Medicinal herbs contain polyphenols and thousands of other chemical constituents which influence metabolic pathways and gene expression. The largest categories include triterpenes (30,000-plus) and alkaloids (16,000-plus). Medical nutrition has focused on the benefits of polyphenol bioflavonoids (antioxidant, anti-inflammatory) and the much-publicized saponins (adaptogenic triterpenoids). Research into the benefits of medicinal plant compounds is still rudimentary, but developing knowledge of the workings of the secondary metabolites of plants is expanding established concepts of metabolic modification and expression of genetic polymorphisms.
Of special interest are medicinal herbs' effects on cytokine production. Proinflammatory cytokines have multiple adverse consequences on tissues, including the delicate endothelium of blood vessels. Many phytochemicals have been shown modify synthesis of tumor necrosis factor (TNF), interleukin-1 (IL-1), interleukin-6 (IL-6), C-reactive protein (CRP), nitric oxide (NO and iNOS) and the critical NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells), which controls DNA transcription and regulates cytokine response. Herbs can downregulate NFkB expression without eliminating its baseline activity, in contrast to pharmaceutical COX and LOX inhibition.
Polyphenols, found in herbs and produce, have demonstrated compelling evidence of anti-inflammatory activity. Epidemiologically, it is noted that populations who consume a diet high in polyphenols have reduced rates of inflammation-related disease. Polyphenols also excite interest because of their potent modulation of oncogenesis, but polyphenols are not even the tip of the iceberg. Plants are estimated to contain up to 500,000 phytochemicals, many with medicinal actions for human health. The Chinese and Ayurvedic traditions have developed sophisticated systems of herbal treatment protocols that have been in use for millenia.
Herbs can be implemented in practice in a step-wise fashion, beginning with singleton herbs (specific herb for specific condition) and progressing to complex formulas with multiple actions and effects. Herbal protocols exist for treating both acute conditions and the longer-term inflammatory states that underlie most chronic diseases. The focus of this discussion is medicinal roots and barks from various traditional systems that can be used conveniently as singletons for treating chronic inflammation.
Ashwaganda
Ashwaganda (Withania somnifera; roots, leaves & seeds) is a powerful Ayurvedic tonic and adaptogen. It is especially indicated for the overstimulated and debilitated, "tired and wired" patient. Its adaptogenic abilities are not as strong as Panax, but it is not stimulatory as the Panax ginsengs can be to patients with genetic polymorphisms. Ashwaganda is therefore more useful for the cardiac patient and for females.
Professional herbalists often shudder while reading labels of formulations by those with knowledge of standardized chemical components, but no background in the traditional and energetic components of clinical herbalism. The Panax ginsengs (Chinese, Korean, red, white, red ice) are male tonics, especially suited for aging men free of cardiovascular disease. Other ginsengs are appropriate for women and children, and Panax use for females and hypertensives can induce undesirable reactions.
Ashwaganda's pronounced anti-inflammatory effects mimic the effects of glucocorticoids. It contains the steroidal lactones withaferin A and withanolide E, plus phytosterols and alkaloids. It balances the chronic inflammatory response in connective-tissue disorders such as lupus and RA. Ashwaganda is documented to reduce proinflammatory plasma protein levels in a superior fashion to hydrocortisone. Withania constituents modulate immunoregulation; both immunosuppressive and immunostimulatory effects upon phagocytes and lysosomal enzymes are seen. The entire plant is deemed to be a selective immune response modulator and normalizer of cortisol.
Importantly, ashwaganda has a GABA-mimetic effect and is therefore useful for anxiety. It is used in the Ayurveda for sedation and as a hypnotic. As with steroids, Ashwaganda enhances benzodiazepine receptor activity.
Despite the fact that Withania is considered to be a very safe herb, caution is prudent with any patient taking benzodiazepines or psychoactive drugs. It is known to have benefit in substance abuse and anti-convulsant regimens, possibly downregulating opiate addiction and seizures via its GABA-ergic actions.
Baikal Scullcap
Baikal scullcap (Scutellaria baikalensis, aka Huang Qin; root) is another important herbal anti-inflammatory widely used in autoimmune syndromes and acute infections including hepatitis, herpes and Staph aureus. "Scut root" is a powerful hepatoprotectant and antioxidant. It inhibits induction of inflammatory leukotrienes and prostaglandins, limits mast cell degranulation, and reduces antigen binding to IgE. Both a LOX and COX inhibitor, its effects for arthridites are similar to prednisone.
Scut root benefits bronchial allergic syndromes via its anti-constrictive actions. Constituents include bitters (specific for hepatic support), flavones and flavone glycosides. Because of its steroidal phytochemistry, caution is advised with any patient using steroids or psychoactive drugs. Scutellaria baikalensis may have anticoagulant activity and is used cautiously for patients on statins, coumadin and "blood-thinning" medications. Substitutions are known, especially in Internet sales, and it is important to use professional suppliers who guarantee sources and provide assays upon demand.
Baicalin, the most studied constituent, has anti-inflammatory and antioxidant actions, and antibacterial activity against gram-positive organisms. This herb also affects GABA receptors via its flavonoids, which exert neuroprotective effects and decrease mast cell histamine degranulation. Apoptosis in hepatic carcinoma lines is also known.
Boswellia
Boswellia (Boswellia serrata, aka Frankincense; gum resin) contains pentacylic triterpene boswellic acids, which benefit chronic inflammation and joint pain via downregulation of leukotriene synthesis and interruption of the inflammatory cascade. A potent inhibitor of (LOX), boswellia is best known for improvement of asthmatic profiles, providing bronchial relaxation, lowering eosinophil counts and ESR.
Histological comparison of pre- and post-treatment colitis sufferers shows improvement for collagenous colitis, and clinical effectiveness has been demonstrated for Crohn's disease and RA. Studies have also shown decreased swelling in knee OA with increased ROM and ease of joint use, with no major side effects and rare toxicity. In animal studies, Boswellia has reduced inflammation and experimentally-induced edema. The critical molecule NF-kB and its signalling pathway were also downregulated by boswellic acids in animal models, which markedly lower proinflammatory TNF-a and the chemokine MCP-1.
Cat's Claw
Cat's claw (Uncaria tomentosa, Una de gato; bark) has demonstrated inhibition of TNF alpha by 65-85 percent in the laboratory, which allows it to be considered a very potent inhibitor of TNF-a synthesis. It has also been shown to inhibit iNOS gene expression induced by lipopolysaccharides, with significant implications for endothelial dysfunction of coronary artery disease. The pentacyclic oxindole alkaloids in cat's claw function as immune modulators, suppressing an overactive immune response and stimulating an underactive one. It decreases TNF alpha production, protects cells against ROS via its scavenging actions. Memorial Sloan Kettering Web site describes studies supporting alkaloid activity to upregulate phagocytosis, and immunomodulatory actions on NFkB and TNF-a, downregulating inflammation.
This rainforest herb is traditional used as a contraceptive. Long-term use beyond one year is not recommended, as it has been associated with reduced estrogen and progesterone levels. It is being studied for its downregulation of estrogen receptor binding in breast cancers. Cat's claw is contraindicated for transplant patients and should not be used during pregnancy. This herb targets DNA of actively proliferating cells including malignancies, which makes it unsuitable for fetuses and growing children. Use for autoimmune conditions requires close clinical supervision. Anticoagulants/ antiplatelets: cat's claw may have an additive anticoagulant effect.
Clinical herbalism is a valuable adjunct in the treatment of the chiropractic patient. Herbs are applicable across a broad spectrum of inflammatory disease, from autoimmune syndromes and the arthridites to diabetes and beyond. Part 2 of this article will continue developing our alphabet of clinically important herbs that can be effectively utilized as singletons in practice.
Resources
Shen J, et al. Association of vitamin B-6 status with inflammation, oxidative stress, and chronic inflammatory conditions: the Boston Puerto Rican Health Study. Amer Jrn Clin Nutr, 2010 Feb;91(2):337-42.
Sandoval-Chacon M, et al. Antiinflammatory actions of cat's claw: the role of NF-kappaB. Aliment Pharmacol Ther, 1998 Dec;12(12):1279-89.
Aquino R, et al. secondary metabolites from the roots of Astragalus trojanus. J Nat Prod, Apr 1999;62(4):563-8.
Bedir E, et al. Cycloartane triterpene glycosides from the roots of Astragalus brachypterus and Astragalus microcephalus. J Nat Prod, Dec 1998;61(12): 1469-72.
Bone K. Clinical Applications of Ayurvedic and Chinese Herbs: Monographs for the Western Herbal Practitioner. Phytotherapy Press, Queensland, Australia, 1997.
Cha RJ, et al. Non-surgical treatment of small cell lung cancer with chemo-radio-immunotherapy and traditional Chinese medicine. Chung Hua Nei Ko Tsa Chih (Chin J Intern Med), 1994;33:462-6.
Gupta I, et al. Effects of Boswellia serrata gum resin in patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study. Eur J Med Res,1998 Nov 17;3(11):511-4.
Sandoval M, et al. Cat's claw inhibits TNFalpha production and scavenges free radicals: role in cytoprotection. Free Radic Biol Med, 2000 Jul 1;29(1):71-8.
Madisch A, et al. Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial. Int J Colorectal Dis, 2007 Dec;22(12):1445-51.
Boswellia. Memorial Sloan-Kettering Cancer Center (Web site): About Herbs, Botanicals & Other Products.Sahelian R. "Anti-Inflammatory Diet, Foods, Supplements, Herbs and Natural Substances as Alternatives to Medications."
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
Some pundits say that the upcoming presidential and congressional races, and many local races, might be the most consequential in our country’s history. We do not have the choice of sitting on the sidelines and hoping our patients will carry our water. Unlike other medical professions such as physical therapists, podiatrists, nurses, etc., the health care class (AMA) will not protect us. We must be in the game.
The most common condition affecting the shoulder is rotator-cuff disease. From acute tears to chronic tendinopathy, it’s common and needs a thorough workup. In fact, even asymptomatic shoulders can have full-thickness rotator-cuff rears in up to 40% of instances. Let’s look at additional conditions that can present to the office with weakness, loss of motion and pain in the shoulder beyond rotator-cuff tears.
