HARNESSING MUSCULOSKELETAL

INFLAMMATION

VIRENDER SODHI, MD (AYURVED), ND

TO BE COVERED

• Ayurveda Introduction/History

• Ayurveda’s Concept of Inflammation

• Treatment

• Nutrition

• Lifestyle

• Panchakarma

• Herbal support

• Protocols

AYURVEDA

A 5,000 year old science of life

Ayu = Life

Ved = Science

The Goal of Ayurved •To treat disease

•To maintain optimal physical, mental, emotional and spiritual health.

•To fulfill the primary desires of:

1) Religious satisfaction (dharm)

2) Financial Stability (arth)

3) Procreative instinct (kama)

4) Supreme happiness through a balanced physical, mental,

emotional, and spiritual body. (moksha)

Ayurvedic Science is

based on 5 basic

elements

Ether

Air

Fire

Water

Earth

The 5 elements in

Nature

The five elements are present in

nature, and in the human

body on many levels. At the

most basic level, however,

they take the form of

chemicals such as:

Carbon, Oxygen,

Hydrogen, Nitrogen

The Doshas and the 5 elements

Vat = Ether + Air

Pit = Fire + Water

Kaph = Water + Earth

AYURVEDIC PHILOSOPHY

DEFINITION OF HEALTH

• Balanced Vat, Pit and Kaph

• Balanced Seven tissues

• Balanced Excretions (Malas)

• Balance at mental, emotional and spiritual

levels

• True Happiness (Sat, Chit, Anand)

AYURVEDIC MODEL OF INFLAMMATION

• Vat and Pitta imbalances

• Vata symptoms:

• Pain

• Stiffness

• Weakness/Paralysis

• Spasms

• Pitta symptoms:

• Heat, redness – inflammation of muscles, tendons, ligaments

INFLAMMATION A NORMAL RESPONSE

• Immune systems ability to mount inflammation is critical to survival

• Imbalances can lead to dysfunctions leading to inflammation and chronic diseases like RA, IBS, dermatitis, psoriasis and others.

• Diseases like Obesity, DM, Atherosclerosis, Hypertension, Alzheimer's, Parkinson’s, Cancer, Depression and Autism

CHRONIC INFLAMMATION - A COMPLEX PROCESS

• Chronic inflammation is a maladaptive state

• So many factors can go wrong

• Inflammation can be triggered via phospholipase, lipo-

oxygenase, cyclo-oxygenase –2, leukotrienes, thromboxane,

prostaglandins, nitric acid, collagenase, elastase,

hyaluranidase, monocyte chemoattractant protein-1 ( MCP-1)

• Interferon- inducible protein, tumor necrosis factor ( TNF) and

interlukin 12 ( IL –12)

• Imbalance in Th1 to Th2 ratios, NF-kappaB

• Histamines

NUTRITION FOR INFLAMMATION

• Avoid any processed foods, which has chemical or

additives; stripped of nutrition

• Avoid simple sugars, coffee and dairy

• Avoid Pitta aggravating foods like red meat, night shade

family, citrus family or any allergic foods. Try to learn to

eat seasonally.

• Favor more whole grain, colorful fruits and vegetables,

nuts and seeds.

• Encourage a variety of oil intake

EXERCISE

• How much to do?

• Sukshm Vyayam: Yoga an excellent start, keep the joint

mobilized

• Walking in Mother Nature

• Stretching

STRESS REDUCTION

• Yoga

• Breathing exercises

• Thai chi

• Meditation

• Prayers

• Accurate amount of rest

FLUID INTAKE

• How much fluids are taken in?

• At least 8 glasses of water in between meals

SLEEP - VAT

• Need at least 6 hours of sleep

• Tendency towards insomnia from nervous/fearful

mentality

Recipe for Restful Sleep

20 Almonds

1 Tsp. Poppy seeds

1 Tsp. Pumpkin Seeds

Blend and Soak overnight. Add honey to taste. Drink before going

to bed.

SLEEP - PIT

• Need at least 7 hrs of sleep.

• Tendency towards Insomnia from Mental Agitation.

Recipe for Restful Sleep

20 Almonds

1 Tsp. Poppy Seeds

1 Tsp. Pumpkin Seeds

3-4 Cardamom Seed Pods

5-10 Saffron threads

Blend and soak overnight. Add honey to taste. Drink before going to bed.

SLEEP – KAPH

•Need at least 8 hrs of sleep

•Tendency towards over sleeping

Recipe for Alertness

Drink a strong ginger or Green Tea in the morning

Avoid Coffee

PANCH KARMA DETOXIFIATION

• PK treatments put the body’s intelligence back to normal

• Gold standard for “curative” treatment

• Remove toxic buildup

• Divided into three stages:

• A) Preparation of PK

• B) PK treatments

• C) Post PK

PK

• Oleation (Snehan):

• Internal: Using different oil preparations

• External: External oil massage including specialized Marma

Points

MARMA POINTS

ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE,

(SEPT/OCT. 2002),VOL. 8, NO.5: PP.93-103.

• The results of the two-month longitudinal study showed that

PCBs and Beta-HCH (beta-Hexachlorocyclohexane) levels were

reduced by 46% and 58% respectively in detoxification group.

• Without this intervention, the expected drop in PCBs and Beta-

HCH over two months would be only a fraction of one percent.

• Previously, no method had been scientifically verified to

reduce levels of these lipid-soluble toxicants in the human

body without causing negative side effects.

AM J PHYSIOL REGUL INTEGR COMP PHYSIOL. 2006 MAR;290(3):R585-94.

EPUB 2005 OCT 27

• An activation of the immune system might contribute to the

therapeutic effect of whole body hyperthermia (WBH) in

cancer patients.

• Increase in human growth hormone (hGH), ACTH, and

cortisol as well as in TNF-alpha, IL-6, IL-8, and IL-12R. We

observed an increase in natural killer (NK) cells and CD56+

NK T cells shortly after initiation of WBH.

• WBH may induce naive and central-memory T cells to enter

lymphatic tissue to await antigen exposure and effector T

cells to migrate into peripheral tissues to exert their effector

function.

MAIN PANCH KARMA

• 1. Vaman (Vomiting)

• 2. Virechan (Purging)

• 3. Basti (Enemas)

• A) Cleansing Enemas

• B) Restorative Enemas

• 4. Shirovirechan/Nasya (Head cleansing)

• 5. Rakt Mokshan (Blood letting)

AYURVEDIC HERBS

• Curcumin (Curcuma longa)

• Boswellia Serrata

• Ashwgandha (Withania somnifera)

CURCUMIN

• Ingredients:

• Curcuma longa (97% pure

curcuminoids)

• Ayurvedic Properties:

• Properties light and dry

• Taste: astringent and bitter

• Post-digestive taste: pungent

• Energies: hot

• Effect: traditional anti-inflammatory

COCURCUMIN

Ingredients: • Curcuma longa (95%) • Coconut milk powder • Co-Q10 • Tirkatu blend: Piper longum, Piper nigrum,

Zingiber officialis) Ayurvedic Properties:

Properties light and dry Taste: astringent and bitter Post-digestive taste: pungent Energies: hot Effect: anti-inflammatory

BMC COMPLEMENT ALTERN MED. 2014 MAY 17;14:159 DECREASE OF A SPECIFIC BIOMARKER OF COLLAGEN DEGRADATION

IN OSTEOARTHRITIS, COLL2-1, BY TREATMENT WITH HIGHLY BIOAVAILABLE CURCUMIN DURING AN EXPLORATORY CLINICAL

TRIAL.

• Twenty two patients with knee OA were asked to take 2x3

caps/day of bio-optimized curcumin (Flexofytol®) for 3

months.

• Monitored after 7, 14, 28 and 84 days of treatment. Pain over the

last 24 hours and global assessment of disease activity by the

patient were evaluated

• Significantly reduced the serum level of Coll2-1 (p<0.002) and

tended to decrease CRP

EUR REV MED PHARMACOL SCI. 2014;18(24):3959-63. MERIVA®+GLUCOSAMINE VERSUS

CONDROITIN+GLUCOSAMINE IN PATIENTS WITH KNEE OSTEOARTHRITIS: AN OBSERVATIONAL STUDY.

• 4-month observational study, conducted in a 'real-life' scenario,

compares the association of Meriva and glucosamine (n=63)

with chondroitin sulphate+glucosamine (n=61) in 124 patients

with grade 1-2 OA of the knee

• Walking distance at the treadmill test after 1 month was also

significantly higher in the meriva+glucosamine group

• Need for concomitant drugs and medical attention decreased

more so in the Meriva+glucosamine group.

• Resulting in faster onset of action and improvement outcomes

J ALTERN COMPLEMENT MED, 9, 1 : 161-168 SAFETY AND ANTI-INFLAMMATORY ACTIVITY OF CURCUMIN: A

COMPONENT OF TURMERIC( CURCUMA LONGA)

• Turmeric is dual inhibitor of arachidonic acid cascade.

• Curcumin has shown to inhibit inflammation via phospholipase, lipo-oxygenase, cyclo-oxygenase –2, leukotrienes, thromboxane, prostaglandins, nitric acid, collagenase, elastase, hyaluranidase, monocyte chemoattractant protein-1 ( MCP-1),

• Interferon- inducible protein, tumor necrosis factor ( TNF) and interlukin 12 ( IL –12)

RHEUMATOLOGY (OXFORD). 2006 FEB;45(2):171-7. EPUB 2005 OCT 25.

CURCUMIN SYNERGISTICALLY POTENTIATES THE GROWTH-INHIBITORY AND PRO-APOPTOTIC EFFECTS OF CELECOXIB IN

OSTEOARTHRITIS SYNOVIAL ADHERENT CELLS.

• OA synovial adherent cells were prepared from human

synovial tissue collected during total knee replacement

surgery.

• Synergistic effect observed in inhibition of cell growth with

increased induction of apoptosis with curcumin and celecoxib

due to similar inhibition in COX-2 activity.

• Suggest use of celecoxib at lower and safer concentrations

when used with curcumin in the treatment of OA and other

rheumatic disorders.

J CLIN IMMUNOL. 2007 JAN 9; EPUB AHEAD OF PRINT

• Traditionally known for its an antiinflammatory effects, curcumin has been shown in the last two decades to be a potent immunomodulatory agent that can modulate the activation of T cells, B cells, macrophages, neutrophils, natural killer cells, and dendritic cells.

• Curcumin can also downregulate the expression of various proinflammatory cytokines including TNF, IL-1, IL-2, IL-6, IL-8, IL-12, and chemokines, most likely through inactivation of the transcription factor NF-kappaB.

• Interestingly, however, curcumin at low doses can also enhance antibody responses. This suggests that curcumin's reported beneficial effects in arthritis, allergy, asthma, atherosclerosis, heart disease, Alzheimer's disease, diabetes, and cancer might be due in part to its ability to modulate the immune system.

ARTHRITIS RHEUM. 2006 NOV;54(11):3452-64.

• In vivo treatment prevented local activation of

NF-kappaB and the subsequent expression of

NF-kappaB-regulated genes mediating joint

inflammation and destruction, including

chemokines, cyclooxygenase 2, and RANKL.

• Consistent with these findings, inflammatory cell

influx, joint levels of prostaglandin E(2), and

periarticular osteoclast formation were inhibited

by turmeric extract treatment.

SAFETY PROFILE

• Toxicity: Turmeric has long standing history of use in China and India.

Curcumin up to 8000 mg/day did not produced any toxicity (Anticancer

Res vol 21, 4B: 2895-2900)

• Large doses may produce GI irritation. Large doses in male rats reduced

fertility.

• Interaction: Has anti-platelet properties, may increase anticoagulants

activity.

• Contraindication: Turmeric is contraindicated in bile duct obstruction,

although I do not agree to this as this is given in gall stones. It has gall

stone dissolving properties.

• Also male and females who wants to conceive should avoid turmeric

BOSWELLIA

• Key functions:

• Healthy inflammatory effect specific to joints

• Healthy muscle movement and function

• Promotes recovery after athletic activity

• Supports healthy muscle and joint repair and nutrition

• Building blocks for healthy cartilage

BOSWELYA PLUS • Ingredients

• Boswellia serrata (150 mg Boswellic acid)

• Zingiber officinalis

• Withania somnifera

• Curcuma longa

• Propierty blend of:

• Bromelain 2400 GDU

• Glucosamine sulphate 2KCl 95%

• Chondroitin sulphate sodium 90%

• Ayurvedic Properties

• Qualities: light, dry

• Taste: astringent, bitter, sweet

• Energy: hot

• Post-digestive taste: pungent

• Doshic effect: balance kapha and pitta

• Effect: promotes a health inflammatory response

J ETHNOPHARMACOL. 2005 JUN 18; EFFECTS OF AN ACETONE EXTRACT OF CARTERII BIRDW.

(BURSERACEAE) GUM RESIN ON ADJUVANT-INDUCED ARTHRITIS IN LEWIS RATS.

• Arthritis was induced by injecting CFA subcutaneously into the

base of the tail, and the extract was administered orally (i.g.) for

10 consecutive days beginning on day 16 after the injection.

• Arthritic scores, paw edema, and the local tissue pro-

inflammatory cytokines tumor necrosis factor alpha (TNF-alpha)

and interleukin-1 beta (IL-1beta) were assessed.

• At 0.90g/kg per day, BC significantly decreased arthritic scores

between days 20 and 25 (p<0.05) and reduced paw edema on days

18, 20 and 22 compared to control (p<0.05).

• It also significantly suppressed local tissue TNF-alpha and IL-

1beta (p<0.05).

• No major adverse effects were observed in animals during the

repeated-dose treatment.

INT J MED SCI. 2011;8(7):615-22. EPUB 2011 OCT 12. A DOUBLE BLIND, RANDOMIZED, PLACEBO CONTROLLED CLINICAL STUDY EVALUATES THE EARLY EFFICACY OF

AFLAPIN IN SUBJECTS WITH OSTEOARTHRITIS OF KNEE.

• Aflapin(®) is a novel synergistic composition derived from

Boswellia serrata gum resin

• Sixty eligible OA subjects

• 100 mg (n=30) of Aflapin(®) or placebo (n=30) daily for 30

days.

• evaluated for pain and physical functions

• Aflapin conferred clinically and statistically significant

improvements in pain scores and physical function scores in

OA

PHYTOMEDICINE. 2003 JAN;10(1):3-7. EFFICACY AND TOLERABILITY OF BOSWELLIA SERRATA

EXTRACT IN TREATMENT OF OSTEOARTHRITIS OF KNEE--A RANDOMIZED DOUBLE BLIND PLACEBO CONTROLLED TRIAL.

• A randomized double blind placebo controlled crossover study was

conducted to assess the efficacy, safety and tolerability of Boswellia

serrata Extract (BSE) in 30 patients of osteoarthritis of knee, 15 each

receiving active drug or placebo for eight weeks.

• After the first intervention, washout was given and then the groups

were crossed over to receive the opposite intervention for eight

weeks.

• All patients receiving drug treatment reported decrease in knee pain,

increased knee flexion and increased walking distance. The

frequency of swelling in the knee joint was decreased.

SCHWEIZ ARCH TIERHEILKD. 2004 FEB;146(2):71-9. DIETARY SUPPORT WITH BOSWELLIA RESIN IN CANINE

INFLAMMATORY JOINT AND SPINAL DISEASE.

• An open multi-centre veterinary clinical trial, comparing conditions before and

after treatment with a herbal dietary supplement consisting of a natural resin extract

of Boswellia serrata, was conducted by 10 practicing veterinarians in Switzerland

• 29 dogs with manifestations of chronic joint and spinal disease were enrolled.

Osteoarthritis and degenerative conditions were confirmed radiologically in 25 of

29 cases. The resin extract was administered with the regular food at a dose of 400

mg/10 kg body weight once daily for 6 weeks

• After two weeks of treatment, an overall efficacy of the dietary supplement was

evident in 71% of 24 eligible dogs. A statistically significant reduction of severity

and resolution of typical clinical signs in individual animals, such as intermittent

lameness, local pain and stiff gait, were reported after 6 weeks.

CLIN DIAGN LAB IMMUNOL. 2005

MAY;12(5):575-80.

• Delivery of the resin extract using a sesame oil solvent

resulted in a dose-dependent inhibition of TH1 cytokines

coupled with a dose-dependent potentiation of TH2

cytokines.

SAFETY PROFILE

• Potential for stomach discomfort, including nausea, acid reflux

(heartburn), feeling full, stomach pain, or diarrhea

ASHWAGANDHA

Ingredients: Withania somnifera Providing Withanoloides

Ayurvedic Properties: Properties light and dry Taste: bitter, sweet, pungent Post-digestive taste: sweet Energies: hot Effect: traditional anti-inflammatory, adaptogen

IND. J MED. RES. 56:1581, 1968

• 46 patients of RA received 4,6 and 9 gram of doses for three to four

weeks.

• Pain and swelling disappeared in 14 patients, considerable

improvement in 10 patients and 11 patients showed mild

improvement.

• There was no improvement in 4 patients and 7 patients did not follow

the treatment.

J. ETHNOPHARMACOL 1991;33:91-95.

• Double-blind, placebo-controlled cross-over study of 42 patients

with OA, randomized to receive a formula containing

Ashwagandha, Boswellia, Turmeric, Zinc or placebo for 1 month.

• Pretreatment and treatment phase, pain and disability scores were

evaluated weekly while SED rate an radiological studies were

done monthly.

• Significant reduction in the severity of pain (p<0.001) and

disability (p<0.05) scores.

• No significant change in radiological appearance or SED rate.

J ETHNOPHARMACOL 1998 MAR;60(2):173-8 EFFECT OF ON LIPID PEROXIDATION IN STRESS-INDUCED

ANIMALS. DHULEY JN

• The aqueous suspension of root extract of an Indian drug ashwagandha (Withania somnifera L. (Solanaceae)) was evaluated for its effect on lipid peroxidation (LPO) in stress-induced animals.

• Simultaneous oral administration of ashwagandha (100 mg/kg) prevented the rise in LPO in rabbits and mice.

CELL DEATH DIS. 2013 AUG 22;4:E778; WITHAFERIN A: A PROTEASOMAL INHIBITOR PROMOTES HEALING AFTER INJURY AND EXERTS ANABOLIC EFFECT ON

OSTEOPOROTIC BONE.

• Withaferin increased osteoblast proliferation and differentiation, suppressed

inflammatory cytokines

• Decreased osteoclast number directly by decreasing tartarate-resistant acid phosphatase

and receptor activator of nuclear factor kappa-B, and indirectly by decreasing

osteoprotegrin/RANK ligand ratio.

• In vitro proteasome inhibition by WFA simultaneously promoted osteoblastogenesis by

stabilizing RunX2 and suppressed osteoclast differentiation, by inhibiting

osteoclastogenesis

• Oral administration of WFA to osteopenic ovariectomized mice increased osteoprogenitor

cells in the bone marrow and increased expression of osteogenic genes

• WFA promoted the process of cortical bone regeneration at drill-holes site in the femur

mid-diaphysis region and cortical gap was bridged with woven bone within 11 days of

both estrogen sufficient and deficient (ovariectomized, Ovx) mice

INHIBITION OF MORPHINE TOLERANCE AND DEPENDENCE BY WITHANIA SOMNIFERA IN MICE.

KULKARNI SK, NINAN I

• Ws (100 mg/kg) also suppressed morphine withdrawal jumps,

a sign of the development of dependence to opiate as assessed

by naloxone (2 mg/kg) precipitation withdrawal on day 10 of

testing.

ASHWAGANDHA

• Its naturally occurring steroidal content has shown more potent

anti-inflammatory action than hydrocortisone

• Rats given powdered root of Withania orally one hour before

being given injections of an inflammatory agent over 3-days

showed that Withania produced anti-inflammatory responses

comparable to hydrocortisone sodium succinate

SAFETY PROFILE

• Adverse reactions: Large doses can cause vomiting and diarrhea

• Toxicity profile: Acute study in animals shows good margins of safety

• Interaction:

• May enhance the effects of benzodiazepine and barbiturates

• May enhance the effects of thyroid medication

• Contraindications: Large doses have aborifacient action, but in

Ayurvedic literature Ashwgandha has been recommended and in my

personal experience I have not seen any adverse effects in

therapeutic doses

PROTOCOLS

• Acute Injury/trauma

• Boswelya Plus 2-3 TID with meals

• Curcumin 2-3 capsules TID OR CoCurcumin 1 tsp 3+ x daily

• Ashwgandha 2-3 capsules TID

• Physical therapy as appropriate

RHEUMATOID ARTHRITIS

• Boswelya Plus 1-3 TID

• Guggulip 1-2 TID

• Curcumin 1-2 TID or CoCurcumin 1 tsp BID-TID

• Livit-2 1 TID

• Trifal 1 TID

• Aswgandha 1-3 TID

• Flucommune 1-3 TID

• Fish Oils 1-3 teaspoon TID

RA

• Diet:

• Avoid: oranges, wheat, dairy, peanuts, nightshade family

• Maintain pitta-pacifying diet

• Exercise:

• Yoga

• Breathing: suukshma pranayama (joint breathing)

• Micro-movements

• Therapies:

• Swimming

• Epsom salt bath

OSTEO-ARTHRITIS

• Boswelya Plus 1-2 TID

• Ashwgandha 1-2 TID

• Curcumin 1-2 TID or CoCurcumin 1 tsp BID-TID

CARPAL TUNNEL SYNDROME

• Boswelya Plus™ one tablet three times a day

• Curcumin 97% ™ two capsules three times a day or

CoCurcumin 1 tsp two to three times a day

• Ashwagandha one capsule three times a day

• Add B-6 and Magnesium

• Massage with traditional massage oil

OSTEOPOROSIS

• Osteoporosis

• Eleg Fem™ two capsules three times a day

• Sitawari one capsule three times a day

• Young Fem™ one capsule three times a day

• Curcumin 1-2 TID (500mg) or CoCurcumin 1 tsp BID-TID

• Add Calcium Citrate, Magnesium

PERSONAL INJURY CASE

VIRENDER SODHI, MD(AYURVED), ND

• 2115 112th AVE NE Bellevue, WA 98004

• 425-453-8022

• WWW.AYURVEDICSCIENCE.COM

• WWW.AYUSH.COM

• virender@ayush.com