Download - East meets West
East meets West
Robert Bennett, MD
Professor of Medicine and Nursing OHSU
Integrative Medicine:
Examples:Traditional Chinese medicine (herbs, acupuncture, gigong)Hands–on therapy (osteopathy, massage), Lifestyle(education, nutrition, exercise)Mind-body therapies (yoga, Tai Chi).
East meets West
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.
1)The Myofascial
Web
2)Mindful
Movement
3)Eastern
Treatments
4)Optimal
Nutrition
The Topics
1)The Myofascial
Web
2)Mindful
Movement
3)Eastern
Treatments
4)Optimal
Nutrition
The Topics
Myofascial Trigger Points
Why is it important to
eliminate myofascial
trigger points ?
Pain generatorsSpinal cord
BrainAnatomyof Pain Central
sensitization
Trigger Point Therapy
1)The Myofascial
Web
2)Mindful
Movement
3)Eastern
Treatments
4)Optimal
Nutrition
The Topics
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
Time Magazine, February 2, 2014
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
Conclusion: Eight weeks of daily yogic meditation reversed the pattern of increased expression of genes associated with inflammation
Science meets Meditation
Epigenetics:Changes in gene
expression related to
environmental factors
1)The Myofascial
Web
2)Mindful
Movement
3)Eastern
Treatments
4)Optimal
Nutrition
The Topics
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 yangMain components: Herbal medications Acupuncture Massage (Tui na) Exercise (qigong)
AcupunctureA 5000-year old medical
system based on the theory that“Qi” (the life force which flows throughout our body) is out of balance
Deare, JC, et al. Acupuncture for treating fibromyalgia. Cochrane database review. 2013, May 31
1.There is low to moderate-level evidence that acupuncture improves pain and stiffness
2.The effect lasts up to one month
Reviewed 9 randomized controlled studies (i.e. sham acupuncture) involving 321 subjects:
Cochrane database review 2013
3. Electro acupuncture is probably more effective than manual acupuncture
4. The effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue
1)The Myofascial
Web
2)Mindful
Movement
3)Eastern
Treatments
4)Optimal
Nutrition
The Topics
Probiotics
Elie Metchnikoff first suggested the possibility of colonizing the gut with beneficial flora in the early 20th century.
WHO definition: micro-organisms which, when administered in adequate amounts, confer a health benefit on the host
1845 - 1916
Kefir
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.
Quigley, EM. Prebiotics and probiotics; modifying and mining the microbiota. Pharmacology Research. March 2010
Recent Review
Your gut harbors 100
trillion organisms
Prevotella copri – rheumatoid arthritisBacteroides prevotella – obesityClostridium perfringens – multiple sclerosisLactobacilli & Bifidobacteria– irritable bowel
Patients with recurrent Clostridium difficile infection 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.
Coprophagy ?
Results of fecal transplantation study
After 2 fecal transplantations there was a 94% cure
rate
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
A prebiotic?
Are you a chocolate lover?
What about the descending
inhibitory pain system ?
Descending Inhibition
RememberActivate your descending
inhibitory system every day
Myofascial Web and Fibromyalgia
Fibromyalgia Information Foundation 2014 Annual Conference
Ginevra Liptan, MD
Fibromyalgia (FM) pain
Hyper-reactive spinal cord and brain called “central sensitization”
Pain generated from muscle tissue
18 tender points used to diagnose FM
Fibromyalgia muscle pain sources
-Fascia –connective tissue around muscle
-Myofascial trigger points
What is fascia? Connective tissue network Surrounds both individual and
groups of muscles Highly sensitive to pain Contracts to give muscles
extra strength
Myofascial “web”
Connective tissue that envelopes muscles
Connective tissue that’s left after muscle cells dissolved
Fascia in FM
Increased tension Inflammation Prone to “ knotting
up”( 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 trigger point
Treatments for fascia/trigger points
Myofascial release (MFR)
Trigger point injections
Self-care
Myofascial release therapy
Manual traction and prolonged assisted
stretching
Breaks up painful adhesions in the
connective tissue surrounding muscle
MFR is not massage
Myofascial release for FM
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
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
Perc
enta
ge c
hang
e in
FIQ
-R
Myofascial release subjects 1–8
A change of 14% or more is considered significant
FIQ-R Percentage Change in Massage Subjects
Perc
enta
ge c
hang
e in
FIQ
-R
Massage subjects 1–4
A change of 14% or more is considered significant
Trigger point injections
Injection of lidocaine
“Dry needling”
Trigger point self-treatment
Resources
www.theracane.comwww.myofascialrelease.com
Book: The Trigger Point Therapy Workbook: Your Self- Treatment Guide for Pain Relief by Clair Davies
Web sites:
Mindful Movement & Meditation
How & Why Yoga Helps those with Fibromyalgia
E.B. Ferdig
E-RYT500, certified yoga therapist
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 discussionThey were also given a DVD video and encouraged to do yoga regularly at home
How & why does yoga help?
Yoga is varied & can be adapted to the student
Primarily a mental practice, but also can be:Physical EmotionalEnergeticSpiritual
We can take what we need & leave the restFor yoga to work, we need to do it. To do it, we need to have experience of it being helpful, so we might build new habits.
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)
The Pain Loop
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 onWorking 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
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 www.unfoldportland.com
Studies referenced in presentation
1) 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
2) Streeter CC1, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DBYoga Asana sessions increase brain GABA levels: a pilot studyJ Altern Complement Med. 2007 May;13(4):419-26
3) Ciraulo DA, Renshaw PF.. Michalsen A, 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 Sci Monit. 2005;11:555–61.
Eastern Treatmentsfor Fibromyalgia:
Making Sense of the DataScott D. Mist, PhD, LAc
Full Disclosure
I am a licensed acupuncturistSome of what I tell you is personal opinion but I will try to between things that are supported by data and opinion
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?
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
DietGenerally 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 syndromeHolton KF, Taren DL, Tomson CA, Bennett RM & Jones KD 2012
State of Published Evidence
LifestyleMeditationMore evidence than for diet but still not muchMostly focuses on mindfulnessImproves 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 Evidence
Herbal MedicineHuge field with very little researchSeveral 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 Evidence
External Therapies•Acupuncture
State of Published EvidenceExternal 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 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 courseof treatment look like?
Exercise• E.B. gave recommendations for exercise
AcupunctureBest 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 courseof treatment look like?
MassageBest if twice a week for 2-4 weeks followed by weekly for additional 4 weeks
Should see improvements in first 4 treatments
MeditationOnly works if you practiceRecommend 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 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
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
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
Optimal Nutrition for FibromyalgiaDr. Katie Holton
Importance of Diet
Nutrition is the single most important factor in optimizing your healthPositive vs. negative aspects to diet:Positive Vitamins, Minerals, Protein, EFAs, Fiber
Negative Food additives, excess sugar, pesticides, herbicides, trans fats
Food Additives
ExcitotoxinsGlutamate, aspartate and L-cysteineFound under a myriad of namesArtificial sweetenersAspartame, acesulfame K, saccharin, sucralose
Artificial colors Interactions w/excitotoxins
GlutamateGlutamate – a non-essential, negatively charged AA from dietThe 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 glutaminergic neurotransmission has been implicated in FMExcess glutamate can lead to excitotoxicity• Also causes oxidative stress
Bound vs free glutamate• Meat versus soy sauce
Hidden ExcitotoxinsAcesulfame-K (Sunett, Sweet One)Aspartame (Equal, NutraSweet, Canderel)Autolyzed yeast (or autolyzed yeast extract)Barley malt extractBouillonBrothCalcium caseinateCarrageenanFlavoringGelatinHydrolyzed corn, wheat, or soy protein L-cysteineMalt extractMalt flavoringModified food starch (any type )Monopotassium glutamateMonosodium glutamate (MSG)
Natural flavoringNutritional yeastPlant protein extract Saccharin (Sweet’N Low)SeasoningSmoke flavoringSodium benzoateSodium caseinateSodium guanylateSodium inosinateSoy (only soybean oil /soy lecithin are OK to eat)Soy protein concentrateSoy protein isolateSpices (this term can hide other ingredients)StockSucralose (Splenda)Textured proteinWhey protein concentrateWhey protein isolateYeast extract
I also recommend avoiding all artificial colors, artificial
flavors, artificial sweeteners
Food Additives
Gelatin
Focus on REAL FoodReal Food – Food that is not highly processedLow in additives, no trans fatsHigh in nutrientsHigh in fiber
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 deficiency causes increased susceptibility to excitotoxicityHas been linked to increased prevalence of epilepsy in developing countries
Excess sugar in the diet also increases susceptibility to excitotoxicityKetogenic diet is used in epilepsy to counter this effect
Artificial sweeteners are not the answer!Hundreds of times sweeter than sugarCause increased cravings for sugar (& alter taste Rs)
Can also cause increased excitotoxicity themselves
Vitamin CSynthesized in all green plantsPotent antioxidant• Protects against oxidative stressVitamin C saturates the brain firstImportant for cartilage formation & immune function, improves endothelial function & lowers BP
Vitamin EImportant antioxidant Has the ability to protect fatty acids from oxidation (i.e. functions in different areas than vitamin C)
Vitamin D
VS.
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 synthesisReduces inflammation & protects against excitotoxicity
Omega-3 Fatty Acids
Important in maintaining fluidity of cell membranes to support cell-to-cell communicationProtects against excitotoxicityPrevents inflammationAlpha-linolenic acid is the basic essential omega-3 fatty acid in the diet• Found mainly in walnuts, flax seeds, and oilsDHA• Found in fish and fish oils• Farmed vs. wild fish
Magnesium
A very important mineral!75% of the population does not meet the RDA of 420 mgMay be lost from GI tract in GI disordersStress can alter magnesium levelsDeficiency causes: Neuromuscular excitability, high BP, dizziness, constipation, seizures, tachycardia
Food sources of Magnesium
ZincAntioxidant FunctionCan block NMDA receptors, protecting against excitoxicityDeficiency caused by diets high in phytates and low in meatPhytates are
high in seeds, bran,
beans, & grainsSoaking
helps lessen phytate load
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 - YogurtDiarrhea/Antibiotic UseGreek yogurtSupplies beneficial probiotics (bacteria)High in proteinCan be consumed by those who are lactose intolerant
Activia is not needed (and contains additives)Plain or vanilla recommendedCan add:Granola, wheat germFresh or dried fruitNuts, honeyLemon/orange cod liver oil
Mediterranean Diet
Bulgur
The End