Episode 91: Integrative Approaches for Osteoarthritis with Dr. Carla Guggenheim, DO

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 Dr. Carla Guggenheim, DO:

So we used to think it was just a disease of mechanics. And we thought that it wasn’t inflammatory because there were no neutrophils in the synovium. Or in the, in the synovial fluid or in the synovial membranes. We thought it was just bad biomechanics. So that’s not how we think about it anymore. It’s much more than that. Although certainly bad. Biomechanics plays a role. But there’s lots of things that play a role in obesity, which changes mechanics and that’s a huge problem across the world. inactivity, stillness this turns out to be really bad for you. overactivity can be bad. We don’t work people to death anymore in this country. But I’m sure there are countries where people get work today. Trauma, particularly if it crosses a joint or tears of tendon, where you lose the biomechanical integrity or nutrition. I mean, this is a you know, as living organisms, we have to put in the things that help us rebuild our bodies because we’re always tearing it down. For instance, bone turns over completely every 10 years. You know, it’s not just your hair grows and you cut it off your skin turns over every month, your bones every 10 years. So if you don’t nourish those cells so they can eat while you’re sitting still. Your joints aren’t gonna last.

Dr. Andrew Wong:

Welcome to another episode of Capitol Integrative Health podcast. I’m your host, Dr. Andrew Wong:, and today we’re bringing you a great conversation with Dr. Carla Guggenheim, a Board Certified rheumatologist southern Indian dancer, Lavon, movement analyst and scientist. This conversation is about root causes of osteo arthritis, which we know affects millions of people worldwide. And Dr. Gubin Guggenheim has personal health journey. Osteoarthritis is a prevalent and debilitating condition that affects millions of people worldwide, and causes joint pain, stiffness and reduced mobility and quality of life. In this episode, we’ll delve into the complexity of the osteo of osteoarthritis, exploring its underlying causes, and innovative treatment approaches. Dr. Carla Guggenheim brings a wealth of experience and a compassionate approach the conversation, whether you’re personally affected by osteoarthritis, or interested in learning more about this prevalent condition. Please join us for a thought provoking discussion with Dr. Carla on osteoarthritis and the holistic path to improve joint health.

Welcome, Dr. Karla to the podcast. Thanks so much for coming on today.

Dr. Carla Guggenheim, DO:

Oh, you’re welcome. It’s good to be here. Thank you.

Dr. Andrew Wong:

So the Dr. Carla Guggenheim, a functional medicine practitioner, and an expert in osteoarthritis, which is what we’ll talk about today. But before we do that, we’d like to just kind of start by if you could tell our listeners a bit about what drew you to become a doctor and then a functional medicine practitioner and what do you enjoy most about what you do?

Dr. Carla Guggenheim, DO:

Oh, wow. I come from a very dysfunctional drug addicted family. And I danced, they, my mother dropped me off at the Dance School. So dancing was my life. And all I ever wanted to be was ballerina. And, and I, I’m a third generation physician, but I never never expected to do medicine. Never wanted to. I did help my dad back in his office. Back in the day when a 12 year old could go into an EMT office and setup press T treatments and plate petri dishes with snot and the autoclave. I did I testing and I did hearing testing in his office as a tween and a team.

Dr. Andrew Wong:

Did he pay you or not? Yeah, I was helping to help him out. Yeah, yeah.

Dr. Carla Guggenheim, DO:

And dot dot dot I was the I was the San Francisco Ballet when I was 16. And, and I really, they told me I could have a scholarship for the year I was gonna drop out of high school. And so I called my parents up. I said, I’m dropping out High School. I’m gonna stay at the San Francisco Ballet and they said how will you pay rent and I said we will say any money? And they said, no. That’s why I graduated from high school. I was. But my contract weight is 110. And I was five foot four and a half. Not 110. My contract was 100. And I was five, four and a half so, and I was solid muscle, and I. So I never really had anorexia, I was hungry, but I didn’t eat whatever. I really liked San Francisco. And then, after high school, I married really poorly. And and that was brief. And then I started studying it. I went to New York to seek my fame and fortune, which didn’t exactly work out but I met a dance style called Bertha Natyam, which is from South India and just fell in love with it. I started doing but at an ashram in 1971 or 72. And that was that was just really fun. I studied art and architecture at NYU, I studied aesthetics at Columbia, Barnard. I mean, it was I was like, in a candy store. It was so fun. I’m not sure why. I mean, that’s not my heritage, but I, I love it. i It’s not cultural appropriation. It’s cultural love, I’m in love with South India. So and then I, you know, certain point, like, you know, you got to get a job. So, like a real job. I also did dance rotation, but I, so I got a job teaching dance and dance history at Sonoma State in California. And married again, again, disastrously, but briefly. And I took science courses in the mornings, because I didn’t have enough to do and I liked science. And I got a degree, and when my marriage fell apart, and went to a friend of mine, the chemistry department, I said, I don’t know what to do with my life. And he goes, Well, you have a isn’t all the pre meds, classes once you get to med school. I mean, I’d taken all kinds of embryology, calculus, you know, whatever. Yeah. I was pretty depressed. And I thought, well, that sounds like a good idea. And I played out in,

Dr. Andrew Wong:

though, and the rest is history. So just the rest

Dr. Carla Guggenheim, DO:

is history. But I went to a do school. And I kind of got through do school, I thought, you know, I don’t know how much I liked this, you know, so I decided to do a really wonderful program at Michigan State University here. That combined manual medicine with a master’s degree in bioengineering, and I really liked bioengineering. So I, I worked. So in the middle of my rotating internship, that program died and went to heaven, and I had to do something else. So I did internal medicine, because they were the nicest, smartest people in town. That’s how I picked it. And I think when you’re picking residencies, you shouldn’t go, Oh, I’m gonna be a neurosurgeon and make a lot or whatever. You know, you should pick it with people that you like, and the kind of life you want to have, like, you know, do you like short stories work in the ER, like last? Go into rheumatology?

Dr. Andrew Wong:

Well, I’m an internal medicine doctor. It’s a bit like a piece of buttered bread now, but thank you, thank you for internal medicine. Yeah,

Dr. Carla Guggenheim, DO:

yeah, my. Yeah, my view of medicines change.

Dr. Andrew Wong:

Yeah, yeah. I’m kind of curious how you have combined. I mean, we can get into this here on our podcast episode today with you, Carla. But how you’ve combined your love of South Indian dance, and I know you have the Taj Mahal of books behind you a collection of dance books with medicine, you know, how do you combine those, those two, you know, passions of yours?

Dr. Carla Guggenheim, DO:

Well, one of my, one of my colleagues at the University of Iowa, I used to go all over eastern Iowa doing outreach clinics in rheumatology and he was Indian and he came to one of my performances that we did in this little town that he was in and he said, I get it. Medicines your hobby.

Dr. Andrew Wong:

Yeah, that’s, that’s very perceptive. Yeah. Yeah.

Dr. Carla Guggenheim, DO:

Yeah, he said, You’re just doing this. Pretty much. I mean, although I do I do like I did like rheumatology. I like rheumatology Part and Part of the reason And I like to rheumatology was because I thought, you know, most of these, this is totally my ignorance as an internist, most of these diseases are self imposed, like I got done with internal medicine residency. You know, people smoked, drank a crap, were massively overweight and sat around watch TV. And I thought, oh my god, I’m going to, I’m going to see these people all day long.

Dr. Andrew Wong:

And that was, that was before Netflix, right? And now now you can binge watch stuff, right?

Dr. Carla Guggenheim, DO:

Yeah. And I thought, I’m, I’m gonna give these people drugs for this

Dr. Andrew Wong:

for self imposed, or lifestyle, basically, lifestyle issues, lifestyle versus lifestyle change.

Dr. Carla Guggenheim, DO:

And I thought, I just don’t see this. So I went to my director who was wonderful. I said, Pat, I can’t do this. I can’t do this. I don’t know what to do. I’d finished the work for my master’s degree in bioengineering. But he said, wanted to apply to rheumatology. And they probably support your research. So I went, Oh, that’s great. So that’s what I did. And I went to the University of Iowa and did. Did rheumatology at the University of Iowa. And fortunately, there was an incredible artist who lived two doors away from me, from South India, who was amazing. So I danced, I thought, I’m going to Iowa. And, you know, so I also reconstruct French baroque dance manuscripts, and I, I love French baroque dance, although it comes out of a horrible culture of Louis the 14th. But anyway, I I danced with the Baroque orchestra. So like, on the weekends, I was dancing with Baroque Orchestra.

Dr. Andrew Wong:

You’re practicing medicine and you’re doing dance as well dance. And then how did you get into functional medicine? Or what was the entry there?

Dr. Carla Guggenheim, DO:

My daughter went to naturopathic school in 2003. Was that Portland OR? Yeah, she went to the Portland school. Yeah, she, she went to the Portland school, and she’d gone to read and they don’t have great inflation and she couldn’t. Anyway, she was very drawn to, to naturopathic medicine. Yeah. And so she went there. And she would come back to Michigan for vacations and visits and whatever, and hanging out in the clinic. And, you know, very perceptive she would say, you know, I, I don’t think your patients really understand what you tell them. You’re using, you know, your words that are too big. I said, we’re wanting you to study it. Why don’t you sit down with patients? I always gave them a copy of their note. This is before, you know, EMRs? Yeah. So I give them a copy of your notes. So she would take them in a room and say, What did Dr. Guggenheim tell you you had? And they say, I don’t know what medicines that she put you on. Our you know what? And I’ve, and she’d say, Well, you can look at your note and read it. Oh, I forgot my glasses today. 15% of those patients were illiterate. The illiteracy rate here is pretty high.

Dr. Andrew Wong:

Yeah. So can’t can’t assume that people are on that grade level to read the read the night. Yeah. And I

Dr. Carla Guggenheim, DO:

took I took Medicaid so and I worked for myself because I’m allergic to perfume.

So the patients couldn’t wear perfume. The staff couldn’t wear perfume. Nobody could wear perfume. But anyway, then, and then she gotten into school a little bit longer. And she kids she said, you know, man, I think there’s some things I could do know that might help your patients. So it started really insidiously. I think the first thing we did was Magna louvers, which is, you know, magnesium with Tori. That’s just amazing stuff, you know?

Dr. Andrew Wong:

Yeah, but those nutrients are really great. Yeah.

Dr. Carla Guggenheim, DO:

So and then she graduated, she did her residency, dot, dot dot and then she’s like, why don’t you start residency for nature paths. They need postdoc training. So I started our residency for nature paths, which was complete it’ll be 100% self funded. I just paid him. I guess that’s what you’re doing. Yeah, yeah. Yeah. So I think it’s the only room naturopathic rheumatology residency there ever was in the world. So, yeah. And I had some really, really wonderful residents. And so, and one of my residents turned me on to the to IFM and the functional medicine thing. And I went through I went through all the courses. And I had there immunology was at that time, incredibly weak.

Dr. Andrew Wong:

It’s okay, we can say that. It can it can, things can always improve. And I’m sure they have so right.

Dr. Carla Guggenheim, DO:

I’m sure they have. So I, I wrote them a letter and I went through a one hour lecture and sent them a 2020 page type letter with citations about what was wrong with that one hour lecture. I said, You can’t do this and give people certification. But anyway, they I did talk for them at one of their annual conferences, I edited one of their textbooks on immunology. And I wrote a chapter in it as well. And I’m not, I didn’t get the polite gene, you know. So

Dr. Andrew Wong:

well, yeah, you’re being the change, right? That’s the Gandhi quote, right? You’re you’re being the change seeing something you’re pointing that out.

Dr. Carla Guggenheim, DO:

Right. So I, what was that leading to?

Dr. Andrew Wong:

What it really sounds

Dr. Carla Guggenheim, DO:

like so I decided not to do the I decided not to take the exam. Because so many of the people that were in my little corner of the field I wouldn’t know how to answer the questions. So I decided not to do it. And I just kind of pulled back and but I did learn a lot. And I I learned some truly transformative things that I fm.

Dr. Andrew Wong:

Yeah, it’s definitely been a great education. And we have a lot of practitioners here who have gone through a lot of the training and certification even just kind of curious about kind of how you got into a while. I mean, I guess that’s more of an obvious question. But as a rheumatologist, now we’re dealing with, you know, across the country in the world, really osteoarthritis? If you could talk about osteoarthritis. That’s kind of what our sources for today. For anyone that’s not familiar, what is the technical definition of Stuart rightous? And then how does it impact people on a day to day basis?

Dr. Carla Guggenheim, DO:

Yeah, the impact of osteoarthritis is huge. Our ideas, the concepts of what it is, are changing. And so we used to think it was just a disease of mechanics. And we thought that it wasn’t inflammatory because there were no neutrophils in the synovial. Or in the, in the synovial fluid or in the synovial membranes. We thought it was just bad biomechanics. So that’s not how we think about it anymore. It’s much more than that. Although certainly bad, biomechanics plays a role. But there’s lots of things that play a role in obesity, which changes mechanics and that’s a huge problem across the world. inactivity, stillness, this turns out to be really bad for you. overactivity can be bad. We don’t work people to death anymore in this country, that I’m sure there are countries where people get work today. Trauma, particularly if it crosses a joint or tears a tendon where you lose the biomechanical integrity. For nutrition, I mean, this is a good you know, as living organisms, we have to put in the things that help us rebuild our bodies because we’re always tearing it down. For instance, bone turns over completely every 10 years. You know, it’s not just your hair and grows and you cut it off your skin turns over every month, your bones every 10 years. So if you don’t nourish those cells so they can eat while you’re sitting still Your joints aren’t gonna last.

Dr. Andrew Wong:

So osteoarthritis as a degenerative joint disease and and I think what you said about how it’s related to inflammation is really timely because I remember also learning in medical school gets bone on bone and but then when you think about sort of OA osteoarthritis versus rheumatoid arthritis, both of them have at the end of that, you know, suffix of that word itis, which is inflammation. So even in that word, it kind of implies that,

Dr. Carla Guggenheim, DO:

well, I think the word is just inaccurate. I think the word is, well, is there there are many inflammatory components to it, but they didn’t know that back when they called it itis. You know, there’s many, many misnomers in medical nomenclature.

Dr. Andrew Wong:

How does so how does inflammation exactly play a role in the development and progression of osteoarthritis?

Dr. Carla Guggenheim, DO:

It does it through a deeper kind cytokines and things like that. So similar to like another rheumatic disease, Paulina algae rheumatica, the the inflammatory cells come, they d granulate. And they leave. So now, you know, only recently have we started looking at the cytokine profiles in those tissues, and figuring out what roles to play and mast cells also, you know, mast cells or resident cells, and you can’t test them by doing a blood test and seeing how many bloods how many mast cells are circulating, you actually have to biopsy the tissue, stain it with a special stain, and then count it takes, there’s not a lot of places that do that even look at mast cells. So but they’re, they’re like little bombs, they they’re just full of cytokines that cause allergy getting the inflammation and the inflammation in a joint doesn’t look like the inflammation in say, your gut. But masks that a lot of mast cells live in the gut, they can live in the skin and they can cause all kinds of problems. But anyway,

Dr. Andrew Wong:

it can mess those living those scenarios synovial fluid as well, or?

Dr. Carla Guggenheim, DO:

I don’t think so. Well, you know,

Dr. Andrew Wong:

they may migrate there for sure.

Dr. Carla Guggenheim, DO:

They they may migrate and leave. I I actually I know they’re implicated somehow in osteoarthritis, and I don’t know the I’ve been ill for almost two years. So I’m kind of out of touch with the current research in mast cells and osteoarthritis, but they are implicated. And I don’t And since they’re resident cells, they probably take up space there but you people don’t look for him. You have to test them with CD 19 stain.

Dr. Andrew Wong:

It’s kind of esoteric. It’s hard to it’s

Dr. Carla Guggenheim, DO:

only esoteric and there’s several different camps of mast cell people. I belong to the Afrin mouldering group, and then there’s the Aiken, the Aiken Milner group, and Milner is not Milner Aiken is actually near me. He’s at the U of M. So he’s an hour away, but I’m not in his camp. He’s, he’s kind of a real allopathic mast cell guy he wants. He says, If you don’t have an elevated tryptase You don’t have mast cell activation disorder. But you know, if you’re, if you’re tryptase is 7.9. He goes, No, they don’t have it. But if you treat them like they do, and they get better, are you gonna say? So

Dr. Andrew Wong:

we were friends with Dr. Efrain. So we’re I guess we’re more in that camp, I would say.

Dr. Carla Guggenheim, DO:

Yeah, yeah, we’ve we are really in the Afrin camp. So my daughter and I both presented there and yeah, great, great. Yeah. in that camp,

Dr. Andrew Wong:

and then what kind of nutritional considerations you said diet influences inflammation and joint health. What kind of nutritional considerations would you I guess, you know, consider for someone with osteoarthritis.

Dr. Carla Guggenheim, DO:

Simply put, eat mostly plants, mostly organic. High on the tricky bits and you know, the greens and yeah, yeah. But I live in Michigan, and this is, uh, this is meat counter. It’s I’ve and I think for the first 15 years I was here I kept telling people you know, you plans and I and slowly people started going, you know, actually feel better and more plants but it’s, it’s, it’s been a hard sell here.

Dr. Andrew Wong:

Really when you say meats What about fish or omega three pastured, you know, meats and stuff?

Dr. Carla Guggenheim, DO:

Yeah, those are those are all good fish. I mean, you gotta be careful where you where you get them. I think the 13th worst environmental disaster was in Michigan 1973 74 And it put polybrominated bifen Olson to the Great Lakes. And so a lot of my patients eat the great they fish on the Great Lakes and they eat the Great Lakes fish and it’s like

Dr. Andrew Wong:

so so all of the lakes have PCBs or

Dr. Carla Guggenheim, DO:

P BBs poly? BPs. Okay. polybrominated bye for now. Yeah. Okay. Yeah, it’s a hideous story. absolutely hideous story of how it happened. And it was partially due to illiteracy of the people that worked in a chemical chemical factory. But anyway, so not to recommend eating the fish around here and but you got to be careful with standard salmon that has mercury in it. I don’t

Dr. Andrew Wong:

know hard to know what to eat now, you know with Elba toxins.

Dr. Carla Guggenheim, DO:

It is hard to know what to eat and you can but you know, when I was a kid, we had a farm, kind of a hobby farm and we had a big garden, two acres of garden. That was right next to the gravel road getting in. And once a year we poured used mortar motor oil on the road. And then we ate the vegetables right next to it. Seemed I mean, yeah. Not a good idea. Yeah,

Dr. Andrew Wong:

hindsight is 2020 I guess on that, definitely recommend organic as well. And, and definitely, I mean, it sounds like there’s a lot of different root causes. You mentioned a few things being sedentary or moving to too much where maybe there’s maybe there’s some overuse, would that be sort of an accurate statement on that?

Dr. Carla Guggenheim, DO:

Yeah. Overuse, overuse, and just, I mean, who’s got perfect biomechanics? I mean, you know, even running, you know, a marathon is probably not a real smart idea, because I, I’ve never looked at how marathoners age, but

Dr. Andrew Wong:

I do know, a lot of marathon runners. Apologies for the people that we know that do run a lot of marathons. But I think at some point, you know, there are some people that are more susceptible to that maybe there’s some ongoing inflammation in those people, but definitely I’ve seen some people were they need like hip replacements and knee replacements and rice. right with that. The other thing that you know, we like to talk about too is because of osteoarthritis has some degree of you know, inflammation and cytokines and, you know, different kinds of things that are affecting the pathogenesis of osteoarthritis. But then also, we know that from studies that taking nonsteroidal anti inflammatory drugs, even though they may increase the person’s pain relief and reduce the, you know, pain, I believe we know that that also can accelerate the development of degenerative joint disease, right? If if people are taking long term NSAIDs?

Dr. Carla Guggenheim, DO:

Yeah, to be honest, I didn’t I hardly used insets and I think a lot of rheumatologists are in that camp. I mean, how many gi bleeds Do you want to see for instance,

Dr. Andrew Wong:

they’re in the camp of using the do not sound okay.

Dr. Carla Guggenheim, DO:

At least where I trained and where and how I practice. I just, you know, I do topical boltaron People can get stuff over the counter. And then Celebrex and Baxter I even forget the name of it Bextra and yeah, there were those those docs, the Cox two inhibitors,

Dr. Andrew Wong:

increase heart heart attack risk and things like that. Yeah,

Dr. Carla Guggenheim, DO:

the only reason still, I guess I shouldn’t use names Celica obviously they still in market because it isn’t a very good Cox two inhibitor. It’s a little safer.

Dr. Andrew Wong:

Oh, I mean, I think just anecdote that you see less people taking that long term. But there are still people taking it, you know, over the counter, you know, sometimes it can be more of a long term thing, sort of, even unintentionally, if it’s sort of over the counter and needing some pain relief. Good. I’m glad to hear that, you know, maybe that’s not as prevalent now. I don’t

Dr. Carla Guggenheim, DO:

know. I’m kind of an outlier, I think, especially now since you know, medicines gotten so politicized and so divided.

Dr. Andrew Wong:

While you’re practicing functional medicine, yes. We hope to make more mainstream and we’re more accessible, more common. Yeah. What About other nutritional supplements or herbs, anything like that, that you have been using in your

Dr. Carla Guggenheim, DO:

luteolin and quercetin, okay. And a lot of magnesium. We tell people to try glucosamine or glucosamine with chondroitin, and they take it for three months or six months. And if it doesn’t work, don’t waste your money. The problem is a lot of that data just isn’t very good. You know, you do a trial for six weeks, that’s a ridiculous length of trial to do. And I’ll see arthritis, which is a disease that progresses. So my daughter’s been using Janiculum gene Nicollet blocks for knee OA. And they do that in the pain. She she’s actually a clinician in the Pain Center at OHSU, okay, and she says the genetic, you know, some patients just won’t walk because their knee OA is so bad. And these Janiculum blocks take the pain away, they’ll walk again. And once you start walking, the cartilage only gets hydrated and nourished if you walk. Because it’s, you know, it’s a little sponge in there, you got to apply that pressure. So if you’re not applying the pressure, then you don’t get the you don’t get the perfusion of nutrients into the cartilage. And that’s it. It’s, you know, it’s vascular in a very small part around the rim. And so you have to you have to push it in. And she has she had a patient that was ready to go to a nursing home, they did a genetic of a box and walked again. So it’s one patient, but they are, you know, I don’t know if you do geniculate blocks, but they

Dr. Andrew Wong:

know is it common? I don’t know that. That familiar with that?

Dr. Carla Guggenheim, DO:

I don’t know. I don’t know how common it is. But she’s found it incredibly helpful.

Dr. Andrew Wong:

That’s great. And then like you said, it’s a huge point to the movement is huge to stimulate the vascular system and cartilage. That’s that’s another huge point, too.

Dr. Carla Guggenheim, DO:

Yeah. Let’s see if I’ve gone through the questions.

Dr. Andrew Wong:

I think manual therapies would be another you know, what is the role of physical therapy, chiropractic care, osteopathic manipulative therapies,

Dr. Carla Guggenheim, DO:

I, I am not terribly fond of manipulation alone as a therapy, I think in conjunction with movement, and this is coming from my dancer part, right? That movement moving should be healing, that you can learn to move in a way that nourishes you. That said, I can tell you, that’s hard. That’s really hard. I happen to have done a lot of work before I went to medical school in movement analysis, all kinds of movement analysis from an dancers standpoint and an expression and that you you know, like, just as you look at me, this shoulder is kind of funny, right? I mean, and it moves weird. I mean, it was moved really different than my other shoulder, right? This has been pretty massively operated on so I fell and tore it apart and the tenants started popping off but, but I’ve learned to, I’ve learned to move it again. And I’ve just had a horrible trauma to it. So and then there’s some other underlying things that that go into causing osteoarthritis and, and a big one is hypermobility, joint hypermobility, because those joints, they just, they just don’t stay in exactly the kind of sub Luxe, maybe not dislocate, but they slide on parts of the rims of things that were they shouldn’t be and then those rooms were out. I tell all my patients go 70% of where you can go.

Dr. Andrew Wong:

Okay, that’s that’s really good advice. Don’t explore

Dr. Carla Guggenheim, DO:

the edges. And as a ballet dancer, and as a gymnast. You spend your days exploring the edges of where you can go

Dr. Andrew Wong:

that’s where the injuries happen more of the edges, right? And then tying it back to us right is you know, we see that knew that this the culture is often very competitive, like, Okay, if we can run a 10 minute mile now we’re gonna run a nine minute run to a minimum, I want to beat this other person and I want to place a little higher. And this is something that the mindset shift, my mindset shift is required to really you know, put Check the joints. And, you know, in addition to hopefully enjoying the sport of choice better,

Dr. Carla Guggenheim, DO:

what you can override it with the pleasure of winning, of how you would do it. If you have that goal to win, you know, you can override your body sense.

Dr. Andrew Wong:

So I think what you’re saying is that short term gains may lead to long term pain. So that sort of thing if someone is trying to compete all the time and overusing the body. Yeah. What about acupuncture? Have you had experience? Either referring or personally with with acupuncture? And maybe Mind Body techniques to like meditation? How do they help with pain management with arthritis?

Dr. Carla Guggenheim, DO:

Acupuncture is pretty incredible. Particularly electro acupuncture, but I think I’ve had personally a lot of acupuncture, and for a whole variety of reasons, not just actually not free for the OEI. But for other reasons. I’ve had acupuncture and I’m definitely a fan I think. I don’t know. I don’t know, I can’t talk in detail about the techniques. But I think balancing the meridians and putting wavelengths of electricity in that are conformed is right. I think they’re really personally helpful. Acupuncture is not licensed in the state of Michigan insurance doesn’t pay for it. And so it’s really for rich people. Which is really, really unfortunate. And I never learned acupuncture. So

Dr. Andrew Wong:

yeah, acupuncture, licensing, I think varies quite a bit from state to state and have certain states where we’re doctors can be acupuncturist, other states, we’re only acupuncturist that have gone to acupuncture school can be acupuncture, it’s kind of an interesting landscape there. I do have a little bit of medical acupuncture training. And in Maryland here, it’s sort of a mixed kind of field where we can work together in our clinic, we work together, we have licensed acupuncturist who do most of our you know, acupuncture, but I agree, it’s really great. And there’s a study by Dr. Berman here in Maryland, it talks about knee osteoarthritis, and how acupuncture is effective for that. I think that was back in the early 2000s. Yeah, did that study? That’s a pretty well known one. Well, I know osteoarthritis, really, it seems like just to recap, there’s there’s a bunch of, you know, points here. But going into testing, I do want to talk a little bit about testing in terms of functional medicine. And I don’t think we can get away from the functional medicine topic without talking about testing. Do you think about testing for people with OA? Do you do testing, like functional testing, or what? What kind of lab analyses or other analysis or looking at for people with OA?

Dr. Carla Guggenheim, DO:

I’m going to backup because we skipped over something that I think’s really important. And that’s good. But yeah, let’s, let’s not skip it long before testing history. So getting a history that to me, that was you know, going through medical school and felt that residency and fellowship were, I just didn’t get the whole hit. I mean, we got the history of presenting illness, and the things that led up to it, and then you know, that that, but the functional medicine history is just so, so important. You know, and it gives you so why, I mean, you’re all functional medicine, people. So, did your parents love each other? Did you have enough to eat when you were a kid? You know, was there violence in your home? Huge? Yes, you know, these things are huge. And so when you look at somebody who’s had the kind of traumas that like, like how much you know, how am I going to organize this? So for me, as a rheumatologist, history and physical have been, you know, a whole lot of it. But once I met the functional medicine history, it’s like, this is so important, the functional medicine history. And then the next thing of course, is physical exam. So when somebody comes in with a sore knee, you don’t look at their knee and send them home. I and I had all my patients on dress, and I would say just strip to what you would wear to the beach. And I’d watch him do it. I didn’t have the MA give him a gown going room. I would say it’s part of the physical exam. You learn all lot watching people dress and undress, you know,

Dr. Andrew Wong:

oh, that’s nice. That’s nice. You you actually watching them undress and you can actually see how they do that. And that can tell you

Dr. Carla Guggenheim, DO:

like how, Oh, you got away in your left hip. I mean, I had half more than half the diagnosis done watching undress.

Dr. Andrew Wong:

That’s really Yes, because it’s a functional movement.

Dr. Carla Guggenheim, DO:

I had a long hallway, my office said, Walk them up and up and down the hall, I’d walk behind him, I’d walk beside them, and I go a little Varus in that knee, you know, that’s not hitting on the right. Places or so there’s history, observation, and then the physical exam. So I think one of the things even in do school, we never learned to do a comprehensive joint exam, which is mind boggling.

Dr. Andrew Wong:

That’s so surprising, especially in do school. Well, yeah, it’s very surprising.

Dr. Carla Guggenheim, DO:

But I have, I had a patient who became a co presenter with me, a she’s an internist. And she. And she rotated she rotated with me long after she’d become an internist. And we did some videos together and gave some talks. And she, I taught her how to examine the knee to see if it was hot. And she was teaching, omm at Michigan State. She had no idea.

Dr. Andrew Wong:

I see what you’re saying.

Dr. Carla Guggenheim, DO:

She had no idea. So I’m going to demonstrate it on my elbow, you have a knee and you run your, the inside the volar part of your wrist, up the shin, and onto the top of the thigh like this. If the knee is the same temperature as the shin, it’s hot. And there may be more than osteoarthritis and then knee.

Dr. Andrew Wong:

If the knee is the same temperature, you’re saying the knee should be cooler temperature colder or be

Dr. Carla Guggenheim, DO:

called. The elbow should be called the shoulder should be called I mean, but okay. Yeah, those big hips aren’t because they typically have a lot of fat on them. And you’re pretty far from the joint when you’re

Dr. Andrew Wong:

out there. Check out my own joint now after this. No, it’s

Dr. Carla Guggenheim, DO:

yeah, it’s really easy. I mean, I think I can get my leg up high enough. Yeah, you just hold it with this one. You go up the shin on my knee is much colder. See that you just

Dr. Andrew Wong:

my my knees seems colder. So I think at least for right now, if I probably have we don’t have osteoarthritis. So

Dr. Carla Guggenheim, DO:

why you don’t and you can get all kinds of other complications, you can get calcium pyrophosphate deposition disease in an OA knee, and, and that’ll be hot. And that’s it again, if it’s the same temperature, it’s hot, low grade inflammatory things. So I didn’t want to miss that. That’s good. Let’s talk about imaging. So one of I, I wasn’t heavy on imaging, I didn’t unlike many of my colleagues in this town who X ray every joint every year. Has they have their own X ray machines, right? I didn’t do that. Because I don’t think you learn that much. Although I they can definitely be helpful. But I unless people really push like, do you think I need an X ray i I get X rays, but it’s, I don’t You don’t need to go to that immediately if it’s mild and you’re not suspecting you know, a bone malignancy or you know, calcium pyrophosphate deposition disease or some some other benign tumor in the bone or,

Dr. Andrew Wong:

and you can get a lot from the history and physical it sounds like you can

Dr. Carla Guggenheim, DO:

get a lot you can get a lot from history and physical. And sometimes the, the the X rays aren’t even that helpful. Like you, you may have a patient with bone on bone

in both compartments, and a varus deformity and a little limp. And they go, you know, I don’t know that much pain. Oh, that’s a really bad knee. I think you do your disservice to your patients. So they got a really bad knee when they’re living with it perfectly. Well. It doesn’t. It doesn’t have to be bad. I mean, that’s actually one of my board questions almost every year. Patient has bone on bone by compartmental Neo a, what do you do? And they give you options like that. Physical Therapy Group knee replacement, whatever. And you know, the answer is, you know, PT at the most, you don’t replace a joint just because it looks ugly if they’re

Dr. Andrew Wong:

functional functioning, right functioning, okay functioning

Dr. Carla Guggenheim, DO:

well, there’s not an advantage because this, you know, joint replacements fail.

Dr. Andrew Wong:

Yeah, there can be side effects or they’re not, they’re not working as well as they would like always. Yeah. When do you when do you decide? Yeah, when that that’s probably something talked about when when do you decide for your patient with osteoarthritis? Hey, we’ve tried all these things. When would you recommend joint replacement?

Dr. Carla Guggenheim, DO:

You know, it’s interesting, I’ll just give you a little example. I have a patient I think he’s 92. Now he has a little he had a little alpaca farms and big dogs and retired math professional. And he he had bone on bone on both his knees and he had trouble getting out of a chair and he was getting older. And he thought, you know, I, you know, I’d like to be more active. And so I said, Well, you know, they take a sawn, cut off the bones and put reasons there and you got a recovery period. I said, you know, he goes, Why just my activity levels gone down so much. I sent him to the surgeon. And he’s, he looked at it and looked at the recovery. And he said, you know, how long am I going to live? And, you know, I don’t need to run around the farm anymore. And he opted for a more sedentary lifestyle than a knee replacement. And that was probably a wise choice. I had another patient who had a lot of trouble walking, he had a bad knee. And he kind of suddenly had this really horrible problem walking on the leg with a bad knee. And he didn’t I think his primary care sent him to the orthopedic surgeon. They replaced the knee. And then he came to me and he goes, this knee replacements a disaster. I can’t get off the walker, I can’t walk. And I looked at him walking. And I said, Oh, you snapped your vastus lateralis right off the trochanter. Oh, and that that gives that gives a what do you call Trendelenburg gait?

Dr. Andrew Wong:

Right? Yeah. Yeah.

Dr. Carla Guggenheim, DO:

I don’t know if I can demonstrate it here. But yeah, it gives you a Trendelenburg gait. And he came in in his walker with a Trendelenburg gait and I said, You didn’t need a knee replacement. Now reattaching the vastus lateralis to the greater trochanter is also fraught with problems.

Dr. Andrew Wong:

Oh, I’m sure why did he need a knee replacement because it was not a knee issue was something else? Yeah. Was

Dr. Carla Guggenheim, DO:

this? Yep. He couldn’t walk because he ripped his. Oh, because, yeah, he goes, Look, I still can’t walk.

Dr. Andrew Wong:

It wasn’t a was to hear something

Dr. Carla Guggenheim, DO:

that was an orthopedic surgeon and they train orthopedic surgeons to at least examine the joint above and below. But this guy didn’t look at the joint above.

Dr. Andrew Wong:

That seems rare. Like I haven’t really seen that kind of case before. Hopefully it’s rare.

Dr. Carla Guggenheim, DO:

I’ve, I think and I think I’ve seen it three times. I think it is pretty rare. But yeah, at least half the joint above and the joint the well.

Dr. Andrew Wong:

That’s a good word. It’s all connected. Right? The bones the the joints, the fascia. Yeah. Carla, thank you so much for coming on today, I think we want to talk about just kind of in closing, because we covered quite a bit of things today, including South Indian dance, so we appreciate you talking some about that. What is one thing you wish everyone knew about taking a root cause approach to osteoarthritis or kind of like a take home, you know, take home point for them.

Dr. Carla Guggenheim, DO:

If you don’t look at the root cause you’re going to be worth Pedic surgeon, you’re gonna think you can just fix stuff. I mean, you have to really have to look at the whole person. You have to look at the whole person.

Dr. Andrew Wong:

And it sounds like the biomechanics is a big part of it, because if even a slight deviation of what would be considered optimal, it might over the years be contributing to

Dr. Carla Guggenheim, DO:

Biomechanics is huge. Another one of my loathed movement techniques. This is yoga And I think that’s really dangerous, because you’re just going too far. The there’s a ton of literature on Tai Chi, in terms of longevity, longevity of what helps. And there’s a relatively new technique called Gyrotonic that I think is really wonderful. It’s not to you know, it’s not like going to the gym, it’s not two dimensional, repetitive, but Gyrotonic is a pretty amazing technique. And Tai Chi, those are the, that’s what has the most literature for movement techniques, because, you know, doing these studies, you don’t make any money out of figuring out what technique is better than any other, right? And you don’t do it long enough. And then you don’t do the follow up long enough to see what people can integrate into their lives. And what’s a blip of, you know, six weeks or eight months or even a year in a lifetime, it’s not much. So you have to give these people alternatives for something they can incorporate into their lives

Dr. Andrew Wong:

pretty frequently. So I think it’s the same with inner running ballet, gymnastics, yoga, tai chi, I mean, anything could be, you know, taken to the extreme, or in the extreme is probably relatively extreme for a different person. So having that person’s health and their body taken into account and visual way is probably going to be safer. Like I know, we can think about, you know, people that take Tai Chi classes or you know, instruction, you know, yoga therapy, it’s probably different ways to, to, you know, make it safer for people. So, I agree.

Dr. Carla Guggenheim, DO:

Very good. There are some very good yoga therapy. Things I shouldn’t have been so harsh on yoga.

Dr. Andrew Wong:

I mean, I think anything has the potential for injury for sure.

Dr. Carla Guggenheim, DO:

Yeah. And but, yeah, so there were just two other things. One was just a little comment about ultrasound. I don’t know if you do ultrasound in your clinic.

Dr. Andrew Wong:

Currently, but yes, let’s talk about ultrasound. Yeah,

Dr. Carla Guggenheim, DO:

I you know, you’re really overdiagnosed stuff. And if you’re doing ultrasound guided whatever, it isn’t going to show to the cartilage. So the orthopedic surgeons will say, you know, you do these ultrasound guided injections to the knee, either with steroids or viscose supplementation, and you just pick the cartilage apart.

Dr. Andrew Wong:

So you’re not a fan of hyaluronic acid or anything without? Nope. Because it actually damages the cartilage. When you go in the needle itself even

Dr. Carla Guggenheim, DO:

then there’s no there’s no good evidence that it works. There might be a subset of there might be a subset of patients in which it works. But, you know, AP therapy may be as good.

Dr. Andrew Wong:

Okay, okay. Well, can we just clarify for the listeners? AP therapy? What do you mean by apitherapy? Stings? Yeah, okay. Okay. It like actually just getting stung by a bee or actually a puppy. You

Dr. Carla Guggenheim, DO:

actually put the bee on the

Dr. Andrew Wong:

knee? Okay.

Dr. Carla Guggenheim, DO:

No, there’s actually some literature for that. And there’s also some literature for leeches.

Dr. Andrew Wong:

We just met a beekeeper at a farm. So we’ll have to ask ask her or him about that. Ask him about that. I think I think the other question I have now that we’re talking about injections is what is your view of going to get into the regenerative question here? PRP stem cells exosomes? Is there any role of that for any of those things for OAE?

Dr. Carla Guggenheim, DO:

You know, I’ve I’ve done a fair amount of it. And I’ve had it done to myself and after I don’t know how long I did it you year a couple of years. And I I don’t die. I think maybe there’s a better way. I don’t know. I bought a very expensive machine and I used it a fair amount and I didn’t see enough change that made me want to keep doing raids. Steroids are pretty overused. I’ve steroids are overused and osteoarthritis, and you have to be careful with them.

Dr. Andrew Wong:

So and again, side effects a lot of side effects.

Dr. Carla Guggenheim, DO:

Yeah, and they’re, again you’re picking the cartilage apart to put it in.

Dr. Andrew Wong:

So if there is one thing that you could really say and maybe there’s more than one thing, but let’s just say you know, one one way to top, you know, favorite thing you would think about for for osteoarthritis, what would that be in terms of treatment, you

Dr. Carla Guggenheim, DO:

know, eat well move well.

Dr. Andrew Wong:

Love it simple and The and really good, thank you. Well thank you Dr. Guggenheim for coming on today. Carla part of our mission at CH here is to make integrative health care more accessible and focusing on the small steps that we can take to improve our health. So we’d love to hear from you personally what is one thing under $20 That you feel has transform your own health

well, it also doesn’t have to cost money so that’s you know what? We’re not talking about five below. Okay, walking

Dr. Carla Guggenheim, DO:

flat shoes with a wide toe box.

Dr. Andrew Wong:

Okay, I think we can talk about brands do you have a specific brand there that you like or I Oh, God, what are my latest shoes it’s not the Asics I have quite a few shoes. Flat meaning rubberized, rubberized. Cushion nice sneakers.

Dr. Carla Guggenheim, DO:

With a little bit of a rocker. Yeah. You know, it should fit your foot really well. It should be comfortable when you put it on and walk for five minutes in the shoe store. Okay, and you should never wear high heels or pointed toe shoes those disrupt the biomechanics of gate the gate massively.

Dr. Andrew Wong:

So don’t wear them at cocktail parties. No ballet shoes, nothing like that point.

Dr. Carla Guggenheim, DO:

No pointe shoes. Okay, no, no pointy toe high heeled shoe shoes, no things I mean, look at the shape your foot and buy a shoe that fits it. Like I’ve got a whole bunch of OA and my foot. And, you know, it’s it’s a really wide foot, it got all kinds of orthopedic problems, but I have to buy a shoe that I can put my foot on top of the shoe. And I can see the shoe all the way around my foot.

Dr. Andrew Wong:

It makes common sense to not not shove a shoe into someone’s foot that that doesn’t fit. But I guess there’s you know, people have Stella’s to concerns and you know different things. But yeah, it’s not good for the biomechanics. So it sounds like it’s

Dr. Carla Guggenheim, DO:

horrible. I actually, that was my research and biomechanics was the biomechanics of pointe shoes. And yeah, those are terrible, but high heeled shoes are equally as bad and People wear them for a lot longer. You know, belly dancers don’t wear them that long in a day. Super stupid things with them, like standing on the tips of the toes, but, but even walking around all day, in high heeled shoes, it’s lunacy.

Dr. Andrew Wong:

And point issues plus a combination ban and alcohol is probably not a good idea either.

Dr. Carla Guggenheim, DO:

Oh, alcohol is never a good idea to poison

Dr. Andrew Wong:

but in terms of the balance of you know, people falling after Oh, right. I didn’t think

Dr. Carla Guggenheim, DO:

and, and it’s true about OAE in general, I mean, a lot of people die of falling. Older people die of falling. So that was bad biomechanics, you foam or if you combine a dead biomechanics and, and non ergonomic shoes, you’re gonna fall more and then add the alcohol. You know?

Dr. Andrew Wong:

Okay, so no alcohol eat well move. Well, don’t wear pointy shoes, reduce inflammation and listen to Dr. Carla here. So thank you so much for coming on today. Send some gratitude to you for coming in today on this call. It’s really been a pleasure. And we’re really, really appreciative. I know that listeners are really appreciative of your wisdom, you know, talking about arthritis and, and your life and just just want to wish you well,

Dr. Carla Guggenheim, DO:

thank you so much. It’s really I really looked forward to this. It was really, really nice. Nice for me to be able to do this. Thank you so much for the opportunity. Really, really appreciate it.

Dr. Andrew Wong:

Thank you, Carla. Yeah. Thank you so much for joining us today for this episode of the capital Integrative Health podcast. A quick reminder that the information we share on this podcast is meant for educational and informational purposes only. It’s not a substitute for professional medical advice, diagnosis or treatment. We highly recommend that you speak to a qualified health care provider before making any medical or healthcare decisions. If you enjoyed this episode, please take a few moments to subscribe and leave us a review. Your reviews help us reach more people and continue to offer innovative insights and information to better optimize your health and wellness.