Oh, hello, good afternoon. Welcome to the Alternative Pain Networking Session. My name is Bruce Hsu, and I see we have a few folks that are here today. I'll just wait a few more minutes. I do have a very, very brief presentation that I discussed about lifestyle medicine and musculoskeletal care, or musculoskeletal problems. So I wanted to thank all of you for coming out on this lovely Thursday evening. I'm sure a lot of you have lots of other obligations, so I do appreciate you for coming out. So I'm going to see if I'm, I'm very technologically challenged, so I'm going to see if I can share my presentation. All right, let me see if I can do this. Let's see, do that. All right, let's see, hit F11, start slideshow, hit F11, all right, and then close this here. All right, so this is just a very brief overview, it's not like a CME robust presentation, it's just kind of an appetizer into lifestyle medicine and musculoskeletal issues. My name is Bruce, as I mentioned, I do primarily interventional pain in central Pennsylvania. Okay, so I'm going to go on to the next slide. So what is lifestyle medicine? I've been to some, you know, talks about it, I do actually see a practitioner of lifestyle medicine who's actually family medicine trained. It's, you know, especially that uses therapeutic lifestyle interventions to treat chronic conditions. It's kind of, you know, I think it's a really good match with, you know, physical medicine and rehab because it's, you know, it's holistic, it's whole person, prescriptive, you know, team-based, and, you know, comprehensive and holistic, as mentioned. So there are six pillars in lifestyle medicine, you know, nutrition kind of goes along with we are what we eat, it kind of goes into like the anti-inflammatory diet using whole foods and predominantly plant-based diet to try to reduce inflammation, inflammation kind of being, you know, contributor to lots of chronic conditions. I'm sure I'm just preaching to the choir talking about, you know, heart disease, obesity, obesity epidemic, and, you know, obviously, and, you know, along with that, musculoskeletal conditions as well. We also want to kind of, you know, encourage or foster and, you know, lifestyle, physical activity, you know, movement, you know, the more you move, the more you move. A lot of Americans are sedentary and kind of into that, you know, they get trapped into this, you know, stress and kind of just being more mobile. So the less you move, the less you move, and I think it's important. Some of these, you know, obviously kind of coming from a medical background seem to be more common sense type things, but, you know, I guess it's nice to kind of delineate them specifically. Stress management also kind of goes along with all of those kinds of things to help reduce anxiety and depression, and you, I'm sure all of you remember some of the things that we talked about, you know, and you, I'm sure all of you remember cytokines and the cortisol response and, you know, hyperglycemia and hyperglycemia kind of being related to inflammation and the inflammatory response. This last one, I actually have a relatively young baby at home, so I don't really get too much sleep and I apologize if my energy level is not super today, but sleep helps to improve alertness, you know, helps to kind of clean out all that, you know, entanglement that goes on throughout the day and also combats negative influence and negative effects of insulin resistance as well, so. Also, I think, you know, social connection is important as one of the six pillars of lifestyle medicine. They've done studies with people in Mediterranean countries and small communities that seem to have more of a connection to their surroundings, and I guess people that are more connected to their communities, they tend to be more resilient. Resilience is, you know, quite important, I think, in terms of being able to thrive and to, you know, build a robust, you know, outlook on life and being able to kind of be able to combat things that might come one's way, so resilience is important. Also helps to reduce kind of the inflammation response, as noted. And then, obviously, substances reducing exposure to tobacco and alcohol. I don't think this one is kind of self-explanatory, so I'm not going to go too much into that. I'm just going to move this over a little bit so I can see. So, musculoskeletal pain, musculoskeletal conditions tend to be related to inflammation, in my experience. I do recall that a lot of it is also kind of degenerative in nature, so along with arthritis is arthrosis, cytokine-mediated, so we're just trying to use kind of the six pillars to impact the common musculoskeletal complaints. I think most of them are related to back pain, neck pain, joint pain, though there are obviously others as well, and kind of being able to reduce systemic inflammation also impacts other systems as well. And then there's kind of the big three, diabetes, heart disease, and hypercholesterolemia. So, I think patients can benefit from an integrative lifestyle medicine approach, and as we noted, because we are in the field of physiatry, we're kind of used to working with teams, so I think integrating kind of this kind of an approach, holistic approach to our patients, I think can be beneficial, and I think it depends on how much you want to integrate, if you have the luxury of resources and time to kind of have more time with your patients to kind of discuss these things more. I know that some of you all probably have very limited amount of time to see each patient and connect with them, but I think, you know, that's another, that's a completely different discussion. So, I guess putting it all together, you know, all the parts of the wheel kind of affect each other, you know, kind of synergistically and across the board, you know, being mindful of healthful eating, physical activity, getting enough sleep, and make sure that quality sleep is, you know, robust, also reducing stress, reducing risky behaviors, not only from substances, but, you know, reducing the incidence of, you know, accidents, morbidity, and mortality, as well as that, related to that, and then building quality relationships, you know, at home, at work, and community. I think being a part of something is important to a lot of us folks. I think that's, you know, beyond work and medicine itself. So, I think those are all important things. Okay, let me see here. Click on look. So, team-based care can be physician-led. We identify risk factors for chronic disease and over help mitigate them, and then just like in our integrative team approach to care, other members of the team include exercise specialists, people with a background in nutrition, psychological counselors, sleep specialists, all working together to try to reduce kind of the burden of lifestyle choices that can impact and negatively care patients' well-being, and in addition to, you know, helping reduce chronic conditions, these can also help to reduce, you know, problems, musculoskeletal problems, as well as other chronic conditions. So, I think some resources one could turn to, obviously, the American College of Lifestyle Medicine, and then there are some articles that I've briefly reviewed as well. I think that there's a lot to learn here, and this is not meant to be, I think, by any stretch of the imagination comprehensive, but just to pique your interest into how we can use, you know, the six pillars of lifestyle medicine to help impact our communities, our patients, and maybe our own lives, because I do feel that in my own personal experience, some of these areas I could definitely work on in my own everyday life, and it's just a matter of being able to fit it in all the 24 hours of the day. So, I'm here for any questions. I'm a new dad, and this is my son, Austin, so I apologize if I seem a little tired, because I am a little stretched thin. So, thank you, all of you, for joining today, and if you have any questions or concerns, I wanted to discuss anything else in terms of alternative pain, I'm here to help facilitate the session as best I can. So, I thank all of you for coming out on a Thursday evening from wherever you might be. Does anyone have any questions or comments or a last slide with websites? Yeah, sure. I'm really terrible at technology. I will do that if I can figure it out. Let's see here. All right. So this was one. So the top slide is the stuff that the top HTML link is for the American College of Lifestyle Medicine and you can actually get a certification on this as well I'm not super familiar with the logistics of that but I actually see a family medicine practitioner who is certified in it. I should probably ask. I'm sure that's easily discoverable. And then there's an article about delivering value. Everyone's always talking about value based medicine these days. And these are some other links. And as I said, this isn't meant to be by any stretch of the imagination comprehensive but more like an appetizer. Let me see. So I'll just leave that up for a minute, I guess, and let me see if I can go back to the chat somehow. I apologize again for my lack of savviness with the computer. First I have a question for you. You have a chance. No, yes, sir. Me. Yeah, go for it. So, you know, you kind of hit on some of the time constraints that we have within the confines of a typical, you know, private practice office visit. Um, you know, what are your thoughts about, you know, scheduling, you know, a separate visit to go into like these types of issues for patients who, you know, one can benefit and to, you know, express an interest in that and what would you code for that it's a typical, you know, 99213 or four follow up visit or are there other like counseling codes that can be used for this or what are your thoughts about that. Yeah, that's a good question. I don't report to know the answer to that specifically I think I think at the last academy meeting that there were some discussion about doing encoding with regard to lifestyle medicine but I think that would be something that would be interesting in going back further as well. But I don't have any specific answer I think. I don't know if there's anything specific with regard to counseling I know there are special codes like for you can code an additional modifier for smoking cessation for example, I forget this specific I used to do that more when I was more into building encoding but I think building coding is another discussion. Sure. Okay, I'm sorry it's not really good answer. No, that's okay. Yeah, this is, you know, sort of new territory for me that I'm looking to incorporate into my practice and so I'm just trying to look at all the logistics of it obviously I think it's the right thing to do and it can be a fulfilling thing to do. I saw, I think there was a thread on a PM and ours blog about someone who was doing some sort of group appointments, I think, is what they were doing with lifestyle medicine. And I didn't have a chance to look into more detail about exactly the logistics of how they were doing that but my sense was that it was, you know, gathering, you know, maybe a half dozen or so patients and one night kind of, you know, going over some of these topics, and I wasn't sure if that was just, you know, something that they were, if they were billing for that or if they were just doing it separately so these are things that I can explore I'm just bouncing some ideas around. Yeah, that's great. Thank you for sharing. Sure, thank you. Thank you for your time tonight. Yeah, thank you for showing up and participating. Hi quick question this assessor. Any, anybody with experience in doing this but for the pediatric population, how does it look like and what are the main points that you need to, you know, talk to them about. Yeah, I don't really generally see a pediatric population I mean I might see an occasional adolescent, I don't really have any specific insight into that I don't know if anyone else here does see the under 18 patient crowd. So I'll defer to anyone else who might have more expertise in that area. Sorry I don't, I usually see adults. So, in terms of what are a couple of the main big go-tos that you would probably suggest to start with, at least for some of the lifestyle issues? Is there one or two that seem to be the biggest bang for your buck so far with chronic pain? Yeah, I mean, I think some of the quote-unquote lower-hanging fruit, I think, are some basic lifestyle changes one can do. But that being said, nothing is really easy, right, and nothing is really free. But I think working on sleep hygiene, obviously not using your smartphone when you're trying to fall asleep, staying away from things that might distract from sleep, like blue light, for example, sleep hygiene, not doing work in bed or not doing anything in bed other than sleeping, I think that's important. I think, you know, just being more mobile, I mean, not everyone lives in a sunny climate so it's not always easy to get outdoors all the time, but I think, you know, trying to, I tell people, like, you wouldn't imagine, like, not brushing your teeth for days at a time, or not brushing your teeth for days at a time, so I think you need to also keep in mind basic hygiene in terms of, like, being active and being fit, and even if it's just walking 20 or 30 minutes a few times a week, it's a lot better than not doing anything at all. I think diet isn't, you know, difficult, but, you know, a lot of our population, I don't know what kind of population you folks see, but, you know, there's, like, issues with food deserts and access to quality foods and, you know, getting away from processed foods and, you know, foods that are, like, high in the glycemic index that basically just convert to sugar once you eat them. I mean, not having a Dorito diet, for example, but, you know, obviously, you know, having an organic spinach and kale and quinoa, you know, salad doesn't always sound appetizing to some folks, but I think a lot of it's just changing mindset. So I think those are some of the easier lifestyle modifications you can do, but, you know, obviously everyone has their own different burdens to bear, and so it's, I think, not necessarily easy. And, you know, it's a lot easier to ask for, you know, a steroid injection than to make lifestyle changes, obviously losing weight would help a lot with joint pain, you know, it's like the 800 elephant in the room, literally. Sometimes when you have a patient who's, you know, three or 400 pounds, and they're wondering why their knees hurt, you know, it's, you know, it's difficult to have that conversation and still trying to be gentle about it and ginger. And sometimes you'll literally have patients like, well, if I lost 100 pounds, do you think my knees would feel better? And then you're just kind of sitting there like, well, I don't know what to really say to that. Because I don't, you know, we don't want to sound like Captain Obvious, but obviously want to be supportive. So it's, you know, it's always very difficult, I think, to really do the right thing in terms of, you know, the cross between being prescriptive and but being also, you know, kind of gentle and kind. So I don't know if that's helpful or not. Well, thank you. First, if you have a patient who's trying to lose weight, and you're talking about different diets, I mean, I know you mentioned the plant based diet, some sort of, you know, the anti inflammatory foods, but someone, you know, is really digging in, and they don't want to go that way. But they still want to lose weight. Are there any particular diets out there that you recommend, or conversely, don't recommend like, you know, intermittent fasting seems to be making a comeback lately? Yeah, things like that. I think it's difficult. I mean, I think a lot of the diets are fat diets, I think. I think no matter what you do, you have to do something that's consistent. I mean, I don't know, I kind of live in, I kind of work in an area that has a lot of problems with obesity. And, you know, a lot of the staff I work with have actually been, they've had bariatric surgery, actually. And I've had more than a few people with they've had bariatric surgery. So it's, I think it's, it's a big struggle. I think, I mean, it's not unconquerable, but I think, you know, it's, I think every person kind of needs an individual, you know, tailored approach. And I don't know that there's a kind of one size fits all approach to everybody and everything. So it's, I think it's a complicated question. I don't, I don't think that, you know, I do any justice to that kind of counseling as well. But I think, I think what's important is being consistent and being consistent over time, because it's very easy to kind of go on the yo-yo diet and to make some changes that are, you know, short term and then, you know, obviously, in the end, it doesn't stick and then you just go back to kind of where you initially started out. So sure. I'm not sure if that really helps. No, I think I don't purport to be an expert on with regard to every little diet that's out there. Yeah. Well, I think you kind of nailed it too. I mean, that's why we call it lifestyle medicine, right? We're trying to, you know, create chronic changes, positive, chronic changes that can be sustained. So it makes sense. Yeah. I think, you know, it's, it's, you know, you do want to make a change and you want to kind of make it effectual and you want to, I think a lot of it has to do with resiliency and things like that. Actually, when I was in business school, we read this book called Grit by, I believe, Angela Duckworth. And I think it's, it's an interesting book because she talks about, and actually I think her brother was head of Press Ganey for a while. But Angela's book talks about how the important thing in life is kind of not just being the smartest or the fastest, but kind of that gumption thing, like really sticking at something and kind of working at it and knowing what you want and kind of trying to always look for that goal. So I think resiliency and, you know, community are some important things. You know, it's not always easy. A lot of people are out there and they don't have that sense of community and resiliency. It's, I mean, resiliency is difficult to, to be there, but anyway, I do recommend the book if you are interested in learning a little bit about grit and determination. So. Thank you. Yeah. I'll check it out for sure. Yeah. Anybody else have any other questions or wanted to chat about any other topics? I think this, I do thank all of you for coming out. I once, I once took my, my kids to story time at one of the local libraries and we were the only folks that were there and we felt bad for the librarian that was going to read them the children's books when someone else came. So I do thank all of you for coming out and attending the session. And I think I'm just, I'm just grateful I'm not talking to an empty room. So no, it was very helpful. Thank you so much. Thanks. Anybody else have any questions? I don't need to belabor you. I'm sure all of you have lots of other family obligations and things like that. But if you do have any questions, I'm here, I'll hang out for a little while. I hope that you will look into lifestyle medicine and maybe if you're interested, you could, you know, talk about, you know, how you could be able to make it part of your private practice or your, you know, hospital-based practice or institution-based practice. I don't know what kind of settings all of you practice in. I worked for both hospitals and private practice settings. So I know everything's a little different. But I guess in the end, there's always that need to satisfy your bean counter, whoever they might be. And it's not always easy, so. I think one of the key things is also like understanding habit formation. And there's a couple books out there that talk about like a couple quick screening questions in terms of figuring out what your patient's kind of like, if they need to have that outer accountability versus the inner accountability, or if they really need to have all the knowledge pieces lined up in a row before they buy into it. And so just kind of asking them like a quick question or two of like, how do they feel about New Year's resolutions? Do they make them for themselves or have they kind of failed that in the past and why? Like a quick question like that kind of sets the tone. And then if you have long-term follow-up with the same patient, you know, and you sort of jot that in your chart in terms of like, oh, this person seems like they need more outer accountability, then you can like generate that in a sense for them or, you know, create like a group setting for them or suggest a group setting. Because there's some programs out there, like for instance, like the veterans, they do have like some nonprofits that have a gym-based, a free program for them where they have group settings for all the veterans to kind of hang out and do, you know, workouts together. So that might be like something that you can lead them in that direction and give them some guidance in terms of a community they can belong to. Yeah, I think those are all great ideas. I mean, I think some programs that do have a robust or a formalized lifestyle medicine program, they do have some group sessions. And I was looking at one of the larger hospitals and they have like, you know, evening events and group sessions and things like that. But I don't know that's possible in every, you know, practice setting because everyone's resources are different. But I do think that, you know, that goes along, you know, back to the six pillars and the sense of community and belonging and all that kind of thing. So I think that, you know, that's really good to kind of be able to, you know, look into habit formation and how habits start and how, you know, it may be possible to break bad habits. Because I think, you know, if you can just help one or two people stop smoking, you've made a really large impact on, you know, them for the rest of their lives. Or if you can, you know, help someone who has a large substance problem with, you know, alcohol or whatnot to cut back or even to stop. I think that makes a big difference. I mean, I've known a lot of people that have suffered with, you know, different vices. I mean, I've had colleagues that have, you know, had their own demons to bear with the kind of this kind of issue as well. So I think those are all great ideas, John. So I thank you for talking about that. Thank you. Thank you so much for tonight. Yeah, thank you for coming out. No one's busy these days. Anybody else have anything to say? About lifestyle medicine or anything else, an alternative thing? All right, well, if no one else has anything else to say, I'm going to, I guess it's approximately 7.45 central and I think I'll probably wind things down, I guess, unless anyone has any other questions or comments, concerns, I'll post some bullets of the presentation in the forum at some point, so, but I want to thank everyone for coming out tonight, I know everyone's busy and I hope you enjoy the rest of the month of May and the community sessions, I also wanted to thank our facilitator, Leon, as well, so thank you so much and I will go ahead and end the session and wish everyone a fabulous evening, thank you.

Alternative Pain Networking Session

Bruce Hsu

lifestyle medicine

musculoskeletal care

nutrition

stress management

American College of Lifestyle Medicine