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