session 14 nervous system disease part i naturopathic ... · nervous system disease part i...

© Endeavour College of Natural Health endeavour.edu.au

WHMC311

Session 14

Nervous System Disease Part I

Naturopathic Medicine Department

1


Topic Overview

o Overview of principles and considerations in herbal

management of the nervous system condition pain.

o Review of herbal actions, indications, applications and

contraindications of: analgesics, sedatives, hypnotics,

tranquilisers, anti-spasmodics, relaxants, nervine tonics,

nervine trophorestoratives, cognition enhancers and

neuroprotectives.

2


Naturopathic Diagnostics: NS

o Dysfunction of the Central Nervous

System can be seen in abnormalities in

the size and shape of the pupil.

o Also at the following regions: cerebral

(brain) area, spinal area, adrenal area,

nerve rings and iris fibre signs.

o Dysfunctions of the Autonomic Nervous

System may also be seen in Autonomic

Nervous Wreath size, shape, colour and

texture abnormalities.(Jensen, 1952)

3


Herbal Medicine for the NS

Receptor Activity

o Herbal remedies are not directly

comparable to conventional drugs

in terms of direct action.

o It is most likely that the primary

effect of plant constituents on the

nervous system is on the synaptic

junctions

o Communication junctions are in

receptor sites on pre and post

synaptic membrane(Bone & Mills 2013, p.270)

4


Receptor Activity

5

o Ca channel activity – opioid alkaloids, ginseng saponins,

coumarin, scoparone (Capillaris) etc.

o Adrenergic effects – Ephedra, ephedrine,

pseudoephedrine, Angelica sinesis and Cnidium

monnieri (Beta-2-adrenergic)

o Acetylcholine – Solanacea family - Nicotiana tabacum

(tobacco) etc.

o GABA and benzodizepine – Valeriana off, Salvia

miltiorrhiza

o Dopaminergic – Mucuna pruriens, Polygala tenuifolia,

Corydalis ambigua(Bone & Mills 2013, p.270-271)


Pain

o Pain is a disagreeable subjective physiological and

psychosocial experience that often serves a biological

purpose (warning of injury)

o Highly subjective, pain does not necessarily correlate

with the degree of tissue damage (Sinclair, 2014, p.803)

6


Pain Classification

o Somatogenic (direct physiological mechanism or insult)

• Nociceptive (ongoing activation)

• Neuropathic (neurological dysfunction)

Or

o Psychogenic (non organic origin)

o Acute (lasting less than 4 weeks)

Or

o Chronic (longer than 12 weeks)(Sinclair, 2014, p.803-6)

7


Pain Management

o Classify/asses the pain

o Identify the cause

o Pain amelioration

o Address the underlying cause

o Address comorbidities (depression, insomnia etc.)

o Enhance mental resilience

o Lifestyle modifications

o Close patient monitoring

o Address social factors(Sinclair, 2014, p.806-7)

8


Treatment Considerations

o Ameliorate pain and reduce suffering

• Eschscholzia californica (GABA binding and anxiolytic, possibly

inhibit catecholamine degradation, synthesis of adrenaline and

bind to opiate and benzodiazepine receptors)

• Corydalis ambigua (tetrahydropalmatine – sedative, analgesic,

dopamine receptor antagonist)

• Passiflora incarnate (anxiolytic, hypnotic and mild sedative –

possibly secondary clinical benefit)

• Piper methysticum (anxiolytic, hypnotic, sedative and skeletal

muscle relaxant, lactones DHK and DHM shown analgesic effect

via non-opiate pathways)(Sinclair, 2014, p.809)

9



o Ameliorate pain and reduce suffering

• Harpagophytum procumbens (iridiod glycosides – anti-inflam

and analgesic, possible iNOS and COX-2 expression through

inhibiting NF-kB and reducing COX-1 activity)

• Salix alba (Acetyl group to salicylic acid led to NSAID and Asprin

development; hyaluronidase/lipoxygenase inhibition, free radical

scavenging may contribute to anti-inflame and analgesic action)

• Piscidia erythrina (central analgesic activity)(Sinclair, 2014, p.810)

10


Indications for Herbal Analgesics

o Pain associated with

inflammation:

• Arthritis

• Tendonitis

• Myalgia


vascular spasm:

• Migraine

• Angina

• Intermittent claudication

11


visceral spasm:

• Gall bladder

• Urinary tract

• Intestinal colic

• Spasmodic

dysmenorrhea

o Neuralgic pain (in limited

cases)

• Shingles


Analgesics

o Some traditional herbal analgesics include:

• Corydalis spp (Corydalis)

• Eschscholzia californica (Californian poppy)

• Salix alba (Willow bark)

• Piscidia erythrina (Jamaican Dog Wood)

• Anemone pulsatilla (Pasque flower)

• Piper methysticum (Kava)

o Topical Analgesics

• Mentha × piperita (Peppermint essential oil)

• Capsicum minimum (Cayenne)

• Arnica montana (Arnica)

12


Corydalis ambigua

o Actions

• Bitter, sedative, hypnotic, analgesic, cardioprotective,

anti-arrythmic

o Uses

• Pain, insomnia, cardiac arrythmia, myocardial

ischemia

o Contraindications

• Pregnancy

13



o Reduce local and systemic inflammation

• Topical anaesthetics – Capsicum frutescans, Piper methysticum,

Gaultheria procumbens (Wintergreen oil), Syzigium aromaticum

• Systemic - Zingiber officinale, Serenoa repends, Curcuma longa,

Glycyrrhiza glabra, Harpagophytum procumbens, Boswellia

serrata, Marticaria recutita, Arnica montana, Salix alba

o Support the immune system

• Dysfunction may impact on autoimmune/infectious disease pain

presentation (Hemidesmus indicus, Tylophora indica, Echinacea

spp. Uncaria tomentose, Andrographis paniculata, Astragalus

membranaceus, medicinal fungi)(Sinclair, 2014, pp.810-812)

14



o Support the nervous system

• Psychological consequence of pain exposure and specific

painful diseases affecting the NS such as herpes zoster etc.

• Adaptogens and nervine tonics

• Address insomnia if present - Sedatives and hypnotics

• Psychological – CBT referral, mindfulness/meditation, anti-

depressants and/or anxiolytics(Sinclair, 2014, p.812-814)

15


Herbal Sedatives, Hypnotics & AnxiolyticsSedatives Hypnotics Anxiolytics

Withania, Bacopa

Bugle weed

Californian poppy

Chamomile,

Cramp Bark

Hops,

Jamaican Dog Wood

Kava, Lemon balm

Lime Flowers

Mexican Valerian

Valerian, Mistletoe

Passionflower

Peppermint, Skullcap

Ziziphus, Wild Cherry

Californian poppy

Hops

Kava

Mexican Valerian

Valerian

Passionflower

Ziziphus

Bacopa

Californian poppy

Oats Green

Kava

Lavender

Mexican Valerian

Valerian

Neem Leaf

Passionflower

Ziziphus

It can be seen from this

table that many of our

nervine herbs cover a

wide range of nerve

related actions

16


Herbal Sedatives,

Hypnotics & Anxiolytics

o Indications

• Modern tension and anxiety syndromes (short term or

intermittent use)

• Insomnia – difficulty getting to sleep first thing at

night.

• Weaning off conventional sedative prescriptions

• Restlessness during convalescence

17


Herbal Sedatives,

Hypnotics & Anxiolytics

o Contraindications

• Generally milder than prescribed sedatives and

should not be seen as immediate substitutes in more

serious indications.

• It would be unwise and possibly dangerous to stop

strong medication without careful planning.

• Insomnia marked by increasing restlessness during

the early morning

• Depression

18


Antispasmodics and Relaxants

o Some traditional herbal antispasmodics and relaxants:

• Viburnum opulus

• Dioscorea villosa

• Leonurus cardiaca

• Matricaria chamomilla

• Passiflora incarnata

• Piper methysticum

• Scutellaria lateriflora

• Tilia spp

• Valeriana off.

19


Antispasmodics and Relaxants

o Indications:

• Anxiety, irritability and restlessness, including in children

• Sleeplessness due to anxiety and irritability

• Nervous dyspepsia

• Irritable bowel and intestinal colic

• Tension headache

• Spasmodic dysmenorrhoea

• Antispasmodics and relaxants may be taken as hot

infusions, though the ordinary tea bag may not be

sufficiently strong compared with a tradition brew.

20


Nervine Tonics &

Nervous Trophorestoratives

o Many conditions of tension are linked with fatigue,

debility and depression

o A group of remedies have emerged to meet the needs of

a modern stressed society

o Anti-depressants: Hypericum performatum, Lavandula

officinalis, Crocus sativa, Rhodiola rosea

21


Nervine Tonics &


• Avena sativa

• Hypericum perforatum

• Scutellaria laterifolia

• Turnera aphrodisiaca

• Verbena off.

• Withania somnifera

22


Nervine Tonics &


o Indications:

• Nervous exhaustion

• Neuralgia, herpes infections

• Depressive states

• Insomnia (waking in the small hours after getting to

sleep easily)

• Convalescence

• Neurasthenia

23


Nervine Tonics &


o Contraindications:

• True trophorestoratives are almost nutritive in their

effects, with few risks of adverse effects except in

those patients with extremely debilitated constitutions.

o Application:

• May be taken as required or before food.

• Long term therapy with trophorestoratives is generally

the norm

24


Pain Example: Headaches

o Headaches – pain located above the orbitomeatal line.

Primary:

• Tension-type

• Cluster

• Migraine - disabling, primary headache, characterised by

unilateral pulsing pain. With or without aura

Secondary:

• Cranial or cervical vascular disorders, non-vascular disorders

e.g. hypertension

• Substance or withdrawal, infection, homeostatic disorder,

psychiatric(Cottingham, 2014, p.330-331)

25


Pharmaceutical Management

Non-Opioid Analgesics - Paracetamol

Mode of Action

o Inhibits prostaglandin production within the CNS, with some COX inhibition (no anti-inflammatory benefits) giving it analgesic and antipyretic properties.

Side Effects

o Occasional incidences of skin rash & nausea if used within

therapeutic dose.

o Paracetamol overdose (10-15gms or 20-30 tablets) will cause severe liver damage due to depletion of glutathione, and possibly lead to death. Doses of 50 tablets is usually fatal unless quickly antidoted with acetyl cysteine.

o Liver toxicity appears to be linked to the concomitant use of excessive quantities of alcohol, or overdose

(Bryant & Knights, 2007; Bullock et.al. 2007)

26



Non-steroidal Anti-inflammatory Drugs (NSAIDs) – ibuprofen, aspirin, diclofenac, indomethacin, piroxicam

Mode of Action

o Non-selectively inhibit the synthesis and release of prostaglandins by inhibiting the cyclo-oxygenase (COX) enzymes in both COX-1 & COX-2 pathways. Also inhibits platelet aggregation.

Side Effects

o Gastro-intestinal (dyspepsia, nausea, vomiting, diarrhoea, constipation, gastritis, and may all potentially lead to ulceration and haemorrhage (COX-1 inhibition)

o Skin reactions, rash, sodium retention, may precipitate asthma attacks .

(Bryant, 2003)

27



COX-2 selective NSAIDs – Celecoxib

Mode of Action

o COX-2 is formed in inflammatory conditions – thus it is this pathway that would seem most appropriate to target when trying to reduce inflammation and pain (Bryant, 2003).

o Don’t inhibit COX-1 so have no GIT side effects or alter platelet aggregation. Useful for patients that can’t use non-specific NSAIDs.

Side Effects

o Associated with an increased risk of cardiovascular and thrombotic adverse effects.

o Renal damage due to inhibition of vasodilator prostaglandins resulting in heart failure and hypertension in some patients.

(Bryant & Knights, 2007; Bullock et.al. 2007)

28



Opioids – Opium, Morphine, Codeine, Oxycodone, Pethidine, Tramadol etc…

Mode of Action

o Opioids stimulate opioid receptors inhibiting the release of

substance P from the dorsal horn neurons reducing pain sensations

and inhibiting local inflammatory reactions.

o Euphoric action inhibits pain perception.

o Opiate analgesics are useful for relieving intense pain, non

responsive to non-opioid analgesics

o The response can vary dramatically between different opioid drugs,

with different rates of absorption

o The more lipophilic the agent, the better absorbed and the greater

the ability to cross the blood-brain-barrier(Bryant & Knights, 2007; Bullock et.al. 2007)

29


Treatment Aims

o Establish the type of headache and underlying cause

o Address of risk factors and triggers (e.g. food

sensitivities and allergic responses)

o Reduce pain and inflammation

o Ensure optimal nutrition and hydration

o Consider detoxification programs to manage medication

overuse headache syndrome

o Assess body mechanics and spinal alignment – refer

o Address lifestyle – exercise, stress reduction (work/life

balance)(Cottingham, 2014, pp.335-342)

30


HerbColeus, Zingiber & Turmeric All work on prostaglandin pathway

Corydalis Analgesic – very large doses required

Californian poppy Analgesic

Willow Bark Analgesic and anti-inflammatory

Chaste tree If hormonal relationship

Rosemary Migraine or hypertensive headache

Skullcap Nervine

Valerian Sedative, nervous excitability

Mistletoe Hypertensive headaches and frequent headaches with flushing face

Lavender For depression associated with digestive dysfunction

Catnip Sedative and for nervousness

Passionflower Nervousness, debility with fullness

Action/Indication

31


Tanacetum parthenium

o Traditionally used for migraines (especially if better with warm

applications)

o Serotonergic pathway addressed by inhibiting phospholipase,

preventing release of 5-HT from platelets and

polymorphonuclear leukocytes

o In-vitro – inhibits nitric oxide release (sensitise migraineurs to

pain and activate vasodilation – trigger)

o May inhibit prostaglandin synthesis

o Long term treatment is necessary - can be up to six months

before effects are noticed(Cottingham, 2014, pp 335-343)

32


Neuralgia/Neuropathy

o Neuropathic pain pathophysiology is largely based on the

causative aetiology in many instances; however, it is heavily

characterised by dysfunction of pain fibres of the CNS

Treatment considerations:

o Neuropathy

• Neuro protective

– Ginkgo biloba

• Capillary protective

– Vaccinium myrtillus

o Neuralgia

• Capsicum spp.

33


Capsicum minimum

o Capsaicin is an active constituent from the fruit of

Capsicum minimum and other species (Cayenne).

• Binds to vanillinoid receptors, promotes release of

substance P, neurokinin, somatostatin and calcitonin

from peripheral nerve fibres (particularly C fibres in

the slow pain network). Initially worsens pain/itching

• Repeated applications, C fibres are depleted of these

neurotransmitters, and are no longer able to transmit

pain or itch signals.

• With continued use, this effect can be sustained

indefinitely. (Yarnell, Abascal 2008)

34


Capsicum minimum

o Conditions in which topical capsaicin has proven effective

in double-blind trials include:

• Various neuralgias

• Diabetic neuropathy

• Dialysis-induced pruritus

• Psoriatic pruritus

• Fibromyalgia

• Osteoarthritis

• Stump pain

• Postmastectomy pain

• Postherpetic neuralgia (Yarnell, Abascal, 2008)

35


Herb-Drug Interactions

Opioids

Panax ginseng

o May reduce drug induced tolerance and decrease

adverse effects (Stargrove et al. 2008)

Opioids – Codeine

Fiber

o May prevent gastric upset and constipation. Concurrent

use of water, fibre, and water rich foods that assist with

bowel motion may be beneficial.

Alcohol

o Impaired alertness, constipation, impaired judgment(Braun & Cohen, 2010)

36



Paracetamol

o Alcohol may have more potential to cause liver damage when taken together (Braun & Cohen, 2010)

o Syzygium aromaticum (Clove) oil due to potential hepatotoxicity of its eugenol content should not be used together (speculative) (Brinker 2010, p.104)

o Cyamopsis tetragonolobus (Guar gum seeds) and Malusdomestica slows absorption due to slower gastric emptying (Brinker 2010, p.364)

37



NSAIDs - Aspirin

Capsaicin

o Found to protect gastric mucosa against aspirin-induced damage.

(Braun & Cohen, 2010)

Grapeseed extract

o Enhances antiplatelet and anti-inflammatory activity of aspirin and may risk of bleeding.

Allium sativum, Zingiber off, Curcumin longa

o Inhibits COX & LOX pathways therefore enhancing the

drug effectiveness. Additive effect.(Sarris & Wardle, 2010)

38


Cognition Enhancement

o Cognition encompasses a broad range of brain

processes, the health of which allows for social

connectedness, a sense of purpose and the ability to

function independently.

o Cognitive decline is significant in the elderly population.

Alzheimer’s disease is the most common dementia.

Cerebrovascular disease – brain lesions connected with

cardiovascular health/risk factors

o Traditional herbal remedies address these

39


Bacopa monnieri

o A traditional Ayurvedic herb used as

a brain tonic, and to improve

memory and learning

o Also used to promote longevity,

nervous deficit due to injury and

stroke

o In India it is called Brahmi - as is

Gotu Kola: Centella asiatica

o The two plants share similar uses,

and they are sometimes confused in

the literature

40

Bacopa monniera (Brahmi)

Centella asiatica (Gotu kola)


Bacopa monnieri

o An Australian clinical trial examined the long-term effects

of an extract of Bacopa monnieri on cognitive function in

54 healthy human volunteers (Calabrese et.al. 2008)

o The study was of double-blind, placebo-controlled design

in which subjects were randomly allocated to receive

Bacopa or placebo.

o Neuropsychological testing was conducted before

treatment and at 5 and 12 weeks after treatment.

41


Bacopa monnieri

o After 12 weeks the largest cognitive change from

Bacopa treatment was a time reduction for the

Inspection Time (IT) test.

o IT is regarded as a measure of the integrity of the early

stages of information processing and may act as a rate-

limiting factor for cognition.

o This indicates that Bacopa significantly improved the

speed of visual information processing.

42


Schisandra chinensis

o Lignans from Schisandra chinensis improved

concentration, fine co-ordination and sensitivity in

healthy young male adults as assessed by tasks such as

threading a needle and telegraphic reception and

transmission.

o Schisandra improved vision, enlarged the visual field,

improved hearing and heightened skin sensory

discrimination

o It was thought that those effects are central rather than

peripheral.(Chang HM 1987 as cited in Bone 2003, p.407)

43


Panax ginseng

o In a double-blind study on students given Ginseng over

thirty-three days significant improvements in

psychomotor ability and intellectual performance were

observed.

o Nurses switching from day to night duty were evaluated

for competence, mood, wellbeing and psychophysical

performance in a double-blind clinical study of Ginseng

versus placebo.

o Ginseng improved the scores for competence and mood,

and performance on the psychophysical test.(D’Angelo et al,1986)

44


Pre-reading for next session

o Reading 1: Braun, L Cohen, M 2010, Herbs and Natural

Supplements: An evidence based guide, 3rd edn, Churchill

Livingstone, Australia pp. 481-489.

o Reading 2: Yeon, KY Kim, SA Kim, YH Lee, MK Ahn, DK Kim, HJ

Kim, JS Jung, SI & OH, SB 2010, ’Curcumin Produces an

Antihyperalgesic Effect via Antagonism of TRPV’ Journal Dental

Research, vol. 89, no. 2, pp. 170-174.

http://jdr.sagepub.com/content/89/2/170.full.pdf+html

o Reading 3: Maroon, JC Bost, JW Maroon, A 2010, ‘Natural anti-

inflammatory agents for pain relief’ Surgical Neurology International,

vol. 80, no. 1.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3011108/

45

http://jdr.sagepub.com/content/89/2/170.full.pdf+html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3011108/


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