FunctionalMedicineAOMA2018 (003).pptx [Read-Only]...Musculoskeletal: Rolled shoulders and poor...

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Learning Objectives1. Describe the Functional Medicine strategies to resolve common chronic diseases through the use

of an applied systems biology approach and how this approach mirrors the Osteopathic philosophy

2. Define and contrast the terms: Naturopathic, Holistic, Integrative and Functional Medicine

3. Appreciate the historical context for the current conventional medical model and describe the emerging paradigm shift in medicine

4. Understand the inflammatory markers that are related to health outcomes and the diseases that are associated with inflammation as the root cause

5. Define the top modifiable triggers that are underlying contributors to inflammation and chronic disease

Perspective…….

50% of all adults have at least one chronic health condition1

25% of adults have two or more chronic health conditions 2

Chronic diseases account for 86% of all healthcare costs($3.2 Trillion in 2015 & growing) 3,4

WHAT are some solutions?

◦ Can we liberate patients from their dependency on costly medications?

◦ Can we adapt a system to address the dual problem of healthcare inflation & chronic dependency on the healthcare system?

Sources 1. Ward et al. Prev Chronic Dis. 2014:11:130389 2. Wang et al. Lancet. 2016;388(10053):1459‐544. 3. Gerteis et al. Agency for Healthcare Research and Quality; 2014. 4. Centers for Medicare & Medicaid Services. NHE Fact Sheet.

Paradigm ShiftFlexner Report of 1910

◦ Changed the future of medical education and research

◦ Biomedical Model forced out other modalities(Osteopathy included)

20th Century to Present: Advances in Emergency Medicine, Trauma Care, Infectious disease and Surgery in US & Worldwide

Acute Care Model fails to address chronic disease epidemic of 21st Century

◦ Team of Doctors(Specialists)

◦ No one asking how everything is connected

◦ Genetics vs Epigenetics, Bad luck vs complex individuals

◦ “ Pill(s) for each ill”

◦ Are we asking the right Questions?

21st Century: Demand for CAM grows

Holistic Medicine◦ Balance Mind/Body/Spirit connection

◦ Description of practitioner’s style

Naturopathic Medicine◦ Broad spectrum of practice incorporating multiple modalities of natural interventions

◦ Licensing board in 20 states currently (AZ)

◦ Standards of practice/continuing education varies

Integrative Medicine ◦ Model integrating Conventional with Non‐Conventional therapies/alternative modalities(such as herbs, homeopathy, chiropractic, acupuncture, etc..)

◦ Dr. Andrew Weil: “Integrative medicine is a healing‐oriented medicine that takes account of the whole person (body, mind & spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”

◦ Approach emphasizes characterizing disorders BUT larger toolbox

Functional Medicine◦ Personalized/Integrative approach that takes from all the models above

◦ Practitioners are trained to use conventional medical model for appropriate acute medical illnesses

◦ Systems biology approach to complex chronic conditions

◦ Essential component of model is determining ROOT CAUSE

Definitions

How is Functional Medicine Different?

FUNCTIONAL MEDICINE

Health Oriented

Patient Centered

Biochemical Individuality

Most effective in dealing with Chronic Disease

Holistic

Cost Effective Long Term

Seeks Root Cause of Disease

Primary Prevention of Disease

CONVENTIONAL MEDICINE

Disease Oriented

Doctor Centered

Minimal Focus on Individuality‐Algorithmic

Most effective in dealing with Acute Disease

Specialized

Expensive Long Term

Diagnosis Based on Symptoms

Early Detection of Disease

©2014 The Institute for Functional Medicine


Road Map to Navigate

in

Functional Medicine

FUNCTIONAL MEDICINE • Addresses the underlying causes of disease,

using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership

• Founded IFM in 1991 by Jeffrey Bland, PhD• Currently >1800 IFM Trained practitioners in

40 Countries• Cleveland Clinic opens Functional Medicine

Clinic in 2014• Outcomes data starting to be released from

Cleveland Clinic 2017• IFM partnering with academic medical

centers & residency programs, VA

◦Reductionistic analysis prevents study of multi‐interventional approaches

◦Whole person outcomes in research is harder to conduct vs a single outcome study

◦Opposite of reductionism = Holism

◦ Clinical practice must piece together research into discrete interventions (fiber, folate, phytonutrients, redox status, vitamin D)

◦ Patient factors such as experience & motivation confound the outcomes

◦ Inherent limitations in translation of research into clinical protocols

◦Research needed into systems approaches for chronic diseases

Research into Systems Biology

Research into Systems Biology

https://p.widencdn.net/rtp7hp/IFM_PLMI_OneSheetl_v7


Functional Medicine: A Clinical Application of Systems Biology

• Networks of Function and Causality

• Core Biologic Systems in Health and Disease

• New Architecture of Thinking and Evaluation

• Two Key Questions to Identify Imbalances

• Environment and Genes Influence Core Physiological Systems

• The Decline of ICD‐10 and Emerging Clinical Models of Systems Medicine


Differential Differential Diagnosis

ICD‐10

7 Biological 7 Biological Systems

PhenomenologyPhenomenologySymptoms

Medication/Surgery

Pathology

Causes/Etiology

Promote BalanceRid‐Get

Imbalances in Function

Imbalances in Function


Is depression a Prozac deficiency?

“Tacks Rule of Medicine”

“If you are standing on a tack, it will take a lot of aspirin to diminish the pain. The treatment for standing on a tack is to remove the tack from your foot. Furthermore, if you are standing on two tacks, taking one out does not make you 50% better. There are often multiple causes to a health problem and all of them need to be addressed before you will get better. “

Sidney Baker, MD



The Biological Systems:

FORM Follows

FUNCTION


The Physiologic Systems:Core Clinical Imbalances

• Assimilation (Digestive, absorptive, and microbiological imbalances)

• Defense & Repair (Immune and inflammatory imbalances)

• Energy (Oxidation-reduction imbalances and mitochondropathy)

• Biotransformation and Elimination (Detoxification)

• Communication & Circulation (Hormonal and neurotransmitter imbalances)

• Transportation (Cardiovascular, Lymphatic System)

• Structural Integrity (imbalances from cellular membrane function to the musculoskeletal system)


The Two Questions


Two Simple Questions:Causes and Function

• Does this person need to be rid of something (toxic, allergic, infectious, poor diet, stress)?

• Does this person have some unmet individual need required for optimal function?


Primary (Proximal) Causes of Disease


Primary Causes of DiseaseWhat do You Need to Get Rid of?

• Toxins (biologic, elemental, synthetic)• Allergens (food, mold, dust, animal

products, pollens, chemicals)• Microbes (bacteria, ticks, yeast, parasites,

viruses)• Stress (physical, psychological)• Poor diet (BAD)


“Ingredients”for Optimal Function


What do You Needto Get to Thrive?

• Foods (protein, fats, carbohydrates, fiber)

• Vitamins, minerals, accessory or conditionally essential nutrients, hormones

• Light, water, air

• Movement

• Rhythm

• Love, community, connection

• Meaning, purpose


Clinical Imbalances

The Map!


The Map: The Journey

• Functional medicine is NOT a test or treatment or supplement

• It is a NEW WAY OF THINKING

• Focus on the map – the Matrix

• Focus on patterns and connections

• Focus on finding the causes that lead to the clinical imbalances

• Focus on learning how to create balance


Case

19yo Caucasian female c/o fatigue and rash. Requests help managing her recent diagnosis of Prurigo Nodularis. Diagnosed one year after starting on BCP. Currently managed with topical steroids with no resolution of symptoms. BCP stopped by gynecologist with no resolution of symptoms . Diagnosed with IBS 6 years ago. GI evaluation including labwork showed mild elevation in tissue transglutaminase antibodies. Endoscopy & colonoscopy showed mild non‐specific colitis in transverse colon & duodenal non‐specific flattening of villi. Given diagnosis of Possible Celiac Disease (inconclusive) and advised to do a trial of gluten free diet. Completed one year gluten free but resumed eating since then. No further f/u with GI. She developed tremors and anxiety around time of IBS diagnosis. Seen by Psychiatry, started on SSRI for last 5 years.

ROS‐Fatigue, Insomnia(falling & staying asleep), Abdominal pain, Bloating, Cramping, Diarrhea, Acne, Dry skin, Weak nails , Anxiety, Tremors, Irritability, Headaches, Chronic Wheezing, Nasal Congestion ,Cough(uses inhaler), Back/Hip pain, Joint stiffness, Muscle Cramps

MSQ=80

CasePMHx‐Asthma, Eczema(as a child), Prurigo Nodularis, Possible Celiac Disease, Born Full‐term/Vaginal‐no complications, Breast fed x 5 months

Menstrual Hx‐Started 16yo, Heavy/Cramps‐resolved w/ use OCP

Surgical Hx‐None

Allergies‐NKDA

Meds‐ Venlafaxine ER 150mg QD, ProAir HFA PRN, Gildess Fe, Topical steroid cream BID

Exercise‐1‐2 x/week. Horse Back Riding, occasionally to gym

Diet‐Dislikes “healthy” food. Craves sugar & carbs. Misses meals. Late night eating. No restrictions @ this time

Tobacco/Alcohol‐Never smoked. No alcohol or drugs

Social Hx‐ Full time art student. Lives w/ parents. Strong family support. Bullied elementary school due to small size. Moved to AZ in Junior High. Parents divorced. Recent devastating breakup w/ boyfriend ”first love”. “Too tired to socialize” Not working due to fatigue. Has emotional support dog w/ her at all times. Draws, rides horses, video games for relaxation. Meditation/deep breathing once/week for stress. No religious practice.

CaseFamHx‐Mother‐ Allergies, “OCD”, Father‐Allergies/Asthma/Panic Disorder, Sister‐Allergies/OCD, Sister‐Bipolar Disorder, Mat GM‐Bipolar Disorder, Pat GM‐Colon Cancer, Lupus, Thyroid, Arthritis, Pat GF‐Prostate Cancer, Allergies, ? Psych d/o, Pat Cousin‐Ulcerative Colitis

Physical Exam:

Height: 64" Weight: 96.1 BMI: 16.5 BP: 98/70 HR: 88/Regular

General: Thin white female in no acute distress, accompanied by mother and emotional support dog

Eyes/ENT: Normal, no amalgams

Thyroid/Neck: Normal

CV/Resp: Normal

GI: Normal

Lymph: Shotty, non‐tender anterior cervical lymph nodes noted

Musculoskeletal: Rolled shoulders and poor posture noted, normal gait, no joint effusions/swelling

Skin: Excoriations over bilateral arms/hands and bilateral hips/upper legs with concentrated clusters of excoriated papules, nodular scarring noted, skin dry, thin nails with vertical ridging

Neuro: Sensation intact extremities, Brisk reflexes noted upper and lower extremities

Psych: Patient is alert and oriented, appears anxious, Patient defers to mother for answers frequently, poor eye contact but does have appropriate affect and thought process

CBC Normal

CMP Normal

ESR‐2

GGT‐11

TSH 1.11, Free T4 1.2, Free T3 3.5, T3 Reverse 14

ANA reflex cascade negative

Vitamin B12 level‐749, Folate‐12.5

Vitamin D3‐25‐OH level‐ 30(low normal)

RBC Zinc‐9.4(low normal), RBC Magnesium‐4.8(low normal)

hsCRP‐0.2

HgA1C 5.0, insulin 9

Total Cholesterol 115, TG 46, HDL 43(low), LDL 66, ApoA1‐117(low), %sdLDL 24%(high), LDL‐P 871

Omega 3 FA Index 2.51%(low)

COQ10 level‐ 0.6(low)

Homocysteine‐6.7

MTHFR 677‐Hetero, 1298‐no variant

DGPIgA 40(high), AGA IgG‐30(high), Total IgA‐154, rest of Celiac panel normal

Food testing showed Multiple 3+ IgG Food reactions(wheat, oat, corn), IgE reaction to all grains and multiple nuts, Total IgE335(high)

Environmental testing showed Multiple significant Tree, Grass, Weed, Cat/Dog and Inhalant mold reactions

Lab Findings

Intervention1‐Gluten Free Diet. Counseled on how to increase phytonutrient rich foods and avoid processed foods. Resources provided‐books, websites.

2‐Dietician evaluation

3‐Probiotic Blend 20 billion daily to start and then transitioned to 100 billion unit multi‐strain/day

4‐Digestive Enzyme with HCL one with each meal

5‐COQ10 300mg/day

6‐B12/Folate/B2/B6 methylated form blend 1mg B12/folate each/day

7‐Vitamin D3 5,000units/day

8‐Magnesium 150mg/Valerian root/Hops/Lemon Balm Blend‐one each night

9‐Omega 3 Fish Oil 2grams/day DHA/EPA

10‐Glutamine/DGL/Zinc powder blend 1 scoop daily, up to 3 scoops daily 3gram glutamine each scoop

11‐Counseling Encouraged

Follow Up6 week f/u‐Reports no new lesions. Tremors continue. Notes more energy “some days”& Has several mornings that feels rested. Has gotten job as receptionist at massage therapist office and in training. Admits that has still gotten a little gluten when "didn't have any other choices" but now really notices a reaction. Bowel movements are less difficult and denies pain in abdomen. Wants to try to wean off SSRI soon. Taking most supplements every day except missing the powder.

Plan: Praise for commitment, continue current supplements, more consistent use of Glutamine blend powder, encouraged counseling appt. Added on IgG Colostrum, Omega 3, and 8,000IU Retinyl Palmitate/Beta‐carotene(Vitamin A )

9week f/u‐Skin completely healed. Off SSRI. No Anxiety. Reports “energy never this good”, Not used inhaler in months. Finding new recipes. Figuring out how to eat out and eat socially.


Preconception

Current Concerns

Antecedents

Triggers or Triggering Events

Signs, Symptoms or Diseases Reported

Prenatal

Birth

FUNCTIONAL MEDICINE TIMELINE

Mediators/Perpetuators

Name: ______________________________ Date: __________________ CC: @2014 Institute for Functional Medicine


Biotransformation & Elimination(e.g., Toxicity, Detoxification)

Energy (e.g., Energy Regulation, Mitochondrial Function)

Communication (e.g., Endocrine, Neurotransmitters,

Immune messengers)

Defense & Repair(e.g., Immune, Inflammation,

Infection/Microbiota)

Structural Integrity(e.g., from Subcellular Membranes to

Musculoskeletal Structure)

Assimilation(e.g., Digestion, Absorption, Microbiota/GI, Respiration)

Antecedents(Predisposing Factors‐Genetic/Environmental)

Triggering Events(Activators)

The Patient’s Story Retold

Modifiable Lifestyle Factors

Nutrition & Hydration

Physiology and Function: Organizing the Patient’s Clinical Imbalances

Mediators/Perpetuators (Contributors)

Spiritual

e.g.,meaning & purpose, relationship with something

greater

e.g., cognitive function,perceptual patterns

e.g., emotional regulation, grief,

sadness, anger, etc.

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine

Stress & Resilience Relationships & Networks

Transport(e.g., Cardiovascular, Lymphatic System)






Immune messengers)













Spiritual


greater




Sleep & Relaxation










Immune messengers)













Spiritual


greater




Sleep & Relaxation


Relationships & NetworksStress & Resilience







Immune messengers)













Spiritual


greater




Sleep & Relaxation




Biotransformation & Elimination

(e.g., Toxicity, Detoxification)





Immune messengers)













Spiritual


greater




Sleep & Relaxation









Immune messengers)













Spiritual


greater




Sleep & Relaxation


Stress & Resilience


Relationships & Networks

Communication (e.g., Hormones,

Neurotransmitters, Immune messengers)





Immune messengers)













Spiritual


greater




Sleep & Relaxation




Structural Integrity(e.g., from Subcellular Membranes

to Musculoskeletal Structure)

SummaryPrimary Trigger‐Untreated Celiac Disease

Main Antecedent‐FamHx Autoimmune Disease

Emotional Stress‐Divorce, Peer relationships triggered GI symptoms w/ ongoing gluten exposure, OCP use tipped her system toward imbalance

Leading to:

Intestinal Permeability, Malabsorption, Neurotransmitter Dysregulation & Immune Dysfunction

Bio‐Markers for Inflammation/Chronic Diseasehs‐CRP

Homocysteine

Vitamin D‐25‐oh level

Omega 3 Index, AA/EPA Ratio

ApoB, sdLDL, LDL‐P

Modifiable Triggers to Chronic DiseaseDiet◦ Phytonutrients

◦ Omega 3/6 content

◦ Elimination Diet

Gut Health(Microbiome)◦ Normal Flora/Pathogens

Stress/ANS Balance◦ Parasympathetics

◦ Mindfullness/Meditation/Breathing


Before You Begin, Remember:

• Always seek the cause FIRST – again and again

• Focus on 5: Learn how to diagnose and treat the 5 causes of illness• Become an expert in toxins, allergens,

infections, nutrition, and stress

• Ingredients for optimal function• Food, nutrients, hormones, environment

(air, light, water), movement, rhythm, love, meaning


The Right Order of Things

• Learn how to restore function IN THE RIGHT ORDER• Doing the right thing in the wrong order can

have adverse effects

• Navigate from the outer layers to inner layers of imbalance and dysfunction

• Seek to reset homeo-dynamic balance


But What is the Right Order?

1. Start with food: whole, real foods and lifestyle medicine first

2. Fix the gut – almost always

3. Remove food sensitivities

4. Optimize nutrient status

5. Balance hormones (thyroid, adrenal, sex)

6. Detoxification is the last step!

ResourcesInstitute of Functional Medicine Education/Certification Program

https://www.ifm.org/certification‐membership/certification‐program/

George Washington University Integrative Medicine Fellowship Program

https://smhs.gwu.edu/integrative‐medicine/

University of Arizona Integrative Medicine Fellowship Program

https://integrativemedicine.arizona.edu/education/fellowship/

Thank you!

Questions or Comments

FunctionalMedicineAOMA2018 (003).pptx [Read-Only]...Musculoskeletal: Rolled shoulders and poor...

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