Clinical nutrition for pain, inflammmation, and tissue healing PDF
Preview Clinical nutrition for pain, inflammmation, and tissue healing
p. iii Contents Preface .......................................................................................................................... ix Chapter 1: Nociceptive processes and spinal dysfunction .......................................... 1 Nociception and the Subluxation Complex ................................................................................. 1 Sympathetic hyperactivity ...................................................................................................................................... 3 Reflex muscle spasm ............................................................................................................................................... 9 Treatment considerations ..................................................................................................................................... 12 Physiology and biochemistry of nociceptors .............................................................................. 12 Chapter 2: Terminology and conceptual issues......................................................... 17 Terminology and conceptual issues related to subluxation/joint complex dysfunction ........... 17 Neuromusculoskeletal specialist .................................................................................................. 20 Conceptual issues related to nutrition ........................................................................................ 21 Food allergies ....................................................................................................................................................... 21 Candida albicans ................................................................................................................................................. 22 Liver detoxification -Fact or fiction? .................................................................................................................. 23 Introduction ................................................................................................................................................... 23 Review of literature ........................................................................................................................................ 24 Phase I and Phase II pathways ...................................................................................................................... 25 Clinical issues related to Phase I pathways ................................................................................................... 26 Clinical issues related to Phase II conjugation pathways .............................................................................. 27 Glycine conjugation ....................................................................................................................................... 28 Sulfate conjugation ......................................................................................................................................... 29 Glucuronide conjugation ............................................................................................................................... 31 Additional testing issues ................................................................................................................................ 33 Summary ......................................................................................................................................................... 33 Nutritional modulation of hepatic detoxification ............................................................................................... 33 Food combining ................................................................................................................................................... 35 Conclusion ................................................................................................................................... 36 Chapter 3: The inflammatory process ....................................................................... 37 Introduction ................................................................................................................................. 37 Inflammation in the healing process .................................................................................................................... 37 The nature of inflammation ................................................................................................................................. 37 The acute inflammatory phase (First 72 hours) ......................................................................... 38 Vascular response ................................................................................................................................................ 38 Platelet activation ........................................................................................................................................... 39 Vasodilation of local arterioles ...................................................................................................................... 40 Increased vascular permeability .................................................................................................................... 41 Cellular response ................................................................................................................................................. 41 !i ~~~~:;~~~:~~~.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Circulating mononuclear cells ....................................................................................................................... 44 Newly formed granulocytes and monocytes ................................................................................................ 46 The Complement System .................................................................................................................................... 46 Proteolytic enzyme release from damaged tissues ............................................................................................... 47 CI 199& NutrAnalysis, Inc. p. iv Clinical Nutrition for pain, inflammation & tissue healing The repair phase (48 hours to 6 weeks) ..................................................................................... 49 Repair vs. Regeneration ...................................................................................................................................... 49 Physiological debridement .................................................................................................................................. 49 Ebb and flow phases of healing (cortisol connection) ........................................................................................ 50 Additional factors that affect tissue healing and repair ................... ................................................................... 51 Granulation tissue ................................................................................................................................................ 52 Angiogenesis ........................................................................................................................................................ 52 Fibroblasts ............................................................................................................................................................. 53 General information ...................................................................................................................................... 53 Chemotaxis .................................................................................................................................................... 53 The fibrin-collagen connection...................................................................................................................... 53 Scar TISsue ..................................................................................................................................................... 55 The remodeling phase ................................................................................................................. 55 Chapter 4: Pharmacological Therapy of Pain and Joint Dysfunction ...................... 59 Pharmacological adjustments .......................................................................................................... 59 Anti-Inflarrunatory Agents .......................................................................................................... 60 Aspirin and NSAlDs ........................................................................................................................................... 60 Side-effects ...................................................................................................................................................... 60 Acetaminophen .................................................................................................................................................... 61 Side effects.................................................................................................................................... .................. 61 Corticosteroids ..................................................................................................................................................... 61 Side effects ...................................................................................................................................................... 62 Muscle Relaxants ......................................................................................................................... 63 Spasticity .............................................................................................................................................................. 63 Side-effects ......................................................................................................................................... ............. 63 Acute muscle spasms ........................................................................................................................................... 64 Side-effects ............................................................................................................................................. ......... 64 Opiate Analgesics ........................................................................................................................ 64 Side-effects................................................................................................................................ ...................... 64 Chapter 5: A Diet-Induced Pro-inflammatory State .................................................. 65 Introduction ................................................................................................................................. 65 Increased Tissue Acidity ............................................................................................................. 66 General information about tissue pH ................................................................................................................. 66 Pain, inflanunation and pH .................................................................................................................................. 67 Dietary regulation of pH ...................................................................................................................................... 67 Inadequate Potassium Intake ...................................................................................................... 68 General information ............................................................................................................................................ 68 Potassium and vasoperfusion .............................................................................................................................. 68 Potassium, hypoxia and reduced A'TP synthesis ................................................................................................. 70 Potassium deficiency in humans .......................................................................................................................... 71 Cerebrovascular disease, heart disease, and cancer ............................................................................................ 72 Inadequate Magnesium Intake ................................................................................................... 73 General information ............................................................................................................................................. 73 Magnesium deficiency in humans? ...................................................................................................................... 74 Cardiovascular disease and cancer ...................................................................................................................... 74 The benefits of magnesium supplementation ...................................................................................................... 75 Suggestions for supplementation ......................................................................................................................... 75 Free radicals ................................................................................................................................. 76 Cellular antioxidant defense ................................................................................................................................ 78 Phytochemicals ..................................................................................................................................................... 79 The free radical-musculoskeletal connection ...................................................................................................... 81 t'> 1998 NutrAnalysis, Inc. p.v Fatty Acid Imbalances ................................................................................................................. 82 Phospholipid synthesis ................................................................... ..................................................................... 82 Prostaglandin production .................................................................................................................................... 84 Fatty acid consumption patterns ......................................................................................................................... 84 Vegetarian diets --fatty acid profile..................................................................................................................... 85 Trans fatty acids ................................................................................................................................................... 86 Diseases promoted by fatty acid imbalances ....................................................................................................... 87 Monounsaturated fatty acids ............................................................................................................................... 87 Summary ..................................................................................................................................... 88 Chapter 6: Glycemic dysregulation and its pro-inflammatory potential .................. 89 High carbohydrate diets .............................................................................................................. 89 Dietary regulation of insulin and glucose ........................................................................................................... 90 Do high carbohydrate diets increase fat deposition by promoting insulin secretion? ...................................... 92 Does the diet and insulin-glucagon connection control eicosanoid synthesis? ................................................. 93 Insulin resistance syndrome ........................................................................................................ 94 Pro-inflammatory aspects of the insulin resistance syndrome may impact upon the musculoskeletal system ............................................................................................................... 95 Cortisol Connection .................................................................................................................... 96 Exercise enhances insulin sensitivity .......................................................................................... 97 The facts on fats .......................................................................................................................... 98 Summary ..................................................................................................................................... 99 Chapter 7: The Food Guide Pyramid-Safe or pro-inflarnmatory? ......................... 101 The problem with the food pyramid ........................................................................................ 102 Fats ...................................................................................................................................................................... 102 ~ickfatty acid review ...................................................................................................................................... 102 Carbohydrates .................................................................................................................................................... 103 Composition of diets based on the food pyramid .................................................................... 104 Caloric balance ................................................................................................................................................... 107 Fats and fatty acids ............................................................................................................................................. 108 Comparison to RDA nutrients .......................................................................................................................... 109 Trans fatty acids .................................................................................................................................................. 111 Composition of a natural diet containing no margarine, grain products, or packaged foods 111 Caloric balance ................................................................................................................................................... 111 Fats and fatty acids ............................................................................................................................................. 111 Comparison to the RDA nutrients .................................................................................................................... 113 Summary ................................................................................................................................... 113 Chapter 8: Chemical Irritants -Generation and nutritional Inhibition .................. 115 Lactic acid .................................................................................................................................. 115 Introduction ........................................................................................................................................................ 115 ATP Production .................................................................................................................................................. 116 Factors associated with increased lactic acid production .................................................................................. 118 Nutritional supplementation ............................................................................................................................. 121 Potassium ions ........................................................................................................................... 123 Nutritional supplementation .............. '" ............................................................................................................ 124 Prostaglandin E-2 ...................................................................................................................... 124 History ............................................................................................................................................................... 124 Synthesis and inhibition of prostaglandins ....................................................................................................... 125 Anti-inflanunatory nature of EPNDHA (fish oil) ........................................................................................... 126 e 1998 NutrAn_lysis, Inc. p. vi Clinical Nutrition for pain, inflammation & tissue healing Is it better to supplement with alpha-linolenic acid or EPA? ............................................................................ 127 Anti-inflammatory nature of GLA .................................................................................................................... 129 Nutritional supplementation ............................................................................................................................. 129 Leukotriene B-4 ......................................................................................................................... 130 Nutritional supplementation ............................................................................................................................. 131 Histamine ................................................................................................................................... 131 General information ........ , ................................................................................................................ ................. 131 Mast cells .................................................................................................................... ....................................... 131 Nutritional factors which modulate histamine release ..................................................................................... 132 Nutritional supplementation ................................................. ............................................................. ............... 132 5-Hydroxytryptamine ................................................................................................................ 132 General information .......................................................................................................................................... 132 Function of 5-I-rr ............. ................... ............ ............ ........ ....... ....... .............................................. ............ ....... 132 Platelets .................................................................................................. ............................................................ 133 Promoters of platelet aggregation ........................................................................ ............................................. 134 Nutritional factors which may inhibit platelet aggregation .............................................................................. 135 Nutritional supplementation to reduce platelet aggregation ............................................................................. 137 Platelets and fibrin deposition ............................................................................................................................ 137 Factors that reduce fibrinolytic activity ............................................................................................................ 138 Nutritional factors that increase fibrinolytic activity ........................................................................................ 138 Nutritional supplementation to enhance fibrinolysis ....................................................................................... 139 Bradykinin ................................................................................................................................. 139 General information ............................................................................................... ........................................... 139 Biochemistry of bradykinin ............................................................................................................................... 140 Physiological inhibition of bradykinin .............................................................................................................. 141 Nutritional inhibition of bradykinin ................................................................................................................. 141 Nutritional supplementation ..................................................... .......................... .............................................. 141 Cytokines ................................................................................................................................... 141 Interleukin-1 (IL-1) ................................ ..................................................................................................... ....... 142 Tumor necrosis factor-a (TNF-a) ..................................................................................................................... 142 Interleukin-6 (IL-6) ............................................................................................................................................ 143 Interleukin-8 (IL-8) ............................................................................................................................................ 143 Colony stimulating factors (CSF) ..................................................................................................................... 143 Cytokine modulation by drugs ......................................................................................................................... 143 Nutritional factors .............................................................................................................................................. 143 Nutritional supplementation: ............................................................................................................................ 144 Chapter 9: Glycosaminoglycans and Tissue Healing .............................................. 145 Connective tissue repair ............................................................................................................ 145 Collagen Production .......................................................................................................................................... 145 Chiropractic considerations regarding collagen production ............................................................................ 146 Nutritional considerations for collagen production .................................. ....................................................... 148 Proteoglycan production ................................................................................................................................... 148 Glycosarninoglycans .......................................................................................................................................... 150 Chiropractic considerations in proteoglycan production ................................................................................. 151 Nutritional considerations in proteoglycan production ................................................................................... 152 Connective tissue repair -hormonal and nutritional factors ................................................... 153 Hormonal factors........................................................................................................................................... .... 153 Nutritional factors ........................................................................................................................................... ·.. 153 GAGS/Proteoglycans as promoters of nociception and inflammation ................................... 154 Q 1998 NutrAnalysis, Inc. p. vii Chapter 10: Nutritional Recommendations ............................................................. 157 Patient Education ...................................................................................................................... 158 Nutritional Evaluation ............................................................................................................... 159 Visual eating guidelines for patients ......................................................................................... 161 Meal Plate .......................................................................................................................................................... 162 Examples of Ideal Foods ................................................................................................................................... 163 Examples of Meals ............................................................................................................................................ 164 Cooking Ideas .................................................................................................................................................... 165 Glycerrllc Indices of Foods ................................................................................................................................ 166 Nutritional supplements............................................................................................................ 167 References .................................................................................................................. 169 Appendix A: Nutrition Education for Patients ........................................................ 199 Appendix B: Reprinted Articles fromJMPT ........................................................... 239 Proprioceptor: An Obsolete, Innacurate Word ........................................................................ 241 Joint Complex Dysfunction, A Novel Term to Replace Subluxation/Subluxation Complex: Etiological and Treatment Considerations ............................................................................... 247 DysafIerentation: A Novel Term to Describe the Neuropathophysiological Effects ofJoint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation ................... 258 Appendix C -The RDA Nutrients ........................................................................... 273 Index .......................................................................................................................... 277 © 1998 NutrAn.lysis. Inc. p. V111 Clinical Nutrition for pain, inflammation & tissue healing e 1998 NutrAnalysis. Inc. PREfACE Members of the chiropractic profession have in search of some answers. Unfortunately, none always urged their patients to exercise regularly were to be found. and eat properly. When I went through chiropractic I entered undergraduate college with the hope college, the need for exercise and good nutrition of pursuing a career in the field of nutrition. was acknowledged and promoted; however, Despite majoring in biology/nutrition, I was unable effective methods of implementation were not to find one course that offered any practical taught. Fortunately, in recent years this has begun information. An exercise physiology elective to change and is particularly evident in the field of provided my first encounter with applied science. rehabilitation. Numerous chiropractic colleges now I thought this practical application ofscience would offer course work in rehabilitation and there are continue in chiropractic college; however, I soon many postgraduate certification programs available discovered that the developing science of to field practitioners. chiropractic was still in its infancy during the early Compared to rehabilitation, students and 1980s when I went to school. doctors do not embrace nutrition with nearly the Upon graduating from chiropractic college in same level ofinterest or excitement. Perhaps this is 1986, I began a masters program in nutrition. because our college curriculums have historically Surely this would provide me with practical offered classes that are introductory and not very nutrition knowledge I could apply in the clinical practical. Subsequently, many students graduate setting. Once again, I was mistaken. from chiropractic college without much interest in making nutrition an integral part oftheir practices. In 1988, at about the time I needed to decide on This lack of interest is demonstrated by the fact a final research project, I happened to attend a that postgraduate programs in nutrition are not weekend lecture taught by Dr. Barry Wyke, who nearly as popular or successful as other disciplines for years was a leading researcher at the such as rehabilitation, sports injuries, orthopedics Neurological Unit, Royal Academy ofSurgeons of or neurology. England. He directed the Unit's research focus into the field of articular neurology, a very My interest in nutrition began when I was in chiropractic-related topic. During that lecture, junior high school. In part, this was probably Wyke outlined what was understood about because I was somewhat of a sickly child with nociceptor and mechanoreceptor innervation of allergies who had a hard time gaining weight. I the musculoskeletal system. He explained that received regular allergy shots for several years nociceptors were depolarized by mechanical during my early youth, without any concurrent trauma and the chemical mediators that were nutritional recommendations. I eventually grew released by injured tissues, including lactic acid, out of my allergies, but was still somewhat sickly, potassium ions, histamine, prostaglandins, 5 prone to injury, and unable to gain weight. As I hydroxytryptamine and kinins. went through junior and senior high school, my mission was to gain weight so I could be more At that point in time, I was aware that competitive on the basketball court and baseball nonsteroidal anti-inflammatory drugs (NSAIDs) diamond. This lead me to a local health food store and certain nutrients could inhibit prostaglandin p. X Clinical Nutrition for pain, inflammation & tissue healing production, which is why they offered an analgesic nociceptive pathways. and anti-inflammatory effect. However, not until In the past ten years I have collected thousands that lecture by Dr. Wyke, did I make the connection of articles devoted to subjects of nociception, that NSAIDs and certain nutrients could reduce inflammation and nutrition. About six years ago, I back pain by altering the excitability of spinal began presenting this information to chiropractors nociceptors. and students at various meetings around the After that lecture, I began to collect articles that country. Most had either forgotten or never learned discussed each of the chemical irritants and their the details about nociception and inflammation, relationship to inflammation and nociception. and most were also unaware of the nutritional Additionally, I sought out articles that explained factors that could influence these two important how dietary and nutritional factors could influence processes. Without this information, it is very the production of each chemical irritant. I also difficult to appreciate how nutrition can support called researchers at various universities around chiropractic care, tissue healing and the functional the country and ask questions about each of these restoration of musculoskeletal structures. topics. To my surprise, experts in the area of The purpose of this text is to address these nociception were unaware that nutritional factors topics. The first four chapters provide foundational could influence nociception and inflammation. information and focus on nociception, Similarly, while nutrition researchers understood inflammation, pharmacology, and important that certain nutrients could inhibit pain and conceptual issues related to chiropractic and inflammation, they were unfamiliar with nutrition. The remaining chapters are devoted to nociceptors and the nature of nociceptor clinical nutrition topics that relate directly to sensitization and thus, had little appreciation for nociception, inflammation, and several conditions how nutrition could influence the activity ofcentral encountered in chiropractic practice. David R. Seaman C 1998 NuttAnalysis, Inc. Chapter 1 NOCICEPTIVE PROCESSES AND SPINAL DYSFUNCTION A text devoted to clinical nutrition will naturally between musculoskeletal structures and the central require a clinical focus. If this were a text for nervous system. In particular, nociceptors are cardiologists, the focus would be heart disease. If specifically designed to respond to injurious stimuli. the intended audience were to be Considering that patients primarily present gastroenterologists, the clinical focus would themselves to our offices with injured spines, our obviously be devoted to nutrition factors related focus should be directed at nociceptor function. to the digestive system. However, this clinical Figure 1-1 lists the various chemicals that stimulate nutrition text is designed primarily for nociceptors, which also happen to be the same chiropractors and our clinical focus is the chemicals which drive the inflammatory process. neuromusculoskeletal system. In particular, Research has clearly demonstrated that our chiropractors endeavor to restore function to the dietary habits can directly influence the production neuromusculoskeletal system, usually through of the various chemical irritants, which means that various methods ofmanual care. Accordingly, our our diet can influence nociception and nutritional approach should be designed with the inflammation. Additionally, a great deal ofevidence same goal in mind and therefore, nutritional suggests that nociception and inflammation can interventions should complement our manual care. promote spinal dysfunction. For this reason, Since the inception of the chiropractic individual chapters have been devoted to both profession, the nervous system has been a chief nociception (Chapter 1) and inflammation center of interest. For many years, chiropractors (Chapter 3). Subsequent chapters discuss the tried to understand and explain how a subluxation nutritional modulation of nociception and could impinge upon nerves and promote body inflammation. dysfunction. Subluxation was not viewed as a type of spinal injury; instead, it was believed that NOCICEPTION AND THE subluxations were injurious to the nervous system. SUBLUXATION COMPLEX This focus took precedence for years, to the exclusion of other important areas. For example, For years, the five component model of the there was never any real effort to understand how spinal structures are innervated by the nervous subluxation complex was described by Dr. L.John Faye(135. 136). The five pathological components system, which would lead us to investigate how injury to spinal tissues might alter the function of included: neuropathophysiology, kinesiopathology, neurological receptors within those tissues and myopathology, histopathology and inflammatory subsequently affect body function. It is somewhat biochemical changes. Lantz(256) revised Faye's surprising that this topic was ignored for so many description of the subluxation complex to include years, especially when we consider that Sherrington the following eight pathological components: first spoke of nociceptors before 1906. kinesiopathology, neuropathology, myopath-ology, connective tissue pathology, vascular abnormalities, It is now well-known that nociceptors and an inflammatory response, histopathology and mechanoreceptors represent the neurological link
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