Integrative Medicine: Magic
or Medicine?
Irene M. Estores, MD
Medical Director
UF Health Integrative Medicine Program
irene.estores@medicine.ufl.edu
{
Disclosures
 I have no relevant financial relationships with a
commercial organization that produces, markets, resells or distributes the products mentioned in this
presentation
 I do not receive any financial or material support
from any of the above mentioned organizations
 I will refer to commercial products using generic
names
Learning Objectives
• Define the philosophy and practice of Integrative
Medicine
• Apply an evidence-based approach in formulating an
integrative health plan
• Select safe and effective botanicals, dietary
supplements, mind-body therapies, biomechanical
and bioenergetic modalities in a treatment plan for
chronic low back pain
When religion was strong and medicine weak,
men mistook magic for medicine;
Now, when science is strong and religion weak,
men mistake medicine for magic.
Thomas Szasz, The Second Sin
An illustrative case of chronic back
pain
 A description of an integrative health
plan that includes the following
modalities:

Nutrition and dietary approaches
 Botanicals and supplements
 Mind-body therapies
 Biomechanical therapies
 Bioenergetic Therapies

{
Sylvia
66-year
old female
with a one
year
history of
back pain
{
Present Illness




Slipped and fell at her
apartment complex
Sustained a pelvic, thoracic
( T4) and rib fractures,
managed conservatively,
received PT
Current pain: 6-7/10 at
best, 8/10 at worst
R side of body and on
thoracic spine, worse with
movement, relieved by
cold, NSAID,
acetaminophen, occasional
tramadol
{
Past History
Medical History







Depression
Hypertension
History of a TIA
History of migraine
Unclear diagnosis of
rheumatoid arthritis
Osteoporosis
Dyslipidemia
Alendronate
 Aspirin-dipyridamole
 Escitalopram
 Meloxicam
 Rosuvastatin
 Valsartan
 Calcium 1.2 gm/day
 Vitamin D 1,000 IU/day
 Topical proprietary blend of menthol,
arnica, boswellia, camphor, lemon balm,
calendula, ilex

Medical History
Cultural and Family background:
 Immigrated to the US from Eastern Europe, divorced,
with two adult children who are successful
professionals
 Raised in a family with many health professionals but
also exposed to folk healing traditions
 Education and Work History
 No college education, worked in medical offices parttime, now retired and “bored”
 Personal Strengths: Considers herself to be creative
and empathic, altruistic and having a young spirit

Psychosocial summary
Stressors: relocation to a different
city, life transitions
Practices to reduce stress: walking,
praying, art
Relationships: good relationships
with children, misses friends from
previous city

Psychosocial summary
Typical daily meals: likes cheese, fruits and
vegetables, eats bread sparingly enjoys nuts olive
oil, and occasional red wine
 “Food” person: she shops and prepares food her
herself; daughter eats most of her meals at work
 Family dynamic: eats most of her meals alone,
takes small, frequent meals
 Strengths: fair information about healthy food
choices
 Obstacles: does not track actual food intake

Nutritional history
Smoked for 20 years, quit for past
2 years
 Drinks wine socially
 No history of illicit drug use

Habits
Typical daily activity: walking
her dog, swimming
Exercise: walking, home PT
program
Sleep pattern: sleeps 5-6
hours/night, has difficulty
falling asleep due to pain

Physical Function, Movement and
Rest
{ Vitals
BP: 156/98
 HR: 68
 T: 36.8
 BMI: 31

Sylvia’s exam
{ Physical Exam
Diffuse tenderness
over the lateral and
posterior thoracic
region from R lower
rib cage to the
thoracic vertebrae
 Moderate muscle
spasm
 No erythema, no heat

Plain radiograph of thoracic spine: healing
minimally displaced fractures of the right
9th-12th ribs, generalized osteopenia
 DEXA:

L fem neck : T- score: -2.0
 Lumbar spine: T-score -1.7

Normal thyroid studies
 Normal Vitamin D levels
 Normal BMP, CBC

Labs and Imaging
Physical therapy
 Psychotherapy
 No previous experience with
complementary medicine modalities(
acupuncture, massage, botanicals,
supplements)

Other therapies received
66 female with osteoporosis, healing fractures,
chronic myofascial pain, with secondary fear
avoidance behavior, slight physical
deconditioning and concomitant depression that
contributes to perpetuation of pain.
 Depression is worsened by limited social
contacts, life transitions
 Has good inner resources (creativity, young and
altruistic spirit), has some financial resources
 Open-minded about using non-conventional
modalities

Initial assessment
Reassurance and encouragement
 Address fear avoidance behavior
 Identify pro-inflammatory triggers
 Consider patient preferences, previous
experience, interest and access in
selection of modalities

Initial integrative health plan
Consider the evidence, risk, benefit
Consider provider experience and
preference
 Intuition

Initial integrative health plan
Nutrition and Dietary
Approaches
 Botanicals and
Supplements
 Pharmaceuticals
 MindBody and Behavioral
therapies
 Biomechanical therapies
 Bioenergetic therapies

Sylvia’s Integrative Health Plan
Nutrition and Dietary Approaches
{
Pro-inflammatory
triggers
Dietary imbalance
 Food intolerance
or sensitivity
 Intestinal
dysbiosis
 Infections
 Physical stress
 Psychological
stress
 Oxidative Stress

{
Anti-inflammatory
strategies
Anti-inflammatory
and anti-oxidant
food
 Low- glycemic index
food
 Elimination or
rotation diets
 Essential fatty acids
 Probiotics

Nutrition and Dietary Approaches
“Here, take this root…………..”
Glycyrrhiza labra
Drug Modulation of Arachidonic Acid Cascade
Cell Membrane
Cortisone
Indomethacin
Aspirin
Ibuprofen
Acetaminophen
(weak)
Sulfasalazine
(topically)
x
Arachidonic Acid
x
cyclooxygenase
2 Series
Prostaglandins
C
Phospholipase A2
lipooxygenase
x
Thromboxane
A2
Leukotrienes
SRS-A
x
Sulfasalazine
(topically)
Colchicine
Botanical Modulation of Arachidonic Acid Cascade
Cell Membrane
Glycyrrhiza labra
Quercitin
x
Zingiber officinale
Curcumin longa
Quercitin (weak)
Bromelain
White Willow Bark
Gaultheria procumbens
x
Phospholipase A2
x
Potentiates cortisol:
Glycyrrhiza labra
Curcumin longa
Arachidonic Acid
cyclooxygenase
Prostaglandins
2 Series
lipooxygenase
Thromboxane
A2
x
Quercitin
Allium cepa
Allium sativuru
Curcumin longa
Boswellia serrata
(specific for 5lipoxygenase)
Leukotrienes
SRS-A
Other Anti-Inflammatory Botanicals
Ananas Comosus - fibrinolysis, inhibits bradkinin, increase Series I Prostaglandins; Tanacetum
parthenium - inhibits platlet aggragation; Scutellaria baicalensis - stabilize mast cell membranes;
Quercitin - stabilize mast cell membranes; Amni Visnaga - stablize mast cell membranes; Capsaicin
Mununm - depletes substance P; Matricaria chamomilla - unknown.

Sylvia’s Integrative
Health Plan
 Magnesium




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
Muscle relaxation
Vasodilator
Promotes sleep
Magnesium glycinate,
chelate or aspartate
Check renal function
RDA: 300 mg/day
Typical dose: 400800/day

Other supplements
to consider:






Curcumin (curcuma
longa)
Boswellic acid (
Boswellia serrata)
Willow bark (Salix sp)
Devil’s claw (
Harpagophytum
procumbens)
Ginger ( Zingiber
officinale)
Omega-3-fatty acids
Botanicals and Supplements

Sylvia’s
Integrative Health
Plan
Guided Imagery
 Psychotherapy
 Introduction to
local arts and
gardening groups
 Breathwork

Mind-Body and
Behavioral
Therapies

Other practices to
consider:
Yoga
 Meditation
 Cognitive behavioral
therapy
 Multidisciplinary functional
restoration programs
 Expressive and
therapeutic writing, using
affirmative scripts



Sylvia’s Integrative
Health Plan:
 Therapeutic
exercise
 Daily walking
program
Other therapies to
Consider




Spinal Manipulation
Short-term use of
massage
Physical modalities
(TENS, LLLT, heat,
cryotherapy, etc)
Postural therapies
Biomechanical therapies
“The cell is a machine driven
by energy. It can thus be
approached by studying
matter, or by studying energy.
In every culture and in every
medical tradition before ours,
healing was accomplished by
moving energy.”
Therapies to
consider:
 Acupuncture
 QiGong
 Energy
Psychology

Albert Szent-Gyorgyi, Nobel
Laureate in Medicine
Bioenergetic therapies
Sylvia, 65 year female with chronic back pain
 Integrative health plan that :
 Provided her with reassurance and
encouragement
 addressed her fear avoidance behavior,
underlying depression and limited social
connection
 considered her preferences, previous
experience, access and personal strengths

Review

Modalities included:
 Nutrition and dietary approaches ( antiinflammatory and low-glycemic diet)
 Supplements ( magnesium)
 Mindbody and behavioral therapies
(guided imagery, psychotherapy, art)
 Pharmaceuticals ( escitalopram, BP
medication)
 Biomechanical therapies ( therapeutic
exercise, daily walking)
Review
Now, for the magic word…………..
RELIEVE
Relationship-centered care built on Empathy and
trust creates a positive environment where the
clinician can Listen to a complicated story that
creates Insight into a problem that results in
an Explanation that is consistent with the
patient's Values leading to Empowerment and
action towards health.
RELIEVE
Used with permission from the University of Wisconsin
School of Medicine and Public Health
The Practice of Medicine
Patient and relationshipcentered
 Addresses the whole person
 Evidence-informed
 Uses safe and effective
modalities
 Utilizes all appropriate
healthcare professionals
and disciplines
 Health and well-being

The Practice of Integrative Medicine

Useful Websites
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www.naturalstandard.com
http://lpi.oregonstate.edu
http://www.consumerlab.com
www.nccam.nih.gov
http://medlineplus.gov
www.naturaldatabase.com
https://www.fammed.wisc.edu/integrative
www.azcim.org
Textbook reference: Rakel, D. Integrative Medicine,
3rd ed, 2012, Elsevier Saunders
Resources
UFHealth Integrative Medicine Program
Supporting people in the journey to realizing wholeness
www.ufhealth.org/integrative-medicine