Pain management as a side effect: the 'Magic Missing Bullet' and case studies of 'Accidental' relief.
However, stoicism is not a virtuous trait when it is used against your body. After years of worsening pain, weekly chiropractic adjustments that wouldn't hold, and bottles of NSAIDs, I was finally granted an MRI as a result of my mother's insistence. She had noted my increasing facial grimaces and how I was unable to stay in one position for significantly shorter time periods. My chiropractor, not my neurologist, complied.
The results of that MRI led to me into a whirlwind of doctor and specialist appointments and an emergency next-day surgery. It was revealed that I would need a L4-L5 partial discectomy in order to prevent any further sacral-plexus degeneration. I had been embarrassed to admit that urinary frequency was becoming a problem, but I hadn't expected that my back pain was linked to this.
I still remember the prestigious neurological surgeon looking at me with compassionate awe, yet appearing disgusted at the clinical oversight by my well-intentioned neurologist. After being told that I reminded him of his own "Sarah-Girl," Dr. S. made an unflinching decision to change his next-day vacation flight to perform my operation. My surgery could not be delayed, and I am sure that the thought of what a 20-something-year-old would do with the loss of bladder and bowel control affected his decision. Fortunately, I didn't have to find out. I will always be grateful for his compassion, intention, and caring, which I sincerely believe positively expedited my healing.
As a result of the surgery, I was forced to drop out of nursing school after having completed half of the course requirements for graduation. My transformation from conventional medicine devotee to natural medicine explorer was ignited by "snake oils." Fortunately for my back, but not my bruised ego, these essential oils worked for pain when nothing else did.
This led me to integrative medicine and to enroll in naturopathic medical school. There, I would begin my journey into deeper healing modalities woven within the context of conventional medicine, biochemical individuality, functional medicine, ancient traditions, structural medicine, and mind-body techniques.
Ultimately, these combinations helped me heal from my first surgery and assisted with the regeneration of my sciatic nerve. These same techniques also prevented a second surgery when my L3-L4 herniated disc "slipped" during medical school. To this day, I have never had to take any medication, including OTC pain relievers. However, I never go anywhere without my oils.
Perhaps my story is why I am so passionate about embracing the naturopathic philosophy tolle causam, with special earnestness on the subject of pain. I realize that I'm probably preaching to the choir with this reader population. Many of my distinguished colleagues have also chosen the route of integrative healing due to their own negative personal experience of the "symptom shuffle" vs. alleviating the total cause.
The therapeutic use of essential oils is not commonly thought of for pain management by many practitioners in the US. They tend to be overlooked and replaced for their dried herbal components or isolated volatile constituents. Yet essential oils can modulate physical healing while simultaneously alleviating the emotional response to symptoms. Therefore, they provide a powerful dual mechanism to addressing chronic pain disorders at the deepest leve1. (1-4)
It is my hope that after reviewing this article, practitioners will begin to consider implementing these oils within their noble healing tool kit for their patients, their loved ones, and themselves. When a skilled physician uses essential oils within the context of the matrix of medicine, the belief in vis medicatrix naturae is accelerated to a higher level.
Properties and Quality of Essential Oils
Essential oils should not be confused with essential fatty acids, such as fish oils or olive oil. Rather, they are the aromatic volatile liquids found in shrubs, flowers, trees, roots, bushes, and seeds. These essential oils are necessary for the plant's survival by providing defense molecules and microRNAs which account for their potent immune-enhancing effects in humans. Oxygenating molecules, amino acids, and various volatile constituents further modulate health via direct antimicrobial action or cellular and neurotransmitter signaling modulation. For these reasons, they have been referred to as the "lifeblood of the plant." (1-5)
The complex chemistry of the many constituents found in an essential oil can be classified as either terpenoids or phenylpropanoids, or alternatively, into hydrocarbons and oxygenated compounds. According to The Therapeutic Benefits of Essential Oils, Nutrition, Well-Being, and Health, the major volatile constituents in these oils include:
... hydrocarbons (e.g., pinene, limonene, bisabolene), alcohols (e.g., linalol, santalol), acids (e.g., benzoic acid, geranic acid), aldehydes (e.g., citral), cyclic aldehydes (e.g., cuminal), ketones (e.g., camphor), lactones bergaptene), phenols (e.g., eugenol), phenolic ethers (e.g., anethole), oxides (e.g., 1,8 cineole) and esters (e.g., geranyl acetate) (Deans, 1992). (5)
Due to the high concentration of active constituents within every drop, essential oils are far more potent than dry herbs and achieve their benefits in smaller amounts. Furthermore, a single drop of an essential oil has the potential to produce potent, synergistic, and immediate healing effects on various organ systems simultaneously. For instance, an essential oil could provide constituents that are anesthetic and nerve promoting while being anti-inflammatory and tonifying to the vascular system.
Examples of actions of various constituents in an essential oil include the following:
* anti-inflammatory: esters, alcohols, and oxides
* analgesic: lactones
* spasmolytic: aldehydes and phenols (1-6)
Adding to the complex nature of essential oils, each constituent itself exhibits more than one property. For example, alcohols possess all of the following characteristics: antimicrobial, antiseptic, tonifying, balancing, spasmolytic, anesthetic, and anti-inflammatory. Alcohol constituents include linalol, menthol, borneol, santalol, nerol, citronellol, and geranio1. (6)
A final intricacy of an essential oil's action to consider is its chemotype or distinct plant population within the same species. These various populations produce differing plant secondary metabolites and have their own specific hormetic effects.
For example, Lavandula angustifolia has three chemotypes that vary in constituent percentages of linalool, linalyl acetate, and caryophyllene. One should be aware of how these different chemotypes affect therapeutic intentions. For example, lavender in the form of Lavandula angustifolia should be the only form used for used burn wounds. (1-4), (5)
Standardization of essential oils and the clinical trials of their use in the US carry similar biases in labeling and marketing as nutritional supplements. For example, an essential oil can be labeled "100% pure" and only contain 5% essential oil. Therefore, when using oils for treatment it's important to be aware of the manufactures' sourcing and standardization of therapeutic value. Verification should include quantification of active constituents, chemotype, and quality control principles employed.
The highest-quality oils are grown and sourced to enhance their potency and therapeutic benefits. The plants themselves must be grown organically in virgin soil and harvested according to the season and time of day that optimizes their therapeutic constituents. Furthermore, they should be extracted through steam distillation in order to maintain the integrity of all the therapeutic molecules present. The distiller must be skilled in how to adjust temperature, timing, and pressure based on the varying components within varying essential oil species.
Finally, the manufacture should be able to provide gas chromatography/mass spectrometry (GC/MS) analysis to establish purity. Standardization should include certification according to the regulatory agencies of AFNOR (Association Francaise de Normalisation) and ISO (International Organization for Standardization). (1-4)
Application and Mechanism of Actions
Essential oils allow for flexibility in application that can based on the patient's preferences and chief complaint(s). They can be applied topically, taken orally, or assimilated through inhalation. For most oils, all of these applications provide rapid absorption systemically. They also have the ability to penetrate the blood--brain barrier. Within the central nervous system, the constituents induce various receptor neurons to produce modulating effects on digestion, relaxation, sleep, and other organ functions. Most components of essential oils are then metabolized by limited phase I, followed by glucuronidation and sulfation and through the kidneys as polar compounds or exhaled through the lungs as CO2. (7)
A summary of the modes of actions are explained below in The Therapeutic Benefits of Essential Oils, Nutrition, Well-Being, and Health:
* biochemical (pharmacological): interacting in the bloodstream and interacting chemically with hormones and enzymes such as farnesene;
* physiological: by acting (e.g., phytohormones) on specific physiological function. For example, the essential oil of fennel contains a form of estrogenlike compounds that may be effective for female problems such as lactation and menstruation;
* psychological: by inhalation, the olfactory area of the brain (limbic system) undergoes an action triggered by the essential oil molecules, and then chemical and neurotransmitter messengers provide changes in the mental and emotional behavior of the person (Buchbauer 1993; Johnson 2011; Shibamoto et al. 2010). Lavender and lemon essential oils are examples for their sedative and relaxant properties. (7)
Mechanisms of Pain Relief
Antimicrobial and antiviral components are abundant in therapeutic oils, providing evidence of the ability of essential oils to modulate the immune response. (1-7) By regulating favorable microbiome balance, they have a resultant cytokine influence via the gut-associated lymphoid tissue (GALT) and the enteric nervous system (ENS). These aspects are important in regulating inflammatory responses and serotonin signaling pathways that promote vagal tone and brain coherence.
Certain inflammatory and painful autoimmune disease processes have been linked to molecular mimicry from microorganisms. In this process, a cross-reaction of disease-specific organisms react with host amino acid motifs over a permeable intestinal lining. In those with a genetic susceptibility to RA, for example, part of pain reduction can be found in eradicating the specific microbes, including Citrobacter, Klebsiella, Proteus, and Porphyromonas correlated to this disease process. (8), (9)
Various mechanisms are speculated for essential oils' powerful and well-known effects on eliminating microbes. (1-5), (10-13) Due to their complex chemistry and various active constituents, it is likely that combinations of these mechanisms are at play. (15)
One of the possibilities for their antimicrobial action is the generation of irreversible damage to the membrane of bacterial cells. This absence of membrane stability induces material losses (cytoplasmic), leakage of ions, and decrease of energy substrates (glucose, ATP). These directly cause the bacteria's cytolysis and death.
Another proposed antimicrobial action of therapeutic essential oils is their inhibition of toxin-producing enzymes (amylase and protease) and electron flow. This results in coagulation of the cellular content. (15)
Essential oils have also been indicated in inhibiting the action of yeast. They seem to accomplish this from an establishment of a pH gradient across the cytoplasmic membrane, blocking yeast growth. This action also involves the disruption of the membrane. (13). (15)
The antiviral activity of essential oils is mostly through their direct virucidal action through interference of structural proteins or glycoproteins. They may also interfere with host entrance, replication, or cell-to-cell virus diffusion. (1-4), (10), (15)
Their vast constituents and actions may be one reason that essential oils are effective against multiple "resistant" microorganisms. Therefore, they can be a welcome alternative to powerful medications that have potential toxic side effects on patients. In simple terms, essential oils may be able outsmart "resistant" organisms with more than one mechanism of action. (1-5), (10)
Whenever a physician is directly manipulating an immune response, it is important to provide additional support for stimulation of the body's innate ability to take over once the therapy is discontinued. Therefore, along with the balancing effects of essential oils, I also implement probiotic support for inflammatory autoimmune diseases or chronic pain conditions.
Probiotics also assist with favorable modulation of the enteric nervous system and cytokine production. Furthermore, they allow for hospitable repopulation of beneficial organisms after an infection or disease process is mitigated. A plethora of studies support the positive effects of a healthy ratio of microflora in our gut for immune modulation. (16)
I prefer the use of Saccharomyces boulardii (Sb) with my inflammatory pain protocols. Although it is most studied as a yeast strain probiotic for the treatment of Clostridium difficile, or traveler's diarrhea, Sb exhibits mechanisms that may have more far-reaching immune effects.
One study demonstrated the anti-inflammatory properties of Saccharomyces boulardii on human HT-29 colonocytes and THP-1 monocytes. They researchers tested the inflammatory effects of Sb by measuring the cytokines IL-1B, TNFa, or LPS in the presence or absence of Sb culture supernatant (Sb S). The researchers concluded:
The probiotic yeast Saccharomyces boulardii exerts an anti-inflammatory effect by producing a low molecular weight soluble factor that blocks NF-KB activation and NF-KB-mediated IL-8 gene expression in intestinal epithelial cells and monocytes. SAIF may mediate, at least in part, the beneficial effects of Saccharomyces boulardii in infectious and non- infectious human intestinal disease. (17)
Furthermore, one study demonstrated the stimulation of immunoglobulin A (IgA) in mice with C. difficile treated with Sb. (18) Although more studies are needed on the vast applications of Sb, I have found that, in conjunction with essential oils, it can promote gastrointestinal integrity after inflammatory or infectious processes.
The Mind-Body Aspect of Pain and Infections
Blunt trauma or stealth infections can release inflammatory signaling molecules including cytokines, chemokines, and neurotransmitters. (19-22) These signaling molecules produce various effects on brain functioning and behavior.
One study in the Proceedings of the National Academy of Sciences demonstrated the effect of mood on mice with imbalanced gut flora. The researchers found that the mice that were germ free had different neurotransmitter patterns in the enteric and central nervous system compared with mice colonized with pathogenic bacteria. As a result, the infected mice produced modified activity and anxietylike behaviors that the germ-free controls did not exhibit. (20)
Emotions with Pain
The mind can contribute to this chronic immune deregulation in pain syndromes. Both sensory and affective processes (behavior) are affected by pain. The anticipation of pain can cause anxiety and relief-seeking behavior, whereas chronic anxiety itself creates negative psychoneuroimmunological effects on healing. This can include immune depletion, dysbiosis, and imbalanced glucocorticoid regulation through feedback into the central nervous system (CNS) and the hypothalamic-pituitary axis (HPA).
It is interesting to note that women are disproportionally affected by autoimmune disorders over men. Taylor et al. found that women's negative stress response was remedied by the social aspect of befriending, most likely through its effect on oxytocin and opioid secretion. However, in her research, Taylor found that women in chronic stress tended to isolate. In so doing, these women would not produce these signaling molecules to alleviate the stress response. (23) Due to the fact that essential oils have been well studied for mood modulation, via regulation of limbic tone, they can serve to tone down this fleeing stress response while modulating inflammatory cytokine release. (1-4), (7)
Essential Oils and Pain Processing
One small, randomized, crossover study with 13 men and 13 women compared lavender, rosemary, and distilled water (control) on quantitative and qualitative measures of pain. Quantitative sensory ratings of pain were evaluated with the use of contact heat, pressure, and ischemic pain. Subjective measures were reported by using visual analog scale (VAS) questionnaires of pain on sensory and affective processing. Finally, salivary cortisol was measured as a subjective measure of neuroendocrine or autonomic response.
Interestingly, although there was absence of change in quantitative pain ratings between conditions, global impression of pain intensity and unpleasantness were reduced with lavender and rosemary compared with control. (24)
It is important to note that there were several issues with this study that could have affected the quantitative and qualitative reporting. First of all, this study had a selection bias of the participants' being aware of the testing and pain perception. As perception of pain can be affected by knowledge of duration, this could have had an effect on cortisol excretion and pain intensity. Furthermore, dosages, chemotype, and constituents were not mentioned to be standardized in this study. All of these factors would modulate inflammation, analgesic, and HPA functioning. (1-4), (5), (7) Still, the fact that substandard essential oils were demonstrated to have a central processing effect of pain perception is impressive.
In another small study, 17 college women in their 20s volunteered to investigate soothing effects of plant fragrance on emotional symptoms in the premenstrual phase of their hormonal cycle. The fragrance was not revealed prestudy.
The severity of premenstrual symptoms was determined through a daily symptom diary based on the Menstrual Distress Questionnaire (Moos) for at least two menstrual cycles. The average value of the increase from the follicular (day 5 to day 11 from the first day of menstruation) to the late-luteal phase (within seven days before the next menstruation) was 10.3 [+ or -] 2.4%, classifying none of the subjects with severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD).
All subjects underwent physical examination and interviews, including menstrual qualities and lifestyle. Cycle phase during the experiment was determined by oral temperature and concentrations of the hormones estrone (El) and pregnanediol-3-glucuronide (PdG), in a urine sample were taken early in the morning, both being indexed to creatinine (Cr) excretion. No cardiovascular or any other endocrine or systemic disorders that could affect the autonomic nervous system were present in the participants, and the subjects were nonobese and nonsmokers. An olfactory function test on all subjects was administered to assure that none had anosmia.
The participants received two separate occasions (an aroma and control trial) timed during the late-luteal phases. The aromatic stimulation was lavender oil and water was used as the control. Autonomic nerve activity was assessed via heart rate variability (HRV), with individual variability taken into account. The psychological index to measure pain perception prior to and after aromatic stimulation was the profile of mood states (POMS) questionnaire.
Constituents and quality control of the lavender essential oil were taken into account in this study, with lavender comprising linalyl acetate (37.18%), linalool (36.83%), trans-[beta]-ocimene (4.25%), [beta]-caryophyllene (3.55%), cis-[beta]-ocimene (2.88%), and lavendulyl acetate (2.06%).
The main findings reflected that inhalation of lavender resulted in an increase in parasympathetic activity of the nervous system within 10 minutes and for at least 25 minutes following the initial inhalation. This was determined by high frequency (HF power) of heart rate. Lavender inhalation showed a decrease in emotional systems, including depression--dejection and confusion, common premenstrual symptoms, in the late-luteal phase. This effect lasted as long as 35 minutes after the aroma stimulation as assessed by the POMS test. Furthermore, sleep was reported to have improved in those subjects in the testing condition, a vital component of healing from pain. (25)
The researchers believed that the pharmacological action of lavender may be from lavender's action postsynaptically. Previous research, they reported, indicated that lavender modulates and can decrease the activity of cyclic adenosine monophosphate (cAMP), which is associated with sedation. Furthermore, linalool has been shown to inhibit glutamate binding, which may account for additive sedative effects. (25)
The confounding factors in this study were small sample size, category of PMS not meeting moderate to severe, and potential of placebo by differentiation of the smell of water vs. lavender. Furthermore, the lab measurement, standardization, and interpretation of luteal phase hormones and interactions were not discussed.
Still, these psychoneuro-immunological effects of essential oils are impressive and warrant more research. They could benefit a wide variety of other chronic pain issues that are currently hard to remediate. For example, one mechanism behind multiple chemical sensitivity (MCS) relates to damage in the neural circuit pathway that produces various sensory disorders. (26) Essential oils' ability to regulate neurotransmission and cross the blood--brain barrier may be a future area of study for this patient population. They may provide a key treatment to mitigate the overactive sensory component in those with MCS.
Inflammation, Pain, and Essential Oils
Various studies have determined the anti-inflammatory effects of essential oils and the resulting relief of pain. These mechanisms may be specifically related to the modulation of cytokine release. (27), (29-31)
A study aimed at determining the efficacy and underlying mechanism of a 20% topical application of essential oil (EO) reported positive results in alleviating the severity of adjuvant arthritis (AA) in Lewis rats. This study found that after 7 days of application, the levels of matrix metalloproteinases (MMPs), pro-inflammatory cytokines TNF-a and IL-1B in synovial fluid (SF), and synovium infiltrating cells (SIC) were significantly reduced (p < 0.05) in the E0 group vs. the controls. Antimycobacterial heat-shock protein 65 (Bhsp65) antibodies were also tested but no effect was found.
The rats who received the E0 had less severe clinical symptoms than the placebo group. The effect was found to be a result of the oils, not the carrier oil. (27)
A pitfall of the above study was that distillation and quality of the oil were not considered. First, the oils were purchased at a local health food store, indicating no quality assurance. Quantitative and qualitative effects from improper distillation would affect all the active constituents, including the whole class of terpene hydrocarbons. (28) Second, delicate constituents would be damaged from the oil's being heated and mixed with beeswax. This could further alter chemical compositions and receptor binding of the oils into the cells.
This effect of using a suboptimal method of extraction would also decrease the essential oils' therapeutic effect on microbes, which could account for the negligible effects on the antimycobacterial heat-shock protein 65 (Bhsp65) antibodies. Finally, the chemotype was not specified, and as mentioned, chemotypes have altering profiles for secondary metabolites. (28) All of these factors being considered, the evidence of even a low-quality oil on inflammation still was supported.
Another study using rat polymorphonuclear lymphocytes (PML) tested the differing effects of secondary plant metabolites in relation to the inhibitory capacity of acetyl-1 1-keto-beta-boswellic acid (AKBA), found in Boswellia cartii, on 5-lipoxygenase (5-LOX). Different chemical constituents antagonized the effects of AKBA or worked synergistically with AKBA to inhibit 5-lipoxygenase. The researchers concluded:
The results demonstrate that the pentacyclic triterpene ring system is crucial for binding to the highly selective effector site, whereas functional groups (especially the 11-keto function in addition to a hydrophilic group on C4 of ring A) are essential for 5-LOX inhibitory activity. (29)
This study supports the importance of using intact essential oils with the proper chemotype to provide the best benefits when modulating inflammation in the body.
Modulating Hormonal Pain Signals
In one randomized, blind, placebo-controlled trial, researchers evaluated the effect of aromatherapy abdominal massage in 95 female nursing students with dysmenorrhea. The intervention was the application of essential oils once daily for seven days prior to menstruation. The essential oils used were cinnamon, clove, rose, and lavender in a base of almond oil. All of the students had regular cycles of 21 to 35 days with secondary causes of dysmenorrhea ruled out. None of the participants were on hormones or taking analgesics for the pain.
In the first phase of the trial, the first group of 48 students received the massage and oil intervention and the second group of 47 students received the same intervention but with placebo oil (almond oil). The two groups then switched interventions for the second phase of the trial. During both aromatherapy treatment phases, duration of pain and bleeding were significantly decreased as compared with baseline measures. No side effects were reported.
This study supported a variety of mechanisms for pain relief with essential oils, as the researchers attributed the effectiveness of aromatherapy to more than one activity. The first effect was attributed to the emotional and limbic system response as discussed above. A second factor was the biochemical properties of the oils themselves. For example, improved blood circulation was attributed to the constituents in the oil of clove. Lavender's constituents' properties were thought to include the analgesic, sedative, and anticonvulsant effects. Furthermore, cinnamon was reported to inhibit the prostanoid system involved in the inflammatory prostaglandin PGE2.
The contribution of this research was in the hormonal effects of the above mechanisms. The authors report that cinnamon also treats excessive menstrual bleeding and supports estrogen balance, while rose has similar effects as well as benefiting the uterus. These oils were assumed to be responsible for the reduction from excessive to average menstrual bleeding on the first and second day of bleeding compared with placebo.
The authors acknowledged the limitations of the therapeutic effects varying with chemotypes and proportions of constituents in this study. Another limitation was dosage and scanty studies existing to support reducing excessive menstrual bleeding. (30)
The Overall Pain Reduction Equation
In conclusion, essential oils can assist with modulating pain by a variety of mechanisms. These include antimicrobial, sensory processing, anti-inflammatory, and hormonal. The power of their analgesic properties on direct receptor modulation was reported by Harvard on the use of peppermint oil for abdominal pain in irritable bowel syndrome (IBS). According to its HealthBeat report in 2007:
Several studies have shown that peppermint oil seems to be fairly effective at relieving irritable bowel syndrome (IBS), a collection of symptoms that includes abdominal cramping and pain, bloating, constipation, and diarrhea. In 2007, Italian investigators reported that 75% of the patients in their study who took peppermint oil capsules for four weeks had a major reduction in their IBS symptoms, compared with just 38% of those who took a placebo bill.... One explanation for how peppermint oil might help IBS sufferers is that the oil--and perhaps especially the menthol--blocks calcium channels, which has the effect of relaxing the "smooth" muscles in the walls of the intestine. (31)
Case Study 1: Pain, Microbiome, and Blood Sugar
K. J., a 54-year-old male, came into my office for an overall wellness review and to assist with recovery or possible prevention of an imminent second shoulder surgery. K. J. was also hoping to gain assistance with hyperglycemia, hyperlipidemia, insomnia, high BMI, and insomnia, the latter being aggravated by his right shoulder pain. Significantly, K. J. was diagnosed with diabetes type 2 (DM2) at 46 years old. His fasting glucose ranged from 150 to 170 mg/dl on dual therapy of metformin (a biguanide) and sitagliptin (a DPP-4 inhibitor), but could sometimes reach 200 mg/d1. K. J. was also on Lovaza (a prescription concentrated omega-3-fatty acid as ethyl esters), Lipitor 20 mg q.d., and Cialis p.r.n.
K. J.'s history included childhood exposure to pesticides and secondhand smoke, traumatic childhood events, nutritional deficiencies, microbiome imbalances (i.e., bottle-fed as a child, CSx birth, and a processed-food diet), stressful times with his marriage, positional changes in his career, and family traumas. Furthermore, he was accustomed to using aspartame (diet soda and Crystal Light) for energy and admitted that he might be addicted to it. K. J. had also experienced a severe motorcycle accident in high school which was emotionally and physically scarring. When charting K. J.'s health history timeline, significant emotional distresses precipitated most of his major diagnoses. The cumulative diagnoses seemed to be exacerbated by a combination of environmental exposures or sabotaging lifestyle coping mechanisms.
Therefore, I thought that we needed to address K. J.'s significant emotional impacts in order to fully alleviate the physical pain that he was experiencing and restore his endocrine function. Once his vagal tone was calm, digestion and assimilation, circulation, energy regulation, immune modulation, and nervous system response would be further supported. (32) The use of essential oils would therefore support the whole comprehensive plan for K. J. and prevent further destructive emotional avoidance patterns as new strategies were implemented.
K. J.'s Plan: I explained to K. J. that in order to speed recovery and support healing, we needed to optimize his nutrition and balance his blood sugar. We discussed how high blood sugar was contributing to his inflammation and pain and its negative effects on proper mineral balance, lipid metabolism, liver health (biotransformation), hormonal signaling, and cellular repair. Therefore, looking at his diet and considering its quality was a major priority.
We started with an initial low-glycemic food plan. We discussed replacing gluten-containing grains with gluten-free options due to gluten's neurological effects in those with compromised digestive integrity. (33), (37) Furthermore, we reviewed the importance of balancing proteins, carbohydrates, and fats with meals to prevent sugar fluctuations. I also provided K. J. some options for adding color to his plate, specifically by introducing a new vegetable or fruit every week. These phytonutrients would support his immune function, and biotransformation, and mitigate oxidative stress. Finally, I explained to K. J. the negative consequence of aspartame on the regulation of insulin, leptin, and hunger and provided him alternatives such as a combination of seltzer water, lemon essential oil, and stevia.
This was quite a few dietary suggestions for the first visit, so I only asked him to start contemplating the importance of more organic options. I explained that this was in order to avoid excess pollutants, antibiotics, and hormones. Furthermore, due to his temperament and sensitivity, calming his vagal tone and finding connection to loved ones at meals would be a powerful heart enhancer. (34), (36)
With the dietary suggestions, I also included the therapeutic essential oils of rosemary, clove, cinnamon, and eucalyptus to diffuse and apply on the bottom of the feet. These oils combined for anti-inflammatory, oxidative stress, antimicrobial, circulatory, and blood sugar support. I also suggested that he purchase an essential oil diffuser to start diffusing this immune-enhancing blend and to alternate it with lavender or another of his favorite scents. Finally, I added S. boulardii, digestive enzymes, and a silver mouth spray to further support the digestive process and assist blood sugar support via microbiome balance. (37-40)
K. J. took a few visits to start implementing the changes, as I admittedly may have been a little overzealous with information at the first visit. Still, although he wasn't 100% compliant with the plan at the second visit, by the third follow-up he had implemented some dietary changes and the supplemental support.
K. J. noted that the use of lemon water assisted his ability to decrease his aspartame consumption by half. Furthermore, he experienced fewer nocturnal awakenings and reported more energy. K. J. reported no longer needing daily naps in his car. He also lost 5 lbs. in four weeks, he was urinating less frequently, and his glucose was no longer regularly spiking into the 200 range. His fasting blood glucose (FBS) was now ranging closer to150 ug/dl, although sometimes he was still spiking within the 170 ug/dl range.
Even with all his improvements, K. J. wished to put his treatment protocol on hold temporarily. K. J. thought that once pain was relieved by surgery, he would be better able to focus on lifestyle adjustments for overall wellness. Therefore, he decided to stop all supplements and medications, except his blood sugar medications, and schedule surgery. He would then follow up for support in healing and modulating postsurgical pain naturally and reimplement our plan. When he returned several months later, K. J. had reinitiated his protocol and made further changes to his diet. He reported that his blood sugar and pain had increased prior to his operation, after discontinuation of the protocol, and he was now eager to start with more support. At that point, we added CoQ10 and an herbal anti-inflammatory support product (containing niacinamide, NAC [N-acetylcysteine], L-glutamine, bromelain, hesperidin, MSM [methylsulfonylmethane], white willow bark, papain, trypsin, chymotrypsin, and serrapeptase) to his regime.
Following this, K. J. stated that he noticed an immediate and significant decrease in pain and was able to discontinue his pain prescription after only two days. He "wowed" himself and his orthopedist and physical therapists with the difference between his recovery speeds from his first and second shoulder surgeries. He noted that it only took a few weeks to see the increased ROM after the addition of CoQ10 and inflammatory support. Furthermore, he was able to get his blood sugar in the 140s and he had discontinued sitagliptin and decreased his dosage of Lipitor with the support of his endocrinologist.
K. J. was pleased with his postsurgical outcomes and was now willing to follow further suggestions to assist his healing. Therefore, we continued his implemented plan and added in a multivitamin that contains additional chromium, vanadium, green tea extract, and alpha-lipoic acid for blood sugar support.
Recently, K. J. became more lenient with the diet and supplements and had a significant work stressor. This resulted in reversion of fluctuations in blood sugar and fatigue. We continue to work interactively on these factors and use emotional and biochemical modulation with essential oils to prevent self-sabotage.
K. J. notes that if he is "on target" and taking good care of himself, he can consistently keep his blood sugar at 150 ug/dl and have more energy. Still, we wish to see his FBG level and HbA1c decrease, and at his upcoming follow-up visit I plan on adding in the herb Gymnema, which has been demonstrated to have potential for lowering FBG, blood lipids, and HbAlc, along with further lifestyle modifications. (41)
The Role of Gut in Inflammation and Pain in Diabetes
As mentioned previously, it was due to K. J.'s history of emotional and inflammatory triggers that led me to first support the enteric nervous system and gut-associated lymphoid tissue, along with the essential oils. Various studies have indicated the role of the gut and microbiome in managing inflammation, blood sugar, and pain. (37-40)
In a small comparison study of 36 men with varying BMIs, in which 18 had DM2, the connection between obesity, blood sugar, and the microbiome was evaluated using the microbiome ratios of the phyla Bacteroidetes to Firmicutes. The authors concluded that the results of the study indicated that DM2 was associated with microbiota composition:
... the ratios of Bacteroidetes to Firmicutes as well as the ratios of Bacteroides-Prevotella group to C. coccoides-E. rectale group correlated positively and significantly with plasma glucose concentration (P = 0.04) but not with BMIs. Similarly, class Betaproteobacteria was highly enriched in diabetic compared to non-diabetic persons (P = 0.02) and positively correlated with plasma glucose (P = 0.04).
Therefore, the authors stated, "The level of glucose tolerance should be considered when linking microbiota with metabolic diseases such as obesity and developing strategies to control metabolic diseases by modifying the gut microbiota." (39)
In 2010, an article review on the role of the microbiome on blood sugar metabolism and optimizing weight provided more mechanisms to support this:
Animals models of obesity connect an altered microbiota composition to the development of obesity, insulin resistance, and diabetes in the host through several mechanisms: increased energy harvest from the diet, altered fatty acid metabolism and composition in adipose tissue and liver, modulation of gut peptide YY and glucagon-like peptide (GLP)-1 secretion, activation of the lipopolysaccharide toll-like receptor-4 axis, and modulation of intestinal barrier integrity by GLP-2. Instrumental for gut microbiota manipulation is the understanding of mechanisms regulating gut microbiota composition. Several factors shape the gut microflora during infancy: mode of delivery, type of infant feeding, hospitalization, and prematurity. Furthermore, the key importance of antibiotic use and dietary nutrient composition are increasingly recognized. The role of the Western diet in promoting an obesogenic gut microbiota is being confirmation in subjects. Following encouraging results in animals, several short-term randomized controlled trials showed the benefit of prebiotics and probiotics on insulin sensitivity, inflammatory markers, postprandial incretins, and glucose tolerance.
Case 2: Physician Heal Thyself
When my mother introduced me to essential oils, I had no idea how her decision to cross over to "the dark side" of "voodoo medicine" would change my life, not just my pain management. I didn't know the analgesic properties of a simple bottle of Mentha piperita. (31) However, I did know that when I applied it every 20 minutes to my lower back, my pain decreased. I was also unaware of the study that supported Lavandula angustifolia aromatherapy for reducing the demand for opioid pain control using a prospective randomized placebo controlled study of 54 patients undergoing LAGB (laparoscopic adjustable gastric banding). (42) However, I noticed that when I smelled lavender in between my application of peppermint, I seemed to feel more hopeful and willing to venture out of my darkened bedroom.
I don't know that if I had read the study "Cinnamon Polyphenol Extract Affects Immune Responses by Regulating Anti--and Proinflammatory and Glucose Transporter Gene Expression in Mouse Macrophages," I would've had a little more faith in its combination for the immune-modulating properties and pain-relief capacity of my blend of wintergreen (Gaultheria procumbens), helichrysum (Helichrysum italicum), clove (Syzygium aromaticum), and Mentha piperita. (43-47) However, I will be forever grateful for that first essential oil chemistry book that I insisted on reading before applying the oils to my body and the continued peer-reviewed research to "back me up."
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(2.) Young G. Essential Oils Integrative Medical Guide. 2nd ed. Canandaigua, NY: Life Sciences Press; April 1, 2003.
(3.) Higley C, Higley, A. Reference Guide for Essential Oils. Spanish Fork, UT: Abundant Health; 2007.
(4.) Balz R. The Healing Power of Essential Oils. 1st ed. Twin Lakes, WI: Lotus Light Productions; 1996.
(5.) Djilani A, Dicko A. The therapeutic benefits of essential oils. In: Bouayed J, ed. Nutrition, Well-Being and Health. InTech; 2012:157. Available at: http://www.intechopen.com/books/nutrition-wel1-being-and-health/the-therapeutic-benefits-of-essential-oils. Accessed June 29, 2013.
(6.) Ibid., 161.
(7.) Ibid., 160.
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(10.) Gordon A. Can cinnamon oil fight this winter's microbial assault? [online article]. GreenMedInfo. February 5, 2012. http://www.greenmedinfo.com/blog/can-cinnamon-oil-fight-winters-microbial-assault?utm_source=GreenMedInfo+Weekly&utm_campaign=5ddc55292b-Greenmedinfo&utm_medium=email. Accessed April 11, 2013.
(11.) Jazani H, Zartoshti M, Babazadeh H, Ali-daiee N, Zarrin S, Hosseini S. Antibacterial effects of Iranian fennel essential oil on isolates of Acinetobacter baumannii [abstract]. Pak J Biol Sci. 2009;12(9):738-741. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19634482. Accessed April 10, 2013.
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(21.) Chaitow L, Trenev N. Probiotics. Northamptonshire, UK: Thorsons Publishing Group; 1990. Available at: http://www.holisticmed.com/detox/dtx-probio.txt. Accessed 2011.
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(24.) Gedney J, Glover T, Fillingim R. Sensory and affective pain discrimination after inhalation of essential oils. Psychosom Med. July 1, 2004;66(4):599-606. doi:10.1097/.01.psy.0000132875.01986.47. Available at: http://www.psychosomaticmedicine.org/content/66/4/599.full. Accessed July 8, 2013.
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(27.) Komeh-Nkrumah SA et at. Topical dermal application of essential oils attenuates the severity of adjuvant arthritis in lewis rats. Phyt other Res. 2012;26(1):54-59. PMCID:PMC3168704. Available at: http://europepmc.org/articles/PMC3168704/reload=0;jsessionid=Ow0Shlh3MuVkikAKsxrx.6. Accessed July 2, 2013.
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(29.) Sailer ER, Subramanian LR, Rall B, Hoernlein RF, Ammon HP, Safayhi H. Acety1-11-keto-beta-boswellic acid (AKBA): structure requirements for binding and 5-lipoxygenase inhibitory activity. Br J Pharmacol. 1996;117(4):615-618. Available at: http://www.ncbi.nlm.nih.goy/pmc/articles/PMC1909340. Accessed July 11,2013.
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(32.) Mate G. Op cit.
(33.) Burk K et al. Sporadic cerebellar ataxia associated with gluten sensitivity. Brain. 2001; 124 (5): 1013-1019. doi:10.1093/brain/124.5.1013
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(35.) Leifheit-Limson EC et al. The role of social support in health status and depressive symptoms after acute myocardial infarction: evidence for a stronger relationship among women. Circ Cardiovasc Qua/Outcomes. 2010;3:143-150. Available at: http://circoutcomes.ahajournals.org/content/3/2/143.full. Accessed August 15, 2011.
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(42.) Kim JT, Ren CJ, Fielding GA, et al. Treatment with lavender aromatherapy in the post-anesthesia care unit reduces opioid requirements of morbidly obese patients undergoing laparoscopic adjustable gastric banding [abstract]. Obes Surg. July 2007;17(7):920-925. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17894152?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum. Accessed August 10, 2013.
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by Sarah A. LoBisco, ND
Sarah LoBisco, ND, is a graduate of the University of Bridgeport College of Naturopathic Medicine (UBCNM) in Bridgeport, Connecticut. She is a licensed naturopathic doctor in Vermont State and holds a BA in psychology from SUNY Geneseo. Dr. LoBisco is a contributing item writer for the North American Board of Naturopathic Examiners (NABNE) and has had published several articles. She is also a speaker on integrative medical topics for medical professionals and is currently an accepted candidate in the Institute for Functional Medicine's (IFM) certification program. Dr. LoBisco currently has a private integrative medical consulting practice in Ballston Spa, New York. She incorporates naturopathic, functional, and conventional medicine with her specialized training in essential oils, herbs, whole-food supplements, mind-body medicine, and psychology to form an integrated approach unique to each client. Her recent blogs and information on her clinic can be found at www.dr-lobisco.com and www.saratoga.com/living-well. She is also a featured expert blogger on Dr. Oz's sharecare.com and 360menopause.com sites.
Contact: firstname.lastname@example.org; 518-339-4788, fax: 518-885-9145
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