Visceral Organ Dysfunctions (VMDs ) are internal organ problems that arise from problems that affect the mobility and motility of these organs. As the treating physician or therapist, VMDs are something to consider when you’ve done what you can for musculo-skeletal problem resolution, and strangely still find yourself unable to deliver results that you are routinely happy with. You may have one of those “this should be fixed by now” moments. So, the question arises: have you found the primary dysfunction? Also, is the primary truly a framework problem? Is it possibly instead an internal organ dysfunction that is causing the constellation of abnormalities you have had problems correcting?
Visceral Organs may be limited in their natural motility or in their mobility in relation to the other organs. This is particularly true for when strong adhesions and scar tissues are present. The inciting history would include focal or generalized inflammation. Often, the first cause was trauma or surgery.
Somatic Dysfunction Recurrences are often due to Visceral Organ Primary Dysfunctions. Keep in mind, however, that the most common reasons for unresolved or recurrent somatic dysfunctions include (1) mis-diagnoses and (2) incorrect treatment. A mis-diagnosis almost always ensures that you then choose the wrong treatment approach. That is why we should always endeavor to treat what we see, and not what we expect. On the other hand, using a hammer where a screwdriver was needed will often make things worse a lot faster.
Other areas to look at would include proper identification of the true Primary Somatic Dysfunction. The “Primary” is the one area that most affects the other areas. By example, a recurrent Shoulder Somatic Dysfunction with multiple supposed primary tendinopathies and Tendinitides can in fact be the result of an incomplete diagnosis. Often, a subacromial bursitis is the inciting primary. In this example, this is the prime pathology that caused the entire rotator cuff weakness via reflexive inhibition. Think of it as the body trying to guard this area by turning off aggravating movements. Without addressing this primary, the involved tendons are kept in an inflammatory cycle, and the muscles are weakened.
Basically, pain begets inflammation, begets the inflammatory cascade, begets muscle spasm, and feeds back upon itself as more pain. In this light, the first rule of osteopathy may be more clearly understood: “the rule of the artery is supreme.” If we can improve circulation and lymphatic clearance, we can cut off inflammation and break the pain cycle.
May we fit in the prime rule of Reflexive De-afferentation Technology? “Turn off Pain first.” Turn off pain. Turn off reflexive guarding and protective modes. Improve circulation. Remind the body of how it functions when it functions best. Then let the body do what it does best: adapt and heal.
Keep in mind that Viscero-somatic reflexes are also a reverberating circuit. We can do all we can for the shoulder, but if the Gallbladder was the “Primary,” all our work would go nowhere.
Visceral mobilization techniques include mobilization techniques and motility enhancement techniques. Mobilization can be direct or indirect. Indirect techniques for mobilization include reflexive releases and long-levered techniques.
Direct techniques involve local contact, or at least contact that is transmitted directly through tissues adjacent to the organs we want to move around. When we break adhesions or scars this way, organs move more freely in relation to the other organs and structures they articulate with.
Long-levered visceral mobilization techniques utilize organ extensions or connections as handholds for transmission of therapeutically corrective forces. By example, the lungs may be moved via articulating the trachea. The stomach may be moved via an esophageal handhold. The heart may be articulated via a carotid handhold. The brain may be similarly articulated via a traction hold on the carotid vessels.
Friday, September 10, 2010
Recombinant Human Growth Hormone Replacement Therapy in Adults
Advances in Recombinant Human Growth
Hormone Replacement Therapy in Adults
by Steven Grinspoon, M.D.
Hormone Replacement Therapy in Adults
by Steven Grinspoon, M.D.
Acquired growth hormone (GH) deficiency results from the destruction of normal pituitary and/or hypothalamic tissue, usually from a tumor or secondary to surgical and/or radiation therapy. Diagnostic criteria and clinical sequelae of GH deficiency, although well established in children, are currently areas of active investigation in the adult. It is now apparent that acquired GH deficiency is associated with significant changes in body composition, bone density, lipid metabolism, cardiovascular function and physical performance. In addition, new information is now available on the use of low doses of recombinant human growth hormone (rhGH) to reverse the sequelae of GH deficiency in adults.
Acquired GH deficiency is characterized by weight gain, increased fat mass and decreased lean body mass. In one recent study, total body fat was shown to be increased by 7% in this population while lean body mass was decreased to a similar degree (1). The increased fat mass is found in a truncal distribution, thereby increasing the waist:hip ratio. In addition, triglyceride levels are increased and HDL levels decreased. The increased lipid levels may explain, in part, the observation of increased vascular wall thickness, as measured by carotid ultrasonography, in this population. These factors all likely contribute to the increased incidence of cardiovascular mortality seen in patients with GH deficiency (2).
Muscle mass and muscle strength are diminished in GH-deficient patients. In the heart, these changes are manifested by a reduced left ventricular mass, decreased fractional shortening of cardiac myocytes, and decreased cardiac output. Such abnormalities may contribute to the striking decline in exercise capacity in this population. In one recent study, exercise capacity, as assessed by cycle ergometry was decreased by 20-25% compared to normal controls (3). Bone density is also known to be reduced in the GH-deficient patient. In a recent study, cortical bone density and spinal (trabecular) bone density were 2.8 and 1.5 standard deviations below the mean for age and sex matched controls (4).
Finally, patients with GH deficiency appear to have impaired psychological well being and potentially significant neuropsychiatric manifestations, such as lack of concentration and memory impairment. Self rating questionnaires consistently demonstrate reduced vitality, fatigue, social isolation and depression (5). However, it is unknown whether this impairment in psychological well being is associated specifically with GH deficiency or is due to another factor associated with hypopituitarism.
Recombinant human growth hormone may become a novel therapeutic option for adults with acquired GH deficiency. Recent studies indicate that many of the metabolic and psychological abnormalities associated with GH deficiency can be reversed with GH replacement, even at low doses which are not associated with side effects.
GH therapy results in profound changes in body composition: fat mass is reduced while lean body mass increases. Growth hormone, at the relatively low dose of 0.003 mg/kg was shown to normalize lean body mass over 6 months in 24 adults with GH deficiency (1). The improvement in lean body mass is associated with increased protein synthesis, muscle mass and muscle function. Total body fat mass also decreases after 6 months of GH administration. The decline in fat mass is most significant in visceral and trunk locations as compared to the arms, neck and legs, suggesting that GH replacement therapy will reverse the truncal redistribution of fat mass associated with GH deficiency and impact on cardiovascular risk (6).
Lipid Metabolism
GH replacement in adults may have a beneficial effect on lipids. In a recent study, it was reported that short courses of GH reduced LDL cholesterol and this reduction correlated with increased mRNA expression of the LDL receptor in the liver (7). The potential benefit of this interaction has yet to be investigated in longer term clinical trials, but it must be noted that dramatic changes in serum lipid levels are not consistently seen with GH administration.
Bone Density
The potential role of GH in the maintenance of the skeleton has recently been investigated. GH is known to stimulate osteoblast proliferation and thymidine incorporation in vitro. Furthermore, GH stimulates systemic and local production of Insulin Like Growth Factor I, another known bone mitogen. In a recent study, GH replacement was shown to increase significantly bone Gla-protein, a sensitive indicator of osteoblast function (8). Less consistent changes in bone density have been demonstrated with GH administration. However, in a recent study using the sensitive techniques of quantitative tomography and single photon absorptiometry, significant increases of 5% and 4% were demonstrated in spinal and cortical bone density over 12 months of therapy in GH-deficient adults (4). It thus appears that GH administration may act to reverse the osteopenia present in the GH-deficient patient.
Cardiovascular Function
Improvements in exercise capacity and cardiac function have been demonstrated among GH-deficient patients receiving GH replacement in several recent studies. Such patients show increased oxygen uptake and power output during cycle ergometry associated with increased skeletal muscle mass and improved cardiac function. Echocardiography has shown that left ventricular mass index, fractional shortening and fiber shortening velocity all improve after 6 months of low dose GH therapy (8).
Side Effects Associated with Low-Dose GH Replacement
The dose of rhGH is an important consideration in the therapy of acquired GH-deficiency. Large, pharmacological doses of GH are often associated with the clinical sequelae of GH excess, including fluid retention and hypertension. However, increasingly smaller, physiological, doses of rhGH are currently being used for replacement in GH- deficient patients without such sequelae. At a dose of 0.03 mg/kg/week, Bengtsson et al. demonstrated only minor side effects including fluid retention and mild arthralgias in the majority of patients but did report carpal tunnel syndrome in one patient (6). In all cases, further reduction of the GH dosage resulted in amelioration of side effects. In another recent study in which a smaller dose of GH was used, 0.01 mg/kg was administered three times per week without any reported side effects (8). It remains unknown, however, whether chronic administration of GH at doses which keep IGF-I levels within the normal range will also improve key metabolic variables.
Future Directions
Growth hormone deficiency is an important cause of excess morbidity and even mortality. Evidence from a number of smaller studies indicates that GH replacement will improve body composition, lipid metabolism, bone density, cardiovascular function and psychological well being. Important issues remaining are the precise clinical definition of partial vs. complete GH deficiency in such patients and clarifying the best tests to make this diagnosis. In addition, it is unclear whether some of the observed beneficial effects reflect pharmacological GH therapy rather than physiologic GH replacement. Nevertheless, it is apparent that small doses, unassociated with sequelae of GH excess, may suffice to achieve the desired metabolic results. Definitive recommendations on dosage and the long term effects of GH therapy, particularly on cardiovascular morbidity and mortality, will be determined by the prospective studies now underway at the MGH and other centers around the country.
References:
1. Salomon F, Cuneo RC, Hesp R et al. The Effects of Treatment with Recombinant Human Growth Hormone on Body Composition and Metabolism in Adults with Growth Hormone Deficiency. New England Journal of Medicine 1989;321:1797-1803.
2. Bengtsson BA. The Consequences of Growth Hormone Deficiency in Adults. Acta Endocrinologica 1993;128 (Suppl 2):2-5.
3. Cuneo RC, Salomon F, Wiles CM et al. Growth Hormone Treatment in Growth Hormone Deficient Adults. II. Effects on Exercise Performance. Journal of Applied Physiology 1991;70:695-700.
4. O'Halloran DJ, Tsatsoulis A, Whitehouse RW et al. Increased Bone Density after Recombinant Human Growth Hormone (GH) Therapy in Adults with Isolated GH Deficiency. Journal of Clinical Endocrinology and Metabolism 1993;76:1344-1348.
5. McGauley GA, Cuneo RC, Salomon F et al. Psychological Well-Being Before and After Growth Hormone Treatment in Adults with Growth Hormone Deficiency. Hormone Research 1990;33 (suppl 4):52-54.
6. Bengtsson BA, Eden S, Lonn L et al. Treatment of Adults with Growth Hormone (GH) Deficiency with Recombinant Human GH. Journal of Clinical Endocrinology and Metabolism 1993;76;309-317.
7. Johnston DG, Bengtsson BA. Workshop Report: the Effects of Growth Hormone and Growth Hormone Deficiency on Lipids and the Cardiovascular System. Acta Endocrinologica 1993;128 (Suppl 2): 69-70.
8. Amato G, Carella C, Fazio S et al. Body Composition, Bone Metabolism, and Heart Structure and Function in Growth Hormone (GH)-Deficient Adults Before and After GH Replacement Therapy at Low Doses. Journal of Clinical Endocrinology and Metabolism 1993;77:1671-1676.
Thursday, September 9, 2010
Similarities between Acupuncture and Chiropractic
From the Book “Dissecting Chiropractic” by Strix Toledo
This ancient method of inserting very fine needles into the body to induce a physiological response is more than 4,000 years old. It relates directly to the idea of so many other complimentary medicine systems, including chiropractic, that the body has an energy running through it. In Chinese, this profound energy is referred to as Qi of Chi, and is pronounced “chee.” Qi has a direct impact on the balance and wellness of all systems in the body.
Just like with nerve signals, Qi “interference” or blockage prevents optimal health. The goal of the acupuncturist is to remove the obstacles, just like the chiropractor endeavors to reduce subluxations. Perhaps this similarity in principle is what has endeared acupuncture to a multitude of chiropractors. Many chiropractors incorporate acupuncture or the non-invasive, more massage-like form, acupressure, into their practices.
Acupuncture also has a map of the body where certain stimulus points are related to organs and systems in the body. Sometimes acupuncture needles are inserted with a small electrical impulse added to further stimulate the local and correspondence areas, with the aim of removing the “interference” and normalizing function.
The Qi, as an energy form, is believed to flow down the pathways called meridians. The meridians need to be free from interference or obstructions and in balance in order to achieve optimal health.
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