Hey, good evening, everybody. Welcome back for part two. First, we want to take care of some housekeeping stuff before we introduce our speakers. Just to let you know, this session will be recorded live. And we're asking you to please mute your microphone if you're not speaking. If you wish to be heard or ask a question, please use the raise the hand function. For the written Q&A, you can ask the presenters using the chat everyone function. And then we're here to support you if you're having some technical difficulty. The tech support person can be reached via the chat function. So you browse over and search for a APM and our producer. And then you can contact that person with any tech issues. So, yes, again, welcome. Welcome back. You had a lot of this tonight, this programming. So we welcome you. And we really thank you for being here. Without any further delay, I'm going to introduce our first speaker, who's going to be exploring the role of nutrition in multidimensional pain management. And this is Dr. Hassan Chaktai. Hassan Chaktai has been a practicing physiatrist for 11 years. He is double boarded in PM&R and pain management with a master's degree in nutrition. He currently practices general physical medicine rehabilitation, treating sports and spinal injuries, as well as concussions. He graduated from New York College of Osteopathic Medicine and completed his residency at Albany Medical Center. So welcome, Dr. Chaktai. Hi, everyone. All right. Good evening. Good evening. I do want to thank the APM&R for the opportunity to speak on this topic. I do also want to thank Dr. Zelnick for inviting me to speak. It's a really great opportunity and it's truly an honor. So with no further ado, as you can see, today's topic will be about pain and nutrition. And this diagram that I have here where you can see pain affects nutrition and nutrition affects pain. So today's talk will be an overview for the physiatrist. And for us, we, you know, many of us who practice outpatient rehab medicine, we're seeing pain, spinal pain, neck pain, back pain, joint pain, arthritis, fibromyalgia, lupus. And almost half the U.S. adults have hypertension, almost 40 percent of hyperlipidemia, a third have prediabetes. And so the dietary habits of these illnesses may all lead to inflammation. And so our treatment options that we commonly use, whether it's therapy, medications, injections, complementary medicine, a home exercise program, and even as well as surgery, we may have to use the same first five things that I have mentioned. And so how often do we eat and how many meals a day do we eat? And some of us eat five times a day, including snacks. And so one modifiable decision that a patient can do and a doctor and their staff can educate them. So one of the things I do want to mention is that, you know, we have our treatment options, eating nutrition is something that can be used and be very effective in our treatment and management of our patients, maybe up to 20 percent, 30 percent. But I'd be willing to argue that even up to 50 percent, we can improve our patients' outcomes and their quality of life. And today, this was the premise of my talk today. So in the spectrum of disease and illness, whether the patient has a genetic predisposition or no genetic predisposition, I believe that nutrition and diet can help the patients. So if the patient has a genetic predisposition and they're completely normal clinically, we may be able to help them and prevent further deterioration of their illness. And even if they do not have a genetic predisposition and they're completely normal, sometimes they can become asymptomatic of becoming of that illness and disease. And so, you know, I think that nutrition and diet really can help with it. And nearly almost a quarter of U.S. adults are affected by joint pain and stiffness, the risk of death after 30 doubles every eight years. The oldest humans have lived up to 120 years. And the resting metabolism holds steady from 20 to 60 years old, even in pregnancy and menopause. And after that, there's a decrease of less than one percent per year thereafter, meaning that it's less about age. It's mostly about lifestyle, including diet, exercise and stress. So what exactly is nutrition? It's the study of nutrients in food and how the body uses them and the relationship between diet, health and disease. And obesity, which many of us encounter on a daily basis, sometimes multiple times a day, is preventable. And in the U.S., severe obesity is almost is greater than nine percent. Over 42 percent of U.S. adults are overweight. Mostly are black adult patients are the highest prevalence in children's, almost 19 percent that are overweight and over a quarter of them are Hispanic. So in 16 states, the adult obesity rates have has risen. And in the last 20 years, there's no state that had adult obesity rate above 25 percent. And black residents in 35 states had obesity rates greater than 35 percent. Hispanics at 22 states and white people had in seven states that obesity rates that were greater than 35 percent. And so the medical complications of obesity, you know, you can have that we're familiar with. You have stroke and arthritis, even like diabetes. Many of our patients have. But it can cause sleep apnea, lung disease, liver disease, cancer. Even in women having abnormal periods of infertility. And, you know, you can have patients who are depressed, secondary obesity, Alzheimer's disease, dementia. Obesity contributed over 53 percent to type two diabetes in middle age and older Americans. Obesity increased the risk of cardiovascular complications of pregnant women with pre-existing heart disease. Pre-cancer is more common in women with obesity. And even features of migraines and headaches were linked with higher with BMI. And so, you know, these are the last, you know, leading cause of death in 2019. But many of these diseases can be, again, prevented by nutrition and diet. And last year, COVID itself had over 300,000 deaths. And many experts have said that a lot of these COVID deaths could have been prevented by diet and eating healthy. And so among US adults, more than 90 percent of type two diabetes, 80 percent coronary disease, 70 percent stroke patients, 70 percent colon cancer. They're potentially preventable with a combination of weight control, healthy diet, moderate alcohol consumption, and even moderate physical activity, which is our expertise. And even in cancer, like you can reduce up to 40 percent all kinds of cancer with a healthy diet and lifestyle measures. And when a diet is compiled with the guidelines, you can decrease up to 70 percent with breast, colorectal, and prostate cancer. Even a 50 percent decrease with lung cancer. And such a diet would be conducive to preventing cancer and would favor recovery. The risk of colorectal cancer is 22 percent higher if they're diagnosed with diabetes. So this heart healthy lifestyle, management of blood pressure, the cholesterol, blood sugar, not as significant for weight, but there are lower risks of developing cancer. So BMI is associated with an increased risk of cancer. And the markers that studied used was BMI, percent body fat, waist hip ratio, and other markers. So malnutrition is a deficiency or an excess or imbalance in the person's intake of energy and nutrients. And that includes undernutrition, inadequate vitamins, minerals, being overweight, and obesity, which results in the disease that we just mentioned. And malnutrition is the main cause of death and disease in this world. And around the world, there's more than enough food to produce to feed the global population. Over 800 million people still go hungry, and 90 percent here in the U.S. who are on food stamp programs, they struggle for a healthy diet. So BMI is a screening tool, but it does not diagnose the body fatness or the health of an individual. It's far from perfect, but it's a decent guideline that one can use. And even for Asian men and women who have been shown to have higher risk of heart disease at lower BMI compared to non-Asians. And in our elderly patients, it can actually be protective having a higher BMI. So what I would say it's better to use percent body fat. And as you can see here, between men and women, that women do need to have more body fat, you know. And even when it's in our athletic or fitness populations, you can see that our female patients do need to have more fat. And so the dietary intake of foods with anti-inflammatory effects, it mediates the relationship of body fat to body pain in healthy people. And the quality of food is equally important. So the obesity and musculoskeletal pain, they're strongly related. And it's showing that body fat, not the weight, may be a better indicator of the risk. And there's a positive association with increased body fat and the widespread and single site joint pain in lower back, knee, and the feet. And some studies suggest that elevated body fat may infer increased risk of incidence and worsening joint pain. So there's different inflammatory markers that can be tested, like CRP, but I'm going to be talking about leptin briefly. And leptin is a pro-inflammatory adipokine that's exposed in subcutaneous adipose tissue and associated with bodily pain in women. Leptin levels in both serum and synovial fluid. And it's associated with arthritis, particularly in women. Functional receptors are in particular chondrocytes and can be involved with cartilage generation. And so the leptin signaling may be blunted with adiposity. And this excessive adiposity increases leptin secretion and compromises the ability to repair joint cartilage. So as you can see, increased BMI, increased body fat, it leads to osteoarthritis. And tendinopathy has the same type of relationship with dietary fats, adiposity, and inflammation. So why does the fat increase your risk for musculoskeletal pain? Is the fatty tissues increase inflammation? And this biochemical effects of this increased body fat accelerates degenerative joint diseases. So it helps to understand that why these high levels of body fat are associated with osteoarthritis in non-weight-bearing joints, such as the hands. Not just necessarily as weight-bearing as we see like in the knees. So let's get to the main point of the lecture today. Today, I will be discussing the overview of the utilization of nutrition and chronic pain management, with current evidence on the influence of dietary changes and outcome measures, including improving function. And the two goals I would like to meet today is that I want to educate the physiatrist on how nutrition and diet impacts common diagnoses in our practice, and for the physiatrist to implement healthy nutrition and diet in a common practice. And so I'm going to talk about various different diagnoses, treatments, foods and food compounds to help pain, and good versus bad diets. But for nutrition to be effective, each aspect must be looked at carefully and initiated and modified at the patient's baseline. Because each one of these factors do impact one another. So whether they have their general medical health, as we mentioned about their weight or cardiovascular issues, it has to be their pulmonary issues, GI issues, various risk factors. Later in the lecture, we will discuss about alcohol, particularly sleep. If you have poor sleep, it leads to obesity, higher BMI, risk of diabetes, their mental, emotional health. And if you can decrease your stress levels by eating healthier, side effects from psychiatric medications. And exercise helps, which is our expertise. So if you eat well, it gives you energy, improves constipation, glucose levels, decrease stress hormonal levels. But if you combine exercise with omega-3s, for example, you can actually further increase your HDL level. And so just exercise itself, you need less sleep, higher quality of sleep, less stress and depression, etc. So let's talk about some diagnoses. So autoimmune diseases affect 8% of the population, where almost 8% are women. So why is that the case? So the leptin levels continue to rise in post-birth females, but not in males due to the suppressive effect of testosterone and leptin secretion. So leptin is necessary for the induction of MS in leptin deficient mice. And if you have recombinant leptin in male mice, they can develop autoimmune encephalomyelitis. And obesity and leptin are therefore implicated in this inflammatory state for these autoimmune states. So the incidence of autoimmunity could be the function of increased leptin. While in men, it's the testosterone acts like an immunosuppressant. So many of these individuals are predisposed to autoimmune disorders and they're triggered by poor diet, lack of exercise, increased levels of stress. And to lessen the severity, you have to emphasize their healthy diet, healthy lifestyle, limit excessive drinking and exercising. And autoimmune disease is the third most common disease in the U.S. after cancer and heart disease. And as I mentioned earlier, cancer and heart disease are very strongly diet related. So these cousins or sister illnesses, these HL variants of these autoimmune diseases all seem to have a relationship. Now, a lot of us would expect autoimmune hepatitis, this affects the liver and also causes celiac disease to be affecting the GI system. But these other ones seem to have a relationship. And there's numerous trials that have demonstrated that omega-3 supplementation in inflammatory and autoimmune diseases and in neuroinflammatory and neurodegenerative diseases. So let's talk specifically about MS. Multiple sclerosis is a chronic inflammatory demyelinating degenerative disease that affects the CNS. And so there's various studies that show that the microbiome data in RRMS is a higher amount of these microbiome data and they're lesser of these microbial populations. And so I don't want to go into too much detail about it, but the point is that each one of these illnesses, they have a different microbiome. And so for the gut, there's a tissue called the gut-associated lymphoid tissue. And the gulf is comprised of the pyropatches, mesenteric lymph nodes, lymphatic vasculature, as well as lymphoid aggregates. So the gut microbiome can modulate neuroimmune function and has an important role in autoimmunity as well. So probiotics would help with reducing the incidence and severity of MS, delaying MS progression, improves motor impairment with favorable alterations of immune inflammatory markers and intestinal microbiome composition. And so the microbiome alterations could lead to differences in disease severity and its response to medications. So evidence suggests that the Western diet, which is rich in fats, refined sugars, and poor in fiber, it promotes the onset of chronic inflammatory state due to modifying this bacteria or flora. And if you change the nutrients, you give them omega-3 fatty acids, fiber, and vitamin D, you can foster proliferation of these microorganisms with an anti-inflammatory action. So the diet quality, looking at the total daily vegetable servings, actually has a greater influence in development and the severity of MS, more than genetics. And so the diet quality is inversely correlated with the risk of developing MS and obesity, and increased BMI can increase the risk of MS by 40%. So a paleo diet is lean meats, fish, fruits, and vegetables, but it removes foods like grains and dairy. And a modified paleo diet, in this particular study we're going to talk about in a second, was supplemented with vitamin D, folate, and B12. And so they used this modified paleo diet with exercise, e-stim, and stress management for improving mood and cognitive function. They actually increased the intake of the recommended vegetables and fruits, but they limited gluten, dairy, and egg products. And what they saw was that they had a significant improvement in memory, learning, attention, language, complex verbal fluency, and verbal and visual reasoning. And by 12 months, their cognitive processing and response speed increased as well. So one of the most prominent risk factors for MS is vitamin D deficiency. And many studies have showed that it can lead to the development of MS, to disease activity, and disease progression. Low vitamin D can affect not only the early disability, but the cognition in newly MS-diagnosed patients. And low vitamin D in smoking after clinical onset predicted worse long-term cognitive function and neural integrity in MS. Some of these sources are foods high in vitamin D, whether it's dairy, yogurt, milk, fortified orange juice, various fish, and some of these quote-unquote milks that some people use. But I think the blood levels should be greater than 50, because I think between 30 and 50 is still not sufficient. And so there's another study that showed that the MS participants with any type of allergy had a 1.22 times higher rate of MS relapse than the no allergy group. And anyone with these food allergies had a 1.38 times higher rate of relapse. And they even were twice as likely to have active lesions on MRI. And so for Black Americans, particularly in our female patients, they can get MS. And Black Americans with MS experience a much higher disease burden than white patients. And our Hispanic Americans have a higher portion of disease severity, particularly in the male individuals. And a higher prevalence of MS is observed in the Hispanic population in the U.S. Because once they assimilate here, they change their dietary habits, their activity levels, and their environmental exposure. And it seems to be one of the reasons. And the Latin Americans with African ancestry with RRMS have a higher risk of transition to secondary progressive disease. Rheumatoid arthritis. There's increasing evidence for the role of nutrition, RA onset, as well as activity. And so there was a study that had osteoarthritis in RA patients with diabetes and a clinical profile of severe diabetes with suboptimal metabolic control. And so these RA patients had insulin resistance that were associated with joint and systemic inflammation. And they more likely exhibit insulin secretion, reduced insulin sensitivity, and insulin resistance. And so what these studies show is that you could target the insulin resistance through the treatment and for joint and systemic inflammation. They even noticed with cardiovascular disease and risk factors associated with RA from inflammation or elderly population. And they also had an increased risk of dementia, almost up to 60%. So they have some vitamin deficiencies here as listed. But what was interesting, if you use fish oil, it benefits them when in combination with DMARC, similar of methotrexate use. It reduced the triple DMARC failure and a higher rate of remission. And regular fish consumptions also would reduce incidence of inflammatory conditions. So if you use a vegetarian or a Mediterranean diet, it decreased the disease and again, the microbiome would be altered. In ankylosing spondylosis, there was a gentleman, Richard Howard, who was the advancement officer, and he himself being a patient of it and said that you can eliminate various different foods and some were vegetarian or paleo and tried different things, but some were successful and others they did not. And so this goes to show that each patient is unique and each disease is unique. Phyromyalgia, one of our toughest clinical patients that we can get. Overweight and obese patients had increased body fat with phyromyalgia. They had more pain, had sleep problems, higher psychological issues, and more tension points. So these cells in the fat tissue, they increase inflammation and up to 50% of them have obesity. And the females with chronic pain with phyromyalgia, they had increased risk of metabolic syndrome. But if they lost three points in the BMI going from obese to overweight, they had less pain, they had less depression, and that improves sleep. Even bariatric surgery with phyromyalgia had shown to reduce their symptoms. And up to 60% of phyromyalgia patients have small fiber neuropathy. So we could try a plant-based diet, vegetarian diet may help with their symptoms and quality of life. Some of these allergens could be like MSG, aspartame, gluten, lactose. Some of these nightshade vegetables can also be causing with phyromyalgia. And there's an anti-exotoxin, cytotoxin diet. They remove certain foods, try some elimination diets, adding certain vitamins, and even adding certain foods like grapes and green beans that may help with some of these phyromyalgia symptoms. And even probiotics have been studied to show that help with neck and shoulder stiffness. So phyromyalgia, migraines, and we're going to talk about initial psoriasis in the next slide, but you can see these overlapping pain conditions again are affecting mostly our female patients, even endometriosis. They may have BIRD and they may have asthma. And there's an unexplained association of IC with other autoimmune diseases, inflammatory bowel disease, lupus, laryngoma, Sjogren's syndrome, phyromyalgia, atopic allergy, and up to 30% of IC patients, they probably have Sjogren's syndrome. The prevalence of allergies is high and up to 80% in IC patients. Small fiber neuropathy was also shown in IC, up to 86%. They also had other syndromes, phyromyalgia, migraines, panic disorders, allergy, as well as asthma. So that previous slide that I mentioned earlier, those same overlapping pain conditions have some type of relationship with these autoimmune diseases. And so even migraines, they have a relationship with insomnia, depression, anxiety, GI issues, circulatory issues, allergies, arthritis, strokes, rheumatoid arthritis, asthma, vitamin D deficiency, psoriasis, arthritis, and the typical diseases that we deal with cardiovascular issues and renal issues and diabetes. And these interstitial diets, some of their triggers could be like milk or lactose intolerance. Sometimes it could be a gluten allergy. Some people for endometriosis have also removed gluten or lactose or histamine. So some of these food elimination diets, whether it's soy, gluten, lactose, or histamine, may benefit. And so the food allergy prevalence has increased in the last 20 years, and up to 8% in children, 10% in adults. So these are the eight most common food allergies, and the ones that I just mentioned, like wheat and gluten, soy, and dairy. Now, what are some symptoms that people can have with gluten? They can have joint pain, headaches, numbness, and tingling. The histamine foods, they may feel a little nervous, getting headaches, heart palpitations, high blood pressure, confusion. And these chronic symptoms lead to fatigue, painful periods in women, insomnia. For South Asians, for tension migraine headaches, some of their triggers could be chocolate or coffee. But the problem is that you can't just say, okay, let's do a gluten-free diet, unless you truly, truly have these allergies. And if they lead to different vitamin deficiencies, they can have low protein. Some may even become more obese because of these gluten-free substitutes. And it's an actual more expensive diet. So the total avoidance of some of these substances, they might lead to malnutrition, as we mentioned in the beginning of the lecture. Now, for osteoarthritis, these are various supplements and food additives and compounds that we can use. Angenescine is one of them, can be found in soy, in soybeans. Definitely, you can add food, curcumin, garlic, ginger, and turmeric, which I'm a huge fan of. But omega-3 fatty acids, which are in various fish, flaxseed, oils, walnuts, that has been helpful with pain, rheumatoid arthritis, headaches, migraines, dementia, cardiovascular risk, ADHD, MS, and even hypertriglyceridemia. But it's not definitive in cancer, macular degeneration, depression, or insomnia. Vitamin E has mixed results, but it may possess some type of anti-osteoarthritic effects, may slow the progression of oxidative stress and inflammation has been shown. It can be helpful in rheumatoid arthritis, and that can be found naturally in olive oil, almonds, peanuts, meats as well. But you have to be careful with that. And then you also have to be careful, it is a fat-soluble vitamin, so it can be toxic if it's supplemented too high. Bromelain is found in pineapples. There's some meta-analyses that show that it might be affected in trismus after third molar surgeries and dental surgeries. You need to be cautioned with a pregnant patient, bleeding disorders, high blood pressure, and other illnesses. You can't take it more than 10 days. It's not one of those things that you can take all the time. And if you're allergic to pineapples or these other things, you might be allergic to bromelain as well. Resveratrol, which is found in grapes and blueberries, it can be neuroprotective, anti-aging, anti-inflammatory, cardioprotective, and blood sugar lowering properties. There was a study that showed that blueberries can help with symptomatic neuroarthritis. But again, high intakes of these supplements, they can cause bruising and bleeding if they're taking any type of blood thinners, anticoagulants, and NSAIDs as well. Now, SAM is something that is made from methothionin. There's numerous studies in depression, liver diseases, where what they did was the participants in these depression studies, they had osteoarthritis, and the joint symptoms actually improved when they took SAM. So there was another bunch of studies that compared SAM with NSAIDs, and they had similar pain relief and improvement in joint function with fewer side effects taking SAM. But you have to be careful. There's small studies that consistently show it to be beneficial. It may not be safe for people with bipolar disorder and some other medications, even dietary supplements. There was a study that wanted to investigate the blood levels of iron, zinc, copper, calcium, and magnesium in RA and OA. And so genetically, their high zinc and copper status was positively associated with OA, not with RA. Copper, zinc, and iron increased the risk of OA, while calcium decreased the risk of OA and its subtype. And the associations between high iron status and OA risk were only significant males. In chronic low back pain, there's some studies that said you may take tryptophan, which is an amino acid that increases the serotonin levels. And it can be found in turkey, chicken, avocados, various fish. Some patients may have low vitamin D who have chronic low back pain. And there's been studies that show the Mediterranean diet has a benefit on axial spinal arthritis, but not as much in psoriatic arthritis. Diabetes. Up to over a third of U.S. adults have prediabetes, and 13% have diabetes, especially in blacks and Hispanics. And 20% don't even know they have diabetes. Up to 85% don't even know they have prediabetes. And one of the biggest risk factors of diabetes for prediabetes is being overweight or obese. That's up to 75% of Americans. And eating meat products increases the risk of diabetes. And many of us were very familiar with our EMGs, their increased risk for peripheral neuropathy and other types of neuropathies in carpal tunnel syndrome, ulnar neuropathy, perineal neuropathy, epithelial head. And so recently the U.S. Preventive Services Task Force lowered the age from 40 years old to 35 in asymptomatic, non-pregnant adults who were overweight and obese. And so patients with diabetes or LVA1c increased sudden arrhythmic death risk in coronary disease. So again, what's the treatment? Eat a DASH diet, a Mediterranean diet. GERD. We're very familiar with GERD. We prescribe NSAIDs and giving corticosteroids, whether it's an injection form orally. 30% of Americans have GERD. It's common to obese patients during pregnancy and smokers. GERD can cause cancer. But the triggers is similar to what we discussed around high-fat meals, but it can also be with alcohol, acidic and carbonated beverages and soda, caffeine, chocolate. And most overweight patients, if they were enrolled in a structured weight loss program and included dietary, physical activity, and behavioral changes, they can have complete resolution of their GERD symptoms. So the five factors that would definitely help with it is if they had normal weight, they're restricted coffee, tea, and sodas to two cups daily, a prudent diet, a vigorous exercise program, and not smoking. But severe GERD, if they're unable to eat at all, they're actually losing weight. And so many of these patients are on proton pump inhibitors. And but the thing you have to be careful is there are vitamins that can be decreased, vitamin B12, folic acid, vitamin C, calcium, iron, and magnesium as well. COVID, our arch nemesis for the last year and a half. So there's many studies that show that if you have a healthier diet, you have less severe COVID. And if you have a plant-based diet, you can decrease the risk of severe COVID by over 40%. And this was based on a survey. Obesity tripled the risk of hospitalization due to COVID. And in our military, obesity was independently associated with hospitalization, need for oxygen therapy, higher viral load, and altered immune response. And the meta-analysis showed that 10% of COVID patients will suffer from MSKA post-COVID pain within the first year of infection. And the BMI is greater than 45, that doubled the risk of mechanical ventilation, hospitalization, and death. And as you can see, many of these illnesses, they're diet-related. And so NSAIDs as well have cardiovascular, GERD, and kidney disease. And again, the Mediterranean DASH diet can help with a lot of these effects. Corticosteroids can increase your glucose levels, reflux, hypertension, but also can decrease your vitamin D and lower calcium resources as well. Methotrexate has side effects. It can lower your folic acid, more mouth sores, headaches, and dizziness. Now, what is this Mediterranean diet? It includes fish, nuts, fruits and vegetables, olive oil, beans, and whole grains. And it can lower your blood pressure, less headaches, migraines, protect chronic conditions from cancer to stroke, help with arthritis by decreasing the inflammation, benefit with the joints and the heart, and lead to weight loss, which can ultimately lessen the joint pain as well. And so fish has these omega-3 fatty acids, and it can change the intestinal microbiome. And if you change the type of the propagandas, glucotrans, and thromboxanes, you can result in anti-inflammatory properties, and it can actually help with tissue respiration. So it's recommended to eat it two to three times a week. And even olive oil, this oil that inhibits the activity of the coxin enzyme, it acts like ibuprofen. And walnut oil has 10 times the omega-3s that olive oil has. And so with whole grains, you've got to be a little careful. As I mentioned earlier, some of them can have gluten sensitivity or allergy, and some of them have celiac disease. And this Mediterranean diet can actually help with less periodontitis as well, gum disease. Fiber can also have a positive impact on the microbiota. And my favorite topic is prebiotics and probiotics. And if you can help with the intestinal diseases, especially after antibiotics, help with obesity, Parkinson's, constipation pain, it's found in yogurt, kefir, kimchi, and sauerkraut. And here you can see it helps with respiratory, psychological issues, liver disease, UTIs, cardiovascular disease, as mentioned earlier, cancer, oral disease, autoimmune diseases, osteoporosis, and GI issues as well. What are these bad foods? Red meat, eggs, and dairy products, they cause a pro-inflammatory. And if you have a lot of salt, it can increase your RA, cardiomegaly, hypertension, kidney disease, osteoporosis. Sugar, sweetened soda increase the risk of RA and inflammation and arthritis development. You have to be very careful about these plant-based burgers as well. There are ultra-processed foods have a lot of preservatives, so we do need to be a little careful. Ultra-processed foods are two-thirds of calories in our adolescents as well. So this diagram really helps where the kind of quality of food and quantity, where 400 calories of oil looks just like that and barely fills you up, and you have 400 calories of vegetables and look at that, it's tremendous. And here's a 500 calorie version of oil and cheese, and again, grains, beans, and fruit and vegetables, it makes a very big difference. Supplements. I tell patients be very careful and cautious, even with our physicians and integrative medicine, functional medicine physicians. You have to be helpful, there's no standardization, there varies in dose, there's other fillers in these products, there's no FDA approval. You also have to be careful drug supplement food interactions. There's, you're not sure about the long-term side effects, and there's not that many long-term studies and meta-analyses. Vitamin D, I'm a huge fan of, it's in the liver, in the kidney, as we mentioned about low vitamin D and MS, but it helps with rickets in children, osteomyasia in adults, helps with osteoporosis, cognition, dementia, diabetes, hypertension, hyperlipidemia, kidney disease, as well as obesity. Fallers have low vitamin D, you know, in our older patients, and vitamin D testers have been positive with walking speed in our adults, may help with fatal cancer, macular degeneration. Low vitamin D levels have been associated with increased pain and opiate doses, and some studies have shown like vitamin D supplementation of cancer pain and muscular pain. It can help with cardiovascular events, it can lower the risk of MIs in adults with no previous history of MI. One in four patients are vitamin D deficient, and many of our obese patients do have it. That's twice as likely to be vitamin D deficient, and in our Black patients, up to 10 times more likely to be vitamin D deficient. But we do need to be careful with vitamin D toxicity like AE and K, and levels are lowered because of steroids. Nutritional psychiatry, I love this topic, you can actually help decrease stress. The physical symptoms include aches and GI issues, sleep loss, but you can consume these unsaturated fats and decrease suicide risk and help with depression, and even a Mediterranean diet can help against depression and anxiety. Even the DASH diet helps with depressive symptoms as well. A high glycemic diet can trigger total mood disturbances, levels of fatigue, and depressive symptoms, and a lower glycemic. So the combination of exercise and nutrition can help with these depressive symptoms. And insomnia affects about 30% of the general population, where sleep apnea is mostly by obesity and being overweight, increasing your cardiovascular risk, diabetes, and stress, and can disrupt sleep. And 40% of insomnia patients have depression. And again, these whole food diets, but they can also have supplements of tryptophan and melatonin, maybe the fatty acids again, red grapes that can help with melatonin, depending on the concentration. Some people have tried tart cherry juice, beetroot juice, kiwis, some are vitamin D deficient, eating fish may help, but again, the DASH and Mediterranean diet may help. You also have to look at what they're having, caffeine or alcohol or big meals before bed. And sometimes exercise can also cause insomnia at night. So some of them may need to do it at daytime, some sleep better when they do it at night. Alcohol can impact various cardiovascular diseases, heart disease, and stroke, increase the risk of AFib. Recent guidelines said to have one drink or less for men and women. And liquor sales, they were increased during the pandemic. So we have to be very careful. It decreases your folic acid, B12, neuropathy, shrinks your brain, risk of stroke, hypertension, but it also increases your risk, especially for breast cancer and other cancers as well. So what do you do after you eat? You floss, you brush. And gum disease itself increases risk for cardiovascular disease, diabetes, rheumatoid arthritis, cancers. Mediterranean helps decrease gum disease. Pre- and probiotics even help with gum disease. And a lot of our post-COVID patients even have dry mouth. So see, these are some of the strategies that you can use with weight loss. And in the first three months, you have to emphasize more weight loss, encouraging to eat at home, avoid processed foods, eating breakfast, more protein, but they got to do this on their own, the self-monitoring. This is the most critical point. And my personal recommendations is have a dietician counsel, have a strict dietary journal with historic intake, elimination diet, evaluate in three months, modify each patient's preference of food and medical issues. Luckily, lately with COVID, there's a lot of telemedicine that we can use, and that may be helpful. And recently, the guidelines have changed to decrease salt, saving up to half a million lives in the next 10 years by decreasing the salt intake. So my vital checks I would recommend, check your blood pressure, heart rate, LDL, HDL, fasting glucose, A1C, but body fat has to be in the context of BMI and weight. With the Apple Watch, you can check your heart rate. You can check, have an EKG, even have a visual device with a pedometer. And so check blood levels of vitamin D, B12, folic acid, kidney function, liver function. So as we can see, nutrition is definitely a great option for treatment and management. And I'd be willing to argue that you can decrease and help their improvement by 50%. And nutrition impacts all levels of disease, whether they have a genetic or no genetic disposition. And these general medical health and risk factors help with sleep, emotional health, exercise, and they're all intertwined. Recently, a lot of physicians are becoming chefs and practicing culinary medicine and teaching their patients what to have. And this diagram shows a diet that impacts every one of these types of things and vice versa. And I wanted to discuss the long-term studies of Lyme disease, the antibiotics, the gut microbiome being changed in ulcerative colitis, prostate cancer, statins are being shown, diabetes progression, and in women who are taking birth control or overweight, their increased risk for clots. And this is the last slide. And I do want to spend a couple of minutes on this, but I do want in the future to have an annual nutrition pain forum with half a full-day course, online lectures, and information on social media updated every three months, have something on the FIS forum, and have a community developed. But to talk about each group, race, gender, minority, religion, whether kosher physiatry, Muslim physiatry, Blacks, women, I want a full section on the APMR and the PMR now. Annual assembly, there should be a three hour session, like continuously. I want a full downloadable PowerPoint for the PMR website and choosing wisely. But I want to work with other academic groups, pain management, rheumatology, nutrition, GI, endocrinology, obesity, how to save the date, upcoming webinars, special events, brand rounds, a dedicated journal supplement every two years, and having even every one of our purple journals have one or two articles per year, and having a journal club about this. Any questions, thoughts? Hey, everybody, welcome back, and we do have a question on the chat board from Dr. Parikh. Is there a probiotic brand you recommend? That's the whole problem. I'm very big on actually eating the foods. These brands, I wish I could say I rely on dot, dot, dot, but I can't. I think each patient and each physician has to be careful with what they feel comfortable with, so if they want to try a certain company, be careful, see how you do, but remember, what is advertised doesn't mean what you're going to get. Anyone else would like to chime in with any questions or comments? All right, well, thank you so much, Dr. Chaktai. I know that you have to go to the board meeting, the virtual town hall, so thank you so much for presenting today, and thank you so much for your talk. Thank you, everyone. Appreciate it. All right, so we're switching over now to mindfulness, so we had an introduction last week about the Mind-Body Connection from Dr. Parikh and his group from JFK Rehabilitation Center, and we're just kind of expanding on that today. We have somebody who is a specialist in mindfulness, and we're going to hear a little bit about how to integrate that into practice and how to use that for the treatment of chronic pain, so I'm going to read the bio for Katie McBee. So Katie McBee earned a doctorate in physical therapy and is board-certified, orthopedic board-certified. As a practicing physical therapist for over 15 years, she specializes in work-related complex chronic pain conditions in an outpatient setting. She's certified in mindfulness meditation, and she completed a 2-year training program with the leading meditation instructors in the US. She teaches at Bellarmine University on the pain program for neuroscience, ergonomics, injury prevention, and exercise physiology. She leads education efforts at Phoenix Physical Therapy to improve clinician knowledge and patient outcomes for complex chronic pain-related conditions. Dr. McBee is also a member of the Motivational Interviewing Network of Trainers and a certified yoga instructor. She is an elected board member for the International Association of the Study of Pain and appointed board member of the Pain Special Interest Group of the American Physical Therapy Association. So welcome, Dr. McBee. Thank you, Dr. Zolnik. All right, let me share my screen and get this PowerPoint started. All right, so an exciting topic, and we should have time for an experiential activity. I was going to share one of my favorite meditations I use with patients who are suffering from chronic pain conditions. So I hope some of you will be able to stay on the line until the very end and get to experience that. I wanted to also just take a moment and just say thank you to one of my dear friends and mentors, Carolyn McManus, as she had introduced me to Dr. Zolnik, and she also inspired some of the slides I'll be using today. So with that, let's get moving forward. Okay, so I've got a couple of quotes up here, and the first one, when we can sit in the face of insanity or dislike and be free from the need to make it different, then we are free. And that's a Nelson Mandela quote. And then a classic from mindfulness perspective, mindfulness is awareness that arises through paying attention on purpose in the present moment, non-judgmentally. So I thought I'd open with those because they were both great definitions to start talking about mindfulness meditation. Before I dive into the research on mindfulness specifically, I wanted to share some information on pain, which a lot of you all probably are very familiar with, so it'll probably just be a review, but we all know pain is a very complex perception, and it's much more complex than the tissue issue that may be driving it, and that makes it very difficult to treat. And research has been building for at least over 30 years, really strong, but even longer, if you look at some of the quotes, that pain needs to be treated with a biopsychosocial model. If you look at some of the stats that came out in recent years, low back pain is the leading cause of disability in the US, nearly twice the burden than any other health condition, and about 30% across the board of individuals that get acute low back pain end up transitioning into chronic low back pain, which means their pain continues on for six months or longer. And depending on the parent class involved, that can change the stats, where POMP has some, I guess, some other potential litigious issues and financial gain issues that may be driving some of that increased transition to chronicity compared to private insurance groups. And some of the factors that are associated with transitioning from acute to chronic include obesity, which was just discussed, so definitely a factor to address, high psychosocial risk stratification, so catastrophizing fear of avoidance, perceived injustice, anger at the situation that you're in or thinking that it got caused by someone else, high self-rated disability, existing depression, anxiety, being a smoker and exposure to non-concordant care in the first 21 days. So that means getting into specialists too soon, to surgeons, getting MRIs and x-rays when there's no red flags to indicate the need in those early weeks and getting higher level medications earlier on. For traumatic condition, anxiety, poor pain control earlier, some of the biggest predictors of chronic conditions and then just across the board looking at individuals with chronic conditions, there's a lot of different factors, including nutrition and overall health and vitamin D, which was just talked about, but it's much more complex than that. So treating pain can be something that is very difficult. I'm sharing this additional slide on pain treatment pathways because it's something we're not currently doing very successfully. Opioid deaths have gone up, I think the latest data I saw was 30% during this COVID situation we're all currently in. So people have had less access to adequate care and problems are getting bigger with either illicit drug use as well as individuals dealing with addiction and chronic pain issues that may be seeking medications if they can't get access to them due to regulations. So pain is an issue, figuring out how to treat it is something we really need to prioritize. And I include this study here, just a slide from a study that was published in the Pain Journal earlier this year by Steven George and his group, and basically showing that we really need to change the way we treat musculoskeletal pain conditions and showing kind of the current way we treat typically in the United States and other developed countries right now is by when people come in and make a contact with the healthcare system, they typically normally get pharmacology as the initial treatment. And then when they don't respond, that's where we either look at non-pharmacologic interventional pain treatments or surgical treatments. And then additional treatments as those don't work out and people just kind of enter that loop of trying things. And what they're suggesting based on the research and the guidelines that are published is that we try to change the way we approach pain in healthcare in general, and that when people make this primary health system contact that non-pharmacologic care, whether that's nutrition interventions, chiropractic, physical therapy, home exercise, CBT, education-based programs and wellness coaching, whatever it may be, or mindfulness. So get ready to talk about this topic. But trying some of these treatments first when there's no red flags and need to escalate the care instead of going into those non-concordant care practices that are associated with increased risk of chronicity and poor outcomes for the patients that we work with. So meditation, where does it fit in all of this as a conservative treatment? Just a review of some of the literature that's out there on meditation. Meditation has been shown to result in small to moderate reductions in multiple negative dimensions of psychological stress, which I'll show in a moment just to describe that relationship with pain and stress, but they're very tightly tied. Pain is stressful. That's the whole point of it is to get your attention and get you to change something. So meditation can improve some of the stress that is a secondary effect or a driving effect behind pain conditions. It can lead to large and significant improvements after doing a mindfulness-based stress reduction program that is a eight-week structured program with a certified mindfulness instructor that improves the physical and psychological status for chronic pain sufferers. And long-term benefits for chronic pain, not just acute improvements, and it can improve prosocial emotions and behaviors, including empathy and compassion and self-compassion that aren't on there. So it improves your connections to others, which may have some of the impacts on depression scores, et cetera, because when you're able to connect with others better, that's gonna improve your overall happiness and joy in life. Mindfulness meditation is associated with statistically significant improvements in depression, physical health-related quality of life, as well as mental health-related quality of life. And I think after the past year and a half, most of us can use some improvements there. So hopefully, even if you're not suffering from a pain condition, you'll get some benefit from the activities we'll do today. And if you're not already a practicing meditator, maybe you'll be willing to test it out and see if it fits and is something rewarding for you. So this next slide, I just wanted to share kind of a stress response. I wanted to think about, like if you're driving or if you're running late, you look down for just a second because you heard your phone ding and you know you're not supposed to look at your text, but you look down anyway, and then you look up, you're still going 50 miles an hour and traffic is dense stuff, just 20 feet in front of you. So you slam on the brakes and you're not sure if you're gonna make it or not, if you're gonna be able to stop your car or if you're about to have an accident. So what happens? Your breathing gets short, your muscles get tense, you start feeling anxious thoughts, your heart rate jumps up incredibly, your blood vessels constrict, you have just stimulated your sympathetic nervous system. If you think of a different situation, what happens when you have pain and you're walking across your floors, you're barefoot and you step on a nail that's sticking out of your wood floors? Immediately, you tighten up, you get tight muscles, your breath gets short, your heart rate goes up and you simulate that sympathetic nervous system again, that fight or flight response comes up. And in acute situation, that means you're able to react to that pain and try and get away from it. Whereas in a chronic situation, you're just staying kind of wound up, but there's not really anything to get away from because the signals have gotten so blurred and confusing in a chronic pain situation, how do you calm down the alarm system? And that I think is where mindfulness fits in beautifully in pain conditions, whether acutely in the preventative realm or for chronic pain to help people have some alternate coping mechanisms that aren't medication or intervention related that they can control and we can empower the patients to get their life back and have some control over their pain. So if you look at the research on the transition from acute to chronic pain, which we already discussed some of it, stress and mental health are implicated in this transition. So managing stress is a big part of potentially managing that transition from acute to chronic pain. And then there's some research from Basson-Pourceau, I think I'm saying that correctly, I apologize if not, a study that basically showed the best way to date that we have found from research to be able to predict people going from acute to chronic is by doing a brain scan and measuring their amygdala and hippocampal volumes and larger volumes in their amygdala and hippocampal volumes and a stronger connection between the right amygdala and the anterior cingulate cortex, which is similar in addiction pathways is associated with a much greater likelihood of transition to chronic pain. So one of the best ways we can measure if people are at risk for developing chronic pain, but in a very expensive way, so not widely available yet. Cool part in the research on mindfulness that was done even before this study that showed that how you can predict the transition to chronic pain is that meditation actually results in a functional decoupling of the cognitive evaluative components of pain and the sensory discriminative components of pain. So basically what they're theorizing is it allows practitioners of meditation to view painful stimuli more neutrally. So you can be with that negative sensation, you can be with the negative thoughts, but not get tied up in them and react to them. That's what meditation training can potentially be. This is a nice study just because I like this one just because it shows how little you have to do to get an impact with patients because people may not want to go through an eight-week mindfulness-based stress reduction course, but what if they could just do four 20-minute sessions, four days, 20 minutes a day? What does that do? No homework, just do it in the clinic, supervised. The study by Ziden showed that individuals who performed in the meditation group just for four 20-minute sessions had a 40% reduction in pain intensity as well as a 57% reduction in pain and pleasantness. There is very little harm that could come from that. And it's kind of like one of those things when I'm working with patients, there's some things you avoid because you gotta weigh that risk-benefit ratio, but with mindfulness, I throw it out there. People are open to it, they're accepting of the education, they're mentally in a stable state, not having an acute mental health issue, then I'll bring mindfulness in. And if they don't like it, we don't have to do it, but I don't hurt them by trying it. It's not like surgery. So meditation, being in the room, meditation, and just reductions in pain intensity have been associated with increased activity in the anterior cingulate cortex and the anterior insula. And that means that that's basically a cognitive regulation of the nociceptive processing. So that increased activity is blocking some of those peripheral signals from the nociceptors, from getting escalated into a pain output. Meditation-induced reductions in pain and pleasantness are associated with orbital frontal cortex activation. So it's basically reframing the contextual evaluation of the sensory events. So instead of maybe finding them as distressful, just being able to accept them and be aware of them. Mindfulness is also associated with decreased gray matter in the right amygdala. And MBSR training, that eight-week structured program developed by Jon Kabat-Zinn and the University of Massachusetts, that training led to decreased right amygdala gray matter density as well, which has correlated positively with reductions in perceived stress. And I think I have a little slide here just to kind of break out the left versus right amygdala. The right amygdala only induces negative emotions, especially fear and sadness, whereas your left amygdala has a little more balance to it. It can induce pleasant or unpleasant emotions, happiness, fear, and sadness. So seeing changes and less structure to that right amygdala hopefully would lead to more of a balance in those emotions. And the amygdala and anterior cingulate cortex functional coupling is also associated with self-reported perceived stress. So the more coupling there, that's also, as I'd said earlier in the Sean Perchaud study, associated with a greater risk of transitioning to chronic pain from an acute situation, but it's also tied with increased perceived stress levels. A three-day mindfulness training has been shown to decrease right amygdala ACC functional coupling relative to a comparison relaxation treatment. So something worth checking out, even though you don't have to physically do anything, you are physically changing the brain and the way it's processing stimuli associated with stress and pain. So mindfulness has been shown to improve pain and depression symptoms and quality of life, but additional studies are definitely needed with larger sample sizes and adequate control interventions and longer follow-ups. So although it's a great potential and low harm type of treatment to implement, additional studies are definitely needed to kind of help guide us on what types of mindfulness meditation practices have the best event, what types of exposure, what's the dosage that's needed. So this one is a study on, oh, no, this is from the Clinical Practice Guideline from the American College of Physicians. And basically putting in that from Kassim 2017, that there is moderate quality evidence for exercise, multidisciplinary rehab, acupuncture and mindfulness-based stress reduction as those early non-pharmacologic treatments to kind of circle back to that third or fourth slide that I showed, we need to treat acute pain differently by emphasizing non-pharmacologic conservative treatments first. Here's a list of options and mindfulness-based stress reduction is one of those top treatments that we might wanna look at for chronic low back pain. Okay, and cost-effectiveness, how cost-effective is mindfulness versus other treatments? So compared to usual care, individuals that went through an MBSR program showed a decrease in costs of $982 per participant to the insurance payer after a year. CBT for this particular study was not found to be cost-saving, although I have seen studies where it is. And then cost savings were associated with individuals who had statistically significant gains in their quality of life over the usual care participants. This one is a study on mindfulness-based functional therapy for chronic low-back pain. This was a pilot study, which was kind of interesting for me as a physical therapist and I implement mindfulness in my practice. Individuals went through this program one time a week for two hours for eight weeks, and they got education on a biopsychosocial model of pain, pain science education, central sensitization information, as well as education on the importance of normal movement and modulating pain, understanding of the fear-avoidance model and the role of stress and negative affect on pain. And in the study, they got mindfulness training and they got taught how to integrate mindfulness into functional movements, which could say dealing in the comp area, a lot of the injuries I see from a low-skill skill perspective and beyond with work-related injuries come from people just losing focus, being distracted, doing things wrong just one time, pushing themselves past their body limits because they weren't paying attention and having an injury. So I love that concept of integrating mindfulness into functional movement, and as well as adding in other general wellness ideas like the graduated cardiovascular program. So these were the three main treatments for the specific pilot studies. And at six months, they saw a medium effect size for pain intensity, anxiety, physical function, energy, and general health with the treatment group. And six months, they saw a large effect size for improvements in catastrophizing, which has been shown to be a big mediator in treatment and being correlated strongly to treatment effects for some chronic pain conditions. So a large effect size for catastrophizing, mindfulness, overall pain acceptance, depression, stress, and social function. I included also a study here on chronic headaches. So for this one, they used pre and post-assessments using the SF-36 and mindfulness-based stress reductions that a week program for individuals who suffered with chronic headaches showed a significant reduction in pain intensity, as well as significant improvements in the subscales in accordance with their roles, their life roles, and limitations to their physical health, both their general health and mental health, bodily pain, and overall energy and vitality. So again, a pretty low-risk conservative treatment that can have some potential positive impacts for patients. So what I wanted to do next, and hopefully you'll bear with me, is I wanted to take you through a 10-minute activity for mindfulness, just to kind of share with you a standard treatment that I do with one of my patients. And this particular meditation is one that was written by a researcher, Eric Garland, who I really love, and he does a lot of work around mindfulness and addiction. So if you have a pain condition, you're welcome to focus on it. If you don't, you're welcome to focus on your breath as I go through some of the cues. But if you want to participate, you can. And what I'm gonna have you do is just find yourself a comfortable seat, if you're not already. And so you can get yourself where your feet are, touching the floor, and your arms are uncrossed, and you're sitting comfortably, but feeling yourself nice and tall, as if you're a king or a queen, with your sides straight and your belly relaxed. And you can allow your eyes to close, or they can remain open and relaxed on a spot in front of you. You can begin to notice the sensation of the body resting in your chair. Probably been sitting in the chair for a while now. Let's see if you can now begin to really notice the sensation. Feel the legs and back making contact with the cushion of the chair. And we have this word contact, but what is it really? A sensation of warmth, or heaviness, or tingling, or some other sensation? Just noticing whatever it is. And in a moment, when you're ready, becoming aware of the state of the body at this moment. Is the body tired or full of energy? Are parts of the body tense or relaxed? It really doesn't matter. Just noticing the state of the body at this moment. And in a moment, notice in the state of the mind. Is it full of thoughts? Or mostly empty of thoughts? Are thoughts moving quickly or slowly? Again, it really doesn't matter. Just noticing the state of the mind at this moment. And when you're ready, you can begin to pay attention to the breath. And there's no need to breathe in any special way. Just noticing the natural sensation of the breath. Becoming aware of the sensation of the air moving into the nostrils. Noticing the temperature of that air. Warmth or coolness. You might even notice that you have tiny muscles in your nostrils that flex or flail as you breathe in. Just noticing the sensation of the breath in this moment. That's right. And in a moment, soon, you may begin to notice that the mind begins to wander. Thoughts, feelings, images, and memories. And if the mind wanders, that's okay. Because that is what minds do, they know it. So noticing where the mind has wandered off to. Acknowledging that thought or feeling. And then letting it go. And gently but firmly, returning the focus of the attention back to the breath. And with each passing breath, becoming more focused, becoming more aware. And soon, you may begin to notice that the mind wanders again. And if the mind wanders, that's okay. Just noticing where the mind has wandered off to. Acknowledging and accepting that thought or feeling. And letting it stay to yourself in the space of your own mind. It's okay to have this thought or feeling right now. And then you can let it go. And gently but firmly, returning the focus of the attention back to the breath. And if you notice uncomfortable sensations, you can pay kind attention to them. Allowing them to be there. And we have a sort of discomfort. But what is it really? Just noticing the sensation. Is it a heat? A tightness? A sharpness? Are there thoughts or feelings associated with those sensations? And can you notice if the sensation's on the center? Can you notice if they have edges? Perhaps the sensation is not solid. Perhaps there are spaces inside the sensation where the sensation is not. And if the sensation becomes too intense, you can notice where the uncomfortable sensation is not. For example, you can focus on the feeling of the air moving into the tip of your nostrils as you breathe. You can always return your attention back to the breath as a way to recenter yourself, as a way to step back from sensation. And now imagine that you can breathe right into the intense sensations in the body. Imagine that you can send your breath right into that part of the body breathing into that sensation to soften it. Allowing the breath and the attention to sink into this part of the body like water seeping down into soil. And then return the focus of your attention back to the sensation. Can you notice how it is changing? Perhaps gradually getting deeper, perhaps becoming more intense, reaching that peak, and then gradually getting deeper. Perhaps the quality of the sensation is changing. Can that heat become a warmth? Can the tightness become heat? A sharpness become a tingling? Perhaps the location is changing. You can notice if the sensation's out of center. You can notice if they have edges. Perhaps the sensation is not solid. Perhaps there are spaces inside the sensation where the sensation is not. And then you can let that sensation go and gently returning the attention to the breathing. Again and again. Each time that you notice that the mind is wondered, and you become aware of where the mind is wondered off to, and you acknowledge and accept that thought or feeling, and you return the focus of the attention back to the breath. Each time you are strengthening your mindfulness, each time you turn your attention back to the breath, you are learning to step back, to step back, to step back from your thoughts and feelings and into the clear, open space in mind. And soon you may begin to notice that sensations, you begin to notice that sensations, thoughts, feelings, images, and memories don't go all on their own like clouds passing in a clear blue sky. All right, so see if you can settle back in and bring your attention back to your breath. And soon you may begin to notice that sensations, thoughts, feelings, images, and memories come and go all on their own like clouds passing in a clear blue sky. Like clouds drifting, these thoughts come out of nowhere, change shape, and then fade into the distance all on their own. And there's no need to hold onto those thoughts or to push them away. You can just let them go. And a part of the mind is like those thoughts passing like clouds, but there's a deeper part of the mind that is more like the space in which the clouds pass, the observing awareness that is open, vast, spotless, and free. Just watching, just observing peacefully. And you can focus your attention on that part of your mind or you can continue to focus your attention on your breathing. That's right. And now you can take a few long moments to focus on the best parts of this experience, appreciating and savoring whatever positive thoughts and feelings have come up for you in this practice. Focusing on these experiences now. Or you can continue to focus on the breath, knowing that you can return to this state of mindfulness whenever you need to, simply by bringing your attention back to the breath. Then very slowly and gently, when you are ready, you may feel a little more comfortable and a little more hopeful about the future when you open your eyes and return your attention to the room. That is, I welcome you to rejoin me. And hopefully you were able to get something out of the practice. And here, that is one of my favorite practices that I use when I'm practicing mindfulness. And here, that is one of my favorite practices that I use with patients if they are open to be using a pain meditation. I'd say about 90% of them have a positive experience with that the very first time. So it sets the stage for a nice relationship with mindfulness as a conservative part of their treatment plan. So I wanted to end with this quote because I don't wanna oversell anything. That's not the way I like to practice. So mindfulness is not the answer for all of life's problems. Rather, it is that all of life's problems can seem a bit more clearly, can be seen more clearly through the lens of a clear mind. So with that, I have some resources if anybody's interested at the end. There's some nice apps, Insight Timer, Headspace Calm. There's more and more every day. There's the MESR program. You can actually take training through Brown University now. You can do it all virtually. It's one of the positive things with COVID. And there's a free MESR course that you could share with patients at this policemindfulness.com website if you wanna share it with your patients but you're not a mindfulness instructor. If you have any questions or need resources, don't ever hesitate to reach out. So with that, I will pass it back to Dr. Selman. Thank you. Thank you so much, Dr. McPhee. I do have a question for you about the MESR course. I know it's eight weeks. It's pretty intensive. How do you know that it's good for you? If it's right for you? I think my patients would ask the same thing. Yeah, I think every individual probably needs to reach out to the instructor that would lead their course and just talk to them about their situation. It may be good to, the course is written in Jon Kabat-Zinn's Full Catastrophe Living book. So if you're just wanting to explore and figure out what you're getting into, that's an easy book to access that you can get fairly cheap and read a little bit more about it. But as long as you're not having any real acute mental health distress or any issues with sitting still, because you can alter the posture pretty easily to make mindfulness fit for a lot of different individuals. It's a great course. If you don't have time for it, it's probably what you need. And that's probably a way to say it. It's something that would definitely have some benefit. I have to say, I went through it the first time because about eight years ago and I was taking it to learn from my patients and about week two realized, oh my gosh, this is really hard and I really need this. And it started my mindfulness journey. So it's tough, it's an hour of meditation every single day plus the weekly courses. So it's definitely a commitment, but I would definitely say it's worth it. And again, if you're having issues with stress, then managing your stress, managing your schedule and all the amazing things life can throw at you or if you have some underlying conditions, high blood pressure, chronic pain, it might be worth giving a try. I haven't had anybody come back to me yet and complain about mindfulness, I have to say that. So I have a question in the chat. Hillary asks, are you referencing the Brown course specifically for MBSR? Well, it used to be at the University of Massachusetts and just this year they transitioned it to Brown University. So the official course is through Brown University, but my first course, I just had a certified MBSR teacher at a local mindfulness education place in Louisville, Kentucky that I went to Earth, Mind and Spirit Center and I took the eight week course. I took the Saturday version because that fit my schedule. So if you go online and look, you can find local MBSR courses. I think there's some value to the live courses if your health is good and you're comfortable with that now, but there's also virtual courses available which makes it easier for a lot of people to access. I know a lot of my patients and myself have had issues with judgment and part of mindfulness is not having that judgment on yourself. Like, can you start to do these activities and then you're noticing different things and your thoughts are coming up. Like, what's your best advice to patients about having that non-judgmental stance? I would say lower your expectations. Basically that we're all judgy. We're not even doing mindfulness. You're gonna learn to be with those thoughts better but you definitely can't eliminate them from a normal human mind. So it's more learning how to be with those thoughts and that kind of build on them with the reactions that you have towards them as opposed to stopping the frequency of their thoughts. Another thing, I think some people would like to know about specific advice for specific exercises combining both mindfulness and movement together for the rehab patient. Yeah, so there's some really nice basic activities if you look at Jon Kabat-Zinn's book that he has built into the MBSR program. But really I've got creative as a physical therapist and yoga teacher. And I just combine the breath and just awareness of the body and breathing patterns with different simple movements that are easy for that patient depending on what their impairments or limitations are. So it doesn't have to be very complicated at all. It can be something as simple as sitting in a chair and doing some gentle rotation or flexion or marching and doing that timed with the breath and just bringing your awareness to what it feels like where you feel the pressure and focusing on the breath in between. So you can just kind of amp up, I guess the benefits of some movement and do it in nice, gentle, safe movements. And okay, great, great. Anybody else have any questions? Okay, thank you so much everyone for being here. Thank you to our speakers, Dr. McBee and Dr. Chentai. And have a good annual assembly everybody.

nutrition

pain management

autoimmune diseases

Mediterranean diet

inflammation

omega-3 fatty acids

curcumin

garlic

ginger

mindfulness meditation

chronic pain

stress reduction