WHMC311. Session 14. Nervous System Disease Part I. Naturopathic Medicine Department. Endeavour College of Natural Health endeavour.edu.

Transcription

1 WHMC311 Session 14 Nervous System Disease Part I Naturopathic Medicine Department 1

2 Topic Overview o Overview of principles and considerations in herbal management of the nervous system condition pain. o Review of herbal actions, indications, applications and contraindications of: analgesics, sedatives, hypnotics, tranquilisers, anti-spasmodics, relaxants, nervine tonics, nervine trophorestoratives, cognition enhancers and neuroprotectives. 2

3 Naturopathic Diagnostics: NS o Dysfunction of the Central Nervous System can be seen in abnormalities in the size and shape of the pupil. o Also at the following regions: cerebral (brain) area, spinal area, adrenal area, nerve rings and iris fibre signs. o Dysfunctions of the Autonomic Nervous System may also be seen in Autonomic Nervous Wreath size, shape, colour and texture abnormalities. (Jensen, 1952) 3

4 Herbal Medicine for the NS Receptor Activity o Herbal remedies are not directly comparable to conventional drugs in terms of direct action. o It is most likely that the primary effect of plant constituents on the nervous system is on the synaptic junctions o Communication junctions are in receptor sites on pre and post synaptic membrane (Bone & Mills 2013, p.270) 4

5 Receptor Activity o Ca channel activity opioid alkaloids, ginseng saponins, coumarin, scoparone (Capillaris) etc. o Adrenergic effects Ephedra, ephedrine, pseudoephedrine, Angelica sinesis and Cnidium monnieri (Beta-2-adrenergic) o Acetylcholine Solanacea family - Nicotiana tabacum (tobacco) etc. o GABA and benzodizepine Valeriana off, Salvia miltiorrhiza o Dopaminergic Mucuna pruriens, Polygala tenuifolia, Corydalis ambigua (Bone & Mills 2013, p ) 5

6 Pain o Pain is a disagreeable subjective physiological and psychosocial experience that often serves a biological purpose (warning of injury) o Highly subjective, pain does not necessarily correlate with the degree of tissue damage (Sinclair, 2014, p.803) 6

7 Pain Classification o Somatogenic (direct physiological mechanism or insult) Nociceptive (ongoing activation) Neuropathic (neurological dysfunction) Or o Psychogenic (non organic origin) o Acute (lasting less than 4 weeks) Or o Chronic (longer than 12 weeks) (Sinclair, 2014, p.803-6) 7

8 Pain Management o Classify/asses the pain o Identify the cause o Pain amelioration o Address the underlying cause o Address comorbidities (depression, insomnia etc.) o Enhance mental resilience o Lifestyle modifications o Close patient monitoring o Address social factors (Sinclair, 2014, p.806-7) 8

9 Treatment Considerations o Ameliorate pain and reduce suffering Eschscholzia californica (GABA binding and anxiolytic, possibly inhibit catecholamine degradation, synthesis of adrenaline and bind to opiate and benzodiazepine receptors) Corydalis ambigua (tetrahydropalmatine sedative, analgesic, dopamine receptor antagonist) Passiflora incarnate (anxiolytic, hypnotic and mild sedative possibly secondary clinical benefit) Piper methysticum (anxiolytic, hypnotic, sedative and skeletal muscle relaxant, lactones DHK and DHM shown analgesic effect via non-opiate pathways) (Sinclair, 2014, p.809) 9

10 Treatment Considerations o Ameliorate pain and reduce suffering Harpagophytum procumbens (iridiod glycosides anti-inflam and analgesic, possible inos and COX-2 expression through inhibiting NF-kB and reducing COX-1 activity) Salix alba (Acetyl group to salicylic acid led to NSAID and Asprin development; hyaluronidase/lipoxygenase inhibition, free radical scavenging may contribute to anti-inflame and analgesic action) Piscidia erythrina (central analgesic activity) (Sinclair, 2014, p.810) 10

11 Indications for Herbal Analgesics o Pain associated with inflammation: Arthritis Tendonitis Myalgia o Pain associated with vascular spasm: Migraine Angina Intermittent claudication o Pain associated with visceral spasm: Gall bladder Urinary tract Intestinal colic Spasmodic dysmenorrhea o Neuralgic pain (in limited cases) Shingles 11

12 Analgesics o Some traditional herbal analgesics include: Corydalis spp (Corydalis) Eschscholzia californica (Californian poppy) Salix alba (Willow bark) Piscidia erythrina (Jamaican Dog Wood) Anemone pulsatilla (Pasque flower) Piper methysticum (Kava) o Topical Analgesics Mentha piperita (Peppermint essential oil) Capsicum minimum (Cayenne) Arnica montana (Arnica) 12

13 Corydalis ambigua o Actions Bitter, sedative, hypnotic, analgesic, cardioprotective, anti-arrythmic o Uses Pain, insomnia, cardiac arrythmia, myocardial ischemia o Contraindications Pregnancy 13

14 Treatment Considerations o Reduce local and systemic inflammation Topical anaesthetics Capsicum frutescans, Piper methysticum, Gaultheria procumbens (Wintergreen oil), Syzigium aromaticum Systemic - Zingiber officinale, Serenoa repends, Curcuma longa, Glycyrrhiza glabra, Harpagophytum procumbens, Boswellia serrata, Marticaria recutita, Arnica montana, Salix alba o Support the immune system Dysfunction may impact on autoimmune/infectious disease pain presentation (Hemidesmus indicus, Tylophora indica, Echinacea spp. Uncaria tomentose, Andrographis paniculata, Astragalus membranaceus, medicinal fungi) (Sinclair, 2014, pp ) 14

15 Treatment Considerations o Support the nervous system Psychological consequence of pain exposure and specific painful diseases affecting the NS such as herpes zoster etc. Adaptogens and nervine tonics Address insomnia if present - Sedatives and hypnotics Psychological CBT referral, mindfulness/meditation, antidepressants and/or anxiolytics (Sinclair, 2014, p ) 15

16 Herbal Sedatives, Hypnotics & Anxiolytics Sedatives Hypnotics Anxiolytics Withania, Bacopa Bugle weed Californian poppy Chamomile, Cramp Bark Hops, Jamaican Dog Wood Kava, Lemon balm Lime Flowers Mexican Valerian Valerian, Mistletoe Passionflower Peppermint, Skullcap Ziziphus, Wild Cherry Californian poppy Hops Kava Mexican Valerian Valerian Passionflower Ziziphus It can be seen from this table that many of our nervine herbs cover a wide range of nerve related actions Bacopa Californian poppy Oats Green Kava Lavender Mexican Valerian Valerian Neem Leaf Passionflower Ziziphus 16

17 o Indications Herbal Sedatives, Hypnotics & Anxiolytics Modern tension and anxiety syndromes (short term or intermittent use) Insomnia difficulty getting to sleep first thing at night. Weaning off conventional sedative prescriptions Restlessness during convalescence 17

18 Herbal Sedatives, Hypnotics & Anxiolytics o Contraindications Generally milder than prescribed sedatives and should not be seen as immediate substitutes in more serious indications. It would be unwise and possibly dangerous to stop strong medication without careful planning. Insomnia marked by increasing restlessness during the early morning Depression 18

19 Antispasmodics and Relaxants o Some traditional herbal antispasmodics and relaxants: Viburnum opulus Dioscorea villosa Leonurus cardiaca Matricaria chamomilla Passiflora incarnata Piper methysticum Scutellaria lateriflora Tilia spp Valeriana off. 19

20 Antispasmodics and Relaxants o Indications: Anxiety, irritability and restlessness, including in children Sleeplessness due to anxiety and irritability Nervous dyspepsia Irritable bowel and intestinal colic Tension headache Spasmodic dysmenorrhoea Antispasmodics and relaxants may be taken as hot infusions, though the ordinary tea bag may not be sufficiently strong compared with a tradition brew. 20

21 Nervine Tonics & Nervous Trophorestoratives o Many conditions of tension are linked with fatigue, debility and depression o A group of remedies have emerged to meet the needs of a modern stressed society o Anti-depressants: Hypericum performatum, Lavandula officinalis, Crocus sativa, Rhodiola rosea 21

22 Nervine Tonics & Nervous Trophorestoratives Avena sativa Hypericum perforatum Scutellaria laterifolia Turnera aphrodisiaca Verbena off. Withania somnifera 22

23 Nervine Tonics & Nervous Trophorestoratives o Indications: Nervous exhaustion Neuralgia, herpes infections Depressive states Insomnia (waking in the small hours after getting to sleep easily) Convalescence Neurasthenia 23

24 Nervine Tonics & Nervous Trophorestoratives o Contraindications: True trophorestoratives are almost nutritive in their effects, with few risks of adverse effects except in those patients with extremely debilitated constitutions. o Application: May be taken as required or before food. Long term therapy with trophorestoratives is generally the norm 24

25 Pain Example: Headaches o Headaches pain located above the orbitomeatal line. Primary: Tension-type Cluster Migraine - disabling, primary headache, characterised by unilateral pulsing pain. With or without aura Secondary: Cranial or cervical vascular disorders, non-vascular disorders e.g. hypertension Substance or withdrawal, infection, homeostatic disorder, psychiatric (Cottingham, 2014, p ) 25

26 Pharmaceutical Management Non-Opioid Analgesics - Paracetamol Mode of Action o Inhibits prostaglandin production within the CNS, with some COX inhibition (no anti-inflammatory benefits) giving it analgesic and antipyretic properties. Side Effects o Occasional incidences of skin rash & nausea if used within therapeutic dose. o Paracetamol overdose (10-15gms or tablets) will cause severe liver damage due to depletion of glutathione, and possibly lead to death. Doses of 50 tablets is usually fatal unless quickly antidoted with acetyl cysteine. o Liver toxicity appears to be linked to the concomitant use of excessive quantities of alcohol, or overdose (Bryant & Knights, 2007; Bullock et.al. 2007) 26

27 Pharmaceutical Management Non-steroidal Anti-inflammatory Drugs (NSAIDs) ibuprofen, aspirin, diclofenac, indomethacin, piroxicam Mode of Action o Non-selectively inhibit the synthesis and release of prostaglandins by inhibiting the cyclo-oxygenase (COX) enzymes in both COX-1 & COX-2 pathways. Also inhibits platelet aggregation. Side Effects o Gastro-intestinal (dyspepsia, nausea, vomiting, diarrhoea, constipation, gastritis, and may all potentially lead to ulceration and haemorrhage (COX-1 inhibition) o Skin reactions, rash, sodium retention, may precipitate asthma attacks. (Bryant, 2003) 27

28 Pharmaceutical Management COX-2 selective NSAIDs Celecoxib Mode of Action o COX-2 is formed in inflammatory conditions thus it is this pathway that would seem most appropriate to target when trying to reduce inflammation and pain (Bryant, 2003). o Don t inhibit COX-1 so have no GIT side effects or alter platelet aggregation. Useful for patients that can t use nonspecific NSAIDs. Side Effects o Associated with an increased risk of cardiovascular and thrombotic adverse effects. o Renal damage due to inhibition of vasodilator prostaglandins resulting in heart failure and hypertension in some patients. (Bryant & Knights, 2007; Bullock et.al. 2007) 28

29 Pharmaceutical Management Opioids Opium, Morphine, Codeine, Oxycodone, Pethidine, Tramadol etc Mode of Action o Opioids stimulate opioid receptors inhibiting the release of substance P from the dorsal horn neurons reducing pain sensations and inhibiting local inflammatory reactions. o Euphoric action inhibits pain perception. o Opiate analgesics are useful for relieving intense pain, non responsive to non-opioid analgesics o The response can vary dramatically between different opioid drugs, with different rates of absorption o The more lipophilic the agent, the better absorbed and the greater the ability to cross the blood-brain-barrier (Bryant & Knights, 2007; Bullock et.al. 2007) 29

30 Treatment Aims o Establish the type of headache and underlying cause o Address of risk factors and triggers (e.g. food sensitivities and allergic responses) o Reduce pain and inflammation o Ensure optimal nutrition and hydration o Consider detoxification programs to manage medication overuse headache syndrome o Assess body mechanics and spinal alignment refer o Address lifestyle exercise, stress reduction (work/life balance) (Cottingham, 2014, pp ) 30

31 Herb Coleus, Zingiber & Turmeric Corydalis Californian poppy Willow Bark Chaste tree Rosemary Skullcap Valerian Mistletoe Lavender Catnip Passionflower All work on prostaglandin pathway Analgesic very large doses required Analgesic Analgesic and anti-inflammatory If hormonal relationship Migraine or hypertensive headache Nervine Action/Indication Sedative, nervous excitability Hypertensive headaches and frequent headaches with flushing face For depression associated with digestive dysfunction Sedative and for nervousness Nervousness, debility with fullness 31

32 Tanacetum parthenium o Traditionally used for migraines (especially if better with warm applications) o Serotonergic pathway addressed by inhibiting phospholipase, preventing release of 5-HT from platelets and polymorphonuclear leukocytes o In-vitro inhibits nitric oxide release (sensitise migraineurs to pain and activate vasodilation trigger) o May inhibit prostaglandin synthesis o Long term treatment is necessary - can be up to six months before effects are noticed (Cottingham, 2014, pp ) 32

33 Neuralgia/Neuropathy o Neuropathic pain pathophysiology is largely based on the causative aetiology in many instances; however, it is heavily characterised by dysfunction of pain fibres of the CNS Treatment considerations: o Neuropathy Neuro protective Ginkgo biloba Capillary protective Vaccinium myrtillus o Neuralgia Capsicum spp. 33

34 Capsicum minimum o Capsaicin is an active constituent from the fruit of Capsicum minimum and other species (Cayenne). Binds to vanillinoid receptors, promotes release of substance P, neurokinin, somatostatin and calcitonin from peripheral nerve fibres (particularly C fibres in the slow pain network). Initially worsens pain/itching Repeated applications, C fibres are depleted of these neurotransmitters, and are no longer able to transmit pain or itch signals. With continued use, this effect can be sustained indefinitely. (Yarnell, Abascal 2008) 34

35 Capsicum minimum o Conditions in which topical capsaicin has proven effective in double-blind trials include: Various neuralgias Diabetic neuropathy Dialysis-induced pruritus Psoriatic pruritus Fibromyalgia Osteoarthritis Stump pain Postmastectomy pain Postherpetic neuralgia (Yarnell, Abascal, 2008) 35

36 Herb-Drug Interactions Opioids Panax ginseng o May reduce drug induced tolerance and decrease adverse effects (Stargrove et al. 2008) Opioids Codeine Fiber o May prevent gastric upset and constipation. Concurrent use of water, fibre, and water rich foods that assist with bowel motion may be beneficial. Alcohol o Impaired alertness, constipation, impaired judgment (Braun & Cohen, 2010) 36

37 Herb-Drug Interactions Paracetamol o Alcohol may have more potential to cause liver damage when taken together (Braun & Cohen, 2010) o Syzygium aromaticum (Clove) oil due to potential hepatotoxicity of its eugenol content should not be used together (speculative) (Brinker 2010, p.104) o Cyamopsis tetragonolobus (Guar gum seeds) and Malus domestica slows absorption due to slower gastric emptying (Brinker 2010, p.364) 37

38 Herb-Drug Interactions NSAIDs - Aspirin Capsaicin o Found to protect gastric mucosa against aspirin-induced damage. (Braun & Cohen, 2010) Grapeseed extract o Enhances antiplatelet and anti-inflammatory activity of aspirin and may risk of bleeding. Allium sativum, Zingiber off, Curcumin longa o Inhibits COX & LOX pathways therefore enhancing the drug effectiveness. Additive effect. (Sarris & Wardle, 2010) 38

39 Cognition Enhancement o Cognition encompasses a broad range of brain processes, the health of which allows for social connectedness, a sense of purpose and the ability to function independently. o Cognitive decline is significant in the elderly population. Alzheimer s disease is the most common dementia. Cerebrovascular disease brain lesions connected with cardiovascular health/risk factors o Traditional herbal remedies address these 39

40 Bacopa monnieri o A traditional Ayurvedic herb used as a brain tonic, and to improve memory and learning o Also used to promote longevity, nervous deficit due to injury and stroke o In India it is called Brahmi - as is Gotu Kola: Centella asiatica o The two plants share similar uses, and they are sometimes confused in the literature Bacopa monniera (Brahmi) Centella asiatica (Gotu kola) 40

41 Bacopa monnieri o An Australian clinical trial examined the long-term effects of an extract of Bacopa monnieri on cognitive function in 54 healthy human volunteers (Calabrese et.al. 2008) o The study was of double-blind, placebo-controlled design in which subjects were randomly allocated to receive Bacopa or placebo. o Neuropsychological testing was conducted before treatment and at 5 and 12 weeks after treatment. 41

42 Bacopa monnieri o After 12 weeks the largest cognitive change from Bacopa treatment was a time reduction for the Inspection Time (IT) test. o IT is regarded as a measure of the integrity of the early stages of information processing and may act as a ratelimiting factor for cognition. o This indicates that Bacopa significantly improved the speed of visual information processing. 42

43 Schisandra chinensis o Lignans from Schisandra chinensis improved concentration, fine co-ordination and sensitivity in healthy young male adults as assessed by tasks such as threading a needle and telegraphic reception and transmission. o Schisandra improved vision, enlarged the visual field, improved hearing and heightened skin sensory discrimination o It was thought that those effects are central rather than peripheral. (Chang HM 1987 as cited in Bone 2003, p.407) 43

44 Panax ginseng o In a double-blind study on students given Ginseng over thirty-three days significant improvements in psychomotor ability and intellectual performance were observed. o Nurses switching from day to night duty were evaluated for competence, mood, wellbeing and psychophysical performance in a double-blind clinical study of Ginseng versus placebo. o Ginseng improved the scores for competence and mood, and performance on the psychophysical test. (D Angelo et al,1986) 44

45 Pre-reading for next session o Reading 1: Braun, L Cohen, M 2010, Herbs and Natural Supplements: An evidence based guide, 3 rd edn, Churchill Livingstone, Australia pp o Reading 2: Yeon, KY Kim, SA Kim, YH Lee, MK Ahn, DK Kim, HJ Kim, JS Jung, SI & OH, SB 2010, Curcumin Produces an Antihyperalgesic Effect via Antagonism of TRPV Journal Dental Research, vol. 89, no. 2, pp o Reading 3: Maroon, JC Bost, JW Maroon, A 2010, Natural antiinflammatory agents for pain relief Surgical Neurology International, vol. 80, no

46 References Barbarino F, Neumann E, Deaciuc I, Ghelberg NW, Suciu A, Cotuţiu C, Racoviţă L, Stroilă C, Nagy S, Părău N, Toader S, Brilinschi C, 1981, Effect of silymarin on experimental liver lesions, Médecine Interne, vol.19, no.4, pp Bone K, 2003, A Guide to Blending liquid Herbs, Churchill Livingstone, Warwick,Australia. Bone, K Mills, S 2013, Principles and Practice of Phytotherapy: A Modern Herbal Medicine, 2 nd Edn, Churchill Livingstone, Edinburgh Bordet R, Devos D, Brique S, Touitou Y, Guieu JD, Libersa C, Destée A, 2003, Study of circadian melatonin secretion pattern at different stages of Parkinson's disease, Clinical Neuropharmacology, vol.26, no.2, pp Braun L, Cohen M Herbs and Natural Supplements, An Evidence-based Guide 3 rd Edition. Churchill Livingstone Elsevier. Brinker, F 2010, Herbal Contraindications and Drug Interactions, 4 th Edn., Eclectic medical publications, Sandy, Oregon Bullock, S., Manias, E. & Galbraith, A Fundamentals of pharmacology. 5 th ed. Pearson, NSW. Calabrese C, Gregory WL, Leo M, Kraemer D, Bone K, Oken B. 2008, Effects of a standardized Bacopa monnieri extract on cognitive performance, anxiety, and depression in the elderly: a randomized, double-blind, placebocontrolled trial, Journal of Alternative Complementary Medicine,vol 14(6): pp Cao F, Sun S, Tong ET, 2003, Experimental study on inhibition of neuronal toxical effect of levodopa by ginkgo biloba extract on Parkinson disease in rats, Journal of Huazhong University of Science and Technology, vol.23, no.2, pp Cha CW, 1987, A study on the effect of garlic to the heavy metal poisoning of rat, Journal of Korean Medical Science, vol.2, no.4, pp Choudhury AR, Das T, Sharma A, 1997, Mustard oil and garlic extract as inhibitors of sodium arsenite-induced chromosomal breaks in vivo, Cancer Letters, vol.121,no.1, pp Cottingham, P 2014, Headache and migraine, in J Sarris & J Wardle (eds), Clinical naturopathy: an evidence based guide to practice, Churchill Livingston Elsevier, Sydney pp

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