Well good morning. It's a pleasure to be here in Phoenix, Arizona with all of you. I left Rochester, New York the other day and I heard it snowed and is below zero, below freezing. So I'm very glad to be here in this beautiful environment with all of you and we're going to be talking about the topic of lifestyle medicine. My background is mostly in EMG, musculoskeletal medicine, spasticity medicine, as well as some inpatient rehab that I do as well. So I've really seen all things through the whole continuum of care of patients going through recovery and I really feel lifestyle medicine has a lot to offer our patients, both all the way through very devastating injuries as well as on the outpatient side for common things we may see in electrodiagnostic practice even. All right and so I'm going to give a brief overview of lifestyle medicine and then Dr. Zeldin is going to go into some depth about some of the more musculoskeletal and peripheral nerve issues that we see in our practice. So I'm going to start off kind of defining lifestyle medicine and we're going to talk about the six pillars of lifestyle medicine. We're going to use the American College of Lifestyle Medicine definition. There's a lot of things that get confused with lifestyle medicine so I'm going to try to clarify that. We're going to talk about some key interventions that we can use to treat lifestyle related chronic conditions. I'll touch on motivational interviewing to assist patients with behavior change. This is really a big topic in and of itself so I'm not going to be able to go into too much depth here but it's important enough that we'll scratch the surface on this and then later in the presentation we're going to talk about some evidence-based interventions for some of the problems that we commonly see and then we'll also discuss some educational and certification opportunities in lifestyle medicine for those that might be interested. So we're going to try to play this video here if we can. What will your last 10 years look like? Will you be quick enough for a game of tag with your grandchild? Strong enough to embrace every moment? Will you grow old with vitality? Or get old with disease? It's time to decide. The average Canadian will spend their last 10 years in sickness. Change your future at makehealthlast.ca Researchers from the University of East England have... ...had mixed feelings. there yet, but you see some of the risk factors, you can do some things to help them so that you can prevent from getting into that situation or reverse a pathway that's headed down that way. So as we get into the presentation, just nothing to disclose. So we're going to talk about the six pillars of lifestyle medicine, healthy eating, physical activity, managing stress, forming and maintaining positive relationships, getting good sleep, and avoiding risky substances. Doesn't sound like rocket science, right? We know these things are good for us. I think that the issue is that we don't appreciate how good the good things are, and we maybe don't realize how bad some of the bad things are and how much it can impact the diseases that we acquire in life. And some of these things are maybe just not well understood in themselves. So when we're talking about healthy eating, we're talking about primarily a whole food plant-based diet, which is recommended by the American College of Lifestyle Medicine. We'll talk about that in a little bit more depth here in the presentation. Physical activity, the minimum physical activity guidelines that people are supposed to hit are 150 minutes of moderate physical activity per week. So that's like a brisk walk, basically 30 minutes, five days a week. And a lot of people don't hit that. Developing strategies to manage stress. Stress certainly can impact a lot of things in our health. We're not going to be able to avoid stress in our life entirely, but managing it constructively with certain tools can really help a lot. I think we've all seen this and appreciated this through the COVID pandemic about relationships and how important that is for our own well-being as well as for health outcomes for people. It's certainly a much bigger thing that we appreciate now than we did in the past. And then sleep is something we don't fully understand. We know we need sleep. We know that it's important for our health and we have to get enough of it, but we don't maybe appreciate how important it is and how many things it may impact for our health. And of course, avoiding risky substances like smoking, alcohol, and drug use affect a lot of problems that people develop. So the American College of Lifestyle Medicine defines lifestyle medicine as a specialty that uses therapeutic lifestyle interventions as a primary modality to prevent and treat chronic conditions. So the word I want to emphasize here is it's the primary modality. This is first line. There's lots of good evidence for it, and we should be offering it to patients, as well as to not only to prevent, but also to treat chronic conditions. It applies evidence-based, whole person, prescriptive lifestyle change to treat, and when used intensively, often reverse such conditions. So this isn't something that I just thought of and people just think is good for your health and we're pushing it. This is evidence-based based on the science and how it impacts people's health. And we're looking at the whole person and prescribing these lifestyle changes as if we were prescribing a treatment like a medication. And the dose is important, too. So we certainly appreciate when people make small changes for their health, but often big changes may be needed to reverse a lot of chronic conditions. And a key thing here is it empowers patients to improve their health and well-being by placing them in the driver's seat with a clinician guiding them. So it's really truly patient-centered care. As opposed to our traditional allopathic medicine model, we put a lot of emphasis on genetic predisposition to disease. Certainly, we recognize that behavior and environment are a factor, but there are several times I've heard people say, when I've been taking care of patients in rehab, they just feel so defeated that it was their destiny. They ended up with this problem because they have bad genetics and there's nothing I can do and it's just going to get worse from here. And it's really sad. And there really is a lot that can be done more than people realize. We tend to take a disease-focused approach with patients as the recipients of care. So we have our itemized problem list in the electronic medical record. We have a certain treatment that we know to prescribe for that certain problem, and we expect the patient to go along with it if they're going to get better. And the patient, therefore, becomes kind of a passive receiver of services, and they're not really in the driver's seat of their own health. So this is some slides from the American College of Lifestyle Medicine. Lifestyle Medicine has really grown a lot in the last few years. You can see people that have gotten certified in Lifestyle Medicine really growing a lot, both in the US as well as around the world. There's other countries that have similar College of Lifestyle Medicine like we have. And growing interest in medical education as well, just exponentially growing at medical schools as well as other programs. And it's really nice to see this is being incorporated into residency programs as well, too. There's close to 200 residency programs that now include Lifestyle Medicine residency curricula so that when residents are finished with their program, they can actually become certified in Lifestyle Medicine. The other way to get certified is you complete your primary specialty, and then after that, with a certain amount of CME and passing an exam, you can get certified in Lifestyle Medicine. This is how I was taught to think about helping people, starting with less invasive things like therapy and then maybe assistive devices, and then escalating medications and injections. And then surgery is your last resort most of the time. But it's important not to forget about this underlying pillars of Lifestyle Medicine that really should be the mainstay of our treatment for a lot of people. And it's important to remember that these pillars are interrelated as well. For example, for somebody to make improvements on their nutrition or their exercise goals, they might need to get their substance abuse in check. They might need, before they can do that, they might need good stress management, mental health, social support, and be able to get enough sleep so that they can even attempt these things. This cartoon may look familiar or feel familiar to some of you that in health care these days, it often feels like we're working really hard trying to clean up a lot of medical problems. And sometimes you feel like you're making limited progress. And certainly, we need to do those things. We need to mop the floor. But we also need to turn off the faucet. And with a Lifestyle Medicine approach, we can teach patients how to fix the underlying issues to turn off the faucet. So why should we care? As physiatrists and neurologists, is this just a primary care issue and we're not responsible for this? Well, we really care about the health and function of people. We're not just trying to help people survive and live long. We want people to live well and enjoy their life to the fullest. And lifestyle interventions can help a lot in the treatment of the problems that we see. Some of these things are more interrelated than are appreciated. And pain can be a motivating factor for people. And the same treatments directed towards that may help with their other medical problems as well. And we're trained well to work with an interdisciplinary team, which is really important when you're taking a Lifestyle Medicine approach to care involving a lot of other health care workers. So I feel like we're often seeing patients show up to clinic with problem lists that look something like this. And it seems to the patient, perhaps, that all of these are distinct problems. And they have so many problems. They're on so many medications. And it's really unfortunate in their eyes that they ended up with so many problems. And we can see the relationship between some of these problems. And I think as the research grows, we're starting to see more of an interrelationship between these, how they're interrelated and lifestyle related as well. It should concern us as neurologists and physiatrists that dietary risks were listed as the number one risk factor contributing to disability in the World Health Organization Global Report on Disability. It's kind of hard to see in this slide here. But that top bar there says dietary risk. It's ahead of smoking and high BMI and high blood pressure. And most of that bar in dietary risk is made up with cardiovascular disease, cancer, and diabetes. And you may think, well, that's not my responsibility. That's a primary care issue. But we know, we've seen these things come through. At least when I'm seeing patients that end up with these problems, they end up on our rehab unit. And I end up seeing these issues, musculoskeletal and neurologic issues, related to these disorders in my outpatient practice. So there's a lot of terms flying around out there. Vegan, plant-based, whole food plant-based. What do these terms really mean? So vegan is avoiding any sort of animal-based products at all. It's often based on people having reasons that may be animal cruelty reasons or environmental reasons, which are good reasons. But I'm approaching this more from a health perspective. And some people may focus on a plant-based diet, not eat any of those things or minimal animal-based foods. But you can get some pretty unhealthy plant-based options. You can get plant-based potato chips, plant-based Oreos. There's a lot of things out there, plant-based ice cream, that are vegan, but they're not necessarily good for you. And a lot of the advertising can be misleading. So the American College of Lifestyle Medicine emphasizes a whole food plant-based diet centered on whole foods, like whole grains, fruits and vegetables, and legumes, which are eaten quite commonly around the world, not as much in our society. And if you eat any of those other things, you keep it to a pretty minimal level. I'm going to touch on behavior change just a little bit here, because it's really important, and it's one of the hardest things to do to help people. It takes a lot of practice, and you may want to partner with somebody to help your patients along with this. This cartoon is, of course, not something I would ever say to a patient. But in reality, it might be the case for some people. And so helping them through this may be life-changing for them. So we've heard about this often in our medical training, the stages of change, where somebody starts maybe with pre-contemplation, where they might not recognize a problem, where they have no interest in changing anytime soon, contemplation, where they're considering making a change in their behavior within the next six months, and then preparation, they're starting to plan to make a change soon within the next month, the action stage, where they're actively working on something for their health, and then the maintenance stage, where they've been sustaining this behavior for at least six months, and then you might add the termination stage, where they're no longer tempted to return to their old and healthy behavior. So let's walk through a couple of these stages here. And I don't know if there are any parks and recreation fans out there, but the character, Ron Swanson, played by Nick Offerman, is somebody that's really in the pre-contemplation stage. He has no interest in changing, or sometimes patients may say, I can't change. And at this stage, you want to discuss the health risks associated with their behaviors and try to highlight some of the benefits associated with behavior change. So then you may get some thinking about this. OK, maybe I'm going to change. And you can now, at this stage, start to personalize it a little bit, weighing the risks and benefits and highlighting the impact on their personal goals. And now you've got somebody that's agreeable to change. They're going to do it. And so at this point, you want to assist them with their commitment, plan some specific changes, and discuss ways to modify their environment. And now you've got somebody that's turned over a new leaf, so to speak. They're making some behavior changes. And at this point, you want to keep them on track. You want to structure the plan, identify sources of barriers to behavior change, make sure they've got good social support, and then helping them problem solve some obstacles that might come up. Using cognitive behavioral therapy to help them reframe some unhealthy thought patterns can be helpful as well. And then when they've been doing this well successfully, trying to just make sure that they're staying on track. So with motivational interviewing, a couple of key points that you want to keep in mind are, first, to express empathy to their situation. Build that rapport, show some understanding of their situation, and then try to build some supporting some self-efficacy, which is their confidence and their ability to succeed. And a lot of evidence-based guidelines for problems really have these self-efficacy programs as a gold standard for helping improve health of a lot of conditions. Try to roll with resistance. Try to kind of resist the writing reflex, so to speak, of telling them what they need to do. And remain nonjudgmental, listening to them and encouraging them to continue to share. And then try to show the discrepancy where the patient is and what the patient wants, presenting it to the patient and allowing them to draw their own conclusions. So we can ask open-ended questions, use affirmations, reflective listening, summarizing what they have shared. And keep in mind, for common things like obesity or smoking cessation, most people have tried to improve upon these things in the past. And just acknowledging that is important to show the patient that they have tried to do something good for their health. That, in and of itself, should be acknowledged. And then you can build upon that for the future. So with cognitive behavioral therapy, you can use this to reframe nonproductive thinking. And there's a lot of different patterns of nonproductive thinking. I'm not going to go into this in too much, but this is kind of here for your reference. But just keep in mind that if you're doing this or somebody else, this can be helpful to restructure their thinking about how they might be able to change. And then a couple of things that you can ask your patient is, on a scale of 1 to 10, how confident are you in your ability to make this change? And how important is it for you to make this change for your health? And generally, if they're at about an 8 or higher, that's good. They're probably going to be more likely to accomplish that goal. If they're lower than that, you want to try to see what you can do to alter the plan or to try to build up some change talk to try to get them at a higher level there. So one thing you can do also is if you ask them how confident or how important do you feel, and they give you, for example, a 6, you could say, why did you choose a 6? Why didn't you choose a 4? And then they may say, well, it's actually fairly important to me to try to get rid of this problem and improve upon it. And I want to be there for my grandkids. And so you can build upon that in that sort of way. Smart goals are probably not new to anybody. We learn this a lot through quality improvements in our training. But it's important to remember to make your plan this way when you're trying to help patients. So if you tell a patient, well, let's just try to walk more, and we'll see you again in three months, that might not be likely to succeed. But if you come up with a prescribed plan, we're going to say, OK, we're going to walk at a moderate intensity, which is going to be being able to talk but not sing. And we're going to do this for 30 minutes a day, five days a week. And then it might be helpful to specify, OK, who's going to help you support through this? Where are you going to do it? Possible barriers that could come up so that they can be more successful in carrying out that plan. And then you've probably heard of the five A's as well. We're at each clinic visit. We're going to assess how they're doing, make some advice on what is based on the research says is helpful for them, try to agree on a plan that's going to work for them and collaboratively set some goals and then assist them with that as I mentioned through these different methods and then again arranging for follow-up and support either with you or with other people that might be able to continue to help them. So in an you know an electrodiagnostic practice you might not have the luxury of spending a lot of time other than you might have the hour that you're there with them shocking them with electricity where you can talk about these things a little bit but you might not be able to follow them up as well and so there are some resources online which I'll talk about and you may have some in your community as well that might be able to take them those further stages to help them out but I think if you can open the door when you're seeing them and talking about these issues that can get them on track and that might be enough to really change somebody's life. So I'm gonna change gears here a little bit we're gonna talk a little bit about some general underlying pathophysiology of chronic disease and I know Dr. Zeldin is going to talk a little bit more about this specifically relating to musculoskeletal and and nerve issues that we see in our practice. So we know that our evolutionary biology that we were hunter-gatherers and but I want to put the emphasis on the gatherers portion of this I think when we think of the paleo age we're thinking of like the Flintstones and we're thinking of like caveman eating a lot of meat and the true paleo diet was really more of a whole food plant-based diet than most people think it might be. Certainly there was certainly some meat and animals that that people consumed but there are certainly no processed food and most of what people could get was based on what they could forage for and so our biology is set up based on this and we're also outdoor animals so we're very much tied to with our circadian rhythms to light and dark social group structure was important for survival and so now we've gone from life outdoors to life indoors where when the Sun goes down we turn on lights and we turn on big-screen TVs and we have our cell phones that we take into bed with us and all those things can really disturb our sleep and we've gone from whole food to processed food, active to sedentary, food scarcity to food abundance and so we could think of many chronic medical issues being the body's natural response to an unnatural environment. It's natural for people to get these things when you're in the environment that we've created today. This is kind of an ominous saying here genetics load the gun lifestyle pulls the trigger but I include it here meaning that there's some hope behind this that your genetics are not your destiny and that there's a lot that can be done with lifestyle to intervene upon this. Like drinking lots of water yeah when you're here in dry Arizona air here. So a lot of us have probably heard of epigenetics we've heard about this in our medical training at some point but these are non DNA sequence components of genetic inheritance that basically can act as switches to modify our gene expression through these different mechanisms. So you may inherit certain genetics but the way that those genetics are expressed can really vary depending on different factors. These are just a few examples that I included here a study by Ornish et al looking at prostate cancer and basically following healthy lifestyle through these six pillars was able to alter the expression of more than 500 genes important in prostate cancer which is quite amazing. Exercise can also affect expression of the GLUT4 gene and skeletal muscle which can help regulate glucose uptake. There's some studies that have looked at the intrauterine environment how this plays out for the health of the baby through their childhood and even through adolescence with obesity and other chronic conditions that's quite interesting. And sleep deprivation can alter the expression of more than 700 genes which is staggering to think of. And just I'm going to touch on sleep a little bit here. Certainly we can't go into this in too much depth because of time but sleep is really important for a lot of things. We know it's important for health and it's maybe not fully appreciated. There's actually a scientist at University of Rochester Mike in Niedergaard who has done a lot of research into the glymphatic system of the brain and how this can help basically clean our brain of waste products. And it's particularly active at nighttime and all our cells kind of go through a process of regeneration at nighttime which is important to take into account. We know that sleep apnea and sleep disorders associated with cardiovascular disease and neuropsychiatric risks. On our inpatient rehab unit we've gotten into the routine of often screening people on the unit. We've got the ability to do home sleep tests on the unit and we detect a lot of sleep apnea and a lot of people that have been admitted with strokes. We know that sleep is important for behavior change. If you're not sleeping well for asking somebody to change their nutrition and exercise is probably going to be hard to do. So it's important to prioritize. And there's also studies that have looked at shift workers being at increased risk for chronic disease. And there is some literature to support that this appears to be circadian related and not just simply that they picked up some fast food on the way to their night shift. So just talking a little bit about this idea of chronobiology and how it affects our health. We have a circadian rhythm that operates at the brain and body level but also at the peripheral cellular level which is interesting if you take cells out and put them like in a Petri dish you can continue to observe them cycling on this rhythm. And sleep quality and quantity is associated with a lot of different biological processes. I'm not going to name them all. I've listed them there. But even some things as some cancers seem to be impacted by this. And so prioritizing our sleep for our health is important. I think we shortcut ourselves a lot with this as physicians going through our jobs and our training. And it's important to prioritize for ourselves and for our patients. There's some evidence that looking at calories eaten later in the day and at nighttime even if it's the same food might be more likely to promote weight gain. So shifting those calories earlier in the day may be helpful. And some studies even that suggest that if you've got a blood pressure medication that's taken once a day instead of taking it in the morning, taking it at nighttime may lead to better blood pressure control as well as fewer major cardiovascular events. So I want to touch on this idea of the microbiome. And some people may have heard of this, know something about it. There's different microbiomes on our body. We have a microbiome in our mouth. We have a microbiome on our skin. I've been talking mostly about the microbiome in our GI tract. And it's staggering to think that these microbes outnumber ourselves ten to one. So you are more bacterial than human in fact. And those bacteria have genes which can be expressed or up-regulated or down-regulated depending on the environment we create for them. And so the microbiome, the type of bacteria that we create in our GI tract is dependent upon what we feed it. And so we can create a healthy microbiome or an unhealthy one depending on what we eat. And they're involved in a variety of different functions listed there. One thing that's important that these bacteria do in our colon is that they can take fiber, which we can't digest, and break it down into short-chain fatty acids, which are the main fuel that our colonocytes use. And they're also absorbed into circulation and can be helpful with a lot of other anti-inflammatory, anti-cancer, metabolic pathways important for our health. And so the general goal here is cultivate the good microbes and not the bad ones depending on what you eat. And based on the research that's been done, what you want to try to do is have a variety of unique plant species that you consume that are that to create this microbial diversity in your microbiome. So it's not just the, you know, the genetics, but it's also our lifestyle and our environment, which can lead to these different ways that chronic disease develops through chronic inflammation of microbiome, dysbiosis, oxidative stress, cellular injury, toxicity from toxins in the environment, carcinogens that we're ingesting, immune dysregulation that happens through this microbiome process, and then other things, hyperglycemia, vascular disease, and even food addictions, which play into account here too. And when we think of nutrition, we're usually thinking about the macronutrients. We're thinking about fats, and proteins, and carbohydrates, and, you know, which one's the villain now, and which one is the hero, and often it's protein is the hero, and we're villainizing carbs or fats, but it's much more than that. It's much more even than just the vitamins and minerals that we're taking in to make sure we have enough of. We know that fiber is good for us, but the vast majority of Americans are deficient in fiber, and we don't really appreciate how much fiber really is important for our health and our microbiome. It's really a much more important nutrient that needs to be prioritized than we recognize. And then there's other things that people may have never even heard of before, or may have heard of and we don't really fully understand, or other things that may not have even been discovered yet in plant-based foods that really affect a lot of pathways as far as inflammation, oxidative stress, and DNA damage, for example. That being said, with animal based foods, there are some good things with animal based foods in that we're thinking of them as sources of protein or sources of certain nutrients, but keep in mind that this is gonna come along with some things that may be harmful. So endotoxins from the bacteria, from those sources, advanced glycation end products, which I'll talk about on an upcoming slide here, heterocyclic amines, which form when you cook meats, basically. So I can't tell you how many barbecues I enjoyed growing up, but unfortunately, when we cook foods those ways and we get that kind of charred formation in the meats, it creates these heterocyclic amines that can be damaging to our DNA and increasing oxidative stress. And heme iron, we may think of as desirable in that it's absorbed better than iron from plant-based foods, but it gets absorbed kind of unchecked. And if we have too much of it, it can also lead to increased reactive oxidant species and DNA damage. With animal based foods, we can get higher intakes of environmental chemical contaminants, which bioaccumulate in the food chain. And then something called TMAO, which I hadn't heard of until recently. So I just want to explain this a little bit here. And this is very much related to our microbiome. So it's thought that certain things that we eat containing carnitine and choline get converted in our gut flora into trimethylamine or TMA, which then gets converted by the liver into TMAO, which has been associated with worsening atherosclerosis and vascular disease. And of course, what part of our body needs blood supply? Everything, right? So this really can be a factor in a lot of medical issues. So just looking at a couple studies here, this was one study that was interesting where the researchers took two different groups of people that had obviously different microbiomes, vegans that followed a plant-based diet and omnivores following a standard American diet. And they fed them some carnitine based supplement and steak. And you can see that the TMAO levels increased in the omnivore group, but actually didn't change in the vegan group despite the fact that they ate the same thing. And then the researchers actually looked at this with eggs, looking at choline. And so they had people ingest the eggs, they measured the TMAO levels, and then they knocked out their gut flora with antibiotics. And even though they were eating the eggs, they were no longer able to produce that TMAO. But then upon reacquisition of the gut flora, they were able to start producing it again. So they were able to demonstrate that the microbiome was very much a part of this. And depending on what microbiome you have, how this might play out. So it's not just what you eat, but it's also the way that the food is prepared, which we may not give it much thought, but might actually be quite important. So I mentioned earlier advanced glycation end products. So these are formed when you have a reaction between an amino acid and monosaccharide and are associated with oxidative stress and inflammation. We make a little bit in our body, but most of it comes from what we eat, typically from animal based foods and foods cooked at high temperatures with dry heat. So things like baking, frying, barbecuing tend to produce the most. And then things cooked with moist heat, such as microwaving, steaming, boiling, stewing, tend to produce less AGEs. And this is important because they can accumulate over time into certain tissues, leading to damage, both from a structural perspective as well as from a biochemical perspective. Especially those cells that we're going to need for a long time. Neurologic tissue, collagen and our musculoskeletal structures and our blood vessels, our eyes. And so of course they're associated with a whole bunch of medical conditions related to these, some of which we may commonly see in our practices. I'm certainly not going to pretend that I understand ALS and all the causes behind it, and certainly genetics is part of that. But there are some studies that have looked at environmental chemical contaminants and toxins produced by blue-green algae in certain marine coastal areas that have been implicated as a possible cause for ALS with higher associations in these areas, especially from shellfish. And based on some systematic reviews here, it's one of the leading causes as well as some other toxins you can see there. Before I hand things over to Dr. Zeldin, I'm going to just touch on those three main things that were in our dietary risk factors for disability. And just touch first here on cardiovascular disease. And I think a lot of us were taught that once you get plaques in your arteries, they're there to stay, try not to make them worse, you know, eat healthy, exercise, take your medications. But there's actually some research to suggest in some cases with intensive lifestyle, this can be reversed. And so this, Dr. Caldwell-Esselstein at the Cleveland Clinic has done a lot with patients here, and there's other places as well, but this is just an example of from their study that they did on some of their patients. And this figure here on the right, looking at the LAD artery, and you can see on the left, there's a lot of stenosis. And then after a year on a whole food plant-based diet, the blood flow was restored again. And on the left, you can see the blood flow to the ventricle much improved as well. In some of their patients that they studied, looking at 200 patients, most of the people that were able to adhere to this actually, even though it sounds like it's a big behavior change, and those that did adhere, it had a really low risk of recurrent cardiovascular events. But those that didn't actually had quite a high risk. And so these are people that were still following their doctor's advice, taking their medications. So lifestyle really can play a big part for people in this. Dean Ornish also looked at this previously, kind of looking at a similar type of approach. Not going to spend too much time, but just kind of making the point here, that in their study they looked and found some regression of stenosis as well, compared to the control group, and that the people that adhered most to this had the fewest recurrence rate of cardiovascular events, as well as the best recurrence of stenosis, or both our best regression of stenosis. So it's generally thought that when the plaque is young, it's easily reversible with these changes. Over time, there's of course fibrosis and scarring calcification of the plaque, which is meant to be protective, so that that plaque doesn't rupture and cause a cardiovascular event. So you may not, in those chronic situations, see that pretty picture of that angiogram going completely back to normal. But even in those people, they found great benefits for lowering their risk for recurrent events with changes, through improving blood flow. So I'm going to talk just about cancer here. So the World Health Organization, International Agency on, I'm drawing a blank here because I don't have my notes, but the IARC, basically looking at all kinds of things that are possibly carcinogenic to humans. And so they've actually classified processed meat as group 1, definitely carcinogenic to humans, and red meat as group 2A, probably carcinogenic to humans. Which is not to say that they're as carcinogenic as other things in that category, but that the research is pretty clear that these things are not good for us. This was the study I mentioned earlier by Ornish, looking at the epigenetic changes with prostate cancer. They also did another study here where they looked at men with early stage prostate cancer, where they weren't really planning to undergo any kind of medical or surgical treatment for it. But those that chose to try the lifestyle medicine approach were able to lower their PSA after a year significantly. And then when they also took the blood of the men that were following the healthy lifestyle approaches, dripped them on a lineage of prostate cancer cells, it had eight times the killing power of the men that were following just a regular lifestyle. And so it's important to think about our lifestyle as being certainly a part in cancer treatment. So we have Movember coming up, and we just finished Breast Cancer Awareness Month. So I'm going to talk a little bit about breast cancer here. This was a similar study where they took women. These women acted as their own controls. And this was done over a two-week period. So they didn't want to wait a whole year. They did this over two weeks. And they took women that were eating a standard diet, took their blood, dripped them on some three different lineages of breast cancer cells, and found that there was some killing power in their blood against the cancer cells. But after they spent two weeks on a whole food plant-based diet, their blood was much more hostile towards the cancer cells with suppressing cancer cell growth as well as increasing apoptosis of the cancer cells, as is seen in these graphs. And then this is kind of a visual pictation of it here, where on the top, you can see top left, there's pre-SAM. Some of the cancer cells are killed out. But then on the top right, after two weeks, only very few of them remain. And then on the bottom left, that's representative of the apoptosis taking place. And then in the bottom right, two weeks afterwards, much greater apoptosis of the cancer cells. And then I'm just going to talk here briefly about diabetes. It's so integrated in a lot of the things that we see. And so I want to just touch on this, because this is really key for people. A lot of people don't realize, a lot of patients don't maybe realize that diabetes is reversible. And in some cases, they might be able to even get rid of it. Sadly, a lot of people are just told that I saw a patient the other day, and they weren't even talked to about any kind of lifestyle interventions that might be helpful to them. They were put on some drugs. The patient had side effects. She thought she just had to take those, and that's the way it is, and there was nothing else she could do. But there really is a lot that people can do. And most people think about carbs, and they think of glucose, and that being important for controlling their blood sugars. But it's not as well appreciated that the pathophysiology of insulin resistance involves intramyocellular lipid accumulation, which interferes with the cell signaling process. So when your insulin binds to the receptors in the muscle cell, it can't work as well. And you can't open those channels and get the glucose into your muscle cells, and so the blood glucose continues to rise. And so there's been studies that have looked at basically a low-fat plant-based diet compared to the American Diabetes Association diet. Both, of course, were beneficial, but the low-fat vegan diet beat it out, actually, in terms of weight loss, improvement in A1C, and in cholesterol as well. So what I like to emphasize with patients is that it's not necessarily following a low-carb diet. If you cut your carbs by getting rid of the hamburger bun and eating the patty, that's not going to do you any favors for your health. And while you get rid of the simple carbohydrates may look good as far as your blood sugar control, you might actually be worsening the underlying issue of insulin resistance if you're taking in a lot of meat, trying to focus on protein, but taking in a lot of saturated fat. That is worsening this insulin resistance and your vascular disease in the process. So what I like to emphasize to patients is focus on eating carbohydrates, proteins, and fats that come from good sources. And when done really well, patients may not even need to carb count in some of these situations. Dr. Zeldin is going to talk about studies in more depth, but I'm just going to mention this study briefly as I'm talking about diabetes. And this is old, and it's not the most robust study by any means, but it's quite impressive to think of, as there haven't been many studies done on this. But these were patients that were a small group of patients, 21 patients with painful diabetic peripheral neuropathy who followed a whole food plant-based diet and moderate physical activity. So basically, a brief walk, I believe, of 30 minutes a day, and rapidly saw improvement in their diabetic neuropathy pain. 17 of the 21 patients with their pain resolved within several days, which is not explained by the change in the glucose control or by nerve regrowth. And it's thought that there might be some other factors. This is a good study diving into this more, but it might have to do with the viscosity of the blood through the microcirculation. And so if the blood is clogged up with cholesterol and fat and is not vasodilating, because we're not getting a lot of those healthy plant-based compounds, those nerves are not getting good blood supply through the microvasculature, basically leading to ischemic-type pain in those situations. So I'm going to end here, and I'm going to just list a few resources that people can explore on their own if they're interested in different areas of lifestyle medicine. The Blue Zones are an interesting project, if you haven't heard of it. These are places around the world that have a lot of really healthy centenarians. And they all, even though they're very different places, different cultures, all have a lot of these lifestyle medicine pillars in common as at the forefront of their culture. There's some videos there, too, that people can check out if they're interested as well. And then I'm going to just mention here the Rochester Lifestyle Medicine Institute. So this isn't connected with the University of Rochester, but it's a nonprofit organization in our community that does a, they do different programs for people, and they do it online. So anybody can sign up for this anywhere in the country, anywhere in the world, in fact. So basically, they're going to give you the knowledge and the skills to change to a whole food plant based diet. They have some other areas of lifestyle medicine they focus on, too, as far as mental health and well-being and other areas as well. But their results are quite impressive. Even just after two weeks, people seeing significant improvements in weight loss, blood pressure, cholesterol, glucose, similar to if you were taking a medication. And it really makes a difference for people. And then the American College of Lifestyle Medicine has got some really good opportunities for education that you can join as a member for yourself, for your own education, as well as for patient education. And then there's also opportunities to get certified in lifestyle medicine through the American Board of Lifestyle Medicine as well. And lastly, the White House is trying to push a lot of this stuff as well. And so there's funding for a free course offered through ACLM for learning food as medicine course that you can take and get a CME for as well. All right. So I'm going to hand things over to Dr. Zeldin to take over the next part of the presentation. I don't need more. Lifestyle. So can everybody hear me? I hope so. Anyway, first of all, to all the people listening online, we see your questions in the chat. And we'll definitely get to them at the end of this presentation. So my name is Evan Zeldin. I'm a clinical assistant professor of PM&R at the University of Cincinnati Department of Neurology and Rehabilitation Medicine. And my goal for this session is to recommend some evidence-based lifestyle interventions for neurological, spine, and musculoskeletal conditions that we commonly encounter in the electrodiagnostic laboratory. I've structured my presentation into different sections, focusing on mononeuropathies, polyneuropathies, radiculopathy, and some musculoskeletal mimics for the physiatrists in the room. And in each section, we'll focus on some of the major diseases in each category, which may or may not be applicable to some of the less common conditions with similar presentations. Oh, and that went backwards. Forwards. Cool. So I have no financial disclosures. So the first section we'll be discussing is mononeuropathies, specifically median mononeuropathy at the wrist, or carpal tunnel syndrome. So the reason I'd like to start with carpal tunnel syndrome is that it's a condition that we all likely use lifestyle medicine as one of our first line interventions today, even if we don't think about it quite as lifestyle medicine. In patients with carpal tunnel syndrome, we commonly ask them to splint their wrists or modify their work environment to put less pressure on their median nerves. Some researchers have moved beyond just these interventions and looked at exercise and mobilization interventions in order to free up the median nerve in the carpal tunnel. So this Cochrane review is from 2012, and it looked at exercise and mobilization interventions for carpal tunnel syndrome. It looked at 16 studies randomizing 741 participants with carpal tunnel syndrome, and it concluded ultimately that there is very limited and low quality evidence for a diverse collection of evidence and mobilization interventions for carpal tunnel syndrome. But since that review, there have been a lot more recent studies trying to readdress the subject of lifestyle interventions on carpal tunnel. So this review from 2017 focused on an analysis of non-pharmacological therapy for carpal tunnel syndrome. So the first is the mind-body practice, and it looked at yoga. So it looked at a well-designed JAMA study in which compared eight weeks of yoga to the standard of care of wrist splinting. So those in the yoga-based intervention experienced increased grip strength and decreased pain when compared to the wrist splinting group. However, there are no physiological changes on nerve conduction studies. It said that patients needed to be counseled on the importance of gentle yoga, particularly a restorative yoga class, and that they should avoid any poses that cause them any sort of discomfort in the risk area and should inform their instructors of their conditions prior to taking these yoga classes. It next looked at acupuncture, and it first noted that there was a 1997 NAH consensus study which concluded that acupuncture might be useful as an adjunctive therapy or an acceptable alternative treatment for carpal tunnel syndrome. There is a more recent systematic review from 2016 which also confirmed these findings, and it showed that acupuncture was as effective as oral steroids over a four-week period, and the effect appears to be sustained about one year after follow-up. And when compared to wrist splinting, patients treated with acupuncture reported fewer symptoms and improved physiological measures with improved nerve conduction studies. So next, we'll look at hand therapy in a bit more detail. So this study was published in the Journal of Hand Therapy in 2020, looking at the effect of a self-home exercise stretching program for carpal tunnel syndrome. So it enrolled 83 different participants who were diagnosed with carpal tunnel across the wrist by nerve conduction studies, and those patients were randomized one-to-one for either sham treatment or self-carpal ligament stretching. So you can see here on the image on the left, but each participant was instructed to extend their hands at 90 degrees against the wall and gently retract their thenar eminence with the contralateral hand to stretch the carpal ligament, whereas patients in the sham group were just holding their hands perpendicularly and lightly massaging down the dorsal wrists. Participants were instructed to perform the self-treatment exercise for 30 seconds at a time, four times a day for six weeks. So the results of this, some of which are shown on the right-hand side of the screen, revealed statistically significant improvements in numbness, tingling, pinch strength, and symptom severity for the treatment group only. So another study of manual techniques, this one looking at neurodynamics therapy. So the neurodynamics therapy is characterized by using specific manual techniques to change the mechanical characteristics around peripheral nerves. And here on this slide, you can see the protocols that they used. This study was published in the Journal of Hand Therapy in 2021, and it was a paralyzed randomized control trial in which 51 patients were randomly assigned to either receive four sessions of neurodynamics and exercise or just home exercise therapy alone as a control group. There were blinded assessments performed throughout before treatment allocation, after treatment completion, and at a six-month follow-up period. And they looked at symptom severity score, the functional status scale, the shortened version of the disabilities of the arm, shoulder, and hand, or the DASH scale, the numerical rating pain scale, grip strength, and range of motion. So the results, they enrolled 52 hands from 41 different individuals, and the neurodynamics group demonstrated statistically significant improvement across all of those outcome measures at one and six months. None of these patients ended up needing surgery one year after treatment. And though both treatments led to positive outcomes, the neurodynamics therapy was superior in improving function and strength, and also decreasing pain. So next we'll look at polyneuropathies. So peripheral neuropathy is pretty prevalent. It's in one to 3% of the general population, up to 7% in the elderly, and a lot of it is attributable to diabetes. As we know, a lot of it is diabetic peripheral neuropathy. It affects nearly half of all diabetic patients. It's a large cause of disability in this country, pain, wounds, amputation. It has huge healthcare costs to the system and to patients, and it's accelerated by metabolic syndrome like we talked a little bit about earlier. So the pathophysiology of diabetic neuropathy is complicated, but it involves the effects of insulin resistance, insulin deficiency, hyperglycemia, dyslipidemia, all of which lead to microvascular dysfunction with ischemia, hypoxia, and impaired vasodilation. All of these lead to DNA damage and inflammatory responses which result in neuronal cell death. And this pathophysiology suggests that managing hyperglycemia, dyslipidemia, and insulin abnormalities resulting from diabetes might end up leading to some different patient outcomes. So first, we'll review the expert consensus of the International Diabetes Foundation, which was published in 2022 on diabetic sensorimotor polyneuropathy. So shown here is their consensus recommended treatment algorithm. So note that under basic measures, the first recommended modification is in fact lifestyle modification with particular attention paid to glycemic control and control of other risk factors. Additionally, lifestyle medicine shows up again in this algorithm towards the bottom left where patients with painful diabetic neuropathy are recommended both pharmacologic and normopharmacologic options for the treatment of neuropathic pain. Here again, from the same expert consensus, is the recommended pharmacologic treatment algorithm. The first, second, and third steps in this algorithm all recommend pharmacotherapy of the typical recommendations that we usually use from gabapentinoids to TCAs to SNRIs and advancing all the way to opioids and even spinal cord stimulation in particularly refractive cases. However, on the left side of the algorithm, the non-pharmacologic treatment options can be recommended as an adjunctive measure including therapy, TENS units, acupuncture, physical measures, and psychosocial support. While these lifestyle modifications as recommended as an adjunct, expert consensus shows that they clearly have a role in the management of painful diabetic neuropathy in addition to the usual pharmacologic treatment. So this figure is from another article on the management of painful diabetic neuropathy published in the Journal of Metabolism in 2021, showing another possible treatment algorithm for painful diabetics with sensory motor polyneuropathy. This figure is very similar to that consensus model we just looked at in the prior slides, showing lifestyle interventions, exercise, weight loss, and glycemic control as the foundation of any treatment for diabetic sensory neuropathy. This algorithm recommends using pharmacologics on top of lifestyle modifications if lifestyle modifications fail. And then again, similar to the previous algorithm, on the right-hand side of the slide shows some non-pharmacologic interventions that can be used as an adjunctive measure to pharmacologic therapy. Both of these treatment algorithms suggest the importance of both lifestyle modification and pharmacologic therapy in order to treat the pain from diabetic polyneuropathy. One without the other will likely not address the underlying causes and result in poorer patient outcomes. So the aim of this review, which was published in the Journal of Lifestyle Medicine in 2020, was to systematically investigate whether a whole food plant-based diet could beneficially affect patients studying for type 2 diabetes and diabetic polyneuropathy. And this table looked at a few of those studies, looking at that plant-based diet on diabetic polyneuropathy. And the study suggested that a plant-based diet may alleviate pain in effective patients while significantly improving glycemic control, their weight, and serum lipids at the same time. And then moreover, a plant-based diet appears to reduce the medication burn in these affected patients. So however, there needs to be a little bit of caution with some of these studies, because the number of clinical trials was pretty limited, and a couple of these studies had some issues with their methodology. Also, they were combined with some other lifestyle interventions like exercise and other supplemental factors, which do confound the results just a little bit. But from that same study, it was hypothesized that the several potential mechanism of action from a plant-based diet could lead to that improved pain. So this included improved blood flow and an optimized intake of important nutrients, which might contribute to improved perfusion of the endodenaryl microvasculature, thus reducing local hypoxia and improving pain. So next, let's talk about weight loss. So weight loss appears to bring some benefits on peripheral neuropathy, mostly in the early stages. So this is the LOOKAHEAD study, which looked at 5,145 obese or overweight patients with type 2 diabetes that reported that weight loss obtained through an intensive lifestyle intervention had significant impact on peripheral neuropathy progression assessed by the Michigan Neuropathy Screening Assessment compared to the control group, figure shown on the right. And it also better preserved their light touch sensation. And it also showed that patients who underwent weight loss through bariatric surgery also seemed to improve their polyneuropathy as well. So, but what about if there are any changes that can be seen with lifestyle modification on the actual pathophysiology of diabetic polyneuropathy? So this study was published in 2006 in the Journal of Diabetes Care, and it looked at lifestyle interventions on pre-diabetic neuropathy. And what they did is they were trying to look at intraepidermal nerve fiber density, or IENFD, as a sensitive measure of neuropathy change in patients with a neuropathy associated with impaired glucose tolerance receiving a lifestyle intervention program. So what they did is they ended up performing three millimeter skin biopsies with measurements of these intraepidermal nerve fiber densities, both at the distal leg and the proximal thigh, both at baseline and one year after this lifestyle intervention in 32 different subjects. Each subject revealed an individualized diet and exercise counseling as the care that they received. And after one year of treatment, there was a statistically significant improvement of intraepidermal nerve fiber density, which correlated with decreased neuropathic pain and also a change in seronerve amplitude on nerve conduction studies. So this is an AANEM monograph published in Muscle & Nerve in 2019 titled Integrative Neuromuscular Medicine, Neuropathy and Neuropathic Pain, Consider the Alternatives, which looked at alternative treatments in addition to pharmacologic therapy for neuropathic pain. So a proposed treatment algorithm further elucidating some of these adjunctive therapies for neuropathic pain is on the right-hand side of the screen. And it could be seen as a possible extension of the consensus algorithms that were previously mentioned. On the left, supplements and exercise recommendations were outlined as well. In this review of the literature, improvements of pain were also shown with moderate aerobic exercise, Tai Chi, and yoga. And it also looked at acupuncture in which the majority of the randomized clinical trials showed the benefit of acupuncture or acupuncture plus the usual medical care over sham acupuncture plus the usual medical care alone for diabetic polyneuropathy. So next, let's move on to radiculopathy. So this review was published in 2007 in the European Journal of Spine looking at cardiovascular and lifestyle risk factors for lumbar radicular pain. And the aim of this systematic literature review was to assess associations between these risk factors and lumbar radicular pain. 22 patients from 19 studies were included in the review which found no consistent association for serum lipid levels or high blood pressure with lumbar radicular pain. But it did find associations of being overweight, a long smoking history, high physical activity, and high CRP levels with lumbar radicular pain. So this meta-analysis published in 2017 looked at the effect of exercise on cervical radiculopathy. And it looked at 10 different studies analyzing 871 patients who all had cervical radiculopathy. And it showed that there were significant differences on the visual analog scale in favor of the exercise treatment group along with other measures that also showed improvement with exercise as well. So finally, we'll look at a European Journal of, the European Journal of Spine clinical practice guidelines for the management of nonspecific low back pain. And this was a 2018 update to their prior guidelines. And what they did was they looked at another, a number of existing clinical practice guidelines across the globe to help form their own consensus guidelines. So for the treatment of patients with acute back pain, the guidelines recommended kind of the usual things, reassurance on the favorable prognosis, advice on returning to normal activities, avoiding bed rest, using EdSeds, and even weak opioids as needed for short periods. And then for chronic low back pain, the guidelines also recommended Nseds and antidepressants, exercise therapy, and psychosocial interventions. Importantly, for all the physiatrists in the room, they also recommended multidisciplinary rehabilitation for all these patients with chronic low back pain. So looking at some of the lifestyle pillars though, they recommended psychosocial strategies in 11 of these guidelines, and almost all of these guidelines endorse the use of CBT as those psychosocial strategies. All of the clinical guidelines provided recommendations for exercise therapy, but there was significant discrepancy in the type of exercise program, whether aquatics, stretching, McKenzie exercise, yoga, or Tai Chi was the most recommended thing. And then the mode of delivery, there was a little bit of debate about whether you should have an individually designed program, go to supervised home exercises, or be enrolled in group therapy or physical therapy. Only four of these guidelines, however, recommended the use of acupuncture. Three of them recommended it for acute and chronic low back pain. Only one guideline recommended it as an adjunctive of an active rehab program for patients with low back pain. And then four of the eight guidelines that looked at acupuncture recommended against it or said it should be completely avoided. So the changes of, they also noted at the end in their conclusions about how these recommendations from them have changed over time. And noted that their prior guidelines never really looked at any of these lifestyle pillars, and more and more studies are starting to assess herbal medicines, acupuncture, and invasive treatments. But at this point, they were sort of on the forefront of being recommended. Finally, we'll move on to musculoskeletal mimics of conditions we see in the electrodiagnostic laboratory. So first, tendinopathy. So this study looked to see if higher serum cholesterol was associated with altered tendon structure or tendon pain. And this was a systematic review of 17 studies looking at 2,600 participants. And patients with altered tendon structure or tendon pain had significantly higher total cholesterol, LDL cholesterol levels, and triglyceride levels, as well as lower HDL cholesterol, indicating that some sort of relationship might exist between an individual patient's lipid profile and their tendon health. This was a systematic review and meta-analysis on the effect of lipid disorders in rotator disease published in 2016. This looked at six different studies and concluded that dyslipidemia was likely associated with a higher occurrence of rotator cuff disease, and additionally recommended that patients who had been diagnosed with rotator cuff disease or other tendinopathies be examined for severe dyslipidemia. So next, we'll look at the effect of diabetes on the rotator cuff. So most rotator cuff tears are the result of age-related degenerative changes, but mechanisms underlying these changes have not been fully reported. So in this study, what they wanted to do was look at the influence of advanced glycation end products, or AGEs, like we were talking about before, on rotator cuff-derived cells in vitro and ex vivo. So what they did was they obtained rotator cuff-derived cells from human supraspinatus tendons. And the cells were cultured in medium with either high AGEs, low AGEs, and regular medium alone as a control. Cell viability in those high AGE groups was significantly suppressed compared to the control group. And the amount of vascular endothelial growth factor secretion was also significantly greater in the high and low AGE groups than in the controls. Under immunofluorescent staining, they demonstrated the enhancement of hypoxia-inducible factor 1 alpha, reactive oxygen species expressions, and cell apoptosis were all higher both in the high and low AGEs group relative to that of the control. In ex vivo mechanical testing, tensile strength was also significantly higher in the control group than any of the AGE groups. All of these results, in summary, indicate that AGEs could lead to degenerative rotator cuff changes. And the reduction of AGEs might end up preventing rotator cuff senescence-related degeneration. So my last slide, this looking at osteoarthritis. So this study, which published in the Journal of Nutritional Metabolism in 2020, and it looked at insulin resistance in osteoarthritis. And it stated that osteoarthritis and type 2 diabetes have common epidemiologic traits, are both heterogenic multifactorial pathologies that develop through the interaction of both genetic and environmental factors, and all have common risk factors. And both of these diseases often manifest together in a single patient. But to cite the differences in clinical manifestation, both diseases are characterized by disturbances in the cellular metabolism and by an insulin-resistant state associated with the production and utilization of energy, as illustrated on this diagram on the slide. However, currently, the primary cause of osteoarthritis development and progression is not clear. And although osteoarthritis is typically manifested as a joint disease, evidence has accumulated that it affects the entire body. So as pathological insulin resistance is usually viewed as the driving force of type 2 diabetes development, this study attempted to demonstrate that the molecular and cellular metabolic disturbances associated with osteoarthritis are linked to an insulin-resistant state similar to type 2 diabetes. And the alterations of cellular energy requirements associated with insulin resistance could affect many metabolic changes in the body that might eventually lead to pathology and could serve as a unifying mechanism that functions in many metabolic disease. So in other words, the theory being that if osteoarthritis is a chronic disease that has systemic modifications in a similar matter as other chronic diseases, such as type 2 diabetes, maybe it can also respond to some of the similar lifestyle modifications we've been discussing. Obesity has been linked to the development of OA, and likely controlling obesity and other lifestyle factors can lead to the prevention or reversal of osteoarthritis. So now we'll take some questions. Thank you. Thank you. We can start with a couple of the online ones, and then as people are forming their questions, come on up to the mic so that we can hear it, and the people online can hear it, too. So somebody was asking about something specifically for PMNR or musculoskeletal medicine and of coming from Canada. So the American College of Lifestyle Medicine has a Canadian special interest group there. So if you join as a member of ACLM, you can join the Canadian member interest group. They've also formed some interest groups in the society as well, one for neurology and one for musculoskeletal and pain. So yeah, lots of opportunity there. And then questions about do you use lifestyle medicine with or without a clinical exercise physiologist. I think that might depend on what you have available to you. So I think it's a great resource to have and certainly helpful if people have really significant cardiovascular disease. So there's been some really interesting research done by Cucurillo et al on modified cardiac rehab for stroke recovery and have found some impressive results through not just the same results that you would see with cardiac rehab in lower mortality, lower readmissions, but also better stroke outcomes from mobility, ADL, and cognitive perspective. So exercise really could do a lot. And so in those cardiac rehab settings, you do have an exercise physiologist that's routinely working with those patients that might be a little bit higher risk. So I think it's helpful to have in those situations, but there's some patients where you may not need that and can work with them individually. We're also aware, I see a comment here, that our slides are not available online yet. So I think something happened with the upload process. We'll make sure that gets up there. Yeah, we submitted them. I'm sorry, we did submit them. I don't know why the link is broken. We'll talk to somebody about it. That was a really excellent presentation. Thank you all so much. One thing that I've noticed since COVID is all these people come into the EMG lab. You never find anything wrong with them in many instances. They have really vague neuropathic symptoms. Have you all found any role for lifestyle medicine in that population? With COVID specifically? Yeah, part of like, sometimes the long COVID will seem to have like a peripheral manifestation to it. People will end up with polyneuropathies from COVID or kind of vague neurologic complaints. And I always wonder if there's a role for lifestyle medicine in that case. Yeah, I don't have enough experience with that to know, but I would think that it certainly wouldn't hurt and probably would help. But it is amazing. I don't know your experience or anyone else's experience when you see patients in clinic and you diagnose them with diabetic neuropathy. And to us making that diagnosis, we're like, yeah, it's diabetic neuropathy. We saw this one coming. The patient may not have, or they may have known that that was a risk that they could have, but now that they have it, they're worried about it. Is it gonna get worse? Like, what do I do? And if your answer is, yeah, it's gonna be there and just try to not let it get worse and try to take some medication so it feels better. Most patients are unsatisfied with that. From my experience. And so if there's something else that we can offer patients and say, I know there hasn't been a whole lot of research done on this, but some people have gotten really good improvement in their symptoms with significant changes to their lifestyle. If you wanna try that, that might be something that could really help you. Hi. Good presentation. I work in an EMG lab at a county hospital that serves underserved people. A lot of the things that are mentioned in this presentation are privileges. Being able to choose what you eat, controlling your sleep. A lot of our patients, the vast majority are people of color. Some don't have homes. So my question is, we lose a lot of these patients in follow-up because they can't make it to their appointments for various reasons. They don't have transportation. They don't have money to get on the bus. I'm just wondering if there's any resources out there that could help institutions like ours care for these people in a better way. Yeah, that's an absolutely an excellent point that, I'm not sure if people online could hear that, but that some of these things may be easier for people to carry out if they're in a more privileged position, right? So I certainly appreciate that. And a lot of the patients that I've seen where they might be working several jobs and they might not have a lot of money and they've already got a lot of things going against them. Yeah, I would say that that is challenging. The American College of Lifestyle Medicine does have a focus particularly towards that. And so that's something that they are actively growing. So they're trying to get people from less privileged backgrounds more educated and supported in lifestyle medicine and also trying to target with some assistance programs towards people that might be able to have trouble affording such things. So I know with our, it's not my program, but with the Rochester Lifestyle Medicine Institute, they get some grant money, for example, from the American College of Lifestyle Medicine to help people that can't afford to sign up for a program like this. So there's often funding through that for those sorts of things. And some, the other thing is a lot of people think that eating healthy is expensive and it doesn't have to be. They've put out, the ACLM has put out some resources on how you can actually eat healthy and save money. So there's some resources that you could share with patients from that perspective as well. You don't necessarily have to go to a gym. You can build physical activity into your day. So they do have some resources directed towards that that could be helpful. Yeah, so a question about any kind of supplements for neuropathic pain. I don't use any particularly. I think that there was some mentioned in one of the studies that you referenced that have some evidence that could be tried, but I don't routinely prescribe supplements. I also don't really particularly prescribe supplements, but there is a monograph in muscle and nerve in 2019 that if you just look at it, they have some recommended doses that people find helpful. And alpha lipoic acid being one of them there as well. I saw a question on that. Thanks again for your talk. What's involved with becoming certified in lifestyle medicine? Time and effort. Right, so basically, you can join the American College of Lifestyle Medicine as a member. And then there's a certain amount of CME that you can do online or in person. So some of it has to be in person, which is basically fulfilled if you go to the conference once. And then there's a bunch of different online CMEs that you can pursue. They have a board review course that's really good. And just doing that board review course meets the criteria. So it's not a lot that you have to do. And then there's an exam that you sign up for that's done at a prometric center and passing that exam. And then I think just a small case study on one patient that you've worked with on lifestyle medicine approaches. So all of that together. Thanks, everybody. All right, thank you. Thank you.

physiatrist

lifestyle medicine

healthy eating

physical activity

managing stress

positive relationships

good sleep

chronic diseases

whole food plant-based diet

cardiovascular disease

cancer

diabetes