17. MUSCULOSKELETAL HEALTH

Question 1

What is the definition of arthritis?

Answer 1

Joint inflammation with pain

Question 2

Name 5 different types of arthritis

Answer 2

• Osteoarthritis
• Rheumatoid arthritis
• Gout
• Ankylosing spondylitis
• Psoriatic arthritis

Question 3

What is osteoarthritis and when/where is it most common?

Answer 3

Degeneration of the articular cartilage, typically affecting the weight-bearing (larger) joints and seen mostly over the age of 45 years.

Question 4

What are the signs & symptoms of osteoarthritis? (6)

Answer 4

• Joint pain (e.g., knee, hip) with a gradual onset unilaterally.
• Often worsened by activity and relieved by rest.
• Associated joint stiffness.
• Joint swelling, deformity (due
  to osteophytes),
• crepitus - creaking sound
• Heberden’s nodes: Swelling at the distal interphalangeal joints.

Question 5

What are the two main components of articular cartilage found in synovial joints?

Answer 5

Extracellular matrix and chondrocytes

Question 6

What is the Extracellular Matrix found in articular cartilage made of? (3)
(give details of the complicated part!)

Answer 6

• Water
• Collagen
• Proteoglycans: Made from a core protein and glycosaminoglycan (GAG) chain(s). GAGs can be made of chondroitin sulphate, keratin sulphate etc. Proteoglycans are attached to hyaluronic acid.

Question 7

What is the role of chondrocytes found in articular cartilage?

Answer 7

Synthesising and maintaining the extracellular matrix

Question 8

What are the 4 stages in the pathophysiology of osteoarthritis?

Answer 8

UPDATE TO MATCH LECTURE NOTES

1) Proteolytic breakdown of cartilage matrix begins. Matrix metalloproteases (MMP) like collagenase degrade the extra cellular matrix. This releases fragments into synovial fluid causing inflammation.

2) Cartilage Begins to Wear Away
- The level of proteoglycans continues to drop causing the smooth cartilage that cushions joints to soften, thin and lose elasticity. Vertical clefts develop.

3) Loss of joint space
The space between the bones narrows, and cartilage wears away exposing the underlying bone.

4) Bone Changes Under the Surface
- As the cartilage thins, the bone underneath becomes denser (eburnation) and may form small bony growths (osteophytes) around the joint edges.

Question 9

Write this in full: “MMP such as _____ degrade the ECM”

Answer 9

Matrix metalloprotease such as collagenase degrade the extracellular matrix.

Question 10

What happens to the level of proteoglycans in osteoarthritis and what does this cause?

Answer 10

It continues to drop, causing cartilage to soften, thin, and lose elasticity.

This compromises joint surface integrity.

Question 11

What are fibrillations in the context of osteoarthritis?

Answer 11

Vertical clefts that develop along the normally smooth articular cartilage

Fibrillations indicate deterioration of cartilage structure.

Question 12

What is ‘eburnation’ in the context of osteoarthritis?

Answer 12

Bone thickening

Eburnation occurs due to increased stress on the bone as cartilage deteriorates.

Question 13

What is the formation of osteophytes in osteoarthritis?

Answer 13

Bone spur formation

Osteophytes are a response to joint instability and cartilage loss.

Question 14

What are the causes and risk factors for osteoarthritis? (8) give mechanisms

Answer 14

• Increasing age ― erosion of
  chondrocyte telomere length
  and mitochondrial dysfunction
  due to oxidative damage.
• Previous joint trauma ― joint inflammation and the onset of cartilage degradation.
• Overweight / obesity ― mechanical load on cartilage.
• T2DM ―insulin stimulates chondrocytes to synthesise proteoglycans. If insulin reduces in later stage T2DM there is lower chondrocyte activity.
• Genetic predisposition.
• Chronic inflammation e.g., metabolic endotoxaemia.
• Other joint diseases ― e.g., gout, RA.
• Nutritional deficiencies ― e.g., vitamin D which regulates bone metabolism.

Question 15

What is the main conventional treatment for osteoarthritis and why might this not be a good idea?

Answer 15

NSAIDs
They increasing the rate of cartilage degeneration (inhibit collagen matrix synthesis and accelerate cartilage breakdown)

Question 16

What are the naturopathic diet and lifestyle treatments for osteoarthritis? (7)

Answer 16

• CNM Naturopathic Diet with a focus on supporting:
  
  • an anti-inflammatory environment
  • sufficient hydration for synovial support.
• Address the cause/s ― e.g., manage weight and improve insulin sensitivity, address dysbiosis / intestinal permeability.
• Change dietary fats and oils
  
  • Decrease arachidonic acid (red meat, fatty dairy)
  • Increase eicosapentaenoic acid (EPA) (oily fish)
• Hydrotherapy
  
  • contrast showers: Start hot, end cold. 3-4 times longer for hot.
  • Epsom salt baths (500g - 1kg per bath).
• Referral to osteopathy, acupuncture.
• Exercise (low-moderate intensity) e.g. swimming, tai-chi, yoga, Pilates.

Question 17

What supplements are useful for osteoarthritis patients? (give dose) (12)

Answer 17

• Glucosamine sulphate (500mg x 3 daily)
• Chondroitin sulphate (200 - 400mg)
• Methylsulfonyl methane (MSM) (1 - 4g)
• Vitamin C (1-5g)
• Vitamin E (200 - 400 IU)
• Vitamin D (Optimise levels)
• Tart Cherry (up to 3,000mg extract)
• Vitamin K2 (50 - 100mcg)
• Turmeric (500 - 2,000mg)
• Ginger (500 - 1,000mg)
• Boswellia (300mg x 3 daily)
• Devil’s claw (100 - 1,000 mg in split doses)

Question 18

How do Glucosamine Sulphate, Chondroitin Sulphate & MSM all support clients with osteoarthritis? (4)

Answer 18

• Support proteoglycan synthesis
• Inhibit Matrix Metalloproteases from degrading cartilage
• Stimulate hyaluronic acid synthesis
• Anti-inflammatory - downregulate NF-KB
• Reduce inflammatory cytokines (e.g. IL-6, IL-17, TNF-α).

Question 19

How do Vitamins C and E support clients with osteoarthritis? (2)

Answer 19

• Required for chondrocyte protein synthesis (e.g., collagen).
• Antioxidant; reduces impact of ROS on genomic stability in chondrocytes.

Question 20

How does Vitamin D support clients with osteoarthritis? (2)

Answer 20

• Regulates collagen turnover and bone metabolism.
• Studies link low vitamin D with increased OA

Question 21

How does Vitamin K2 support clients with osteoarthritis? (1)

Answer 21

Inhibits cartilage calcification by binding to proteins in joints.

Question 22

How do tart cherry, turmeric, ginger, devil’s claw and boswelia support clients with osteoarthritis? (2)

Answer 22

• Antioxidant
• Anti-inflammatory - downregulate NF-KB
• Reduce inflammatory cytokines (e.g. IL-6, IL-17, TNF-α).

Question 23

What topical treatments can be used for osteoarthritis?

Answer 23

• Devil’s claw
• MSM
• Essential oils in carrier cream/oil e.g.
  
  • Ginger
  • Rosemary
  • Peppermint

Question 24

What is the definition of Rheumatoid Arthritis?

Answer 24

A chronic inflammatory
autoimmune disease characterised by synovial joint
inflammation, potentially affecting all organs except the brain.

Question 25

What are the signs & symptoms of rheumatoid arthritis?

Answer 25

- Symmetrical polyarthritis ― usually initially affecting small distal joints of the hands / feet and progressing to proximal joints. * Hand deformities (e.g., swan neck). * Subcutaneous nodules.

Question 26

What are the complications of rheumatoid arthritis? (6)

Answer 26

- C1/2 vertebral subluxation - Pleurisy - Pulmonary fibrosis - Kidney disease - Sjögren’s syndrome - Carpal tunnel syndrome

Question 27

What are the 5 stages in the pathophysiology of seropositive rheumatoid arthritis?

Answer 27

1) Citrullination occurs: PAD enzymes convert arginine residues into citrulline in proteins, altering their structure. 2) Antigen-presenting cells (APCs) detect these citrullinated proteins as abnormal, process them, and present them to CD4+ T-helper cells. 3) T-cell differentiation leads to B-cell activation and production of: - Anti-Citrullinated Protein Antibodies (ACPAs) - Rheumatoid Factor (RF) (autoantibodies against a portion of IgG) 4) Activated T-cells and B-cells migrate into the synovial membrane, where T-cells activate macrophages, which secrete pro-inflammatory cytokines: TNF-α, IL-1, IL-6. These amplify inflammation and recruit more immune cells. 5) These cytokines also: - Stimulate fibroblast-like-synoviocytes (FLS) to release matrix metalloproteases (MMPs) that degrade cartilage - Promote osteoclast activation, leading to bone erosion

Question 28

Causes & risk factors for rheumatoid arthritis give mechanisms (7). - One point includes the names of 4 microbial species which are raised/reduced in RA.

Answer 28

* Genetics – e.g. HLA-DRB1. * Smoking― Associated with oxidative damage; raised pro-inflammatory cytokines (e.g., IL-17); increased MMP expression; epigenetic changes. * Periodontitis (e.g. from p. gingivalis) ― produces enzymes which induce citrullination. * Silica dust exposure - increases inflammatory cytokines (e.g., TNF- α) and MMP activity. * Other infectious agents, e.g., EBV, Proteus mirabilis (often UTIs). * Intestinal dysbiosis:‒ - Increased Prevotella copri can induce Th17-related cytokines. - Increased Collinsella increases gut permeability and IL-17. - Reduced Bacteroides spp. and Bifidobacterium spp. abundance. ‒ Many RA patients have positive SIBO breath test. * Links with disturbed gut barrier function (e.g. metabolic endotoxaemia) and intestinal inflammation.

Question 29

What do blood tests of RA patients typically show? (3)

Answer 29

* Raised inflammatory markers (ESR / CRP). * Rheumatoid factor (RF) in 70% of cases ― an IgM antibody that targets the constant region of IgG antibodies. * Anti-citrullinated protein antibodies (ACPAs) ― can be present in the serum up to 10 years before the onset of clinical symptoms.

Question 30

What are the conventional treatments for RA? (4)

Answer 30

* DMARDs (e.g., methotrexate) - NSAIDs, - Corticosteroids - Biologics (e.g., infliximab).

Question 31

What diet and lifestyle support would you give, and what problem areas should be targeted as part of a rheumatoid arthritis plan? (not supplements) (8)

Answer 31

* CNM Naturopathic Diet with a focus on reducing inflammation (e.g., no refined sugar, trans fats, dairy, limited red meat; high omega-3, etc.). * Abundant antioxidants (rainbow diet) - RA sufferers typically have low serum levels of antioxidants, and high levels of oxidative stress, which can contribute to tissue damage. * Gluten-free ― as gluten is a key food source of molecular mimicry and inducer of intestinal permeability (triggering zonulin release). * Oral microbiome support – Anti-microbials and biofilm disruptors e.g., colloidal silver, ginger, turmeric, aloe vera, clove, garlic and neem mouthwashes. * Stop smoking - Stress management * Gut barrier and microbiome support. * Target latent EBV infections with immune support (e.g. Vit C) and anti-virals (e.g., L-Lysine, berberine, resveratrol, turmeric, EGCG.)

Question 32

What nutritional supplements (including herbs) can be used for rheumatoid arthritis? Give the dose. (11)

Answer 32

- Vitamin D (optimise levels) - Omega-3 (1 g+ of EPA) - Borage oil (for GLA) (1–2 g daily) - Resveratrol (200 mg / day) - Alpha lipoic acid (Up to 1200 mg / day) - EGCG (2–3 green tea / day) - Probiotics (min. 100million CFU) - Turmeric (500 - 2,000mg) - Ginger (500 - 1,000mg) - Boswellia (300mg x 3 daily) - Devil's claw (100 - 1,000 mg in split doses)

Question 33

How does Vitamin D support Rheumatoid Arthritis treatment? (3)

Answer 33

- modulates the immune system - reduces inflammation - deficiency is common in RA and supplementation may help manage symptoms

Question 34

How does Omega-3 support Rheumatoid Arthritis treatment? (2)

Answer 34

- Anti-inflammatory - downregulates NF-KB - Reduces inflammatory cytokines (e.g. IL-6, IL-17, TNF-α).

Question 35

How does GLA support Rheumatoid Arthritis treatment? (3)

Answer 35

- Anti-inflammatory - downregulates NF-KB. - Reduces pain, stiffness and swelling in RA. - Converted to DGLA, which forms the anti-inflammatory PGE1.

Question 36

How does Resveratrol support Rheumatoid Arthritis treatment? (1 main point and 1 specific)

Answer 36

- Anti-inflammatory - downregulates NF-KB. - Reduces Th17 cells

Question 37

How does Alpha Lipoic Acid support Rheumatoid Arthritis treatment? (3)

Answer 37

- Anti-inflammatory― downregulates NFκB - Reduces inflammatory markers such as CRP - Antioxidant, raises intracellular glutathione.

Question 38

How does EGCG support Rheumatoid Arthritis treatment? (2)

Answer 38

- Anti-inflammatory —inhibits NF-κB - Induces apoptosis of dysregulated fibroblast-like-synoviocytes and osteoclasts.

Question 39

How does Quercetin support Rheumatoid Arthritis treatment? (1 main reasons and 2 additional details)

Answer 39

- Anti-inflammatory —inhibits NF-κB - Reduces inflammatory cytokines (e.g. IL-6, IL-17, TNF-α). - Inhibits the invasion of Fibroblast-like-synoviocytes (FLSs)

Question 40

How does Zinc support Rheumatoid Arthritis treatment? (2)

Answer 40

* Deficiency / insufficiency is common in RA, which can predispose to inflammation by reducing delta-6-desaturase activity. * Low levels are associated with increased NF-kb activation, CRP, IL-1β, and TNF-α.

Question 41

- How do probiotics support Rheumatoid Arthritis treatment? (1) - Which strain has the strongest evidence?

Answer 41

- Decreases inflammatory cytokines (e.g. IL-6, IL-17, TNF-α). - Lactobacillus casei

Question 42

What "if in doubt answer" can apply to most nutritional advice & supplements for RA? (3)

Answer 42

- Anti-inflammatory - Downregulates NF-kB. - Reduces inflammatory cytokines (e.g. IL-6, IL-17, TNF-α). - Shown to be beneficial in RA.

Question 43

What is the definition of Gout?

Answer 43

Arthritis due to deposition of monosodium urate (MSU) crystals within joints causing acute inflammation.

Question 44

What are the signs & symptoms of gout? (7)

Answer 44

* Monoarticular arthritis most commonly affecting the big toe. - Most often affecting men. * Pain, swelling, redness and heat. - Shiny skin. * Can affect other joints (e.g., knee). * Inability to use the joint during symptomatic episode. * Reaches its peak within 24 hours, often with fever and malaise.

Question 45

What is the pathophysiology of gout? (4 stages)

Answer 45

1) Serum uric acid is raised (hyperuricaemia) from the breakdown of purine metabolism. 2) Monosodium urate (MSU) crystals form within joints. 3) Interleukin-1β mediates inflammation. 4) Raised uric acid increases NF-kβ, disrupts eNOS activity, is pro-oxidant, increases RAAS activity.

Question 46

What are purines? How are they released? What process releases purines?

Answer 46

- Purines are part of the chemical structure of DNA and RNA found in all of the body’s cells, and in virtually all foods. * When cells die, the purines in the DNA and RNA are released and recycled. - Metabolism of foods release purines

Question 47

What other conditions is gout associated with? (4)

Answer 47

- Hypertension - CVD - T2DM - Kidney disease

Question 48

What are the causes and risk factors for gout? 2 key reasons and related causes of this.

Answer 48

-Over production of Uric acid due to: - excess dietary purines (shellfish , oily fish, organ meat) - leukaemia - chemotherapy - high fructose diets - Under-excretion of uric acid due to: - Medication side effects ― e.g., diuretics, aspirin increase urate renal retention. - Chronic kidney disease - impairs uric acid excretion. - Alcohol - decreases urate excretion and increases urate production. - Genetics― ABCG2 mediates urate secretion. - Obesity and insulin resistance (IR) ― reduces urate renal excretion. - Dehydration Or as a rhyme… Alcohol aspirin - Diuretics dehydration - CKD T2D - Genetic propensity

Question 49

How is gout diagnosed?

Answer 49

Clinical presentation

Question 50

What medications are used for prevention / treatment of gout?

Answer 50

Prevention: Allopurinol (inhibits xanthine oxidase) Treatment: NSAIDs Colchicine

Question 51

What is the naturopathic approach to addressing gout? (9)

Answer 51

- CNM Naturopathic Diet with a focus on reducing uric acid levels. * Avoid / minimise: Alcohol, fructose-containing beverages, pro-inflammatory foods (e.g., refined carbohydrates, trans fats). * Low purine diet. * Address specific causes, e.g., IR, weight loss strategies where appropriate. * Optimise omega-3:6 ratio to reduce inflammation. * Minimum of 2L of water daily ― dilutes urine and promotes uric acid excretion. - Moderate protein (under 0.8g/kg) - Avoid getting cold feet - Castor oil packs

Question 52

What categories of foods contain high levels of purine? (150 - 1,000 mg/100g)? (5)

Answer 52

- Game meats - Organ meats - Oily fish - Lobster, crayfish, scallops - Alcoholic drinks

Question 53

What categories of foods contain medium levels of purine (50 - 150 mg/100g)? (8)

Answer 53

- Wholegrains - Brassicas / leafy greens - Avocado - Mushrooms - Legumes (incl peanuts) - Non-oily fish - Shellfish (prawns, oysters) - Red meat & poultry

Question 54

What categories of foods contain low levels of purine (0 - 50 mg/100g)? (6)

Answer 54

- Refined grains - Fruit - Most vegetables (except brassicas, avocados, mushrooms) - Eggs - Nuts - Dairy

Question 55

What nutritional supplements are beneficial for gout patients? Give dose. (6)

Answer 55

- Quercetin (200‒400mg x 3 daily) - EPA (3g) - Methyl folate (400 - 800 mcg) - Tart cherry (up to 3,000 mg) - Celery (juice of 1 celery / 1tbsp celery seeds) - Nettle tea (1 tbsp twice daily)

Question 56

How does quercetin support Gout treatment? (4)

Answer 56

* Reduces uric acid by inhibiting xanthine oxidase (XO) enzyme - Promotes urate excretion transporters. * Anti-inflammatory * Antioxidant - reduces inflammatory effects.

Question 57

How does EPA support Gout treatment? (2)

Answer 57

- Increases renal urate excretion (by inhibiting urate transporter 1). - Anti-inflammatory

Question 58

How does methyl folate support Gout treatment? (1)

Answer 58

* Reduces uric acid by inhibiting xanthine oxidase (XO) enzyme

Question 59

How does tart cherry support Gout treatment? (3)

Answer 59

Its polyphenols (e.g., anthocyanins): * Are anti-inflammatory - NFκB * Reduce oxidative stress * Reduce uric acid levels

Question 60

How does celery support Gout treatment? (3)

Answer 60

- Reduces uric acid by inhibiting xanthine oxidase (XO) enzyme - Reduces oxidative stress - Anti-inflammatory

Question 61

How does nettle support Gout treatment? (2)

Answer 61

- Diuretic: Increases excretion of uric acid - Alkalising

Question 62

What is the definition of Fibromyalgia? How is it diagnosed?

Answer 62

- Chronic widespread pain and abnormal pain-processing mechanisms. - A widespread pain index (WPI) score of 7+ and a symptom severity (SS) score of 5+ OR WPI 4+ with SS score 9+. Symptoms lasting at least 3 months and no other health problems that would explain the symptoms.

Question 63

What are other key symptoms of fibromyalgia? (7)

Answer 63

- Fatigue - Sleep disturbance - Stiffness - Headaches - Bowel disturbances - Anxiety - Depression

Question 64

Causes / risk factors of fibromyalgia (8) Give details about each - e.g. mechanism, which nutrients.

Answer 64

* Physical / emotional trauma -causes hyper-activated stress response and HPA dysregulation. * Hypothyroidism― thyroid hormones normally inhibit the synthesis and secretion of substance P. - Dysbiosis * SIBO - elevated breath test hydrogen levels correlate with higher pain in FM. * Reduced SCFA-metabolising bacteria (e.g. Bacteroides spp.) which normally modulate nociception (pain). * Infections― e.g., raised EBV antibodies correlate with pain intensity and other key symptoms. * Nutritional deficiencies:‒ - Vitamin D normally decreases inflammatory cytokines and modulates central pain processing. - Vitamin B12 normally inhibits pain signals and supports myelination. - Magnesium normally inhibits substance P. * Gluten allergy / sensitivity / coeliac is common in FM. * Genetic SNPs affecting methylation and detoxification, e.g.:– MTHFR, COMT * Heavy metals (e.g., mercury) decrease glutathione, and methylation, ↑ pro-inflammatory cytokines.

Question 65

What is the naturopathic approach to treating fibromyalgia? (10)

Answer 65

- Address stress - Support sleep - Address mitochondrial dysfunction * Gluten-free and/or low FODMAP diet. * Support the thyroid, adrenals, GIT * Reduce glutamate levels ― by increasing glutamate decarboxylase (GAD) co-factors (Mg, vitamin B6, Zn, vitamin C, taurine). Avoiding glutamate sources (e.g., MSG) and alcohol (inhibits GAD). - Reduce toxic load: detox & liver support, optimise glutathione levels, saunas. - Epsom salt baths with lavender. - Support methylation for NT synthesis & detoxification. - Aerobic exercise improves pain perception. Avoid high intensity.

Question 66

What nutritional supplements can be used to support fibromyalgia patients? Give the dose. (9)

Answer 66

- Magnesium (200 - 500mg) - Vitamin D (optimise levels) - Vitamin B6 (50 - 100mg) - CoQ10 (300mg) - 5-HTP (100 - 300mg) - Ashwaganda (300 - 600mg x 3 daily) - St John's wort (600 - 1,200mg) divided doses - Devil's claw (100 - 1,000 mg in split doses) - Capsaicin

Question 67

How does magnesium support fibromyalgia treatment? (1)

Answer 67

- Blocks NMDA receptors reducing pain perception

Question 68

How does Vitamin D support fibromyalgia treatment? (2)

Answer 68

- Modulates central pain processing - Reduces inflammatory cytokines

Question 69

How does Vitamin B6 support fibromyalgia treatment? (1)

Answer 69

- Co-factor for conversion of glutamate to GABA

Question 70

How does CoQ10 support fibromyalgia treatment? (3)

Answer 70

- Deficiency correlates with symptom severity - Antioxidant - deficiency is associated with mitochondrial dysfunction - Vital in Electron Transport Chain for energy production

Question 71

How does 5-HTP support fibromyalgia treatment? (3)

Answer 71

- Precursor to Serotonin - Serotonin is deficient in FM - Serotonin is part of pain regulation - Supports melatonin synthesis

Question 72

How does Ashwaganda support fibromyalgia treatment? (3)

Answer 72

- Increases GABA expression to: - Supports the HPA axis - Supports sleep - Anti-nociceptive

Question 73

How does St John's Wort support fibromyalgia treatment? (4)

Answer 73

Anti-noiciceptive by increasing: - Serotonin - Dopamine - GABA - MAO

Question 74

How does Devil's Claw support fibromyalgia treatment? (2)

Answer 74

- Antioxidant - Anti-inflammatory (inhibits NF-kB, COX-2, IL-6, TNF-α)

Question 75

Which structures are often implicated in mechanical back pain? (4) For each, give things that make it worse and/or alleviate it

Answer 75

- Muscles (strains, spasms) - Rest & heat - Facet joints - worse with spinal extension - resolves quickly - Intervertebral discs (degeneration, herneation) - worse with spinal flexion, coughing, sneezing - Bones (vertebral fracture) - unremitting pain, trauma

Question 75

Causes and risk factors of mechanical back pain (4)

Answer 75

- Physical trauma - Emotional stress - contraction of muscles. - Inflammation - Age related degeneration

Question 76

What are examples of non-mechanical back pain? (7)

Answer 76

* Systemic diseases (e.g., ankylosing spondylitis). * Fibromyalgia. * Endometriosis. * Renal disease (e.g., infection / stones). * Shingles. * Malignancy — often secondary in the vertebral column from other sites. * Osteomyelitis (bone infection).

Question 77

What is the naturopathic approach to back pain? (not supplements) (8)

Answer 77

* CNM Naturopathic Diet with a focus on reducing inflammation (e.g., no refined sugar, trans fats, dairy, limited red meat; high omega-3, etc.). * Mediterranean diet in reducing MSK pain. Its antioxidant / anti-inflammatory actions are largely attributed to the polyphenol content. * Address chronic inflammation (e.g., gut protocol, sleep hygiene etc.) * Address stress * Referral to an acupuncturist, osteopath etc. * Movement - Pilates and yoga * Hydrotherapy - contrast showers (starting with heat, ending with cold, and with heat being 3–4 x longer than cold) to areas of pain. Epsom salt baths (500g–1kg). * Essential oils mixed in a carrier oil: Lavender and frankincense (relaxing and anti-inflammatory); peppermint (anti-spasmodic).

Question 78

What nutritional supplements are beneficial for back pain? (6) herbs come under 2 categories, not counted as individual items!

Answer 78

- Magnesium (200 - 500mg) - Omega-3 (1g+ of EPA) - Phosphatidylserine (200 - 400mg) - Proteolytic enzymes: Serrapeptase (up to 75mg), Bromelain (up to 1,500mg) - Anti-inflammatory herbs: Devil's Claw, Turmeric, Ginger, Boswellia - Nervine herbs: Lemon balm, passion flower, chamomile

Question 79

How does Magnesium support back pain patients? (1) | Same as for RA

Answer 79

- Blocks NMDA receptors reducing pain perception

Question 80

How does Omega-3 support back pain patients? (2) | Same as for RA

Answer 80

- Anti-inflammatory - Downregulates NF-kB. - Reduces inflammatory cytokines (e.g. IL-6, IL-17, TNF-α).

Question 81

How do proteolytic enzymes support back pain patients? (3)

Answer 81

* Inhibits PGE2 synthesis. - Reduces pain mediators (e.g., bradykinin). - Fibrinolytic—aiding fluid drainage

Question 82

How do nervine herbs support back pain patients? (1)

Answer 82

- Increase GABA levels / effects

Question 83

What is the definition of ankylosing spondylitis?

Answer 83

Chronic autoimmune inflammatory arthritis mainly affecting the spine and sacroiliac joints.

Question 84

What are the signs & symptoms of ankylosing spondylitis? (5)

Answer 84

* Chronic back pain and stiffness (especially in mornings, > 30 minutes). Often improves with movement. Typically starts as sacroiliac joint (SIJ) pain. * Often with Achilles tendonitis, plantar fasciitis and arthritis. * Extra-articular manifestations: Uveitis (~25%), psoriasis (~10%), IBD (~6.5%). * Systemic symptoms (e.g., fever, fatigue). * In advanced stages, a loss of lumbar lordosis and an exaggerated thoracic kyphosis.

Question 85

What are the causes and risk factors of ankylosing spoindylitis? (6)

Answer 85

* Genetic SNPs: HLA-B27 - molecular mimicry. * Biomechanical stress — repetitive strain causing chronic inflammation. * Microbial cross-reactivity - e.g. Klebsiella pneumoniae chlamydia. * GI inflammation. * Gut dysbiosis - e.g. increased E. coli. * Impaired intestinal barrier with upregulated zonulin & high serum LPS levels.

Question 86

What is the naturopathic approach to ankylosing spondylitis? (8)

Answer 86

* CNM Naturopathic Diet; esp dairy exclusion. * ‘Low starch diet’ due to reduced growth of intestinal microbes and reduced serum LPS. * Fasting - improved GIT health and immune-modulation. * Restore GIT health - e.g. 5R protocol. * Manual therapy (e.g., osteopathy). * Exercise — daily stretching (e.g., Pilates) for mobility. * Breathing exercises — to maintain thoracic mobility. * Contrast showers; Epsom salt baths (500 g‒1 kg).

Question 87

What nutritional supplements can be used for Ankylosing Spoindylitis? Give dose. (4 - herbs count as 1 point)

Answer 87

- Vitamin D (optimise levels) - Resveratrol (200mg day) - Omega-3 (1g+ EPA) - Anti-inflammatory herbs: Devil's claw, turmeric, ginger, boswellia.

Question 88

How does Vitamin D support Ankylosing Spondylitis? (same as for RA) (2)

Answer 88

- Th17 pathogenicity inhibitor. - Promotes T-regulatory (Treg) cell differentiation.

Question 89

How does Resveratrol support Ankylosing Spondylitis? (same as for RA) (2)

Answer 89

- Reduces Th17 cells - Anti-inflammatory - downregulates NF-KB.

Question 90

How does Omega-3 support Ankylosing Spondylitis? (1)

Answer 90

Shown to reduce AS disease activity in 21 days!

Question 91

What is the definition of osteoporosis?

Answer 91

Low bone mass and deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.

Question 92

What are the signs & symptoms of osteoporosis?

Answer 92

* Asymptomatic until a fracture occurs. * Most common fracture locations: vertebrae, hip, distal radius. * Vertebral ‘crush’ fractures — results in loss of height and kyphosis.

Question 93

What cells are involved in bone remodelling and what does each do? (2)

Answer 93

- Osteoclasts (BONE RESORPTION) - increase the production of enzymes that dissolve minerals and protein in bone. - Osteoblasts (BONE BUILDING) - create a protein matrix (mainly collagen), resulting in remineralisation of bone.

Question 94

What cellular process imbalance does osteoporosis result from?

Answer 94

OC bone resorption not being compensated by OB bone formation.

Question 95

What are the causes & risk factors for osteoporosis? Explain the mechanisms (15)

Answer 95

* Increasing age — age-related bone loss of 0.5-1% per year begins at age 40. * Female / post-menopause - Oestrogen normally inhibits OC formation and induces OC apoptosis. * Low body weight — due to lack of mechanical stress and load from the weight itself. * Dairy products — countries with high dairy intakes have higher rates of osteoporosis. * High red meat (high methionine) — acid-forming. * Nutrient deficiencies — e.g., - vitamin D (facilitates intestinal calcium absorption) - calcium (needed to mineralise bone) - magnesium (vitamin D co-factor). * Carbonated beverages — high acid load due to phosphoric acid. * Caffeine and alcohol - decreases intestinal calcium absorption. * Smoking — Nicotine binds to OBs and promotes cell death. * Inactivity — mechanical forces stimulate OBs. * Hypochlorhydria — calcium must be ionised by HCl to be absorbed. * Inflammation — Inflammatory cytokines promote osteoclast activity. * Drugs —e.g., corticosteroids promote OC activity. * Gut dysbiosis: – reduced microbiome production of vitamin K2. – SCFAs inhibit bone resorption. – Lactobacillus & Bifidobacterium promote mineral absorption ( – A diverse gut microbiome can promote the production of T-reg cells in the intestine. * Other diseases – e.g., Cushing's, coeliac, hyperparathyroidism.

Question 96

What is the diagnostic method for osteoporosis including the different scores and status.

Answer 96

DEXA scan - Normal - Above -1 - Osteopenia - Between -1 and -2.5 - Osteoporosis - Below -2.5

Question 97

What are the conventional treatments for osteoporosis?

Answer 97

* Bisphosphonates to inhibit osteoclast activity. * Calcium carbonate. * HRT

Question 98

What are the naturopathic treatments for osteoporosis? (4)

Answer 98

- CNM Naturopathic Diet, with a focus to: * Avoid / limit: Dairy products, coffee, alcohol. * Eat / include: ‒ Anti-inflammatory foods: omega-3, turmeric, ginger. * Phytoestrogens (e.g. fermented soy, flax) if post menopausal. * Protein: 1.0‒1.2 g / kg of bodyweight / day. * Address risk factors e.g., stop smoking, support gastric HCl / digestion, optimise body weight, support the gut microbiome etc. * Exercise: 3 x weekly, 30 minutes sessions of resistance / weight-bearing exercise.

Question 99

What nutritional supplements & herbs can be used to support osteoporosis patients? (6)

Answer 99

- Calcium (500mg day supplement) (foods: dark green leafy veg, sardines with bones, sesame seeds). - Vitamin D (optimise levels) - Vitamin K2 (50 - 100 mcg) - Magnesium (200 - 500 mcg) - Multi-mineral supplement: Boron, Zinc, Manganese - Horsetail (1tsp per tea x 2-3 daily)

Question 100

How does Calcium support osteoporosis patients? (1) What factors reduce calcium in the body? (3)

Answer 100

- Needed to mineralise bone Calcium is reduced by: - Low HCL (reduced absorption) - High phytates (reduced absorption) - High salt (increased urinary loss)

Question 101

How does Vitamin D support osteoporosis patients? (3)

Answer 101

- Facilitates calcium absorption. - Involved in bone turnover - Low levels are associated with bone loss and fractures.

Question 102

How does Vitamin K2 support osteoporosis patients? (1)

Answer 102

- Required for production of osteocalcin which draws calcium into bone.

Question 103

How does Magnesium support osteoporosis patients? (2)

Answer 103

- Plays a role in bone mineralisation - A co-factor for Vitamin D

Question 104

How do these other minerals support patients with osteoporosis? - Boron - Zinc - Manganese

Answer 104

Boron—reduces urinary excretion of calcium and magnesium and increases oestradiol and testosterone in postmenopausal women. * Zinc —inhibits osteoclast activity;. * Manganese—assists bone calcium deposition.

Question 105

How does Horsetail herb support osteoporosis patients?

Answer 105

Rich in silica, which is good for bone mineralisation.

Question 106

# Summary Quiz Question What is the typical daily pattern of inflammatory lower back pain?

Answer 106

For inflammatory conditions: - Morning stiffness - Pain is often relieved by movement. For muscular or degenerative issues: - Pain often worsens through the day.

Question 107

# Summary Quiz Question Describe the link between ankylosing spondylitis and the gut. (4)

Answer 107

* Microbial cross-reactivity (with HLA-B27) — e.g. Klebsiella pneumoniae, chlamydia. * GI inflammation is thought to be present in approx. 70% of AS patients. * Gut dysbiosis patterns — e.g. increased E. coli. * Impaired intestinal barrier —upregulated zonulin, high serum LPS levels and a thin mucosal barrier causing increased proinflammatory cytokines.

Question 108

# Summary Quiz Question For what might magnesium be useful in fibromyalgia?

Answer 108

Magnesium blocks NMDA receptor channels and must be removed for excitation to occur. This leads to anti-nociceptive and analgesic effects.

Question 109

# Summary Quiz Question Describe the mechanism of action of tart cherry in relation to gout

Answer 109

Its polyphenols (e.g., anthocyanins): * Anti-inflammatory - e.g. Inhibit COX-1, COX-2, NFκB and IL-1β. * Reduce uric acid levels. * Reduce oxidative stress.

Question 110

# Summary Quiz Question Describe the link between the oral cavity and RA.

Answer 110

Periodontitis induces citrullination. Citrullinated proteins are key targets of autoantibodies in RA.

Question 111

# Summary Quiz Question What are the benefits of glucosamine sulphate and chondroitin sulphate in relation to OA? What supplement dosages would you recommend?

Answer 111

Glucosamine sulphate (500 mg x 3 daily) - Supports proteoglycan synthesis - Stimulates chondrocyte production of collagen - Provides sulphate ions for synthesis of chondroitin sulphate - Inhibits Matrix Metalloproteases from degrading cartilage - Reduces inflammation in chondrocytes by inhibiting COX-2, PGE2 and NF-kB. Chondroitin sulphate (200 - 400mg) - Increases the amount of hyaluronic acid in joints; keeping synovial joints lubricated. - Inhibits many cartilage-degrading enzymes.

Question 112

# Summary Quiz Question Describe ONE hydrotherapy technique for lower back pain

Answer 112

Contrast showers (starting with heat, ending with cold, and with heat being 3–4 x longer than cold) to areas of pain. OR Epsom salt baths (500g–1kg per bath)

Question 113

# Summary Quiz Question Describe how you might optimise calcium status in osteoporosis. (5)

Answer 113

- Supplement with calcium (500mg day - Consume foods rich in calcium: dark green leafy veg, sardines with bones, sesame seeds. - Support HCl with bitters, betain Hcl (HCl is needed for calcium absorption). - Avoid a high phytate diet (esp wheat bran) (reduces absorption). - Avoid a high salt diet (increases urinary loss)

Question 114

What are key X-ray findings in osteoarthritis (3)

Answer 114

- Joint space narrowing - Osteophytes - Subchondral sclerosis