CAM You can Use:
Preventing Headaches
Kathi J Kemper, MD, MPH
General Pediatrics, Integrative
Medicine
2nd Opinion Clinic (Monday
mornings)
kkemper@wfubmc.edu
716-9640
Disclaimer
• I have no conflicts of interest to report
regarding this presentation; I published a
CME article on this topic with MedScape
for which my institution received payment
• The presentation includes no description of
any proprietary items for screening,
diagnosis, or treatments
Objectives
By the end of this session, participants
will be able to
– Counsel patients on dietary
modifications to prevent headaches
– Discuss the scientific evidence about the
effectiveness of stress management
practices in preventing headaches
– Find evidence-based resources about the
effectiveness of acupuncture in
preventing headaches (See AAP Section
for Complementary and Integrative
Medicine; join the listserv)
– NOT focused on diagnosis or
medications
Headache
• Common! (in teens, > 4 HA in past
month by 6% males; 14% females)
(Linet. JAMA, 1989)
• 90% Migraine or Tension-Type
Headache
• 10% other : sinusitis, eye, trauma,
ice cream, cervicogenic, myofascial
pain, TMJ, hemorrhage, infection,
pseudotumor, vasculitis, tumor,
CAM Use for Tension-Type HA
• 40% used CAM
• 60% did not tell MD (how many MD’s
asked?)
• Types of CAM
– Chiropractic 21%
– Acupuncture 17%
– Massage 17%
Rossi et al. Headache 46:622-631, 2006
* CAM – Complementary or Alternative Medicine, somewhat
outdated and useless term
CAM at UNC for Headache
• Biofeedback (thermal, muscular,
heart rate variability, autonomic)
• Hypnotherapy
• Osteopathy
• Acupuncture
• Mindfulness Meditation
• Herbal and supplement counseling
Prevention options
Bioenergetic
Patient-Centered
Care
LIFESTYLE
Prevention/health promotion
lifestyle
•
•
•
•
•
Avoid triggers!
Nutrition and supplements
Exercise/sleep
Environment
Stress management
Lifestyle – AVOID TRIGGERS
• Non-modifiable: genetics, gender, weather
• Semi-modifiable: air pollution (including
tobacco smoke, CO, SO2, NO2), menses
• Modifiable
-
Lack of sleep
Missing meals
Allergens
Foods – tyramine containing, nuts, cheese, smoked
fish, artificial sweeteners, nitrate preservatives, MSG,
caffeine withdrawal
- Stress – physical, psychological
!!KEEP A HEADACHE DIARY!!
Diet: Avoid Food Allergens
• Clinical trial of 43 patients
• Allergy skin testing
• 69% responded to diet modification
(p<0.005)
• People with IgE-specific food allergy
benefited more from the elimination diet
than people with negative skin tests.
Mansfield L et al.. Ann Allergy, 2004
Diet and Migraine
• Regularization of meals
• Normalize blood sugar (glycemic index)
• Elimination Diet 1: Caffeine, cheese, nuts,
chocolate, shellfish, onions, aspartame,
wine, beer, dairy, processed meats
• Elimination Diet 2: Lamb and rice – add back
• Reduction in omega-6 fatty acids – red meats, fast
food
• Increase in omega-3 fatty acid intake-fish oil
Dietary Supplements
• B vitamins
• Minerals: calcium,
magnesium
• Fatty acids/fish oil
• CoQ10
• Melatonin
Supplements: B vitamins
• B2
– Migraine sufferers suspected of having a mitochondrial
defect -> impaired O2 utilization
– Riboflavin (B2) is the precursor to key molecules in the
electron transport chain in the mitochondria
– 200 mg BID with meals for 3 months -> 68% reduction
in migraine attacks in RCT (next slide)
– Side effect: yellow urine
Schoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007
• B6 essential in converting tryp to serotonin
– More than 100 mg daily -> nausea, abd pain, sleepiness,
lower B12 levels; >1000 mg daily -> sensory neuropathy
* High Dose Riboflavin vs. Placebo
Change from
baseline to month 4
Placebo
N=26
0
Riboflavin
N=28
-2.00
P value
0.50
-3.00
0.0001
Severity
0.05
0.00
0.031
Duration (hr)
0.23
-1.30
0.018
Attack
Frequency
Migraine Days
0.0001
Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis: a randomized controlled trial.
Neurology 50(2): 466-70; 1998.
Supplements: Minerals
• Calcium for PMS-related migraines
– 44% of boys and 58% of girls 6-11 insuff
– 64% of boys and 87% of girls 12-19 insuff
• Ensure 1200- 1500 mg daily
Thys-Jacobs. J Am Coll Nutr, 2000
• Magnesium (1 gram iv acutely) or 300 – 500
mg daily po to prevent (soy beans, black beans,
tofu, seeds, nuts, whole grains, shellfish)
Mauskop. Headache, 2002; Pfaffenrath. Cephalgia, 1996
Mazzotta. Cephalgia, 1999; Wang, Headache, 2003
Peikert. Cephalgia, 1996; Facchinetti F, Headache, 1991
* Magnesium - mechanism
• Ionized magnesium levels low in 50% of MHA patients
• Migraines associated with platelet aggregation, serotonin
release
• Magnesium reduces platelet aggregation
• Magnesium decreases the affinity of serotonin for
vascular receptor sites
• Magnesium acts as an NMDA receptor (glutamate
receptor) antagonist
– NMDA receptors & pain transmission
– Inhibits one type of neuronal spreading depression in
experimental models
* OPTIONAL SLIDE – for participant reference
* Consequences of Reduced Mg++
• Vasoconstriction of scalp arteries
• Reduced affinity of serotonin receptors
• Lower threshold for activation of N-methyld-aspartate receptors
• Enhanced platelet aggregation and serotonin
release
* Trials with Mg++ Supplements
• An infusion of 1.0 g of magnesium sulfate
in 40 patients with acute migraine
– 52% responded to therapy
– 86% of the responders had low serum ionized
Mg++ levels
– 16% of the non-responders had low serum
ionized Mg++ levels.
Mauskop A. Alternative therapies in headache – Is there a role? Medical Clinics of
North America 85(4): 1077-84; 2001.
* Trials with Mg++ Supplements
• Four trials with oral magnesium
supplementation
• Three of the four showed efficacy
• The one negative trial used a poorly
absorbed magnesium salt which resulted
in diarrhea
*Current Use of Mg++ Supplements
•
•
•
•
•
500 mg/day K+ Mg++ aspartate
Avoid combining with Fe, Ca, Zn
May cause temporary diarrhea
Magnesium gluconate – an alternate
Menstrual migraine – months to benefit
Mann, Doug et al. “Migraine and Tension-Type Headache.” Integrative Medicine. Ed. David
Rackel MD. Philadelphia: Sanders, 2006 143-156.
Omega-6 Fatty Acids
Omega-3 Fatty Acids
Linoleic Acid (18:2n-6)
a-Linolenic Acid (18:3n-3)
∆-6 Desaturase
(GLA)γ -Linolenic Acid (18:3n-6)
Stearidonic Acid (18:4n-3)
Elongase
(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)
Eicosanoids
Eicosatetraenoic Acid (20:4n-3)
∆-5 Desaturase
(AA)Arachidonic Acid (20:4n-6)
(EPA) Eicosapentaenoic Acid (20:5n-3)
Elongase
24:5n-3
Eicosanoids
Leukotriene 4-series
Prostaglandins E2
Thromboxanes A2
∆-6 Desaturase
β-Oxidation
24:6n-3
Eicosanoids
Leukotriene 5-series
Prostaglandins E3
Thromboxanes A3
(DHA) Docosahexaenoic Acid (22:6n-3)
Phospholipid
Bilayer
Changing Fatty Acid Intake:
Omega 6: Omega 3
n-6 fats
n-3 fats
• Prehistoric
• 1:1
~ 1900
4:1
~ 2000
25:1
Why EFA Imbalance in US?
• Diet is high in Omega-6 and low in Omega-3
(previously 1:1 ratio, now 20:1)
• Hydrogenated oils
• Enzyme cofactor deficiency (B-3, B-6, Biotin, C, Zinc,
Magnesium)
• Genetic polymorphism (biochemical individuality)
• Hyperinsulinism from high glycemic load diet
(increase DGLA to AA)
• Increased stress -> increased demands.
Fatty acids: Omega 3s
• Popular approach to decreasing
inflammation
• Open studies suggest it helps reduce
headaches; doses 1-3 grams daily
• RCTs – mixed results; olive oil may
not be a placebo!
• Supplements – generally free from
mercury, dioxins, PCBs; palatable
Harel. J Adolesc Health, 2002
Pradalier. Cephalgia, 2001
Puel. Br J Nutr, 2004
Coenzyme Q-10
• Open label, 150 mg qd - for 3 months
• 62% had > 50% reduction in number of HA
days
• Migraine Days: 7.34 -> 2.95/mo
• Frequency: 4.85 -> 2.81/month
• No side effects; except pain in pocketbook
Rozen and Silberstein, Cephalalgia 22: 137-141, 2002
Melatonin and Headache
• Mechanism
– Potentiates GABA; Modulates Ca entry in
to vascular smooth muscle cells
– Modulates 5HT2 receptor – like Bblockers; Inhibits the synthesis of
prostaglandin E2 - inflammation mediator
• Melatonin low and out of phase in menstrual
migraine, chronic daily headache, migraine,
status and cluster HA
• Effective preventive for cluster HA and HA
associated with delayed sleep-phase syndrome
Melatonin:
Sleep phase delay or cluster HA
• Corrects delayed sleep-phase
syndrome
• An alternative to benzodiazepines
• Dosing 6-12 mg one hour before bed
• Few side effects
• ConsumerLab reviews show consistent
quality
Rozen. Headache, 2006
Vogler. CNS Drugs, 2006
Rozen, Neurology, 2003
Pringsheim. Headache, 2002
Miano. Neurol Sci, 2008 – PEDIATRIC STUDY
Lifestyle: Stress management
• Stress is common
• Stress triggers/worsens pain
• Managing stress: exercise,
sleep, nutrition,
mind/emotion/body/spirit
– Biofeedback
– Hypnosis
• Reducing stress helps 50% 70% of headache sufferers
The Many Forms of Mind-Body
Medicine
Stress and Physiological
Activation
High Arousal/High Energy
SYMPATHETIC
Low Arousal/Low Energy
PARASYMPATHETIC
Institute of HeartMath
Biofeedback-What and why?
• Use of electronic equipment to measure and feed back
information about physiologic functions—which are then
modulated in desirable direction
• Goal-balancing ANS (& CNS) activity
• “video-games for your body” kid-friendly
• 2007 meta-analysis showed > 50 controlled trials of BF for
HA; EFFECTIVE!
• Strong treatment effect that persists for over 12 months
after training
Allen Pediatr Ann, 2004
Kaushik R. Complement Ther Health Med, 2005
Trautman. Cephalgia, 2006
Nestoriuc. Pain, 2007
*Biofeedback - Example
• Blanchard - 116 patients with migraine
• Assigned to either thermal biofeedback, thermal
biofeedback with relaxation training, or
pseudomeditation, headache monitoring
• Six month follow-up
• 51% of the subjects in the thermal biofeedback
groups improved in frequency compared to
5% and 22% for the monitoring and
pseudomeditation groups
Blanchard E et al.. J Consult Clin Psychol; 1990.
Biofeedback Modalities
Home or Office Use
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–
–
–
Peripheral Temperature
Heart Rate Variability
Surface EMG
Skin Conductance
*Biofeedback-Temperature
• Theory-the more relaxed, the lower sympathetic nervous
system activity, the more peripheral blood flow, hands and
feet warm up
• Resources
– Dermatherm Bands Sharn, Incorporated
www.sharn.com
– BioDots
• www.futurehealth.org
• www.cliving.org
– Digital Temp Portable Units
• www.Bio-medical.com
• www.thoughttechnology.com
*Heart Rate Variability (HRV)
m Volts
2
1.5
76 BPM
.793 sec.
70 BPM
.859 sec.
1
0.5
83 BPM
.726 sec.
0
-0.5
0
1
2
2.5 seconds of heart beat data
Hypnosis/Guided Imagery
• Hypnosis: An altered state of awareness usually
but not always involving relaxation during which
the participant can give himself/herself
suggestions for desired changes to which he/she is
more likely to respond that in their usual state of
awareness.
• Guided Imagery: A technique that involves using
the imagination and mental images to promote
relaxation, changes in attitude or behavior, and
encourages physical healing. AKA- visualization.
Children Enjoy It
• To teach self hypnosis for a specific purpose (such as
reduction of pain or elimination of a habit) involves
helping young children focus on their natural thinking
styles.
• Kids move in and out of altered states and imaginary
activities all the time. Think IMAGINARY PLAY!
• The child is in control.
• We serve as the teacher or coach.
• Offer choices and options.
• The child can use this skill when he or she chooses.
• Ask that parents not remind the child to practice self
hypnosis; it’s up to the child/adolescent
Hypnosis – Prevention
• Meta-analysis – strong evidence of benefits
for tension HA (Hammond. Int J Clin Exp
Hypnosis, 2007)
• Better than wait-listed controls for migraine
prevention (Melis. Headache, 1991)
• Superior to propranolol or placebo in
juvenile classic migraine prevention (next
slide)
Hypnosis : Headache
• Children 6 to 12 years with classic migraine
• RXT: propanolol vs. placebo for 3 months
each
• Then hypnosis training
• Placebo: 13.3 HA/ 3 mos
• Propanolol: 14.9 HA/3 mos
• Hypnosis: 5.8 HA/3 mos (P<0.05)
Olness. Pediatrics. 1987
Hammond: Int J Clin Exp Hypn. 2007
* Hypnosis Misconceptions
• Patient is under control of the
hypnotherapist
• Patient is unaware of surroundings
and/or activities around him/her
• Patients defenses are impaired (there is
improved access to subconscious
material)
• Symptoms are masked
• Patient can be forced to do things they
would not normally do
Contraindications to Hypnosis
• Ignoring underlying disorder
• Used for fun or entertainment
• The problem is more effectively treated
with another modality
• Patient is psychotic, acutely depressed
• Patient (child) does not want to engage in
hypnosis (but parent wants them to)
Mind-Body: Autogenic Training
• Form of hypnosis
• Repeat phrases
–
–
–
–
–
–
My hands and arms are heavy and warm
My legs and feet are heavy and warm
My heartbeat is calm and regular
My breathing is easy and free
My forehead is cool
My belly is relaxed
• Reduces need for headache medication
• Reduces frequency of migraine attacks
Zsombok. Headache, 2003
Juhasz. Headache, 2007
Massage for Migraines
• Massage improves blood flow and
decreases inflammation, relaxes
muscles, reduces stress, provides
tangible social support
• Can combine with physical therapies
such as ice, heat; aromas
(peppermint)
• RCT for migraines showed
significantly decreased frequency
and improved sleep
Lawler SP. Ann Behav Med, 2006
Pieovesan. Arq Neuropsiquiatr, 2007
Chiropractic
• Commonly used
• Older studies support use of chiropractic
in migraine; frequency and severity were
reduced
• Little other evidence supporting use in
headache of different types
Tuchin. Australas Chiropr Osteopathy, 1997
Parker. Aust NZ J Med, 1978
Osteopathy - Headache
• Five of six studies showed positive results for
tension, cervicogenic and post-traumatic HA
• No studies specifically for migraine
• No control groups or long term results
• Two of 6 studies: results comparable to TCA
Hoyt. J Am Osteopath Assoc, 1979
Fernandez-de-las-Penas. J Orthop Sports Phys Ther, 2006
Bronfort. J Manipulative Phys Ther, 2001
Acupuncture for Chronic Daily
Headache – UNC study
• RCT of usual medical care (UMC) vs UMC
+ acupuncture
• Medical care alone: no change
• Medical care +acupuncture
– Improvement in headache impact (function)
– Improvement in general mental health domains
(SF-36)
– 3.7 times >likely to report reduced suffering
Coeytaux R. Headache, 2005
Gottschling. Pain, 2008 – PEDIATRIC STUDY LASER ACUP.
Witt. Cephalgia, 2008 – COST EFFECTIVENESS
*Acupuncture: Mechanism of Action
• The documented effects of acupuncture
include:
• 1) Release of opioids in the central nervous
system
• 2) Changes in regulation of blood flow,
blood pressure, body temperature, and
alterations in immune function.
*Mechanism of Action
• Functional MRI: Single point stimulation
– Activation of occipital lobes with lateral foot
VA1 stimulation
– Reduction in limbic structure activity with true
acupuncture (pressure sensation)
– Activation of somatosensory cortex with sham
point activation or painful response to
needling
*Mechanism of Action: Biomedicine
• Release of opioid-like substances into CSF
• Substance P, neurokinin A, neuropeptide Y
• Serotonergic and dopaminergic systems
activated
• Descending pain inhibitory systems
activated
• Thalamic relay nuclei inhibition
• Dorsal root entry zone inhibition
*Acupuncture for Headache
•
•
•
•
5 or more weekly 20-40 minute sessions
Electrical stimulation
Prolonged benefit after 6-10 weeks
70% respond to acupuncture -frequency
Morrisey, H et al. Headache 43, 221-228, 2003
*Acupuncture
30 patients
6 treatments in
4 weeks
Pain Score
Reduction %
Medication
Use
Reduction %
Acupuncture
Benefits at 1 year
43%
38%
Vincent C. A controlled trial of the treatment of migraine by acupuncture. Clinical
Journal of Pain. 5(4): 305-12; 1989.
Acupuncture – Migraine
Reviews involving > 1000 patients
• Acupuncture benefits adults and pediatric
patients in preventing migraines
• NOT for acute treatment
• 1-2 treatments weekly for 4-6 weeks
• Effects last at least 6 months
• Side effects rare
Melchart et al. Cephalalgia, 1999
Manias.The Clinical Journal of Pain, 2000
Healing Touch
And
Therapeutic
Touch
Biofield Therapies
• Rapid increase in use and availability of
Healing Touch, Therapeutic Touch, Reiki,
QiGong, Polarity Therapy
• RCT showed decreased tension headache
pain with TT
Keller E. Nurs Res, 1986
Herbs In Migraine
• Feverfew – yes for prevention
if you can get British and use
it daily
• Valerian –to help with sleep
• Petasites (Butterbur) – yes for
prevention if you can get
quality product
* Feverfew
• Feverfew (Tanacetum parthenium)
• 270 adult migraine patients
• 70% reduction in intensity and frequency of
migraine
• Other trials have not been as promising but
all show benefit of feverfew > placebo
• Variability in quality of products!
Murphy J et al.. Lancet 1988.
Ernst E et al.. Public Health Nutrition .2000.
*Feverfew
• Significant reduction in frequency, not in duration
• No head to head studies with other modalities
• Dosing: 125mg/day of the dried leaf standardized
to a minimum 0.2% parthenolide
• Maximum effect after 4-6 weeks
• Adverse effects: Aphthous ulcers and
gastrointestinal side effects in 5-15%
• Avoid abrupt cessation: agitation & increased HA
• Contraindicated during pregnancy
Valerian
•
•
•
•
•
•
Used for sleep, anxiety
150-300 mg of dried root hs or tid
Few side effects
Avoid prolonged use – rebound headache
Used during headache
Smells very bad
Petasites hybridus Root Extract
• Large, 3arm, dose-finding RCT (Lipton,
Neurology, 2004)
• Reduced frequency by more than 50% in
68% of those with highest doses.
• Few dropouts.
• Two other confirmatory studies, one in
children.
RESOURCES
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Acupressure / acupuncture
Self care
Hypnosis
Biofeedback
Acupressure resources
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–
www.omsmedical.com (supplies)
www.auricularacupuncturecollege.com
www.khtsystems.com (korean hand acu)
www.hmieducation.com (Helms course)
www.aaaom.org (training and certification)
www.acupressure.com (resources)
* HRV Biofeedback - Resources
•
•
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•
•
•
•
www.heartmath.com (products and training)
www.heartmath.org (research)
www.aapb.org
www.stresseraser.com
www.bcia.org
www.stens-biofeedback.com
www.wildDivine.com
Self-Care Training Resources
• Books
– Be the Boss of Your Body” Series
• www.freespirit.com
• “Ways to Wellness” Videos
– http://www.childrensmn.org/Communities/IntegrativeMed.asp
• Music and Recorded Relaxation Exercises
– www.therelaxationcompany.com
– www.healthjourneys.com ****
– www.Pzizz.com
• Home Computer Biofeedback Fun
– www.wilddivine.com
– www.heartmath.com
Web Resources
• AAP Section on CHIM
– www.aap.org/sections/CHIM
– Will post this presentation
• Integrative Pediatrics Council
– www.integrativepeds.org
– CAM bibliography
– IPC Network
Training and Certification
• Society For Developmental and Behavioral
Pediatrics Annual Pediatric Hypnosis Training
• American Society for Clinical Hypnosis
• Society for Clinical and Experimental Hypnosis
• International Society for Hypnosis
• Academy for Guided Imagery
Text Resources
• Culbert & Olness, ed: Integrative Pediatrics
• In press, March 2009 (Oxford University Press)
• Loo: Integrative Medicine for Children (2008)
• Rosen & Riley, ed: Complementary and Alternative Medicine,
Pediatric Clinics of North America (December 2007)
• Schwartz & Andrasik: Biofeedback: A Practitioners Guide
• Shannon: Handbook of Complementary and Alternative Therapies in
Mental Health
• Schnaubelt: Medical Aromatherapy
• Reed Gach: Acupressure Potent Points
PCIM Director: Kemper
Medical School:
Arcury (Family Med)
Avis (Public Health)
Chilton (Phys/Pharm)
Curl (Orthopedics)
Tegeler (Neurology)
Hospital:
Atkinson (Business Dev.)
Johnson (Operations/Nursing)
Parker (Home & Community)
Small (Quality)
Snelgrove (Operations)
Yates (Pastoral Care)
Stant: newsletter/Web
Zachary: (meetings)
Program leaders
Medical School:
Bailey: Ambience Sound/Music
Best Health
Black: ActionHealth/ Farmer’s Market
Dailey/McCarty: Meditation
Danhauer: Yoga
Feldman: Guided imagery
Kilbourne: Green Initiative
LaRose: HM – Hospital
Larrimore – Healing Touch/HeartMath
McClenny – Arts
Melcher – Massage
NW Area Health Education Center
Pashayan: Hypnosis
Sackett – RN Research
Wilson – Recreation/Aqua
Woodard - Nutrition
Zachary – Healthy Living
Julie Milunic: Advisory Board
Library Staff: resources
Mark Wright: PR and Marketing
Hospital:
How: Behavioral Medicine
•
•
•
•
•
•
•
•
Identify the goal
Consider various strategies
Pick a strategy
Identify a small, achievable step that the patient
and family can support
Explore pros and cons of change
Anticipate barriers; identify resources
Plan rewards/celebrations!
Re-evaluate; take the next step
Goal-setting
• Pick a POSITIVE goal
– E.g., healthier lifestyle.
Example: Healthier lifestyle
To promote
Better mood
Better focus or concentration
Greater calm
More resilience
More cheerfulness Greater adaptability
More confidence More creative
More clarity
Better memory
More harmonious relationships
Higher self esteem
More consistent with personal values
other?
Pick a specific strategy
•
•
•
•
•
•
More exercise
Better nutrition
Judicious use of supplements
Better sleep
Healthier environment
Stress management; biofeedback; journal;
meditation
• Use medication
• Massage, psychotherapy, acupuncture or other
professional help
Identify a small, achievable step
• Rome was not built in a day; habits are not
changed overnight: BABY STEPS.
• For exercise, go from sedentary, to 5 minute
walks with the dog 5 days a week.
• Be specific (with or without an MP3 player;
with or without a friend; regardless of
weather?; distance vs. time)
How important is this to you?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
Why did you pick that number and not a lower number?
(e.g. a 7 instead of a 5)
Asking this question helps the patient/family provide their
own rationale for why this is important. They talk
themselves into it!
How confident are you that you
can do
this
for
one
month?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
If they pick an 8 or higher (pretty confident), proceed with next
step of making a chart and planning rewards and follow-up.
If they pick a number less than 8,
“What would it take for you to go from the number you picked
to a higher number?” Begin to explore their ambivalence….
It’s OK to be ambivalent about change!
Identify Pros and Cons
PRO
Change
CON
More cheerful
Change routine
More fit and cool
Brother might tease
Clothes fit better
Yucky dog clean up
Better sleep
Better self-esteem
No Change
Easy
Continued mood probs
Mom does yucky job
Get fat
Feel ugly
Sleep badly
Unhappy with myself
Identify Barriers and Resources
• In addition to (cons listed above), what other barriers
or challenges might you anticipate as you try to make
this change? Need new tennis shoes; need leash; need
pooper-scooper
• What resources do you have/need to help you make
this change? Will Mom commit to getting new shoes,
leash, etc. ? Will the child want/need a reminder? Is it
helpful for Dad to do that? Do they need a chore
chart? A calendar?
Plan celebrations/rewards
• Pick a tangible reward and timing (will it be offered after
week 1, 2, 3, 4?)
• Samples: new walking shoes; Support the patient’s
choices.
• Emphasize the importance of the reward/celebration. If the
patient says they expect “good” behavior, suggest they
consider celebrating it (instead of rewarding it).
Sample behavior diary (OK to copy)
Goal
Sample:
M
Walk dog 5 minutes 5 days
a week
Week 1
Week 2
Week 3
Week 4
Re-evaluate.
Celebrate.
Next steps?
√
T
W
Th
Fr
i
√
√
√
Sa
√
Su
Total
5
Follow Up
• Follow- up in 4-6 weeks.
• Ask patient to bring chart and say you
plan to be proud of them (build
expectation of success) and will ask
them what they’d like to do for next step
(involve them in problem solving).
• Do it!
Behavioral Medicine
•
•
•
•
•
•
•
•
Identify the goal
Consider various strategies
Pick a strategy
Identify a small, achievable step that the patient
can embrace
Explore pros and cons of change
Anticipate barriers; identify resources
Plan rewards/celebrations!
Re-evaluate; take the next step