Carpal Tunnel Syndrome

Carpal Tunnel Syndrome: a condition in which the nerve that travels within the carpal tunnel--a "tunnel" in the wrist containing ligaments, bones, tendons, and the nerve--gets squeezed and eventually can no longer function normally
here is no single magic pill to treat carpal tunnel syndrome (CTS). A variety of methods may be considered to prevent it, treat it, or at least reduce its severity. Recommended management of carpal tunnel syndrome should employ an integrative medicine approach that brings together standard clinical medicine with nutritional medicine.

What Is Carpal Tunnel SyndromE?

Incidence of carpal tunnel syndrome (CTS) is steadily increasing with the widespread use of computer keyboards. CTS is the most common peripheral compression neuropathy. The U.S. National Center for Health Statistics estimates that there are over 2 million cases, making CTS a very common form of repetitive stress injury (RSI) in the United States. It is an entrapment neuropathy of the median nerve at the wrist. It is similar to having someone step on your foot and stay there, causing pain. The difference is that CTS is usually self-induced due to repetitive hand and wrist movement.

Where Is the Carpal Tunnel?
The carpal tunnel is located within each wrist. Specifically, the carpal tunnel is the transverse carpal ligament and nine flexor tendons that surround the median nerve as it passes through the wrist and the palm area. The bones of the wrist are on the bottom of the tunnel, and the transverse carpal ligament is on the top of it. Through this opening, called the carpal tunnel, the median nerve and the flexor tendons run into the hand. The median nerve lies just under the transverse carpal ligament. The flexor tendons are important because they allow the fingers and the hand to move and grasp objects. The tendons are covered by a material called tenosynovium. Tenosynovium is very slippery and allows the tendons to glide against each other as the hand is used to grasp objects. The hand is supposed to work as a well-oiled machine. In CTS, the nerve that travels from one's hand to parts of the hand gets entrapped within the carpal tunnel, a passage between the flexor retinaculum of the hand and the carpal bones.

Any condition that causes irritation or inflammation of the tendons can result in swelling and thickening of the tenosynovium. This inflammation is called tenosynovitis. As the tenosynovium covering all of the tendons begins to swell and thicken, the pressure begins to increase in the carpal tunnel. This is because the bones and ligaments that make up the tunnel are not able to stretch in response to the swelling. Increased pressure in the carpal tunnel begins to squeeze the median nerve against the transverse carpal ligament. This is because the nerve is the softest structure in the carpal tunnel.

What Happens in More Serious Cases?
Eventually, pressure created by the compression reaches a point at which the nerve can no longer function normally. The median nerve may demyelinate, or lose its protective covering resulting in more serious and even permanent damage. In CTS, particularly in more severe cases, the median nerve commonly undergoes focal (nodal) or segmented demyelinization after compression on carpal tunnel 3-4 distal to the wrist. Inflammatory demyelinization is loss of myelin due to inflammation. Demyelinization involves specific locations of a free-radical type of activity, a form of on-site destruction of the protective myelin sheath located at the carpal tunnel in the wrist. This is an ongoing process involving the release within the wrist of so-called free radicals in the development of more serious forms of CTS.

Nature's Natural Insulation to Protect the Wrist

Myelin is a soft, somewhat fatty material that forms a thick myelin sheath about the protoplasmic core of a myelinated nerve fiber in the wrist. It operates like a warm, protective coat on a cold winter day or like electricians' tape wrapped around a sizzling, hot, exposed wire. It is intimately involved in protection of the underlying nerve that it covers, as well as allowing for and furthering nerve conduction to sustain electrobiochemical signals. In the case of the hand in CTS, its role is to sustain and encourage necessary electrobiochemical currents to all parts of the hand through the ulnar and median nerves in order to facilitate full hand, wrist, and arm function. Like any other tissue, there is an ongoing dynamic process of (1) myelinization (i.e., growth of myelin); (2) demyelinization (i.e., loss of myelin); and (3) remyelinization (i.e., routine regrowth of new myelin) going on in normal metabolism in order to retain normal myelin protective and conductive status. There is balance in nature and in the use of the wrists. Free radicals involve themselves in normal metabolism in continuing the breakdown, growth, and repair of all human tissue, not just myelin. However, when the net accumulation of free radicals in tissue exceeds the rate of repair without regrowth, there is degradation, breakdown, and loss of function in that tissue. Common repetitive use and other sources of injury discussed here may produce inflammatory demyelination in the nodal and segmental locations on the median nerve. This is the biological equivalent of hard wiring with shorting out (i.e., numbness or pain as power surges), like electrical problems developing in a car.

What Are the SymptomS?

Pain and numbness begin in the hand. One of the first symptoms of CTS is numbness in the distribution of the median nerve. This is quickly followed by pain in the same distribution. The pain may also radiate up the arm to the shoulder and sometimes the neck. If the condition is allowed to progress, weakness of the ulnar muscles can occur. This results in an inability to bring the thumb into opposition with the other fingers and hinders one's grasp. As part of the patient history, commonly, patients first complain of waking in the middle of the night with pain and a feeling that the whole hand is asleep. Careful investigation usually shows that the little finger is unaffected. This is because that finger is serviced by the ulnar nerve while the median nerve services the thumb and other fingers. This can be a key piece of information to make the diagnosis. If you awaken with your hand asleep, pinch your little finger to see if it is numb also, and be sure to tell your doctor if it is or is not. Other complaints include numbness and/or growing weakness while using the hand for gripping activities, such as sweeping, hammering, or driving. The major physical findings reflect that pressure is increased in the carpal tunnel.

1. Here is a summary of common symptoms:
2. Pain in the wrist that radiates into the hand and sometimes the forearm
3. Numbness and tingling in the thumb and index and middle fingers
4. Weakness in the hand

What Other Diseases or Conditions Are Associated with CTS?

A number of diseases and other conditions are also associated with CTS. Besides occupational injury usually involving repetitive stress (the most common cause), acute trauma, systemic illness such as untreated or under-treated diabetes, rheumatoid arthritis, and even loss and degradation of muscle and connective tissue (i.e., atrophy) due to nonuse, aging, or other causes may precipitate carpal tunnel syndrome.

There are many conditions that can result in irritation and inflammation of the tenosynovium and eventually cause carpal tunnel syndrome. Different types of arthritis can directly cause inflammation of the teno-synovium. This includes rheumatoid arthritis, osteoarthritis, gout, bursitis, reactive arthritis, and tendinitis. A fracture of the wrist bones may later cause carpal tunnel syndrome if the healed fragments result in abnormal irritation on the flexor tendons. Remember that anything that causes abnormal pressure on the median nerve will result in the symptoms of pain, numbness, and weakness of carpal tunnel syndrome.

The presence of carpal tunnel syndrome has also been found in the third trimester of pregnancy when fluid in the wrist joint from the edema of pregnancy may produce median nerve compression. It was discovered through nerve conduction evaluation in one study that was able to detect that nearly 80% of the pregnancy subjects were asymptomatic but had impaired nerve conduction (Atisook et al. 1995). Besides pregnancy, edema to the wrist producing CTS-like symptoms has been commonly caused by the use of oral contraceptives, drug side effects, and water retention associated with menstruation. This underscores the importance of a detailed patient history in diagnosis and treatment.

Who Is Affected by CTS?

CTS is a particularly severe example of RSI, affecting not only computer keyboard operators (who have gotten most of the popular media publicity) but also many dentists, surgeons, and skilled craftsmen of every kind who have had to quietly change jobs. This is devastating to people who have had years of advanced training in their chosen fields. Recently, physicians have begun to recognize that any activities that involve highly repetitive use of the hands can result in carpal tunnel syndrome, such as an assembly line worker who may make 25,000 repetitive movements each day. And of course, pregnant women with wrist edema run the risk of median nerve compression.

When Is Surgery Required? HoW Is It DoNE?

The entrapment or compression of the median nerve may be mild, moderate, or severe. This is determined by clinical or electrodiagnostic testing, or both. Surgery may not be necessary if CTS is caught and treated in the early, mild, or more moderate stages. If a person suspects this condition is developing, immediate, early treatment is the best approach. When the problem is treated early, complete recovery without surgery is likely, without difficult treatment. If treatment is delayed, surgery may be required. If surgery is not successful, CTS may become irreversible.

General treatment considerations include the cause, length, and amount of compression (i.e., pressure on the median nerve) that may dictate the level of treatment. Severe CTS usually requires surgery. Even in severe cases, a new approach involving a single injection of methylprednisolone (a steroid) with lidocaine proximal to (not into) the carpal tunnel may result in long-term improvement and should be considered before surgery to take pressure off the nerve. Vitamins and nutrition alone will not work to take pressure off of a severely affected nerve. Two types of surgery are commonly used, primarily for taking pressure off of the median nerve and other related surgical concerns.

1. Open carpal tunnel release (OCTR), with better recovery of certain conditions such as nerve palsy
2. Endoscopic carpal tunnel release (ECTR), which is much less invasive and reduces the cost and treatment time

Steroid Injections for CT

There is a big difference between injecting steroids proximal to the wrist (once) rather than directly into the wrists as repeated treatments. It has long been known that corticosteroid (steroids) injections into the carpal tunnel may damage the nerve and any treatment improvement may be of short duration. However, in a study published in the British Journal of Medicine in October 1999, a single injection with steroids (methylprednisolone with lidocaine) proximal to the carpel tunnel improved 77% of patients with CTS 1 month after treatment. This single injection was found still effective at 1 year in half of the patients. According to the study that was conducted at the University of Amsterdam (Department of Neurology at the Academic Medical Center, the Netherlands), injections proximal to the carpal tunnel have no side effects and are easier to carry out than injections into the carpal tunnel. This center had been using this surgical technique for the last 20 years with success. The duration of improvement demonstrated in this study seemed to be longer than that reported in other studies. This technique should be considered before surgery to take pressure off of the nerve (Dammers et al. 1999).

Testing for CTS

Testing procedures include the following:

1. Physical examination with a range of motion study and pain severity assessment along with detailed patient and family history, including occupational history
2. Phalen's test or wrist flexion test checks for pain, tingling, or numbness that may suggest carpal tunnel problems
3. Tinel's test, whereby the doctor taps your inner wrist directly over the median nerve; if pain, tingling, or numbness occurs, CTS is suggested
4. Nerve conduction studies by EMG. Several tests including this one are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV). This test measures how fast nerve impulses are conducted through the nerve. Testing usually involves electrodiagnostic assessment of both median and ulnar sensory nerves
5. MRI studies for selected, atypical cases or when there is conflict between clinical and EMG findings

Conventional Therapies to Treat CTS

Most physicians, including those practicing complementary medicine, recognize the necessity for surgery in severe cases. Most doctors agree that patients need to

1. Stop repetitive movement that causes CTS
2. Change jobs or occupations
3. Take more frequent breaks from the pain-causing movement to reduce swelling
4. Wear wrist splints at work and/or at home at night during sleep. (Wearing splints at night is important because circulation may decline, starving your median nerve of required oxygen and nutrients required for healing)
5. Wear a forearm brace, which is a narrow cuff worn just below the elbow
6. Apply ice to the wrist for 10 minutes at a time to reduce swelling and inflammation
7. Use cooling pain gel on the wrist instead of ice
8. Use massage of the neck, shoulders, and back to relieve tension in the forearm and wrist
9. Use a wrist rest in front of your keyboard and keep your keyboard level, not elevated, at your computer workstation

Conventional therapy for inflammation and wrist pain has included the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs by generic and brand name include aspirin (e.g., Anacin), ibuprofen (e.g., Motrin or Advil), naproxen (e.g., Aleve or Anaprox), indomethacin (e.g., Indocin), tolmetin (e.g., Tolectin), phenylbutazone (e.g., Butazolidin), diclofenac (e.g., Voltaren), diflusinal (e.g., Dolobid), piroxicam (e.g., Feldene), oxyphenbutazone (e.g., Oxalid), sulindac (e.g., Clinoril), and fenoprofen (e.g., Nalfon).

When wrist pain has become resistant to the drugs, therapy has been shifted to some of the so-called "second-line" disease-modifying anti-rheumatic drugs (called DMARDs, e.g., the corticosteroids). Although NSAIDs are sometimes useful for reducing pain and stiffness in the wrists, their effect tends to wear off over time and their impact has not been significant to retard disease progression. NSAIDs also have significant side effects that include allergic reactions, altered gut permeability, gastritis or gastric ulcers, and chronic intestinal bleeding; this can become a life-threatening hemorrhage. DMARDs can control symptoms in the short term, but tend to be less effective over time. DMARDs can be even more toxic than NSAIDs, causing renal disease, bone marrow suppression, and chronic oral ulcers.

Although the use of steroids (i.e., corticosteroids) can produce dramatic improvement in symptoms, they do not prevent disease progression. Side effects from corticosteroids (prednisone, methylprednisone, cortisone, and dexamethasone) include muscle weakness; mood changes or confusion; frequent infections; elevated blood sugar, especially in diabetics; cataract formation; stomach irritation or bleeding; skin rashes; aseptic necrosis of the bones, usually of the hips in more serious cases; acne; fluid retention; increased appetite and weight gain; menstrual problems; round and puffy face; nervousness and restlessness; and insomnia.

Further, severe rebound can occur when the drug is stopped. These conventional drug therapies for long-term use in particular have many limitations. Fortunately, vitamin B6 and B2 therapies have broken into mainstream conventional treatments for CTS (Folkers et al. 1984; 1990).

Alternative Approaches to Treat CTS

Complementary medicine stresses more patient-centered, safe, painless, noninvasive, nonsurgical, inexpensive, self-administered home treatment applications for more mild-to-moderate CTS. The goal of alternative treatment is to stimulate healing while also stimulating the body's own production of natural, morphine-like opiates like endorphins, dynorphins, and enkephalins to block and overpower the pain. Ten times stronger than morphine, tolerances to them are not built up as with many standard, conventional medications. This approach is designed to reduce or in many cases eliminate standard pharmaceuticals. The complementary items listed below do not produce chemical tolerances, requiring increases to stop pain. For example, long-term opioid use tends to cause patients to build up tolerances to them, requiring higher and higher dosages to kill the pain.

The possible side effects of pain drugs (i.e., sedatives, analgesics, NSAIDs, beta-blockers, antidepressants and muscle relaxers) include brain fog, memory loss, poor reaction time for motor skills, kidney damage, liver damage, lethargy, vomiting and nausea, heart disease, ulcers, osteoporosis, anxiety, depression, high blood pressure, decreased immunity, stroke, insomnia, rashes, intestinal bleeding, convulsions, loss of libido, and death. An exception to this is the single injection with methylprednisolone, 40 mg, with 10 mg of lignocaine (lidocaine) proximal to the carpal tunnel, the method discussed above.

Complementary physicians may also favor regular chiropractic manipulation of the hand, wrist, and forearm, acupressure, acupuncture, or magnotherapy (placing of magnets around the wrist or a wrap with magnets worn around the wrist to expedite healing of the median nerve).

Low-Level Laser Acupuncture and Transcutaneous Electrical Nerve Stimulation (TENS) for CTS
In mild or moderate cases when surgery may not be necessary, differences in treatment are important and might include laser or TENS applications, or both.

Similar to the red beam laser light coming from a grocery store checkout scanner, a red beam laser light with a fixed on/off switch in the form of a pen is held in a 90-degree position so that the laser beam is entering the various shallow acupuncture points of the hand at a perpendicular angle for maximum penetration. A trained acupuncturist or doctor is usually required to perform this procedure. Additional acupuncture points may be treated on the forearm or up to the shoulder area according to the distribution of possible radiating pain (Branco et al. 1999).

Vitamin Therapies
Most doctors agree that early treatment in the progression of symptoms is the key to successful treatment. If CTS is severe, B vitamins and related nutritional therapies are unlikely to reverse it. Catching it early indicates there is only pain and tingling with no weakness and the condition involves only nocturnal awakening but no problems with it during the day. Only immediate surgery or, possibly, the new single injection of prednisolone with lidocaine method will relieve the compression in severe cases. While surgery will take pressure off of the nerve, it does not correct for a deficiency in vitamin B6, pyridoxine, or vitamin B2, riboflavin, or biotin. Likewise, the single steroid injection method does not correct for vitamin B deficiencies.

Various clinical biochemistry tests described below tend to show that carpal tunnel patients have distinct and often severe deficiency of vitamin B6. Numerous studies debate the point whether vitamin B6 deficiency causes CTS. Regardless, the volume of studies weighs heavily in favor of its adjunctive use in treatment and rehabilitation of carpal tunnel patients whether surgery or the single steroid injection method is to be used or not.

Doctors are divided on why vitamin B6 (pyridoxine) seems to provide relief from CTS. At least five published studies have demonstrated the benefits of vitamin B6 for CTS (Ellis et al. 1979; 1981; Folkers et al 1984; Kasdan et al. 1987; Fuhr et al. 1989). It appears that synovium swelling and inelasticity are caused by a B6 deficiency. The synovium refers to the dense, connective tissue membrane that secretes synovia, a transparent, visceral lubricating fluid. This membrane, necessary for wrist joint lubrication for extension, flexion, and rotation, lines the articular surfaces of ligamentous capsules, tendon sheaths where free movement is necessary.

Other doctors believe that vitamin B6 acts as a diuretic, helping the body to eliminate excess fluid. During pregnancy, the hands and feet swell and rings don't fit anymore. Fluid is retained, especially in the wrists. The problem may worsen when the person lies down because fluid that makes the ankles swell during the day is redistributed throughout the body, including the wrists. B6 helps get rid of the extra water gain that causes CTS. Several other studies suggest that vitamin B6 somehow short-circuits an angry nerve's ability to transmit pain signals. Too much B6 can cause damage to the central nervous system, neuropathy, or neuronopathy syndromes that may include oversensitivity to sunlight, which in turn produces skin rashes and numbness. Doctors generally recommend 50-200 mg of vitamin B6 daily to treat this condition, along with other types of nutritional support. Threshold levels of response have been found at as little as 25-50 mg of vitamin B6 a day.

Synergy is important: the whole is greater than the sum of its parts in nutritional applications. There is a net free radical quenching, handholding effect among all the antioxidants together, by using a variety of other antioxidants with vitamin B complex. Inflammation, hyperemia (increased flow of blood to the site of inflammation), and resultant pain invariably involve release of random oxygen and nitrogen species or free radicals at the pain site (Smith et al. 1999). So an adequate program should include vitamins C and E and organic and inorganic selenium. Gamma-tocopherol, a fat-soluble form of vitamin E, has the ability to rid the body of a highly destructive chemical called peroxynitrate, which is produced by inflammation. This is best taken in conjunction with vitamin B complex, C, and selenium. These nutritional building blocks are taken together in amounts that relate to the severity of CTS. Generally speaking, more symptoms will create the need for higher loading requirements as well as other preventive techniques earlier outlined.

Testing for B6 Deficiencies
Does a person need vitamin B6 and how much? Determining vitamin B6 requirements for a carpal tunnel patient is no longer a matter of speculation, conjecture, or surmise. Both the existence and magnitude of a vitamin B6 deficiency state may be determined by competent, standard assays offered by laboratories licensed under the Clinical Laboratory Health Improvement Act. Methods used include (1) amino acid assays for essential amino acids, (2) measuring plasma homocysteine, elevations of which may indicate B6 deficiencies as well, and (3) erythrocyte enzyme assay for erythrocyte glutamate oxaloacetate transaminase (EGOT).

There is much evidence that vitamin B6 won't work properly unless a person is getting adequate amounts of riboflavin, biotin, and other B vitamins. Vitamin B6 is best applied in conjunction with other B vitamins. Synergism among the B vitamins is recognized in clinical practice. Vitamin B complex supplementation (single capsule or pill), 50-100 mg a day of each 1-2 times a day, is favored in most cases. Older adults, alcoholics, and those with nutritionally poor diets are at particular risk for these vitamin deficiencies. Some doctors believe that B6 may interfere with Parkinson's patients' absorption of levadopa medications.

Other Forms of Nutrition for CTS
Eating the right kinds of fat helps the body to produce mostly good prostaglandins that cause blood clot-forming platelets to flow easily and not stick together. When blood flows easily, it quickly exits the inflamed area and does not collect in painful pockets of swollen tissue (such as in the wrist). Bad prostaglandins cause blood platelets to clump together, reducing the blood flow and increasing inflammation.

A fatty acid profile from simple blood work with numbers and reference ranges shows potential deficiencies in over 30 different essential fatty acids. The more common ones associated with pain reduction that operate as powerful anti-inflammatories include docosahexaenoic acid (DHA), gamma-linolenic acid (GLA), and alpha-linolenic acid (ALA). These fatty acids should be included in diets of carpal tunnel patients. For example, EPA, an omega-3 fatty acid that comes from seaweed and algae found in the meat and oils of darker coldwater fish, such as salmon, tuna, herring, mackerel, and sardines is a powerful anti-inflammatory that may be obtained from 2-5 servings of fish a week.

Other nutrients that help to put out the fire of inflammation include curcumin from turmeric, found to be equally effective as phenylbutazone (a drug that causes gastrointestinal ulcers and immune suppression); sodium curcuminate, a form of curcumin, is stronger than the drug cortisone. Boswella and ginger have powerful anti-inflammatory value. Protein-digesting enzymes such as protease, bromelain, trypsin, lipase, pancreatin, and papain have also been found to have significant anti-inflammatory effects.

Pain, even from the wrist, lowers serotonin levels because serotonin gets used up at the site of inflammation. This creates greater vulnerability to more pain. Serotonin levels may be measured for deficiency states by measurement through an amino acid profile, a simple blood test that yields a number and a reference range for tryptophan, the precursor to serotonin. If low tryptophan levels are found, moderate replacement may consist of dietary support with milk, soybeans, turkey, chicken, cheddar cheese, halibut, peanuts, peanut butter, and eggs.

Cranial Electrical Stimulation
Another way to increase serotonin levels for improved pain tolerance without pharmaceuticals includes cranial electrical stimulation (CES), which raises beta-endorphin and serotonin levels and lowers serum cortisol levels. CES devices include the FDA-authorized Liss Body Stimulator, which can only be sold by a physician according to federal law. This is a home-based, external device, a personal, patient management tool the size of a Sony Walkman that runs off of a 9-volt battery, providing for patient control. This device may be used to raise serotonin levels and also to electroporate all of the above anti-inflammatory nutritionals into the targeted carpal tunnel area.

SUMMARY

What happens when a person is in a pain state for CTS? Instead of getting the neurotransmitter system to pump out calming neurotransmitters when in a pain state, the cortex and limbic system put in an order for the stimulating neurotransmitter norepinephrine, which is a form of adrenaline. The result is the "fight or flight" (stress) response and the beginning of chronic pain. Once the pain cycle starts, with insufficient production of the body's own serotonin, endorphins, dynorphins, and enkephalins, the pain signals may become engraved, with neural tracks laid down in the brain within the nervous system. Carpal tunnel pain may be crushing and debilitating to normal range of motion and basic function of the hand. Besides other techniques outlined earlier, nutritional components to defeat this include the following:

1. To reduce the inflammation associated with CTS, one or more of the following fatty acids and herbal extracts may be taken:
   • Super GLA/DHA contains a balanced blend of essential fatty acids. Three softgels daily contain 450 mg of GLA from borage oil and 500 mg of DHA and 200 mg of EPA from marine lipid extract. Up to 6 softgels may be taken daily.
   • Mega EPA contains 400 mg of EPA and 300 mg of DHA in each softgel capsule. Up to 8 softgels may be taken daily for therapeutic purposes.
   • Boswella, one 300-mg capsule daily.
   • Curcumin (from the spice turmeric), 900-1800 mg daily.
   • Ginger extract, 1000 mg daily in capsule form.
   • Inflacin topical cream.
2. The proper synergy of vitamins and minerals quenches free-radical damage that increases pain and inflammation:
   • Gamma E Tocopherol/Tocotrienols (vitamin E), 1 softgel daily taken with food.
   • Vitamin B Complex, 3 capsules daily. This dose should provide at least 75 mg of vitamin B6 in the total daily dose.
   • Vitamin C, 2000 mg daily in divided doses.
   • Vitamin A, 10,000-25,000 IU daily.
     
   • Pregnant women should only take vitamin A under medical supervision.
     
3. • Vitamin D, 400 IU daily.
   • Selenium, 200 mcg daily.
4. Protein-digesting enzymes such as protease, bromelain, trypsin, lipase, pancreatin, and papain have significant anti-inflammatory effects. One or more of the following nutrients may be considered:
   • Super Digestive Enzymes containing protease, lipase, cellulase, and amylase from pancreatin; 2 capsules at the beginning of each meal.
   • Bromelain Powder enhances protein absorption and turnover, including protein found in joint tissue. The suggested dosage is 1/8-1/4 tsp with each meal.
   • Papain Powder aids in protein digestion and repair. The suggested dosage is 1/8-1/4 tsp with each meal.
5. Magnesium is often deficient from the diet. It is important for arterial health and has a relaxing effect.
6. Magnesium also helps regulate calcium uptake in the body. The recommended dosage is 500 mg of elemental magnesium daily.
7. Phosphatidylserine (PS) improves neurotransmitter functioning and enhances the metabolism of cellular energy throughout the body. One 100-mg capsule daily is suggested.
8. D, L-phenylalanine will help boost endorphin levels. Endorphins are our body's natural painkillers. The suggested dose to achieve painkilling effects is 1500-3000 mg daily (refer to Phenylalanine Precautions).
   TENS wrist applications may be beneficial (subject to medical direction and supervision requirements).

For more informatiON

Contact the National Jewish Center for Immunology and Respiratory Medicine, (800) 822-5864.

Product availabiliTY

Super GLA/DHA, Mega EPA, flaxseed oil, boswella capsules and topical cream, Super Curcumin with Bioperine, Gamma E Tocopherol/Tocotrienols, vitamin B complex, vitamin C, vitamin A, vitamin D, selenium, Super Digestive Enzymes, bromelain powder, papain powder, elemental magnesium, phosphatidylserine, and D,L-phenylalanine may be ordered by calling (800) 544-4440 or by ordering online .