A MAGIC INJECTION

Over the almost half-century that I have been doctoring, I have injected thousands of patients who were contending with local pain syndromes, using dozens of medications. These were in nerve roots, trigger/tender points, joints, tendon insertions and even into the spinal canal. In the last twenty-five years, I have used Sarapin as part of a healing, pain relieving cocktail. Although there are other specialists who do similar injections such as pain specialists, orthopedists, rheumatologists and prolotherapists, my medicines and or technique seem to work better.

Prolotherapy that has been used for over 60 years heals tendons, joints, and muscles by injection of curative substances of which an irritant initiates the therapeutic process by proliferation of new cells. It is also called sclerotherapy because it hardens limp tissue. Proliferants used in Prolotherapy are basically substances that lead to new collagen formation. Collagen is the naturally occurring protein in the body that makes up ligaments and tendons. Prolotherapy solutions help strengthen these structures by initiating the first step in the wound-healing cascade, which is local inflammation. Once the inflammation has begun, fibroblasts are stimulated. These are the cells that make the collagen. New collagen is produced, making the ligaments and tendons stronger and tighter. The solution I now employ contains Serapin from the pitcher plant and 50% glucose as the proliferant. No cortisone is used because the inflammatory process is therapeutic and the steroid is anti-inflammatory

The Pitcher plant (Sarracenia purpurea) is also known as Eve's Cup, Fly Catcher, Huntsman's Cup, and Water Cup. It looks like a pitcher or water jug. Like the Venus flytrap, it catches and “eats” small bugs. The Pitcher plant has been used for stomach and digestive problems, for urinary tract disorders, and formerly as a cure for smallpox. 
Since it has been used medicinally for several millennia, it has not been evaluated by the FDA for safety, effectiveness, or purity. All potential risks and/or advantages of pitcher plant may not be known, but I have found this to be an excellent and extremely safe medicine. Sarapin is a biological medicine – which means it is derived from a naturally occurring source (the Pitcher plant). It works by stopping pain signals and initiate healing in the nerves. It does not affect any other nerve functions or motor functions as does local anesthesia such as lidocaine.

Research published by Bernard Judovich MD in 1935, who did not only original in vitro research, but also used this preparation in over 5,000 patients, found it to be almost a miracle drug. He was chief of the Intercostal Neuralgia Clinic at the University of Pennsylvania Graduate Hospital. Later, he taught C. Hollander, the father of modern day Rheumatology who in the late sixties mentored my best friend Chucky Kahn. Dr. Hollander was chief of Rheumatology at the University of Pennsylvania Medical School for three decades and published the definitive textbook on joint injections. It was Dr. Kahn who taught me the science and the art of this technique 35 years ago.

Toxicity tests on Serapin published by William Bates, MD in the Ohio State Medical Journal in 1942 revealed that it was harmless and no evidence of tissue coagulation or sclerosis could be found. In that it is an alkaline extract, which releases an ammonium ion from the organic matrix, it was theorized that this was the active ingredient in the solution. It is known that this ion does affect nerve conduction, but Sarapin does more. Perhaps the plant's special amino acid content, because of the organisms it ingests, it was postulated that there was another yet unidentified biological fraction of the plant that is in the mix that is the active ingredient along with the ammonium molecule. We know the C fibers in the nerve carriy the pain sensation and this chemical tells them not to. Acute pain is a useful mechanism for us to know that there is something wrong that must be remedied. But once it has been identified and there is no easy fix, then to quiet these C fibers makes sense. Serapin does not only that, but also initiates the healing process.

Science probably will never know the true mechanism of action because SarapinR lacks profitability and marketing. As a biological medicine that has been in use for over 70 years, Sarapin cannot be patented. As a result, it can be made and sold on the open market without the huge price mark-up that are afforded to patent protected medicines. (Patent protection is the same reasons why branded drugs are so much more expensive that generic drugs that have the same chemical composition.) Not surprisingly, Sarapin has never had the financial sponsorship of a large pharmaceutical company to pitch it to doctors via the pharmaceutical company’s national network of drug representatives. I tend to believe in success and despite the fact that more research is needed, my patients have had much success. I use lots of it. Thank God there is a manufacturer.

SHOULDER PAIN

The three main causes of chronic (long standing) shoulder pain are Impingement Syndrome (from the Rotator Cuff)-72%, Adhesive Capsulitis (Frozen Shoulder)-12% and Bicipital Tendinitis-6%. The other 10% are from rare problems that are not obvious such as a missed fracture or bone tumor. Of course this assumes that you went to a good doctor that has ruled out a pinched cervical spinal nerve or one of the several shoulder bursas that can become inflamed. The main source of impingement is where the insertions of the Rotator Cuff tendons enter onto the head of the upper arm bone (humerus) from the scapula. There are only narrow conduits for the muscle/tendon to enter and exit. With damage to these insertions such as injury or tear of the tendon/muscle they are unable to slide through that narrow space without a slight hang-up that produces anything from discomfort to pain or distinct inability to do that required motion.

The rotator cuff is made up of four muscles from the scapula. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. The rotator cuff is made up of four muscles and their tendons. These combine to form a " cuff " over the upper end of the arm (head of the humerus). These are the Supraspinatous, Infrascapular, and the Terres Minor on the back side and the Subscapular on the underside of the scapula. Depending on the specific tendon involved there are 5 different anatomical sites that are impinged. The most common is with damage to the end of the Supraspinatus muscle. The pathology varies from just swelling of the tendon (Stage I) to a partial tear (Stage II) to a full tear (Stage III). Usually Stages II and III are related to acute trauma and commence right after the injury, while Stage I is due to overuse of that muscle group in overworking that muscle such as pitching or repetitive light weight lifting. Usually these problems occur in folks over the age of thirty.

Some of the signs of a rotator cuff tear include:
• Atrophy or thinning of the muscles about the shoulder
• Pain when lifting the arm
• Pain when lowering the arm from a fully raised position
• Weakness when lifting or rotating the arm
• Crepitus or crackling sensation when moving the shoulder in certain positions

Symptoms of a rotator cuff tear may develop right away after a trauma, such as a lifting injury or a fall on the affected arm. When the tear occurs with an injury, there may be sudden acute pain, a snapping sensation and an immediate weakness of the arm. Symptoms may also develop gradually with repetitive overhead activity or following long-term wear. Pain in the front of the shoulder radiates down the side of the arm. At first, the pain may be mild and only present with overhead activities, such as reaching or lifting. Over the next several weeks, it is present when just moving the shoulder. The patient, however, has no problem lying on their shoulder in bed.

A pinched cervical nerve has more of a burning sensation and is brought on by moving the neck rather than the upper arm.. It also has a specific nerve root anatomic distribution called a dermatome noted on many charts of which one is up on your doctors wall. A specific test is a nerve conduction study or maybe an MRI of the neck which has as many false positives as negatives. The test that I recommend is a “drag pin exam” where the observer takes a safety pin and drags it lightly over the affected area of pain manifestation, the dermatone, and more “friction” is noted on the pin at the same time the patient feels an accentuation of the discomfort. Very rare problems such as thoracic outlet syndrome, or brachial plexus injury will take more studies to confirm, but can be usually ruled out by a good history of the cause and the symptoms. With the bursitis, the sensitive spot is directly over the anatomical location. Also movement of the arm will increase the pain at that tender place.

Another shoulder problem is Bicep Tendenopathy where this structure is damaged due to trauma and occurs acutely in people under the age of 30. Most likly there is a labial tear in the Gleno-Humeral junction. This results in instability of the shoulder joint and can lead to dislocation of the shoulder joint. When the arm is extended by the observer, immediately the patient feels this is an impending problem and will wince or push the observers hand away lest his shoulder will come out of the socket. In older people, the tendon may rupture and a “popeye” muscle will occur. In the past these were operated, but now we leave them be and they generally resolve with the knot shrinking over the years and only a small loss of bicep muscle strength. The other head of the biceps takes over.

Capsulitis or frozen shoulder is usually the result of unresolved tendon impingement. Rehabilitation with physical therapy helps, but they will never be as good as new. Certainly surgery is not the answer in that their rehab will be more prolonged and not as successful. Next week we discuss the magic of a shoulder injection.

New Help for Diabetics and a Skinnier You

INCRETINS which were discovered in the saliva of a Gila Monster in 1965 have been on the market for the last two years in the synthetic form, mainly pramlitide with the brand name of SYMALIN . The incretins are at least two hormones that work naturally to balance insulin secretion and sugar (glucose) regulation from other endocrine target organs. There are two main incretin hormones in humans. They are GIP (glucose-independent insulinotropic peptide) and GLP-1 (glucagon-like peptide -1). Both hormones are secreted by the endocrine cells, L and T respectively in the intestinal lining in response to glucose in the gut. The glucose is from the break down of sugars and starches that we eat. The hormone, which is then absorbed, goes into our circulation and travels to the various target organ receptors. Therefore in addition to the food we consume this is yet another mechanism that controls our metabolic state and fat production. The excess calories that we absorbed if not going to manufacture protein produces fat! In yesteryear we needed this extra fat for times of famine. But now in times of plenty it is harmful and in those who are so genetically disposed, which is 25% of our population, leads to excess blood sugar (Diabetes).

The PANCREAS has both Alpha and Beta cells. The Beta secretes INSULIN and AMYALIN, while the Alpha, produces GLUCAGON. Glucagon stimulates the liver to release glucose from its store of glycogen and to manufacture glucose from fat and protein. This raises the blood sugar and is normally secreted in time of need and in adrenal response to stress. Hence glucagon is elevated in physical trauma and mental pressure which raises blood sugar. AMYLIN or artificially SYMALIN, suppresses Glucagon release thus lowering the blood sugar by slowing its production from the liver.

Symalin also binds to the receptors in the area postrema in the BRAIN. This causes satiety and suppresses the appetite. Moreover this substance again mimicking Amylin slows STOMACH emptying into the intestine causing less food (glucose) into the digestive tract for absorption. These mechanisms together lower the blood sugar in diabetics and decrease fat production in the normal person. Another form of Amylin is BYETTA also used to treat diabetes. Both of these are by subcutaneous injections. The Symylin is given before meals with insulin and the Byetta with or without insulin. It is more than coincidence both are manufactured by the same company, Amylin Pharmaceuticals, Inc. Both are overridden by a sudden decrease of blood sugar, but because of the extreme effect of taking insulin, the usual dose can be reduced by as much as 50%.

Since both Byetta and Symalin decrease appetite by controlling both the brain and stomach they do help to weight loss. I have given both in patients on off- label use for weight (fat) control usually in pre-diabetics to prevent weight gain and in real diabetes. In the future there will be a long acting Byetta given weekly and a Symalin combination. The later will be with two natural hormone look a-likes. LEPTIN and NEUROPEPTIDE –Y. All three of these will work in concert for weight reduction, which is so needed in the 21st century.

Energy Balance and Weight Loss

The law of thermodynamics states that there is no free energy. Energy in equals energy out! All this is to say that if one consumes less energy (measured in calories)than is burned that a person will loose weight. But to do that some may have to eat like a bird and work like a horse. Others can eat like a horse and work like a bird and still lose weight. The difference is in the metabolic rate and lifesyle, not excercise. As mentioned on last week's blog, caloric burn can easily be measured on the $50 test called a RESTING MEATABOLIC RATE (RMR). The burn is determined by Exercise, Lifestyle Activity and RMR and the supply is determined by food consumption-what we eat. Although all calories consumed are not the same, but this is a topic for another blog, but for now let us assume they are.

Exercise, although healthy, burns a surprising little energy. Three hundred calories for an hour of very strenuous workout is about all one can get out of it-an extra candy bar a day. However, Life Style Activity is just moving through one's daily doings and can be greatly modified. An increase of simple activities such as never using an elevator, parking two blocks from work, walking up and down your house stairs twice instead of the once that you would ordinarily do and the technique of dynamic tension will double your caloric outgo in this equation of health.

Dynamic tension is working two opposing muscle groups against each other with out moving the limbs to which they are attached. Pushing your palms together as hard as possible or “making the biceps muscle” hard are examples. This can be done many times a day at times of wait like at red lights, standing in line, while talking or waiting for the party to answer the phone. This will loose fat in two ways. One, by burning extra calories by using these and two, building muscle. For every pound of muscle one makes, it takes a hundred calories a day to service and maintain it. Not only that but it will decrease one's anxiety during the delay which is interpreted as stress by many type A personalities and produces harmful free radicals and fat-gaining cortisol. It is said that Charles Atlas, the body builder of the 1950’s kept his body in good muscular form and in prime health by this method.

Again one's exercise must include heavy resistant (weight) training to build muscle that will translate into raising the RMR and loss of fat. Other ways to increase the RMR is by supplements as mentioned last week. Medically, hormones are adjusted by giving that which is missing, not so much by its decrease in the blood, but with the natural down regulating of insulin, thyroid, and testosterone receptors. Aging, free radicals and organic disrupters like Biphenol A found in most plastics Pthalates that leached into our water supply from modern farming is only now catching the eye of government concern. Lipotropics such as methionine, choline, inositol and HcG do this as well as giving more of the necessary hormone particularly thyroid despite normal blood tests. As noted on last week's blog, medical doctors are finially recognizing that low thyroid does exist despite normal blood tests. This is Type II hypothyroid and is diagnosed today as it was 75 years ago by the RMR.

So if one is “dieting” and it is not working or eating the same foods and now gaining fat, consider the above. Dieting is not an answer to the problem but a short term fix until lifestyle will prevail.. That is why in a large study done recently 94% of those that lost significant weight dieting found it within the ensuing two years. With the help of the RMR, your health care worker can not only guide you into achieving your weight goal which is not too difficult, but keeping it there for the rest of your life.

BMR - An Underused But Vital Medical Test

Basal metabolic rate (BMR), and the resting metabolic rate (RMR) are medical tests used extensively in the last century but has been all but forgotten by modern medicine. However they are still important in this era despite the marked advance of other technology. These are useful in many nutritional problems but it is particularly helpful in weight loss and thyroid disease. They cost $50, take 15 minutes and are done in the doctors office These measurements are the amount of energy used resting after fasting done at room temperature.. The release of energy in this state is sufficient only for the functioning of the vital organs, such as the heart, brain and liver. They decrease with age and loss of muscle and altered by hormones, drugs and diseases.

Cardiovascular fitness has been shown in the 1990s not to correlate with BMR and RMR, when fat-free body mass was adjusted. New research has shown aerobic exercise does not increase resting energy consumption. But stress levels can. BMR and RMR are measured by gas analysis through by direct calorimetry with devices such as the Reevue but a poor estimation can be acquired through an equations using age, sex, height, and weight.

Whether we gain or loose weight is dependent on our food consumption and energy expenditure. About 70% of a human's total energy outlay is due to the basal life processes of our vital organs. About 20% of one's energy expense comes from physical activity and another 10% from digestive and caloric heat processes. These mechanisms are referred to as Thermogenesis which comes from shivering and the volume of innate and genetic brown fat endowed to the individual. Life requires an intake of oxygen along with coenzymes (vitamins and minerals) to metabolize food. Anaerobic such as resistance training, but not aerobic builds additional muscle mass, which is fat free mass. Additional fat free mass will lead to a higher resting metabolic rate.

The regular Aerobic exercise is beneficial for cardiovascular reasons as well as direct calorie burning. Recent studies indicate that heavy endurance exercise increases resting metabolism. But light cardiovascular training has not the same effect. Continuous moderate exercise such as jogging or doing many light weight repetitions does consume calories, but not an “after burn”. On the other hand Aerobic Interval Training (AIT) or Progressively Accelerated Cardiovascular Exercise (PACE) not only consumed calories but also gives a significant after burn by increasing the BMR and RMR for 72 hours. This is why I recommend Burst Training (pushing to temporary respiratory fatigue)when doing aerobics. For example, when jogging, periodically run so fast that one is unable to do more than a minute because of extreme shortness of breath. This pushes past the aerobic state into an anaerobic one with an oxygen debt! This then resets the metabolic rate to a higher level. Doing a RMR/BMR not only predicts who will be overweight (obesity), but what how much one needs to do to loose that fat. For example there are ways to increase thermogenesis such as cosumption of bitter orange, ginger, capacisin, ephedra, guarana, and caffeine.

BMR/RMR is very helpful in diagnosing thyroid disease. In an overactive thyroid it is high and low in hypothyroidism, which has several varieties. A Secondary in which the pituitary is at fault and two Primaries which are Type I Hypothyroidism in which there is suboptimal Thyroxin production, but even more common is the Type II in which there is enough Thyroid Hormone, but the cellular receptors are blunted. The cell is less metabolically active despite adequate amounts of Thyroxin in the blood. With Type I the T4, and T3 are low and the Pituitary tries to stimulate the Thyroid by making more TSH that therefore is higher than normal. With Type II like in Type II Diabetes in which there is enough insulin but the cells are resistant to the effects of the hormone all these blood tests are normal. It is almost impossible to diagnose Type II Hypothyroidism for certain and to properly treat it without these test of metabolism, the BMR/RMR. In this day and age when we ingest so many hormone receptor disrupters in our pollutants (pesticides, plastic molecules etc) in our food and drink, no wonder why we are having an epidemic of Type II Hypothyroid that we physicians ignore. If you are having trouble losing weight or have symptoms of low thyroid such as fatigue, cold intolerance and yet have normal thyroid tests, get a RMR. You deserve to be fixed.

DIABETES BY THE NUMBERS

The American Diabetes Association has recently endorsed the new criteria of Hemoglobin A1c (Hgb A1c) of 6.5% or greater to make the diagnosis of Diabetes 1 or 2. This blood test which has been around for 20 years is now highly standardized, and commonly preformed in physician's office with a pin prick of blood. The Hgb A1c is a reflection of the last 3 months of sugars. If the sugar was 100 all the time it would be 4.5. The higher the sugars, the higher the number and the worse outlook for the patient. The older standard of a fasting blood sugar of greater than 126 or a 2 hour after eating level greater than 200 (or 2 hours after 75 gms glucose), in a patient with classic high blood sugar symptoms, a random blood sugar of the same 200 makes the diagnosis of diabetes.

Many known diabetics test their fasting blood sugars. This is in error in that this is usually the lowest blood sugar of the day, after all night fast and gives the patient a false sense that their diabetes is doing well. Let them do it 2 hours after a meal particularly a high carbohydrate one and it will give a more accurate status of the diabetes. The only time a fasting blood sugar helps is when one suspects a low level.

Most doctors would be happy if the A1c would be 7% or less. Not this doc. I want it under 6! Studies have shown, the closer the sugar is kept to 100, the less complications from the diabetes will occur. However, if very tight control is sought and the patient is taking sugar lowering medicines, the possibility of too low a sugar (hypoglycemia) could happen with dire and even lethal consequences. Levels above 8 % are associated with a significant all-cause mortality risk.

The doctor and you should know that anemia causes a false lowering of the A1c. Also older folks have a higher levels than younger people, and blacks have higher levels than whites for any given level of sugar. Nine percent of the population are “high glycators” or “low glycators” and give a falsly high or low reading in these cases This can be easily determined over the next several months with blood sugars or immediately with another similar test, a fructosamine.

The Metabolic Syndrome, a more malignant form of prediabetes or “increase risk for diabetes” is a level of Hgb A1c of 5.7. This corresponds to a fasting blood sugar between 100 and 125 or a 2 hour after eating height of greater than 140. This syndrome has in common with diabetes ear creases and the morbid complicators of diabetes. These are increased triglycerides, blood pressure, abdominal girth and a low HDL (healthy/good) cholesterol. In particular that individual has a 7 times higher incidence of having a cardiovascular event in the next 5 years than a person of the same age and sex without these gruesome characteristics!!

COCONUTS FOR THE BRAIN

The brain uses mainly glucose for its fuel, but works far better when fed ketones. Ketogenic diets have been used in medicine since 1924 initially to prevent seizures, and recently to treat degenerative neurologic diseases such as Multiple Sclerosis, ALS, Strokes, and Dementia. Thirty years ago, Medium Chain Triglycerides were found to be metabolized into ketones by the liver. No longer did one have to eat the very stringent ketogenic diet, which was 70% fat 25% protein and only 5% carbs. A person could ingest a given amount of MCTs and produce their own ketones. The ketones do supply cerebral energy metabolism (provide alternative fuel), protect cerebral function, suppress cerebral edema and reduce the extent of cerebral infarction in brain injury.

The presence of ketone in circulation, even at low levels, increases cerebral blood flow by as much as 40%. Ketones also prevent diseases involving free radical damage such as occurs in coronary reperfusion, diabetic small blood vessel disease, inflammatory bowel disease, and pancreatitis. MCTs do not behave like the more common long chain fats. Because of their shorter structure, they are metabolized directly in the liver into ketones, rather than going into storage in fat cells. They are used as an alternative source of energy when glucose stores are exhausted.
Two years ago a drug company applied for and received a patent to bring this out as a prescriptive functional medical food. The Acerra Company brought out Axona® to treat Alzheimers disease.

The neurons work 30% better using ketones rather than the usual glucose. It is like putting high-test gas in an old high compression engine, it runs much better without the "pings". In a review article on Alzheimers in this week New England Journal of Medicine, the metabolism of the brain cell was detailed as "Type 3 Diabetes" in which the glucose receptors were blunted and could not transport the sugar into the brain cell to produce ATP, for cellular energy. Not only could the cell take in the ketone, but more efficiently made ATP (energy) from it. MCTs have been medically used in the past for feeding premature infants, recovering surgical patients and for malnutrition. Off label it has been used for liver support, antimicrobial therapy, enhancing the immune system and to increase athletic performance. Contrary to popular opinion these tropical saturate fatty acids inhibit atherosclerosis instead of producing it. They also decrease appetite and help people lose weight much like the ketoses of Atkins diet. Also there is not a tendency for diabetics to have problems of "diabetic coma", keto-acidosis with MCTs.

Coconut oil, which is a misnomer, in that it is solid at room temperature contains over 60% MCTs. Not only is this a healthy cooking oil in that it has a high smoke point, but it has a pleasant taste. It can be used in baking, oatmeal, spreads and salad dressings. Costing $8 for 14 oz for organic and $5 for the regular it is almost a best buy for this cooking oil that doesn't smoke unless the temperature exceeds 280 degrees. Butter smokes/burns at a much lower temperature producing free radicals that rust our body. Research at NIH by Richard Veech, MD. indicates that ketones which are made from coconut oil and MCTs work better since a higher dose is more easily achieved. However, they are not yet available.
To treat Alzheimers today and give that high of a dose of MCTs (20 grams per meal), you need to combine 16 oz. of MCT oil with 12 oz. of coconut oil and use 7 teaspoons at a time. It should be stored at room temperature, and increased gradually from 2 teaspoon per meal up to 7 teaspoons. Given too much at a time initially will cause abdominal cramps and diarrhea.

Although costing twice as much, one can use Axona® which may be paid by some insurances and for sure by flex plans. It has a pleasant coconut taste when used as a cold drink with a meal. There are no omegas 3s in this mixture, therefore I recommend some fish or fish oil during the day because this compliments the MCTs for improved brain function. Several varieties of Alzheimers and the APOE negative types respond better to this therapy. Since the brain starts developing defects in glucose metabolism decades before the development of the disease, those who have a strong family history, or memory problems earlier in life might consider doing this treatment now!