East meets West
Robert Bennett, MD
Professor of Medicine and Nursing
OHSU
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).
The Topics
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
Myofascial Trigger Points
Why is it important to
eliminate myofascial
trigger points ?
Anatomy
of Pain
Brain
Central
sensitization
Pain generators
Spinal cord
Trigger Point Therapy
The Topics
1) The Myofascial Web
2) Mindful Movement
3) Eastern Treatments
4) Optimal Nutrition
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
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
The Topics
1) The Myofascial Web
2) Mindful Movement
3) Eastern Treatments
4) Optimal Nutrition
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 (Tui na)
Exercise (qigong)
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
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:
1. There is low to moderate-level evidence that
acupuncture improves pain and stiffness
2. The effect lasts up to one month
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
The Topics
1) The Myofascial Web
2) Mindful Movement
3) Eastern Treatments
4) Optimal Nutrition
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
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
Prevotella copri – rheumatoid arthritis
Bacteroides prevotella – obesity
Clostridium perfringens – multiple sclerosis
Lactobacilli & Bifidobacteria– irritable bowel
Coprophagy ?
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.
Results of fecal transplantation study
After 2 fecal
transplantations
there was a 94%
cure rate
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
What about the
descending
inhibitory pain
system ?
Descending Inhibition
Remember
Activate your
descending inhibitory
system every day
Myofascial Web and
Fibromyalgia
Ginevra Liptan, MD
Fibromyalgia Information Foundation
2014 Annual Conference
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 postintervention
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
Percentage change in FIQ-R
A change of 14% or more is considered significant
Myofascial release subjects 1–8
FIQ-R Percentage Change in
Massage Subjects
Percentage change in FIQ-R
A change of 14% or more is considered significant
Massage subjects 1–4
Trigger point injections
 Injection of lidocaine
 “Dry needling”
Trigger point self-treatment
Resources
Web sites:
www.theracane.com
www.myofascialrelease.com
Book:
The Trigger Point Therapy Workbook: Your SelfTreatment Guide for Pain Relief by Clair Davies
Mindful Movement &
Meditation
E.B. Ferdig
E-RYT500, certified yoga therapist
How & Why Yoga Helps
those with Fibromyalgia
OHSU Study Shows Yoga Effectiveness
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
Result:
Pain reduced an average of 24%
Fatigue reduced an average of 30%
Depression reduced by 42%
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 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 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
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 fibromyalgia
Pain, 2010; 151 (2): 530
2) Streeter CC1, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DB
Yoga Asana sessions increase brain GABA levels: a pilot study
J 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 yoga
Med Sci Monit. 2005;11:555–61.
Eastern Treatments
for Fibromyalgia:
Making Sense of the Data
Scott D. Mist, PhD, LAc
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
 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
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 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 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 Evidence
External Therapies
•Acupuncture
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 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?
Exercise
Acupuncture
• E.B. gave
recommendations for
exercise
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 nonresponder
Often see sleep improve first
What does a common course
of treatment look like?
Massage
Meditation
Best if twice a week for 2-4 Only works if you practice
weeks followed by weekly Recommend that you find a good
for additional 4 weeks
instructor in the beginning
Should see improvements Changes happen in the first 4
in first 4 treatments
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
Fibromyalgia
Dr. Katie Holton
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
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 – 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 glutaminergic neurotransmission
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
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)
I also recommend avoiding all artificial
colors, artificial flavors, artificial
sweeteners
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
Food Additives
Gelatin
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?
 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
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
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
Important antioxidant
Has the ability to protect fatty acids from oxidation
(i.e. functions in different areas than vitamin C)
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
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
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
Food sources of Magnesium
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
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
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
Mediterranean Diet
Bulgur
The End