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Dr. Sulak's Provider Wellness
1. Provider Wellness:
Simple Tools to Enhance Your
Health and Improve Patient
Outcomes
Dustin Sulak, D.O.
Maine Osteopathic Association
Annual Oceanside Convention 2014
2. Introduction
I have no relevant financial relationships with commercial interests.
Founder and Medical Director
Maine Integrative Healthcare in Manchester, Maine
Integr8 Health, LLC in Falmouth Maine
Director of Education
Integr8 Massachusetts, Burlington, Mass
6 DOs, 4 MDs, 6 NPs, 1 LCPC, 1 LMT, 1 DN
Integrative Medicine and Medical Cannabis Consultations,
Family Medicine, OMT, laser therapy, hypnotherapy, and more.
3. 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.
4. 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
6. “To find health
should be the object
of the doctor.
Anyone can find
disease.”
Andrew Taylor Still
Founder of Osteopathy
7. • 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.
9. 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
10. 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
12. 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 Psychosom
55:197-200, 1991
Heim E: Job stressors and coping in health professions. Psychother Psychosom 55:90-99, 1991
15. Medical Training
• Fear of Failure
• Perfectionism Obsession
• Social isolation (long hours)
• Exhaustion, disrupted biological rhythms
• Emotional and Physical Dissociation
• Compassion Fatigue Syndrome, Burnout
16. 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.
18. The Physiology of Health
The Endocannabinoid System
Physiologic Coherence
19. 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 citations
2014: 6,141 citations
22. CB Receptors Evolved 600 Million Years Ago
human
monkey
rat
mouse
finch
newt
Fugu fish
sea squirt
Caenorhabditis
Drosophila, Apis
McPartland et al., 2005
23. 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
25. anandamide (AEA)
Devane, Mechoulam et al., Science (1992) 258:1946-1949
Endogenous Cannabinoid Ligands:
The Endocannabinoids
2-arachidonoylglycerol (2-AG)
Mechoulam et al., 1995
Sugiura et al., 1995
26. 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
27. Depolarization-Induced Suppression of Excitation
Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cell
action 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
28. AMPA
Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cell
action 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
29. Ca2+
channel
Na+, K+
channels
glutamate
presynaptic cell
action 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
30. Ca2+
channel
Na+, K+
channels
GABA
presynaptic cell
action 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
31. • 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
32. 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.
33. 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)
34. Osteopathy and
the 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
35. Osteopathy and
the 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
36. Osteopathy and
the 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.
37. 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.
38. 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?
39. How To Enhance the
Endocannabinoid System?
Pre-Clinical and Clinical Review:
40. 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 eCB
signaling, except perhaps in areas involved in reward and
motivation to self-administer this substance of abuse
41. 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.
42. 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
43. 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)
44. 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.
45. “When all of the
fulcrums are
synchronized there
will be peace and
harmony.”
-W.G. Sutherland
DO
46. 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
47. Heart Rate Variability (HRV)
0 1 2
-0.5
0
0.5
1
1.5
2
mVolts
2.5 seconds of heart beat data
.859 sec. .793 sec. .726 sec.
70 BPM 76 BPM 83 BPM
48. 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 death
Circulation, 1996;93: 1043-1065
49. 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
50. 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
51. 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.
52. 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.
53. 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.
54. 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.
56. “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
57. 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. =
ganglionated
plexi
61. 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
63. 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 )
64. 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
65. 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
66. 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)
67. 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.
68. 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.
69. 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
70.
71. 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.
72. 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
73. Health is Contagious
So often it is not what we do, but simply
our presence that allows healing.
74. “It is no use walking anywhere to
preach unless our walking is
preaching.”
St. Francis of Assisi
75. 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
