Integrative Rehabilitation: Need Of The Hour

Dr. Manoj Kumar Physiatrist, Ayurvedic Consultant Dubai Herbal & Treatment Centre

 There is no end to the learning of Science. Hence you should carefully and constantly devote yourself to it. You should increase your skill by learning from others without jealousy. The wise regard the whole world as their teacher, whereas the ignorant considers it as their enemy. Charaka Samhita ( 200 BC)

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Whats CAM?

CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

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Whats Rehabilitation Medicine?

Development of a person to his / her fullest physical, psychological , social, vocational, avocational and educational potential consistent with his/ her physiology or anatomical impairment and environmental limitations.
Braddom RL, Physical Medicine & Rehabilitation, Philadelphia: W.B. Saunders 8/12/2011 Rehab Dubai 2008 4

Integrative Medicine
Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness.

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Various CAM practices

Whole Medical Systems: Ayurveda ( Indian Traditional Medicine), Traditional Chinese Medicine, Homeopathy, Naturopathy Mind Body Medicine: Biologically Based Practices: Dietary Supplements, Herbal Products Manipulative Body Based Practices: Chiropractic / Osteopathic Manipulation, Massage Energy Medicine: Biofield Therapies (Tachyon,Reiki , Qi gong, Therapeutic Touch) ;Bio electromagnetic based therapies
www.nccam.nih.gov

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Main Areas of Integration CAM & Rehabilitation Medicine

Back Pain Muscle Pain due to trigger points, posture defects, Fibromyalgia Arthritis: Osteoarthritis, Rheumatoid arthritis, spondyloarthopathies Sports injury Rehabilitation Post Stroke rehabilitation
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Why Integration
Reductionist approach many a times fail in systemic ailments To reduce systemic toxicity and the side effects from chemical preparations Better outcome than single approach

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All systems are complementary

All systems are for curing diseases or maintaining health So all medical systems should complement each other Practitioners must try to understand and incorporate different treatment systems for the benefit of their patients
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Diet has a role in diseases?

Yes, but never accepted by Conventional Medicine Limited to restrictions of certain foods in conditions like kidney failure, gout, hypertension etc But it is never considered as a causative factor in diseases
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Diet Cause of many disorders

Degenerative conditions: parkinsonism
Prospective study of dietary pattern and risk of Parkinson disease, American Journal of Clinical Nutrition, Vol. 86, No. 5, 1486-1494, November 2007

Metabolic syndromes
Ravi Dhingra et al, Soft Drink Consumption and Risk of Developing Cardiometabolic Risk Factors and the Metabolic Syndrome in Middle-Aged Adults in the Community: Circulation published online Jul 23, 2007

Gouty arthritis: High Beer consumption, Sugary foods

Hyon K Choi and Gary Curhan, Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study: BMJ published online 31 Jan 2008 Kuang-Hui Yu et al,Dietary Factors Associated with Hyperuricemia in Adults ; Semin Arthritis Rheum 37:243-250

AMD
Chung-Jung Chiu ,Dietary carbohydrate and the progression of age-related macular degeneration: a prospective study from the Age-Related Eye Disease Study ; American Journal of Clinical Nutrition, Vol. 86, No. 4, 1210-1218, October 2007

Coronary artery disease due to high inflammatory diet

Katherine Esposito and Dario Giugliano, Diet and inflammation: a link to metabolic and cardiovascular diseases; European Heart Journal (2006) 27, 1520

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Sugars & Diet has a role in diseases

Soft Drinks & High Fructose cause Gout
Hyon K Choi and Gary Curhan, Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study: BMJ published online 31 Jan 2008

Soft Drinks has a role in Metabolic syndrome

Ravi Dhingra et al, Soft Drink Consumption and Risk of Developing Cardiometabolic Risk Factors and the Metabolic Syndrome in Middle-Aged Adults in the Community: Circulation published online Jul 23, 2007

Mean serum urate level over the past 40 years is increased, attributed reasons are changes in diet and consumption practices
Kuang-Hui Yu et al,Dietary Factors Associated with Hyperuricemia in Adults ; Semin Arthritis Rheum 37:243-250;

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Diet Disease link

It cannot be concluded, of course, that diet causes gout, but diet does seem to be a factor in its development in hereditarily prone people. * Osteoarthritis, or degenerative arthritis, has been produced clinically in animals by diet, although we cannot state that diet is the cause of the disease in man. * An increasing amount of epidemiologic data show that persistent, low-grade inflammation is an independent predictor of ischemic heart disease, stroke, diabetes, and all-cause mortality **
*Betty

Herndon, Diet in the Treatment of Rheumatic Disease, A Review: Am J Clin Nutr 68 Vol. 18, January 1966 **Barbara J Niklas, Diet-induced weight loss, exercise, and chronic inflammation in older, obese adults: a randomized controlled clinical trial; Am J Clin Nutr 2004;79:544 51.

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Diet Produces Inflammation

Diets High in Fats ( butter/ Cream), glucose or mixed carbohydrates and fats produce acute post prandial inflammation
S. Wayne smith, Diet & leukocytes, Am J Clin Nutr 2007;86:1257 8.

Post prandial elevation of Endotoxins from gut could be the possible mechanism through Toll Like Receptor 4 ( TLR 4 ) complex
S. Wayne smith, Diet & leukocytes, Am J Clin Nutr 2007;86:1257 8.

Saturated fatty acids ( lauric, myristic palmitic & stearic acids) stimulate macrophage activation of NF kB and expression of pro inflammatory cyokines
Shi H, Kokoeva MV, Inouye K, Tzameli I, Yin H, Flier JS. TLR4 links innate immunity and fatty acid-induced insulin resistance. J Clin Invest 2006;116:301525.

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Diet and Immune function

Modulation of immune function by Food; eCAM 2004;1(3)241250 8/12/2011 Rehab Dubai 2008 15

Diet and Immune function

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Chronic Inflammatory Diseases Threat to Mankind

More than 5 million people in US suffer from chronic inflammatory diseases. RA alone accounts for about 1% of the US population
Ronenn Roubenoff, Catabolic effects of high-dose corticosteroids persist despite therapeutic benefit in rheumatoid arthritis; Am J Clin Nutr 1990;52: 1 1 13-7.

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RA Conventional Approach
NSAIDs Steroids DMARDs Biologicals Optional

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Physio Bracing/splinting
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Problems of this approach

Side effects: NSAIDs Steroids: Osteoporosis, Hypertension, Drug induced DM, Cushinoid features, Gastric ulcers, Bleeding, Cataract, Muscle wasting- CS producing decreased LBM* a significant number of RA patients were unwilling to consider treatment with oral corticosteroid. E. Morrison, Attitude of rheumatoid arthritis patients to
treatment with oral corticosteroids; Rheumatology 2003;42: 12471250

DMARDs; Liver problems Biologicals: Increased infections, ?Lymphoma, Demyelinating Ds, Skin Cancers & possible other side effects that may reveal as they are used more frequently *Ronenn Roubenoff, Catabolic effects of high-dose corticosteroids persist despite therapeutic benefit in rheumatoid
arthritis13; Am J Clin Nutr 1990;52: 1 1 13-7.

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Biological agents Side Effects

Patients may cease therapy with anti-tumour necrosis factor (TNF) agents due to inefficacy at 12 weeks (termed primary non-response) or later. patients treated in clinical practice with infliximab demonstrated that secondary non-response occurred in around half the patients in the first year. The data highlight the need to continue development of other therapies as well as investigation of the underlying causes of this loss of response.
M. H. Buch, Long-term infliximab treatment in rheumatoid arthritis: subsequent outcome of initial responders: Rheumatology 2007 46(7):1153-1156
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Biologics have increased skin cancers?

patients receiving such therapy had a significantly elevated OR (1.5) for nonmelanotic skin cancer. Biologic therapy also was of borderline significance in promoting melanoma, and infliximab and etanercept individually were associated with higher rates of melanoma.
Frederick Wolfe and Kaleb Michaud, Biologic Treatment of Rheumatoid Arthritis and the Risk of Malignancy; ARTHRITIS & RHEUMATISM Vol. 56, No. 9,

September 2007, pp 28862895

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RA Integrative approach
Diet to reduce inflammation CAM DMARD? Taiwan herb, Plectranthus amboinicus can be used as DMARD: Jia-Ming Chang, Potential Use of Plectranthus amboinicus in the Treatment of
Rheumatoid Arthritis; eCAM 2007

Boswellia ( Boswellia serratia) Aswagandha ( Withania somnifera)* Curcumin Bromelain

*Divya Singh et al, Withania somnifera inhibits NF- B and AP-1 transcription factors in human peripheral blood and synovial fluid mononuclear cells; Phytotherapy Research; 21(10):905-913 *Lakshmi-Chandra Mishra, Scientific Basis for the Therapeutic Use of Withania somnifera (Ashwagandha): A Review; Alternative Medicine Review,2000:5 (4) 8/12/2011 Rehab Dubai 2008 22

RA Useful Herbal Medicines

GLA Feverfew (Tanacetum parthenium) Flaxseed oil Tripterygium wilfodii Capsaicin Ganoderma ( Ganoderma lucidum)**
K. L. Soeken, S. A. Miller and E. Ernst, Herbal medicines for the treatment of rheumatoid arthritis: a systematic review; Rheumatology 2003;42:652659 Ernst E, Chrubasik S. Phyto-anti-inflammatories: a systematic review of randomized, placebo-controlled, doubleblind trials. Rheumatic Diseases Clinics of North America, 2000; 26(1): 13-27 **Edmund K. Li,Safety and efficacy of Ganoderma lucidum (lingzhi) and San Miao San supplementation in patients with rheumatoid arthritis: A double-blind, randomized, placebo-controlled pilot trial, Arthritis Care & Research,2007: 57 (7), 1143-1150.

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RA Useful Ayurvedic Medicines

Ayurvedic Medicines single or in polyherbal Combinations are effective in RA Combinations using Aswagandha, Salai Guggul, Turmeric and Jasad Bhasma proven to be effective* Indian Ayurvedic herbal formulation Triphala has promising antiinflammatory activity compared with Indomethacin.**
*RR. KULKARNI, EFFICACY OF AN AYURVEDIC FORMULATION IN RHEUMATOID ARTHRITIS:A
DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSS-OVER STUDY; Indian Journal of Pharmacology 1992; 24: 98-101. **M. Rasool *, E. P. Sabina, Antiinflammatory effect of the Indian Ayurvedic herbal formulation

Triphala on adjuvant-induced arthritis in mice; Phytotherapy Research, Volume 21, Issue 9 , Pages 889 8/12/2011 894 Rehab Dubai 2008 24

Osteoarthritis
Standard advises given NSAIDS Intraarticular Injn TKA Supplementary Advises
Exercises Braces ES
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Integrative approach
Diet to reduce inflammation Herbs which has a role in reducing pain and inflammation Minimize NSAIDs and chemicals: Use only if needed, instead use physio modalities Identify imbalances in the system & try to correct it through diet, lifestyle and various modalities
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OA Alternatives
Glucosamine sulphate alone or combination with chondroitin and MSM Green lipped mussel extract" SAMe: as effective as NSAIDs in pain* Magnetic Bracelets?**
Comparison of glucosamine sulfate and a polyherbal supplement for the relief of osteoarthritis of

the knee: a randomized controlled trial; BMC Complementary and Alternative Medicine 2007, 7:34 "S. Brien et al, Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis; QJM 2008 101(3):167-179 *Wadie I Najm et al, S-Adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: A double-blind cross-over trial; BMC Musculoskeletal Disorders 2004, 5:6 **Tim Harlow, Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee; BMJ VOLUME 329 18-25 DECEMBER 2004 8/12/2011 Rehab Dubai 2008 27

OA Herbs
Articulin F: Ayurvedic compound Avocado Soyabean Unsaponifiables Capsaicin Devils Claw ( Harpagophytum procumbens) Ginger Willow bark Homeopathic preparation: Zeel Comp:*
L. Long et al, Herbal medicines for treatment of Osteoarthritis: A systemic Review; Rheumatology 2001;40:779-793 *Heinz Birnesser, THE HOMEOPATHIC ANTIARTHITIC PREPARATION ZEEL COMP. N: A REVIEW OF MOLECULAR AND CLINICAL DATA, Explore 2007; 3:16-22.

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Back Pain Integrated Mngmt

Ayurveda & Yoga Acupuncture Chiropractice Herbal/ Homeopathic Medicines for pain Physiotherapy Posture Correction Correcting muscle imbalance & core strengthening
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Acupuncture/ acupressure Back Pain

Acupuncture effective in persistent non specific back pain Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain.* Acupressure was effective in reducing low back pain in terms of disability, pain scores, and functional status. The benefit was sustained for six months.**
J Thomas et al, Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain; BMJ 2006;333;623 ** Lisa Li-Chen Hsieh et al, Treatment of low back pain by acupressure and physical therapy: randomised controlled trial; BMJ 2006;332;696-700
*K

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Fibromyalgia
Integrative approach more beneficial than single Mind body interactions more important Mud Bath effective* Some herbal and nutritional supplements (magnesium, S- adenosylmethionine) and massage therapy have the best evidence for effectiveness with FM.**

*Fioravanti et al, Effects of mud-bath treatment on fibromyalgia patients: a randomized clinical trial;Rheumatology International, 27 (12) October 2007pp. 1157-1161(5) **Sarac AJ, Gur A, Complementary and alternative medical therapies in fibromyalgia,Curr Pharm Des. 2006;12(1):47-57.

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Integrative Stroke Rehabilitation

Primary prevention: Preventive aspect of Diet in reducing inflammation Even in acute rehabilitative setting the use of Marma therapy along with standard western Rehabilitation approaches would be having greater efficacy than single approach *
*Mary Fox, Marma Therapy For Stroke Rehabilitation, A pilot study;
271 J Rehabil Med 2006; 38: 268-

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TCM in Stroke
Pharmacological studies show that TCM herbs are beneficial in stroke Acts by
dilating the cardiocerebral vessels, suppressing the aggregation of platelets, improving circulation, removing blood stasis, protecting against ischemic reperfusion injury enhancing the tolerance of ischemic tissue to hypoxia.
Bo Wu et al, Meta-Analysis of Traditional Chinese Patent Medicine for Ischemic Stroke; Stroke. 2007;38:1973-1979

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Ozone Stroke
Ozone treatment is a non conventional therapy used for Cancer, ischaemic limbs. Studies were done on effect of IV Ozone in MCA & CCA: using colour doppler to quantify the increase in vascular flow. Study found out a statistically significant increase in cerebral blood flow both in CCA & MCA. Its rheological and vascular effects ( liberation of vasoactive substances) suggest that it can be used as coadjuvant to decrease the vasoconstriction.
Bernardino Clavo, Ozone Therapy on Cerebral Blood Flow: A Preliminary Report; eCAM 2004;1(3)315319

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Conclusion
Incorporating alternative therapies into physiatric practice is a desirable future direction for the specialty* Musculoskeletal pain syndromes involving the spine and extremities were the most common problems for which patients sought both physiatric and alternative care. Of the patients who used alternative treatments 53% reported some degree of efficacy. Stanley F. Wainapel, MD et al, Use of alternative therapies by
rehabilitation outpatients; Archives of Physical Medicine and Rehabilitation 1998; 79(8) 1003- 1005
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Thank You