Hi everyone, good afternoon, thank you so much for spending the last session of the day with us. We're going to start promptly so everyone can get to happy hour on time. Apologies for my voice, I'm getting over a cold. We're so excited that so many people of you, so many people came to spend this afternoon session with us, something that the three of us feel very passionate, passionately about. So our talk today is going to be managing pain without medications, an integrative approach to chronic musculoskeletal pain. And this is the three of us in a nutshell, sort of all up and down the East Coast and Atlantic. Jack is actually my brother-in-law, so kind of forced him to do this with me. And then Solani I met last year and she just totally blew me away and has become a really big inspiration to me. I encourage you all to follow her on social media after this. And she has a really unique and interesting background. So I hope you learn something today and get something out of it. And we're really excited to be here with you. So for today, we really wanted to focus on sort of non-pharmacologic treatment because I think most people here know musculoskeletal pain conditions have become the biggest cause of disability in the world. A contributor to this problem is poor quality health care, which we've already heard a lot about today, includes overuse of certain medications, surgery, and really just failure to provide patients with appropriate education and advice. And so a lot of clinical practice guidelines are now recommending non-pharmacologic strategies that should be prioritized in the treatment of multiple chronic musculoskeletal conditions, low back pain, which we're going to touch on, knee osteoarthritis, rotator cuff disorders, the list goes on. We're going to review the principles of acupuncture and osteopathic manipulative treatment. And then we're also going to dive into lifestyle medicine and sort of talk about how these three things can be really helpful. Oh my gosh, I'm so excited how many people are here. There's more seats in the front. So let's jump in. I have no financial disclosures. And for the acupuncture talk specifically, this is what we're going to be focusing on. So I want to talk to you about the theories of acupuncture in terms of mechanism of action. There's a lot of theories. We're going to talk about the evidence focusing in on two clinical conditions. So for me, chronic low back pain and knee osteoarthritis. And what I really want you to get out of this is how do you talk to not only your patients, but also your fellow providers, especially if you have people that you think would be really good to refer patients to. What do you need to know about that and how can you talk to your patients about this? So acupuncture belongs to something called traditional Chinese medicine. It's a broad range of disciplines that covers acupuncture, massage, herbal medicine. And we're going to talk about some of the common concepts that exist within all of these. And so the first is yin-yang theory, which is looking at the same thing in two aspects. And so yin and yang represent the duality of nature. So yang is active, bright, hot, yin is inactive, dark, and cold. And when there's an imbalance of these two, that's what leads to illness. And so the theory of five elements, so there's five elements, wood, fire, earth, metal, water. And these represent five categories of sort of all things in the world. And again, there can be these normal or abnormal interactions between them, and again, can lead to illness. So this is the definition of acupuncture. I think the main thing I want you to take away is that it is different from dry needling. That's something that a lot of people ask me, in Georgia especially, because PTs can do dry needling there. So a lot of my patients will ask me that. And so we use pretty much the same needles, but we are going to talk about why acupuncture uses specific acupoints, and we're going to talk about what actually defines an acupuncture point. Whereas dry needling, it can be anywhere, along muscle, fascia, tendons even. But really, with the muscle, you're sort of moving that needle back and forth, and it has a very specific idea of we're trying to break up the fascial planes. We're trying to kind of break up trigger points, tender points, which you can do in acupuncture. But again, that's not usually the main goal. We're actually activating the acupuncture points, and then letting the patient sort of sit there with the needles. So again, we're just going to kind of talk about the principles of acupuncture, and we're not going to go too deep in the weeds here, but talk about a few things that sort of define what acupuncture is. So there's something called the Zhang-Fu theory, which is where we classify the internal organs. And it actually is that you have Zhang organs, and they are paired with Fu organs. And generally, Zhang equals Yin, and Fu equals Yang. There's Qi, which I would argue is the most important thing. This is when patients ask me, like, how does acupuncture work? This is sort of what I start with. And so Qi is matter, it is energy, and it flows along these channels or meridians that we're going to talk about on the next slide. Qi is considered to be the most active of the body's substances, so compared to, like, blood or other body fluids. And when there's imbalances, that's when we can correct these with acupuncture. And then there's these meridians. So there's 12 regular meridians, 8 extra. And these can become blocked during disease, and these are what carry the acupuncture points. And so there are more than 361 acupoints, but traditionally, this is sort of what we're taught. And when you are putting a needle into an acupuncture point, you're trying to elicit something called Daji, which can feel like this heaviness, tingling, sort of pressure-like sensation. And it's due to the polarization and ionization of the pathway tissues. And that's what you're asking the patient to sort of report to you. They should not be feeling like, okay, you hit my sciatic nerve, and I'm feeling this into my leg. Like, no, that's too much. You went too far. But you are looking for something like, oh, my leg is feeling a little heavier. And that's kind of the sensation you're going for. So they've done studies, and they've actually looked at what defines an acupuncture point. And so the video I'm going to show at the end, you're going to see there's a palpable surface depression. So when I'm running my finger on a patient's back, I'm starting at the spinous process, and I'm moving over the paraspinals, and my finger's going to drop down into the bladder meridian there. And it's, sorry, drops into a point. And you'll see that on our knee video at the end. There's physics, hashtag physics, decreased electrical resistance, increased conductance. They are generally hypersensitive. So usually when you palpate these points, they're a little bit more bothersome to the patient. They have generally a higher body temperature. And there's a lot more nerve endings there, probably why they're more hypersensitive. And when we insert the needle, it depends on where, obviously, if you're around like the lung field, we're not going to be going as deep as if you're in like the glute area. But you really want to go about usually 0.5 to 0.8 centimeters. And again, we're eliciting that dot G sensation. So there's a lot of theories. We're going to talk about sort of the older and the newer ones, which have changed like, you know, with fMRI and things like that. But the older ones say that basically by stimulating these acupuncture points, this is causing biochemical changes and affects the body's natural healing abilities, usually by the release of some form of neurotransmitter. So the humoral theory is saying that acupuncture affects the release of endorphins, norepine, serotonin, ACTH, and endocannabinoids. The gate control theory, which I think everyone here is familiar with, is saying that it's acting via synaptic inhibition at the level of the spinal cord. And then specifically electroacupuncture, we're adding electricity to stimulate these needles even further. It differs if you're using low frequency and high intensity versus high frequency and low intensity. But basically, again, you're sort of activating endorphins, neurotransmitters, serotonin, ACTH. These are a lot of the big ones. The newer theories, though, so there's been some really cool fMRI studies, and they've shown that there's actually changes in cerebral blood flow in somatosensory areas, but also in affective and cognitive processing areas. And they've looked at that before and after acupuncture and compared. So those are actually pretty fascinating studies. And they've also seen local release of adenosine and activation of A1 receptors, both in animal and human studies. When I talk to my patients about this, I'm like, this is literally the safest procedure I do. I'm not using an 18-gauge needle and stabbing you in the knee. I'm not putting in any steroids. Generally, I would say, when someone is asking me for the least invasive thing that I do, it's this. It's very safe. The FDA, for the most part, is regulating the manufacture and use of needles. I actually get all of mine through a company that sources them from Korea and Japan. They are single-use needles. So you take them out. They go right in the sharps container. The most common side effects are fatigue, local pain, headache, dizziness, about 10%. I generally tell my patients to eat before coming in. They can feel a little bit dizzy after. And I say, if they work out, I'm like, eh, maybe don't work out today. You can go back to normal activities tomorrow. And you really have to know your anatomy. So again, when you're around the lung fields, people remember there was an NFL player who got a pneumothorax on the sideline because someone put a needle in the wrong place. So you want to know where you're going. You want to know the anatomy there. Generally for physicians, we're very good at that, especially PM&R. And you want to count how many needles you put in and count how many you take out. Make sure those numbers add up. Simple things, but you never know. This guy thinks I'm funny. I love that. There is very few absolute contraindications to acupuncture, which is one of the other things I really love. So pregnancy is a big one, and it's because there are certain points that can actually induce labor. So you have to know which ones those are and stay away from them if you have a pregnant patient. Blood thinners, I just talk to my patients the same way I do when I do injections. But there really is no reason you can't do this when someone's on blood thinner. Extreme debility in the sense that, again, it can make you feel fatigued and weak after. So you just, again, want to educate these patients. I actually have had that for some of my 80-year-olds. They've shown up in clinic looking completely dehydrated and malnourished, and we've actually not done a treatment, and I've sent them home. Active malignancy, active infections. And the pacemaker is a big one because you can't use electroacupuncture. You can use moxibustion, which is a Chinese herb that you can use to stimulate the needles instead. And so that's generally what I'll do if someone has a pacemaker. So we're going to switch gears and sort of talk about how we're using this in clinical practice. It's most commonly used for pain. The NIH consensus statements, interestingly, have said that the clear evidence actually exists for post-op and chemo-related nausea and vomiting, and post-op dental pain. Interesting. Have not read that literature. But they also said that it can be effective as a standalone or adjunct treatment in a lot of other conditions. So I only do it for musculoskeletal. I actually have gotten asked by some of the primary care doctors to do it for peripheral neuropathy, which I did learn when I was doing my training. And there are some really cool points, and I have had good success with that. So that's something I'm starting to work into. But there are protocols for smoking cessation, I mean, literally for everything. It's pretty incredible. And there have been a lot of studies. The issue is that research is very challenging to create around acupuncture, because there's not really a standard definition for what defines sham acupuncture. And so in that sense, we don't have a good control. And so that makes it really difficult to do research on it. So I think this is why people shy away from it, because they don't, they're like, the evidence is mixed. But we're going to talk about two situations where the evidence is actually pretty good, and that's chronic low back pain and knee OA. So I don't know how many of you are familiar with this, but four years ago, CMS announced a decision to cover acupuncture for Medicare patients with chronic low back pain. So 12 weeks or longer. They were covering 12 visits in 90 days, but you could justify another eight visits if they were medically necessary. And this basically came into effect because of the public health opioid crisis. And so basically, they were saying that while actually there were not a lot of patients 65 years or older included in the studies, that patients with chronic low back pain showed improvement in function and pain. And so they basically said, we're going to support clinical strategies that are utilizing non-pharmacologic treatments first, and then we can go into the other things. So this really was huge, because I think this sort of justified to the other commercial insurance companies that there is some value here, and we definitely did see a spike in commercial insurances covering acupuncture after this. I'm not going to run through all the studies, but just point out a couple that if you want to take a look through, they have some really interesting findings. So this is a systematic review from 2017 published in Annals, and they actually looked at multiple non-pharmacologic therapies. So things like Tai Chi, mindfulness, psychological therapies, yoga, massage, acupuncture. And they basically went through each of them. It's a great paper. And they found that the evidence actually does support the effectiveness for acupuncture with chronic low back pain. They said low to moderate strength of evidence, but again, for it being so low harm, which is the thing you're going to see now in these consensus statements, they did recommend it. So the 2017 ACP guidelines for treating non-radicular low back pain, they are recommending that initially we are thinking about non-drug therapy first, and that includes acupuncture. So for me, I'm sports-based, so I actually don't see spine patients unless they're coming to me specifically for acupuncture, but this is what I talk to with my athletes and then my patients who are referred for acupuncture. I ask what their other physicians have done, and I'm really sad when they tell me they've already come in and done like four epidurals, or they have had a spinal stimulator. I mean, I'm like, this is really, I really wish that we were sort of starting a little bit earlier with all of these other things that we all know work. And I think it's just talking to other physicians and especially primary care and other spine physicians for low back pain especially. 2020 NAS guidelines also said that the addition of acupuncture to usual care is recommended. Specifically, they said for short-term improvement of pain and function. They said that they did find conflicting evidence that acupuncture provides improvement in pain and function compared to sham acupuncture, which again, I think is justified just given the weakness of some of the literature we have, but that it is the most cost-effective treatment that we have, which again, is another thing. These needles cost about like a cent. I'm the most expensive part of it usually. We have payment plans for these patients, so this is something that definitely becomes a much more cost-effective option when you're comparing it to like, again, an epidural. So that's kind of the wrap-up on low back pain. Definitely we can come back to it if people have questions at the end. But I did want to dive into knee, specifically knee arthritis, and kind of the treatment that we do for this. This is a meta-analysis actually from a while ago, 2007, and they found that acupuncture was superior to sham acupuncture for pain, and they looked at WOMAC function scales in short-term and long-term follow-up, and that it was actually superior to doing nothing. So that's important also. But this study, which is a different meta-analysis, more recently from 2016, found that acupuncture could improve short- and long-term physical function, but actually only short-term pain relief. So they looked up to 26 weeks and found that the control groups had kind of evened out to the acupuncture groups there. These are the various groups and sort of where they stand. So ORSI, I put first, that's the ORSI Arthritis Research Society, they actually conditionally don't recommend, but they also don't recommend genicular nerve block, PRP, things that some of us do know work, so take it with a grain of salt. American College of Rheumatology, conditionally recommend. I think this is actually one of the most important statements. So while the true magnitude of effect is difficult to discern, the risk of harm is minor. And that, I think, is such a key statement, and I really like that they included that. And then AOS actually revamped their guidelines a couple years ago, and now they actually came back and said, we do conditionally recommend acupuncture with some of the newer literature. So they actually weren't recommending it in their prior consensus statement. And this is just a couple of my clinical pearls. So kind of when you're talking to a patient, so generally what I'll do is my schedule will be once a week for six to eight weeks, and then we can consider maintenance if needed. Some patients, rarely, I've pushed out to like 10 weeks if they're like, I'm getting such benefit. Okay, fine. Most patients will notice improvement in pain after two sessions. Again, a small sub-portion will have, like, they'll feel amazing after one session. That's generally not the norm, unless you get like a really good trigger point in there, and then they feel really good. And I'll generally stop after three sessions if they're not improving at all. This is, I mean, I've been practicing now for three years, but there's been two patients that I have gotten zero benefit from acupuncture. I will tell you, anecdotally, I work in, part of my clinic is an underserved population. My patients generally have higher BMIs. We've been looking at it a lot for our patients who are sort of trying to bridge to a knee replacement. And I will tell you anecdotally that the effects are potentially limited in more obese patients. I do change my needle sizes, so I'm using closer to a spinal length needle, especially around the quad area in the knee. And there's no literature around this. Again, this is just sort of my experience. And then in terms of, this is what I get asked all the time, is with insurance. And unfortunately, it does vary state by state. So we did talk about chronic low back pain now covered by Medicare. And like I'll tell you in Georgia, state Medicaid straight up does not pay for any acupuncture. Some of the Obamacare plans do pay for it for certain conditions. So when you get authorization, you have to say, this is for chronic neck pain. And they'll be like, we only do chronic low back pain, or we only do hip pain. So it's very specific, unfortunately. There was a survey done in 2018 of 45 insurance plans that found acupuncture was only covered by a third. And so that was pre the Medicare decision to cover for low back pain. And so insurance coverage has definitely been increasing, but most patients do still pay out of pocket. I trained at NYU, and we actually, that's where we got built into our residency curriculum for training. But there's physician training all over and out of the country, it's pretty incredible. And that sort of can depend on how much you charge is sort of where you are. Usually I would say it's $100 to $2 a session. But what I tell my patients who are not able to afford that, is that look for a place, a school usually that does acupuncture training. And they'll usually have a group class, and they're so much cheaper, it's like $30 a session usually. And that's a really great option for some patients. So I just wanted to end, I don't know if any of you know Alex Moroz, this is my program director from NYU. This was during COVID, and we were giving a virtual talk on acupuncture. So this is my knee, no HIPAA issues. But I just wanted to show you just kind of what it looks like in case you've never seen what an acupuncture treatment looks like. This treatment essentially surrounds the knee joint from the front. And it's a lovely treatment for any knee problem, but you know I use it a lot for osteoarthritis. Seven needles with electrical stimulation. This one here, spleen nine. Some people argue you need to go periosteal in order to get good effect for osteoarthritis, which I'm not going to do, but in general, you can go until you touch the bone on this one. These two are the eyes of the knee. You okay? So this does not hurt at all for most patients. The spleen nine can be kind of painful when you get around periosteum, but generally most people don't feel this at all. And then you're looking for that, again, that dodgy sensation and kind of asking them for feedback. In this case, instead of Moxa, we're going to use electrical stimulation. I'm taking gloves off because it's easier to manipulate the wires without. And the wires always tangle. And I'll just talk over. So he's going to connect them in like a daisy chain, so alternating red and black going up and then the head dings so the one retro patella doesn't get stimulation. And you turn it on and you basically go until the patient can feel it. I tell them they should feel like a tapping sensation, but it shouldn't hurt. And then they'll usually not feel it after about 10, 15 minutes, but I'll leave them on with the stim. And the treatment sessions, so I didn't go into, generally I aim for a minimum of 30 minutes. You bill in 15 minute increments. So the first, and it goes with stim or without stim. So if you bill the first 15 minutes, the work RVU is 0.65. And then for each 15 minutes after that is 0.55. And to do that, you technically have to check in on the patient every 15 minutes. And some people get in trouble because they don't do that. My patients usually fall asleep. So I'm just not going to be like, you're alive, you're breathing. Generally, I'm not going to do it now, but I would increase the intensity until the patient just feels it. And I think part of it, there are patients who come in, they bring reading, they bring their phone. I really actively try to get them to not do that and try to really engage them with the mindfulness piece. I think that's so important. But yeah, that's sort of the, I think we're done. So that's just kind of the general knee pain. And then I'll add some. You can kind of go down into the leg, get some of the gallbladder points there. But that's the main one that we use for knee pain. Thank you. These are my babies. Please reach out if you have any questions at the end or connect with me on social. Thank you. These are my references. Thank you. This is a massive crowd. Like, I'm just going to get a photo of that, because it's kind of dope. Cool. All righty. So real quick, by round of applause, how many MDs are here? Awesome. And by round of applause, how many DOs are here? And by round of applause, how many trainees are here? School? Yes. Good. All right. Let's dance. All right. So my name is Jack Anunziato, and I'm talking about osteopathic manipulative treatment. Sadly, I get no money out of this. I did my undergrad at Providence. I went to Rowan SOM, which was UMDNJ when I started. And now it's Rowan Virtual. And this is going to be a theme of just explaining and talking. And you guys are all very used to this as physiatrists. We're going to keep going with this. So in the next 15 minutes, we're going to go through about 150 years of osteopathic medicine, four years of medical school, clinical practice. We're going to talk about things that are board-relevant for your ABPMNR exam, that kind of crossover into OMT. We're going to talk about the utility and the evidence for doing this with chronic musculoskeletal pain. I'm going to give you some take-home actions. Sounds good, right? So 1874, Andrew Taylor Still, an MD, begins practicing what is later coined osteopathy. Good. 1892, the first DO school. And by 2023, about 11% of physicians are DOs. And about 25% of them are medical students. For my MD colleagues, the curriculum is basically the same. You get two years. The first year is your basic sciences, all your basic blocks. Year two, it's system-based blocks. Year three is your clinical clerkships. Year four is your electives, your auditions. And the osteopathic curriculum is built into usually years one and two. The first year is kind of this anatomy, physiology, learning the styles. Year two, you're integrating it into the clinical applications that maybe come through it. Year three is a clinical course. So I think it's important, Rosa kind of talked about, knowing what to tell your patients. Like, oh, how are they different? What do they know? This is what they know. It's very similar. So this is the Rancho 6. Physiatry or PMNR, yes. Some of those people are like, oh, brain injury, get me out of here. Like, I don't want to talk about that. So it's physiatry, physiatry. I'm not psychiatry. I'm not a physical therapist. You have these conversations all the time with your patients. Let's get even more confused. So osteopathic manipulation, OM, OMM, some places call it OPP. You can call me an osteopathic physician. If you call me an osteopath, that's technically for those who practice manual medicine. But abroad, if you use that term, they're not physicians. So the verbiage matters and gets kind of confusing and bogged down. Then they changed our fellowship, and now it's called osteopathic neuromusculoskeletal medicine. Not to be confused with neuromusculoskeletal medicine. The EDX lectures, those are down the hall. So we are certified by a new board. And now you'll see letters as of 1999. It's C-N-M-M-O-M-M, because the letters just roll off the tongue. All right, this is the Rancho 4. So any DO can do OMT purely based on their DO degree. Some schools offer an undergraduate fellowship where you kind of have this gap year, you're doing research, and they get called fellows. But then there are other programs who use the fellowship as a graduate medical education program. That's something that I did. So I'll jump to the post-GME merger options. So there are people who do a three-year residency in just manual therapy. Then there are people who do a one-year internship and then a two-year OMT residency. And then there are people who do another ACGME residency entirely, like PM&R. And then you do another year. So that's what I did. So the training matters, because if you think about who you would refer for a spine injection, you're like, all right, I want to make sure their credential, they know what they're doing. So you should try to know who you're sending to and what backgrounds they have. Now, granted, not everybody has a fellowship, but experience matters. And education is an easy way to distinguish what you're sending these patients for. So then we talk about complementary and alternative medicine. The NIH organized the National Center for Complementary and Alternative Medicine 98 to study these therapies. There's about five different blocks, alternative medical systems, mind-body interventions, biologically-based therapies, manipulative and body-based therapies, and energy therapies. And then there's another definition of integrative medicine, which is evolving. But I like to call it the practice of combining mainstream medical therapies and CAM, which is the complementary alternative medicine, for which there's some high-quality scientific evidence for safety and effectiveness. Osteopathic medicine is considered both an alternative medical system and a manipulative therapy. We use different terminology than chiropractors. So some people call them subluxations. Osteopathic physicians call them somatic dysfunctions. I think the thing for you to ask your patients is, if they've had some sort of manual work, ask them what they've had, and ask them to be specific. Because a manipulation, a mobilization, a massage, they're all totally different. Some people say manipulation requires a thrust or a crack versus a mobilization, no thrust. But again, we have such a language problem. Ask them. That's the best way you can figure this out. So let's go forward and then back. So this is a spinal manipulation. So this sports med resident, his back hurts. And I just do a thrust. And that's a crack. Then there's massage. And massage gets this bucket of everything. So this might get described in your PM&R board exam. So there's effleurage, which is kind of gliding. There's petrissage, which is kind of pinching. Which is karate chops. Soft tissue mobilization is a catch-all term. You do it with fascia. And there's kind of relaxed or shortened myofascial release. There's light pressure in different planes. And there's acupressure, which is kind of like acupuncture. You're hitting those points, but you're using a lot more force. So again, I implore you, ask what they've had. So this is myofascial release. There's a lot of physiatrists in this room. They're all kind of in, they're manipulating the tissues in different ranges, applying a little force, getting release. It's very fun, it feels good. Some question you could ask is, do they have direct techniques or indirect techniques? And this is important, because direct techniques go into the barrier. These are your thrusts, these are technically your muscle energy, your reflexive relaxation. If any of you were at the manipulation lecture a couple hours ago, they talked about this a lot. There's more lectures going forward. So if you want to learn more, please show up. Indirect techniques go into the ease. These are things like counterstrain, balance-segmented tension, craniosacral. I could spend like four hours just talking about that, and what's direct and indirect, but that's a separate lecture. So counterstrain, muscles are shortened for a prolonged period of time, which shortens the muscle spindles. You get gamma motor neuron firing. That increases. Then you get a hypersensitive muscle spindle fiber. And then basically, if you were to lengthen this short hypersensitive muscle, you would trigger an alpha motor neuron response, causing more spasms. So what you're doing is you're actually shortening these muscles, bringing the spindles even closer together, and then that resumes normal firing, and then subsequently normalizes your gamma motor neuron firing. That takes about 90 seconds. This is suboccipital myofascial release. We have a cancer rehab physician manipulating a sports medicine physician. Patient supine just applying a little pressure underneath the suboccipital. Sometimes you can add some rhythmic motions, although that's debatable. This is rib raising. You're underneath the scapula. You're kind of feeling the rib heads. You're applying a ventral pressure. And what are you doing? You're mechanically stimulating the sympathetic chain ganglion. You're improving the sympathetic tone. And then if you're working up high, you're stimulating the vagus nerve to reset the parasympathetic response. So I have a brain injury attending. He's really skittish. He gets really nervous. And then I do some rib raising. He's like, oh, I kind of calmed down. Sorry. So this was the seminal narrative review. It basically kind of highlighted all of the research that has been going on. This is as of 2020. So a couple of things that he highlighted. There was a 2005 meta-analysis of six trials, 525 patients, that basically showed that OMT reduced back pain intensity in an effect that was comparable to NSAIDs and knee pain. And you guys give out NSAIDs like candy. And you definitely give it out for knee pain. So if you're thinking about using an NSAID for knee pain, on the same par for your patients, think about adding manual therapy for their aches and pains. Food for thought. There was a meta-analysis of 10 trials, over 1,000 patients, that also noticed that OMT reduced back pain intensity. Now, granted, these studies were done outside of the US. But a lot of the techniques are similar. It's tough to tell unless you ask questions. Then there was the osteopathic trial that had 455 patients, which showed a medium treatment effect in reducing chronic back pain and decreased use of prescription medicine, something that we would love for our patients to not have, especially if they have comorbidities. Maybe they're bad diabetics, and they can't take medicines because of their kidneys. Or they are on blood thinners, and they can't use them. There was a small meta-analysis of three trials. That was about 123 patients that showed a medium treatment effect in OMT, but they didn't show statistically significant change in functional status. But it felt better. And then there was another review, OMT for headache. Five trials, 265 patients, improvement in pain intensity, frequency, and medication use. Though the meta-analysis component of this was tough because the studies were very different. So lastly, I just want you to kind of leave with one last thought. What can you do? Number one, if you are interested, try to learn more. We have lectures later this conference that you can come and learn more techniques. There are outside courses open to MDs and DOs. You can learn more. You want to refer to your patients. And then lastly, if you have trainees, enable them, allow them. I went to Kessler, to my residency there. There was not anybody who was doing this. But you know what they said? Go half at it. They already have a complete spinal cord injury. Go nuts. It's like, yeah, OK. Thank you for putting your faith in me. I'm just going to do soft tissue. Yeah, I know, crazy. Go nuts. But you can't hurt them. It's very soft. It's very gentle. A lot of these techniques, you go indirect. You set your boundaries. So if you are in the process of training future physiatrists who have an interest in this, let them try. Give them ground rules. You can say, hey, no cracking, all indirect. That's fine, because you're enabling somebody who might want to do this someday. So these are my dogs. And yeah, thank you. All right, here we go. Hi, my name's Loni Sharma. And we were all talking about a similar topic. We want to help people manage pain without a lot of medications. I will not dwell on introductions. Trying to, oh, green. Oh, the other green one. There's two green ones. I got it. These are my disclosures. I wrote a book. It's more for patients. And I'm a consultant at Carillon. So these are our objectives. To recognize how lifestyle factors impact pain and function. We want to talk about nutrition. Really going to delve into that just in the interest of time. And to sort of have some practical points. This is a little different than the other two talks, which were wonderful and very heavy evidence-based. This is more, what can you do in your practice now? So it's a little bit of a different term, but also with evidence-based to it. So luckily, my colleague, Chuck, sort of talked about some of these things. But alternative is non-mainstream approach. So alternative means instead of, right? So we don't really like that term as much. We like complementary, which means in conjunction with. So using conventional treatments in conjunction with other treatments like acupuncture, yoga, tai chi. And then integrative, like Jack was talking about, is sort of a combination. It's combining conventional and complementary, and really looking at the whole person. So it'd be taking something like acupuncture and yoga, plus physical therapy and injections. And this is sort of, just sort of to be familiar with the definitions. This is a hard topic to cover, because I know people in here, from medical students to some people who I see were my attendings. So it might seem a little basic, but I think it sort of helps to have the definitions down. So orthopedic integrative health. So this is sort of what I practice, an orthopedic integrative health center. I have my regular practice, which is all spine patients. And then on the side, I have this integrative health center within my practice. And it's a combination, like I said. So it optimizes conventional care. It's not instead of. It's in addition to typical back care or neck care, just spine care. And it really builds health and pain resilience. So it's really looking at whole health, but with a pain focus. Why does this matter? This data is a little bit old. The number's actually gone up. But if you look at the, and I'm going to be dangerous and try to use the other green. If you look at the blue columns, greater than 55% of people turn to complementary medicine on their own. So your patients most likely are using this for their spine and musculoskeletal issues, whether they talk about it with you or not. If you look over here, neck pain, 50%. Back pain, somewhere in the 40s. So people are using this. This is over a one year period. More than 50% of people are using these type of treatments. So if we aren't educated, we really can't help our patients and empower them with evidence-based and practical tools. So, sorry, that's my throat lozenger. This is the whole health person. This is actually from that center that Jack was talking about. So the National Complementary and Alternative Medicine. They keep changing their name, but center. It's interesting because it's really the whole mind-body approach, sort of broken down with a pain perspective. So that was too fast. Wrong green. No, I did a red. OK, I'm going green. So there's medications, so typical medications like prescription medications, non-prescription medications, botanical drugs, dietary supplements, vitamins, natural products, prebiotics and probiotics, phytochemicals. We'll talk about all three of those shortly. Food first, so food is medicine. Psychological, and it's sort of neat to see the overlaps here. For example, psychological nutritional, it's mindful eating, right? So not like that blind eating in front of Netflix and just like shoving it down your face nonstop. It's sort of being mindful. Oh, there it is, the left. And then meditation, movement, yoga, acupuncture, which we had a great talk about. Manual therapies, which we had a great talk about. Heat, cold, and I guess physical therapy would sort of be lumped in there. Stimulation with acupuncture, without. What's interesting is they don't seem to have injections here. I guess that would be above surgery. I'm not sure. But this is otherwise, aside from the epidural missing piece, this is a pretty good visual of the treatments, the whole health kind of integrative approach. So this is what we're up against, taking that nutrition focus, right? This is what our patients see nonstop. This is what you see nonstop. This one is even more appalling. It just blew my mind, OK? So it's about as processed as you can get, I think. I mean, there's probably something worse. But I want to point out the melon does not look well, OK? I don't think it's really good advertising to get this product. But this is what we're up against. And as physicians, it's our job to really have a different message and let them know lifestyle matters. When I was a resident, kind of long ago, but not that long ago, kind of like I'm in that middle area, these were the five ways we were taught to teach, excuse me, taught to treat pain. So it's lifestyle, physical therapy, medications, injections, and surgery. Lifestyle just meant weight loss. That's what I was taught. That was it. It was also the elephant in the room that you never talked about. And it was just you sort of skipped over it. So it's number one for a reason. And there's a reason why pharmaceutical commercials say, if exercise and diet fail, right? Because it's number one, right? And that's the mission by them, that it is number one. So this is a great article from Pain, the Pain Journal in 2021. And it talks about barriers to pharmacological treatment and non-pharmacological treatment for older patients. And they have these three A model, which I like. So I did the wrong grade. I'm going to go back. There we go. So it's appeal. And sort of this is something they consider effective, worthwhile, comfortable, and you guys can read through, awareness. So that's where we come in, right? People even realize that food impacts pain? I mean, I don't think so. A lot of my patients don't think that. Sleep, stress, relationships, of course, we know it does. But I don't think that a typical patient thinks, oh, wow, you know, that cheeseburger, French fries, and Coke I just had might affect my pain, right? And the reason is because no one tells them. So it's education, like my colleagues were talking about. And access can be an issue, but a lot of these things are available online. Some of the resources we're going to talk about. So I will go to the right green. So in my integrative health center, when I sit with a patient, I actually show them this diagram. This is the first picture I show them. And I say, we're talking about things on this side of the box because what it impacts is this, your pain, disease, and dysfunction, right? So that's why it seems like it's far off, but we're talking about your diet, your lifestyle, in terms of your activity level, your stress, addictive behaviors, and that's not always drug and alcohol, but social media, eating, other things, and social isolation, so your social connection. This is a really five-hour plan. I just came up with this because people like things that are sort of concrete and easy to remember. Refuel is just food, so unprocessed food. Revitalize is activity. Recharge is restorative sleep. Refresh is mindset and resiliency. And relate is connection with others, right? All right, so show of hands, does anyone have a survey or questionnaire that they ask their patients about these lifestyle factors? Several, good. That's the first step, right? And the reason some of us don't is because we don't have time to do all this stuff. So I will say with my regular patients in my spine clinic, I don't have time to go through all this. This is with my integrative patients. We do something like this. But it's something that I bring up to my regular patients. And we'll talk about that balance about when you don't have a lot of time, how to sort of bring some of these things up. But the first thing is asking. And that signals to them that it matters, that impacts their health, right? And then you can sort of have a sketch outline of, oh, this is something we can sort of touch on. And maybe just touch on one each visit. But it's just a little tiny piece that can be helpful. I love this picture because it sort of shows the big value meal, the Big Mac. And it really has a nice way of saying that this is how the standard American diet, which the acronym is SAD, can affect pain and inflammation really at a spinal level. This is from the American Heart Association. They talk about some of the surveys they've done that more than 90% of Americans have a poor intermediate score on their diet scores. What that means is that they have diets full of extra sugar, extra salt, unhealthy fats, and artificial ingredients with a lack of vegetables and fruits. We know this feeds more inflammation, more pain. We know it leads to longer recovery times from injuries. We know it leads to more fat mass, more painful flares, more heart disease, more systemic disease, and less lean body mass. So we know it's not good. But once again, this is what we're up against. This is actually genius. This is a sundial. It tells them every hour what processed food to buy. So it's very clever. It's actually very clever. We need to have one with like what vegetable to eat every hour and what exercise to do. So again, this is what you need to be. You need to be the billboard for your patients because this is what we're up against. And so they need to know these lifestyle factors impact their pain and of course their overall health. Okay. So we're talking about the Mediterranean diet. So sometimes it's easy just to start with patients the Mediterranean diet. Most people have heard of it. So it's very accessible. These studies are on osteoarthritis and rheumatoid arthritis. And it shows, here we go with the pointer, on the left that if you have a good omega-3, omega-6 ratio, high fiber, low glycemic index, high antioxidants, vitamin D, and probiotics, and I'm always sort of food first so we'll talk about that. It can reduce excess inflammation, help with weight control, and with your gut microbiome, and better joint health. And this is a sad diet that we talked about just on the other side, sort of the opposite. And for some people, gluten and milk were an issue too in terms of inflammation. So phytonutrients. Maybe some of you have heard of phytonutrients, maybe you haven't. Basically, they're what give plants their color, their strength. It protects them from injury. For humans, they act like antioxidants and they help limit inflammatory damage. Okay. So I'm sure we've all heard of polyphenols. They're things found in berries, turmeric, green tea. This visual is a summarization of a study on knee pain and knee degenerative joint disease. They found that increased dietary polyphenols lead to decreased oxidative damage, decreased self-death, and increased joint strength. So a tip you can tell your patient, what I call a micro-boost, and I'll talk about that in a minute. So you've got resveratrol-rich foods, because I'm always food first as opposed to supplements, right? So like blues and purples is an easy way to think about, like grapes, small berries, blueberries. And there's a list of studies there. This is my favorite Mediterranean diet picture. Before I get to the visual, I want to just talk about this study. A lot of this study is hard, and that's just what Rosa was talking about. Some of the stuff is subjective. You don't know what people are really eating at home, if they're reporting what they're eating. That's what's so great about this study. There's over 700 participants. It's from the Osteoarthritis Initiative, and they found that their MRI changes actually validate that following a Mediterranean diet results in increased cartilage volume and thickness. This was knee-specific, and that's adjusting for confounding factors. This is objective data, right? It's not subjective, which is fantastic. I love this picture because the bottom of the pyramid is people socializing, having dinner together, being active, and then it gets into the food piece of it, which we, you know, are familiar with. Okay, you can try to read this. You're right. Doctor, I don't feel well, and I'm not sure why. Do you like the voices? Okay. I want you to meditate for 20 minutes twice a day, exercise for at least 30 minutes a day, avoid processed food, eat plenty of organic fruits and vegetables, spend more time in nature, less indoors, stop worrying about things you can't control, and ditch your TV and internet. Come back in three weeks. So, that's ridiculous, right? So, like, no one can actually do that, right? Like, that would be a nice thing to say. That's why I was talking about microboost. What we want to do is make things simple, so break things down to little steps that are actually doable for our patients, and that's sort of the how of the plan. So, we're talking here about the gut microbiome. I told you I'd talk about that. So, I think we're all familiar with the gut microbiome, so I won't dwell on that, but the term gut dysbiosis may not be as familiar. That's an imbalance in the gut. That's sort of where, to be very simplistic, that there's more bad bacteria than good bacteria, and that can lead to a lot of inflammation, and there's things that impact that. So, diet and supplements, again, food first. So, nutrition, exercise, prebiotics and probiotics, and again, food first, and depending on what you're doing with these, that can either lead to an unhealthy or healthy gut microbiome. That can affect your joint health, and it can also affect your muscle health. As we age, we have glucose impairment, we have sarcopenia, there's a risk of falls. This is a key sort of point where you can sort of drift into more disease and dysfunction or not. This is also from the Annals of Internal Medicine 2021, and they're talking about how dysbiosis, again, that gut imbalance, can lead to the progression of osteoarthritis, and they're suggesting that that should be a target for osteoarthritis treatments. So, not sort of treating it after the fact, but really sort of optimizing the gut health before for better joint health. This is a visual, again, this is more patient-geared. It's sort of what's good for your gut and what's not as good for your gut. So, hydration, high fiber, real foods, so not that processed Mountain Dew, watermelon, I don't know what thing, fermented foods, and avoiding a lot of artificial stuff, trying to work on stress reduction, limiting processed food, low fiber foods, chronic infections, so sort of working on overall health, and then NSAID excess use, anti-inflammatory excess use, and acid medication excess use that changes the pH and can affect your gut balance. So, they talk about the SAD diet directly affects the gut joint access. So, you've heard of other accesses, but there's a gut joint access as well. It causes more inflammation, more swelling, more dysfunction, more pain. So, prebiotics, probiotics, just to be quick, hopefully most people know this part, but prebiotics are foods that support a healthy gut microbiome. So, it's sort of fibrous things like green leafy vegetables, onions, leeks, they feed the good guys, and then probiotics are actually the good guys. So, there are things that continue to contain beneficial bacteria like unsweetened yogurt, so you got to watch the sugar, cultured and fermented foods, miso, temp, sauerkraut, certain pickles. Those are the kinds of things you can actually talk to your patients about. So, we talked a lot about nutrition. The refuel revitalize is exercise. I mean, hopefully I'm preaching to the choir on that one, but there's, you know, no age limit. It helps with healthspan, lifespan, longevity, decreased fracture risk, systemic diseases, some cancers, stroke, depression, anxiety, insomnia, joint disease, osteoporosis, perimenopause. It helps with a lot of things. I like to talk about the secret sauce of exercise. So, it releases endorphins, it helps activate endocannabinoids, it helps improve mood, and helps reduce inflammation through myokines. So, if you think about it, exercise is sort of an opioid, marijuana, SSRI, and an Advil, right? All in one, and sometimes when you talk to patients about that, it's a little more relatable and more motivating. This is a study that came out from Sports Madison 2022. They basically found that just don't sit after you eat, just move. So, if you can move within 60 minutes after eating, even five minutes of light intensity walking, literally walking around your house, walking around your neighborhood, if that's safe, that can impact your inflammation level and your glucose processing. My mom's an endocrinologist, and she was like, this is ridiculous. Everyone knows this. Why is this in a journal? But, in terms of pain and inflammation, that's sort of the different approach. So, it helps with blood sugar control, which helps with pain and inflammation. So, that's sort of that second step. So, we talked about refuel, revitalize, recharge. I mean, this could be like five million talks in itself, but, you know, having a sleep routine, sleep hygiene, there's CBT for insomnia, there's specialists who just do that, so you could refer to that. I will not dwell on this in the interest of time, but just sharing with you. There's also sort of integrative treatments, mindfulness, meditation, breathing, yoga, body scan, progressive relaxation, acupuncture. A lot of these things, the first several at least, are things that people can use free apps for. I like Insight Timer. It has a free version. You can put it so you don't have to look at the screen. After you do this for a while, you can just do it yourself in your head without any type of device. There's guide imagery, there's massage, there's lavender aromatherapy, there's melatonin, magnesium, and again, I'm more food first, so I listed the foods there, vitamins, KMLT, ashwagandha, so adaptogens. There's a lot of different ways to go after this. Refresh is stress reduction. I think, you know, with all the politics that's been going on, a lot of us are in this sort of chronic fight-or-flight-or-free sort of mood, and that leads to chronic muscle tension, brain fog. It affects your immune systems. You can have autoimmune issues, up blood sugars, up your blood pressure, lead to more chronic pain or more disease, more inflammation, right? So it's breaking that stress cycle. Everyone here, I'm sure, knows, right, about mindfulness meditation and the impact on pain. So this is one study that looked at 30 randomized controlled trials, and they found that mindfulness meditation helped reduce depression symptoms, increase quality of life, increase pain relief. So it's sort of, and again, this is more visual for kind of the patients, but less inflammation, less pain, less muscle tightness, less depression, less stress, less anxiety, better for everything. You can just write, like, better for everything checkbox, and it helps with all kinds of conditions. So here's the micro boost, like I said, sort of making it more practical. You want to trigger the relaxation response, right, and activate it with a longer exhale. So just a simple breathing exercise that people can use, and you can actually do this with your patients, and I will show this to some of my patients, depending on if they're open and where they are with it. It helps with that parasympathetic response. Common ones are 4-7-8 breathing, box breathing, and teenage size. So teenage size, a little ageist, but I'll get there. Here's the relaxation response. This is 4-7-8. It's actually an Ayurvedic principle that Andrew Weil sort of made popular. It helps with lower heart rate, lower blood pressure, relaxes muscles. So basically it is, you have your tongue touch the roof of your mouth, and you inhale for a count of four, you hold for a count of seven, and exhale for a count of eight. You do that four times. The idea is a longer exhale, right? So if your patients are getting caught up on numbers, it's just a longer exhale is sort of the basic point you want to get across. I talk about SOCOM, which is a variation on a Hindu SOHUM, but it's the larger, longer exhale. That's what you want. Box breathing. This is the American Heart Association's visualization. This is more just about focusing the moment. It's not the longer exhale, but it's sort of just being concentrating and present, and so it's inhale for four, hold for four, breathe out for four, and then again hold for four. So the teenage size. Oh boy. So this is what I learned about in my mindfulness training. I did not come up with a term, but if you were a teenager or have a teenager or know a teenager, have seen a teenager on TV, then you have probably seen teenage size. So they are the full body sigh, eye roll, shoulder shrug, and it's a longer exhale. So it's genius. So this is a nice tool to use before a difficult patient, after a difficult patient, before talking to your boss. Yeah, it's a really nice one. Before or after. We can, I can, you know, sort of be the guinea pig. We can do some together, but let's try one together. So let's try three together, okay? So go one, two, three. I want to see some eye rolls and shoulder shrugs. Oh, I love the eye rolls. Okay, one more. Last one. My traps are all loose. I just need a little acupuncture, osteopathic, and I'll be, I'll be good now. So those are the ones. This is, again, it could be like a whole talk. We know being lonely is bad. We know it's not good for your health, sort of across the board, systemically, but especially for pain. When people are incarcerated, the worst thing you can do is get solitaire. So, you know, that really points out that that's sort of the worst punishment a human can have. People who are in solitaire have higher rates of musculoskeletal pain and depression after, chronically, not just in a short period. I won't dwell on this. I think it sort of makes sense, and going back to our triangle, though. Oh, I got the right green. Okay, so awareness. Do you know that something, this is for your patient, do you know that acupuncture, yoga, tai chi may be able to help with your pain, right? So have they even thought of that? Do you know that nutrition changes may be able to help with your pain? Again, something that maybe no one's ever approached with them. Appeal. Would you be willing to try acupuncture, tai chi, yoga, nutrition changes? Can you think about something you wouldn't like? And does anything make you think that acupuncture would not help with your pain? And these are sort of like a baby version of motivational interviewing, which is much more involved and works really well if you have the time to do it, but it's sort of a more, it's like the quick and easy, the hack of it, and then access. And again, a lot of these things are available for free online. If they don't have access to things online, a lot of community centers have tai chi, yoga, mindfulness, meditation, things like that, YMCA's as well, arthritis foundations. So this is sort of like the future and what my colleagues talked about a little bit. Does integrative medicine reduce prescribed opiate use for chronic pain? And in this study, they looked at several things. Look at medical cannabis, multi-disciplinary approaches, CBT, acupuncture, a whole bunch of other stuff. There's mindfulness in there, physical therapy as well, and the bottom line is it did help, but it was a very small sample size. So that's something that we can look more into the future, but there is some data showing that it can help with opiate reduce and opiate tapering, and I think, you know, the cannabis data is growing even faster, but I think a whole multi-disciplinary approach, it really makes sense. This is from the integrative center that I run. Surprisingly, the mean age was 64 years old. I don't know why that surprised me. I just thought it would be like 22-year-old, 23-year-old people, like, let's stay healthy, but no. It was older women, so 80% of the people were women, and they had taken care of everyone their whole lives, and now they're finally gonna take care of themselves, and it was really about wanting to function better and not age poorly, and that's what we saw. We used the Global 10 Promise scores and 84% improved, and the rest just no change, so we were pleased with those results. I have a quote from a patient, but I think I'm just gonna go over that. So these are tools you can use. It's always food first, right, and just even telling them that food impacts pain. Your lifestyle choices impact your pain. Be that billboard, be the messenger. There's handouts. So there's the anti-inflammatory handout. The pyramid you see there is Dr. Andrew Wiles. It's very similar to Mediterranean diet, which is fine. There's a Harvard healthy eating plate, which is similar to my plate that the US government puts out. It's plates, half fruits and vegetables, half whole grains, and a healthy protein, water, healthy oils, and then it says stay active around the corner. Lifestyle medicine, the ACLM, they have, or the ACLM, they have a lot of great resources that you can access for free. They're sort of like pretty visuals. You can make your own handout. It doesn't take that long. It's just like a Word document, and that way you're really not spending a lot of time, but you're reinforcing that message that food matters, your lifestyle choices matter, and it's important enough that the physician, not the medical assistant, not the front desk person is handing you this paper and saying this matters. There's my book. There's podcasts. There's all kinds of resources for people. So be the billboard. This is my info, and thank you very much. So we'll just say, if anyone has questions, we'll hang out. There's mics up in the front. Hello. I really enjoyed the talks. How operator-dependent is acupuncture, and how do I find someone in my town that is good at doing it? Great question. So I would say it's not as operator-dependent as something like ultrasound or something else I do, but you definitely want someone to have gone through proper training channels. For physicians, there are specific courses that you can do as a physician that are different from like a licensed acupuncturist, and it's because they understand that we have more anatomy training. We've already done sort of physiology, so we kind of have different didactic and clinical requirements. It varies state-by-state as well, depending on where you're going to practice. So for me, I was in New York. The training I did was actually through SUNY Downstate, and they're one of the ones in New York, in the New York City program, that offer it for physicians, and it's a hundred and, no, sorry, it's 200 hours of didactics done over a six-month period. Then New York requires a hundred clinical hours of training. I actually did 150 because I was living in New Jersey, and that's actually the highest one in the entire country, so I just did 150 to be safe, and then that actually translates to pretty much any state I want to practice in. Harvard has one. There's one in California. There's now, I think, a couple in Texas. So as for you, for training, I would just Google physician acupuncturists. They tend to be kind of expensive, and then as for finding people in your area, you know, you can Google. I have found, I actually go to other acupuncturists, and sort of, I've introduced myself, and because, like, like I said, when I can't get someone in, or they can't afford the physician co-payment, I try to find, like, a licensed acupuncturist that I trust and can send to, and so unfortunately there's not a great, like, find-a-physician resource, unfortunately, but so I would say is just start with Google, and then I would encourage you to reach out and go find out what their qualifications are or send an email, because we, and it depends, like I said, if you want them to see a physician or not. Yeah. For Dr. Sharma, so I have a lot of patients who are very health conscious. They're very food conscious, and they come to me in pain, and they're looking for some additional things they can do. For this population that's kind of taking the extra steps, is there a silver bullet or, you know, bronze bullets that you can sort of give to them that's something that they may not be doing that they probably should, whether it involves the type of food or maybe that the way that they're consuming? Yeah, sure. That's a great question. There's a couple things. One is that there's some studies that show that food order matters, so you could talk to them about that. The sort of generic example is like a, you know, restaurant Italian meal where you get the bread, salad, and then spaghetti and meatballs. It's due the fiber first, so it's due the salad and vegetable first, then the meatballs, and then the bread and pasta last, and that'll slow down that blood sugar spike. They're probably not eating that kind of food, but with whatever food they're eating, it's sort of the carb last. The other thing is circadian eating, which is sort of a variation on intermittent fasting. It's really just eating in daylight hours, and the thought is that that's what our body is more designed to do. A hundred plus years ago, there were no fridges, you know, etc., etc., and so sort of eating like 7 a.m. to 7 p.m. A lot of your patients who are kind of like high-level, like you're talking about nutrition, they might already do time-restricted eating, but a lot of people do it like 1 p.m. to 8 p.m. You really want to do it, want to be eating more in the morning, in the daylight hours, and less in the evening, and I know for social reasons people do it that the other way, but it's really better to do it earlier in the day, earlier in the day. How long does it take to feel any effect, like patients are asking? Is it going to take weeks, months? Yeah, so I mean, that's tricky, especially with those types of patients, because they're probably type A, and so they probably have stress and other issues, so it's not like it just fixed the nutrition or tweaked nutrition, you're going to be better. So you like to say like this is a process, and it's a way of living, and we have to sort of work on all these factors. So I wouldn't give them a time, but I would sort of ask them to sort of log their pain levels and be able to look back, because I see with a lot of my pain patients is they're like, oh my gosh, really just a little bit better, and you know their pain was a 9 an ounce of 4, and you're like, well, I mean, here's what you wrote, and they're like, oh, I guess, yeah, I guess it was, and then the functional things, too. You could walk up, you know, you couldn't walk two blocks, and now you're walking two blocks. So something's, you know, changed, so I think just having them maybe log it could be helpful. I have a question, I think it's for Dr. Sharma. I really appreciate the talk. I do speak to my patients quite a bit about food, and one of the things you had mentioned is that Yeah, I don't consider myself, you know, the oil expert or anything like that, but, you know, these processed oils are everywhere, so if you can get things that aren't processed and then, obviously, encourage them just to cook with olive oil, extra virgin olive oil. You want it in a glass jar, you want to keep it in a dark place, not the plastic green one that, you know, is at every grocery store. That's better than other oils, so if that's what you have access to, that's what you have access to. But I think it's more, again, avoiding sort of the deep fried kind of that kind of oil. I think that's what makes a difference, so I think they don't have to get stuck on that if everything else they're doing is the right sort of way. So omega-3, omega-6 ratio, and so it's sort of looking at the other foods that contribute to that too, not just the oils, but the fish and whatever other ways they're getting their omegas. My question is for you as well, are you lifestyle medicine board certified? Double board certified in PM&R and pain management. Okay. And lifestyle medicine? So I took the, I was talking earlier about this, I took the integrative fellowship with Andrew Wilds, two year, so I could sit for the lifestyle boards. I have not, I don't think a third board certification helps me. Okay. And have you considered doing any group medical visits? You talked about the challenges of clinically having time, group medical visits might be helpful so you have that time to educate, and even the social support in a group. I love that, yeah. So the shared medical appointment, there's a lot of great data around that for all kinds of conditions besides pain as well. I went to my administration, they kind of looked at me like I had 10 heads, so we're not there. But I think if you can make that work in your practice, I think that's excellent. And like you said, that builds that camaraderie and community, which is something that you really can't put a price on. Yeah, and it gives more time because it's nutrition, but like you said, it's sleep, it's stress, it's all the pillars of lifestyle medicine. And it's too much information to get in in a visit, so it really takes that incorporation a lot of information and support. So thank you. They have some new videos out to help with training, especially during shared medical appointments. So, I just find them helpful and just wanted to bring that up. Oh, I love it. I'm so glad you're doing that. I hope more people can get to do that. That's great. Yeah. I have a question to the second speaker with respect to manual medicine and manual therapies. You mentioned different tissue techniques, mobilization and manipulation. And the latter one, manipulation, is actually high acceleration, low amplitude intervention. And we have clear indications. So, my question is what the indications are. Is it purely reflexive therapy or is it also used manipulation in the sense of free adjustment? Is there a difference or is it the same? That's a great question. And it really depends on who's answering the question. So, the way that I was taught and the way they tend to teach it now in osteopathic medical school is that for your thrusting techniques, they are specifically for the bones. So, that can be the spine, but it can also be like a fibular head, a radial head, a carpal that is not in place. And then, or at least the way that I had kind of was taught to me in my fellowship is that when you're doing kind of a layered palpation and you're working with the tissues and you try to mobilize the things that move the bones. So, it's like, all right, let me focus on the ligaments. Let me focus on the muscles, that attachment. If you're not getting that range of motion that you have been trying to achieve with manipulating the tissues that affect the bones, then you go for your thrusting or your high velocity, low amplitude technique. Now, there are indications that you don't wanna do it. If the person is hypermobile, if the patient has a history of osteoporosis, they're more prone to fracture. So, like, no, I do not tend to crack anyone over the age of 65. Do I do it sometimes? Yes, if I have a good rapport with the patient, I know their history well and we've done some body work before. So, it's a little operator dependent, but I hope that kind of answers your question of you work your way towards the tissues first, then you mobilize the bones later. At least, that's my approach. Okay, and in the case of, so, you have to find a blue cat in order to do re-adjustment, right? Sometimes, yeah. And the second question is, if you do manipulation in the sense of reflexive therapy, how often would you recommend to do that? Another good question. So, if, there's a lot of philosophical reasons of timing of treatment. The way that I was taught is that you want your body to allow a period where they can recover and learn what their baseline is. And so, if you're seeing a patient repeatedly, meaning, all right, they're coming in once a week, twice a week, that's almost not enough time to know, are you getting better or are you just coming in from my hands? Because the hands feel good as soon as you do it. So, I personally, with the exception of pregnant patients, I only see a patient once a month, at most. I don't, pregnant patients are a little different because their bodies actually change. Like, their center of gravity change towards the third trimester, like, every two weeks. So, then I'll see them sooner. But I don't do any spinal manipulation outside of a month in between, yeah. Thank you very much. No problem. There seems to be a major difference to chiropractic. Yes, 100%. I may see them twice in a month and you might exhaust 30 visits in a month. Yeah, totally different. This probably is more so for Dr. Sharma. Because I'm sure you've experienced this. What happens when you're seeing someone with chronic pain, trying to help them get away from opioids and they're saying, oh, but I tried that. Oh, but I tried that. Oh, but I tried that. You know, oh yeah. And they'll say it, it can help for a little while, but no. Do you have any answer for them? That's a hard one. I mean, I think it depends where you are in your journey with them. I mean, if you're at the place of, well, we're gonna start a weed, so you need to try some alternatives. Or if you're just sort of kind of wishy-washy, like, let's just try some other things. And so, I think sometimes it's, well, and it obviously depends on what the reasonings are. And you know, for whatever reason, you're trying to lower their dose or try to get them off. They have to be motivated to want to do that. And if they're not, you're not gonna really get anywhere, you know? So, it's sort of having them talk out, well, what would be the pros of coming off or lowering my opioid dose? And then saying, okay, maybe you did these things five years ago or 10 years ago, but you're a different person in a different place now. We're in a different situation. We're trying to come off this medicine. And I don't want to leave you hanging. So for you, I want to do this. So, I think it just depends on where you are, you know, with them and where they are. Yeah, it's a tough one. Yeah. Great talk. You guys have talked a lot about the one end of the age range. I'm at a children's hospital and mainly treating teens and preteens. For specifically the acupuncture and OMT, is there an appropriate age range for those treatments? Specifically, obviously, 17, 18, probably not a big deal, but as you go lower, kind of a lower age range that those might be appropriate for? Yeah, it's a great question. So, I treat a lot of high school athletes and I'll actually do like sideline acupuncture sometimes. So, there's nothing contraindicated in the literature. I don't treat generally less than high school, but for my patients, there's nothing contraindicated for doing that. Again, most of them, by the time they're reaching 14, 15 or getting to the point where they're done growing, growth plates are closing. But to my knowledge, I'm not familiar with any contraindications. We had during my training on the inpatient PEDS unit during residency, we did have people who did acupuncture. So, I know that you can. Again, I'm just not as familiar because I don't practice it. But- Issues with needle phobia. Yeah, exactly. And then I do it for, so I'm head team physician for Emory and I actually do it a lot for my back pain patients at Emory. So, we have, you know, chronic spondees and spondylolisthesis, a lot of myofascial pain during the season. I do it all the time for my back pain patients. I actually build it into my training room now. They do extremely well. And yeah, I think just, I don't know, I'll let Jack talk about the OMT, but I think no contraindications that I'm aware of for PEDS patients. I mean, again, I think to an extent, I probably wouldn't be doing it just because I think the same way you would approach like talking about a needle with like a six-year-old, like I just, I don't think they're gonna be, but like, I think for middle school and above, totally appropriate, yeah. Yeah, and for OMT, OMT is womb to tomb. So, you know, I have small population of newborns that I'll help with latch. I do a lot of like intraoral to cope with suck and colic. I have a number of teenage girls, back pain, your soccer players, your gymnasts, and they hurt because they're growing and it's awful. So the short answer is there's no restrictions, there's no limitations, just knowing the right techniques for the right patient. Yeah, that's great. Thank you, man. Just for the last question, I'm an acupuncturist as well. I think acupressure might play a role in some of the younger kids just as a mom. And acupuncture is just using the acupressure points. And there's things that you can buy online if you're acupuncturist or if you're comfortable. There's little seats that can actually be like taped and things. So if there's no needle involved, that might be an option. Quick question, do you do any cupping? I don't do it in clinic, I do it in training room with my athletes. I just kind of became interested in it and I do it with the athletic trainers. During training room, but yeah. Is there a specific question with cupping? No. And you said something about moxa. Yeah. Do you do that in the clinic? Yes. Yes, I do it. And then I get yelled at because the entire floor smells like marijuana. So I do it and I'm not allowed to do it. Yeah. I was sort of shocked because- Yeah, we had Jayco come through, I had to hide all my stuff. And so yes, I do do it. They would allow us to do it. Yes, I do it. And the way I justify it is I actually find it very helpful with our post-op patients. So I've had a lot of hand and wrist patients that have hardware in and I don't feel comfortable doing. So I'll do it for like spinal fusions where it's a little bit deeper. I know I'm not getting anywhere close to the hardware. In theory, you're increasing if you use electroacupuncture over the increased risk of an infection. So that's actually how I justify doing moxa with these patients. And generally my admin doesn't give me a hard time unless the higher-ups are walking around. And then I also do it at the end of the day when nobody's around to yell at me. So ask forgiveness, not permission. I was one of them. Thank you. Yeah. Do you use or are you familiar with the little magnets that are being so widely used over in Asia? Yeah, I've seen them. I don't use them. Do you? No, yeah, I haven't used them at all. But yeah, actually one of my patients just brought it up to me. And so I am actively looking more into it but I haven't used it yet. Thank you all so much. Hope to see you out later today, tomorrow. Come say hi. Thank you.

chronic musculoskeletal pain

non-pharmacologic treatments

acupuncture

osteopathic manipulative treatment

lifestyle modifications

yin-yang

Qi and meridians

chronic low back pain

Mediterranean diet

gut microbiome

holistic care