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Too Much of a Good Thing

Posted By Administration, Monday, July 25, 2011
Updated: Friday, April 18, 2014

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by Lena Edwards, MD, FAARM

The stress response is in place to allow us to survive hostile environments and adapt accordingly. It is when the stress response system (HPA Axis) is chronically stimulated that maladaptation and disease arise. Every organ system and hormone produced by the body is ultimately affected. 

Prolonged stress inhibits the non-essential functions of growth and reproduction. Both Corticotropin releasing hormone (CRH) and cortisol inhibit the release of Growth Hormone, Thyrotropin releasing hormone (TRH), Thyroid stimulating hormone, and Gonadotropin releasing hormone (GnRH), all of which are required for the production of the anabolic steroid hormones. Since these hormones antagonize the effects of cortisol, their absence further potentiates the actions of the unopposed catabolic corticosteroids further impairing growth, repair, and reproductive functions. Furthermore, even if present in small amounts, the anabolic hormones Growth hormone, DHEA, and testosterone are unable to exert their physiologic effect because of target tissue insensitivity. 

Stress induced GnRH deficiencies have been shown to cause delayed puberty, anovulation, and spontaneous abortion in women and decreased testosterone levels, impaired spermatogenesis, and decreased libido in men. In fact, stress induced abnormalities in cortisol are believed to contribute to up to 40% of infertility cases. Growth and reproduction are also influenced by thyroid hormone function which is adversely affected not only through CRH induced inhibition of TRH release but also by impaired peripheral conversion of the relatively inactive tetraiodothyronine into active triiodothyronine. 

Thus, when cortisol levels are chronically and abnormally elevated, numerous other hormone systems are adversely affected which may result in symptomatology despite 'normal' lab results. Keep this is mind when initiating hormone replacement with hormones since the catabolic action of cortisol can overpower the anabolic effects of the other hormones, DHEA in particular. Checking anabolic/catabolic balance via urine is an available diagnostic tool.

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Prolotherapy in Primary Care Practice

Posted By Administration, Friday, July 22, 2011
Updated: Friday, April 18, 2014

Prolo

This case study was published on the National Library of Medicine (NLM) website.

Authors: David Rabago, MD, Andrew Slattengren, DO, and Aleksandra Zgierska, MD, PhD

Introduction

Prolotherapy is an injection-based complementary and alternative medical (CAM) therapy for chronic musculoskeletal pain. It has been used for for approximately 100 years, however, its modern applications can be traced to the 1950s when the prolotherapy injection protocols were formalized by George Hackett, a general surgeon in the U.S., based on his clinical experience of over 30 years. While prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences, a core principle is that a relatively small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions, and in adjacent joint space over the course of several treatment sessions. Interest in prolotherapy among physicians and patients is high. It is becoming increasingly popular in the U.S. and internationally, and is actively used in clinical practice. A 1993 survey sent to osteopathic physicians estimated that 95 practitioners in the US were estimated to have performed prolotherapy on approximately 450,000 patients. However, only 27% of surveys were returned, likely dramatically underestimated true number of practitioners.  No formal survey has been done since 1993. The current number of practitioners actively practicing prolotherapy is not known but is likely several thousand in the US based on attendance at CME conferences and physician listings on relevant websites. Prolotherapy has been assessed as a treatment for a wide variety of painful chronic musculoskelatal conditions which are refractory to “standard of care” therapies. While anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence-based decision-making for the use of prolotherapy exists for low back pain, several tendinopathies and osteoarthritis.

The name of prolotherapy has changed over time. Consistent with existing hypotheses and understanding of possible mechanisms of action, the name of this therapy has evolved. Nomenclature has reflected practitioners’ perceptions of prolotherapy’s therapeutic effects on tissue. Historically, this injection therapy was called “sclerotherapy” because early solutions were thought to be scar-forming. “Prolotherapy” is currently the most commonly used name, and is based on the presumed “proliferative” effects on chronically injured tissue. It has also been called “regenerative injection therapy” (“RIT”),  and some contemporary authors name the therapy according to the injected solution. The precise mechanism of action is not known.
The National Institute of Health identifies prolotherapy as a CAM therapy and has funded two ongoing clinical prolotherapy trials. The Centers for Medicare and Medicaid Services and the Veteran’s Administration have reviewed the prolotherapy literature for low back pain and all musculoskeletal indications, respectively, and determined existing evidence to be inconclusive. Neither recommends third party compensation for prolotherapy. However, neither included the most recent clinically positive studies or reviews in their review. Private insurers are beginning to cover prolotherapy for selected indications and clinical circumstances; however, most patients pay “out-of-pocket”.

Prolotherapy Technique

While no formal practice guidelines have been published, prolotherapy treatment commonly consists of several injection sessions delivered every 2 to 6 weeks over the course of several months. During an individual prolotherapy session, therapeutic solutions are injected at sites of painful and tender ligament and tendon insertions, and in adjacent joint spaces. Injected solutions (“proliferants”) have historically been hypothesized to cause local irritation, with subsequent inflammation and tissue healing, resulting in enlargement and strengthening of damaged ligamentous, tendon and intra-articular structures. These processes were thought to improve joint stability, biomechanics, function and ultimately, to decrease pain.


Mechanism of Action

The mechanism of action for prolotherapy has not been clearly established and, until recently, received little attention. Supported by pilot-level evidence, the three most commonly used prolotherapy solutions have been hypothesized to act via different pathways: hypertonic dextrose by osmotic rupture of local cells, phenol-glycerine-glucose (P2G) by local cellular irritation, and morrhuate sodium by chemotactic attraction of inflammatory mediators and sclerosing of pathologic neovascularity associated with tendinopathy.The potential of prolotherapy to stimulate release of growth factors favoring soft tissue healing has also been suggested as a possible mechanism.

In vitro and animal model data have not fully corroborated these hypotheses. An inflammatory response in a rat knee ligament model has been reported for each solution, though it was not significantly different from that caused by needle stick alone or saline injections. However, animal model data do suggest a significant biological effect of morrhuate sodium and dextrose solutions compared to controls. Rabbit medial collateral ligaments injected with morrhuate sodium were significantly stronger (31%), larger (47%), and thicker (28%), and had a larger collagen fiber diameter (56%) than saline-injected controls; increase in cell number, water content, ground substance amount and a variety of inflammatory cell types were hypothesized to account for these changes. Rat patellar tendons injected with morrhuate sodium were able to withstand a mean maximal load of 136% (± 28%) – significantly more than the uninjected control tendon. Interestingly, in the same study, tendons injected with saline control solution were significantly weaker than uninjected controls. Dextrose has been minimally assessed in animal models. Recent studies showed that injured medial collateral rat ligaments injected with 15% dextrose had a significantly larger cross-sectional area compared to both non-injured and injured saline-injected controls. P2G solution has received the least research attention; although it is in active clinical use, no animal or in vitro study has assessed P2G effect using an injury model. Clinically, most clinicians report using these solutions as single agents, though concentration varies. In clinical practice, physicians sometimes mix prolotherapy solutions, or use solutions serially in a single injection session depending on experience and local practice patterns. Neither effect of varied concentration nor mixtures have been assessed in basic science nor clinical studies and no clinical trial has compared different solutions against one another.
Clinical Evidence
Early Research
Since its inception, prolotherapy has been primarily utilized outside of academic centers. This has lead to a pragmatic orientation of existing prolotherapy studies, and a relative paucity of major rigorous clinical trials in spite of significant clinical activity. While the first randomized controlled trial (RCT) did not appear until 1987, clinicians have enthusiastically reported the results of more modest, pilot-level clinical trials.
A 2005 systematic review of prolotherapy for all indications found 42 published reports of clincal prolotherapy trials since 1937. Thirty-six of the studies were case reports and case series that included 3928 patients aged from 12 to 88 years. These uncontrolled studies provide the earliest and most clinically-oriented evidence for prolotherapy. Each study reported positive findings for patients with chronic, painful, refractory conditions. Report quality of the included studies varied widely; their internal methodological strength was generally consistent with publication date. The older case studies documented injectants and methods that are no longer in use. Contemporary solutions were noted to start with P2G in the 1960s, dextrose in the 1980s, and morrhuate sodium in the early 1990s. The case reports and case series highlighted the fact that, over time, prolotherapy has been used and studied for a continually growing set of clinical indications. These case studies have also been used as pilots to develop new assessment techniques that could help elucidate pathophysiology of the condition in question, and test methodology for future, more robust randomized trials. In general, while lacking control groups and randomization, these pragmatic studies had the advantage of assessing effectiveness of prolotherapy in “real life settings” that patients encounter, including the prolotherapist’s ability to select the patient and to individually tailor the injection protocol. Most of the subjects (72%, 2691/3741) assessed in the early literature were treated for low back pain. However, other indications assessed by these early studies included knee osteoarthritis, shoulder dislocation, neck strain, costochondritis, lateral epicondylosis and fibromyalgia.
Contemporary Research
Since the mid 1980s, research on prolotherapy effects has accelerated and the number and methodological quality of studies assessing prolotherapy have increased dramatically (Figure 1).
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To date, prolotherapy has been best assessed as a treatment for low back pain, osteoarthritis and tendinopathy, each of which is a significant cause of pain and disability, and is often refractory to best standard-of-care therapies. The severity and prevalence of each condition is age-related. Because the U.S. population is aging, finding new effective therapies for these conditions can have an impact on both individual patient care and overall public health. In addition, prolotherapy has been assessed as a treatment for non-specific, non-surgical low back pain, osteoarthritis of the knee and hand, and for several tendinopathies, including lateral epicondylosis, Achilles, adductor and plantar fasciitis. The following section gives a brief description of studies assessing prolotherapy for these clinical indications, and level of evidence associated with each condition; this information is additionally summarized in Table 1.
Table 1
Strength of evidence for prolotherapy as a treatment for chronic musculoskeletal conditions: Low Back Pain (LBP), Osteoarthritis (OA) and Tendinopathy.
Key Clinical Recommendation on ProlotherapyEvidence RatingReference/s
Non-specific LBP: may be effective; conflicting results in several RCTs B 2528
Sacroiliac Joint Dysfunction: may be effective in patients with documented failure of load transfer (disability) at the sacroiliac joint B 34
Coccygodynia: may be effective based on prospective case series B 35
Lateral epicondylosis: likely effective based on strong positive data in these small RCTs A 6, 7
Achilles tendinopathy: may be effective based on high quality prospective case series B 9
Plantar fasciitis: may be effective, based on high- quality prospective case series B 60
Osteoarthritis: may be effective for knee and ? finger OA, based RCTs of moderately strong methodological quality B 17, 61
Low Back Pain (LBP)
LBP is among the most common reason patients see a primary care provider. Approximately 80% of Americans experience LBP during their lifetime. An estimated 15–20% of patients develop protracted pain, and approximately 2–8% experience chronic pain. LBP is second only to the common cold as a cause of lost work time. Productivity losses from chronic LBP approach $28 billion annually in the U.S.
Non-specific LBP
Four RCTs evaluated prolotherapy for musculoskeletal LBP; three used P2G as the injectant and the fourth used Dextrose. Each study used a protocol involving injections to the ligamentous insertions of the L4-S1 spinous processes, sacrum and ilium. While outcome measures varied, a common measure was the percentage number of participants reporting greater than 50% improvement in pain/disability scores at six months.
Two of these four RCTs reported positive findings compared to control injections. Ongley et al. and Klein et al. compared the treatment effects of prolotherapy combined with an adjacent treatment with injected steroids, spinal manipulation and exercise. In the Ongley study, the intervention and control groups differed markedly on the make-up of initial injections and type of spinal manipulation associated with the injections. Significantly more subjects in the prolotherapy (88%) group reported at least 50% reduction in pain severity compared to controls (39%). Also, prolotherapy subjects, compared to controls, reported significantly decreased pain and disability levels. Klein et al. used more similar treatment protocols in the two assessed groups, with subjects in both groups receiving steroid injections and spinal manipulation prior to prolotherapy. Again, significantly more prolotherapy subjects improved by 50% or more on pain or disability scores (77%) than controls (53%). Pain grid scores were also significantly lower in the prolotherapy group, with individual pain (p=0.06) and disability (p=0.07) scores trending toward significance, compared to the control group.
Two of the four RCTs reported negative outcomes compared to control injections. Dechow et al. implemented a refined study protocol; subjects in both groups underwent three injection therapy sessions without adjacent spinal manipulation or physical therapy. While both groups showed a trend toward improved severity scores on pain questionnaire, pain grid, and somatic perception measures, these changes did not reach statistical significance over time, within or between groups. At 6 months, improvements in both groups were smaller than those of the other RCTs. The largest and most methodologically rigorous prolotherapy study published to date has been conducted by Yelland et al. Study subjects (N=110), with an average of 14 years of LBP, were randomized to one of four intervention groups: dextrose and physical therapy, dextrose and “normal activity”, saline injections (“control” injection) and physical therapy, or saline injections and “normal activity”. By 12 months, subjects in all groups reported improved pain (26%–44%) and disability (30%–44%) scores, without significant differences between groups. The majority of subjects (55%) stated that their improvement in regards to both pain and disability had been worth the effort of undergoing the intervention. The percentage of subjects who reached at least 50% pain reduction varied between 36% and 46% though these differences were not statistically significant.
Overall, interpretation of findings from these 4 RCTs is challenging. Both experimental and control groups received different treatment protocols, and none of the trials was designed to elicit a possible mechanism of prolotherapy action. Therefore, it is impossible to attribute effects to prolotherapy or any other specific intervention. A recent Cochrane Collaboration systematic review did not find sufficient evidence to recommend prolotherapy for non-specific LBP. However, these four RCTs present overall promising results, calling for well-designed, sufficiently-powered research. All RCTs report improvements for pain and disability in all treatment groups consisting of subjects with chronic, moderate-to-severe LBP. In particular, Yelland et al. reported clinical improvement in excess of minimal clinical important difference, and in excess of subjects’ own perception of the minimum improvement necessary for prolotherapy to be worthwhile (25% for pain and 35% for disability).
LBP due to Specific Causes
Prolotherapy research methods for LBP have been evolving amid much debate surrounding effectiveness, indications, treatment protocols and solution types. Given the promising aspects of the above RCTs for non-specific LBP, combined with anecdotal clinical success, recent clinical researchers have begun to assess prolotherapy in patients with more specific forms LBP and loss of function in an effort to determine specific causes of LBP for which prolotherapy may be most effective.
Cusi et al. assessed 25 subjects with sacroiliac joint dysfunction and pain, refractory to 6 months or more of physical therapy, and with documented failure of load transfer (disability) at the sacroiliac joint. They used a strong prolotherapy solution of 18% dextrose, delivered in 3 sets of injections over 12 weeks. Compared to baseline, pain and disability scores on 3 multidimensional outcome measures significantly improved at 26 month follow-up in excess of minimal clinically important difference.
Khan et al. assessed 37 subjects with refractory coccygodynia. Using 25% dextrose in up to 3 prolotherapy injection sessions over 2 months, average pain scores, evaluated using a 0–10 visual analog scale (VAS), significantly decreased from a baseline score of 8.5 to 2.5 points at 2 months, far in excess of reported minimal clinical important difference for chronic pain. The authors reported “good” pain relief for 30 of 37 subjects, and “no improvement” for the remaining 7.
In an especially novel study, Miller et al. assessed prolotherapy for leg pain due to moderate-to-severe degenerative disc disease as determined by CT spell out discography. Subjects (N=76) who failed physical therapy and had substantial but temporary pain relief with two fluoroscopically-guided epidural steroid injections were included. After an average of 3.5 sessions of biweekly, fluoroscopically-guided injections to the relevant disc space with 25% dextrose with bupivacaine, 43% of responders showed a significant, sustained treatment response of 71% improvement in pain score, with VAS score for responders at 8.9 (± 1.4), 2.5 (±2.0), and 2.6 (± 2.2) at baseline, 2 and 18 months, respectively. While these three recent studies of prolotherapy for “specific” LBP were uncontrolled, they suggest the need for future RCTs with more focused clinical indications of axial pain and disability.
Tendinopathies
The strongest data supporting the efficacy of prolotherapy for any musculoskeletal condition, compared to control injections, is for chronic, painful overuse tendon conditions that were formerly called “tendonitis” and are now more correctly termed “tendinosis” or “tendinopathy” to reflect existing, underlying pathophysiology. Tendinopathies are common reasons why patients present to primary care providers and various medical specialists. Tendinopathies are sometimes discussed as a group because the current understanding of over-use tendinopathies identifies them as sharing underlying non-inflammatory pathology, resulting from a repetitive motion or overuse injury, and associated with painful degenerative tissue. Histopathology of tendon biopsies in patients undergoing surgery for painful tendinopathy reveals collagen separation, thin, frayed, and fragiletendon fibrils, separated from each other lengthwise and disruptedin cross-section, increase in tenocytes with my of ibroblastic differentiation (tendon repair cells), proteoglycan ground substance and neovascularization. Classic inflammatory cells are usually absent. Although this aspect of tendinosis was first described 25 years ago and content experts have advocated a change in nomenclature (from “tendonitis” to tendinosis), the misnomer and use of the term “tendonitis” continues. Prolotherapy has been assessed as a treatment for four tendon disorders: lateral epicondylosis, hip adductor, Achilles tendinopathies and plantar fasciitis.
Lateral epicondylosis (LE, “tennis elbow”) is an important common condition of the upper extremity with an incidence of 4–7/1000 patients per year in primary care settings. Its greatest impact is on workers with repetitive and high-load upper extremity tasks and on athletes. Its most common cause may be low-load, high-repetition activities such as keyboarding, though formal data is lacking. Cost and time away from job or activity are significant. While many non-surgical therapies have been tested for LE refractory to conservative measures, none have shown to be uniformly effective in the long term. Scarpone et al. conducted an RCT to determine whether prolotherapy improves self-reported elbow pain, and objectively measured grip strength and extension strength in patients with chronic LE. Twenty adults with at least 6 months of moderately-to-severely painful LE refractory to rest, non-steroidal anti-inflammatory medications (NSAIDs) and corticosteroid injections, were randomized to prolotherapy with dextrose and morrhuate sodium (1 part 5% sodium morrhuate, 1.5 parts 50% dextrose, 0.5 parts 4% lidocaine, 0.5 parts 0.5% sensorcaine and 3.5 parts normal saline)or control injections with normal saline. Three prolotherapy sessions were administered, with injection at the supracondylar ridge, lateral epicondyle and annular ligament. Compared to controls, prolotherapy subjects reported significantly decreased pain scores at 8 and 16 weeks. These between-group differences in pain scores were associated with a significant improvement in prolotherapy subjects (from 5.1±0.8 at baseline, down to 0.5±0.4 at 16 weeks), while the controls did not report significant change (4.5±1.7 to 3.5±1.5). In addition to pain reduction, prolotherapy subjects also showed significantly improved isometric strength compared to controls, and grip strength compared to baseline. These clinical improvements seen in prolotherapy subjects were maintained at 52 weeks.
Achilles tendinopathy is a common overuse injury seen both in athletes and in the general population. This painful condition is a cause of considerable distress and disability. Maxwell et al. conducted a well-designed case series to assess whether prolotherapy, administered during a mean of 4 injection sessions, at 6 week intervals, would decrease pain in 36 adults with painful Achilles tendinopathy. In this study, 25% dextrose solution was injected into hypoechoic regions of the Achilles tendon under ultrasound guidance. In addition to self-reported measures, the authors also assessed ultrasound-based tendon thickness, and the degree of hypoechogenicity and neovascularity - ultrasound findings recently reported to correlate to tendinopathy severity. At 52 weeks, prolotherapy-treated subjects reported decrease in VAS-assessed pain severity by 88%, 84% and 78% during rest, “usual” activity or sport, respectively. In addition, tendon thickness decreased significantly. The overall grade of tendon pathology, hypoechoic and anechoic tendon regions, and neovascularity were all improved in some, but not all subjects who reported clinical improvement. Therefore, the relationship between ultrasound-assessed characteristics and the degree of clinical improvement remains unclear.
Hip adductor tendinopathy, associated with groin pain, is a common problem among those who engage in kicking sports. Topol et al. conducted a case series assessing prolotherapy for chronic groin pain, a condition involving pain and tenderness at tendon and ligament insertions at the groin area. Male athletes (N=24), with an average duration of 15.5 months of groin pain in spite of standard therapy, were injected with 12.5% dextrose at the thigh and suprapubic abdominal insertions of the adductor tendon, and at the symphysis pubis at four-week intervals until pain resolved or subjects had no improvement for two consecutive sessions. On average, subjects received 3 prolotherapy sessions. At a mean of 17 months, subjects reported dramatic significant improvements on two pain scales (VAS and the Nirschl Pain Phase Scale). Of 24 subjects, 20 had no pain and 22 returned to sports without restrictions after therapy.
Plantar fasciitis is a common injury among athletes engaged in sports requiring running and among general primary care patients. It is reported to account for 15% of all adult foot complaints requiring professional consultation, and, in a 2002 survey of running-related injuries, plantar fasciitis was the third most prevalent injury. Among “standard of care” approaches, there is limited evidence for the effectiveness of any one treatment for plantar fasciitis, including steroid injections. Ryan et al. assessed prolotherapy for chronic plantar fasciitis refractory to conservative care. Twenty adults with an average of 21 month duration of heal pain underwent ultrasound-guided 25% dextrose injections for an average of 3 treatment sessions delivered at 6 week intervals. Pain scores were assessed, using a 100-point VAS, at baseline and at 11.8 months. Pain severity significantly improved at rest, during activities of daily living and sport activities by 26.5, 49.7 and 56.5 points, respectively, compared to baseline, and 16 of 20 subjects reported good or excellent treatment effects.
Osteoarthritis (OA)
Prolotherapy has been assessed as a treatment for knee and finger osteoarthritis and is the subject of ongoing studies. Arthritis is a leading cause of disability in the world and in the US, where it affects 43 million persons. OA is the most common form of arthritis and the most common joint disorder. In the US, symptomatic knee OA is present in up to 6% of the population over 30 years old, and has an overall incidence of 360,000 cases per year. Incidence increases up to 10-fold from ages 30 to 65 and more thereafter. OA results in a high burden of disease and substantial economic impact through its high prevalence, time lost off work, and frequent utilization of health care resources.
Allopathic and CAM treatment recommendations for OA, aimed at correcting modifiable risk factors, symptom control and disease modification, have been published. While these modalities may help some patients, none has proven to provide definitive pain control or disease modification for patients with knee OA. The Agency for Research Health and Quality (AHRC) has recently evaluated the most common standard treatment options including glucosamine, chondroitin, visco supplementation and arthroscopic debridement. These have not shown to be effective compared to placebo. The high burden of knee OA and the absence of cure continue to stimulate intense search for new agents to modify disease and control symptoms.
Reeves et al. assessed prolotherapy as a treatment for knee and finger OA. Subjects with finger or knee pain and radiological evidence of OA were randomly assigned to receive 3 injection sessions of either prolotherapy with 10% dextrose and lidocaine, or lidocaine and bacteriostatic water (control group). In the finger OA trial, intervention subjects significantly improved in ‘pain with movement’ and ‘flexion range’ scores compared to controls; pain scores at rest and with grip showed a tendency to improvement without reaching statistical significance. In the knee OA trial, subjects in both groups reported significant improvements in pain and swelling scores, number of buckling episodes, and flexion range of motion compared to baseline, but without statistically significant differences between the groups. Surprising and potentially important 12-month follow-up in both studies included improved radiological features of OA on plain x-ray films: authors reported decreased joint space narrowing and osteophyte grade in the finger study, and increased patellofemoral cartilage thickness in the knee study. These radiological findings may suggest disease modification properties of prolotherapy. Whether or not subjects in the knee study had a baseline concomitant meniscal pathology was not reported or included in entry criteria. Furthermore, the ability of plain x-ray to quantify patellofemoral cartilage thickness is questionable, limiting impact of these findings.
CONTRAINDICATIONS, SIDE EFFECTS AND ADVERSE EVENTS
Contraindications
Absolute contraindications to prolotherapy are few and include acute infections such as cellulitis, local abscess or septic arthritis. Relative contraindications include acute gouty arthritis and acute fracture.
Common side-effects
The main risk of prolotherapy is pain and mild bleeding as a result of needle trauma. Patients frequently report pain, a sense of fullness and occasional numbness at the injection site at the time of injections. These side effects are typically self-limited. A post-injection pain flare during the first 72 hours after the injections is common clinically but its incidence has not been well documented. An ongoing study of prolotherapy for knee OA pain has noted that 10–20% of subjects experience such flares. Pain flares are likewise typically self-limited, and usually respond well to acetaminophen (500–650 mg every four hours as needed). On rare occasions, the occurrence of strong, post-injection pain may require treatment with narcotic medication. Non-steroidal anti-inflammatory agents are not routinely used after the procedure, but may be indicated if the pain does not resolve with other measures. Most patients with pain flares experience diminution of pain in 5–7 days after injections; regular activities can be resumed at this time.
Adverse events
While prolotherapy performed by an experienced injector appears safe, the injection of ligaments, tendons and joints with irritant solutions raises safety concerns. Theoretical risks of prolotherapy injections include lightheadedness, allergic reaction, infection or neurological (nerve) damage. Injections should be performed using universal precautions and the patient should be prone if possible. Dextrose is extremely safe; it is FDA approved for intravenous treatment of hypogylcemia and for caloric supplementation. As of 1998, FDA records for intravenous 25% dextrose solution reported no adverse events to Abbott Labs in 60 years. Morrhuate sodium is a vascular sclerosant, used in gastrointestinal procedures and vein sclerosing. Allergic reactions to morrhuate sodium are rare. Although P2G is not FDA approved for any indication, it has not been reported in clinical trials to cause significant side effects or adverse events.
Historically, a small number of significant, prolotherapy-related complications have been reported. They were associated with perispinal injections for back or neck pain, using very concentrated solutions, and included 5 cases of neurological impairment from spinal cord irritation and 1 death in 1959 following prolotherapy with zinc sulfate for low back pain. Neither zinc sulfate nor concentrated prolotherapy solutions are currently in general use. In a survey of 95 clinicians using prolotherapy, there were 29 reports of pneumothoraces after prolotherapy for back and neck pain, two of which required hospitalization for a chest tube, and 14 cases of allergic reactions, although none classified as serious. A more recent survey of practicing prolotherapists yielded similar results for spinal prolotherapy: spinal headache, pneumothoraces, nerve damage and non-severe spinal cord insult and disc injury were reported. The authors concluded these events were no more common in prolotherapy than for other spinal injection procedures. No serious side effects or adverse events were reported for prolotherapy when used for peripheral joint indications.
Practical Prolotherapy Incorporating Prolotherapy Into Practice
Similar to corticosteroid injections, prolotherapy is an unregulated procedure without certification by any governing body. Formal training is not provided by most medical schools, residencies and fellowships. However, prolotherapy, to be performed appropriately and safely, requires specialized training. In the U.S., it is taught to physicians and other health care providers (authorized to deliver joint-type injections) in semi-formal workshops and formal continuing medical education (CME) by several organizations, including university settings (Table 2).
Table 2
Educational and Informational Prolotherapy Resources
Name/URLComments
“The Anatomy, Diagnosis, and Treatment of Chronic Myofascial Pain with Prolotherapy”
http://www.ocpd.wisc.edu/Course_Catalog/
Continuing medical education (CME) on the basics of prolotherapy. This 3.5 day conference is offered through the University of Wisconsin School of Medicine and Public Health. All aspects of clinical and research aspects of prolotherapy are covered.
Hackett-Hemwall Foundation List of Prolotherapists
http://www.hacketthemwall.org/HHF/List_of_Prolotherapists.html
The Hackett-Hemwall Foundation is a non-profit medical foundation whose mission is to provide high-quality treatment of musculoskeletal problems to underserved people around the world. Physicians listed on the site have completed the Foundation’s high-volume continuing medical education experience in prolotherapy.
Commercial Prolotherapy Physician Listing
http://www.getprolo.com
This site lists physicians by state who perform prolotherapy. It includes contact information and a short biography and prolotherapy credentials. Physicians pay to list themselves on this site.
American Association of Orthopaedic Medicine
http://www.aaomed.org
The American Association of Orthopaedic Medicine is a non-profit organization which provides information and educational programs on comprehensive nonsurgical musculoskeletal treatment including prolotherapy. This searchable site lists AAOM members who perform prolotherapy.
Patients and physicians who desire consultation for prolotherapy may have difficulty finding an appropriate consulting prolotherapist. Online resources (Table 2) are available that can help locate a prolotherapist, though information is limited by lack of a credentialing structure and governing body for prolotherapy.
Despite limited institutional support, interest in prolotherapy is increasing, and it is performed in increasing numbers, primarily in two settings. For several decades, prolotherapy has been mostly performed outside of mainstream medicine by independent physicians. More recently, multi-specialty groups that include family or sports medicine physicians, physiatrists, orthopedic surgeons, neurologists or anesthesiologists have been incorporating prolotherapy as a result of positive clinical experience and research reports. Prolotherapy is one of several injection therapies that may promote healing of chronically injured soft tissue. Other therapies receiving active clinical and research attention for chronic musculoskeletal pain include whole blood, platelet rich plasma and polidocanol injections. In both settings, prolotherapy is viewed as a valued procedure, primarily reserved for patients who have failed other treatments or in patients who are not surgical candidates.
The authors’ clinic
The authors practice in a community in which several primary care physicians and specialists perform prolotherapy; receptivity to prolotherapy in our setting is growing. Some health insurance plans in our area cover prolotherapy for the indications discussed. Referrals can be made similar to those for more conventional procedures. An initial consultation, including a complete history and physical, is performed by the prolotherapist to determine if the patient is a candidate for prolotherapy. If so, side effects, adverse events and expected course of injections are explained, and the patient is asked to sign a procedure consent form. Information is also provided to patients in written form. (Table 3) The patient is then scheduled for up to three outpatient prolotherapy sessions, typically four- six weeks apart. At each subsequent visit, an interval history is obtained and physical exam is performed. If the patient does not report improvement after three prolotherapy sessions, alternative interventions are pursued.
Table 3
Prolotherapy at a glance
What is prolotherapy? Prolotherapy is an injection-based complementary and alternative medical (CAM) therapy for chronic musculoskeletal pain. This treatment aims to stimulate a natural healing response at the site of painful soft tissue and joints.
What is involved? Prolotherapy treatment typically involves getting a series of 2–5 monthly injections of a topical anesthetic and a solution of other medicines directly on sore tendon or ligaments, or into painful joints.
What conditions is it used for, and is it effective? Prolotherapy is generally used for musculoskeletal pain of greater than 3 months. Conditions that have responded well to prolotherapy in published studies include tennis elbow, Achilles tendinopathy, and other overuse injuries involving tendons. Prolotherapy is also likely effective for knee osteoarthritis and low back pain, though studies assessing these conditions are less conclusive.
Is it safe? Studies indicate that prolotherapy is safe when performed by an experienced practitioner. It does not appear to have a greater risk than other injection techniques, such as steroid injections.
Does it hurt? No one loves getting a shot, though prolotherapy injections typically hurt less than most immunizations. Most patients tolerate prolotherapy injections related pain quite well with only topical and conservative measures. Physicians can pre- treat with a pain reliever if necessary.
Clinical Recommendations
Present data suggest that prolotherapy is likely an effective therapy for painful overuse tendinopathy. Specifically, Scarpone et al. provides level A evidence for prolotherapy as an effective therapy for lateral epicondylosis. Subjects with refractory lateral epicondylosis and treated with prolotherapy reported significant reduction in pain and improved isometric strength compared to those who received control injections. These findings are supported by the Maxwell, Topol and Ryan studies that report strong case series results for Achilles, hip adductor and plantar fasciitis, respectively and provide level B evidence for these conditions. Given that the underlying mechanism of injury and pathophysiologic effects are similar for tendinopathies, prolotherapy is a reasonable option for these conditions as well. Randomized controlled trials for all three tendinopathies and for other tendinopathies are indicated.
Recommendations are more difficult to make for osteoarthritis and low back pain, both of which are associated with more complex anatomy and less clear pathophysiology than that seen in tendinopathies. Side effect and potential adverse events of prolotherapy are likely to be more serious when performed for spinal or intra-articular indications and must be weighed against the potential for improvement. Existing studies provide level B evidence that prolotherapy is effective for non-specific low back pain compared to a patient’s baseline condition. Given that subjects with refractory, disabling low back pain significantly improved compared to their own baseline status in the Yelland study, patients may reasonably try prolotherapy when performed by an experienced injector. Future studies with more focused inclusion criteria may help determine which specific low back pathologies respond to prolotherapy. Existing studies provide level B evidence that prolotherapy is effective for knee and finger osteoarthritis compared to control injections. Prolotherapy by an experienced physician is a treatment modality worth of consideration by primary care physicians for these conditions, especially when they are refractory to more conventional therapy.
Acknowledgments
Jeffrey Patterson, DO
Grant Support: None
Contributor Information
David Rabago, University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, 777 S. Mills St., Madison WI, 53715, Ph 608-265-2487, Fax 608-263-5813.
Andrew Slattengren, University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, 777 S. Mills St., Madison WI, 53715.
Aleksandra Zgierska, University of Wisconsin-Madison, Department of Family Medicine, 777 S. Mills St., Madison WI, 53715.
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A Little Less Beef Please!

Posted By Administration, Wednesday, July 20, 2011
Updated: Friday, April 18, 2014

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Copyright © Environmental Working Group, www.ewg.org. Reprinted with permission.

 

Report Finds Wide Variation in Environmental, Health Impacts of Foods

WASHINGTON, D.C.–The Environmental Working Group today released its groundbreaking Meat Eater’s Guide to Climate Change and Health, a powerful, multi-featured tool that allows both consumers and experts to understand easily how food choices affect both their environmental footprint and their health.

Taking into account every stage of food production, processing, consumption and waste disposal, the guide documents in unprecedented detail how consumers who eat less meat and cheese can significantly reduce the greenhouse gas emissions, pollution and health risks linked to their dietary choices. Previous studies have focused mostly on emissions from the food production phase only.

The calculations reveal that if everyone in the U.S. ate no meat or cheese just one day a week, over a year, the effect on emissions would be the equivalent of taking 7.6 million cars off the road.

The research also highlights the surprisingly large environmental impact of meat that goes into the trash, which accounts for more than 20 percent of all meat-associated emissions.

“By eating and wasting less meat, consumers can help limit the environmental damage caused by the huge amounts of fertilizer, fuel, water, and pesticides, not to mention the toxic manure and wastewater, that goes along with producing meat,” said Kari Hamerschlag, EWG senior analyst and author of the report. “Choosing healthier, pasture-raised meats can also help improve people’s health and reduce the environmental damage associated with meat consumption.”

Mario Batali, chef, restaurateur, award-winning author, and television personality, said, “The fact is, most people in the U.S. eat way more meat than is good for them or the planet, but even knowing this, the chances are little that we are all going to become vegetarians, much less vegan. Asking everyone to go vegetarian or vegan is not a realistic or attainable goal, but we can focus on a more plant-based diet and support the farmers who raise their animals humanely and sustainably. This is why I am such a big believer in the Meatless Monday Movement and the Environmental Working Group’s Meat Eaters Guide to Climate Change and Health.” 

The study points to abundant research showing how eating large quantities of beef and processed meats increases exposure to toxins and increases the risk of heart disease, cancer, and obesity.

EWG teamed up with CleanMetrics, an environmental analysis and consulting firm, to calculate complete lifecycle assessments of the “cradle-to-grave” carbon footprint of 20 types of conventionally raised (not organic or grass-fed) meat, fish, dairy and vegetable proteins, counting emissions generated both before and after the food leaves the farm. These assessments included every step of the food cycle, from the pesticides and fertilizers used to grow animal feed through to the grazing, processing, transportation, cooking and finally, disposal of unused food. 

Other key findings of the report:

  • Beef generates more than twice the emissions of pork, nearly four times that of chicken, and more than 13 times that of vegetable proteins such as beans, lentils, and tofu.
  • Cheese has the third-highest emissions. Less dense cheese (such as cottage) results in fewer greenhouse gases since it takes less milk to produce it.
  • 90 percent of beef’s emissions, 69 percent of pork’s, 72 percent of salmon’s and 68 percent of tuna’s are generated in the production phase. Just half of chicken’s emissions are generated during production.

“The report also points out that making significant cuts in emissions will not come solely from individual action, but also citizen action,” said Ken Cook, EWG’s President. “Consumers need to convince Washington to enact comprehensive policies that put the nation on a path to green energy. Reducing meat production’s negative impact on soil, air and water quality will also require better policies and regulatory enforcement as well as curbing meat consumption.”

EWG recommends that consumers buy right-size portions to reduce waste, avoid eating meat and cheese at least one day a week and choose “greener” options such as grass-fed, organic and pasture-raised animal and dairy products that are produced in a more ethical manner and without antibiotics or hormones.

To make the report and findings as widely useful as possible, EWG’s Meat Eater’s Guide website includes a variety of consumer-friendly features, including an interactive graphic, an available printed wallet card and brochure that summarize the results, consumer tips, a quiz and a guide to decoding the maze of labels on meat other food products.

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Eat Your Greens

Posted By Administration, Thursday, July 14, 2011
Updated: Friday, April 18, 2014

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by Therese Patterson, NC

Most people don’t realize that not all types of salad greens are created equal. I personally like to include a variety of different types of lettuce in my salad. Not only will a variety of greens allow you to enjoy a variety of different flavors and textures, but you also get to enjoy the range of nutrients each green has to offer. And while lettuce or salad greens are not often recognized as a great source of nutritional value, some varieties pack a surprising vitamin and mineral punch as you can see from the chart below.

Nutritional Comparison of Salad Greens Based on a 1 Cup Serving

Salad Greens Calories Vit A (IU) Vit C(Mg) Calcium (Mg) Potassium (Mg)
Romaine 8 1456 13 20 65
Leaf Lettuce 10 1064 10 38 148
Butterhead (Bib and Boston) 7 534 4 18 141
Arugula 5 480 3 32 74
Mixed Greens 9 1495 9 30 174
Baby Spinach 7 1200 8 20
Iceberg 7 182 2 10 87

Iceberg lettuce is included in the chart, not because I recommend it, but because it is so commonly served when eating out. Romaine lettuce has eight times more vitamin A and six times more vitamin C than iceberg lettuce, so iceberg would not be my lettuce of choice. After selecting your salad greens, creating a wonderful salad is only limited by your imagination— nuts, seeds, fish, poultry, beans, cheese, grains (try a spinach salad with lentils, garbanzo beans, tomatoes, cucumbers, feta and a light vinaigrette of olive oil and lemon juice-yum-o!).

Calorie for calorie, leafy green vegetables like spinach, with its delicate texture and jade green color, provide more nutrients than any other food. Baby spinach is a good source of calcium, fiber, iron, magnesium, provitamin A and vitamin C.

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Building Better Bone Health

Posted By Administration, Monday, July 11, 2011
Updated: Friday, April 18, 2014

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by Andrea Purcell, ND

I was sitting around with a group of my colleagues the other day and we were discussing Integrative medicine and how it always seemed to have the other side of the story.

Lets take bone health for example. When we think of bone health we instantly think of bone mineral density (BMD). This is what is measured in the gold standard test, the DEXA scan, to evaluate osteoporosis risk. All of the bisphosphinate drugs are focused on maintaining and improving BMD, and all fracture prevention efforts have been focused on it. However BMD is one component of bone health, it contributes to the density and the rigidness of the bone.

The other side of bone health is its flexibility, which is determined by its collagen content. It is both of these that determine how susceptible a bone is to fracture; we must have both for good bone health.

The collagen matrix provides the bones with its shock absorption nature and its spring and helps to complement bone mineral density. We can easily think of our bones like a tree. Without a certain level of flexibility a tree in a windstorm would snap in half if it did not have a collagen matrix.

Bone health declines with age so it is important to provide and supplement our bones with a combination of items that will support the bone at both levels.


Medications that lead to bone demineralization:

**Oral Glucocorticoids – increase fracture risk significantly
**Antibiotics – interfere with Vitamin K absorption
**Acid Blocking Medications – interfere with mineral absorption

Testing to determine bone health:

In addition to the DEXA scan, blood markers of homocysteine and osteocalcin are useful in determining vitamin deficiencies that can lead to weakened bones. Elevated homocysteine shows vitamin B6, B12, And folate deficiencies and Osteocalcin shows vitamin K deficiency.


Supplements for better bone health:

**Calcium citrate, Magnesium & Vitamin D
**Vitamin K can improve bone health and improve fracture risk. In the US it comes in K1 (MK7), found in leafy greens, and K2 (MK4), produced by digestive bacteria, both of these are non-toxic and important for bones. K2 has the most impact on bones and collagen formation and a dose of 45 mg has been approved for treatment of osteoporosis in Japan.
**Strontium ranelate (SR) at a dose of 2.0 g/day was been shown to reverse osteoporosis, without side effect. Due to its higher mass than calcium, strontium can alter DEXA scans and the radiologist doing the test must be informed of this. Strontium citrate is the most common form in the US but is it best to find SR when at all possible.

Note from Dr. P:
Bone Health is just another example that without holistic medicine we are missing key pieces to the story. When we only focus on one component of a disease or expect one action of a drug to completely fix a problem we are setting ourselves up for failure and more disease. By only treating bone Mineral Density we are completely ignoring 50% of the bone story and that’s why women are still falling and breaking bones! It is essential that we embark on comprehensive care so that all pieces to the story are addressed and the patient is restored to health!

-Be Happy, Healthy, & Holistic

Tags:  bone health 

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Curcumin for Inflammatory Bowel Disease: A Review of Human Studies

Posted By Administration, Friday, July 8, 2011
Updated: Friday, April 18, 2014

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Case study from the Alternative Medicine Review (AMR) - the official journal of the American College for Advancement in Medicine (ACAM)

by Rebecca A. Taylor, PharmD, MBA, BCPS and Mandy C. Leonard, PharmD, BCPS

Abstract

OBJECTIVE: To evaluate the use of curcumin in inflammatory bowel disease. DATA SOURCES: ALTMEDEX, Comprehensive Database of Natural Medicines, MEDLINE/PubMed were searched from January 1980 through May 2009 using the terms curcumin, turmeric, ulcerative colitis, Crohn’s disease,
Curcuma longa, Curcuma domestica, Indian saffron, inflammatory bowel disease. Data was limited to human trials. References of identified articles were reviewed. DATA SYNTHESIS: Data evaluating the use of curcumin in inflammatory bowel disease (including ulcerative colitis and Crohn’s disease) is limited to two studies comprising data for only 99 patients. Curcumin in conjunction with mainstream therapy, consisting of sulfasalazine (SZ) or mesalamine (5-aminosalicylic acid [5-ASA] derivatives) or corticosteroids was shown to improve patient symptoms and allow for a decrease in the dosage of corticosteroids or 5-ASA derivatives. In one small study of 10 patients, some patients even stopped taking corticosteroids or 5-ASA. CONCLUSIONS: Although two small studies have shown promising results, all authors conclude
that larger-scale, double-blind trials need to be conducted to establish a role for curcumin in the treatment of ulcerative colitis. In addition to improving results when used in conjunction with conventional medications for UC, curcumin may pose a less-expensive alternative. (Altern Med Rev 2011;16(2):152-156)

Background

Turmeric, used as a spice in curry powders and mustard, is known scientifically as Curcuma longa or Curcuma domestica. The perennial herb has multiple ingredients, including curcuminoids, the most active ingredients for medicinal use. These curcuminoids, comprising the yellow-pigmented fractions of turmeric, include diferuloylmethane (curcumin I), demethoxycurcumin (curcumin II), bisdemethoxycurcumin (curcumin III), and the recently discovered cyclocurcumin. The major components of commercial curcumin are curcumin I (77%), curcumin II (~17%), and curcumin III (~3%). Curcumin is also known by many synonyms and translated into various languages around the world; in Tibetan language it is known
as Gaser, in Swahili it is known as Manjano.

Curcumin has well-documented historical use in Chinese, Hindu, and Ayurvedic medicine. Curcumin has been used for a variety of disorders, from respiratory conditions to dyspepsia to malignancy. To date, no studies in animals or humans have discovered significant toxicity related to curcumin, even at very high doses.

Mechanisms of Action

Much is known about the molecular targets and interactions of curcumin with receptors, growth and transcription factors, cytokines, enzymes, and genes. Curcumin is often cited as pleiotropic, meaning it has the ability to interact with many cell targets. For the purposes of this discussion, curcumin’s molecular targets will be confined to those involved in gastrointestinal inflammation. Curcumin has been shown to inhibit the activity of lipoxygenase4 or binding to phosphatidylcholine micelles, thereby inhibiting lipoxygenase I. Of note in gastrointestinal disorders, curcumin has been found to inhibit the activation of various transcription factors that play a key role in inflammation, cell survival and proliferation, and
angiogenesis. These include nuclear factor-kappaB (NF-kB), activated protein-1 (AP-1), signal transducer and activator of transcription (STAT) proteins, peroxisome proliferator-activated receptor-gamma (PPAR-γ), and β-catenin. Inflammatory stimuli activate one of three independent mitogen-activated protein kinase (MAPK) pathways leading to activation of the p44/42 MAPK, JNK, or p38 MAPK pathway.
Cyclooxygenase-2 (COX-2) proteins are crucial to the inflammation cascade and have been linked to
certain cancers. There are several ways in which curcumin inhibits COX-2, both directly and indirectly. Curcumin downregulates the expression of COX-2, most likely through the downregulation of NF-kB that is required for COX-2 activation. In cancer cells, curcumin exerts anti-inflammatory and growth-inhibition by inhibiting expression of interleukin-1beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α).


Pharmacokinetics

Curcumin studies in animals show it is rapidly metabolized, conjugated in the liver, and excreted in the feces with minimal amounts found in the urine. A 40 mg/kg intravenous dose of curcumin given to rats resulted in complete plasma clearance at one hour post-dose, showing its rapid metabolism; data in humans is inconclusive. A phase I clinical trial conducted on 25 patients with precancerous lesions showed oral doses of 4, 6, and 8 g curcumin daily for three months yielded serum curcumin concentrations of only 0.51 ± 0.11, 0.63 ± 0.06, and 1.77 ± 1.87 µM respectively, indicating poor absorption of straight curcumin. In this study serum levels peaked one and two hours post-dose and declined rapidly.

Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease is a chronic immune disorder that involves an overactive immune component in the intestinal mucosa. IBD is divided into two major categories, ulcerative colitis (UC) and Crohn’s disease (CD). The two diseases have a fair amount of overlap, including presenting symptoms, quality of life issues, and treatments. Patients with IBD often have symptoms of abdominal pain, cramping, diarrhea, rectal bleeding, urgency, nausea, fever, and weight loss. Major differences of the two types of IBD are listed in Table 1.11 Proctitis is ulcerative colitis confined to the rectal area.

Certain cytokines have been associated with IBD, including TNF-α, IL-1, IL-6, IL-8, and others. Targeted drug therapies, specifically infliximab, have been successful in treating IBD. Infliximab is an anti-TNF-α monoclonal antibody that has been extensively studied in myriad inflammatory disorders, including CD and UC. Widespread use of infliximab is limited because of adverse effects, cost, and the emergence of antibodies that result after multiple administrations.

Most recently, the role of NF-kB in IBD has been elucidated. Colon biopsies in IBD patients with active disease show increased levels of NF-kB p65 protein (a member of the NF-kB family of proteins). The amount of NF-kB p65 in the tissue samples correlated with the severity of intestinal inflammation. This increased expression of NF-kB results in an increased ability to secrete inflammatory cytokines, such as
TNF-α, IL-1, IL-6, IL-12, and IL-23, the latter of which are directly responsible for mucosal damage in IBD. TNF-α is also able to up-regulate the production of NF-kB, resulting in a cyclical feedback loop of inflammation.

Table 1. Differential Diagnosis of Ulcerative Colitis and Crohn's Disease

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 Diagnosis and Staging of IBD in Clinical Studies

Ulcerative colitis is diagnosed through a colonoscopy, while the severity of symptoms can be rated on a number of severity index scales. Although several endoscopic indices are available to characterize the severity of ulcerative colitis, those currently used in clinical trials are not uniform. Hanai and colleagues, in the double-blind study discussed below, did not disclose their specific methodology for endoscopic index. The Clinical Activity Index (CAI) was used to assess UC severity in this same study. A CAI of ≤4
indicated remission, whereas a CAI ≥5 indicated relapse. A Crohn’s disease activity index (CDAI) is
often used to evaluate disease severity in CD – as was the case in the small pilot study discussed below.

Clinical IBD Studies
Small Pilot Study

Holt and colleagues conducted a small, open-label, pilot study of curcumin in five patients with ulcerative colitis/proctitis and five patients with Crohn’s disease. Five patients with ulcerative proctitis, who were currently using 5-aminosalicylic acid (5-ASA) compounds and corticosteroids (four of five patients were on corticosteroids + 5-ASA compounds), were given 550 mg curcumin twice daily for one month, then 550 mg three times daily for the second month. The five patients with Crohn’s disease received curcumin at a dose of 360 mg orally three times daily for one month and then 360 mg four times daily for an additional two months. Patient characteristics and demographics are reported in Table 2.

Patients were assessed at baseline and after two months of curcumin via hematological, biochemical, and inflammatory analysis (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) as well as sigmoidoscopy and biopsy. Subjective analysis was via a self-reported symptom diary. In the ulcerative
proctitis group, all five patients had significant improvement. Two patients stopped taking 5-ASA compounds, two reduced 5-ASA dosages, and one stopped corticosteroids entirely. Although only four of five CD patients completed the study, they also experienced a reduction in CDAI scores, ESR, and CRP. The Crohn’s disease group also reported symptomatic improvements of fewer bowel movements, less diarrhea, and less abdominal pain and cramping. In the absence of a clearly stated primary endpoint, it was considered to be the symptom diary. Based on the symptom diary (p<0.02), all patients improved from baseline after two months and inflammatory markers decreased to normal limits. The authors recommended larger scale, double-blinded, placebo-controlled trials in the future.

Table 2. Patient Characteristics and Medications at Study Entry

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Adapted from: Holt PR, Katz S, Kirschoff R Curcumin therapy in inflammatory bowel disease; a pilot study. Dig Dis Sci 2005;50:2191-2193.

5-ASA = 5-aminosalicyllic acid

SZ = sulfasalazine

6-MP = 6-mercaptopurine

Double-blind, Placebo-controlled Trial

Hanai and colleagues conducted a randomized, multicenter, double-blind, placebo-controlled trial of curcumin plus sulfasalazine (SZ) or mesalamine compared to placebo plus SZ or mesalamine in 89
patients with UC. After a four-week washout period, subjects were randomly assigned to a six-month regimen of either placebo (n=44) or curcumin 1,000 mg after breakfast and 1,000 mg after dinner (n=45) in combination with SZ (1-3 g/ day; median 2 g/day) or mesalamine (1.5-3 g/day; median 2.25 g/day). The inclusion and exclusion criteria were extensive (Table 3).

Patients were followed during treatment and for six months after the treatment ended; patients received only SZ or mesalamine during the six-month follow-up. Seven patients requested to be excluded, leaving 82 evaluable patients. The relapse rate was significantly higher in the placebo group (20.5% [8/39]) than in the curcumin-treated group (4.7% [2/43]). Curcumin also suppressed disease-associated CAI and endoscopic index (EI) scores. The mean CAI in the curcumin group was improved from 1.3 to 1.0 at six months (p=0.38), while CAI in the placebo group increased from 1.0 to 2.2 (p=0.0003). Patients in the curcumin group also had significantly improved EI (1.3 to 0.8 [p=0.0001]), while EI values in the placebo group showed no significant improvement. The authors provided only before- and after-treatment data,
despite assessments every two months. There was a statistically significant (p=0.049) difference between the percentage of patients with recurrence at six months in the curcumin (4.44 [95% confidence interval (CI) 0.54-15.15]) compared to the placebo (15.15 [CI 8.18-32.71]) group. This difference was not significant at 12 months.

Side effects reported by study subjects included abdominal bloating, nausea, hypertension (one patient), diarrhea, and elevated γ-guanosine triphosphate (GGTP) levels (one patient). This latter patient was a heavy drinker. With the exception of the patient that experienced hypertension, no patient discontinued curcumin therapy due to side effects.

Only two of 43 patients treated with curcumin in combination with SZ or mesalamine relapsed during six months of therapy; whereas, eight of 39 patients who received placebo with SZ or mesalamine relapsed during the same period. Although this difference was not statistically significant, the authors postulate curcumin may have an effect on suppressing relapse. The authors drew three major conclusions: (1) curcumin had better clinical efficacy over placebo in the prevention of relapse, (2) curcumin significantly improved the CAI and EI, and (3) curcumin was well-tolerated. The authors, stating their results might have
been better had they used a higher dose of curcumin, recommend that future studies use dosages greater than 2 g/day.

Table 3. Inclusion and Exclusion Criteria in Hanai Study

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Precautions and Contraindications

Patients with gallstones or bile duct obstructions should use curcumin with caution, primarily due to curcumin’s ability to cause gallbladder contractions. In a randomized, double-blind, cross- over study involving 12 healthy volunteers, 20 mg curcumin produced as much as 29-percent reduction in gallbladder size, indicating gallbladder contraction (statistically different than placebo). A subsequent study indicated
that doses of 40 and 80 mg curcumin produced 50- and 72-percent decreases in gallbladder volume, respectively.

Because curcumin inhibits platelet aggregation in vitro and in animal studies, it is theorized it could be additive in effect to antiplatelet medications such as aspirin, clopidogrel, and non-steroidal anti-inflammatories (NSAIDS).18,19 In a mouse model, 100 mg/kg curcumin or 25 mg/kg aspirin resulted in 60- or 61.1-percent protection from thrombosis, respectively. The concomitant use of curcumin and
anticoagulant or antiplatelet medications should be approached with caution.

Conclusion

Although this review discusses just two clinical studies of inflammatory bowel disease, the uses of curcumin far exceed the scope of this article. Curcumin shows promise in treating myriad disorders. It has recently been studied, at wide-ranging daily dosages of as little as 20 mg and as much as 12 g, for ailments such as psoriasis, colorectal cancer, renal graft function, pancreatitis, dyspepsia, and chronic anterior uveitis, to name a few. Larger-scale, prospective studies are needed to confirm its effect for IBD. Curcumin has an advantageous safety profile as well as low relative cost, making it an attractive option for IBD patients.

References
1. Goel A, Kunnumakkara AB, Aggarwal BB. Curcumin as “curecumin”: from kitchen to clinic. Biochem Pharmacol 2008;75:787-809.
2. Jurenka JS. Anti-inflammatory properties of curcumin, a major constituent of Curcuma longa: a review
of preclinical and clinical research. Altern Med Rev 2009;14:141-153.
3. Hanai H, Sugimoto K. Curcumin has bright prospects for the treatment of inflammatory bowel disease. Curr Pharm Des 2009;15:2087-2094.
4. Skrzypczak-Jankun E, Zhou K, McCabe NP, et al. Structure of curcumin in complex with lipoxygenase and its significance in cancer. Int J Mol Med 2003;12:17-24.
5. Began G, Sudharshan E, Appu Rao AG. Inhibition of lipoxygenase 1 by phosphatidylcholine micelles-bound curcumin. Lipids 1998;33:1223-1228.
6. Shishodia S, Singh T, Chaturvedi MM.  Modulation of transcription factors by curcumin. Adv Exp Med Biol 2007;595:127-148.
7. Cho JW, Lee KS, Kim CW. Curcumin attenuates the expression of IL-1beta, IL-6, and TNF-alpha as well as cyclin E in TNF-alpha-treated HaCaT cells; NF-kappaB and MAPKs as potential upstream targets. Int J Mol Med 2007;19:469-474.
8. Sharma RA, Steward WP, Gescher AJ. Pharmacokinetics and pharmacodynamics of curcumin. Adv Exp Med Biol 2007;595:453-470.
9. Ireson C, Orr S, Jones DJ, et al. Characterization of metabolites of the chemopreventive agent curcumin in human and rat hepatocytes and in the rat in vivo, and evaluation of their ability to inhibit phorbol esterinduced prostaglandin E2 production. Cancer Res 2001;61:1058-1064.
10. Cheng AL, Hsu CH, Lin JK, et al. Phase I clinical trial of curcumin, a chemopreventive agent, in patients with high-risk or pre-malignant lesions. Anticancer Res 2001;21:2985-2900.
11. Friedman S, Blumberg RS. inflammatory bowel disease. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, eds. Harrison’s Principles of Internal Medicine. 17th ed. Columbus, OH: McGraw-Hill Professional; 2008:1886- 1898. http://www.accessmedicine.com/ content.aspx?aID=2883197
12. Papadakis KA, Targan SR. Role of cytokines in the pathogenesis of inflammatory bowel disease. Annu Rev Med 2000;51:289-298.
13. Atreya I, Atreya R, Neurath MF. NF-kappaB in inflammatory bowel disease. J Intern Med 2008;263:591-596.
14. Hanai H, Iida T, Takeuchi K, et al. Curcumin maintenance therapy for ulcerative colitis: randomized, multi- center, double-blind, placebo-controlled trial. Clin Gastroenterol Hepatol 2006;4:1502-1506.
15. Holt PR, Katz S, Kirschoff R. Curcumin therapy in inflammatory bowel disease: a pilot study. Dig Dis Sci
2005;50:2191-2193.
16. Rasyid A, Lelo A. The effect of curcumin and placebo on human gall-bladder function: an ultrasound study. Aliment Pharmacol Ther 1999;13:245-249.
17. Rasyid A, Rahman AR, Jaalam K, Lelo A. Effect of different curcumin dosages on human gall bladder. Asia Pac J Clin Nutr 2002;11:314-318.
18. Srivastava KC, Bordia A, Verma SK. Curcumin, a major component of food spice turmeric (Curcuma longa) inhibits aggregation and alters eicosanoid metabolism in human blood platelets. Prostaglandins Leukot Essent Fatty Acids 1995;52:223-227.
19. Srivastava R, Dikshit M, Srimal RC, Dhawan BN. Anti-thrombotic effect of curcumin. Thromb Res 1985;40:413-417.
20. Srivastava R, Puri V, Srimal RC, Dhawan BN. Effect of curcumin on platelet aggregation and vascular prostacyclin synthesis. Arzneimittelforschung 1986;36:715-717.

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Detox - What Does that Mean?

Posted By Administration, Tuesday, June 28, 2011
Updated: Friday, April 18, 2014

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by Marsha Nunley, MD

I have gone through many changes on my journey to health: gluten-free/dairy-free diet, limited alcohol, no processed foods, bio identical hormones, many, many supplements, meditation, yoga, etc. and for me, doing a detox is the last frontier. I think I have resisted because I did not really understand and honestly, it seemed a bit daunting. Juice, shakes, and limiting food intake? Really, I love my food and because I have adrenal issues, I am used to eating frequently. Yes, I pretty much eat whole organic foods and even try to get in as many raw foods as possible, but I do love a good steak every now and then. (Sushi does not count on a raw food diet.) So let’s explore the reasons we should consider doing a detox every six months (or at least annually).

In medical school, I learned about detoxification that occurs in the body to remove waste – a part of normal bodily processes. We also learned about how the body metabolizes drugs and other foreign invaders. The assumption seemed to be that the body had a system that would readily get rid of whatever it needed to, when it needed. Not much was taught about augmenting the process of detoxification. In medicine, it is referred to as a metabolic process. To your average physician, drugs and toxins are metabolized (not detoxified), so detoxification in the sense of patient treatment is not something that your average physician will be interested in or familiar with necessarily. Not to criticize, just to let you know that if you try and talk to your family doc about detox, you will probably be met with a questioning look and dismissed. I think it is really that most doctors are simply not aware of the burden we are putting on our bodies’ detoxification capabilities.

Toxins can be classified as inner toxins, which are generated within the body, or outer toxins, which are toxins that enter the body from the outside. Inner toxins come from the body’s normal metabolic processes and from invaders, such as an infection. So where do outer toxins come from? Read this article from the Environmental Working Group about a study where they tested volunteers for 210 chemicals (San Francisco Chronicle, 2004).

“There are more than 75,000 chemicals licensed for commercial use; more than 2,000 new synthetic chemicals are registered every year; the Environmental Protection Agency has tallied close to 10,000 chemical ingredients in cosmetics, food and consumer products. The 210 we were tested for are just a few of the industrial chemicals in our world. We can surmise that the actual number of manufactured chemicals in our bodies is far greater than our results show. Very few of these chemicals were in our environment, or our bodies, just 75 years ago.

In 1998, U.S. industries reported manufacturing 6.5 trillion pounds of 9,000 different chemicals, and in 2000, major American companies — not even counting the smaller ones — dumped 7.1 billion pounds of 650 different industrial chemicals into our air and water.”

We are living in a sea of toxins and there is good evidence that it is affecting our health in a major way. Many chronic conditions such as arthritis, chronic fatigue, fibromyalgia, elevated cholesterol and triglycerides, depression, and on and on are related to our toxic world. These chemical toxins are stored in fat in the body and are likely a major contributing factor to the obesity epidemic in the U.S. and the world.
We are living in a different world from our parents and grandparents. Clearly, regular augmentation of the body’s detoxification process is essential for us to remain healthy and vital. Even though it’s not easy, I am putting regular detoxification into my health regimen and encourage you to do the same. I am currently a week into a 21-day detox. I will keep you posted on how it goes.

Good resources on detox and toxicity in our world:

Cleanse Your Body, Clear Your Mind. by Jeffrey Morrison, MD
Essential Cleansing. by Brenda Watson
Healing Digestive Illness. by Russell Mariani
Detoxify or Die. by Sherry Rogers
Environmental Working Group

Dr. Marsha Nunley is a Texas native who moved to California in 2000. She earned her medical degree from the University of Texas at San Antonio and is Board Certified in Internal Medicine. She currently practices Internal as well as Functional Medicine in San Francisco and Oakland, California. Dr. Nunley is also an expert in menopause, andropause and bio-identical hormone therapies. She has completed specialty training in Geriatric Medicine, Palliative Care, and Pain Management, and is also certified in the new area of Aging Medicine through the American Academy of Anti-Aging and Regenerative Medicine. She has completed an Associate Fellowship in Integrative Medicine at the University of Arizona, where she explored the benefits of mind-body medicine, chiropractics, acupuncture, homeopathy, craniosacral therapy, hypnotherapy, and energy healing. Visit Dr. Nunley's website at: www.marshanunleymd.com.

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Anti-Aging Lifestyle Prolongs Life

Posted By Administration, Wednesday, June 22, 2011
Updated: Friday, April 18, 2014

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by Andrea Purcell, ND

In a study published in the Journal of Internal Medicine, researchers in Sweden have studied 900 men over the last 50 years and have come up with predictors of longevity. Of all of the subjects, 111 lived to 90 and had the following predictors:

  • They did not smoke
  • Moderate coffee intake < 2 cups
  • Good socio-economic status by age 50
  • Engaged in good physical work capacity at age 54
  • Low Cholesterol at age 50

In another study by the National Institutes of Health on 400,000 people showed that those who ate high fiber diets were 22% less likely to die over a nine-year period. The average American consumes 15 grams of fiber daily. Recommendations are 25g/day for women and 38g/day for men. Fiber is beneficial for heart health, respiratory and infectious disease, and cancer. Fiber’s benefits come from vitamins, micro-nutrients, and antioxidants which assist the body in detoxification and are present in whole grains, especially rice bran.

Consider Brown or Black Rice:

Most of us have heard of brown rice but black? Black rice also called forbidden rice, is nutty and chewy and filled with anthocyanins (same antioxidant found in blueberries.) This antioxidant rich food comes with all of its bran layers intact, and the black rice bran has more antioxidants per spoonful compared to blueberries along with less sugar, more fiber and more vitamin E. So go on cook up a pot tonight!

Note from Dr. P:

Reducing toxicity and body cleansing from the inside out are essential for longevity. Fiber is an essential component of this especially rice bran found in brown or black rice. Chlorophyll found in dark leafy greens is also essential in cleansing the body while providing fiber. Drop the coffee and have 2 cups of green tea instead and we have a winning combination.

Move your body! As we age we lose muscle due to inactivity and loss of hormones, this results in loss of mobility, strength and balance. In the words of Jack LaLanne “Let exercise be your king and nutrition be your queen and then you have a kingdom” Stay Healthy, Keep Moving!

-Be Happy, Healthy, & Holistic

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Hydration Nation

Posted By Administration, Tuesday, June 21, 2011
Updated: Friday, April 18, 2014

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by John Gannage, MD, MCFP, DH

This article, as the warm weather arrives, is intended to provide guidance to those committed to physical activity as part of a healthy lifestyle. In the shorter term, the information will assist the prevention of electrolyte disturbances from exercise and improper fluid replacement which are common, and which can be dangerous. Long term, owing to the relationship between chronic mineral depletion and chronic disease, the article is also pertinent.

As a personal anecdote, I continue to play hockey at least twice a week in the winter months, and have found that, as I have optimized my detoxification metabolism and overall fitness, I actually sweat to a much greater degree. In recent years, this had led to a different kind of challenge for me - post-exertion fatigue and severe headaches. In fact, I was often wiped out into the next day after a particularly vigorous session, and for a while floundered trying to find the correct formula to prevent such debilitating episodes.

The answer lies in proper hydration - before, during and after exercise - with the understanding that when it comes to hydration and exercise, the rules are different compared to a non-athletic general population. My mistakes were too much plain water intake, risking low blood sodium concentration (hyponatremia), and inadequate pre-loading (i.e. entering exercise well hydrated) with fluid AND electrolytes, particularly sodium. Also, the widely available sport drinks didn't work well with me - I have since read (at www.migraineweb.com) that MSG is used as a flavour enhancer (not good for headache sufferers or anyone else) in some sports drinks, but have yet to confirm this.

I have had better success with a sport drink product named “e-load”, developed by a Toronto Sports Medicine specialist, Dr. Doug Stoddard. I like the formula for its sodium content and its “anti-bonking” effects. Not to be understated, it has had a huge impact on my life and allowed me to perform better, more vigorously and with longer endurance, while negating all of the previous post-exertion adverse effects. Simply, it kept me in the game.

Let it be known that dehydration is the most common performance-sapping mistake that athletes make, but it's also the most preventable. Here are some guidelines to help athletes stay well hydrated. Remember that everyone sweats differently (in sweat volume and sodium content - in fact I am likely a “high-salt sweater”) and therefore needs vary as to fluid and salt requirements before and during exercise. A general recommendation is 1 gram of sodium per hour of intense exercise.

DO:

Hydrate before exercise begins.

Drink 2-3 cups (475-700 ml) of fluid 2-3 hours before exercise to allow excess fluid to be lost as urine. This may mean drinking the evening before for early AM exercisers. About one-half hour before exercise, drink 5-10 oz (150-300 ml). Use a sports drink with adequate sodium content, as indicated below.

Drink during exercise.

Most athletes find it helpful to drink every 10 to 20 minutes during a workout. Heavy sweaters can benefit from drinking more often (e.g., every 10 minutes) and light sweaters should drink less often (every 20+ minutes).

Ingest sodium before and during exercise.

Sodium lost in sweat must be replaced during exercise. That's one reason why a good sports drink is better than plain water. Before a long endurance activity, increasing dietary salt 10 -25 grams for the few days prior is helpful.

Use weight as your guide.

The best way to determine if you'd had enough to drink during a workout is to check to see how much weight you've lost. Minimal weight loss means that you've done a good job staying hydrated. Remember that weight loss during an exercise session is water loss, not fat loss, and must be replaced.

DON'T:

Don't rely solely on water.

For the athlete, drinking large amounts of water is not only unnecessary, but can be downright dangerous. Drinking water alone keeps you from replacing the electrolytes lost in sweat (and from ingesting performance-boosting carbohydrates that help you train longer and stronger). Bloated stomach, swollen fingers and ankles, a bad headache, and confusion are warning signs of hyponatremia, a harmful electrolyte disturbance that can occur due to excessive water intake.

Don't gain weight during exercise.

A sure sign of too much fluid intake is weight gain during exercise. If you weigh more after your activity than you did before, that means that you drank more than you needed. Be sure to cut back for the next time.

Don't restrict salt in your diet.

Ample salt (sodium chloride) in the diet is essential to replace the salt lost in sweat. Because athletes sweat a lot, their need for salt is much greater than for non-athletes. During non-activity (or for the sedentary), I recommend a teaspoon of sea salt for every 2 litres of purified water - consumed daily.

Don't use aspirin, ibuprofen and other non-steroid anti-inflammatories
These medications increase the risk of hyponatremia in athletes, and should be avoided.

THE BOTTOM LINE

Drink adequate amounts of fluid designed for exercise, and enter your activity well hydrated while finding a drinking routine that suits your individual needs. (On the day of a hockey game, I'll drink 3.5 litres of sport drink - totalling the before, during and after fluid consumption.)

Disclaimer: The information contained in this article is for educational purposes only. One should always seek the personalized advice from a qualified practitioner before making the dietary and behaviour changes listed, as the needs and medical status of individuals are highly variable.

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Lowering Cholesterol Without Statin Medications

Posted By Administration, Monday, June 20, 2011
Updated: Friday, April 18, 2014

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by Allan Magaziner, DO

Just last week, the FDA issued yet another warning regarding the use of  a statin medication, this time Simvastatin, which is frequently prescribed to lower cholesterol levels.  They noted that there is a significant risk of muscle damage (myopathy) in those patients taking high dose Simvastatin (brand name: Zocor).  In addition, the FDA warned against taking this drug along with some commonly utilized anti-fungal, antibiotic and cardiac medications.

I have always been critical of the use of high dose and, often, low dose, statin use especially in light of the numerous alternative treatments that are extremely effective.  In fact, in my previously published book, The All-Natural Cardio Cure, I highlighted many of the problems with statin drugs such as Zocor (Simvastatin), Lipitor (Atorvastatin), and Crestor (Rosuvastatin) and presented many effective options.  

Do all people with high cholesterol levels require cholesterol-lowering medications?  Of course not.  Drew, a 48 year old male, consulted with me when  struggling with seasonal allergies and a long history of sinus problems.  After a thorough evaluation, his cholesterol level was found to be high at 255 (with a normal range of 120-199) and the “bad” LDL cholesterol was also elevated at 184 (normal <99).   

Rather than starting him on a statin to lower his cholesterol, he was placed on an anti-inflammatory diet and I recommended the use of natural supplements including red yeast rice, plant sterols and omega-3 fatty acids.  

Within three short months, Drew’s lipid profile was greatly improved.  His latest total cholesterol had declined to a normal level of 177, while the LDL also fell to 101. Best of all, perhaps, Drew’s energy was better than ever, he felt his immune system was far stronger, he had not been sick at all and his allergy symptoms were completely gone...and all of this without any statin medications or any other prescription medicines!   

Drew is one of hundreds of patients who have been successfully treated at the Magaziner Center for Wellness for high cholesterol without the use of statins or other medications. 

In my opinion, statins should not be taken as first line therapy and should be used only as a last resort.  We have plenty of effective options…let’s use them. 

For more information about lowering your cholesterol level or other cardiac risk factors, contact the Magaziner Center for Wellness at 856-424-8222.

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Sickness Syndrome Depression - The Link Between Seasonal Allergies, Inflammation, and Depression

Posted By Administration, Wednesday, June 8, 2011
Updated: Friday, April 18, 2014

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by Gina Nick, NMD, PhD

A recent article in the New York Times discusses several large studies that link seasonal allergies to  depression and anxiety. The cause is an increase in inflammatory cytokines that lower serotonin levels.  This is a classic example of Sickness Syndrome Depression, a condition identified years ago and finally gaining media attention.  We often see cases of wrongly diagnosed anxiety and depression at our practice where patients are prescribed antidepressant medications instead of being treated for Sickness Syndrome Depression. To learn more about the syndrome click here. One treatment that is not yet mentioned on the site but that we have recently been using successfully in practice to treat Sickness Syndrome Depression and other psychiatric illnesses with an inflammatory component is BRM4 by Daiwa Health Development- an immunomodulator that alters levels of inflammatory cytokines throughout the body. The effective dosage is 4 capsules three times per day for 4 weeks, and then 4 capsules per day thereafter.

In health and healing,

-Dr. G

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Ease Anxiety Naturally

Posted By Administration, Monday, June 6, 2011
Updated: Friday, April 18, 2014

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by Andrea Purcell, ND

In this fast paced life anxiety is presenting itself in many different forms. Patients will describe nervousness, irritability, edginess, heart palpitations, difficulty breathing, hurriedness, and inability to turn off the mental motor. These are just a few descriptions that I hear daily in private practice. Stress is present, people become overwhelmed by it and then get stuck in an anxiety cycle that leads to sleeplessness and becomes very difficult to get out of.

Here are a few tools that can be used on a daily basis to help re-boot our nervous system and break the fight or flight cycle.

The top three-lifestyle ways to soothe anxiety are physical exercise, breathing exercises, and meditation.

Physical exercise has physical in the name so we forget how much it helps our mental health. Daily exercise can lift our moods, influence our food choices, which influence our moods, and act as a mental stress reliever. It helps us get out of our heads, and allows us to take a mental health break.

Deep breathing increases the amount of oxygen in the blood which acts to boost our immune system and give us more energy. It also calms down the sympathetic nervous system and in turn decreases our adrenalin output. So we feel like there is less of an emergency all the time. Breathing abdominally is better than chest breathing. I recommend the “breathing in a box technique”. Inhale slowly for 4 counts, hold your breath for 4 counts, exhale for four counts, and hold for four counts. And repeat. The slower you do it, the more you can focus on the air entering, moving through, and exiting your body. Posture is important! Sit up straight with your shoulders down and pulled back, align your neck over your spine and breathe. Poor posture promotes shallow breathing and more anxiety.

Meditation is a daily practice just like exercising and breathing. Many patients say that they have difficulty completely emptying their mind and find this practice hard to do. My recommendation is to get yourself a tape that will take you through a very short say 1 minute meditation to begin and then expands as you practice your meditation muscle. The Chopra Center has free online meditations; they gradually introduce a new-comer to meditation.

www.chopra.com/library/guidedmeditations
You do have to subscribe to their free online library.

Supplements to use when you are overwhelmed:
Rescue remedy by Bach flower
Calms forte –homeopathic remedy for an over stimulated nervous system.
Double bag of chamomile tea
L-theanine – found in green tea it has calming properties. 200mg capsule, 1-2 capsules usually help take the edge off.

Note from Dr. P
Stress is here to stay, so we all need to get a game plan that works for us to manage stress on a regular basis. I recommend calendaring everything, yes, even exercise. Items on your calendar will not get pushed to the side they will get done with everything else. Every woman I know has a daily list of items to accomplish that is greater than what is humanly possible. Have the immediate list and then the list that can be done over more time. I call it my doing “now” list and my “not” doing now list.
Another stress reduction tip is to be present! The gift is in the present! The present is all we have, so enjoy it, soak it up like a good piece of Italian bread in garlic and oil, ummm, that will help diffuse the anticipation of what is next on the to do list.
Finally, if you find that you just can’t keep it together, and that your day is running you instead of you running your day, there could be other factors that need to be evaluated by a trained professional. You may have a hormonal imbalance and need good council by an integrative doctor. So get the help, get balanced, and get on with your life!

-Be Happy, Healthy & Holistic

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Case Study - Neuroendocrine and Immune Contributors to Fatigue

Posted By Administration, Friday, June 3, 2011
Updated: Friday, April 18, 2014
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Marni N. Silverman, PhD, Christine M. Heim, PhD, Urs M. Nater, PhD, Andrea H. Marques, MD, PhD, and Esther M. Sternberg, MD
 
Abstract
 
Central fatigue, a persistent and subjective sense of tiredness, generally correlates poorly with traditional markers of disease. It is frequently associated with psychosocial factors, such as depression, sleep disorder, anxiety, and coping style, which suggest that dysregulation of the body's stress systems may serve as an underlying mechanism in the maintenance of chronic fatigue (CF). This article addresses the endocrine, neural, and immune factors that contribute to fatigue and describes research regarding the role of these factors in chronic fatigue syndrome as a model for addressing the biology of CF. In general, hypoactivity of the hypothalamic-pituitary-adrenal axis, autonomic nervous system alterations characterized by sympathetic overactivity and low vagal tone, as well as immune abnormalities, may contribute to the expression of CF. Noninvasive methods for evaluating endocrine, neural, and immune function are also discussed. Simultaneous evaluation of neuroendocrine and immune systems with noninvasive techniques will help elucidate the underlying interactions of these systems, their role in disease susceptibility, and progression of stress-related disorders.
 
 
INTRODUCTION
 
Fatigue comes in various forms. Acute fatigue is a normal, protective mechanism in healthy individuals, is usually linked to a single cause, and is often relieved by rest or life-style change (ie, diet, exercise, rest, stress management). Rarely is it associated with long-term cognitive dysfunction, a state that most often returns to baseline after rest and recovery. However, chronic fatigue (CF) is considered maladaptive or pathologic, lasts 6 months or more, adversely affects physical and mental function, and may have multiple and unknown causes. Generally, no relief is gained from usual restorative measures aimed at relieving fatigue [1]. CF is especially apparent in individuals with chronic disease, such as autoimmune diseases (rheumatoid arthritis [RA], multiple sclerosis, systemic lupus erythematosus [SLE]), psychiatric disorders (major depressive disorder [MDD]); neurologic disorders, eg, stroke; cancer (during and after treatment); and idiopathic chronic multisymptom illnesses, eg, chronic fatigue syndrome [CFS] and fibromyalgia (reviewed in [2]). Peripheral fatigue is observed in chronic diseases associated with muscle wasting and inflammation or joint abnormalities, as often occurs in RA and SLE, myasthenia gravis, and cardiorespiratory diseases. Peripheral fatigue can be attributed to organ-system dysfunction and usually is not associated with cognitive loss.
 
Central fatigue generally correlates poorly with traditional markers of disease [2] and is frequently associated with other psychosocial factors, such as depression, sleep disorder, anxiety, and coping styles [3,4], which suggests that dysregulation of the body's stress systems may serve as an underlying mechanism of CF. Indeed, there appears to be an intricate interplay between the neural, endocrine, and immune systems in regulating the body's response to stress and the maintenance of homeostasis.
 
 


 
CROSS TALK AMONG NEURAL, ENDOCRINE, AND IMMUNE STRESS SYSTEMS
 
That the nervous and immune systems communicate with each other in a bidirectional manner is well established (reviewed in [5-12]). There are 2 main pathways by which psychogenic stress is relayed from the brain to the body: (1) via the hypothalamic-pituitary-adrenal (HPA) axis with the resultant release of glucocorticoids (cortisol in humans and primates; corticosterone in rodents) and (2) via the sympathetic nervous system (SNS), with the resultant release of catecholamines (noradrenaline and adrenaline). These neuroendocrine stress systems coordinate the response of many other physiologic systems to a stressor, including the immune and cardiovascular systems, as well as energy production and/or utilization and behavior, therefore, bringing the physiologic systems back to homeostasis [13].
 
However, maintenance of homeostasis during an immune challenge involves activation of the immune system, resolution of the challenge, and protection of the host against potentially detrimental inflammatory processes. Relevant to the latter, interleukins (IL) and/or cytokines (tumor necrosis factor [TNF]-α, IL-1, and IL-6 in particular) activate the same stress pathways to coordinate an appropriate immune response [5,6,12]. Cytokine receptors have been detected at all levels of the HPA axis, and, therefore, each level can serve as an integration point for immune and neuroendocrine signals [5]. In turn, glucocorticoids negatively feedback onto immune cells to suppress the further synthesis and release of innate proinflammatory molecules. Glucocorticoids also shape immunity by influencing immune cell trafficking to sites of inflammation and alter downstream adaptive immune responses by causing a shift from cellular (Th1 inflammatory) to humoral (Th2 anti-inflammatory) type immune responses [14,15]. Therefore, in contrast to the traditional view of glucocorticoids as immunosuppressant hormones, a more accurate view is that they are immunomodulatory hormones that stimulate as well as suppress immune function, depending on glucocorticoid concentration, type of immune response, immune compartment, and cell type. Glucocorticoids also play an important role in the regulation of the SNS. In addition to subserving permissive effects on relevant synthetic enzymes and receptors for catecholamines, endogenous glucocorticoids restrain SNS responses under resting conditions and after stress [16].
 
In addition to HPA axis-immune interactions, there is strong evidence for interactions between the immune system and the autonomic nervous system (ANS) (SNS and parasympathetic nervous system [PNS] pathways) and peripheral nerves. Whereas, circulating hormones, such as glucocorticoids, regulate immunity at a systemic level, neural pathways regulate immunity at a local and regional level. The SNS and peripheral nervous system innervate immune organs, where sympathetic influences can be both pro- and anti-inflammatory, depending on the type of adrenergic receptor to which the catecholamine binds [8,9]. Neuropeptides released from peripheral nerves, such as substance P, tend to be proinflammatory [7]. Locally released norepinephrine or circulating epinephrine also affect lymphocyte trafficking, proliferation, function, and cytokine production. With regard to the peripheral nervous system, both afferent and efferent parasympathetic activities have been shown to be immunomodulatory. Whereas, afferent vagal fibers express IL-1 receptors on paraganglia cells situated in parasympathetic ganglia [12], efferent vagal fibers have been shown to exert anti-inflammatory action via the release of acetylcholine [10, 11]. Therefore, the vagus nerve also serves as a source of negative feedback on the immune system, with the brain being an integral relay station.
 
Dysregulation of any of these stress systems can lead to dysregulation of multiple physiological and behavioral systems, which leads to a maladaptive response to stress [13-17]. Indeed, dysregulation of neural-immune interactions is described in many stress-related disorders, including inflammatory, autoimmune, metabolic, and cardiovascular disease, as well as psychiatric and somatic disorders.
 
The capacity of proinflammatory cytokines to cause changes in behavior, including symptoms of fatigue, psychomotor retardation, anorexia, anhedonia, hyperalgesia, somnolence, lethargy, muscle aches, cognitive dysfunction, and depressed mood, has led to the suggestion that proinflammatory cytokines may contribute to the behavioral features of depression [18,19] as well as somatic disorders, such as CFS and fibromyalgia [20].
 
The first indication that inflammation may induce psychosomatic symptoms came from research about depression. There is a strong similarity between neurovegetative symptoms (anorexia, sleep disturbance, psychomotor retardation, fatigue, and pain) of depression and inflammation-induced sickness behavior [21]. Indeed, cytokine-based immunotherapy (interferon [IFN]-α) induces 2 distinct behavioral syndromes: a neurovegetative syndrome, which appears early, persists, and is minimally responsive to classical antidepressants; and a mood-cognitive syndrome, characterized by depressed mood, anxiety, and cognitive dysfunction, which appears later and is responsive to classic antidepressants (ie, selective serotonin reuptake inhibitors [SSRIs]) [22]. Moreover, differential clustering of mood-cognitive and neurovegetative syndromes is observed in patients with cancer. Indeed, cancer-related fatigue does not respond well to antidepressants, which suggests that it is not exclusively a mood or behavioral problem. [23]. Of note, cancer-related fatigue has also been associated with elevated inflammatory biomarkers and impaired HPA axis function [24,25].
 
It appears that these 2 categories of symptoms are mediated by different biological mechanisms. For example, dopaminergic pathways may play a more prominent role relative to other monoamine neurotransmitters (serotonin, norepinephrine) in the neurovegetative subset [3,22]. In support of this notion, Meeusen et al [26] proposed a central fatigue hypothesis and suggested that an increase in the brain ratio of serotonin to dopamine is associated with feelings of tiredness and lethargy, which accelerates the onset of fatigue, whereas, increased dopamine levels favor improved performance through the maintenance of motivation and arousal.
 
Given the role of corticotropin-releasing hormone (CRH) in behavioral and HPA-axis activation, it has been hypothesized that defective central CRH synthesis and/or release may also contribute to symptoms of fatigue [27]. Indeed, abnormal central CRH pathways have been detected in various chronic disease states with a fatigue component, including SLE, multiple sclerosis, RA, fibromyalgia, and CFS [2,27]. Moreover, both psychogenic and immune stressors can induce similar neuroendocrine and neurotransmitter changes in the brain, therefore, sensitizing the brain to subsequent stressors, and, hence, inducing a state of increased stress vulnerability as seen in various psychiatric and psychosomatic disorders [28].
 
In the next section, we discuss how hypoactivity of the HPA axis, ANS alterations characterized by sympathetic over-activity and low vagal tone, as well as immune abnormalities, may play a role in CFS.
 
BIOLOGICAL CORRELATES OF FATIGUE: DYSREGULATION OF STRESS SYSTEMS EXEMPLIFIED BY CFS
 
A diagnosis of CFS requires that an individual displays severe CF for more than 6 months without a defined cause (with all other medical conditions being excluded), as well as the presence of 4 of the following 8 symptoms: myalgia, arthralgia, sore throat, tender nodes, cognitive difficulty, headache, postexertional malaise, or sleep disturbance [29]. (See Clauw later in this supplement.)
 
HPA Axis
 
A substantial body of research on the pathophysiology of CFS has focused on dysregulation of the neuroendocrine systems. The HPA axis is the key neuroendocrine system that adapts the organism to various challenges, including emotional, physical, chemical, and immune stressors. These stressors have been associated with risks for developing CF. The secretion of glucocorticoids from the adrenal cortex results in multiple metabolic, behavioral, and immune regulatory responses that help the organism adapt to such challenges. Dysregulation of these regulatory functions may be causally associated with symptoms of CFS. Thus, insufficient glucocorticoid signaling has been associated with increased immune activation and inflammatory responses, potentially promoting symptoms of fatigue, malaise, somnolence, myalgia, and arthralgia (reviewed in [13,17]).
 
Dysfunction of the HPA axis, characterized by lower than normal cortisol secretion, is one of the hallmark biological features of CFS, although the literature is somewhat inconsistent. Poteliakhoff [30] first described attenuated basal plasma cortisol levels in patients with CFS. After these initial observations, Demitrack et al [31] reported lower than normal cortisol excretion in patients with CFS. Results of several subsequent studies confirmed lower than normal cortisol levels in plasma or saliva [32-39], flattened cortisol diurnal secretion [38-40], and decreased urinary free cortisol secretion in patients with CFS [41-44].
 
However, results of a substantial number of studies failed to identify hypocortisolism in CFS (eg, reviewed in [45-46]). Similarly, results of an array of endocrine challenge studies revealed signs of hypocortisolism in CFS, including enhanced negative feedback inhibition of the pituitary [47-50] or mild adrenal insufficiency [31,51], although results are inconsistent [45,46]. Results of a recent study found decreased glucocorticoid sensitivity of immune cells in persistently fatigued adolescent females [52], which suggests decreased cortisol signaling, consistent with the idea of a lack of cortisol effects contributing to CFS. However, in vitro studies on glucocorticoid sensitivity are also inconsistent [53]. Of note, glucocorticoid sensitivity was shown to be regulated in a tissue- and cell-specific manner (reviewed in [6]).
There may be important subgroups of patients with CFS, depending on etiologic pathways or clinical features. Heim et al [54], for example, demonstrated, in a population-based sample, that only those patients with CFS who reported childhood traumatic experiences exhibited low cortisol levels compared with well controls, whereas patients with CFS and without a history of severely stressful circumstances had normal cortisol levels. Thus, it is plausible that several of the neuroendocrine features of CFS covary with risk factors other than illness state and reflect a vulnerability to develop CFS in response to challenge [54]. Of note, hypocortisolism, as reported in patients with CFS, has been observed in animal models of early life stress (reviewed in [55]). Thus, CFS could be conceptualized as a disorder of adaptation that is promoted by developmental risk factors.
 
Some researchers have suggested that hypocortisolism in CFS might be a consequence of having the disorder, because low cortisol secretion has been associated with illness features, for example, inactivity [56]. In addition, the stress of symptoms themselves, such as fatigue, sleep and mood disturbances, and pain, can contribute to the further dysregulation of biological stress pathways, which lead to a positive feed-forward cascade. Whether or not hypocortisolism is a cause or a consequence of CFS remains to be evaluated in longitudinal studies. Perhaps it is both.
 
ANS
 
A number of studies examined the involvement of the ANS in the pathophysiology of CFS. The rationale for these studies is based on the observation that several symptoms of CFS, namely fatigue, dizziness, diminished concentration, tremulousness, and nausea, could be explained by autonomic dysfunction. In addition to the neuroendocrine system, the ANS is another key regulation system that adapts the organism to challenge. Thus, autonomic dysregulation could further trigger symptoms of CFS in response to challenges that disturb homeostasis.
 
Initial studies found an increased prevalence of neurally mediated hypotension and orthostatic intolerance in patients with CFS, measured by using a prolonged standing or a head-up tilt table test [57-64]. However, results of several studies failed to find differences between CFS and control groups regarding dysautonomia [65-68].
 
Another line of research in the study of ANS alterations in CFS has focused on cardiovascular autonomic measures. Results of most studies found increased heart rate measures in CFS, both at rest and in response to challenge [65,69-74]. Increased heart rate and/or reduced heart rate variability (HRV) is in accordance with other studies that reported low vagal tone [69,75-77] or general sympathetic overactivity [62,78-80], although inconsistent results exist (reviewed in [46]). Whether or not there are subgroups with CFS and altered autonomic function based on etiologic factors or illness features is unknown. Sympathetic overactivation, in concert with low glucocorticoid signaling, may contribute to an overactive immune system, particularly in response to challenge, which may lead to symptoms of CFS.
 
Immune System
 
Many findings suggest that infectious agents (viral and bacterial infections) and immunologic dysfunction (eg, inappropriate production of pro- and anti-inflammatory cytokines) may play a role in the pathophysiology of at least some cases of patients with CFS (reviewed in [81-83]). Indeed, persistent postinfection fatigue has been well documented [84]. Results of early studies showed that many individuals with CFS had evidence of enhanced antibody responses to Epstein-Barr virus (EBV). However, subsequent reports showed that many patients with CFS lacked evidence of EBV reactivity, although they displayed elevated antibody titers to a number of other viral agents. Interestingly, acute viral infection studies found that initial infection severity was the single best predictor of persistent fatigue [85]. Taken together, results of these studies suggest that, although some cases of CFS may be triggered by an infectious agent, the chronic symptoms of this syndrome are unlikely to be caused by an active infection.
 
Results of other studies indicated signs of immune disturbance in patients with CFS, especially in the form of elevated proinflammatory cytokine levels [86,87], such as IL-6 and TNFα in serum and cerebrospinal fluid [88,89]. Consistent with these findings, increased in vitro inflammatory cytokine release has been reported in stimulated peripheral blood mononuclear cells of patients with CFS [90]. Other indices of cytokine-mediated immune alterations that have been reported in patients with CFS include increased levels of auto-antibodies, decreased natural killer cell activity, high levels of type 2 cytokine–producing cells, activated T lymphocytes, CD19+ B cells, neopterin (a marker of activated cell-mediated immunity), and activated complement [91-94]. In addition, alterations in the expression of genes involved in immunity have been detected [95]. However, despite multiple indications of immune system activation in CFS, the best-replicated immunologic findings in this disorder are suppression of several immune functions, especially natural killer cell activity and mitogen-induced lymphocyte proliferation [94-96]. Nonetheless, these multiple findings need to be interpreted in light of a meta-analysis [81] that found no evidence for clear immune abnormalities in CFS.
 
Interestingly, results of a recent and robustly designed study by Raison et al [97] showed that fatigue not only in its severe and chronic form, as in CFS, but also in its milder forms, is associated with increased inflammation, as indexed by elevated plasma C-reactive protein levels and white blood cell count, even after adjusting for depressive status. This study further supports the notion that the symptom of fatigue, rather than a diagnosis of CFS itself, may be what is clinically associated with inflammation. In addition, childhood traumatic experiences appear to be an important risk factor for a hypocortisolemic profile in CFS [54], and adults with a history of childhood trauma exhibit elevated markers of inflammation, even in the absence of depression [98]. Moreover, patients with depression and childhood trauma show even higher levels of inflammation than with either risk factor alone [98,99]. Whether immune status is different in patients with CFS, with or without a history of childhood trauma, remains to be determined.
 
In summary, chronic (pathologic) fatigue can be attributed to hypoactivity of the HPA axis; ANS alterations characterized by sympathetic overactivity and low vagal tone; and immune abnormalities, including reduced cellular responses and enhanced inflammation and humoral responses. CFS is an exemplar, but not the only example, of fatigue conditions, with these associations. Disparate findings among various studies may be because of (1) differences in methodology, recruitment, and analysis; (2) comorbidities, including depression and/or other chronic diseases; (3) lack of an epidemiologically comparable control group; and (4) biological changes not present in all cases of a heterogeneous disorder, such as CFS, but rather related to particular symptoms or risk factors of the disorder. The latter indicates the importance of grouping by symptom subtypes rather than an arbitrarily defined disorder. Indeed, different symptom categories of CFS may be mediated by different biological mechanisms, as seen in cytokine-induced depressive symptomatology [22]. To help elucidate a “molecular signature” for clinical sub-types within a heterogeneous disorder, noninvasive methods for evaluating neural, endocrine, and immune function are available without causing further pain or distress, which could confound outcome measures of interest.
 
NONINVASIVE METHODOLOGIES TO EVALUATE STRESS SYSTEMS
 
Measurement of hormones, cytokines, and neuroactive substances has frequently posed a problem for clinicians and investigators because of the need to perform invasive tests, such as drawing blood. Noninvasive and ambulatory methodologies of neural, endocrine, and immune biomarker collection can overcome several limitations intrinsic to invasive methods, reducing the stress triggered by collection of samples and allowing a wider application to community-based settings. Collection of sweat and saliva and measurement of HRV are noninvasive methods that can be applied to evaluate neuroimmune interactions. Ultimately, simultaneous evaluation of neural and immune systems with noninvasive techniques will help elucidate the underlying interactions of these systems and their role in disease susceptibility and progression of stress-related disorders.
 
HPA Axis: Salivary Cortisol
 
Because (1) the HPA axis is a self-regulated dynamic feedback system and (2) cortisol is secreted in a pulsatile fashion, single time-point measures of cortisol cannot be used to accurately interpret HPA axis function. An adequate assessment of HPA axis function requires multiple serial sampling (to test basal activity and circadian profiles) or dynamic testing by using pharmacologic or psychologic challenges (to test reactivity and/or feedback sensitivity). More recently, the salivary cortisol response to awakening has received considerable scientific attention and has been shown to be sensitive to detect HPA axis dysregulation related to stress and disease, including CFS [39,100]. When collected in the context of such sampling protocols, cortisol can be reliably measured in saliva as an index of HPA axis function [101].
 
The majority of circulating cortisol is bound to corticosteroid-binding globulin, which inactivates the biological actions of cortisol. Only the free fraction of cortisol is biologically active and can bind to glucocorticoid receptors to influence gene expression and protein synthesis. In saliva, only the free fraction of cortisol can be measured. Free cortisol measures in saliva reliably reflect the amount of free cortisol circulating in the blood stream [101]. In studies that focus on the actions of cortisol in target systems, it is advantageous to measure the free and biologically active fraction of cortisol. However, for studies that focus on assessment of total cortisol output of the adrenal gland or ratios of bound versus unbound cortisol and corticosteroid-binding globulin activity, blood measures are necessary. These differences must be considered when interpreting data from salivary cortisol studies.
 
ANS: Salivary α-Amylase and Heart Rate Variability
 
Because the transfer of norepinephrine from blood to saliva takes approximately 1 hour [102], which is too long for accurate assessment of stress-induced changes, salivary α-amylase (sAA), a digestive enzyme, has become an emerging biomarker for stress as an indicator of SNS activity. Both the sympathetic and parasympathetic branches of the ANS innervate the salivary glands, where SNS stimulation increases protein secretion and PNS stimulation increases salivary flow rate [103]. sAA has repeatedly been found to increase in response to physical stress or exercise, as well as psychological stress, and also correlates with plasma norepinephrine responses to those same stressors, although to a lesser extent to psychosocial stress (reviewed in [104]). sAA concentration can also serve as an index for pathologic dys-regulation of the ANS in specific clinical and subclinical conditions, such as anxiety and somatic disorders [104]. One important caveat of measuring sAA is that, in the presence of stress and SNS activation, the PNS is inhibited, which leads to reduced salivary flow rate, and hence, decreased saliva production. Therefore, stress-induced increases in sAA could be confounded with parallel decreases in salivary volume, thereby increasing sAA concentration.
 
Evaluation of the ANS can also be performed noninvasively through measurement of HRV. The heart is under tonic control by parasympathetic influences. Heart rate is characterized by beat-to-beat variability, which also implicates vagal dominance, because the sympathetic influence on the heart is too slow to produce rapid beat-to-beat variability. HRV is a term that describes variations of both instantaneous heart rate and the interval between consecutives beats. A prominent circadian variation in HRV, with significant increases during the night and decreases during the day, is observed in healthy individuals. Results of previous studies showed that this increase in nighttime HRV is blunted by acute stress and that decreased HRV is associated with increased overnight urinary cortisol and increased proinflammatory cytokines and acute-phase proteins [105]. Decreased HRV, indicative of reduced parasympathetic-vagal tone, is an independent risk factor for morbidity and mortality.
 
Neural and Immune Biomarker Profiles: Cutaneous Sweat Patch
 
Another noninvasive and nonstressful approach to evaluating neural and immune systems is through collection of sweat via a 24-hour cutaneous sweat patch. In our initial validation studies, we showed that immune biomarkers, such as proinflammatory cytokines, in sweat were tightly correlated with plasma levels in healthy women [106]. In addition, we have shown that a population of women with MDD in remission exhibited elevated sweat levels of proinflammatory cytokines, sympathetic neuropeptides (neuropeptide-Y), and pain-related neuropeptides (substance P, calcitonin gene–related peptide) but decreased parasympathetic (vasoactive intestinal peptide) neuropeptide levels relative to controls, which strongly correlated with plasma levels [107]. This pattern is consistent with a shift in MDD from parasympathetic to sympathetic tone and an underlying proinflammatory state that could account for enhanced susceptibility to conditions known to be comorbidly expressed with MDD, including cardiovascular disease, osteoporosis and diabetes. Moreover, biomarker levels strongly correlated with symptoms of depression and anxiety, which indicate functional significance of these biomarker profiles. A similar biomarker profile was reported in pain- and fatigue-related syndromes [2].
 
Ultimately, these noninvasive methodologies could provide a “molecular signature” for clinical subtypes within a heterogeneous disorder to be used for (1) diagnostic and prognostic purposes; (2) earlier intervention in asymptomatic conditions; (3) optimization of individualized treatment regimens; (4) patient monitoring in remote areas and in large-scale epidemiologic settings; (5) monitoring patients in whom invasive methodologies are unfeasible, especially vulnerable populations, including pregnant women, infants, children, and the elderly; and (6) to shed light on mechanisms that underlie individual vulnerability or resiliency to develop stress-related diseases and/or disorders.
 
CONCLUSION
 
In summary, CF states have been shown to be attributable to a dysregulation of stress systems, including hypoactivity of the HPA axis, ANS alterations characterized by sympathetic overactivity and low vagal tone, and immune abnormalities, such as reduced cellular responses and enhanced inflammation and humoral responses. Hypocortisolemia may develop through reduced synthesis or depletion of HPA-axis hormones, receptor downregulation, and/or increased negative feedback sensitivity [108]. Fries et al [108] proposed that the phenomenon of hypocortisolism may occur after a prolonged period of hyperactivity of the HPA axis because of chronic or traumatic stress, in which this “switch“ may prevent possible deleterious effects of excessive glucocorticoid exposure. CFS and related pain and fatigue disorders may then be interpreted as a maladaptive overadjustment, in which the HPA axis is then functioning at an alternate, more stress-sensitive steady state [109]. Interestingly, the consequences of insufficient glucocorticoid signaling, including hyperactive SNS activation and enhanced inflammation, result in similar deleterious effects to that of hyperactive glucocorticoid signaling, such as altered metabolic, cardiovascular, immune, neurologic, and behavioral functions [17], including the potentiation of fatigue and related symptoms. Given the complex nature of fatigue, with its many physiologic and behavioral risk factors and correlates, the most effective therapeutic strategy may require multimodal action. The simultaneous evaluation of a large array of neural, endocrine, and immune biomarkers, when using noninvasive methodologies, may help inform the design of more effective pharmacologic therapeutic interventions to be used along with nonpharmacologic interventions, such as cognitive-behavioral therapy. It may also inform clinicians of mechanisms by which these interventions act and how successful they are in altering the neuroendocrinologic and immunoregulatory aspects of fatigue.
 
Contributor Information
 
Marni N. Silverman, Section on Neuroendocrine Immunology and Behavior, National Institute of Mental Health, National Institutes of Health, Rockville, MD.
 
Christine M. Heim, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.
 
Urs M. Nater, Department of Clinical Psychology and Psychotherapy, University of Zurich, Switzerland, Centers for Disease Control and Prevention, Atlanta, GA.
 
Andrea H. Marques, Genetic Epidemiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.
 
Esther M. Sternberg, Section on Neuroendocrine Immunology and Behavior, National Institute of Mental Health, National Institutes of Health, Integrative Neural Immune Program, 5625 Fishers Lane (MSC-9401), Rockville, MD 20852.
 
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73. van de Luit L, van der Meulen J, Cleophas TJ, Zwinderman AH. Amplified amplitudes of circadian rhythms and nighttime hypotension in patients with chronic fatigue syndrome: improvement by inopamil but not by melatonin. Angiology. 1998;49:903–908. [PubMed]
74. Winkler AS, Blair D, Marsden JT, Peters TJ, Wessely S, Cleare AJ. Autonomic function and serum erythropoietin levels in chronic fatigue syndrome. J Psychosom Res. 2004;56:179–183. [PubMed]
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77. Stewart JM. Autonomic nervous system dysfunction in adolescents with postural orthostatic tachycardia syndrome and chronic fatigue syndrome is characterized by attenuated vagal baroreflex and potentiated sympathetic vasomotion. Pediatr Res. 2000;48:218–226. [PubMed]
78. De Becker P, Dendale P, De Meirleir K, Campine I, Vandenborne K, Hagers Y. Autonomic testing in patients with chronic fatigue syndrome. Am J Med. 1998;105:22S–26S. [PubMed]
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80. Boneva RS, Decker MJ, Maloney EM, et al. Higher heart rate and reduced heart rate variability persist during sleep in chronic fatigue syndrome: a population-based study. Auton Neurosci. 2007;137:94–101. [PubMed]
81. Lyall M, Peakman M, Wessely S. A systematic review and critical evaluation of the immunology of chronic fatigue syndrome. J Psychosom Res. 2003;55:79–90. [PubMed]
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83. Klimas NG, Koneru AO. Chronic fatigue syndrome: inflammation, immune function, and neuroendocrine interactions. Curr Rheumatol Rep. 2007;9:482–487. [PubMed]
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87. Patarca R. Cytokines and chronic fatigue syndrome. Ann N Y Acad Sci. 2001;933:185–200. [PubMed]
88. Borish L, Schmaling K, DiClementi JD, Streib J, Negri J, Jones JF. Chronic fatigue syndrome: identification of distinct subgroups on the basis of allergy and psychologic variables. J Allergy Clin Immunol. 1998;102:222–230. [PubMed]
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91. Mawle AC, Nisenbaum R, Dobbins JG, et al. Immune responses associated with chronic fatigue syndrome: a case-control study. J Infect Dis. 1997;175:136–141. [PubMed]
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94. Whiteside TL, Friberg D. Natural killer cells and natural killer cell activity in chronic fatigue syndrome. Am J Med. 1998;105:27S–34S. [PubMed]
95. Steinau M, Unger ER, Vernon SD, Jones JF, Rajeevan MS. Differential-display PCR of peripheral blood for biomarker discovery in chronic fatigue syndrome. J Mol Med. 2004;82:750–755. [PubMed]
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98. Danese A, Moffit TE, Pariante CM, Ambler A, Poulton R, Caspi A. Elevated inflammation levels in depressed adults with a history of childhood maltreatment. Arch Gen Psychiatry. 2008;65:409–415. [PMC free article] [PubMed]
99. Pace TW, Mletzko TC, Alagbe O, et al. Increased stress-induced inflammatory responses in male patients with major depression and increased early life stress. Am J Psychiatry. 2006;163:1630–1633. [PubMed]
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Bran Cancer Risk from Cell Phone Use

Posted By Administration, Thursday, June 2, 2011
Updated: Friday, April 18, 2014

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by Nalini Chilkov, LAC, OMD

A scientific report released Tuesday by the World Health Organization concludes radio frequencies and electromagnetic fields – including those routinely emitted by mobile phones – are “possibly” carcinogenic to humans.

The World Health Organization and its subsidiary investigative panel, the International Agency for Research on Cancer, or IARC, stated today what many scientific studies have been suggesting for decades: that there is a possible connection between mobile phone use and malignant brain tumors.  Dr. Jonathan Samet, who heads IARC’s Working Group of 31 international scientists from 14 countries, made the announcement at the conclusion of the group’s week-long meeting in Lyon, France.

“The working group classifies the radio and electromagnetic fields as possibly carcinogenic to humans; that is within the classification used by the International Agency for Research on Cancer,” he said.

The group advised that, because five billion people around the world currently use mobile phones, therefore, much further research in the subject is needed.  The report places at most risk those with the greatest use of cell phones and exposure to other sources of radiation. ”We also carefully consider the sources of exposure of populations to radio frequency electromagnetic fields, the nature of these fields as they come from various devises, including wireless phones, and we look carefully at the physical phenomenon by which exposure to such fields may perturb biological systems and lead to cancers,” he said.

The IARC working group had gathered in France for the past eight days, reviewing all previous studies done on electromagnetic radiation’s effects on humans and animals over the past decade.

Health advocacy groups that have been warning of possible cell phone-cancer links are praising the WHO pronouncement.

Camilla Rees, the founder of a U.S. based group called Electromagnetic Health, says she is pleased but said much more needs to be done. ”They focused on brain cancer, and brain cancer includes a relatively small number of people.  But we only have had this technology for about 15 years and most carcinogens will take several decades before they develop into a cancer.  Early indicators from scientists are projecting a tsunami of brain cancer unless we do something to educate people to lower their exposure,” she said.

Rees says there are many other health effects of radiation, including damage to human cell tissue, that the World Health Organization has yet to recognize. But for now, she believes the most urgent need is to begin a campaign to protect children from the effects of electromagnetic fields, and in  particular, from cell phones.

“What microwave radiation does in most simplistic terms is similar to what happens to food in microwaves, essentially cooking the brain,” said Dr. Keith Black, chairman of neurology  and world class brain surgeon at Cedars-Sinai Medical Center in Los Angeles. “So in addition to leading to a development of cancer and tumors, there could be a whole host of other effects like cognitive memory function, since the memory temporal lobes are where we hold our cell phones.” Dr Black recommends using ear buds or texting to keep the cell phone away from the head.

While wireless carriers instruct users to keep cell phones a certain distance from their heads, such as Apple’s iPhone 4 safety manual that says to keep the device at least 15 millimeters from the body, CTIA – The Wireless Association noted that WHO’s announcement does not mean that cell phones cause cancer. In addition, the association denounced WHO’s results since it “did not conduct any new research, but rather reviewed published studies.”

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My Kid has ADD/ADHD

Posted By Administration, Tuesday, May 31, 2011
Updated: Friday, April 18, 2014

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by Matt Angove, ND, NMD

No doubt, genetic susceptibility plays into the whole ADHD paradigm but that goes for everything. Whatever your state of being, good or bad has to do with how you bathe your genes.

I find it to be a modern day miracle that more people aren’t suffering from ADHD, depression, anxiety disorders, bipolar, schizophrenia, and the like considering the laboratory derived concoctions we douse our bodies with daily.

Before you put your child on Ritalin, a compound that has marked similarities to amphetamines and actions consistent with cocaine, just dampened somewhat, let us consider our options.

Let us Consider

Consider the Red No. 40, Yellow No. 5, MSG, aspartame, Splenda, partially hydrogenated oils, high fructose corn syrup, soybean oil (Is there anything in a box it is not in?), caffeine (Monster drinks, Red Bull, Soda, coffee), phosphorus (soda pop) and refined sugars.

Consider the refined foods and naked grains they are consuming.

Consider the hormone buffed and corn stuffed meats they are putting on their sandwiches.

Consider the hours of reckless television and video games that are being sprayed across their eyes and mind.

If you or your child is consuming items such as JELL-O, Lucky Charms, Pop-Tarts, Butterfinger bars, Skittles, Hostess Twinkies or Frito-Lay Doritos, to name a few, you should fully expect marked neurological dysfunction.  It is only natural!!!

Nutritionally based therapies for ADHD can be EXTREMELY beneficial!!!  Understand that 8-10% of school age children are considered to be in this spectrum.  So, there are plenty of children who are suffering and in most cases, I would suggest needlessly.

Available therapies

Sports

Avoidance of possible food sensitivities (start with gluten, refined sugars, dairy, chocolate, citrus, peanuts, eggs, soy) –an elimination and reintroduction diet may be in order.

Elimination of synthetic sweeteners, colors and whatever isn’t FOOD from the diet.

Evening Primrose oil coupled with Fish Oil

Flaxseed oil with Vitamin C

Nutrient optimization ( Magnesium, Zinc, Calcium, Iron, Potassium, B vitamins)

Probiotics

Amino acid combination’s (as monitored by your health provider)

Lifestyle is High Style

You have to realize that getting ADHD under control isn’t an overnight affair.  Just like any other chronic condition, you must set forth and live out a lifestyle conducive to the sustaining of life.  I know it is not easy.  Our current available knowledge state has given everyone the opportunity for abundant health.  However, the societal pace rarely allows us to utilize and practice that knowledge.

You simply have to choose what lane you want to live in.

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Gluten Free - The Latest Fad Diet

Posted By Administration, Wednesday, May 25, 2011
Updated: Friday, April 18, 2014

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by Andrea Purcell, ND

The shocking news in 2003 was that 1 in 133 people had celiac disease. Celiac disease is a genetic intolerance to gluten contained in wheat, rye, and barley. Eating and cooking gluten free means consuming a whole food diet devoid of gluten containing grains.

Celiac disease once considered rare, is now a common autoimmune disease afflicting 1 in 133 people. If you or a loved one has Celiac disease there is a good chance that first and second-degree relatives have the diagnosis as well. As a medical necessity, there are three groups of people who should avoid gluten.

*Any person with a diagnosis of Celiac disease.

*Any person with an allergic reaction to wheat as determined either by an IgG or an IgE blood test.

*Any person with gluten sensitivity.

Many people are sensitive to wheat and/or gluten but do not have the diagnosis of celiac disease. Sensitivities can cause symptoms such as skin reactions, congestion in the throat, ears, or sinuses, digestive upset, or other body inflammation such as fatigue and aching joints. A recent study in 2010 found that people could lose their tolerance to gluten as they age. These people are not born with the genetic intolerance commonly seen with celiac disease but are developing the intolerance later on in life. This suggests a weakening of digestive function due to repeated exposure to gluten, which can cause leaky gut, toxin exposure, antibiotics, medications, and even vaccines.

The information about gluten and the awareness around celiac disease seems to have thrown the nation into a gluten free frenzy. Many people are eating gluten free as a type of fad diet. These people have heard that gluten is bad and have chosen to avoid it as a way to be healthy. As the awareness builds so does the variety of gluten free products. It is easier than ever to find gluten free cake, cookie, brownie mixes, breads, need I say more? Even if you are going gluten free filling your day with these will not bring you closer to health. Moving towards a plant-based diet however, will.

 


Cooking Gluten Free…

For those first diagnosed with Celiac disease the act of cooking and eating initially becomes very stressful. Learning a few tried and true recipes that you know you can whip up in a flash will be extremely helpful.

The first thing you should do when you find out that you need to eat gluten free is to focus on a plant based diet. This includes vegetables, fruits, nuts, seeds, and lean proteins. These foods will become the foundation of your daily food plan.

Experiment with alternative grains such as brown rice, wild rice, quinoa, amaranth, buckwheat, sorghum, and teff.

There are many benefits to home cooking. You have complete control over what you eat and the quality of ingredients, plus there will always be leftovers for lunch the next day, hooray!

Baking Gluten Free…

Cooking is one thing and baking is another. The general rule of thumb for mastering any gluten free baked good recipe is to experiment with the recipe at least three times. The first will be a flop, the second will be better, and you will try a different flour, moisture ingredient or sweetener, and by the third try you will be satisfied. Then you can actually bring the finished product to a social gathering. Making a bread or cupcake with one type of flour is not recommended, the success in baking gluten free comes from mixing the flours. You can mix bean flour with a gluten free flour to help with the texture. In gluten free baking many things can come out dry and crumbly so items must be added that create more moisture. These items could be mashed banana, tofu, honey, eggs, pumpkin, or xantham gum. In order to succeed you must experiment with a variety of flours. Become familiar with the tastes and textures of the alternative flours, then you can combine them. Once you master the moisture content, then you can experiment with the level of sweetness. Many recipes just have you add plain old white sugar but I prefer stevia, agave, brown rice syrup, honey or a combination of two sweeteners to reduce the calorie and sugar content of the recipe.

Note from Dr. P

In order to determine if you are sensitive to gluten you can do this simple experiment at home. Avoid all gluten for 14 days. This means all gluten. Read labels carefully because many items contain hidden gluten such as cereals, deli meats, and canned soups. After 14 days reintroduce gluten containing foods 1-2x daily for three days in a row. Observe your body for any signs of gluten sensitivity that I listed above. Looking for healthy gluten recipes? Get my book!

 

-Be Healthy, Happy, & Holistic

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You Have a Right to Make Healthy Choices!

Posted By Administration, Wednesday, May 18, 2011
Updated: Friday, April 18, 2014

It's no secret that pesticides are harmful to humans and the environment. According to the National Institutes of Health, pesticides are linked to diabetes, Parkinson's Disease, cancer and more. Below is a letter from the Environmental Working Group that invites you to sign their petition to urge the FDA not to cave in to the chemical agribusiness's campaign to limit the public's information to pesticides.


Dear Friend,

Since 1991, the U.S. Department of Agriculture has been testing fresh produce for pesticide residues and releasing the findings. Environmental Working Group analyzes these detailed technical reports to produce our Shopper's Guide to Pesticides. But this year, the USDA may cave in to an industry campaign to alter the results and give consumers less information. That's bad news for us all.

Chemical agribusiness interests have launched an expensive all-out campaign to silence EWG and deny you information you need to make healthy choices. Just last year, nearly $200,000 of taxpayers' money was used to support a misinformation campaign run by the Alliance for Food and Farming, a pro-agricultural chemicals lobby dedicated to combating pesticide critics like EWG.

Chemical agribusiness interests want to suppress the truth about pesticides. We can't let them get away with it. USDA officials need to hear that you want the truth, all of it and nothing but. Please join the more than 36,000 people who have called on USDA to not cave in to industry.

Click here to sign our petition that tells USDA officials to not cave to industry pressure and to stop funding industry's disinformation campaigns!

The evidence linking pesticides to health problems -- such as increased risk of cancer -- is overwhelming. New studies show that pesticide exposure may lead to developmental delays and lower IQs in children. Last year, the President's Cancer Panel recommended that consumers avoid foods with pesticide residues.

Instead of kowtowing to industry groups like the Alliance for Food and Farming, the USDA and other federal agencies should compile and analyze more information about pesticides. Industry spin should not drive disclosure of critical information about pesticides in our food. If you want to know whether your kids' lunch boxes contain fruits and veggies high in pesticide residues, take action today!

Click here to sign our petition today. It's unpalatable that your tax dollars fund disinformation about pesticides in food.

Thank you for standing with EWG against the pesticide lobby.

Sincerely,

Ken Cook
President, Environmental Working Group

 

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Saffron - Research Shows Anti-Cancer Activity

Posted By Administration, Tuesday, May 17, 2011
Updated: Friday, April 18, 2014

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by Nalini Chilkov, LAC, OMD

 

Saffron, Crocus sativus, also known as Hong Hua in Traditional Chinese Herbal Medicine, has been used both as a culinary spice and as a medicinal botanical on many continents throughout history for over 3,000 years. Recent research demonstrates that a component of saffron, a orange-red colored carotenoid called crocetin shows promise as an anti-cancer agent. Saffron also contains other carotenoids including zeaxanthin, lycopene, and various alpha- and beta-carotenes

According to researcher Fikrat Abdullaev, who is so impressed with saffron’s multiple medicinal properties that he suggests there be a new scientific discipline called “saffronology”

Considerable scientific evidence has suggested that plant-based dietary agents can inhibit the process of carcinogenesis effectivelySince cancer is the most common cause of death in the world population, the possibility that readily available natural substances from plants, vegetables, herbs, and spices may be beneficial in the prevention of cancer warrants closer examination. Saffron in filaments is the dried, dark red stigmata of Crocus sativus L. flowers and it is used as a spice, food colorant, anda drug in medicine. A growing body of research has demonstrated that saffron extract itself and its main constituents, the carotenoids, possess chemopreventive properties against cancer.

Studies show that crocetin, only one of several carotenoids found in saffron, acts affects four important functions in cancer cells:

  • inhibiting nucleic acid (DNA and RNA) synthesis (affecting gene expression, growth and replication)

  • enhancing anti-oxidative system (acting as a free radical scavenger and reducing oxidative stress)

  • i

    nducing apoptosis – promoting normal cell death

  • hindering growth factor signaling pathways (growth inhibition)

 

These are the characteristics of a valuable anti-tumor, anti-cancer therapeutic agent.

 

 


Here is the abstract of the recent study

Crocetin: An Agent Derived from Saffron (Hong Hua) for Prevention and Therapy for Cancer

Cancer is one of the leading causes of death in the United States and accounts for approximately 8 million deaths per year worldwide. Although there is an increasing number of therapeutic options available for patients with cancer, their efficacy is time-limited and non-curative. Approximately 50-60% of cancer patients in the United States utilize agents derived from different parts of plants or nutrients (complementary and alternative medicine), exclusively or concurrently with traditional therapeutic regime such as chemotherapy and/or radiation therapy. The need for new drugs has prompted studies evaluating possible anti-cancer agents in fruits, vegetables, herbs and spices. Saffron, a spice and a food colorant present in the dry stigmas of the plant Crocus sativus L., has been used as an herbal remedy for various ailments including cancer by the ancient Arabian, Indian and Chinese cultures. Crocetin, an important carotenoid constituent of saffron, has shown significant potential as an anti-tumor agent in animal models and cell culture systems. Crocetin affects the growth of cancer cells by inhibiting nucleic acid synthesis, enhancing anti-oxidative system, inducing apoptosis and hindering growth factor signaling pathways.

Gutheil WG, et al. Kansas City Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA. adhar@kumc.edu. Curr Pharm Biotechnol. 2011 Apr 5. Source: PubMed

Prior Studies include:

Oost, Thorten K. et al Discovery of Potent Antagonists of the Antiapoptotic Protein XIAP for the Treatment of Cancer J. Med. Chem., 2004, 47 (18), pp 4417–4426

FIKRAT I. ABDULLAEV Cancer Chemopreventive and TumoricidalProperties of Saffron (Crocus sativus L.) Laboratory of Experimental Oncology, National Institute of Pediatrics, Mexico City 04530, Mexico Cancer Lett. 1991 May 1;57(2):109-14.Antitumour activity of saffron (Crocus sativus). Nair SC, Pannikar B, Panikkar KR. Amala Cancer Research Centre, Kerala, India

Asian Pac J Cancer Prev. 2009;10(5):887-90.Crocin from Kashmiri saffron (Crocus sativus) induces in vitro and in vivo xenograft growth inhibition of Dalton’s lymphoma (DLA) in mice. Bakshi HA, Sam S, Feroz A, Ravesh Z, Shah GA, Sharma M.

Exp Oncol. 2007 Sep;29(3):175-80. Crocin from Crocus sativus possesses significant anti-proliferation effects on human colorectal cancer cells.

Aung HH, Wang CZ, Ni M, Fishbein A, Mehendale SR, Xie JT, Shoyama CY, Yuan CS. Tang Center for Herbal Medicine Research, The Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA.

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High-Dose Vitamin C for People with Cancer: A Promising Adjunct to Mainstream Cancer Treatment

Posted By John C. Pittman, MD, and Mark N. Mead, MSc, Monday, May 16, 2011
Updated: Friday, April 18, 2014

It may come as a surprise to learn that most people with cancer do not die from the disease itself, but from life-threatening infections such as sepsis.  A great many cancer sufferers also die from chronic inflammatory problems that are associated with the disease, such as cancer cachexia.  A recent report published in the March 2011 Journal of Translational Medicine presents a powerful argument for using intravenous (IV) vitamin C in the context of life-threatening infections and cancer.  The authors report that IV vitamin C has been effective in directly treating cancer as well as in helping to reverse chronic inflammation and stave off life-threatening infections in these patients.

Vitamin C is the most widely used single-nutrient supplement in the United States, and has long been lauded by the general public for its supposed powers to treat many ills, from colds to cancer, from herpes to heart disease.  Back in the 1970s, two-time Nobel Prize winner Linus Pauling did much to bolster the vitamin’s profile by touting it as an immune-enhancing and tumor-killing therapy.  Pauling asserted that the anti-cancer potential of vitamin C depended on getting the proper dosage, and toward the end of his life, he further emphasized that vitamin C was best combined with various other anti-cancer agents that worked synergistically with the vitamin.

Dr. Pauling was among the first scientists to recognize that it’s impossible to attain the therapeutically optimal level of vitamin C by taking the vitamin orally—that is, in the form of the standard vitamin C pills or tablets.  On one hand, it's virtually impossible for people to overdose on oral vitamin C, since the body only assimilates a certain quantity through the mouth and then stops allowing it to build up.  On the other hand, this prevents health care professionals from being able to achieve the blood levels that have been linked with killing tumors.  One solution, of course, is to use intravenous (IV) vitamin C.

With IV vitamin C, you can bypass the digestive system and thus circumvent the body’s normally tight regulation of vitamin C levels.  As researchers recently reported in a recent issue of the Proceedings of the National Academy of Sciences, IV vitamin C generates hydrogen peroxide which will destroy primitive cells like bacteria, viruses and cancer cell, and this in turn leads to the shrinkage of aggressive tumors—including ovarian, pancreatic and brain tumors—in laboratory animals.   Despite the very high levels of vitamin C used in these studies normal cells appear to be completely unharmed by the therapy.  The researchers stated that it’s feasible to intravenously boost levels of vitamin C in humans to the same levels used in the mice.
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Indeed, numerous studies have suggested that high-dose IV vitamin C may help eliminate cancer, even when combined with conventional treatments.  For example, in a report for the August 8th 2010 issue of Cancer Chemotherapy and Pharmacology, Dr. Mark Levine, chief of the U.S. National Institutes of Health's Molecular and Clinical Nutrition Section, concluded that exposing tumors to vitamin C made them more vulnerable to the killing effects of at least four widely used chemotherapy drugs.  Previously, Dr. Levine had published research with mice suggesting that IV doses of vitamin C could one day reduce the size of malignant tumors in people.

Dr. Levine’s findings confirm what we have been seeing for the past 15 years at the Carolina Center for Integrative Medicine.  On numerous occasions, we have observed that IV vitamin C enabled patients with advanced cancers to respond to chemotherapy drugs to which they had previously failed to respond.  We therefore believe that it can enhance the effectiveness of cancer chemotherapy and pave the way for therapeutic success.  In a recent issue of PloS One, Dr. Levine concluded that high-dose IV vitamin C is in wide use by integrative practitioners and that “high dose intravenous vitamin C appears to be remarkably safe. Physicians should inquire about IV vitamin C use in patients with cancer [and] chronic, untreatable, or intractable conditions…”

A Short History of Vitamin C Therapy
Vitamin C has long been the most widely used dietary supplement, and much of the initial excitement surrounding this vitamin can be traced back to studies conducted in the 1970s by Dr. Pauling and his Scottish colleague Ewan Cameron, MD. The scientists published two studies that demonstrated an approximate quadrupling in survival in “terminal” cancer patients who received vitamin C by a combination of IV and oral routes.  These findings were subsequently replicated by a clinical trial in Japan.  In addition, the Scottish and Japanese clinical studies found significant improvements in the quality of life for cancer patients receiving high-dose vitamin C.

A chemist by training, Dr. Pauling had publicly questioned the adequacy of the Recommended Daily Allowance (RDA) for vitamin C, and he suggested that taking gram doses of vitamin C—that is, 1000 milligrams (mg) or more—could be effective in the prevention and treatment of colds.  At the time, the RDA was a mere 45 mg per day, an amount considered sufficient to prevent scurvy, the classic disease of vitamin C deficiency. (Today, the RDA is 90 mg per day for men, and 75 mg per day for women.)

Pauling took the controversy up another notch when he proposed daily doses of 5 to 30 grams—5000 to 30,000 mg—for the treatment of advanced cancers.  To this day, the very mention of Pauling’s vitamin C research still sparks heated arguments among medical professionals, oncologists in particular.Clinical studies of the potential therapeutic value of high-dose vitamin C began in Scotland in 1971.  The findings from these early investigations were dramatic indeed.  In addition to the aforementioned three studies showing a four-fold increase in survival, one other study of 100 “terminal” cancer patients showed a nearly six-fold increase in survival for patients with advanced cancer.  

To date, six out of a total of seven clinical studies have concluded that high-dose vitamin C did increase survival in patients with advanced cancers. Many of these patients also noted significant improvements in their energy levels, pain reduction, appetite, and other measures of quality of life. Understandably, these findings attracted much media attention and ignited an explosion of public interest in using vitamin C for cancer therapy.  Many thousands of cancer patients began self-prescribing the vitamin.  At the same time, however, some scientists sharply criticized Pauling’s research on the grounds that his early studies were not randomized controlled clinical trials, the “gold standard” of medical research.  For this reason, the studies’ findings were deemed unreliable or preliminary at best.Controlled clinical trials are indeed the best way to assess the true value of any proposed treatment strategy.  In the case of vitamin C, the ideal study would randomly assign cancer patients to receive either vitamin C or a placebo (a substance having no biological or therapeutic activity), and to do so without the patients knowing which one they were receiving.

In the late 1970s, researchers from the Mayo Clinic did conduct two randomized clinical trials, but alas, these studies only focused on oral, not intravenous, vitamin C.  In the first study, the cancers were too far advanced to reasonably expect any intervention to affect the outcome. (the average survival for all patients was only 51 days).  In the second trial, there was no difference in survival for colorectal cancer patients who received the high-dose oral vitamin C.  Strangely, neither study adhered to Dr. Pauling’s recommended protocol for achieving “bowel tolerance”—that is, in order to prevent diarrhea, the oral dose was supposed to have been increased gradually over time.

Because neither of the Mayo Clinic studies provided vitamin C in oral form, they have no bearing on the issue of whether high-dose IV vitamin C can be an effective treatment for advanced cancers.  Thus the jury is still out on vitamin C as a potential cure for cancer, and no one has adequately tested Pauling’s hypothesis with the appropriate controlled clinical trial design. 

Intravenous Vitamin C May Be Essential
In order to achieve the doses that have a therapeutic impact, as noted earlier, it seems necessary to use intravenous (IV) vitamin C.  The original protocol recommended by Drs Pauling and Cameron involved a 10-day course of IV vitamin C in which the vitamin was given as a slow-drip infusion of 10 grams sodium ascorbate. After this, vitamin C was given orally in the form of a syrup, at a dose of 2.5 grams every 6 hours for a total dose of 10 grams per day.  This strategy enables patients to avoid the diarrhea that otherwise accompanies vitamin C doses in excess of 6 to 7 grams per day.   Subsequent studies used oral and intravenous doses ranging from10 to 30 grams per day.

The recommended dose for IV vitamin C has steadily increased over the past two decades, and physicians continue to report striking benefits.  In the March 2008 issue of Puerto Rico Health Sciences Journal, researchers reported that, “only by intravenous administration, the necessary [vitamin C] levels to kill cancer cells are reached in both plasma and urine.”  By giving the vitamin intravenously, one can readily achieve the blood levels (at least 20 mM) that have been reported to selectively kill tumor cells.   In at least two clinical trials now in progress, scientists are trying to determine the safety, tolerability, best therapeutic dose, and other key aspects of using IV vitamin C.

The power of this approach has been well documented in mainstream medical journals.  In March 2006, the Canadian journal CMAJ (Canadian Medical Association Journal) told the story of three patients with advanced cancer who had received IV vitamin C.  One was a 49-year-old man with “terminal” bladder cancer who had declined chemotherapy. Nine years after receiving the deadly prognosis, he was still alive and apparently free of cancer. Another patient, a 66-year-old woman, had an aggressive lymphoma with an extremely poor prognosis. After IV vitamin C, her disease went into remission and she was alive and well 10 years later.  In a third case, IV vitamin C was given to a 51-year-old woman with kidney cancer that spread to her lungs.  Two years later, she had a normal chest X-ray, and a pathologist confirmed the findings.  

Why did these patients succeed where others have not?  It could be that the secret is in the dosage.  Only two controlled clinical trials of vitamin C have been done, and both used oral vitamin C rather than the IV route.  But oral doses can never achieve the high blood levels provided by IV methods, the levels necessary for killing cancer.  Dr. Levine recently demonstrated that, indeed, only IV vitamin C can achieve the desired blood levels.  The reason for this is that your kidneys will get rid of vitamin C as fast as your gut can absorb it.  With the IV approach, the blood levels are immediately elevated, and it takes much more time for the kidneys to eliminate the excess. Thus, for an extended period, you’re able to expose cancer cells in your body to the levels that can make a difference.

Dr. Levine also confirmed that vitamin C is metabolized to hydrogen peroxide.  Unlike normal cells, cancer cells lack the internal defenses to protect themselves from this highly unstable and reactive ( compound.  As a result, they die.  (Many chemotherapy agents operate, in part, through a similar mechanism.  Green tea, resveratrol, and artemisinin may have similar effects; taken in combination, these natural agents may reach levels of peroxide lethal to malignant tumors.) These days, IV vitamin C doses may range from 10 grams to as high as 300 grams per day (300,000 mg!), though most doses are in the range of 30 to 80 grams per day.  The optimal strategy, as designed by Dr. Hugh Riordan, includes certain other nutrients, such as alpha lipoic acid.  

The good news is that, in contrast with conventional chemotherapy, IV vitamin C is not a particularly expensive therapy. If you have cancer, talk to your Integrative Medicine physician about IV vitamin C.  Preliminary reports from a clinical trial in Kansas City indicate that giving IV vitamin C prior to chemotherapy can dramatically reduce the toxicity of those treatments while bolstering the tumor-killing impact of the chemo.  


John C. Pittman, MD, is the Medical Director of the Carolina Center for Integrative Medicine in Raleigh, NC, and is certified by the American Board of Clinical Metal Toxicology.  Mark N. Mead, MSc, serves as the Center’s Integrative Medicine Research Consultant.


References

  • Ichim TE, Minev B, Braciak T, Luna B, Hunninghake R, Mikirova NA, Jackson JA, Gonzalez MJ, Miranda-Massari JR, Alexandrescu DT, Dasanu CA, Bogin V, Ancans J, Stevens RB, Markosian B, Koropatnick J, Chen CS, Riordan NH.  Intravenous ascorbic acid to prevent and treat cancer-associated sepsis?  J Transl Med. 2011; 9:25

  • Duconge J, Miranda-Massari JR, Gonzalez MJ, Jackson JA, Warnock W, Riordan NH.  Pharmacokinetics of vitamin C: insights into the oral and intravenous administration of ascorbate. P R Health Sci J. 2008; 27(1):7-19.

  • Padayatty SJ, Riordan HD, Hewitt SM, Katz A, Hoffer LJ, Levine M. Intravenously administered vitamin C as cancer therapy: three cases.CMAJ. 2006; 174(7):937-42.

  • González MJ, Miranda-Massari JR, Mora EM, Guzmán A, Riordan NH, Riordan HD, Casciari JJ, Jackson JA, Román-Franco A.  Orthomolecular oncology review: ascorbic acid and cancer 25 years later. Integr Cancer Ther. 2005; 4(1):32-44.

  • Riordan HD, Riordan NH, Jackson JA, Casciari JJ, Hunninghake R, González MJ, Mora EM, Miranda-Massari JR, Rosario N, Rivera A.  Intravenous vitamin C as a chemotherapy agent: a report on clinical cases. P R Health Sci J. 2004; 23(2):115-8.

  • Block KI, Mead MN.  Vitamin C in alternative cancer treatment: historical background.  Integr Cancer Ther. 2003;2(2):147-54.

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Food Allergy and Disease

Posted By Administration, Friday, May 13, 2011
Updated: Friday, April 18, 2014

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by Matt Angove, ND, NMD

Food allergies are no doubt becoming a bigger and bigger part of our lives.  Unfortunate indeed for food lovers everywhere.  But  to be fair to our body, it can only be dragged through so much before its ability to continue in pristine rhythm gets interrupted.

How do we get allergies to food?

Allergies to foods are generated by an over-reactive immune system coupled with a porous digestive tract.  What happens is that small undigested protein particles, namely polypeptides and peptides of food pass through the intestinal wall into the blood stream and are recognized by the immune system as an invading factor.  This occurs because the genetic make up of the food proteins doesn’t belong to you.

The immune system is actually doing precisely what it was engineered to do.  However, this overactive arm of the immune system against food proteins actually makes us more susceptible to cancer.   The immunoglobulins that cause the allergic symptoms, actually depress the production of  your bodies own immune cancer killers.  Most notably, natural killer cells and tumor necrosis factor.   What you end up with is an imbalance in the immune system.

Imbalances in the immune system not only create opportunity for cancer but also a host autoimmune and inflammatory conditions.

There are many ways to check for food sensitivities.  The gold standard is to limit a food category (i.e. dairy products) for a certain period of time.   After that time has elapsed you then reintroduce that food category in its purest form (i.e. glass of milk) to your diet.

Example

Cut out dairy for 4 weeks and then at 4 weeks drink 8 ounces of milk at breakfast, lunch and dinner.  If you had any symptoms previous to cutting out the dairy write them down and notice if any symptoms disappeared and then notice if any symptoms reappeared upon adding dairy back in.

Something to note is that allergic reactions to food are not always instant and can show up days later.  This makes it all the more important to take note of your symptoms during this time period.

You may also get blood tests to check for food sensitivities.  These tests also allow you to see your allergic intensity to specific foods.

Most Common Food Allergies

The most common allergenic foods are milk, wheat, eggs, corn, peanuts, non-organic soybeans, chicken, and shellfish.

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When Medicine Fails...A Holistic Approach to Allergies, Chronic Fatique, Fibromyalgia, & Chronic Pain

Posted By Administration, Thursday, May 12, 2011
Updated: Friday, April 18, 2014

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ACAM member Charles Scott, DC, wrote the book When Medicine Fails... A Holistic Approach to Allergies, Chronic Fatigue, Fibromyalgia, and Chronic Pain. Within its pages reveals a synthesis of Dr. Scott's 25 years of clinical experience as a holistic nature doctor. This book presents proven, comprehensive and highly effective holistic approaches to the major chronic, degenerative diseases that plague mankind.

Dr. Scott is the founder of Scott Chiropractic and Wellness Center in Odessa, Texas. His holistic clinic focuses on helping patients become pain free, healthy and optimally functional. Among his services and therapies he provides are: nutritional programs, allergy elimination techniques, applied kinesiology (AK), and detoxification.

Visti Dr. Scott's website at: www.scottchriopracticwellness.com

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Natural Migraine Relief

Posted By Administration, Wednesday, May 11, 2011
Updated: Friday, April 18, 2014

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by Andrea Purcell, ND

Twelve percent of Americans suffer from migraines. Women are affected three times more than men. Of migraine sufferers 98% rely on acute treatment and symptom suppression.

Natural Integrative medicine asks the question, why? Why does this person suffer with migraines? Typically, the cause is different for each person.

Integrative medicine is effective as a preventative therapy for migraine sufferers and works the best through identifying the underlying cause of the migraines. Successful treatment is more likely if we determine each individual’s cause of migraines.

Every person’s biochemistry is unique and individualized care is the only way to ensure successful treatment.

CAUSES

1) Triggers: Many things can trigger Migraines; food, stress, environment, wherein the patient is hypersensitive to these stimuli and it initiates a headache.

2) Histamine release: This most often happens in allergic patients wherein some allergen causes a release of histamine and triggers constriction and head pain. Often an avoidance of environmental and food allergens as well as anti-histamines can prevent this migraine. The herb Butterbur works as a natural anti-histamine and will help these migraine patients.

3) Lack of energy production from brain cells: Recent data has confirmed that some migraine sufferers actually cannot produce adequate energy from brain cells to meet the demands, which results in vasospasm. Supplements such as CoQ10, Magnesium, Riboflavin (vitamin B2), and d-ribose can be beneficial in these patients.

4) Dietary allergens: Food allergens should be determined via IgE (acute) and IgG (delayed) allergy testing. Avoiding allergic foods can decrease body inflammation, eliminate triggers, and prevent migraines long term.

Note from Dr. P:

If you have migraines or know someone who does this is a terrible disease. Especially since conventional medicine only suppresses the acute symptoms with drug therapy. Symptom suppression is fine short term but isn’t it better to find out why the cycle is continuing and what you can do about it? This is where Integrative Medicine shines, as we work to uncover the underlying cause and the unique biochemistry of the individual.

Tags:  migraines 

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Patch Up Your Menopause

Posted By Administration, Friday, May 6, 2011
Updated: Friday, April 18, 2014

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by Shira Miller, MD

You are at the top of your game.  Why not stay there?  

Menopause causes permanent hormone deficiencies which accelerate the aging process, make you feel old, and increase your risk of chronic diseases.  The good news is that it doesn’t have to be that way.  Believe it or not, menopause is already a luxurious experience for many proactive and well-informed men and women.  Yes, even after Mother Nature quits, you can keep your mind, body, and sex life healthy as you age!

This is the premiere post of the “Patch Up Your Menopause” blog, where I will teach you how the hormone deficiencies caused by menopause and male menopause can be, and need to be, safely patched up with bio-identical hormone replacement therapy.  My unique concierge wellness and anti-aging practice, The Integrative Center for Health & Wellness, uses bio-identical hormones and a cutting-edge, science-based, holistic approach to help educated and motivated men and women stay healthy and productive as they age.  

As both menopause and male menopause occur at different ages for different people and may have inconspicuous symptoms, the sooner you know about them the better, especially if you are over 40.

What are your thoughts about menopause and male menopause?

To your luxurious menopause!

 

Tags:  menopause 

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Prolotherapy for Pain

Posted By Administration, Friday, May 6, 2011
Updated: Friday, April 18, 2014
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Medical innovations are transforming the science of pain management.

Many South Jersey sports fans remember several years back to when former Flyer Simon Gagne was benched mid-season due to severe post-concussion symptoms, including debilitating head, neck and shoulder pain. Gagne, his coaches and the fans all wondered if he would ever return to the ice.

Dr. Scott Greenberg of the Magaziner Center for Wellness and Anti-Aging in Cherry Hill had also suffered from severe head and neck pain for more than a decade. None of modern medicine’s advanced treatments worked—until he discovered prolotherapy, a nonsurgical, holistic procedure that Greenberg says stimulates the body’s own ability to heal.

Greenberg cured himself by injecting an irritant directly into the affected area, causing his immune system to react and heal the damaged tissue or tendon. Then, he went to work on Gagne—who eventually went on to play in the 2010 Stanley Cup Finals—and many other professional athletes and South Jersey residents of all ages.

Chronic pain is a condition that affects many people. Many hope at most to merely manage that pain, whether with over-the-counter painkillers like Motrin or Tylenol or narcotics like oxycodone. But pain-management specialists in South Jersey say there are better ways. These include everything from plasma injections to tiny needle-pricks to attack muscle spasms, to interdisciplinary treatments that target psychosomatic symptoms. The results, say local doctors, have been entirely revolutionary revolutionary.

“Chronic use of anti-inflammatory medications can actually make joint problems worse,” Greenberg says. “It’s well documented that they accelerate arthritis, they’re not good for kidneys and liver, they can cause ulcers. They block the healing processes that happen in the body. Instead of masking pain, we want to cure the pain.”

Greenberg does this by seeking out the source: damaged tissue, joints, muscles, nerves, ligaments or tendons. In many cases, he says, prolotherapy can be the solution. “Patients that have tried chiropractic, epidural steroids, nerve blocks and even surgery, can be cured by prolotherapy and platelet-rich plasma treatments,” Greenberg says. Greenberg makes several injections to the damaged area with either a prolotherapy solution or platelet-rich plasma taken directly from the patient’s own bloodstream. Treatment can be effective in as little as a few months or up to a year, depending on the extent of the problem. These therapies can even treat post-concussion symptoms such as dizziness and loss of balance, for which there is no traditional medical remedy. Greenberg says he’s also found success treating cumulative pain problems, too, such as arthritis, tendinitis and carpal tunnel syndrome.


One of the more unique pain management treatments currently available is biopuncture, in which patients are injected with natural, FDA-regulated homeopathic products that stimulate the immune system to promote natural healing. This practice, popularized in Europe, is gaining steam in the United States.

Locally, Dr. Polina Karmazin and Dr. Robert Davis of Integrated Family Medicine in Voorhees are among just a handful of physicians in the country trained to administer the treatment, which can help with everything from localized pain and arthritis to bronchitis and the flu. After a consultation and evaluation, each patient receives a customized treatment targeted to their specific condition.

Thanks to the positive response from South Jersey patients, including 610-WIP radio personality Angelo Cataldi, biopuncture is surging in popularity. “This year, we have been seeing a number of new patients with a serious interest in biopuncture,” says Davis.

Adds Karmazin: “With biopuncture, the healing effect comes from within your body, as opposed to some conventional drugs that tend to simply suppress the symptoms or potentially cause significant side effects.”

As interest in the treatment grows, Davis warns that biopuncture is not the cure-all some may be looking for, but it certainly has a place in pain management.

It has also been indicated for a broad range of other purposes. For one, he notes, “Biopuncture is a great, natural way to prevent and treat colds. Of course, nothing can truly replace the flu shot, but biopuncture is a safe and gentle therapy that can modify a patient’s illness and shorten its duration and intensity.”

However, as people age and cope with life-threatening diseases like cancer, the nature of pain management changes focus. Dr. Stephen Goldfine, chief medical officer for Samaritan Hospice in Marlton, must often address the chronic pain associated with end-of-life care, and his approach is more than physical.

“What I try to bring to the table is looking at the whole person,” Goldfine says. “I really look at who that person is and then try to handle the physical pain as well as the spiritual and emotional side. I even engage with chaplains, who will come in and help me hold spiritual counseling.”

Goldfine finds that, in his patients, physical pain is often compounded by depression. “Looking at a life-threatening illness, the depression can be overwhelming, which turns up the volume on the pain,” he says.

So, he partners with specialists including psychologists, psychiatrists and social workers, to work with clients on things like setting goals for the future. “This is a way we create hope,” Goldfine says. As well, he notes, anti-depressants can also be helpful, taken along with traditional counseling.

Treating both physical and emotional pain is the key to truly improving quality of life for patients—both in palliative care and elsewhere. “We don’t focus on death,” Goldfine concludes. “We focus on our patients living their life.”

Source: Twining, Stephanie. 

Pain, Pain, Go Away. South Jersey Magazine. May 2011 Issue.

 

Tags:  pain  prolotherapy 

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Autism and the Environment: An Undeniable Link

Posted By Administration, Friday, April 29, 2011
Updated: Friday, April 18, 2014

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by Allan Magaziner, DO

I just returned from the annual meeting of the American College for Advancement in Medicine (ACAM), on whose Board I serve. As always, I left excited about the many advances being made in the field of integrative medicine. 

At the conference, there was much discussion about the impact of the environment on a person’s health and wellbeing. I felt compelled to touch on this topic here immediately as April is Autism Awareness Month and, in my professional opinion, there is no way to deny the link between environmental factors and the appearance – and, often, the severity – of autism and related disorders. 

Consider this alarming finding from a recent study of 10 newborn children: Upon birth, the average person has already been exposed to more than 200 chemicals. In fact, when the cord blood of these infants was analyzed, 287 different chemicals were identified…at birth!  

This is incredibly dangerous since, at birth, the blood-brain barrier is not yet developed so these chemicals are not blocked in any way and therefore can adversely impact brain function. 

So what does this have to do with autism? 

There’s been an increase in recognition of autism over the last 10 years – presently one out of every 90 children have some form of the disorder, which is a condition that causes difficulties with perception, thought, language, behavior and sociability. 

To really understand autism, we need to look at what has changed during this period of rapid diagnosis of the disorder. We know that genetics hasn’t changed. What has changed are environmental factors, including the increasing number of chemicals we are exposed to from pesticides, flame retardants, plasticizers, solvents, personal care products, medicines, artificial sweeteners and flavors. These varied factors have a clear impact on the expression of our genes. 

Each of us is biochemically different, which is why two brothers may have the same genes, but one may develop a disorder while the other never does – even if exposed to the same environmental factors in utero or beyond. Simply put, some people are predisposed to react to a chemical substance differently than others.

It has been found that many autistic children have a defect in their ability to excrete certain chemicals; therefore, they were more genetically susceptible to the chemicals’ effects. Many also have mitochondrial dysfunction and an inability to metabolize high levels of metals which results in neuro-inflammation, oxidative stress, impaired mitochondrial function and neurotransmitter imbalances.  They also often have liver toxicity and gastrointestinal problems. 

What does this mean for prevention of autism? 

While the cause of autism is still not clear, nobody can say definitively at this point that doing one thing or another will completely prevent the disorder. However, looking at the data and reviewing the common denominators in these children, what is clear is that there is an undeniable link between the chemicals found in our environment and autism. The best we can do – to help reduce the numbers and/ or the severity of cases – is to eliminate these chemicals from our lives as much as we can by eating a healthy diet of natural, unprocessed foods rich in vitamins and nutrients, rounding out our diets with nutritional supplements as advised by a healthcare professional and reducing our exposure to phthalates (like those in nail polish), organophosphates (often found in pesticides), PCBs, (found in plastic products including most baby bottles), solvents (found in furniture and new carpets) and heavy metals such as lead and mercury. These measures should, if possible, begin with the mom in the pre- or peri-conception time, at the latest, and continue with the birth of the child.

And what if my child has autism? 

At the Magaziner Center for Wellness, our goal is to help maximize a child’s potential by setting up an individualized program aimed at diagnosing and treating often hidden problems that may be impeding his or her development. We support the use of behavioral counseling and speech, physical and occupational therapies that are often recommended as part of the overall treatment regimen. 

We analyze each patient individually – because, as I’ve said before, each person is biochemically different and, even among those on the autism spectrum, not every treatment works for every person. We administer safe, nontoxic dietary supplements, antifungal agents, and dietary modifications. We also place great emphasis on the detoxification and evaluation and treatment of toxic metals, including mercury, lead, cadmium and aluminum. Treatment may also include improving digestion and assimilation and asking a child to avoid certain foods which could be harmful to his or her wellbeing. We often recommend hyperbaric oxygen therapy, which greatly increases oxygen uptake to the brain, nervous system, skeletal muscle, and all body tissues and has been been found useful in the treatment of the symptoms of autism.

What’s Next? 

While autism is still quite a mystery, great strides have been made in increasing the awareness of the disorder and uncovering some clues to its potential causes. With more research, increased commitment and willingness for doctors and patients alike to ask tough questions and demand a change in our environment, I am confident the next 10 years will yield much better news on this front than the previous decade has.

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Integrative Boot Camp 101: The Fundamentals of Integrative Medicine

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