beyond basic joint health: advanced musculoskeletal ... · advanced musculoskeletal support through...

Beyond Basic Joint Health: Advanced Musculoskeletal Support

Through Nutrition

Presented by Jeff Lavell, DC

Disclaimer Standard Process® sponsors these webinars to provide health care information to health care professionals and to provide them with the opportunity to hear about the views, recommendations, and experiences of other health care professionals.

Standard Process has not evaluated the legal status of any products, other than its own or those of MediHerb®; services; or recommendations with respect to state or federal laws, including scope of practice. Standard Process does not and cannot accept responsibility for errors or omissions or for any consequences from applications of the information provided and makes no warranty, expressed or implied, with respect to the information provided.

Dr. Lavell’s recommendations for Standard Process and MediHerb product dosages are sometimes different than the doses that appear on the product labels. Please refer to the product labels or to the product descriptions found in the product catalogs and at standardprocess.com for the Standard Process dosage recommendations.

Dr. Jeff Lavell holds a doctorate of chiropractic from Northwestern College of Chiropractic (now Northwestern Health Sciences University). He completed undergraduate studies at the University of Minnesota at Duluth and holds a bachelor’s degree in human biology from Northwestern, where he is now an associate professor and instructor.

Dr. Lavell established Specific Family Chiropractic in Minnesota in 1998 and opened a satellite office in 2001 to meet growing demands of his patient base. Spinal Decompression of Minnesota soon followed. Although he has a true family practice, he has developed a unique approach combining chiropractic, massage, physical therapy, nutrition, and exercise to get people well as fast as possible following sports-related and other injuries. Nutrition is one of Dr. Lavell’s true passions.

For many years, he assisted bodybuilders with conditioning. He is team chiropractor for the Minnesota Menagerie women’s rugby team and for many athletes from the University of Minnesota men’s rugby team.

Joint Health & Nutrition Recap

• One of the most prevalent problems in our aging and expanding society is and will continue to be musculoskeletal and joint health

• Many patients will fall into one of three categories:

– “Tech neck” syndrome

– Aging joints

– Active-lifestyle wear and tear

Joint Health & Nutrition Recap • No two patients are the same. • Each individual patient will have different

musculoskeletal and joint health challenges that will require an individualized evaluation.

• The more thorough and precise your evaluation, the more targeted your nutritional protocols will be.

• This will result in better outcomes for your patients.


• Because minor joint pain is typically associated with the body’s natural inflammatory response as it relates to periodic challenges like strenuous activity or consumption of a high-fat meal, avoidance of inflammation-related foods is recommended.

• Certain foods, particularly those containing refined sugars and trans fats, contribute to inflammation response in the body and should be avoided by patients with joint issues.

• These foods include prepackaged snack foods, margarine, fried fast foods, white bread, and even most processed cereals.


• A patient with joint health challenges should follow a diet that is rich in raw or minimally processed complex carbohydrates, healthy (essential) fats, lean proteins, and fruits and vegetables that are nutrient rich and fiber filled.


• There is a wide range of supplements and herbs to choose from to help your patients deal with their particular joint health challenges.

• Helping patients understand the role nutrition can play in the maintenance of joint health and the support nutrition can provide for healing is crucial to getting them on the road to wellness and enjoying a better quality of life.

• Complete musculoskeletal support is a complex issue that extends beyond healthy joints.

Musculoskeletal supplementation has been around a long time

Think about all the different evolution for help in musculoskeletal issues. Many have been around for centuries if not thousands of years. From the Greeks and Romans eating legumes and animal protein to enhance recovery up to the times of our first modern day body builder Eugene Sandow who in the 1800s developed a very impressive physique utilizing nutritional supplements of protein and eggs.

What are the key areas we can focus on nutritionally for musculoskeletal issues?

Bone Bone matrix is a living growing tissue: • 25% collagen, the protein that

provides the flexible framework

• 50% crystallized mineral salts including calcium phosphate, calcium carbonate, magnesium hydroxide, fluoride & sulphate provides the strength & hardens the framework

• 25% water

Tortora, GJ, Grabowsky, SR. Principles of Anatomy and Physiology 10th Ed. John Wiley & Sons, NY, 2003, pp 162-184

Bone • Allows for movement • Defines the human form • Provide support for internal organs and tissues • Protects organs

– Your skull protects your brain, your sensory organs (eyes and ears), the vertebral column protects your spinal cord and your ribs protect your heart and lungs

• Produces red and white blood cells – Specialized bones contain red bone marrow

that produce RBC and WBC Tortora, GJ, Grabowsky, SR. Principles of Anatomy and Physiology 10th Ed. John Wiley & Sons, NY, 2003

Bone

• Stores energy in the form of fat (triglyceride)

– Yellow bone marrow

• Store minerals, e.g. calcium and phosphorus

– Vital for the functioning of all the cells in your body

– If the body needs to use these stored minerals (not enough is obtained from the diet), then the bone tissue releases them into circulation

Bone Functions: • Acid/Base Balance

– Buffers excessive acidity by releasing alkaline salts

• Stores important growth factors such as insulin-like growth factors – Mineralized bone matrix

• Acts as an endocrine organ – Helps control phosphate metabolism

by releasing fibroblast growth factor - 23 (FGF-23); which acts on kidneys to reduce phosphate reabsorption

• Supports the detoxification processes in the body by storing heavy metals such as lead and cadmium

Glucosamine

• Glycosaminoglycans (GAGs) are protective carbohydrates that are linked to proteins known as proteoglycans.

• Proteoglycans, which contain sulfur, make these compounds effective joint lubricants and repair molecules.

NOTE: The formation of GAGs is more complex than just supplying glucosamine or chondroitin

Glucosamine

• Conclusions:

– The data suggests that the mechanism of decreasing collagen degradation in this in vitro model system by glucosamine may be mediated by the inhibition of advanced lipoxidation reaction, preventing the oxidation and loss of collagen matrix from labeled chondrocyte matrix.

Source: Tiku ML, Narla H, Jain M, Yalamanchili P. Glucosamine prevents in vitro collagen degradation in chondrocytes by inhibiting advanced lipoxidation reactions and protein oxidation. Arthritis Res Ther. 2007;9(4):R76.

Glucosamine

• In vitro and in vivo studies have uncovered glucosamine's mechanisms of action on articular tissues (cartilage, synovial membrane and subchondral bone) and justified its efficacy by demonstrating structure-modifying and anti-inflammatory effects at high concentrations. However, results from clinical trials have raised many concerns. Pharmacokinetic studies have shown that glucosamine is easily absorbed, but the current treatment doses (for example, 1,500 mg/day) barely reach the required therapeutic concentration in plasma and tissue. The symptomatic effect size of glucosamine varies greatly depending on the formulation used and the quality of clinical trials.

Henrotin Y, Mobasheri A, Marty M. Is there any scientific evidence for the use of glucosamine in the management of human osteoarthritis? Arthritis Research & Therapy. 2012;14(1):201. doi:10.1186/ar3657.

Glucosamine

• In addition, research suggests (but does not confirm) that glucosamine hydrochloride in combination with chondroitin sulfate showed a lower plasmatic level, meaning that chondroitin sulfate inhibits glucosamine hydrochloride absorption and decreases its biodisponibility (bioavailability).

The human pharmacokinetics of oral ingestion of glucosamine and chondroitin sulfate taken separately or in combination.Jackson CG, Plaas AH, Sandy JD, Hua C, Kim-Rolands S, Barnhill JG, Harris CL, Clegg DO Osteoarthritis Cartilage. 2010 Mar; 18(3):297-302.

Glucosamine

• Glucosamine hydrochloride and sulfate are identical from a chemical and structural point of view. The addition of salt does not justify the difference in efficacy or biological effects observed in different studies. Indeed, both glucosamine sulfate and hydrochloride dissociate in the acidic milieu of the stomach, resulting in the release of glucosamine itself.

Review The effects of oral glucosamine on joint health: is a change in research approach needed?Block JA, Oegema TR, Sandy JD, Plaas A. Osteoarthritis Cartilage. 2010 Jan; 18(1):5-11.

Glucosamine Synergy® Glucosamine Synergy combines glucosamine, Boswellia serrata, and manganese to help maintain healthy joint function. • Maintains healthy connective tissue • Supports the body's normal connective tissue

repair process • Supports joint health • Contains many of the same ingredients as Ligaplex® II,

with the added benefit of glucosamine and boswellia for relieving discomfort in the affected areas after strenuous exercise*

*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.

Recovery and Healing

• It’s been well established that protein is essential for tissue repair. You can find numerous studies to back this point up. I would like to focus on a product you can utilize in almost any situation and it’s whey protein.

• Whey also promotes anti-oxidant activity through glutathione production (more later).

• Timing of protein for exercise vs. injury.

Whey Protein • There are a number of things to consider with whey protein and one of them is

the denatured vs. undenatured argument. Each has advantages and disadvantages.

• Undenatured is whole proteins that are processed at low temperatures. Denatured protein while not bad at all from a protein standpoint does affect the amino acid profile.

• Cold processing of concentrate allows some of the beneficial bacteria to remain active. This also significantly boosts levels of the master antioxidant glutathione. As we all know oxidation causes cellular damage, regardless of the cell type. Increase glutathione levels you increase cellular health/protection.

• Whey also contains glutamine which is essential in musculoskeletal recovery.

Protein and Glutathione Production

• Glutathione is not an essential nutrient for humans, since it can be biosynthesized in the body from the amino acids L-cysteine, L-glutamic acid (which makes glutamine), and glycine. The sulfhydryl group (SH) of cysteine serves as a proton donor and is responsible for its biological activity. (from Wikipedia)

• Cysteine as it occurs in whey is very sensitive and if broken does not provide glutathione enhancement. It is broken by pasteurization at too high a temperature, excessive agitation and oxidation.

Cysteine and Glutathione Production

• Cysteine is a sulfur-containing amino acid that contributes to the sulfhydryl group in the glutathione molecule. This makes cysteine the most crucial of the three building blocks for glutathione.

• The amount of cysteine in your system is the limiting factor in how much glutathione you can make.

• Whey protein contains cysteine.

Whey Protein

• Whey protein also provides critical co-factors, immunoglobulins, lactoferrin and alpha Lactalbumin (also a great source of cysteine), which together help create the right metabolic environment for high glutathione activity.

Whey Protein

• Amino acids are needed for connective tissue repair, whey provides a complete amino acid profile (all essential amino acids that your body cannot produce). – Elastin is made by linking many soluble tropoelastin protein

molecules, in a reaction catalyzed by lysyl oxidase. – The amino acid responsible for these cross-links is essential

amino acid lysine. » Source: www.ncbi.nlm.nih.gov/books

• Elastin becomes important when ligaments are part of the injury. – Ligaments are elastic; when under tension, they gradually lengthen, unlike

tendons which are inelastic.

http://www.ncbi.nlm.nih.gov/books

Cytokines and Inflammation

These substances need to be balanced to promote tissue response.

Cytokines

White Blood Cells

• Part of our immune response.

• The body has the ability to know it has been insulted and has cytokines that act as messengers to mount a response appropriate to that insult.

• Secreted primarily from leukocytes (white blood cells), cytokines regulate the hosts’ response to challenges.

Source: Nietfeld A, et al. Cytokines and proteoglycans. In: Jolles P (ed.). Proteoglycans. Basel: Birkhäuser 1994

Elenkov IJ, Chrousos GP. Stress hormones, proinflammatory and anti-inflammatory cytokines, and autoimrnunity. Ann NYAcad Sd. 2002 Jun; 966:290-303

Slide courtesy of Michael Greer

Cytokines

White Blood Cells


• Cytokines are cellular growth factors that are synthesized by nearly every cell of the body

• Generally produced only in response to “stress”

• Cytokines may be either:

• Pro-inflammatory

• Anti-inflammatory

Source: Elenkov IJ, Chrousos GP. Stress hormones, proinflammatory and anti-inflammatory cytokines, and autoimrnunity. Ann NYAcad Sd. 2002 Jun; 966:290-303

Cytokines and Interleukins

Th1

IL-2

IL-8

IFNy

TNFa

IL-12

Il-18

Th2

IL-4

IL-5

IL-6

IL-10

IL-13

Cell mediated immune system

Humoral mediated immune system


Prostaglandins

• Closely related to cytokines in that they affect the inflammatory cascade.

• Prostaglandins are lipid autacoids derived from arachidonic acid. They both sustain homeostatic functions and mediate pathogenic mechanisms, including the inflammatory response. They are generated from arachidonate by the action of cyclooxygenase (COX) isoenzymes.

• Prostaglandins may function in both the promotion and resolution of inflammation.

Simplified Prostaglandin/EFA

Tuna Omega-3 Oil

• Tuna Omega-3 Oil delivers essential omega-3 fatty acids

• Natural profile of tuna oil—not concentrated

• Supports normal lipid profiles within normal range

• Supports the body's natural inflammatory response function as it relates to periodic challenges like consumption of high-fat meal or strenuous activity

• Third-party tested for environmental contaminants*


Tuna Omega-3 Oil

• Supports cognition • Supports skin and hair health • Supports emotional balance • DHA is important for proper fetal eye and

brain development. • Supportive but not conclusive research has

shown that EPA and DHA omega-3 fatty acids may reduce the risk of coronary heart disease.*


Boswellia Complex • Boswellia Complex contains Boswellia,

Celery Seed, Ginger and Turmeric.

• The compounds within Boswellia Complex work together to:

– support the normal function of the maintain and support healthy joints

– support healthy circulation

– provide antioxidant activity*


Boswellia’s Action On Compliment System

Inhibition of C3 Convertase

• Two studies demonstrated the effects of boswellic acids on the compliment system*, namely C3a and C5a.

– These intermediaries participate in the release of pro-inflammatory anaphalactic peptides.

*The compliment system is an immune pathway.

Int J Immunopharmacol. 1992 Oct;14(7):1139-43. Anticomplementary activity of boswellic acids--an inhibitor of C3-convertase of the classical complement pathway. Kapil A1, Moza N.

Phytomedicine. 1996 May;3(1):77-80. Effects of boswellic acid of Boswellia serrata and other triterpenic acids on the complement system. Knaus U1, Wagner H.

Ginger

Ginger • A study published in 2010 showed Ginger’s effectiveness in post

exercise pain reduction in what is commonly known as DOMS or delayed onset muscle soreness.

• This study demonstrates that daily consumption of raw and heat-treated ginger resulted in moderate-to-large reductions in minor muscle pain (reduced exercise-related muscle pain by 23-25%). Our findings agree with those showing hypoalgesic effects of ginger in osteoarthritis patients and further demonstrate ginger's effectiveness as a post exercise pain reliever.

J Pain. 2010 Sep;11(9):894-903. doi: 10.1016/j.jpain.2009.12.013. Epub 2010 Apr 24. Ginger (Zingiber officinale) reduces muscle pain caused by eccentric exercise. Black CD1, Herring MP, Hurley DJ, O'Connor PJ.

Turmeric

Turmeric

• Has post-exercise anti-inflammatory and immune system enhancing properties.

• Turmeric is a component of curry. One of Turmeric’s derivative is CURCUMIN, which inhibits the formation of prostoglandin E2.

Vitamin C

• Importance of vitamin C in collagen I formation – Hydroxylation of lysine and proline amino acids occurs

inside the lumen – This process is dependent on vitamin C as a cofactor

• An essential co-factor in collagen synthesis – Exercise-damaged collagen will be weaker and more prone

to continued wear leading to exercise-related tissue damage and inflammation

Source: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminC

Collagen I formation

Bioavailability of Whole Food C

Source: 1. J.A. Vinson and P. Bose. Nutrition Reports International, 27, no.4, 1983. Comparative Bioavailability of Synthetic and Natural Vitamin C inGuinea Pigs. Department of Chemistry, University of Scranton, Scranton, PA 18510, USA.

2. Anitra C. Carr* and Margreet C. M. Vissers. Nutrients. 2013 Nov; 5(11): 4284–4304. Synthetic or Food-Derived Vitamin C—Are They Equally Bioavailable?

• In many animal model studies the bioavailability of the natural vitamin C was significantly greater (148%, p < 0.001) than that of the synthetic ascorbic acid. (1)

• In more recent studies (2) they have shown that humans do show near equal absorption from both sources. However, urinary output was less in many food groups and since ascorbic acid is a water soluble vitamin either the subjects reached saturation or other factors within the good form enabled better absorption. We don’t know yet based upon the research currently.

• We also must mention that bioflavonoids found within food sourced vitamin C have antioxidant abilities and other benefits that cannot be found in ascorbic acid supplementation alone.

Biochemistry of Tendons

Source: Textbook of Biochemistry with clinical correlations 6th Ed., Wiley-Liss 2006 pg 100 - 103

• Collagen – a polypeptide helix • Rich in proline and lysine • Synthesis of hydroxyproline and

hydroxylysine is dependent upon vitamin C • Galactose and glucose residues form

glycoprotein • Disulphide and OH Cross linkages

create strength

Vitamins A & C

• For supporting the body’s response to acute phase of intersegmental joint challenge.

• Stressed connective tissue needs certain minerals and vitamins to repair. Some of the key nutrients needed are manganese, vitamin A and the vitamin C complex.

• Vitamins A & C are beneficial for supporting soft tissue repair.

• These key nutrients are found in Ligaplex® I.

Manganese

• Manganese is required for the activation of prolidase, an enzyme that functions to provide the amino acid proline, for collagen formation.

Source: http://lpi.oregonstate.edu/mic/minerals/manganese

Cataplex® A-C-P

Cataplex A-C-P supports cardiovascular health as well as immune system function and the maintenance of cells and tissues.

• Promotes vascular integrity

• Helps maintain healthy mucous membranes

• Supports a healthy immune system

• Supports healthy cholesterol levels already within a normal range

• Supports dental health in relation to gums*


Other C Factors

• P factor strengthens collagen

– A flavonoid that prevents capillary fragility

• J factor improves oxygen carrying capacity

• Vitamin K aides the formation of protein

Rutin

• Rutin inhibits platelet aggregation.

• Rutin has exercise stress anti-inflammatory activity.

• Rutin also strengthens the capillaries.

– Rutin, as ferulic acid, can reduce the cytotoxicity of oxidized LDL cholesterol and lower the risk of heart disease.

– Rutin is also an antioxidant, along with quercetin, acacetin, morin, hispidulin, hesperidin, and naringin, it was found to be the strongest.

Bioflavinoids

– There is evidence to suggest that flavonoids may be beneficial to connective tissue for several reasons, which include the limiting of inflammation and associated tissue degradation, the improvement of local circulation, as well as the promoting of a strong collagen matrix.

Source: Teixeira S. Bioflavonoids: proanthocyanidins and quercetin and their potential roles in treating musculoskeletal conditions. J Orthop Sports Phys Ther. 2002 Jul;32(7):357-63

Buckwheat

• Buckwheat is rich in “vitamin P”

• P factor is a flavinol that is essential to the functional vitamin C complex

Source: Nature 140, 426-426 (04 September 1937 Vitamin P A. BENTSÃ TH & A. SZENT-GYÃ–RGYI

Gotu Kola • Gotu Kola extract or the triterpenes of Gotu Kola (TGK)

have demonstrated the following effects:

– Increased collagen content and promotion of collagen cross-linking in granulation tissue of dermal wounds (I.e. an increased rate of synthesis and maturation of collagen)

– Improved mechanical properties of the scar tissue (e.g. improved strength)

Source: Vogel HG, De Souza N, D'Sa A. Acta Therapeut 1990; 16: 285 Source: Suguna L et al. Indian J Exp Biol 1996; 34: 1208

Gotu Kola

• Connective Tissue Support

– Wound/scar tissue control:

Reduces fibroblast formation, scar tissue, and supports connective tissue healing

• Therapeutic dose: 120 mg per day

Source: Gotu Kola – The Healing Herb the Phytotherapist Perspective, No. 115, Oct 2007

Gotu Kola • The aerial parts of the plant contain the active constituents:

• Pentacyclic triterpene esther saponins which are also known as asiaticosides or TFGK (triterpene fraction of Gotu Kola)

• TFGK demonstrated natural wound healing activity in many experimental models

• The mechanism of action is an increase in production of type I collagen and decrease in inflammatory myofibroblast production

Source: Tenni R, et al. Effect of the Triterpenoid Fraction of Centella asiatica on Macromolecules of the Connective Matrix in Human Skin Fibroblast Cultures. Ital J Biochem. 1988;37(2):69-77.

Gotu Kola Complex Gotu Kola Complex is a combination of Gotu Kola, Grape Seed and Ginkgo biloba. These herbs contain pentacyclic triterpene ester saponins (especially asiaticoside), oligomeric procyanidins, flavonoids, terpene lactones (including ginkgolides, bilobalide) and other phytochemicals. Together these herbs and the compounds within them help to: • promote healthy skin and connective tissue • promote healthy blood circulation • provide antioxidant activity • support healthy capillaries*


Myotrophin PMG®

• This provides many key nutrients that are hard to find to support muscle health.

• Also contains the Protomorphogen™ extracts that promote healthy tissue response and function. – These Protomorphogen™ extracts are organ specific, in this

case muscle tissue – Provides unique profile of minerals, nucleotides, and

peptides – Twin product to Cardiotrophin PMG*


Myo-Plus®

• Think of this product as a food based muscle support • Supports muscular health and function • Supports the healthy functioning of muscles, including the heart • Supports normal coronary blood flow • Provides ingredients with antioxidant activity • Support for increased oxygen demand during exercise • Twin product to Cardio-Plus®

• Contains a combination of key ingredients from Cataplex® G, Cataplex® E2,Cardiotrophin PMG®, and Cataplex® C*


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