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K30 IntroductoryK30 Introductory
PresentationPresentation
Marc Brodsky, MDMarc Brodsky, MD
UCLA Center for East-West MedicineUCLA Center for East-West Medicine
January 31, 2007January 31, 2007
Patient presentationPatient presentation
2424 yo yo female medical female medicalstudent with a one-student with a one-year h/o neck pain thatyear h/o neck pain thatbegan during a time ofbegan during a time ofintense stress during aintense stress during avisit with her parentsvisit with her parents
DyspepsiaDyspepsia
ConstipationConstipation
DysmenorrheaDysmenorrhea
Dry, red eyesDry, red eyes
Cold intoleranceCold intolerance
InsomniaInsomnia
Mechanistic (parts,Mechanistic (parts,
objects, contents)objects, contents)
Problems in isolationProblems in isolation
Analytical thinkingAnalytical thinking
Treatment aims toTreatment aims to
block, stimulate, orblock, stimulate, or
replacereplace
Holistic (whole,Holistic (whole,
relationships, patterns)relationships, patterns)
Problems of the systemProblems of the system
Principles ofPrinciples of
organizationorganization
Treatment emphasizesTreatment emphasizes
self-healingself-healing
How is CAM classified?How is CAM classified?
ttp://nccam.nhih.gov/
Integrative MedicineIntegrative Medicine
Healing oriented medicine that takes account of theHealing oriented medicine that takes account of thewhole person (body, mind and spirit) including allwhole person (body, mind and spirit) including allaspects of lifestyle. It emphasizes the therapeuticaspects of lifestyle. It emphasizes the therapeuticrelationship and makes use of all appropriate therapies,relationship and makes use of all appropriate therapies,both conventional and alternative.both conventional and alternative.
Curriculum in Integrative Medicine: A Guide for Medical EducatorsCurriculum in Integrative Medicine: A Guide for Medical Educators. 2003, Consortium of. 2003, Consortium ofAcademic Health Centers for Integrative MedicineAcademic Health Centers for Integrative Medicine
Wellness treatment planWellness treatment plan
http://www.ehcca.com/presentations/hitsummit2/5_01_3.pdf
What is quality of lifeWhat is quality of life
The World HealthThe World HealthOrganizationOrganizationdefined "quality ofdefined "quality oflife" in itslife" in itsconstitution in 1948constitution in 1948to include physical,to include physical,mental, and socialmental, and socialwell-being, and notwell-being, and notjust the absence ofjust the absence ofdisease or illness.disease or illness.
Physical Health
Physicalfunction
(10)
Physicalfunction
(10)
Role–physica
l (4)
Role–physica
l (4)Pain (2)Pain (2)
GeneralHealth
(5)
GeneralHealth
(5)
SF-36: Physical healthSF-36: Physical health
Mental Health
EmotionalWell-
Being (5)
EmotionalWell-
Being (5)
Role-emotional
(3)
Role-emotional
(3)
Energy/fatigue (4)
Energy/fatigue (4)
Socialfunction
(2)
Socialfunction
(2)
SF-36: Mental healthSF-36: Mental health
Change in SF-36 scores for groupChange in SF-36 scores for group
of 52 consecutive patientsof 52 consecutive patients
0
5
10
15
20
25
30
35
40
45
50
PF Role-P Pain Gen H Energy Social Role-E EWB PCS MCS
Baseline
Followup
Hays RD, Brodsky M, Johnston MF, Hui KK: Evaluating health-related quality of life change in individual
patients. Evaluation & the Health Professions, 2005 Jun;28(2):160-71.
Statistical significance ofStatistical significance of
group changegroup change
.0067.00672.822.823.93.9MCSMCS
.0021.00213.233.232.82.8PCSPCS
.0023.00233.203.204.34.3EWB-5EWB-5
.3400.34000.960.961.51.5RE-3RE-3
.0009.00093.513.514.74.7SF-2SF-2
.0001.00014.334.335.15.1EN-4EN-4
.0061.00612.862.862.42.4GH-5GH-5
.0125.01252.592.593.63.6BP-2BP-2
.0004.00043.813.814.14.1RP-4RP-4
.0208.02082.382.381.71.7PF-10PF-10
prob.prob.t-testt-testDeltaDelta
Integrative approach toIntegrative approach to
patients with neck painpatients with neck painPilot data from aPilot data from acohort of 50cohort of 50consecutive patientsconsecutive patientswith neck painwith neck painrecruited for 2000-recruited for 2000-2010 Neck Pain Task2010 Neck Pain TaskForceForce
Compare change inCompare change inhealth-related qualityhealth-related qualityof life (HRQOL) atof life (HRQOL) atbaseline and after 6baseline and after 6weeks of treatmentweeks of treatment
Change in SF-36 scoresChange in SF-36 scores
34
36
38
40
42
44
46
PF Role-P Pain Gen H Energy Social Role-E EWB
Baseline
Followup
Score
Multi-item scales
Statistical significanceStatistical significance
.0500.05002.032.032.72.7EWB-5EWB-5
.4152.41520.820.821.51.5RE-3RE-3
.1324.13241.541.542.32.3SF-2SF-2
.0090.00902.762.763.33.3EN-4EN-4
.0287.02872.282.281.91.9GH-5GH-5
.0038.00383.093.092.82.8BP-2BP-2
.0081.00812.802.803.43.4RP-4RP-4
.0334.03342.212.212.62.6PF-10PF-10
prob.prob.t-testt-testDeltaDelta
Change in SF-36 scores forChange in SF-36 scores for
individuals (improved)individuals (improved)
22%22%EWB-5EWB-5
8%8%RE-3RE-3
14%14%SF-2SF-2
16%16%EN-4EN-4
16%16%GH-5GH-5
16%16%BP-2BP-2
16%16%RP-4RP-4
8%8%PF-10PF-10
SEp SEp 9090
FibromyalgiaFibromyalgia diagnosis and diagnosis and
treatmenttreatmentLow doseLow dose tricyclic tricyclic +/- +/-
cyclobenzaprinecyclobenzaprine and and
analgesics during theanalgesics during the
day, if necessaryday, if necessary
SSRI can beSSRI can be
consideredconsidered
Stimulation of tenderStimulation of tender
pointspoints
Lifestyle modificationsLifestyle modifications
Research interest: FMS treatmentResearch interest: FMS treatment
Natural, topicalNatural, topical
preparation topreparation to
stimulate tenderstimulate tender
pointspoints
EffectiveEffective
SafeSafe
AffordableAffordable
Easy to useEasy to use
Capsaicin and VR1 receptorCapsaicin and VR1 receptor
Capsaicin binds to aCapsaicin binds to a
vanilloidvanilloid type I type I
receptor (VR1) on areceptor (VR1) on a
trigeminal non-trigeminal non-
myelinatedmyelinated group C group C
fiberfiber
Influx of sodiumInflux of sodium
and calcium ionsand calcium ions
results inresults in
depolarizationdepolarization
Capsaicin: CNS mechanismCapsaicin: CNS mechanism
Depolarization opensDepolarization opensvoltage gated sodiumvoltage gated sodiumchannels (VGSC) andchannels (VGSC) andgenerates an actiongenerates an actionpotential along the nervepotential along the nervefiberfiber
Transmitter substancesTransmitter substancesincluding glutamate,including glutamate,Substance P (SP) undSubstance P (SP) undCalcitoninCalcitonin Gene Related Gene RelatedPeptide (CGRP) transfersPeptide (CGRP) transfersthe signal to centralthe signal to centralneurons responsible for theneurons responsible for theperception of irritation andperception of irritation andpainpain
Capsaicin: PNS mechanismCapsaicin: PNS mechanism
Peripherally,Peripherally,
tachykininstachykinins such as SP, such as SP,
CGRP andCGRP and Neurokinin Neurokinin A A
(NKA) are released(NKA) are released
Mediate mediateMediate mediate
hypersecretionhypersecretion,,
vasodilationvasodilation and and
inflammatory cellinflammatory cell
infiltrationinfiltration
Topical capsaicin and analgesiaTopical capsaicin and analgesia
Diabetic and post-Diabetic and post-
herpetic neuropathyherpetic neuropathy
OsteoarthritisOsteoarthritis
Rheumatoid arthritisRheumatoid arthritis
Post-mastectomy painPost-mastectomy pain
(Whittaker AL, Kennedy DT, Small RE.(Whittaker AL, Kennedy DT, Small RE.
Adjuvant agents for managing chronicAdjuvant agents for managing chronic
pain. pain. APS Bulletin.APS Bulletin. 1999:9) 1999:9)
Evaluation question and standardEvaluation question and standard
StandardStandard
StatisticallyStatistically
significant significant in post- in post-
intervention scoresintervention scores
on quality of lifeon quality of life
instrument (global asinstrument (global as
well as well as fibromyalgiafibromyalgia--
specific) relative tospecific) relative to
placeboplacebo
Evaluation QuestionEvaluation Question
Does topicalDoes topical
capsaicin 0.025%capsaicin 0.025%
applied to tenderapplied to tender
points 4 times a daypoints 4 times a day
for a period of 1for a period of 1
month improvemonth improve
quality of life inquality of life in
patients withpatients with
fibromyalgia fibromyalgia relativerelative
to a matched sampleto a matched sample
that uses a placebothat uses a placebo
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