Medical Manual Therapy Clinical Review Series

Insulin Resistance

Copyright 2003 American Health Source All rights reserved. No part of this manual shall be reproduced, stored in a retrieval system, or transmitted by any means electronic, mechanical, photocopying, recording, or otherwise, without written permission from Gregory T. Lawton, American Manual Medicine Association, and American Health Source, Inc.

THE BLUE HERON ACADEMY OF HEALING ARTS AND SCIENCES MEDICAL MASSAGE, INCORPORATED 2040 RAYBROOK SE, SUITE 104 GRAND RAPIDS, MICHIGAN 49546 888-285-9989 Toll Free 616-285-9999 Grand Rapids info@BlueHeronAcademy.com www.BlueHeronAcademy.com

AHSPUBLICATIONS American Health Source, Inc. 6475 28th Street SE, Suite 190 Grand Rapids, Michigan 49546 Every effort has been made to ensure that permission has been obtained for use of text references herein. If any required acknowledgement has been omitted or any rights overlooked, please notify the publishers and omissions will be rectified in future editions.

1

CLINICAL REVIEW SERIES Insulin Resistance as a Pro-inflammatory Factor in Degenerative Joint Disease

T

his clinical review series is a brief review of the central facts surrounding dietary and metabolic disorders that directly cause or significantly contribute to degenerative joint disease. Reviewed in this series are the central causes of joint disease separate from repetitive joint strain and joint injury caused by trauma. This series provides clinical notes on the following conditions: — — — — — —

INSULIN RESISTANCE OBESITY DIABETES THYROID DYSFUNCTION ADRENAL DYSFUNCTION MENOPAUSE

These six factors are the central cause of all nontrauma related joint disease.

Joint degeneration is a process, not an event. The process of joint degeneration is firmly based upon diet and nutrition. Insulin resistance is directly related to the over consumption of refined sugar and starches, too many of the wrong kind of carbohydrate calories, and a lack of exercise and a sedentary lifestyle.

Insulin resistance causes joint degeneration by directly contributing to joint and soft tissue inflammation and by causing clinical and morbid obesity. Insulin resistance, obesity, and dysglycemia cause and lead to diabetes. The metabolic disruptions that occur in the diabetic state also cause soft tissue inflammation and joint degeneration.

Thyroid imbalances, such as hypothyroidism, and adrenal exhaustion further contribute to abnormal muscle and joint conditions and present with numerous musculoskeletal symptoms. Perimenopause, menopause, and postmenopause stages in women also cause and contribute to inflammatory states, musculoskeletal disorders, metabolic disruption, and the inability to heal and recover from the combined effects of injury, tissue trauma, and the general effects of aging.

It is the role of the medical massage therapist to educate the patient with pain and degeneration regarding these central contributing causes to their conditions and health problems.

There is a great deal of denial and avoidance regarding the role of diet and nutrition as a cause of degenerative joint disease, inflammation, and pain among the general public and therapists. Many people would rather blame these disorders on “aging,” instead of bad health habits and food addiction.

2

I N S U L I N R E S I S TA N C E : A Potent Cause of Joint Degeneration Hypoglycemia is recognized as a condition that affects a significant number of Americans in varying degrees with about four percent of the population being diagnosed with this clinical disorder. Insulin resistance is a more recently recognized condition that involves increased levels of insulin but impaired cellular responses to insulin’s actions. This condition results in increased insulin, increased stress on the beta cells of the pancreas, and dysglycemia.

Obesity is a disease. It is increasing at alarming rates in the U.S. Obesity is the most common pathological disease in modern Western society. Over fifty percent of the US population is overweight, clinically or morbidly obese.

Obesity is a recognized risk factor in a number of cancers, including breast cancer.

Insulin is an anabolic hormone that plays a role in sugar, fat and protein metabolism. Insulin is involved in cellular utilization of blood glucose by the cells of the body. It is released by the pancreas in response to increased blood glucose levels. Insulin facilitates the entry of glucose into the muscle and fat cells to form glycogen, fatty acids to form triglycerides, and amino acids to form proteins. Insulin also has catabolic activity and inhibits gluconeogenesis, which is the production of glucose from lactate and amino acids. Insulin is involved in the breakdown of glycogen and fat. Basically, insulin communicates to the cell that glucose is available for cellular metabolism.

Insulin resistance results when there is an interference with the ability of insulin to facilitate the entry of glucose into the cell. When insulin utilization is impaired, the cells have less glucose available as fuel. This results in higher levels of glucose in the blood which the pancreas detects as requiring more insulin, which it produces and releases into the blood stream. This results in hyperinsulinemia. (high blood insulin) Insulin resistance has been calculated to affect over twenty-five percent of the nondiabetic adult population of the US. Poor insulin utilization and elevated blood glucose levels are causation factors in the following diseases: — Hypertension — Obesity — Ischemic Heart Disease — Dyslipidemia (raised triglycerides, reduced HDL, high cholesterol, high LDL) — Type 2 Diabetes Patients who have hypertension, dyslipidemia, and hyperinsulinism have what is now diagnosed as Syndrome X. 3

The relationship of hyperinsulinism (insulin resistance) and these diseases can be understood in relationship to the anabolic functions of insulin. Insulin stimulates fat production in arterial and adipose tissues and facilitates the entry of triglycerides and glucose into these tissues. Insulin also increases the production of cholesterol in the liver.

Hypertension occurs in over fifteen percent of the US population, but in over forty percent of those over the age of sixty-five. It is estimated that fifty percent of the hypertensive population has glucose intolerance or hyperinsulinism. Insulin may contribute to high blood pressure by its effects on sodium retention in the kidney, by increasing sodium and calcium transport in the cell, the stimulation of sympathetic nervous system activity, and increasing the hypertonicity of vascular smooth muscle.

Insulin resistance causes cardiovascular disease by contributing to obesity, hypertension, vascular smooth muscle hypertonicity and proliferation, and dyslipidemia. Insulin resistance also reduces fibrinolysis and lowers DHEA levels. DHEA is anti-atherogenic, inhibits fibroblasts, and lowers blood fat levels.

In addition to hyperinsulinisms effects on DHEA, insulin has other hormonal effects including: 1. Blocks conversion of DHEA from pregnenolone.

2. Increases free androgens. (male traits in women) • Associated with acne • Masculizing effects (hirsutism) • Visceral obesity • Prostatic hypertrophy • Polycystic ovary syndrome • Increased LDL levels • Infertility • Imbalances in hormonal activity and levels • Impedes ovulation Of particular interest to the medical manual therapist is hyperinsulinism’s proinflammatory effects. Eicosanoid production is disrupted by hyperinsulinism.

Eicosanoids include prostaglandins, leukotrienes, and thromboxanes and are synthesized from omega 3 and 6 fatty acids. Western industrialized diets are high in Omega 6 fatty acids which form the pro-inflammatory eicosanoids.

Current diets are about ten to thirty times higher in Omega 6 fatty acid sources than they should be. Pro-inflammatory states in the body increase the levels of cytokines (inflammatory chemicals) (bradykinin) and free radical production. This pro-inflammatory chemical cascade contributes to autoimmune and degenerative disorders. Omega 3 fatty acids are precursors to antiinflammatory eicosanoids such as PGE3.

4

Chronic recurrent renal oxalate calcui (kidney stones) have also been linked to hyperinsulinism.

Maturity onset diabetes is also associated with insulin resistance. In the early stages of insulin resistance the pancreas is able to produce enough insulin to “overcome” the resistance. However, long term resistance results in an inability of the pancreas beta cells to produce enough insulin to continue to overcome the insulin resistance. The degree of insulin resistance and the degree of loss of function by the beta cells of the pancreas will determine the severity of the disease. The condition will initially be a non insulin dependent diabetes followed by failure of the pancreas beta cells and insulin dependent diabetes.

There are currently over eighteen million Americans diagnosed with diabetes.

Several factors are known to contribute to insulin resistance: • • • • • • • • • • • • • • • • • •

Genetics Lifestyle Obesity Lack of Exercise Stress (cortisol levels/adrenal function) Refined Carbohydrates Refined Fats Trans Fatty Acids Omega 6 Fatty Acids High Glycemic Index Foods Low Chromium Calcium and Magnesium Imbalances High Sodium Chloride Levels (lowers magnesium) Low B Complex, and Biotin Level Adrenal Dysfunction or Insufficiency High Cortisol and Adrenalin Levels High Cytokines Elevated Androgens

5

PRO-INFLAMMATORY AND ANTI-INFLAMMATORY DIETARY FACTORS Current scientific research has largely established that diet is the cause of insulin resistance, obesity, diabetes and other metabolic disorders. Diet is also the cause of pro-inflammatory responses in the body’s tissues, organs and systems.

Pro-inflammatory factors cause or contribute to: 1.

2.

3.

4.

5.

6.

Heart Disease Cancer Pain Neurodegenerative Disorders Musculoskeletal and Joint Degeneration Most Degenerative Disorders

A major component of pro-inflammation in the body is the imbalance of omega 6 (n6) and omega 3 (n3) fatty acids. N6 and n3 fatty acids are polyunsaturated acids. Studies of traditional diets revealed that early man consumed polyunsaturated oils at a ratio of 1:1. The contemporary goal should be to consume polyunsaturated n6 and n3 Omega’s at a ratio that is less than 4 to 1. Current ratios are found to be at 10:1 to 30:1.

The desired n3 Omega fatty acids are found in: • • • • • • •

•

Olive oil (primarily Omega 9 fatty acids) (does not contribute eicosanoids) Flax Seed Oil Flax Seeds in Cereal or on Salads N3 Rich Eggs Wild Game Seafood and Fish Vegetables Including – Kale Broccoli Cauliflower Spinach Collard Greens Mustard Greens Swiss Chard Chicory Some n3 is found in – Walnuts Pumpkin Seeds

6

N6 fatty acids are found in: Almost all Grains Almost all Seeds and Nuts Some grains like oatmeal contain both n6 and n3 fatty acids. In oatmeal the n6 to n3 ratio is 10:1.

THE SIGNIFICANT ROLE OF EXERCISE IN GLYCEMIC HOMEOSTASIS Exercise plays a major role in the normal regulation of blood sugar levels. It is exercise and activity that create the cells demand for glucose. No matter how good the diet or how balanced the dietary sugars are, without exercise and activity to create the demand, dysglycemia, obestity, and diabetes will result. The insulin and glucose regulation system (the cells and endocrine system) are driven by two main factors, the types of sugars and fats that are consumed and the quantity and quality of exercise and activity that create the demand and use of glucose. Exercise and activity will provide protection from dysglycemic disorders even when the consumption of dietary sugars and fats is inappropriate.

Additional Notes:

7

CLINICAL REVIEW SERIES P RO - I N F L A M M ATO RY PAT H O L O G Y Conditions Contributing Degenerate Joint Disease

Inflammation

Masculinizing Insulin Resistance

Thyroid Cold Intolerance Appearance Edema Muscle Pain Joint Pain

Improper Diet Obesity Dysglycemia Diabetes

These conditions are the central causes of pro-inflammation in the body and degenerative joint disease leading to arthritis Adrenal

Menopause

Fatigue Infection Illness Allegergies Fibrocystic Breasts

Hot Flashes Age Sex Insomnia Vaginal Changes

Muscle Problems

Skin (Acne) Fatigue

8

Thyroid and Somatic Dysfunction

Copyright 2003 American Health Source All rights reserved. No part of this manual shall be reproduced, stored in a retrieval system, or transmitted by any means electronic, mechanical, photocopying, recording, or otherwise, without written permission from Gregory T. Lawton, American Manual Medicine Association, and American Health Source, Inc.

THE BLUE HERON ACADEMY OF HEALING ARTS AND SCIENCES MEDICAL MASSAGE, INCORPORATED 2040 RAYBROOK SE, SUITE 104 GRAND RAPIDS, MICHIGAN 49546 888-285-9989 Toll Free 616-285-9999 Grand Rapids info@BlueHeronAcademy.com www.BlueHeronAcademy.com

AHSPUBLICATIONS American Health Source, Inc. 6475 28th Street SE, Suite 190 Grand Rapids, Michigan 49546 Every effort has been made to ensure that permission has been obtained for use of text references herein. If any required acknowledgement has been omitted or any rights overlooked, please notify the publishers and omissions will be rectified in future editions.

1

CLINICAL REVIEW SERIES Insulin Resistance as a Pro-inflammatory Factor in Degenerative Joint Disease

T

his clinical review series is a brief review of the central facts surrounding dietary and metabolic disorders that directly cause or significantly contribute to degenerative joint disease. Reviewed in this series are the central causes of joint disease separate from repetitive joint strain and joint injury caused by trauma. This series provides clinical notes on the following conditions: — — — — — —

INSULIN RESISTANCE OBESITY DIABETES THYROID DYSFUNCTION ADRENAL DYSFUNCTION MENOPAUSE

These six factors are the central cause of all nontrauma related joint disease.

Joint degeneration is a process, not an event. The process of joint degeneration is firmly based upon diet and nutrition. Insulin resistance is directly related to the over consumption of refined sugar and starches, too many of the wrong kind of carbohydrate calories, and a lack of exercise and a sedentary lifestyle.

Insulin resistance causes joint degeneration by directly contributing to joint and soft tissue inflammation and by causing clinical and morbid obesity. Insulin resistance, obesity, and dysglycemia cause and lead to diabetes. The metabolic disruptions that occur in the diabetic state also cause soft tissue inflammation and joint degeneration.

Thyroid imbalances, such as hypothyroidism, and adrenal exhaustion further contribute to abnormal muscle and joint conditions and present with numerous musculoskeletal symptoms. Perimenopause, menopause, and postmenopause stages in women also cause and contribute to inflammatory states, musculoskeletal disorders, metabolic disruption, and the inability to heal and recover from the combined effects of injury, tissue trauma, and the general effects of aging.

It is the role of the medical massage therapist to educate the patient with pain and degeneration regarding these central contributing causes to their conditions and health problems.

There is a great deal of denial and avoidance regarding the role of diet and nutrition as a cause of degenerative joint disease, inflammation, and pain among the general public and therapists. Many people would rather blame these disorders on “aging,” instead of bad health habits and food addiction.

2

Clinical Notes THYROID CONDITIONS Introduction – The thyroid gland is located in the neck just under the “Adam’s apple” where it produces the hormones thyroxin (T4) and triiodothyronine (T3). The thyroid produces hormones that regulate metabolism, the energy processes of the body’s trillions of cells, protein synthesis, cell growth, temperature regulation, and the oxygen consumption of cells. Imbalances in thyroid function, whether hypo or hyper can cause mild, moderate, to serious problems in how our body functions and regulates itself. Abnormalities in thyroid function can also magnify other conditions and disorders related to endocrine function such as adrenal insufficiency, female reproductive problems, diabetes, and menopause.

Statistically women have an overall higher incidence of hypo- and hyperthyroid conditions than men do. Estimates of incidents of hypothyroidism run from fifteen to forty percent of the female population of the U.S. with 40 percent of the population considered to have suboptimal thyroid function. This translates into seventy five million Americans who could be benefited by thyroid education and care. Fifty-five percent of the U.S. population is clinically obese, with an eight-five percent increase in obesity occurring over the last few years.

By the end of 2003 fifty-million women will have reached menopause and they will account for nearly twenty percent of the total U.S. population. Many of the signs and symptoms of menopause and thyroid disease are identical. It is therefore possible that a patient may be suffering from either of these disorders individually, or both at the same time. If proper analysis and evaluation is not performed the assumption may be made, in a case where the woman is of menopausal age, that the woman is experiencing the natural progression from peri-menopause to menopause and thyroid disease may be medically overlooked. Additionally, the symptoms of thyroid disease tend to worsen during the onset of menopause, due to changes in hormonal levels and hormonal bio cycles.

Surveys have shown that one third of women over the age of forty have not discussed menopause with their physician and that physicians only screen one in four women for thyroid conditions, even when these women have clear indicators for thyroid disease. Currently, more than thirteen-million Americans have an active thyroid problem. Undiagnosed thyroid conditions cause a significant increase in obesity, diabetes, heart disease, depression, autoimmune disease, musculoskeletal pain and dysfunction, and other hormonal disorders.

Undiagnosed or subclinical hypothyroid disease can also be a cause of hypertension in peri menopausal, menopausal, and post menopausal women.

3

Common thyroid conditions Hashimoto’s Thyroiditis - an autoimmune disorder with chronic inflammation of the thyroid caused by the immune system targeting its own tissues.

Hyperthyroidism (Grave’s Disease) - excessive production of thyroid hormone due to abnormal thyroid gland function, nodules, or excessive thyroid function.

Hypothyroidism - deficiency of thyroid activity.

Myxedema - a condition that presents with swelling of the skin and other tissues, especially around the eyes and cheeks. This condition is caused by a severe deficiency of thyroid hormone.

Secondary hypothyroidism - a rare condition that is caused by a deficiency of pituitary TSH secretion. The deficient pituitary TSH is caused by insufficient thyroid releasing hormone secretion.

Subclinical hypothyroidism - characterized by a mildly elevated TSH level with normal T3 and T4 levels. This condition is more common than was previously recognized and usually presents with minor or mild symptoms of hypothyroidism.

Thyroiditis - a disorder that can cause either hyper- or hypothyroid, it can be treated with antibiotics and inflammatory medications.

Thyrotoxicosis - a toxic condition caused by increased amounts of thyroid hormones in the body. Related to hyperthyroidism.

Wilson’s Syndrome - a condition that results when the body cannot convert T4 into T3. Patients have the symptoms of hypothyroidism, but have normal blood levels of T3 and T4.

The top indicators of thyroid disease include: Extreme fluctuations in weight Rapid weight loss Inability to lose weight Depression and anxiety Fatigue Family history Bowel problems Constipation Diarrhea History of IBS Gas Indigestion Hair loss Hair changes. (dry and brittle) Skin changes. (lines and thinness) Skin dryness Nail brittleness Neck pain and discomfort Neck swelling Muscle and joint pain Muscle weakness Active trigger points General muscle soreness Tendinitis Carpal Tunnel Intolerance to heat or cold Menstrual irregularities, PMS, and fertility problems Neuritis

4

Differential Diagnosis: Both menopause and thyroid conditions share these symptoms: Exhaustion/fatigue Poor concentration Depression Lethargy Mood swings Skin texture and moisture changes Hair loss Changes in libido Sleep disturbances Anxiety Nervousness Heart Palpitations Changes in temperature tolerance and regulation Irregular or missed menstrual periods The following are differences between menopausal conditions and thyroid disease: Probably Menopause if • The patient experiences hot flashes and night sweats.

• The patient has vaginal dryness.

Probably thyroid related if • Neck pain.

• Visual disturbance.

• Swelling of arms and legs.

• Loss of hair or change in hair quality (brittle and dry) • Loss of hair from eye lashes.

• Weight gain or extreme fluctuation.

Another possible general indicator is when the woman is being treated for menopausal symptoms with hormone replacement therapy and still has active symptoms.

Additional symptoms of hyperthyroid disease include Anemia Muscle wasting Shortness of breath Dyslexia Erratic behavior Bulging eyes Ear ringing High blood pressure High cholesterol Increased sweating Muscle weakness Osteoporosis Skin rashes Tachycardia Tremors (shaking hands) Voice changes Difficulty swallowing

5

Additional symptoms of hypothyroid disease include Allergies. (changing, increasing, or worsening) Dizziness. (vertigo) Facial puffiness. (eye lids) Ear ringing.

Sleep apnea.

Slow pulse.

Taking the Patient History A careful patient history with a concentration on the primary and secondary signs and symptoms of thyroid disease is the first step in identifying the thyroid patient and making an appropriate medical referral and recommendations for treatment and therapy.

Physical Examination and Differential Diagnosis The detailed physical examination that attempts to identify the main physical signs of either hyperthyroid or hypothyroid disease is the next appropriate step in determining whether your patient has a thyroid problem.

Keep in mind, that a patient does not have to have all of the signs and symptoms listed in this clinical review, and an individual patient may have a mixture of symptoms that indicate an anomaly or idiosyncratic case.

Even if this is true the patient will still have either a hypo or hyper thyroid condition.

Laboratory Testing and Evaluation The medical diagnosis and treatment of hypothyroid conditions is often a poorly defined and haphazard approach. The standard TSH test is inadequate for determining hypothyroidism. Most patients who undergo this testing are told that they do not have a thyroid problem and that their symptoms are related to depression, overeating, and a lack of exercise. A better analysis of thyroid conditions results from the measurement of actual thyroid hormones, the serum free T4 and free T3 levels (FT4/FT3).

Self-Monitoring Basal Temperature An easy procedure for monitoring basal temperature is taking an axillary body temperature reading and recording this information over a period of several days. Axillary temperature is determined by inserting a thermometer under the arm pit and leaving it in position for several minutes and until a correct axillary reading is achieved. Axillary temperature should be taken in the AM and before the patient has left the bed or begun any activity. Reading below 97.6 degrees are considered low.

6

Readings below 97 degrees are considered significant. Any readings above or below 98.6 would be considered as a positive symptom when that reading is recorded over a period of several days.

Treating Both Hypothyroid Conditions and Menopause Because of the overlap between menopausal and thyroid symptoms, in many cases, both conditions will have to be treated. Fortunately, many of the alternative treatments for these two conditions are the same. Dr. John Lee has noted that many of the symptoms of hypothyroidism in women respond to progesterone therapy because progesterone is known to increase the activity of T3. T4 therapy alone for hypothyroidism is known to increase bone loss while progesterone will actually build bone tissue.

Progesterone therapy is also effective in the treatment of skin, hair, and nail conditions associated with both hypothyroidism and menopause.

Approaches in Treatment - Natural and Alternative Medicine -

Traditional Chinese Medicine From the view point of TCM hypothyroidism is a cold condition with yang deficiency. From this perspective hypothyroidism would be treated with TCM by: (note: Acute hypothyroidism, Hashimoto’s (autoimmune) is considered hot because it is an inflammatory condition.)

1.

2.

3.

4.

5.

6.

Using mild yang tonics. (kidney meridian) Building chi through food, breath, and exercise.

Regulating the digestion, with digestive stimulants.

Tonifying the spleen and stomach meridians.

Using Cooked Rehmania or Shizandra.

Using soy (which is considered very cold) cooked with hot or warm spicy foods. (Ginger, Sesame oil, hot peppers and green onions)

Manual Chinese medicine for hypothyroidism would include: • Gua Sau. • Moxa.

• Vigorous joint stimulation, grasping and shaking.

7

Traditional Herbal Medicine Traditional herbal medicine utilizes herbs that stimulate energy, warm the body, improve digestion, and supply potassium and iodine in an organic plant based form. The steps to the herbal treatment of hypothyroidism include: • Using hot spicy foods and herbs. (Ginger) • Using diaphoretics. (Yarrow and Cayenne) • Using Aiodine herbs like Kelp, Dulse, Irish Moss, and Kombu.

• Using Bancha tea.

• Using Dandelion root for potassium and digestive system stimulation.

• Black Walnut Hulls (powdered) A common herbal formula for the treatment of hypothyroid conditions: Bladderwack Fritillary Bulb Poke Root Bugleweed Mullein Leaf Irish Moss Saw Palmetto Berry Bayberry Root Bark Black Walnut Hulls Cayenne Pepper Fruit The above formulation is taken at a dose of 1 dropper 3 to 6 times per day.

Edgar Cayce also has several specific dietary and herbal recommendations for hypothyroid conditions which include the Cayce formula 636.

Naturopathic Medicine The naturopathic medicine approach for the treatment of hypothyroidism would include the herbal procedures listed above as well as other naturopathic methods in the following sequence: 1.

2.

3.

4.

Mild, short term fasting.

Digestive stimulation (cleansing) Using bitters.

Anti-fat and cholesterol herbs and foods including dandelion, garlic, Chinese red yeast, guggul, ginger, and cayenne.

5. Anti-yeast treatment.

6. Probiotic therapy.

7. Heat therapy.

8

Medical Manual Therapy Medical manual therapy protocol would include the appropriate treatment of both local and regional soft tissue and joint complex conditions. The hypothyroid patient frequently presents with symptoms of fibromyalgia,Tendinitis, and neuritis. These conditions require specific treatment techniques and modalities. In addition the two following manual techniques should be considered and if appropriate utilized: • •

Manual tapping directed at the upper thoracic region Bony lever technique directed at the upper thoracic region

General Dietary Considerations: In traditional naturopathic medicine diet is used as primary treatment of hypothyroid conditions. Hypothyroidism is viewed as a failure of the metabolic regulatory mechanisms of the body that results from poor diet and excessive food consumption over a long period of time. From this perspective the following foods should be avoided: • • • • • • • • • •

All cold producing foods Refrigerated or cold foods Cola and pop Ice cream Refined sugar Dairy products Processed high fat foods Cigarette smoking Alcohol Many drugs, especially pain, sleep, and antidepressive medications

Foods that should be consumed would include: 1. A diet containing fifty percent raw or low cooked natural foods like vegetable salads and fruits 2. Eggs, carrots, and dark green and yellow vegetables 3. Fish and sea vegetables 4. Vegetable seasoning salts 5. A variety of spices added to prepared foods 6. Seeds and nuts 7. Black and red radishes

9

Recommendations specific to hair loss related to hypothyroidism 1.

2.

3.

4.

5.

6.

7.

All of the recommendations listed above.

Lysine 2000 milligrams daily.

Multi-vitamin supplement. (with A, E, and Zinc) Silica supplement (Horsetail Grass) Evening Primrose Oil. (500mg. BID) Virgin Coconut Oil (medium chain fatty acids) Selenium (200ug Selenite)

Please note that some commonly prescribed thyroid medications like Synthroid cause hair loss.

Other Dietary or Supplemental Products to Avoid • • • •

Calcium Carbonate, as well as some other forms of calcium Hormone replacement therapy Caffeine Ephedra

Food Products to Reduce 1.

2.

3.

4.

5.

6.

7.

8.

9.

Pear Strawberry Peach Broccoli Brussel Sprouts Cabbage Canola Oil Cassava Root Cauliflower

10.

11.

12.

13.

14.

15.

16.

17.

18.

Kale Millet Mustard Greens Peanut Pine Nut Rutabagas Soybeans Spinach Turnips

Protomorphogen Therapy Protomorphogen therapy is also called glandular or organo therapy.

Protomorphogen therapy is the use of desiccated animal tissue and cell preparations. Protomorphogen products deliver multiple factors that encourage organ growth including nuclei acids, enzymes, peptide hormones, neuropeptides, glycosaminoglycans, glycolipids, phospholipids, cofactors, mineral storage proteins, and other substances. In the case of hypothyroid disease a thyroid protomorphogen product would be consumed.

Exercise Therapy Exercises like tai chi, chi kung, dao yin, and yoga are all specifically recommended for hypothyroid conditions. The patient should dress warmly and wear long sleeves and pants during exercise. Exercising in shorts and short sleeves should be avoided as should swimming.

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A Novel Approach to the Treatment of Thyroid Conditions Some authorities in the alternative community who treat thyroid conditions view these conditions as an autoimmune response that results in a glandular disorder. This viewpoint has some merit. Taking this perspective into consideration the natural treatment of thyroid conditions should include tonification and normalization of the digestive track, specifically the small and large intestines. Treatment therefore should include probiotic therapy and the use of tumeric for both its anti-inflammatory and probiotic supporting qualities.

Terminology Autoimmune Disorder - a condition where the body’s immune system reacts against it’s own tissues or organs.

Levothyroxine sodium (T4) - a synthetic hormone used to treat patients with hypothyroid conditions.

Liothyronine - the synthetic isomer of the thyroid hormone triiodothyronine.

L-triiodothyronine (T3) thyroid hormone that is the more biologically active.

Thyroxine (T4) - an iodine containing hormone produced by the thyroid gland.

TSH (thyroid stimulating hormone) - thyrotropin, a pituitary hormone that promotes the growth of the thyroid gland and stimulates hormonal secretion of the thyroid gland.

Additional Notes:

11

CLINICAL REVIEW SERIES P RO - I N F L A M M ATO RY PAT H O L O G Y Conditions Contributing Degenerate Joint Disease

Inflammation

Masculinizing Insulin Resistance

Thyroid Cold Intolerance Appearance Edema Muscle Pain Joint Pain

Improper Diet Obesity Dysglycemia Diabetes

These conditions are the central causes of pro-inflammation in the body and degenerative joint disease leading to arthritis Adrenal

Menopause

Fatigue Infection Illness Allegergies Fibrocystic Breasts

Hot Flashes Age Sex Insomnia Vaginal Changes

Muscle Problems

Skin (Acne) Fatigue

12

Adrenal and Somatic Dysfunction

Copyright 2003 American Health Source All rights reserved. No part of this manual shall be reproduced, stored in a retrieval system, or transmitted by any means electronic, mechanical, photocopying, recording, or otherwise, without written permission from Gregory T. Lawton, American Manual Medicine Association, and American Health Source, Inc.

THE BLUE HERON ACADEMY OF HEALING ARTS AND SCIENCES MEDICAL MASSAGE, INCORPORATED 2040 RAYBROOK SE, SUITE 104 GRAND RAPIDS, MICHIGAN 49546 888-285-9989 Toll Free 616-285-9999 Grand Rapids info@BlueHeronAcademy.com www.BlueHeronAcademy.com

AHSPUBLICATIONS American Health Source, Inc. 6475 28th Street SE, Suite 190 Grand Rapids, Michigan 49546 Every effort has been made to ensure that permission has been obtained for use of text references herein. If any required acknowledgement has been omitted or any rights overlooked, please notify the publishers and omissions will be rectified in future editions.

1

CLINICAL REVIEW SERIES Insulin Resistance as a Pro-inflammatory Factor in Degenerative Joint Disease

T

his clinical review series is a brief review of the central facts surrounding dietary and metabolic disorders that directly cause or significantly contribute to degenerative joint disease. Reviewed in this series are the central causes of joint disease separate from repetitive joint strain and joint injury caused by trauma. This series provides clinical notes on the following conditions: — — — — — —

INSULIN RESISTANCE OBESITY DIABETES THYROID DYSFUNCTION ADRENAL DYSFUNCTION MENOPAUSE

These six factors are the central cause of all nontrauma related joint disease.

Joint degeneration is a process, not an event. The process of joint degeneration is firmly based upon diet and nutrition. Insulin resistance is directly related to the over consumption of refined sugar and starches, too many of the wrong kind of carbohydrate calories, and a lack of exercise and a sedentary lifestyle.

Insulin resistance causes joint degeneration by directly contributing to joint and soft tissue inflammation and by causing clinical and morbid obesity. Insulin resistance, obesity, and dysglycemia cause and lead to diabetes. The metabolic disruptions that occur in the diabetic state also cause soft tissue inflammation and joint degeneration.

Thyroid imbalances, such as hypothyroidism, and adrenal exhaustion further contribute to abnormal muscle and joint conditions and present with numerous musculoskeletal symptoms. Perimenopause, menopause, and postmenopause stages in women also cause and contribute to inflammatory states, musculoskeletal disorders, metabolic disruption, and the inability to heal and recover from the combined effects of injury, tissue trauma, and the general effects of aging.

It is the role of the medical massage therapist to educate the patient with pain and degeneration regarding these central contributing causes to their conditions and health problems.

There is a great deal of denial and avoidance regarding the role of diet and nutrition as a cause of degenerative joint disease, inflammation, and pain among the general public and therapists. Many people would rather blame these disorders on “aging,” instead of bad health habits and food addiction.

2

Clinical Notes Adrenal Disorders Introduction – The adrenal glands are two triangular shaped organs, weighing about three to five grams (about the size of a large bean). The two glands are situated on top of the kidneys (ad renal). The adrenal glands are composed of two parts, the outer cortex, about eighty to ninety percent of the gland mass, and the inner medulla. The inner medulla component of the adrenal glands produces adrenalin, also know as epinephrine. The medulla also produces noradrenalin.

This hormone is produced when the body is under stress and it speeds up cellular metabolism and assists the body in handling anxiety and danger. The adrenal cortex, the outer layer of tissue, produces cortisone, DHEA(s), and aldosterone. Cortisol, DHEA(s), and adrenalin are the three stress hormones of the body. Aldosterone helps in the regulation of electrolyte and water balance in the body. The adrenal glands also promote the metabolism of carbohydrates and blood sugar regulation. The adrenal glands have one of the highest levels of blood flow per gram of tissue in the body and they also have the highest concentration of cellular vitamin C. If the adrenal glands fail or become completely deficient this condition is called Addison’s disease and is one of the disorders that President John Kennedy was treated for. If the adrenal glands become overactive a condition called Cushing’s syndrome (hyperadrenalism) will result.

The adrenal glands have many important physiological and biochemical functions in the body. These functions include: • • • • • •

The synthesis of cholesterol for conversion into steroid hormones.

The synthesis of hormones that travel to cells and promote growth and repair processes in the tissues.

The “digestion” of carbohydrates and proteins through glucosteriods.

Regulation of sodium and potassium levels and maintenance of the potassium and water balance in the body.

The regulation of blood sugar levels.

The secretion of sex hormones like those produced in the ovary and testes.

The adrenal cortex is divided into three zones: 1. Glomerulosa – outer layer – produces aldosterone 2. Fasciculata – middle layer – produces cortisol and glucocorticoid precursors 3. Reticularis – inner layer – produces adrenal androgens

3

Cortisol is made from cholesterol and about eighty percent of the cholesterol that is used for the formation of cortisol comes from low density lipoproteins (LDL). When the hormone from the pituitary gland ACTH stimulates the cells in the fasciculate the number of LDL receptors is increased there and the amount of cortisol is increased as well.

The hippothalamus gland also plays a role in cortisol production via corticotrophin releasing hormone. Corticotrophin is then released by the pituitary gland and this hormone travels through the blood stream and to the adrenal cortex where it stimulates the conversion of cholesterol into cortisol. The cortisol that is released by the adrenal glands is transported through the blood stream bound to plasma proteins, specifically transcortin but also to albumin and sex hormone binding globulin. Somewhere between 90 and 97 percent of the cortisol in the body is bonded to a protein. It is only the nonbonded cortisol, the free fraction, that is available to the cells.

It is important to note that some adrenal hormones facilitate the conversion of thyroid T4 to T3 and may assist in the action of T3 on target tissues. Some researchers believe that the activity of thyroid hormones is dependent upon adrenal hormones.

Studies performed on animals in their natural habitat have found profound adverse adrenal and endocrine disruption in a large variety of animal species caused by zenobiotics, zenoestrogens, heavy metals, PCBs, and DDT.

The Stress Relationship The most significant factor in the progressive development of chronic adrenal problems is stress. Stress is simply cellular aging. Some of the causes of clinically significant stress are intangibles like anger and anxiety and others are caused by physical forces or biochemical factors. The seminal research into the field of stress was performed by Dr. Hans Selye and in 1956 he described the three phases of stress including: • • •

Alarm (fight or flight response) Resistance (adaptation to stress) Exhaustion (decreased resistance and adaptation, failure state)

In the alarm phase of stress both cortisol and DHEA increase. This phase is usually asymptomatic. In the early stages of physiological failure cortisol increases but DHEA decreases. The symptoms and signs of stress begin to appear. In the later stages of physiological failure both cortisol and DHEA are low and many of the signs and symptoms of adrenal exhaustion are apparent.

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Interwoven within the major causes of stress, chronic adrenal dysfunction, and the aging process are these eight factors: 1. Impaired cellular energy biochemistry (impaired mitochrondrial function) 2. Blood glucose imbalances (dysglycemia) 3. Chronic inflammatory conditions (EMFA) 4. Cardiovascular risk factors (Imbalanced methylation reactions) 5. Impaired detoxification (autointoxification) 6. Allergen/antibody reactions (Poor immune function) 7. Adrenocortex stress responses (chronic stress responses) 8. Endocrine imbalances (Thyroid/adrenal/Testes/Ovary) The above listed factors are endemic conditions in the U.S. and can be modified by life style and dietary changes.

Common Adrenal Conditions Addison’s Disease – Adrenal gland failure resulting from a chronic destruction of the adrenal cortex. This leads to a progressive loss of sodium and water in the urine, muscle weakness, and low blood pressure. The skin turns a bronze color due to increased production of the pigment melanin.

Adrenal Insufficiency – Also called adrenal exhaustion or low adrenal function. The adrenal gland is compromised in its production of epinephrine, norepinephrine, cortisol, corticosterone, and aldosterone. Adrenal insufficiency can be primary, secondary, or tertiary and this is dependent upon where the pathology is located. A common cause is autoimmune adrenalitis which may be specific to the adrenal gland or part of a more generalized disorder. Other causes can include TB, cancer, and HIV. In secondary adrenal insufficiency the pathology is located in the pituitary gland and the secretion of corticotrophin is impaired. In tertiary adrenal insufficiency the hypothalamus and its release of corticotrophin releasing hormone is insufficient. A diagnostic determinant between primary and secondary or tertiary adrenal insufficiency is the absence of skin bronzing in the later two forms of adrenal insufficiency.

Cushing’s Syndrome (hyperadrenalism) – Is any condition where there is an increase in glucocorticoid activity. The most common cause of this condition is the medical prescription and use of glucocorticoid agents for the treatment of chronic inflammatory diseases such as rheumatoid arthritis or post organ transplant. Other causes include adrenal cancers and the use of nasal corticosteroid inhalers for allergy treatment.

The symptoms of Cushing’s syndrome include: • • •

Increased obesity Acute Hypertension Skin changes, bruising, striations 5

• • • • • • •

Poor wound healing Moon face Hirsutism Acne Muscle weakness and atrophy Peripheral edema Mood swings, depression and/or mania

Subclinical Adrenal Exhaustion – Suboptimal or subnormal adrenal function in the absence of positive serological tests, but manifesting with physical signs and symptoms of the disorder.

Most common form of adrenal dysfunction.

The role of cortisol in the body – Cortisol is called the stress hormone. It is the only hormone in the body that actually increases as we age. Cortisol can elevate blood glucose levels up to 50 percent and it induces insulin resistance.

Facilitates amino acid metabolism in the liver Stimulates the conversion of amino acids to glucose in the liver Stimulates glycogen (stored glucose) in the liver Increases fatty acid levels in the blood Acts as an anti-inflammatory agent Reduces allergy reactions Helps to maintain blood volume and pressure Increases resistance to stress Balances mood and emotional stability

Excess cortisol results in – Decrease in the cellular metabolism of glucose Increased blood sugar levels Decreased protein synthesis Increased protein breakdown Muscle atrophy Loss of minerals in bones and osteoporosis Shrinking of the thymus gland Shrinking of lymphatic nodes Decrease in WBC numbers and activities Decrease in IL-2 Decrease in natural killer cell activity Gastritis and gastrointestinal bleeding Decreases secretory antibody production resulting in allergy reactions, infection, and degenerative diseases (RA and Lupus) Decrease in sex hormones Increased antigen penetration

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An important clinical note regarding cortisol is that chronic elevations or releases of cortisol in the body cause physical signs and symptoms in the patient similar to those seen in Cushing’s syndrome (see preceding list).

The top causes of adrenal stress include: Chronic anger and rage Depression Overwork, physical and mental fatigue Insomnia Trauma and physical injury Chronic pain Starvation Maldigestion Chronic illness Hypoglycemia Poor light stimulation Noise

Worry, anxiety and fear Mental dysfunction (negative mood states) Excessive exercise Surgery Chronic inflammation and infection Temperature extremes Malabsorption Malnutrition Chronic allergies Toxic Exposure SAD

The top physical indicators of impaired adrenals: Low body temperature Poor tolerance of cold or heat Weakness Hair loss Muscle wasting Muscle weakness Difficulty developing muscle tissue Muscle loss Fatigue Nervousness and anxiety Inability to concentrate Mental confusion Poor memory Depression Irritability Inability to gain weight Excessive hunger Food craving Alternating diarrhea and constipation Osteoporosis Autoimmune diseases Auto immune hepatitis Allergies Severe allergies Food allergies Heart palpitations Postural hypotension Dizziness Poor resistance to infection Frequent colds or flu Low blood pressure Insomnia PMS Dry thin skin Headaches Anhydrosis Acute alcohol intoxification Clinical or morbid obesity Frequent or chronic inflammatory conditions

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Differential Diagnosis: Low thyroid, menopause, and low adrenal share these symptoms: Fatigue Sleep disturbances Intolerance to cold Poor concentration Depression Lethargy Mood swings Skin texture and dryness changes Hair loss Changes in libido Anxiety Nervousness Heart Palpitations Changes in temperature tolerance and regulation Irregular or missed menstrual periods The following are differences between menopausal conditions and thyroid disease: Probably menopause if – • •

The patient experiences hot flashes and night sweats.

The patient has vaginal dryness.

Probably thyroid if – • • • • • •

Neck pain Visual disturbance Swelling of arms or legs Loss of hair or change in hair quality (brittle and dry) Loss of hair from outer eyebrow Weight gain or extreme fluctuation.

The following are differences between low thyroid and low adrenal – • • • • • • •

Intolerance to heat Food allergies Constant or frequent thirst Craving for salt Loss of hair on the calf History of fibrocystic breast disease Diagnosis of lupus

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Another important determinant is when the patient is being treated for low thyroid with thyroid medication and they get noticeably worse on thyroid hormone.

Other symptoms shared by low thyroid and low adrenal – • •

Visual disturbances Muscle soreness

Other symptoms shared by perimenopause, menopause, and low adrenal – • • • • •

Hot flashes during period Acne during period Sore muscles and joints during period Breast tenderness during period Loss of libido

Basic diagnostic screening for low adrenal – • • • • • • • • • • • • • •

Check for low systolic and diastolic blood pressure Assess current history of food and environmental allergies Assess current history of abnormal bowel function Observe hair loss, especially on calf Assess for hypo-and hyperglycemic symptoms (type 2 diabetes) Ask about food cravings (sweets and salts) Assess for lack of perspiration Assess for fibrocystic breast disease Assess corticosteroid use Assess for libido, impotency and erectile dysfunction Dark pigment in nails Dark circles under the eyes Look for red palms Assess for signs of premature aging

Other possible signs and symptoms of low adrenal – •

Enlarged sexual organs or male characteristics in females

Taking the Patient History A careful patient history with a concentration on the physical signs and symptoms of low adrenal function is the first step in identifying the low adrenal patient and making an appropriate medical referral and recommendations for treatment and therapy.

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Physical Examination and Differential Diagnosis – The detailed physical examination that attempts to identify the main physical signs of subclinical low adrenal, adrenal insufficiency, or hyperadrenalism is the next appropriate step in determining whether your patient has an adrenal, thyroid, or reproductive system problem. Keep in mind, that a patient does not have to have all of the signs and symptoms listed in this clinical review on adrenal disorders, and an individual patient may have a mixture of symptoms that indicate an anomaly or idiosyncratic case that combines problems associated with all two or three of the disorders addressed in this clinical review.

Laboratory Testing and Evaluation – The standard tests used to diagnose adrenal conditions include: •

• • • •

Blood levels of – ACTH Cortisol Aldosterone Urine levels of – Cortisol (24 hour) Salivary levels of – (correlates closely with blood levels) Cortisol CT Scan – Adrenal glands MRI Scan – Pituitary gland Hypothalamus gland

Additional blood laboratory findings may include findings of – • • • • •

Low sodium levels High potassium levels Mild acidosis Hypoglycemia High calcium

Treating Low Thyroid, Low Adrenal, and Menopausal Disorders There are many overlapping symptoms shared by these three disorders. For men the combination of male menopause, erectile dysfunction, and impotency equals the female equivalent of this disease triad. As previou9sly noted in these clinical notes, Dr. John Lee has referenced that progesterone therapy for menopausal conditions increases the activity of T3 and alleviates some low thyroid symptoms.

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The same can be said for the treatment of low adrenal conditions. The treatment of low adrenal disorders can have the same positive effect on low thyroid conditions. In female patients going through or in menopause the combination of menopausal therapy and low adrenal therapy can correct the low thyroid disorder.

Approaches in Treatment – Natural and Alternative Medicine – Traditional Chinese Medicine approaches adrenal conditions as a problem related to the yang component of the Kidney meridian or a yang deficiency condition. Approaches would be used to “clear energy” and “restore vitality.”

From this perspective low adrenal conditions would be treated with TCM by: 1.

2.

3.

4.

5.

Using mild to strong yang tonics. (Kidney meridian) Building the chi through food, breath, and exercise.

Regulating the digestion, with digestive stimulants.

Using astringent tonics or reproductive blood moving herbs.

Modern adaptogenic herbs like Ginseng.

Other Chinese tonic herbs would include: • • •

Schizandra Astragulus Rehmania

Manual Chinese medicine for low adrenal conditions would include: • • • • • • •

Gua Sau over the kidney region Cupping over the kidney region Tonification of Kidney yang points Tonfication of Bladder meridian points adjacent to kidney region Vigorous tapping over the Kidney region Stimulation of Conception Vessel points between lower abdomen and the genitals.

Chi Kung breathing techniques

The Traditional Chinese Medicine approaches to patient assessment would include: 1. Observation 2. Listening 3. Questioning 4. Palpation

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Traditional Herbal Medicine Traditional herbal medicine utilizes herbs that are steroidal, stimulant, and/or warming. One of the main herbs utilized in western herbal medicine for adrenal conditions would be licorice root. Another herb that might be considered would be American Ginseng.

One possible formula for adrenal problems would include: • • • • • •

Wild Oats Licorice Root Dandelion Root American Ginseng Ho Shou Wu (Fo-Ti) Black Cohosh

(sweeten the above with black molasses) Other herbal approaches include sedative and hypnotic herbs to reduce stress, these herbs include: • •

Passion Flower Valerian

Naturopathic Medicine The naturopathic approach to the treatment of low adrenal disorders is to support the adrenals and reproductive system through nutrition, diet and supplementation. Frequently, in addition to food and herbs, the naturopathic approach includes nutraceuticals. One common approach to low adrenal therapy utilized in naturopathic medicine is the use of adrenal protomorphogens, or specially prepared bovine or porcine adrenal preparations. The herbal alternative to these animal product preparations is licorice root.

Nutraceutical products that are used in naturopathic medicine include: • • • • • • • • • • •

High doses of vitamin C (1000 mg plus per day) B complex vitamins PABA (100 to 400 mg per day) Pantothenic acid (1500 mg per day) DHEA (25 mg per day female/50 mg per day male) Pregnenolone (1 to 3 mg per day) L-tyrosine (TMG-betaine tyrosine) (100mg per kg, per day) Magnesium (250 mg per day) Zinc (50 mg) A E (<400 IU per day)

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Medical Manual Therapy Medical manual therapy directed at adrenal support would include passive range of motion of the upper cervical vertebra and compression/holding technique to the sacrum.

General Dietary Considerations: In traditional naturopathic medicine, diet is used as a primary treatment for low adrenal conditions. Low adrenal conditions are seen as the combined effect of a poor nutrient deficient diet combined with high levels of stress. The following foods and habits should be avoided: • • • • • • • • •

Refined and simple sugars and all products that contain refined and simple sugars.

High glycemic foods (same as above) Some grains (possible food allergens) Alcohol Caffeine (avoid all stimulants) Tobacco and nicotine products Processed fats and fried foods All biochemical stress provoking foods (poor quality/adulterated) Corticosteroid drugs

Foods that should be consumed include: 1. A diet that contains 50 percent raw natural foods like vegetable salads and fruits, and/or low cooked foods like a vegetable stirfry.

2. Eggs, carrots, and dark green and yellow vegetables.

3. Fish (especially cold water) and sea vegetables.

4. Vegetable seasoning salts.

5. Sea salt.

6. A variety of spices added to prepared foods.

7. Seeds and nuts.

8. Brown rice.

9. Brewers yeast.

10. Lentils.

11. Olive oil.

12. Beans.

General dietary recommendations: Consume a high protein diet derived from vegetable, grain and legume sources. The best protein source on earth is beans. Eat high fiber natural complex carbohydrate foods to avoid mood swings and blood sugar cravings. Choose only nutrient dense foods. Avoid simple sugars and stimulants. Add a small amount of quality fat or oil to each meal, equaling about one tablespoon total per day.

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Exercise Therapy Utilize stress reducing relaxation promoting exercises like tai chi, yoga, dao yin and meditation. Encourage relaxing low impact recreational activities like walking, biking, or canoeing.

Additional Notes:

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CLINICAL REVIEW SERIES P RO - I N F L A M M ATO RY PAT H O L O G Y Conditions Contributing Degenerate Joint Disease

Inflammation

Masculinizing Insulin Resistance

Thyroid Cold Intolerance Appearance Edema Muscle Pain Joint Pain

Improper Diet Obesity Dysglycemia Diabetes

These conditions are the central causes of pro-inflammation in the body and degenerative joint disease leading to arthritis Adrenal

Menopause

Fatigue Infection Illness Allegergies Fibrocystic Breasts

Hot Flashes Age Sex Insomnia Vaginal Changes

Muscle Problems

Skin (Acne) Fatigue

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Menopause and Sonamic Dysfunction

Copyright 2003 American Health Source All rights reserved. No part of this manual shall be reproduced, stored in a retrieval system, or transmitted by any means electronic, mechanical, photocopying, recording, or otherwise, without written permission from Gregory T. Lawton, American Manual Medicine Association, and American Health Source, Inc.

THE BLUE HERON ACADEMY OF HEALING ARTS AND SCIENCES MEDICAL MASSAGE, INCORPORATED 2040 RAYBROOK SE, SUITE 104 GRAND RAPIDS, MICHIGAN 49546 888-285-9989 Toll Free 616-285-9999 Grand Rapids info@BlueHeronAcademy.com www.BlueHeronAcademy.com

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CLINICAL REVIEW SERIES Insulin Resistance as a Pro-inflammatory Factor in Degenerative Joint Disease

T

his clinical review series is a brief review of the central facts surrounding dietary and metabolic disorders that directly cause or significantly contribute to degenerative joint disease. Reviewed in this series are the central causes of joint disease separate from repetitive joint strain and joint injury caused by trauma. This series provides clinical notes on the following conditions: — — — — — —

INSULIN RESISTANCE OBESITY DIABETES THYROID DYSFUNCTION ADRENAL DYSFUNCTION MENOPAUSE

These six factors are the central cause of all nontrauma related joint disease.

Joint degeneration is a process, not an event. The process of joint degeneration is firmly based upon diet and nutrition. Insulin resistance is directly related to the over consumption of refined sugar and starches, too many of the wrong kind of carbohydrate calories, and a lack of exercise and a sedentary lifestyle.

Insulin resistance causes joint degeneration by directly contributing to joint and soft tissue inflammation and by causing clinical and morbid obesity. Insulin resistance, obesity, and dysglycemia cause and lead to diabetes. The metabolic disruptions that occur in the diabetic state also cause soft tissue inflammation and joint degeneration.

Thyroid imbalances, such as hypothyroidism, and adrenal exhaustion further contribute to abnormal muscle and joint conditions and present with numerous musculoskeletal symptoms. Perimenopause, menopause, and postmenopause stages in women also cause and contribute to inflammatory states, musculoskeletal disorders, metabolic disruption, and the inability to heal and recover from the combined effects of injury, tissue trauma, and the general effects of aging.

It is the role of the medical massage therapist to educate the patient with pain and degeneration regarding these central contributing causes to their conditions and health problems.

There is a great deal of denial and avoidance regarding the role of diet and nutrition as a cause of degenerative joint disease, inflammation, and pain among the general public and therapists. Many people would rather blame these disorders on “aging,” instead of bad health habits and food addiction.

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Clinical Notes Perimenopause, Menopause, and Postmenopause Introduction – Jokes about menopause probably aren’t funny because women who are going through menopause, or who have gone through menopause, don’t find them so funny. One female comedian quipped that menopause is called men –opause because women lose interest in sex. Another suggested that this change in life should be called men –o- begin, because women turn into men during it. Menopause actually means, the time that menstruation stops.

A woman’s estrogen levels begin to decline during her third decade of life and continue to decline into postmenopause. Most of the symptoms of menopause don’t begin to appear until a woman is in her mid to late forties, and during the perimenopausal phase. The average time for the onset of perimenopause is usually considered to be around forty-five years old. The most common signs and symptoms of menopause include: Hot Flashes – The most common symptom of menopause.

Night Sweats – These are hot flashes with profuse sweating.

Sleep Disturbances – This symptom may be related to hot flashes, night sweats, heart palpitations, and a disruption of the normal sleep cycles by fluctuations in hormone cycles.

Menstrual Irregularities – Usually occur during the perimenopausal phase. The menstrual cycle becomes shorter, longer, irregular, disrupted, heavier or lighter. As menopause progresses, the period cycle becomes farther and farther apart until it ceases altogether.

Vaginal Changes – This includes bleeding, dryness, and atrophy.

Symptoms may also include itching, burning, soreness, and recurrent inflammation or infection.

Libido Changes – The negative symptoms related to vaginal changes may decrease the desire for sex, or the freedom associated with nonfertility may increase the desire for sex.

Urinary Changes – This may include urinary incontinence or the inability to control urination. Small amounts of urine may leak out during physical activity, laughing, coughing, sneezing, or sex. A burning sensation or pain may accompany these symptoms especially if an infection is present.

Skin Changes – This is related to the loss of the growth factor of estrogen (due to declining estrogen levels). The skin becomes dryer, thinner, and less elastic.

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Palpitations – The woman may experience rapid, irregular, and pounding heart beats.This is sometimes associated with a hot flash.

Mood Changes – Changes in mood states frequently occur with perimenopause and these symptoms include irritability, depression, and anxiety. Mental confusion and disorientation can also accompany perimenopause and menopause.

Headaches – This is a common symptom of menopause. The headaches may be severe and be classified as “migraines.”

Menopause is a three-phase change in a woman’s reproductive cycle. The woman’s period of menstruation ends, along with her fertility. The three phases of menopause are called: Perimenopause Menopause Postmenopause

First Phase Second Phase Third Phase

First Phase - During the onset of menopause (perimenopause) the ovaries begin to produce less estrogen and as a result of the lower levels of estrogen the early symptoms of menopause appear. This stage usually appears about five years before menopause sets in.

Second Phase – As the estrogen levels continue to decrease, the processes that it used to support related to reproduction come to a halt.

In addition, the benefits of estrogen related to the growth and repair of cells and tissues significantly decline. Recognition that a woman has entered this phase occurs after a woman has not had a period for 12 months.

Third Phase – The postmenopausal phase is the last phase of menopause and it includes the period of time after menopause.

When the woman enters the postmenopause period the ovaries are unable to produce sufficient amounts of estrogen and instead the male hormones, the androgens, are produced. Androgen production, and loss of estrogen, accounts for the masculinizing effects seen in women at this stage of their life. Some women have very little problem with menopause and other have many problems and symptoms. No two women experience menopause in the same way.

As a woman approaches her late thirties or early forties she has fewer eggs (follicles) in her ovaries and many of those that are present are often defective. This results in less ovulation and a decline in the estrogen that is available to the body, Fat cells, the adrenal glands, and breast tissues do produce some estrogen, but not enough to counteract the losses from the ovaries and ovulation.

4

Some women will experience early menopause or signs and symptoms of menopause that occur before the normal onset of menopause is expected.

The causes of early menopause may include: 1.

2.

3.

4.

5.

Surgical Menopause (Bilateral Oophorectomy) Premature Ovarian Failure (cause unknown).

Genetic Abnormalities (Fragile X Chromosome) Radiation Viral Infections

The Combined Clinical Indicators of Menopause: Hot flashes Chills Irritability Crying episodes Irregular periods Heavier periods Phantom periods Dry vagina Anxiety Depression Memory loss or lapses Itchy skin Hypertonic muscles Changes in hair quality Increased facial hair Weight gain Headaches Flatulence Bloat Increased infections Changes in body odor Burning tongue Tinnitus

Night sweats Heart palpitations Mood swings Insomnia Short lighter periods Longer cycles Loss of libido Fatigue Nervousness Dread and apprehension Incontinence Aching, sore joints and muscles Osteoporosis Changes in skin quality Changes in finger and toenail quality Breast tenderness GI distress Nausea Increase in allergies Dizziness Bleeding gums Bad taste in mouth Difficulty concentrating, disorientation, mental confusion

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Differential Diagnosis: Menopause, low thyroid, and low adrenal share these symptoms: Fatigue Sleep disturbances Intolerance to cold Poor concentration Depression Lethargy Mood swings Skin texture and dryness changes Hair loss Change in libido Anxiety Nervousness Changes in temperature tolerance and regulation Irregular or missed menstrual periods Heart palpitations The following are differences between menopause and thyroid disorders: Probably menopause if – • The patient is sex and age appropriate.

• The patient experiences hot flashes and night sweats.

• The patient has vaginal dryness.

The condition is probably thyroid if – • Neck pain • Visual disturbance • Swelling of arms or legs • Loss of hair or change in hair quality – brittle and dry • Loss of hair from outer eye lashes • Weight gain or fluctuation The following are differences between low thyroid and low adrenal – • Intolerance to heat • Food allergies • Constant of frequent thirst • Craving for salt • Loss of hair on the calf • History of fibrocystic breast disease • Diagnosis of Lupus Other • • • • •

symptoms shared by perimenopause, menopause, and low adrenal – Hot flashes during the period Acne during the period Sore muscles and joints during the period Breast tenderness during the period Loss of libido

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Symptoms shared by menopause, low thyroid, and low adrenal – • Low body temperature • Chill • Weakness • Fatigue • Nervousness and anxiety • Inability to concentrate • Mental confusion • Poor memory • Depression • Irritability • Hair changes • Nair changes • Skin changes • Osteoporosis • Allergies • Muscle wasting • Muscle loss • Muscle weakness • Heart palpitations • Dizziness • Poor resistance to infection • Frequent colds or flu • Insomnia • Weight gain • Changes in libido • Irregular or missed periods Physical examination (signs) for perimenopause: 1. Age 2. Sex 3.Vaginal dryness 4. Low abdominal soreness and tenderness 5. Breast tenderness 6. Skin atrophy 7. Breast tissue atrophy 8. Muscle atrophy 9. Skin fold and body fat levels elevated 10. High or low blood pressure 11. Subnormal body temperature 12. Skin moles, warts and growths 13. Changes in hair and nail quality 14. Changes in spinal posture and structure Recognizing the effects of high or toxic estrogen levels: 1. Breast enlargement and tenderness.

2. Salt and fluid retention.

3. Increase percentage of body fat.

4. Decreased lidido.

5. Impaired blood sugar function.

6. Increased blood clotting.

7. History of endometrial problems.

8. History of breast cancer.

9. Skeletal changes or malformation.

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Treating Low Thyroid, Low Adrenal and Menopausal Disorders There are many overlapping symptoms shared by these three disorders. For men the addition of male menopause, erectile dysfunction, and impotency equals the female equivalent of this disease triad, the endocrine triad. As previously noted in these clinical notes, Dr. John Lee has referenced that progesterone therapy for menopausal conditions increases the activity of T3 and alleviates some low thyroid symptoms. The same can be said for the treatment of low adrenal conditions. The treatment of low adrenal disorders can have the same positive effect on low thyroid conditions, additionally, in female patients going through or in menopause, the combination of menopausal therapy and low adrenal therapy can correct the low thyroid disorder.

Pharmacological Approaches in Natural Medicine – Soy Products – Various soy products are contributors of isoflavones. In one study using a soy protein supplement that contained 40 mg of protein and 76 mg of isoflavones, the women in the study reported a 45 percent reduction in hot flashes.

Black Cohosh – Black Cohosh has an estrogen-like action on the body’s cells and tissues, although studies have been conflicting. About a dozen studies have shown that women using Black Cohosh report a reduction in negative menopause symptoms.

Evening Primrose – Evening Primrose is commonly recommended for mastalgia, mastodynia, PMS, menopause, and bladder symptoms. Its active components are gamma linolenic acid (GLA) and several anti-coagulant substances.

Although women using Evening Primrose have reported a significant reduction in their symptoms, no studies have supported the use of Evening Primrose for this purpose.

Tang Kuei – Tang Kuei and Tang Kuei combinations and formulas are the most commonly used herbal products in Chinese medicine for menopausal problems. A double blind study using 4.5 grams of Tang Kuei did show a 25 percent reduction in hot flashes.

Saint John’s Wort – Is commonly used to treat depression. It contains hypericin, pseudohypericin, and flavonoids. It is thought to suppress corticotrophin releasing hormone. Analysis of 15 controlled trials with Saint John’s Wort have shown significant decreases in depression at doses as low as 1.2 mg per day. (61 percent reduction in depression)

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Valerian Root – It is thought to have activity related to gamma aminobutyric acid (GABA).

Chasteberry (Vitex) – Vitex contains hormone-like substances which can bind to estrogen receptor sites. It is also thought to be antiandrogenic. A randomized trial of Vitex showed significant improvements to mood, anger, headache, and breast fullness on a self-assessment instrument.

Ginseng – Is a recognized adaptogen.

Wild Yam – Wild Yam contains diosgenin, an estrogen-like substance found in plants. It is thought to have significant estrogen-like effects on cells and tissues.

Approaches in Treatment – Natural and Alternative Medicine – Traditional Chinese Medicine approaches to menopause would be based on the following traditional diagnoses: (to list a few) Blood stasis Cold in the uterus Blood heat Kidney Yang deficiency Kidney Yin deficiency Blood deficiency Treatment approaches would include herbal combinations and formulas that: Move blood Increase heat Decrease heat Restore Yang Restore Yin Build the blood A classic TCM blood building and blood moving formula is Tang Kuei 4.

A formula to restore Kidney yang might contain: Cooked Rehmannia Dioscorea Cornus Lycium Cinnamon bark Cuscuta Antler gelatin Eucommia

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Traditional Herbal Medicine – Traditional herbal medicine for the treatment of menopausal disorders would include herbs that regulate menstruation, that are warming, that have a vaso motor effect, that are steroidal, that are stimulants, and herbs that specifically address the individual’s signs and symptoms of perimenopause, menopause, and postmenopause.

These herbs would include: Black Cohosh Chasteberry Black Haw Motherwort Ginseng Wild Yam Valerian Root Passion Flower Licorice Root A possible herbal formula for the treatment of menopausal symptoms is: Chamomile Flower Dandelion Root Licorice Root Anise Seed Fennel Seed Black Cohosh Oregon Grape Root Red Clover Blossom Horsetail Grass Irish Moss When Symptoms warrant the use of sedatives, herbs like Passion Flower or Valerian Root may be helpful.

Naturopathic Medicine: The naturopathic approach to the treatment of menopausal disorders may include the use of a supplementation program or diet that provides the following nutritional support.

Boron – at a dose of 1 to 2 mg per day. Boron assists calcium absorption by the skeletal system and may facilitate the actions of estrogen.

Calcium – at a dose of 12 to 15 grams per day in the form of calcium citrate or calcium malate.

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Folic Acid – 800 mcg per day. Folic acid helps to reduce homecysteine the amino acid that increase heart disease risk. Folic acid is found in dark green leafy vegetables like spinach.

Magnesium – at a dose one third of the amount of calcium supplementation.

Manganese – at a dose of 20 to 40 mg per day. Manganese is another important mineral for skeletal bone mineralization.

Silicon – available in the herb Horsetail Grass and in the herbal formula recommended in the herbal medicine section.

Zinc – at a dose of 50 mg per day. This mineral is also essential for bone growth and vitamin D activity.

Vitamin B6 – at a dose of 10 to 40 mg per day. Like folic acid, vitamin B6 is important in protecting against the negative effects of homocysteine.

Vitamin D – at a dose of 400 to 800 IU per day.

Vitamin E – at a dose of 400 to 800 IU per day. Vitamin E is an antioxidant and it facilitates the action of estradiol.

Vitamin K2 – at a dose of 50 to 100 mcg per day. Vitamin K is important in bone calcification. Eat avocados for vitamin K. Most of the vitamins and minerals listed above can be obtained in a single multivitamin/mineral tablet or capsule.

Medical Manual Therapy Medical manual therapy would include treatment of the upper cervical region and compression/holding technique to the sacrum.

General Dietary Considerations: The dietary approach to menopause is both general and specific. The general rules include: 1. The avoidance of all stimulants like caffeine.

2. The avoidance of all refined and processes sugars and starches.

3. The avoidance of all high glycemic foods. (low glycemic index foods) 4. The avoidance of alcohol.

5. The avoidance of tobacco and nicotine products.

6. The avoidance of all processed fats and oils and foods that contain them.

7. The avoidance of all steroidal drugs.

8. The avoidance of xenoestrogens.

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Foods 1.

2.

3.

4.

5.

6.

7.

8.

that should be consumed: Seeds and nuts Fish and seafood Eggs Carrots, and dark green or colored vegetables Fruit Whole grains and beans Legumes, soy and garbanzo beans Olive oil and other natural oils like black currant and flax seed oil

General dietary recommendations: Consume a high protein diet derived from vegetable, grain, and legume sources. The best protein source on earth is beans. Also, consume natural seeds and nuts daily. Eat high fiber natural complex carbohydrate foods to avoid mood swings and blood sugar imbalances. Choose only high quality nutrient dense foods. Avoid all refined and simple sugars. Avoid all stimulants.

Add a small amount of high quality fats or oils to each meal, or about one tablespoon per day.

Additional Notes:

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CLINICAL REVIEW SERIES P RO - I N F L A M M ATO RY PAT H O L O G Y Conditions Contributing Degenerate Joint Disease

Inflammation

Masculinizing Insulin Resistance

Thyroid Cold Intolerance Appearance Edema Muscle Pain Joint Pain

Improper Diet Obesity Dysglycemia Diabetes

These conditions are the central causes of pro-inflammation in the body and degenerative joint disease leading to arthritis Adrenal

Menopause

Fatigue Infection Illness Allegergies Fibrocystic Breasts

Hot Flashes Age Sex Insomnia Vaginal Changes

Muscle Problems

Skin (Acne) Fatigue

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