Tools and Techniques for Managing Pain · Director of Pain Management Scripps Center for Integrative Medicine Assistant Clinical Professor UCSD, School of Medicine (vol.) @DrB_Well

Tools and Techniques for Managing Pain: Complementary and Integrative Approaches

July 9, 2020

Robert Bonakdar, MD© 2020 OptumHealth Education 1

Tools and Techniques for Managing Pain: Complementary & Integrative Approaches

Robert A. Bonakdar, MD FAAFP FACNDirector of Pain Management

Scripps Center for Integrative Medicine

Assistant Clinical ProfessorUCSD, School of Medicine (vol.)

@DrB_Well

Objectives

The prevalence and rationale for the use of complementary and integrative therapies in pain care

Review

The evidence for complementary and integrative therapies in the treatment of common pain conditions

Examine

Effective models and techniques for coordinating immediate and long‐term pain management

Evaluate

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A Treatment by Any Other Name…

• Non‐Pharmacologic (NP) treatments

• Complementary/Alternative Medicine (CAM)

• Integrative Medicine (IM)

• Integrative Health

http://www.hopkinsmedicine.org/integrative_medicine_digestive_center/index.html

Integrative medicine is an approach that uses the best evidence‐based practices to enhance conventional care.

https://nccih.nih.gov

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Pain in America – Common

• Over the last 2 decades, pain prevalence has increased by 25%• The number of American adults suffering from pain increased from 120.2 to 178 million or 41% of the adult population

Pain in America – Costly

America spends >$600 billion per year on the treatment of pain, more than is spent on cancer, heart disease and diabetes.

NIH Fact Sheets - Pain Management https://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=57http://nationalacademies.org/hmd/Activities/Global/InnovationHealthProfEducation/2018‐DEC‐5.aspx

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Chronic pain Cardiovaculardisease

Cancer, all sites Diabetes

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286264

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IOM Report 2011 AHA 2007 ADA 2007 ACS 2010

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Pain in America – Catastrophic

• Mean numbers of co-morbid + activity limiting conditions 6

• “There is a need for clinical care models and other interventions that simultaneously address the complexity and interrelationships of multiple chronic health conditions...”

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Pain in America Complex

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Vachon‐Presseau E, Roy M, Martel MO, et al. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function in humans. Brain. 2013 Mar;136(Pt 3):815‐27.

⬆ cortisolIn CBP

…sustained stress response … contribute to persistent pain

Further research…implementation of novel management strategies and therapies targeting parasympathetic dysregulation in chronic pain

J. Neurosci. 2004 Apkarian et al. 24 (46): 10410.Rodriguez‐Raecke, R. et al. J. Neurosci. 2009;29:13746‐13750

The decreased volume was related to pain duration, indicating a 1.3 cm3 loss of gray matter for every year of chronic pain

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• 2012 National Health Interview Survey

• 41.2% used CAM in the past year

• 45% with more limiting pain

• 58.1% of those who used CAM perceived a great deal of benefit.

• The most popular options: supplements, chiropractic manipulation, and massage…

Dubois J et al. Chronic low back pain patients' use of, level of knowledge of and perceived benefits of complementary medicine: a cross‐sectional study at an academic pain center. BMC Complement Altern Med. 2017 Apr 4;17(1):193.

• Predictors: Female, higher education & longer pain

• Discussion: Most obtained information from family & friends

• Half didn’t discuss with providerReason: “Doctor didn’t ask”

• …integrative therapies in combination or combined with conventional medical care…more effective than select single therapies alone for treating LBP

• Most Promising:• Spinal manipulative combined with exercise

• Acupuncture combined with conventional medical care or with exercise therapy

www.gahmj.com • September 2014

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• The higher‐quality studies indicate potential cost‐effectiveness, and even cost savings across a number of CIM therapies and populations.

Dusek JA, Griffin KH, Finch MD, Rivard RL, Watson D. Cost Savings from Reducing Pain Through the Delivery of Integrative Medicine Program to Hospitalized Patients. The Journal of Alternative and Complementary Medicine. 2018;24(6):557–563. doi:10.1089/acm.2017.0203.

• Subjects: 2730 adult inpatient admissions

• Intervention: IM services provided to inpatients

• Results: For patients receiving IM therapies, pain was reduced by an average of 2.05points and was associated with a cost savings of $898 per admission.Herman PM, Poindexter BL, Witt CM, Eisenberg DM. Are complementary

therapies and integrative care cost‐effective? A systematic review of economic evaluations. BMJ Open. 2012 Sep 3;2(5). pii: e001046. doi: 10.1136/bmjopen‐2012‐001046. Print 2012.

Summary: Rationale for Considering CAM in Pain Care

• Pain Care in America is not optimal• 2011 IOM Report: all too often treatment is delayed, disorganized, inaccessible or ineffective

• 2019: Inter‐Agency Task Force: Patients with pain face a crisis because of significant challenges in obtaining adequate care

• Costly, Complex & potentially Catastrophic

• Patients turn to CAM/IM…often without guidance

• Coordinated IM improves outcomes and may address pain complexity

This Photo by Unknown Author is licensed under CC BY‐NC

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Objectives


Review


Examine


Evaluate

Recent Articles/Best Practices on the Topic:

• IPM Clinics of North America

• BMJ Headache

• Anesthesia Review• Brain Plasticity• ACP Guidelines• Academic Consortium White paper

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The Pain Task Force of the Academic Consortium for Integrative Medicine and Health

• https://www.ncbi.nlm.nih.gov/pubmed/29735382

• https://www.explorejournal.com/article/S1550‐8307(18)30022‐3/fulltext

Tick H, Nielsen A, Pelletier KR, Bonakdar R et al. Evidence‐Based Nonpharmacologic Strategies for Comprehensive Pain Care. EXPLORE. 2018;14(3):177–211. doi:10.1016/j.explore.2018.02.001.

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Strong recommendation:• For patients with chronic low back pain, clinicians and patients should initially select non‐pharmacologic treatments:

• Exercise • Multidisciplinary

rehab

• Acupuncture• MBSR

• Relaxation (progressive)• Biofeedback• Tai chi• Yoga• Spinal manipulation• CBT• Laser Therapy

Foundational:AwarenessBreathBodyEmotion

The Basics

• Improving• Breath

• Body Awareness / Tension

• Movement

• Up to 75% of pain patients exhibited faulty breathing mechanics

Perri MA, Halford E. Pain and faulty breathing: a pilot study. Journal of bodywork and movement therapies. 2004 Oct 31;8(4):297‐306.

• 12 sessions of breath retraining vs PT

• VAS: ‐2.7 with breath therapy, ‐2.4 with physical therapy

• Comparable changes in measures of pain and disability vs PT

• Qualitative data suggested improved coping skills and new insight into the effect of stress on the body as a result of breath therapy

Mehling WE et al. Randomized, controlled trial of breath therapy for patients with chronic low‐back pain. Altern Ther Health Med. 2005 Jul‐Aug;11(4):44‐52.

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Dhyani D, Sen S, Raghumahanti R, Kour J. Effect of Progressive Muscular Relaxation on Stress and Disability in Subjects with Chronic Low Back Pain. Journal of Nursing and Health Science. 2015;4(1):40‐5.

Control

RelaxationMuscle Relaxation

From Nestoriuc Y, Martin A, RiefW, et al. Biofeedback treatment for headache disorders: a comprehensive efficacy review. Applied Psychophysiol Biofeedback 2008;33:125–40

Whitney A. Biofeedback: a way to regain some control over pain. J Fam Pract. 2014 Jun;63(6 Suppl):S12‐7. https://www.ncbi.nlm.nih.gov/pubmed/25061629

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Key Points

• Those with chronic pain often have respiratory, autonomic and myofascial dysfunction

• Breath & Body Awareness can be starting points in addressed and reversing autonomic dysfunction

Tai Chi

This Photo by Unknown Author is licensed under CC BY

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• 3 RCTs (10‐28 wks) for Tai Chi in LBP • Tai Chi significantly improved LBP pain (SMD, −0.81; P<0.001)

• Other studies have also noted improvement in OA (SMD−0.52 to ‐ .54)

Kong LJ, Lauche R, Klose P, et al. Tai Chi for Chronic Pain Conditions: A Systematic Review and Meta‐analysis of Randomized Controlled Trials. Scientific Reports. 2016;6(1). doi:10.1038/srep25325.

• AAFP FMS Guidelines

• Exercise for Fibro:

Kodner C. Common questions about the diagnosis and management of fibromyalgia. American family physician. 2015 Apr;91(7):472‐8. https://www.aafp.org/afp/2015/0401/p472.html

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• 12 weeks of Tai Chi:

• Sig. decreases in sympathetic tone, pain & fatigue

• Significant increases in parasympathetic tone

• The changes in autonomic tone were correlated with changes in pain

Wong A, 2018: Effectiveness of Tai Chi on Cardiac Autonomic Function and Symptomatology in Women With Fibromyalgia: A Randomized Controlled Trial.

Tai Chi Improves Autonomic Function

Journal of Aging and Physical Activity. 2018;26(2):214–221.

Yoga

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Meta- Analysis Yoga - Pain

• MA: 10 RCTs (2011): reduction in pain vs• Standard care• Self care• Therapeutic exercises• Manipulation

• MA: 8 RCTs LBP• SMD = - 0.59 low back pain

disability

Posadzki P, et alIs yoga effective for pain? A systematic review of randomized clinical trials. Complementary Therapies in Medicine. 2011 Oct;19 (5): pages 281‐7 . 2011 Oct;19 (5): pages 281‐7BMC Complement Altern Med. 2016; 16: 279.

…yoga practice can shift the autonomic balance towards vagal dominance in patients with chronic low back pain

• At 12 weeks, yoga compared to usual care

• Participants reported: (control vs yoga)• Less analgesic use (13% vs 73%)• Less opiate use (0% vs 33%)• Greater overall improvement (27% vs 73%)

Saper RB, Sherman KJ, Cullum‐Dugan D, Davis RB, Phillips RS, Culpepper L. Yoga for chronic low back pain in a predominantly minority population: a pilot randomized controlled trial. Altern Ther Health Med. 2009 Nov‐Dec;15(6):18‐27.

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• Yoga similar to traditional PT in pain reduction

• Yoga and PT participants were 20% less likely to use pain medication at 12 weeks.

• Improvements in yoga and PT groups were maintained at 1 year

• Frequency of adverse events = mild

Grotle M, Journal of physiotherapy. 2018 Jan 1;64(1):57.

Key Points

• Yoga and Tai Chi may be as effective as traditional PT and exercise for pain

• May be bolstered by autonomic modulation

• Yoga may reduce medication requirement

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k851 (Published 21 March 2018)

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Acupuncture

This Photo by Unknown Author is licensed under CC BY‐SA‐NC

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Date of download: 5/14/2018

From: Mechanisms of Acupuncture–Electroacupuncture on Persistent Pain Anesthes. 2014;120(2):482-503. doi:10.1097/ALN.0000000000000101

From: Mechanisms of Acupuncture–Electroacupuncture on Persistent Pain Anesthes. 2014;120(2):482-503. doi:10.1097/ALN.0000000000000101

…acupuncture was an effective treatment that could significantly reduce the severity of disease in the patients with depression…

II. Endorphins and FrequencyElectroacupuncture

Frequency of electroacupuncture

Neuropeptidesreleased in CNS

Opioid receptors

Physiological andtherapeutic effects

Antinociceptionand many other effects

2 15 100 Hz

DYNEM/ENK/ßEP

μ δ κ

EA=electroacupuncture.Schematic diagram showing the opioid mechanisms of EA-induced analgesia.

Partially blocked by naloxone

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•

Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9) (March 5):955‐956

• Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain.

• Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects.

• Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.

https://www.sciencedirect.com/science/article/pii/S1526590017307800

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AAFP

• cLBP

• aLBP

• Knee OA

• Tens. HAs

• Migraines

• MPS/TrPs

• Acupuncture for Pain Review

Am Fam Physician. 2019 Jul 15;100(2):76‐78.

https://www.aafp.org/afp/2019/0715/p89.html

Acupuncture in Guidelines: NICE

• For Tension Type Headaches:

http://www.nice.org.uk/nicemedia/live/13901/60853/60853.pdf

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ACP / Auriculotherapy

• Auricular ‐ 17 Trials • 8 perioperative, 4 acute, 5 chronic pain • Superior to controls: • pain intensity analgesic use

Asher GN, Jonas DE, Coeytaux RR, Reilly AC, st al. Auriculotherapy for pain management: a systematic review and meta‐analysis of randomized controlled trials. J Altern Complement Med. 2010 Oct;16(10):1097‐108.

Acupuncture vs IV morphine in ED (Annals of Emerg Med)

In patients with acute pain presenting to the ED, acupuncture

was associated with more effective and faster analgesia with

better tolerance.

300 patients Acupuncture 150 IV morphine 150

Pain score reduction ≥50% 92% success 78% success

Resolution time 16+8 (8‐24 minutes) 28 +14 (14‐42 minutes)

89 patients (29.6%) AE 4 (2.6%) AE 85 (56.6%) AE

Grissa M, Baccouche H, Boubaker H et al. Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med. 2016;pii: S0735‐6757(16) (July 20):30422‐3.

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• We found that patients treated with acupuncture …had less pain and used less opioid analgesics on the first day after surgery compared with those treated with control (P< 0.001)

• Our findings support the use of acupuncture as adjuvant therapy in treating post‐op pain.

PLOS ONE | DOI:10.1371/journal.pone.0150367 March 9, 2016

http://www.iasp‐pain.org/GlobalYear

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Key Points

• Acupuncture mechanism goes beyond endorphin theory

• In addition to chronic pain, may be helpful in the setting of pain associated comorbidities

• Requires a series of treatments for sustained benefit


Manual Therapy

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• For Bodily Pain 49.4% were clinically improved at 12 weeks, 40% at 24 weeks.

• Adults older than age 49 years had better pain and disability outcomes than younger adults.

• Important to find Therapist experienced with: • Treating chronic pain

• Using myofascial release/acupressure

Elder WG, Munk N, Love MM, Bruckner GG, Stewart KE, Pearce K. Real‐world massage therapy produces meaningful effectiveness signal for primary care patients with chronic low back pain: Results of a repeated measures cohort study. Pain Medicine. 2017 Mar 14;18(7):1394‐405.

Key Concepts• Moment to moment awareness without judgment

• Element of self‐compassion/self‐acceptance

• MBSR: Formal 8 week class incorporating mindful breathing, yoga and mental training

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JAOA (2011;111[1]:3)

Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness‐Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back PainA Randomized Clinical Trial. JAMA. 2016;315(12):1240–1249. doi:10.1001/jama.2016.2323Jain S, Shapiro SL, Swanick S, Roesch SC, Mills P et al. Ann Behav Med. 2007 Feb;33(1):11‐21.

N =342

• Mindfulness training vs relaxation training:

• Mindfulness meditation is: “able to reduce distractive and ruminative thoughts and behaviors…

• This ability may provide a unique mechanism by which MM reduces distress”

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• 20+ fMRI studies

• Demonstrable functional and structural changes in the prefrontal cortex, cingulate cortex, insula and hippocampus

(reverse of those seen withchronic pain)

• MBSR led to changes in the amygdala consistent with improved emotion regulation

Key Points

• Mindfulness can improve pain similar to CBT

• Able to approach affective/ distress component of pain

• May be able to reverse pain related brain changes

• Requires ongoing trainingBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k851 (Published 21 March 2018)

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Diet, Inactivity, and Pain

This Photo by Unknown Author is licensed under CC BY‐NC‐ND

•

PAIN

Stone AA, Broderick JE. Obesity and pain are associated in the United States. Obesity (Silver Spring). 2012 Jul;20(7)‐1491‐5.

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Totsch SK, Waite ME, Tomkovich A, Quinn TL, Gower BA, Sorge RE. Total Western Diet Alters Mechanical and Thermal Sensitivity and Prolongs Hypersensitivity Following Complete Freund's Adjuvant in Mice. J Pain. 2016

• 13 week of “…exposure to poor diet quality resulted in altered acute nociceptive sensitivity, systemic inflammation, and persistent pain…“• Increase in low grade pro‐inflammatory cytokines (TNFα and IL‐6)

S.A.D.

• Standard American Diet • Energy‐dense & nutrient poor• High in carbohydrates and inflammatory fats

• Low in fiber, fruits, vegetables, and omega 3’s

Cross‐Promoters:Obesity

Nutrient DeficiencyOxidative Stress

Microbiome changesEpigenetic changes…

⬆ PainChange:Activity FunctionMoodSleep…

S.A.D.

Low Grade Systemic

Inflammation / Hyperalgesia

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• 6588 subjects aged ≥50 years

• Knee pain score decreased significantly with ⬆ intake

• Our findings suggest that intake of whole fruits and vegetables may help improve knee pain in older adults.

Han HS, Chang CB, Lee DC, Lee JY. Relationship between total fruit and vegetable intake and self‐reported knee pain in older adults. The journal of nutrition, health & aging. 2017 Jul 1;21(7):750‐8.

Ramsden CE, Faurot KR, Zamora D, et al. Targeted alterations in dietary n‐3 and n‐6 FA improve life functioning and reduce psychological distress chronic headache patients‐ Pain. 2015;156(4)‐587‐596. doi‐10.1097_01.j.pain.0000460348.84965.47.

H3 = High Omega‐3 L6 = Low Omega‐6

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The IDEA Trial 18 Month randomized trial of 450 osteoarthritis subjects to: Diet, Exercise, or Combination

A 5% weight loss = 30% reduction in pain 24% improvement in functionSignificant reduction in IL‐6

More Than Just Pain…

• …the Mediterranean diet was inversely associated with insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early morning awakening)

St‐Onge M‐P, Mikic A, Pietrolungo CE. Effects of Diet on Sleep Quality. Advances in Nutrition. 2016;7(5):938–949. doi:10.3945/an.116.012336.Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Maggi S. Adherence to the Mediterranean diet is associated with better quality of life: data from the Osteoarthritis Initiative. The American Journal of Clinical Nutrition. 2016;104(5):1403–1409. doi:10.3945/ajcn.116.136390.

•Higher Mediterranean diet adherence associated with • Better QOL • Decreased pain• Disability• Depressive symptoms

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Take two zaps and call me in the morning…

Salazar AP, Stein C, Marchese RR, Plentz RD, Pagnussat AS. Electric Stimulation for Pain Relief in Patients with Fibromyalgia: A Systematic Review and Meta‐analysis of Randomized Controlled Trials.

New migraine

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• 20 studies• VR is an effective treatment for reducing acute pain. There is some research that suggests VR can reduce chronic pain during the intervention; however, more evidence is needed to conclude that VR is effective for lasting reductions in chronic pain.

https://health.usnews.com/health‐care/patient‐advice/articles/2019‐01‐14/how‐virtual‐reality‐can‐help‐treat‐chronic‐pain

Key Points

• Lifestyle can have a positive effect on pain even with minimal changes

• Benefits appear to be synergistic• Technology and virtual therapies will play a larger role in pain management

• Important to find approaches which are personalized for long‐term compliance


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Objectives


Review


Examine


Evaluate

• Education—of providers, patients, and other key stakeholders––was identified as a major barrier…

• Lack of adequate knowledge and familiarity with these therapies among patients, frontline clinicians, and other key stakeholders also needs to be addressed with a national education campaign with clear messaging about the benefits of non‐pharmacological interventions

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Patient Centered Incorporation of CAM / Integrative Medicine

This Photo by Unknown Author is licensed under CC BY‐SA

EducationDiscussion & Decision Making

Coordination

AAFP Am Fam Physician. 2019 Jul 15;100(2):76‐78.https://www.aafp.org/afp/2019/0715/p89.html

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Models for Integrating Integrative Medicine

• Referral (appendix)• In‐house practitioners • Group Medical Visits…

• Jeff Geller MD et al

• https://im4us.org/toolkit

Gardiner P, et al. Medical Group Visits: A Feasibility Study to Manage Patients With Chronic Pain in an Underserved Urban Clinic. Global Advances in Health and Medicine. 2014;3(4):20‐26

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• Nurse led group medical visit (GMV)• Check‐in • Discussion / refills

Incorporation of:• stretching• tai chi• yoga• guided imagery…

• behavior therapy• visualization• mindfulness• Goal setting• Homework

• ~ 20% D/C opiates• ~ 20% reduced• Improvement in pain & QoL

Mehl‐Madrona L, Mainguy B, Plummer J. Integration of Complementary and Alternative Medicine Therapies into Primary‐Care Pain Management for Opiate Reduction in a Rural Setting. The Journal of Alternative and Complementary Medicine. 2016;22(8):621–626. doi:10.1089/acm.2015.0212.

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Our Most Powerful Techniques…

Greater practitioner empathy or communication of positive messages can have small patient benefits for a range of clinical conditions, especially pain.

Howick J, Moscrop A, Mebius A, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta‐analysis. Journal of the Royal Society of Medicine. 2018;111(7):240–252. doi:10.1177/0141076818769477.

I Feel Your Pain

Perception of pain in others allows the sense of knowing their experience and can lead to empathic concern and the adoption of a prosocial stance toward them.

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• Patient‐rated physician empathy was strongly correlated with patient satisfaction in a pain clinic consultation.

• Patient satisfaction plays a significant role in adherence to treatment and contributes to a positive working patient‐physician therapeutic relationship.

• This research supports the growing body of research citing the importance of investing in, promoting and developing … empathic communication skills within the clinical setting.

Walsh S, O’Neill A, Hannigan A, Harmon D. Patient‐rated physician empathy and patient satisfaction during pain clinic consultations. Irish Journal of Medical Science (1971 ‐). 2019;188(4):1379–1384. doi:10.1007/s11845‐019‐01999‐5.

Conclusions

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• Mean numbers of co-morbid + activity limiting conditions 6

• “There is a need for clinical care models and other interventions that simultaneously address the complexity and interrelationships of multiple chronic health conditions...”

The association of comorbid conditions with patient‐reported outcomes in Veterans with hip and knee osteoarthritis.JRheum.2014

+

Example Acupuncture:

Ref

treatment combination appears to result in greater therapeutic efficacy than medication therapy alone

Zhi WI, et al. Integr Cancer Ther 2018 ‐ Clinical Trial.X. Yin et al. / Sleep Medicine 37 (2017) 193e200Acupuncture in Medicine. 2019 Aug;37(4):211‐22Complement Ther Clin Pract , 31, 31‐37 May 2018

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U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter‐Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory‐committees/pain/reports/index.html

Conclusions: Improving Pain Care Through CAM/IM

• A number of CAM/IM therapies have evidence of reducing pain and supporting the bigger pain picture• Improved Function, Mood, Stress, and Quality of Life

• May also have potential benefit in reducing Cost and Medication use

• Innovative models exist to help incorporate CAM/IM

• Currently, much CAM incorporation is fragmented…

• Increased Education, Empathetic Discussion and Patient‐Centered Decision‐Making are key in closing gaps and improving pain care

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Integrative Medicine / Pain Resources / CME

• NIH: National Center for Complementary and Integrative Health• https://nccih.nih.gov

• University of Arizona Integrative Pain Management Series• https://integrativemedicine.arizona.edu

• University of Wisconsin Integrative Medicine Resources • https://www.fammed.wisc.edu/integrative/resources/modules/

Tools and Techniques for Managing Pain: Complementary & Integrative Approaches

Robert A. Bonakdar, MD FAAFP FACNDirector of Pain Management

Scripps Center for Integrative Medicine

Assistant Clinical ProfessorUCSD, School of Medicine (vol.)

@DrB_Well

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Documents

Tools and Techniques for Managing Pain · Director of Pain Management Scripps Center for Integrative Medicine Assistant Clinical Professor UCSD, School of Medicine (vol.) @DrB_Well