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What to put in your cupboard after you clear out the NSAIDs? If you are the type who depends on Ibuprofen for sprains/strains and headaches, start with Proteolytic Enzymes or Pancreatic Enzymes such as Wobenzyme N (which you can find at Pharmaca), or Intenzyme Forte by Biotics Research Corp. This company is not open to the general population. I can place an order on your behalf at your request. These products are combonations of digestive enzymes such as amylase, lipase, protease, trypsin, chymotrypsin and bromelain. Some people use these enzymes to help boost their body’s digestive potency when taken with food but this posting is focused on the ability of these enzymes to combat inflammation in an acute setting when taken on an empty stomach.

Bromelain’s theraputic properties include: (1) interference with growth of malignant cells; (2) inhibition of platelet aggregation; (3) fibrinolytic activity; (4) anti-inflammatory action; (5) skin debridement properties. (J Ethnopharmacol. 1988 Feb-Mar;22(2):191-203.)

Bromelain has been shown in a recent 2008 study to decrease neutrophil migration to sites of acute inflammation. What that means is that this is what you want to have in your gym bag when you injure yourself training or at an event and you want to give yourself your best chance at rapid recovery. The 2002 review article by Maurer does a great job of explaining the biochemistry of proteolytic enzymatic activity anti-tumor and anti-inflammatory effects.

Toxicity and Contraindications
Allergy to pineapple
Proteolytic/Pancreatic Enzymes have a potential anti-coagulant effect so they are not advised if you are having surgery or if you are already taking an anti-coagulant medication

Dosage and Administration
Bromelain can be used in isolation and has a dose-dependent effect. Doses as small as 200mg per day have been demonstrated in a study by Walker et al to be effective treatment of osteoarthritis. Acute inflammation responds well to doses as large as 400mg taken 3 times throughout a day. Most products are a polyenzyme preparations consisting of pancreatin, bromelain, papain amylase, trypsin etc. and dosage is determined by product. (Vasquez, Integrative Rheumatology)

Additional Information
Some studies have shown Proteolytic Enzymes to have enhanced effect when taken with 500mg Citrus Bioflavinoids. The research on these alternatives is not performed as often as with mainstream drugs but I recommend these as your first line of defense for life’s aches and pains because they are an effective, safe alternative to NSAIDs that help you to feel better but often at the expense of your own long-term health and strength.

The research on bromelain’s effect on headaches is sparse. There were some studies that looked promising for the treatment of acute sinusitis but they were performed in the 60’s with little follow-up. Will pancreatic enzymes knock-out a headache like an Advil liquid-gel? Usually not, but what do you have to lose by treating proteolytic enzymes as your first line of defense? At a minimum you are decreasing your systemic inflammation, improving your digestion and possibly decreasing your chances of tumor growth. You can’t say that about liquid-gels.

A wise man once said that as much as of 50% of what we call “fitness” may be pain tolerance. This may be true. In life it is sometimes necessary to continue on long after we exceed our comfort zone in order to do what we must. Whether you are a working person (kids or job) or an athlete we all have times that we do not “listen to our bodies.” We have those critical moments when we tell our bodies to shut their yaps and do as they are told. Anyone who has run 400 meters for time or has risen for a 5th time in the night to care for the needs of a child knows what I am saying. Whenever you push your body beyond its previous limits, it sounds the alarm. That sensation that your blood is on fire or that you are so tired that you feel stuck to the bottom of the ocean- that is your body panicking, having a tantrum: “STOP. YOU ARE CRAZY. YOU ARE GOING TO KILL US.” With training and experience we become familiar with this warning and decipher true alarms from the pangs of exertion.

The point to all of this is that we all bite off more than we can chew at times and in order to cope with the pain of injury or growth we do what we must to continue on with life. Most people reach without thinking for a bottle of NSAIDs to ease the pain. What do you reach for when you are in pain?

Disclaimer: I am not a pharmacist or a medical doctor. I do not prescribe drugs nor do I recommend changes to prescriptions that I don’t make. If you are self medicating with NSAIDs I’m about to give you some good reasons to stop. If they were prescribed to you, I’m going to give you some good reasons to discuss the necessity and safety of that prescription with your physician.

NSAID stands for nonsteroidal anti-inflammatory drugs. The most common over the counter versions that many of us have in our cupboards are Ibuprofen, Aspirin, Aleve, Motrin etc. These drugs act by counteracting the Cycloxygenase (COX) enzyme that produces prostaglandins that begin the body’s inflammation cycle which is the first stage of injury repair. Most people self-medicate common aches and pains or mild fevers with NSAIDs but they are also prescribed for cardio-protective and anti-inflammatory purposes. The intended effects of NSAID use are decreased pain and swelling.

The less desirable effects include:

Promotion of bone necrosis, cartilage destruction, and prolonged tissue healing time:
This is the horrible and ironic byproduct of NSAID use. The very joints that these drugs are effective at relieving the pain of inflammation in the short-term are degraded and weakened in the long-term. The mechanism of action is the interference by NSAIDs on chondrocyte function and thus cartilage formation within synovial joints.(7,3) This is likely the reason why NSAID use slows tissue healing time in athletes with severe muscle strains.(6) Think that over the next time you have a sore muscle. You can have relief from the bottle in the cabinet but it is relief on credit. It is relief that makes you weak and vulnerable to future injuries.

Gastric Ulceration and gastrointestinal bleeding: Nearly all NSAIDs promote gastric ulceration and gastrointestinal bleeding. Endoscopic studies indicate that among people who chronically use NSAIDs, up to 30% will develope gastroduodenal ulceration.(3,4) Conservative calculation estimates that approximately 107,000 patients are hospitalized annually for NSAID-related gastrointestinal (GI) complications. According to a research review article by Singh (5) 16,500 NSAID related deaths occur annually among arthritis patients alone.(3) There are no reliable warning signals for impending serious GI complications. – >80% of patients with serious GI complications had no prior GI symptoms and currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events. (5)- These effects are compounded by the co-administration of or chronic use of alchohol.

Increased intestinal permeability due to damaged mucosa- “Leaky Gut” contributes to many rheumatic and musculoskeletal disorders by promoting the formation of immune complexes that are deposited into synovial tissues causing local inflammatory responses within the joints. (2,3) Anyone familiar with the Paleo Diet and the adverse effects of gluten on the small intestine is well aware of the importance of a patent intestine. For more information see my posting titled The New Balance Paleo Challenge: 30 Uncomfortable Days to Define Your Optimal Nutrition.

Kidney Disease: Chronic NSAID use is a critical risk factor in renal failure. (8,3)

Liver Disease: Liver disease is not as common in NSAIDs but is prevalent with Tylenol (Acetaminophen) this damage is especially likely when Tylenol is used with alcohol. The take home here is that Tylenol is not an acceptable solution for a hangover.

*All of the previously stated side-effects are compounded by the co-administration of alcohol or the chronic use of alcohol.

Inflammation is a necessary step in the tissue healing process- it is how broken materials are cleared out of the area before new tissues are laid down. That being said, the healing process is faster and more effective when this step is reigned in. In an on-line lecture Kelly Starette recently likened the degree of inflammation that the body mounts in a common injury to ripping a building down to its foundation to begin the process of fixing a small dent in one of the walls. This excessive and reactionary response was likely useful and necessary for our ancestors who had no access to sterile dressings or clean hot water to manage possible infection that often comes with tissue damage.

So what to do to reign in the inflammation process and speed healing time without the harmful and counterproductive effects of NSAIDs? Stay one step ahead of acute inflammation with an anti-inflammatory lifestyle that includes: Paleo Nutrion and regular supplementation of fish oil and glucosamine sulfate.

Prevention is key but sometimes sprains and strains happen. Then what?
The inflammatory phase of the tissue healing process lasts approximately 72 hours. For quicker healing times and stronger recovery from injury, follow a combination of these suggestions for the initial 3 Days post-injury:

1) Ice. Yes ice. It is almost too simple to take seriously, but seriously, take ice. You know the routine, now use it. That muscle that is sore after a workout/ game/ bout with lawn maintenance- ice it down through a towel for 20 minutes of every hour for the first 3 days following injury. If you are unwilling to make the time for icing try ice massage instead. It only takes 5 minutes of rubbing an ice cube directly into the injured area to achieve the effect of 20 minutes passive icing through a towel. While you’re at it, you may as well compress and elevate the area as well.

2) What to put in your cupboard after you clear out the NSAIDs? Start with Proteolytic Enzymes such as Bromelain. Bromelain has been shown in recent studies to have measurable anti-inflammatory effects for acute injury (9,10) and the only major side-effect for those without pineapple allergies is an anti-tumor and anti-cancer effect. (11,12)

There are several other well researched and well established herbal and natural anti-inflammatory products on the market but each deserves its own posting. Look out for future postings on Citrus Bioflavinoids, Boswellia, and Arnica etc. to guide you in the acquisition and administration of your own gym bag injury kit.

(1) Brandt KD. J Rheumatol Suppl. 1991 Feb;27:120-1. The mechanism of action of nonsteroidal antiinflammatory drugs.
(2)Inman RD. Antigens, the gastrointestinal tract, and arthritis. Gheum Dis Clin North Am. 1991 May; 17(2): 309-21
(3) Vasquez, Alex. Integrative Rheumatology 2007 :147
(4) Blower AL. Scand J Rheumatol Suppl. 1996;105:13-24; discussion 25-7. Considerations for nonsteroidal anti-inflammatory drug therapy: safety.
(5) Singh G. Am J Med. 1998 Jul 27;105(1B):31S-38S. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy.
(6) S Afr Med J. 1995 Jun;85(6):517-22. Non-steroidal anti-inflammatory drugs fail to enhance healing of acute hamstring injuries treated with physiotherapy.
(7) Brandt KD. Am J Med. 1987 Nov 20;83(5A):29-34. Effects of nonsteroidal anti-inflammatory drugs on chondrocyte metabolism in vitro and in vivo.
(8) Segasothy M Br J Rheumatol. 1995 Feb;34(2):162-5. Chronic nephrotoxicity of anti-inflammatory drugs used in the treatment of arthritis.
(9) Walker AF, Bundy R, Hicks SM, Middleton RW Phytomedicine. 2002 Dec;9(8):681-6. Bromelain reduces mild acute knee pain and improves well-being in a dose-dependent fashion in an open study of otherwise healthy adults.
(10)Walker JA, Cerny FJ, Cotter JR, Burton HW. Med Sci Sports Exerc. 1992 Jan;24(1):20-5. Attenuation of contraction-induced skeletal muscle injury by bromelain.
(11) Chobotova K, Vernallis AB, Majid FA Bromelain’s activity and potential as an anti-cancer agent: Current evidence and perspectives. Cancer Lett. 2010 Apr 28;290(2):148-56. Epub 2009 Aug 22. Review.
(12) Bhui K, Prasad S, George J, Shukla Y. Bromelain inhibits COX-2 expression by blocking the activation of MAPK regulated NF-kappa B against skin tumor-initiation triggering mitochondrial death pathway.
Cancer Lett. 2009 Sep 18;282(2):167-76. Epub 2009 Mar 31.

Six years ago, for my 25th birthday my wife sent me on a ski trip with friends. A trip which I took as an opportunity to research the process of injury and recovery. After overshooting the landing on a tabletop and fracturing my right scaphoid and dislocating my lunate, I was left with two large pins stabilizing my wrist for the following four months.

Joints do not like to be immobilized. The hyaline cartilage that prevents bone on bone contact in synovial joints lacks any direct blood supply. It depends on regular compression and decompression to act as a pressure pump that draws blood from the surrounding chondrocytes. Because of this, even in ideal situations where the scaphoid heals well and the articulation with the lunate is restored, severe cartilaginous degeneration and resulting arthritis is a likely long-term outcome from this sort of trauma.

With my hobbies, goals, and livelihood I am well aware that it is worth the minimal investment to get the right nutrition and supplementation to give me my best opportunity to have wrists that are both mobile and pain free.

Glucosamine Sulfate is marketed for its promotion of cartilage regeneration. Glucosamine is not necessarily a building block for cartilage in your synovial joints but it along with Chondroitin stimulate the synthesis of glycosaminoglycan, proteoglycan and hyaluronic acid, which are the “building blocks” of joint cartilage. Recent studies have shown that glucosamine sulfate 500 mg TID (3 times per day) and/or Chondroitin Sulfate 1200mg are effective treatments for joint degeneration and pain seen in osteoarthritis.(1) They have also been shown to be as effective and safer than Ibuprofen in the treatment of knee pain.(2)

I have supplemented Glucosamine Sulphate and fish oil for the past several years and they seem to have helped my recovery. I now experience nearly full ranges of motion and my wrist causes me only minimal discomfort and only when I push it into full weight bearing extension during presses and handstands. That being said, as with all things nutrition I recommend you try for yourself and see if it works for you. If you have a demanding physical lifestyle and pain that localizes to a particular joint try 8 weeks of glucosamine/chondroitin supplementation. There is an anti-inflammatory effect that is useful in the short-term, but do not judge this product’s effect until you give it at least 8 weeks. That’s how long it will take to have an effect on cartilage regeneration.

Toxicity and Contraindications:
Glucosamine is derived from shellfish sources so beware if you have a known allergic reaction to shrimp, crab or lobster.
Dosage and Administration:
Glucosamine Sulfate: 1500 mg divided into 3 seperate 500mg doses (1500mg TID)
Chondroitin Sulfate: 1200 mg
Can be taken with or without food.

Additional Information:
Stay away from HCl. The cheaper products on the market are typically bound to HCl instead of Sulfate (Glucaosamine HCl/ Chondroitin HCl) It is cheaper to produce this way and the product MAY be just as effective but the above research and major studies that validate the use of Glucosamine /Chondroitin were done with Sulfate bound supplements.

Should I take Glucosamine alone or compounded with Chondroitin?
Some studies show that these two products have a cumulative effect. I have seen studies that show Glucosamine to be just as effective on its own. The important thing to remember when selecting the supplement is dosage; many compounded products will water down the amounts of each supplement to get more names on the label. If you find something that has both and they are both bound to sulfate, and the dosages add up, go for it. Otherwise keep it simple and stick with Glucosamine Sulfate alone.

(1)– Alex Vasquez, N.D., D.O.,D.C. Integrative Rheumatology Pg. 449
(2)– Muller-Fassbender H. Bach GL, HasseW, Osteoarthritis Cartliage. 1994 March;2 (1) 61-9

The number one problem that people on the paleo challenge struggle with is getting that sweet tooth under control. I feel your pain. Three days into my first challenge I felt like I would rather eat my own shoes than eat another salad. Enter the Paleo Frosty. This is NOT a pre or post workout shake. This is what you turn to after dinner when you start to here the siren song of Cupcake Royale.

This thing is loaded with natural fats and sugars. Several sugar starved cave people have told me that it is the best shake they’ve ever had. Of coarse this is akin to having the best saltine of your life after not eating for 2 weeks. Just the same, it scratches the itch and keeps you from falling off the paleo-wagon and depending on how you are scoring your challenge, can cost zero points against your caveman cred.

The Paleo Frosty:
1 can coconut milk. (I prefer the regular milk but some can only handle the low fat)
2-3 whole pitted dates (all the sugar, none of the points!)
5 ice cubes
1.5 Tablespoons baking cocoa- the unsweetened bitter stuff

That is the base I add cashew butter sometimes and frozen fruits are solid too.

Put it all in a food processor or a burly blender and serve it in a champagne glass.

"Do you know how much teeth weigh? I lost 4 pounds on the scurvy diet!"

Let’s start from the end and work our way back here-
If you are a person you should take a fish oil supplement. Good. I’m glad we have that covered. The following paragraphs will explain how much to take. A future posting will explore the fats debate in detail but in the immortal words of Hans and Franz: “Believe me now and listen to me later.”

How Much Do I Need To Take Per Day?
Disregard the label on your supplement. Serving sizes are not determined by physiologic need, they are determined by price. Ever notice that a serving size almost always amounts to 1$/ day regardless of the supplement?

This is how much you should take per day:

There are two ends of this spectrum.  At one end is the minimal daily dose of a teaspoon per day of whatever is in the product you bought.  This dose has a proven cardiovascular benefit and should be considered your buy-in.  The other end of the spectrum is promoted by the likes of Robb Wolf and has added benefit for tissue healing, fat ratio balancing, is anti-inflammatory and is especially useful in high stress situations.  The following is how you determine your high end intake:

Between .5 Gram to 1 gram per day for every 10 pounds of body weight. If you are demanding on your body either from heavy training and high stress load or from deficient sleep your body requires the higher 1 Gram per 10 pounds body weight. (Robb Wolf) When I say .5-1 gram I do not mean one gram of “total fat.” I mean one gram of EPA/DHA. That’s the good stuff. (1000 mg=1gram)

If you are confused because your product is measured in ml’s instead of mg’s then dig a little deeper. You are probably looking at the number at the top of the label under “Serving Size.” That number is not of interest because it is a volume measurement that includes flavoring agents etc. Follow along with the label below:

Example:
For your typical crossfitter or other highly active 180 lbs. individual the calculation looks like this:
1 gram/10lbs body weight= 18 grams/day.
For your average sedentary or 3 days of cardio/ week type that is .5grams/10lbs = 9 grams/day

This is the Innate Choice Omega Sufficiency supplement facts label from the gel caps. That’s why there is a range.

I use Innate Choice in my office which is pure but not necessarily significantly different than market brands such as Carlson’s. Innate Choice smells good and does not degrade in the bottle so it’s the one I go with. My product has 4 grams “total fat” per teaspoon but total fat is not what we are interested in right? We want the good stuff: EPA/DHA so look further down the label under “Omega-3 Fatty Acids”

Per teaspoon (5ml) my product has:
825mg EPA/ 550mg DHA= 1375 mg= 1.375 grams per teaspoon.

For our 180 pound crossfit athlete to get 18 grams we divide 18 by 1.375 to determine the number of teaspoon sized servings he needs. This equals 13 teaspoons of fish oil per day. This would be obnoxious and who uses teaspoons anyway? So use 4.3 Tablespoons instead. (3 teaspoons= 1 Tbs.) Answer= 4.3 Tablespoons/day.

Your average person (Low stress load/ minimal training) requires half that amount: about 2 tablespoons per day.

This amount is not a problem as long as you can tolerate taking the oil straight without the gel cap which gets cumbersome quickly: To get the same amount of fish oil in 4.3 Tbs. from gel caps would require 52 caps per day!
So if you are a person, find a product that you like the taste of and follow the formula below.
(#pounds body weight divided by 10) times .5-1.0 grams= grams EPA/DHA per day.

For those of you who eat a lot of wild fish you can subtract the amount of omega-3’s that you get from your diet from the amount that you supplement. Every serving (3 oz. piece) of wild salmon has about 2 grams of omega-3 oils. Other seafood has about half that; 1 gram per 3 ounce portion. A three ounce serving is about the size of a deck of cards. That’s a little serving so you can get a significant amount from diet alone.

This equation is appropriate for anyone who weighs under 200 pounds.  If you do the math it starts to get out of control at higher body weights. Exercise some restraint and common sense. If your fish-oil bill competes with your mortgage payment you have a problem. It is most important to get started and to be consistent. A large randomized trial called the GISSI Prevention Trial demonstrated that 1 gram/ day regardless of body weight decreased 3 year mortality rates by 10%.