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