CAM You can Use: Preventing Headaches

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CAM You can Use Preventing Headaches

• Kathi J Kemper, MD, MPH
• General Pediatrics, Integrative Medicine
• 2nd Opinion Clinic (Monday mornings)
• kkemper_at_wfubmc.edu
• 716-9640

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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

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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

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Headache

• Common! (in teens, gt 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,

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CAM Use for Tension-Type HA

• 40 used CAM
• 60 did not tell MD (how many MDs asked?)
• Types of CAM
• Chiropractic 21
• Acupuncture 17
• Massage 17
• Rossi et al. Headache 46622-631, 2006

CAM Complementary or Alternative Medicine,
somewhat outdated and useless term
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CAM at UNC for Headache

• Biofeedback (thermal, muscular, heart rate
  variability, autonomic)
• Hypnotherapy
• Osteopathy
• Acupuncture
• Mindfulness Meditation
• Herbal and supplement counseling

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Prevention options
Bioenergetic
Patient-Centered Care
Biomechanical
Biochemical
LIFESTYLE
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Prevention/health promotion lifestyle

• Avoid triggers!
• Nutrition and supplements
• Exercise/sleep
• Environment
• Stress management

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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!!

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Diet Avoid Food Allergens

• Clinical trial of 43 patients
• Allergy skin testing
• 69 responded to diet modification (plt0.005)
• 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
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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

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Dietary Supplements

• B vitamins
• Minerals calcium, magnesium
• Fatty acids/fish oil
• CoQ10
• Melatonin

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Supplements B vitamins

• B2
• Migraine sufferers suspected of having a
  mitochondrial defect -gt 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 -gt 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 -gt nausea, abd pain,
  sleepiness, lower B12 levels gt1000 mg daily -gt
  sensory neuropathy

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High Dose Riboflavin vs. Placebo
Schoenen J et al. Effectiveness of high-dose
riboflavin in migraine prophylaxis a randomized
controlled trial. Neurology 50(2) 466-70 1998.
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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

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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

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Consequences of Reduced Mg

• Vasoconstriction of scalp arteries
• Reduced affinity of serotonin receptors
• Lower threshold for activation of
  N-methyl- d-aspartate receptors
• Enhanced platelet aggregation and serotonin
  release

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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.
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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

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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.
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Omega-6 Fatty Acids
Omega-3 Fatty Acids
Linoleic Acid (182n-6)
a-Linolenic Acid (183n-3)
?-6 Desaturase
(GLA)? -Linolenic Acid (183n-6)
Stearidonic Acid (184n-3)
Elongase
(DHGLA) Dihomo-?-Linolenic Acid (203n-6)
Eicosatetraenoic Acid (204n-3)
?-5 Desaturase
Eicosanoids
(AA)Arachidonic Acid (204n-6)
(EPA) Eicosapentaenoic Acid (205n-3)
Elongase
245n-3
Eicosanoids Leukotriene 5-series Prostaglandins
E3 Thromboxanes A3
?-6 Desaturase
Eicosanoids Leukotriene 4-series Prostaglandins
E2 Thromboxanes A2
246n-3
ß-Oxidation
(DHA) Docosahexaenoic Acid (226n-3)
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Changing Fatty Acid IntakeOmega 6 Omega 3
n-6 fats n-3 fats

• Prehistoric 1900 2000
• 11 41 251

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Why EFA Imbalance in US?

• Diet is high in Omega-6 and low in Omega-3
  (previously 11 ratio, now 201)
• 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 -gt increased demands.

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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

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Coenzyme Q-10

• Open label, 150 mg qd - for 3 months
• 62 had gt 50 reduction in number of HA days
• Migraine Days 7.34 -gt 2.95/mo
• Frequency 4.85 -gt 2.81/month
• No side effects except pain in pocketbook
• Rozen and Silberstein, Cephalalgia 22 137-141,
  2002

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Melatonin and Headache

• Mechanism
• Potentiates GABA Modulates Ca entry in to
  vascular smooth muscle cells
• Modulates 5HT2 receptor like B- blockers
  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

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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

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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

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The Many Forms of Mind-Body Medicine
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Stress and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Low Arousal/Low Energy
PARASYMPATHETIC
Institute of HeartMath
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Biofeedback-What and why?

• Use of electronic equipment to measure and feed
  back information about physiologic
  functionswhich are then modulated in desirable
  direction
• Goal-balancing ANS ( CNS) activity
• video-games for your body kid-friendly
• 2007 meta-analysis showed gt 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

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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.
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Biofeedback Modalities

• Home or Office Use
• Peripheral Temperature
• Heart Rate Variability
• Surface EMG
• Skin Conductance

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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

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Heart Rate Variability (HRV)
2
1.5
76 BPM
83 BPM
70 BPM
m Volts
1
.793 sec.
.726 sec.
.859 sec.
0.5
0
-0.5
0
1
2
2.5 seconds of heart beat data
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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.

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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 its up to the child/adolescent

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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)

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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 (Plt0.05)
• Olness. Pediatrics. 1987
• Hammond Int J Clin Exp Hypn. 2007

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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

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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)

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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

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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

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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

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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

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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 gtlikely to report reduced suffering
• Coeytaux R. Headache, 2005
• Gottschling. Pain, 2008 PEDIATRIC STUDY LASER
  ACUP.
• Witt. Cephalgia, 2008 COST EFFECTIVENESS

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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.

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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
  

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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

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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
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Acupuncture
Vincent C. A controlled trial of the treatment of
migraine by acupuncture. Clinical Journal of
Pain. 5(4) 305-12 1989.
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Acupuncture Migraine Reviews involving gt 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

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Healing Touch And Therapeutic Touch
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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

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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

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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 gt placebo
• Variability in quality of products!
• Murphy J et al.. Lancet 1988.
• Ernst E et al.. Public Health Nutrition .2000.

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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

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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

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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.

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RESOURCES

• Acupressure / acupuncture
• Self care
• Hypnosis
• Biofeedback

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Acupressure resources

• 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)

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HRV Biofeedback - Resources

• 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

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Self-Care Training Resources

• Books
• Be the Boss of Your Body Series
• www.freespirit.com
• Ways to Wellness Videos
• http//www.childrensmn.org/Communities/Integrative
  Med.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

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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

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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

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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

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PCIM Director Kemper
Medical School Arcury (Family Med) Avis (Public
Health) Chilton (Phys/Pharm) Curl
(Orthopedics) Tegeler (Neurology) Stant
newsletter/Web
Hospital Atkinson (Business Dev.) Johnson
(Operations/Nursing) Parker (Home
Community) Small (Quality) Snelgrove
(Operations) Yates (Pastoral Care) Zachary
(meetings)
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Program leaders Bailey Ambience Sound/Music Best
Health Black ActionHealth/ Farmers
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
Medical School
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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

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Goal-setting

• Pick a POSITIVE goal
• E.g., healthier lifestyle.

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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?

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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

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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)

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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!

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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. Its OK to be ambivalent
  about change!

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Identify Pros and Cons
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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?

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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 patients
  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).

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Sample behavior diary (OK to copy)
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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 theyd like to do for next
  step (involve them in problem solving).
• Do it!

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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