Hello, welcome to our presentation. Today we're talking about non-invasive pain management changes, basically evidence-based lifestyle modifications. We're going to go into nutrition, supplements, mindfulness, acupuncture, and exercise. Don't mind my eyes wandering, I have two screens up today. So our learning objectives, basically the idea is to review the current evidence on supplements, mindfulness, acupuncture, and exercise. And this is very relevant because of the opioid crisis that we're all well aware of, and it's also something that's underutilized. So you know when I was a medical student resident, we were taught the five ways to treat pain. And the first way is lifestyle changes, yet this is often neglected. So I'm going to dive into this a little deeper. And the other thing that comes up with this is all the commercials. So you see commercials for pain medications and other medications, and they always say when diet and exercise fail, there's pill X. And this sort of points out that the idea that really you should try diet and exercise first. So we're really going to jump into that. We have some excellent speakers today, and Dr. Eric Enserad is going to talk about exercise and physical therapy. He is out in Oregon, is a professor of orthopedics and rehabilitation medicine. We have Dr. Ayman Akai from Texas Orthopedics. He's also faculty at the University of Texas and a pain management specialist. Myself, I'm active with the Academy, and I'm at Rothman Orthopedics. And my colleague, Dr. Maynard, is also the Rothman Institute and focuses on pain management and sports medicine. So evidence-based lifestyle changes, that's really the root of building wellness and receiving long-lasting pain relief. So I will hand it over to myself, and we'll talk about nutrition. So the learning objectives here are, again, to sort of emphasize how diet changes can reduce inflammation and therefore pain. And I really want to get into some practical resources. So part of it is education for the provider, but also education for the patient. So we know this problem, right? We know the pain problem is that there is an epidemic of pain. In a one-year period, over 54% of people report musculoskeletal pain, and 20% actually report low back pain. If we look at numbers, that's 46 million Americans every year are complaining just about low back pain. If you look at daily pain, there's more than 25 million Americans complain of daily pain, more than 23 million consider it severe. So this is definitely an issue. We know the whole opioid epidemic. I don't want to dwell too much on that. If you look at the upper right-hand corner here, or maybe you can see my arrow, 10.3 million people misuse prescribed opioids. And, you know, that's people who I'm assuming actually admitted to misusing them. So this is a huge problem. We've, you know, made some progress in the last couple years, but it's still a big issue. Many of you who treat pain are familiar with this. This is the ACP and American Pain Society's recommendations and algorithm for low back pain. And it's interesting because they mention education, they mention exercise, they mention CBT, acupuncture, and some other evidence-based lifestyle changes, but they really leave out dietary changes, sleep quality, stress reduction, supplements, but they're short to mention opioids. So, you know, our buddy opioids are still there. The other part of the problem, even if we put opioids aside, are NSAIDs and steroids. We all know the lethal side effects and dangerous side effects of these medications. Here's a pathway, the mechanism pathway. The idea is that, as we know, NSAIDs also block beneficial substances, especially non-selective COX inhibitors. Steroids, you know, there's a whole laundry list. We could do a whole talk just about steroid side effects. So that's really not the best answer for us. And the other thing that's interesting, and this data is a couple years old, but it's still really relevant, is that people are looking for something different. People are tired of sort of the traditional treatment with injections and surgeries, medications. And what this slide here shows is the number of people who actually went for a complementary health approach, and it's over 50% for neck pain in a one-year period. It's over 40% for low back pain. So this is a real thing that people want, and people are seeking it out. And if we don't discuss it with people, they're just going to find it elsewhere, and it may or may not be the safest and best way. Things that we never even talked about a few years ago, such as probiotics, prebiotics, supplements, the gut microbiome, none of these things were even mentioned a few years ago, and now it's on the tip of the tongue of most patients. So it's something we really need to educate ourselves on as well. So getting more into the science of it, this is work out of Pittsburgh by Dr. Maroon. He's a famous neurosurgeon and also very soon discovered a triathlete. And on the left is our traditional pathway. You can see the Cox inhibitors there circled in red, selective and non-selective. And then over here on the right, this is actually very interesting, is where some food and supplements come in and help. And Dr. McKay is going to give us a great talk on supplements, but just a little alert, this also can be obtained through some dietary modifications. You can see where ginger plays a role, Boswellia, omega-3s, turmeric, green tea, and they work on some of the same pathways that NSAIDs work. So it's almost like a natural anti-inflammatory with hopefully some less side effects. So getting more into studies now, the idea is that pain and inflammation are linked. So following an anti-inflammatory diet results in less pain, less disability, less depression, and a better quality of life. This is a study done of over 2,600 women, mean age is 61 years, and they use validated scales including the WOMAC and a validated depression scale, you know, as well as SF-12. So there was another study done also about progression, and they actually found sort of the opposite is true too as well. Following a diet of processed unhealthy food actually increases pain and disease progression, meaning a diet rich in fruits, vegetables, fish, whole grains, and legumes reduces not just pain and what people may consider objective findings, but radiographic findings as well. This is a neat picture as it talks about different factors that contribute to inflammation and disease. This is actually work out of some people at the group I'm at at Rothman. The idea is from the SPORT trial, and this is focusing on lumbar disc herniations and operative versus non-operative treatments, and they really focused on obesity, and they found people with obesity just didn't do as well whether they receive operative or non-operative treatments, but the key factor that I bring this slide up for is diet, that diet is a key factor in pain. And this is a nice slide talking about systemic inflammation. If there's more systemic inflammation, then there's just more pain, and it sort of goes through the pathway of the different inflammatory markers and how that results in more chronic inflammation, more pain, and more disability. But this is a Mediterranean diet for osteoarthritis, and that's sort of the godfather of all anti-inflammatory diets is the Mediterranean diet, and the idea, once again, is if you lower inflammation, you'll lower systemic inflammation and local inflammation, and therefore, you lower pain. And the big components of it are what we talked about a little bit, the fruits and vegetables, legume, fish, eggs, poultry, and if you get into meats and poultry, it's really about high-quality meats and proteins, and even plant-based proteins. But you can see this resulted in increased antioxidants, polyphenols, increased fiber, and increased what we call good fats. And this was a nice study. It was focusing on rheumatoid arthritis, but it really applies to lowering inflammation in all pain syndromes. The idea is to reduce inflammation, consider Mediterranean diet, or really just an unprocessed diet. And you can see above the little dot-to-dot line are negative factors. They talk about food antigens, environmental factors, epigenetic, and genetic factors, which all lead to increased RA progression, inflammation. And the bottom of the dot-to-dot there is a vegan diet, elemental diet, elimination diet, or Mediterranean diet all lead to less inflammation and less RA progression. And that's really the bottom line. And a sample of the diet they use is off to the right, and it's primarily fruit-based, legumes, whole grains, herbs, good oils, and a Mediterranean-style diet. This is a classic anti-inflammatory diet that's purported by Dr. Andrew Weil. It's really similar to the Mediterranean diet, just with an addition of a few of what they call Asian elements that he added on. It's a similar concept. And the reason I mention this is because, you know, we see this all the time. We see this in our office where two different people in rooms right next to each other, they both have severe stenosis, and one person is crippled by it, and the other person is totally fine, and maybe has, like, a mild backache they came in for. And some of it has to be lifestyle factors, right? This is something we're taught in residency. You don't treat an MRI, you treat the patient. And you have to treat the factors in their life that are affecting their pain. And that's where CBT and some of the other stuff comes in. But once again, nutrition sort of gets dumped on and sort of left out in the cold. This is another example of another study that was done specifically for pain. And you see the base actually starts out with water, vegetables, and fruits, and then works its way up. The idea is to use low glycemic index carbs, olive oil, anti-inflammatory spices, including turmeric and ginger, and really focusing on legumes and fish. There's just yet another example. This is, again, based on arthritis in the knees. And you can see on the right, they call it...they're focusing on rheumatoid arthritis, specifically in this one, but they talk about the SAD diet. The SAD diet's a standard American diet of processed food, and all the consequences of taking that in and what that involves. And it really includes, like, high-caloric processed chemical foods, high salt, fat, and really just not real food. So real food, like on the left side, is the fruits and vegetables that we've talked about. And I know I'm kind of beating you over the head at this, but I think it's really important that there is data there too. It's not just, you know, something our grandmothers told us. So what does it really involve? And phytonutrients are a key factor. They're the thing that gives colors, gives plants, excuse me, color, protection, and strength. They're needed for good human health. They act as antioxidants and decrease inflammation, and that's really the key. And you can see that they make up the base of this anti-inflammatory food pyramid, and it really focuses on fruits and vegetables. And a better way to say that to patients is vegetables and fruits. And the other thing I wanted to point out is that phytonutrients are also synergistic. So they really work together. So this study was focusing on how does dietary anthocyanins and flavonols affect anti-inflammatory and inflammation markers. And they found that inflammatory score, which included following CRP interleukin 6 and TNF and TNR studies, with higher intakes of apples and pears, red wine, strawberries, overall had lower inflammatory markers. And that's really the takeaway. There is data here, especially with the phytonutrients and flavonols. So you may have heard the old adage, and this is great advice, it's simple advice for patients, which is eat the rainbow. Always think about vegetables before fruits. And rather than sort of focusing on what you can have, think about what you can have. Some of the recommendations is to use the governmental myplate.gov. They have a nice picture and they go through each of these little shapes here and colors and explain how much and why. And I think it's more of a mind shift as opposed to calorie counting or picking what you can have. It's really focusing on what you can have, focusing on in-season fruits and plants, and thinking about that for more nutritious value and cost savings. I'm not going to go through this whole slide. I just wanted to put it in there so you can see there's data, and I have even more data that shows this. But the idea is that dietary changes reduce inflammatory markers. Seen time and time again, these are some of the main components of the anti-inflammatory Mediterranean diet. Cruciferous vegetables, extra virgin olive oil, healthy omega-3 fatty acids, legumes, fibers, whole greens, flaxseed flour, magnesium, walnuts, red wine, you know, appropriately, and spices. This takes us to my favorite, the food of gods. So, chocolate's been called the food of gods. And this study just came out this year, and it's really interesting because they really dive into how, you know, the cacao and chocolate is loaded with phytochemicals. And they really have anti-inflammatory and anti-noceptive effects. So now, I'm not talking just about inflammation but also about pain. They also delve into depression and how it activates GABA and serotonin. It's almost like a plant antidepressant, which is interesting. And it activates the dopamine reward system, which we all know about. So, it is with precaution. You know, you want to recommend greater than 70% dark chocolate and only a few ounces a week. And obviously, it has to be cleared with a physician or nutritionist to consider their other medical conditions. So, this is sort of the summary. You want to reduce systemic chronic inflammation to reduce pain. You want to avoid the SAD, standard American diet. And you want to consider a diet high in omega-3 fatty acids, nuts, vegetables, seeds, legumes, whole grain, lean protein, and spices. And the number one piece of advice to give patients is really just try to limit processed manufactured food. If you can give them a couple other pointers, there would be variety of fresh foods, especially things that doesn't naturally have a UPC symbol on it. Try to avoid fast food and limit added sugars. And the two resources, like I said, this is the Anti-Inflammatory Food Pyramid. You can just Google that or MyPlate, choose myplate.gov. They also have a lot of resources that can be helpful. And then these are my references. And with that, I'm going to pass it on to Dr. Ayme Kaye to talk about supplements. Thank you. All right. Let me center myself. There we go. So, thank you, Dr. Sharma. So, this is kind of a nice way to continue her talk. I'm in Austin, Texas. So, we have a saying called Keep Austin Weird, where a lot of patients really gravitate towards more holistic, complementary, alternative medicine and, you know, really trying to stay away from medications and surgeries and opioids. And so, I get a lot of questions about natural remedies and supplements that they can consider. And I try to only recommend things that have at least some evidence behind it and also keeping in mind the safety profile of that supplement. So, this was a nice opportunity when Dr. Sharma asked me to be part of this talk, to be able to do a little bit more of a deep dive into some of the supplements that I routinely recommend to my patients. So, just in general, in terms of supplements, piggybacking onto Dr. Sharma's slide, we know that there's a good amount of patients that have been diagnosed with rheumatoid or osteoarthritis or just have pain in general. And it's estimated that a third of those patients will have used some kind of supplement to treat their arthritis pain. Herbal and alternative medicines is a $20 billion industry in the US. And so, obviously, there's a lot of marketing and resources that are directed towards our patients that they get to navigate through. I wanted to really look at the evidence behind the supplements. And just as a reminder, when looking at evidence levels, we know that there's level A, B, and C. And I try to look for meta-analysis studies because those tend to be higher quality since they're aggregating data from multiple studies. Probably the most common supplement that I get asked about, especially because I'm in an orthopedic group, is glucosamine chondroitin, and specifically for knee arthritis. So glucosamine is probably the more studied out of the two, but a lot of supplements combine glucosamine and chondroitin together. Some of them even have MSM and other things that are mixed together in a complex. And it seems like there is some weak evidence that glucosamine seems to help with slowing down progression of knee osteoarthritis. There's also some evidence that chondroitin helps as well, but there's no evidence that taking those two things together gives you any more benefit than taking one alone. There's some concern about chondroitin being derived from bovine sources. So theoretically, there may be some concerns about disease transmission from taking those supplements. So if you wanted to play it safe, then since there's no real advantage to taking both at the same time, I would probably recommend glucosamine by itself. As adenosylmethionine, so there's a little typo on that slide, or SAMe, basically shows, there's an analysis that showed that it does seem to help in terms of helping with reducing pain and inflammation for osteoarthritis. There's theoretical mechanism that it may increase cartilage thickness by stimulating the chondrocytes, and then it may also decrease cytokine-induced chondrocyte damage. It seems to take a few weeks to notice effectiveness. It is an expensive supplement, and it's an unstable compound, so quality is a concern. So that's just something to consider. It can also impact the neurotransmitters. So some people have side effects such as anxiety, headache, insomnia, and nervousness. So those are all things to consider, especially if you're going to be recommending this supplement to anyone who has any of those underlying issues to begin with. It may exacerbate their condition, and also if they're taking any SSRIs, or if you're prescribing tramadol, there may be some interactions that have to do with the serotonin pathway. Fish oil. So fish oil omega-3 has a good amount of evidence behind it. There was a study that looked at fish oil supplementation in rheumatoid arthritis and osteoarthritis patients. It showed better outcomes in the rheumatoid arthritis subset. Theoretically, this could be because there may be more of an inflammation mechanism to pain for the rheumatoid arthritis patients versus osteoarthritis. Specifically, the EPA-DHA ratio of 1.5 is what you're looking for. A lot of the earlier studies looked at really high doses of omega-3, up to 4 grams to 8 grams a day. At really high doses, it can be a blood thinner. So I usually caution patients who are on blood thinners about taking high, high dose omega-3. And there's been studies that show that there's really not much of an advantage in taking any higher than 2.6 grams a day. So I usually tell patients to stick to about 1 to 2 grams a day if you're going to be supplementing, especially because there are probably going to be some dietary sources that they're ingesting omega-3. Vitamin D. So even in sunny Austin, whenever I check vitamin D levels, it's much more common to find low vitamin D levels. And I've had several patients really remark on the difference that it made for them when I prescribed prescription-level supplementation of vitamin D. And I mostly do that when the vitamin D level is very low on lab work, so single digits or teens, anything over that, I usually just tell them to take over-the-counter vitamin D3, and I tell them that it's fat-soluble, so it would be good to take it with a little fat so that it's easier to absorb that way. And vitamin D has been shown to help with joint and muscle pain, and there's been several studies that show that it improves pain when it relates to osteoarthritis. I found a really cool study out of the Special Operations Forces personnel study where they looked at different supplements and its impact on chronic musculoskeletal pain, and after they did their meta-analysis, they recommended several supplements that are listed here, one of which is vitamin D. That same study recommended against certain supplements such as devil's claw, vitamin E, willow bark extract, because of safety or long-term data issues. And this is, if you wanted to look it up later, it's in the reference section. This was a nice graphic looking at all the different supplements that they studied in the meta-analysis, and it's the evidence behind each supplement. Sorry about that. Okay, so magnesium is another one that I recommend fairly routinely. It seems to help a lot with muscle spasms and tightness. I'd recommend it to pregnant women who get Charlie horses and stuff, and it's a natural muscle relaxer, and so I usually tell patients to try taking that at night to see if that might help with their sleep. And then what was interesting was when I started looking into magnesium, there were several more recent studies looking at the use of magnesium perioperatively, so coupling that with spinal anesthesia, doing intrathecal magnesium infusions, specifically looking at orthopedic surgeries such as total knee replacement, but also looking at lumbar spine surgeries, lumbar luminectomy, and that one actually used IV magnesium. And both intrathecal magnesium as well as IV magnesium seems to help with post-operative pain and they reduced pain medication requirements post-operatively. And then there was also a systematic review of 27 studies that showed that systemic administration of magnesium during general anesthesia seems to attenuate the post-op pain reduction without increased risk of adverse events. And then there's been some studies that show that a lot of fibromyalgia patients are deficient in magnesium. And so I do routinely recommend magnesium. I do caution them that if they take the oral form, it can be a laxative if you take too much. And so they should titrate the dose based on what they can tolerate. Other supplements from that same mental analysis that I started looking at, looking at MSM. So MSM is usually used in combination with glucosamine chondroitin. There's some limited studies that show that it can help with pain and swelling, but it doesn't really reduce joint thickness. However, there weren't any long-term trials at the time of the mental analysis. And so that was not recommended due to insufficient evidence. Devil's Claw is another supplement that I found in a lot of different mental analyses. And most of them did not recommend that supplement because of the side effects of diarrhea, abdominal pain, skin reaction, and there's insufficient long-term safety data. In 2008, they started looking at curcumin or turmeric extract because it seems to have anti-inflammatory effects from COX-2 in addition that Dr. Sharma talked about. Now in 2019, there was another meta-analysis that looked at it, and now it's recommended. Back in 2008, it wasn't, but it seems like more current evidence is pointing towards recommending curcumin or turmeric supplementation for anti-inflammatory effects. And then ginger, again, at that time, insufficient evidence, but we're seeing more data on ginger, and that seems to also be a safe supplement to consider. I looked at more current studies. There was a 2018 meta-analysis in BMJ looking at hand, knee, and hip osteoarthritis, and they identified seven supplements with large and clinically important effects of pain reduction short-term, and that includes the curcumin, the passion fruit, boswellia was one that Dr. Sharma talked about in her talk. Curcumin, so they differentiated between curcumin and curcuma longa extract. I'm guessing it's because there's turmeric that has multiple different curcumins part of turmeric, but if you concentrate the curcumin part, then they call it curcumin supplement. And then a couple others listed there. And then there were a few that were still unclear, and that includes collagen, avocado, and then they included glucosamine chondroitin in that meta-analysis as unclear benefit clinically. I then decided, since I see a lot of spine pain, to look specifically for back pain, and the meta-analysis that I could find when my literature search was from 2007, so it's a little bit old, but they looked at devil's claw that seemed to show that it might help, but it showed, again, side effects of increased stomach acid and blood pressure issues and blood sugar issues. Capsaicin actually has some good data. However, as you can imagine, there's a good amount of side effects, especially with any contact to skin or eye, and then GI upset if you try to ingest it. And then looking at B12 injections. So they did some vitamin B12 injections in patients without signs of vitamin B12 deficiency, and they did an injection every day for two weeks to see if that helped with back pain, and that study showed that the B12 group had greater decrease of pain and decrease of disability index and paracetamol consumption. So bottom line, after looking through all those studies, I think I would continue to recommend vitamin D, omega-3, glucosamine likely by itself versus taking it with things like chondroitin, SAMe, or MSM. And then there's some emerging evidence about curcumin being effective. So I have started mentioning turmeric to my patients, and then considering magnesium supplementation for a lot of different conditions, not just joint pain, but also for central sensitization, myofascial pain, nerve pain. There's some evidence about devil's claw and capsaicin, but again, those have more side effects and safety issues. And then I've never considered vitamin B12 for back pain. I do think that injecting it every day is probably not the most practical thing to do, but certainly you could recommend oral vitamin B12 supplementation, since it's water-soluble, they're gonna pee any extra out anyways. The one thing I couldn't find a lot of information on yet was CBD. I know that's been on the radar for a lot of you, and we see a lot of the CBD vendors out there. The problem, I think, is that we don't have consistent quality where we know exactly what is in those supplements, and we don't know about the THC level in those supplements. But it seems that medical cannabis has been shown to help with chronic pain, we just don't have enough long-term safety data. So I'll tell patients if they wanna try it, they can certainly try it, but I'm not necessarily going, I'm in Texas, so I'm certainly, I'm not gonna prescribe it, but at this time, and I may change my mind if I see better data. Then I have my list of references. And that's my portion of the talk. Okay, so I'm Dr. Michael Maynard, and Dr. Sharma, thank you for the introduction. So moving right along, I'm gonna be speaking about evidence-based mindfulness and acupuncture. So also, no real disclosures. And I will say, as a brief introduction, my interest in this comes somewhat from intellectual curiosity. Meditation has always had a bit of a following in popular culture, going back to the Beatles and Maharishi Mahesh Yogi in transcendental meditation, and that's been popular with some high-profile people in the entertainment industry. I read a book called 10% Happier by Dan Harris, who is a news anchor, and I think that really kinda got me to dip my toe into meditation more for myself. And then from there, I kind of had an interest in offering it to patients. There's been a lot of work by Jon Kabat-Zinn, who actually did medical studies, went on to write books that are pretty high on the bestseller lists, and I think those are things I recommend to my patients. And also, just to talk about acupuncture. So we have some providers in our own practice who offer that, and it's something else that I wanted to be able to kind of recommend or offer to my patients, but have some good knowledge and insight to back it up. So this is an attempt to scratch the surface of some deep concepts, and there's a saying in the world of mindfulness and meditation that even a shallow dip in the pool can provide refreshment. So that's our goal here today, to kind of not take a deep dive, but to get some information that we can make available to our patients in a practical way. We're gonna discuss briefly the theory and practice of mindfulness and acupuncture. We're gonna focus on applications for treatment of pain, and try and actually provide good evidence, or at least a review of what evidence is available to support the use of these techniques. So we have to remember that pain is basically an experience, right? It's something that our patients perceive, and it doesn't matter if it's real, it matters if it's perceived. And it's arising from actual or even potential tissue damage. And it includes both the perception of that stimulus and how we respond to that perception, and that's from the IASP. The gate control theory of pain, going back to Melzack and Wall, suggests that the experience of pain or the perception of pain isn't necessarily concordant with how damaged the tissue is physiologically. The processing of pain in the central nervous system affects how it's perceived. And in addition to the physical effects of pain, there's gonna be an impact on emotions, on thoughts, behavior, and wellbeing. And given that pain in this model is such a complex entity, anything we can do to alter some of the contributing factors, like the emotional burden or the psychosocial impacts, can improve life experience and can improve function. So we're gonna talk first about mindfulness. So if you think about the term mindfulness, to be mindful of something is to be aware of it or to pay attention to it. And that's basically what a mindfulness practice is. It's a focus or attention on something. And generally, mindfulness includes not just focusing on something, but being open to it and aware of it and accepting it. So it's not really supposed to be judgmental when you perceive an emotion or a response to something you're feeling. So you have this lack of emotional appraisal, which the term that's used is non-elaborative. So you're noticing your pain, you're noticing your body's response to that pain and your stress level, and you're trying to uncouple the two. So that's kind of the basic description of it. And that goes back to John Kabat-Zinn in the 1980s. So the therapeutic model of this, or the summation of it, is to be aware of the condition or the pain, to accept and uncouple from that pain behaviors that are not necessarily helpful. So this can be a little bit problematic, at least in my experience, with patients who want to be fixed because you're asking them to start with, well, accept the condition, and then let's focus on how you're dealing with it. Now, that being said, it may have greater benefit or results in patients who have chronic pain and are struggling to accept it. So again, we're focusing on this idea of addressing the secondary effects of pain. And really, you're talking about the experience of pain versus the experience of suffering. And those are two very different things, at least when it comes to a functional perspective. So we know that in patients who practice mindfulness and in long-term meditators, there's neurophysiologic changes that occur with effects on processing. And that's pretty fascinating from a physiologic point of view, a little bit outside the scope of this brief talk, but still valid and helpful. So mindfulness strategies include one called open monitoring and that's the idea of basically just kind of being at peace and being aware of and processing what comes to mind. And there was a good study that showed that this practice can be achieved in novices pretty easily, even when compared to long-term meditators. And then there's another strategy, which is focused attention meditation, where you basically say, okay, I'm aware of the pain and now I wanna start shifting my focus onto something else. But both of these are training methods. So you're trying to provoke changes in emotional and attentional regulatory training. So it's basically a practice and that involves some investment and some buy-in from the patient. And the efficacy lies not so much in changing the physiological or physical effects of pain, but more how you react to them. And there's this inherent concept, which I've mentioned of existing and accepting. And sometimes that acknowledgement of a lack of control is helpful in terms of stress relief. So going back to some of the original stuff from Jon Kabat-Zinn, these are stress relief programs. They were actually called Mindfulness-Based Stress Reduction or MBSR. And being mindfulness of an urge, even the urge to act on pain is a core tenet and acceptance of that can lead to an effort to resume normal function. So this is a study from 1985 where 90 chronic pain patients went through a 10-week stress reduction and relaxation program. And we tried to lump the pain sensations and the accompanying thoughts as two separate entities. And the study concluded that there were improvements in present moment pain, negative body image symptoms, mood disturbance, and anxiety and depression. So there was some value here, but it's a small study back in the 1980s. And then moving forward, more recently there were some trials where we had randomized patients. So 2016, 342 patients were randomized to either Mindfulness-Based Stress Reduction or Cognitive Behavioral Therapy or what was termed usual care. And both the MBSR and the Cognitive Behavioral Therapy groups had greater improvement in low back pain and functional limitations than the usual care group. And those results were confirmed at one year. And then again, a similar study in 2016, similar number of patients, 282, and they were randomized to either Mindfulness-Based Stress Reduction or Healthy Aging Education. And the MBSR group had significantly reduced pain at six months, greater short-term physical function, but both groups had improvement in self-efficacy. And the control in this study was eight weeks of healthy aging education. So again, there may be a mindfulness component to just learning about aging and pain and degeneration and anything that comes along with that. As Dr. Mukai had mentioned, there certainly can be some value in large-scale meta-analyses or reviews. These will sometimes look at multiple studies and under that umbrella, bring in a large number of patients. So for fibromyalgia, there were some reviews, 2013 and 2015, that showed very low or low-quality evidence for improvement in pain. There was a 2012 review for low back pain that basically said that MBSR showed limited evidence to improve pain acceptance. And there was another study in 2014 for other musculoskeletal pain that found small to moderate reductions of psychosocial stress. So these are not that promising, but I still think it's important to talk about them. And then if you keep looking, you might be able to find something you like. So we don't wanna cherry-pick the evidence, but we wanna talk about a 2004 meta-analysis that said an MBSR practice showed good pain modulation improvement. So improvement in the emotional components of anxiety, depression, and stress. So a little bit of contradictory information here, but to me, there's some support, but not enough support. In 2013, there was a review of the literature that incorporated a large number of studies. And the conclusion of this particular review was that most studies showed benefit of mindfulness-based interventions, what they called MBIs, to decrease the intensity of pain for chronic pain patients. So the results were generally well-maintained. And this is, in my opinion, a very low-risk intervention. So anything in the realm of mindfulness or MBSR is low-risk. So the question is, do we have enough evidence to try it? And my feeling on it is yes. When you get into finances, so what I call dollars and cents, there was a 2017 study which basically said that when you looked at CBT, cognitive behavioral therapy, and mindfulness-based stress reduction versus usual care, there was a high probability that these interventions were at the least cost-effective, and mindfulness-based stress reduction may be cost-saving. So sure, there's value for payers and maybe for society, but I really think there's value for patients and providers in just having another option for some of these patients. Acupuncture, which we'll move on to, is a traditional Chinese medicine practice which involves the insertion of very fine needles through the skin at specific points on the human body. And the Chinese medicine explanation is that we're drawing energy through the body's meridians or pathways for treatment of disease, and that rebalancing qi or energy is thought to affect health. So even though true neural pathways may not perfectly approximate acupuncture points or meridians, there are some fMRI studies that show that acupuncture needle insertion can change brain activity. And there are some biochemical changes that we see involving neurotransmitters, so it's been described as a complicated mechanism. So unlike a mindfulness practice, the patient is really on the passive or receiving end of the treatment. It has a long history of utilization, which can be appealing to patients, and again, it's regarded as safe. And some of the studies incorporate a sham acupuncture treatment, which is a good advantage because that really helps you understand is there something about true acupuncture in the traditional Chinese medicine that's helpful, or is it really just needles piercing the skin, perhaps provoking an endorphin response or something along those lines. So there's a meta-analysis in 2012 from the Archives of Internal Medicine that's often cited, which demonstrated significant differences between acupuncture and a sham procedure and in 2014 with similar results said about 50% pain relief was noted which was regarded as good and in my practice I consider that good. The Mayo Clinic proceedings did a pretty comprehensive review of complementary health approaches for pain management and they did look at acupuncture and they had four controlled trials with about a thousand patients and they looked at a mod they discovered a modest pain improvement in function when compared to usual care but when they compared it to sham acupuncture there were mixed results so two of the randomized controlled trials showed no significant difference one of them did find a difference and then you know the top line of this slide shows what we're talking about from that study where they had you know some improvement for back pain not much for fibromyalgia two trials showing benefit for away of the knee and one showing benefit for severe headaches and migraines. Interestingly interestingly in pregnancy with auricular acupuncture a significant decrease in pain intensity and improved functional status was noted and again in my experience of big advantages there's no real adverse effects. Clinical practice guideline in 2017 showed moderate quality evidence for acupuncture and MBSR for low back pain but not so much for acute or subacute pain and the guidelines that were published did take into account that oftentimes patients will improve for acute or subacute pain regardless of treatment so there wasn't a lot of evidence to recommend acupuncture. When it came to chronic low back pain the recommendations actually took into consideration the benefits of trying to offer something other than opioids and avoid pharmacologic treatments. 2017 literature reviews suggested that there was benefit for acupuncture to treat chronic low back pain, neck pain, headaches, knee and shoulder pain and they felt that acupuncture was effective safe and cost-effective. Limited evidence for perioperative analgesia and for use as an adjunct or alternative to opioids. There was a 2020 review which suggested it covered actually a good number of patients, 16 review articles and 11 randomized control trials and they felt that acupuncture did have short-term pain relief benefits for Neo-A but interestingly not Hippo-A and for chronic low back pain and it may be beneficial for fibromyalgia but again evidence did not support the use of it for rheumatoid arthritis. So again the majority of studies concluded the superiority of short-term analgesic effects over other controls and there may be some benefit for chronic musculoskeletal pain. So we have a lot of data and all of these data suggest efficacy but I wouldn't say they actually confirm it but I do think there's enough here that I feel comfortable offering this to my patients and it may be more helpful for managing chronic pain conditions and really no significant adverse effects and some of our barriers to treatment or challenges may be that when you recognize recommend a mindfulness practice to a patient or an acupuncture treatment they may feel like you're not validating their pain, they may feel like you're ignoring their request to get to fix the physiologic cause of their pain. Some patients really just want a quick fix and it does require an investment from the patient whether it's participation in a mindfulness practice or taking the time or money to go pursue acupuncture and sometimes alternative medicine treatments can have some associated coverage or access issues but like I said I'm pleased to pursue some of these things in my own life. I find some value in offering them to my patients and I think more patients than not are interested in accepting of it but I do think you know further literature, better evidence-based studies would lend support to that. So these are my references and at this point I'd be happy to turn it over to Dr. Eric Ensrud who's going to be talking about evidence-based exercise and physical therapy. My name is Eric Ensrud I'm coming to you from Portland Oregon and I'm here to discuss some factors in evidence-based exercise and physical therapy. So when we talk about physical therapy for pain management you know one thing we have to back up right away and kind of address is the wide spectrum of what is included in the field of physical therapy. There's really quite a wide range of different interventions that are done and we as physiatrists are well known for being more specific in our physical therapy prescriptions rather than just checking PT and it's certainly a way that most of us were trained in residency to think about what do you actually want the physical therapist to work on with communication and so on. So I've divided up here into five different categories the first what PTs do would be considered instruction or education and this may be related to exercise or it may not like ADLs. A second thing would be interventions and those would be things like assistive products or technologies and the evidence of those of course is variable and related to the specific product or technology. A next intervention would be a functional control for example gait training which is training that complex movement. A third category which many of us have maybe a less higher opinion of is a passive a manual therapy meaning that it's something that the patient sits back or lies down and doesn't actively engage in the therapy and that would be things like chiropractic manipulations and physical therapists many of them do similar manipulations less focused on the spine usually. Passive range of motion a massage which would be very passive right you are completely inactive while the practitioner operates or massages you. Lymphatic drainage could be considered a passive therapy although somewhat different you know because there's a visible change at the conclusion of lymphatic drainage therapy. The next category would be that big category of therapeutic exercise and a lot of that is instruction in-person instruction and a lot of times we think about its relation to compliance because the patients develop a relationship with their physical therapist and don't want to come back and say that they haven't done the exercises so that helps with compliance. And then the last category to be therapeutic technologies like biofeedback these are all very passive therapeutic ultrasound FES TENS traction etc so obviously can't cover all of this in 15 minutes along with exercise but I pulled some studies that are interesting so let's go ahead and review those. So the first one is a systematic review on the effects of exercise and manual therapy on pain associated with HIPAA this is from 2016 and they looked at the effects of exercise both water-based and land-based with or without manual therapies on patients with clinically and or radiographically diagnosed HIPAA and these publications the latest was July 2014 included they looked at modified Pedro scores at looking at study qualities if you wondered what that is as I did Pedro stands for physical therapy evidence database there's a 10-point scale for assessing the quality of this case study it actually is quite good so the best available evidence the conclusion here was that exercise therapy whether land or water-based was more effective than minimum control in the short term in managing pain associated with HIPAA also a strong conclusion here was that there were no medium or long-term benefits of combining exercise therapy with manual passive therapy when compared to minimal control so this next systematic review I pulled you don't want to get recent papers was on a very passive therapy cranial sacral therapy where manipulations of the cranium and sacrum are felt to induce waves and the CSF this is from last year systematic review of cranial sacral therapy for chronic pain these trials went up to inclusion latest would be August 2018 and these were all randomized controlled trials they found 10 that fit their criteria with nearly 700 patients with a wide range of chronic pain conditions or your spine pain headache fibromyalgia epicondylitis and even pelvic girdle pain and cranial sacral therapy showed greater post-intervention effects on pain intensity and disability compared to treatment as usual also on pain intensity and disability compared to manual or non-manual sham treatments on pain and disability compared to active manual treatments and it's six months cranial sacral therapy showed greater effects on pain intensity and disability versus sham and secondary outcomes were all significantly more improved in CST patients than other groups so you know this is a reputable a reputable journal and a pretty strong result for a quite passive therapy certainly made me think about reassessing my use of this in patients so you know a lot of times when we're doing the more classic physical therapy intervention there's often feedback from patients that you know initiating it increases pain so I thought this was interesting systematic review from 2017 should exercises be painful in the management of chronic MSK pain and this looked to compare the effect of exercise where pain is allowed or encouraged kind of it didn't come out and say no pain no gain but compared with non painful exercises on pain function or disability in patients with chronic MSK pain and these are all within randomized controlled trials their inclusion criteria were met by nine papers with nearly 400 patients and they found a short-term significant difference in pain with a small effect size in favor of pain painful exercises but not for the medium or long term and so their conclusion here was because pain some pain in the short term actually was had a effect size in favor of versus non painful exercises that pain during therapeutic exercise for chronic MSK pain needn't be a barrier to successful outcomes that having pain with initiation of exercise or physical therapy doesn't result in worse outcomes so this next one this is you know something a lot of us have done in this year of COVID is either telephone visits or virtual visits and this is interesting this was looking at adding you know there's also quite a strong push at my institution there is they've hired multiple people whose goal is to get us to do more and more telephone visits or phone visits in the future I think you know we save the capital expense of the clinics and so on and this looked at also from this year from July just telephone delivered exercise advice and support by PT's improve pain or function in people with neo a large study 175 patients you can see the inclusion and exclusion criteria there that look good and they had multiple calls from a nurse or five to ten telephone visits and they had really good retention ninety four and ninety percent at six and twelve months and at six months exercise advice in support did have some result in a greater improvement of function but not overall pain but at twelve months there was no difference in outcomes with adding on that telephone delivered advice so their conclusion was this this added five hundred and fourteen dollars per patient I think those are Australian dollars and did not save on other health service resources so it was just an additive cost when we think about cost considerations I mean what does PT really cost you know what is the cost and this can vary widely in the area of the country in the particular physical therapy practice but on average it's about a hundred dollars for 45 minutes passive therapies can be much more expensive because these can be billed every 15 minutes like electrical stimulation and ion tophoresis and so on those can cost anywhere from 75 to 135 dollars per per 15 minutes very close or exceeding physician cost for outpatient CPT codes so in conclusion of this brief survey you know PT is certainly a reasonable addition and a lot of us have a bias towards active therapies and exercise and there is evidence for that but you might step back I'm certainly going to and consider if passive therapies can be more effective than many of us may have given them credit for so our next section is to talk about exercise and you know we always have to back up you know physiatrist as a group tend to be very exercise and diet focused and we think about exercise and jump to thinking about you know this famous planet planet fitness ad that offended so many bodybuilders you know the guys walking around I lift things up and put them down the guy directs him outside and locks the door and you know we think about very high-level athletes this is a very high-level triathlete doing things like high intensity interval training or Tabata and it's really helpful to frame shift and think about lower intensity things like pool therapy you know exercise at places like Y or community center JCC and even chair therapy this is offered at my dad's senior building and is quite popular and you know low intensity and even with our more active patients doing exercise at a lower intensity many exercise studies utilize a talk test which is significant exertion but retaining the ability to maintain a conversation and that actually correlates very well with exercise at a VO2 max of 65% which most aerobic exercises are our studies are based at you know another we got to kind of frame shift thinking about exercise for a lot of our patients shopping can be a great exercise you know there are less malls these days but there are plenty of you know Costco's and supertargets and so on and it's a great thing to recommend to patients because you've got a gate aid the shopping cart you've got a uniform floor and you know the same thing that makes us drives us nuts when we're trying to find something in one of these super stores that everything's so spread out we don't know everything is is a great way to encourage exercise and walking in many of our patients and I'll often recommend to patients just go and you know it's there are other people there they're not walking around by themselves and there are interesting things to look at and and hopefully they won't develop spending habits to break the bank but um so let's take a look at a systematic review for exercise this looks at 2017 annals of internal medicine non pharmacological therapies for a difficult problem low back pain it found good evidence that some particular types of exercise Tai Chi was effective for chronic low back pain found some evidence on yoga and so they can continue to show evidence for the effectiveness of exercise for chronic low back pain interestingly the same authors did a review the same year as pharmacologic therapies and found that for opioids evidence remain limited to short-term trials showing modest effects and the trials didn't assess serious harm so exercise comes out of this looking pretty good which is a lot different than many of us would have thought say 10 years ago and some might call the golden so-called golden years of Oxycontin and so on and not that Oxycontin doesn't have a place for some patients but so here's a trial looking at the effects of Tai Chi and neck exercises and the treatment of chronic non-specific neck pain from 2016 114 patients 12 weeks Tai Chi or conventional neck exercises and so interesting there really wasn't a difference between the two I thought there might be a difference between the two because Tai Chi off and the difference between conventional neck exercises is it has meaningful breathing or you know inhalation and exhalation that tends to boost the parasympathetic response and thought that would provide a boost for Tai Chi over standard exercises but did not and then there was a Cochran review and logo on yoga in low back pain and that same year 2017 and low to moderate certainly evidence that yoga compared to non-exercise controls did result in small to moderate improvements in back related function at three and six months so this can be very helpful you know hopefully not necessarily for the very intense types of yoga and then how about isolated lumbar extension for back pain this is a article from our own journal PM&R review of the clinical value of isolated lumbar extension resistance training for chronic low back pain this would show that isolated lumbar extension produced significant and meaningful improvements in perceived pain disability and global perceived outcomes and a low frequency once per week at high intensity effort appears sufficient and best for significant and meaningful outcomes very interesting just once a week this would be something like a Roman chair or this extension exercise machine so important you know as we some things up here of course a very important part of exercise is that in regards to patients is the locus of control instead of a passive therapy where things happen to you like pain and people help you externally things happen to you it's an internal locus of control which is very important for outlook depression quality of life exercises something that that promotes an internal locus of control so cost considerations I mean what if insurance paid for 230 minute personal training sessions per week we can we can you know be optimistic dream a little hot so the Southdale YMCA in Minneapolis 830 minute personal training sessions is three hundred and forty dollars a month it does cost less than physical therapy of course a personal trainer has less expertise than a physical therapist but you know how many of the treatments we prescribe for patients cost three hundred and forty dollars a month so it's actually quite cost-effective so exercise is a reasonable addition to consider to a chronic low back pain treatment plan so the summary is that PT can help when you look into it we really got some good evidence for different techniques of physical therapy and that exercise helps and is evidence-based thank you very much

non-invasive pain management

evidence-based lifestyle modifications

nutrition

supplements

mindfulness

acupuncture

exercise

underutilization of lifestyle changes

anti-inflammatory diet

comprehensive treatment plan