New Functional Healthcare Therapies and Protocols to Help You

Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Today I spoke with Dr. Joe Mather from the clinic. We kind of go all over the map in terms of how we are operating at the clinic, what therapies and tests we’re using, what we’re not using, and how we’re learning. We discuss a couple case studies in thyroid. We discuss one case study that saw a marked reduction in thyroid antibodies after using herbal anti-microbial therapy. We touched on the meta-analysis that found a third of patients have potentially been misdiagnosed as hypothyroid and can successfully discontinue their thyroid medication. Some facets of sleep medicine, some new therapeutics that we’re experimenting with, including sleep interventions, a cream for pelvic floor and also anal rectal health, a hiatal hernia self adjustment protocol, and just at large how we, meaning the doctors at the office, are all using our collective experiences and our individual observations to contribute to collective discussion and constant evolution of our clinical model.

DrMR:

So there’s a lot here that I think will be beneficial for both patients and providers alike. I really hope that you enjoy the conversation. Remember that if you need help, you can always reach out to the clinic. We are here to aid you however we can and prevent you from pitfalls and/or taking longer to improve your health than you need, because no one wants to feel poorly any longer than they need to. And also if you’ve been enjoying the podcast, please consider giving us a quick review over on iTunes. Okay, here we go to the show.

DrMR:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with Dr. Joe Mather, and we are going to be having kind of a clinicians’ round table or powwow about things that we’re seeing that we feel patients and healthcare providers should be aware of and tie that into what we’re seeing and how we’re integrating what we’re seeing into our clinic, our clinical model, and how we’re trying to progressively help patients get well and also avoid the pitfalls of overzealous lab testing, misdiagnosis, and some of the shenanigans that occur in the field of functional and integrative medicine.

DrMR:

So Joe, welcome back to the show my friend.

DrJoeMather:

Michael, always good to be here.

Clinic Update

DrMR:

Always good to chat, and maybe I should just announce this here that you have fully onboarded to the clinic and stepped into the role of medical director. I wanted to take a moment to thank you for that and also to clarify for our audience what that means. It’s probably somewhat obvious, but perhaps not for all. So as the clinic has been growing and we are not only trying to pioneer this GI-focused, patient-centered, science-based, and cost-effective model, we’re also pioneering improving our therapeutics by releasing some new probiotic formulas. We’re doing research at the clinic with the trio-smart breath test and we also have a few other initiatives that are rolling out. We’re pursuing some university affiliations. We have new clinicians who’ve started with Hannah and Omar. So there’s just a lot going on, and it’s really not something that I think one person can manage by themselves.

DrMR:

So as we’ve grown, Joe and Rob have have stepped into two respective roles of medical director and research director. This doesn’t mean that I’m going to be going on vacation and not paying attention to what’s happening at the clinic, but Joe and I will be working together pouring over our clinical model, ensuring that we are staying accurate, that we’re incorporating new information, that we’re overseeing our new clinicians as they onboard and plug into the systems and that they’re able to implement all the systems effectively and use this as a basis to help publish research.

DrMR:

But really outside of the research, where Joe and I come together is obsessing over our quality getting better and better and better and the model getting more accurate, pouring over our clinician data, auditing clinical files, giving our clinical team support, and really working together so that as we grow everything that all of our clinicians are seeing is integrated into and helps evolve and sharpen our clinical model.

DrMR:

That’s the way I would describe it, Joe. Do you maybe want to add anything to that in terms of how you see yourself interfacing into this project of having the best clinic in functional medicine in the country if I may put that audacious goal on the board here?

DrJM:

I’m glad you put it on the board because it’s how I feel. I’m just so excited and thrilled to be in this position. For the audience, it may be unclear how much work Michael has put in into building this far. It’s really exciting to be in a place where I can help him move it forward even more because when new hire doctors are coming in, we’ve got a really top-notch clinical training program that we’re putting the new doctors through, and future clinical hires are all going to go through this model. It’s just so exciting to be in a position where we can continually update our training so that we can get great outcomes for patients. I mean, we’re both really proud of what we’re offering and it’s so exciting to be in a position where we’re so proud of the outcomes we already get, but know that the more research we’re able to do, we can get even better. And so it’s just so exciting to be able to think of what we’re going to be able to offer patients in two or three years by being a part of a clinic that’s continually improving and growing. It’s a fantastic dream job. It’s awesome.

DrMR:

It’s so exciting. One of the things in particular that I want to share with patients and providers because there’s a lot of relevance to how we can help people with this is as we grow there’s this flow of one or two clinicians on our team being able to start experimenting with a new therapeutic. And once they feel they have their hands around that, then we’re going to be doing these monthly rounds, so to speak, where we’re going to do a presentation for our clinical team on, let’s say, now we’ve got our hands around something in sleep medicine, which is what I’m experimenting with now. I’m running some of these WatchPAT ONE home sleep tests, referring from myofunctional therapy, and it’s going to take me a little while to figure out what’s the best way to sequence this, what are the early indicators, what’s the best time to indicate or to use the test, what sort of response time until symptoms improve after doing malfunctional therapy?

DrMR:

But once I have that more mapped out, now we can do a presentation to our clinical team and five times the amount of individuals that we’re seeing and putting through this system and really accelerate our learning. I mean, we’re going to be able to get five months of learning done in one month or five years of learning done in one month. It’s just such a gift because now we get a chance to really have multiple people trying these protocols, using their experience to even further refine it, and accelerate how quickly we evolve being better at whatever facet of healthcare that we’re operating in.

DrJM:

It’s so exciting. The sleep one is going to be fantastic. I’m queuing up one on HDDS, hereditary abdominal syndrome. There’s just a high percentage of patients who have this, a higher than average percent in our patients coming in than the general population. I think addressing this specifically will take another group of patients a nice step forward. And so when you combine that and you also have Rob working on a pet project as well, this is going to accelerate pretty quickly. The whole goal is still to be able to help as many patients as we can as quickly as we can.

DrMR:

And maybe to just pepper in one of the things that Rob and I have been working on, because I’m not even sure if I’ve looped you in on this yet, Joe, we had a meeting with the folks from Clear Passage, Larry and Belinda Wurn. This isn’t official yet, but what we’re going to try to do is beta test a shorter course of therapy with Clear Passage and see if perhaps doing a therapeutic intervention that’s about half the time and therefore half the expense may still be able to benefit some people because we’re getting some resistance from patients due to the cost. And I think it’s worth it, but not all patients are in the same financial position. So that’s another thing that we’re working on.

DrMR:

And boy, wouldn’t that be great if we could determine here’s a subset of people who need to be referred for adhesion therapy. And just for our audience, the Clear Passage therapy is essentially almost like a really intense massage, but it’s this visceral therapy that breaks down scar tissue that can cause abdominal pain, infertility, recurrent SIBO, and potentially constipation, but the therapy can cost $6,000 to $7,500. If we can get that cost cut in half, that’s a huge service that we’re going to provide for people.

DrMR:

So that’s another thing that Rob and I are working on and just a good affirmation for how as we’re growing, we’re really growing effectively. To juxtapose that with what I’ve seen in some centers, and it’s a little bit sad, but you have these other doctors in there and I think everyone’s probably good and talented and doing their best, but they’re all kind of doing their own thing. That’s such a lost opportunity to learn and grow stronger as a collective rather than just having a team of people who are all doing good work but all doing their own thing and not getting that synergy.

DrJM:

Yeah. Even if we’re adding pieces here and there, the core of our clinical models doesn’t change. We’re still going to be able to deliver really cost-effective, practical, gut-based functional medicine at the core of what we do and always be able to add more effective pieces because we’re always learning. And the amount of research that comes out on a daily basis is tremendous and overwhelming, but to be able to harness some of that into clinical improvements is a really exciting thing.

Hypothyroid Overdiagnosis

DrMR:

Here’s a good tie-in taking us to the next topic I wanted to hit but also incorporating something else. If our audience hasn’t come across our FFMR Plus, that’s the Future of Functional Medicine Review, the “Plus” aspect is a weekly synopsis of the latest research. This is what Gavin and I and our team have been working together on. As people may know, I would spend about an hour a night reading through my research study updates. I get an email every time a study is published on probiotics, IBS, IBD, Hashimoto’s, Levothyroxine, and all these things I follow and I get an abstract on the latest research. So Gavin and I have been working together to teach him how to go through that filtering process so it’s not all dependent upon me and to come up with a weekly brief that’s about 15 pages that summarizes all the latest research. And he also does an audio read of it so that clinicians can be doing their morning routine in the morning, making breakfast, brushing their teeth, whatever, and they can get this valuable download.

DrMR:

Now from this download that, by the way, all the clinicians in our office have access to as does anyone who subscribes to the FFMR Plus, we came across this study entitled, and I’ve discussed this before, but “Clinical Outcomes After Discontinuation of Thyroid Hormone Replacement: A Systematic Review and Meta-analysis,” published in the journal Thyroid, this year, 2021. And they found that 34% of individuals were able to successfully come off thyroid hormone medication and maintain normal thyroid function, which to me is obviously really powerful enforcement of what you and I, Joe, and on the podcast we’ve been discussing. And at the clinic, we’re continuing to see that there is this over and incorrect diagnosis of thyroid and hypothyroid. And to see this be a meta-analysis for about a third of patients makes it that much more powerful and makes me that much more confident in this observation.

DrJM:

Huge, huge kudos to the authors for this paper. I mean, from a conventional medicine standpoint, Levothyroxine is worshiped and patients are put on this for a lifetime. So it’s just so nice seeing this done in a really high-quality, efficient way. It’s a really well done cite and great writeup. For anyone who cares to pull it up, the PubMed ID is 33161885. And really well done. It is so helpful just to be able to at least have the idea out there that patients can go off Levothyroxine. It doesn’t have to be a lifelong treatment in some patients, particularly when the gut is cleaned up.

DrJM:

I mean, you and I have seen this probably on a monthly basis where we get these patients having their gut cleaned up, we get their SIBO down, we get things working better, and all of a sudden they need less thyroid help. Some patients get off completely, but maybe about half are able to reduce their dose. It’s fairly regular in our perspective. I mean, how often do you think you’re seeing it?

DrMR:

Well, I’m probably seeing one case almost per day. Definitely one per week, but definitely one per day that has either been incorrectly diagnosed hypothyroid or there is a decent suspicion. And the reason why I say decent suspicion is sometimes the diagnosis was made 11 years ago. They don’t have access to the labs, the doctor has since retired, so I can’t definitively say. And typically what we’ll do in these cases is we won’t advise them to discontinue the thyroid hormone medication out of the gate unless we suspect there’s being overt iatrogenic harm being done, meaning they’re having insomnia, they’re having fatigue, or they’re having periodic palpitations.

DrMR:

But if that’s not present, I’ll typically wait until we’ve gotten a little bit of a foundation underneath them, meaning their gut health seems to be in better position, they have fewer symptoms, so now there’s a clearer symptomatic picture against which to perform the thyroid withdrawal and we don’t have this up and down in symptoms that’s being driven by their gut that could falsely lead someone to say, “Oh my God, I came off the hormone and I’m more fatigued and more constipated. I must’ve really needed it.” So, understandable. So we want to get those variables out of the way.

DrMR:

So in my observation there’s one of these per day. Now that I’m thinking about it, I don’t have one case that has needed to go back on the thyroid hormone. Meaning, as there’s been follow-up TSH and T4 testing, no one has seen their TSH go screamingly high and their T4 go down into low. By the way, we’re not cherry picking to try to get people off of thyroid hormone.

DrJM:

We want the inappropriate thyroid hormones.

DrMR:

Yeah. We’re not going into the realm of being heretically anti-thyroid, we’re just trying to look at this information objectively. But when we’re positioned relative to much of the field that’s so overzealous, it makes us look like we’re anti-thyroid, so to speak. But when we go through it objectively and look at this, so far the results have been great. But to your question, Joe, one per day, and what’s been interesting to see is this is seemingly a similar frequency that you and Rob are seeing. I haven’t followed up with Hannah and Omar on this just yet, so I’ll be curious to get their notes. I just haven’t asked them this question specifically.

RuscioResources:

Hi everyone. Just a few fairly important updates. I’ve been working diligently behind the scenes tweaking and updating our paperwork, our clinical systems, our treatments, our data gathering, data organization, reporting and patient monitoring. I’ve refined the algorithm to be even better than it was before. How confident am I in our clinical team? Well, my mother is working with our health coach and my father just started working with one of our doctors, so about as confident as you can get. Collectively, we are moving towards our goal of reforming functional medicine. We are gathering data on our patients, working toward publishing our data, and we have taken big steps in this direction. So you are part of something big here. You’re not only a patient we aim to serve and help, but also as one of our patients you become an example of how people can improve their health in less time and for less money compared to what appears to be commonplace in the functional medicine field. So I encourage you to look forward not only to potentially working with me, but also with any of our tremendously skilled, attentive, and empathetic clinicians. Thank you for being a part of it or thank you for waiting to be a part of it if you’re about to be seen soon. If you have not yet reached out and you’re in need of help, we would be pleased and honored to work with you.

DrMR:

What’s the frequency that you’re seeing, Joe?

DrJM:

I would say the same. I’d say one patient a day. It’s pretty clear that this might be an issue. Yeah, one a day, and we’re typically seeing eight patients a day.

DrMR:

Yeah. It’s not like we’re seeing 40 patients a day. So it’s a pretty high ratio of one in eight.

DrJM:

I had a follow-up visit from a patient. One of the first things we actually did was reduce the thyroid dose because this patient was having palpitations and insomnia and had been on thyroid medicine for 12 years and no one had ever thought to question if it was a good idea or not. And dropping the dose fixed the sleep, fixed the anxiety, and fixed the palpitations. And guess what? When she started sleeping, her GI symptoms went down and it made all the GI recommendations that I subsequently followed up so much easier. And so the key for her case was fixing the medication.

DrMR:

It’s so ironically, and I don’t think there’s enough discussion about this, but if you give someone hormone who doesn’t need it there’s a fair probability they’re not going to feel well. In fact, I did an experiment at one point. This was maybe five years ago now, before I knew as much as I do now about how this all works. I did a trial on T3, and my most notable symptom was fatigue. I was notably fatigued from this.

DrJM:

Yeah, yeah. I wonder if primarily you get a big upregulation in albumin and the thyroid binding globulins and are soaking up other hormones as well. So you get an inappropriate, exogenous hormone and then your body is trying to protect against that bump in hormone. It’s just soaking up other helpful hormones.

DrMR:

The theory I’ve heard posed, and I actually really liked the one that you’re posing because it seems equally as plausible, is you may increase the metabolism of cortical hormones, your cortisol and your adrenaline. I don’t like the term, but you actually get adrenal fatigue in the sense that you have low cortisol production because you’re increasing your metabolic rate. And part of what’s that’s doing is metabolizing cortisol. And it could be both, but whatever the reason was, it was alarming.

DrMR:

That was kind of a pivotal observation, because up until then I was operating under, “Thyroid is so important. You’ve got to be in the upper end of the range, and you want to look at your reverse T3 and make sure that’s good.” It was one data point, but over time, if you keep collecting the data points, you may discover that the theory that’s circulating doesn’t seem to have really great evidence. So it took me a few years to figure it out, but that was definitely one of the key insights early on.

DrJM:

So let me circle back to this paper. I think there’s just a little point that worth hammering home. Again, a third of patients were able to discontinue thyroid medication. Just for our listeners, the patients we see coming in to our clinic have often had a diagnosis of subclinical hypothyroidism and Hashimoto’s. In our opinion, those two conditions are probably going to be a little more likely to get off of a thyroid hormone, if you have either Hashimoto’s or subclinical hypothyroidism. Hashimoto’s because the disease itself naturally can wax and wane, spike up and then calm down, and with subclinical hypothyroidism we know a large number of cases will spontaneously resolve. So two points there that if you have those diagnoses, you just may want to consider talking to your doctor.

DrMR:

I think that’s also a point worth reiterating. We have covered this on the podcast before and also in our clinicians’ newsletter. The best data, at least that I’m aware of, and Lord knows we’ve checked, looked at a prospective sample of individuals. I believe it was prospective. And they only found a 9% to a 19% conversion of patients who had Hashimoto’s to actually becoming hypothyroid. The mistake oftentimes is, “Oh, you have Hashimoto’s!” It’s almost equivalent to hypothyroid. And I think it’s important that people understand that you have well over a 50% chance, almost, in this case, an 80% chance that you will not actually become hypothyroid.

DrJM:

That’s over over a lifetime, right?

DrMR:

Well, I think this follow-up was three to five years. So there are some limitations in terms of the length of the follow-up, but at least with this the best data was looked at. And they also did not find that there was progressively more conversion over time. Meaning, at year one it was 3%, at year two, it was 8%, and then at year three, it was 19%. So there doesn’t seem to be a trend, at least from this one study, that time is going to automatically dictate.

DrJM:

It’s really helpful to put the risk in perspective based on what you hear, because the reality is more that you have a very low chance of becoming truly hypothyroid. And the likelihood is that the progress will happen over decades or many, many years.

DrMR:

Yes. Now, there’s also this other point, kind of to play devil’s advocate to our position. There is evidence that has found that taking thyroid hormone medication will lower thyroid antibodies. Okay, that’s a perspective, but it’s probably overkill since we also have data for vitamin D, certain dietary changes, and selenium all being able to lower thyroid antibodies, and those don’t have the potential iatrogenic risk that you have from the medication. But even worse than that is not fully explaining to the patient that this should be something that we use temporarily. Because like this paper has suggested, what ends up happening is once someone goes on thyroid hormone, people don’t tend to question it or double-check it, and so they are on lifelong medication.

DrMR:

There was one other finding from this paper. I’m not sure how practically useful it is for people, but ultrasound findings did also predict someone’s ability to successfully come off the hormone. Said simply, the more abnormal the ultrasound findings were, the more likely you were to need thyroid hormone in perpetuity. Essentially it’s called heteroechogeneity, or when the ultrasound is going up and down your thyroid gland, the tissues should seem uniform. The scar tissue will have a lower resonance. And that’s where we’ll see the heterogeneity, meaning a difference in the ultrasound echoing.

DrMR:

So if you had an abnormal ultrasound, it still doesn’t mean you couldn’t go through this exercise with your doctor, but you may have a lower chance of being able to do so successfully. You still run the same experiment, which is discontinue and then follow up six to eight weeks later and do a retest as your first benchmark, but there may be a lower chance of successfully doing so if you did have abnormal ultrasound findings prior.

Herbal Treatment Case Study

DrMR:

So yeah, those are a few thoughts on thyroid. I was actually discussing earlier today, Joe, one of your case studies. I believe her name was Cathy. After going on anti-microbial therapy, she saw a sharp reduction in her thyroid antibodies, which is an interesting clinical anecdote to see. The data here in terms of will anti-microbials reduce thyroid antibodies is mixed. There is one Italian study, and I did mention this in Healthy Gut, Healthy You, that found after treating H. pylori with antibiotics there was a notable reduction in TPO antibodies. But there are also studies that haven’t found that, so I do want to be careful in how we represent it. But you were using herbal anti-microbials in someone who had symptoms that would suggest they would benefit from herbal anti-microbials. And there was this secondary effect benefit of a sharp reduction in her TPO antibodies, and she also felt better. Was there anything there that you wanted to mention about Cathy’s case?

DrJM:

Oh man, this was a case that I loved because there were so many things that I learned from it. Early on in my functional medicine career, I was really struggling with her. I was trying adding Cytomel, switching to Armour thyroid, going back to Synthroid, just trying to get the dose right. We did nutrient replacement and a whole bunch of supplements to try to target nutritional pathways, methylation. I’m almost embarrassed to say this, but I actually tried her on an anti-lectin diet, a low-lectin diet. That didn’t work. And finally, the thing was that I started learning from you and put her on some herbals, and then she just did fantastic.

DrJM:

So her TPO antibodies were routinely between 650 and 750. They dropped like a rock, down initially to around 350 and then below 200. The coolest thing was she just felt immediately better. The dysbiosis was treated and she just felt great. I actually lost touch with her for a few months because I just put her on herbals and then she just felt better. I hadn’t seen her for around four months and it was because she just felt amazing.

DrJM:

The other cool thing was her lipid panel improved hugely. Her triglycerides dropped. They were in the low 300s, which is fairly high. They normalized; her LDL normalized. So again, it’s just the power of treating the right thing. This is what we see in good functional medicine. Treat the right thing and everything tends to get better. For patients and practitioners, that’s the sort of response you look for. You typically know you’re on the right track fairly quickly when you do the right thing.

DrJM:

And kudos to Cathy for sticking with me while I was figuring this stuff out. When I did things that didn’t work like messing around with too many supplements, messing around with the low-lectin diet, she did not get better. But you treat the gut. That was her problem, and she got better. So yeah, I love that case.

DrMR:

It’s such a great case study. Especially the fact that you were going through the standard functional medicine recommendations of, “Okay, it’s got to be a combination of T4 plus T3. I’m going to bump this up and try all these other things,” which there is a time and a place for. But I think in this case, it wasn’t being done at the right time point. The sequencing was off. And this is what I also think is so important about what we’re doing at the clinic. We’re not saying that some of these possibilities are off the table completely. It’s just, what is the most probable to help you and what is the least probable to help you? Let’s line these up in a somewhat linear sequence so that we’re not spinning our wheels.

DrMR:

And also, we’re not doing all of this at once, because to your earlier point, if you do all of this at once, you can’t tell if someone’s responding the way they should or if they shouldn’t. And this is another thing that I think really thwarts clinicians from being able to learn. It’s the ultimate, “I’m trying to do the right thing, but I’m actually unintentionally doing the wrong thing. I really want to help someone, so I’m going to change the diet, go on probiotics, go on vitamin D, start exercising, take a fish oil, take anti-microbials, take methylation support, take adrenal support,” because you really want to help.

DrMR:

And it truly is well-intentioned. I felt that pressure internally early in my career, but it really robs the clinician of being able to say, “Oh, you’re now four weeks into anti-microbials and we’re seeing zero response. This is reducing the probability that there is something that can be addressed with anti-microbials. I am going to start thinking about going on to the next line of therapy.” And you learn over time what these responses look like, and it really helps give you an intuition. So yeah, that’s why your case study is so important because it illustrates right place, right time, and then also the importance of doing one thing instead of doing seven things and it gives you a clear signal.

DrJM:

I can’t wait to just teach more clinicians this because it can just speed up this learning curve. I mean, I’ve been doing this for over a decade now, just one at a time, observing each patient and paying a lot of attention. You’ve been doing this for a long time. We can teach clinicians it’s reproducible. There’s no reason patients have to suffer longer than they need to.

DrMR:

Fully agreed.

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Limbic Retraining Case Study

DrMR:

I just want to do a quick tangent. At some point in the near future, we should be releasing this as one of our video patient conversation videos. But this patient I had been working with years ago had done really well. And kind of like what happens is people drop off who are feeling well, which is great. I was less intentional about saying, “Well, let’s check back in once per year just to keep tabs.” I’m actually learning that’s more important than I thought, because as this gal just went and did her own thing, a few years later she started having some symptoms return. She checked in with a different doctor, and this guy put her through the ringer and actually actually got mad at her because she had dysbiosis on a stool test and said, “You are really sick. You need to be taking these recommendations seriously,” in a patient who clearly had limbic imbalance.

DrMR:

So it was just like turning a knife in someone. The worst thing he could have done psychologically was use that language in this person who was already very worried about her health to begin with. And part of this was probably limbicly driven. She sent me the lab. Dysbiosis is still ill-defined, so to tell someone, “You are really sick,” based upon this measure that we’re still not really sure how to define is just so egregiously harmful and idiotic. I mean, there was no overt pathogen. So if you had something like an amoeba like I had, that’s a conversation of, “Hey, you have to take this seriously. This organism is highly pathogenic and it can screw you up.”

DrMR:

I still wouldn’t say you’re sick. I think it’s never good to say that to an individual because I just don’t agree with the frame. But this was, “Some of the populations are a little bit skewed in terms of the relative abundance. And there’s some suggestion that this is what it should look like. This biosis picture is one that we’re still trying to figure out how we label it.” Telling someone that they are sick, like you’re really sick and you’ve got to take this stuff seriously in a patient who by the way was very compliant and baseline, so I’m not even sure why you’d ever need to fear cajole them into further compliance, but it just wrecked her psychologically.

DrMR:

We had her do a couple things. I kind of gave her a sequence of a few different steps. Before I mentioned the others, I want to let her follow up with them one more time so I can have a more definitive signal on them. But the one thing that was hugely helpful for her was limbic retraining. She saw immediate improvements and her follow-up paperwork said, “I feel tons better, 90%. I have so much more tolerance to food.”

DrMR:

So this is a good example of how she was just getting pounded by gut supports, anti-microbials, all these different theories about there’s some researcher in Israel who thinks that this bacteria gets high because of ‘X, Y, Z’ and so we’re going to use this really esoteric herb. She was just getting ground down further into gut. So as gut-centric providers, there’s also a pivot to, “Okay. I don’t think your gut with any more poking and prodding in the gut is going to get any better. There’s probably an adjacent issue present that’s driving this.” Here, it was limbic retraining and it was just game-changingly helpful for her within a couple of weeks.

DrJM:

I love limbic retraining. We have to buy Ashok Gupta a birthday cake or something. It’s so clearly helpful in the right patients. I’ve done it myself. We’ve talked about this before, but it’s so helpful for a lot of the patients that we see.

DrMR:

Yeah, just a really powerful tool for the right people. I mentioned this because this is another thing that we have integrated into our clinical model, the consideration of limbic retraining. And we’re on the lookout for this out of the gate. I’m hesitant to say psychological, because then sometimes people say, “Are you saying it’s all my head?” A patient and I had the same conversation, and I said, “It’s not correct to say it’s all in your head, but your brain could be driving some of your symptoms.” Just like we have gut-brain, and people with inflammation in their gut can have depression or brain fog, there’s also brain to gut like we’ve discussed even with Titus Chiu and something like post-concussive disorder.

DrMR:

Well, this is a different manifestation. It wasn’t a concussion, it was an emotional trauma, but there still is this mechanism or this connection directionally from the brain to the gut. So it’s not all in your head, but your head is part of what’s driving the symptoms.

DrJM:

It’s absolutely true. It’s a physical manifestation. It’s immune activation that’s being driven by your central nervous system. I would even go farther. I would take away this idea that it’s in your head at all. I mean, I think this is an immune system problem that you need to retrain. That’s something that we’ve definitely incorporated. This has become one of my go-tos very frequently, especially more and more in the last year.

Hiatal Hernias

DrJM:

Do you want to know what else I’m doing?

DrMR:

Please.

DrMR:

We’ve had this talk before. I’m finding more hiatal hernias. We’re becoming more aware that hiatal hernias are causing some low-grade symptoms for patients. This is interesting because I think we had a little bit of different experience on this. It’s your show, so do you want to start?

DrMR:

I’m so glad that you brought this up. I think this is a good additional example of how we as a clinic are growing stronger as a team, and these exact conversations are what I mean by that. So you had a few cases where you’ve recommended they do this self-adjustment for a hiatal hernia, so to speak, and it’s been really helpful. And I was on a different side of opinion spectrum, so to speak. But part of that may have been due to bias.

DrMR:

Coming from some of my background being in chiropractic, it felt to me like hiatal hernias we’re just being “diagnosed” willy-nilly and everyone who had reflux, heartburn, indigestion, or dyspepsia was being diagnosed with hiatal hernia. It was just being given out like hotcakes to everyone. And I was seeing a lot of the problems were being driven by more dysbiotic and food choices. So we’re seeing really powerful results with not doing hiatal hernia and focusing on other things. And then I combine that with some of the feeling that hiatal hernia was a prevalent diagnosis that was coming from providers, it just seemed so dogmatic. So all of that polarized me away from it.

DrMR:

But, if confronted with an observation from someone who I feel is objective, I’m always willing to listen. And so when you, as someone who I trust and respect your opinion, I immediately perked up. And it was, “Tell me more.” And we’re now integrating this, and you and I will be continuing to experiment with this, firm this up, and once we feel like we have a full handle on it, we’ll integrate it into the clinical model more broadly. But it sounds like you’re already getting your hands partially around it. I just want to try to run my own experiments and see if I can replicate that. But tell us more about what you’ve seen.

DrJM:

Well, it’s definitely not everybody, but there are a couple of hints that I think lead us in this direction that a hiatal hernia might be causing issues. I came to this because once I’ve worked someone through our algorithm and we’ve treated probiotics, we’ve used herbal anti-microbials if need be, we’ve done the dietary work, cleaned up the sleep, and we’ve used the immunoglobulins, there was just a chunk of patients kind of mild to moderate ongoing GI symptoms.

DrJM:

And so I’m thinking, what am I missing? We’ve cleaned up this infection, we’ve treated ‘X, Y, and Z,’ but there’s still the symptom. This cadre of patients would have a feeling of epigastric pressure, discomfort, or pain. They would often get full easily with meals, maybe a little bit of burping and nausea. And I was like, “I wonder if these patients have hiatal hernia?” So I actually cornered Dr. Steven Sandberg-Lewis, who treats patients somewhere out west. He’s considered one of the guys who really understands hands-on visceral manipulation. I cornered him at a SIBO conference. I’m teaching how to find these introductions. But in this group of patients, this makes a big difference. If patients had a hiatal hernia, the reduction technique helps really quickly, and in about a week there should be significant reduction in symptoms. And if it doesn’t work, you probably don’t have a significant hiatal hernia.

DrJM:

I had one gal in particular with all sorts of chronic skin issues, chronic pain, fatigue, and really tons of constipation. Nothing was moving the needle on her. We probably worked together for 18 months and I finally had her try this hiatal hernia manipulation. It was like night and day. All of a sudden her bowels started moving, her skin cleared up, her pain was down, fatigue was better. She described doing the manipulation or reduction, and people can Google this and then learn some techniques to do it on your own. It’s very safe, very easy. It’s putting pressure right under your rib cage and firmly pressing down. And she felt more relaxed from doing it, and then a few days into doing this regularly, she swallowed and describe the sensation of everything falling into place. She finally swallowed and felt like food was going in the right place.

DrJM:

I think what happened is she had a displaced hiatal hernia that finally got reduced. And one of the interesting tie-ins is that I think there can be some Vagal nerve compression or irrotation with a hiatal hernia. And I think that was contributing to her constipation. So we got the physical stomach back in line. I think that Vagus kind of opened up. I’m sure there’s a more scientific way to explain that, but the Vagus turned on or opened up and everything started improving.

DrJM:

I’ve seen a couple of cases like that, enough to convince me that this is real, at least in some patients. The other thing to know is I think this is probably more common in the HDDS or the joint hypermobility patients who have maybe underlying weakened connective tissue. So there’s a couple tie-ins to the patients who we’re seeing, and they’re people who’ve seen a couple of doctors and are still struggling.

DrMR:

Yeah. It’s really exciting. I already have a Rolodex, if you will, in my mind of people who I was considering this for. And actually, for this same case study of mine that I mentioned before who saw the provider that told her she was really sick, that was the next thing I was considering because some of her symptoms were this upper GI, food reactive bloating, distension. Fortunately she was doing so well, I didn’t think it was necessary to recommend, but it did go into the hierarchy and it is something that I’ll be considering for her. And I also just want to commend you in terms of the way that you applied this. I’m going to do one thing, so I’m isolating for this variable, so as a clinician I can learn if this is helping the person. And again, it’s just so important because it’s incredibly challenging to evaluate the success of a therapy if there’s multiple things going on at the same time.

DrJM:

That’s why I have patients do this on its own for a week. So when I’m giving treatment recommendation, I’ll say to try the hiatal hernia for a week, and whatever else I want them to do, I’ll sequence that next so they can really get a yes or no read if it’s helping. If this is not helping, they don’t need to keep doing it. But for the patients for which this works, it’s a game changer and it can be life-changing. So not everybody needs this, but it’s super helpful in some of those tricky cases.

Isolating Treatment Variables

DrMR:

No, I love it. This is fantastic. And I’m very much so curious to see the response I get as I try to replicate the application. And I just want to circle back or I guess transition over to this being the way that I evaluated immunoglobulin therapy in the clinic. Whenever there’s a therapy that you’re new to using and are really trying to get a read on, I think it’s even more important to isolate that variable. I’m going to put this therapy under the microscope because I’m trying to figure out if it’s bunk or if it works. And so that’s when you really want to cue this up to be done in a very isolated trial.

DrMR:

So just like you were doing the hiatal hernia self-adjustment technique at one time, I was isolating just for immunoglobulins and it didn’t take me long to see that it definitely helps. So for the providers or for patients who are trying to work with your provider to get the best care that you can, there’s so much merit to this concept of slowing down. I understand if you’re not feeling well, you want to get there as fast as you can. I totally get that; I’ve been there and I’m empathetic to it. But in The Tortoise and the Hare, the tortoise won over the hare because while it may seem slower, if you’re not learning from your success of interventions, then all you’re really coming away with is, “Okay, if I want to feel better, I’ve got to shotgun it with these 15 things.” Not only is that messy, people can also be reacting to one of those 15 things or two of those 15 things, and then they have a really hard time knowing why they’re not improving. So just even more reason why slowing down and being measured is incredibly valuable.

DrJM:

Take good notes and bring it back to your doctors because that makes our life easier. You can say, “I tried this and it worked. I tried this and it didn’t work.” Because all of that information helps us make better decisions for patients and get them better quicker.

DrMR:

Yes, that’s a really, really important note.

RuscioResources:

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DHEA Treatments

DrMR:

What else, Joe? Anything else new or interesting? Well, let me throw one out there since we’re going into some things. We did a recent podcast with Anna Cabeca. It probably will have aired before this one, but if not, it should be airing really soon. She’s a gyno-obstetrician and she has this cream that is meant to be for women. It’s kind of like this DHEA-based cream that a woman would apply vagina through rectum to help nourish the vaginal tissues, the parineum tissues, and the rectal tissues if there’s been damage, inflammation, or laxity, but it also helps with men. And in patients who’ve had pelvic floor disorders, who have had chronic diarrhea and potentially hemorrhoids, fissures, or anal irritation, or perhaps women with incontinence, she’s found this to be quite helpful.

DrMR:

So it’s something that I’ve already recommended to a few patients, and I’ll be curious to see if for anal, rectal, or pelvic floor irritation or weakness, this DHEA-based youthanizing, repairative cream moves the needle. It’s early to say, and clearly not for everyone, but that may be something for a certain cohort of individuals that may also be really beneficial.

DrJM:

That’s interesting. I never thought of a topical DHEA that way. Of course, I’ve seen topical estrogen creams for vaginal atrophy being extremely, extremely helpful and a game-changer for some women. Some women with what they think are chronic or frequent UTIs, it’s vaginal dryness and irritation of the urethra, and DHEA is a precursor hormone. Maybe we’re kind of improving all sorts of hormones with the DHEA locally or DHEA is having a primary effect by itself. I don’t know. It’s certainly interesting and intriguing.

DrMR:

Yeah. It is very interesting and intriguing. And I think it’s probably a little bit of both, the direct youthanizing effect and then it functioning as a precursor. And there’s also some stem cells. I think these are plant-derived stem cells, which I still don’t fully understand how plant-derived stem cells work or how efficacious they are, but this is where speaking with someone has a focus in this area, if she’s finding it beneficial for part of her focus, which is female health, that overlaps with our focus in GI, then we’ll run the experiment. But I think the important take home for our audience is that I will be, as I know you are with everything you do, Joe, equally trying to prove this as disprove it so only the therapeutics that have merit will stand.

DrJM:

Yeah. While we’re on the topic, are you still using oral DHEA in patients with chronic fatigue?

DrMR:

I’ve been using it less, but I still do use it. I’ve been using it less. The reason I’ve been using it less is so much of fatigue is lifestyle, and that’s usually fairly well addressed by the patients we see at the office. But between tweaking their sleep, tweaking their diet, and for some people they’re just going to bed too late and/or some people are way undereating or undereating carbs, or they’re eating foods that are causing an inflammatory reaction and that’s leading to the fatigue. Between lifestyle diet and then strongly getting their gut health improved, I have just seen phenomenal results with fatigue to where it’s very seldom that I have to use the DHEA. And it’s more so a complimentary cherry on top. Let’s see if we can give you a little bit of boost or an accent to the process that we’re already going through.

DrMR:

And just to build upon that in terms of what about non-responsive fatigue? That’s where I think it’s early. I still need to get patients to follow up and see what sort of effect was had. But this is where I think things like sleep disordered breathing, whether it be apnea or upper airway resistance syndrome, and then the resultant supports for that, like myofunctional therapy, I have a strong suspicion that there’s a subset of patients for whom their non-responsive fatigue is being driven by poor breathing at night.

DrMR:

It’s known that fatigue, daytime sleepiness, and other cognitive impairments are some of the hallmark symptoms of apnea or airway resistance. I just haven’t seen the patients have the results yet other than what I’ve shared in the podcast. Nick Hedberg had nice results from myofunctional therapy and a family member had nice results from a mandibular advancement device. I haven’t seen this yet, so again, I’m trying to bridle myself, but that’s the other area where I think fatigue may be driven by a breathing disorder. So DHEA sometimes, but more selectively.

DrMR:

And what about you? I’m assuming we’re doing similar?

DrJM:

Yeah. I’m using it primarily in those non-responsive fatigue cases or the more complicated fatigue cases. If it’s someone who’s coming in with more of a chronic fatigue syndrome, fibromyalgia, and we’ve already worked on that lifestyle, gut, and we’ve ruled out sleep stuff. I was a little disappointed. I actually thought that it would work better than I think it does. It seems to make a mild or moderate impact to maybe one out of every three patients I try with a low dose. And so again, I was just curious to get any more feedback on that. It’s a smaller player.

DrMR:

Yes, a smaller player, something to consider, but yeah, I think we’re in agreement of using it as something like an accent. Gosh, I’m so curious to see if the sleep is something that’s going to move the needle.

Sleep Disorders

DrMR:

And I do just want to share on the sleep one reflection from my day in the clinic yesterday, because it illustrates that we want to look at lab tests, but not exclusively. It’s like one-third or one-fourth of the data to make a decision.

DrMR:

So with this one individual, we got her WatchPAT ONE home sleep test results back. The report concluded mild obstructive sleep apnea, but mild. So there are levels of severity, which are mild, moderate, severe. So me, not being overzealous, I look at mild as mild, meaning it may not really be a problem. Now this patient did have some fatigue and she did have some brain fog. So those both strengthen my prognostic thinking that the myofunctional therapy or other sleep interventions will help her. So I look at mild going into the consult as not a super strong signal. Her symptoms make me feel a touch more confident that there actually could be something from a sleep disordered breathing perspective.

DrMR:

I also had her do an experiment before this visit with mouth taping, and she felt the mouth taping really helped her. So now I’m even more confident. And after I explained the test results and what apnea is, she said, “Oh, I definitely feel like sometimes my throat closes up at night.” So this is where context takes a mild finding on the lab and makes me very confident that that mild finding is actually substantially impacted.

DrJM:

I tell my patients, I prefer that they breathe on an ongoing basis. Ongoing breathing is pretty key for for health optimization.

DrMR:

It helps, yeah, I’ll tell you. Many of us have tried Wim Hoff, and that’s not something I’d want to be doing multiple times per night. A little bit of it is like coffee. A little bit of coffee is great. Too much of it can spin you out and make you feel tired and just foggy and weird.

Episode Wrap-Up

DrMR:

But boy, Joe, we’ve been all over the map here. Anything else you want to touch on as we move over to a close?

DrJM:

Well, all my kids are quarantined. My son had COVID, and it’s a small miracle that they haven’t barged into the home office yet. So we should probably get off the call before chaos reigns.

DrMR:

All right, well, I guess we’ll pin it there. Joe, thanks so much for taking the time and chatting and welcome into your new role at the clinic. I’m just excited for us to continue to have this ability to have back and forth, to learn, and to share these conversations with people so that they can learn. Hopefully we can continue to make an impact in the direction of healthcare.

DrJM:

I love it. Thank you my friend. Thanks for the opportunity. Of course, we could talk clinic all day long. I’d love it.

DrMR:

Definitely. Alright my friend, talk to you soon.

DrJM:

Goodbye.

Outro:

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