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Neurophysiology Of Pain | El Paso, TX. | Part II

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Clinical Neurophysiology

Neurophysiology: There are two ways that nociceptive information reaches the central nervous system. One is the neospinothalamic tract for quick pain and two is the paleospinothalamic tract for slow pain that increases.

Contents

Neurophysiology Of Pain Part II

Intensity, Location & Quality of Pain…

… involve Spinothalamic and Trigeminal Pathways

The trigeminal pathway brings information from the face area.
The spinothalamic pathway brings information from the rest of the body.
Both these pathways project to the sensory cortex, which also receives information on innocuous stimuli such as touch, pressure and warmth via a separate pathway.

2 Pain Transmission Pathways For Location Intensity Quality

Neuroscience Purves et al.

Spinothalamic pathway
(Anterolateral Pathway)
Trigeminal pathway

Unpleasant Quality & Autonomic Affective Motivational Pathway For Pain

Brain Areas Involved In Processing Of Nociceptive Signals

The Anterior Cingulate & Insula Cortex Are Activated In Human Subjects

… in connection with an intense burning sensation following hand contact with the thermal grill.

Adapted from Craig et al. 1994, 1996. From Principles of Neural Science, Kandell et al.

Control Of Pain Perception

There is difference between the objective and subjective aspects of injury and pain.
Despite similar injury, people can differ in how much pain they feel.
Depending on the context, pain may not be felt despite injury, e.g. battlefield injury, during intense sports.
This suggests that there is a physiological mechanism that controls the transmission of nociceptive signals to the brain or modifies the interpretation of pain.
The pain control system can also explain the placebo effect.

Pain Modulation Pathway

Nerve signals are sent form the somatic sensory cortex and hypothalamus to the periaqueductal gray matter (PAG).
PAG sends signals to the parabrachial nucleus, medullary reticular formation, locus coeruleus, and Raphe neulei.
These in turn can control the in the transmission of nociceptive signals from the spinal cord to the brain.
This involves different involves different neurotransmitters.

Endogenous Opioids

Internally produced molecules with opioid-like action which regulate transmission of nociceptive signals.

Three classes of these molecules have been identified. All are peptide molecules

Enkephalins
Endorphins
Dynorphins

Despite these being powerful, endogenous modifiers of nociceptive signals, it has been difficult to produce and administer them in a way than can used in clinical practice.

Location Of Nerve Cells With Endogenous Opioid Receptors

Spinal cord, Medulla, Periaqueductal gray matter (PAG)
In the spinal cord, endogenous opioids can prevent transmission between 1st order nerve cells (bringing signals from the periphery) and 2nd order spinal nerve cells that transmit the signals to the brain.
Also can prevent the increased synaptic efficiency, which plays a role in hyperalgesia.

(Center for Brain Research, Uni Vienna)

Modulation Of Pain Signal Transmission In The Spinal Cord

Connections in the spinal cord where opiates act.

Neurotransmitters � serotonin (5- HT) and norephinephrine (noradrenaline) � in the spinal cord can block transmission of pain signals to the brain.

Inflammatory Soup – Hyperalgesia

Tissue damage results in the release of a number of chemicals.
These increase nociceptors� response to a stimulus (=hyperalgesia) & produce inflammation.
Hyperalgesia = when the magnitude of the response to a nociceptive stimulus is higher than normal.

Julius-D & Basbaum-AI, Nature 2001;413:203

Clinical Application

Knowing the molecules involved in the �inflammatory soup� and how they are synthesized provides possible targets for pain reduction.
e.g. prostaglandins are produced by the COX enzyme. The activity of this enzyme is blocked by non-steroidal anti- inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac.

Allodynia

A condition when normally non- painful stimuli cause pain, e.g., touch, light pressure, cold.
Involves changes in the synaptic sensitivity of the nociceptive neurons in the spinal cord (central sensitization).
Drugs such as ketamine, block NMDA receptors and so reduce transmisison of the nociceptive stimuli.

Gate Control Theory of Pain

Mother says to child, �Come I will rub the area which is painful and this will make it feel better.�
After stubbing a toe, we instinctively rub the area; this reduces the sensation of pain.
Ronald Melzack and Patrick Wall in 1962 provided an possible explanation for this effect.

Ascending Tracts | Pain Modulation: Gate Control Theory

Gate Theory

Rubbing the area that hurts stimulates receptors of innocuous stimuli like touch, pressure and vibration.

These mechano-receptors send signals along the A? nerve fibers that:

(1) stimulate spinal nerves (inhibitory inter-neurons) that in turn inhibit signaling in the 2nd order neurons (projection neuron) and (2) directly inhibit the 2nd order neuron to reduce or stop pain signal from being sent to the brain

http://wikidoc.org/images/f/fe/Gate_control_A_firing.png

Clinical Application

Transcutaneous Nerve Stimulation (TENS) is based on the Gate Control Theory. Nerves of the innocuous sensory system are stimulated and they in turn, inhibit transmission of nociceptive stimuli in the spinal cord.

Abnormalities Of Pain System

Phantom Pain

Patients with amputation often have burning or tingling pain in the body part removed.
One possible cause is that nerve fibers at the stump are stimulated and the brain interprets the signals as originating in the amputated portion.
The other is the rearrangement within the cortical areas so that area say for the hand now responds to signals from other parts of the body but still interprets them as coming for the amputated hand.

Peripheral Sensitization

Peripheral sensitization represents a reduction in the threshold and/or an increase in magnitude of responsiveness at the peripheral ends of sensory nerve fibers.
This occurs in response to chemical mediators released by nociceptors and non-neuronal cells (e.g. mast cells, basophils, platelets, macrophages, neutrophils, endothelial cells, keratinocytes and fibroblasts) at the site of tissue injury or inflammation.
Basically, it is an increased sensitivity to an afferent nerve stimuli.

Central Sensitization

Peripheral & Central Sensitisation

A condition of the nervous sytem that is associated with the development and maintenance of chronic pain.
Known as �wind-up� or persistent high reactivity.
�Plastiticity in pain pathways� or the persistence of pain even after an injury has healed.
Is this negative or positive plasticity?

Central Sensitization & C Fibers

Two Main Characteristics Of Central Sensitization:

� Allodynia � occurs when a person experiences pain with things that are normally not painful, ie, soft touch causes pain.

� Hyperalgesia � occurs when a stimulus that is typically painful is perceived as more painful that it should be, ie, a simple bump.

Both are due to hyperreactivity of the nervous system.

Somatosensory Cortex Organization

Cortical Reorganization

Neuroscience. 2nd edition. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Fig 25.14

Referred Pain

Often originates from a visceral organ.
May be felt in a part of the body remote from the site of the pathology.
The mechanisms may be spinal convergence of visceral and somatic afferent fibers on spinothalamic neurons.
Common manifestations: cutaneous and deep hyperalgesia, tenderness, muscular contractions.

Pain Sensation Referred From Visceral Organs …

… to another part of the body surface

Pain Hypersensitivity Mechanisms At A Glance

Neurophysiology Of Pain | El Paso, TX. | Part I

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Clinical Neurophysiology

Neurophysiology of pain: Pain�defined is the unpleasant sensation that accompanies injury or near injury to tissues, though it can also occur in the absence of such damage if the nociception system is not functioning. Nociception means the system that carries pain signals of injury from the tissues. This is the physiological incident that comes with pain.

Contents

Neurophysiology Of Pain

Objectives

Basics of the nervous system
Synaptic function
Nerve impulses
Transduction of peripheral painful stimuli
Central pathways
Central Sensitization
PeripheralSensitization
Control or modulation of pain signals
Pathophysiology of pain signaling pathway

Definition Of Pain

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

(The International Association for the Study of Pain)

The Nervous System

It is important to know the basic structure of the nervous system.
This will help in:
� Understanding the mechanism by which nociceptive signals are produced.
� Know the different regions of the nervous system involved in processing these signals.
� Learn how the different medications and treatment for pain management work.

Nervous System

Central nervous system (CNS)

Brain and Spinal Cord

Peripheral Nervous System (PNS)

Nerve fibers go to all parts of the body.
Send signals to the different tissues and send signals back to the CNS.

Nerve Cells

The nervous system is made up of nerve cells which send long processes (axons) to make contact with other cells.

Nerve Cell-To-Nerve Cell Communication

Nerve cells communicate with other cells by releasing a chemical from the nerve endings � Neurotransmitters

Basic Steps In Synaptic Transmission

Synaptic Transmission

Steps in the passage of signal from one nerve cell to other.

Drugs are used to block the transmission of signals from one nerve cell to other.

These drugs can effect:

Ca2+ ion channel to prevent Ca2+ inflow which is essential for neurotransmitter (NT) release, e.g., the action of gabapentin.
Release of NT.
Prevent NT from binding to its receptor so stop further transmission of the signal.

Electrical Impulse

Signals move along a nerve process (axon) as a wave of membrane depolarization called the Action Potential.
The inside of all nerve cells has a negative electrical potential of around � 60 mV.
When stimulated this negative electrical potential becomes positive and then negative again in milliseconds.
The action potential moves along the nerve process (axon) to the nerve ending where it cause release of NT.

Action Potential

When there is no stimulation the membrane potential is at its Resting Potential.
When stimulated, channels in the nerve membrane open allowing the flow of sodium ions (Na+) or calcium ions (Ca2+) into the nerve or cell. This makes the inside less negative and in fact positive -the peak of the action potential (+40 mV).
These channels than close and by the opening of K+ channels the membrane potential returns to its resting level.

Stopping Action Potentials To Stop Nociceptive Stimuli

Nociceptive stimuli are those that will create a sensation of pain after they are processed in the CNS.
Nociceptive signals can be prevented from reaching the CNS by blocking the action of the channels that control the movement of ions across the nerve membrane.
A number of anesthetic agents stop Na+ channel from working and hence stop the generation of actions potentials and transmission of signals to the CNS.

Sensory Systems

The sensory system that can be divided into two divisions:

A Sensory System that transmits innocuous stimuli such as touch, pressure, warmth.
A System that transmits stimuli that indicate that tissues have been damaged = nociceptive .

These two systems have different receptors and pathways in the PNS & CNS

Skin Receptors

Neuroscience. 2nd edition. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Sunderland (MA): Sinauer Associates; 2001.

Nociceptors

Nociceptors are free nerve endings that respond to stimuli that can cause tissue damage or when tissue damage has taken place.
Present in membrane of free nerve endings are receptors (protein molecules) whose activity changes in the presence of painful stimuli.
(Note the use of the same term receptor is used for cell or organs or molecules that involved in transduction of a stimuli.)

Transduction

Transduction is the process of converting the stimuli into a nerve impulse.
For this to occur the flow of ions across the nerve membrane has to change to allow entry of either Na+ or Ca2+ ions to cause depolarization of the membrane potential.
This involves a receptor molecule that either directly or indirectly opens the ion channels.

Chemical Agents…

… which can cause the membrane potential at the free nerve ending (nociceptor) to produce an action potential.

Fields HL. 1987. Pain. New York: McGraw-Hill.

Summary Of Transduction Process At The Periphery

TRP Channels

Many stimuli � mechanical, chemical and thermal � give rise to painful sensation making transduction a complex process.
Recently receptor molecules have been identified�� Transient Receptor Potential (TRP) channels � that respond to a number of strong stimuli.
TRP receptors are also involved in transmitting the burning sensation of chili pepper.
In time, drugs that act on these receptors will be developed to control pain.

Different TRP Channels

Capsasin, the active ingredient in chili pepper, is used in patches for relief of pain.
Menthol and peppermint gels are used to relieve muscle pain.

Motor Output & Sensory Input To Spinal Cord

Sensory nerves have their cell body outside the spinal cord in the dorsal root ganglia ( = 1st order neurons).
One process goes to the periphery, the other goes to the spinal cord where it makes synaptic contact with nerve cells in the spinal cord ( = 2nd order neurons).
The 2nd order neuron sends processes to other nerve cells in the spinal cord and to the brain.

2nd Order Nerve Cells Send Nerve Fibers In The Spinal Cord White Matter

Transmission Of Nociceptive Signals From The Periphery To The Brain

Silverthorn

A Delta (?) & C Nerve Fibers

Nerve fibers are classified according to the:

� (1) diameter of the nerve fiber and
� (2) whether myelinated or not.

A? and C nerve fiber endings respond to strong stimuli.
A? are myelinated and C are not.
Action potentials are transmitted 10 times faster in the A?
(20 m/sec) fibers than in C fibers (2 m/sec).

A? & C fibers

A? fibers respond mainly to mechanical and mechno-thermal stimuli.
C fibers are polymodal, i.e. the nerve ending responds to several modalities � thermal, mechanical and chemical
This polymodal ability is due to the presence of different receptor molecules in a single nerve ending.

Fast & Slow Pain

Most people when they are hit by an object or scrape their skin, feel a sharp first pain (epicritic) followed by a second dull, aching, longer lasting pain (protopathic).
The first fast pain is transmitted by the myelinated A? fibers and the second pain by the unmyelinated C fibers.

Central Pain Pathways

Nociceptive signals are sent to the spinal cord and then to different parts of the brain where sensation of pain is processed.

There are a pathways/regions for assessing the:

Location, intensity, and quality of the noxious stimuli
Unpleasantness and autonomic activation (fight-or-flight response, depression, anxiety).

Dr. Sletten Discussing Central Sensitization Syndrome (CSS)

Gate Control Theory and Pain Management in El Paso, TX

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chronic Pain, Clinical Neurophysiology, Treatments

Pain perception varies across different people based on their mood, psychological condition and previous experience, even when pain is brought on by similar physical stimulation and ends in a similar level of damage. In 1965, Ronald Melzack and Patrick Wall summarized a scientific theory about the psychological influence on pain perception; known as the gate control theory.

If it wasn’t for this theory, pain perception would still be connected to the intensity of the pain stimulation and the degree of damage caused to the affected tissue. But Melzack and Wall made it clear that pain perception is far more complicated than we believe.

Based on the gate control theory, pain signals aren’t free to travel to the brain as soon as they’re generated in the region of the damaged or injured tissues. These first need to encounter specific neural gates found at the level of the spinal cord level, where these gates ascertain whether the pain signals should reach the brain or not. To put it differently, pain is perceived when the gate gives way to the pain signals and it is not as intense or it is not sensed at all when the gate closes for the signs to pass through.

This theory provides the explanation for why people find relief by massaging or rubbing a damage, injured or painful site. Although the gate control theory cannot demonstrate the whole picture of the fundamental system which underlies pain, it’s visualized the mechanism of pain perception and it has created a pathway to various pain management treatment approaches.

Contents

Nerve Fibers in Transmission of Sensory Signals

Every organ, or portion of the human body, has its own nerve supply which are in charge of carrying electric impulses generated in reaction to several senses, such as touch, temperature, pressure and pain. These nerves, which make up the peripheral nervous system, transmit these sensory signals, to the central nervous system, or the brain and the spinal cord. These impulses are then translated and perceived as senses. The peripheral nerves send signals to the dorsal horn of the spinal cord and from there, the sensory signals are transmitted into the brain through the spinothalamic tract. Pain is a sensation which alarms a person that a tissue or certain portion of the human body has been damaged or injured.

Due to their axonal diameter and their conduction speed, nerve fibers can be categorized into three different types, nerve fibers A, B and C. The C fibers are considered to be the smallest among the three different types. Moreover, there are four subtypes within the A fibers: A-alpha, A-beta, A-gamma and A-delta. From the A fiber subtypes, the A-alpha fibers are the largest and the A-delta fibers are the smallest.

The A fibers which are larger compared to the A-delta fibers, carry sensations, such as touch, pressure, etc., into the spinal cord. The A-delta fibers as well as the C fibers carry pain signals into the spinal cord. A-delta fibers are faster and carry sharp pain signals while the C fibers are slower and carry diffuse pain signals.

When thinking about that the conduction velocity of nerve fibers, the A-alpha fibers, which are the biggest A nerve fibers, have greater conduction speed compared to A-delta fibers and C fibers, which are considered to be the smallest nerve pathways. When a tissue is damaged or injured, the A-delta fibers are activated first, followed by the activation of the C fibers. These nerve fibers have a tendency to carry the pain signals to the spinal cord and then to the brain. However, the pain signals are transmitted through a much more complex process than what is simply explained above.

Ascending Tracts | Pain Modulation: Gate Control Theory

What is the Gate Control Theory of Pain?

The gate control theory implies that the sensory signals or impulses which are transmitted by the nerve fibers encounter neural gates at the level of the spinal cord and these will need to get cleared through those gates to reach the brain. Various factors determine how the pain signals ought to be treated in the neurological gates, including:

The intensity of the pain signals
The degree of another sensory signal, such as touch, temperature and pressure, if produced at the site of damage or injury
The message from the brain itself to deliver the pain signals or not

As previously mentioned, the nerve fibers, both large and small, carrying the sensory signals, end in the dorsal horn of the spinal cord from where the impulses are transmitted into the brain. According to the original postulate of Melzack and Wall, the nerve fibers project to the substantia gelatinosa, or SG, of the dorsal horn and the initial central transmission (T) cells of the spinal cord. The SG consists of inhibitory interneurons that behave as the gate and ascertain which sensory signals should get to the T cells then go further throughout the spinothalamic tract to finally reach the brain.

When the pain signals carried by the small nerve fibers, or the A-delta fibers and the C fibers, are somewhat less intense compared to another non-pain sensory signal like touch, temperature and pressure, the inhibitory neurons stop the transmission of the pain signals through the T cells. The non-pain signals override the pain signals and therefore the pain is not perceived by the brain. When the pain signals are somewhat more intense compared to the non-pain signals, the inhibitory neurons are inactivated and the gate is opened. The T cells transmit the pain signals into the spinothalamic tract which carries those impulses to the brain. As a result, the neurological gate is influenced by the relative amount of activity from the large and the small nerve fibers.

How Emotions and Thoughts Affect Pain

The gate control theory also suggests that the pain signal transmission could be affected by thoughts and emotions. It’s well known that people do not feel that a chronic pain or, more appropriately, the pain does not disturb them if they concentrate on other activities which interest them. Whereas, people who are depressed or anxious may often feel intense pain and can also find it challenging to cope with. This is due to the fact that the brain sends messages through descending nerve fibers which stop, reduce or enhance the transmission of pain signals through the gate, depending on the emotions and thoughts someone may be going through.

Gate Control Theory in Pain Management

The gate control theory has caused a radical revolution within the field of pain management. The theory suggested that pain management can be accomplished by influencing the larger nerve fibers that carry non-pain stimulation. The concept has also paved way for more research on cognitive and behavioral strategies to achieve pain relief.

Among the most tremendous advances in pain management research is the arrival of Transcutaneous Electrical Nerve Stimulation (TENS). The gate control theory forms the cornerstone of TENS. In this procedure, the selective stimulation of the large diameter nerve fibers taking non-pain sensory stimulation from a particular region nullifies or reduces the impact of pain signals from the region. TENS is a non-invasive and affordable pain control strategy that has been widely used for the treatment of chronic and intractable pain by various healthcare professionals, which may otherwise have been non-responsive to analgesics and surgical interventions. TENS is tremendously advantageous over pain drugs from the aspect that it does not have the problem of medication interactions and toxicity.

For instance, many doctors of chiropractic, or chiropractors, utilize TENS and other electrotherapeutic procedures in their practice. These are generally utilized along with spinal adjustments and manual manipulations to increase circulation as well as to aid in the support of chiropractic care. Several other invasive and noninvasive electrical stimulation techniques are discovered to be helpful in several chronic pain conditions such as arthritic pain, diabetic neuropathy, fibromyalgia, etc.. The theory has also been extensively studied in treating chronic back pain and cancer pain. However, favorable results are not attained in some conditions and the long term efficacy of these techniques based on the theory still remains under consideration.

Dr. Alex Jimenez’s Insight

Chiropractic care is widely utilized to benefit patients with chronic pain. Symptoms of persistent pain and discomfort have become a big health issue in the United States where many years of research have found that drugs and/or medications are not necessarily a solution to the problem. The gate control theory, which was first proposed over half a century ago, has offered healthcare professionals new insights on the perception of pain, providing a variety of pain management treatment methods, such as the use of transcutaneous electrical nerve stimulation, or TENS, as well as other electrotherapeutic procedures. Chiropractors can help with pain management through spinal adjustments and manual manipulations, and through the use of TENS.

Nevertheless, the gate control theory has radically revolutionized the area of pain research and it has achieved to get numerous studies which aim at presenting a pain-free lifestyle into the patients who suffer from chronic pain. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Sciatica

Sciatica is medically referred to as a collection of symptoms, rather than a single injury and/or condition. Symptoms of sciatic nerve pain, or sciatica, can vary in frequency and intensity, however, it is most commonly described as a sudden, sharp (knife-like) or electrical pain that radiates from the low back down the buttocks, hips, thighs and legs into the foot. Other symptoms of sciatica may include, tingling or burning sensations, numbness and weakness along the length of the sciatic nerve. Sciatica most frequently affects individuals between the ages of 30 and 50 years. It may often develop as a result of the degeneration of the spine due to age, however, the compression and irritation of the sciatic nerve caused by a bulging or herniated disc, among other spinal health issues, may also cause sciatic nerve pain.

EXTRA IMPORTANT TOPIC: Chiropractor Sciatica Symptoms

Infantile Colic And Chiropractic Treatment | El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Children, Chiropractic News

Infantile Colic: If you have ever cared for an infant with colic, you know how frustrating and helpless it can make you feel. It is so hard to see a little one in such obvious discomfort and you can�t help them no matter what you do. When you have a baby who experiences frequent colic it can be heartbreaking. An infant is so small and they can�t tell you where it hurts or what is wrong; all they can do is cry.

Chiropractic has been proven to help with infantile colic. It can soothe fussy babies and ease the nerves of frazzled parents. Some moms and dads may be a little ambivalent about the idea of having a chiropractor �work� on their baby, but the benefits are incredible � and baby�s comfort is definitely worth it.

Contents

What Is Colic?

Colic is a condition that has frustrated parents since the beginning of time. The most prevalent symptom is the severe distress that occurs over predictable periods of time. It is labeled colic when there is no obvious underlying condition that could cause the distress, and occurs in babies that are newborn to 3 months (sometimes up to 6 months), healthy and well fed.

The bouts of crying and distress can last hours, days, or even weeks. Often it seems that there is no way to comfort the baby or provide relief. Symptoms of colic include:

Crying that does not seem to have a reason
Crying that is intense and indicates obvious distress
Crying that occurs at predictable times
Changes in posture that include tense abdominal muscles, clenched fists, and curled legs.

What To Expect When You Take Your Infant To A Chiropractor

Some parents may balk at taking their infant to a chiropractor, their minds filled with images of the stereotypical snap, crackle, and pop that is so often associated with the practice. However, infant chiropractic is different and much milder. Chiropractic adjustments for infants are very gentle.

The chiropractor will use his fingers to gently apply pressure to areas on the back and neck. Most babies completely relax as the doctor corrects the misalignments � some even fall peacefully asleep. When you are choosing a chiropractor for your baby, ask if he or she is experienced in working with babies.

How Chiropractic To Treat Colic Works

Childbirth is not a gentle experience. As the baby�s tiny body is compressed and stretched as it is emerging into the world, it can cause the vertebrae of the neck and back to become misaligned. If the delivery included vacuum extraction, forceps, or prolonged pushing, or other things that doctors or midwives must do to assist in delivery, the chances that the baby will experience misalignment are very good.

When these misalignments, called vertebral subluxations, are significant enough, it can impede on how well other major systems in the body are able to function. Digestion is one area that can be greatly impacted and when digestion of formula or breastmilk is compromised it can be the cause of major distress and discomfort for the baby. This can lead to episodes of colic.

Studies That Support How Chiropractic Helps Infantile Colic

There have been several studies that explores the efficacy of chiropractic for colic. The majority of this research has shown that it is a very effective treatment.

A 1999 study published in the Journal of Manipulative and Physiological Therapeutics reported that spinal manipulation for colic is a very effective treatment for the condition. Babies treated using chiropractic experienced a decrease in crying by 67 percent. Babies who received medication experienced a decrease in crying by 38 percent. Another study showed similar results. Chiropractic improved crying behavior in babies that had colic.

Chiropractic is an effective, gentle, and drug free way to treat colic. Babies can thrive and be free of distress and discomfort while mom and dad can get some much needed sleep � and peace of mind.

Injury Medical Clinic: Migraine Treatment & Recovery

Cerebral Palsy And Chiropractic Treatment | El Paso, TX. | Video

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Cerebral Palsy, Clinical Case Reports, Testimonies, Video

Robert “Bobby” Gomez was born with cerebral palsy. Bobby describes how he felt like an outcast, growing up with the disorder, but he explains how much he can accomplish when he’s not underestimated. While Robert Gomez describes experiencing no setbacks due to his cerebral palsy, he suffered from pain and limited mobility. That’s when he decided to seek chiropractic care with Dr. Alex Jimenez and found much more help than he expected. Through spinal adjustments, manual manipulations, and rehabilitation exercises, Robert “Bobby” Gomez has regained some mobility and has experienced decreased pain symptoms. Bobby recommends Dr. Jimenez as the non-surgical choice for back pain and encourages others to educate themselves on cerebral palsy.

Chiropractic Treatment For Cerebral Palsy

Cerebral palsy is a permanent movement disorder that appears in early youth. Signs and symptoms vary among people. Symptoms often include poor coordination, stiff muscles, weakness, and tremors. There may be problems with feeling, vision, hearing, swallowing, and talking. Usually, infants with cerebral palsy don’t roll over, sit, walk or crawl as early as other kids of their age. Other symptoms may include seizures and problems with reasoning or thinking, which happen in about one-third of individuals with cerebral palsy. While the symptoms may get more noticeable over the first few years of life, the underlying problems don’t worsen. Cerebral palsy is caused by abnormal development or damage to the areas of the brain that control movement, balance, and posture. Most often, the problems occur during pregnancy; however, they may also happen during childbirth or soon after birth.

We are blessed to present El Paso s Premier Wellness & Injury Care Clinic to you.

Our services are specialized and focused on injuries and the complete recovery process. Our areas of practice include Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Headaches, Sports Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

At El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we are passionately focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility, and agility programs tailored for all age groups and disabilities.

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Thank You & God Bless.

Dr. Alex Jimenez DC, C.C.S.T

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Injury Medical Clinic: Herniated Disc Treatment & Recovery

Chiropractic Rehabilitation | El Paso, TX. | Video

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Athlete Recovery, Athletic Testimonies, Clinical Case Reports, Testimonies, Video

Malik Decquir is an athlete who has learned how to accomplish anything he sets his mind to through chiropractic rehabilitation. The trainer’s at Push have taught Malik never to give up, always being there to help him achieve his fitness goals and offering nutritional as well as fitness advice when he needs it. Malik Decquir has found tremendous mental and physical support with the trainers at Push.

Chiropractic Rehabilitation

Sports medicine, also referred to as sport and exercise medicine is a branch of medicine that deals with physical fitness and the treatment and prevention of injuries related to exercise and sports. Although most sports clubs have used team doctors for several years, it is only because the late 20th century that sports medicine has emerged as a distinct field of healthcare in order to help treat sports injuries.

We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process.�Our areas of practice include:�Wellness & Nutrition, Chronic Pain,�Personal Injury,�Auto Accident Care, Work Injuries, Back Injury, Low�Back Pain, Neck Pain, Migraine Headaches, Sport Injuries,�Severe Sciatica, Scoliosis, Complex Herniated Discs,�Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

If you have enjoyed this video and/or we have helped you in any way please feel free to subscribe and share us.

Thank You & God Bless.

Dr. Alex Jimenez DC, C.C.S.T

Facebook Clinical Page: https://www.facebook.com/dralexjimenez/

Facebook Sports Page: https://www.facebook.com/pushasrx/

Facebook Injuries Page: https://www.facebook.com/elpasochiropractor/

Facebook Neuropathy Page: https://www.facebook.com/ElPasoNeuropathyCenter/

Facebook Fitness Center Page: https://www.facebook.com/PUSHftinessathletictraining/

Yelp: El Paso Rehabilitation Center: http://goo.gl/pwY2n2

Yelp: El Paso Clinical Center: Treatment: https://goo.gl/r2QPuZ

Clinical Testimonies: https://www.dralexjimenez.com/category/testimonies/

Information:

LinkedIn: https://www.linkedin.com/in/dralexjimenez

Clinical Site: https://www.dralexjimenez.com

Injury Site: https://personalinjurydoctorgroup.com

Sports Injury Site: https://chiropracticscientist.com

Back Injury Site: https://elpasobackclinic.com

Rehabilitation Center: https://www.pushasrx.com

Fitness & Nutrition: http://www.push4fitness.com/team/

Pinterest: https://www.pinterest.com/dralexjimenez/

Twitter: https://twitter.com/dralexjimenez

Twitter: https://twitter.com/crossfitdoctor

Injury Medical Clinic: Sport Injury Treatments

What is Central Sensitization? | El Paso, TX Chiropractor

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Clinical Neurophysiology

Central sensitization is a state of the nervous system that’s related to the development and maintenance of chronic pain. When central sensitization occurs, the nervous system goes through a procedure known as wind-up and gets regulated in a constant condition of increased reactivity. This persistent, or regulated, state of reactivity decreases the threshold for what causes pain and subsequently learns to keep pain after the initial injury has healed. Central sensitization has two major characteristics. Both have an increased sensitivity to pain and to the feeling of touch. These are referred to as allodynia and hyperalgesia.

Allodynia occurs when an individual experiences pain with circumstances that are normally not supposed to be painful. For instance, chronic pain patients often experience pain even with things as simple as touch or a massage. In these situations, nerves in the region which has been touched sends signals through the nervous system into the brain. Because the nervous system is in a constant condition of heightened reactivity, the brain doesn’t generate a mild feeling of touch as it should, given that the stimulus that initiated it was an easy touch or massage. Instead, the brain produces a feeling of pain and discomfort.

Hyperalgesia occurs when a stimulus that’s usually considered to be somewhat painful is perceived as a much more debilitating pain than it ought to be. For instance, chronic pain patients that experience a simple bump, which generally would be mildly painful, will often feel intense pain. Again, once the nervous system is in a constant condition of high reactivity, it amplifies pain.

Contents

Peripheral and Central Sensitization

Chronic pain patients sometimes believe they might be suffering from a mental health issue because they understand from common sense that touch or simple bumps produce tremendous amounts of pain or discomfort. Other times, it’s not the patients themselves who feel this way, but their friends and family members. Individuals who don’t suffer with chronic pain may witness others who have central sensitization experience pain at the slightest touch or cry out at the simplest bump. However, because they don’t have the condition, it may be difficult for them to understand what someone who does is going through.

In addition to allodynia and hyperalgesia, central sensitization has other well-known features, though they may occur less commonly. Central sensitization may lead to heightened sensitivities throughout all senses, not only the feeling of touch. Chronic pain patients can sometimes report sensitivities to light, smell and sound. As such, regular levels of light may seem overly bright or even the perfume aisle in the department shop can produce a headache. Central sensitization can also be associated with cognitive deficits, such as poor concentration and poor short-term memory. Central sensitization also interferes with increased levels of psychological distress, particularly fear and axiety. After all, the nervous system is responsible for not merely senses, like pain, but also emotions. If the nervous system is trapped in a constant condition of reactivity, patients are going to be nervous or anxious. Lastly, central sensitization is also correlated with sick role behaviors, such as resting and malaise, and pain behavior.

Central sensitization has long been known as a potential consequence of stroke and spinal cord injury. However, it is increasingly believed that it plays a part in several different chronic pain disorders. It may happen with chronic low back pain, chronic neck pain, whiplash injuries, chronic tension headaches, migraine headaches, rheumatoid arthritis, osteoarthritis of the knee, endometriosis, injuries sustained in an automobile accident, and even following surgeries. Fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, all appear to occur due to central sensitization as well.

Central Sensitization and C Fibers

What Causes Central Sensitization?

Central sensitization involves specific changes to the nervous system. Changes in the dorsal horn of the spinal cord and in the brain occur, particularly at the cellular level, such as at the receptor sites. As mentioned previously, it has long been proven that fractures and spinal cord injuries can cause central sensitization. It stands to reason. Strokes and spinal cord injuries cause harm to the central nervous system, including the brain, in the event of strokes, and the spinal cord, in the case of spinal cord injuries. These injuries change the sections of the nervous system which are involved in central sensitization.

However, what about the other, more prevalent, types of chronic pain disorders, recorded above, such as headaches, chronic back pain, or pain in the extremities? The accidents or conditions which lead to these kinds of chronic pain are not direct injuries to the brain or spinal cord. Rather, they include injuries or condition which affect the peripheral nervous system, particularly in that are of the nervous system which lies outside the spinal cord and brain. How can health issues associated with the peripheral nervous system contribute to modifications in the central nervous system and cause chronic pain in the isolated area of the initial injury? In summary, how can isolated migraine headaches eventually become chronic daily headaches? How can an acute low back lifting injury become chronic low back pain? How does an injury to the hand or foot turn into a complex regional pain syndrome?

There are probably multiple factors that cause the development of central sensitization in these ‘peripheral’ chronic pain disorders. These variables may be divided into two classes:

Factors that are associated with the state of the central nervous system before onset of the initial pain or injury condition
Factors that are associated with the central nervous system following onset of the initial pain or injury condition

The first group involves those factors that might predispose individuals to developing central sensitization once an accident occurs and the next group involves antecedent factors that boost central sensitization once pain begins.

Dr. Alex Jimenez’s Insight

Chronic pain can often modify the way the central nervous system itself functions, so much so that a patient may become more sensitive to pain with less provocation. This is what’s referred to as central sensitization and it generally involves changes in the central nervous system, or CNS, more specifically, in the brain and the spinal cord. Central sensitization has been associated with several common diseases and it’s even been reported to develop with something as simple as a muscle ache. Central sensitization has also been documented to persist and worsen even in the absence of obvious provocation. Several factors have also been attributed with the development of central sensitization, although the true cause is still unknown.

Predisposing Factors for Central Sensitization

There are probably biological, emotional, and environmental predisposing factors for central sensitization. Low and higher sensitivity to pain, or pain thresholds, are perhaps in part due to numerous genetic factors. While there’s absolutely no research as of yet to support a causal link between pre-existing pain thresholds and following development of central sensitization after an incident, it’s largely assumed that it will be eventually found.

Psychophysiological factors, like the stress-response, are also apt to play a part in the development of central sensitization. Direct experimental evidence on animals and humans, as well as prospective studies on humans, have demonstrated a connection between stress and the decrease of pain thresholds. Similarly, different kinds of pre-existing anxiety about pain is consistently related to higher pain sensitivities. All these psychophysiological aspects suggest that the preexisting state of the nervous system is also an important determinant of creating central sensitization after the onset of pain. If the stress response has made the nervous system responsive prior to injury, then the nervous system might be more prone to become sensitized once onset of pain happens.

There is considerable indirect evidence for this theory as well. A prior history of anxiety, physical and psychological trauma, and depression are predictive of onset of chronic pain later in life. The most common denominator between chronic pain, anxiety, nervousness, injury, and depression, is the nervous system. They’re all states of the nervous system, especially a persistently changed, or dysregulated, nervous system.

It’s not that such pre-existing health issues make individuals more vulnerable to injury or the onset of illness, as injury or illness is apt to happen on a somewhat random basis across the populace. Instead, these pre-existing health issues are more inclined to make people prone to the development of chronic pain once an injury or disease occurs. The dysregulated nervous system, at the time of injury, for instance, may interfere with the normal trajectory of healing and thereby stop pain from subsiding once tissue damage is healed.

Factors Resulting in Central Sensitization After Onset of Pain

Predisposing factors may also be part of the development of central sensitization. The onset of pain is frequently associated with subsequent development of conditions, such as depression, fear-avoidance, nervousness or anxiety and other phobias. The stress of those responses can, in turn, further exacerbate the reactivity of the nervous system, leading to central sensitization.�Inadequate sleep is also a frequent effect of living with chronic pain. It’s associated with increased sensitivity to pain as well. In what’s technically known as operant learning, interpersonal and environmental reinforcements have long been proven to lead to pain behaviors, however, it is also evident that such reinforcements may lead to the development of central sensitization.

Mayo Clinic Discusses Central Sensitization

Treatments of Central Sensitization

Treatments for chronic pain syndromes that involve fundamental sensitization typically target the central nervous system or the inflammation which corresponds with central sensitization. All these often generally include antidepressants and anticonvulsant medications, and cognitive behavioral treatment. While usually not considered to target the central nervous system, regular mild aerobic exercise changes structures in the central nervous system and contributes to reductions in the pain of many ailments which are mediated by central sensitization. As such, moderate aerobic exercise is used to treat chronic pain syndromes marked by central sensitization. Non-steroidal anti-inflammatories are utilized for the inflammation associated with central sensitization.

Finally, chronic pain rehabilitation programs are a standard, interdisciplinary treatment that employs each of the above-noted therapy strategies in a coordinated manner. They also make the most of the research on the role of operant learning from central sensitization and also have developed behavioral interventions to reduce the pain and discomfort associated with the health issue. Such applications are typically considered the most effective treatment option for chronic pain syndromes.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Sciatica

Sciatica is medically referred to as a collection of symptoms, rather than a single injury and/or condition. Symptoms of sciatic nerve pain, or sciatica, can vary in frequency and intensity, however, it is most commonly described as a sudden, sharp (knife-like) or electrical pain that radiates from the low back down the buttocks, hips, thighs and legs into the foot. Other symptoms of sciatica may include, tingling or burning sensations, numbness and weakness along the length of the sciatic nerve. Sciatica most frequently affects individuals between the ages of 30 and 50 years. It may often develop as a result of the degeneration of the spine due to age, however, the compression and irritation of the sciatic nerve caused by a bulging or herniated disc, among other spinal health issues, may also cause sciatic nerve pain.

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EXTRA IMPORTANT TOPIC: Chiropractor Sciatica Symptoms

Is It Really Autoimmunity? | El Paso, TX. | Part II

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Functional Medicine

Autoimmunity:�One of the most common things is to leave the doctor�s office with a diagnosis of an autoimmune disease and no nutritional or lifestyle changing insight. Autoimmune diseases are related to inflammation. Keeping� the inflammation down is the goal with autoimmune attacks. The foods you eat make a huge difference in the frequency and severity of flare-ups. Steady dietary changes can help you reach your optimal self.

Contents

Is Autoimmune Disease A Result Of The Collective Perturbations Of The Exposome & Its Impact On The Immunometabolic System?

http://science.sciencemag.org/content/330/6003/460.summary?sid=1ab5a992-4406-499c-b24f-6e7a46c1dc95

The Exposome

Semin Arthritis Rheum. 2018; 47(5): 710?717.

Exposome Influence On SLE

The Ecology Of The Exposome

Exposome & The Alteration Of �Self�

The Exposome Connections To Autoimmune Diseases Converting Self Into Non?Self

Immunometabolic dysfunctions through diet and lifestyle imbalances
Gut Ecology and the Microbiome
ViralorBacterialInfections
Hormones
Drugs
Chemicals
IonizingRadiation
PsychologicalStress

FEBS Lett. 2017 Oct;591(19):3119?3134.

Cell. 2018 Jan 11;172(1?2):22?40.

Cross?Talk Among The Endocrine, Immune & Metabolic Systems

Multi?Organ Network Biology

In Autoimmunity, Warburg Metabolism Is Increased Through Increased Activity Of GAPDH

Science. 2018; 360: 377?78. Dietary Influence?

Blocking Immune Cell Glycolysis & �Starving� Its Function

Science. 2018; 360: 449?54.

Ketogenic Diet�s Potential Impact On GAPDH Immunometabolic Regulation

Cell. 2018 Jan 11;172(1?2):162?175.

Gut Microbes. 2016;7(1):82?9.

Front Immunol. 2017 Mar 21;8:311.

Origin Of IL?17 Producing Th17 Cells

What Is The Relationship Of The Gut Microbiome To Autoimmune Disease?

https://www.cell.com/cell/issue?pii=S0092-8674(17)X0006-8

Science. 2018 Mar 9;359(6380):1097?98.

Science. 2018 Mar 9;359(6380):1156?61.

Allergol Int. 2018 Jan 6;67(1):32?42.

Int J Mol Sci. 2015 Sep 1;16(9):20841?58.

Science. 2018 Mar 9;359(6380):1151?56.

High Fiber Influences On Diabetes In Animal Model

80% Of Patients With Autoimmune Disease Are Female

Why?

Estrogen & Autoimmunity

The greatest association with autoimmune diseases is the female gender
17?beta estradiol seems to play a role in activating T cells in autoimmune disease
T cells have ER?alpha receptors that are activated by 17?beta estradiol resulting in the production of inflammatory cytokines
Blocking ER?alpha receptors may have a beneficial effect on autoimmune activation

Sci Signal. 2018 Apr 17;11(526). piieaap 9415

Eleanor Rogan, PhD IFM Linus Pauling Award Winner

www.JeffreyBland.com

Estrogen & Androgen Metabolism

4?Hydroxyestrogens & DNA reactivity

https://www.ncbi.nlm.nih.gov/pubmed/22155198

https://www.ncbi.nlm.nih.gov/pubmed/21432907

Indole?3?Carbinol (I3C) Inhibition Of ER?Alpha

https://www.ncbi.nlm.nih.gov/pubmed/27312859

Relationship Of Hepatic Drug Detoxification To Anti?Nuclear Antibody Development

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780240805

https://www.ncbi.nlm.nih.gov/pubmed/24763537

Biomed Res Int. 2015;2015:194031.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365752/

https://www.ncbi.nlm.nih.gov/pubmed/18995849

https://www.ncbi.nlm.nih.gov/pubmed/24530186

Making Friends With Ourselves: Clinical Implications

Reduce exposure to agents that activate immunometabolic dysfunction through the exposome
� Dietary
� Infection
� Parasites
� Xenobiotics
� Hormone
� Allergy
� Specific medications
� Dysbiosis
Reduce exposure to DNA damage (radiation, chemicals)
Support hepatic detoxification
Implement gastrointestinal restoration program
Reduce metabolic inflammation and endotoxin
Reduce psychological stress factors that activate HPA axis

Jeffrey Bland, PhD

Chairman Emeritus & Member, Board of Directors The Institute for Functional Medicine

Integrated Chiro and Rehab El Paso, TX CHiropractor | Video

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Athletes, Clinical Case Reports, PUSH-as-Rx, Testimonies, Video

Integrated: Brian Filidor is an aspiring wrestler who’s had a life-changing experience through chiropractic and agility training with Dr. Alex Jimenez. Over a variety of lifestyle modifications, Brian Filidor has achieved a higher conditioning, including improved performance in his strength, reaction time and overall health. Brian Filidor appreciates the help of all the trainers towards helping him become a better athlete.

Integrated Chiro & Rehab

Physical fitness is a state of health and well-being and, more specifically, the capacity to perform aspects of sports, jobs and daily activities. Physical fitness is usually accomplished through proper nourishment, moderate-vigorous physical exercise, and adequate rest. Fitness is defined as the quality or state of being healthy.

We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process.�Our areas of practice include:�Wellness & Nutrition, Chronic Pain,�Personal Injury,�Auto Accident Care, Work Injuries, Back Injury, Low�Back Pain, Neck Pain, Migraine Headaches, Sport Injuries,�Severe Sciatica, Scoliosis, Complex Herniated Discs,�Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

If you have enjoyed this video and/or we have helped you in any way please feel free to subscribe and share us.

Thank You & God Bless.

Dr. Alex Jimenez DC, C.C.S.T

Facebook Clinical Page: https://www.facebook.com/dralexjimenez/

Facebook Sports Page: https://www.facebook.com/pushasrx/

Facebook Injuries Page: https://www.facebook.com/elpasochiropractor/

Facebook Neuropathy Page: https://www.facebook.com/ElPasoNeuropathyCenter/

Facebook Fitness Center Page: https://www.facebook.com/PUSHftinessathletictraining/

Yelp: El Paso Rehabilitation Center: http://goo.gl/pwY2n2

Yelp: El Paso Clinical Center: Treatment: https://goo.gl/r2QPuZ

Clinical Testimonies: https://www.dralexjimenez.com/category/testimonies/

Information:

LinkedIn: https://www.linkedin.com/in/dralexjimenez

Clinical Site: https://www.dralexjimenez.com

Injury Site: https://personalinjurydoctorgroup.com

Sports Injury Site: https://chiropracticscientist.com

Back Injury Site: https://elpasobackclinic.com

Rehabilitation Center: https://www.pushasrx.com

Fitness & Nutrition: http://www.push4fitness.com/team/

Pinterest: https://www.pinterest.com/dralexjimenez/

Twitter: https://twitter.com/dralexjimenez

Twitter: https://twitter.com/crossfitdoctor

Injury Medical Clinic: Sciatica Treatment & Recovery

Is It Really Autoimmunity? | El Paso, TX. | Part I

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Functional Medicine

The western diet is associated with inflammation, and inflammation is central to autoimmunity and autoimmune diseases. Keeping the inflammation down can help in lengthening time between attacks. What to eat and what not to eat are the common questions. In order to quiet� inflammation triggers, educate ourselves and live a normal life is the focus.

Contents

My 2006 Seminar Series

�Understanding the Origins of Autoimmune Disease�

Autoimmunity:

The Central Question I Asked In This series,

Are We Allergic to Ourselves?

� Autoantibodies

� Are they really �autoantibodies�?

� Self or Non?self?

I would like to re?explore this question using what we have learned in 2018.

www.aarda.org

Endocrine

Endocrine Thyroid

Endocrine?Thyroid

Musculoskeletal

Musculoskeletal & Kidney

Neurological

Autoimmunity

Our Immune system in battle with our self?

Presence of Anti?Chromatin, DNA and RNA Antibodies

What Biological Processes May Make Self Into Non?Self?

Post?translationalmodificationofProtein
� Glycation of protein
� Protein Oxidation
� Amino Acid Conjugation of Protein (Citrullinated Protein/AntiCCP and RA)
ProteinSynthesisErrors
DNA and RNA Changes
� Radiation Induced Crosslinking of DNA
� Oxidation of DNA
� Copy Errors not corrected by DNA repair process � Epigenetic Changes (the methylome)

Where Do Anti?Cyclic Citrullinated Peptides (AntiCCPs) Come From?

Activation of the immune system resulting in increased iNOS production of nitric oxide
Arginine residues in proteins can be converted in situ into citrulline with the release of nitric oxide by iNOS
The citrulline produced in the protein is now �foreign� and can be recognized by the immune system as such
Antibodies can then be produced against this �foreign protein�

Disease Modifying Anti?Rheumatic Drugs (DMARDs)

The Facts on Methotrexate For Rheumatoid Arthritis Treatment

Methotrexate is the most commonly prescribed drug to treat rheumatoid arthritis, yet it only helps about half of those who try it. Find out how it works and how to lessen its side effects.