APP Podcast Series Part Two Save

My name is Iris Zink. I am a rheumatology nurse practitioner in East Lansing, Michigan. I have been in rheumatology for the last twenty six years. I am passionate about taking care of my patients. We have two locations in East Lansing, and we are a rheumatology nurse practitioner clinic.

Today, we're going to talk about intimacy and chronic disease and why sexual health is relevant in rheumatology. So sexual problems are frequent in every single autoimmune disease. Every single form of arthritis has sexual health impact. So why is this relevant? It is very relevant to rheumatology.

The problem is that it is not a routine diagnostic process for any office to ask about sexual health nor to have any kind of plan created around sexual health problems. Sexual health is not yet a routine part of any diagnostic workup or therapeutic planning. Intimacy, what does that mean? Intimacy is not purely physical. It's the act of connecting with someone on such a deep level that you feel like you can see down into their soul.

Many of our patients cannot have penetrative sex. So when I talk about sexual health, I'm not talking about penetrative sex. Many of our patients, that's just not possible because of pain. So when I talk about sexual health, I'm talking about intimacy, maintaining normalcy. Sexual health is a normal physiological function, just like being able to cough, just being able to have a bowel movement, just being able to stop having the hiccups.

Having an orgasm is a normal physiological process that we need to have a conversation with our patients about how is that going? How is your sexual life? How is your autoimmune disease impacting your physical and sexual health and your relationship status? So when I use the words like intimacy and sex, sometimes I use them interchangeably. But know that I'm talking about maintaining a relationship with a partner.

I'm not talking about penetrative sex. Why is sexual health relevant in rheumatology? Two thirds of patients with hip and back osteoarthritis experience sexual health problems. Sixty two percent of patients with rheumatoid arthritis reported difficulties with sexual performance. Fifty percent of patients with ankylosing spondylitis report issues with decreased desire, satisfaction, and frequency of sex.

And seventy one percent of patients stated that fibromyalgia put a strain on the relationship. We know how many fibromyalgia patients have issues with intimacy, with issues of being touched, with issues of being chronic pain, and we know that the divorce rate is double in the patients with fibromyalgia. It is our obligation to treat patients holistically and bring up sexual health. We've all seen this picture of ankylosing spondylitis. That's how I became so passionate about talking to patients about sexual health.

I had a 54 year old patient who was a teacher who told me that she could not open her legs wide enough to have intimacy with her husband any longer. Her sacroiliac joints were fused. It was the old days before we had biologic medications that we could use readily for these patients, and she was unable to have penetrative intercourse with her husband anymore because of her ankylosing spondylitis. Back then, she asked me what to do, and I just looked at her. I got several articles from the library.

I told her I was gonna get back with her. I called her back two weeks later. We set her up with an osteopathic doctor in town. We set her up for some osteopathic manipulative medicine, some physical therapy, And she states that that really did make a difference in her ability to get some flexibility so that she can have what she would consider a normal process or a normal intimate relationship with her partner. But I didn't know what the answer was.

The most important thing was that I didn't give up, that I didn't say I didn't know, that I sought out these answers and that we need to communicate with our patients. So not just ankylosing spondylitis. What about Sjogren's? We know about dry eyes. We know about dry mouth.

We know about dry vagina. But it's dry vagina to the point where they can actually have fissures. They can have bleeding. They can have extreme pain with penetrative intercourse. They can get infections because of the fissures that they experience.

And not to mention the fact that they have neuropathy. They cannot feel their vulva or their clitoris. Men with Sjogren's tend to have less ejaculate. They have more difficulties with erectile dysfunction. So are we addressing that need with our patient when we don't address their sexual health at all?

There are lots of things that we can do that'll make a huge difference in these patients. We can recommend hyaluronic acid inserts or hyaluronic acid gel that they can put in their vagina to help plump the tissue, to help make penetrative intercourse possible, or at least make it so it's not painful. There are many options now, not just estrogen cream, and the gynecologists are not also addressing this with our patients. We need to be informed about the options for our patients. If the patients cannot feel their fingers and toes because they have such extreme ring odds, they probably can't feel their clitoris or their vaginal area.

So let's go over the 10 myths of sexual health. Sex is intercourse. That is not true. You can have intimacy without penetrative intercourse. The goal of sex is orgasm.

A lot of our patients are just not able to achieve orgasm anymore, so the goal cannot be orgasm. You can have intimacy without the goal of achieving orgasm. General health does not affect my sexual health. Well, we know that that's a myth because every single disease, even sleep apnea, blindness, multiple sclerosis, everything affects your sexual health. What about the use of sexual aids?

Is that not sexy? Well, if you can't feel your clitoris and you can't fear feel your vaginal area, you may need lots of extra stimulation. The same thing is true if you have osteoarthritis and it's impacting your exiting L4-five nerve roots. You may have lost sensation That may be causing erectile dysfunction. And so you may need a lot more stimulation in order to get to the point of erection or orgasm.

Good sex just happens. That's another myth. You need to plan for it. You have to have privacy. You have to have a date.

You have to be physically ready. Again, if you have a a woman with vaginal dryness, she has to be prepared for that penetration. You have to have enough lubricant. She has to be using hyaluronic acid inserts regularly so that her vaginal health is good. She may need pelvic floor physical therapy.

So you have to have a timeframe when everyone is prepared for intimacy. Disabled people are not sexual. Disabled people are sexual. We are sexual from the time we are born until the time we are put into the grave. That is our sexual life.

We are always sexual beings. So there's not a cute little man sitting in a wheelchair who's just being cute. He's being sexual. We're all sexual beings and we all have sexual desires and sexual needs. That's another thing I wanted to mention is that a lot of women, after they're diagnosed with autoimmune disease, they say, you know, I just don't feel like I am in the mood anymore.

There's something really wrong with me. I don't have sexual desire anymore. But when you're thinking about chronic pain and you're thinking about how you're gonna get your work done and you're thinking about your kids and their problems and getting the laundry done and doing the dishes and just cooking a healthy meal, your own physical pleasure sometimes takes last priority. And you can help your female partner, if you have a female partner, get in the mood by saying it's okay to take a time out. It's okay to feel pleasure.

What kind of activities can I do around the house to help get off of your plate so that we can have intimate time together? But that requires planning and communication. There comes a time when sex is not important. I hope that's not true. But because sex is normal, it's a normal act.

And when people are diagnosed with autoimmune disease, they feel like they've lost periods of normalcy. So we have to help the patients maintain that normalcy in their life. My health and physical changes no longer make me attractive. Again, that's a lot of psychological baggage that these patients are carrying around. When I'm diagnosed with lupus and I have this malar rash or I have psoriasis on my genitals, Am I just not physically sexually attractive anymore?

We need to help them get counseling and to realize that they are still sexually attractive because that comes from within. It is not having all kinds of plastic surgery and fake boobs that makes us sexual people. It comes from within. Sexiness is comes from within our soul and being confident and being pain free maybe or being comfortable in our own skin. That's where sexuality comes from.

I am who I am because of my parts. We know that a lot of ladies who have mastectomies, hysterectomies, men who have prostatectomies, they feel like they've lost their sexual self, and can we help them regain that? And have they been to counseling, and have they discussed these issues with other people? And lastly, there is nothing more I could possibly learn about sex. That is so not true.

We are all lifelong learners, and we can help our patients learn about their own anatomy. A lot of people don't realize that there are more than one places for stimulation. I mean, had a classic patient that was a quadriplegic that always wanted his home healthcare nurse to rub him from the nipples up. That was his sexual stimulation area. So we need to really be aware of where the stimulation is coming from and that we can learn how to make our intimacy change as we age and as we evolve with our own health problems.

So the most important thing we need to do with our patients is communicate. I have done this lecture across The United States to healthcare providers and to patients over and over again for the last fifteen years, and the most important thing is that you try, that you care, You care enough to communicate with your patient. And if you don't feel comfortable communicating with your patient, find a nurse in your office who does feel like they can communicate with their patient. Find a resource, find a pelvic floor physical therapist that's very comfortable talking to the patient. Find a asexual therapist that the patient can go to.

It's about helping the patient achieve normalcy. And lastly, because so many people ask me, I wrote a book called Sex Interrupted. It's available on Amazon. I coauthored it with a lady who's working at the Lupus Foundation just for patients and also for health care providers about feeling comfortable talking about sex and chronic disease. There's a lot of resources out there, but this is just one of the resources that your patients can reach for.

I have lots of references for this talk. If you have questions, please reach out to me. I would love to discuss this topic more. Please call me, email me. Jack Cush, Doctor.

Jack Cush will have my contact information, and please tune in to RheumNow for more information. Thank you so much for sharing this time with me, and I really appreciate you. Go talk to your patients about their sexual health. Hello, I'm Christine Stamatos. I'm talking to you from Long Island, New York.

I'm a nurse practitioner with Northwell Health and I have been running a fibromyalgia wellness clinic. So I'm here, I was asked to talk about managing chronic pain in rheumatic disease. So what I'm going to do today is I'm going

give you some highlights. I'm going to give you sort of approach, my philosophy to approaching patients in with rheumatic disease. I want you to just stop and think for a second. I'm going to go through a slew of patients that you probably see in any given day. 37 year old with severe foot pain and swelling, had a sudden onset, severe third time in the past year, but only one joint involved.

Another patient that day, 35 year old with pain and fatigue all over, severe morning stiffness, trouble using hands, swelling diffusely. You have another patient on your schedule, 65 year old with knee pain and fatigue, pain is worse at the end of the day, a 24 year old with a large, swollen, red, hot knee and trouble walking, a 53 year old that comes into the office with widespread pain, fatigue, and discognition everywhere. These are very typical patients that we see in our day and how we approach them, as you can tell, is likely going to be different. No two patients are going to be the same, but how we approach them should be the same. Going to talk just also, I wanted to give you a little bit of epidemiology.

And as we work in rheumatology, we see patients with various conditions. Osteoarthritis, sixteen percent of people with osteoarthritis live with chronic pain. Twenty one to fifty five percent of patients with rheumatoid arthritis live with chronic pain. Thirty six percent of lupus patients live with chronic, I'm sorry, chronic pain. Scleroderma, up to seventy percent of patients live with chronic pain.

And in the spondyloarthritis, we don't have an exact number because of the diversity, but we know it takes onwards of ten years to acquire a diagnosis. So we believe it's probably fifty percent to seventy percent of patients that live with these diseases have chronic pain. And so how do we manage these patients? What is the best approach to make? And I think of Maslow's hierarchy, if you remember that from your days back in school, and for the most part, you have to address those physiologic needs at the bottom and the physiologic needs are taken care of ensuring that you're addressing any inflammation, sleep, and mood.

If you don't do those three things, you'll never be able to manage anyone's pain. We'll do that through a variety of disease modifying agents, but often it's also some behavioral health issues and again, behavioral strategies in general. So targeted pain management, the first thing you have to do is identify inflammatory versus non inflammatory. Obviously inflammatory, we're going to treat in one direction, non inflammatory in another. So make sure that you do your basic labs looking for systemic inflammation.

Then we need to address sleep. So every patient should be asked about their sleep. Do they have trouble falling asleep, staying asleep? If they have trouble falling asleep, what's the problem? Is it that they can't stop their mind or is it because they have too much myofascial pain, for example, in their upper back or neck or their lower back, or do they have terrible joint pain that needs to be addressed?

And then if they say they, you know, if you've figured out what the issues with falling asleep are, you need to then ask about, well, do you have any trouble staying asleep? And then again, you want to ask why do you have trouble falling or staying asleep? If the issues are addressed and there's no trouble falling and no trouble staying asleep, but people say that they have non restorative sleep, then you need to start thinking about, you know, sleep apnea, either a central or an obstructive sleep apnea. So we really need to tackle that sleep because even if you do everything right with regards to managing someone's inflammatory arthritis, but you don't address their sleep, fatigue will be severe and that will contribute to pain and pain will be more significant than it should be even after you've controlled all the inflammation. Sleep hygiene, I did just want to touch on that.

Don't ever forget talking to your patients about sleep hygiene. I won't have time to go into it any more than that, but remember that the biggest issue that people have with sleep hygiene is that they use their phones or TVs right before bed. So tell your patients, they should be avoiding any specific screen time for thirty to forty minutes before sleep. Next, I just want to make sure that you all address mood issues. So again, even if I control someone's inflammatory condition, if I have not addressed a mood problem, they're still going to end up complaining of chronic pain.

So again, I want to give you some of the epidemiology. So in rheumatic diseases, we know that twenty one to eighty three percent of patients have some depression, eighteen to sixty percent of people have anxiety and thirty to fifty percent of people have both. And up to twenty three percent of our patients have PTSD, twenty one percent of our patients have bipolar disease and up to twenty five percent of our patients have substance abuse disorder. So there's lots of issues to consider. I would encourage you to make sure that you're having a PHQ or some kind of a depression assessment and some kind of an anxiety assessment for all of your patients at least once a year and with any significant change in treatment.

And then again, when I'm thinking about chronic pain, it's just I can't emphasize enough, it's more than just a scale of one to 10, a visual analog scale. In addition to the mood and the sleep issues, you have to identify whether there's other social determinants of health that need to be addressed. And I'm going to go through a little bit about that in showing you two patients that I sort of have tried to highlight to pull out these issues. Next, you also want to ask about the impact of the pain on someone's quality of life. So if they say that they've got severe horrible pain, but they're still able to go to work and they're functioning, still able to socialize, still able to enjoy life, that's very different than the person who says that they have severe pain and they're stuck in bed and they haven't gone on to work in the last two weeks.

Those are two very different levels of pain and it's important to understand the difference between the two. It's also important to get a family history, a trauma history, a full medical history as well. So let me just give you two examples of patients. One is a 48 year old with a BMI of sixty eight with widespread pain all over, came into my clinic with untreated psoriasis and hydronata supertiva, severe tri compartmental osteoarthritis of the knee, severe sleep apnea, works from home and is married happily. And then a second patient, and again, as I'm talking about these patients, why don't you think about all the different things that are probably going on with these patients?

In the second case, it's a 54 year old, again with a BMI that's high at forty eight. She describes severe burning pain everywhere, stiffness and fatigue. She has poorly controlled psoriatic arthritis, type two diabetes, and bipolar disease. She has a peripheral neuropathy. She's on disability for behavioral health issues, huge financial stressors, she has restless sleep, her husband is in jail at the time and she doesn't drive.

So if you think about how am I going to take care of these patients' pain, I have to think about so many different factors to get their pain under control. I did want to highlight what to think about when you're worried about people who may go on to develop chronic pain and some of the modifiable and non modifiable factors. So non modifiable factors, we know women of younger age, poor socioeconomic background, if there's a genetic history of chronic pain in the family, certain attitudes and beliefs. I don't know if you've ever heard of catastrophic thinking, but people who have catastrophic thinking tend to have a little bit more pain. History of abuse.

So these are non modifiable causes for chronic pain. And then there's a whole slew of modifiable causes. Let me just quickly go into the pain prone phenotype. And I wanted to do this because I think it's important that you identify who your pain prone patients are because you want to really be aggressive at addressing all the different, components of their pain in order to get them under control, so that they're not, living with chronic pain despite taking care of whatever other condition they may have. So females genetic early life trauma, I can't emphasize enough, early life trauma is associated with a centralized pain processing problem.

Cognitions, as I mentioned, the catastrophizing and then its exposures to certain stressors, psychological stressors, and often having a disease in our one of our rheumatic diseases is something enough to turn some of these pain conditions on. So my philosophy for pain is to A, recognize that you have to identify the primary etiology of the pain. You have to understand that pain is individualized. And you have to understand that it doesn't take one pill to fix a problem. It's an armamentarium of approaches.

And it's often a multitude of different strategies at any given time that's going to take to get the pain under control. The other really important point that I want to make, and this is sort of stating the obvious and most of us know it, but the therapeutic relationship that you establish with your patients is probably as important, if not more important than almost anything else that we can do for them. I did want to just talk about briefly how hard it is to study pain. As you can imagine, I've just given you all these different reasons that you have to reasons for problems in assessing and treating pain. And it's because it's so diverse.

As a result, it's hard to study pain. And studying pain has been a problem for years because of the heterogeneity of the patients, the multiple comorbidities, the fact that for most drugs, for example, you want to have a washout period and that's hard to do in somebody who's living with chronic pain. Monotherapy is often a difficult thing to do and almost all pain studies don't follow somebody past twelve months. So these are some of the challenges in being able to study chronic pain or pain in general. I do want to make sure that you understand that there are different types of pain and each different type of pain is treated in a different way, right?

So you have nociceptive pain, you have neuropathic pain and you have hypersensitivity. The current term is nocoplastic pain. Nociceptive pain is that immediate stimuli is triggered. The message goes to the brain. It says there's pain here.

Nociceptive pain is inflammatory pain, bone fracture pain. Those are acute pain conditions that respond very well to anti inflammatories and analgesics. Neuropathic pain is when nerves are disrupted, so carpal tunnel syndrome, diabetic peripheral neuropathy, lumbar radiculopathy, any kind of nerve pain that's disrupted. Shingles is another example of neuropathic pain. And the way that we treat neuropathic pain is often different.

Neuropathic pain does not respond as well to your standard analgesics and anti inflammatories, even opiates. It responds far better to the gabapentinoid type of agents and some of the different CNS pharmacotherapy for psychiatric issues. And then lastly, we have nociplastic pain or centralized pain. So this is when the pain processing has been completely disrupted and messaging is getting up to the brain at an excessive level and then being able to modify that pain is disrupted for a whole number of reasons. And there's lots of really interesting information about that.

But I just want you to understand that how we treat each of those different states does vary as well. And if I go back to those two case studies, both of the case studies I mentioned to you are mixed pain states. So you have in the first case study, somebody who had the psoriasis that had never been diagnosed. She in turn had a case of inflammatory arthritis that was not being treated. She also has severe OA tri compartmental.

So those are nociceptive pain states. And as a result of living with that for a number of years, she's gone on to develop a centralized pain or nociceplastic pain state. And so how we're going to treat that is going to be different. And then in the other patient, you had, again, poorly controlled inflammatory state that needed to be addressed and she had multiple behavioral health issues that needed to be addressed and then the chronic stress was impacting her pain as well. I really probably, if you walk away from anything else, it's going to be this tire analogy.

It's it's living life with chronic pain is like driving your car with your tires flat. This is not an analogy I came up with but I've sort of morphed it. Penny Cowan is the leader of or the founder I should say of American Chronic Pain Society And she describes that living pain, living with chronic pain is like driving your car with your tires flat. And when I talk to my patients, I tell them you have to fill all four tires. One tire is medical treatments.

It's what we can do for you. It's drugs, injections, interventions, but that's only one tire and if that's the only thing that you focus on, you're still probably not gonna move smoothly through life. The second tire is your physical strength and endurance. So that's the strength that you have in your body, the muscles that you maintain, the food you put into your body, the weight you maintain, the sleep that you get. It's your ability to restore your body.

So if those issues, all of those different issues aren't being addressed, that's a whole tire that's flat. The third tire is your social worth and value in this world and the need to make sure that you maintain that social value. It's the ability to still have find joy in your your relationships with other people. It's feeling like you're making a difference on the planet. So, that's a whole tire and then, the last tire is your own personal strategies.

The ability to change the way you're thinking if you start thinking in a negative way or the ability to pace yourself when you know you don't have the energy to get through a day and do what you used to do before you had a chronic pain condition. So these four things have to be addressed to run smoothly through life. And when I talk to my patients, I say, you're coming to us, we are going to help give you some direction, but it's really on you to be able to move forward to make these things happen for your life so that your pain is controlled. And when it comes to pharmacotherapies, there are not any one drugs out there that fixes your problems. You know, patients always ask me or people ask me all the time, how do you take care of fibromyalgia patients?

What's your treatment approach? My treatment approach is very much an individualized approach based on all the questions I've already talked to you about. So no two patients are the same. Again, you need to identify if there's an inflammatory issue and treat that appropriately with DMARDs. You need to identify if there's a sleep problem and treat that ideally with non pharmacologic therapies.

But when that's not working, sometimes you need a bridge and use pharmacotherapy. You need to treat any mood disorders. You need to also think about any GI or GU problems. So if someone has IBS and that's what's keeping them up at night, you need to maybe focus on ways to treat the IBS. If their problem is an interstitial cystitis and they have to void for five or six times at night, you need to treat that problem.

And then pain, there's a whole slew of medicines that we can use very specifically for analgesia. There are also multiple interventional techniques that we have. Trigger point injections for muscles that are spastic and teaching patients how to do self management for trigger points is also really important. Joint injections, tendon sheath injections, epidurals, these are all different types of interventional strategies we use every day to manage chronic pain. And then I just can't emphasize enough our need to be able to share with patients that there's lots they can do for themselves.

So there's wonderful sites for information about self management for chronic pain. I've listed a couple of books on here. You can't see my slides, but there's a new book that came out in 2024 that I absolutely love. It's called The Chronic Pain Reset Book. And that was written by Doctor.

Afton Hassage. She's a psychologist, a pain psychologist at the University of Michigan. University of Michigan is where most of the some of the best science is coming out on chronic pain. And she's taken everything that she's learned over her career and put it into this book, which is user friendly. It goes through case studies and then has exercises for you to do to help learn what kind of strategies are going to work for me to help manage my pain.

I also can't emphasize enough how helpful apps can be. So there's the Calm app, Insight Timer, and 10% Happier. These are just three of my favorites. There are over 350,000 apps. But these apps often can be used.

I find that they're very, very helpful for people that have issues with sleep, trouble falling or staying asleep using some of these different apps and listening to bedtime music or bedtime stories is often very helpful. And then another resource I wanted you to walk away with is the University of Michigan's pain guide. So if you go to their website, their pain guide gives patients self management strategies. You can also go to the Department of Health has a whole, self management approach for chronic pain. And I hope that I've given you sort of a broad overview and the key that I wanted you to walk away with today is understanding that pain treatment is based on a diverse and complicated but easily attainable evaluation of a patient in order to individualize the care that's needed for them.

I thank you for your attention. And if you have further questions, RheumNow is loaded with lots of good information and studies about any number of the things I've talked about today.

Hello, and welcome to Lifestyle Medicine in Action, How Sleep Transforms Rheumatic Disease. Thanks for joining us. Today, I am talking about the importance of lifestyle medicine and importantly for patients that have rheumatic diseases and how sleep, one of the most important pillars I believe in lifestyle medicine, can really transform the life, not only for us as providers, but also for our patients. My name is Barb Schlesher. I'm a physician associate.

I work at Hope Health. It is a federally qualified health clinic in rural South Carolina, rural Manning, South Carolina. I also have a degree in social work, so I'm a little bit different than probably most providers. But I've been working in rheumatology since approximately 2006. I also have a little bit of background in allergy and asthma as well as oncology.

So, you may be thinking, what does lifestyle medicine have to do with rheumatic and musculoskeletal diseases And why is it why is it important? So, first and foremost, lifestyle medicine is a actual medical specialty. It uses therapeutic lifestyle interventions as the primary modality to treat chronic conditions. There's a lot of data looking at cardiovascular disease, type two diabetes and obesity, and I would argue inflammatory RMDs as well. So lifestyle medicine is the application of evidence based.

And I really want to emphasize that it's evidence based whole person prescriptive lifestyle change to treat and when used intensively often reverse such conditions like type two diabetes, cardiovascular disease. So lifestyle medicine can be used to treat, prevent and even reverse chronic diseases. I think that's an important message for us to hear as far as providers. So what really is lifestyle medicine? It encompasses and provides a framework of six pillars and the six pillars are a whole food plant predominant eating pattern, physical activity, restorative sleep, stress management, positive social connections, avoidance of risky substances.

So you can see how they all kind of come together. And there's not one pillar that's more important than the other. But for the purposes of this talk, I will certainly focus more deeply on the sleep pillar of lifestyle medicine. So why would lifestyle medicine be important for rheumatology providers and really all healthcare professionals? By flipping the script, and so we're talking about lifestyle medicine actually being prescribed, We're not only going to prescribe lifestyle medicine for our patients, we're first going to prescribe it for ourselves.

And I like to use the analogy of lifestyle medicine as our oxygen mask. So, you know, when you're on the airline, you're getting ready to start a flight, the admonition is, should the cabin experience a sudden pressure loss, oxygen masks will drop from the ceiling. Place the mask over, they usually say, your own mouth and nose first so that you can help others. And I think that's what lifestyle medicine is for us as clinicians. When I am healthy as a clinician, it enables me to provide patient care.

So basically, I am better able to take care of my patient when I am mentally, physically and emotionally healthy. Taking care of myself as a tool that needs to be sharpened helps me to help my patients. Also, is some data to support that lifestyle medicine actually helps with burnout reduction. There was an article by in 2023 that looked at practitioners that actually implemented lifestyle medicine and found that providers that practice a greater proportion of lifestyle medicine was actually associated with less burnout and more accomplishment and connection. There was less depersonalization that's well known for burnout and more connection with patients.

So, a way that data acknowledges the important therapeutic relationship we are building with our patients that has the power to impact patient related outcomes. And then better health and coaches and counselors. We're talking about lifestyle medicine, it's a really a very different approach. It's not an expert approach. It's more of a coach approach.

And so, we find that clinicians and any really health care professional that practices healthy behaviors themselves are more likely to counsel patients on those healthy lifestyles themselves. For instance, if I practice yoga and meditation, I'm more likely to recommend yoga and meditation to my patients. If I'm a runner, I'm more likely to espouse the benefits of running with my patients. So overall, if I have experience in implementing healthy lifestyle behaviors, I'm more likely to share from my personal experience. So, what's the importance of sleep for us and then more specifically for our patients with rheumatic and musculoskeletal diseases?

Today, we're only focusing on the sleep pillar, as I said earlier, but all lifestyle medicine pillars are equally important. From the coach approach. It's important to let the patient decide what it is that they would like to focus on. But for purposes of our presentation today, we'll dive a little bit deeper into sleep. I am certainly biased.

I do believe that restorative sleep is the absolute foundational pillar of health, because without a good night's sleep, I cannot make healthy food choices. I don't have the energy to exercise. I don't have the mental capacity for creative problem solving at my job, nor the psychological resilience to be kind to my children, my family, my coworkers, etcetera. So, you can see how important sleep is from sleep. All good things flow.

So there's an article by Patty Katz et al that was published in 2022 that looked at almost two thirds of patients with rheumatoid arthritis met criteria for one sleep disorder. Sleep disorders included obstructive sleep apnea, restless leg and then short sleep. And that was a large population about four thousand two hundred patients. And secondly, RA disease activity was associated with each sleep disorder. So, it really puts it front and center that it's important for us to think about sleep in our patients.

There was a study by AdaMir that looked at early rheumatoid arthritis across multiple centers, and they found that sleep disturbance predicted greater pain interference six months later. And that was independent of Co founders. So, the opportunity to potentially influence the progression of early RA is critical here as well as the point of pain interference, not just asking patients to rate their pain on a pain scale. And then there's an article by Butani et al from UCSF that found that sixty percent of patients with psoriasis reported trouble sleeping with forty percent sleeping less than seven hours per night and poor sleep was associated with more severe psoriasis. Psoriatic arthritis was associated with female gender as well as obesity and smoking.

So, smoking nicotine is considered it increases activity. So, smoking close to bedtime absolutely increases your likelihood of having sleep disorders. And overall, found also the Bichani group that patients with psoriasis were almost twice as likely to report sleep disturbance compared to non psoriasis patients. So, the takeaway is patients with RMDs carry a higher burden of sleep disorders and that poor sleep heightens pro inflammatory cytokines like IL-one, IL-six, TNF alpha, as well as C reactive protein. It also decreases IL-ten, the anti inflammatory cytokine.

So, the other takeaway from these studies is that sleep and disease activity is bidirectional. When there's more inflammation, it increases disease activity and the more disease activity patients have, the lower their quality of sleep. So, we can see that played out in exacerbation of pain, disease activity, as well as mood symptoms as well. So, our takeaway for clinicians is to definitely screen for sleep disturbances. If you have a patient that you're treating with multiple medicines, you're treating with maximal DMARDs, really take a look first for mood disorders.

Make sure that that's treated and then secondly, for sleep disorders. You can address sleep hygiene, rule out obstructive sleep apnea, consider referring for cognitive based therapy, CBT for insomnia. It's highly very effective. And then also, we should have an eye to minimize sedating polypharmacy when we can. So, is lifestyle medicine different concerning sleep or other lifestyle factors?

I have a list of top five strategies that I'll focus on at the end of the presentation. But I first like to emphasize here that the difference between the traditional medical model of the expert, the provider giving advice to patients is different in lifestyle medicine. Lifestyle medicine focuses on the coach approach and we use different kind of interviewing techniques, motivational interviewing that helps us really kind of tease out what's most important to our patients. So, when discussing lifestyle factors, we have to know what's important to the patient. What is their life like?

What are they already incorporating in their lifestyle that is working for them? So, I can't really prescribe lifestyle measures for a patient if I don't take time to understand their culture, their current living situation, their finances, the clinic that I work in now, social determinants of health. Have to know all of those things before I can really put an adequate treatment plan together. So that's important for me. I can only write the best prescription for my patient when I truly understand where they're coming from and what their knowledge is and what the resources are.

And if I don't understand that it's frustrating, not only for me as a provider, but also, it's very frustrating for the patient. So, the view for lifestyle medicine is that providers are partners. We stand on the same side of the problem with the patient. We work with patients to set goals. We think typically of smart goals.

That's SMART specific, measurable, achievable, relevant and time based. And we encourage self monitoring. Self monitoring is really critical. The patients really need to find out, Okay, what am I doing on a regular basis? How am I able to implement these things?

Then when they come back, can report that to us during their visits. So you can see how this approach takes the focus off of the provider to provide a pill for each symptom or concern and places control or empowers patients via modifiable lifestyle factors to take control of their health. And this is considered self efficacy or agency to take care of yourself. I don't think any of us really like to be told what to do. So I know for me, I'd much rather have a partner or coach that comes alongside me and encourages me to achieve things on my own.

So let's review some of the top tips for patients. And I have like a top five tip to improve our superpower and the power of healing sleep. So first and foremost, both the CDC and the American College of Lifestyle Medicine recommend seven to nine hours of sleep for adults. There was an article by Nielsen at all in 2024. And interestingly, it's titled What You Believe is What You Get.

A systematic review examining health beliefs and attitudes about sleep are associated with sleep duration and nonclinical samples. So, they note that sleep is a modifiable health behavior with important consequences for daytime functioning and well-being. They report approximately thirty percent of The United States adult population sleeps less than seven hours. And then most studies reported more favorable attitudes and beliefs towards sleep were associated with longer and more appropriate sleep duration. So, and then less favorable attitudes and beliefs were generally associated with short sleep durations.

And this is where cognitive behavioral therapy for insomnia comes in, because they found that the evidence suggested that recognizing the benefits of sleep and believing that one has a degree of control over their sleep is associated with healthier sleep durations. So, this is critically foundation for all providers to understand not only for ourselves, but also for our patients. When I explain to patients that sleep is important for their immune system functioning and that their immune system recalibrates at night while they're sleeping. And then a second example, gut microbiome is enhanced with cleaning of your digestive tract and that your brain is able to clean itself when you're sleeping. They have a different understanding for sleep and now they have a respect for sleep.

And I know that also for myself. I used to think that sleep was a waste of time. You know, why not stay up till midnight, get things done, burn the midnight oil. But now I understand how truly important it is and that it is really my superpower. So, to the top top five tips.

The first tip, I would say, is to educate yourself about the importance of sleep and really understand why sleep is foundationally important and that educating your patients about these things really makes a difference for them and for their motivation and really sets that belief and intention. Tip number two is to think before you're going to bed. What is your intention for sleep? Do you want to get adequate sleep and wake up well rested? And I think that's important to set our intentions for sleep and think of positive affirmations such as I'm helping my brain, my immune system.

This is my time for rest and restoration. Tip number three is consider keeping a gratitude journal. This would be something that you keep at your bedside. You write your top three gratitudes for the day. It's a great way of ending your day and putting your mind to rest.

You're focusing on something positive and you're really focusing on the glass half full versus the glass half empty. Tip four would be breathing. There are plenty of yoga apps and meditation apps that can help you do that. But you can do something as simple as the four, seven, eight breathing technique and do three rounds of that. And basically, you're telling your parasympathetic system that all is well and that you're relaxed.

And tip five would be to consider like a mental journey or beautiful imagery. Think of a favorite place that you've been before that gives you very good feelings and put yourself there and think of yourself going to sleep there. And then if I had to say one extra thing that I think applies to our patients is to decrease caffeine, nicotine, and alcohol overall, but certainly before bed. I stated before, nicotine really can be very adrenergic and can really be something that increases our alertness, so having cigarettes close to bedtime could be an issue as well as alcohol and of course caffeine. You have to discontinue caffeine earlier in the day and really they say nothing, no caffeine after 2PM in the afternoon.

And that is considering that there really is a long half life for caffeine that can influence our sleep. So I hope you that you found this helpful. It's lifestyle medicine in action, how sleep transforms rheumatic disease, and just a brief look. If you're interested for more, certainly go to the American College of Lifestyle Medicine website. There are opportunities to become certified in lifestyle medicine and really reach out if you have any questions.

If you want to know more about lifestyle medicine and rheumatic diseases. Thanks so much for your time and attention.