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10 Articles in Volume 16, Issue #9
Health and Economic Benefits of Exercise Programs for Seniors
Role of Physical Activity in Managing Chronic Pain in Older Adults
Levorphanol: An Optimal Choice for Opioid Rotation
Incorporating Functional Medicine Into Chronic Pain Care
Expanded Use of EMG-NCV Helps Guide Treatment of Lower Extremity Neuromuscular Disorders
Application of Acupuncture to Treat Low Back Pain
People With Sickle Cell Trait at Greater Risk of Rhabdomyolysis
A Case of Statin Therapy in a Patient With Rhabdomyolysis
Overview of Exertional Rhabdomyolysis
Benzodiazepines and Opioids: Only Trained Pain Practitioners Should Prescribe

Incorporating Functional Medicine Into Chronic Pain Care

A 4-session functional medicine program can help patients take ownership of their health by teaching them about proper diet, sleep hygiene, exercise, and stress management.

According to the Centers for Disease Control and Prevention (CDC), chronic diseases and conditions, such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis, are among the most common, costly, and preventable of all health problems.1 More concerning, the incidence of chronic pain is greater than that of heart disease, diabetes, and cancer combined.

In the US, 86% of all health care spending in 2010 was directed at people with 1 or more chronic diseases.1 Alarming projections suggest future generations may have shorter, less healthy lives,2 and health care costs are estimated to rise to $4.153 trillion—the equivalent of 4 Iraq wars in a single year, if current trends continue.3 Specific behaviors, including being sedentary, poor nutrition, tobacco use, and excess alcohol consumption, lead to much of the illness, suffering, and early death related to chronic diseases and conditions.1

According to the American College of Preventive Medicine, most chronic diseases are preventable and reversible if a comprehensive, individualized approach that addresses genetics, diet, stress, physical activity, and sleep is implemented through integrated functional medicine teams and based on empirical research.4 In this way, health is perceived as more than the absence of illness, just as illness is more than the absence of health.

What Is Functional Medicine?

Functional medicine (FM) addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership.5 In effect, the focus is better understood as the medicine of why, not what. By changing the disease-centered focus of medical practice to a patient-centered approach, the practitioner is able to support the healing process by viewing health and illness as part of a cycle—all components of the human biological system interact dynamically with the environment. FM also takes as its focus 1 relationship: the sacred trust between the physician and the person who chooses to be that provider’s patient. FM is further guided by 6 core principles5:

  • Understanding the biochemical individuality of each person, based on the concepts of genetics and environmental influence
  • Emphasis on a patient-centered rather than a disease-centered approach to treatment
  • Searching for a dynamic balance among the internal and external experiences
  • Familiarity with the complex connections of internal physiological factors
  • Identification of health as a positive vitality, not merely the absence of disease

Promotion of organ preservation as the means to enhance the health span, not just the lifespan of each patient. The role of FM practitioners is to spend time with their patients, listening to their histories and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex, chronic disease, such as chronic pain. Numerous experiences can contribute to the maintenance of chronic pain—diet, exercise, thoughts, feelings, and environmental toxins.

Science has lent support to what may be known intuitively—how we live, the quality of our relationships, the food we eat, and how we use our bodies, have a much larger impact than genetics ever will. In other words, FM treats chronic pain by addressing these poor habits. This is also a fundamental principle of sustainable health. Implemented correctly, FM can help practitioners to prevent, treat, and often cure chronic conditions more effectively and at lower cost than the conventional medical paradigm.6

The “i” in illness underlines how disease affects the body or mind of the individual, and the “w” in wellness directs us to work together to reach a state of being in good physical and mental health. Thus, the FM approach to the management of chronic pain is delivered in a group format with individual follow-up sessions as needed. The group treatment protocol consists of 4 sessions that are approximately 60 to 75 minutes each in duration. The interdisciplinary treatment team consists of an osteopath physician, a dietitian, and a health psychologist. Patients are coached to change their environment and live an anti-inflammatory lifestyle through 4 key pillars: 1) diet, 2) exercise, 3) stress management, and 4) sleep hygiene.

The Functional Medicine Clinic: How It Works

The FM clinic was established by relying on the aforementioned 6 core principles combined with a vital osteopathic principle. The osteopathic principle teaches that the body is capable of self-regulation, self-healing, and health maintenance.7 In order for the body to live up to this principle, it needs to be supplied with the necessary nutrients through a healthy diet, adequate sleep, movement/exercise, and management of stress.

The FM clinic teaches patients that their body is engineered to give a level of health through their genetic cellular code. If our cells are provided with the optimum necessities to thrive, they will express their greatest health through the genetic code. However, each person harbors a different genetic code—thus, every patient must be treated individually to achieve optimal health. As noted, patients are instructed on common factors of health, such as an anti-inflammatory diet, sleep hygiene, increased physical movement, and coping skills.

The onus is placed on the patient’s self-care to process this information and to determine what specific healthy behaviors are best for their cells. This process is not easy for most; it takes determination, focus, and dedication. For example, each patient is placed on a modified elimination diet for 3 weeks. Each patient performs a small, but quite important, self-experiment to determine foods that may be contributing to his or her medical symptoms (food log). Each patient is asked to identify side effects, whether positive, negative, or different from others, allowing them to start painting their own self-portrait of health (health journal).

Session 1: Employing Pillar 1—An Elimination Diet

Keep in mind that every time a person eats, that changes body chemistry. Therefore, during the first session, the FM clinic guides patients to implement a modified elimination diet.8-13 Patients are taught about removing specific foods, such as those containing gluten or dairy, and are encouraged to adjust (increase) the intake of vegetables and fruits that encompass every color of the rainbow. Patients are advised to remove all added sugars. This process is often difficult for people; therefore, the FM team must work with patients to encourage their compliance with the elimination diet.

We are often asked what foods to eliminate. Specific foods are removed from the diet to uncover any potential causes of adverse food reactions. Some reactions can occur immediately after eating a food (ie, an allergy or intolerance) but in most cases signs of food sensitivity may be delayed by hours.

Use of an elimination diet necessitates that a patient remove the most common causes of food sensitivity (dairy, gluten, high saturated fats, highly processed foods) while monitoring clinical symptoms to see if there is an improvement in how he or she feels. In addition, patients are advised to consume healthy fats, protein, nuts and seeds, legumes, and beverages to support a more anti-inflammatory lifestyle. Whenever possible, we recommend that patients select meats that are organic, wild-caught, and grass-fed. Basically, patients are directed to eat only “real” food—meaning food options that are not processed.

Patients are advised to follow this diet for 3 weeks (detoxification period) and log any changes that occur within their body. Patients should have regular bowel function and urine flow. Patients are instructed to read and understand food labels, to ask questions of manufacturers and restaurants, and to ask their health care team about any food ingredients of concern. At the end of 3 weeks, patients are given the choice to go back to their former dietary lifestyle or continue with the outlined diet.

Session 2: Review Pillar 1 And Introduce Pillar 2—Physical Exercise

The focus of the second session is to review the patient’s progress on his or her detoxification process through the elimination diet. Patients are encouraged to raise questions about any foods that they should have more or less of, or avoid, add, or refrain from eating. This is done by reviewing a patient’s food logs, and then guiding the steps each patient plans to take with regard to dietary adjustments during the next week.

This process is further facilitated using mindfulness eating techniques (Table 1). Mindfulness is an exercise in awareness, or just noticing. We believe that mindfulness is the foundation that has been missing for many people, and is the key to helping them overcome food cravings, addictive eating, binge eating, emotional eating, and stress eating—as well as resistance to or limits in their physical activity plan. This technique is also useful in other aspects of their health, such as sleep and stress.

The purpose of mindfulness is not to change anything so much as to allow the mind to go where it wants, and to be aware when it wanders. Being mindful involves the ability to observe one’s thoughts and sensations (eg, taste, smell, preferences). The aim of mindfulness is to increase patients’ awareness of their body functions, feelings, and content of thoughts.14

The second pillar focuses on physical exercise. Physical exercise is any activity that enhances or maintains physical fitness and overall health and wellness, and includes stretching, strengthening, cardiovascular health, or other exercises. During this session, we especially emphasize the importance of strength training and stretching, knowing that cardiovascular exercises are generally promoted. Strengthening exercises work on muscles to help give added strength and physical stability. Stretching exercises provide a good alternative when strengthening exercises are not recommended. Cardiovascular (aerobic) exercises can include walking, biking, and swimming, and should be done regularly for a minimum of 30 minutes each or to the person’s tolerance.15

When working with people with chronic pain, it is important to adjust an exercise program to accomodate the individual needs and capabilities of the patient. Many chronic pain patients are very deconditioned, while others may be sore or stiff. Some people are prone to pushing through pain to complete a task, while others may be preoccupied with fear of pain that causes an avoidance of the activity altogether. Often, people wait for a “good day” to complete rigorous activity. A cycle of overactivity can happen on a recurring basis and lead to negative consequences, such as injury or reinjury. Engaging in activity daily, at a moderate pace if possible, is advised to avoid an all-or-nothing pattern.

During this session, patients receive education on time-based activities to help them pace themselves while completing daily tasks. In pacing, time provides the guide for activity engagement, rather than the sensation of pain. In other words, patients should measure the amount of time they can engage in an activity before sensing pain, rather than waiting for the sensation of pain to increase to signal them to stop. Pacing involves taking breaks at regular intervals and helps to maintain a consistent activity level over time, which is rehabilitative.

Session 3: Apply Pillar 3—Sleep Hygiene & Pillar 4—Stress Management

In the third session, the provider begins with a review of the previous session to assess a patient’s progress toward his or her personal goals. The focus is to introduce education on the psychology of proper sleep hygiene16 and stress management.17 Many patients who suffer from chronic pain typically have poor or unsatisfactory sleep patterns. Table 2 reviews factors that commonly affect sleep.

During this session, patients are educated about sleep influencers and are encouraged to make changes to any factor that may be impeding sleep in a negative way. Providers may also suggest stimulus control (associating the bed only with sleep and sex) and offer guidance designed to associate bedtime with the rapid onset of sleep and to establish a regular sleep-wake schedule that is consistent with the person’s circadian sleep cycle.

The psychologist and patient also identify any emotional issues and stressors that may exert a negative impact on sleep. Patients are instructed to use relaxation techniques to help reduce tension and initiate sleep and are guided through a progressive muscle relaxation (PMR) exercise that can be employed at home to promote sound sleep (Table 3).18 PMR is a technique that helps reduce muscle tension by alternately tensing and relaxing the muscles. PMR entails a physical and mental component. The physical component involves tensing and relaxing different muscle groups, whereas the mental component focuses on differentiating between feelings of tension and relaxation. With practice, the patient learns how to effectively introduce relaxation to achieve a reduction in muscle tension, which should enhance sleep and reduce stress.

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Session 4: Review Progress and Continuation of Care

The group treatment protocol concludes in the fourth session with a brief review of key topics from the prior sessions, with an emphasis on progress made toward individual goals, problem-solving against any barriers to treatment recommendations, and encouraging each participant to create personal goals for posttreatment.

Patients are challenged to maintain their diet regimen going forward or opt to reintroduce foods back into their diets. Patients who choose to add foods back into their diet must be encouraged to add back select foods 1 at a time—each for a single day—with close monitoring of symptoms for 2 days. If no detectable negative symptoms or sensitivity reactions occur, patients are instructed to incorporate the food back into the diet.

This consideration is presented to reinforce the concept that adding back foods may result in the resurfacing of symptoms that were eliminated or greatly reduced when certain foods were removed from the diet, permitting the patient to make a decision about his or her priorities based on his or her level of commitment.

Although this is a 4-session program, patients are also encouraged to make follow-up appointments for individual consultation visits to explore targeted concerns and needs. The goal of the program is to educate and support selfcare among chronic pain patients, not just for the duration of the program, but for a lifetime.

Last updated on: June 16, 2020
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Expanded Use of EMG-NCV Helps Guide Treatment of Lower Extremity Neuromuscular Disorders

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