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Naturopathic Management of Chronic Pain in the Older Adult

Naturopathic Management of Chronic Pain in the Older Adult. Diana Quinn, ND Hygeia Center for Healing Arts Beaumont Hospital Integrative Medicine. Naturopathic Medicine. Licensed Naturopathic doctors ( NDs ) are general practitioners with a specialty in natural medicine.

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Naturopathic Management of Chronic Pain in the Older Adult

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  1. Naturopathic Management of Chronic Pain in the Older Adult Diana Quinn, ND Hygeia Center for Healing Arts Beaumont Hospital Integrative Medicine

  2. Naturopathic Medicine • Licensed Naturopathic doctors (NDs) are general practitioners with a specialty in natural medicine. • Pre-med undergraduate degree, four years at nationally accredited naturopathic medical school, pass North American licensing exams (NPLEX) • NDs specialize in evidence-based complementary and alternative medicine (EBCAM).

  3. Naturopathic Medical Schools in North America

  4. Naturopathic Medical Education • Basic Sciences • Organ Systems • Clinical Training • Naturopathic Modalities

  5. Naturopathic Modalities • Clinical Nutrition • Botanical Medicine • Homeopathy • Hydrotherapy • Physical Medicine • Lifestyle Counseling and Stress Management • Chinese Medicine, Acupuncture

  6. Naturopathic Philosophy • The Healing Power of Nature • Identify and Treat the Cause • Treat the Whole Person • First Do No Harm • Doctor as Teacher • Prevention

  7. Who Uses CAM? • Between 42%- 68% of Americans are using some form of complementary and alternative modality as part of their healthcare. • Nahin, RL, Barnes PM, Stussman BJ, and Bloom B. Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007. National health statistics reports; no 18. Hyattsville, MD: National Center for Health Statistics. 2009. • Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990–1997 Results of a follow-up national survey. JAMA. 1998;280(18):1569–1575. • Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, Kaptchuk TJ, Eisenberg DM. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001;135(4):262–268.

  8. CAM Use in Older Adults • 2007 National Health Interview Survey found that 38% of U.S. adults reported using CAM in the previous 12 months, with the highest rates among people aged 50–59 (44%) • 42 percent of adults who used CAM in the past 12 months disclosed their use of CAM to a physician (MD or DO) • Barnes PM, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. CDC National Health Statistics Reports #12. 2008.

  9. Disclosure of CAM Usage • AARP & NCCAM Survey Report (2010): telephone survey of 1000 participants ages 50+: • Over half surveyed use CAM and over 1/3 take herbal or nutritional supplements. • …Yet only a third of patients using CAM disclosed to their health care provider. • Complementary and Alternative Medicine: what people aged 50 and older discuss with their health care providers. NIH National Center for Complementary and Alternative Medicine, AARP

  10. CAM for Pain Management • Other studies have found that pain is the primary reason that older adults seek out CAM therapies • Astin JA, Pelletier KR, Marie A, Haskell WL. Complementary and alternative medicine use among elderly persons: One-year analysis of a Blue Shield Medicare sup-plement. J Gerontol A BiolSci Med Sci2000;55:M4–M9. • Cheung CK, Wyman JF, Halcon LL. Use of complementaryand alternative therapies in community-dwelling older adults. J Altern Complement Med 2007;13:997–1006.

  11. CAM for Persistent Pain • Persistent pain is defined as a prolonged experience of pain that continues for an extended period of time and may or may not be associated with a well-defined disease. • Negative outcomes associated with persistent pain include poor health, depression, cognitive decline, and higher usage of pharmaceuticals. • Munk et al. Massage therapy usage and reported health in older adults in experiencing persistent pain. J Alt Complementary Med 2011;17(7):609-16.

  12. Causes of Persistent Pain • Musculoskeletal pain • Osteoarthritis, Rheumatoid Arthritis, Fibromyalgia • Visceral pain • Cancer, gastrointestinal disorders, urogenital disorders • Neuropathic pain • Herpes zoster, neuralgia, neuropathy, MS

  13. Integrative Therapeutics for Pain Management Anti-Inflammatory Agents Analgesics Supportive Nutrients Acupuncture Massage Mind/Body Medicine

  14. Natural Anti-Inflammatory Agents • Turmeric (Curcuma longa) • MSM • Others include Holy Basil (Ocimum sanctum), Rosemary (Rosmarinusofficinalis) and Green Tea extract (Camellia sinensis)

  15. Turmeric (Curcuma longa) • Anti-inflammatory through inhibition of LOX and COX, antihistamine • Antioxidant and hepatoprotective • Anti-nociceptive • Basnet P, Skalko-Basnet N. Curcumin: an anti-inflammatory molecule from a curry spice on the path to cancer treatment. Molecules 2011, 16, 4567-4598. • Liju V et al. An evaluation of antioxidant, anti-inflammatory and antinociceptive properties of essential oil from Curcuma longa. Indian J Pharmacol. 2011 Sep;43(5):526-31. • Arora RB, Basu N, Kapoor V, Jain AP. Anti-inflammatory studies on Curcuma longa (turmeric). Ind J Med Res 1971;59:1289–95.

  16. Turmeric (Curcuma longa) • A preliminary trial in people with RA found curcumin to be useful for reducing inflammation, pain and stiffness. • Deodhar SD, Sethi R, Srimal RC. Preliminary studies on antirheumatic activity of curcumin (diferuloyl methane). Ind J Med Res 1980;71:632–4. • In a blinded studay, curcumin was superior to placebo or phenylbutazone (an NSAID) for alleviating post-surgical inflammation. • Satoskar RR, Shah SJ, Shenoy SG. Evaluation of anti-inflammatory property of curcumin (diferuloyl methane) in patients with postoperative inflammation.Int J ClinPharmacolTherToxicol 1986;24:651–4.

  17. Turmeric (Curcuma longa) • Contraindications • Pregnancy, gallbladder disease • Adverse effects • None documented • Drug interactions • May inhibit CYP3A4 drug clearance • Supplementation considerations • Poorly absorbed in whole form, quality of supplement imperative for efficacy • Dosage of standardized 90% extract 375-500 mg TID

  18. Methylsulfonylmethane (MSM) • Organosulfur molecule that can be synthesized commercially from dimethylsulfoxide (DMSO). • Anti-oxidant, chemoprotective properties, anti-atherosclerotic action. • RCT of 49 subjects aged 49-90 received either 1.125 g TID or placebo. After 12 weeks, total symptoms decreased in treatment group by 20% and increased in placebo group by 14%. • Debbi et al. Efficacy of methylsulfonylmethane supplementation on osteoarthritis of the knee: a randomized controlled study. BMC Complementary and Alternative Medicine 2011, June 11:50

  19. Methylsulfonylmethane (MSM) • Contraindications • None documented • Adverse effects • Rare diarrhea, rash, headache reported • Drug interactions • None documented • Supplement considerations • Dosage

  20. Botanical Analgesics • A Cochrane Review published in 2007 found ten trials of herbal analgesicsDevil’s Claw Harpagophytumprocumbens), White Willow Bark (Salix alba) and Cayenne pepper (Capsicum frutenscens) were found to reduce pain more than placebo. • Gagnier J et al. Herbal Medicine for Low Back Pain: A Cochrane Review. Spine. 32(1):82-92, January 1, 2007.

  21. Devil’s Claw (Harpagophytumprocumbens) • Has a broader mechanism of action than NSAIDs by interacting with both COX- and LOX-mediated pathways of the arachidonic acid cascade as well as with the release of cytokines • Loew D et al. Investigations on the pharmacokinetic pro- perties of Harpagophytum extracts and their effects on eicosanoid biosynthesis in vitro and ex vivo. ClinPharmacolTher 2001;69:356–64. • Fiebich B et al. Inhibition of TNFa synthesis in LPS-stimulated primary human monocytes by Harpagophytum extract. Phytomedicine 2001;8:28–30.

  22. Devil’s Claw (Harpagophytumprocumbens) • In subjects taking 50 mg of Devil’s Claw, the percentage with no pain or mild pain increased over the 4-week period (from 2% in week 1 to 24% in week 4), whereas the percentage with unbearable or severe pain decreased over the 4 weeks (from 59% in week 1 to 35% in week 4). • Chrubasik S, Junck H, Breitschwerdt H, et al. Effectiveness of Harpagophytum extractWS1531 in the treatment of exacerbation of low back pain: a randomized, placebo-controlled, double blind study. Eur J Anaesthesiol 1999;16:118–29.

  23. Devil’s Claw (Harpagophytumprocumbens) • RCT of 88 patients aged 45-72 having chronic LBP were randomized to receive either 2400 mg of the active compound harpagoside plus placebo, or 12.5 mg tablet of Vioxx plus placebo. • 79 subjects completed the study with 20% of patients receiving Devil’s Claw pain-free and 10% reofecoxib pain-free. • Chrubasik S et al. A randomized double-blind pilot study comparing Doloteffin and Vioxx in the treatment of low back pain. Rheumatology 2003;42:141–148

  24. Devil’s Claw (Harpagophytumprocumbens) • Of the original 88 patients in previous study, 53 patients remained in a one-year follow-up. • At 24, 43 and 54 weeks there continued to be no difference between treatment with Devil’s Claw and rofecoxib on Arhus Index and health assessment questionnaire scores (HAQ) • Long-term treatment with Devil’s Claw was effective and well tolerated. • Chrubasik S et al. A 1-year follow-up after a pilot with Doloteffin for pain. Phytomedicine. 2005 Jan;12(1-2):1-9.

  25. Devil’s Claw (Harpagophytumprocumbens) • Contraindications • Cardiovascular disease, patients taking warfarin • Adverse reactions • Dyspepsia – increases stomach acid production • Drug interactions • Medications cleared by the liver via CYP450 2C19, H2 blockers, PPIs • Supplement considerations • Dosage 2400 mg BID

  26. White Willow Bark (Salix alba) • Contains salicin • Anti-inflammatory and anodyne • Slow-acting and long-lasting pain relief

  27. White Willow Bark (Salix alba) • A total of 228 subjects were given a daily dose of 240 mg salicin against 12.5 mg per day of rofecoxib in a 4-week trial. • Both the rofecoxib and the salicin groups improved on the pain scale (by 44% in both groups), the Arhus scale invalidity index, pain index, and physical impairment index. • The percentage of patients requiring NSAIDs and/or tramadol was 10% for the S. alba group and 13% for the rofecoxib group.   • … there are no differences in effectiveness between a 240-mg salicin dose of an extract of S. alba and 12.5-mg rofecoxib per day in treatment of acute episodes of chronic pain

  28. White Willow Bark (Salix alba) • 4-week RCT of 210 subjects tested two doses of S. alba, standardized to either 120 mg or 240 mg salicin per day, against placebo. • In the 4th week, greater number of subjects with pain-free days in treatment groups than placebo. • 120 mg salicin dose of an extract of S. alba was more effective in relieving pain than placebo, with the effect being dose-dependent and greater at 240 mg. • Chrubasik S, Eisenberg E, Balan E, et al. Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med 2000;109:9–14.

  29. White Willow Bark (Salix alba) • Total of 261 patients in two studies demonstrated an increased number of pain-free patients, decreased number of patients requiring relief medication, and improved Arhus index scores. • Significant differences between the 120 mg and 240 mg groups, demonstrating that 240 mg reduces pain more than placebo and 120 mg dose of S. alba. • Chrubasik S, Kunzel O, Model A, et al. Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain. Rheumatology 2001;40:1388–93.

  30. White Willow Bark (Salix alba) • Contraindications • Pregnancy and breastfeeding, patients with gastritis or ulcers, children • Adverse effects • Stomach upset, tinnitus at high doses • Drug interactions • Anticoagulants, beta blockers, diuretics, methotrexate and phenytoin • Supplement consideration • Dosage 60, 120 or 240 mg QD

  31. Cayenne (Capsicum frutescens) • Topical preparations containing 0.025% to 75% of capsaicin are applied TID-QID. • The mechanism of C. frutescens is partially related to its ability to deplete substance P. • Numerous double-blind trials have proven C. frutenscens to be effective for both musculoskeletal and neuropathic pain.

  32. Cayenne (Capsicum frutescens) • In a recent RCT, 130 patients with severe fibromyalgia were randomized to receive 0.075 % capsaicin cream three times daily in a 6-week trial. • While no difference in Visual Analog Scale for pain, there were significant improvements in myalgic score and pain threshold in study group. • Reduced fatigue and depressive symptoms were also observed in trial group. • Casanueva et al. Short-term efficacy of topical capsaicin therapy in severely affected fibromyalgia patients. RheumatolInt2012 July (Epub ahead of print)

  33. Cayenne (Capsicum frutescens) • Contraindications • None documented • Adverse effects • Caution must be used to avoid touching eyes and mucous membranes • Drug interactions • None documented • Supplement considerations • Topical preparations range from 0.025%-0.075% capsaicin

  34. Nutrients for Pain Support • Magnesium • Vitamin D • L-DLPA • D-Ribose

  35. Magnesium citrate • Persistent pain syndromes that can be improved with magnesium supplementation include restless legs, MS, fibromyalgia and migraines. • Deficiency of magnesium is associated with many chronic disease states, such as diabetes, chronic fatigue syndrome and fibromyalgia, hypertension and arrhythmia. • Many drugs deplete magnesium, and supplementation is recommended to replenish.

  36. Magnesium citrate • 60 patients with fibromyalgia were randomized to receive either 300 mg magnesium, amytriptiline, or amitryptaline + magnesium. • The number of tender points, tender point index, FIQ and Beck depression scores decreased significantly with the magnesium citrate treatment. • Amitryptaline + magnesium was only group improved on all parameters. • Bagis et al. Is magnesium citrate treatment effective on pain, clinical parameters and functional status in patients with fibromyalgia? Rheumatol Int. 2012 January 22 (Epub ahead of print).

  37. Magnesium citrate • Contraindications • Patients with kidney disease • Adverse effects • Diarrhea at high doses • Drug interactions • Dexamethasone, misoprostol, spironolactone, triamterene • Supplement considerations • Magnesium citrate or glycinate are best absorbed forms

  38. Vitamin D • Vitamin D deficiency and insufficiency is prevalent, and correlated with many chronic disease states including diabetes, cancer and cardiovascular disease. • Insufficient vitamin D intake exacerbates conditions causing persistent musculoskeletal pain, such as osteoarthritis, osteoporosis and fracture, and fibromyalgia.

  39. Vitamin D • British study of 2070 adults >65, measurements included serum 25(OH)D, pain status and covariates (age, sex, social class, season of examination, use of vitamin supplements and physical health status). • Results show that the symptoms of moderate/extreme pain (present in 53 % of the sample) were associated with poor vitamin D status, independent of other covariates. • Hirani V. Vitamin D status and pain: analysis from the Health Survey for England among English adults aged 65 and over. Br J Nutr. 2012 Apr;107(7):1080-4.

  40. Vitamin D • Contraindications • Hyperparathyroidism, sarcoidosis • Adverse effects • Increased thirst, increased urination, kidney stones • Drug interactions • Verapamil, warfarin • Supplement considerations • Cholecalciferol (D3) is best absorbed form, daily doses range 2000-10,000 IU

  41. D,L-phenylalanine (DLPA) • Amino acid precursor, can be converted into L-tyrosine and subsequently L-dopa, norepinephrine and epinephrine. • Believed to up-regulate the endogenous analgesia system (EAS). • Promotes enkaphalin activity by inhibiting enkephalinase.

  42. D,L-phenylalanine (DLPA) • Improves mood, may alleviate persistent pain. • Mixed responses in clinical trials for improvement of persistent pain, little effect on acute pain. • Several studies demonstrated that DLPA improved the efficacy of acupuncture for relief of persistent pain. • May improve efficacy of opioid pain medications. • Russel AL, McCarty MF. DL-phenylalanine markedly potentiates opiate analgesia – an example of nutrient/pharmaceutical up-regulation of the endogenous analgesia system. Med Hypotheses. 2000 Oct;55(4)283-8.

  43. D,L-phenylalanine (DLPA) • Contraindications • Patients with tardivedyskinesia, PKU • Adverse effects • Nausea, dyspepsia, transient headaches • Drug interactions • L-dopa, potentiates opioids • Supplement considerations • Dosage range from 500-1500 mg

  44. D-Ribose • A 5-carbon sugar produced in the body from glucose • Important role in synthesis of RNA, DNA and ATP. • D-ribose shown to increase cellular energy production in heart and skeletal muscle, may improve pain from fibromyalgia. • Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Altern Complement Med. 2006 Nov;12(9):857-62.

  45. D-Ribose • Contraindications • None known • Adverse effects • Greater than 10 g daily may cause diarrhea • Drug interactions • None known • Supplement considerations • Powdered dose of 5 g BID

  46. Acupuncture • Acupuncture is thought to directly modulate the affective-cognitive aspect of pain perception, and changes in brain function have been observed using MRI during acupuncture treatment. • Useful for: • Neuropathy (diabetic, CIPN) • Musculoskeletal pain • Visceral pain in oncology patients

  47. Acupuncture for Persistent Pain • A meta-analysis of 29 RCTs with a total of 17,922 found that acupuncture was superior to both sham and no-acupuncture for the relief of neck and back pain, shoulder pain, osteoarthritis and headaches. • Vickers et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012 Sep 10:1-10.

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