LESLIE AXELROD, ND, LAc

Five years ago, I was offered the opportunity to work in aRheumatology practice. When asked to join, my initial thought

was this is a very difficult population and I don’t feel very compe-tent treating autoimmune disease. Besides, I don’t have a “cure.”Five years later, I have come to some different realizations. I stilldon’t have a “cure,” but I can significantly improve the quality oflife of patients with autoimmune disease by applying basic natur-opathic principles. This article will discuss why adrenal hor-mones, digestion, and diet must be addressed. Specific therapeuticstrategies will be discussed.

It is not uncommon to find a history of high levels of stress,environmental exposures or other issues that may have precededchronic illness. Patients may have been able to tolerate them, untila major stressor occurred which put them into a state of chronicdisease. A common finding in patients with autoimmune diseaseis an abnormal cortisol response.

Multiple studies have shown a dysregulation of cortisolresponse to various stressors, including cytokines, surgery, exer-cise and circadian rhythms. Interleukin-6 (IL-6), a pro-inflamma-tory cytokine which is elevated in rheumatoid arthritis (RA), hasdiurnal variations. It was found that RA patients did not have the

DAVID M. BRADY, ND, DC, CCN, DACBN

This is the first in a series of ClinicalRounds, which will be appearing as a part

of ND News & Review. In these ClinicalRounds real case studies from my practice willbe presented. It is my aim to present interest-ing cases, which will facilitate thought anddiscussion about novel diagnostic and thera-peutic techniques for a myriad of clinical con-ditions that are likely to appear in your offices.

PATIENT PRESENTATION AND HISTORYA 32-year-old female presented to mypractice with the primary complaint offatigue. Her entire symptom/complaintlist was as follows:

FatigueWeight gainColdness

EczemaHair lossAnkle swellingHand and foot numbnessDizziness upon standingChronic sinus infectionsPMSBreast tendernessMuscle painNeck pain

The onset of her symptoms wasapproximately five years prior to presenta-tion. Upon completing her medical his-tory and questioning the patient careful-ly I learned that the onset of her fatigueand other symptoms correlated with aperiod of extreme stress in her life. In theyear of onset she experienced the death ofher father and a difficult non-viable preg-nancy. She stated that she has been notic-ing hair coming out into her hairbrush at

ever-increasing levels recently. She alsofelt “swollen” all the time, suffered fromworsening PMS and breast tendernessassociated with her cycle, dizziness uponstanding, skin dryness, allergies, general-ized muscle aches, and neck and shouldertightness. Her hands also tended to “gonumb a lot.” The patient had tried aplethora of diets to lose weight withoutsuccess and freely admitted that she was a“carbohydrate junkie.”

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Naturopathic Doctor News & ReviewPO Box 8626Scottsdale, AZ 85252-8626

V O L U M E 1 I S S U E 3 S E P T E M B E R 2 0 0 5

TOLLE CAUSAM

Exploring Blood TypesBlood type is a guide and a foundation, howev-er it is always important to understand andtreat the whole person. >> 5

PRIMUM NON NOCEREBreakthrough Techniques forManaging Fibromyalgia SyndromeThe treatment course will depend on the influ-ences the patient has experienced from the envi-ronment, various stressors, an accident or injury,infection, toxicity, and genetic patterns. >> 8

Naturopathic Treatment ofAnorectal DisordersA considerable number of patients suffer fromsome type of anorectal condition in their lives,but often do not discuss it with their physicianuntil it becomes very uncomfortable. >> 15

DOCEREPhilosophy in Action: The 2ndAnnual NaturopathicGathering >> 10

BUSINESS OF MEDICINECommercial Leasing:For most healthcare professionals, real estate istheir second largest overhead expense.Businesses spend significantly more money ontheir physical work environment than theyshould-particularly when leasing space. >> 11

BOTANICAL INSIGHTSImmunomodulating Herbs andAuto Immune DiseaseSimplistic ideas about the mechanisms of theseherbs based on in vitro studies or theoreticalmodels are not a sound basis for making clinicaldecisions. >> 12

ORIENTAL MEDICINEBut It’s a Dry Heat!Clinical dehydration and yin deficiency in chronicdisease. >> 13

GROWING YOUR PRACTICEHow to Avoid Three CommonPitfalls that Stunt Your PracticeGrowth >> 17

NATUROPATHIC NEWS >> 19

NATUROPATHIC ORTHOPEDICSComprehensive Treatment forTennis Elbow Including AutologousBlood Injection Therapy >> 20

EDUCATIONThe Problem with the ‘NormativeCurriculum’The third of a four-part catalytic series aboutCNME-based naturopathic medical education inNorth America. >> 22

VIS MEDICATRIX NATURAENaturopathic Management ofCoagulation in Atrial FibrillationAlternatives to Warfarin Therapy- Part Two >> 23

NATUROPATHIC DOCTOR NEWS & REVIEW

continued on page 4

The art of healing comes fromnature, not from the physician.

Therefore the physician must startfrom nature, with an open mind.

Philipus Aureolus Paracelsus

T o l l e T o t u m

Clinical Rounds in Functional and Nutritional Medicine

INSIDE

V i s M e d i c a t r i x N a t u r a e

Treating Autoimmune Disease Using Naturopathic Principles

continued on page 6

FATIGUE: FUNCTIONAL HYPOTHYROIDISM

Prior ManagementThe patient was previously seen by aphysician who is a family friend. Heordered a basic thyroid panel including aTSH. While the lab analysis was consid-ered normal by the pathological ranges setby the testing laboratory, the physiciandecided to put her on thyroid hormonereplacement therapy (HRT) based on hersubjective symptoms. She was prescribedlevothyroxine sodium (Synthroid). TheSynthroid did not seem to produce anydramatic results, even after the physicianhad increased the dosage several times.She was also given Zyrtec for her sinuscongestion and allergies. A visit to a der-matologist resulted in a diagnosis ofeczema. Eventually, a family member ofthe patient whom is a chiropractor and col-league of mine, informed her about ourintegrative medical practice and she pre-sented to us for a second opinion and pos-sibly an alternative approach.

PHYSICALEXAMINATIONThe patient had a somewhat swollen andbloated appearance. She was moderatelyoverweight. Close examination of thepatient’s head, neck, and face revealed thatshe had a significant loss of her lateral eye-brows (Hertoghe sign), coarse dry hair (noobvious hair loss), and an obvious bilateralswelling of the thyroid. Thyroid palpationdid reveal fullness, but no masses, nodules,or tracheal deviation. Standard EENT exam-ination was normal. However, upon expo-sure of the pupils to sustained light sheexhibited an initial pupillary constriction,followed by significant dilation and pulsa-tion, often a sign of adrenal stress. She hadmultiple silver amalgam fillings, as well asone gold crown (dissimilar metals). Heartevaluation revealed a normal rate andrhythm without murmur, and lung exami-nation revealed normal breath sounds. Herseated brachial blood pressure was 108/68mm Hg. Upon quickly standing from asupine position there was a 12 mm Hg dropin her systolic pressure and an 8 mm Hgdrop in her diastolic pressure (+ Ragland’stest). Abdominal examination was essential-ly normal with the exception of mild ten-derness to deep palpation in the RUQ andLLQ. A dry eczematous rash was observedon both arms. A basal temperature trackingsheet mailed to the patient and completedprior to her initial visit revealed an averagemorning axillary temperature of 96.2degrees when performed on the first fivedays after the start of her menses.Musculoskeletal examination revealed mul-tiple myofascial trigger points (TrPs) in thelower cervical and upper thoracic muscula-ture, particularly in the bilateral uppertrapezius muscles, which referred pain intothe proximal upper extremities. Globalrestriction of cervical ROM was noted, withmultiple areas of segmental dysfunction.

Initial ImpressionsThe presence of this many overlappingsymptoms should always cause the func-tional medicine practitioner to consider amulti-faceted problem. It is tempting torecognize that the patient has a multitudeof hypothyroid-related symptoms and toaggressively direct your therapy to the thy-roid alone. The initial treating clinician didjust that. However, he must be given creditfor at least attempting thyroid HRT basedon subjective symptoms alone and not justassuming that the patient was “normal”

just because her labs were within normalranges. The initial lab work-up by the con-ventional physician was useful in that ithelped to rule out a significant primarycentral dysregulation of the thyroid andpointed toward peripheral resistance or athyroid hormone conversion disorder as amore likely etiology for the low thyroidfunction. However, given the full array ofendocrine-related symptoms seen in thispatient (ie, PMS, breast tenderness, etc.) itis wise for the functional medicine practi-tioner to consider more foundational prob-lems within the endocrine system. Thecorrelation of her onset with highly stress-

ful events, the dilation of the pupils to sus-tained light, postural hypotension, carbo-hydrate cravings, among others, suggestsdifficulties in the hypothalamic-pituitary-adrenal (HPA) axis.

Discussion of DiagnosticsThe CBC was performed in order to evalu-ate the patient for anemia due to thefatigue, as well as to check infectious sta-tus. The patient did not appear to be ane-mic or to have an acute infection. Serumchemistries did not reveal any significantinternal pathology that would account forthe patient’s fatigue and other symptoms.A standard thyroid panel with TSH waspreviously performed and was normal.Salivary cortisol and DHEA testingrevealed elevated cortisol, depressedDHEA, and a lack of circadian cortisolrhythm.

INITIAL THERAPEUTICPLANThe initial therapeutic strategy was meantto balance the endocrine system, supportproper adrenal and thyroid function,enhance immune function, provide rejuve-nation of the skin, provide general nutri-tional support, and reduce musculoskeletalpain and instability. The patient was veryinterested in discontinuing thyroid HRTand her Synthroid was phased out overtime with the assistance of the prescribingphysician.

Explanation of formulary products used:Multi-herbal adaptogenic: *Panax quin-quefolius (American ginseng),Eleutherococcus senticosus (Siberian gin-seng), Withania somnifera (ashwagandha),Rhodiola rosea, Glycyrrhiza glabra(licorice), P-5-P, R-5-P, folate, pantothenicacid, vitamin C, N-acetyl L-tyrosine.

Proprietary Thyroid Supplement: *N-acetyl L-tyrosine, iodine, selenomethion-ine, Panax quinquefolius (American gin-seng), Coleus forskohlii, Zn, Cu, Mn, Cr,vitamin A.

Stress Reduction and Sleep Counseling• Deep breathing exercises• Guided imagery instruction• Instructions on proper and predictable

sleep (in bed by 10PM, up by 7AM)• Sun / light exposure first thing in morn-

ing with light activity

Physical Medicine ProtocolThe patient was treated with ActiveRelease Technique (ART), post-isometricstretching, and mild ischemic compressionto the located TrPs in the cervical andupper thoracic musculature. Cervical andthoracic manipulation and mobilizationtechniques were used, in addition to homestretching and strengthening exercises.

6-WEEK FOLLOW-UP • Less fatigue• Slightly higher basal temps (96.8°F avg.)• Improved exercise tolerance

Upon follow-up examination it was deter-mined that the patient may benefit to amore significant degree by the addition ofsome level of thyroid HRT. It was decidedto provide the patient with T3, as well asT4. The previously taken Synthroid,which is synthetic T4 only, was not pro-viding any T3. Therefore, Synthroid isoften ineffective for patients with aperipheral T4 to T3 conversion disorder,which can be due to persistent cortisol

elevations. The patient did not want touse synthetic T3 (Cytomel) due to thereported side-effects (palpitations, etc.)and frequent dosing. She also expressed astrong desire to use non-synthetic com-pounds if possible. It was decided to useArmour thyroid at 1 grain per day. Herdosage was later increased to 2 grains perday in the morning.

12-WEEK FOLLOW-UP• Dramatic reduction in fatigue• Normalization of basal temperature

(97.8°F avg.)• Greatly improved exercise tolerance• 12-pound weight loss• Less hand and foot numbness• Decreased ankle swelling• Less hair loss (reported subjectively)• Reduction in PMS symptoms and breast

tenderness• Reduction in neck and shoulder pain

Future DiagnosticConsiderations• Food intolerance and allergy testing• Comprehensive digestive stool analysis • Heavy metal burden testing (provoked

urine)

DISCUSSIONIt is disconcerting to most functionalmedicine providers just how mismanagedmany thyroid disorders are by most con-ventionally trained physicians. I makethis statement fully aware of the successof the conventional HRT approach whenthe thyroid problem is one of central dys-regulation. That is, when the thyroidgland is truly not producing enough hor-mone (primary hyothyroidism), or whenit is not being told to make enough hor-mone by the pituitary gland or hypothal-amus (secondary or tertiary hypothy-roidism). In these cases, the conventionalapproach, which is to give synthetic T4therapy, often works just fine. Thesetypes of hypothyroid conditions are alsoquite accurately detected via standardthyroid laboratory assays designed tofind dysregulation of the HPT axis (ie:low T4 and elevated TSH in the case ofprimary hypothyroidism). We have allbeen trained to detect these overt types ofthyroid conditions before they result inovert myxedema, with severe symptomsand characteristic facial features.

However, many of our patients havemore subtle, yet still very clinically signif-icant conditions. Problems such as thy-roid hormone receptor insensitivity, ordifficulty in the conversion of T4 (a rela-tively inactive hormone) into T3 (themain acting thyroid hormone) in theperipheral tissues, are examples of disor-ders often referred to as sub-clinicalhypothyroidism, functional hypothy-roidism, peripheral thyroid disease, lowT3 syndrome, euthyroid sick syndrome,or Wilson’s syndrome. Standard labassays often do not pick these variants ofhypothyroidism up and conventionalHRT may not work very well at all.

When the body peripherally convertsT4 to either active T3 or inactive reverseT3 (aka: rT3), the proper ratio of the twoproducts must be maintained.Perturbations in cortisol levels due tostress, Cushing’s disease, or the overuseof exogenous cortizone-based drugs, cantip the scales toward the overproductionof rT3, with a resulting low thyroid con-dition. Reverse T3 occupies a position on

NATUROPATHIC DOCTOR NEWS & REVIEWSEPTEMBER 20056

T o l l e T o t u m

Test ResultCBC and Serum Chemistry Panel: WNL

Serum Thyroid Antibodies: Negative (to r/o Hashimoto’s)

Adrenal Stress Test Elevated salivary cortisol throughout the midday and low DHEA-S

Initial Diagnostic Work-up

Intervention Goal

Multi herbal adaptogenic* adrenal support Proprietary thyroid supplement* thyroid supportVitamin C adrenal/immune supportMSM lotion skin health/itching reliefGLA skin healthMycelized vitamin A/E skin health/breast painHCL & Pepsin digestive aid/allergyDigestive enzymes digestive aid/allergyStress reduction counseling adrenal support Light aerobic exercise stress reduction/wellnessPhysical therapeutics neck and shoulder painMacronutrient-balanced elimination diet general/allergy/wt. loss

low simple carbsmoderate lean protein and complex carbsmonounsaturated fatsgluten and dairy elimination

Tolle Totum: Clinical Rounds, continued from page 1

Initial Therapeutic Plan

the cellular nuclear receptor, but does notprovide much in the way of thyroiddrive. This phenomenon has been wellstudied in patient populations whodevelop hypothyroid-like symptomspost-surgically, but who maintain normalblood thyroid studies (aka: euthyroidsick syndrome). Clinically, those of us inambulatory practice seeing chronically illand fatigued patients have observed thisphenomenon in relation to all types ofstressful events (ie, pregnancy, divorce,loss of a loved-one, physical trauma, psy-chological trauma, etc.). Lower levels ofchronic stress, such as poor dietary andlifestyle habits, digestive problems, leakygut, toxicity, food intolerance, and aplethora of other problems, can all havea cumulative effect, inducing adrenaldysfunction via up-regulation of the HPAaxis, and ultimately contributing to aperipheral thyroid condition. The result-ing hypothyroid state produces lowbody temperature, which can lower theefficiency of virtually every enzyme uti-lized in our internal biochemistry. Thisprovides an explanation for the far-reaching symptoms of hypothyroidism,including a multitude of musculoskele-tal complaints. The overproduction ofcortisol can also imbalance all hormonalproducts of the cholesterol- synthesis

pathways, such as androgens and estro-gens. This may result in PMS, menstrualirregularity, difficult menopause, and ahost of female-related problems in addi-tion to thyroid dysfunction. Of recentinterest is cited studies out of Europeand Japan implicating immune com-plexes created from food allergens (ie,gluten) and gut pathogens (ie, Yersiniaenterocolitica) in stimulating an autoim-mune process against the thyroid tissue,as in Hashimoto’s thyroiditis, which canultimately produce a significanthypothyroid state.1-3 Celiac patients areknown to have approximately ten timesthe rate of immunogenic thyroid dis-ease as compared to normal controls,further implicating gluten and otherfood allergens in thyroid disorders.Therefore, a comprehensive functionalapproach is essential in overall patientmanagement of thyroid, adrenal, andother endocrine disorders.

CONCLUSIONThis particular patient has not had a sig-nificant return of her symptoms to datewith the outlined treatment approach.However, it would have been my prefer-ence to evaluate her intestinal health,detoxification ability, and food intoler-ance using ALCAT technology in order

to provide the patient with the mostcomprehensive solution to her condition,particularly in light of the dermatologi-cal manifestations. In this case, thepatient had such dramatic improvementin her overt symptoms with the initialintervention she did not opt for theseadditional evaluations. Her case waschosen in order to illustrate the impor-tance of the accurate detection and man-agement of functional endocrine disor-ders in our patients with chronic healthproblems. This case also serves to out-line the integrative functional medicineapproach to the management of thefatigued patient. Intestinal health, diges-tive function, detoxification, intoleranceand endocrine function all need to beconsidered for evaluation. Treatmentshould be directed based on the findingsin order to comprehensively treat thesedifficult conditions, which often defy aclear diagnosis in the conventional med-ical paradigm.

For a more comprehensive look atfunctional hypothyroid disorders pleaselink to publications on the topic via myweb site at: www.DrDavidBrady.com

I encourage and welcome questions andcomments regarding this case, as well asother clinical issues. Please direct your ques-tions to me at: dbrady@bridgeport.edu

SEPTEMBER 2005NATUROPATHIC DOCTOR NEWS & REVIEW 7

T o l l e T o t u m

David M. Brady, ND, DC, CCN, DACBN is a

Naturopathic Physician, a Board Certified Clinical

Nutritionist, and a Doctor of Chiropractic. Dr. Brady

is the Chief Medical Officer of Designs for Health,

Inc. He is also presently the Director of the Human

Nutrition Institute at the University of Bridgeport,

and an Associate Professor of Clinical Sciences at

the University of Bridgeport, Colleges of

Naturopathic Medicine and Chiropractic in

Bridgeport, Connecticut. Dr. Brady also maintains a

private practice at The Center for the Healing Arts

in Orange, CT, where he specializes in “Functional

and Metabolic

Medicine”. Dr. Brady

has been a product for-

mulator and technical

consultant to various

nutraceutical companies

and clinical laboratories

for the past ten years.

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“The resulting hypothyroid state produces low body temperature, which can lower the efficiency of

virtually every enzyme utilized in our internal biochemistry. This provides an explanation for the far-

reaching symptoms of hypothyroidism, including a multitude of musculoskeletal complaints.”

1. Takuno et al. Prevalence of Yersinia antibodies in thy-roid disorder patients. Endocrinol Jpn 1990Aug;37(4);489-500.

2. Stunzner et al. Antibodies to Yesinia enterocolitica inimmunogenic thyroid disease. Acta Med Austriaca1987;14(1):11-4.

3. Tomer et al. Infection, thyroid disease, and autoimmu-nity. Endocrine Rev 1993 Vol 14, No 1.

REFERENCES