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 Brain

of Pain
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

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

A change of 14% or more is considered significant

Percentage change in FIQ-R

Myofascial release subjects 1–8

 FIQ-R Percentage Change in
Massage Subjects

A change of 14% or more is considered significant

Percentage change in FIQ-R

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 Self-
Treatment 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 Best if twice a week for 4-6
recommendations for weeks followed by weekly
exercise 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 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) Natural flavoring
Aspartame (Equal, NutraSweet, Canderel) Nutritional yeast
Autolyzed yeast (or autolyzed yeast extract) Plant protein extract
Barley malt extract Saccharin (Sweet’N Low)
Bouillon Seasoning
Broth Smoke flavoring
Calcium caseinate Sodium benzoate
Carrageenan Sodium caseinate
Flavoring Sodium guanylate
Gelatin Sodium inosinate
Hydrolyzed corn, wheat, or soy protein Soy (only soybean oil /soy lecithin are OK to eat)
L-cysteine Soy protein concentrate
Malt extract Soy protein isolate
Malt flavoring Spices (this term can hide other ingredients)
Modified food starch (any type ) Stock
Monopotassium glutamate Sucralose (Splenda)
Monosodium glutamate (MSG) Textured protein
Whey protein concentrate
I also recommend avoiding all artificial Whey protein isolate
colors, artificial flavors, artificial Yeast extract
sweeteners
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