NMT Final Exam Charts W9-15 PDF

NMT Final Exam Weeks 9-15 LD Week 9: Non-specific Low Back Pain Physical Medicine Low back pain treatment: IFC (Interferential Current): treatment involves electrical current (sensory-level response @ higher frequencies, motorlevel response @ lower frequencies), used to help relieve pain and relax mu...

NMT Final Exam Weeks 9-15 LD Week 9: Non-specific Low Back Pain Physical Medicine Low back pain treatment: IFC (Interferential Current): treatment involves electrical current (sensory-level response @ higher frequencies, motorlevel response @ lower frequencies), used to help relieve pain and relax muscle Distance between electrodes à further apart gets deeper into tissue, close is more superficial, if they are too close the arc might not form or burn patient 4 pads required à produced by interfering 2 waveforms that diPer in frequency resulting in low to medium frequency à gets deeper into tissues to improve circulation via muscle pump, decrease pain and muscle spasm, and decrease healing time Tens: transcutaneous electrical neuromuscular stimulation Works with Pain Gait Control Theory à distraction & endorphin release Used from controlling pain in acute stages of injury (chronic too); provides temporary relief (20 mins) Ultrasound: sounds waves go 2-5cm into soft tissue à good for tissues that have a high collagen content (tendons, ligaments, joint capsules, fascia, connective tissue) Bone has high absorption but set too high will damage periosteum à avoid boney areas Thermal e8ects: accelerate metabolic healing, controls pain and muscle spasms, alter nerve conductive velocity, increase circulation, increase soft tissue extensibility Non-thermal e8ects: enhance tissue fluid interchange and mobility, diPusion rates and membrane permeability, tissue repair via immune stimulation, enhance orientation of new collagen fibers à change from type 3 to type 1 collagen (more tensile strength) Contraindications: malignant tumor, pregnancy, laminectomy, joint replacement, pacemaker, thrombophlebitis, eyes, reproductive organs Laser: light amplification by stimulated emission of radiation à penetrates a few millimeters w/ deeper physiological ePects à helps with would healing, fracture & bone healing, reduce inflammation, pain management Cellular ePects: increases ATP production, stimulates macrophages, stimulates fibroblasts (+ collagen), alters nerve conduction and regeneration, + vasodilation (rid cellular debris) Contraindications: eyes, malignancy, open lesions/wounds Manipulation (grade 5 mobilization): “controlled act” to help joints that are fixated or stuck à allows for better motion of joint (stuck joint means muscles are moving properly), joints are fixed from hypertonic muscles à work on muscle relaxation once joint mobilized Homeopathy LBP w/ depression: Sepia (cuttlefish): acts on the portal system Pain better with activity (vigorous), cold, sad, faint, pain down back, weal, feels struck by hammer, heavy, bruised Circulation à COLD extremities alternating with heat à venous stasis + heaviness of the organs = prolapse (esp female genitalia prolapse) Pain better with pressure, concomitants = chloasma during pregnancy, herpes, shingles Salt (Natrum): emotional vulnerability leading to introversion, closed oP person, avoids rejection Botanical Medicine Nutrition Wants to be alone, rude, weak knees, pain in back, cracking joints, want to lay on floor, worse in the morning, thirst, mapped tongue, grief, tingling/numb in extremities Craving salty foods, edema, anemia, unquenchable thirst during fever Rhus tox: restlessness, must keep moving and stretching the part due to the painful stiPness, better with hot showers, red triangular tip of the tongue Bryonia: rheumatism with excruciating, stitching pain, averse to being examined or moved QUESTIONS: 1. 35 YO female with CC of back pain; pain started after giving birth, taking care of two children, became chronic, pain is worse before and during periods, relief with vigorous exercise à Sepia 2. 55 YO female w/ chronic pain, can’t sit comfortably w/o firm support, relief with supine, depressed, grief, avoids seeing friends, hates being consoled à Nat.mur Adaptogens and anti-inflammatories key actions for NSLBP Adaptogens: most to least stimulating Panax ginseng (Korean red ginseng): stimulating adaptogen, immune stimulant, libido stimulant, cardiotonic, strong tang-qi, adrenal adaptogen, keep cold/damp out Convalescence, end of life care, depression Rhodiola rosea: stimulating, can cause dizzy/palpations, powerful adaptogen, vascular tonic, good for ongoing stress of mind/body, drying Astragalus: immune adaptogen Panax quinquefolaris (North American ginseng): immune adaptogen (stimulant and modulator), antiviral Withania somnifera (Ashwagandha): hypotensive, adrenal adaptogen, qi tonics, comes in root or powder, aPordable, well tolerated, less stimulating, immune modulator Rehmania: adaptogen, yin herb, grounding, can be used to help with stimulating ePects of other meds/herbs (anxiety, insomnia, palpitations) Smilax o8icinalis (Sarasaparilla): adaptogen, alterative, anti-inflammatory Western diet is linked to increased inflammation à + DII = pro-inflammatory in diet - DII = anti-inflammatory in diet Anti-inflammatory = increased fruit, veg, nuts, legumes, whole grains, and unsaturated fats, moderate intake of animal products, low glycemic index/load o Ex: med diet, DASH diet and veg diet Dietary inflammatory index (DII) = inflammatory potential of a diet High glycemic load (regular consumption of carbs) = increased ROS and pro-inflam cytokines (high fiber = less sugar) o High insulin = increased arachidonic acid = more pro-inflam cytokines Low ratio of omega 6 to omega 3 (below 5:1) = pro health *want more omega 3* Trans fats = bad because more solid when hydrogenated = proinflammatory (TNF, CRP, IL6) Polyphenols (++ colour in fruits and veg) = neutralize free radicals and inhibit gene trans in inflammatory pathways Pharmacology Excess caloric intake in sedentary individuals = chronic inflammation Increased adipose tissues = activate stress response Caloric restriction enhances endogenous corticosteroid production, promoting anti-inflamm ePects (BMI, weight, cals), calorie restriction = anti-inflammatory unless under nourished 2/3s total food volume should be vegetables in an anti-inflammatory diet Plant source proteins = superior for inflammatory, ++ colours at each meal, fish good source of omega 3s Soy decreases inflammatory markers Healthy fats: cold water fish or fish oil supplementation to an anti-inflamm diet at 3000mg/day, flex seeds, chia seeds, walnuts, hemp seeds Opioids are not recommended for acute LBP, only used if no benefit from other meds/therapies Should be short term use, if possible, do not used in depression, PTSD, anxiety and PSUD Provide modest, short-term relief of pain Opioid classes: Full opioid agonists = morphine, codeine (high aPinity to opioid receptors à significant conformational change) Fentanyl > morphine > codeine Partial opioid agonists = Tramadol (less conformational change + receptor activation but plateaus) Opioid antagonists = Naloxone Opioids agonists: S/S: analgesia, resp/cough inhibition, euphoria, sedation, hypotension, vasodilation, constipation, N/V, flushing, itch Full opioids agonists: well -tolerated if strong (full) but increased dose of partial/moderate opioids = more side ePects, so better to give lower dose of stronger opioid Morphine: from opium poppy, DOA = 4 hours, excreted in urine/liver, orally/IV Fentanyl > Morphine > Codeine Partial opioid agonists: Tramadol: like an SSNRI, incorrectly considered the safe, decreased seizure threshold, DOA 4, half-life 6 hours Opioid antagonists: competitively and rapidly reverse opioid agonist ePects, used for overdose, ex: naloxone (IV/IM, halflife is 2 hours so many doses sometimes needed) TCM: Heart, small intestine, pericardium, triple warmer di6erentials FIRE element à heart, small intestine, pericardium, triple warmer à secretion = sweat, emotion = joy, odor = burnt/scorched, flavor = bitter + sharp, laughter + talkative, belching, taste + speech, summer, hot climate, heart (11am – 1pm) + SI (1-3pm) Heart functions à governs blood, controls sweat + manifests in complexion, opens into the tongue, houses the mind (shen), mental activity + consciousness Heart BLOOD stagnation Heart QI deficiency Heart YANG deficiency Heart BLOOD deficiency Heart YIN deficiency Causes: insuPiciency of Causes: poor constitution, Causes: poor constitution, Causes: prolonged illness, Causes prolonged illness, heart blood + yang, mental prolonged illness, severe prolonged illness, hemorrhage, poor hemorrhage, poor irritation, exposure to cold disease, congenital congenital deficiency or old production of blood, production of blood, deficiency or old age age emotional issues emotional issues Symptoms: palpitations, stabbing pain in the heart region radiating to left arm or shoulder, feeling of constriction, cyanosis of the lips and nails TONGUE à dark purple or dark purple spots PUSLE à thready + hesitant with missed-beats Heart FIRE Causes: mental depression, external pathogens turning to heat inside the body, interior heat excess Symptoms: palpitations, thirst, mouth ulcers, mental restlessness, agitated, insomnia, red face, dark urine/blood, bitter taste in morning TONGUE à red with redder tip PULSE à full and rapid pulse Symptoms: palpitations, SOB on exertion, low/hoarse voice, fatigue, spontaneous sweating, dizziness, pale face, watery/clear sputum, catches colds easily TONGUE à pale, thin, white coating PULSE à weak or empty Phlegm-Fire Harassing Hrt Causes: mental depression, phlegm accumulation in the body Symptoms: mental restlessness, palpitations, bitter taste in morning, dream-disturbed sleep, easily startled, incoherent speech, aphasia, muttering, irritable, scolding people, uncontrolled laughter/crying/shouting TONGUE à red with yellow stick coat PULSE à wiry + slippery Symptoms: same as heart QI deficiency + chills, cold limbs, chest pain, bright pale face TONGUE à pale, swollen with white smooth wet coating PULSE à weak and deep, slow *Heart yang collapse can occur in severe deficiency = lip cyanosis + hidden pulse Phlegm misting the mind Causes: congenital in children, phlegm accumulation in body Symptoms: palpitations, insomnia, excessive dreams, poor memory, dizziness, anxiety, startled easy, dull pale complexion + lips Symptoms: heart blood deficiency + malar flush, low grade afternoon fever, dry mouth and throat, 5 center heat sensation, night sweats, insomnia TONGUE à pale and thin with thin white coat PULSE à weak and thready TONGUE à red body little or no coat, red tip with papules, deep midline crack (bifurcating tip) PULSE à rapid + thready Heart stagnation Causes: emotions (worry, stress, anxiety), suppressed or excessive Heart vessel obstructed Causes: emotions, excessive dairy + greasy foods, excessive physical work Symptoms: mental confusion, unconsciousness, lethargy, vomiting, rattles in throat, aphasia, staring at wall, muttering, introverted, depression Symptoms: palpitations, distention or heavy chest, lump in throat, slight SOB, sighing, poor appetite, weak/cold limbs, pale complexion, slightly purple lips TONGUE à thick, sticky coat with swollen body PULSE à slippery + slow TONGUE à purple on the sides PULSE à empty but overflowing in left cun Symptoms: palpitations, SOB unable to lay down, depression, mental restlessness, heaviness in chest, sharp stabbing pain in chest radiating to shoulder, worse with cold, better with heat TONGUE à purple sides, swollen sticky coat PULSE à wirey, choppy, knotted Heart deficiencies think palpitations, anxious + mental symptoms, depression, sweating, pale, insomnia, irritability, red tongue + thin white coat, weak/empty/slow/thready pulses Phlegm think STICKY + slippery Stagnation + obstruction think PURPLE Small intestine: separates “pure” from “turbid”, communicates with the stomach, spleen, bladder, and large intestine Full heat in SI SI QI pain SI deficient + cold Cause: excessive anxiety Symptoms: mental restlessness, tongue ulcers, pain in throat, deafness, tightness in chest, abdo pain, thirst, scanty urine, painful urination, blood in urine Causes: excessive consumption of cold + raw foods, factors which cause liver Qi stagnation Causes: excessive consumption cold + raw foods TONGUE à red w/ redder tip + Symptoms: lower abdo twisting pain, radiating to back, abdo distention, borborygmi, flatulence, relieved by passing wind, pain in testes TONGUE à white coat PULSE à deep + wiry Symptoms: abdo pain, desire for hot drinks, relieved with pressure, borborygmi, diarrhea, pale + copious urine yellow coat TONGUE à pale body white Pericardium functions à protects the heart, governs PULSE à rapid + full coating blood, and houses the Shen PULSE à deep, slow, weak Protection: acts as a cover to protect heart from external pathogens à Xin Zhu “master of the heart”, Xin Bao “envelope of the heart”, Xin Bao Luo “connecting channel of the envelope of the heart”, believed to be extension of the heart (6th organ) Govern: similar to heart, helps move blood and clear heat from blood, heart is better with blood deficiency Shen: mainly heart function but assisted by pericardium, PC points stimulate mind + manage emotions, presents as depressed w/ anxiety PC channel influences the thorax: channel runs internally to the center of the chest (Shan Zhong), AKA “the palace of the pericardium” (Xin Zhu) à influences gathering qi (Zong Qi) along w/ heart and lungs PC connected to uterus à connected to liver since both are terminal Yin channels, uterus connected to heart + PC via uterus vessel (Bao Mai), PC channel points can be used to treat menstrual function and emotions Triple warmer functions à mobilizes Original Qi, controls transportation and penetration of Qi, controls water passages and excretion of fluids Mobilization of qi: Original qi (Yuan qi) is the yang component of essence, diPerentiates Yuan qi à provides heat to spleen for transformation and transportation, facilitates production of True qi (Zhen qi) from gathering qi (Zong qi) in the chest, and aids in production of blood in the heart from food qi (gu qi) Controls transportation/penetration of qi à controls qi mechanism (movement up/down, entering/exiting), TW considered to have free passage (tong) o Upper = gathering (yuan qi), Middle = nutritive qi (Ying qi), Lower = defensive qi (Wei qi) Controls water passage and excretion à irrigation transporting fluids for use in burner system o Upper = sweat from skin + muscles, Middle = stomach fluids (moisten body, move blood), Lower = urine + stools TW considered the 6th yang organ (function but no form), connected to the gall bladder + chest (FIRE element), w/o TW organs wouldn’t be able to function Week 10: IBS/GI Botanical Medicine Homeopathy Naturopathic approach to IBS: remove food sensitivities (IgG testing, elimination), + fiber (bulk laxative), relieve flatulence (carminatives), eliminate cramping (antispasmodics), stimulating laxatives, antimicrobials, probiotics, stress management Peppermint: Carminative (gas, bloating), anti-emetic, cramping (antispasmodic), cooling/analgesic Safe Essential oils, phenolics, and flavonoids Can aggravate GERD, improves IBS systems and pain Lemon Balm: Carminative (gas, bloating), anti-emetic, cramping (antispasmodic) Mint family Sedative for nervous stomach Essential oils, phenolics, and flavonoids Can aggravate GERD Fennel: Indigestion, bloating + gas, infant colin, antispasmodic, carminative, anti-inflammatory Anise family Hormone regulation Essential oils Can aggravate GERD + harmful in pregnancy Curcumin + fennel combo to reduce IBS pain Psyllium: bulk laxative/fiber rich for constipation + diarrhea, blood sugar and cholesterol, demulcent Need to add water, can create blockage Flax seed: constipation, bulk laxative, demulcent, phytoestrogen Less problems with water Mucilage, lignans and omega 3s Harmful in pregnancy Senna: stimulating laxative for acute constipation Anthraquinone glycosides Very strong with + side ePects (caution in people with IBS, children, kidney disease, heart medications, if nursing) Barberry: infectious diarrhea/indigestion Antimicrobial, digestive bitter, antidiarrheal, laxative Not safe in pregnancy & lactation Nux vomica: “vomiting nut” too much work/stress, muscle spasms, ambitious person, reversed peristalsis, constipated type A person, chilly symptoms Erectile dysfunction, bloating, constipation, anxiety, migraine Podophyllum peltanum: IBS like problems, may apple/ground lemon, constipation or headaches alternating with diarrhea, gall bladder pain, prolapse of rectum + uterus, bloating, gas, sociable + impulsive person Cina maritima: good for parasites/worms, daisy family, wormwood, restless, fitful, irritable, spasm, behaviour problems/ADHD Nutrition QUESTION: 1. Podophyllum + Cina children can both have diarrhea and colic, how do you diPerentiate b/w the 2 remedies à if the child gets stiP before and during a coughing fit, I’d give Cina 2. Which remedy would you give an impatient patient with vomiting, diarrhea, irritability and great clumsiness à Nux vomica 3. Patient with food allergies, mainly fast foods, symptoms worse after eating out à Nux vomica + podophyllum Low FODMAPs Diet: Used to control IBS symptoms (also ePective for SIBO), help reduce carb that are poorly digested in the SI and fermented by bacteria and lead to bloating, gas, diarrhea, etc. Reduce alcohol, especially if it exacerbates the symptoms of the patient. Alcohol also changes microbiome. Also, wines from certain regions contain pesticides. CaPeine should be less than 400 mg/day which is the same for all adults. Reduce spicy foods, as well as onions and garlic. Caspian accelerates GI transit time. Increase fiber (gradually) in people with IBS-C and increase water ingestion when doing so. Best source is flax seeds. Can consider gluten and lactose free diet but only if able to get nutrients other ways. Probiotics have been found to help reduce the symptoms of IBS. Particularly helpful in IBS-D people. Food additives: + ginger, turmeric (curcumin is better) - pesticides or sugars *SIBO occurs in up to 80% of people with IBS* Allergy/Sensitivity Reaction: IgE, occurs after 2nd exposure to the allergen (2nd time you eat food), immediate reaction (type I hypersensitivity) IgG and IgA are delayed reactions, can be up to a few days after the exposure (may be sensitivity) IgG – type III hypersensitivity (delayed) Enzyme deficiencies/intolerance, dose dependant reaction (30 mins – 2 days later) and usually missing the enzyme (lactose), treat by limiting food Autoimmune disease – celiac disease Sensitivity components: lectins, histamines, sulphites, gluten Food allergy = immune reaction to tiny quantity immediate Food intolerance = no immune activation, normal portion size elicits symptoms, delayed reaction Intolerance = abdo pain, diarrhea, flatulence, migraine, heart burn, nausea Pharmacology Elimination diet: exclude foods that contain refined sugar, wheat, dairy products, corn, eggs, citrus fruits, any foods they eat 3x/week, coPee, tea, alcohol, food additives, soy, yeast, and nightshades Reintroduction: 1 food every 3rd day à observe à once symptoms resolve another food can be challenged GI Motility Drugs: treat ITT (time to move through tract, should be 30 – 40 hours, reduced in constipation and increased in diarrhea) - ITT Bulk Forming laxatives: Retain fluid and do not alter peristalsis Increased stool weight and improve consistency Psyllium (12-72 hr) for both constipation + diarrhea Add slowly and need with increased water Osmotic laxatives: Draw water into intestine and increase colonic peristalsis, hydrates + softens stools Magnesium citrate, hydroxide, sulfate salts Lactulose Careful in renal issues Stimulant laxatives: Act on myenteric plexus, increase secretions + motility, and decrease water absorption in gut Senna (6-12 hrs) short term treatment of constipation SSRI Decrease ITT, used for IBS-C, low doses Citalopram OD (start low and titrate) + ITT Opioid Agonists: Act like opioids but not cross the BBB, treat diarrhea (cause constipation) Loperamide (Imodium), caution with microbes, not for children eructations (belching + passing gass) Causes of GERD: stress, poor sleep, food sensitivities Avoid triggers (alcohol, acidic, spicy, carbonated drinks, chocolate) Eat smaller more often Low allergen diet, nutrient dense Avoid eating near before bed Sit up straight while eating and wait to exercise after eating Chew gum/drink water Recommended foods Veg diet, less meat Antioxidants Intermittent fasting Supplements Magnesium Zinc Carnosine = repair damaged mucous membranes, inhibits inflammation Vitamin B12 Ginger, licorice root, slippery elm, chamomile Probiotics Lactobacillus strains (L. gasseri, L. casei, L. plantarum, etc.) Take supplement or eat probiotic rich foods SPOTLIGHT: upper + lower GI symptoms Dietary recommendations: IBS à low FODMAP diet = avoiding foods + in carbs (add lots of fiber and probiotics) IBD à low residue diet during flare up to promote healing (avoid high fiber, raw fruits/vegs; more protein + healthy fats) GERD à low acid, no spicy foods, eating small meals Celiac Disease à gluten-free (damages SI), avoid wheat, barley, rye Diverticulitis à avoid high fiber foods, raw vegetables + fruit, whole grains during flare ups Intermittent fasting: eating only during specific time period (~8-10 hours) or fasting every other day or 5:2 fasting Avoid if pregnant, lactation, children + adolescents, elderly, weakened immune system, cognitive impairments, eating disorders Benefits = improved gut microbiome diversity + reduced inflammation, improved insulin sensitivity, reduced acid reflux, weight loss, improved CV health Improved insulin sensitivity and reduce insulin resistance, increases growth hormone levels (promote fat burning + muscle growth), short term increase of cortisol levels IBS/IBD/GERD all see improvements in symptoms w/ IF Zinc à shellfish, beef, red meats, nuts, legumes Deficiency symptoms = dermatitis, impaired immune function, hair loss, growth retardation, delayed sexual maturation, impaired taste, white spots on fingernails Zinc lozenges for common cold – shorten duration of symptoms Also indicated in diarrhea, stomach ulcers, acne, child growth, macular degeneration, ADHD, depression, diabetes, cold sores COPPER should be added when supplementing with zinc to prevent copper deficiency Pharmacology Stomach acid suppression + H. pylori eradication Antacids à aluminum + magnesium hydroxides most common combo Work on H+ in the gut to neutralize Short term ePect – can cause constipation/diarrhea Alginates à natural polysaccharides derived from seaweed Form a gel on contact w/ acid; floats on stomach contents to create a barrier to LES; gel refluxes instead of acid Take after meals – can cause nausea/vomiting/eructation/flatulence H2 Antagonists à “-tidine” Ranitidine Similar to histamines à competitively binds and blocks H2 = decreased acid Indications: dyspepsia/GERD/heartburn/PUD PPI à “-prazole” Stops the proton pump and reduces acid (once activated bind to H+/K+ ATPase and irreversibly inactivate the pump) Omeprazole/ Pantoprazole Better for peptic ulcer disease and Zollinger’s à used in patients taking NSAIDs to prevent ulcers Prostaglandin Analogues à cytoprotective drugs “chemical bandage” Enhances mucus production and bicarb secretion, down regulates proton pump by stopping adenylate cyclase (lower cAMP) Misoprostol = prostaglandin E1 analogue Indication for ulcers related to NSAID use Contraindication in pregnancy – cause uterine contractions H. Pylori eradication à first line management = quadruple therapy Quadruple Therapy for 14 days: Adding antibiotics (amoxicillin, metronidazole, clarithromycin) x2-3, PPI or Pepto bismol PIT: GERD Diagnostic + management consideration: GERD = inappropriate lower esophageal sphincter relaxation Commonly treated with PPI trial Reasons for gastroscopy à heart burn with red flags (bleeding, weight loss, dysphagia, vomiting, fHx of GI cancer), persistent symptom after PPI trial (4-8 weeks), high risk for Barett’s esophagus (male, >50 YO, white, smoker, obese, hx of symptoms) Risk factors: >50 YO, smoking, frequent NSAID or aspirin use, obesity, low socioeconomic status, alcohol, sleep deprivation Diet Lifestyle NHP Other Management consideration Excluding food triggers (symptom management): alcohol, caPeine, smoking, fried foods, chocolate, mint, spicy foods, citrus, tomatoes Low FODMAP diet Weight loss Symptoms @ night – elevate head Small meals, avoid late snacks gut-brain connection: mindfulness, meditation, CBT, hypnotherapy Melatonin (3mg/day 8 weeks) Artichoke leaf (GERD with functional dyspepsia, biliary concerns DGL (licorice) à GERD, H. pylori, peptic ulcer disease PPIs: can cause nutrient deficiencies à B12, vitamin C, calcium (fracture risk), iron, magnesium TCM: Pulse + tongue charting, acupuncture treatment plans Pulse palpation: 1. Locate styloid process of radius using opposite hand from one you are palpating 2. This marks the spot for your middle finger 3. Index and ring finger should fall on the first and third positions, respectively 4. Leave room between fingers based on size of patient – more room for taller and less room for shorter patients 5. Once the 3 positions are located, arch fingers as though playing a guitar. Tips of your fingers are more sensitive than the pads (able to feel subtle changes in pulse with this technique) 6. 1st position is known as cun, 2nd as guan, 3rd as chi 7. After arching fingers onto radial artery of both hands, compare the two sides – with all 3 fingers staying on the same level, begin palpating the superficial level then middle, followed by deep 8. Observing for pulses that stand out for being diPerent from the others at that level – then palpate the cun pulse at all 3 levels 9. If one pulse stood out form earlier – may want to palpate another pulse at the same time to use as reference 10. Follow same procedure for guan and chi pulses Normal variations in pulses Athletes à slower Women à softer, faster Children à faster Heavier set à deep, slow Thin à superficial Fasting individuals à deficient, weak Pulse variables: Speed Fast > 90 bpm à heat Slow < 60 bpm à cold Moderate = 60-90 bpm Types of pulses: see slides Seasonal changes Spring (wood) = wiry Summer (fire) = flooding Late summer (earth) = slippery Autumn (metal) = floating Winter (water) = sinking Depth Superficial – yang = exterior Middle – normal Deep – yin = interior Intensity * most important Strong = excess Weak = deficiency Treatment plans à written as Zang-Fu diagnosis (Lung-Qi deficiency or Heart fire), multiple organs can be included, objective is to treat the underlying dysfunction Treatment principles: example Lung Qi deficiency Based on Zang-Fu diagnosis Based on sings + symptoms Based on dysfunctions Based on indications Tonify lung and tonify qi Sx: productive cough, chest pain, Cough – descend lung qi or subdue Treat the branch symptoms over the nasal congestion rebellious qi root (diagnosis) Tx: relieves coughing, resolves SOB – disperse lung qi Symptomatic relief phlegm, opens the chest + nose Chest pain – move stagnant lung qi Point actions: Tonifies Increase or build Subdues Prevents ascending by holding down (i.e. for rebellious qi and yang) Nourishes Strengthen or build Harmonizes Bring into balance or return to normal levels Regulates Bring movements into balance (i.e. qi circulation) Clears Removes from body à mainly for heat Use emunctories Opens Increases movement/removes obstruction (stagnation, dampness/phlegm, cold) Benefits Directs qi and blood to a certain area Descends Forces down (natural function of lung + stomach organs) Point classifications: o 5 transporting points à Well-Spring-Stream-River-Sea o Source points à 12 regular meridians o Influential points à Qi, blood, zang, fu, bone, marrow, sinews, vessels o Command points à face/mouth, posterior neck, abdomen, back o Back shu à 12 primary meridians, mainly for physical concerns and less emotional/spiritual o Outer back shu à more emotional/spiritual, next to back shu points o Front mu à 12 primary meridians, for both physical + emotional concerns Week 12: Hypertension and CVD Botanical Medicine Hypotensive + cardiotonic, physical activity essential (remove all caPeine) Lily of the valley (Convallaria): hypertension, CHF, any cardiovascular conditions Contains cardiac glycosides aka use with caution +++ Avoid in pregnancy Hawthorn (Crataegus oxyacantha): cardiotonic, hypotensive, vascular tonic, nutritive à use in hypertension or CVD/CHF Flavonoids SAFE – can eat the berries/leaf Homeopathy Nutrition Linden (tilia cordata): cardiotonic, circulatory tonic, nervine, hypotensive w/ anxiolytic properties à use in anxiety, CVD related to stress/anxiety, hypertension, URTIs Volatile oils, flavonoids, mucilage, tannins SAFE – may interfere with iron absorption Garlic (allium sativum): vascular tonic, antimicrobial, hypotensive, stink-producer à use in digestive infections, skin infections, URTI, CVD, hypertension SAFE, eat raw bulb or in oil/honey Cayenne (capsicum frutescens): stimulant, circulatory tonic, rubefacient à use in circulatory deficiencies, arthritis, pain relief, SAFE (great with ginger) Hibiscus à ePective hypotensive + vascular tonic, use in hypertension, inflammation, and heat patterns Flavonoids, vitamin C, tannins, anthocyanidins Mild uterine tonic à indicated for recurrent miscarriages Calcarea carbonica (oyster shell): atherosclerosis, obesity, diabetes, fat, overworked, fatigue, weakness, slow, shy, depressive/fearful, cold feet + legs APinities = metabolism, bone tissue, lymph nodes + tonsils Desire for eggs, sweets, candies, sour excretions, + localized cold sweats Sulphur: more robust person, stooped shoulders, less fatty QUESTIONS: 1. Which of the following symptoms is not a keynote of Calc.carb à aggravation from 4-8pm (keynote of Lycopodium) 2. Which of the following aggravates symptoms of patient who needs calc.carb à full moon FIBERS à gums, mucilage, beta-glucans, fructans, cellulose, hemicellulose, lignans, pectins Solubility in water Water-holding capacity Absorption/binding ability Fermentability Cellulose: bran legumes, root vegetables (help bulk stool), non-soluble (helps plants remain stiP + upright) Hemicellulose: bran, grains, nuts, some soluble sources (digested better than cellulose) Pectin: glue that holds cells together + foods together, can completely be digested, gel like substances (jams) à apples, pears, strawberries, citrus fruits Lignans: make up cell walls, insoluble, flax/roots à antioxidant & phytoestrogenic properties (flax seed highest natural source of lignans/lignins) Flex seeds good for chronic constipation, inhibit cancer growth, menopause symptoms Beta-glucans: soluble fibers in cell walls of bacteria, fungi, yeasts, plants à immune stimulating, might lower CVD risk, BP and cholesterol) à barely fiber, oats, whole grains, yeast, reishi + shiitake mushrooms, seaweed, algea Gums: secreted @ sight of plant injury (sugars & derivatives) à oats, barley, legumes Psyllium: high fiber & mucilage à constipation or diarrhea, high cholesterol Fructans: included in FODMAP group of carbs, prebiotic + immune modulator à chicory, onions, artichokes, asparagus, garlic, bananas Pharmacology Fructans intolerance = gas, bloating, belching, constipation or diarrhea Clinical application à soluble fibers (hyperglycemia, hyperlipidemia, diarrhea or constipation) or insoluble fibers (constipation, maintaining bowel regularity, immunomodulation) Low fiber diet can lead to GI diseases, CVD, obesity, type 2 diabetes Most common side ePects of high fiber diet à gas + bloating, constipation, obstruction Antihypertensive drugs: Renin-angiotensin-aldosterone drugs: short term + long term control of blood volume determined by kidneys using BP + fluid volume as driving force Angiotensin converting enzyme inhibitors (ACEi) à Quinapril à inhibits production of angiotensin II (potent vasoconstrictor + aldosterone release) o Decreases both arterial + venous pressure reduces cardiac load o Renal sodium retention decreased, + renal potassium o Application: hypertension, diabetes, ischemic heart disease, post MI, chronic kidney disease o Adverse ePects: dry cough, hyperkalemia, angioedema, renal failure w/ NSAID use, do not combine w/ potassium supplementation, contraindicated in pregnancy Angiotensin receptor blockers (ARB) à Candesartan à antagonist BLOCKING angiotensin II signalling (vasoconstriction, aldosterone secretion, sodium absorption) o Same adverse ePects as ACEs o Primary diPerence b/w quinapril + candesartan = candesartan does not interfere with bradykinin metabolism reducing potential for dry cough o Do not combine ACE + ARB Direct renin inhibitors à Aliskiren à binds to active site of renin preventing cleavage of angiotensinogen, inhibits formation of angiotensin I + II o Most common adverse ePect = diarrhea, lower incidence of cough o Contraindication in pregnancy Calcium channel blockers: L-type calcium channel antagonists (expressed on cardiac myocytes, pacemaker cells and arteries) à Calcium induced calcium release resulting in muscular contraction (ryanodine receptors) 1. Dihydropyridine à amlodipine = more aPinity for calcium channels in vasculature o Useful in heart failure or uncomplicated hypertension à rebound tachycardia can happen due to vasodilation + hypotensive ePect 2. Non-dihydropyridine à (a) phenylalkyamine class = verapamil (heart aPinity); (b) benzothiazepine class = diltiazem (vasculature + heart aPinity) o Do not exhibit rebound tachycardia and can be used in ischemic heart conditions like arrythmias Short half lives for CCBs recommended to use extended release Sympatholytics: interfere with adrenergic signalling Alpha-adrenoreceptor antagonists à alpha blockers à Prazosin o Inhibition of signalling results in decreased vasoconstriction, decreases peripheral resistance o Hypertension Beta-adrenoreceptor antagonists à beta blockers à atenolol APinity for beta receptors; primarily act on heart to reduce HR Multiple indications: hypertension (not first line), heart failure, post MI, coronary heart disease, arrhythmias Centrally acting sympatholytics à clonidine à acts on CNS reducing sympathetic outflow decreasing periperhal resistance, HR + BP o More potential for adverse ePects: sedation, dizziness, dry mouth, orthostatic hypotension, rebound hypertension w/ abrupt withdrawal Diuretics: drugs that reduce blood volume Loop diuretics (Loop of Henle)à Furosemide Thiazide diuretics (distal convoluted tubule) à Hydrochlorothiazide (diuretic of choice for hypertension) K+ sparing diuretics (collecting duct) à Spironolactone Thiazide diuretics first-line therapy for uncomplicated hypertension Loop diuretics are only valuable when patient is experiencing significant edema (heart failure) o o PIT: primary prevention of CVD Most scenarios of sub-optimal body composition and metabolic sequalae are related to lifestyle: Increased risk for CVD à more invasive treatments, prescriptions, side ePects, costs, decreased QOL, risk for premature mortality Decreased risk for CVD àdecreased for chronic disease, better physical fitness, improved QOL Prevention: Nutrition: gradual increase in intake in vegetables, fruits, whole grains, limit saturated fats, added sugar, sodium, processed foods Smoking cessation Obesity and T2D: assess risk; prevent, manage, improve Exercise and sleep (7-8 hours target, screen for sleep apnea) TCM: point actions continued Point actions: Releases exterior Forces out the layer b/w skin + muscle Works as diaphoretic (sweating) Good for external pathogens (wind, heat, cold, dampness, dryness) Most ePective when first symptoms appear Resolves phlegm (damp) Converts phlegm into less viscous more mobile substance Symptom treatment vs. root cause Expels wind Specficially for wind, opens gates to allow wind to escape (wind gate, posterior neck) Exterior wind caught in Wei Qi layer Calms the mind Slows overactive mind or quickens slow mind Helps with insomnia from over active mind Depression, anxiety, stress Treats symptoms over root cause Removes obstruction Obstructions usually manifest as pain or lack of flow Can be used for stagnation (gi, blood, phlegm/damp, cold) Symptom treatment vs. cause Dissipates masses Masses generally caused by qi stagnation, blood stagnation, or phlegm-damp accumulation Reduces size + impact of mass on meridian flow Treats symptoms over the root Week 13: Erectile dysfunction and weight Botanical Medicine Key treatment principles: DiPerentiate b/w physical + mental/emotional causes DiPerentiate b/w diPiculty w/ arousal vs. challenges w/ performance Nutrition, physical activity, stress reduction Adaptogens: warm + drying herbs Alteratives: hepatics + laxatives to restore liver function and elimination Rhodiola rosea: stimulating, can cause dizzy/palpations, powerful adaptogen, vascular tonic, good for ongoing stress of mind/body, drying Withania somnifera (Ashwagandha): hypotensive, adrenal adaptogen, qi tonics, comes in root or powder, aPordable, well tolerated, less stimulating, immune modulator Korean ginseng (panax ginseng): stimulating adaptogen, immune stimulant, libido stimulant, ++ Glycosides, saponins Non-toxic but very stimulating (part used = root) Lepidium meyenni (Maca): testosterone modulator, adaptogen, anti-inflammatory Lowered libido, convalescence Improves physical + sexual performance Horny Goat Weed Homeopathy Lycopodium clavatum (wolfs claw): flatulence, indigestion, procrastinator, low confidence, enlarged prostate, ED, bloated, larger lower body, fluctuating appetite, craving sweats, “worry wort” Alkaloids similar to morphine in structure Diuretic properties APinity to genital system, liver and GI tract, metabolism of uric acid, skin + mucous membranes, NS Aggravation b/w 4-8pm and with contradiction Better w/ cold air and warm foods QUESTIONS: 1. Not a key note of Lycopodium à craving for eggs 2. Aggravates symptoms of a patient who needs Lycopodium à contradiction Nutrition Want to prevent cardiometabolic syndrome and reduce markers (ApoB + LDL), management of hypertriglyceridemia with fish oils, and increase low HDL Weight management = behaviour modification, CBT, physical activity +, reduce caloric intake Mediterranean diet DASH diet Body mass index: BMI = 18.5-24.9 considered healthy, BMI > 25 = overweight, BMI > 30 = obese Consider waist circumference and waist to hip ratio VAT à visceral adipose tissue important marker for metabolic risk à releases FFAs and inflammatory proteins Factors that impact basal metabolic rate = weight, height, age Prevalence of obesity in Canada rising dramatically year over year à consequences = CVD, hypertension, type 2 diabetes, cancer, cholecystectomy, back pain, fatigue, + mortality rate Pharmacology Appetite hormones: Leptin suppresses appetite as its level increases à produced by fat tissue o Berries + unsweetened beverages (low triglycerides) help boost leptin + healthy oils, raw/steamed/roasted vegetables, legumes, lean meats, whole grain, salad greens, mushrooms PYY – suppresses appetite, secreted by SI after meals (counters ghrelin) Ghrelin signals hunger Insulin à responsible for weight gain Recommendations: Eating less frequently, largest meal in morning, eating more protein Low glycemic diet may not be ePective for weight loss (be careful with very low calorie diets long term) Metabolic syndrome is a cluster of conditions that + risk of heart disease, stroke, diabetes Healthy diet + regular exercise important Intermittent fasting may be beneficial Consuming diet rich in fruits, veggies, whole grains, healthy fats lowers risk of HD Smoking cessation, BP control, cholesterol management for vascular health RISK: Absolute risk (AR) = number of events (+/-) in treated or control group / number of ppl in that group Absolute risk reduction (ARR) = AR of events in control group – AR of events in treatment group Number needed to treat (NNT) = measures impact of medicine (est. number needed to treat to benefit 1 person) Number needed to harm (NNH) = measure of how many ppl need to be treated for 1 person to have an adverse ePect Antihypertensive therapy à MI ARR = 0.7% NNT = 143, 20-40% risk reduction for first major cardiovascular event vs. placebo, adverse ePects related to specific medications used Statin therapy à cardiovascular event ARR = 1.39% NNT = 52 (similar with MI and stroke), most common adverse ePect is myalgia Low-dose ASA à major cardiovascular event ARR = 0.4% NNT = 241 (similar for MI and major bleeding), major bleeding usually within GI tract Drugs that lower cholesterol (lipid lowering drugs): HMG CoA Reductase inhibitors AKA statins à Atorvastatin Lower LDL-C, prevent CVD, stabilize plaques Can cause rhabdomyolysis Absorption Inhibition: Ezetimibe: cannot absorb cholesterol into the lumen (bile acid binding resins) Cholestyramine: bile acid binding, allows more LDL-C to be used up Fibrates à Fenofibrate Not as good for LDL-C, better for increasing HDL and decreasing cholesterol (reducing triglycerides) Benefit best in diabetic populations Can cause rhabdomyolysis Niacin: broadest spectrum but needs to be a huge dose, which causes intense flushing/itching Works by inhibiting lipolysis in adipose tissue à reduced formation and secretion of VLDL (precursor to LDL) QUESTION 1. Which of the following drugs can cause rhabdo à fenofibrate + atorvastatin PIT: hypertension and erectile dysfunction Nonpharmacological interventions for prevention of hypertension: Non-pharma intervention Weight loss Weight/body fat Healthy diet DASH diet Reduced intake of dietary sodium Dietary sodium Increased potassium intake Dietary potassium Physical activity Aerobics, resistance (dynamic, isometric) Moderation in alcohol intake Alcohol consumption Impact on BP hypertension -5 mmHg -11 mmHg -5 to -6 mmHg -4 mmHg ~-5.5 mmHg -4 mmHg Etiologies of ED: Vascular à CVD, hypertension, DM, smoking, major surgery, radiotherapy, hyperlipidemia Neurologic à spinal and brain injuries, Parkinson disease, Alzheimer disease, multiple sclerosis, stroke, major surgery, radiography of prostate Local penile (cavernous) factors à Peyronie’s disease, cavernous fibrosis, penile fracture Hormonal à hypogonadism, hyperprolactinemia, hyper/hypothyroidism, hyper/hypercortisolism Drug-induced à anti hypertensives, antidepressants, antipsychotic, recreational drugs, alcohol Psychogenic à performance anxiety, PTSD, relationship issue, anxiety, depression, stress TCM: connecting points (Luo), back shu points and front mu points Connecting Luo 15 connecting points throughout the body (12 reg. meridians, 1 governing vessel, 1 conception vessel, 1 great spleen) points Connecting channels à areas governed by the connecting point, each point has 2 areas to govern (along a path to a defined area for each meridian AND between the main meridian and the skin) o Main meridians run deeper in body, connecting channels cannot pass through large joints Uses for connecting points à o In conjunction with source points = using connecting point with source point increases ePect of the source point for ex: Lung 9 + LI6 = treats lung qi deficiency o Connecting points are used on their own for FULL/EMPTY symptoms o APect the area governed but the connecting channel à Lung 7 for thenar eminence or Heart 5 for tongue + eye Back Shu points Direct connection to respective organ à can transport qi directly to the organ (sympathetic chain ganglia or chakras) Used mainly for chronic conditions à treats diseases of Yin organs over yang organs, can also treat excess conditions Located on the back (yang area) – ePective in treating conditions of feeling cold or yang deficiency Outer back shu line (3 cun lateral to midline) à psychological and emotional concerns (mainly yin organs) Front Mu points Mu = alarm or collecting Locaed on anterior torso of body (directly over organ itself) front = Yin area = cooling ePect Used to treat mainly YANG organs à both acute and chronic but mainly ACUTE EXCESS conditions Examples: Liver Mu = hepatitis or cirrhosis Lung Mu = emphysema or pneumonia Back shu + front mu points can be used together to enhance treatment à best to use either back shu or front mu if the treatments are more frequent* Can be used for treatment and diagnosis: tenderness in area of point can carry lots of information o Sharp or excess type pain à indicates sedation is required o Dull or empty type pain à indicates tonification required