Visit 4: Integrative Medicine & Mind - Body Practices for the Management of Fibromylagia

Transcript

1. Integrative Medicine & Mind - Body Practices for the Management of Fibromyalgia 4th Group Visit “ Inside Out” 4th Group Medical Visit presented by Integrative Medicine Specialist Marc Fierro, PA-C, L.Ac., Frank Russell MFT, Lauren McDaniel CNC, FMHC and Kimberly Defazio LVN, FMHC, at the Sutter Institute for Health and Healing
2. Welcome back! • Today’s class is the 4th in the series. • In today’s group visit, the participants will have the opportunity to share how much they were able to implement the therapeutic recommendations from the initial group visit and assess how it is affecting their quality of life. • Today’s topics will include teaching how to implement the approaches from the categories of: • Inside Out – Diet, nutritional supplements, prebiotics, probiotics, herbs, essential oils, cannabinoids, Low Dose Naltrexone, Psilocybin and the medications Lyrica, Gabapentin, Amitriptyline, Cymbalta, Savella and Ketamine. New research on Mestinon for post exertional fatigue at Brigham Young University and Harvard. • Additional Tai Chi – Qi Gong exercises - will be taught today.
3. Quick summary review of last group visits Tri flex approach to the management of Fibromyalgia. • 4 therapeutic directions organizes the 5’ R’s and 7 Seeds into a workable action plan, especially if you do ONE SMALL item from each group. • Top Down – Sleep, stress, and emotional regulation management techniques, MBCBT, journaling, counseling, cognitive training programs, biofeedback, meditation, observing nature, socializing, engaging in joyful activities. • Bottom Up – We all have 2 hearts, 1 in the chest and the 2nd is the entire body! Move daily any way you can. PACED, short interval graduated exercise, aquatic therapy, recumbent biking or pedal device, especially if dysautonomia w/ low BP, modified Yoga, Tai Chi, Qi Gong . It is okay to take a short nap before you exercise and afterwards if needed. • Inside Out – Diet, nutritional supplements, prebiotics, probiotics, herbs, essential oils, cannabinoids, low dose Naltrexone, Psilocybin and medications Lyrica, Gabapentin, Amitriptyline, Cymbalta, Savella and Ketamine. New research on Mestinon for post exertional fatigue at Brigham Young University and Harvard. • Outside In – Neurostim, laser, red light, IR sauna, acupuncture, TMS, massage, somatic therapy, craniosacral, osteopathy, chiropractic, injections, surgeries. • Bundled Activities – Listen to music while dancing, walking outside, Tai Chi, Yoga, Qi Gong and more exercises that use all the directions by design. Exercise with friends and pets. Participating in support groups and volunteering.
4. Patient check in: Patient check-in time! How have you been doing since last class? Please feel free to tell us what you have tried to incorporate from the Tri-Flex Lifestyle Changes into your self-care program since we met last. Please limit your comments to 2 minutes or less so everyone has a chance to share if they would like. Please raise your hand to speak or leave comments in chat. Thank you!
5. Sharing group wisdom and progress, 4th group visit check in topics • TRI-FLEX CHECK IN: Which activities from the 4 therapeutic Directions, 7 S. E. E. D. S. and 5 R’s did you choose since the initial group visit? • Did you start or plan on seeing the health coach? • Did you start the Happiness Trap and practice with the Mindfulness Coaching program app? • Did you start reading the TIGER protocol book? • What has been the impact on your health and well-being since doing those activities?
6. A Speech Pathologist’s Story of Recovery Angie a 39 Y.O. F, married with pre-teen children, who works as a pediatric speech therapist for children with special needs with an 8 year hx of brain fog effecting language skills that interfered with her work, fibromyalgia, chronic fatigue, migraines, DUB, IDA, insomnia, IBS-D that makes her unable to consume gluten and dairy. All started with a Giardia infection. Neural hormonal testing of thyroid, estrogen, progesterone, cortisol and DHEA showed a “Wired and Tired” pattern of dysregulation along with a stool test that showed SIBO and dysbiosis [but no more Giardia]. T.I.G.E.R. protocol therapy, MBCBT/ACT, Acupuncture and Neurostim were implemented along with supplements to treat the neural hormonal, and gastrointestinal abnormalities. After 3 mo patient’s fatigue, pain and brain fog dropped 80%, now she was able to work normally, and she was able to reintroduce gluten and dairy into her diet with no IBS symptoms.
7. Tai Chi - Qi Gong Therapy Form • Cloud Hands • Serve Tea • Dragon Swings its Tail • Dragon Pushes Its Palm • Crane Spreads it Wings • Take A Step And Push The Mountain • Pulse Breathing
8. Tai Chi - Qi Gong Therapy Form • Clouds Hands
9. Tai Chi - Qi Gong Therapy Form • Serve Tea (Grasping Sparrow’s Tail)
10. Inside Out - Diet HEALTH COACHES PRESENTATION • Discuss: • Phase I, T.I.G.E.R Protocol Elimination Diet – is used to decrease inflammation, dysbiosis, perpetual food allergy triggers, eliminate environmental toxin accumulation causing immune dysregulation. • Phase II, T.I.G.E.R. - to maintain a new healthier gastrointestinal, immune regulating environment to promote repair, detoxification and overall healing. • Health Coaches to the discuss details of elimination diet today. • Leaky gut and management of SIBO. • Specific Detoxification recommendations.
11. Inside Out - Pharmaceuticals verses Nutraceuticals: Anti-inflammatories • ANTI-INFLAMMATORY MEDICATIONS: help by reducing prostaglandins that contribute to inflammation and pain. • They work well when there is inflammation as the cause of pain and swelling. Example is osteoarthritis or tendonitis. • They do not work well in the absence of inflammatory COX-1 Type prostaglandins and in fibromyalgia where they are not present. • COX- 1 inhibitor side effects are quite common and contribute to making fibromyalgia worse by injuring the liver, kidneys, heart and immune system via the gastrointestinal track. • Examples of common COX - 1 anti-inflammatory nonsteroidal medications include aspirin, ibuprofen, naproxen, meloxicam. • Example of a steroid based anti-inflammatory would be prednisone, which can be very helpful in autoimmune disease but can also cause serious side effects; such as osteoporosis, ulcers, cataracts, high blood pressure, high blood sugar and even exacerbate anxiety or bipolar disease to the point of psychoses in some cases.
12. Inside Out - Pharmaceuticals verses Nutraceuticals: Anti-inflammatories • NUTRACEUTICAL ANTI-INFLAMMATORIES: Help by working on decreasing immune cytokine activity by regulating the immune system and decreasing inflammation. • Because they do not affect prostaglandins and they do not block the protective actions of the prostaglandins [Cox-1] such as keeping a healthy biofilm present in the gut to prevent ulcers and leaky gut from developing. They work on COX-2 and 5-Lox inflammatory systems instead. • They have lots of other benefits such as protecting the heart, liver, and GI tract. They're also immune regulating and kill bad bacteria and viruses. They help with detoxification. They support the immune system and fighting cancer. • Some people have trouble tolerating them as many of them are spices, so consider using aroma therapies of the same spices instead. • Common examples are: [Partial list] • Turmeric - 250 mg 1-2 times per day. [Theracurcumin HP best] • Ginger - 250 mg 1-2 times per day.. • Cinnamon - 250 mg 1-2 times per day. • Boswellia - 250 mg 1-2 times per day. • Mint - 250 mg 1-2 times per day. Enteric-coated form best if you have IBS [Peppermint Gels NOW brand]. • Angelica known as Dang Gui. - 250 mg 1-2 times per day • Saffron Extract[ Life Extensions] 75 mg 1 cap 2 times a day[treats depression too.]. • Consider using OTC compounded supplements: • Now Brand D-Flame • Health Concerns Brand Channel Flow, AC-Q, and Clear Phlegm, 3 capsules twice a day of each.
13. Inside Out - Pharmaceuticals versus Nutraceuticals: Non opioids for pain • Much of the pain from Fibromyalgia is coming from the central nervous system, therefore drugs from several classes are utilized. • Amitriptyline • Increases serotonin and norepinephrine. • It is often used when there is a combination of insomnia, pain and IBS. For some people this works very well. • Gabapentin and Lyrica • Decreases pain signaling from cell to cell. • Used often for neuropathy and fibromyalgia. • Has side effect of improving anxiety and sleep in some cases. • Savella and Cymbalta • Increases serotonin and norepinephrine to improve mood and decrease pain. • Wellbutrin • Can be used for brain fog / ADHD, low motivation, low mood and fatigue as it increases dopamine and norepinephrine. • Often these medications are combined. • There are many side effects which can include: dizziness, fatigue, worsening brain fog, significant changes in mood, dissociative states, changes in bowel and bladder habit. Occasionally changes heart rhythm and blood pressure.
14. Inside Out - Pharmaceuticals versus Nutraceuticals: Non opioids for pain • Antioxidants and minerals – support normal neurologic function. • B12 - methyl cobalamin 1000-2000 mcg per day. • B6 -100 mg per day. Do not exceed 200 mg per day or will cause neuropathy. • B1 - 100 mg per day • Alpha Lopaic Acid - 600 mg twice a day. • Magnesium - 250 mg twice a day or just 500 mg before bed. If there is constipation, citrate is best if there is no constipation, then glycinate or theonate is best. • Amino acids – • Gamma-amniobutyaic acid [GABA] 100-200 mg, 1-2 times per day. • Taurine 200 mg, 1-2 times per day. • Glycine 200 mg, 1-2 times per day. • L-theanine 200 mg, 1-2 times per day. • True Calm: Now brand has these in each capsule. • Herbs • Corydalis - 200 mg, 1-2 times per day. • Mucuna bean [Natural Levadopa for stiffness and RLS] - 60mg to 120 mg in AM • CBD and Cannabis oil – 150 mg – 30 mg 10:1 CBD to THC formula from a dispensary for best results. Creams also can work well for neuropathic pain. And [https://www.charlottesweb.com/thc-free-cbd-oil-25mg-cbd-1ml] • Previously mentioned anti-inflammatory herbs [D-Flame combo] • Gastrodia 1000 mg 2-3 times a day for migratory pain, neuropathy, headaches, light and sound sensitivity.
15. Inside Out - Pharmaceutical versus Nutraceuticals for Fatigue • Pharmaceuticals- • Nuvigil - Has no known mechanism of action but is classified as a mental stimulant. Usually prescribed for narcolepsy and severe daytime sleepiness. • Wellbutrin - increases Dopamine and NE, good choice with depression and low motivation, pain and fatigue as previously discussed. • Midodrine, Mestinon, LDN as previously discussed in the ”off label” medication section. • Traditional Adaptogenic Chinese Herbs used for fatigue from Yin and Qi deficiency: • Astragalus 250 mg, Rhodiola 250 mg , Sichuan Lovage 250 mg, Ophiopogon 250 mg, Schisandra Fruit 250 mg, Cordyceps 250 mg, Pseudostellarie 250 mg, White Atractylodis 250 mg, Dong Quai 250 mg, Simple-leaf Chaste Tree 250 mg, Fresh Ginger 250 mg, (mix-fried) Chinese Licorice 250 mg, Chinese Cimicifuga 250 mg 250 mg, Bupleurum 250 mg, Pr. Citri, 50 mg Fr. Aurantium, 50 mg Rz. Cori 28 mg, Rz Coptidis mg Poria Cocus 45 mg. • If Yang deficiency noted add both Cinnamon and Ginger 250 mg each. • Consider the compounded formula Immortal QI and Modified 11 Flavors to Warm the Gallbladder [Shi Yi Wei Wen Dang Tang] from Blue Poppy herbs available at peoplesherbs.com • Optimize Electrolytes Plus Mitochondrial and Antioxidant Support: • Niacin ... 25mg (as inositol hexanicotinate) • Magnesium ... 150mg • Sodium ... 140mg • (as sodium bicarbonate) • Potassium ... 510mg • D-Ribose ... 2g • Taurine ... 250mg • Creatine ... 225mg • Consider the product Optimize Electrolytes Seltzer: Seeking Health Brand a powder. Recommend adding Co Q10 100 mg + L-carnitine 250 mg to enhance mitochondrial function to this formula. • Consider multi vitamin with plant antioxidants like Metagenics phyto- multi product. • Optimize Hormones if needed • DHEA 5-20 mg in the morning • Pregnenolone 10-50 mg in morning • Bioidentical Estrogen 0.25 to 1 mg patch or cream • Bioidentical Progesterone 100 mg orally or cream at lower dose. • Bioidentical testosterone very low dose in cream for women, can inject or cream for men. • Thyroid medications including levothyroxine, Cytomel, glandular thyroid such as Armour or NP Thyroid. • Cortef, if truly extremely low cortisol measurements found in urine samples but not saliva samples. Given under the care approval of an endocrinologist.
16. Tai Chi - Qi Gong Therapy Form • Cloud Hands • Serve Tea • Dragon Swings its Tail • Dragon Pushes Its Palm • Crane Spreads it Wings • Take A Step And Push The Mountain • Pulse Breathing
17. Tai Chi - Qi Gong Therapy Form • Crane Spreads Its Wings Take a Step and Push the Mountain
18. Inside Out - Pharmaceutical versus Nutraceuticals for Sleep, Depression and Anxiety • Sleep - Medications: • Ambien, Lunesta, Trazodone, Remeron, Doxepin, and Benadryl products that work by increasing nervous system inhibition and sedation via the GABA or histamine systems. • Day Vigo is a newer medication that works on inhibiting the arousal system instead of the inhibition system. • All are very useful for acute short duration insomnia; However, they do not work well for chronic severe insomnia. • Long term use usually exacerbates the problem and provides low quality sleep, worsening brain fog and causes rebound side effects when drug wears off. • Ambien, Sonata and Lunesta can be addicting. Cognitive behavioral therapy for insomnia works best which includes sleep drive regulation and conditioned arousal management as previously discussed. • Depression - Medications: • Amitriptyline, Cymbalta, Wellbutrin, Effexor, Pristiq, and Savella. • These work on the norepinephrine, serotonin and dopamine [Wellbutrin only] systems. • Can be very helpful in the right situation. • Side effects as previously discussed. • Anxiety - Medications: • Lexapro or Celexa have better profiles than the other antidepressants for anxiety. They work on the serotonin system only as SSRI’s. • BuSpar, Xanax, lorazepam or Klonopin. These work on the GABA receptor which is where alcohol also works and has a down regulating effect. Unfortunately, lots of side effects; dizziness,, dissociative states, worsening fatigue, low motivation, rebound insomnia and often addiction with this group of benzodiazepine class medicines. • Best to use sparingly for breakthrough panic symptoms. If you are having symptoms daily, it is better to learn cognitive behavioral therapy for long-term management. • Sleep - Nutraceuticals • Magnesium [Theonate or Glycinate] 250-500 mg 1 hr. before bed. • Is very helpful for both insomnia muscle spasms. can help with a racing mind. Also, can help with palpitations and high blood pressure. Works by slowing down neuron to neuron transmission. Side effects can include diarrhea, low blood pressure, slow heart rate, MCI, fatigue if taken in excess. • Amino Acids – works on GABA receptor. • Gammamino-Butyaic Acid [GABA] 100-200 mg • Taurine 200 mg • Glycine 200 mg • L-theanine 200 mg • True Calm: NOW brand has most of these in each capsule. Take 1 -3 before bed • Melatonin 3-20 mg • Adaptogens for high brain cortisol and indirectly low DHEA [High stress, always aroused] • Rhodiola 250 mg • Ashwhaganda, 250 mg • Magnolia Extract, 250 mg • Phosphatidylserine, 200 mg • Or consider taking the Cortisol Manager formula, take 1-2 before bed. • Many others are available but to numerous to list here. See previous slide. • Depression • 5 HTP 50 -100 mg 2-3x a day [usually extracted from mushrooms] for Serotonin support • L - Tyrosine if low motivation and for dopamine support. 500 mg 1-2x a day, don’t to use if high blood pressure. • Above-listed Adaptogens • Emotional wellness formula from Pure Encapsulations has everything listed above plus more. 2-3 caps 2x a day. • Anxiety • Mindfulness Based Cognitive Behavioral Therapy • True Calm formula listed above. Take one, 3 times a day or 2 before bed. • CBD with THC also helpful here. [https://www.charlottesweb.com/thc-free-cbd-oil- 25mg-cbd-1ml] • Otherwise, nutraceuticals listed above for sleep and depression.
19. Other Off-Label Uses of Medications • Low-dose Naltrexone 3mg to 9 mg [average dose is 4.5 to 6 mg.] • Helps decrease pain, fatigue and autoimmune antibodies to help decrease inflammation. • For pain, it does this by up regulating opioid receptors. Note: one cannot be on opioids at the same time as their effect will be blocked. • Decreases neuro cytokine activity in the brain’s neurons at the TLR-4 receptor site to decrease inflammation in the brain. • Usually takes 3-6 months to start working. • Doctor’s prescription and compounding pharmacy is necessary to obtain Rx or can order on the Internet at AgelessRX.com without the need for a doctor’s prescription or compounding pharmacy. • Midodrine • Helps severe fatigue, dizziness from low blood pressure and dysautonomic-like symptoms. • Works by increasing norepinephrine [adrenalin] that causes vasoconstriction like caffeine and exercise does to increase blood pressure. • Cannot be taken at night because blood pressure will be too high laying down flat. • Cardiologists and neurologist can prescribe this. • Mestinon • Helps with severe fatigue, dizziness from low blood pressure. • Works by increasing acetylcholine a neurotransmitter that causes vasoconstriction and helps with dysautonomia. • Does not have the side effect of high blood pressure when laying down like midodrine. However, can cause GI side effects. • Ketamine • Is used to help decrease pain, PTSD and depression. • Works by dissociating painful memories from physical sensations. Increases neurotrophins and neuroplasticity. • Is delivered in a nasal spray, muscular injection, or IV usually under supervision of Pain Management or psychiatry specialists. • Can cause temporary hallucinations, patient often takes this with a counselor present in the doctor's office, some patients can learn to do at home with nasal sprays on their own and with a support person present. • Psilocybin Micro dosing to 30 mg single doses. • Is used to help decrease pain, PTSD, alcoholism and depression. • Works by stimulating a novel serotonin 5-HT 2A receptor in the brain. • The effect is like ketamine, especially useful in increasing neuroplasticity. • May cause hallucinations and vomiting. Usually very well tolerated when counselor is present during treatment session. • For more information and research studies please see https://neurotherapeutics.ucdavis.edu
20. Gut Dysbiosis – Leaky Gut / Hyper Permeability of Small Intestine
21. Management of Gut Dysbiosis and SIBO • Think Like a Gardener – Prepare the Soil and then Weed, Seed & Feed to grow the things you want. • Follow the Tiger protocol on Gut Dysbiosis Management and if needed consider the following Nutraceutical support regimen: Medications/Nutraceuticals Phase I : WK 1-4 Phase II Wk 4-8 Phase III Wk 8-12 Notes on starting Biocidin botanical antimicrobial extract 15 drops 2x a day 15 drops 2x a day Stop 1st wk 5 drops 2x day then increase to full doses to bowel tolerance Megasporebiotic probiotic 1 a day 2 a day 2 a day Start every other day and as above Megaprebiotic fiber 1 a day 2 a day SBI Protect immunoglobulin anti-inflammatory 4 a day GI Detox- used for die off reactions if needed. 1-2 caps before bed 1-2 caps before bed As needed Not a must
22. Detox - Reducing Environmental Toxins to Improve Mitochondrial Function and Immune Regulation. Environmental Toxin Reduction – because we know that environmental toxins can contribute to fibromyalgia and chronic fatigue along with hormone and immune dysregulation. • Follow the TIGER protocol recommendations regarding management of this domain. • Externally • Consider a reverse osmosis filter to purify your water supply. [Blue Zone from Costco] • Consider Air Doctor air purifier to purify the air. • Consider using organic toxin free cosmetics, body care products, and household cleaners. Please see Environmental Working Group, EWG.Org website to see which are the best and safest products to use as replacements recommended by the experts. • Infrared sauna is helpful here to promote detoxification. 5-20 minutes every other day to every day to tolerance. • Internally • Elimination/Detoxification diet recommended in the TIGER protocol. • Eat minimally processed or completely whole foods and pasture raised, antibiotic and hormone free animal products. • Consider Nutraceutical support to help with mobilizing, binding and eliminating of toxins more efficiently if needed. • Take care of your gut health be able to eliminate toxins efficiently and safely.
23. Detoxification with Nutraceuticals. Consider taking the nutraceutical formula HM Complex from Pure Encapsulations. – take 3 capsules 2-4 times per day between meals and away from other supplements and medicines. Note, one can add 1000 mg of activated charcoal taken before bed to enhance the binding effect. Ingredients: • Zinc ... 10mg • Selenium ... 100mcg • Potassium ... 70mg • (as part of modified citrus pectin) • Sodium ... 50mg • (as part of modified citrus pectin) • Modified citrus pectin ... 1, 000mg • Chlorella powder ... 300mg • Broccoli sprout concentrate ... 250mg • (standardized to contain a minimum of 1, 000 mcg sulforaphane) • N-acetyl-l-cysteine ... 300mg • L-methionine ... 200mg • Alpha lipoic acid ... 100mg
24. Next Class Topics: • Outside In – Neurostim, laser, red light, IR sauna, acupuncture, TMS, massage, somatic therapy, craniosacral, osteopathy, chiropractic, injections, surgeries. • Bundled Activities – Listen to music while dancing, walking outside, Tai Chi, Yoga, Qi Gong and more exercises that use all the directions by design. Exercise with friends and pets. Participating in support groups and volunteering. • Will learn more extensive Tai Chi and Qi Gong movements
25. Program support literature, and software apps are highly recommended for long- term success. Aim to read 3 chapters a week of the books and 3 minutes a day on the apps.
26. For best results get support and get started with your Health Coaches right away!