Course Outline Hour 1 - Allied Health Education · 2020-06-18 · Physiotherapy Theory and...

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Garner©2014. All Rights Reserved.

Nutrition and Osteoarthritis: Integrative and Conventional

Clinical Update

For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 1


Course Outline – Hour 1

• Epidemiology – OA & FGID

• Research update

• OA & Nutrition

• The gut microbiome

• The epigenome

http://www.cdc.gov/Features/OsteoarthritisPlan/

Centers for Disease Control - OA and You


Objectives, Hour 1

1. List predisposing risk factors for & epidemiology of osteoarthritis based on the latest review of evidence.

2. Identify joint pathophysiology in osteoarthritis in order to understand preventive methods and the categories used in managing acute and subacute or chronic OA in medical therapeutic yoga.

3. Identify the critical role that cellular inflammation & inflammatory biomarkers play in osteoarthritis development in order to understand how it can be prevented and mediated through holistic methods in medical therapeutic yoga.

4. Identify how functional gastrointestinal disorders (FGID) can impact patient outcomes in your clinical practice in rehabilitation and your role in intervention.

5. Identify precursors of FGID and critical risk factors that influence cellular and genetic transcription and overall health in order to understand the historical and contemporary context and of Complementary and Alternative Medicine (CAM) intervention and how it can be used in improve orthopedic function.

http://www.cdc.gov/Features/OsteoarthritisPlan/

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What is OA?

• Erosion of articular cartilage, inflammation of synovial membrane, resorption of subchrondralbone

• Associated with excessive proinflammatorymolecules, interleukin, 1β (IL-1β) and tumor necrosis factor α (TNFα)

• Imbalance of synthesis and degradation of matrix yields progressive destruction of joint/tissue

Current nutraceuticals in the management of osteoarthritis: a reviewNahid Akhtar, Tariq M. Haqqi

Ther Adv Musculoskelet Dis. 2012 June; 4(3): 181–207. doi: 10.1177/1759720X11436238


Hip Pathophysiology


Hip Intra-Articular Pathology

Femoral Acetabular Impingement

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400101/

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Knee Pathophysiology


Spine Pathophysiology

© 2012 Ginger Garner. Living Well, Inc. excerpt from PYT Texts ©2001-2012. All rights reserved.

Foot & Hand

Pathophysiology

Foot Hand

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Current OA Management

• PT – Physical activity, assistive devices, footwear, modalities

• CAM – although, acupuncture and glucosamine chondroitin sulfate (molecular building blocks of articular cartilage) RCT’s are inconclusive and only show reduction of symptomatology (study did not include yoga)

• Pharmacology – NSAIDS, analgesics improve function but with hefty side effects; COX-2 inhibitors have GI, CV side effects; MMP inhibitors = more severe side effects; injections posited to accelerate cartilage breakdown

Need prevention, safer alternative strategies, & more use of adjunct therapies

Current nutraceuticals in the management of osteoarthritis: a reviewNahid Akhtar, Tariq M. Haqqi

Ther Adv Musculoskelet Dis. 2012 June; 4(3): 181–207. doi: 10.1177/1759720X11436238


Needed: A Paradigm Shift in OA Management


Our Loss, Who’s Gain?


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Partnership in Health Care Promotion

• Shift in health care during 20th

century

• Lack of partnership in healthcare

• Clinical practice not currently consistent with World Congress PT & WHO recommendations

• Incongruent training in healthcare education

• Nutrition as vital aspect of orthopaedic care

Eisler & Potter 2014, Dean et al 2011


Partnership in Medicine

• "Diet & Lifestyle Risk Factors Associated With Incident Hypertension in Women." JAMA 302(4):401-411, 2009.

• "Relation Between Modifiable Lifestyle Factors & Lifetime Risk of Heart Failure." JAMA 302(4):394-400, 2009.

• Dean et al 2011. First PT Summit on Global Health: Implications and Recommendations for the 21st

Century. Physiotherapy Theory and Practice. 27(8):531-547.

Figure Source: JAMA 2009, JAMA 2009


Observations Relevant to

an Emerging Model of OA Care

COAMI – Chronic OA Management Initiative 2013

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Nutrition & Physical Inactivity: “Joined at the Hip”

Poor Nutrition

• CVD

• Cancer

• Stroke

• Diabetes

• Osteoporosis

• Musculoskeletal health

• Obesity

Physical Inactivity

• CVD

• Cancer

• Stroke

• Diabetes

• Osteoporosis


• Obesity

Dean 2009 (Part 1)

Inflammation’s Long Arm of Destruction

Top Three Risk Factors

Pro-inflammatory Agents in:

1. Poor nutritional choices

2. Poor lifestyle choices

(physical inactivity or environmental pollution)

3. Obesity

Disease Sequelae

• CVD

• Cancers (breast, colorectal)

• Dementia

• Chronic lung disease

• OA

• Diabetes

Nathan C. Epidemic inflammation: Pondering obesity. Mol Med. 2008;14(7-8):485-492. doi: 10.2119/2008-00038.Nathan; 10.2119/2008-00038.Nathan.

Think about how you will answer her questions

Problem:A patient comes to you with diffuse pain in her joints. She has been diagnosed with osteoarthritis by a rheumatologist, and it was recommended she do aquatic therapy and take several medications on a long-term basis. She tried it but she reports the water temperature made her “bones and joints ache even more” and the medications “upset her stomach and make it impossible to function normally, not to mention aggravate her incontinence.” She wants a more holistic approach and heard physical/physiotherapy can embrace both integrative and conventional concepts that can help with OA. So she has come to you with questions about what to do…

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Is this very common?

In order to answer her question, you must know:

• The most common joint disease in America today is OA, which also exacts a terrific economic burden on the healthcare system (Bitton 2009).

• The incidence of OA has increased 30% in the last 10 years (Altman 2010).

• Bioarcheaology of OA suggests tibiofemoral OA and large joint OA in general is considered a modern disease (Baetsen et al 1997, Waldron 1991)

• Arthritis/rheumatic disease is the leading cause of disability in adults*

• Projected prevalence of persons ≥ 65 yrs with arthritis or chronic joint disease expected to increase from 13.2% in 2010 to 20.0% in 2030**

•*http://www.cdc.gov/arthritis/data_statistics/national_nhis.htm#disability**.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5221a1.htm


Is this serious?• In order to answer her question, you must know:

• If left untreated, OA could result in:

• Inability to complete even basic ADL’s

• Joint disease leading to arthroplasty

• Chronic tendonitis or bursitis

• Weakness, debility

• Increased risk for injury

• Increased risk for being homebound


How can you be sure the problem is arthritis?

In order to answer her question, you must know:

Patients with OA might experience the following symptoms:

• Joint soreness after periods of overuse or inactivity.

• Stiffness after periods of rest that goes away quickly when activity resumes.

• Morning stiffness, which usually lasts no more than 30 minutes.

• Pain caused by the weakening of muscles surrounding the joint due to inactivity.

• Joint pain is usually less in the morning and worse in the evening after a day’s activity.

• Deterioration of coordination, posture and walking due to pain and stiffness.

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How did this happen?

Currently, conventional (western) medicine identifies the most common local risk factors for development of the rheumatic disease affecting synovial joints known as osteoarthritis or DJD, as:

1. Obesity (BMI > 25)

2. Mechanical factors or heavy physical stress such as previous joint injury

3. Episodic, low-grade inflammation is now a well documented phenomenon and believed to be involved in the disease progression (Sokolove & Lepus 2013, Martel-Pelletier et al 1999)

Arto et al 2010, Blagojevic et al 2010, Hunter 2009, Chaganti et al 2011


What are inflammatory agents?

OA is a modern phenomenon that is strongly attributed to obesity and the low level of inflammation that adipose tissue secretes.*

• Chronic inflammation is no longer defined in terms of time.

• Definition - “a state in which pro-inflammatory cytokines are 2-3 times

above the level considered to be normal.” (Mathur and Pedersen 2008, Stockert 2011).

• Cytokines release

• Adipose tissue as a biomarker (Pantsulaia et al 2010, Sutton et al 2009).

*(Lau et al 2005, Fantuzzi 2005)


How Does Inflammation’s Snarky Cousin (“Low-Grade”) Affect My Joints?

Sokolove, J. MD, Lepus CM. Role of

Inflammation in the Pathogenesis of OA. Ther Adv Musculoskel Dis. 2013;5(2):77-

94.

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Inflammatory messengers set up chronic states of inflammation in the body which contributes to chronic diseases such as CVS, CA, diabetes, obesity, dementia, and OA (Matur and Pedersen 2008,

Stockert 2011, Martel-Pelletier et al 1999, Ratheeet al 2009, Watzl 2008, Jin et al 2009, Serafini2010).

Handschin and Spiegelman; Nature 2008

Why is Low Grade Systemic Inflammation Important?

How can I prevent this from getting worse?

Avoid poor exercise habits

• Cumulative wear and tear at the joint surface

• Damage to articular cartilage

• Friction over damaged surfaces

• Being sedentary

• Inflammatory-inducing choices (too little or too much exercise)

Avoid poor dietary habits

Consumption of inflammatory agents in foods

• Processed foods

• High glycemic foods

• Saturated fatty acids

• Low fiber foods

Georgiou et al 2011, Mathur and Pedersen 2008, Petersen and Pedersen 2005, Pederson et al 2007, Pedersen and Saltin 2006, Stewart et al 2007, McAlindon and Felson 1997, Kraan 2010, Messier 2010


PT as Partners in Prevention

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What would happen if I don’t change my lifestyle?

In order to answer her question, you must know that continued poor lifestyle choices could result in:

• Articular cartilage damage

• Progression of disease process

• Loss of joint mobility and function

• Immobility

• Progressive debilitation

• Development of comorbiditiesrelated to inflammatory process & debility

• Psycho-emotional issues such as depressive S&S



What about Gut Health?

Death sits in the

bowels…bad digestion is the

root of all evil.

Hippocrates~ 400 B.C

Number of publications related to the intestinal microbiota in the last two decades, per year.

Sekirov I et al. Physiol Rev 2010;90:859-904

©2010 by American Physiological Society

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The Gastroenterology News of the United States Department of Health & Human Services (HHS) reports (AHRQ 2006):

• Hospital admissions for GI dysfunction increased by more than 33% from 1994-2004.

• The three most common GI disorders treated in hospital patients were: gastrointestinal hemorrhage, diverticulosis & diverticulitis, and intestinal obstruction. Each accounted for more than 300,000 admissions.

• Hospital stays for diverticulosis, appendicitis, gastroesophageal reflux disease, and other GI disorders increased from 33 percent to 46 percent.

• $20 billion was spent at US hospitals on GI disorders in 2004. Medicare was billed for more than half of all stays for intestinal obstruction, diverticulosis, and gastrointestinal hemorrhage.

GI Epidemiology


FGID Facts

• Lack of pathology

• Negative diagnostic tests

• Not psychiatric disorder

• Stress-related phenomenon

• Psychoemotional exacerbation(s)

• Prevalence rate of FGID in western countries is between 10-20% (Jones et al 2007, Sandler 1990, Drossmanet al 1993).

• 40% of gastroenterologist’s practice

• 50-80% do not seek help


What is the Gut Microbiome?

• Why are certain foods “bad for us?”

• Why is stress harmful?

• Can we manage our microenvironment for optimal health?

• How might yoga/CAM affect gut microbes?

Lecture from Jo Alock, Dept. of Emergency Medicine, University of New Mexico, USA. 2nd Annual

Symposium on Medicine and Yoga. Copper Mountain, 2012.

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Bischoff 2011, (graphic): Maslowski KM, Mackay CR. Diet, gut microbiota and immune responses. Nat Immunol. 2011;12(1):5-9. doi: 10.1038/ni0111-5; 10.1038/ni0111-5.

Gut Microbiome

Figure 1:

Diet, microbial

compositio

n and

regulation

of the immune

system.


How Quickly Can I Affect My Gut Microbiota?

• Gut flora – host specific micro-organisms that contribute to probiotic and prebiotic activity and determine metabolism of nutrients

• 90% of the cells in the body are living bacteria alive in the human gut.

• “Real-time” microevolution

• Antibiotics, SFA’s, low fiber, high glycemic

Alcock J, Franklin ML, Kuzawa CW. Nutrient signaling: Evolutionary origins of the immune-modulating effects of dietary fat. Q Rev Biol. 2012;87(3):187-223.


What Can I Do To Avoid Dysbiosis& Subsequent Inflammation?

Preventive Components

• Poor Lifestyle Choices

• Poor Dietary Habits

• Impaired Stress Response –Allostatic Load & HPA Axis Regulation

Sound familiar?

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What is the Epigenome?

Nutritional choices

affect gene expression

• Nature is not distinct

from nurture

• Diet and lifestyle

choices can change our genes through influence of cells network

“collectively known as the epigenome”

http://www.genome.gov/27532724

Source: National Human Genome

Research Institute, NIH, www.genome.gov

Leave your drugs

in the chemist's pot if you can

heal the patient

with food.~Hippocrates

460-377 B.C.

OA as a chronic disease is the perfect

paradigm of a pathology the treatment of which could be addressed by nutrition. ~

Ameye and Chee 2006; Arthritis Research

and Therapy

Ameye and Chee Arthritis Research & Therapy 2006 8:R127 doi:10.1186/ar2016


Diet, fatty acids and the actions of anti-inflammatory GPCRs.Maslowski KM, Mackay CR. Diet, gut microbiota and immune responses. Nat Immunol. 2011;12(1):5-9. doi: 10.1038/ni0111-5;

10.1038/ni0111-5.

Gut Microbiota & Diet


http://www.genome.gov/

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Physiology of Prebiotics: Who are They?

• Prebiotics: non-digestible food ingredients

• Stimulate growth, activity, or both in intestinal bacteria (BIFIDOBACTERIUM), resistance to gastric acidity, able to be fermented by gut microbiota

• Facilitate normal gastrointestinal motility/transit time, reduction of CVD, CA, DM, infections, allergies, osteoporosis, obesity, and other inflammatory-related disorders, control appetite

Laparra JM. Interactions of gut microbiota with functional food components and nutraceuticals.

Pharmacological research. 2010;61(3):219; 219-225; 225.


Anthropological Context of CAM

Georgiou NA. Pharma–nutrition interface: The gap is narrowing. Eur J Pharmacol.

2011;651(1-3):1; 1-8; 8.


Nutritional Nomenclature


From Neutraceuticals to Functional Foods (Ameye & Chee

2006)

• Review of 53 RCT’s • Functional Food – whole food or drink consumed as part of the

daily diet

• Neutraceuticals – food or direct derivative from food that provides

medical or health benefits

• Dietary supplement – FDA deemed name for neutraceuticals

• Organic, whole-food derived, probiotic (Shen & Nahas 2009) multi-vitamin

• Non-GMO & Organic

Mueller et al 2010, Jurenka 2009, Aggarwal and Harikumar 2009, Aggarwal et al 2007, Menon and Sudheer

2007

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Plant-Based Diets: Love A Plant Today

Use of plant-based diet ((Kiecolt-Glaser 2010) and dietary herbs, to aid in*:

• Digestive motility

• Anti-inflammatory action

• Microbiota protection

• Metabolic activity

• Immunity

• Cardiovascular health


• Minimize postprandial hyperglycemia and oxidative stress (avoiding refined sugars and starches)


Resources

• The Human Epigenome: http://www.genome.gov/27532724

• The Gut Microbiome: http://ehp.niehs.nih.gov/121-a276/

• Biomarker Test for Inflammation - CRP Testing: http://www.nlm.nih.gov/medlineplus/ency/article/003356.htmor http://drhyman.com/blog/2010/07/11/is-your-body-burning-up-with-hidden-inflammation-2/

• The Arthritis Foundation - https://www.arthritis.org

• The Chronic OA Management Initiative (COAMI): http://www.usbji.org/projects/project_op.cfm?dirID=335


Selected Sources

• US Bone and Joint Initiative. Chronic OA Management Initiative. Building a Model for OA Care. Setember 22-24, 2013. IL. http://www.usbji.org/Files/COAMI-Care-Model-Mtg-Summary.pdf. Last accessed March 5, 2014.

• The Economist, Health care Bill of health. Health-care spending in rich countries. Jun 26th 2009. http://www.economist.com/node/13932149. Last accessed March 4, 2014.

• Bitton R. The economic burden of osteoarthritis. Am. J. Manag Care. 2009; Sep; 15(8)Suppl.

• Dean E, Al-Obaidi S, De Andrade AD, et al. The first physical therapy summit on global health: Implications and recommendations for the 21st century. Physiother

Theory Pract. 2011;27(8):531-547. doi: 10.3109/09593985.2010.544052; 10.3109/09593985.2010.544052.

• Dean E. Physical therapy in the 21st century (part I): Toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5-6):330-353.


http://ehp.niehs.nih.gov/121-a276/

http://www.nlm.nih.gov/medlineplus/ency/article/003356.htm

http://drhyman.com/blog/2010/07/11/is-your-body-burning-up-with-hidden-inflammation-2/

https://www.arthritis.org

http://www.usbji.org/projects/project_op.cfm?dirID=335

http://www.usbji.org/Files/COAMI-Care-Model-Mtg-Summary.pdf

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Sources 2

• Eisler, Riane; Potter, Teddie M. 2014. Transforming InterprofessionalPartnerships: A New Framework for Nursing and Partnership-Based Health Care. Sigma Theta Tau International.

• Eisler, R. (2007). The real wealth of nations: Creating a caring economics. San Francisco, CA: Berret-Koehler.

• Waldron, HA. Prevalence and distribution of osteoarthritis in a population from Georgian and early Victorian London. Ann Rheum Dis 1991;50:301-307 doi:10.1136/ard.50.5.301

• Hunter DJ. Focusing osteoarthritis management on modifiable risk factors and future therapeutic prospects Therapeutic Advances in Musculoskeletal Disease October 2009 1: 35-47

• Akhtar N, Haqqi TM. Current nutraceuticals in the management of osteoarthritis: a review. Ther Adv Musculoskelet Dis. 2012 June; 4(3): 181–207. doi: 10.1177/1759720X11436238


Sources 3

• "Diet & Lifestyle Risk Factors Associated With Incident Hypertension in Women." JAMA 302(4):401-411, 2009.

• "Relation Between Modifiable Lifestyle Factors & Lifetime Risk of Heart Failure." JAMA 302(4):394-400, 2009.

• Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society 1 January 2010

• Altman RD. Early management of osteoarthritis. Am. J. Manag. Care. 2010 Mar; 16(Suppl Management: S41-7.

• The Gastroenterology News of the United States Department of Health & Human Services (HHS) reports (AHRQ 2006)


Sources 4

• Arto T. Toivanen AT, Heliövaara M, Impivaara O, Arokoski JPA, Knekt P, Lauren H, Kröger H. Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis—a population-based study with a follow-up of 22 years Rheumatology (2010) 49(2): 308-314.

• Chaganti RK, Lane NE. Risk factors for incident osteoarthritis of the hip and knee. Current reviews in musculoskeletal medicine (2011). Volume: 4, Issue: 3, Publisher: Humana Press (999 Riverview Drive, Suite 208, Totowa NJ 07512-1165, United States), Pages: 99-104

• Sokolove, J. MD, Lepus CM. Role of Inflammation in the Pathogenesis of OA. Ther Adv Musculoskel Dis. 2013;5(2):77-94.

• Sekirov I et al. Physiol Rev 2010;90:859-904

• The Arthritis Foundation.


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Sources 5

• Sokolove, J. MD, Lepus CM. Role of Inflammation in the Pathogenesis of OA. Ther Adv Musculoskel Dis. 2013;5(2):77-94.

• Ameye and Chee Arthritis Research & Therapy 2006 8:R127 doi:10.1186/ar2016

• Handschin C & Spiegelman BM. The role of exercise and PGC1 in inflammation and chronic disease Nature 454, 463-469(24 July 2008)

• Maslowski KM, Mackay CR. Diet, gut microbiota and immune responses. Nat Immunol. 2011;12(1):5-9. doi: 10.1038/ni0111-5; 10.1038/ni0111-5.

• Nathan C. Epidemic inflammation: Pondering obesity. Mol Med. 2008;14(7-8):485-492. doi: 10.2119/2008-00038.Nathan; 10.2119/2008-00038.Nathan.

• Garner G and Meriage-Reiter T. Is Stress Making You Sick and Sad? Yang Sheng Magazine. 《養生》(Vol 3. No 2) March/April 2013. http://yang-sheng.com/?p=9166

http://www.nature.com/nature/journal/v454/n7203/full/nature07206.html

http://yang-sheng.com/?p=9166

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Nutrition and Osteoarthritis:

Integrative and Conventional Clinical Update

For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 2


• Conventional Research Update – Gut-Brain-Body Axis and HPA Axis Dysregulation

• Pyscho-emotional Health Considerations

• Systemic Dysfunction and Biopsychosocial Intervention

Objectives

1. Describe the “gut-brain” connection in order to understand the role that functional gastrointestinal disorders play in PYT conceptual model intervention in orthopedic rehabilitation.

2. Identify the role of the amygdala and the psychoneuroendocrinology of HPA Axis Dysregulation Phenomenon in order to understand how to affect change in the “gut-brain” interaction.

3. Describe how medical yoga can improve health care through a holistic evaluative methodology.

4. Describe how the two major categorical areas of CAM intervention for affecting GI and orthopedic health can effectively operationalize the

holistic conceptual model for evaluation and management of all orthopaedic dysfunctions and diagnoses.

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Mind Over Matter

Gut “Second Brain”• The Enteric Nervous

System

• 100 million neurons in a 9 meter long canal (esophagus to anus)

• 95% of serotonin in

bowels – IBS “mental illness of the second brain”

Hadhazy 2010, Nograndy, Bianca. 2013. Gut bugs - the bacteria you need. ABC Health and Wellness.

JONES MP, CROWELL MD, OLDEN KW,FRANCIS F. Functional Gastrointestinal Disorders: An Update for the Psychiatrist.

Psychosomatics 48:2, March-April 2007.Jones MP, Dilley JB, Drossman D, et al: Brain–gut connections in functional GI disorders: anatomic and physiologic

relationships.Neurogastroenterol Motil 2006; 18:91–103

Gut-Brain-Body Axis

Del Chierico al 2012

http://www.abc.net.au/health/thepulse/stories/2013/04/22/3737778.htm#.UYe0wispbGL

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Anthropological Etiology

Dis-Health

Characteristics of “Dis-health”Evidence of imbalance in an individual’s physical constitution include:

• Chronic Inflammation - Positive hsC-Reactive Protein (CRP) test

• Low energy or motivation

• Sedentary lifestyle due to GI distress, fatigue, or lack of knowledge

• Poor body awareness

• Postural dysfunction

• Poor breathing

• Hyperactive nervous system –increased sympathetic activity

• Depressed immune function

• Feelings of separation from self/identity

• Insomnia

• Poor cognition - memory and concentration

• FGID

• Adrenal Fatigue

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CRP Clinical Range

Wolfe F. The C-reactive protein but not erythrocyte sedimentation rate is associated with clinical severity in patients with

osteoarthritis of the knee or hip. J Rheumatol. 1997;24(8):1486-1488.Ridker PM, Libby P. Risk Factors for Atherothrombotic Disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds.

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa; Saunders Elsevier; 2007: chap 39.

Functional GI Disorders

Clinicians are often “poorly trained or poorly motivated to deal with theses issues,” yet FGID can:

• cause pain, abnormal bowel habit, decreased QOL, increased medical costs, disability and absenteeism. (Jones et al 2007, Tanaka et al 20011, Drossman et al 2000, Longstreth et al 2005, Ananthakrishnan et al 2010).

• and are “best evaluated and treated via biopsychosocial model that incorporates

digestive-tract function and

psycho-social assessment.”


JONES MP, CROWELL MD, OLDEN KW,FRANCIS F. Functional Gastrointestinal Disorders: An Update for the Psychiatrist. Psychosomatics 48:2, March-April 2007.

FGID

• FGID, according to the Rome II Criteria, include:

• Dyspepsia** related to ulcer, dysmotility or nonspecific dyspepsia

• Bowel disorders

• IBS* (up to 20% of adults [Tanaka et al 2011, Gwee et al 2010]) - 70% of persons do not seek care (Jones et al 2007)

• Bloating

• Constipation

• Diarrhea

• Unspecified functional bowel disorder

•*Most common (Jones et al 2007)

•**2nd most common disorder


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Psychoneuroendocrinology &HPA Axis Dysregulation

An abnormal process which is neurophysiologically related to FGID and the inflammatory process (Bellingrath

et al 2008, Bellingrath & Kudielka 2008).

• A form of illness related to work-life balance and health and well being

• “21st Century Stress Syndrome”

• Adrenal Fatigue is a mild form of Addison’s disease (low functioning or under-active adrenal glands), also known as adrenal insufficiency or adrenal exhaustion

Kudielka and Wust 2010, Boudewiin et al 2009, and excerpt from Wilson 2011


Interactions between the intestinal microbiota, immune system and brain-gut axis, and their

effects on intestinal function and functional gastrointestinal (GI) symptoms.

Ringel Y , and Maharshak N Am J Physiol Gastrointest Liver Physiol 2013;305:G529-G541


Central role of the brain in allostasis and the behavioral and physiological response to

stressors. [From McEwen (211), copyright 1998 Massachusetts Medical Society.].

McEwen B S Physiol Rev 2007;87:873-904


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Four types of allostatic load.

McEwen B S Physiol Rev 2007;87:873-904


© 2012 Ginger Garner. Living Well, Inc. excerpt from PYT Texts ©2001-2012. All rights reserved.Joseph E. LeDoux (2008), Scholarpedia, 3(4):2698.

Am I Having an Amygdala Highjack?

Recognition of when an amygdala highjack is occurring can include these three signs (Horowitz 2011):

1. You have a strong emotional reaction.2. Your emotional reaction was sudden.3. In retrospect, you realize your reaction was inappropriate.

(Goleman 1996, 2005)

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Changing the Gut-Brain Interaction

Breaking the Stress

Response for:

• Telomere Preservation

• Inflammation Reduction

• Allostasis

Mindfulness through:

• Meditation

• Nutrition

• Movement

Epel, Blackburn, et al. Can Meditation Slow Rate of Cellular Aging? Cognitive Stress, mindfulness, and telomeres. Ann NY Acad. Sciences 2009 August 1172:34-53.

Why the Biopsychosocial Model?

• FGIDs comprise the largest segment of patients seen in gastroenterology practice

(Dorn et al 2007), and patients believe that their care is unsatisfactory and their needs

are unmet.(Drossman et al 1993, Drossmanand Whitehead 2009)

• OA surpasses back pain, spine, heart, lung and respiratory problems as the most

common cause of disability in the US today. (USBJI 2013)

• 88% of those with arthritis have comorbidity – Obesity, CVD, &/or DM (USBJI 2013)

• WHO (2001) and IOM support (2011)


Quinn F, Johnston M, Dixon D, Johnston D, Pollard B, Rowley D. Testing the integration of ICF and behavioral models of disability in orthopedic patients: Replication and extension. Rehabilitation Psychology [serial online]. May 2012;57(2):167-177.

Integrated Biomedical and Behavioral model worked better together (to predict

and explain activity limitation) than on their own in 342 patients with arthritis

awaiting joint replacement surgery. Biomedical + behavioral

models = Biopsychosocial Model

The Biopsychosocial Model

Based on a biopsychosocial model of care, the patient-

centered approach has been shown to be the most

effective and cost-effective way to address pain.

~ Institute of Medicine 2011 report “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and

Research”

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WHO ICF Model

WHO ICF 2002. International Classification of Functioning, Disease, and Health. Geneva, Switzerland.

Precept 13.

PYT emphasizes

protection of joints,

especially the small joints

of the hands and feet,

during all postures

(asana).

Biopsychosocial vs. Biomedical Medicine

Integrated Model for

Systemic Health

1. Mindful Eating -

Adoption of a holistic bio-psycho-socio-spiritual

model when dealing with FGID patients (Chen et al 2010)

2. Mindful Movement –Medical therapeutic yoga

Systems-Based

Team Approach

Healthy Systemic Function including:

• Epigenetic regulation

• Immunity & Longevity via Telomere Preservation

• HPA Axis Regulation and Allostasis

• High bone mineral density and low pro-inflammatory activity

• High parasympathetic input

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Historical Context of Prevention

The traditional vegetarian diet can be superior in providing essential building blocks for gene

transcription Improves health and heredity to prevent cancer, diabetes, and

other chronic diseases.

(Thaler et al 2009, Murakami et al 1998, Lefall & Kripke 2010; President’s Cancer Panel: NIH, National Cancer Institute and US Dept. of H&H Services, Fleming et al 2008, Jablona & Raz 2009, Titus-Ernstoff et al

2008, National Academy of Sciences 1993).

Culinary Consciousness

Sample Food Entry from Food Diary

• Time Location Food Ate Why

• 10:15 AM Work Doughnut Co-worker was sharing

them with everyone. I didn’t want to seem rude, so I took one.

• How Felt Afterward - Terrible. I had low energy the rest

of the morning, an upset stomach, and on top of that - a

headache from too much coffee. I want to remember

how badly this doughnut made me feel so I won’t eat one again.


Gut-Brain-Body Axis:The Pyschoemotional Facet

The Energy Inventory: Are The Relationships In My Life Prana Builders or Depleters?

1. Make a list of people, things, or activities which:

• Build your energy or prana.

• Suck away or deplete your energy.

2. Alternately, make a list of things, people, or activities which inspire or motivate you.

3. Encourage yourself or your patient to begin eliminating “Prana Suckers” from their life which may include:

• Relationships

• Things/possessions

• Activities

10

“Amygdala Highjack” Prevention

Respond, rather than React.

1. Avoid placing blame.

2. Wait. Breathe.

3. Ask the question: “What is really going on?”

4. Resist the amygdala’s urge to react.

5. Listen.

6. Self-reflect.

Polyvagal Theory:A Unifying Theory

© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.

Yogic Respiration Categories

•Stress Management & Relaxation/SNS Downregulation

•Hemispheric Focus (alt. nostril breath)

•Increasing Alveolar

Ventilation/PNS Activity

•Progressive Relaxation

1. Practice daily in the AM or before your yoga practice, preferably.

2. Be comfortable. Sit against the wall if free-sitting becomes uncomfortable, or perform in bolstered reclined supine lying in lateral left side-lying.

3. Begin on exhale, end on inhale.

4. Work to equalize the inhalation with the exhalation.

5. Work to reduce RPM to < 12 and for therapy, 3-6 RPM for HRV.

6. Repetitions: 5-10 cycles each or a minimum of 2-5 minutes of breathing practice.

Pranayama/Breath Categories Guidelines

©2001-2014 Ginger Garner. All rights reserved.

11


Sexual Medicine

Reviews 2016 4, 303-328DOI: (10.1016/j.sxmr.2016.04.002)

Fourth Limb: Breath & Energy (pranayama)

Prana

• breath, respiration, life, vitality, wind, energy, or strength.

Ayama

• length, expansion, stretching, or restraint.

Rhythmic Control of the Breath

• Starts on Exhale (puraka)

• Ends on Inhale (rechaka)

• Retention (kumbhaka)

• Two Phases of Retention

Respiration in Yoga contains 5 parts

“A yogi’s life is not measured by the number of his days but by the number of his breaths.”

Therefore, he follows the proper rhythmic patterns of slow deep breathing. Yoga Sutras of

Patanjali ch 2. v. 16©2001-2014 Ginger Garner. All rights reserved.

Orofacial Assessment©

• Only to be performed by licensed HCP

• Self-assessment

1. Clenching, grinding, TMJ issues?

2. Mandible, hyoid, digastric, , platysma, SCM, mastoid process

3. Lip seal and jaw position; tongue position

4. Lingual frenulum

5. Respiratory screen


12

Orofacial Phonation Relaxation (OPR) Response

©

Three-Pronged Approach

1. Resonation

2. Projection

3. Yogic Breathing


Functional Breath Patterns

1. Abdomino-diaphragmatic breath

2. Victorious – ujyaiipranayama

3. TATD breath


The Yoga “Couch” – Three Tier Approach & A-D Breath

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

13

Mason, H et al. 2013

Science of Ujyaii

•Victorious breath “Ujyaii” (ooh-jai-ee)

• Pursed lip breathing

• Increased cardiac-vagal baroreflexsensitivity (BRS)

• Improves oxygen saturation

• Lowers BP

• Reduces anxiety

• Increases parasympathetic activation correlated with improved physical and mental health

• Vagal stimulation

• Increased O2 absorption

• Greater tidal volume

•Action

•Contraction of glottis creates “resistance breath”

•Equal inspiration/expiration showed greater clinical significance for improving baroreflex sensitivity in beginner yoga subjects.


Let’s NAP!What does a neutral larynx feel like?

• No sound• Palpation

• Interoception

• Proprioception

• Resonation

• Sound • “Ah” • “Uh” • “Mm”

M

U

A

© 2016. Ginger Garner. Medical Therapeutic Yoga.

Tri-Diaphragm Downtraining


14

2.-4. Transversus abdominis-assisted Thoracodiaphragmatic Breath (TATD)

TATD Breath

• Root Locks - FIRST

• Abdominal Lock- SECOND

Biological Plausibility

• Psychobiological

• Physiological

• Neuromotor


TATD Breath©: Optimal Arousal


2-4. TATD Breath© Components

(TA-assisted thoraco-diaphragmatic breath)

• Respiratory Diaphragm

• External Palpation

• Transversus Abdominis

• External palpation

• Multifidus


• PFM


• Internal (PT only)


15

Identifying Diaphragmatic Dysfunction

Garner, G. 2016. Medical Therapeutic Yoga.; Patrick Koo et al. J Appl Physiol 2015;118:142-147

Relaxation Response

Outcome Measures & Identification of Psychometrics

Well-Being and Gut Function in OA

• SF-36 (short-form 36) Health Survey (Quinn 2012)

• SF-12 (short-form 12) Health Survey (Bischoff 2011)

• Eating Habits – 7 day dietary journal (Bischoff 2011)

• GI Symptom Profile (Bischoff 2011)

Quinn F, Johnston M, Dixon D, Johnston D, Pollard B, Rowley D. Testing the integration of ICF and behavioral models of disability in orthopedic patients: Replication and extension. Rehabilitation Psychology [serial online]. May 2012;57(2):167-177.

Bischoff SC. 'Gut health': A new objective in medicine? BMC medicine. 2011;9(1):24.

16

Resources

• Adrenal Burnout/Fatigue

• Urban pollution – air, noise, water, electromagnetic, chemical pollution

• Fear based lifestyle

• www.gingergarner.com

• http://www.gingergarner.com/2011/03/18/update-on-avoiding-worklife-burnout-recognizing-adrenal-burnout/

Selected Sources

• Quinn F, Johnston M, Dixon D, Johnston DW, Pollard B, Rowley DI. Testing the integration of ICF and behavioral models of disability in orthopedic patients: Replication and extension. Rehabil Psychol. 2012;57(2):167-177. doi: 10.1037/a0028083; 10.1037/a0028083.

• WHO. World Health Organization International Classification of Functioning, Disease, and Health. 2001. Geneva.

• McEwen BS. Physiological ReviewsPublished 1 July 2007Vol. 87no.873-904DOI: 10.1152/physrev.00041.2006

• Bischoff SC. 'Gut health': A new objective in medicine? BMC medicine. 2011;9(1):24.

• Tul, Y., Unruh, A. and Dick, B. D. (2011), Yoga for chronic pain management: a qualitative exploration. Scandinavian Journal of Caring Sciences, 25: 435–443. doi: 10.1111/j.1471-6712.2010.00842.x

Sources 2

• Garner, G. 2010. Adrenal Fatigue Syndrome: http://www.circlebloom.com/overstressed-things-you-should-know-about-adrenal-burnout-and-fertility/

• Heather Mason, Matteo Vandoni, Giacomo deBarbieri, Erwan Codrons, VeenaUgargol, and Luciano Bernardi, “Cardiovascular and Respiratory Effect of Yogic Slow Breathing in the Yoga Beginner: What Is the Best Approach?,” Evidence-Based Complementary and Alternative Medicine, vol. 2013, Article ID 743504, 7 pages, 2013. doi:10.1155/2013/743504

• Nograndy, Bianca. 2013. Gut bugs - the bacteria you need. ABC Health and Wellness.

• Hadhazy. Think Twice: How the Gut’s Second Brain Influences Mood and Well-Being. Scientific American. 2010

• Joseph E. LeDoux (2008), Scholarpedia, 3(4):2698.

http://www.gingergarner.com

http://www.gingergarner.com/2011/03/18/update-on-avoiding-worklife-burnout-recognizing-adrenal-burnout/

http://www.circlebloom.com/overstressed-things-you-should-know-about-adrenal-burnout-and-fertility/

http://www.abc.net.au/health/thepulse/stories/2013/04/22/3737778.htm#.UYe0wispbGL

17

Sources 3

• Del Chierico F, Vernocchi P, Bonizzi L, et al. Early-life gut microbiota under physiological and pathological conditions: The central role of combined meta-omics-based approaches. J Proteomics. 2012;75(15):4580-4587. doi: 10.1016/j.jprot.2012.02.018; 10.1016/j.jprot.2012.02.018.

• Wolfe F. The C-reactive protein but not erythrocyte sedimentation rate is associated with clinical severity in patients with osteoarthritis of the knee or hip. J Rheumatol. 1997;24(8):1486-1488.

• Ridker PM, Libby P. Risk Factors for Atherothrombotic Disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa; Saunders Elsevier; 2007: chap 39.

• Epel, Blackburn, et al. Can Meditation Slow Rate of Cellular Aging? Cognitive Stress, mindfulness, and telomeres. Ann NY Acad. Sciences 2009 August 1172:34-53.

• Ringel Y, Maharshak N. Intestinal microbiota and immune function in the pathogenesis of irritable bowel syndrome. Am J Physiol Gastrointest Liver Physiol. 2013;305(8):G529-41. doi: 10.1152/ajpgi.00207.2012; 10.1152/ajpgi.00207.2012.

Sources 4

• Grenham S, Clarke G, Cryan JF, Dinan TG. Brain-gut-microbe communication in health and disease. Front Physiol. 2011;2:94

• Heather Mason, Matteo Vandoni, Giacomo deBarbieri, Erwan Codrons, Veena Ugargol, and Luciano Bernardi, “Cardiovascular and Respiratory Effect of Yogic Slow Breathing in the Yoga Beginner: What Is the Best Approach?,” Evidence-Based Complementary and Alternative Medicine, vol. 2013, Article ID 743504, 7 pages, 2013. doi:10.1155/2013/743504

• Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasisin epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. 2012 May;78(5):571-9. doi: 10.1016/j.mehy.2012.01.021. Epub2012 Feb 24.

• Renovato F, Thomaz FA, Burke N, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain – a comparative study. CLINICS 2010;65(10):1013-1017. http://www.scielo.br/pdf/clin/v65n10/v65n10a15.pdf

Sources 5

• Hides J, W, MendisMD, Sextona M. The relationship of transversusabdominis and lumbar multifidus clinical muscle tests in patients with chronic low back pain. Manual Therapy. Volume 16, Issue 6, December

2011, Pages 573–577

• França FR, Burke TN, Caffaro RR, Ramos LA, Marques AP. Effects of

Muscular Stretching and Segmental Stabilization on Functional Disability and Pain in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial. Journal of Manipulative and Physiological Therapeutics Volume 35, Issue 4, May 2012, Pages 279–285.

• Garner, G. Medical Therapeutic Yoga. Prospectus for Publication. 2015. Handspring Ltd. UK.

1

Garner©2014. All rights reserved.

Nutrition and Osteoarthritis: Integrative and Conventional Clinical Update

For Professional Yoga Therapist candidates: This CE corresponds to Module 10, Part 3



Clinical Application –Assessment

• Biopsychosocial Model and the Systems Approach

• Virtual Lab/Case Study - Algorithm Assessment

• Hip, Knee, Spine, and Hand OA Intervention

• Resources, Evaluating Existing Yoga Programs, Trends

in Yoga as Medicine


Objectives

1. Describe the guidelines, indications, and contraindications for the safe application and appropriate use of medical therapeutic yoga for osteoarthritis.

2. Identify evidence-based methodology for incorporating the PYT medical yoga model into current rehabilitation programs.

3. List the four remaining facets in the conceptual model, signs and symptoms of imbalance, and a minimum of 2 interventions for early intervention in each facet, which can be implemented to improve patient outcomes and satisfaction.

4. Analyze 21 yoga postures used in management of osteoarthritis in the hip, knee, shoulder, and spine.

5. Evaluate existing yoga programs for content, safety, and validity.

2


Clinical Decision-Making

1. Lifestyle choices (nutrition and exercise)

2. Repetitive stress syndrome & poor ergonomic set up

3. Poor technique in sport, including yoga, execution

OA disability causes fall into 3 categories:


Summary Recommendations from a Systematic Review of Recommendations and Guidelines for

the Management of OA: Theme 1

Theme 1

• First line: acetaminophen/paracetamol

• Second line: topical capsaicin, and topical or oral NSAIDs (with appropriate risk stratification)

• Refractory symptoms: consider tramadol, opioids, or possibly duloxetine

• Intra-articular therapy

• Use IA corticosteroids for hip or knee OA

• Consider IA hyaluronans for knee OA in select patients

The Annotated Bibliography of OA Guidelines and Recommendations team included: Joanne Jordan, MD, MPH; Amanda E. Nelson, MD, MSCR; Kelli D. Allen, PhD; Yvonne M. Golightly, PT, MS, PhD; and Adam P. Goode, PT, DPT, PhD.


Summary Recommendations from a Systematic Review of Recommendations and Guidelines for the

Management of OA: Theme 2

Theme 2

• Joint replacement is recommended for appropriate patients.

• Arthroscopy with debridement is not indicated for symptomatic OA

The Annotated Bibliography of OA Guidelines and Recommendations team included: Joanne Jordan, MD, MPH; Amanda E. Nelson, MD, MSCR; Kelli D. Allen, PhD; Yvonne M. Golightly, PT, MS, PhD; and Adam P. Goode, PT, DPT, PhD.

3


Summary Recommendations from a Systematic Review of Recommendations and Guidelines for the

Management of OA: Theme 3

THEME 3 -

• Provide or refer patients to self-management programs.

• Provide education, regular contact to promote self-care, joint protection strategies, and individualized treatment plans.

• Advise patients to engage in low-impact aerobic exercise and, if overweight, to lose weight.

• Consider range of motion, flexibility, endurance, and strengthening exercises, exercise combined with manual therapy, and PT/OT referral.

• Recommend walking aids and assistive devices to improve Activities of Daily Living (ADLs).

• Discuss thermal modalities for hand, knee and hip OA.

The Annotated Bibliography of OA Guidelines and Recommendations team included: Joanne Jordan, MD, MPH; Amanda E. Nelson, MD, MSCR; Kelli D. Allen, PhD; Yvonne M.

Golightly, PT, MS, PhD; and Adam P. Goode, PT, DPT, PhD.


“Increased knowledge of CAM practices

would enable comprehensive patient

assessment and a better plan for

meaningful

interventions that meet

the needs of the individual patient.”

(Stake-Nilsson et al 2012)

Gut-Brain-Body Integrated Medicine

1. Nutritional

2. Drugs/Bio

3. Psychological Activity

4. Physical Activity

Stake-Nilsson K, Hultcrantz R, Unge P, Wengstrom Y. Complementary and alternative medicine used by persons with functional gastrointestinal disorders to alleviate symptom distress. Journal of Clinical Nursing. Vol. 21 Issue 5-6. Pg 800-808. March 2012.


US Bone and Joint Initiative

4


Biopsychosocial Model in Action

Acute phase pain relief and comfort measures:

• Adequate rest/sleep

• Holistic meds (i.e. arnica) or NSAIDS PRN

• Aquatic therapy

• Yoga toys: blocks, straps, blankets, wall, chair, ball

• Nutritional changes

• Yoga breathwork and postures/restoratives

Subacute & Chronic phases require acute measures plus:

• Strength

• Functional mobility & neuromuscular re-education

• Advocating for own health care

• Lifestyle change & acceptance

• Inspiration & Support

• Service yoga (karma) “pay it forward”


Inflammation and Pain

Tennant F. A diet for patients with chronic pain.

Pract Pain Manage. 2011;11(6):22-30.

• Arachidonic acid and prostoglandin/leukotriene accumulation

• Relationship of n-6 to n-3 levels

Garner©2014. All rights reserved.Tennant F. A diet for patients with chronic pain. Pract Pain Manage. 2011;11(6):22-30.

5


Physiological Effects of Phytochemicals

• Flavonoids – anticarcinogenic, antimicrobial-viral, antioxidative, antithrombotic, immunomodulatory, antiinflammatory, BP-modulating, cholesterol lowering, blood-glucose modulating

• Phenolic acids – all but antithromobitic, cholesterol, and BP modulating

• Sulfides – all but blood-glucose modulating

• Carotenoids – all but antimicrobial, antithrombotic, BP-modulating

Watzl B. Anti-inflammatory effects of plant-based foods and of their constituents. Int J Vitam Nutr Res. 2008;78(6):293-298. doi: 10.1024/0300-9831.78.6.293; 10.1024/0300-9831.78.6.293.

Flavonoids & Phenolics

Flavonoids

• 83% of flavonoids consumed in the US are flavanols

• Tea, red wine, dark chocolate, apples

Phenolics

• Tea, olives, red wine, berries

• Strong antimicrobial effect • Bacteriodes, clostridium (c.

difficile), E. coli, and Salmonella.

Watzl B. Anti-inflammatory effects of plant-based foods and of their constituents. Int J Vitam Nutr Res. 2008;78(6):293-298. doi: 10.1024/0300-9831.78.6.293; 10.1024/0300-9831.78.6.293.

Laparra JM. Interactions of gut microbiota with functional food components and nutraceuticals. Pharmacological

research. 2010;61(3):219; 219-225; 225.


Anti-Inflammatory Sources

• Vegetables: asparagus, broccoli, brussel sprouts, cabbage, cranberry, fennel, garden pea, kale, onions, garlic (anti-bacterial), chiles

• Leafy greens: chard, collards, lettuces, spinach

• Legumes: black beans, chickpeas, kidney beans, lima bean, peas, soybeans

• Citrus and other fruits: grapefruit, lemon, lime, orange, pomegranates, pear

• Berries: blackberries, blueberries, raspberries, strawberries, red grapes

• Beta-carotene: apricots, carrots, mango, pumpkin, sweet potato, orange

Meggs 2004, Larrosaa et al 2010, Hsu et al 2010, Hermsdorff et al 2010, González-Gallego J et al 2010

More Flavonoid, Beta-Carotene, and Phenolic Sources

6


Anti-Inflammatories, Antioxidants, Prebiotics, and Probiotics

Dietary herbs include:

• Red chili, cloves, ginger, bay leaves, licorice, nutmeg, oregano, sage, thyme, allspice, cinnamon, cardamom, black pepper, Turmeric (Aggarwal 2010, Gupta et al 2012), Peppermint (Shen & Nahas 2009)

Stomach soothing herbs include:

• Lavender, Chamomile, Mint (Srivastava et al 2010, Barocelli et al 2004, Abbaszadeh et al 2009)

Natural probiotic sources include:

• Live culture yogurt; fermented dairy, vegetables, and soybean products such as soy sauce and tempeh

Prebiotic sources

• Phytochemical consumption (bioactive

non-nutrient plant compounds) (Laparra and Sanz 2010)

• Phenolics – wine, tea, berries, olives (also antimicrobial)

• Flavonoids

• Phytoestrogens

Polyunsaturated fatty acids, omega-3’s (Kiecolt-Glaser 2011, Alcock et al 2012, Laparra and Sanz 2010)

• Flaxseed, cold-water fish, chia seeds, walnuts, basil, oregano, cloves

• These are also cardioprotective, immunomodulating, antiestrogenic, and anticarcinogenic.

Garner & Reiter 2013


Fatty Acids

• n-3 PUFA’s – soybean, canola, flaxseeds, walnuts, fish oils

• n-6 PUFA’s – safflower, corn, soybean, sunflower oils, and meat

• n-3/n-6 diet ratio

• 25:1 – Modern Western

• 2:1 – Western pre-industralized societies

• Articular cartilage content

• n-6 pre-cursor eicosanoids acid correlated with OA severity (arachidonic acid)

• n-3 eicosanoids are anti-inflammatory



Vitamin D

• Vit. D

• Suboptimal vitamin D –impair bone metabolism and predispose to OA

• Framingham study found 3-fold increase in OA

progression risk for those with low vitamin D serum levels.

• Predicted loss of joint space

• Osteophyte growth


7


Vitamin D Concentrations

• Table 1: Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health* [1]

• nmol/L** ng/mL* Health status

• <30 <12 Associated with vitamin D deficiency, leading to rickets in infants and children and osteomalacia in adults

• 30–50 12–20 Generally considered inadequate for bone and overall health in healthy individuals

• ≥50 ≥20 Generally considered adequate for bone and overall health in healthy individuals

• >125 >50 Emerging evidence links potential adverse effects to such high levels, particularly >150 nmol/L (>60 ng/mL)

• * Serum concentrations of 25(OH)D are reported in both nanomoles per liter (nmol/L) and nanograms per milliliter (ng/mL). ** 1 nmol/L = 0.4 ng/mL

http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/


Vitamin D RDA

David Creighton, Andrew Ignaszewski, Gordon Francis. Vitamin D: New D-fence against cardiovascular disease?. BCMJ, Vol. 54, No. 3, April, 2012, page(s) 136-140


Vitamin C

• L-ascorbic acid, dehyro-L-ascorbic acid, and L-ascorbic acid salts

• L-ascorbic acid – 80-90% of vit. C in foods

• Framingham study

• 3-fold risk reduction of OA with medium to high vitamin C levels

• Inverse association of vit. C intake and cartilage loss


http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

8


Vitamin C RDA

• Age Male Female Pregnancy Lactation

• 0–6 months 40 mg* 40 mg*

• 7–12 months 50 mg* 50 mg*

• 1–3 years 15 mg 15 mg

• 4–8 years 25 mg 25 mg

• 9–13 years 45 mg 45 mg

• 14–18 years 75 mg 65 mg 80 mg 115 mg

• 19+ years 90 mg 75 mg 85 mg 120 mg

• Smokers Individuals who smoke require 35 mg/day more vitamin C than nonsmokers.

http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/


Other vitamins and minerals

• Vit. E - 5 RCT’s –conflicting evidence of improving symptoms (but 3 of 5 trails showed decreased pain) in the “medium-term”

• Vit. A,C,E,B2,B6, and selenium decreased OA severity in mice



Vitamin E Sources

http://ods.od.nih.gov/factsheets/VitaminE-HealthProfessional/

Foods Mg/Serving Percent DV*

Wheat Germ oil, 1 tbl. 20.3 100

Sunflower seeds, dry roasted, 1 ounce 7.4 37

Almonds, dry roasted, 1 ounce 6.8 34

Sunflower oil, 1 tbl 5.6 28

Safflower oil, 1 tbl 4.6 25

Peanut butter, 2 tbl 2.9 15

Peanuts, dry roasted, 1 ounce 2.2 11

Olive or corn oil, 1 tbl 1.9 10

9


Neutraceuticalsfor OA

a. Pomegranate

b. Green Tea

c. Cat’s Claw

d. Cat’s Claw

e. Devil’s Claw

f. Ginger

g. Frankincense

h. Turmeric

i. Pineapple extract

Current nutraceuticals in the management of osteoarthritis: a review

Nahid Akhtar, Tariq M. HaqqiTher Adv Musculoskelet Dis. 2012 June; 4(3): 181–207.


Anti-Inflammatory Diet

Serving Sizes

• Vegetables: 1 cup of raw leafy vegetables (about the size of a small fist), 1/2 cup of other vegetables or 1/2 cup of vegetable juice.

• Fruits: 1 medium fruit (medium is defined as the size of a baseball); 1/2 cup chopped, cooked or canned fruit; or 1/2 cup juice.

• Meat, Poultry, Fish, Dry Beans and Nuts: 2 to 3 ounces of cooked lean meat, poultry or fish; 1/2 cup cooked dry beans; or 2 tablespoons of peanut butter.

• Milk, Yogurt and Cheese: 1 cup of fat-free or low-fat milk or yogurt, 1 1/2 ounces fat-free or low-fat cheese.

• WHAT ABOUT GLUTEN? Grains: 1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal, rice or pasta (about the size of a 1/2 baseball).

Tennant F. A diet for patients with chronic pain. Pract Pain Manage. 2011;11(6):22-30.; AHA 2014.


Reducing Oxidative Stress: Eat the Antioxidant “Rainbow”

10


What are GMO’s?

• Genetically Modified Organisms

• WHO says GMO’s are “organisms in which the genetic material (DNA) has been altered in such a way that does not occur naturally.”

• Unlike natural breeding processes (i.e. hybrid tomatoes, etc.) have been occurring safely for thousands of years

• “GE crop technology abrogates natural reproductive processes, selection occurs at the single cell level, the procedure is highly mutagenic and routinely breeches genera barriers, and the technique has only been used commercially for 10 years.” (American Academy of Environmental Medicine, Freese & Schubert 2004)

• Assumption of safety for GE food is, according to AAEM and the author of Genetic Roulette say, “based on the idea of “substantial equivalence”, which means that “if a new food is found to be substantially equivalent in composition and nutritional characteristics to an existing food, then it can be regarded as safe.”

GMO Dangers

GMO risks reported in preliminary research which the AAEM states “indicate serious health risks associated with GM food” include:

• Infertility

• Immune problems

• Accelerated aging (upregulation of cytokines associated with asthma, allergy, and inflammation)

• Faulty insulin regulation

• Changes in major organs and the gastrointestinal system.

• *Hill 1965, Finamore et al 2008, Malatesta et al 2008, Velimirox et al 2008, Ewen & Pustzai 1999, Killic and Aday 2008

GM Foods as of 2011

• (transgenic) Wheat

• Corn

• Soy

• Canola

• Alfalfa

• Salmon

• Sugar Beets

USDA Economic Research Service 2011


Public Health Safety Recommendations

• The AAEM recommends that physicians educate their patients and the public to avoid GM foods when possible and provide educational materials concerning GM foods and health risks based on the fact that:

• GM foods have not been properly tested for human consumption

• There is ample evidence of probable harm

• There should be a moratorium on GM food and implementation of immediate long term independent safety testing, and labeling of GM foods, which is necessary for the health and safety of consumers.

• Also physicians/heath care providers should:

• Consider the possible role of GM foods in the disease processes of the patients they treat and to document any changes in patient health when changing from GM food to non-GM food.

• Gather case studies potentially related to GM food consumption and health effects, begin epidemiological research to investigate the role of GM foods on human health, and conduct safe methods of determining the effect of GM foods on human health.

Dean A, Armstrong J. 2009. Statement Paper on GMO’s. American Academy of Environmental Medicine. Last accessed March 7, 2014.

11


Organic?Conventional Organic

Apply chemical fertilizers to promote plant growth

Apply natural fertilizers(manure, compose) to feed soil and plants

Spray synthetic insecticides to reduce pests/disease

Spray pesticides from natural sources; use beneficial birds, insects,

mating disruption, or traps to reduce disease/pests

Use synthetic herbicides to manage weeds

Use environmentally-generated plant-killing compounds; rotate crops,

till, hand weed, or mulch to manage weeds

Give animals antibiotics, growth hormones, and medications to prevent

disease and force growth

Give animals organic feed and allow them access to the outdoors. Use

preventive measures, such as rotational grazing, a balanced diet, and clean

housing, to minimize disease.

Mayo Clinic 2014.

Yoga as Physical Therapy

Movement provides:

• A strong protective anti-inflammatory effect

• Musculoskeletal conditioning allows the musculoskeletal system to function like an

endocrine organ

• Immunologic function contributing to

immunologic health

• Lowers resting levels of inflammation in the body

Being sedentary contributes to:

• Chronic inflammatory disorders

• Obesity

• Chronic noncommunicablediseases

Petersen and Pederson 2005, Petersen and Pedersen 2006, Lau et al 2005, Fantuzzi 2005, Pedersen and Saltin 2006, Pedersen and Edward 2009, Nielson and Pedersen 2008


Precepts: Safety & Efficacyfor Joint Health

12


Bone and Joint Algorithm Medical Therapeutic Yoga

Nomenclature Guidelines1. TATD Breath2. Dynamic

Modifications3. Static Restorative

Approximations

Acute phase:• No WB standing postures in acute

phase(s).• Use SRA’s (Static Restorative

Approximations) on land.• Use Dynamic Modifications in water.• No emphasis of end-range in any posture.


Postures - Hand

Acute and beyond:

• Use of elbows for weight bearing surface vs. hand use.

• Do not grip the fingers or toes in any posture, especially in

the closed kinetic chain position.

• Use of blocks under hands.

•Left to right:Top Mudras: Lotus, Wisdom/Surrender of Ego

•Bottom Mudras: Bird, Elephant, Contemplation


Dynamic Modifications: Hand/Foot

Fingers on outside OR Thumb on inside OR perform from forearms

Acute & Beyond

• Blocks and/or blankets placed under heels when in a weight bearing position (at right)

• Chair downward facing dog (adhomukhasvanasana)

• Wall downward facing dog

• Kneeling postures at chair or in water


13


Postures - Hip

Acute & Beyond

Aquatic, Chair, &/or Ball Yoga

• Warrior Series (top right)

• Legs up the wall (top far right)

• Staff (bottom right) to forward seated bend

• Reclined tree (bottom far right)

• Seated pigeon

Wall

• Cobra

• Camel


Postures – Spine

Acute & Beyond

• Hip mobility correlates with spine health i.e. triangle (top), reclined tree, staff (bottom left),

gate (bottom middle), threading the needle (bottom right)



Spine – Progressive Extension

Mobility & Function Floor

Sequence Example

• Top row:

• Supine on pranayama fold blanket

• Middle row:

• Tabletop/Eastern stretch

• Gate

• Bottom row:

• Cobra

• Half upward facing bow

14



Nutritional Counseling

Science provides us with ample evidence that a plant (vegetarian) based diet high in flavonoids :

• Diminishes the presence of pro-inflammatory genes (ICAM1, ILR1, TNFα, and NF-κB1)*

• Significantly lowers circulating white blood cells*/Immunomodulatoryeffects**

• Maintains good circulation**

• Maintains intestinal motility**

• Reduces cancer risk**

• Reduces CVD risk**

• Improves mood stability**

• Diminishes inflammation**

• Increases longevity**/***

*Hermsdorff 2010, Garcia-Lafuente et al 2009, Elenkov et al 2005 **Garcia-Lafuenta et al 2009, Tice et al 2003, Gonzalez-Gallego et al 2010

***(Sticher et al 2010, Marsh and Brand-Miller 2010, Craig 2010)


Mediation of the Stress Response

MTY focuses on:

1. Neurophysiological Safety

• BPS Practice

• MTY Precepts

• FMA Algorithm

2. Psychobiology Safety

• PVT

• Hydration

• Guided imagery

• Guided relaxation/Physical stress and restriction release

• Manual therapy

3. Systemic facilitation of:

• Stability

• Suppleness

• Strength

• Flexibility

• Motility

15


MedicalTherapeuticYoga.com

OnsalenowOrderat:

www.medicaltherapeuticyoga.com

Aninteractivetextforrehabprofessionals,includesfreedigitallibrary

forpatientcare,completewithsubscriptionoptions.$40US

Dr.GingerGarnerPT,

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Dr.Garnerisaveteran

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astherapyand

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drivenhealthcarevia

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www.medicaltherapeuticyoga.comVimeo Video Subscription

MTY© Library of videos for patient education and self-care

http://www.medicaltherapeuticyoga.com/

16

http://www.gingergarner.com/publications/

http://www.gingergarner.com/site/wp-content/uploads/2012/02/Garner-from-978-1-63463-259-1.pdf

The Role of Relationship in Creativity Dec (2014)Nova Press NYC

www.gingergarner.com

http://www.gingergarner.com/publications/

http://www.gingergarner.com/site/wp-content/uploads/2012/02/Garner-from-978-1-63463-259-1.pdf

http://www.gingergarner.com/

18


Selected Sources

• WHO ICF 2002. International Classification of Functioning, Disease, and Health. Geneva, Switzerland.

• The Annotated Bibliography of OA Guidelines and Recommendations team included: Joanne Jordan, MD, MPH; Amanda E. Nelson, MD, MSCR; Kelli D. Allen, PhD; Yvonne M. Golightly, PT, MS, PhD; and Adam P. Goode, PT, DPT, PhD.

• Watzl B. Anti-inflammatory effects of plant-based foods and of their constituents. Int J Vitam Nutr Res. 2008;78(6):293-298. doi: 10.1024/0300-9831.78.6.293.

• Laparra JM. Interactions of gut microbiota with functional food components and nutraceuticals. Pharmacological research. 2010;61(3):219; 219-225; 225.

• Ameye and Chee Arthritis Research & Therapy 2006 8:R127 doi:10.1186/ar2016

• David Creighton, MSc, Andrew Ignaszewski, MD, FRCPC, Gordon Francis, MD, FRCPC. Vitamin D: New D-fence against cardiovascular disease?. BCMJ, Vol. 54, No. 3, April, 2012, page(s) 136-140

• Dean A, Armstrong J. 2009. Statement Paper on GMO’s. American Academy of Environmental Medicine. Last accessed March 7, 2014.


Sources 2

• Meggs, William J. MD, Ph.D The Inflammation Cure Contemporary Books Chicago

2004.

• Larrosaa M, González-Sarríasb A, Yáñez-Gascónb MJ, Selmab MV, Azorín-Ortuñob

M, Totia S, Tomás-Barberánb F, Dolaraa P, Carlos Espín J. Anti-inflammatory

properties of a pomegranate extract and its metabolite urolithin-A in a colitis rat

model and the effect of colon inflammation on phenolic metabolism. The Journal of

Nutritional Biochemistry. Vol 21, Issue 8, pp 717-725. August 2010.

• Hsu A, Bray TM, Ho, E. Anti-inflammatory activity of soy and tea in prostate cancer

prevention. Exp. Biol. Med. 2010 235: 659-667.

• Hermsdorff, H.H., et al., Fruit and vegetable consumption and proinflammatory gene

expression from peripheral blood mononuclear cells in young adults: a translational

study. Nutr Metab (Lond), 2010. 7: p. 42. 2010

• González-Gallego J, García-Mediavilla MV, Sánchez-Campos S, Tuñón MJ. Fruit

polyphenols, immunity and inflammation. Br J Nutr. Oct;104 Suppl 3:S15-27. 2010.

http://www.jnutbio.com/article/S0955-2863(09)00099-0/abstract

http://www.jnutbio.com/article/S0955-2863(09)00099-0/abstract#aff1
















19


Sources 3

• Nahid Akhtar, Tariq M. Haqqi. Current nutraceuticals in the management of osteoarthritis: a review, Ther Adv Musculoskelet Dis. 2012 June; 4(3): 181–207.

• Tennant F. A diet for patients with chronic pain. Pract Pain Manage. 2011;11(6):22-30.

• Mayo Clinic. Organic Foods: Are they Safer? More Nutritious? http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/organic-food/art-20043880. Last accessed March 16, 2015.

• American Heart Association. What is a Serving? http://www.heart.org/HEARTORG/Caregiver/Replenish/WhatisaServing/What-is-a-Serving_UCM_301838_Article.jsp. Last accessed March 16, 2014.

• Garner G. Medical Therapeutic Yoga. Prospectus for publication 6.2015. Handspring Publishing. Scotland, UK.

• Centers for Disease Control. OA Recommendations. www.cdc.gov

http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/organic-food/art-20043880

http://www.heart.org/HEARTORG/Caregiver/Replenish/WhatisaServing/What-is-a-Serving_UCM_301838_Article.jsp

http://www.cdc.gov

Course Outline Hour 1 - Allied Health Education · 2020-06-18 · Physiotherapy Theory and...

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