CAM You can Use: Preventing Headaches

Kathi J Kemper, MD, MPHGeneral Pediatrics, Integrative

Medicine2nd Opinion Clinic (Monday

mornings) kkemper@wfubmc.edu

716-9640

Disclaimer

• I have no conflicts of interest to report regarding this presentation; I published a CME article on this topic with MedScape for which my institution received payment

• The presentation includes no description of any proprietary items for screening, diagnosis, or treatments

ObjectivesBy the end of this session, participants will be

able to – Counsel patients on dietary modifications to

prevent headaches

– Discuss the scientific evidence about the effectiveness of stress management practices in preventing headaches

– Find evidence-based resources about the effectiveness of acupuncture in preventing headaches (See AAP Section for Complementary and Integrative Medicine; join the listserv)

– NOT focused on diagnosis or medications

Headache

• Common! (in teens, > 4 HA in past month by 6% males; 14% females) (Linet. JAMA, 1989)

• 90% Migraine or Tension-Type Headache

• 10% other : sinusitis, eye, trauma, ice cream, cervicogenic, myofascial pain, TMJ, hemorrhage, infection, pseudotumor, vasculitis, tumor,

CAM Use for Tension-Type HA• 40% used CAM• 60% did not tell MD (how many MD’s

asked?)• Types of CAM

– Chiropractic 21%– Acupuncture 17%– Massage 17%

Rossi et al. Headache 46:622-631, 2006

* CAM – Complementary or Alternative Medicine, somewhat outdated and useless term

CAM at UNC for Headache

• Biofeedback (thermal, muscular, heart rate variability, autonomic)

• Hypnotherapy

• Osteopathy

• Acupuncture

• Mindfulness Meditation

• Herbal and supplement counseling

Prevention options

Patient-Centered Care

LIFESTYLE

Bioenergetic

Prevention/health promotion lifestyle

• Avoid triggers!

• Nutrition and supplements

• Exercise/sleep

• Environment

• Stress management

Lifestyle – AVOID TRIGGERS• Non-modifiable: genetics, gender, weather• Semi-modifiable: air pollution (including

tobacco smoke, CO, SO2, NO2), menses• Modifiable

- Lack of sleep- Missing meals- Allergens- Foods – tyramine containing, nuts, cheese, smoked

fish, artificial sweeteners, nitrate preservatives, MSG, caffeine withdrawal

- Stress – physical, psychological

!!KEEP A HEADACHE DIARY!!

Diet: Avoid Food Allergens

• Clinical trial of 43 patients

• Allergy skin testing

• 69% responded to diet modification(p<0.005)

• People with IgE-specific food allergy benefited more from the elimination diet

than people with negative skin tests.

Mansfield L et al.. Ann Allergy, 2004

Diet and Migraine• Regularization of meals• Normalize blood sugar (glycemic index)

• Elimination Diet 1: Caffeine, cheese, nuts, chocolate, shellfish, onions, aspartame, wine, beer, dairy, processed meats

• Elimination Diet 2: Lamb and rice – add back• Reduction in omega-6 fatty acids – red meats, fast

food• Increase in omega-3 fatty acid intake-fish oil

Dietary Supplements

• B vitamins

• Minerals: calcium, magnesium

• Fatty acids/fish oil

• CoQ10

• Melatonin

Supplements: B vitamins• B2

– Migraine sufferers suspected of having a mitochondrial defect -> impaired O2 utilization

– Riboflavin (B2) is the precursor to key molecules in the electron transport chain in the mitochondria

– 200 mg BID with meals for 3 months -> 68% reduction in migraine attacks in RCT (next slide)

– Side effect: yellow urineSchoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007

• B6 essential in converting tryp to serotonin– More than 100 mg daily -> nausea, abd pain, sleepiness,

lower B12 levels; >1000 mg daily -> sensory neuropathy

* High Dose Riboflavin vs. Placebo

Change from baseline to month 4

Placebo

N=26

Riboflavin

N=28

P value

Attack Frequency

0 -2.00 0.0001

Migraine Days 0.50 -3.00 0.0001

Severity 0.05 0.00 0.031

Duration (hr) 0.23 -1.30 0.018

Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis: a randomized controlled trial. Neurology 50(2): 466-70; 1998.

Supplements: Minerals

• Calcium for PMS-related migraines– 44% of boys and 58% of girls 6-11 insuff– 64% of boys and 87% of girls 12-19 insuff

• Ensure 1200- 1500 mg dailyThys-Jacobs. J Am Coll Nutr, 2000

• Magnesium (1 gram iv acutely) or 300 – 500 mg daily po to prevent (soy beans, black beans, tofu, seeds, nuts, whole grains, shellfish)

Mauskop. Headache, 2002; Pfaffenrath. Cephalgia, 1996Mazzotta. Cephalgia, 1999; Wang, Headache, 2003

Peikert. Cephalgia, 1996; Facchinetti F, Headache, 1991

* Magnesium - mechanism• Ionized magnesium levels low in 50% of MHA patients

• Migraines associated with platelet aggregation, serotonin release

• Magnesium reduces platelet aggregation

• Magnesium decreases the affinity of serotonin for vascular receptor sites

• Magnesium acts as an NMDA receptor (glutamate receptor) antagonist

– NMDA receptors & pain transmission

– Inhibits one type of neuronal spreading depression in experimental models

* OPTIONAL SLIDE – for participant reference

* Consequences of Reduced Mg++

• Vasoconstriction of scalp arteries

• Reduced affinity of serotonin receptors

• Lower threshold for activation of N-methyl-d-aspartate receptors

• Enhanced platelet aggregation and serotonin release

* Trials with Mg++ Supplements

• An infusion of 1.0 g of magnesium sulfate in 40 patients with acute migraine

– 52% responded to therapy– 86% of the responders had low serum ionized

Mg++ levels– 16% of the non-responders had low serum

ionized Mg++ levels.

Mauskop A. Alternative therapies in headache – Is there a role? Medical Clinics of North America 85(4): 1077-84; 2001.

* Trials with Mg++ Supplements• Four trials with oral magnesium

supplementation

• Three of the four showed efficacy

• The one negative trial used a poorly absorbed magnesium salt which resulted

in diarrhea

*Current Use of Mg++ Supplements

• 500 mg/day K+ Mg++ aspartate

• Avoid combining with Fe, Ca, Zn

• May cause temporary diarrhea

• Magnesium gluconate – an alternate

• Menstrual migraine – months to benefit

Mann, Doug et al. “Migraine and Tension-Type Headache.” Integrative Medicine. Ed. David Rackel MD. Philadelphia: Sanders, 2006 143-156.

Omega-6 Fatty Acids Omega-3 Fatty Acids

Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3)

(GLA)γ -Linolenic Acid (18:3n-6)

(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)

(AA)Arachidonic Acid (20:4n-6)

EicosanoidsLeukotriene 4-series

Prostaglandins E2

Thromboxanes A2

Eicosanoids

Stearidonic Acid (18:4n-3)

Eicosatetraenoic Acid (20:4n-3)

(EPA) Eicosapentaenoic Acid (20:5n-3)

24:5n-3

24:6n-3

(DHA) Docosahexaenoic Acid (22:6n-3)

EicosanoidsLeukotriene 5-seriesProstaglandins E3

Thromboxanes A3

∆-6 Desaturase

Elongase

∆-5 Desaturase

Elongase

∆-6 Desaturase

β-Oxidation

Phospholipid Bilayer

Changing Fatty Acid Intake:Omega 6: Omega 3

• Prehistoric ~ 1900 ~ 2000• 1:1 4:1 25:1

n-6 fatsn-3 fats

Why EFA Imbalance in US?

• Diet is high in Omega-6 and low in Omega-3 (previously 1:1 ratio, now 20:1)

• Hydrogenated oils• Enzyme cofactor deficiency (B-3, B-6, Biotin, C, Zinc,

Magnesium)• Genetic polymorphism (biochemical individuality)• Hyperinsulinism from high glycemic load diet

(increase DGLA to AA)• Increased stress -> increased demands.

Fatty acids: Omega 3s• Popular approach to decreasing

inflammation• Open studies suggest it helps reduce

headaches; doses 1-3 grams daily• RCTs – mixed results; olive oil may

not be a placebo!• Supplements – generally free from

mercury, dioxins, PCBs; palatableHarel. J Adolesc Health, 2002

Pradalier. Cephalgia, 2001Puel. Br J Nutr, 2004

Coenzyme Q-10

• Open label, 150 mg qd - for 3 months

• 62% had > 50% reduction in number of HA days

• Migraine Days: 7.34 -> 2.95/mo

• Frequency: 4.85 -> 2.81/month

• No side effects; except pain in pocketbookRozen and Silberstein, Cephalalgia 22: 137-141, 2002

Melatonin and Headache • Mechanism

– Potentiates GABA; Modulates Ca entry in to vascular smooth muscle cells

– Modulates 5HT2 receptor – like B-blockers; Inhibits the synthesis of prostaglandin E2 - inflammation mediator

• Melatonin low and out of phase in menstrual migraine, chronic daily headache, migraine, status and cluster HA

• Effective preventive for cluster HA and HA associated with delayed sleep-phase syndrome

Melatonin: Sleep phase delay or cluster HA

• Corrects delayed sleep-phase syndrome

• An alternative to benzodiazepines • Dosing 6-12 mg one hour before bed• Few side effects• ConsumerLab reviews show consistent

qualityRozen. Headache, 2006

Vogler. CNS Drugs, 2006Rozen, Neurology, 2003

Pringsheim. Headache, 2002 Miano. Neurol Sci, 2008 – PEDIATRIC STUDY

Lifestyle: Stress management

• Stress is common• Stress triggers/worsens pain• Managing stress: exercise,

sleep, nutrition, mind/emotion/body/spirit– Biofeedback– Hypnosis

• Reducing stress helps 50% - 70% of headache sufferers

The Many Forms of Mind-Body Medicine

Stress and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Institute of HeartMath

Biofeedback-What and why?

• Use of electronic equipment to measure and feed back information about physiologic functions—which are then modulated in desirable direction

• Goal-balancing ANS (& CNS) activity• “video-games for your body” kid-friendly• 2007 meta-analysis showed > 50 controlled trials of BF for

HA; EFFECTIVE!• Strong treatment effect that persists for over 12 months

after trainingAllen Pediatr Ann, 2004

Kaushik R. Complement Ther Health Med, 2005Trautman. Cephalgia, 2006

Nestoriuc. Pain, 2007

*Biofeedback - Example• Blanchard - 116 patients with migraine• Assigned to either thermal biofeedback, thermal

biofeedback with relaxation training, or pseudomeditation, headache

monitoring• Six month follow-up• 51% of the subjects in the thermal biofeedback

groups improved in frequency compared to 5% and 22% for the monitoring and pseudomeditation groups

Blanchard E et al.. J Consult Clin Psychol; 1990.

Biofeedback Modalities

Home or Office Use– Peripheral Temperature– Heart Rate Variability– Surface EMG– Skin Conductance

*Biofeedback-Temperature• Theory-the more relaxed, the lower sympathetic nervous

system activity, the more peripheral blood flow, hands and feet warm up

• Resources– Dermatherm Bands Sharn, Incorporated

www.sharn.com– BioDots

• www.futurehealth.org• www.cliving.org

– Digital Temp Portable Units• www.Bio-medical.com• www.thoughttechnology.com

*Heart Rate Variability (HRV)

0 1 2-0.5

0

0.5

1

1.5

2

m V

olt

s

2.5 seconds of heart beat data

.859 sec. .793 sec. .726 sec.70 BPM 76 BPM 83 BPM

Hypnosis/Guided Imagery

• Hypnosis: An altered state of awareness usually but not always involving relaxation during which the participant can give himself/herself suggestions for desired changes to which he/she is more likely to respond that in their usual state of awareness.

• Guided Imagery: A technique that involves using the imagination and mental images to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization.

Children Enjoy It• To teach self hypnosis for a specific purpose (such as

reduction of pain or elimination of a habit) involves helping young children focus on their natural thinking styles.

• Kids move in and out of altered states and imaginary activities all the time. Think IMAGINARY PLAY!

• The child is in control.• We serve as the teacher or coach.• Offer choices and options.• The child can use this skill when he or she chooses.• Ask that parents not remind the child to practice self

hypnosis; it’s up to the child/adolescent

Hypnosis – Prevention

• Meta-analysis – strong evidence of benefits for tension HA (Hammond. Int J Clin Exp Hypnosis, 2007)

• Better than wait-listed controls for migraine prevention (Melis. Headache, 1991)

• Superior to propranolol or placebo in juvenile classic migraine prevention (next slide)

Hypnosis : Headache

• Children 6 to 12 years with classic migraine

• RXT: propanolol vs. placebo for 3 months each

• Then hypnosis training

• Placebo: 13.3 HA/ 3 mos

• Propanolol: 14.9 HA/3 mos

• Hypnosis: 5.8 HA/3 mos (P<0.05)

Olness. Pediatrics. 1987

Hammond: Int J Clin Exp Hypn. 2007

* Hypnosis Misconceptions• Patient is under control of the

hypnotherapist• Patient is unaware of surroundings

and/or activities around him/her• Patients defenses are impaired (there is

improved access to subconscious material)

• Symptoms are masked• Patient can be forced to do things they

would not normally do

Contraindications to Hypnosis

• Ignoring underlying disorder

• Used for fun or entertainment

• The problem is more effectively treated with another modality

• Patient is psychotic, acutely depressed

• Patient (child) does not want to engage in hypnosis (but parent wants them to)

Mind-Body: Autogenic Training• Form of hypnosis• Repeat phrases

– My hands and arms are heavy and warm– My legs and feet are heavy and warm– My heartbeat is calm and regular– My breathing is easy and free– My forehead is cool– My belly is relaxed

• Reduces need for headache medication • Reduces frequency of migraine attacks

Zsombok. Headache, 2003Juhasz. Headache, 2007

Massage for Migraines

• Massage improves blood flow and decreases inflammation, relaxes muscles, reduces stress, provides tangible social support

• Can combine with physical therapies such as ice, heat; aromas (peppermint)

• RCT for migraines showed significantly decreased frequency and improved sleep

Lawler SP. Ann Behav Med, 2006Pieovesan. Arq Neuropsiquiatr, 2007

Chiropractic

• Commonly used

• Older studies support use of chiropractic in migraine; frequency and severity

were reduced

• Little other evidence supporting use in headache of different types

Tuchin. Australas Chiropr Osteopathy, 1997

Parker. Aust NZ J Med, 1978

Osteopathy - Headache

• Five of six studies showed positive results for tension, cervicogenic and post-traumatic HA

• No studies specifically for migraine• No control groups or long term results• Two of 6 studies: results comparable to TCA

Hoyt. J Am Osteopath Assoc, 1979Fernandez-de-las-Penas. J Orthop Sports Phys Ther, 2006

Bronfort. J Manipulative Phys Ther, 2001

Acupuncture for Chronic Daily Headache – UNC study

• RCT of usual medical care (UMC) vs UMC + acupuncture

• Medical care alone: no change• Medical care +acupuncture

– Improvement in headache impact (function)– Improvement in general mental health domains

(SF-36)– 3.7 times >likely to report reduced suffering

Coeytaux R. Headache, 2005Gottschling. Pain, 2008 – PEDIATRIC STUDY LASER ACUP.

Witt. Cephalgia, 2008 – COST EFFECTIVENESS

*Acupuncture: Mechanism of Action

• The documented effects of acupuncture include:

• 1) Release of opioids in the central nervous system

• 2) Changes in regulation of blood flow, blood pressure, body temperature, and alterations in immune function.

*Mechanism of Action

• Functional MRI: Single point stimulation– Activation of occipital lobes with lateral foot

VA1 stimulation– Reduction in limbic structure activity with true

acupuncture (pressure sensation) – Activation of somatosensory cortex with sham

point activation or painful response to needling

*Mechanism of Action: Biomedicine

• Release of opioid-like substances into CSF• Substance P, neurokinin A, neuropeptide Y• Serotonergic and dopaminergic systems

activated • Descending pain inhibitory systems

activated• Thalamic relay nuclei inhibition• Dorsal root entry zone inhibition

*Acupuncture for Headache

• 5 or more weekly 20-40 minute sessions

• Electrical stimulation

• Prolonged benefit after 6-10 weeks

• 70% respond to acupuncture -frequency

Morrisey, H et al. Headache 43, 221-228, 2003

*Acupuncture30 patients

6 treatments in

4 weeks

Pain Score Reduction %

Medication Use Reduction %

Acupuncture

Benefits at 1 year

43% 38%

Vincent C. A controlled trial of the treatment of migraine by acupuncture. Clinical Journal of Pain. 5(4): 305-12; 1989.

Acupuncture – Migraine Reviews involving > 1000 patients

• Acupuncture benefits adults and pediatric patients in preventing migraines

• NOT for acute treatment

• 1-2 treatments weekly for 4-6 weeks

• Effects last at least 6 months

• Side effects rareMelchart et al. Cephalalgia, 1999

Manias.The Clinical Journal of Pain, 2000

Healing TouchAnd Therapeutic Touch

Biofield Therapies

• Rapid increase in use and availability of Healing Touch, Therapeutic Touch, Reiki, QiGong, Polarity Therapy

• RCT showed decreased tension headache pain with TT

Keller E. Nurs Res, 1986

Herbs In Migraine• Feverfew – yes for prevention

if you can get British and use it daily

• Valerian –to help with sleep• Petasites (Butterbur) – yes for

prevention if you can get quality product

* Feverfew

• Feverfew (Tanacetum parthenium)• 270 adult migraine patients• 70% reduction in intensity and frequency of

migraine• Other trials have not been as promising but

all show benefit of feverfew > placebo• Variability in quality of products!

Murphy J et al.. Lancet 1988.Ernst E et al.. Public Health Nutrition .2000.

*Feverfew

• Significant reduction in frequency, not in duration• No head to head studies with other modalities• Dosing: 125mg/day of the dried leaf standardized

to a minimum 0.2% parthenolide• Maximum effect after 4-6 weeks• Adverse effects: Aphthous ulcers and

gastrointestinal side effects in 5-15% • Avoid abrupt cessation: agitation & increased HA• Contraindicated during pregnancy

Valerian

• Used for sleep, anxiety

• 150-300 mg of dried root hs or tid

• Few side effects

• Avoid prolonged use – rebound headache

• Used during headache

• Smells very bad

Petasites hybridus Root Extract

• Large, 3arm, dose-finding RCT (Lipton, Neurology, 2004)

• Reduced frequency by more than 50% in 68% of those with highest doses.

• Few dropouts.

• Two other confirmatory studies, one in children.

RESOURCES• Acupressure / acupuncture• Self care• Hypnosis• Biofeedback

Acupressure resources

– www.omsmedical.com (supplies)– www.auricularacupuncturecollege.com– www.khtsystems.com (korean hand acu)– www.hmieducation.com (Helms course)– www.aaaom.org (training and certification)– www.acupressure.com (resources)

* HRV Biofeedback - Resources

• www.heartmath.com (products and training)• www.heartmath.org (research) • www.aapb.org• www.stresseraser.com• www.bcia.org• www.stens-biofeedback.com• www.wildDivine.com

Self-Care Training Resources

• Books– Be the Boss of Your Body” Series

• www.freespirit.com

• “Ways to Wellness” Videos– http://www.childrensmn.org/Communities/IntegrativeMed.asp

• Music and Recorded Relaxation Exercises– www.therelaxationcompany.com– www.healthjourneys.com ****– www.Pzizz.com

• Home Computer Biofeedback Fun– www.wilddivine.com– www.heartmath.com

Web Resources

• AAP Section on CHIM– www.aap.org/sections/CHIM– Will post this presentation

• Integrative Pediatrics Council– www.integrativepeds.org– CAM bibliography– IPC Network

Training and Certification• Society For Developmental and Behavioral

Pediatrics Annual Pediatric Hypnosis Training• American Society for Clinical Hypnosis• Society for Clinical and Experimental Hypnosis• International Society for Hypnosis• Academy for Guided Imagery

Text Resources

• Culbert & Olness, ed: Integrative Pediatrics • In press, March 2009 (Oxford University Press)

• Loo: Integrative Medicine for Children (2008)• Rosen & Riley, ed: Complementary and Alternative Medicine,

Pediatric Clinics of North America (December 2007)• Schwartz & Andrasik: Biofeedback: A Practitioners Guide• Shannon: Handbook of Complementary and Alternative Therapies in

Mental Health• Schnaubelt: Medical Aromatherapy• Reed Gach: Acupressure Potent Points

Medical School:Arcury (Family Med)Avis (Public Health)Chilton (Phys/Pharm)Curl (Orthopedics)Tegeler (Neurology)

Stant: newsletter/Web

PCIM Director: Kemper

Hospital:Atkinson (Business Dev.)Johnson (Operations/Nursing)Parker (Home & Community)Small (Quality)Snelgrove (Operations)Yates (Pastoral Care)

Zachary: (meetings)

Medical School: Hospital:

Program leadersBailey: Ambience Sound/Music

Best HealthBlack: ActionHealth/ Farmer’s Market

Dailey/McCarty: MeditationDanhauer: Yoga

Feldman: Guided imageryKilbourne: Green Initiative

LaRose: HM – HospitalLarrimore – Healing Touch/HeartMath

McClenny – ArtsMelcher – Massage

NW Area Health Education CenterPashayan: Hypnosis

Sackett – RN ResearchWilson – Recreation/Aqua

Woodard - NutritionZachary – Healthy Living

Julie Milunic: Advisory BoardLibrary Staff: resources

Mark Wright: PR and Marketing

How: Behavioral Medicine

• Identify the goal• Consider various strategies• Pick a strategy• Identify a small, achievable step that the patient

and family can support• Explore pros and cons of change• Anticipate barriers; identify resources• Plan rewards/celebrations!• Re-evaluate; take the next step

Goal-setting

• Pick a POSITIVE goal– E.g., healthier lifestyle.

Example: Healthier lifestyleTo promote

Better moodBetter focus or concentrationGreater calm More resilienceMore cheerfulness Greater adaptabilityMore confidence More creativeMore clarityBetter memoryMore harmonious relationshipsHigher self esteemMore consistent with personal valuesother?

Pick a specific strategy

• More exercise• Better nutrition• Judicious use of supplements• Better sleep• Healthier environment• Stress management; biofeedback; journal;

meditation• Use medication• Massage, psychotherapy, acupuncture or other

professional help

Identify a small, achievable step

• Rome was not built in a day; habits are not changed overnight: BABY STEPS.

• For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week.

• Be specific (with or without an MP3 player; with or without a friend; regardless of weather?; distance vs. time)

How important is this to you?

0 1 2 3 4 5 6 7 8 9 10Not Very

Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5)

Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it!

How confident are you that you can do this for one month?

0 1 2 3 4 5 6 7 8 9 10Not Very

If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and planning rewards and follow-up.

If they pick a number less than 8, “What would it take for you to go from the number you picked

to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent about change!

Identify Pros and Cons  PRO CON

Change More cheerful Change routine

 More fit and cool Brother might tease

 Clothes fit better Yucky dog clean up

  Better sleep  

 Better self-esteem  

No Change Easy Continued mood probs

 Mom does yucky job Get fat

   Feel ugly

    Sleep badly

   Unhappy with myself

Identify Barriers and Resources• In addition to (cons listed above), what other barriers

or challenges might you anticipate as you try to make this change? Need new tennis shoes; need leash; need pooper-scooper

• What resources do you have/need to help you make this change? Will Mom commit to getting new shoes, leash, etc. ? Will the child want/need a reminder? Is it helpful for Dad to do that? Do they need a chore chart? A calendar?

Plan celebrations/rewards

• Pick a tangible reward and timing (will it be offered after week 1, 2, 3, 4?)

• Samples: new walking shoes; Support the patient’s choices.

• Emphasize the importance of the reward/celebration. If the patient says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it).

Sample behavior diary (OK to copy)Goal                

Sample:M T W Th

Fri Sa Su Total

Walk dog 5 minutes 5 days a week √   √ √ √ √   5

Week 1                

Week 2                

Week 3                

Week 4                

Re-evaluate.Celebrate.Next steps?

Follow Up

• Follow- up in 4-6 weeks.

• Ask patient to bring chart and say you plan to be proud of them (build expectation of success) and will ask them what they’d like to do for next step (involve them in problem solving).

• Do it!

Behavioral Medicine

• Identify the goal• Consider various strategies• Pick a strategy• Identify a small, achievable step that the patient

can embrace• Explore pros and cons of change• Anticipate barriers; identify resources• Plan rewards/celebrations!• Re-evaluate; take the next step