dr. sulak's provider wellness
TRANSCRIPT
Provider Wellness:Simple Tools to Enhance Your
Health and Improve Patient Outcomes
Dustin Sulak, D.O.Maine Osteopathic Association
Annual Oceanside Convention 2014
Introduction
I have no relevant financial relationships with commercial interests.
Founder and Medical DirectorMaine Integrative Healthcare in Manchester, MaineIntegr8 Health, LLC in Falmouth Maine
Director of EducationIntegr8 Massachusetts, Burlington, Mass
6 DOs, 4 MDs, 6 NPs, 1 LCPC, 1 LMT, 1 DNIntegrative Medicine and Medical Cannabis Consultations, Family Medicine, OMT, laser therapy, hypnotherapy, and more.
Introduction
Learning Objectives:
1. Define Health and Healing.
2. Describe mechanisms by which the health of the practitioner impacts the health of the patient.
3. Become competent in simple self-governance tools that can modulate biological oscillations, relieve stress, and improve health.
Outline
• What is Health? What is Healing?
• The Importance of Provider Wellness
• Caring for your Endocannabinoid System
• Physiologic Coherence, Heart Rate Variability
• Emotions, Optimism
• Practice
What is Health?What is your health?
Can you feel it?Can you observe it?
“To find health
should be the object
of the doctor.
Anyone can find
disease.”
Andrew Taylor Still
Founder of Osteopathy
• Health is a natural phenomenon like gravity, the tendency for two bodies to attract, or entropy, the tendency towards randomness.
• Health is the tendency for living beings to grow and adapt.
• Health is the force or presence that sustains life.
• Health is both entropic and negentropic.
• Health is a biological oscillation with the period of a lifetime.
Health includes both
wellness and illness.
What is Healing?
• Homeostasis– The tendency of a biological system to regulate
its internal conditions to maintain function in response to fluctuations in the external environment
• Tissue remodeling• The emergence of new patterns that allow
freedom in function and fitness in one’s environment
Emergence of New Patterns
• Systems Theory– As system in perfect equilibrium does not have
the internal dynamics to enable it to respond to its environment, and it dies.
– A system in chaos ceases to function as a system.
– The reciprocal relationship between equilibrium and disequilibrium promotes the emergence of new patterns
The Importance of Provider Wellness
Physicians
• Smoke less, exercise more, and eat healthier than our patients
• Yet our per-capita rates of heart disease, depression, and stroke are higher than any other working group.
Why?
Arnetz BB: White collar stress: What studies of physicians can teach us. Psychother Psychosom55:197-200, 1991
Heim E: Job stressors and coping in health professions. Psychother Psychosom 55:90-99, 1991
Stress
Sleep Deprivation
Medical Training
• Fear of Failure
• Perfectionism Obsession
• Social isolation (long hours)
• Exhaustion, disrupted biological rhythms
• Emotional and Physical Dissociation
• Compassion Fatigue Syndrome, Burnout
Suicidal Ideation Among American Surgeons
• 1/16 of surgeons reported suicidal ideation within the last year.
• Only 26% of these surgeons sought mental health services.
• There are many factors which conspire to isolate physicians– 60% of these surgeons were unwilling to seek help
because of the potential that doing so would adversely affect their licensure.
» Shanafelt, Tait D., et al. "Special report: suicidal ideation among American surgeons." Archives of surgery 146.1 (2011): 54-62.
“Physician, heal thyself”Luke 4:23
The Physiology of Health
The Endocannabinoid SystemPhysiologic Coherence
The Endocannabinoid System
Endocannabinoid synthesis is an adaptive response to cellular stress, aimed at re-
establishing cell homeostasis.
Pubmed search results for “endocannabinoid”1993: 10 citations2014: 6,141 citations
secondary structure tertiary structure
The Cannabinoid Receptor: CB1
CB1 located in: CNS Testes, uterus Adipose tissue Connective tissue Endocrine glands Exocrine glands Leukocytes Spleen Heart GI tract Liver
CB2 located in: Monocytes Macrophages B-cells T-cells Liver Spleen Tonsils CNS Enteric nervous
system(McPartland, 2008)
Cannabinoid Receptors
CB Receptors Evolved 600 Million Years Ago
human
monkey
rat
mouse
finch
newt
Fugu fish
sea squirt
Caenorhabditis
Drosophila, Apis
McPartland et al., 2005
CB1 Receptor Distribution• Most common G protein coupled
receptor in the brain
• Highest densities:– hippocampus– cerebral cortex– cerebellum,– amygdaloid nucleus– basal ganglia
• Accounts for effects:– short-term memory– cognition– mood and emotion– motor function– nociception.
• Virtually absent in brainstem cardiorespiratory centers – no lethal overdose
Glass M et al. Cannabinoid receptors in the human brain. Neuroscience 1997;77:299-318
CB2 Receptor Distribution
anandamide (AEA)Devane, Mechoulam et al., Science (1992) 258:1946-1949
Endogenous Cannabinoid Ligands: The Endocannabinoids
2-arachidonoylglycerol (2-AG)Mechoulam et al., 1995Sugiura et al., 1995
AEA and 2-AG:
• Retrograde messengers in nervous system.
• Autocrine or paracrine mediators elsewhere.
• Synthesized “on demand” from cell membrane precursors and immediately released.
• Degraded by enzymatic hydrolysis (FAAH).
Endogenous Cannabinoid Ligands: The Endocannabinoids
Depolarization-Induced Suppression of Excitation
Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cellaction potential
NMDA
postsynaptic cell
AMPA
• Action potential from depolarized neuron arrives at axon terminal and opens voltage-gated calcium channels.
• Ca2+ influx releases glutamate vesicles, glutamate diffuses across synaptic cleft to activate receptors in postsynaptic cell.
Wilson & Nicholl, 2002
AMPA
Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cellaction potential
NMDA mGLU NMDA
postsynaptic cell
• Strong stimulus of presynaptic cell increases glutamate release, which upregulates other glutamate receptors in the post-synaptic cell.
• Upregulated glutamate receptors open Ca2+ channels in the post-synaptic cell.
Ca2+
channel
Wilson & Nicholl, 2002
Depolarization-Induced Suppression of Excitation
Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cellaction potential
postsynaptic cell
NMDA mGLU NMDA
• Ca2+ influx into post-synaptic cell stimulates the synthesis and release of 2-AG.
• 2-AG diffuses retrograde to presynaptic CB1, which closes pre-synaptic Ca2+
channels and stops vesicle release.
Ca2+
channel AMPA
Wilson & Nicholl, 2002
Depolarization-Induced Suppression of Excitation
Ca2+
channel
Na+, K+
channels
GABA
presynaptic cellaction potential
postsynaptic cell
GABAA
• Ca2+ influx into post-synaptic cell stimulates the synthesis and release of 2-AG.
• 2-AG diffuses retrograde to presynaptic CB1,which closes pre-synaptic Ca2+
channels and stops vesicle release Ca2+
channel
Depolarization-Induced Suppression of Inhibition
GABAB
Wilson & Nicholl, 2002
• Sprouting and pruning of synapses, changes in dendritic spine density, and changes in neurotransmitter pathways.
• Gives rise to all types of adaptive learning, including:
• Conscious act of gaining a new skill.
• Unconscious acquisition of a new emotional response.
• Subcortical events leading to a facilitated spinal segment.
Neural Plasticity
Mechanisms:• Neurogenesis• Depolarization-induced suppression of excitation• Depolarization-induced suppression of inhibition
• Long-term potentiation• Long-term depression
Cannabinoids Modulate Neural Plasticity
Fishbein, Miriam, et al. "Long-term behavioral and biochemical effects of an ultra-low dose of Δ9-tetrahydrocannabinol (THC): neuroprotection and ERK signaling." Experimental brain research 221.4 (2012): 437-448.Lovinger DM. Presynaptic modulation by endocannabinoids. Handb Exp Pharmacol 2008;184:435–77.
Cannabinoids Modulate Neural Plasticity
• Cannabinoids modulate– HPA axis reactions to mood and stress– Fear conditioning
– Habituation
– Fear extinction (Passie, 2012)
• Phyto-cannabinoids enhance fear extinction in humans• THC (Rabinak, 2012)• CBD (Das, 2013)
Osteopathy andthe Endocannabinoid System
“Suppose again the nerves of nutrition should fail to apply the nourishing showers, we would surely die in sight of food”
–Philosophy of Osteopathy, 1899
Osteopathy andthe Endocannabinoid System
• Endocannabinoid system requires the presence of CB1 in the peripheral terminal of the nociceptor.
• CB1 receptors are synthesized in the dorsal root ganglion of nociceptors and are carried by axoplasmic flow to peripheral sites.
• By obstructing axoplasmic flow and cellular trafficking of CB1, the pathophysiology of somatic dysfunction perpetuates itself.
Hohmann AG, Herkenham M. Cannabinoid receptors undergo axonal flow in sensory nerves. Neuroscience.1999; 92:1171 -1175
Osteopathy andthe Endocannabinoid System
• A blinded, randomized controlled trial of 31 healthy subjects measured AEA levels pre- and post-OMT.
• The OMT intervention consisted of myofascial release, muscle energy and thrust techniques. The control intervention consisted of a sham cranial method.
• In subjects receiving OMT, serum levels of AEA obtained after OMT more than doubled the pre-OMT levels. No change was seen in control subjects.
• However, the doubling of AEA was not statistically significant (P=.139) because of a large degree of response variability.
McPartland JM, Giuffrida A, King J, Skinner E, Scotter J, Musty RE. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc. 2005;105:283-291.
Endocannabinoids affect every biological oscillator or pacemaker cell investigated to date, including: • Circadian rhythms• Traube-hering waves• Peristalsis slow wave• EKG rhythms• EEG rhythms.
Biological Oscillators
Pacher P, Bátkai S, Kunos G. The endocannabinoid system as an emerging target of pharmacotherapy [review]. Pharmacol Rev. 2006;58:389-462.
Caring For Your ECS
• The Endocannabinoid System (ECS) plays a key role in 3 types of healing:– Homeostasis– Tissue Remodeling– Emergence of New Patterns
• How can you support your ECS?
How To Enhance the Endocannabinoid System?
Pre-Clinical and Clinical Review:
Caring for your ECS
• Probiotics– Upregulate CB2 in colonic epithelial cells in mice.
– Decrease pain behavior following colonic distension with butyrate, reversed by the CB2 antagonist
• Ethanol dampens the effects of the ECS.– Chronic consumption and binge drinking likely
desensitize or downregulate CB1 and impair eCBsignaling, except perhaps in areas involved in reward and motivation to self-administer this substance of abuse
Caring for your ECS
• Exercise– Medium to high-intensity voluntary exercise increases
ECS signaling, via increased serum AEA levels, and possibly increased CB1 expression.
– Forced exercise does not increase AEA and can decrease CB1
• Stress and Social Play– Chronic stress impairs the eCB system, via decreased
levels of AEA and 2-AG.– Social play in rats increased CB1 phosphorylation (a
marker of CB1 activation) in the amygdala and enhanced AEA levels in the amygdala and nucleus accumbens.
High and repeated doses: CB receptor desensitization
Phyto-Cannabinoid Effects
• Persistent agonism• Phosphorylation
by GRK or PKC
• Binding by -arrestin
• Receptor pulled into a clathrin-coated pit
• Endosome internalization
Phyto-Cannabinoid Effects
Low and acute doses: ECS Upregulation
• THC increases the production of endocannabinoids in brain cells. (Burstein, 1995)
• THC upregulated CB1 receptors in mouse spinal cords. (Cichewicz, 2001)
• Acute dose of THC increased cannabinoid receptor affinity in rats. (Oviedo, 1993)
• Sub-therapeutic does of THC enhance the pain relief imparted by endocannabinoids in rats. (Suplita 2008)
Coherence
• Ordered patterning within one system• Synchronization between multiple systems
• Physiologic coherence describes a number of related physiological phenomena frequently associated with more ordered and harmonious interactions among the body’s systems.
“When all of the fulcrums are
synchronized there will be peace and
harmony.”
-W.G. Sutherland DO
Reduced blood pressure in hypertension (McCraty,
2001)
Increased functional capacity in CHF patients(Luskin, 2002)
Improvements in asthma (Lehrer, 2000)
Increased calmness and well-being (Friedman, 2000)
Increased emotional stability (McCraty, 2001)
Improved cognitive performance (McCraty, 2001)
Benefits of Physiological Coherence
Heart Rate Variability (HRV)
0 1 2-0.5
0
0.5
1
1.5
2
m V
olt
s
2.5 seconds of heart beat data
.859 sec. .793 sec. .726 sec.
70 BPM 76 BPM 83 BPM
Heart Rate Variability
• Key indicator of autonomic function
• Low HRV indicates high sympathetic and parasympathetic tone = high cardiac risk
• High HRV indicates low sympathetic and parasympathetic tone = low cardiac risk
• Decreases with age
• Low HRV is predictive of MI and sudden deathCirculation, 1996;93: 1043-1065
Low HRV Predicts CHD & All Cause Mortality
• 14,672 men and women• HRV measured between 1987 and 1989• Low HRV increased risk of CHD
formation and death by 40%
• Dekker et al, Circulation 2000:102:1239
Low HRV is an Independent Predictor:
• Sudden death from MI• Fatal arrhythmias• All cause mortality• In many demographic populations:
– ICU– Hemodialysis– Middle-aged and older men– Women post-MI and post-cardiac
revascularization
References• Camm AJ, Pratt CM, Schwartz PJ, et al: Mortality in patients after a recent myocardial infarction: A
randomized, placebo-controlled trial of azimilide using heart rate variability for risk stratification. Circulation 2004; 109:990-996.
• La Rovere MT, Pinna GD, Hohnloser SH, et al: Baroreflex sensitivity and heart rate variability in the identification of patients at risk for life-threatening arrhythmias: Implications for clinical trials. Circulation 2001; 103:2072-2077.
• Dekker JM, Crow RS, Folsam AR, et al: Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary heart disease and mortality from several causes: The ARIC Study: Atherosclerosis Risk In Communities. Circulation 2000; 102:1239-2344.
• Katz A, Liberty IF, Porath A, et al: A simple bedside test of 1-minute heart rate variability during deep breathing as a prognostic index after myocardial infarction [see comment]. Am Heart J 1999; 138:32-38.
• Migliaro ER, et al: Relative influence of age, resting heart rate and sedentary life style in short-term analysis of heart rate variability. Braz J Med Biol Res 2001; 34:493-500.
• Hayano J, et al: Postural response of low-frequency component of heart rate variability is an increased risk for mortality in patients with coronary artery disease. Chest 2001; 120:1942-1952.
• Lucreziotti S, et al: Five-minute recording of heart rate variability in severe chronic heart failure: Correlates with right ventricular function and prognostic implications. Am Heart J 2000; 139:1088-1095.
Poor HRV helps stratify risk for• Worsening CHF
• Bonaduce D, et al. Am Heart J 1999; 138:273-284.
• Yoshikawa T, et al. Am Heart J 1999; 137:666-671.
• Nolan J, et al. Circulation 1998; 98:1510-1516.
• Colhoun HM, et al. Diabetes Care 2001; 24:1108-1114.
• Developing CAD in DM-1• Liao D, Carnethon M, Evans GW, et al. Diabetes 2002; 51:3524-3531.
• Atherosclerotic plaques in otherwise young, asymptomatic adults• Colhoun HM, et al. Diabetes Care 2001; 24:1108-1114.
• Worsening Atherosclerosis• Wennerblom B, et al. Heart 2000; 83:290-294.
• Huikuri HV, et al. Arterioscler Thromb Vasc Biol 1999; 19:1979-1985.
• Elevated Triglycerides• Jensen-Urstad M, et al. J Intern Med 1998; 243:33-40.
Poor HRV correlated with
• Early insulin resistance• Laitinen T, et al. Diabetes 1999; 48:1295-1299.
• Obesity• Karason K, et al. Am J Cardiol 1999; 83:1242-1247.
• Hypertension• Schroeder EB, et al. Hypertension 2003; 42:1106-1111.
• Singh JP, et al. Hypertension 1998; 32:293-297.
Poor HRV correlated with
• Depression• Social Isolation• Suppressed Anger
• Carney RM, et al. Circulation 2001; 104:2024-2028.• Hughes JW, Stoney CW. Psychosom Med 2000; 62:796-803.• Horsten M, et al. Psychosom Med 1999; 61:49-57.• Armour J: Neurocardiology, New York: Oxford University Press;
1994.
Heart Rate Variability Patterning Influences Cortical
Function And Emotions
“Nerves are the children and associates of one mother – the heart…
She is the mother, nerve, and soul of all nerves pertaining to this body.”
A.T. Still, The Philosophy and Mechanical
Principles of Osteopathy, 1892, p.47
The Heart Has a Nervous System• Afferent and efferent neurons• Ganglia• Local Circuit Neurons
Neurocardiology, Armour, JA and J. Ardell Eds. NY,NY, Oxford University Press, 1994
G.P. = ganglionatedplexi
Vagal Afferent Neurons
Amygdala: Emotional Memory
Thalamus: synchronizes
cortical
activity Locus
coeruleus
Cortex: Thinking Brain
Cortical Inhibition and Facilitation
Inhibits cortical functionFacilitates cortical function
Stress
• Stress is almost always an emotional reaction to a situation.
• Stress impacts our ability to think clearly, respond appropriately and perform at our best.
• Our stress level directly impacts– How we feel at the end of the day– Our health– Our relationships
Heart Rate Variability Can Be Intentionally Modified
Mantras & Rosary Prayer
• Both practices:– Decreased sympathetic tone– Synchronized respiratory and cardiovascular
cycles– Improved HRV
Luciano Bernardi et al BMJ 2001;323:1446-1449 ( 22-29 December )
Improving HRV improves
• Immune Function• McCraty R, Childre D: The Appreciative Heart: The
Psychophysiology of Positive Emotions and Optimal Functioning, Boulder Creek, Calif: Institute of HeartMath; 2003.
• Hormone Balance• Bernardi L, et al: Effect of rosary prayer and yoga mantras on
autonomic cardiovascular rhythms: Comparative study. BMJ 2001; 323(7327):1446-1449
• Depression• McCraty R, et al: The impact of a new emotional self-management
program on stress, emotions, heart rate variability, DHEA and cortisol. Integr Physiol Behav Sci 1998; 33:151-170
Quick Coherence Practice
1. Heart Focus: Focus your attention on the area around your heart, the area in the center of your chest.
2. Heart Breathing: Breathe deeply, but normally, and imagine that your breath is coming in and going out through your heart area. Continue breathing with ease until you find a natural inner rhythm that feels good to you.
3. Heart Feeling: As you maintain your heart focus and heart breathing, activate a positive feeling. Recall a positive feeling, a time when you felt good inside, and try to re-experience the feeling. One of the easiest ways to generate a positive, heart-based feeling is to remember a special place you’ve been to or the love you feel for a close friend or family member or treasured pet. This is the most important step.
http://www.heartmath.com/personal-use/quick-coherence-technique.html
The Power of Positive Emotions• Increased longevity (Danner et al., 2001)
• Reduced morbidity (Goldman et al, 1996; Russek & Schwartz, 1997)
• Increased cognitive flexibility (Ashby et al., 1999)
• Improved memory (Isen et al., 1978)
• Improved decision making (Carnevale & Isen, 1986)
• Increased creativity and innovative problem solving (Isen et al.,
1987)
• Improved job performance & achievement (Wright & Staw, 1994; Staw
et al.,1994)
• Improved clinical problem solving (Estrada et al.,1997)
Optimists live longer• 999 men and women over 9 years divided into four
groups based on their level of optimism.
• Compared to pessimists, optimists had:– 55% lower risk of death from all causes
– 23% lower risk of cardiovascular death
• Optimists lead healthier lifestyle, but when matched to pessimists with similar lifestyles optimists still do better
• Giltay, E. Archives of General Psychiatry, November 2004; vol 61: pp 1126-1135.
Physician’s Mood Influences Care
• On days the doctors felt positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests and issued fewer referrals.
• If the physicians’ burnout level was higher, their moods more strongly impacted their behaviors.
• 188 family physicians, anonymous self-reporting questionnaire
Kushnir, talma, et al. "Exploring physician perceptions of the impact of emotions on behaviour during interactions with patients." Family practice 28.1 (2011): 75-81.
Health is Contagious
• Bioenergy– Magnetic fields of the heart (ECG) and brain
(EEG) can be measured several feet away from the body.
– The transference of these signals between individuals in physical contact and even several feet apart has been measured and documented.
Rosch, P, Markov, M. Bioelectromagnetic Medicine. Informa Health Care, 2004:551-560
• Autonomic tone, other aspects of physiology
Health is Contagious
• Psychologist Albert Bandura: Observational Learning– The most powerful way of learning is watching
others do something.
• Healthy behavior is contagious– Physical Activity, Healthy Eating
– Ball, Kylie, et al. Int J Behav Nutr Phys Act 7.1 (2010): 86.
Make the Shift
• Self-Awareness
• Acceptance (non-judgment)– It isn’t important for us all to be perfectly fit and
balanced – but it is important that we are taking that journey.
– Being whole is accepting who you are – you can do this for yourself and your patients.
• Choice
Health is Contagious
So often it is not what we do, but simply our presence that allows healing.
“It is no use walking anywhere to preach unless our walking is
preaching.”
St. Francis of Assisi
Chung Breath Practice
1. Forcefully and completely exhale through pursed lips.
2. Close your mouth, relax, allow inhalation to occur passively without any influence.
3. Pause and repeat.
Yunjo Chung, MD
