9/9/08

Clinical Nutrition—An IntroductionJo Lee, MS, DC

Nutrition: “the science of food, the nutrients, and the substances therein, their action, interaction, and balance in relation to health and disease, and the process by which the organism ingests, absorbs, transport, utilizes, and excretes food substances”

General Vs. Clinical Nutrition General Nutrition—how a physically fit body and an alert mind depend on good nutrition Clinical Nutrition—how poor nutrition can accelerate the development of degenerative diseases and how nutrition

therapy can improve the symptoms or prevent the development of these conditions

What is clinical nutrition? Using diet, botanicals and nutritional supplements to prevent and treat disease, trauma or mental conditions,

practical application in clinical setting. Basic nutrition is the study of the effects of nutrients in a normal, healthy body, as well as the properties of

individual nutrients and their interaction, basic science application.

The Nutrition Care Process Assess nutrition status Analyze assessment data to determine nutrient requirements Develop a plan of action for meeting nutrition needs, include education Implement the care plan Evaluate the effective of care plan through ongoing assessment and make changes as needed.

Incorporate nutrition into practice Baseline nutrition for maintenance/Whole Foods—nourishing rather than controlling Mega-dose to affects biochemistry to address deficiencies—drug effects “Vitaminology” – symptoms lead to recommendation, instead of using pharmaceuticals

Assessing Nutrition Status Historical information Physical examinations Anthropometric data Biochemical analysis (Lab tests)

Tools used to evaluate a patient’s nutritional status Symptoms survey questionnaires Physical exam—anthropometrics Food diary, frequency, recall Blood and urine analysis Hair analysis Saliva hormone Energetic evaluation, AK. EAV

Health factors contribute to or affects a patient’s underlying inflammatory status Digestion/assimilation Gallbladder/liver function (toxicity) Food allergies Candida albicans Food combining issues (pH) Stress—physical, emotional, chemicals

-stress is a common component of digestive problems

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Major components of the vertebral subluxation complex Kinesiopathology Neuropathophysiology Myopathology Connective Tissue Pathology Vascular Abnormalities Inflammatory Response Histopathology Biochemical Abnormalities

Management approach to the vertebral subluxation complex 5 FOLD-APPROACH:

Joint adjusting Muscle lengthening/stretching Trigger Point Therapy Rehabilitation Exercises Nutritional interventions

Manage inflammation and PAIN Disc injury

Anti-inflammatory herbs—boswellia, turmeric, ginger Essential Fatty acid—omega-3 Proteolytic enzymes—mega dose of bromelain, papain

Muscle spasms associated with a strain injury Magnesium, calcium, turmeric, gingko biloba, white willow bark, boswellia, vitamin E, omega-3 fatty acid

Soak in Epsom salt (magnesium): muscle relaxant and CNS suppressant effects

Fruits and Vegetables The latest version of the USDA Food Guide Pyramid recommends Americans to consume 5-13 servings of fruits

and vegetables per day depends on your age, sex and activity level. A serving of fruit and vegetables is one cup raw, half cup cooked http://www.mypyramid.gov/global_nav/media_animation-presentation_eng_pc.html Controversial topic, will discuss more later.

Fruit and vegetable consumption and stroke: meta-analysis of cohort studies. Increased fruit and vegetable intake in the range commonly consumed is associated with a reduced risk of stroke.

Our results provide strong support for the recommendations to consume more than five servings of fruit and vegetables per day, which is likely to cause a major reduction in strokes. (Lancet. 2006 Jan 28;367(9507):320-6)

Folate, vitamin B6, multivitamin supplements, and colorectal cancer risk in women. Total folate and vitamin B(6) intakes were not significantly associated with the risk of colorectal cancer. However,

dietary intakes of folate and vitamin B(6) were significantly inversely associated with colorectal cancer risk among women who were not taking supplements containing folate and vitamin B(6). Multivariable relative risks among women in the highest quintiles of intake versus the lowest were 1.16 (95% confidence interval (CI): 0.76, 1.79) for total folate, 1.14 (95% CI: 0.77, 1.69) for total vitamin B(6), 0.46 (95% CI: 0.26, 0.81) for dietary folate, and 0.69 (95% CI: 0.41, 1.15) for dietary vitamin B(6). The use of multivitamin supplements was not related to colorectal cancer risk. These findings suggest that higher dietary intakes of folate and vitamin B(6) may reduce the risk of colorectal cancer in women. An alternative explanation is that other factors related to dietary intakes of folate and vitamin B(6) account for the inverse associations. (Am J Epidemiol. 2006 Jan 15;163(2):108-15)

There is no panacea No one diet or supplement will work for everybody, every time Detective work and problem solving Effective communication and education skill Build upon clinical experience and learning from others Commitment to continuing education

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9/16/08

Nutritional Status AssessmentAssessing Nutritional Status

• Information on how well a patient’s nutrient needs are being met. Subjective and objective findings based on:1. Historical data2. Physical examination3. Anthropometric data4. Biochemical analysis (lab tests)

A Team Approach• The patient is an active member of his/her care• The doctor will work in conjunction with other providers to insure the success of the nutritional care plan:

– Family members, primary care provider, nutritionist/dietitian, social worker, teachers, daycare providers, counselors

http://www.aafp.org/afp/980301ap/edits.html

The Nutrition Care Process• Assess nutrition status• Analyze assessment data—determine dietary and nutrient requirements• Develop a plan of action to meet nutritional and educational needs• Implement the nutrition care plan• Evaluate and reevaluate the plan through ongoing assessment and make changes as needed.

Assessment Tools (temperature extremes can increase nutritional needs)

Nutritional Assessment: Subjective Data• Usual Weight / weight changes• Food allergies or intolerances• Special diet: vegetarian, low-fat, high-protein, etc.• 24 Hour Dietary Recall• Drugs: Rx or illegal

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• Alcohol / drug abuse, smoking• Vitamin / minerals supplements• Social /economic pressures• Physical activities frequency and intensity

Historical Data tools• Health history questionnaire• Symptoms Survey questionnaires• Drug history• Socioeconomic history• Diet history

– 24 hours recall– Food intake diary– Food frequency questionnaire– Using food models--children

Interviewing Patient• Pay attention to help patient feel comfortable to communicate freely and openly• Focus on these areas:

– Appetite and food intake– Digestion and absorption– Metabolism– Excretion– Emotional and mental health

Drug History• A record of all the medications, OTC or Rx, nutritional supplements, herbal suppl, that a patient takes routinely• Note frequency, dosages and duration of intake• Note any signs of adverse reactions or positive effects• Adverse drugs reactive is a major concern

Drugs Alters Food Intake• Altering appetite (amphetamines)• Interfering with taste or smell (methotrexate)• Causing nausea or vomiting (digitalis)• Changing the oral environment (phenobarbital/dry mouth)• Irritating the GI tract (NSAIDs, cyclophosphamide)

http://pods.dasnr.okstate.edu/docushare/dsweb/Get/Document-2458/T-3120web.pdf

Drugs Alter Nutrient Absorption• GI acidity (antacids)• Digestive juices (cimetidine alters fat digestion positively)• Motility of GI tract (laxative)• Inactivate enzymes (neomycin lowers lipase activity)• Damage mucosal cells (radiation and chemo)• Binding to nutrients

Foods Interfere with Drugs Absorption• Candy decreases GI pH, lead to fast dissolution of slow-acting drugs• Some drugs absorb better with foods• Some drugs absorb slower with foods• Foods can bind to drugs (calcium and tetracycline)• Competing with drugs for absorption sites in the intestinal cells (amino acids and levodopa)

Food/Herb/Drug Interaction Alters Metabolism• Acting as structural analog (anticoagulants and Vit. K)• Competing with each other for metabolic enzyme system (methotrexate and folate)• Alter enzyme activity and produce phamacologically active substances (MAO inhibitors and tyramine)

http://www.i-care.net/herbdrug.htmhttp://ethnomed.org/clin_topics/herbal_medicine/herb-drug_rev.pdf

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Health history—health factors that affects nutrition status

Drug—interaction with nutrients

Socioeconomic—personal, financial and environmental influences on food intake, nutritional needs and dietary habits

Diet history—nutritional intake excesses or deficiency will be reveled reflecting imbalances.

Tyramine Containing Foods• Red wines• Aged cheeses• liver• Dried, smoked or pickled fish• Sausage, salami, dried meats• Fava beans, broad beans• Sauerkraut

(Induction of serotonin syndrome, GI upset, hypertension, seizure, headaches)

Drugs/Nutrient Excretion• Kidney reabsorption (some diurectics increase sodium and potassium excretion)• Displacing nutrients from their plasma protein carriers (aspirin and folate)• Altering urine pH (vitamin C can reduce aspirin excretion this way)

Folate and Methotrexate -methotrexate (cancer tx) blocks the function of folic acid (cuz the molecular structure is so similar)

Socioeconomic Factors • Access to grocery stores, Activities, Age, Education, Ethnicity, Income, Geographical area, Kitchen facility,

Household size, Occupation, Religion, Culture, Sex http://www.investigatorawards.org/downloads/research_in_profiles_iss06_feb2003.pdf

Diet History• 24-Hour Recall—record of all food and beverage for one 24-hour period• Food frequency Checklist• Food Diary—an extensive, accurate log of all foods and beverages eaten over a period of several days or weeks• Food Intake Data Analysis—computer programs that analyze nutrients content from food intake data

http://www.aafp.org/afp/990315ap/1521.html

Nutritional Assessment: Objective data, Somatic Compartment • Physical examination• Anthropometry:

• Weight • Height• Body Mass Index• Body composition• Ideal body weight (IBW)

• Female: IBW=100 Lb +(5 Lb X every inch >5 Ft)• Male: IBW=106 lb +(6 lb for every inch >5 FT)

• Laboratory analysis

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• Snow peas• Pickles and olives• Brewer’s yeast• Soy sauce• Miso• All fermented products and cheeses

Physical Assessment• Observe any signs of overweight, underweight, lethargy, confusion, inability to feed self, dehydration, brittle nail

and hair, pale membrane under eyes, adjustment to light, skin thickness, color, condition of skin, swollen glands, heart rhythm, heart rate, blood pressure, abdominal organ enlargement, abnormal digestion, paresthesia, irritability, muscle wasting, edema

• Anthropometric measurements

• Hair, Face, Eyes, Lips, Cardiovascular System, GI System, Nervous System, Tongue, Gums, Face, Skin, Nails, Muscular & Skeletal System

• Scaly, desquamating, hyperpigmented skin lesions on the hand of a diabetic with inadequate dietary intake (pic)• Patient With Multiple Deficiencies exhibits cheilosis, glossitis, and scorbutic gums (see pic)

Face Assessment• Skin color should be uniform with a smooth, pink, healthy appearance; not swollen• Skin should not be dark over cheeks and under eyes• Should not be swollen• There should not be lumpiness or flakiness of skin of nose and mouth

Hair Assessment• Hair should be shiny, firm, and not easily plucked• Hair should not be dull, dry, thin, sparse, easily plucked or demonstrate color change

Eye Assessment• Should be bright, clear, shiny, no sores at corners of eyelids; membranes are a healthy pink and are moist. No

prominent blood vessels • Should not have ring of blood vessels around cornea• Membranes should not be pale or red• Should not have fissuring in corners• Should not have dry membranes

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Whitney et al, “Understanding Normal and Clinical Nutrition”, Fifth Edition, WestAnthropometry

Measurement of body size, weight and proportions, data indicates:• Health status• Developmental status• Nutritional status

Parameters• Length/height• Stature• Head circumference• Weight, frame• Body composition• Body fat• Skin fold thickness• Waist-to-hip ratio• Body Mass Index

Anthropometry• Weight

– scale (calibration, accuracy, fluctuations, ability to read)• Height

– board for recumbent (0.5 cm longer)– various means for upright (standing)

• Arm Circumference: tape

Most Common Indicators• Weight for Height (W/H) - "wasting"• Height for Age (H/A) - "stunting"• Weight for Age (W/A) – “growth faltering”• Median Upper Arm Circumference (muscle mass)

Body Mass Index: an index of a person’s weight in relation to height.BMI=weight (lb) x 705/height (in)2

orBMI=weight (kg)/height (m)2

• BMI Calculator: http://www.nhlbisupport.com/bmi/

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9/19/08Symptoms Surveys

• Collections of symptoms group according to systems• Extensive clinical correlation collected by practitioners over time• Different versions from supplement companies• Standard Process Labs published the first form • Can be modified to use with other companies product line

Biochemical Analyses• Determine what is happening to the body internally• Indicates fluid, nutrition, electrolytes, acid-base balance, organs function• Based on analysis of blood, urine samples:

– Nutrients, enzymes, metabolites

Limitation of Biochemical Tests• Skill require to interpret data• State of patient’s hydration status• Interactions of several nutrients may not be detected easily• Only show short-term intake—blood levels of many nutrients are normal while the tissues are deficient• Must be used in conjunction with other data

Routine Lab Tests• CBC, Total proteins, Electrolytes, Glucose, BUN, Calcium, Phosphorus, Magnesium, Cholesterol, Uric acid,

Creatinine, Serum enzymes (CPK, LDH, ALT/SGPT, AST/SGOT, Alkaline phosphatase, Amylases, lipase)

Nutritional Assessment: Objective Data, Somatic Compartment

MARKER Normal Mild Moderate Severe t 1/2

Albumin > 3.5 3.1-3.5 2.1-3.0 < 2.1 20 d

Transferrin >200 151-200 100-150 <100 8 d

Prealbumin >15 10-15 5-10 <5 2-3 d

Total Lymphocyte Count (TLC)

> 2000 1200-2000 800-1199 < 800  

Nutritional Assessment: Classification of Malnutrition-Marasmus

-Depletion in the somatic compartment-Kwashiorkor

-Depletion in the visceral compartment-Marasmus-Kwashiorkor Mix

-Depletion in both compartments

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Other Lab Tests• Controversial, not accepted by conventional medicine, but popular among holistic practitioners.

– Hair Analysis—looking at minerals ratios which reflect imbalances in endocrine functions, an intracellular assessment

– Saliva Hormone tests—adrenal, sex, thyroid, pancreas (endocrine fxn)– Stool Analysis—digestive fxn, dysbiosis, food allergy, GI bleeding

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Case Study • 38 year old female accountant• Scheduled for hysterectomy in two weeks• Wants advise on how to be ready nutritionally for the surgery and aids recovery• Health history reveals:

– 5 ft 5 inches, 185 lbs, BP: 85/130– General good health in last ten years– Gradual wt gain the last 3 year, unable to lose– No supplement, use OTC pain pills frequently

• On birth control since 21, stop 10 years ago, resumed after child birth• Irregular prolonged cycles, endometriosis, significant bleeding during cycle• High stress workload, married with one child, age 8• No regular exercise• Does not eat regular meals• Eat out frequently—on the run• Symptoms: interrupted sleep, indigestion, depression, fatigue• Where to start?

Case Study • A 53 year old patient wanted advice on improving his risk of developing heart disease.• According to him, his doctor did a cholesterol check and a resting EKG and said everything looked fine and not to

worry.• He still worried and had learned about the comprehensive cardio profile.• He wanted to get a comprehensive cardiovascular blood profile to see where he stood.

Nutrition Assessment : Useful Web URLs• http://www.faqs.org/nutrition/Met-Obe/Nutritional- Assessment.html • http://depts.washington.edu/growing/Assess/index~2.htm • http://www.nutritionperspectives.com/content/members/Nutriti onAssessProcedures.cfm • http://www.fantaproject.org/downloads/pdfs/Uganda_BMI.pdf • http://www.dshs.state.tx.us/wichd/nut/pdf/GuidelinesNutAssm nt_06.pdf • http://healthlinks.washington.edu/nutrition/section2.html

Food Frequency Questionnaires URLs• http://findarticles.com/p/articles/mi_m0887/is_4_23/ai_n6047684 • http://www.aston.ac.uk/downloads/lhs/food_freq_quest.pdf • http://aje.oxfordjournals.org/cgi/content/abstract/152/11/1072 • http://www.cancervic.org.au/about-our-research/our-research- centres/cancer_epidemiology_centre/

nutritional_assessment_se rvices • http://cebp.aacrjournals.org/cgi/content/full/16/1/182 • http://www.ajcn.org/cgi/content/abstract/71/3/746

9/23/08

Symptom Survey Form• It is one the simplest ways to start assessing the nutritional needs of a patient• Started by practitioners using products of Standard Process• Many years of collective clinical experience contribute to current survey• Correlate systemic symptoms to metabolic imbalances and nutritional needs • It is used by many health practitioner • Found to be very helpful for beginners as well as “experts”• Correlate well with history, lab work and physical exam• Combine with AK

-A form that has 212 commonly found symptoms arranged in 9 groups:Group 1: Sympathetic DominanceGroup 2: Parasympathetic DominanceGroup 3: Sugar HandlingGroup 4: CardiovascularGroup 5: Liver and Biliary

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Group 6: DigestionGroup 7: Endocrine (thyroid, pituitary, adrenals)Group 8: Foundational Issues (B-vitamin deficiency)Group 9: Male/Female issues

Patient are instructed to color in the circles that best describes their symptom frequency and severity1. Mild-occur once or twice a year2. Moderate-occur several times per month3. Severe aware of constantly

-List 5 Major Complaints

-refined wheat removes about 80% of the B-complex vitamins

Some of the reasons the symptom survey is an essential tool:• Inexpensive for the patient• Non-invasive• A great opportunity to explain/educate patient the relationship between symptoms and organic disorders• Introduce the concept of the “nutritional exam”

Understanding physiology-Each group offers the practitioners an insight to a possible underlying organ dysfunction, some basic nutritional needs

as well as giving them a look at some of the underlying abnormal physiology that might involve the whole body

The Symptom Survey Form• It is grouped into systems.• These systems are the key areas that nutritional products were designed to support.• Use to monitor patient’s improvement.

Group 6 – Digestion: The KEY to successful nutritional therapy!• This is the most important area to address first.• To enable you to quickly and accurately evaluate your patients digestive systems and apply the appropriate digestive

support.-if a person has very poor digestion, they might not be able to handle natural food-80% of our food dollars go towards processed food

Important Information• The digestive system is a beginning to end process. If you have a problem at the end (i.e.-colon/ large intestine),

always look to the beginning.• If in doubt, always start with the big three: stomach, pancreas and gall bladder. These are extremely important in

digestive health.• The digestive system should always be checked before doing any nutritional therapy because… • Nutritional supplements can tax/strain the digestive system, especially when the patient’s systems are weak.

Symptom Survey Form - Digestion• Digestive issues don’t always appear on the patients SSF, therefore, use other tools such as asking direct questions,

stool test or use AK.• Use the SS software to make your practice easier.• Correlate your findings with your exam findings and make necessary changes, if any.• Learn products from CRG (Clinical Reference Guides) and Product Bulletins.

Supplements for Digestive Support• Betaine HCl, Pepsin, pancreatin• Pancreatic enzymes• Bromelain, cellulase, lipase, amylase• Beet juice, taurine, Vit C, Bile salt, turmeric, ginger, mint• Water soluble and non-soluble fiber• Probiotics (don’t take probiotics with food)• Homeopathic remedies

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Relationships Between Groups• The First Relationship is between Groups 1 and 2. This is a relationship of balance.

What Does This Mean?• Sympathetic or Parasympathetic Dominance? • What does this have to do with nutrition?

Fight or Flight: Sympathetic Side• Emergency situations, where the body needs a sudden burst of energy, are handled by the sympathetic system • The sympathetic system increases cardiac output and pulmonary ventilation, routes blood to the muscles, raises

blood glucose and slows down digestion, kidney filtration and other functions not needed during emergencies • Whole sympathetic system tends to "go off" together • In a controlled environment the sympathetic system is not required for life but it is essential for any stressful

situation • Governs Catabolism

Rest & Digest : Parasympathetic Side• The parasympathetic system promotes normal maintenance of the body- acquiring building blocks and energy from

food and getting rid of the wastes.• It promotes secretions and mobility of different parts of the digestive tract. • Also involved in urination, defecation and reproduction. • Does not "go off" together; activities initiated when appropriate.• The vagus nerve (cranial number 10) is the chief parasympathetic nerve. • Governs Anabolism

From a Nutritional Perspective• There is a relationship between the Autonomic Nervous System and Mineral Balance.• Acid Ash Minerals—Cl, P, H (from meats, grains) promote the Sympathetic side of the ANS.• Alkaline Ash Minerals—Na, K, Mg, Ca, (from fruits and vegetables) promote the Parasympathetic side of the ANS.

Autonomic Imbalance• Sympathetic dominance—carbohydrate intolerance, difficulty metabolizing sugar, carbohydrate enzymes

deficiency, K deficiency, acidosis (higher demand for nutrients, but more difficult absorbing from GI tract)• Parasympathetic dominance—protein and calcium deficiency, essential fatty acid deficiency, protease deficiency,

alkalosis

Other relationships between groups • What could produce indications for symptoms of both Sympathetic and Parasympathetic sides of the ANS?• Having both the break and the accelerator engaged at the same time! You’re going in circles.

Blood Sugar Fluctuations• Liver, pancreas, and adrenal• When High ? Mimics Sympathetic Dominance• When Low? Mimics Parasympathetic Dominance • Adrenal stress response, insulin resistance and liver toxicity

Improve Autonomic Balance• Chiropractic adjustment• Dietary changes• Relaxation technique to reduce stress• Digestive enzymes for carb, protein and fat• Minerals supplementations• Increase vegetables and fruits• Adequate protein intake

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The Big Exception• #52 THE DEAD GIVEAWAY!!!• Group 5 heavily marked

#52: Awaken After A Few Hours of Sleep • Hard to get back to sleep• Chinese Meridian Clock - Liver 1-3 a.m. • People w/stress insomnia often wake up at 1 or 2 am

-90% of fructose is processed exclusively by the liver9/26/08

Support Liver and Gallbladder• Beet juice, taurine, Vit C, pancreolipase with or w/o bile salt• Liver phase II detox nutrients• Herbs that protect and cleanse liver (milk thistle)• Glutathione, N-acetyl cysteine, glycine• Detox products

Group 3 – Sugar Handling• Eat when Nervous• Excessive appetite• Hungry between meals• Irritable before meals• Get “shaky” if hungry• Fatigue, eating relieves• “Lightheaded” if meals delayed ...

Why does this exception exist?• How could all of the symptoms of Group 3 (with one exception) not be checked and the patient have problems in

Group 3 (Carbohydrate Metabolism)?

• Why don’t the other symptoms show? • Nibbling cover up the inability to properly store and release energy• Nibbling all day long indicates a sugar handling problem

High Priority Groups• Group 3 (Carbohydrate Metabolism)• Group 6 (Protein Digestion)• Group 5 ( liver)• These three groups tend to be most commonly marked. • Is there something wrong?

Yes! It’s the diet!• As Weston Price, DDS used to call processed food “the food of commerce”• Diet and Stress are the primary reasons why group 3, 5 & 6 are so commonly (and heavily) marked

Let’s look at some other patterns• Symptoms 56-62 in Group 4 relate to oxygen metabolism • If these symptoms are heavily marked, consider the balance of Groups 1&2 again • If Group 1 is heavily marked (in relationship to Group 2) you may be looking at “systemic acidosis”• This is significant because, without addressing the acidosis, the results will be limited. What products do you think

of here? Green products, leafy greens (they are highly inflamed)

Consideration For Group 6

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• The rest of the “Liver Group” group 5 is naturally associated with Group 6 for the following reasons.• If food is not properly digested and absorbed:

• essential nutrients needed for the liver’s myriad functions may be not available • toxicity caused by incomplete breakdown of food may further tax the liver and allow for allergies to begin.

A lack of HCl may limit the triggering of both pancreatic digestive juices (secretin) and bile flow (CCK)

Diet and Lifestyle Changes to Support the Digestive System1) Don’t eat processed food. Eat real food. 2) Take the time to eat. Not while driving in your car. Eat slowly. 3) Chew food completely before swallowing. Fletcherizing: http://en.wikipedia.org/wiki/Horace_Fletcher4) Decrease the amount of life stress and have fun. 5) Drink enough pure, clean water. Dehydration impairs digestion. 6) Digestive enzymes and gallbladder support

Group 7 (think insulin)

Pituitary (7C), Thyroid (7A), Adrenal (7E & 7F)

-insulin is the most important substance to regulate, if have endocrine problems-insulin transports amino acids, vitamins, minerals, etc (it is the gate-keeper that helps many nutrients to enter cells)

9/30/08

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Pattern 1 (most common, usually has to do with adrenal fatigue)• A (hyperthyroid) and B (hypo-thyroid) evenly and or both heavily marked. • Often relates to Hypo-Adrenal Function, consider Group F as possible underlying issue. • This relates to the feedback loop between the Adrenal and Thyroid glands (also involves the Pituitary gland)• May be a toxicity problem

Pattern 2 (Group 7)• Groups A, C, &E more heavily marked than B, D, & F - Hyper across the board.• Relates to Sympathetic Dominance Group• Possibly a Type A personality.• Alarm stage of stress• Excessive cortisol production—adrenal stress

Pattern 3 (Group 7)• Groups A,C, and F heavily marked in relation to the other sub-groups in Group 7• We are looking at Pattern 2 again just farther down the road (now the adrenals are giving out)—adrenal fatigue• Snapdragon: my mind is snapped and the body is draggin’. (This is a joke!)

Pattern 4 (Group 7)• Groups B, D, & F heavily marked (hypothyroid, hypopituitary, hypoadrenia)• Generalized collapse of the endocrine system• Adrenal exhaustion (chronic fatigue)• Big Trouble!

Murphy’s Sign (Acute)• Cortisol Insulin resistance sluggish GB• Palpate at location of the Gall Bladder, under ribs.

• This indicates a need for beet extract or bile salt at 6-15 caps per day. • With a history of Gallstones, start with beet extract at 6-15/day, for 1 month. If acute and unresponsive, consider

Choline, Inositol, ortho phosphoric acid, riboflavin, or pancreatic enzyme and other enzymes.

Right Thumb Web (Chronic)• CMRT—Tenderness and nodulation (pea) at the thumb web of the right hand. Support is the same as Murphy’s

Sign. • Absent reflex tells when the problem is gone.

Group 8 B-Complex Deficiencies-Always take care of “physical complaints” first in addition to digestion

Barnes Thyroid TestDeveloped by Dr. Broda Barnes MD

• Measurement of underarm temperature to determine thyroid function• Patient takes temperature every morning BEFORE getting up or exertion. • Test is invalid if patient exerts any energy prior to test• Shake down a regular thermometer the night before.• Have patient place thermometer under arm and leave for 10 minutes. Write down result.• Men, pre-menstrual women and menopausal females – take temperature any day of the month (2 or 5 days in a row)• Women having a menstrual cycle – the 2nd and 3rd day of flow OR any 5 days of the month in a row but avoid mid

cycle

0.5 – 0.45 is the normal range for thyroid hormone

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Barnes Thyroid Test

THYROID TEMPERATURE TESTPATIENT NAME_____________________________________________________

Date Temperature

Day 1 _______________________________Day 2 _______________________________Day 3 _______________________________Day 4 _______________________________Day 5 _______________________________

To figure average ® Total ______________ ¸ 5 = ___________

An average temperature of between 97.8 and 98.2 degrees considered normal.

COMPLETION OF SURVEY• Focus on 5 main complaints, or results of symptom survey (cause)• Groups where the score is 10 or more may need addressing• Address Digestion problems first if symptoms present.• Change diet and manage stress• Select 2-3 products plus a multiple • Re-evaluate every 45-60 days, having patient fill out a new symptom survey

Example: Symptom Survey of 36 yr old Female0 Score1 9

2 33 64 55 106 87A 67B 67C 77D 37E 07F 08 5Female 12

-if group 1 (symp) and group 2 (parasymp) involvement, then look at group 3-when adding the points, can ignore the “1’s” and instead add up all the “2’s” and “3’s” that are circled

Gall Bladder flush:

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5 Main Physical Complaints:Ears ring and itchPMSGas and indigestionAllergic to dairy, wheat and chocolateFatty food intolerance

-olive oil + lemon juice + Epson salt

-high epinephrine tends to suppress HCl, and high cortisol tends to increase HCl production-** Have cover page for our report****************************************************************

10/3/08

Clinical Nutrition II “Clinical Nutrition for Pain, Inflammation & Tissue Healing”

by David R. SeamanNociception & the Subluxation Complex

Chapter 1http://deflame.com/introduction2.htmlMost patients seek chiropractic care because of some kind of pain problem. We know an properly administered adjustment can do miracle to a patient with pain. However, in most cases, understanding the physiology and nutritional influence on pain could offer us more tools to help those slow-to-respond patients to speed up healing.

Nociception & the Subluxation ComplexSubluxation According to Faye :

Neuropathophysiology Kinesiopathology Myopathology Histopathology Inflammatory biochemical changes

Subluxation According to Lantz (revised Faye’s description): • Kinesiopathology• Neuropathology• Myopathology• Connective tissue pathology• Vascular abnormalities• Inflammatory response• Histopathology• Biochemical abnormalities

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Nociception and Inflammation• The various chemicals that stimulate nociceptors also drive the inflammatory process.• Our dietary habits directly influence the production of the various chemical irritants• Diet can influence nociception and inflammation

No Pain is Not No Pain• Nociception stimulation leads to sympathetic hyperactivity, muscle spasm, but may not show pain.• Patient may be asymptomatic• Yet the pathologies that lead to systemic inflammation and autonomic concomitants will silently damaging various

organs of the body—digestion, cardiovascular, respiratory symptoms.For example, asymptomatic H. pylori infection is linked to increase rate of stomach cancer and other gastric pathologies.

Nociception & the Subluxation Complex “Nociception does not equate with pain”

• Nociceptors are stimulated by biochemicals found in injured tissue, leading to:– Sympathetic hyperactivity– Reflex muscle spasm– Autonomic concomitants or symptoms– Pain

Quote: Page 2 SeamanAutonomic concomitants refer to symptoms which are induced by nociceptive bombardment of the brain stem and hypothalamus, such as digestive, cardiovascular, and respiratory symptoms.In summary, nociceptors specifically receive injurious tissue damaging stimuli which is transmitted into the CNS via nociceptive axons leading to the above results

T4 Syndrome, JMPT, Jan. 1995

Chemicals drive nociception and inflammation processes are the same.

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Spinal Structures with NociceptionAll tissues are innervated by C-fiber EXCEPT

• Articular cartilage• Nucleus pulposus• Inner 2/3 annulus

“These are the only three spinal structures which DO NOT have nociceptive input” -SlosbergNociception is transmit by A-delta and C fibers. They are located in nearly every tissue in the body except the three listed.Nociceptors specifically receive injurious tissue damaging stimuli which is transmitted into the CNS via nociceptive axons.How may the various pathological components of the subluxation complex develop from sympathetic hyperactivity and reflex muscle spasm?

Sympathetic Hyperactivity• The precise mechanism by which the sympathetic nervous system promotes pain, inflammation, and reflex

sympathetic dystrophy is not known.• Likely involved mechanisms that promote tissue injuries other then vasoconstriction

There is a lot we are not sure of.What does the SNS do? Flight or fight, vasoconstriction, increase heart rate, up regulate serum glucose, immunosuppression, fibrinogenic activity.Nociceptive input will excite sympathetic preganglionic fibers which enter into the sympathetic chain and synapse with postganglionic fibers. The postglanglionic fibers enter the peripheral tissue where they innervate blood vessels, sweat glands and piloerector muscles. The precise….is not known. Therefore it would be impossible to define how the sympathetic NS influences the genesis of the subluxation complex.

“It is likely that sympathetic hyperactivity promotes tissue injury by mechanisms other then vasoconstriction.” What other mechanisms would you propose?

We may be able to conjecture in terms of the HPA axis which might help explain the sequence of events from stress to increase adrenal output—epinephrine—to increase sympathetic activities.

Inflammation Response• Inflammation is a response to injuries not a disease itself• Factors that cause inflammation:

– Hypoxia– Physical traumas– Chemical traumas– Drugs– Infections– Nutritional imbalances

Cotran R, Kumar V. Robbins S. Robbins Pathologic Basis of Disease. 5th ed. Philadelphia: WB Saunders: 1994. p. 1-34, 770-1

HPA Axis--Body/Mind Control (Bruce Lipton - Biology of Perception)

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In the movie, What the bleep do we know, scientists found that the kind of thinking we engage in determines the kinds of cellular receptors we make on cell membrane. If we are thinking depressed thoughts, they make more depressed NT receptors and decreases receptors for nutrients and other hormones.

Bruce Lipton, PhD—proposed that the HPA axis plays an important part in how we are responding to stress by our perception and lead to sympathetic overactivity, adrenal gland activation and general immune system reaction and suppression.What we perceive cause more problems than we think. Watch the videos of Bruce Lipton, Ph.D. explains how our perception drives our pain or joy.

immediate response to stress-The brain becomes more alert.-Heart rate increases.-Adrenal glands produce stress hormones.-Muscles tense.-Breathing quickens.-Digestive system slows down.

effects of chronic of prolonged stress-Stress hormones can damage the brain’s ability to remember and cause neurons to atrophy and die.-Baseline anxiety level can increase.-Persistently increased blood pressure and heart rate can lead to potential for blood clotting and increase the risk

of stroke and heart attack. -Cortisol and other stress hormones can increase appetite and thus body fat.-Cortisol increases glucose production in the liver, causing renal hypertension.

-Stress can contribute to headaches, anxiety, and depression.-Sleep can be disrupted.-Stress can contribute to menstrual disorders in women.-Stress can contribute to impotence and premature ejaculation in men.-Muscular twitches or “nervous tics” can result.-Mouth ulcers or “cold sores” can crop up.-The lungs can become more susceptible to colds and infections.-Immune system is suppressed.-Skin problems such as eczema and psoriasis can appear.-Stress can cause upset stomachs.

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Diseases of Inflammation• acid reflux/heartburn • acne• allergies and sensitivities• Alzheimer’s disease • asthma • atherosclerosis • bronchitis • cancer • carditis • celiac disease • chronic pain • Crohn’s disease • cirrhosis • colitis • dementia • dermatitis

Sympathetic Hyperactivity“Fright or Flight” Response & Exercise produces the following in skeletal muscles

• An adrenergic factor (fight and flight)• Leading to peripheral vasodilation to somatic muscles (β receptors) and• Resulting in vasoconstriction to cutaneous, digestive (α receptors,) and lungs’ blood vessels • Reflex sympathetic dystrophy is caused by sympathetic overactivity leading to vasoconstriction and hypoxia organ

tissues involved.These are the normal of the activation of SNS to prepare for FOF.

Reflex Sympathetic Dystrophy• Abnormal and excessive response of autonomic system following immobilization• Increased sensitivity to touch, redness of skin, atrophy, depression• Refer to MD

Sympathetic Hyperactivity• Vasoconstriction• Hypoxia

– Reduced ATP synthesis– Reversible cell damage—Ca++ influx, K+ efflux, decrease intracellular pH, mitochondrial and ER

swelling.– Mitochondrial failure– Irreversible cell damage—anaerobic metabolism, profound cell membrane disturbance

Especially in the fine motor muscles and viscera smooth muscles not involve in FOF.

Sympathetic Hyperactivity• Activation of adrenergic receptors applies during exercises• DOES NOT APPLY to Sedentary lifestyles, during tissue injury, inflammation, pain and joint dysfunction. Why

not????? DIET!!!! Mental states!SMOOTH MUSCLES:

- Non-nervous stimuli- Contraction by stimulating factors acting directly on smooth muscles:1. Local tissue factors 2. Circulating hormones

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• diabetes • dry eyes • edema • emphysema • eczema • fibromyalgia • gastroenteritis • gingivitis • heart disease • hepatitis • high blood pressure • insulin resistance • interstitial cystitis • joint pain/arthritis/RA • metabolic syndrome (syndrome X) • myositis

• nephritis • obesity • osteopenia • osteoporosis • Parkinson’s disease • periodontal disease • polyarteritis • polychondritis • psoriasis • scleroderma • sinusitis • Sjögren’s syndrome • spastic colon • systemic candidiasis • tendonitis • UTI’s • vaginitis

Why not applied to sedentary lifestyles? It caused pain and dysfunction by another mechanism—diet induced inflammation cascade that is being self perpetuated in the periphery, increase pain and inflammation and eventually cause sympathetic responseCan you be asymptomatic yet subluxated?What are these local factors and hormones?

The major control of visceral smooth muscle is by non-nervous stimuli, but rather by these local control factors—eicosanoids collectively.Simply by restricting microcirculation, the nervous system can create hypoxia and inflammation. But how? Actual menchanism is complex but mostly likely mediate by neurotransmitters and cyotokines release. Candice Pert, Molecule of emotions, shows that biochemicals mediate emotions and might link to physical symptoms.

Sympathetic Hyperactivity• Arteries, veins, venules are innervated.• Arterioles, precapillary sphincters and capillaries have little or NO nerve supply, yet highly contractile• Responds to local conditions in surrounding interstitial fluid: chemicals concentrations• Low 02 levels ● CO2• H+ ● Lactic acid• Adenosine• Reduced Ca++ concentration• Increased K+ ion concentration (functions as vasodilator)

Sympathetic HyperactivityPotassium is released from contracted muscles:

Increasing extracellular potassium Leading to local vasodilation Nitric oxide may play a similar role

“Potassium is one of the most important local regulators of blood flow…. Muscle contraction activates K channels, results in the release/extrusion of intracelllular K. The subsequent increase in extracellular K is thought to be a major mechanism underlying metabolic inhibition of sympathetic vasoconstriction in exercising skeletal muscle.” p. 5

Sympathetic dominance can lead to K+ depletion.

Blood-borne hormones that affect smooth muscle contraction Epinephrine (systemic) – 80% Norepinephrine (local)—20% Acetylcholine Angiotensin Vasopressin Oxytocin Serotonin Histamine

That is the reason why sympathectomies often fail to reduce sympathetic hyperactivity and pain returns or remain for patients with sympathetic reflex dystrophy is due to local release of catecholamines from the adrenals medulla and stimulate the local neural and tissue alpha-erceptors and perpetuates the painful syndrome. P. 5

Sympathetic HyperactivityVasomotor Control

• Segmental control of sympathetic tone• Suprasegmental vasomotor control (vasomotor center in the reticular formation upper medulla and lower pons).• Feedback from vagus and baroreceptors.• Vasoconstrictionhypoxic injuries• Reperfusion injuries by free radicals• Can the brain cause pain and inflammation without physical injuries? Yes. TMS

P. 6

FREE RADICALS• Cause a number of injuries, tissue damage, and chronic disease increase the level of oxidative stress.• Oxidative stress is strongly linked to the aging process

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GSDL offers an Oxidative Stress Analysis (blood and urine sampling)Free radicals are produced during reperfusion when blood flow is restored to previous constricted vessels bring a host of free radicals. Reperfusion injuries damage tissues of the heart, kidneys, bowel, liver, brain and eyes.YOU can experience this effect after exposure to cold temperature, your extremity can become painful when more blood returns to a previous cold and vasoconstricted part.

Free Radicals lead to: Hypoxia, (vasoconstriction) leading to muscle spasm and hypomobility of affected joints Hypoxia in tissues of fibromyalgia patients Changes in muscle tissue Mitochondrial abnormalities with concurrent decreased levels of ATP and phosphocreatine Promote osteoarthritis Promote inflammatory processes which subsequently increases nociception

Free Radical Burden Assessment• Great Smokies Diagnostic Laboratory-- Oxidative Stress Analysis by sampling the blood and urine.

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Treatment ConsiderationsChiropractic Adjustment intervenes in 2 ways:

1. Restores biomechanical integrity: decreases mechanical and mechanically-induced chemical irritation of the articular nociceptors

2. Caused a reflex inhibition of vasoconstriction and myospasm: decreases mechanical and chemical irritation of extra-articular nociceptors

The connections between nociceptive afferents and somatomotor neurons

Nociceptive induced sympathetic hyperactivity causes histopathology in at least three ways: 

a)    sympathetic hyperactivity can cause vasoconstriction, hypoxia-induced myopathologyb)    can promote muscle spasm resulting in muscle tightness and hypomobilityc)    promote neurogenic inflammation by activating adrenergic receptors enhancing tissue injury

http://www.angelfire.com/journal2/sadhelp/np.htm10/7/08

Somatovisceral ReflexSomatovisceral reflex is a result of histo- and myopathologies and neurogenic Inflammation or sympathetic hyperactivity (according to Dr. Irvin Korr)

o Peptic ulcero Neurogenic pulmonary edemao Pancreatitiso Arteriopathyo Cardiovascular-renal syndromes 

Under chronic hypersympathetic outflow, reduced visceral blood flow and hypoxia can lead to damage to the visceral organs. That is why any stress is very damaging to the internal organs systems.

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Somatovisceral Reflex• Somatovisceral reflex as a result of histo- and myopathologies and neurogenic Inflammation or sympathetic

hyperactivityAND

• possible segmental vertebral lesions• dysfunction of the vertebral column leading to visceral disease and symptoms• Involves a suprasegmental relationship• Viscerosomatic reflex

Reflex Muscle Spasm• Nociceptive afferents have direct input to the alpha-and gamma-motor neuron• May result in muscle tension and spasm associated with spinal dysfunction

– Dvorak and DvorakTwo Consequences:

1. Vascular compression: leads to ischemia, increases rate of local metabolism, leads to release of pain inducing chemical substrates** muscle contraction of 60% occludes blood flow due to the increase in intramuscular pressure

2. Joint hypomobilitySee figures 1.1 and 1.3.Guyton, “Muscle spasm is a very common cause of pain, and is the basis of many clinical pain syndromes, This pain probably results partially from the direct effect of muscle spasm in stimulating mechanosensitive pain receptors. However, it possible results also from the indirect effect of muscle spasm to compress the blood vessels and cause ischemia, Also, the spasm increases the rate of metabolism in the muscle tissue at the same time, thus making the relative ischemia even greater, creating ideal conditions for release of chemical, pain-inducing substances.” **”When a muscle is contracts to about 60% of its force generating capacity, blood flow to the muscle is occluded due to elevated intramuscular pressure. With a sustained static or isometric contraction, the compressive force of the contraction can actually stop the flow of blood.”—McCardle

Pathological changes that develop when musculoskeletal tissues are immobilized.

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Tension Myositis Syndrome-to eliminate TMS symptoms, the sufferer needs to become aware of the very feelings he’s trying to avoid. And he

needs to know (deep down in his gut, not just intellectually) that it’s completely ok to experience those feelingshttp://www.stjohn.org/innerpage.aspx?PageID=2480unconscious fear/anger physiological changes physical symptoms psychological & and social factors add to the

symptoms creating a full-=blown syndrome that practically rules your life

c

http://www.deflame.com/portals/0/1Diet_inflammation2002.pdf

A proposed dynamic relationship between the pathological components. The problem with the dynamic diagram is that it breaks down a pathological process into a step by step sequence of events. In reality, the various pathological changes may occur simultaneously and/or at different rates. Also many more arrows should be added to show a interactive and complicated interrelationships between these processes.Nutritional status determine the inflammatory potential which is not influenced by chiropractic adjustment. If a pro-inflammatory potential exists, tissues are predisposed to produce excessive amounts of chemical irritants. Such is the case in many chronic degenerative disease, Alzheimer's, cancer, arthritis, autoimmune, heart disease and diabetes.

Physiology and Biochemistry of NociceptionGuyton: “…most activities of the nervous system are initiated by sensory experience emanating from sensory receptors,

whether they are visual receptors, auditory receptors, tactile receptors on the surface of the body or other kinds of receptors [such as vestibular receptors].”

Receptor physiology is important if one to truly understand nociceptor physiology. To a large extend, sensory receptor activity dictates central nervous system activity.

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Nutritional Status

Inflammatory Potential

TMS

DIET

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Only 1% of the sensory input is consciously aware. Most of the input is processed unconsciously and autonomically. You don’t need to be conscious of nociceptive input, yet they set up the same autonomic reflex and concomittant symptoms just the same. A qraudraplegic will have increased blood pressure from pressure wound without feeling the pain.

Receptor Categories1. Mechanoreceptors (proprioceptors)2. Thermoreceptors3. Nociceptors4. Electromagnetic receptors5. Chemoreceptors

Sensory afferent fibers carrying info to the CNS via action potential transduction“proprioception as defined by Sherrington (in 1906), refers to perception of joints and body movements as well as position of the body, or body segments, in space. More specifically, proprioception enables us to check on the spatial orientation of our bodies or body parts in space, the rate and timing of our movements, how much force our muscles are exerting, and how much and how fast a muscle is being stretched. Although Sherrington identified the muscle afferents, joint receptors, and vestibular labyrinth as proprioceptors and will confine our discussion in this section to the non-vestibular proprioceptors.” this is confusing as Guyton and other texts do not consider proprioceptors to be a class of sensory receptors.

Terms to keep in mind:1. Receptor potential2. receptor adaptation3. receptor threshold4. peripheral nociceptive sensitization5. central nociceptive sensitization

Receptor Potential-a change in the membrane potential of a receptor-sodium influx will change membrane potential-RP will incr with rising stimulation-threshold must be reached before action potential occurs-nutrients directly affecting this process:

-EFAs (esp omega-3)-Na and K

The resting potential of the afferent fiber is -90mV, and -60mV is the threshold that must be reached before an action potential fries.Receptor potential is gradedAction potential is a all-or-none phenomenonNutritional status affect receptor potential by increasing or decreasing the threshold for AP

Receptor Adaptation• Adaptation is the process by which a receptors stops responding to a stimulus Rapidly adapting: Phasic receptors Slowly adapting: Tonic receptors Non-adapting receptors

When a stimulus is applied to a receptor it will usually respond at a very high impulse rate at first, then at a progressively lower rate until finally it may not respond at all. Despite the continued presence of the stimulus. Over time, a receptor potential will diminish despite the continued presence of a stimulus.

Examples:Ø  Taste receptors

-      Geriatric patients often need to add salt-      Nutrient directly related to taste: Zinc

 Ø  Retinal receptors

-    Geriatric patients may experience slow or little adaptation to darkness and light-    Nutrient directly related to vision: Vitamin A 

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Zinc activates areas of the brain that receive and process information from taste and smell sensors. Its importance to appetite was first demonstrated in 1972 when researchers showed taste disorders responded to zinc supplementation. Zinc deficiency may increase the RP for taste receptor and make it more difficult for the cell to fire at a lower amount of flavor concentration.Rich sources of zinc are oysters, beef, liver, crab, seafood, poultry, nuts and seeds, whole grains, tofu, peanuts and peanut butter, legumes and milk. Zinc found in breast milk is better absorbed than that in formula milk. Fruits and vegetables are not generally good sources of zinc.

Zinc Deficiency Test      Zinc levels in blood, hair and other tissues are indicators which have been inconclusive and sometimes misleading. In the early 1980s a simple taste test was developed and reported in The Lancet. To create a test solution, dissolve 0.1 percent zinc sulfate (available at health some food stores and your local pharmacy) in a base of distilled water. You should refrain from eating, drinking or smoking for at least an hour before the test, then place about a teaspoon of the solution in your mouth and swish it around for 10 seconds. If it tastes unpleasant or metallic, your level of zinc is probably adequate. However, if the solution tastes like water, you may be receiving less zinc than you need.

Vision and the Role of Vitamin A Photoreception in the eye is the function of two specialized cell types located in the retina; the rod and cone cells. Both rod and cone cells contain a photoreceptor pigment in their membranes. The photosensitive compound of most mammalian eyes is a protein called opsin to which is covalently coupled an aldehyde of vitamin A. The opsin of rod cells is called scotopsin. The photoreceptor of rod cells is specifically called rhodopsin or visual purple. This compound is a complex between scotopsin and the 11-cis-retinal (also called 11-cis-retinene) form of vitamin A. Rhodopsin is a serpentine receptor imbedded in the membrane of the rod cell. Coupling of 11-cis-retinal occurs at three of the transmembrane domains of rhodopsin. Intracellularly, rhodopsin is coupled to a specific G-protein called transducin. When the rhodopsin is exposed to light it is bleached releasing the 11-cis-retinal from opsin. Absorption of photons by 11-cis-retinal triggers a series of conformational changes on the way to conversion all-trans-retinal. One important conformational intermediate is metarhodopsin II. The release of opsin results in a conformational change in the photoreceptor. This conformational change activates transducin, leading to an increased GTP-binding by the a-subunit of transducin. Binding of GTP releases the a-subunit from the inhibitory b- and g-subunits. The GTP-activated a-subunit in turn activates an associated phosphodiesterase; an enzyme that hydrolyzes cyclic-GMP (cGMP) to GMP. Cyclic GMP is required to maintain the Na+ channels of the rod cell in the open conformation. The drop in cGMP concentration results in complete closure of the Na+ channels. Metarhodopsin II appears to be responsible for initiating the closure of the channels. The closing of the channels leads to hyperpolarization of the rod cell with concomitant propagation of nerve impulses to the brain.

Zinc Deficiency Test• In the early 1980s, a taste test was developed and reported in The Lancet. To create a test solution, dissolve

0.1 percent zinc sulfate (available at health food stores or pharmacy) in a base of distilled water. • Refrain from eating, drinking or smoking for at least an hour before the test, then place about a teaspoon of

the solution in your mouth and swish it around for 10 seconds. • If it tastes unpleasant or metallic, your level of zinc is probably adequate. However, if the solution tastes like

water, you may be receiving less zinc than you need.

Zinc Deficiency Test      Zinc levels in blood, hair and other tissues are indicators which have been inconclusive and sometimes misleading. In the early 1980s a simple taste test was developed and reported in The Lancet. To create a test solution, dissolve 0.1 percent zinc sulfate (available at health some food stores and your local pharmacy) in a base of distilled water. You should refrain from eating, drinking or smoking for at least an hour before the test, then place about a teaspoon of the solution in your mouth and swish it around for 10 seconds. If it tastes unpleasant or metallic, your level of zinc is probably adequate. However, if the solution tastes like water, you may be receiving less zinc than you need.

*What tissues are devoid of nociceptive input?

Receptor Threshold• Receptors are having either low or high threshold• Receptors responding to very subtle forms of stimulus, such as light touch, are classified as low threshold receptors.

Examples:Type I: Ruffini’s endings, Meissner corpuscles, Golgi-Manzooni endingsType II: rapidly adapting, dynamic receptors

Pacinian corpuscle, Golgi-Manzooni body

Receptors responding only to intense forms or noxious stimuli are known as high threshold receptors.Examples:

Type III: mostly found in joints and also in the cervical zygapophyseal joints, slow adaptingType IV: nociceptors, found in all spinal tissues, except for the articular cartilage, nucleus pulposus, and the inner

two thirds of the annulus.

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Nutrients directly involved in receptor threshold:– EFAs (especially Omega 3’s)– Na and K

Other factors: pH, [H2O]EFA affect RT by mediating the structure of cell receptors as well as eicosanoid production

Review of Joint ReceptorsType I (slow), Type II (rapid), Type III (slow), are mechanoreceptors which respond to tension in the connective tissue structures. Type IV are nociceptors responding to tissue damaging stimuli, most sensitive to chemical irritants. Otherwise they have a very high threshold of activation.

In normal situation, nociceptor have very high threshold of activation. Light touch and normal joint movements do not stimulate them. They become activated when tissue are exposed to sufficiently severe mechanical distortion or alterations in the chemical composition of the tissue fluid that bathes them. Nociceptors are thought to be the most sensitive to chemical irritants.

Review of Joint Receptors Sensitization occurs to an abnormally low nociceptor threshold that develops due to the presence of:

acidic pH irritant chemicals (PGE2, leukotrienes B4, 5HTP, bradykinin & possibly norepinephrine) EFA deficiency

Chemical irritants are responsible for sensitization process.

Stress and Cancer• Recent studies using ovarian cancer cells have shown that the catecholamine hormones norepinephrine and

epinephrine may influence cancer progression by modulating the expression of matrix metalloproteinases and vascular endothelial growth factor.

• The data suggest that catecholamine hormones produced by the sympathetic-adrenal medullary axis may affect NPC (Nasopharyngeal Carcinoma) tumor progression, in part, through modulation of key angiogenic cytokines.

• Norepinephrine Up-regulates the Expression of Vascular Endothelial Growth Factor, Matrix Metalloproteinase (MMP)-2, and MMP-9 in Nasopharyngeal Carcinoma Tumor Cells. Cancer Res 2006; 66(21):10357-64

Receptor SensitizationIn a sensitized state, normal, low threshold innocuous movements such as normal head turning will activate nociceptors.Peripheral nociceptors are

- more sensitive to stimulation- display prolonged and enhanced responses to such stimulation.

Central nociceptors (central neurons) are- sensitized, or facilitated, as a consequence of noxious input.- hyperexcitable, amplify, “wind-up”- “neuroplasticity”

http://www.annalsnyas.org/cgi/content/abstract/933/1/157http://academic.sun.ac.za/medphys/neurosc1.htm

Thought and neuroplasticityThe Dalai Lama invited Richard Davidson, a Harvard-trained neuroscientist at the University of Wisconsin-Madison's W.M. Keck Laboratory for Functional Brain Imaging and Behavior to his home in Dharamsala, India, in 1992 after learning about Davidson's innovative research into the neuroscience of emotions. Could the simple act of thinking change the brain? Most scientists believed this idea to be false, but they agreed to test the theory. One such experiment involved a group of eight Buddhist monk adepts and ten volunteers who had been trained in meditation for one week in Davidson's lab. All the people tested were told to meditate on compassion and love. Two of the controls, and all of the monks, experienced an increase in the number of gamma waves in their brain during meditation. As soon as they stopped meditating, the volunteers' gamma wave production returned to normal, while the monks, who had meditated on compassion for more than 10,000 hours in order to attain the rank of adept, did not experience a decrease to normal in the gamma wave production after they stopped meditating. The synchronized gamma wave area of the monks' brains during meditation on love and compassion was found to be larger than that corresponding activation of the volunteers' brains. Davidson's results were published in the Proceedings of the National

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Academy of Sciences in November, 2004 and TIME recognized Davidson as one of the ten most influential people in 2006 on the basis of his research

Peripheral Sensitization• Lowered nociceptor threshold due to chemical irritants: Acidic pH, PGE2, leukotriene B-4, 5-hydroxytryptamine,

bradykinin, possibly norepinephrine, lactic acid, K+, Substance P• Display prolonged and enhanced responses to stimulation—slow adapting• Initiate excessive AP firing to nociceptive afferents.• Promoting neurogenic inflammation

AP Action potentialResearch demonstrated that upon stimulation, nociceptive receptors release various neuropeptides, neuropeptide Y, galanin, met-enkephalin, leu-enkephalin, calcitonin gene related peptide (CGRP) and substance P. The last two are thought to work synergistically to produce plasma extravasation. Substance P cause vasodilation, increased vascular permeability, pavementing of leukocytes in venules, PMN phagocytosis, local PG synthesis and mast cell degranulation, serotonin and leukotrienes leading to local inflammation and more nociceptor stimulation.

Sensitizing agents are: PGE-2, bradykinins, leukotriene B-4, Serotonin, histamine, possibly norepinephrine

Irritating and stimulating are: Lactic acid and K ions (not considered sensitizing agents)

Neurogenic Pain • “There is nothing like a little physical pain to take your mind off your emotional problems.”

– Charles Schultz

Central Nociceptive Sensitization- Cord plasticity is responsible for development of central nociceptive sensitization- Chemical irritants are indirectly responsible for sensitization process - Increased reflex synaptic activity

http://www.angelfire.com/journal2/sadhelp/np.htmCord plasticity is

Woolf—experimentally that central neurons are sensitized or facilitated as a result of noxious input. “Brief stimulation of afferent C fibers caused changes of excitability in motor reflexes and expansions of receptive fields of dorsal horn neurons which outlasted the actual stimulus. The presence of ‘central changes’ implies that there are not only alterations in the afferent drive of central neurons, but that the sensitivity to afferent inputs in the central neurons themselves is enhanced.” (p. 16)

Nociception in Clinical Practice• A condition in which pain is produced by normally painless stimuli is known as Allodynia. • A condition in which abnormally intense pain sensation is produced by normally painful stimuli is known as

Hyperalgesia. • In both cases excessive chemical irritants are present in the patient’s tissue.• NSAID’s are used to reduce pain.

• GI bleeding--common NSAID’s side effect• Some 16500 deaths occur each year due to bleeding ulcers induced by NSAID’s

• Rich M, Scheiman JM. Nonsteroidal anti-inflammatory drug gastropathy at the new millennium: mechanisms and prevention. Sem Arth Rheum 2001;30:197-79.

Better options: Antioxidants, bromelain, ginger, turmeric. Alkaline diet (80% alkaline to 20% acidic). Addressing food allergies, yeast, liver detoxification, fasting and other measures.http://www.drugdanger.com/Elderly/4-12-14DrugInteractions.htm

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