Capsicum

There's a great topical drug that helps facilitate back pain control. We used to use it for Shingles (a form of viral herpes skin infections) which is very painful and sometimes leads to morphine sulfate use for control of pain. It's uses have been extended to standard pain issues. Many people will see it in the pharmacy next to the Icy Hot or Tiger Balm. Most folks pass right by it since packaging isn't eye catching. I've seen several great forms of capsaisin in the form of Zostrix cream (my personal favorite in the emergency room for people with back pain or neck pain) and salonpas adhesive patches (my personal favorite -most of my older relatives in the Philippines used to walk around with these pads stuck to them and before medical school I used to think of it a some form of voodoo). Any topical pain reliever is made to cause a sensation to the skin that will overpower normal sensation. Example, when a baby is given a cap/hat for the first time, kid usually pulls it off since it doesn't feel right. Soon after trying over and over again, the baby gets used to it. When applying zostrix to skin, it burns. It's a dull sensation but the feeling is like applying hot pepper to skin. Actually, the active ingredient is from hot peppers. The feeling is distracting to the person in pain and one of the methods of relief is to make them think about something else....well, hot pepper will make you do that!

The other relief in pain is more scientific and separates this component from the Icy Hots and Tiger Balms. RCT (randomized clinical trials) performed with capsicum the active ingredient in capsaisin cream, revealed it reduced the amount of Substance P to the area it's applied to. Substance P is a neurotransmitter found in pain fibers and when depleated, pain fibers don't fire to send messages of pain to the brain. Overall, pain sensation if reduced. Practical problem for the cream has always been accidentally applying too much or getting it in the eyes. One of the reasons I like the patches of Salonpas (walgreens) is you could cut as much of a size as you like and not get the hands greasy. Caution: there are salonpas patches at walgreens that don't have capsicum so read ingredients before you buy.

The place it comes from is the seed and little ribs found in red peppers. Different peppers have different ratings usually measured in Scoville heat units (SHU). This rating is usually talked about during the pepper eating contests of Texas. (some people have too much free time although I find myself attracted to watching this and hotdog eating contests while riding my stationary bike at Planet Fitness)

So far, I have not read any info on chronic use and becoming accomodated to it. There have been no other problems aside from people with allergies to peppers using it without reading ingredients. The Saguil Approach to proper use is to apply it 4 times a day and after achieving pain relief, work to stretch the triggered/spasmed muscle. Usually it will be painful at first like any stretch done properly. If continued on a regular basis, the stretch will lengthen muscle fiber and help overall to reduce pain and inoperability of the muscle causing the pain. More stretching leads to more blood flow to injured muscle and faster healing. Alone it may work for small spasms, for larger and more chronic areas, it would be an excellent adjunct to other therapies. Should always inform the massage therapist or physical therapist of it's use. I remember when doing my sports medicine fellowship, we used to comment on russian coaches spraying every injury they had with topical anesthetic and i would always laugh at the technique. Now that I am wiser-(herbally), they actually had a great technique overall in attempting to distract the athlete while ultimately stretching injured muscle. Now using it for a fracture .....not!

*Capsicum also comes in oral form....obviously since it is derived from pepper. But I think its best application it topically, as you will read from other posts, I prefer the use of turmeric, white willow bark boswelia for inflammation. In the future I will talk about arnica and tea tree oil.





(Altman RD et al, Semin Arthritis Rhean 1994, 23:25-33).

(Watson CPN et al Clin Ther 1993, 15:510-526)

(Diabetes Study Group, Diabetes Care 1992, 15: 159-165).

Probiotics

While working the ER today, I unfortunately had alot of true infections that I diagnosed and required treatment. With some, like asthmatics, the infection should be quieted quickly so the asthma isn't triggered. With a mom who has 4 kids and one has a severe infection, better to treat than have the other 3 suffer. With a staff member who will be flying in 4 days, she may infect patients all day today and not be able to make an important flight this weekend. There always is the opposite where the signs and suffering is mild so I always give the option to consider waiting and helping the body fight back, more mucous clearing, hydration, temporary diet change, pain and suffering control all for the hopefully short duration of a few days on the road to recovery.

Back to today, as some needed fast answers and couldn't wait, I prescribed antibiotics but always with the education that we will kill the bad bacteria but at the sacrifice of losing good protective bacteria in the GI tract (gastrointestinal). When this happens, the bowel function will alter. The colon must have normal flora (a mixture of several bacteria, all at specific ratios to each other depending on the individual). When the ratios are off balance such as after an antibiotic wipes out all but one or two kinds of bacteria, the normal everyday changes that occur when partially digested food comes from the stomach into the small intestine and colon go into a dysfunction. Some not so desireable bacteria can grow into large numbers and when they are exposed to food sources, irritation to the lining of the small intestine and colon can occur which starts poor function. In alternative medicine, the colon is the source of the immune response and soon, immunity changes and we have altered reactions to normal infection, stress and trauma. There will also be altered absorption of nutrient further hampering the rebuilding process of the body, (leaky gut syndrome, malabsorption, IBS). Arthritis, eczema, and fibromyalgia are sometimes thought to stem from an initial trauma or infection. And you thought the GI tract was just for taking food from the stomach to the toilet!

The suggestion I always give is to try "acidophyllus". Most people know probiotics this way. Many folks have tried it in the form of yogurt, but this form is very limited in the bacteria it posesses and they may not be alive by the time the lid is opened. Advertising will be deceiving...."live bacteria" before pasturizing isnt mentioned. Probiotics usually come in refrigerated liquid form or capsule form. The content us usually lactobacillus acidophyllus and bifidobacterium longum. These are found in the GI tract and dairy products. They have good roles in the GI to help digest Lactose to lactic acid. People who are lactace enzyme deficient, can't digest the sugar and will rely on having good levels of the bacterias to aid in break down. Probiotics are also thought to decrease candida overgrowth and are also thought to be anticancer.

In the cases today, most antibiotics are twice a day and I would suggest taking the probiotic 2 hours after the antibiotic is in the stomach. Remember, the antibiotic can also kill the probiotics. Sending patients has been a challenge since Whole Foods is far away and I don't like off the shelf brands. Skeptics also warn that bottles that say refrigerate but it is thought the trip from the plant to the stores whould be in a refrigerated truck, but this is hard to keep track of.

I would ask the herbalist that works at the store you go to and see which he/she recommends. Also may want to check if there is a date for expiration. Sometimes enteric coated capsules work better to hold on to the ingredients until after in the small intestine. Some formulations will come with pancrease and lipase to help digest some other proteins. One should always becareful in going slow. The Gi may not want alot of new bacteria all at once. Starting slow and building up to 2-3 times a day would be suggested. The week you are adjusting, there may be a slight increase of gas and bloating.

Most bottles write 1-2 billion bacterial. Many will die going from factort to shelf, or from not keeping the bottles refrigerator or from just not being sold and keeping it on the shelf to long past expiration.

Probiotics can also be used in those with crohns disease or ulcerative colitis. Not necessarily to stop the dsease but more to improve absorption. Truthfully, this is usually how I break into a conversation with a patient. Once I find they have tried it once, we get into other herbs for the particular disease process they have. Then the floodgates open. They can be taken for a long time or just in 2-4 weeks bursts. If one brand doesnt provide much response then switch to different brand or type. If diarrhea still comes with the antibiotic, just finish the medicine and be sure to start the herbal after all antibiotics are finished.

I remeber several years ago, I had a cough that was productive with sinus pressure and I took ZPack (a five day macrolide family medicine) and after the first day I developed pseudomembranous colitis. Most pain I have ever experienced. Tried some acupuncture on myself but eventually had to call a GI specialist to help with the cramping gas and bloody diarrhea. That was the most intense night I have ever experienced and I told myself I would never take antibiotics again. So far so good!

Glucosamine Sulfate

When I finished my sports medicine fellowship at DePaul University, I was doing the usual family practice thing in the office but then applying physical medicine to all patients. I was seeing a large number of knee pains especially during spring and summer. Many consults were from my partners and at that time they had a large number of older patients. With the multitude of medicines they were on already, I dedided to try something I read about in a journal. At the time glucosamine sulfate was just gaining momentum in the US. All the studies available were from Europe comparing glucosamine sulfate to naprosyn and ibuprofen in joint range of motion. Of course the results were equal if not better than the two medicines. With the lack of gastrointestinal side effects. I began asking patients to try 1500 mg daily of the supplement but there was no place to buy it aside from walgreens. Nothing against that chain (thats when they didnt have drive through) but I found only a small group had nice results. Usually it was the patient that went a step further and found a distributor that marketed their own brand. So quality was proving a better impact with knee pain patients that the quanitity driven chain stores.

Glucosamine sulfate studies were usually with chondroitin sulfate. The action was thought to be stimulation of that little cell called a chondroblast. These are the ones that build up the cartilage matrix when damage has occurred to the smooth moving surface of a joint. There were later studies in the US, a big one was teh GAIT study which said it didnt help compared to celebrex. Problem is that the study doesnt specify if the glucosamine was pharaceutical grade or off the "walgreens shelf" brand. They also only used glucosamine not g-sulfate or g-HCL. Well, my patients respond and no side effects to stomach ulcers, renal failure or heart disease like they do with celebrex.

The "Saguil Approach"= remember, glucosamine is a means to get to an end. I always combine it's use with a proper diet, an antiinflammatory diet and visits with a good physical therapist (that knows McConnell Taping-I believe she is an Austrailian therapist). One the patient and therapist develop better flexibility and Quad control and fix the "Q-angle" of the knee, should be able to decrease the supplement. Omega 3 fish oil is good as well as turmeric, ginger, boswelia, white willow bark (see previous posts) and cryotherapy.

St Johns Wort for Depression

Well studied and mass produced. Many have tried this supplement and have had great results. Others have had mediocre to no results. As an MD, I have to see reproducible studies stating low risks and high benefits for its use. Several problems exist in that it is not controlled by the FDA so quality varies tremendously with over the counter brands. If there are no great US studies on its uses for mild to moderate depression I would feel comfortable with "other data outside the US". European studies show it has equal to or/better than results compared to anti-depressant drugs in the treatment of mild to moderate depression. Multiple studies found in the a Roswell Park Cancer Institute reveiwed information and the results were concluded that St Johns Wort was no help with major depression. (It's unusual that most US studies state it doesnt make a difference with major but they dont mention it is equal to antidepressants in treating mild to moderate depression.)

http://www.aafp.org/afp/20051201/2249.html

With the season in Chicago about to go dark and gloomy for 4-6 months, no doubt that a few of us with Seasonal Affective Disorder will feel the pressure of the "season" in a few months. (It was not until I moved to Florida for 18 months that I realized how productive and fun the winter could be. I believe we, in Illinois, make it a point to hold the picture of the first days of spring as a stimulus to get through the harsh winters). People with SAD or different types of depression already have symptoms that effect social interaction, job performance, sex and/or sleep. With the side effects of prescription drugs being well established, some would shy away from the use of the medicine for the holiday season. Certainly, if the diagnosis of mild to moderate depression is untreated or undertreated, the symptoms do have a possibility of worsening. One should always be diagnosed by a specialist first and then treatment plan started. Most important is for the patient to realize that treatment includes oral medications, psychotherapy, lifestyle modifications and dietary changes. The herb is not without it's drawbacks. There have been documented interactions with several medications:

Amitriptyline (Elavil)- Decreased blood levels

Carbamazepine (Tegretol)- No change

Cyclosporine (Sandimmune)- Decreased levels

Digoxin- Decreased levels

Midazolam (Versed)-Decreased levels

Oral contraceptives-Decreased levels

Sertraline (Zoloft)- Decreased levels

Simvastatin (Zocor)- Decreased levels

Theophylline- Decreased levels

Warfarin (Coumadin)- Decreased levels

If the above drugs are already in use, caution should be exercised when attempting to use St Johns Wort. Dose starts out at 300 mg usually taken three times a day. This would be in the Dry Herb form tablet or capsule. It also comes in extract, and tea leaf form. The doses are given three times a day like other herbal supplements because of the short half life. The effects would hopefully be felt in 2-3 weeks. If not either the brand is poorly absorbed or the dose is to low. One of the reasons to look into if the company states they sell pharmaceutical grade supplements. Side effects include photophobia, gastric irritation, dizzyness, confusion, fatigue. The mechanism of action is not well studied but surmised to be blocking the reabsorption of serotonin by the active ingredients of hyperforin and hypericin.

The symptoms of depression can fall into:

Ongoing sad mood
Loss of interest or pleasure in activities that the person once enjoyed
Significant change in appetite or weight
Oversleeping or difficulty sleeping
Agitation or unusual slowness
Loss of energy
Feelings of worthlessness or guilt
Difficulty "thinking," such as concentrating or making decisions
Recurrent thoughts of death or suicide

If there are no other medical problems occurring then a short attempt of the herb for three to four weeks may be started. I would always suggest being seen by a physician first and ruling out other disease. (Had a lady come into the ER the other day and chief complaint was fatigue, irritability, diffculty with sleep and headache worsening over 6 months. After doing several tests all come back normal except for a red blood cell level that was 1/5 that of a normal human. Hopefully iron deficiency but if her heart was stressed out in its normal duties over the few months prior, it will have hypertrophied and she's on her way to see the cardiologist...all because she thought it was going to get better).

The "Saguil Approach" is to first get the right diagnosis by listening to symptoms, rule out other causes with physical exam and testing appropriately. Then look into changing the home and work environment, both could be a large stressor and time away can help in the healing. Psychotherapy always suggested with close follow up and conversations between psychologist and primary care doctor. I try to enforce sleep hygiene or at least a structure to sleep. Diet will probably be poor but proper supplementation and elimination of certain foods would be important. (There is a doctor in clermont florida I met who had a great dietary approach to kids with ADHD. Consequently when I used the same diet with my mild to moderately depressed patients results were also just as good. Check ADHD diets in the FAQ section of my website) Some form of exercise would be important to maintain structure to the day anddevelop meditation skill, yoga or tai chi (watch for my tai chi blog in FAQs section with pod casting a local instructor). Medications that start with St Johns Wort, Omega 3 Fish Oil, then possibly the perscription meds if all else fails. Light therapy may also provide improvement in symptoms. If a patient is in severe depression or all the above aren't producing positive results, time to call the psychiatrist in for extra help. Now we should all have a good winter season but it's good to look out for others. (....a trip to the bahamas never hurt either).