MD and ND Collaboration. Practical Approaches to Chronic Pain

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Giles Caldwell
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1 MD and ND Collaboration Practical Approaches to Chronic Pain

2 Disclosures Talks for Allergan Founder and Director of Headache, Migraine and Concussion Centre, Ajax, ON, Canada Founder and Medical Director of Pure Life Science Inc.

3 Definition of Chronic Pain 1 Chronic pain is often defined as any pain lasting more than 12 weeks. Chronic pain persists often for months or even longer. Acute pain is a normal sensation that alerts us to possible injury; chronic pain is very different /spring11pg5-6.html

4 Who Has Chronic Pain According to the American Academy of Pain Medicine, more than 1.5 billion people around the world have chronic pain. Most common cause of long-term disability in the United States, affecting about 100 million Americans

5 Most Common Types of Chronic Pain headache postsurgical pain post-trauma pain lower back pain cancer pain arthritis pain neurogenic pain (pain caused by nerve damage) psychogenic pain (pain that isn t caused by disease, injury, or nerve damage)

6 What Is Common to All Inflammation Inflammation Inflammation!

7 What is Inflammation Inflammation is part of the body's immune response, usually acute injury or infection Chronic inflammation can be thought of as an imbalance between energy demand and energy supply When cells are deprived of oxygen or nutrients, inflammatory factors are released a call for help

8 Inflammatory Factors involved with Migraine cytokines, tyrosine metabolism, homocysteine; and factors associated with pain transmission and emotions e.g.: serotonin, hypocretin1, calcitonin generelated peptide (CGRP), glutamate and substance P Molecular factors in migraine, Marta Kowalska et al, Oncotarget Aug 2; 7(31):

9 Chronic Inflammation and Chronic Pain Can you have one without the other? Chronic low grade inflammation is increasingly seen as a part of other orthopaedic conditions such as osteoarthritis once considered a cold wear and tear problem (as opposed to the far more overt and hot inflammation of rheumatoid arthritis) Summer is coming Frozen Shoulder, Cocks (Noijam.com) 1.

10 Migraine As a Reflection of Inflammation Vascular theory of migraines does not reflect reality Nerve Blocks should not work yet they do Alternate explanation needed Is Migraine really a neurogenic inflammation issue?

11 New Neuro-anatomy

12 Neuroanatomy of the Rat and Human Innervation of Rat and Human Dura Mater and Pericranial Tissues in the Parieto- Temporal Region by Meningeal Afferents Markus Schueler, MD; Winfried L. Neuhuber, MD; Roberto De Col, MD; Karl Messlinger, MD Headache 2014 American Headache Society

13 The Skull

14 This Explains It Nerve Blocks work! Botox? How does it work?

15 Botox as a Management Tool 1 Neuromuscular Paralysing Agent Anti-Inflammatory? BTX-A affects secretion of substance P in nerves cultured from the dorsal root ganglion of mouse embryos and decreases the secretion of calcitonin gene-related peptide (CGRP) in cultures of neurons from the trigeminal ganglion. Subcutaneous injection of BTX-A showed decreased inflammation from stimulus, secretion of glutamate in the nociceptor's axon, and activity of spinal dorsal horn neurons in mice 1. Botulinum toxin in pain treatment. Colhado OC, Boeing M, Ortega LB Rev Bras Anestesiol May-Jun; 59(3):366-81

16 We Have Management Tools Is there a CURE? Energy Imbalance: All energy comes from mitochondria If cells can t get energy then mitochondria must be damaged

17 Mitochondrial Injury: The New Paradigm Becoming increasingly clear that mitochondrial dysfunction is responsible for many chronic diseases These are acquired diseases through exposure to pesticides, herbicides, heavy metals and processed foods

18 Central Characteristic of Mitochondria

19 The Importance of Membranes All membranes are made of essential fatty acids and saturated fat The importance of composition to function cannot be understated The 2 essential fatty acids are Linoleic Acid (Omega-6) and alpha Linolenic Acid (Omega-3) 99% of ingested Omega-6 gets incorporated directly into the membrane!

20 Almost All Reactions Take Place on the Membrane Specifically, Cardiolipin Entirely made up of Omega-6, Linoleic Acid No Omega-3, No DHA, No EPA Why?

21 Small but Significant Fact Look at this curve Ian M. Campbell, Douglas N. Crozier, Robert B. Caton, Fatty Acid Composition and Impaired Oxygen Supply in Cystic Fibrosis Patients,.

22 The oxygen complex of linoleic acid (Omega-6) dissociates at relatively high pressures, whereas that of oleic dissociates only at low pressures. Accordingly, excessive substitution of oleic for linoleic acid in membrane lipids would be expected to decrease the intracellular oxygen pressure to a level where hemoglobin oxygenation and any other oxygen-requiring processes would be impaired.

23 Oxygen Handling Cannot be Passive Oxygen (O2) is a very reactive compound It cannot be allowed to roam freely in the cell It is handled by the cell and mitochondrial membrane, specifically by Linoleic Acid (LA)

24 Damaged Omega-6* Processing of all commercial cooking oils damages LA Heating multiple times with hexane extraction, de-odorization and filtering The oil can no longer absorb oxygen, therefore can never rot (become rancid) *

25 Oils That Never Rot Our cell membranes, especially the mitochondrial membrane need oxygen for respiration Accumulation of processed LA inhibits this process, causing energy imbalance and inflammation

26 Functional LA Can only come from plants Must be organic and as close to raw as possible Seeds and nuts are best sources

27 Other Causes of Dysfunction Heavy Metals such as Lead, Mercury, Cadmium, Aluminum: Interfere with enzymatic reactions and also interfere with the lipid bilayer 1 Heavy metals enter plant, animal and human tissues via air inhalation, injection, diet and manual handling 1. (Appl Environ Microbiol Aug; 63(8): )

28 Vitamin D in Migraines Cholecalciferol (Vit D) therapy augments muscle mitochondrial maximal oxidative phosphorylation after exercise in symptomatic, vitamin Ddeficient individuals Should be the same in brain mitochondria Improving the vitamin D status of vitamin D deficient adults is associated with improved mitochondrial oxidative function in skeletal muscle. Sinha A1, Hollingsworth KG, Ball S, Cheetham T, J Clin Endocrinol Metab Mar;98(3):E50913

29 How to Fix? How should I know? We didn t take this in medical school Hence, the role of NP s become more substantial as our world becomes more toxic

30 Pesticides? Herbicides? Again, medicine is stumped Detoxing from these increasingly pervasive issues does not fall under allopathic medicine

31 Medications? Our chronic pain ammunition is becoming increasingly dated There has been no new medications approved in 15 years CGRP antagonists hold some promise but expense is daunting

32 The Future of Medicine Increasingly looks like a collaborative model We must look at the whole body, we are not just parts put together We must recognize the limitations of each of our specialties

33 Basic Testing hscrp is essential as well as CK to find evidence of mitochondrial dysfunction Vit D levels should be optimized to as close to 150 mmol/l (60 ng/dl) Thyroid function with free T4 and free T3 as well as reverse T3 and possibly thyroid antibodies Vit B12, Zn, Mg levels

34 Summary Most things we do manage pain Treating underlying causes complicated, start with the basics Cellular membrane health (essential, plantbased fatty acids) Eliminating toxic exposures including some drugs Optimizing vit D, it s more important than you think

35 Words to Live By When I know Everything, I realize I know nothing Dr. Jeff Matheson, after 15 years of Emergency Room work, bitten in the ass too many times

Where are we now? Expected New Cancer Diagnosis in 2016 American Cancer Society. Cancer Facts & Figures Atlanta: American Cancer Society; 2016.

Dr. Pat Buchar, DC Where are we now? Expected New Cancer Diagnosis in 2016 American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016. Why haven t we made progress? 1.