Integrative EastWest Medicine: Good for Primary Care

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Integrative East-West Medicine Good for Primary
Care

• Edward K. Hui, MD
• Assistant Clinical Professor of Medicine
• Center for East-West Medicine
• Division of General Internal Medicine and Health
  Services Research/Department of Medicine
• David Geffen School of Medicine at UCLA

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83 yo female with psoriasis since 1988 who was
well until several yrs ago when she initially
noted low back pain shooting down into her knees.
This pain was progressive over the ensuing 3 yrs
with generalization to the entire body resulting
in quality of life and functional status that has
been less than desirable for her. During this
time, she has been referred by her primary care
physician to multiple specialists for evaluation
of other problems including skin rashes, chronic
diarrhea, urinary incontinence, lumbosacral pain
and bilateral lower extremity paresthesias.
Workup has revealed lumbar spinal stenosis, mild
peripheral arterial disease and peripheral
neuropathy of unclear etiology. The patient is
wary of medications, but does take gabapentin 600
mg twice daily and celecoxib intermittently for
her painful conditions. She wonders if there are
other approaches or interventions that might be
helpful for her.
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About me

• Biochemistry at UCLA
• Traditional Chinese medicine (TCM) and
  integrative East-West medicine
• David Geffen School of Medicine at UCLA
• Internal medicine at UCLA

Geriatric medicine
TCM and integrative East-West medicine
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• What is primary care?
• the provision of a broad range of personal
  medical care (preventive, diagnostic, palliative,
  therapeutic, curative, counseling and
  rehabilitative) in a manner that is accessible,
  comprehensive and coordinated by a licensed MD/DO
  physician over time. Care may be provided to an
  age-specific or gender-specific group of
  patients, as long as the care of the individual
  patient meets the above criteria.
• Excerpted from American Medical Association
  Policy -200.969 Definition of Primary Care

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Patients I might see in a typical day

• 48 year old gentleman with hypertension,
  dyslipidemia and prediabetes in for routine
  followup
• 88 year old female with dementia, hypertension
  and osteoporosis in for routine followup with
  caregiver reporting worsening irritability and
  sleep disturbance
• 71 year old gentleman with coronary artery
  disease, ischemic cardiomyopathy, benign
  prostatic hyperplasia, chronic kidney disease,
  failed back syndrome and depression who comes in
  with worsening abdominal pain
• 54 year old female presenting as a new patient
  with complaints of fatigue, pain all over,
  intermittent abdominal pain, burning urination,
  headaches, brain fog, etc.
• 68 year old otherwise healthy female in to
  discuss the results of her recent screening
  mammogram which suggests the presence of breast
  carcinoma
• 39 year old female here to establish primary care
  and who has longstanding neck pain and headaches

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Survey of 1177 4th year medical students in 11 US
medical schools - only 2 of medical students
planned a career in primary care internal medicine
Hauer et al. JAMA 2008300(10).
Prestige Compensation Administrative
paperwork/regulatory requirements Information
overload
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Changes are coming

• New models of primary or principal care, e.g.,
  advanced medical home
• Incorporating information technology
• Reimbursement reform (patient-centered
  longitudinal coordinated care versus episodic,
  illness-oriented complaint-based care)

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EFFECTIVENESS
How best to solve my patients problem(s) in a
timely, cost-efficient, safe and accessible
manner?
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The Human Condition
Feeling GREAT!
Illness
Disease
Wellness
Death
- Headaches - Irritable bowel - High blood
pressure - Overweight
Doing ok
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Complementary and alternative medicine (CAM)
MANIPULATIVE AND BODY-BASED METHODS
CLASSIFICATION OF THERAPIES
National Center for Complementary and Alternative
Medicine. http//nccam.nih.gov/. Accessed
February 2005.
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All ends with the patient

• Biopsychosocial framework
• Individualization

McEwen BS. NEJM 1998.
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• What is integrative East-West medicine?
• An approach to health care developed at UCLA
  comprising judicious incorporation of principles
  and therapeutic modalities of traditional Chinese
  medicine (TCM) into conventional care, emphasis
  on a biopsychosocial approach to health and
  disease and a sharp focus on disease prevention
  and health promotion.

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Concepts of TCM
Chinese Medical Model

• Theory of Yin and Yang
• Theory of balance
• Five Phases Theory
• Theory of interdependence/correspondence
  positive and negative feedback
• Zang-Fu Theory
• A functional, energetic, physiologic,
  biochemical, and anatomic system
• Meridian/Channel System
• A communication system

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Traditional Chinese medicine (TCM) Core
principles

• Importance of a normal flow of an adequate amount
  of energy
• Optimal interaction of man and the natural/social
  environment
• Inseparable nature of body and mind
• Focus on process and function over structure

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Therapeutic goals of TCM

• Restore normal balance and flow
• Individualization
• Focus on enhancing the bodys endogenous
  resistance (homeostatic reserve) to disease
• Less emphasis on specific causal factors

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TCM therapeutic modalities and strategies

• Acupuncture and variants
• Bodywork (tuina)
• Chinese herbal medicine

• Chinese dietetics
• Mind-body exercise (taijiquan and qigong)
• Lifestyle measures

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What is acupuncture?

• A method of sending a signal to the body (by
  needle or other means) to turn on its own
  self-healing or regulatory mechanisms

Hui KK. Center for East-West Medicine. David
Geffen SOM at UCLA.
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Stimulation of acupuncture points

• Simple manual needling
• Acupressure
• Moxibustion
• TENS
• Acupoint injection (TPIs-trigger point injection)
  
• Topical application of medicated patch
• Cupping
• Others including laser, magnetic beads

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The meridian system

• 14 regular meridians
• Communication network thru which Qi and Blood
  flow
• Maintenance of health requires adequate amount
  and proper flow of Qi
• Acupuncture and variants allow access into the
  body to effect change

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Acupuncture How does it work?

• Hyperstimulation analgesia (gate control theory)
• Endogenous opioids
• Neurotransmitters
• Defined spinal, subcortical, cortical loci
• Diffuse noxious inhibitory control (DNIC)

Cho ZH et al. Proc Natl Acad Sci U S A. 1998. Han
JS. Neurosci Lett. 2004. Mayer DJ. Progress Brain
Res. 2000. Ma SX. Evid Based Complement Alternat
Med 2004.
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• Witt C et al. Acupuncture in patients with
  osteoarthritis of the knee a randomised trial.
  Lancet. 2005 Jul 12366(9480)136-43.
• Zhou Y et al. Effect of acupuncture given at the
  HT 7, St 36, St 40 and K 3 acupoints on various
  parts of the brains of Alzheimers disease
  patients. Acupunct Electrother Res. 2008
  33(1-2)9-17.
• Forbes A et al. Acupuncture for irritable bowel
  syndrome A blinded placebo-controlled trial.
  World J Gastroenterol. 2005 Jul 1411(26)4040-4.
• Emmons SL et al. Acupuncture for overactive
  bladder a randomized controlled trial. Obstet
  Gynecol. 2005 Jul106(1)138-43.
• Che-Yi C et al. Acupuncture in haemodialysis
  patients at the Quchi (LI11) acupoint for
  refractory uraemic pruritus. Nephrol Dial
  Transplant. 2005 Jun
• Xie Y et al. Acupuncture for dysphagia in acute
  stroke. Cochrane Database Syst Rev. 2008 July
  16(3)CD006076.

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Two prospective studies of acupunctures safety
574 UK acupuncturists
7050 German physicians

• 760000 treatment sessions
• 6 potentially serious adverse events
• 6936 mild adverse events
• Arch Intern Med 2004164104-5

• 34000 treatment sessions
• 43 minor adverse events
• BMJ 2001323486-7

Prevalence of (mild) adverse events 7
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Soft tissue dysfunction has a prominent role in
health and disease
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Sleep disturbance
Macrotrauma

• Motor vehicle accidents
• Athletic injuries
• Falls

Chronic microtrauma
TRIGGER/TENDER POINTS

• Improperly designed tools or machinery
• Nonergonomic work environment
• Excessive weightlifting and other activities that
  result in overload

Psychosocial stress

• Occupational
• Relationships
• Family and friends

Systemic/metabolic influences
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Myofascial trigger point concept other
applications?

• Head and neck dizziness/vertigo, tinnitus,
  blurry vision, excessive tearing, dry eyes
• Cardiopulmonary asthma, dyspnea, chest pain,
  arrhythmia
• Gastrointestinal nausea, IBS, reflux/heartburn
• Genitourinary IC, frequency, urgency,
  dysmenorrhea

ACTIVE pain
LATENT nonpain symptoms
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Treatment of myofascial pain trigger point
therapy

• Massage
• Acupressure
• Ultrasound
• Heat/ice/fluorimethane/diathermy

• TENS
• Electroacupuncture/DC stimulation
• Acupuncture/trigger point injections

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Manual therapies

• Tui Na
• Traction
• Massage
• Manipulation
• Myofascial release

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Problematic issues with herbal medicines

• Dietary Supplement and Health Education Act
  (DSHEA) of 1994
• No requirement to prove claims about safety or
  effectiveness
• No regulation to ensure quality control
• Natural does not mean safe
• Tremendous variation in concentration of active
  ingredients and other chemicals

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Chinese herbal medicine

• Drugs of plant, animal, and mineral origin used
  for many years to treat patients under the
  guidance of the theory of traditional Chinese
  medicine (TCM)
• Careful diagnosis of the patient required, using
  the pathophysiological pattern of the patient to
  serve as a guide for herbal formula selection

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How does it taste?
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What is tai chi, and what are its benefits?
Klein PJ and Adams WD. Am J Phys Med Rehabil
2004.
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Tai Chi Research highlights

• VZV specific immunity and health functioning in
  older adults Irwin M et al. Psychosom Med 2003.
• Functional status and exercise capacity in
  patients with chronic heart failure Yeh GY et al.
  Am J Med 2004.
• Falls in older adults, both robust and
  transitionally frail Wolf SL et al. JAGS 1996
  Sattin RW et al. JAGS 2005.

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Importance of self-care

• Many patients are not requested or encouraged to
  participate in recovery
• Doctor as teacher, not only therapist
• Empowering the patient is important to the
  healing/rehabilitative process
• Involvement of family and caregivers is crucial

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Interventions to reduce allostatic load and
achieve balance

• Eat healthy
• Stop smoking
• Exercise
• Learn coping skills
• Recognize limitations
• Relax
• Avoid isolation
• Regain control in work environment

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Rational pharmacotherapy
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83 yo female with psoriasis since 1988 who was
well until 3 yrs ago when she initially noted low
back pain shooting down into her knees. This
pain was progressive over the ensuing 3 yrs with
generalization to the entire body resulting in
quality of life and functional status that has
been less than desirable for her. During this
time, she has been referred by her primary care
physician to multiple specialists for evaluation
of problems including chronic diarrhea, urinary
incontinence, lumbosacral pain and bilateral
lower extremity paresthesias. Workup has revealed
lumbar spinal stenosis, mild peripheral arterial
disease and peripheral neuropathy of unclear
etiology. The patient is wary of medications, but
does take gabapentin 600 mg twice daily and
celecoxib intermittently for her painful
conditions. She wonders if there are other
approaches or interventions that might be helpful
for her.
Mildly overweight Motor strength intact
throughout diminished sensation to light touch
and pinprick in the lower extremities reflexes
symmetric Tender points noted diffusely axially
and in the extremities, particularly in the
paraspinal musculature and medial calves
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• Acupuncture Du 20, Sp 6, Sp 10, Sp 9, LI 11, LI
  4, Liv 3, BL 60, BL 40, St 40, GB 34, K 7 and BL
  meridian (back shu) points
• Trigger point injections into lumbosacral and
  gluteal regions
• Therapeutic massage/myofascial release to
  paraspinal musculature and lower extremities
• Pt taught self massage/acupressure techniques (BL
  meridian with tennis balls, Sp/Liv/K meridians in
  the lower extremity, K1 with golf ball, GB 20 and
  21, dorsal forearm to elbow)
• Pt advised to walk in water
• Referral for epidural steroid injection
• Celecoxib discontinued and gabapentin
  discontinued (with some improvement in lower
  extremity edema)

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Integrative East-West medicine

• Appropriate and careful diagnostic workup
• Attention to emotional and environmental (both
  natural and social) factors
• Appreciation of soft tissue dysfunction

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Integrative East-West medicine

• Acupuncture/acupressure and variants
• Therapeutic massage (TuiNa)
• Appropriate exercise (walking, TaiJiQuan,
  QiGong) self-care approaches

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Integrative East-West medicine

• Healthy diet according to traditional Chinese
  medicine (TCM) and modern nutritional concepts
• Rational pharmacotherapy

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Integrating CAM into the healthcare system
Clinical Practice
Research
Licensure Credentialing Reimbursement Product
delivery
Funding sources Investigator pool Collaboration
Education
Trainees and practicing physicians Lay public
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THANK YOU
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UCLA Center for East-West Medicine http//www.cewm
.med.ucla.edu/ UCLA Collaborative Centers for
Integrative Medicine http//www.ccim.med.ucla.edu/
UCLA Internal Medicine Residency
Program Categorical Training Program Primary
Care Track http//www.imresidency.med.ucla.edu/