Contact Sports and the Brain

In general, our society has shown great diligence in pursuing prevention of many serious diseases such as diabetes mellitus, cardiovascular disease, cancer, and infectious diseases. We adhere to diet, exercise, early monitoring, vaccination schedules and use of lipid lowering drugs. There is one preventable condition, however, that we have been slow to recognize. That is Chronic Traumatic Encephalopathy (CTE). It is the delayed result of multiple traumatic brain injuries, commonly known as concussions. A prime example would be the Parkinson’s Disease suffered by the great heavyweight champion, Muhammed Ali.

Symptoms and Signs

• cognitive impairment
• short term memory loss
• emotional instability: depression, impulsive behavior, irritability, aggression suicidal and even homicidal tendencies,
• speech and motor impairment
• related conditions are Alzheimer’s disease, Amyotrophic Lateral Sclerosis, Parkinsonism, Fronto-temporal Degeneration

Diagnosis- clinical signs can point to it but the diagnosis is established only at autopsy. Findings are:

• brain atrophy- decrease in weight
• neuronal loss (decrease in number of cells)
• Tau deposits

Disease Process-CTE is thecumulative result of multiple traumatic brain injuries which may not necessarily involve a direct blow to the head. The brain sits in fluid in the skull. Any force which may cause the brain to abut against the skull, commonly acceleration-deceleration in nature, occurring in any number of contact sports, can cause injury to brain cells. The cell wall can be disrupted and leak out some of its content, which may explain the presence of Tau deposits. The axons, or fibers that interconnect brain cells can also be stretched, torn and injured as well.

Risk factors:

• developing brain- the brain is not mature until age of 25, making children and young adults vulnerable
• female- women are more vulnerable

Activities that increase risk

• Boxers and football players-In a report in 2009 of 47 cases proven by autopsy to have CTE, 90% were in athletes, 85% boxers and 11% football players whose careers lasted 14-23 years
• Other high impact sports include ice hockey and soccer, also victims of domestic violence are at risk

Prevention

1. Avoid sports that involve repeated concussions: Boxing is at the top of the list since the object of the sport is to cause traumatic brain injury to the opponent. Football is a close second.
2. Improve Concussion Monitoring

• • When to quit the sport- it has been established that a total of 3 concussions increases the risk of long term neuro-cognitive deficit. This recommendation probably is not stringent enough. Any concussion should be regarded seriously. Studies have shown that there is some brain shrinkage among football players who have not even been diagnosed with concussion.

• • When to return to the game- this is an area still being researched. Pre-concussion baseline tests of brain function should be done on all athletes. There is an online program called XLNT Brain (xlntbrain.comthat enables athletes, coaches, and parents to evaluate concussions.

Chronic Traumatic Encephalopathy is a relatively new discovery that should awaken us to some real risks involved in some of our most revered national pastimes. We need to weigh the risk as well as the benefits of sports such as boxing and football.

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The Marijuana Controversy

At present, 26 states and District of Columbia have legalized marijuana. The topic is fraught with controversy. Proponents tout the benefits without paying attention to the risks of widely available marijuana. Opponents raise warnings about the risks without recognizing the benefits. In medicine, we must always consider the risks as well as the benefits of any treatment in light of specific circumstances.

Cannabis sativa is a plant containing 483 compounds. Besides the most well recognized, form, delta 9 tetrahydrocannabinoid (THC) with mind-altering effects, there is cannabinol (CBD) without mind-altering effects. Cannabinol (CBD) has been tested to treat childhood epilepsy. Sometimes they are used separately and other times in combination. FDA has approved two drugs: Dronabinol and Nabilopne, both containing THC and CBD. They are being studied for effects on nausea and anorexia.

Medical Uses

Neurological Disorders: the following conditions respond to Cannabis

• neuropathic pain- common in HIV/AIDS, and a side effect of cancer chemotherapy
• childhood epilepsy
• spasticity of multiple sclerosis- cannabis seems to diminish the patients perception of spasticity and urinary frequency

Glaucoma– while Cannabis does lower the intraocular pressure, the benefit for glaucoma is limited because of several factors: concomitant lowering of blood flow to the eye, short duration of action requiring extremely frequent applications, and development of resistance to the drug

Cancer- Cannabis potentiates the cancer-killing effect of radiation therapy
Pain– Cannabis has analgesic properties that seem to be synergistic with opiods. The positive outcomes are that for cancer patients, the dosing for opioids can be lowered. Incidentally, where marijuana use has increased because of legalization, heroin use seems to be dropping.

Nausea and Anorexia– so far, there are conflicting reports on the efficacy of Cannabis for these conditions

Risks

There are cannabinoid receptors in the brain (Cb1 receptors) and other organs (Cb 2 receptors) Side effects therefore involve multiple organ systems

Mental State:

• altered senses (heightened color perception)
• altered sense of time
• altered mood
• paranoia
• impaired body movement
• altered cognitive functions: impaired problem solving, verbal, and math skills, impaired memory

Especially vulnerable are developing brains, e.g. adolescent brains (which do not reach maturity until about 22 years). During pregnancy, a mother who smoked marijuana can transmit these impairments to her baby. Cannabis can also be passed to baby through breast milk.

• psychosis- there is a link between cannabis use and schizophrenia (for individuals predisposed to schizophrenia, cannabis use can precipitate its onset), depression, and suicidal ideation

Respiratory– smoking marijuana entails more tar deposited in the respiratory tract than cigarettes resulting in chronic bronchitis. It is not yet known to cause COPD. Second hand smoke may affect vulnerable individuals like asthmatics, but not a normal person unless smoking occurs in an extremely enclosed area.

Heart– marijuana causes tachycardia (rapid heart beat) and increases the risk of heart attacks after the first sixty minutes of smoking

Endocrine– associated with infertility

Social–

• increased school drop-out rate
• increased absence from job, accident and injury rate

Addiction

• 10-30% of users will become addicted
• association with use of other addictive chemicals, e.g. alcohol and tobacco. It has not been associated with subsequent use of harder drugs

Considering the above, so far we can conclude that cannabis does offer benefits mainly for some neurological conditions like childhood epilepsy and multiple sclerosis and for pain control because of its synergistic effects with opioids. These conditions involve specific segments of the population. When possible, the non- THC cannabinoid, if effective, should be the treatment chosen. But for the healthy young adolescent, who use cannabis for its psycho-active component, the risks far outweigh any benefit. Since it is legalized in so many states, there should be regulations on its sale as there are for tobacco and alcohol.

These are our current societal problems

• opioid addiction epidemic
• motor vehicle fatalities from impaired drivers
• homelessness
• dismal world scholastic ranking (in math, we rank 25^th out of 34 nations)

Unregulated widespread use of marijuana can only make them worse.

Our Toxic Environment

 

“All progress is precarious, and a solution of one problem brings us face to face with another problem”  Martin Luther King Jr.

In the 1967 classic motion picture, The Graduate, a family friend , Mr. Mc Guire, told Ben, the new college graduate, “I want to say one word to you. Plastics. There is a great future in plastics.”

It is now 50 years later, and we are realizing the havoc that plastics, along with other synthetics have caused.

Problems

At the pump

• Lead- since the 1970’s it has been phased out of gasoline, and no longer present since 1996
• Benzene- still present in gasoline. The advice is to avoid topping off, and when pumping gas, stand upwind from the nozzle.

Outdoors

• Insect Repellent- those containing DEET which is a central nervous system depressant
• Various Pesticides
• Plastic bags are invading the oceans and harming sea life

At the Beauty Salon

• Nail products: plasticizers contain phthalate, harmful to the endocrine system and reproductive organs of fetuses, readily transmitted through the placenta from mother to fetus. Toluene a solvent for polish remover, Artificial nails- ethyl methacrylate- can cause eye and skin irritation and dizziness

At Home

• Volatile Organic Compounds (VOC)- in paint and glue used for flooring or wood furniture, e.g. formaldehyde in particle board
• Brominated Flame Retardant- found in foam products sold before 2005. Present in most mattresses, carpet pads, couches (in California, all couches were made with these chemicals until 2014 when the standard changed)
• Lead- used in paints of homes built before1978
• Chloroform- is byproduct of chlorine in water mixed with organic matter
• Dioxin – in many household cleaning products
• Plastic containers and tin cans – Bisphenol A (found in lining of tin cans) and Polyvinyl Chloride (indicated by recycle code 3 or V on bottom of plastic container)
• Phthalates- in air fresheners, personal care products such as lotions, conditioners
• Paraffin- in candles, when burned releases carcinogens. Also, scented candles can contain lead

In Food

• Mercury- found in tuna, king mackerel, tile fish, sword fish, shark, orange roughy, marlen, white albacore
• Volatile compounds concentrate in the fat of red mead and poultry
• Pesticides- the dirty dozen are foods with heavy concentrations if not grown organically: apples, celery, collard green, U.S. grown blueberries, grapes (imported), bell pepper, kale, lettuce, nectarines, peaches, potatoes, strawberries, spinach

Practical Measures -A lot has to do with avoidance

• For home improvement, look for VOC free and water based products
• For upholstered furniture, select “flame-retardant-free”
• Avoid dry cleaning clothes
• Avoid using teflon or scotch guard cookware
• Avoid canned foods and beverages
• Avoid heating foods with plastic containers
• Use non-toxic personal products and household cleaners
• Wet mop and dust floors and furniture
• Remove shoes when entering the house to avoid spreading outside toxics indoors
• Choose foods keeping in mind how they are affected by toxics
• Acquire some indoor plants to absorb CO2 and emit oxygen

Progress comes with a price. Indeed, Dr. King’s words ring true.

Prescription Drug Addiction: A Growing Epidemic

The Problem

It has been widely recognized that America is suffering from a growing epidemic of addiction to prescription pain medications. According to the National Institute on Drug Abuse, there are about 2.1 million individuals suffering from substance use disorder related to opioid pain relievers. The number of overdose deaths (20,000 in 2014) have quadrupled since 1999. Among drug abusers, more than a quarter began by abusing a prescription medication. Yet little has been said about what led to this alarming trend.

The Causal Factors

• Litigation– Reviewing history will inform us of how this trend evolved.In the 1990’s the jury in two lawsuits ruled against doctors for underpresribing opiates. In 1991, a North Carolina jury awarded $15 million to the family of Henry James, a nursing home patient who died a painful death from terminal metastatic prostate cancer when a nurse refused to administer opiates because of the potential for addiction. In 1998, William Bergman was admitted to Eden Medical Center in Castro Valley, California where Dr. Wing Chin became his physician. Over a period of five days, the patient complained of 7/10- 10/10 magnitude pain, not adequately treated. While a definitive diagnosis was not reached, chest X-Rays strongly suggested lung cancer. The patient declined further tests and requested hospice care. The disgruntled family reported Dr. Chin to the California medical board, which did not find grounds to discipline him. They later resorted to sue him for gross negligence and was awarded $1.5 million. Eden Medical Center settled out of court.

• Legislation-In the 1990’s several states enacted Pain Laws protecting physicians from prosecution for prescribing opiates for intractable pain

California’s Pain Patient’s bill of Rights states that “A patient suffering from severe chronic intractable pain has the option to request or reject the use of any or all modalities in order to relieve his or her severe chronic intractable pain. The patient’s physician may refuse to prescribe opiate medication for the patient who requests a treatment for severe chronic intractable pain. However, that physician shall inform the patient that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates.”

California’s Intractable Pain Law states “No physician or surgeon shall be subject to disciplinary action by the board for prescribing or administering controlled substances in the course of treatment of a person for intractable pain.”

Perhaps as an overreaction to the lawsuits of the 1990’s, in the year 2000, in order to renew their licenses to practice, California physicians were required to take mandatory training in pain management where liberal prescription of opioid drugs were advocated. Physicians’ prescribing habits were then influenced by these factors:

• the risk of being sued for under-prescribing opiates
• protection from prosecution for liberal prescribing of opiates.
• The option to refer chronic pain patients to so-called pain specialists who could prescribe opiates with impunity.

These factors have led to the perfect storm currently occurring: growing numbers of opiates prescribed and growing rates of addiction to these drugs. It is sad that there was no distinction made between terminally ill cancer patients where the risk of addiction is irrelevant vs. chronic pain sufferers where the risk of addiction is high. These laws did not reflect the need for caution.

Some Proposed Solutions by the Medical Establishment

• Stricter prescribing legislation. It is obvious that Pain Laws have caused the pendulum to swing too far in favor of over-prescribing. Tighter prescribing laws are now, perhaps too late, being enacted
• Development of non-opiate non-addictive pain medications
• Educating the public- many uninformed patients have perhaps been unaware of the addiction potential of drugs they have been prescribed.

The Obstacle to Reform

The pharmaceutical industry is perhaps the hugest obstacle to solving this crisis. In his farewell speech to the nation in 1961, President Dwight Eisenhower warned “Beware of the military industrial complex,” pointing out that the huge defense industry America developed during WWII needed to promote warfare to thrive and succeed. Perhaps the same can be said about the pharmaceutical industry. To thrive and succeed, it needs to promote disease. America is one of only two nations in the world that, since 1997, allows drug advertising. Bombarded by ads, Americans have been brainwashed to think that for any ailment, you need to take a pill. For side effects of medication, you can take yet another medication, e.g. for Opiod Induced Constipation, there is a pill designed to relieve it. For chemotherapy induced nausea, there is a pill for that. Big Pharma spends huge sums lobbying for legislation that benefit them and throttles competitors. In 1982. when I treated patients for pain with acupuncture and billed using a code for injection, I was audited by Medicare. “ What are you injecting?” the agent asked. My answer: “I am injecting energy.” He stated, “If you injected a narcotic, Medicare would pay for it, but not if you merely injected energy. Acupuncture is considered an experimental treatment.” The irony is obvious. A narcotic injection offers temporary relief for a matter of hours, side effects, and risk of addiction. My treatments confers longer lasting relief, minimal side effects, and no risk of addiction. Which is more efficacious? Which is safer? Fast forward 35 years to the present, Medicare still does not pay for acupuncture. Most experimental treatments get approved after 5 years of research as to safety and efficacy. If Medicare does not cover this form of therapy, neither will any Medicare supplemental insurance, shutting out payment for seniors who might greatly benefit from it. Big Pharma has effectively eliminated a huge competitor.

Some Additional Solutions

• Revise Existing Pain Laws. There should be a distinction made between allowing use of drugs with addictive potential for the dying and the living, where the addiction potential has differing relevance
• Tort Reform- it is noteworthy that the awards granted to the two lawsuits I cited have a tenfold difference. That is because in 1991, North Carolina had no limitation on malpractice awards whereas in 1998, California did. As of 2001, North Carolina has put a cap on how much is awarded for pain and suffering. This can be a big factor in controlling healthcare cost.
• Prohibit drug advertising to the public
• Prohibit lobbying
• Train primary care physicians in non-pharmaceutical pain management.
• Revise how insurers pay for treatments. In the past, when insurances began paying for acupuncture, health plans would stipulate that acupuncture could be used after all conventional treatments were tried and failed. Because of research, the paradigm has shifted for management of the most common forms of pain: headache, back pain, and joint pains:

1. First use non-pharmaceutical treatments, i.e., physical modalities like acupuncture, physical therapy, chiropractic, yoga, massage

2. second, use non-prescription analgesics
3. last, use prescription drugs

Unfortunately our present drug addiction epidemic is the result of some unwise legislation which spawned unwise medical practices. The genie has been let out of the bottle. Let’s hope it can be put back in.

Seasonal Allergies

In the U.S., 30% of adults and 40% of children suffer from allergic reactions to various inhaled allergens. Food allergies have risen by 50% since 1997. This spring, after torrential rainfalls in California, seasonal allergies have been exceptionally prevalent. Many sufferers are sneezing, coughing, wheezing, and tearing despite using maximal doses of synthetic anti-allergy formulations. The following might be considered supplemental ways to approach the problem.

Human Microbiome

Recent studies have strengthened the idea that the human gut flora plays a large role in our immune response. It seems that individuals prone to seasonal allergies lack biodiversity in their gut flora, and seem to have a preponderance of bacteroides, an undesirable bacteria.

• Lactobacilli seem to be desirable
  • In Japan, a double blind placebo controlled study in 2006 found an immunobiotic (killed probiotic bacteria), lactobacillus acidophilus L-92 , a strain commonly used in fermented milk products improved symptoms of seasonal and perennial allergic rhinitis and atopic dermatitis
  • An American study (American Journal of Rhino Allergy 2016) found the use of Lactobacillus paracasei (LP33) yet another strain of lactobacillus effective against allergic rhinitis
• Bacteroides seem undesirable
  • Allergies in Estonia and Finland are 2-6 x higher than in Russia. A study comparing the fecal flora of Estonian and Finnish newborns with those of Russian newborns found this difference. The former had a predominance of bacteroides whereas the latter a predominance of bifidobacterium
  • An American study of fecal flora from allergic vs. non-allergic individuals also showed that allergic individuals had a less biodiverse flora and predominance of bacteroides.

Flavonoids

These are plant pigments that have anti-oxidant and anti-inflammatory properties. They are found in common foods such as carrots, celery, olive oil, red wine, apples, onions, berries, gingko biloba, green tea, and buckwheat.

• A study in South London found that a population who consumed flavonoid-rich apples and red wine had a lower incidence of asthma.
• Two commonly used flavonoids are Quercetin and Luteolin (found in Perillea frutescens, a commonly used Chinese herb). A scientific study in 2015 showed a supplement containing Quercitin, Perillea fructescens, and Vitamin D3 effective in diminishing symptoms of seasonal allergies.

• Luteolin blocks mast cells from stimulating an abnormal immune response associated with autism and autoimmune diseases. When mast cells are activated, they stimulate mitochondria to divide and move out of the cell into the extracellular space, releasing DNA and other molecules. The body mistakenly identifies these molecules as pathogens and mounts auto-immune and auto-inflammatory responses. Luteolin appears to block this mitochondrial migration.

Boswellia Serrata (Indian Frankincense)

The Ayurvedic medicine derived from the bark of this tree growing in the mountainous regions of India, North Africa, and the Middle East, is well known for treating arthritic conditions. It is a mast cell stabilizer and inhibits multiple inflammatory molecules. It is effective in the treatment of bronchial asthma and autoimmune diseases. Some commercial formulations are: Boswellin, Niltan (topical cream), and Rheumatic X.

Stinging Nettle(Urtica dioica)

This is a very common weed-like plant found worldwide.The leaves have prickly hairs, which when touched, can cause a painful skin reaction. The leaf is known to have anti-inflammatory and anti-histaminic properties. The root is often used to treat symptoms of benign prostatic hyperplasia. It is also a diuretic, and can affect blood glucose(lowering or raising) and blood pressure(lowering).Because it affects bleeding and clotting, it is not recommended during pregnancy. It has been recommended for seasonal allergies by Dr. Andrew Weil (founder of Arizona Center for Integrative Medicine at University of Arizona).

Besides commonly used antihistamines and steroid products, consider these ways to augment treatment. As a bonus, they may also help other inflammatory conditions.

• Probiotics
• Flavonoids
• Boswellia Serrata
• Nettle Leaf

Aconite ( 附子Fu Zi): a word of Caution

Primum non nocere (First do no Harm)

The above dictum is one of the principle precepts of bioethics.

Recently the San Francisco Chinese community has been severely shaken by the news that two people were poisoned by an herb purchased in a San Francisco Chinatown shop. One victim subsequently died as a result. From media news, the poisoning was the result of ingesting the herb, aconite. So far as is known to date, the herb was not included in the prescription written by the herbalist. How aconite became included in the packages of herbs dispensed is under investigation.

With any form of therapy, the physician needs to weigh the risk/ benefit ratio.

Risk

Aconite is known to be toxic and is often used as a poison. Its medicinal use is recorded in the Divine Husbandman’s Classic Materia Medica, in a section describing herbs with both therapeutic and toxic properties ( oral history dated about 2800 B.C., put into writing about 200 A.D.) Evidently it is the most common source of herbal poisoning in Hong Kong. Aconitum is the genus of 250 species belonging to Ranunculaceae. Most species are poisonous. A common name is monkshood or devil’s helmet which describes the shape of the bluish flower. Every part of the plant is poisonous. The root is what is used medicinally. The toxic dose range is 25-100 gm the therapeutic dose is 0.5-15 gm. The degree of toxicity varies depending on the source of the herb, when it was harvested, how it was processed, and how it was decocted. Plants from different locales can have an eight-fold variation in toxicity.

Benefit

In TCM (traditional Chinese medicine) parlance, the herb “restores devastated yang, strengthens kidney fire, and expels cold.” What comes to mind is the condition of patients after a debilitating illness, where circulation is poor, and there is generalized vasoconstriction. In the pre-antibiotic era, if one survives an infectious disease, this condition was probably common. Contemporary use of the herb is for facial paralysis, joint pains and numb or cold extremities. It most likely has a sympathomimetic and/or adrenergic effect to stimulate cardiac output and circulation. Toxic signs include nausea, vomiting, abdominal pain, irregular heart beat, and paresthesias. Lethal poisoning usually involves the heart in the form of serious abnormal rhythms. Atropine is a known antidote, but in extreme cases, anti-arrhythmic drugs don’t work, and actual cardiopulmonary bypass have been required to treat the poisoned individual.

Regarding whether this herb should be used at all, one must ask:

• Are the benefits so great that its use is warranted despite known toxicity? The answer is no. The main indication for using it is poor circulation, a condition which can be treated in other ways
• Are there other herbs that have similar actions without the toxicity of Fu Zi? The answer is yes. There are two known herbs which, like Fu Zi, can improve circulation but are not toxic. They are Gan Jiang, Rhizoma Zingibere (ginger root) and Ro Gwei C. Cinnamon ( inner cinnamon bark)
• Are there ways to completely eliminate toxicity and ensure the herb is safe? The answer is probably not since the factors determining degree of toxicity can vary so greatly. The smallest toxic dose can be 25 gm, and the largest therapeutic dose is 15 gm. That leaves a relatively narrow margin of safety.

From weighing the risks and benefits, it appears that the risk far outweigh the benefit of Fu Zi, and if we adhere to the dictum of “First do no harm”, I conclude that it should be eliminated from any herbal formulary.

Sleep

“Sleep that knits up the raveled sleeve of care
The death of each day’s life, sore labor’s bath
Balm of hurt minds, great nature’s second course,
Chief nourishes in life’s feast.”

-William Shakespeare, Macbeth

We are now just beginning to realize Shakespeare’s timeless insight into the subject of sleep. In the past, sleep was viewed as just an intrusion into an otherwise productive life, and a shame it took up one third of our time. Now we realize it is a vital part of preserving health, even more important than food.

Effects of Sleep Deprivation

• Shortened life span- mice who were deprived of sleep died earlier than those deprived of food.

• Diseases associated with sleep deprivation include: some cancers, dementia, heart disease,type 2 diabetes, chronic pain, and mental illness

• Endangered Driving- a sleep-deprived driver can be more dangerous than alcohol or drugs. Some drivers needing to meet a schedule but with inadequate sleep are actually sleep-driving, equivalent to sleep-walking

Why we need sleep

• Cleaning for the brain- one might think of it like computer disk clean-up. The brain comprised of multiple neurons that interconnect, require some rest time to allow for cleaning. During sleep, brain cells contract to allow debris to be washed away. Interestingly with neurodegenerative conditions such as Alzheimer and other dementias, there are presence of various deposits such as amyloid, tau, and Lewy bodies. Could this be a failure of clean-up?

• Reprocessing memories- many memories are accompanied by intense emotions. During sleep, the brain reorganizes them as to importance and also unloads emotional responses. Post Traumatic Stress Disorder is an example of failure to reprocess emotions.

How much sleep is needed?

• Recommended minimum for adults- 7 hours, a little less for older folks, a little more for adolescents

Aids to Sleep

• Prescription Drugs

  • Sedatives- e.g. Ambien, Lunesta, Sonata. They target GABA, a neurotransmitter that decreases alertness. Side effects can be hallucinations, memory disturbance, sleep-walking or sleep-driving. They are addictive

  • Benzodiazapines, e.g. Xanax, Valium,,. Restoril, Halcion, Ativan,- they activate GABA receptors resulting in sedation and relaxation. Also are addictive

• Non-Prescription Drugs- these are antihistamines, the commonest being benadryl ( diphenhydramine) .They have the side effect of drowsiness and dry mouth and can cause dependency

• Supplements

  • Melatonin- a hormone normally secreted to induce sleep when the body senses decreasing daylight. It is available in supplement form. Suggested uses: for jet lag and for shift workers who need sleep during the day. Try lowest dose, not to exceed 3 mg, and choose product with label USP Verified to ensure purity.

  • Various herbs: valerian, passion flower, chamomille, lemon balm

• Foods:

  • kiwi fruit ( effect may be attributable to its serotonin content)

  • cherries (effect may be attributable to its melatonin content)

  • malted milk (contains Vitamins B and D for those who may be deficient)

• Cognitive Behavioral Therapy- studies show a 70- 80% response for chronic insomnia

• Yoga- certain poses seem to induce relaxation and promote sleep

• Traditional Chinese medicine- balancing Yin and Yang, which actually means parasympathetic/sympathetic nervous system. Often patients will find when in balance, insomnia disappears