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Bill Klaproth (Host): Welcome to Oasis Room Attainment, a podcast with Dr. George Munoz, Chief Medical Officer, and founder of both the AOTRC, the Arthritis and Osteoporosis Research Institute and the AARA Arthritis and Rheumatology Association Care Center and the Oasis Institute. A fully integrative multidisciplinary clinic in Aventura, Florida.

And on this episode, Dr. Munoz is going to take us through the second Integrative Rheumatology Pre-Conference for the Florida Society of Rheumatology 2021 conference. And of course, this started with the first ever Integrative Rheumatology Conference in the USA and globally in 2017, which was a huge success. So, now we have the 2.0 version in Orlando, and it's coming up on Thursday, July 8th. Dr. Munoz, thank you for your time. It's always a pleasure to talk with you. Excited to learn more about this pre-conference. So, what is the theme or underlying connection for this Pre-conference?

George Munoz, MD (Guest): Bill, this is an exciting event that is going to interpose conventional rheumatology approaches with the whole person integrative multi-disciplines that encompass the whole part, that whole person approach in the domains of lifestyle, of exercise, of sleep, of nutrition, diet, the mind, body connection, and also looking at pertinent supplements, vitamins, and how they interact with the microbiome and inflammatory pathways that are very dominant and important in autoimmune conditions. That's the underlying pinning of this conference that's going to be world-class with an amazing faculty.

Host: So, a whole person approach. So, you are the perfect person to be speaking at this Pre-conference. In fact, you are opening the conference with what appears to be the big overview. Tell us about that. What is the big overview?

Dr. Munoz: So, the Integrative Overview of Inflammatory Mediated Disease is the actual title of this first lecture, that's going to set the tone for the day, Bill. We're going to look at those domains that we just spoke about. We're going to look at the role of nutrition, diet, dietary patterns, how that affects inflammation, how that affects the microbiome from a high altitude perspective.

And we're gonna delve deeper into what happens with exercise or lack of it. Talk about the sweet spots in terms of not creating inflammation, but having just enough activity that it's a positive factor in terms of controlling inflammation in the body and being an asset, not a liability. We're going to overview supplements because later on one of our very talented speakers that actually follows my initial lecture, Dr. Lise Alschuler is going to really take a deep dive into vitamins and supplements as they relate to immune health and antiviral activity. We're going to look at sleep, the immunology of sleep, and we're going to look at what's the role of stress, depression, anxiety in the inflammatory patient with autoimmune conditions. And how does this affect the patient journey? What can we do to identify people who are having difficulties before it becomes a critical situation and really try and keep them from escaping into a cycle of increased pain and suffering that can be avoided by early intervention, detection and some proactivity.

So, that's the overview of the - of what we're going to talk about throughout the day. And that's how we open up this Integrative Rheumatology Pre-conference, the second one, but ever that we’ve had really in Florida and in the United States, to my knowledge.

Host: Right. Version 2.0 happening in Orlando on Thursday, July 8th. So, your big overview, Dr. Munoz, you're going to cover the whole gamut here in nutrition and diet, exercise. You're going to go over supplements. You're going to go over sleep. You're going to talk about stress and depression and anxiety and the role of all of that on inflammation in the body. It is going to be a great opening keynote from you. And then you mentioned it, Dr. Lise Alschuler is going to be following you. She is from the Arizona Center of Integrative Medicine and on the itinerary, she is going to be discussing vitamins and supplements. You mentioned supplements and their antiviral role. That's what she's going to be delving into. So why was this topic chosen?

Dr. Munoz: This topic was chosen because COVID, while it was a challenge for all of us globally, but certainly in healthcare and with our patients, we had lots of questions about how can the immune system be improved during COVID. What can people do to strengthen their immunity to protect against COVID and other viral infections? So, this became a very common theme, and we decided that since there were so much activity on the internet, with very little scientific background or scientific proof, we decided to put together something that would be helpful to physicians, patients, practitioners and bring together some of the science into a logical and a usable format to talk about specific supplements as we view them not only against COVID-19, but in terms of viral immunity in general. And what do we know? What we don't know. And what is clearly well-documented versus what seems to be more fictitious. So, we want to have that hard edge of ,what does the science tell us versus what is a fad? Because that's important for us to be able to differentiate that for our patients who depend on us for reliable, scientific, and proven approaches.

Host: That makes sense. And sounds like the perfect person to follow you after your big overview. And then it doesn't let up there next up on this world-class faculty is none other than the professorial areodite Chief of Clinical Rheumatology and Immunology at the Cleveland Clinic, Dr. Leonard Calabrese who will speak on Integrative Immunology. So, what does this topic integrative immunology mean? Because it sounds very interesting. And how is it relevant to the clinician, the care team and the patient?

Dr. Munoz: So, that was a mouthful of an introduction that you just gave on doc, on

Host: best.

Dr. Munoz: Yes, you do. And you do more than that. Len Calabrese, first of all, is a gentleman, a scholar, a genteel and you said it areodite, professorial, scientific teacher educator and you know, just a marvelous human being. He is going to speak as an immunologist, and being the Chief of Rheumatology Immunology at the Cleveland Clinic, they see tertiary care, very complicated cases that are referred from all around the United States and really globally. And his approach to this integrative immune health is very fascinating and interesting because he's looking at the immune system as its own silo of what can actually be affecting immunity, normal immune function and consequently in the same domains that we've already spoken about in the general overview; what specifically in the immune system is effected by excessive or inappropriate exercise, sleep. The role of mind body abnormalities is with respect to stress and depression, and what happens to the immune response. What happens to the auto immune response? What happens to the immune response during COVID and is that auto immune response being predisposed to what we call cytokine storm.

So, he's going to look at all these interactions, which are within the immune system and also looking at the other systems in the body that interact with immunity, meaning the neuro-endocrine systems that are part of and parcel of the reaction of the body to stress, to how and what activities can be done to bring the immune system, in an integrative fashion, to a more steady state if it is overactive, if it is underactive. And if the immune response is exaggerated, as we see, and in certain, in many autoimmune conditions that are part and parcel of what the rheumatologist takes care of in present day clinical practice.

Host: It seems really interesting. Integrative immunology and understanding what is going on and happening with the immune response or starting with your big overview view then we're going to Dr. Lise Alschuler talking about supplements and their antiviral role. We're going to Dr. Calabrese talking about integrative immunology.

And if that weren't enough, the pre-conference then pivots to focus on a fascinating area not usually discussed at traditional medical conferences, the topic of intuition. Oh my goodness. How cool is that? So, tell us about this, Dr. Munoz. We are really interested in this. Tell us about Dr. Nisha Manek. A little about her background. And this topic choice.

Dr. Munoz: So, Nisha Manek is another fascinating physician, rheumatologist, really a colleague and friend. She was one of the originals trained at the Arizona Center for Integrative Medicine as a Rheumatologist. And now is an Integrative Rheumatologist and one of her areas of expertise, of interests, of continued study and have continued education to other physicians and patients and the lay public, is the role of intuition and unseen energies and their effect on health, wellness, and disease and how this can be accessed by an individual, by a patient, by anyone as well as the clinician. So, this is a fascinating topic because we all say things like my gut tells me or I believe this to be true. I'm not quite sure why.

Using that type of phrasiology, we talk about intuition. We've all had instances in our lives where we either pre-empted and thought something was going to happen, a premonition, or we felt something to be true, but we couldn't quite prove it or say exactly why we believed something to be true that later was found out or proven to be true; but at the moment we didn't have the evidence. So, this is what we call intuition. And the role of intuition in science and healing in medicine is an area that perhaps was somewhat taboo because it's not part of the usual Western scientific paradigm of evidence-based science.

But it is something that seems to be hard wired into the psyche and the subconscious of many Western writings, including Jungian psychology. And it is also a very fascinating area to understand, to tap into and to overview as it relates to self care of our patients and how we are able to interface this concept with the classic scientific construct. So, they're not mutually exclusive, and these are topics that Dr. Nisha Manek is going to broach and discuss. She's very passionate about this area and I can't wait to hear her dissertation on this topic.

Host: Well when you say this is an area not usually discussed that traditional medical conferences, you are correct. I love how you put that, unseen energies. It's really interesting and how they can be accessed by the person. You know, when you say my gut tells me, or I'm feeling this or a premonition, those unseen energies, this is really fascinating.

And then another fascinating thing is you moved to group classes in the integrative rheumatology space. With Dr. Jose Pando of Delaware. Again, very interesting. How and why did group classes surface as a thing, if you will. How did that become a topic in this setting and is Delaware Arthritis Clinic headed by Dr. Pando and his wife a model in rheumatology?

Dr. Munoz: That is really part of the exciting direction that is being broached, not only in theory, but in actual practical execution by Dr. Pando and his wife, Catherine, at the Delaware Arthritis Center. They have an very impressive facility where conventional rheumatology is integrated with both physical and virtual classes of disciplines, such as yoga, of movement, of Tai Chi, of meditation. And he also treats patients conventionally like rheumatologists would, including the usual diagnostics, laboratory and using advanced biologic therapies as we, rheumatologists utilize for auto-immune conditions, such as rheumatoid arthritis and psoriasis and psoriatic arthritis and lupus, et cetera.

But the addition of these other disciplines and actually physically teaching it, modeling it and being able to have the concept of the clinic being a place of empowerment, the clinic being a place of education, not simply a place where one goes and things happen to them, but also for the patient to be empowered and understand that this is a place where they go and learn how to take care of themselves, how to improve their overall wellness. How to be empowered and be part of the care team, not just be passively, a patient that something is happening to them. Not something that they are part of the team and really actively participating in one's care. That's the difference. So, we're going to hear how Dr. Pando has physically done this with his wife Catherine in executing this in a community clinical model and how it works, how patients respond and what has been the results that they've seen in their patients with auto-immune conditions where this approach is taken. So, it's going to be very exciting to hear what their experience is. And then perhaps others may follow this type of pattern and approach in their own clinical practice to any degree that's possible.

Host: This approach of the clinic being a place of empowerment really sounds like it would be a place where people could really start to heal themselves. So, being a model for this type of empowerment at the clinic sounds really interesting and it could be informative to a lot of people. So, then you close the clinical section with a physical therapist and athletic trainer, Frank Musumeci, who is highly qualified and experienced. So, what will Frank Musumeci focus on and teach these extremely accomplished rheumatologists? And why did you include this in the pre-conference?

Dr. Munoz: So, it's fascinating because the modern day rheumatologist typically is coming from fellowships where what we call tertiary care centers, which are teaching hospitals and attached many times, mostly to university centers where difficult cases are referred to the centers that the fellows get trained in best approaches scientifically on how to treat these very complex autoimmune conditions. And what's happened to medical education many times is that the scientific minutiae and mechanisms of action of medications and how they interact with the immune system and why we choose one drug over another for a specific disease states; that is pounded into the psyche, the memory, the education, backwards, forwards inside out to the fellow, to the house staff, the doctors in training, residents, interns and to the medical students, but what is many times left out, forgotten, devoid, are some very basics in the combination of both physical exam, observation and understanding the body chain of injury in biomechanics.

And as skeletal physicians, rheumatologists are not just auto-immune specialists looking at the immune system and the disease state, but we are also skeletal physicians who think, or should be thinking at a very high level. While we are not orthopedists, while we are not neurologists, while we are not necessarily sports medicine practitioners; we are skeletal physicians with our expertise in the immune system, but yet we have to have a foot, both in the immune system and in the biomechanics of the body, because other forms of arthritis, such as osteoarthritis, bursitis, tendonitis affect the structure of the human body. And if we understand biomechanics and if we understand proper movement, and if we understand the ability to recommend proper exercise versus the improper form of movement and exercise; we can actually improve, and diagnose and treat conditions for which surgeries have been recommended or are being considered. Simply treating them by recognizing the problem, creating a proper exercise and physical therapy plan, correcting imbalances and preventing unnecessary procedures.

So, the reason this has been included is that we really should not forget our basics in rheumatology, as far as structure and function. Yes, the immune system is critical. We've spent most of the day talking about it, but this is an area that I felt needed to be reemphasized, retaught, or perhaps taught for the first time too many. And I have one of the most amazing educators, Frank Musumeci, who works at the Pritikin in Miami; who's worked with athletes with the Miami Dolphins, with the lay public. In fact, he was my physical therapist about 25 years ago when I was rehabbing from an injury. And I've known Frank this whole time, we co-manage patients.

And he has really developed a passion for education, in this space. And so I really felt it was essential to share his knowledge, his wisdom, and his approaches with our rheumatology colleagues. And he's really gonna look at two areas because time is going to limit it two areas the low back, the lumbar spine and shoulder specific specificity in terms of dysfunction and exercises that everyone in rheumatology should be aware of and how to approach this on a day-to-day basis.

Host: Right. Well, under the heading of whole health, big letters is exercise. So, when you talk about the proper form of exercise and therapy and how important it is, this really does need to be included and then correcting imbalances. And then for the goal of limiting unneeded surgeries or procedures if you will. So, I mean, that's kind of what we're all looking for are these non-surgical interventions and exercise certainly does play a big part of that. And then focusing on the low back and shoulder you're right, that's where most of us have our problems. And then to round out this great Pre-conference, you’re going to go into how to pay for a number of the integrative modalities discussed through health insurance and answer the question. Why would insurance carriers want to pay for these services such as wellness, anxiety, depression, lifestyle and prevention. Are there codes that cover these? Talk to us about that Dr. Munoz.

Dr. Munoz: I'm glad you brought that up, Bill. This is going to be the piece de la resistance, if you will, because a lot of times physicians they'll say, this is all great. And it's good to know. And at least you're telling me a little bit about how I can begin to utilize this and integrate it, but how do we get paid for it? That is always a very practical, fair and honest question that physicians will have because this takes extra time, takes extra education. And luckily we're going to have Gina Savedo, who is a reimbursement consultant for the Florida Society of Rheumatology talk to us about specific codes that are new, that we can look at billing for time which is a certainly an option, since a lot of these services will take more time. And if you spend more time talking about lifestyle, about prevention, about wellness, about exercise, about disease prevention, then with the new ACA requirements and mandates, the affordable care act, which is now quadruple aim, which includes improvement in experience not only of the patient, but also of the practitioner, that the ability to spend this time and be properly and appropriately compensated for it, is what has been needed. And we now have some solutions and that's what's going to be discussed. I might also add that because of the pandemic, the use of virtual Telehealth became a thing to borrow an expression that is more colloquial now. And the use of technology, leveraging technology in these areas of integrative approaches in both singular and group classes are going to be discussed and what the billing nuances in terms of CPT coding and what practitioners may want to do on an individual basis, depending on their practice setting.

So, we're really excited about that. You know, Bill I, in the excitement of giving you some of this background, I did forget that there's actually one more lecture that was missing, which was a late edition. And it's entitled the Gut Joint Access Microbiome Science And Integrative Interventions in RA and Inflammatory Diseases. Now that's a mouthful and you know, just breaking it down, gut joint access, gut is the GI gut, joint is obviously joints, access microbiome science. So, there's a connection between the bowel and joints. And between the microbiome, which we've talked about, which is the good bacteria, bad bacteria balance and in the GI tract and the skin and the respiratory tree.

But we're going to talk about the science and what are some integrative interventions that are used in rheumatoid arthritis and inflammatory conditions that can affect that gut joint access microbiome immune response to improve, to decrease inflammation and to be part of the solution and not the problem.

So, towards the end of the day, and right before Gina Savedo gives the How to Bill for Integrative Care, I'll be finishing the day with this connector of the guts, the joint, the microbiome, the things we've covered throughout the day. And I got to tell you, the colleagues and speakers that we have are world-class. Lise Alschuler is coming from the Arizona Center for Integrative Medicine and the University of Arizona. Len Calabrese needs no other introduction as the Chief of Rheumatology at the Cleveland Clinic. Jose Pando is an NIH trained Fellow of the American College of Rheumatology, Board Certified Rheumatologist Internists, Integrative Rheumatologist. Nisha Manek, also Board Certified Internist Rheumatologist formerly practiced at the Mayo Clinic and fully trained in Integrative Medicine. So, between those individuals, Frank Musumeci, with his unusual and very experienced background in biomechanics and physical therapy, athletic training, sports medicine, injury prevention, and rehab, and his ability to lecture and teach as an educator really puts together a quite a grouping of individuals that are focused on this integrative approach to rheumatology and how it combines with best practices in advanced auto-immune approaches to our patient in 2021.

Host: Joint access microbiome science, another fascinating session at the conference. Wow. This has really been fascinating, Dr. Munoz. So, thank you so much for updating us and reviewing this fantastic FSR Integrative Pre-conference. It is going to be fantastic. Once again, it is the second Integrative Rheumatology Pre-conference for the Florida Society of Rheumatology. It is in Orlando on Thursday, July 8th, headed up by Dr. George Munoz. We love it. We love all the work that you've put into this. The lineup is fantastic. We can't wait to hear your big overview as well. And thank you so much for leading the charge as medicine is changing for the better, including whole person approaches and it's people like you that are making us all aware of this whole person approach and the importance of it. So thank you Dr. Munoz and good luck at the conference. I know it's going to be great.

Dr. Munoz: Thank you, Bill. Thank you for your time. I do want to put one last plug and thank you without forgetting our program director for the whole meeting, the 2021 Annual FSR meeting, which follows this pre-conference, which is Dr. Olga Kromo, the outgoing president of the Florida Society of Rheumatology currently training herself, in integrative medicine at the University of Arizona Center as a Fellow and who through her leadership was a big factor in pushing forth the conference. So, we want to thank her, her vision, her oversight, and the rest of the conference that follows. The conventional conference, July 9th through the 11th at the World Center Marriott in Orlando is going to be fantastic as well Bill.

Host: Got it. Thank you so much. This Pre-conference is going to be a spectacular, so thank you so much for talking to us about it today. We appreciate it. Thank you again.

Dr. Munoz: Thank you Bill. Till the next time.

Host: Yes. Until the next time. Thank you, Dr. Munoz. And this is the Oasis Rheumatology podcast featuring Dr. George Munoz. And for more information. Please call 305-682-8471, that's 305-682-8471. Or visit, theoasis institute.com. Thanks for listening.