JEEVANA_N & Y management for FSS .pptx

naturopathy and yoga for functional somatic syndromes

1. NATUROPATHIC AND YOGIC INTERVENTIONS FOR FUNCTIONAL SOMATIC SYNDROMES DR. K. JEEVANA MD 2 ND YEAR NATUROPATHY (CLINICAL)

2. FUNCTIONAL SOMATIC SYNDROMES The term ‘functional somatic syndrome’ (FSS) has been applied to several related syndromes characterized more by symptoms, suffering and disability than by consistently demonstrable tissue abnormality. Patients with FSS have explicit and highly elaborated self-diagnoses and their symptoms are often refractory to reassurance, explanation and standard treatment of symptoms.

3. Types Fibromyalgia syndrome (FMS) Chronic fatigue syndrome (CFS) Syndromes defined by environmental exposures Persian Gulf syndrome Sick building syndrome Organ-specific or localized syndromes & symptoms

4. Organ-specific or localized syndromes & symptoms

5. Overlap between disorders characterized by chronic pain and fatigue – common pathophysiology?

6. Common disorders FMS CFS IBS

7. PATHOPHYSIOLOGY Genetic predisposition Environmental triggers, including various emotions, physical and immune stressors Psychological co-factors which modulate symptom expression Sustained dysregulation of the human stress response Blunting of numerous hypothalamo-pituitary axes including adrenal, growth hormone and gonadal Autonomic dysfunction with low baseline sympathetic tone and inability to respond to stressors Diffusely increased nociception due to loss of descending inhibitory influences, with chronic local or widespread pain

8. THE NORMAL HUMAN STRESS RESPONSE

9. A bnormal stress response in FSS Low CRH Low sympathetic output Or both Hypoarousal or fatigue Increased peripheral & visceral nociception Dysautonomia Smooth muscle dysmotility Abnormalities in cardiovascular function Mostly noted in chronic pain and fatigue cases. Opposite to the changes seen in acute stress.

10. Epiphenomena FMS – effect on muscle or peripheral tissues (tissue hypoxia & decrease in high energy phosphates) – pain &weakness (tender points). CFS – chronic pain and fatigue, triggered by a potent viral infection (due suppression of immune system by stress) IBS – leaky gut – damage of intestinal permeability – hypersensitivity – mast cell degranulation – chemical release & signalling – symptoms (bloating, diarrhoea /constipation, etc.)

11. Management The aim is to reduce the underlying stress and correct the presenting symptoms and eventually to improve the quality of life.

12. Stress management YOGA Mindfulness Meditation Pranayama Sithilikarana vyayama (loosening exercises) Breathing exercises Basic or simple asanas Guided imagery/deep relaxation technique Chanting – MSRT (mind sound resonance technique)

13. Root of disease – AADHI Aadhi – manomaya kosha Vyadhi – annamaya kosha

14. How does yoga reduce stress?

15. Helps in the management of FSS

16. Yoga for IBS Vajrasana, shashankasana , ushtrasana , marjariasana , bhujangasana , dhanurasana , padahastasana , trikonasana , paschimottanasana Surya nadi pranayama R elaxation Meditation Taneja et al. Yoga versus conventional treatment in diarrhoea -predominant irritable bowel syndrome: a randomised controlled study. Applied psychophysiology and biofeedback. 2004.

17. Research evidence Article Summary of evidence Langhorst et al. Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Rheumatology international. 2013. Meditation reduced sleep disturbances, fatigue, depressed mood and restrictions of HRQOL at final treatment and sleep disturbances and restrictions of HRQOL at follow-up. In subgroup analyses, only Yoga yielded significant effects on pain, fatigue, depression and HRQOL. Carson et al. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010 November. The results suggested the yoga intervention led to a beneficial shift in how patients cope with pain, including greater use of adaptive pain coping strategies (i.e., problem solving, positive reappraisal, use of religion, activity engagement despite pain, acceptance, relaxation) and less use of maladaptive strategies (i.e., catastrophizing , selfisolation , disengagement, confrontation)

18. Buckelew et al. Biofeedback/Relaxation Training and Exercise Interventions for Fibromyalgia: A Prospective Trial. Arthritis care and research. 1998. This study demonstrated that biofeedback/relaxation training and structured exercise programs produce short- and long-term benefits for persons with FMS in the areas of self-efficacy, disease severity, and physical activity Dhansoia et al. Immediate effect of mind sound resonance technique on state anxiety and cognitive functions in patients suffering from generalized anxiety disorder: A self-controlled pilot study. International journal of yoga. 2015. MSRT may have a potential role in reducing state anxiety and enhancing psychomotor performance in patients suffering from GAD immediately after the practice. Smith et al. A randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complementary Therapies in Medicine (2007). Yoga and relaxation provides improvement in stress, anxiety and health status.

19. Steps Diet therapy: Elimination diet – eliminate the foods which trigger the symptoms Gluten free diet Foods to reduce the fatigue Sleep enhancing foods Foods to reduce anxiety & depression (psychiatric comorbidities as well as central mechanisms for FSS) Maintaining a healthy body weight Simultaneous steps for pain reduction Massage Acupuncture & TENS Hydrotherapy (aquatic exercises/pool exercise therapy)

20. DIET THERAPY DISORDER FOODS TO ELIMINATE Fibromyalgia & Chronic fatigue syndrome Wheat, refined sugars, coffee and tea, food additives and preservatives Irritable bowel syndrome Dairy, eggs, wheat Migraine Beef, chocolate, coffee, corn, eggs, histamine (fish, cheese, wine, beer), monosodium glutamate (mushrooms, preserved, packed and canned products, preserved meats, Chinese food), nitrates (processed meats), oranges, sugar, tea, tyramine (aged cheeses, some red wines), yeast. ELIMINATION DIET

21. Gluten free diet Dysregulation of brain-gut axis – leaky gut – IBS Gluten – causes the gut cells to release ‘ zonulin ’, a protein that disrupts the cellular integrity by breaking the tight junctions leading to increased intestinal permeability Gluten rich foods should be avoided – wheat, bread, pasta, noodles, pastries, etc.

22. Foods to reduce fatigue Indian ginseng – Ashwagandha ( Withania somnifera ) Whole grain products Fresh fruits and vegetables particularly rich in magnesium- green leafy vegetables, bananas, figs, nuts, seeds, legumes such as black beans, chick peas & k idney beans, sprouts. Maintaining proper gap between two meals for aiding digestion and absorption so that energy is properly gained.

23. Sleep enhancing foods Melatonin rich foods – dose: 1-1.5 mg/day Fruits & vegetables: corn, tomatoes, cucumber, pomegranate, olives, grapes, etc. Grains: rice, barley, oats Nuts & seeds: walnuts, peanuts, sunflower seeds, flax seeds. Serotonin rich foods – dose: 200-400 mg/day Milk – α lactalbumin has highest tryptophan (contraindicated in IBS) Fruits such as bananas, pineapple, plum, kiwi, tomatoes, dates, grapes.

24. Pain in FSS In FMS & CFS metabolic abnormalities were noted in the areas of painful muscle. Decrease in muscle high energy phosphates Decrease in muscle tissue oxygenation (local tissue hypoxia) – due to sustained muscle contraction and resultant decreased blood flow As a result there is pain and weakness in the muscles & tendons.

25. Massage Relieves stress, reduces pain, increases flexibility and induces good sleep by: increasing blood supply to the tissues elimination of toxic wastes stored in the muscles correcting the derangements in the immune system Oils such as primrose oil, borage seed oil, ginger oil, valerian oil can help in enhancing the above effects.

26. Types of massage used Swedish massage Manual lymphatic drainage massage Connective tissue massage Myofascial release Trigger point release Aromatic massage

27. Acupuncture analgesia Acupuncture Moxibustion E lectro-acupuncture (high intensity & low frequency) A δ , C fibre mediated Pain inhibitory systems Opioid/central – descending inhibition Non – opioid/ segmental – gate control mechanism PAIN RELIEF TENS Electro-acupuncture (low intensity & high frequency) Vibration Touch A β fibre mediated

28. Hydrotherapy Aquatic exercise regimen Aerobic exercise Strength training Flexibility training Relaxation training Activates endogenous opioid system Increases pain threshold and pain tolerance Improves sleep and mood Improves health related quality of life

29. References Clauw et al. chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation . 1997. Kawakita et al. Mechanisms of action of acupuncture for chronic pain relief – polymodal receptors are the key candidates. Acupuncture in medicine. 2006. Gecse K et al. Leaky Gut in Patients with Diarrhea- Predominant Irritable Bowel Syndrome and Inactive Ulcerative Colitis. Digestion. 2012. Chadwick et al. Activation of the Mucosal Immune System in Irritable Bowel Syndrome. Gastroenterology. 2002. Evcick et al. Effectiveness of aquatic therapy in the treatment of Fibromyalgia syndrome : a randomized controlled open study. Rheumatology international. 2008. Carabotti et al. The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Annals of gastroenterology. 2015.

30. Sarac et al. Complementary and Alternative Medical Therapies in Fibromyalgia. Current pharmaceutical design. 2006. Holtmann et al. Pathophysiology of irritable bowel syndrome. Lancet. 2016. Langhorst et al. Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Rheumatology international. 2013. Carson et al. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010 November. Buckelew et al. Biofeedback/Relaxation Training and Exercise Interventions for Fibromyalgia: A Prospective Trial. Arthritis care and research. 1998. Dhansoia et al. Immediate effect of mind sound resonance technique on state anxiety and cognitive functions in patients suffering from generalized anxiety disorder: A self-controlled pilot study. International journal of yoga. 2015. Smith et al. A randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complementary Therapies in Medicine (2007).

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