Integrative Medicine & Mind - Body Practices for the Management of Fibromyalgia 3 group medical visit series 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

Team Introductions: Marc Fierro, P.A., L.Ac. Frank Russel, MFT Lauren McDaniel, CNC, FMHC Kimberly Defazio, LVN, FMHC

Patient Introductions: Welcome and nice to meet you! Please limit your introduction to 2 minutes or less. There will be time for questions and answer at the end of the presentation today. Thank you!

What is Integrative Medicine? • Integrative Medicine focuses on uncovering and addressing the underlying causes of the common chronic conditions that afflict a growing number of people. Rather than just looking at only individual symptom patterns it instead looks at how the organ systems affect each other, and how they may cause dysregulation that will manifest as a constellation of symptoms that otherwise seem unrelated. • Integrative Medicine focuses on treating the root causes known as T.I.G.E.R.,and managing symptoms through therapeutic lifestyle recommendations with ongoing support by utilizing a team of specially trained medical providers, health coaches, dietitians, counselors, acupuncturists, chiropractors, massage therapists and other specialists. • Additionally, modern technology, i.e., biofeedback, neurostimulation w/TENS, light therapy and biometric tracking modalities along with compounded medications and nutritional supplements are often employed.

Where Should We Start and What is Fibromyalgia? Let’s talk about what we know about Fibromyalgia: rather than a disease of a single organ, it is a functional disease of multiple physiological systems that cause a centralized pain sensitization syndrome. • It affects approximately 5,000,000 people in the U.S. • Main symptoms include: • Widespread pain lasting longer than 3 months • Chronic fatigue in general and especially after exercise or episodes of emotional distress/conflict. • Cognitive dysfunction known as brain fog: difficulties with memory, word retrieval, problem solving and attention • Sleep disturbance

Where Should We Start and What is Fibromyalgia? • Associated secondary symptoms can also include: • Dizziness from orthostatic blood pressure and dysautonomia/POTS-like symptoms • Multiple chemical sensitivities • Irritable bowel syndrome with or without constipation and diarrhea or mixed symptoms. • Neurogenic overactive bladder or interstitial cystitis. • Pelvic floor dysfunction • Chronic migraine • Neuropathy-like symptoms, ie: atypical chest pain, pressure sensations, contracting or expanding sensations. Phonophobia, photophobia and sensitivities to odors. • Positive autoimmune markers, such as antinuclear antibodies known as ANA or Hashimoto Abs without diagnosis of autoimmune disease is very common. • Secondary anxiety, frustration, resentment, depression, hopelessness and helplessness. Poor distress and problem-solving tolerance. • Decreased capacity to participate in pre illness way of life in all domains. • Unresolved history of sexual abuse, physical and psychological abuse or neglect or both is very common. Studies show it is found in about 60% of the cases. • Development of maladaptive lifestyle behaviors.

The Invisible Disease • Fibromyalgia is a disease that people cannot see or may not be diagnosed easily. Patients with the disease often face not only the symptoms of the disease, but also medical and social misunderstanding, rejection, dismissiveness and isolation. This further increases individual patients' distress and intensifies the symptoms as well as the decrease in the quality of their relationships with family, friends, coworkers, the medical community and eventually the quality of their life as a result.

What are the common causes? Multifactorial combination of causes: • T.I.G.E.R. an Integrative Medicine mnemonic for understanding the most common causes of Fibromyalgia and other chronic diseases: • Toxins/Trauma • Infections • Gut Dysbiosis • Eating poorly • Rest / Restorative insufficiencies.

What are the details of the causes Multifactorial combination of causes. Research shows us the following: • Genetics • Mutations with genetic predisposition for low pain tolerance that can run in families. • Epigenetic (which means that which influences our genetic expression). • Trauma including physical (especially car accidents, physical and sexual abuse or neglect), social and psychological distress that is ongoing and untreated. Environmental toxins, infections and especially persistent poor lifestyle habits. • Immunological • Including: Infections, especially retroactive viruses and Lyme disease, autoimmune disease (especially systemic lupus erythematosus but not limited to that), food allergy, sensitivity and celiac disease. IL 6, IL 8, increased substance P. • Gastrointestinal • Dysbiosis, small intestinal bacterial overgrowth, dysmotility, mal-digestion and absorbability issues. Imbalances of pancreatic elastase and other digestive enzymes, acid, stool Ph and bio films. • Neural hormonal and metabolic imbalances. Central Sensitization Syndrome develops in the nervous system: • Hypothalamus: Pituitary- adrenal dysregulation, autoimmune thyroid disease. Obesity. Also, pre-existing sleep disturbance; anxiety and depression contribute to this part. Imbalances of norepinephrine, dopamine, serotonin, HGH, cortisol, DHEA, insulin and thyroid hormones. • Sleep apnea is very involved in the fatigue component. • Environmental Toxins Especially metabolites from petroleum, pesticides, heavy metals and hormones found in cleaning products and animal proteins. I also include antibiotics and other medications in this category. Unhealthy lifestyle habits • Alcohol and other recreational drugs, poor nutrition with over or under eating, inadequate sleep, emotional dysregulation, social isolation and loneliness, no engagement in pleasurable activities, being sedentary with lack of movement/exercise, little exposure to nature, spiritual disconnection.

All is well when the master, the leash and dog are working together. • The master represents the nervous system and hormones which communicate and coordinate with the rest of the body. • The leash represents the regulatory part of the immune, metabolic, gastrointestinal and parasympathetic nervous systems. • The dog represents the protective and destructive traits of the immune system. • All of it has to work together for good health.

Not so good when the master, the leash and dog are not working together. • Usually when we become ill many of these systems have become dysregulated and incoordinated to produce the symptoms of chronic pain and fatigue in fibromyalgia.

Understanding Complex Pain Experiences - Centralized Pain Syndrome in the development of Fibromyalgia. 12 Acute Pain – Mechanical Problem • Usually related to injury or tissue damage. • Usually a clear physical source of the pain. • Physical functioning is impaired or stops. • Once healed, one usually resumes their lifestyle. Anticipatory Pain – Anxiety and Stress • Psychological pain, based on past experience. • Fear of a negative outcome and suffering. • Tension and stress build in the body and mind. Somatic Pain – Emotional, involving Memory • Experienced as both physical and psychological. • Unclear source, origin, or cause for pain. • Hurt doesn’t equal harm. But pain is REAL and feels REAL. • Generates great deal of stress, tension and exhaustion. Chronic Pain+ Acute pain + Anticipatory pain + Somatic pain lead to Centralized Pain • Central Nervous System becomes over-sensitive to normal stimulus[pressure, touch, temperature, or stretch]. • Original source of pain is known, but now can also involve many parts. Pain can be fixed and now can move around. • Problems with mood (depression/Anxiety), and catastrophizing are usually involved. • Sensitivities to normal movement, touch, temperature changes, stress and are perceived as painful.

13 THE DOWNWARD SPIRAL WHEN THE PAIN/STRESS REACTION PROCESS BEGINS CAN’T SLEEP DUE TO WORRY AND PHYSICAL TENSION LESS AND LESS MOTIVATION AND PHYSICAL ACTIVITY NO ENERGY, CAN’T STAY FOCUSED ON WORK OR TO COMPLETE TASKS STRESS INCREASES, MALADAPTIVE ADAPTATION DEVELOPS, PHYSICAL OR MENTAL SYMPTOMS WORSEN, STRUGGLING TO COPE FEELING DOWN, DEPRESSED, ANXIOUS, WORRIED AND OVERWHELMED MORE SICK DAYS, EMPLOYMENT CONCERNS OR FINANCIAL WORRIED INCREASED DOCTOR VISITS, DECONDITIONING AND MORE PHYSICAL PROBLEMS, OR ADDICTIONS PROBLEMS RELATIONSHIPS ARE STRAINED, CONFLICTS AND ISOLATION WORSENS DESPERATION, FEAR POWERLESS, LOST AND CONFUSED, DON’T KNOW WHAT TO DO i STARTS WITH: A PHYSICAL CHALLENGE, PAIN, TRAUMATIC EVENT, OR A STRESSFUL SITUATION

Jackie’s Downward Spiral • Jackie is 68-year-old female, who is married with 1 adult child and worked as a special education teacher. She presented with a 30-year history of fibromyalgia that caused 8/10 level of pain from her neck to her thighs. • She also had 8/10 level of chronic fatigue that worsened with exercise and activities of daily living. • Additionally, she had trouble with attention, concentration, word retrieval, problem solving and memory. • She had significant sleep disruption. • She had chronic heartburn and irritable bowel syndrome with diarrhea. She had an overactive bladder. • She has a positive ANA but no diagnosis of rheumatologic disease. • She had become very demotivated, deconditioned, sedentary and became very overweight . • All of this is on top of a history 50-year history of chronic low back pain along with being a breast cancer survivor and having diabetes with high blood pressure. • It all started when she was pregnant, and her husband had a heart attack and survived. • She saw many doctors and had many treatments that did not help. • To make matters worse her husband has now developed Parkinson’s disease and she is his primary caregiver.

Mind - Body Rest, Respite and Rejuvenation Time • Tai Chi - Qi Gong • Hands Drift Like Clouds • The Bow and Arrow • The Camel • Yin Breathing

There may not be cure but there is hope, let's look and see what it looks like and how to get there…

17 THE UPWARD SPIRAL WHEN THE PAIN/STRESS REACTION BEGINS TO BE MANAGED A GOAL IS SET, AND ONE SMALL STEP OR ACTION IS TAKEN A LITTLE BIT OF PROGRESS, CONTROL AND HOPE IS EXPERIENCED AN INTENTION, CHOICE OR DECISION IS MADE FROM DEEP WITHIN CONFIDENCE IS BEGINNING, FEELING MORE POSTITIVE AND EMPOWERED BEGIN TO LEARN MORE ABOUT WHAT TO DO, DEVELOP AWARENESS AND SKILLS A LITTLE SUCCESS, CALMER AND ACCEPTING OF CHANGES SUCCESS INCREASES, HEALTH IMPROVING, REDUCED FEAR AND ISOLATION, ENGAGED IN LIFE FEELING MORE MOTIVATION TO TAKE ACTION, TAKE ON A CHALLENGE, AND ACCEPT LIMITATIONS YOU’VE ADAPTED TO THE CHANGES IN YOUR LIFE AND ARE AWARE OF YOUR STRENGTHS AND YOUR LIMITS i STARTS WITH: A CHOICE OR DECISION, AND TO MAKE A CHANGE, WITH VISION OF POSITIVE OUTCOME

Jackie’s Upward Spiral • Jackie was referred to me by her rheumatologist. • We implemented the 5 R, 7 Seeds, and 4 Directions support program. • I treated her for suspected small bacteria overgrowth/dysbiosis. • She also had high stress hormones. • She saw a counselor and she learned mindfulness-based cognitive behavioral therapy. • Started acupuncture and home neurostimulation. • Saw our health coach/nutritionist for a modified Mediterranean food plan and mild,and a modified exercise program. • She got some caregiver support and respite. • She did an excellent job sticking to the plan of care even though she had many challenges. • As a result, her fibromyalgia and back pain scores decreased from 8/10 to 0-2/10 on a pain scale, her fatigue decreased from 8/10 to a level of 0-2/10. • IBS and overactive bladder symptoms decreased significantly. • Her mood, energy, sleep, ability to do activities of daily living and overall quality of life greatly improved. • Her condition has remained improved for the last 1.5 years to date and she has gone back to work part time.

The Tri -Flex Approach to the Management of Fibromyalgia • Includes combining the knowledge and use of: • 5 R’s • 7 Seeds • The 4 Therapeutic Directions

Integrative Medicine Approach to Disease “One Cause, Many Conditions” • Integrative Medicine uses an organized stepwise approach to evaluating, diagnosing, treating disease and the concerns of our patients. • These concepts are known as the 5 R'S : 1. Recognize root causes and branches of disease and distress. 2. Remove toxins, allergens, infections and unhealthy habits. 3. Replenish macro and micronutrients, digestive elements, hormones, immunity support components, energy and vitality. 4. Regulate behavior, exercise, sleep, stress management skills, physical, cognitive and social networks. [ 7 SEEDS ] 5. Repair injury and illness as a result of the first 4 R's to the extent in which it is possible with the 7 SEEDS and the other parts of treatment plan.

The 7 Seeds of Thriving and Resiliency - Better to Thrive Instead of Just Survive! [ Regulate what you can control ] S – Sleep. E - Exercise your brain, mind and regulate your emotions. E - Exercise your body with movement. D – Diet; supportive and realistic. S – Socialize, stress management and avoid harmful substances and behaviors .

The 7 Seeds of Thriving and Resiliency - Better to Thrive Instead of Just Survive! S - Sleep - Keep the same wake time, try to get 6 to 8 hrs. Create sleep drive by staying active during the day making sure the room is cool, quiet and dark. Avoid watching lighted screens 1 hr before bed. If you wake up in the middle of the night get up and do something quiet and enjoyable away from your bed until sleepy again, then go back to bed to avoid turning the bed into a mental wrestling mat. Additionally, Sleep Restriction CBT-I is #1 proven treatment if needed if all else fails. E - Exercise your brain - Crossword puzzles, Sudoku, listen or read stories to engage your imagination, brain games (Lumosity, Brain HQ, learn a new language or musical intsrument). Also, emotional regulation techniques; such as, mindfulness based cognitive behavioral therapy, consider a mindfulness coach app and the Happiness Trap book. E - Exercise your body - Dancing, hiking, gardening, doing tasks, adaptive yoga, Tai Chi, pedal exerciser and moving any way you like at least 30 minutes a day, and it is ok to break it up. D - Diet - Lean, green and clean avoiding excessive alcohol and caffeine. A Modified Mediterranean Mitochondrial diet, which is generally best tolerated long term. S – Socialize - Stress management and avoid harmful substances. Connect with family, friends, pets, Mother Nature, spiritual activities and deep breathing. Act and do what matters to you.

The 4 Therapeutic Directions • Last part of the strategic system for applying the 5 R’s 7 S.E.E.D.S. in the TRI - FLEX APPROACH for holistic health and management of Fibromyalgia is the 4 Therapeutic Directions concepts which include: • Top Down • Bottom Up • Inside Out • Outside In

Details of the 4 Therapeutic Directions • This organizes the 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, engage 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, sauna, acupuncture, 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.

Benefits of sharing, story telling and group wisdom • Research has shown having a place to come together with other people suffering with a similar disease and participating in group discussions provides a sense of safety, understanding, connection and inspiration which can improve quality of life and decrease symptom impact. • Helps combat loneliness and misunderstanding of an invisible disease. • Additionally, it can be a great source of knowledge to be applied to your own symptoms and improve one’s capacity to do more activities in life that matter to you.

So where do we start today? • Start with very small experiments. • Choose 1 thing from each of the previously listed 4 Therapeutic Directions from matching the 7 Seeds of Resiliency and Recovery. • Apply it in a realistic way that is modified just for you, by you. • Use our health coaches. They are experts in getting you started and staying on track! • Being in the group is healing as discussed.

First Group of Therapeutic Recommendations • Start with one activity from each of the 4 Directions that includes the ideas from the 7 S. E. E. D. S. and 5R’s. • Start reading or listening to: • Happiness Trap, either the illustrated or the regular version by Russ Harris. Illustrated version is better if you have severe brain fog. • Mindfulness Coach program app from the VA on your phone or tablet device. • CBT-I sleep app to improve your sleep now can work as fast as 3 weeks! • T.I.G.E.R. Protocol by Dr. Akil Palanisamy for autoimmunity. There is an overlap with the treatment of Fibromyalgia as they share common causes of disease, especially if you have autoimmune markers. • Contact our health coaches NOW to start your new food plan/diet, HeartMath and modified exercise plan.

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.

For best results get support and get started with your Health Coaches right away!

Questions and Answers …

Next Visit Agenda • Next 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. • Additional topics will include approaches from the categories of: • Top down • Experiential practices of ACT based mindfulness cognitive behavioral therapy with Frank. • HeartMath Biofeedback discussion and demonstration with health coaches. • Bottom up • Discussion of best forms of exercise for managing FMS. • Additional Tai Chi – Qi Gong exercises will be taught.

End of first class. Thank you for your participation!