we have an Amazon list so that the patients can go through our website and see, you know, some of the things that we discuss during clinic visits. Okay. Well, so thank you for being here. That's the, that's my talk on nutrition. If you have any questions, you can put it in the chat box. We'll probably get to it at the end of the whole talk. Um, and next we have Dr. Singh, who's going to be talking about therapeutic exercises. Thank you. I'm going to share my screen. Go. Well, thank you all for joining us this afternoon. My name is Adipa Singh. I'm a private practice physician at Spine Options in Harrison. And today I'm going to be talking about some ways to incorporate therapeutic exercises into your practice. I have no financial disclosures. So the, I would like to go over today, the benefits of therapeutic exercise, how to include this in patient lifestyles and how to counsel patients and demonstrate to them how to do these exercises with handouts. The handouts I'll be demonstrating today are not my own. However, they do come from a nonprofit fitness organization. And I've tried these stretches, these stretches and exercises myself before I asked my patients to do them. So they are doable. And they're very practical. There is strong evidence that physical activity and active lifestyle has significant benefits, including improved bone health and weight status, reduced risk of cancer, cognitive benefits, including improved cognitive function, reduced anxiety, depression, improved sleep, quality of life. For pregnant women, it reduces risk of excessive weight gain, gestational diabetes and postpartum depression. And in older adults, it also reduces the risk of fall related injuries, all cause and disease specific mortality and improves physical function and quality of life. Exercise can improve strength, mobility, endurance, and functional disability. And therapeutic exercise has been shown to reduce disability faster and more effectively than manual physical therapy or massage alone. There are several ways to treat lower back pain and several different kinds of therapeutic training programs. We'll go through these in a little bit more detail on my next slide. However, no single particular exercise has been shown to be superior. So it's really what works for the patient and what's the most practical way for them to incorporate exercise into their lifestyle. So there are many different kinds of training programs. Here are just a few. And later on in this session, you'll also hear about some of them as well. Resistance training is any exercise that causes the muscles to contract against external force or resistance, which increases strength, tone, muscle mass, and endurance. Yoga involves physical, mental, and spiritual practice that creates self-awareness and is associated with a series of postures that actually can build strength, flexibility, coordination, and help with balance as well. Pilates is a low impact exercise program with a focus on core strengthening, flexibility, and endurance. Stabilization and motor control exercises really involve strengthening the deep stabilizing muscles of the core, the muscles of the spine, and the hip. And these actually improve neuromuscular control, strength, and endurance of these muscles that are central to maintaining the dynamic spinal and truncal stability. They really help build a strong base of support and help support posture as well. Aerobic exercises involve high to low intensity activities that can improve cardiovascular conditioning and help with weight management. Water-based exercise programs are usually done in a pool or immersed in water and can have lower impact than land-based programs. And these are great for patients who have chronic pain and can involve things like water jogging or walking on a treadmill underwater. Interval training is also great and includes alternating between high and low impact exercises to get benefits of strengthening and cardiovascular programs together. There is some evidence that Pilates, stabilization, resistance, and aerobic training are the most effective for treatment of nonspecific lower back pain. And this is given their core strengthening and flexibility components. As we said before, exercise on its own is more effective than hands-on treatment alone. I find the easiest programs for patients to incorporate with the least number of resources are resistance programs, yoga programs, and stretching and aerobic programs. And I'll go through some of those as well. So when we're introducing exercise for patients who are already in pain, this can be difficult and they can actually meet your recommendation with lots of limitations. And I find this every day in my own practice. Patient education is really key. And so some of the limitations that I've heard are, I have no time. I don't have time to do that. I'm really busy. So really you have to schedule it. I ask my patients to sit down with me and make a list of all the things they do in a day from the time that they wake up to the time that they go to bed. And there's definitely gonna be 30 minutes that we can factor in for them to incorporate some sort of exercise. Pain, I have a lot of pain. My knees hurt, my back hurts. How can I exercise with all this pain? So again, it's counseling. I explain to them that our muscles are organs that really heal with movement and more activity promotes healing and growth factors. If they're still limited, we can prescribe them physical therapy and therapeutics so that they can actually receive modalities that can help them resolve some of their painful issues before they begin a structured exercise program. They might be afraid and they might say, okay, well, that looks really hard, I can't do it. What if I hurt myself more? It's really important at this point to break things down into simpler exercises, use simpler programs to start and then progress them as they get stronger. And you can help them with resources such as handouts or videos or specific exercise programs. Motivation, I don't feel like it, I'm not motivated. I ask them to find a buddy or a partner or something that really makes them accountable. There are virtual support groups as well that can help with this and really kind of push them forward. I also recommend using your reward system. So if you get a jar and put a quarter in your jar every time you spend 10 minutes exercising, at the end of 50 minutes, you have 25 quarters. If you build up to a certain amount of money, you can treat yourself with some sort of treat. Another way to reward yourself during the workout is to watch a show that you like, listen to some music that you enjoy, work out with friends, listen to an audio book, attend a class. There are also virtual classes that you can do. Resources, so a lot of times patients say, I don't have equipment. I don't have the space to work out. I live in New York City. My apartment's really small. So there are several no equipment exercise programs that they can do, including online programs, including YouTube programs. They can go outside and take a walk. There are walking programs that they can do. There's definitely a way to fit in exercise, even if you don't have equipment. Fatigue and lack of desire. These are the two most common ones that I encounter. I'm really tired all the time and I just don't feel like it. So let's explore that. So in our practices, we don't always have time to really delve into it, but it is important in these situations to figure out why do you feel this way? Let's talk about it a little bit more. Are you not getting enough sleep? Are you feeling depressed? Is nutrition a factor here? Is there something else going on? Do you have a chronic illness? And sometimes it's really helpful at this point to loop in their primary care physician if we need to do a workup and get some labs as well. And finally, infectious exposure. So patients don't wanna go to the gym because they're afraid to be exposed to coronavirus. You don't need to go to the gym to exercise. You can do a home exercise program. There are specific programs that you can do on your own. There's walking programs. Again, there are different ways to get around this. It's really important to tailor exercise programs according to your specific patient and their fitness level. So when thinking about giving exercise to a patient, don't give an older person who hasn't exercised in 20 years 50 pounds to curl with their biceps. Think small. So think bicep curls with soup cans. They might even, you might even just say, walk around the house three times today, four times tomorrow, and then next week walk around the block. So in order to truly incorporate exercise into their lifestyle, it really needs to be convenient and easy to fit in. So how do I include this in a busy day? Exercise on your commute. So to or from work. Think about how you can get to work without driving, if it's possible to walk to work or if it's possible to walk to your errands. If you can't walk to the grocery store because it's too far, park farther away in the parking lot. So that way you're walking to the entrance and you're walking back to where your car is. Wear clothing that permits movement or take it with you so that you can change into them and you can do some exercise. And importantly, schedule your exercise like you schedule your meetings and your appointments. Put them on your calendar, on your phone, and actually keep these appointments. These are appointments to yourself. Some patients tell me, I have a lot of, I have kids. I have one or two kids. I have three kids. I have four kids. They have a lot of activities after school and I just don't have time. Exercise with them. Take them to the park while you wait to check their homework. Do a few of your home programs while they're napping. Do a few no equipment exercises or stretches. Try to fit it in any way, any way you can. Even five minutes is more than zero. And if that doesn't work, wake up before they do. So 30 minutes, adding 30 minutes to your day to get some exercise in just for you, that's your time. And the most important thing that I find is finding something that they enjoy. Mindset's everything. And if they really enjoy it, it doesn't feel like a chore anymore. When you're giving patients instructions about exercise, it's really important to take your time. Be very specific, answer their questions and use specific language. You can even talk about it in conjunction with nutrition. Simply saying, you know, your back hurts and you need to exercise so that it doesn't hurt anymore. That's not enough, because they might feel like they're already exercising every day. They could be running on the treadmill or they could be using the Peloton and they still have back pain and they don't understand why they still have back pain if they're exercising. So you do have to be specific. Which exercises should they do? What kind of, which muscle groups? What form? What positioning? And you can do this by demonstrating them, showing them videos, using handouts, being clear about how many repetitions for how many minutes, how many times per week, and asking them to be accountable. Sometimes that means journaling and reviewing their journal at their follow-up. What I find that's been helpful recently is I have the patient perform the exercise in my office and using their cell phone or their device, take a picture of them or video them so they can actually review it later and remember how to do it, or recall how to do it on their own. So now I'm gonna go through a couple of my handouts or some of these slides based on my handouts. I don't have a lot of time, so I won't go through them in much detail. But again, it's really important to be specific and have detailed pictures and instructions of how to do the exercises. So here's an example of some exercises that I use for back pain involving strengthening the core. And what's not on this page are planks, but I do have some prone exercises, some standing ab exercises, and I have specific way to kind of build up their strength and gradually progress them. Another set of exercises that I have here are my hip abductor strengthening. So this is important in patients who have back pain because it also incorporates the core with some glute bridges. They can strengthen their lower back and their glute muscles with some clamshells or hip abductions. And again, this also includes, it also includes the number of sets that I want them to do, the number of repetitions, and really they're gonna be using very little equipment to do these exercises. I also offer them some stretches and these can include some basic yoga poses. My favorite are cat and cow, which are here. If they're not able to get onto the ground and do a downward dog, we have some chair poses that they can use, which are easier on the wrists, on the shoulders. And this I find to be helpful. Here's one of my neck pain stretching exercises. It involves really engagement of the cervical paraspinals, involvement of the thoracic paraspinals and some of the shoulder girdle muscles as well. And very quickly, I'll go through the next set. Here's a walking program that I like. It's from Livestrong. And what I really like about it is that it really progresses the patient through four weeks of walking until they are able to get to 30 minutes. It builds in rest periods and also comes, it also has a few warmup stretches or recovery stretches. And this is great for patients who wanna go from being sedentary to factoring in some simple cardiovascular exercises. So there are many resources available, lots of apps that you can download onto your phone. Most of them have a free trial. Some of them you do have to pay after that. 8Fit specifically has YouTube videos that are free. You might wanna go through them before you actually give them to your patient. But I've done several of their programs myself and they're actually really great for being active when you don't have equipment and when you don't have time or space. Again, you can use handouts. Physical therapists are great for helping structure exercise programs. And there are several online programs that are free listed here. And these slides are available on PDF. So you can feel free to print out any slides or use any of the information on here. Here are some handouts I offer to my patients who have more sedentary jobs and feel like they don't have time to incorporate exercise in their lives. This is also really gonna be helpful for us during this conference because they're all seated exercises. So I hope that you can all take part in some of them. A few more stretches based on body parts. This is a chart that I actually have my patients download into their phone. So they can always review it when I say, you should do more stretches for your shoulder. And these are the ones that we'll go through together with them. This is actually, these handouts are actually from a great book called the Sports Medicine Patient Advisor book. And the publisher actually has granted permission to reproduce the information for patient education. And these are great because they have schematic pictures, they have lots of instructions on how to do the exercises, which what you should feel when you're doing them and what you shouldn't feel. And they have them for several body parts and I have them here for the neck and for the lower back. And here is one last slide regarding neck and back pain. And that is all I have for you guys today. Thank you so much. I will hand the microphone off to Dr. Yaniv who will be discussing mindfulness. Thank you. Thank you. Okay. So thank you, Dr. Singh. I read through some of your exercises so I'm all warmed up for my talk. Thank you for having me here. I'm going to be talking about mindfulness and how to incorporate it into your practice. So why is mindfulness needed? Actually, let me go back a slide, sorry. Here we go. So what is mindfulness? I mean, we're throwing that word out here and I wanted to give a little bit more of a definition to it. So from the Oxford Dictionary, it's a mental state achieved by focusing one's awareness on the present moment while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations used as a therapeutic technique. One of my favorite quotes is from Viktor Frankl, between a stimulus and a response is a space. And in that space is our power to choose our response. In our response lies our growth and our freedom. Mindfulness, for example, in pain management is a state of presence that creates a pause between a physical or emotional trigger and a pain response that's often learned. And so why is mindfulness needed? As a society, we've become disconnected from others and from ourselves. We talk about body-body connection, connection to one another. Social connection is known to be a key ingredient in happiness and longevity. And then there's the mind-body connection, which is an intra-personal connection. And that's just connecting our brain and our body and really getting out of our own head. As many of us are, we're distracted constantly as our attention jumps from one crisis or event to the next. And it creates a constant fight or flight sort of state of mind and body. So we're constantly bombarded in our cell phones or social media. We have television at our fingertips and then we're dealing with kids and parents, work, et cetera. And so there's this constant going and going and going and we kind of never stop to take a breath. We're either regretting or thinking about yesterday or worrying about tomorrow. And that doesn't really create an ability to be present in the moment. So how about mindfulness and pain? So most of us know that pain is a primitive brain signal that is wired to keep us out of danger. So you talk about the, it's a very simple rudimentary reflex arc. So if your hand touches a hot stove, there's a quick reaction, the brain senses that danger and you remove your hand. And if you have knee or back pain, that reflex arc becomes stopping or freezing. And so these are very ingrained systems that are there to protect us. The pain also triggers the sympathetic nervous system, and that's responsible for our fight or flight response. It's very reflexive and reactive and accounts for a lot of the supplement like the other symptoms that we have when we have pain, the sweating and the heart rate and all that stuff. What's unique about pain is that it creates both a physical and an emotional response that is stored in the brain. So pain is, I'm always telling my patients, pain is not just a physical experience, there's an emotional attachment to that experience as well. And so that is stored in our brain as trauma. This memory, this traumatic memory can be triggered by subsequent physical or emotional trauma or, and by the mere threat or anticipation of a physical or emotional threat. So you think about a kid that's getting their shot and just the mere fact of the needle being in there, going into the doctor's office, they get an emotional response and they might actually have a heightened sensitivity to the injection because of all that. So it's a very complex interaction of systems. So where mindfulness-based strategies can help is they can bring awareness, just by bringing awareness to that trigger-response relationship, that one that Viktor Frankl talked about and understanding its role in persistent pain long after the injury is over, right? So what is the science? And this is a much harder nut to crack than a vitamin or an exercise because mindfulness is a unique prescription to each individual. And it's kind of hard to study it because it's such a subjective experience. But there was a recent study that came out in JAMA titled the Effect of Mindfulness-Based Stress Reduction Versus Cognitive Behavioral Therapy on Back Pain. And they basically studied two groups that went into either a mindfulness-based program or just your traditional cognitive behavioral therapy. And they compared that with usual care and both the mindfulness and the CBT fared greater than in terms of getting, improving in functional limitations at 26 weeks. However, there was no difference between the mindfulness-based stress reduction and the cognitive behavioral therapy, but still it brought this into sort of a limelight as a legitimate option for some of our patients. Another study found that low mindfulness predicts pain catastrophizing in fear avoidance model of chronic pain. And we've all seen or we'll see come across patients that are just kind of wear their pain on their sleeve. They're super obsessed about it and there's a lot of anxiety involved in it or completely in their head about it. And you can see that how that low mindfulness and catastrophizing play into each other. In addition, here's some more studies. Davidson and Al looked at individuals that completed a mindfulness-based training program and they were actually shown to have reductions in inflammatory cytokines. So if you have somebody that is on an inflammatory diet, plus mindfulness, you're really working on reducing their inflammatory load in regards to their chronic pain. Holtzall and Al looked actually at brain regions that are associated with attention, self-control and compassion and bodily awareness. And they saw an increase in the activity in those areas that are all associated with mindfulness and self-awareness. And so there's actually something physiological that's happening as well, which is pretty neat. So getting into mindfulness techniques in clinical practice, this is gonna be really fluid and variable depending on the practitioner's specific interests. So for me, I break it down into unstructured and structured. So unstructured, these are simple tools that you can do anywhere, anytime. They don't require much in terms of equipment or really a lot of hassle in terms of environment, but it's really just ultimately about paying attention and being in the moment. One of the tenets of yoga is to meet yourself where you are and accept yourself as you are. And so in doing so, that kind of presents yourself to what's going on in your mind and body. Also a really big tool that I love is breath work. There's all kinds of different counts. One of the popular ones is four, seven, eight, and I try not to get too bogged down with my patients about how to breathe, but really it's just ultimately to bring awareness to how they're breathing and then just to take deeper inhales and exhales. Breath work has been shown to reduce that fight or flight sympathetic nervous system firing, and it activates the parasympathetic nervous system, which is our relax and restore. And so it can bring down the blood pressure, bring down that sense of fear and that is associated with an emotion or a physical trigger that might be associated with their pain. Then there's more structured meditation, right? So really having them lay down or sit down in a comfortable position, shut their eyes, you know, the kind of the traditional meditation that we think about and taking a mental body scan, really trying to feel each part and kind of listen to the signal that it's giving you and then breathe through it. Breathing meditation, again, maybe a more structured form of sort of sitting in a quiet room in a comfortable position and taking actually calculative breathing motions of inhale and exhale. Then there's the sitting self or guided meditation. And there's a multitude of apps out there that are available. Again, some of them are free and some of them require a monthly subscription, but there's Insight Timer. Curable is a really cool app all around chronic pain. There's Calm. Here in Austin, there's actually Meditation Bars. I don't know if that's unique to us. As Dr. McKay said, we definitely have a very mindful population, if you will, with all different types of things happening. So there's Meditation Bars. You can also get a meditation teacher. Other techniques, journaling. So I often recommend pain journaling to my patients just to give themselves kind of a score throughout the day and kind of know what mood they're in, what they might've done so that we can get a better understanding of the pattern of their pain and also bring awareness to them as well. Daily affirmations, gratitude journals, and there's just getting the angry out of you and onto paper. Sometimes just that repressed anger that's going on throughout the day builds the tension. Movement meditation. Dr. Singh referred to some of these things, but just getting moving, yoga, tai chi, floating. We have floating studios here in Austin. Walking, forest bathing is kind of on trend. And then of course, there's digging into yoga a little bit. The beautiful thing about yoga is you can couple movement to deep breathing to try to break that fight or flight sort of sympathetic nervous system response and especially useful for patients that have sort of that freeze or fear avoidance response. Clinical challenges. Mindfulness meditation is not a designated health service, designated health service, so is therefore not covered by insurance. So you have to either consider billing for time if you take insurance and documenting under face-to-face counseling and education, just giving them some tools that I described in that structured or unstructured slide. You can also consider providing a cash or out-of-pocket service. It's not considered a kickback since it's not a Medicare covered service. And it separates the service from the medical clinic side of things. So you can kind of do both, but have them separate. You can also consider, like I said earlier, referring to a meditation or mindfulness coach in your community. And like Dr. McKay was saying, I'm also on this Austin Wellness Group and can access wonderful resources of people that can do this. Some of the other challenges, our patients are skeptical or resistant like they are with nutrition and exercise. You do need a motivated patient that has sort of a self-care mindset. So I try to kind of walk these patients slowly towards that side. It's also important to identify any other psychopathology or comorbidity and understand when you might need to refer to a therapist or counseling. Snapshot of Austin Spine Health. In terms of mindfulness techniques, like I said earlier, I talk about breath and pain journaling as a wonderful place to start. It's really easy and it's like a good step A for getting people moving in that direction. I do a lot of mind-body education. I have read and recommend Dr. John Sarno's Healing Back Pain. He talks about tension myositis syndrome. I'm not gonna get into that, but it ultimately talks about how repressed anger presents as tension in our muscles and maybe the underlying root issue of a lot of chronic pain. It's really about reframing the dialogue and changing the story and understanding how emotional mediated pain can manifest as persistent chronic pain. I also offer a cash-based yoga program with me. I'm a certified yoga teacher in the community. And so I offer private sessions with my patients slash clients. So talking about mindful movement, coupling movement with breath work and just trying to overcome that fight-flight-free cycle of chronic pain. I also work with patients that just want some modifications and to work around some of the poses that are particularly bothersome to them. This is a video of a patient of mine with permission that here let me actually turn the microphone off that she's been a patient of mine for like over eight years, chronic low back pain and neck pain, stuck in that fight-flight-or-freeze, didn't wanna move. She's now practicing yoga on her own three or four times a week. We did about eight sessions. And so this is me working with her and she went down from six tramadol down to three and we're working on continuing taping her off of her pain medications. And that's the end of my talk. This is my website and my social media handles. So if you wanna connect there, I'd love to see you. Thank you. And now I will turn over to Dr. Grice. He'll talk about cannabis. One second. Where did my talk? Thank you so much for inviting me to speak today. And it is a pleasure to be here. Sorry about that. So we're gonna talk about practical ways to add medical cannabis into your practice. I have a lot to cover and in the sake of getting done here on time, I'm just gonna move right along. And get into our objectives today. So by the end of this session, hopefully all of you can identify appropriate rehab patients for medical cannabis, how to educate patients on the chemical constituents of cannabis, and to recall how to provide product recommendations during a medical cannabis certification appointment if you choose to integrate this into your practice. Medical cannabis is becoming more and more prevalent in our country and legalization efforts are really gaining steam. We now have 36 states plus the District of Columbia that have medical cannabis available for certain qualifying medical conditions. And almost all states have pain or some form of neurological dysfunction relevant to the physiatry community as one of the qualifying medical conditions. Medical cannabis or cannabis in general has over a hundred different chemical compounds that have been identified known as cannabinoids. And cannabis comes in a few different varieties including hemp, which is traditionally grown for industrial purposes. And then the flowering female cannabis sativa plant produces a number of chemicals within it that aren't necessarily found in hemp. The two most prevalent cannabinoids, however, are THC or tetrahydrocannabinol and CBD also known as cannabidiol. Hemp by definition has less than 0.3% THC but is rich in CBD and medical cannabis has not just THC and sometimes CBD but other minor cannabinoids and even terpenes. And terpenes are aromatic compounds found in certain fruits and vegetables as well as cannabis that may have therapeutic effects. So cannabis is really a constellation of compounds with a variety of different therapeutic actions many of which are related to anti-inflammation and analgesia. And you can see the difference in the flowers of these two plants and see how much richer the medical cannabis is compared to hemp products in terms of its chemical compound makeup. So the first thing to be able to do is to really identify appropriate patients in your physical medicine and rehabilitation community. And so, although there is limited evidence for the efficacy of cannabis for certain conditions, there are qualifying medical conditions in each state that cannabis may or may not be beneficial for. I see mostly adults with chronic pain including patients with spinal stenosis, degenerative joint disease, disc herniations and fibromyalgia. Many of our rehab patients have impaired sleep, anxiety, ALS, multiple sclerosis, cancer, neuropathies, PTSD, spinal cord injuries, neurodegenerative disorders. And if you look at the evidence which we don't have a ton of time to review, there is pretty good evidence for cannabis in treating pain, MS, and chemotherapy-induced nausea and vomiting. But it's important to check your state's qualifying medical conditions because each one of us has a different sort of set of qualifying conditions. And in Pennsylvania, where I practice, there are 23 different conditions that qualify patients. There are always gonna be certain patient populations or vulnerable populations that should avoid certain drugs including cannabis. And I think that this is predominantly related to THC. We are giving CDD to children with seizure disorders safely. However, pregnant and breastfeeding patients should largely avoid THC products. Patients who are younger and have not met full brain development such as less than 25 years old should generally avoid THC. If a patient has a history of mental health disease or a family history, especially at a young age, they should also avoid THC because THC can induce psychosis and may be associated with the development of schizophrenia especially in younger patient populations. I think certain patients with a history of substance abuse need to be really careful with using any compounds that stimulate the reward system. However, if you compare the safety of cannabis and THC products to other addictive substances such as alcohol and opioids, I think some of us find that certain patients with a history of substance abuse can still safely use cannabis as long as they're keeping their THC dosages low. And then any patient with a history of lung disease, COPD or asthma should avoid inhalable products. In my experience over the last three and a half years, I've certified over 1,200 medical cannabis patients. Most of them are over the age of 50 with chronic back pain and other peripheral joint issues as well as fibromyalgia. Many of my patients have never used cannabis a day in their life and are looking for alternatives for chronic conditions that they have not had success in managing. Many of our patients are seeking to wean off of opioids and other patients who may have used cannabis recreationally have noticed that it helps with some of their symptoms, whether it may be anxiety or sleep. So what we have found in general has been that a majority of patients are able to find products that decrease pain and improve sleep. There are very few side effects with products that contain low dosages of THC combined with CBD, and there's great variability in the preferred dosage and route of delivery amongst patients. So the way the process works for patients is most states require registration with the Department of Health. Then they need to see a qualified physician to get certified. They next need to purchase a medical cannabis identification card, which they use to shop at an approved dispensary. And then they follow up with their doctor. Most states do have products that are tested by the health department for things like heavy metals and pesticides and to make sure that there's nothing in the product that shouldn't be and that the dosage is accurate. On the doctor end, what I do in my practice is I obtain informed consent. I collect outcome measures that are specific to patient's pain condition. I perform an online certification at the time of the visit and discuss active ingredients, the different delivery methods, ways to minimize the chance of intoxication and side effects. And then I actually pull up a local dispensary menu that the patient might actually shop at and make product recommendations. There are a variety of different routes of delivery, different ways to ingest cannabis, including inhalation methods, which includes smoking and vaporization. It is believed that vaporization, which uses lower temperatures and avoids combustion is easier on the respiratory track. However, I think most of us would agree that using oral products would be preferred for medicinal use and that can come in capsules, pills, tablets, edibles and sublingual tinctures that are placed underneath the tongue and get into the body through the oral mucosal route. There are also topical cannabinoids that are very effective for pain patients and do not cause intoxication because they're generally not absorbed into the bloodstream efficiently. In medical cannabis dispensaries, you'll see products with different ratios of CBD to THC. Most of the literature studying the efficacy of cannabis looks and has found that a combination of THC and CBD is most effective and more effective than using either cannabinoid alone. Generally products that have high amounts of CBD and low amounts of THC are gonna have minimal to no intoxication effect. And products that have a one-to-one ratio are gonna be equal part. And I think that can sometimes be limiting because the CBD dose can be kind of low. So in terms of dosing guidelines, this is what I have come up with and I think could be used by anyone who's getting started in medical cannabis. Generally recommend oral and topical routes of delivery. I think the sublingual round is the easiest way for patients to titrate their dose because it's a volume of liquid that they're putting in their mouth. Whereas many of the cannabis capsules are difficult or impossible to cut in half. The tincture can be used at 0.25 milliliters then up to a half an ml, three quarters and a full milliliter and so on. Each tincture has a different dosage of THC and CBD. I like to use a combination of THC with equal or more CBD. And then I have the patient titrate up on their THC dose just by one to two milligrams. For a majority of patients, less than five milligrams is a non-intoxicating dose. And I do mention using hemp derived CBD, which is oftentimes cheaper than what's found at the medical dispensary. And it's a way that patients that can use a higher dose of CBD, something like 20 or 30 milligrams in conjunction with five or so or less milligrams of THC. I think vaporization is helpful for some patients with breakthrough pain because the onset of action is within minutes and peaks at around 15 to 20 minutes. But, and I have also found that topical THC appears to be more effective for pain than topical CBD. But the overall goal is to minimize intoxication and to find products that people can use during the day. At night, when a mild intoxication may be accepted or for sleep, patients will oftentimes increase their THC dosage. And many people obviously are concerned about the fact that you can get high from THC, you can get too high from too much THC. And that is most commonly occurs with edible products when patients are unsure of the dosage or they don't realize how long it takes for an oral product to kick in, which can sometimes be up to two hours. And they take a second dose before the first dose has hit. But I feel that a lot of patients that experience mild intoxication do report feeling happier or slightly euphoric, more relaxed or sedated, less anxious, or just a change in their outlook, which is important when you're dealing with a chronic illness. Interestingly, in our data that we've collected, almost half of our patients do not experience intoxication. This is a survey of over 300 patients in my practice and 52% felt that they felt no feeling of being high or intoxicated after using medical cannabis. And of those patients, 80% reported symptom relief. So I think that's the perfect window that we're shooting for as a patient who doesn't get intoxicated, but does get some symptom relief. These are just some outcome measures. We're seeing that most of our patients see improvement in their chronic back pain in the first three months of using medical cannabis, and then they plateau. We also see improvements in the Oswestry Disability Index as evidenced in the D section of this slide. And then lastly, patients who were using opioids six months prior to medical cannabis certification, we saw statistically significant drops in opioid consumption, and almost 40% of patients who are on opioids had completely ceased using opioids at the six month mark after their cannabis certification. So just to wrap up, cannabinoids work on receptors throughout our bodies. They provide physiological functions that may benefit patients with chronic pain and neurological dysfunction relevant to the physiatry community. THC and CBD in combination has been shown to improve chronic pain in adults. And physician involvement in medical cannabis recommendations can reduce the incidence of intoxication and controlled substance use. Thanks so much for your attention. Thank you. Hi, well, thank you, everyone. That was a great session. We had a great discussion going in the chat room. Hopefully you all got to see that as well. Most of the questions there were already answered, but there were some questions about cash-based versus insurance and thoughts about maybe building a hybrid practice, also using the American College of Lifestyle Medicine for resources about how to bill for some of this lifestyle counseling and treatments. Other discussion about omega-6 versus omega-3 foods. Dr. Makai provided some great details about testing for vitamin D and also prescription dosing for that. Some people were asking about a Facebook community. So there's a community, it's called Lifestyle Medicine for Physicians. There's a ton of resources there. People post all the time. If you're a physician, you can join. Dr. Singh has some questions about feeling safe in our neighborhood, and she recommended using online resources if a patient's not safe exercising outside. There was a bunch of talk about different apps and also breathing exercises for kids and adults. So I think we had a great session. And if you have any questions, I believe all our faculty can be very approachable and you can reach out to us. And just want to say thank you to all of our panelists and to all of you for attending. Have a great day. Thank you.

integrative medicine

nutrition

pain management

supplements

anti-inflammatory diet

exercise therapy

mindfulness

medical cannabis

chronic pain

health outcomes