The Fisher Institute - patient directed specialty care

04/19/2026

I am hoping to make an insightful post this week. For now, here is a flyer for an upcoming event I am looking forward to participating in. Hopefully my patients can find resources and engage with fellow hypermobile patients. I just hope you all don't share contortion poses and party tricks. Keep those joints in line!

03/28/2026

No affiliation. Just really appreciate this for my patients.

03/19/2026

Fatigue Is Not Just “Being Tired.”

Yes—I said it. (Sorry, colleagues.) Here is a great article: https://www.aafp.org/pubs/afp/issues/2023/0700/fatigue-adults.html

One of the most common—and most misunderstood—symptoms I hear in clinic is fatigue. It’s challenging because it doesn’t have clean, objective boundaries.

But let’s be clear:
Fatigue is not just needing a nap.
It’s not laziness.
It’s not a lack of motivation.

True fatigue is a deep, persistent exhaustion that sleep does not fix.

Why Fatigue Is So Complex?? Fatigue is multifactorial. It often reflects an interplay of:
• Aging and hormonal shifts
• Chronic stress and modern overstimulation
• Nutritional status
• Underlying medical or psychological conditions

For many patients with autoimmune or inflammatory disease, fatigue can be just as debilitating as pain—sometimes even more so.

Common overlapping contributors include:
• Active inflammation
• Anemia
• Macro- and micronutrient deficiencies
• Thyroid dysfunction
• Medication side effects
• Dysautonomia
• Poor sleep quality or untreated sleep disorders
• Depression and anxiety
• Hormonal changes (especially perimenopause)
• ADHD and chronic cognitive load
• Nutritional imbalance or blood sugar instability

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PATIENT PERSPECTIVE
One often overlooked driver is nervous system regulation. Sometimes fatigue isn’t just “low energy”—it’s misregulated energy.

👉 Ask yourself: Am I under-stimulated or over-stimulated?

If under-stimulated:
• Gentle movement (walk, light activity)
• Bright or refreshing sensory input (mint, citrus)
• Light massage

If over-stimulated:
• Reduce input (light, noise, screens)
• Calming sensory tools (lavender, dim lighting)
• Deep pressure (weighted items, compression)
• Slow breathing (even something simple like blowing bubbles)
• Cold, thick drinks through a straw (vagal stimulation)
• In kids, we see this clearly—when they’re overstimulated, they often need “heavy work” (pushing, pulling, resistance) to regulate. I make my kids do contests pushing full laundry baskets or throwing weighted balls.

👉 The goal: a “just right” state—regulated enough to function, and resilient enough to expand your capacity over time.

A Simple Daily Framework
1. Body Check-In
What am I feeling?
What is my body telling me?
What do I need right now?
What can I control?
2. Reflect & Adjust
What helped?
What didn’t?
What will I do differently next time?

What to Track Over Time
• Sleep quality
• Mood, stress, and cognitive load
• Hormonal patterns (when appropriate)
• Nutrition (especially protein intake and balance)
• Movement (keep it sustainable)
• Recovery time
• Nervous system regulation—not just productivity
• Symptom patterns and cycle changes

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PROVIDER PERSPECTIVE
Fatigue is one of the top reasons patients seek care—yet even with a full workup, a clear cause is often not identified. This is where clinical judgment matters. Know your patient. Understand their baseline.

Ask better questions:
Have they changed jobs or routines?
Stopped hobbies? Why?
Any family history of chronic disease?

We often focus so heavily on checklists that we forget to gather insight simply by being human and curious.

Fatigue can be categorized as:
• Physiologic
• Secondary
• Chronic (≥6 months)

And yes—fatigue can be measured subjectively using validated tools:
FSS, PROMIS Fatigue, FACIT-F.

My Clinical Reality:
In rheumatology, no single lab test is diagnostic. Labs support a diagnosis—they don’t replace clinical reasoning. I frequently see delayed autoimmune diagnoses because referrals rely too heavily on labs rather than pattern recognition and clinical skill.

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FINAL THOUGHTS

For providers: Take the time to listen. Patterns live in the story.

For patients: Be patient with the process. Medicine doesn’t move at the speed of social media.

One of the most common patterns I see? Pushing harder instead of more effectively. Do less but more consistently and sustainably whether it is personal lifestyle, exercise, diet, work tasks, or even professional medical practice.

* Fatigue is real.
* Fatigue is complex.
* Fatigue deserves to be taken seriously.

** A “normal” lab panel does not mean a patient feels normal.
Listening matters.
Validation matters.
Clinical intuition matters.
A whole-person approach matters.

Fatigue is among the top 10 reasons patients visit primary care offices, and it significantly affects patients' well-being and occupational safety. A comprehensive history and cardiopulmonary, neurologic, and skin examinations help guide the workup and diagnosis. Fatigue can be classified as physiol...

03/07/2026

I just finished a 60-minute endurance spin class, and it struck me that I often feel bored at the recommended moderate intensity levels. It makes me wonder how many patients struggle to recognize their actual exercise tolerance.

Personally, my body-type tends to prefer short, high-intensity workouts and often avoid longer endurance sessions. I build muscle very easily. The problem is that when I overdo it, I end up more fatigued and have a harder time maintaining consistent exercise day to day. When I stay within recommended aerobic intensity levels, I’m actually less tired, sleep better, eat less, and recover faster.

Also as someone with hypermobility, I have noticed that skipping a proper warm-up makes workouts much harder. I tend to get a symptomatic drop in blood pressure when I start exercising and experience more muscle burn when I don’t warm up properly. It make me wonder how many people avoid exercise because of this as I see a surprisingly large number of people with hypermobility that do not qualify as the trendy "POTS".

I want to encourage everyone to pay attention to their heart rate while exercising. You may be surprised how your body feels when you stay within appropriate intensity zones.

Here’s a heart rate chart based on American Heart Association guidelines. 🏃‍♀️‍➡️🏃‍♂️‍➡️

03/02/2026

Trigger Finger: When Your Finger “Sticks”

Have you ever tried to straighten your finger and it catches… clicks… or even locks in place?
That’s called trigger finger (medical term: stenosing tenosynovitis). It happens when the flexor tendon that bends your finger becomes inflamed and has difficulty gliding smoothly through its pulley system in the palm.

Common symptoms: ✔️ Clicking or popping with movement ✔️ Finger stiffness (often worse in the morning) ✔️ Tenderness in the palm at the base of the finger ✔️ Finger locking in a bent position

Who is at risk? • Repetitive gripping movements • Women, most commonly 40-60 years old • Inflammatory conditions (diabetes, rheumatoid arthritis, psoriatic arthritis, severe hand eczema, etc.) • Sometime there is no clear reason at all

The good news? Treatment is usually effective.
Options may include:
• My favorite first line for almost everything: Therapy - occupational therapy or home exercises with “hand yoga” (simple flexion exercises, rubber band finger spread, towel crunches, etc.)
• Activity modification
• Splinting
• Anti-inflammatory strategies
• Targeted steroid injection by a medical provider
• Minor outpatient surgery

Early treatment often prevents progression and prolonged discomfort. If your finger is catching or locking, don’t ignore it — it’s much easier to treat effectively before it becomes truly "stuck".

As always, my goal is keeping your hands moving and your life functional. 🤟

(Here is a much more official resource than myself. I have no affiliation with Mayo Clinic.)

https://www.mayoclinic.org/diseases-conditions/trigger-finger/symptoms-causes/syc-20365100

02/13/2026

Any smoldering Rheumatology questions out there? I have some topics to write about but thought I would give people a chance to shout out. There are absolutely no dumb questions. There are however endless possibilities for dumb answers ...

02/07/2026

Coincidence? I think NOT!

To summarize: increased air pollution correlates with more rheumatic disease. Ammonium contributed most to this increased risk. The study was completed in Quebec, Canada. Vanderburgh county is listed as #7 in the country for particulate matter in this article based on 2000-2016 data.

Job security for me. Terrible risk for my family and community. I hope the tristate is doing better now.

https://www.healthline.com/health/allergic-asthma/air-pollution -10-worse-air-quality

https://pubmed.ncbi.nlm.nih.gov/40509744/

Air pollution can impact health and may contribute to death from COVID-19. The results of recent data point to these 10 U.S. cities with the worst air pollution.

01/31/2026

I found this resource helpful, as many of my patients—and I myself—struggle with sleep. A significant number of my patients also deal with malabsorption, which can affect how well vitamins and medications are absorbed. I’m always looking for thoughtful, creative ways to improve absorption and optimize treatment. Compounding is an excellent resource that is often overlooked by providers. Every incremental improvement matters, and I strongly support using evidence-based natural therapies alongside prescription medications when appropriate. I have even been known to recommend "grandma remedies".

Need healthy night snack ideas? RDNs share their favorite tips for making smart snack choices between dinner and bedtime.

01/29/2026

Scleroderma: one word that includes different levels of autoimmune chaos.

The main types of scleroderma include:

�1. Morphea or localized scleroderma is a form of scleroderma limited to the skin. It causes areas of skin thickening or fibrosis that may appear as one or multiple plaques. Importantly, morphea does not involve internal organs, but it can still be painful, progressive, and affect quality of life.

�2. Limited Scleroderma or CREST syndrome is an acronym that stands for:�
• Calcinosis�
• Raynaud’s phenomenon�
• Esophageal dysmotility (reflux or swallowing issues)�
• Sclerodactyly (tight skin of the fingers)�
• Telangiectasias (small red spots on the skin)
Limited scleroderma typically affects the skin of the face, neck, hands, forearms (below the elbows), and lower legs (below the knees). It is indolent in nature and many patients have mild symptoms for years before establishing a full diagnosis. Early symptoms often include GERD, Raynaud’s phenomenon, and telangiectasias. Raynaud’s is a condition that affects contiguous fingers at once, with color changes from white → purple → red in response to cold, stress, or vibration. Certain antibodies, such as anti-centromere (ACA) and anti-Scl-70 (anti-topoisomerase), help support the diagnosis and guide monitoring.� Despite the name “limited,” this form can still cause serious long-term complications, particularly involving the lungs, heart, and gastrointestinal tract.

�3. Diffuse or systemic scleroderma involves the same skin areas as limited disease but also includes more proximal areas, such as the upper arms, thighs, and trunk.�This form often begins more abruptly, with symptoms like:�
• Puffy or swollen hands�
• Raynaud’s phenomenon�
• Inflammatory arthritis or carpal tunnel symptoms�
• Fatigue�
• Rapidly progressive skin thickening
Patients with diffuse disease are at higher risk for interstitial lung disease and pulmonary hypertension. Those with RNA polymerase III antibodies are at increased risk for scleroderma renal crisis, a sudden form of kidney injury that—when recognized early—responds very well to specific blood pressure medications (ACE inhibitors).�

Scleroderma is a challenging disease to treat because management can range from very mild medications to aggressive immune-suppressing therapies, depending on disease type and organ involvement. Knowing when to escalate treatment is one of the most important—and difficult—parts of care. My focus in care is early recognition and intervention to prevent progression while providing support through complex, long-term care.

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01/25/2026

❄️ Winter Question of the Weekend from My Hypermobile / EDS Patients ❄️

💬 “Why do I get light-headed in hot showers or baths?”

Great question—and no, you’re not imagining it.

Many people with hypermobile EDS or benign hypermobility have mild dysautonomia. Think of it as a cousin of orthostatic hypotension—even without changing positions.

🔥 Here’s what’s happening:
Heat causes your peripheral blood vessels to dilate. In hypermobile patients, the autonomic nervous system is often a bit slow to respond. Blood pools “downstairs,” and the body doesn’t compensate quickly enough to push blood back “upstairs” to the brain → light-headedness, wooziness, or near-syncope.

🚫 Important myth to bust:
Most of these patients do NOT have POTS—even though that term gets all the attention. POTS is real, but it is completely different dysautonomic diagnosis.

✨ Which brings me to my mission:
We desperately need a better, more accurate, attention grabbing name for this very common hypermobility-associated autonomic issue. Something that medical providers do not roll their eyes at.

📣 Help me out!
Drop your catchy, patient-friendly phrases below—something we can actually make mainstream for hypermobile / EDS-associated orthostatic intolerance or dysautonomia.

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01/12/2026

Polymyalgia rheumatica, a.k.a. PMR— this is a sneaky one.

It typically affects people over 50. One morning you wake up and suddenly can’t lift your arms, or you struggle just to stand up.

It’s caused by inflammation around the shoulders and hips, and interestingly, we still don’t know exactly why it happens. Many patients end up in an urgent care or the ER, and it’s frequently misdiagnosed. Bloodwork usually shows elevations in nonspecific inflammatory markers. Most patients get admitted for not being able to walk.

What I can tell you is that it often seems to appear after a major stressor— like the holidays, an infection, the loss of a loved one, a child leaving for college, or other significant life events.

The good news? It’s very treatable. Most patients do well with a moderate dose of steroids slowly decreased over about six months. The majority of cases do not recur.

If someone has trouble tolerating steroids or can’t taper off successfully, we now have biologic options as well as “old-school” disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate.

It’s not a fun situation to be in, but in my book, it’s one of the few conditions I can truly treat all the way into remission.

Here’s hoping your New Year is PMR-free. 🎉

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01/09/2026

Happy Friday! The warmer moister weather is making me feel motivated. I know there are many happy joints out in our community today. 🫶

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