An Ancient Science with a Modern Evidence-Based Approach

A 15-year-old patient walked into the clinic with her mom presenting with symptoms of constipation, lower abdominal spasms, and pain with bowel movements. Over the course of the visit, I learned that she was on medication for depression and was also suffering from chronic anxiety. Anxiety pervaded every aspect of her life, from things happening during the day to her near and far future. Her symptoms were worse when her anxiety was high and she struggled to relax her body and mind.

So, in addition to teaching her a program with breathing exercises, self-abdominal massage, pelvic girdle stretching, and the use of a squatty potty, I also taught her perineal self-acupressure at the acupoint Central Vessel 1 (CV 1) for constipation and two self-regulation points Central Vessel 17 (CV 17) and Yintang (EX-HN 3) for alleviating her anxiety.

CV1 also known as Huiyin is located at the perineum. A study by Abbott et al. reported that the perineal self-acupressure technique was found to be remarkably effective with statistically significant and clinically meaningful improvements in Patient Assessments of Constipation Quality of Life (PAC-QOL All), modified Bowel Function Index (BFI), and the Short-Form Health Survey (SF-12v2). Huiyin is used in Traditional Chinese Medicine (TCM) not only to treat constipation, but also a variety of conditions including impotence, hemorrhoids, rectal prolapse, and dysmenorrhea. CV17 is located at the center of the chest and is known to be a point for emotional healing while Yintang (EX-HN 3) is located between the eyebrows and is known to have a mentally stabilizing effect in Traditional Chinese Medicine (TCM).

The patient returned the next visit and reported that her abdominal spasms were 50% better and she no longer had pain with bowel movements. She also reported that she felt calmer and was able to use the perineal self-acupressure technique to evacuate very quickly. Over the past several years, I have found that adding Acupressure to my clinical practice has added so much value as an Integrative holistic tool to complement traditional care.

Evidence-based Integrative health and medicine practices blend traditional physical therapy methods with holistic practices that address the whole person-physically, mentally, emotionally, and spiritually (Justice et al). Acupressure is considered an Integrative medicine practice and is based on traditional Chinese meridian theory in which acupuncture points are pressed to stimulate the flow of energy or Qi. Acupuncture meridians are believed to form a network throughout the body, connecting peripheral tissues to each other and to the central viscera. This tissue network is also continuous with more specialized connective tissues such as periosteum, perimysium, perineurium, pleura, peritoneum, and meninges (Kaptchuk).

There is robust scientific evidence supporting acupressure as an effective non-pharmacological therapy for the management of a host of conditions such as anxiety, insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, digestive disturbances, and urinary dysfunctions to name a few.

Acupressure has demonstrated the ability to improve heart rate variability, and thus decrease sympathetic nervous system activity. By decreasing sympathetic nervous system stimulation, the release of stress hormones such as epinephrine and cortisol is decreased, and the relaxation response can be augmented, which may correlate with decreasing levels of pain, stress, and anxiety (Monson et al).

To learn more about Acupressure, join the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for October 12th-13^th. This course introduces practitioners to the basics of traditional Chinese medicine (TCM), acupuncture & acupressure, and provides an introduction to Yin yoga. Of the 12 major Meridians or energy channels, the focus is on the majority of acupoints in the Bladder, Kidney, Stomach, and Spleen meridians. In addition, there are other important meridian points that stimulate the nervous system and can be used for self-regulation, improving the flow of Qi the life force energy to improve the physiological functioning of the organs. The course also explores Yin poses within each meridian to channelize energy through neurodynamic pathways with powerful integrative applications across multiple systems. If you are not able to attend the October course date, then check out the website for the options scheduled for 2025.

References

1. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256
2. Abbott R, Ayres I, Hui E, Hui KK. Effect of perineal self-acupressure on constipation: a randomized controlled trial. J Gen Intern Med. 2015;30(4):434-439.
3. Kaptchuk TJ. 2000. The web that has no weaver. Understanding Chinese medicine. Chicago: Contemporary Publishing Group, Inc.
4. Justice C, Sullivan MB, Van Demark CB, Davis CM, Erb M. Guiding Principles for the Practice of Integrative Physical Therapy. Phys Ther. 2023;103(12):pzad138. doi:10.1093/ptj/pzad138
5. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.
6. Abaraogu UO, Igwe SE, Tabansi-Ochiogu CS. Effectiveness of SP6 (Sanyinjiao) acupressure for relief of primary dysmenorrhea symptoms: A systematic review with meta- and sensitivity analyses. Complement Ther Clin Pract. 2016;25:92-105
7. He Y, Guo X, May BH, et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233

AUTHOR BIO
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University, New York with a Doctor of Physical Therapy degree. Rachna has been working in outpatient hospital and private practice settings for over 15 years with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer County, New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner, and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. The majority of her clinical orthopedic practice has focused on treating musculoskeletal, neurological, pre- and post-operative surgical conditions to name a few. She specializes in working with pelvic health patients who have bowel & bladder issues with high pelvic pain which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional, and energy body.

In this brief blog, I hope to explore several lifestyle medicine strategies (sleep hygiene, stress management, social connectedness) and how they may be included in therapeutic interventions to improve clinical outcomes. Frates and colleagues define lifestyle medicine as "The use of evidence-based lifestyle therapeutic approaches, such as a predominately whole-food and plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use, and other non-drug modalities to treat, oftentimes reverse, and prevent the lifestyle-related, chronic disease that's all too prevalent."¹ Figure 1, adapted from the American College of Lifestyle Medicine, outlines the six pillars of lifestyle medicine.

Figure 1. Components of lifestyle medicine

Sleep Hygiene in Patient Education
The following are some simple patient education strategies that may help patients improve sleep:^2-5

• Establish a regular bedtime and waking hours (avoid or minimize "social jet lag" that may be due to work, school, or your personal schedule).
• Create a comfortable room that is cool, dark, and quiet.
• Sleep in a comfortable bed and make sure it's not too old.
• Use a supportive and comfortable pillow and ensure it's not too old.
• Eliminate nighttime caffeine and limit daytime caffeine.
• Do not wear tight or restrictive clothing during sleep
• Avoid alcohol within 3 hours of bedtime.
• Do not smoke or use nicotine.
• Eliminate/limit after-dinner and late-night snacking.
• Limit or avoid computer use and smartphone use near bedtime.
• Avoid intense exercise near bedtime. However, do exercise and be physically active during the day.
• Maintain a healthy body mass index (BMI).
• Avoid watching intense television shows before bedtime.
• Turn off the radio and television before going to sleep.
• Avoid bright light near bedtime, but do increase daytime exposure to sunlight.
• Consider reducing your fluid intake near bedtime to avoid (or minimize) getting up to go to the bathroom, but maintain adequate hydration during the day.
• Minimize sugar and salt intake near bedtime as it may cause increased trips to the bathroom.
• Learn strategies to reduce daily stress so it does not result in poor quality and quantity of sleep.
• Minimize a tense or stressful lifestyle since this may carry over into sleep.
• Embrace mindfulness before bedtime
• Consider meditating close to bedtime or using a body scan or progressive muscle relaxation technique.
• Consider tai chi, qigong, or yoga later in the day.
• Establish a bedtime ritual such as:
• One hour before going to sleep, shut down all phone and computer devices. Then you can either read a book or watch a funny television show (drama may be too stimulating).
• Five minutes before you go to sleep, brush your teeth and floss, wash your hands and face with lavender soap, and shut off all the lights before slipping into your cozy bed with gratitude and pleasant thoughts.

Stress Management Patient Education
The following are some simple patient education strategies that may help patients manage stress:⁶

• Try yoga, tai chi, qigong
• Use aromatherapy (such as lavender)
• Engage in outdoor physical activities such as walking, hiking, and biking
• Engage in outdoor activities such as gardening
• Participate in hobbies such as reading, pottery, painting, and playing music
• Play with pets
• Get a massage
• Get involved in social activities such as volunteering, coaching, and community dancing
• Listen to music
• Smile and laugh more by watching comedy movies or television shows

Social Connectedness Patient Education
The following are some simple patient education strategies that may help patients improve socialization and social connectedness to form nurturing and constructive relationships:^7-13

• Attend local sporting events, music performances, or art and museum exhibits.
• Connect with family and friends locally or on Zoom.
• Connect with your physician, therapist, wellness, or fitness professional via telehealth-delivered services.
• Create or join a community garden club.
• Create or join a lunchtime walking, yoga, or tai chi club.
• Engage in conventional group exercises such as softball, volleyball, basketball, pickleball, paddle tennis, or tennis.
• Engage in mind-body exercises such as yoga, tai chi, or Pilates.
• Engage in work-related community activities and fitness programs.
• Engage in small conversations with cashiers and employees at various stores you visit.
• Engage with members at your community place of worship.
• Enroll in art-based community activities, such as art, dance, drama, music, poetry, pottery, or expressive writing classes.
• Enroll at a local or community college to take cooking, history, or astronomy classes.
• Get a library card and participate in book club events.
• Get involved in nature-based activities, such as bird watching, botanical garden and park visits, farmer's market shopping, forest bathing or hiking, gardening, or walks at a lake, river, or beach.
• Join a group, such as a local bicycling club, chess, or table tennis club, or participate in your favorite hobby.
• Join a gym or fitness center.
• Join self-help groups.
• Join social media platforms like LinkedIn, Facebook, Twitter, Instagram, or TikTok.
• Play with your pets.
• Volunteer at a community center, hospital, school, or library.
• Volunteer to coach sports or mentor students.
• Walk with a mall club or create one in your neighborhood

If you are interested in learning more about these topics and others, please see my course Integrative and Lifestyle Medicine Toolbox for Rehab and Pain Management with Herman & Wallace.

Resources for Clinicians:

Learn how to include integrative and lifestyle medicine into your clinical practice with these resources:

• Academy of Integrative Health & Medicine
• American College of Lifestyle Medicine
• American College of Preventive Medicine
• Institute of Lifestyle Medicine
• National Center for Complementary and Integrative Health

Instructor Bio:
Ziya "Z" Altug, PT, DPT, MS, OCS is a board-certified doctor of physical therapy with 32 years of clinical experience treating musculoskeletal injuries. Z currently provides outpatient physical therapy in the home setting in Los Angeles, California, and serves as a continuing education instructor.

Z received his Bachelor of Science in Physical Therapy at the University of Pittsburgh in 1989, Master of Science in Sport and Exercise Studies in 1985 and Bachelor of Science in Physical Education in 1983 from West Virginia University, and a Doctor of Physical Therapy from the College of St. Scholastica in 2015. Z is a long-standing member of the American Physical Therapy Association and a member of the American College of Lifestyle Medicine. He has attended workshops in yoga, tai chi, qigong, Pilates, Feldenkrais Method, and the Alexander Technique.

Z is the author of the books Integrative Healing: Developing Wellness in the Mind and Body (2018), The Anti-Aging Fitness Prescription (2006), and Manual of Clinical Exercise Testing, Prescription, and Rehabilitation (1993). In 2020, he published the chapter Exercise, Dance, Tai Chi, Pilates, and Alexander Technique in The Handbook of Wellness Medicine. In 2021, he published the article Lifestyle Medicine for Chronic Lower Back Pain: An Evidence-Based Approach in the American Journal of Lifestyle Medicine.

References:

1. Frates, B., Bonnet, J.P., Joseph, R., & Peterson, J.A. (2019). Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning.
2. Altug Z. Integrative Healing: Developing Wellness in the Mind and Body. Springville, UT: Cedar Fort, Inc.; 2018.
3. Kryger MH, Roth T, Goldstein CA. Principles and Practice of Sleep Medicine (2 Volume set), 7th ed. Philadelphia, PA: Elsevier; 2021
4. Matsuo T, Miyata Y, Sakai H. Effect of salt intake reduction on nocturia in patients with excessive salt intake. Neurourol Urodyn. 2019;38(3):927-933.
5. Vitale KC, Owens R, Hopkins SR, Malhotra A. Sleep hygiene for optimizing recovery in athletes: review and recommendations. Int J Sports Med. 2019;40(8):535-543.
6. American College of Lifestyle Medicine. Handout: Lifestyle stress reduction. American College of Lifestyle Medicine; 2019.
7. Leavell MA, Leiferman JA, Gascon M, Braddick F, Gonzalez JC, Litt JS. Nature-based social prescribing in urban settings to improve social connectedness and mental well-being: a review. Curr Environ Health Rep. 2019;6(4):297-308.
8. National Institutes of Health. Social Wellness Toolkit. Bethesda, MD: National Institutes of Health. Accessed on June 2022.
9. Roland M, Everington S, Marshall M. Social prescribing - transforming the relationship between physicians and their patients. N Engl J Med. 2020;383(2):97-99.
10. Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry. 2020;28(7):698-708.
11. Davidson KW, Krist AH, Tseng CW, et al. Incorporation of social risk in US Preventive Services Task Force recommendations and identification of key challenges for primary care. JAMA. 2021;326(14):1410-1415.
12. Eder M, Henninger M, Durbin S, et al. Screening and interventions for social risk factors: technical brief to support the US Preventive Services Task Force. JAMA. 2021;326(14):1416-1428.
13. Steinman L, Parrish A, Mayotte C, et al. Increasing social connectedness for underserved older adults living with depression: a pre-post evaluation of PEARLS. Am J Geriatr Psychiatry. 2021;29(8):828-842.

Integrative and Lifestyle Medicine Toolbox for Rehab and Pain Management

Course Dates:
January 21, 2023

Price: $125
Experience Level: Beginner
Contact Hours: 4.5

Description: This course was written and developed by Ziya “Z” Altug, PT, DPT, MS, OCS, a board-certified doctor of physical therapy with 32 years of experience in treating musculoskeletal conditions, Brief lectures on the research and resources and labs will cover a toolbox approach for creating clinically relevant pain, anxiety, depression, and stress management strategies using lifestyle medicine, integrative medicine, expressive and art-based therapies, and the impact of nature on health. Participants will be able to practice Tai Chi/Qigong, expressive and art-based therapies including Music, Dance, and Drama Therapy, nature and aromatic therapies, self-hypnosis, and self-massage. 

Ziya Altug, PT, DPT, MS, OCS is a board-certified doctor of physical therapy with 32 years of clinical experience treating musculoskeletal injuries. Z currently provides outpatient physical therapy in the home setting in Los Angeles, California, and serves as a continuing education instructor. He received his Bachelor of Science in Physical Therapy at the University of Pittsburgh in 1989, a Master of Science in Sport and Exercise Studies in 1985, a Bachelor of Science in Physical Education in 1983 from West Virginia University, and a Doctor of Physical Therapy from the College of St. Scholastica in 2015. Z is a long-standing member of the American Physical Therapy Association and a member of the American College of Lifestyle Medicine. He has attended workshops in yoga, tai chi, qigong, Pilates, Feldenkrais Method, and the Alexander Technique.

Dr. Altug is the author of the books Integrative Healing: Developing Wellness in the Mind and Body (2018), The Anti-Aging Fitness Prescription (2006), and Manual of Clinical Exercise Testing, Prescription, and Rehabilitation (1993). In 2020, he published the chapter Exercise, Dance, Tai Chi, Pilates, and Alexander Technique in The Handbook of Wellness Medicine. In 2021, he published the article Lifestyle Medicine for Chronic Lower Back Pain: An Evidence-Based Approach in the American Journal of Lifestyle Medicine. Z joins the H&W faculty and is presenting his personally curated course Integrative and Lifestyle Medicine Toolbox for Rehab and Pain Management. This week he sat down with The Pelvic Rehab Report to discuss his course.

What made you want to create this course?
My father was a physician specializing in internal medicine. He specialized in treating conditions such as tuberculosis, chronic obstructive pulmonary disease (COPD), and asthma. Starting in elementary school, I remember discussing with my Dad the importance of nutrition, sleep, stress control, and sustainable activity in healing. Of course, as a ten-year-old, I played with his stethoscope and reflex hammer for hours! My father used “lifestyle medicine” principles to help his patients recover. My Mom introduced me to the benefits of aromatherapy for relaxation. She used to wash our clothes with lavender-scented soaps, and there was lavender-scented potpourri throughout our house. My mother used to say the lavender was to “keep the wolves away so the sheep can sleep.” She also taught me how to prepare and cook healthful meals in high school. Now, I have a fascination with culinary medicine. I am very grateful for all of these childhood experiences.

Before entering PT school, I majored in physical education and exercise science. After I graduated from PT school, I wanted to use my interest in wellness, health, fitness, and self-care strategies to help patients heal and recover. Recently, I have followed the American College of Lifestyle Medicine research and webinars to gain additional knowledge. Currently, I treat patients in their homes and teach continuing education courses in integrative and lifestyle medicine.

What need does your course fill in the field of pelvic rehabilitation?
This course provides practical tools to help clinicians manage pain. For example, my course will cover research, resources, and labs to create clinically relevant pain, anxiety, depression, and stress management strategies using lifestyle medicine, integrative medicine, and expressive and art-based therapies. Participants will be able to practice Tai Chi/Qigong, expressive and art-based therapies including Music, Dance, and Drama Therapy, nature and aromatic therapies, self-hypnosis, and self-massage. All of these strategies may be helpful for clinicians specializing in pelvic rehabilitation.

Who, what demographic, would benefit from your course?
Rehabilitation providers of any experience level would benefit from taking this course.

What patient population do you find most rewarding in treating and why?
I currently focus on orthopedics and geriatrics. I especially enjoy working with older patients in their homes and designing creative home exercise programs they can use to stay healthy.

What do you find is the most useful resource for your practice?
I enjoy using resources from the following organizations:

• American College of Lifestyle Medicine
• American College of Sports Medicine
• International Association for the Study of Pain

What books or articles have impacted you as a clinician?
I enjoyed reading the following three books to expand my knowledge of lifestyle medicine and integrative medicine:

• Lifestyle Medicine by James Rippe
• Lifestyle Medicine Handbook by Beth Frates and colleagues
• Lifestyle Medicine by Garry Egger and colleagues

What is your message to course participants who are just starting their journey?
I recommend all clinicians collaborate with professionals outside their own profession. For example, I recommend physical therapists work with the following:

• Acupuncturists, massage therapists, registered dietitians
• Practitioners in yoga, Pilates, qigong, tai chi, Alexander Technique, Feldenkrais Method
• Specialists in expressive therapies such as dance, music, art, drama, poetry, and play.

Integrative and Lifestyle Medicine Toolbox for Rehab and Pain Management

Course Dates:
January 21, 2023

Price: $125
Experience Level: Beginner
Contact Hours: 4.5

Description: This course was written and developed by Ziya “Z” Altug, PT, DPT, MS, OCS, a board-certified doctor of physical therapy with 32 years of experience in treating musculoskeletal conditions, Brief lectures on the research and resources and labs will cover a toolbox approach for creating clinically relevant pain, anxiety, depression, and stress management strategies using lifestyle medicine, integrative medicine, expressive and art-based therapies, and the impact of nature on health. Participants will be able to practice Tai Chi/Qigong, expressive and art-based therapies including Music, Dance, and Drama Therapy, nature and aromatic therapies, self-hypnosis, and self-massage.