Integrating Complementary and Alternative Medicine into a Chiropractic Practice

1. Integrating Complementary and Alternative Medicine into a Chiropractic Practice Geoff Lecovin, D.C., N.D., L.Ac., CSCS

2. Education/Training • BS Human Biology (1989 LACC) • DC (1990 LACC) • MS Nutrition (1992 University of Bridgeport) • MS Acupuncture (1994 Bastyr University) • ND (1994 Bastyr University) • CSCS (2006 NSCA) • CES/PES (2007 NASM)

3. What is CAM? Complementary and Alternative therapies that have been shown to be safe and effective. (NIH) e.g. naturopathic medicine, acupuncture, manipulation, guided imagery, supplementation

4. Naturopathic Medicine

5. Naturopathic Medicine • Four-year graduate level naturopathic medical school • Holistic and nontoxic approaches emphasizing prevention and wellness • Professional board exams to be licensed as a primary care general practice physician

6. Philosophy of Naturopathic Medicine • Do no harm • Find the cause • Treat the whole person • The healing power of nature • Prevention

7. Scope of Practice (WA) • Nutrition and food science • Supplements • Physical modalities/manual therapy • Minor office procedures • Homeopathy • Botanical medicines/nutritional supplements • Hygiene and immunization • Contraceptive devices • Common diagnostic procedures • Counseling and hypnosis • Intramuscular and intravenous therapies • Prescription drugs (all legend/limited controlled substances) • Diagnostic procedures (e.g. lab, imaging, etc.)

8. Naturopathic Patient Demographics • Pain/sports injuries/auto & work injuries • Family practice • Obesity • Cardiovascular disease/hypertension/diabetes • Wellness • NHRT, depression, ADD/ADHD, women’s/men’s health, pediatrics, oncology, fertility

9. Naturopathic physicians are currently licensed in these states: • Alaska • Arizona • California • Connecticut • District of Columbia • Hawaii • Kansas • Maine • Montana • New Hampshire • Oregon • Utah • Vermont • Washington • US Territories: Puerto Rico and Virgin Islands

11. Acupuncture

13. Acupuncture • Traditional Chinese Medicine (TCM) • Neuro-anatomic acupuncture (“dry needling”)

14. TCM • The practice of acupuncture dates back nearly 5000 years, where it began in China and other Asian countries. • Over the course of its development, ancient practitioners developed concepts and systems reflecting the religious, medical and cultural beliefs of their time.

15. Neuro-Anatomic Explanations for Acupuncture Lesions created by inserting sterile needles in the soft tissue activate the body’s main systems: • Nervous • Cardiovascular • Endocrine • Immune This promotes homeostasis and stimulates healing. (Yun-tao Ma, Mila Ma, Zang  Hee Cho, Biomedical Acupuncture)

17. Effects of Dry Needling • Strengthen tendons & ligaments by inducing local inflammatory reactions • Stimulates GTO & muscle spindles inducing muscle relaxation • Mechanically disrupts trigger points • Treats overactive motor points • Provides blood & growth factors, which can increase circulation, disrupt micro-scars and repair tissue • Alters neural control via neurotransmitters • Stimulates neural reflex mechanisms

22. Chiropractic, Manual Therapies and Exercise

23. Beyond chiropractic help

24. Kinetic Chain

26. Muscle Imbalance/Joint dysfunction(upper & lower crossed syndromes) • Altered reciprocal inhibition • Synergistic dominance • Myofascial dysfunction • Arthrokinetic dysfunction

27. Manual Therapy • Spinal and extremity manipulation • Mulligan techniques • Soft tissue manipulation -NMR -Soft tissue release -Gua Sha -Active isolated stretching • Modalities • Exercise

28. Corrective Exercise Protocol(NASM) • Inhibit- self myofascial release with foam rollers • Lengthen- stretching • Activate- isolated intramuscular strengthening • Integrate- full body intermuscular movements

29. NASM Exercise Model

30. Case Study:An Integrative Approach

31. Triad of Health Psychological Biochemical Structural

32. History • 28 y/o female Caucasian presents with headaches 3-5x/wk that started during high school and have progressively worsened. They are 3-6/10 (10 being worst). Massage, chiropractic and heat are temporarily palliative. Stress and working on the computer are provocative. History of minor rear-end collision in high school. Symptoms worsen during menses. Other complaints include low energy and difficulty losing weight.

33. Review of Systems • General – NAD, A&O x 3, overweight • EENT, cardiovascular, respiratory, gastrointestinal, genitourinary and neurological are unremarkable • Musculoskeletal - neck pain & headaches • Skin - eczema • Psychiatric - high stress job • Endocrine - heavy menses • Hematologic - history of anemia • Allergy/immunologic - seasonal allergies

34. PMhx/Family hx/Social hx • PMhx - unremarkable • Family hx - mother has hypothyroidism • Social hx - single; non-smoker; light drinker • Occupation - Microsoft software engineer • Sleep – poor (5-6 hrs interrupted) • Exercise – occasional yoga • Diet - high refined carbohydrate/fast foods; often skips breakfast and/or lunch

35. Examination/Diagnostic Testing • Vitals (Ht 5’4”; Wt 137 lb; BP 90/68; P 77 • Eyes - 20/20 vision • Head and neck - normocephaly. No thyromegaly. • ENT - tender frontal and maxillary sinuses • Cardio/Pulm/Abdomen - unremarkable • Skin - dry • Cervical X-ray – loss of cervical lordosis • Blood work - TSH 5.3; D3 22; Ferritin 20 - CBC and Chem within normal limits

36. Assessment • Chronic tension headaches • Hypothyroid • Overweight • Iron deficiency • Vitamin D deficiency • Insomnia

37. Naturopathic Treatment • Dietary modification • Supplement prescription • Armour thyroid • Systematic relaxation/guided imagery/breathing home exercises

38. A Balanced Approach to Diet Focus on fueling the body with nutrient dense, anti-inflammatory foods that satisfy energy requirements Optimize nutrients Shift balance of omega-3:omega-6 fats Change carbohydrate sources to fruits and vegetables (low glycemic load) Incorporate lean protein sources with every meal and snack Increase phytonutrients and water (In other cases, it might be indicated to identify potential food sensitivities through food elimination/challenge)

39. Starch Non-starchy veggies Protein Healthy Plate • Corn • Peas • Potatoes • Pumpkin • Squash • Sweet potatoes • Yams • (Brown/wild rice, oats, Quinoa) • Broccoli • Cabbage • Carrots • Cauliflower • Dark green leafy veggies (e.g. Spinach, kale, chard, Brussels sprouts etc.) • Green beans • Peppers • Tomatoes • Beans & lentils • Beef (grass fed) • Poultry (w/o skin) • Dairy (Yogurt) • Eggs • Fish • Nuts & nut butters • + healthy fats, including: • Avocado • Nuts and seeds • Olive & Canola oil

40. The Power of Color RED(anthocyanins, lycopenes) - strawberries, cranberries, raspberries, cherries, grapes, beets, peppers, water melon, pomegranates, apples, onions, pink grapefruit ORANGE-YELLOW(beta carotene, lutein, zeaxanthin) - carrots, sweet potatoes, yellow potatoes, orange, mangoes, cantaloupe, pumpkin, squash, apricots, corn, banana, turmeric, ginger GREEN(beta carotene, lutein)- spinach, chard, kale, avocado, asparagus, artichokes, broccoli. Brussels sprouts, cabbage, green tea BLUE-PURPLE (anthocyanins)- blueberries, blackberries, grapes, red wine, eggplant WHITE- garlic, onion, cauliflower BLACK/BROWN- Coffee, dark chocolate, nuts, stout beer The Color Code. James A. Joseph, Ph.D., Daniel A. Nadeau, M.D., Anne Underwood

41. Supplements (Thorne)/Prescriptions • Multiple with iron • Iron - 20 mg qd • Vitamin D - 2000 IU qd • Fish oil (Nordic Naturals) - 1000 mg tid • L-Tryptophan - 1000 mg at bed time • Armour Thyroid (Rx) - 60 mg away from iron and multiple • TSH to be re-tested after 1 month • Ferritin and D3 to be re-tested after 12 weeks

42. Acupuncture Treatment 1. Symptomatic points - local trigger points 2. Paravertebral points - cervical and thoracic 3. Homeostatic points – facial, upper extremity and shoulder region

43. Chiropractic Treatment • Soft tissue release/NMR to address shortened muscles (upper crossed syndrome) • Spinal manipulation to cervical/thoracic/lumbar areas of segmental dysfunction • Headache SNAGS (Mulligan) • Home corrective exercises

44. Home Corrective Exercises • Self-myofascial release with tennis balls and foam rollers • Static stretches • Isolated strengthening - scaption, deep neck flexors • Integrated movements - squat to row

45. Outcome • Patient was seen two times per week for one month • Headache frequency was reduced to once per week • Sleep, energy and feeling of wellbeing were improved • Skin hydration improved • TSH after one month decreased to 2.1 (thyroid Rx was refilled for 6 additional months) • Frequency of visits reduced to once qo wk for four more visits, at which time headaches were minimal • Exercise progressed from corrective to strength training 2x/wk, + yoga 1-2 x/wk • At 12 weeks, headaches were infrequent. Vitamin D level was 52 and Ferritin level was 68 • Next follow-up was scheduled for 3 months

46. Recommended Resources • Certifications: NASM - CES and PES • Seminars: • NMR training with Peter Levy, DC • Mulligan technique • Hands on Seminars – trigger point therapy • Gaby/Wright – medical nutrition • Stuart Taws – soft tissue release • Stuart McGill, PhD (books and seminars) • Books: • Natural Hormonal Enhancement – Rob Faigin • Good Calorie, Bad Calorie – Gary Taubs • The Gunn Approach to Pain – Chan Gunn • Acupuncture, Trigger Points and Musculoskeletal Pain – Peter Baldry • Trigger point manuals, Travell and Simons • Biomedical Acupuncture, Yun-tao Ma, Mila Ma, Zang  Hee Cho • New Rules of Lifting, Schuler and Cosgrove • Internet: www.vitasearch.com, www.nutraingredients.com

47. Dr. Geoff Lecovin Evergreen Integrative Medicine www.eimed.com geofflecovin@hotmail.com