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East meets West. Robert Bennett, MD. Professor of Medicine and Nursing OHSU. East meets West. Integrative Medicine: .

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slide1

East meets West

Robert Bennett, MD

Professor of Medicine and Nursing OHSU

slide2

East meets West

Integrative Medicine:

A marriage of conventional Western medicine with other healing modalities, including complementary and alternative medicine (CAM), for which there is evidence of safety and effectiveness.

Examples:Traditional Chinese medicine (herbs, acupuncture, gigong)Hands–on therapy (osteopathy, massage), Lifestyle(education, nutrition, exercise)Mind-body therapies (yoga, Tai Chi).

slide3

The Topics

The Myofascial Web

Mindful Movement

Eastern Treatments

Optimal Nutrition

slide4

The Topics

The Myofascial Web

Mindful Movement

Eastern Treatments

Optimal Nutrition

slide5

Myofascial Trigger Points

Why is it important to eliminate myofascial trigger points ?

slide6

Anatomyof Pain

Brain

Centralsensitization

Pain generators

Spinal cord

slide8

The Topics

The Myofascial Web

Mindful Movement

Eastern Treatments

Optimal Nutrition

slide9

Time Magazine, February 2, 2014

The raisins sitting in my sweaty palm are getting stickier by the minute. They don't look particularly appealing, but when instructed by my teacher, I take one in my fingers and examine it

The ability to focus for a few minutes on a single raisin isn't silly if the skills it requires are the keys to surviving and succeeding in the 21st century

slide10

Science meets Meditation

Epigenetics:

Changes in gene expression related to environmental factors

Conclusion: Eight weeks of daily yogic meditation reversed the pattern of increased expression of genes associated with inflammation

slide11

The Topics

The Myofascial Web

Mindful Movement

Eastern Treatments

Optimal Nutrition

slide12

Traditional Chinese Medicine

Yin and yang symbol for balance. In Traditional Chinese Medicine, good health is believed to be achieved by a balance between yin and yang

Main components:Herbal medications

Acupuncture

Massage (Tuina)

Exercise (qigong)

slide13

Acupuncture

A 5000-year old medical system based on the theory that“Qi” (the life force which flows throughout our body) is out of balance

slide14

Cochrane database review 2013

Deare, JC, et al. Acupuncture for treating fibromyalgia. Cochrane database review. 2013, May 31

Reviewed 9 randomized controlled studies (i.e. sham acupuncture) involving 321 subjects:

There is low to moderate-level evidence that acupuncture improves pain and stiffness

The effect lasts up to one month

Electro acupuncture is probably more effective than manual acupuncture

The effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue

slide15

The Topics

The Myofascial Web

Mindful Movement

Eastern Treatments

Optimal Nutrition

slide16

Probiotics

WHO definition: micro-organisms which, when administered in adequate amounts, confer a health benefit on the host

Kefir

Elie Metchnikoff first suggested the possibility of colonizing the gut with beneficial flora in the early 20th century.

1845 - 1916

slide17

Recent Review

Quigley, EM. Prebiotics and probiotics; modifying and mining the microbiota. Pharmacology Research. March 2010

A new era in medical science has dawned with the realization of the critical role of the "forgotten organ", in generating a variety of functions which sustain health and, when disrupted, leads to disease.

Your gut harbors 100 trillion organisms

Prevotellacopri – rheumatoid arthritis

Bacteroidesprevotella – obesity

Clostridium perfringens – multiple sclerosis

Lactobacilli & Bifidobacteria– irritable bowel

slide18

Coprophagy ?

  • Patients with recurrent Clostridium difficileinfection underwent therapy with donor feces that were infused, through a naso-duodenal tube.
  • This treatment was compared to a a group of patients treated with a conventional 14 day vancomycin regime.
slide19

Results of fecal transplantation study

After 2 fecal transplantations there was a 94% cure rate

slide20

Are you a chocolate lover?

A prebiotic?

The good microbes, such as Bifidobacterium and lactic acid bacteria, feast on chocolate

When you eat dark chocolate, they grow and ferment it, producing compounds that are anti-inflammatory

slide22

Descending Inhibition

Remember

Activate your descending inhibitory system every day

myofascial web and fibromyalgia

Myofascial Web and Fibromyalgia

Ginevra Liptan, MD

Fibromyalgia Information Foundation 2014 Annual Conference

fibromyalgia fm pain
Fibromyalgia (FM) pain
  • Hyper-reactive spinal cord and brain called “central sensitization”
  • Pain generated from muscle tissue
what is fascia
What is fascia?
  • Connective tissue network
  • Surrounds both individual and groups of muscles
  • Highly sensitive to pain
  • Contracts to give muscles extra strength
fascia in fm
Fascia in FM
  • Increased tension
  • Inflammation
  • Prone to “ knotting up”( myofascial trigger points)
myofascial trigger points
Myofascial trigger points
  • Hyper-irritable or taut band of muscle
  • Painful on compression
  • Refers pain
  • Can occur in any muscle under strain
myofascial release therapy
Myofascial release therapy
  • Manual traction and prolonged assisted stretching
  • Breaks up painful adhesions in the connective tissue surrounding muscle
castro sanchez et al 2011
Castro-Sanchez et al . 2011
  • 20 weeks myofascial release therapy
  • Compared to sham ultrasound
  • Significant improvement in pain and tender points
  • Pain reduction persisted at 1 and 6 months post-intervention
our study mfr vs massage
Our study- MFR vs. massage
  • Women between the ages of 21 and 50 with a confirmed FM diagnosis
  • Randomized to myofascial release or Swedish massage
  • Therapists had advanced training using the John F. Barnes MFR approach
  • 90 minutes weekly for 4 weeks
fiq r percentage change in myofascial release subjects
FIQ-R Percentage Change in Myofascial Release Subjects

A change of 14% or more is considered significant

Percentage change in FIQ-R

Myofascial release subjects 1–8

fiq r percentage change in massage subjects
FIQ-R Percentage Change in Massage Subjects

A change of 14% or more is considered significant

Percentage change in FIQ-R

Massage subjects 1–4

trigger point injections
Trigger point injections
  • Injection of lidocaine
  • “Dry needling”
resources
Resources

Web sites:

  • www.theracane.com
  • www.myofascialrelease.com
  • Book:
  • The Trigger Point Therapy Workbook: Your Self- Treatment Guide for Pain Relief by Clair Davies
mindful movement meditation

Mindful Movement & Meditation

How & Why Yoga Helps those with Fibromyalgia

E.B. Ferdig

E-RYT500, certified yoga therapist

ohsu study shows yoga effectiveness
OHSU Study Shows Yoga Effectiveness
  • Result:Pain reduced an average of 24%
  • Fatigue reduced an average of 30%
  • Depression reduced by 42%

Participants attended weekly classes of gentle stretching, meditation, breathing exercises & group discussion

They were also given a DVD video and encouraged to do yoga regularly at home

how why does yoga help
How & why does yoga help?
  • Yoga is varied & can be adapted to the student
    • Primarily a mental practice, but also can be:
      • Physical
      • Emotional
      • Energetic
      • Spiritual
    • We can take what we need & leave the rest
    • For yoga to work, we need to do it. To do it, we need to have experienceof it being helpful, so we might build new habits.
benefits of breathing
Benefits of Breathing
  • If we can breathe, we can do yoga
  • The pain that comes with Fibromyalgia keeps many people in “fight or flight” mode
  • By breathing very slowly for just one minute, we can take brain from fight or flight mode, to “executive functioning,” so we can make good decisions (or just relax)
moving mindfully
Moving Mindfully
  • Movement is important:
    • our joints need movement for lubrication for healthy function
    • Tight muscles restrict our movement in the world and cause more tight muscles
    • Strong and flexible muscles help us prevent injury
  • With fibromyalgia, we often don’t know what kind of movement will hurt – especially later on
  • Working slowly and carefully, and observing like a reporter will help establish safe boundaries
yoga improves mood
Yoga has been proven in studies to improve mood. Several study shows increased GABA (hormone brain that inhibits stress feelings) levels

Any style of yoga – but always a combination of movement, mindfulness, meditation, relaxation and breath.

As little as 20 min/day

Must be done regularly to have effect

Yoga improves mood
ways to access yoga instruction
Work with someone experienced in chronic pain or adaptive yoga

Group classes (gentle, yin, restorative)

Specialty group classes (yoga for chronic pain, adaptive yoga, meditation, mindfulness-based stress reduction)

Individual yoga therapy

Ways to access yoga instruction

www.unfoldportland.com

studies referenced in presentation
Studies referenced in presentation
  • James W. Carson, Kimberly M. Carson, Kim D. Jones, Robert M. Bennett, Cheryl L. Wright, Scott D. Mist. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgiaPain, 2010; 151 (2): 530
  • Streeter CC1, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, TerhuneDBYoga Asana sessions increase brain GABA levels: a pilot studyJ Altern Complement Med. 2007 May;13(4):419-26
  • CirauloDA, Renshaw PF.. MichalsenA, Grossman P, Acil A, Langhorst J, Ludtke R, Esch T. Rapid stress reduction and anxiolysis among distressed women as a consequence of a three-month intensive yogaMed SciMonit. 2005;11:555–61. 
full disclosure
Full Disclosure
  • I am a licensed acupuncturist
  • Some of what I tell you is personal opinion but I will try to between things that are supported by data and opinion
overview
Overview
  • What do I mean by Eastern treatments?
  • What is the evidence?
  • What does a common course of treatment look like?
  • How to select a practitioner?
what do i mean by eastern treatments
What do I mean by Eastern treatments?
  • Diet
  • Lifestyle
    • Meditation
    • Exercise such as tai chi, yoga, qigong, and nejang
  • Herbal Medicine
  • External Therapies
    • Acupuncture
    • Massage such as tuina, shiatsu, and kunye
    • Cupping
state of published evidence
State of Published Evidence
  • Diet
    • Generally poor evidence due to lack of studies
    • Few studies of fibromyalgia patients without additional diseases
    • Interesting study by Holton, et al at OHSU found that MSG worsened fibromyalgia severity in patients with
    • irritable bowel syndrome

Holton KF, Taren DL, Tomson CA, Bennett RM & Jones KD 2012

state of published evidence1
State of Published Evidence
  • Lifestyle
    • Meditation
      • More evidence than for diet but still not much
      • Mostly focuses on mindfulness
      • Improves quality of life, symptom severity but not pain
    • Exercise1
      • Much more evidence but covered by Ms. Ferdig’ presentation

1 Mist SD, Firestone KA, Jones KD 2013

state of published evidence2
State of Published Evidence
  • Herbal Medicine
    • Huge field with very little research
    • Several Chinese medicine formulas have been evaluated but study quality is low and none have been replicated
    • Topical capsaicin has been shown to improve sleep disturbances and tenderness but not pain.
state of published evidence3
State of Published Evidence
  • External Therapies
    • Acupuncture
state of published evidence4
State of Published Evidence
  • External Therapies
    • Acupuncture
      • Many more studies!
      • But conflicting information.
      • Great Britain, Germany, Canada and Israel all include acupuncture among the highest level of evidence and suggest it be used depending on the individual’s interest.
      • Wait a minute. It isn’t better than placebo?
state of published evidence5
State of Published Evidence
  • External Therapies
    • Cupping

Interesting but small study showed that

fibromyalgia patients improved on pain and tender point count with cupping

    • Massage

Recent review showed that massage for greater than 5 weeks improved pain, anxiety and depression.1

1 Yan-hui Li, Feng-yun Wang, Chun-qing Fen, Xia-feng Yang, Yi-hua Sun 2014

what does a common course of treatment look like
What does a common courseof treatment look like?
  • Exercise
    • E.B. gave recommendations for exercise
  • Acupuncture
    • Best if twice a week for 4-6 weeks followed by weekly treatments to 20 treatment
    • If you don’t get improvements in the first 6 weeks you may be a non-responder
    • Often see sleep improve first
what does a common course of treatment look like1
What does a common courseof treatment look like?
  • Massage
    • Best if twice a week for 2-4 weeks followed by weekly for additional 4 weeks
    • Should see improvements in first 4 treatments
  • Meditation
    • Only works if you practice
    • Recommend that you find a good instructor in the beginning
    • Changes happen in the first 4 weeks but may take as long as 12
    • There are many different types of meditation
cupping
Cupping
  • CAVEAT – few studies and little best practices
  • Best if weekly for 6 -8 weeks
  • Should see improvements in first 4 treatments
  • Warning, will leave bruises
how to select a practitioner
How to select a practitioner
  • First ask your friends!
  • Second, look at national and state licensing agencies
  • If you are looking for a Chinese herbalist, go to NCCAOM website.
conclusions future directions
Conclusions & Future Directions
  • Eastern practices and therapies are promising and should be considered for adjunctive therapies
  • A lot more research is needed in all areas of CAM and fibromyalgia
importance of diet
Importance of Diet
  • Nutrition is the single most important factor in optimizing your health
  • Positive vs. negative aspects to diet:
  • Positive
      • Vitamins, Minerals, Protein, EFAs, Fiber
  • Negative
    • Food additives, excess sugar, pesticides, herbicides, trans fats
food additives
Food Additives
  • Excitotoxins
    • Glutamate, aspartate and L-cysteine
    • Found under a myriad of names
  • Artificial sweeteners
    • Aspartame, acesulfame K, saccharin, sucralose

Artificial colors

    • Interactions w/excitotoxins
glutamate
Glutamate
  • Glutamate– a non-essential, negatively charged AA from diet
  • The most ubiquitous excitatory neurotransmitter in mammals – very important!
    • Functions all over body (gut, immune system, pancreas, neuromuscular junction and brain)
    • Precursor to the inhibitory neurotransmitter GABA
  • Disordered glutaminergicneurotransmission has been implicated in FM
  • Excess glutamate can lead to excitotoxicity
    • Also causes oxidative stress
  • Bound vs free glutamate
    • Meat versus soy sauce
hidden excitotoxins
Hidden Excitotoxins
  • I also recommend avoiding all artificial colors, artificial flavors, artificial sweeteners
  • Acesulfame-K (Sunett, Sweet One)
  • Aspartame (Equal, NutraSweet, Canderel)
  • Autolyzed yeast (or autolyzed yeast extract)
  • Barley malt extract
  • Bouillon
  • Broth
  • Calcium caseinate
  • Carrageenan
  • Flavoring
  • Gelatin
  • Hydrolyzed corn, wheat, or soy protein
  • L-cysteine
  • Malt extract
  • Malt flavoring
  • Modified food starch (any type )
  • Monopotassium glutamate
  • Monosodium glutamate (MSG)
  • Natural flavoring
  • Nutritional yeast
  • Plant protein extract
  • Saccharin (Sweet’N Low)
  • Seasoning
  • Smoke flavoring
  • Sodium benzoate
  • Sodium caseinate
  • Sodium guanylate
  • Sodium inosinate
  • Soy (only soybean oil /soy lecithin are OK to eat)
  • Soy protein concentrate
  • Soy protein isolate
  • Spices (this term can hide other ingredients)
  • Stock
  • Sucralose (Splenda)
  • Textured protein
  • Whey protein concentrate
  • Whey protein isolate
  • Yeast extract
focus on real food
Focus on REAL Food
  • Real Food – Food that is not highly processed
    • Low in additives, no trans fats
    • High in nutrients
    • High in fiber
what nutritional factors are important for optimal glutamatergic function
What Nutritional Factors are Important for Optimal Glutamatergic Function?
  • Adequate protein and low sugar
  • Antioxidants - Vitamins C & E
  • Vitamin D
  • Omega-3 Fatty Acids
  • Magnesium
  • Zinc
protein and sugar
Protein and Sugar
  • Protein deficiency causes increased susceptibility to excitotoxicity
    • Has been linked to increased prevalence of epilepsy in developing countries
  • Excess sugar in the diet also increases susceptibility to excitotoxicity
    • Ketogenic diet is used in epilepsy to counter this effect
    • Artificial sweeteners are not the answer!
      • Hundreds of times sweeter than sugar
      • Cause increased cravings for sugar (& alter taste Rs)
      • Can also cause increased excitotoxicity themselves
vitamin c
Vitamin C
  • Synthesized in all green plants
  • Potent antioxidant
    • Protects against oxidative stress
  • Vitamin C saturates the brain first
  • Important for cartilage formation & immune function, improves endothelial function & lowers BP
vitamin e
Vitamin E
  • Important antioxidant
  • Has the ability to protect fatty acids from oxidation (i.e. functions in different areas than vitamin C)
vitamin d
Vitamin D
  • Synthesized from cholesterol
    • Inhibited by cholesterol lowering meds
    • Also inhibited by older age, northern latitude, season, sunscreen, clothing, dark skin, obesity
  • Important for calcium regulation, immune function,
  • serotonin synthesis
  • Reduces inflammation & protects against excitotoxicity

VS.

omega 3 fatty acids
Omega-3 Fatty Acids
  • Important in maintaining fluidity of cell membranes to support cell-to-cell communication
  • Protects against excitotoxicity
  • Prevents inflammation
  • Alpha-linolenic acid is the basic essential omega-3 fatty acid in the diet
    • Found mainly in walnuts, flax seeds, and oils
  • DHA
    • Found in fish and fish oils
    • Farmed vs. wild fish
magnesium
Magnesium
  • A very important mineral!
  • 75% of the population does not meet the RDA of 420 mg
  • May be lost from GI tract in GI disorders
  • Stress can alter magnesium levels
  • Deficiency causes: Neuromuscular excitability, high BP, dizziness, constipation, seizures, tachycardia
slide88
Zinc
  • Antioxidant Function
  • Can block NMDA receptors, protecting against excitoxicity
  • Deficiency caused by diets high in phytates and low in meat

Phytates are high in seeds, bran, beans, & grains

Soaking helps lessen phytate load

prebiotics fiber
Prebiotics - Fiber
  • Benefits
  • Mucosal Barrier
  • Reduction in bowel pH
  • Synthesis of Vitamin K
  • Production of short chain FAs
  • Lowering of Cholesterol
  • Improved glucose tolerance
  • Gut-brain axis
probiotics yogurt
Probiotics - Yogurt
  • Diarrhea/Antibiotic Use
  • Greek yogurt
    • Supplies beneficial probiotics (bacteria)
    • High in protein
    • Can be consumed by those who are lactose intolerant
  • Activia is not needed (and contains additives)
  • Plain or vanilla recommended
  • Can add:
    • Granola, wheat germ
    • Fresh or dried fruit
    • Nuts, honey
    • Lemon/orange cod liver oil