Lifestyle and Other Interventions

Transcription

1 Lifestyle and Other Interventions Integrated Pain Management Conference December 1-2, 2017 KELLY WOODWARD, DO, MPH MEDICAL DIRECTOR Park city Live Well Center

2 Objectives Describe the role lifestyle interventions have in pain management Explain how to identify effective sleep and its importance in pain management Recognize the potential benefits weight loss and inflammationreducing diets can have on reducing chronic pain Discuss adjunct therapies that have a role in acute and chronic pain management

3 Bottom-Line Regardless whether there are effective drug and/or procedure therapies for patients pain, improving patients healthimpacting behaviors will benefit their pain as well as their overall well-being We need capacity and processes to make available a wider range of pain management options and to build an acceptance among patients for new strategies

4 Outline Lifestyle interventions Cognitive Behavioral Therapy, biofeedback Acupuncture Therapeutic massage

5 Introduction o Chronic pain is many different conditions; a wide variety of etiologies; localized, generalized, dynamic o o The biopsychosocial construct encompasses this diversity An entourage of comorbidities: depression, anxiety, addiction, rheumatologic diseases, etc. o While specific curative treatment is desired, ongoing management is often the more realistic expectation

6 Maximize Lifestyle Interventions Exercise Sleep Diet / Nutrition Mindfulness

7 Physical Activity and Exercise Recommended for adults with musculoskeletal pain and rheumatic conditions 1 Flexibility, range of motion, muscle strengthening, aerobic conditioning Improve strength, movement and aerobic capacity Decrease fear-avoidance due to activity and reduce pain-related disability Long-term adherence is necessary

8 Exercise Evidence Overall, evidence for benefit is strong; short-term, long-term Specifics vary by condition Some differences for low versus high intensity OA: benefit from low and high-intensity aerobic and aqua-based 2,3 FMS: supervised aerobic and strength training effective for improving pain 4 Back pain: a broad range of exercises have positive, lasting effect 5

9 Evaluate Sleep in Pain Management o Improves physical and mental performance in all dimensions restores and replenishes o Aids weight control and metabolism o Reduces risks for heart disease, diabetes, dementia, depression o Aids immune system and hormone functions o Pain interferes with sleep and poor sleep impedes pain mgmt

10 Diet / Nutrition Direct effects Inflammation: Research supports link between diet and systemic inflammation 6 Fibromyalgia: Low-FODMAP diet improved pain in FMS 7 Diet effects comorbidities such as depression / anxiety 8

11 Mindfulness, Imagery, Yoga Mindfulness and Imagery: Very safe; some evidence of effectiveness for pain9, 10 Yoga: Emerging evidence for improvement in FMS pain and function 11

12 Cognitive Behavioral Therapy (CBT) Treatments designed to ameliorate pain, distress and disability Methods focused on Thoughts associated with pain Avoidance of unpleasant thoughts and painful experiences Beliefs about pain and related behavior CBT plus biofeedback Reduces sympathetic arousal Employs computer-assisted instruction

13 CBT Evidence Cochrane review of 42 studies found small positive effect on pain, mood and disability in patients with chronic pain including RA, low back pain, fibromyalgia, osteoarthritis 12 Only positive mood effects persisted beyond 6 months may need booster sessions Meta-analysis data on CBT for back pain show positive effects on pain intensity, mood, disability, quality of life and depression 13 CBT is more effective for some conditions when combined with exercise 14

14 Acupuncture Positive effects on outcomes in individuals with lumbar pain15, 16 Good evidence for pain relief in patients with knee OA 17 May be beneficial for pain relief in patients with RA 18 Mixed results in FMS19, 20 On track to begin offering acupuncture at the Park City LiVe Well Center by January 2018

15 Therapeutic Massage Preliminary evidence of beneficial effects in OA and FMS 20 Pain reduction in OA Reduced helplessness Systematic review found 9 randomized studies (404 patients) demonstrating significant improvement in pain, anxiety and depression in patients with FMS 21 Offering therapeutic massage at Park City LiVe Well Center

16 Conclusions o Pain management requires a multifaceted approach o o Maximize overall well-being through lifestyle interventions Much clinical research, by design, studies highly specific conditions with discrete interventions and outcomes; can t necessarily generalize results o Very low risk to many non-pharmacologic treatments exercise, CBT, acupuncture, massage, etc. o Small additive benefits can greatly aid management

17 Closing Thoughts o Keep an open mind o We don t understand everything that may benefit chronic pain patients o We have to increase therapeutic options o Need to greatly increase capacity for non-pharmaceutical options o Expertise o Interdisciplinary, team-based care processes

18 References 1. Cunningham NR, Kashikar-Zuck S. Nonpharmacologic Treatment of Pain in Rheumatic Diseases and Other Musculoskeletal Pain Conditions. Current rheumatology reports. 2013;15(2): Brosseau L, MacLeay L, Welch V, Tugwell P, Wells GA. Intensity of excercise for the treatment of osteoarthritis. Cochrane Database of Systematic Reviews. 2003;(2) 3. Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samoe B. Aquatic excercise for the treatment of knee and hip osteoarthritis (Review) Cochrane Database of Systematic Reviews. 2009;(4) 4. Hooten WM, Qu W, Townsend CO, Judd JW. Effects of strength vs aerobic exercise on pain severity in adults with fibromyalgia: A randomized equivalence trial. Pain. 2012;153(4): Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain. 2004;107(1 2): Roager HM, Vogt JK, Kristensen M, Hansen LBS, Ibrügger S, Mærkedahl RB, Bahl MI, Lind MV, Nielsen RL, Frøkiær H, Gøbel RJ, Landberg R, Ross AB, Brix S, Holck J, Meyer AS, Sparholt MH, Christensen AF, Carvalho V, Holst JJ, Rumessen JJ, Linneberg A, Sicheritz-Pontén T, Dalgaard MD, Blennow A, Frandsen HL, Villas-Bôas S, Kristiansen K, Vestergaard H, Hansen T, Ekstrøm CT, Ritz C, Nielsen HB, Pedersen OB, Gupta R, Lauritzen L, Licht TR. Whole grain-rich diet reduces body weight and systemic low-grade inflammation without inducing major changes of the gut microbiome: a randomised cross-over trial. Gut Nov Marum AP, Moreira C, Saraiva F, Tomas-Carus P, Sousa-Guerreiro C. A low fermentable oligo-di-mono saccharides and polyols (FODMAP) diet reduced pain and improved daily life in fibromyalgia patients. Scand J Pain Oct;13: Null G, Pennesi L. Diet and lifestyle intervention on chronic moderate to severe depression and anxiety and other chronic conditions. Complement Ther Clin Pract Nov;29: Astin JA. Mind-body therapies for the management of pain. Clin J Pain Jan-Feb;20(1): Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial. Pain Feb;152(2): Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist SD. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010;151(2): doi: /j.pain

19 References, continued 12. Eccleston C, Williams AC, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews. 2010;(4). 13. Williams DA. Psychological and behavioural therapies in fibromyalgia and related syndromes. Best Practice & Research Clinical Rheumatology. 2003;17(4): Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychology. 2007;26(1): Chung W, Xu S, Eken A, He J. Current status of complementary and alternative medicine in the treatment of rheumatic disease pain. Current Rheumatology Reviews. 2009;5(4): Manheimer E, White A, Berman BM, Forys KL, Ernst E. Meta-analysis: acupuncture for low back pain. Annals of internal medicine. 2005;142(651-63). 17. Kwon YD, Pittler MH, Ernst E. Acupuncture of peripheral joint osteoarthritis: a systematic review and meta-analysis. Rheumatology (Oxford, England) 2006;45: Sarzi-Puttini P, Atzeni F, Lubrano E. [Complementary medicine in rheumatoid arthritis]. La medicina complementare nell artrite reumatoide. Reumatismo. 2005;57(4): Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clinical rheumatology. 2012;31(1): Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clinical rheumatology. 2012;31(1): Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PLoS One Feb 20;9(2).