38 minute read
Healthy Recipes by Rachel Knight
Healthy Recipes
Rachel Knight is a Chef and Nutritionist in Melbourne. Her passion for seasonal and locally sourced produce has led her to a career in recipe development aimed at optimal health. Rachel currently works for Lamanna Supermarket as a Nutritionist and Product Developer.
Spiced Pumpkin Bread with Chai Butter
Categories:
• Gluten-Free • Breakfast • Low-Carbohydrate High-Fat • Low Carbohydrates • Keto • Diabetic Friendly • Kids Treat • Lunch Box Treats
Recipe Data:
Serves: Preparation: Cook / Chill:
Nutrition:
9 15 minutes 1.5 hours
Carbohydrates Protein Fats 6g 11.8g 38.7g Energy (KJ) Calories Serving Size 1770 KJ 423 125g
Ingredients: • 450g Pumpkin, grated • 1 tsp Cinnamon • ⅛ tsp Nutmeg • 4 Eggs • 60ml Olive Oil • 300g Almond Meal • 2 tsp Baking Powder • Pinch of Salt • Pepitas and Sunflower Seeds (optional) Chai Butter • 125g Butter, softened • 1 tsp Ground Cinnamon • 1 tsp Ground Ginger • ⅛ tsp Ground Nutmeg • Pinch of Ground Cloves • 1 tsp Honey • ⅛ tsp Ground Cardamom Method: 1. Preheat oven to 160°C (fan-forced). Grease
and line a loaf tin with baking powder. 2. Combine the pumpkin, spices, eggs and oil in a bowl. Mix well to combine. 3. Add the almond meal, salt and baking powder and mix again. 4. Spoon the mixture into the prepared loaf tin and sprinkle with pepitas and sunflower seeds (optional). 5. Place into the oven for 1 ½ hours or until a skewer inserted comes out clean. 6. To make the chai butter, combine all of the ingredients in a bowl and mix well until smooth and creamy. 7. Remove from the oven and allow to cool in the tin for 15 minutes before transferring to a wire rack to cool completely. 8. Serve warm with chai butter.
Nutritional Information Tips/Tricks: • Nutritional information is per piece with 2 teaspoons of butter.
Palak Tofu
Categories:
• Dairy-free • Gluten-free • Low-Carbohydrate High-Fat • Keto • Low Carbohydrates • Diabetic Friendly • Vegan • Dinner
Recipe Data:
Serves: Preparation: Cook / Chill:
Nutrition:
Carbohydrates Protein Fats 6.6g 17.9g 22g
Ingredients: Spiced Tofu • 450g Firm Tofu, cut into cubes • 2 tsp Nutritional Yeast • ½ tsp Salt • 1 tsp Ground Cumin • 1 tsp Garam Masala • 1 tsp Cayenne Pepper
Spinach Curry • 120g Baby Spinach • 1 tbsp Coconut Oil • 1 Brown Onion, diced • 60ml Water (¼ cup) • 180ml Coconut Milk (¾ cup) • 2 Tomatoes, roughly chopped • 8 Garlic Cloves, minced • 2 tbsp Ginger, minced • 1 tsp Garam Masala • 1 tsp Salt
To serve (optional) • Coconut Milk • Fresh Coriander • Slivered Almonds • Rice
Method: 1. Preheat the oven to 200°C. 2. Place all of the ingredients for the spiced tofu
in a bowl and toss to combine ensuring the tofu is coated. Place onto a baking tray and bake for 15 minutes. 3. For the spinach curry, heat the oil in a large frying pan over a medium heat. Add the onion, ginger and garam masala, and cook until the onion is soft and translucent. 4. Add the tomatoes, salt and garlic and cook until the tomatoes have softened (3-4 minutes). 5. Add the spinach, water and coconut milk and cook until the spinach has wilted (around 30 seconds). 6. Place into a food processor or high-speed blender and blitz until smooth. 7. Pour the mixture back into the frying pan over a medium heat and cook for 3-4 minutes. 8. Add the tofu to the pan and cook for a further 2-3 minutes. 9. Adjust the seasoning to taste and serve with a drizzle of coconut milk. Top with fresh corriander, slivered almonds and a side of rice.
4 35 minutes 35 minutes
Energy (KJ) Calories Serving Size 1350 KJ 323 260g
Nutritional Information Tips/Tricks: • Nutritional Information is calculated per serve without rice. • The flavours will develop over the next few hours so be careful not to over season the dish if you are not serving it straight away.
MAppSc (Chinese Medicine) BHSc (Acupuncture) BHSc (Musculoskeletal Therapy) ANTA Chinese Herbal Medicine Branch Chair
Thoracic Outlet Syndrome (TOS) is a neurogenic syndrome that may affect the neck, chest, shoulder and upper limb1, however, it is most frequently experienced in the medial aspect of the upper extremity along the C8 and T1 dermatomes2. Patients may experience symptoms that are quite debilitating, and mostly include pain, numbness and tingling2,3 , and paraesthesia1,3. The symptoms of TOS are caused by entrapment of the neurovascular bundle that passes through the thoracic outlet, which is how the syndrome was first termed in 1958 by Rob and Standeven4. The ‘neurovascular bundle’ is comprised of the brachial plexus, subclavian artery and subclavian vein2; and the ‘thoracic outlet’ may be defined as the anatomical space bordered by the anterior and middle scalene muscles, the clavicle, and the first rib1,2,3,4 .
The patient with TOS often presents a challenge for the clinician, as the diagnosis and treatment are rarely straightforward1,5,6. Firstly, the presenting symptoms can vary because of the various structures that may be compressed. As such, there are three subgroups of TOS consisting of neurogenic (nTOS), venous (vTOS), and arterial (aTOS)1,2,3. However, the most frequent cause of TOS tends to be neurogenic (brachial plexus compression)4. The second dilemma is to establish the site of compression within the thoracic outlet. Generally, compression may occur in one (or more) of three regions within the thoracic outlet: between the anterior and middle scalenes (scalene triangle), between the clavicle and first rib (costoclavicular space), and between the coracoid process and pectoralis minor (retro-coracopectoral space)1,2,3,4,5. Other structural anomalies such as cervical ribs and extended transverses process could also be responsible for compression of the neurovascular bundle4. Often, these anomalies may require surgery for correction.
In order to determine the site of obstruction, specific orthopaedic tests must be employed. When the neurovascular bundle is compressed within the scalene triangle, the condition is referred to as ‘Scalene Syndrome’. There are two tests that can assist the clinician to ascertain impingement within the scalene triangle, the Adson’s Test2,3,4,6,15 and Halstead’s Test16. Both tests monitor the radial pulse while the arm is extended and abducted to around 30°. In the Adson’s Test, the patient is instructed to rotate their head to the side being tested, slightly extend the neck, and hold in their breath. For the Halstead’s Test, rotation of the head is to the opposite side whilst holding their breath. If the pulse is diminished or absent, it will indicate Scalene Syndrome15,16. Compression between the clavicle and the first rib (Costoclavicular Syndrome) can be determined by a positive Costoclavicular Test. The positioning is the same as the Adson’s Test without head or neck movement, however the clinician is required to press down on the affected shoulder girdle. The finding will also be a diminished or absent pulse15,16. A Wright’s Test is used to determine when the obstruction is caused through impingement at the retro-coracopectoral space (Pectoralis Minor Syndrome)15,16. The way the neurovascular bundle passes through this space lends itself to impingement in two ways. Firstly, by compression from the coracoid process which lies directly superior, and secondly from a hypertonic pectoralis minor muscle pressing against it anteriorly. It is for this reason that the Wright’s Test has two variations. In the first variation, the patient’s arm is flexed to a full 180°, which puts excessive tension on the bundle if the coracoid process is inferiorly displaced. The second variation involves horizontally abducting the arm until resistance is met. A significantly diminished or occluded pulse in both variations will indicate Pectoralis Minor Syndrome15,16 .
Other orthopaedic tests that are commonly mentioned are the Elevated Arm Stress Test (EAST) also called the Roo’s Test2,3,4,6,15, and the Upper Limb Tension Test (ULTT)2,3,4,6. These tests may lack specificity, as in, positive findings will indicate impingement of the neurovascular bundle, however the tests will not aid in pinpointing the location of the obstruction. More significance could be placed on the orthopaedic tests discussed above, as diagnostic accuracy is imperative for the most appropriate treatment to be applied4 .
With regard to treatment, it has been suggested that a multimodal approach is often required to ensure the best outcomes7. TOS has been widely documented in manual therapies literature, however, from a Chinese Medicine perspective TOS is seldomly discussed, especially in English8. When analysing the main symptoms of TOS (numbness and tingling), they are classified in Chinese Medicine as Má Mù9,10,21 . The aetiology and pathogenesis of numbness and tingling can be attributed to some form of obstruction restricting the nourishment of Qi and Blood to muscles or limb supplied. In some cases, the source of the obstruction is an external pathogen, mainly cold and/or phlegm. In other cases, Qi stagnation and/or Blood stasis may be responsible for the obstruction, which may correlate to a postural dysfunction from the aspect of Western Medicine. In each case, the numbness and tingling are a direct result of the malnourishment of Qi and Blood10,11. It is interesting to note that even from a Western Medicine perspective, stress5,12 (Liver Qi stagnation), and cold are known aggravators of the symptoms of TOS12 .
Bäcker and Hammes7 support the above aetiology of neuropathic pain, stating that acute scenarios are often associated with a Bi Syndrome, whereas the later stages fall under the category of Wei Syndrome. In addition, Bäcker and Hammes7 state that Spleen involvement should also be considered. Furthermore, they reinforce that treatment in Traditional Chinese Medicine (TCM) must typically follow a phenomenologically oriented approach, as the nervous system does not exist as an independent entity7, and thus pattern differentiation is essential for correct treatment.
Example herbal formulae that address the patterns discussed are presented in Table 1 below13. The formulae are the same as those used in the treatment of periarthritis of the shoulder, as they follow very similar treatment principles and are guided to the same area. An important factor worth noting when building an appropriate formula is the inclusion of guiding herbs. Qiang Huo is used to guide the action of the other herbs in a formula to the upper body; Jiang Huang to the shoulder; and Gui Zhi to the extremities14. The formulae suggested below are only examples and could therefore be modified and expanded on by the experienced herbalist.
Table 1: Herbal Formulae for Thoracic Outlet Syndrome
Formula Wu Tou Tang Jia Jian (modified)
Qiang Huo Sheng Shi Tang Jia Wei (modified)
Shen Tong Zhu Yu Tang Jia Jian (modified)
Ban Xia Fu Ling Wan Jia Wei (modified)
Huang Qi Gui Zhi Wu Wu Tang Jia Jian (modified) Ingredients Bai Shao (Radix Paeoniae Albae) Huang Qi (Radix Astragali) Gui Zhi (Ramulus Cinnamomi) Jiang Huang (Rhizoma Curcumae Longae) Processed Chuan Wu (Radix Aconiti Carmichaeli) Qiang Huo (Radix Et Rhizoma Notopterygii) Gan Cao (Radix Glycyrrhizae) Qiang Huo (Radix Et Rhizoma Notopterygii) Du Huo (Radix Angelicae Pubescentis) Goa Ben (Rhizoma Ligustici) Fang Feng (Radix Saposhnikoviae) Chuan Xiong (Rhizoma Chuanxiong) Man Jing Zi (Fructus Viticis) Jiang Huang (Rhizoma Curcumae Longae) Gan Cao (Radix Glycyrrhizae) Qin Jiao (Radix Gentianae Macrophyllae) Tao Ren (Semen Persicae) Hong Hua (Flos Carthami) Qiang Huo (Radix Et Rhizoma Notopterygii) Ru Xiang (Olibanum) Dang Gui (Radix Angelicae Sinensis) Chuan Niu Xi (Radix Cyathulae) Di Long (Pheretima) Jiang Huang (Rhizoma Curcumae Longae) Chuan Xiong (Rhizoma Chuanxiong) Xiang Fu (Rhizoma Cyperi) Gan Cao (Radix Glycyrrhizae) Ban Xia (Rhizoma Pinelliae) Fu Ling (Poria) Ze Xie (Rhizoma Alismatis) Han Fang Ji (Radix Stephaniae) Luo Shi Teng (Caulis Trachelospermi) Zhi Ke (Fructus Aurantii) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Jiang Huang (Rhizoma Curcumae Longae) Huang Qi (Radix Astragali) Sheng Jiang (uncooked Rhizoma Zingiberis) Dan Shen (Radix Salviae Miltiorrhizae) Ji Xue Teng (Caulis Spatholobi) Bai Shao (Radix Paeoniae Albae) Da Zao (Fructus Jujubae)
Treatment Principle Dispel wind, scatter cold, and free the flow of the network vessels.
Dispel wind, overcome dampness, and free the flow of the network vessels.
Quicken the blood, transform stasis, and stop pain.
Fortify the spleen and dispel wind dampness, transform phelgm and free the flow of the network vessels.
Supplement the qi and nourish the blood, harmonise the constructive and stop pain.
From an acupuncture standpoint, and according to the trajectory of the symptoms, the main dysfunctional meridians are the Small Intestine and Heart from a Channel perspective. This could also extend to the Pericardium and San Jiao meridians. One could further expand on the acupuncture prescription by considering the Sinew Channels. According to Dr Kendall17, the anterior scalene is encompassed by the Gall Bladder Sinew Channel, whilst the middle scalene belongs to the Large Intestine. The posterior scalene, which is governed by the San Jiao17, could also be considered since the whole group of muscles may be hypertonic in Scalene Syndrome. Whilst not mentioned by Dr Kendall, the subclavius muscle is likely encompassed by the Lung Sinew Channel18 , as is the pectoralis minor17. The upper portion of pectoralis major is governed by the Pericardium17 , which along with the subclavius muscle may be, in part, responsible for Costoclavicular Syndrome. As one would expect from the nomenclature, the pectoralis minor muscle is mainly responsible for Pectoralis Minor Syndrome28. This muscle is also bound by the Lung Sinew Channel17.
As we map the pathway of pain and numbness inferiorly along the upper limb, affected muscles and their respective Sinew Channels are as follows. The short head of the biceps belongs to the Lung; the medial head of the triceps and hypothenar muscles to the Heart; flexor carpi ulnaris and abductor digiti minimi belong to the Small Intestine Sinew Channel; and extensor carpi ulnaris and extensor digiti minimi belong to the San Jiao.
This opens up the treatment enormously, bringing in more possibilities for effective results. With all the above in mind, example local points to help disperse stagnation in the obstructed region for the diagnosis of Scalene Syndrome, could include GB-12 Wangu8 , GB-21 Jianjing8, SJ-16 Tianyou, SI-16 Yuanchuang, LI-17 Tianding, LI-18 Futu, ST-12 Quepen, and any Ahshi points found in or around the scalene muscles. ST13 Qihu, ST-14 Kufang and KID-27 Shufu are worthy options for Costoclavicular Syndrome. Pectoralis Minor Syndrome can be treated with ST-16 Yingchuang, LU-1 Zhongfu and LU-2 Yunmen. Useful adjacent points could include LI-15 Jianyu5, LI-16 Jugu8, SJ-14 Jianliao5 , HT-1 Jiquan, HT-2 Qingling and P-2 Tianquan. Possible distal points that could be chosen from are numerous when considering treating the Sinew Channels. Examples would include LI-11 Quchi5, LI-4 Hegu5,8 , LU-5 Chize, P-3 Quzi, HE-3 Shaohai, SJ-6 Zhigou (also for numbness of the hand)19, SI-3 Houxi, SI-6 Yanglao, ST-38 Tiaokou5,19 and GB-41 Zulinqi. In addition, Wang and Robertson20 recommend the use of Jing Well points when there is numbness and tingling in the limbs. They advise that the Jing Well points be bled for excess conditions and needled for deficiency syndromes20 .
Heart Meridian
As stated earlier, it is advantageous to balance the pattern/s of disharmony and treat from the aspect of pattern differentiation7 as opposed to merely just treating the condition from a Channel and/or Sinew Channel perspective, which will lead to more synergistic results. Some example points for the pattern of Wind Cold are (but obviously not limited to): LU-7 Lieque and LI-4 Hegu; LU-7 Lieque and SP-9 Yinlingquan for wind dampness; LI-4 Hegu, SP-10 Xuehai and BL-17 Geshu for Blood stasis; LIV-3 Taichong, BL-18 Ganshu and LI-4 Hegu for Qi stagnation; and ST-36 Zusanli, SP-4 Gongsun and SP-6 Sanyinjiao to tonify Qi and Blood21,22. Again, these points are used as an example, and may be manipulated and expanded upon by the experienced acupuncturist.
This article on TOS would not be complete without discussion of the manual therapy treatment aimed at the dysfunctional muscles, as addressing the mechanical component is crucial in aiding to resolve the condition effectively7. Treatment should be aimed at relaxation of tight muscles and correction of faulty posture since most cases of TOS involve shoulder stooping22 .
The first of the three subgroups of TOS identified above, Scalene Syndrome, is essentially due to hypertonic scalene muscles, which then entrap the neurovascular bundle between the anterior and middle scalenes. Posturally, this is represented with a ‘head forward’ presentation. Manual therapy techniques (including Tuina) that aim at lengthening the scalene muscles and deactivating trigger points should be employed. Example methods of treatment include longitudinal stripping, cross fibre frictions, Small Instestine Meridian
deep compressions, muscle energy technique (MET), and self-stretching. Myofascial release techniques are equally as important, as facial adhesions and shortening develop over time in hypertonic muscles due to faulty postures23. Needling Ahshi points and/ or trigger points in the scalene group would also have a beneficial effect in lengthening the muscles25 . However, care should be taken not to needle into the neuromuscular bundle, and even greater care taken when approaching the inferior aspect of the muscles because of the proximity to the apex of the lung. Chin tuck exercises are a valuable addition to the treatment procedure, as they will help strengthen the deep cervical flexors, which are generally weakened in patients with a head forward posture23 .
Similar procedures should be taken to resolve Costoclavicular Syndrome. This commonly presents with a stooping posture23, where the shoulders are rolled forward. The mechanism of entrapment may potentially arise because the clavicle rolls forward onto the first rib and compresses the neurovascular bundle26. Another possible mechanism is that the first rib may be slightly elevated due to hypertonic anterior and middle scalene muscles23,26, and thus the neurovascular bundle is compressed in the opposite to the previously stated manner. In this scenario, the treatment involves lengthening the scalene muscles as discussed earlier. Careful assessment of the posture in conjunction to orthopaedic tests is very helpful in ascertaining exactly where the dysfunction lies. To address the clavicle rolling forward against the first rib, there are two components that need to be considered. Firstly, tightness of pectoralis minor, subclavius and possibly the clavicular fibres of pectoralis major will have to be addressed using the same techniques listed for hypertonic scalenes. Secondly, the rhomboids and middle trapezius (shoulder retractors) are usually fatigued and weak, thus allowing the hypertonic muscles to be rolling the shoulders forward. These muscles will therefore require strengthening. Simple rowing exercises whilst squeezing the shoulder blades together would be beneficial to begin with. The third subgroup of TOS, Pectoralis Minor Syndrome, is likely caused the depression or ‘ptosis’ of the scapula23,26, which may also be referred to as a droopy shoulder. This is generally caused by a weakened upper trapezius and/or levator scapulae muscle, which is generally seen in the middle or older age group23. It may also be accompanied by a hypertonic pectoralis minor which traps the neurovascular bundle, and along with the depressed position of the scapula, it allows the coracoid process to compress and place traction on the bundle. Treatment is accordingly aimed at strengthening the scapular elevators (upper trapezius and levator scapulae) and releasing tension in the pectoralis minor with methods suggested earlier. Strengthening the shoulder elevators can be accomplished with simple shoulder shrug exercises27 .
Having analysed the anatomy, presentation of symptoms, pathomechanism of the condition and the various treatment methods based on each subcategory of TOS, it is hoped that the complexity of this challenging condition has been made somewhat clearer. Having a good understanding of these concepts, the patterns of disharmony, dysfunctional sinew channels and meridians, along with carefully conducted assessment procedures will ensure optimum treatment is applied.
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ANTA Multi-Modality Branch Chair
Three Useful Trauma Therapies: A Practical Perspective
There are many therapies that can be commonly used with trauma related injuries. The purpose of the following editorial is to explore some of the more unusual therapies that I commonly employ in clinical practice. These therapies include Dit Da Jiao; Tao Hong Si Wu Tang, and White Flower Oil. It is my sincere hope that by the editorials conclusion other practitioners will consider the use of these therapies within their practice.
‘Dit Da Jiao’ also known as ‘Die Da Jiu’ is a topical therapy that I initially encountered through Chinese martial arts practice. It is commonly employed as both a conditioning and trauma remedy, however, through clinical application I have also found it useful in rehabilitation. I would characterise its use in the management and conditioning of bruising and tissue trauma of soft and hard tissues where the surface skin of the effected region is relatively intact. Therefore, a practitioner would consider this for soft tissue and bone bruising and hairline fractures to aid in recovery.
Application of Dit Da Jiao requires the topical application of this therapy to the effected region 1-2 x/day. From an herbalist’s perspective, the formulae typically contain strong blood moving herbs, so I recommend all practitioners exercise caution when applying this to patients with blood thinning medications. Further, it is contraindicated in patients with haemophilia or similar blood type disorders. Unfortunately, there is no set generic formulae for this remedy with many different versions available on the market. The easiest to use version of this remedy in the Australian marketplace is a ‘Die Da Jiu’. This version comes in a spray bottle for easy application.
Herb Latin Name Temperature Taste Group
Tao Ren Prunus persica semen Neutral
Hong Hua Carthamus tinctorius flos
Warm
Shu Di Huang Rehmanniae glutinosa radix praepararta
Bai Shao Paeonia lactiflora radix
Warm
Neutral Dang Gui Angelica sinensis radix Warm Chuan Xiong Ligusticum chuanxiong rhizoma
Warm Pungent Invigorate the Blood
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Bitter, Sweet Invigorate the Blood Pungent Sweet Invigorate the Blood Tonify the Blood
Bitter, Sour Tonify the Blood Pungent, Sweet Tonify the Blood
Tao Ren Hong Hua Shu Di Huang Bai Shao Dang Gui Chuan Xiong
Tao Hong Si Wu Tang or Hong Si Wu Wan is a patent Chinese Herbal Medicine remedy for pain and trauma. Like Dit Da Jiao, practitioners should apply caution when using this with patients on blood thinning medications. Further, it is contraindicated in patients with haemophilia or similar blood type disorders. That said, I have commonly employed this remedy in the management of trauma where soft and/or hard tissue damage has occurred. Orally administered, a practitioner needs to refer to the directions outlined on the bottle as a starting point. See the table above for a herbalist’s perspective, the formula consists of the certain agents and associated properties.
The final remedy for discussion is White Flower Oil or Pak Fah Yeow. Manufactured in Hong Kong this topical remedy is excellent in managing soft tissue injury. It is a clear liquid that, to my experience, does not discolour clothing or linen when applied. It has a strong eucalyptus smell which is generally well tolerated. When applied it gives a hot/cold sensation on the applied region. I advise caution with sensitive areas and do not apply it to the eyes. It has also been my experience that young children often find the application of this remedy too uncomfortable to tolerate. Further, I strongly discourage the use of White Flower Oil over recently sun burnt regions.
Application of White Flower Oil requires the topical application of this therapy to the effected region 1-2 x/ day or as required. From a Herbalist’s perspective, the formula includes Eucalyptus Oil, Camphor, Lavender Oil, Methyl Salicylate, and Menthol Crystal.
In conclusion, it is my hope that the following editorial has provided an insight into alternative methods for practitioners to consider when rehabilitating a range of stabilised trauma-based pathologies encountered in clinical practice.
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ANTA Nutrition Branch Chair
Harnessing the Power of Nutritional Compounding
Introduction: Most natural medicine healthcare practitioners have heard the term ‘compounding’, however a surprisingly large number of practitioners still remain relatively unfamiliar with its true nature, how it can be (and/ or should be) performed, and ultimately its power to transform their practice.
Some reasons for this may include uncertainties around what is allowed under current Australian regulations, how best to navigate some of the technical complexities involved, and the currently relatively limited level of training available (including within various natural medicine college courses). Even though the term ‘compounding’ does imply the combining of ingredients, it is important to note that this is not compulsory (i.e. the dispensing of a single ingredient as a medicine on its own still constitutes a form of compounding).
Therefore, a compounded medicine may be comprised of multiple ingredients, or a single ingredient, and may come in any number of ‘dosage forms’ e.g. liquids, creams, and of course… powders.
Some of the benefits of choosing powders as the primary dosage form to use (especially in the case of Nutritional Compounding) include:
It therefore continues to be of benefit, to both experienced practitioners as well as new students alike, to revisit and explore the topic of compounding. The following overview is intended to serve as a summary of the key concepts involved, as well as some of the main requirements, techniques and tools available, to assist more practitioners to build their confidence with this powerful and important aspect of personalised medicine.
What is Compounding? Quite simply the act of ‘compounding’ simply refers to the making of ‘custom’ medicines (as opposed to those that are mass manufactured for commercial sale in stores). • They are stable (when free from moisture) • They avoid the need for many additives (stabilisers, preservatives, antioxidants, etc.) • They are easy to blend (create an even mixture) • They are easy to dose (deliver predictable quantities) • Most nutrient/nutraceutical ingredients are produced in powder form • They can free us from the mortar and pestle!
Despite the above benefits of using pre-powdered ingredients, the somewhat cliché imagery of a mortar and pestle often continues to be used when illustrating the practice of compounding. This is primarily a nod to past medical traditions that involved
manually breaking down raw ingredients into powder form prior to use for ease of mixing, rather than a literal representation of what is actually involved in the practice of modern compounding.
Historically, it could be said that compounding has been performed since the dawn of medicine. It can also be said that modern pharmaceutical medicine derives much of its origins from related ancient herbal medicine practices. Due to this strong historical heritage, modern Western Herbal Medicine has continued the tradition of custom compounded medicines, most typically in Australia in the form of liquid tinctures.
The reasons perhaps why custom Nutritional Compounding has been somewhat less familiar to some practitioners relates to the relatively more historically recent discovery and synthesis of isolated pure nutrients and nutraceuticals, their clinical benefits, and how to use them. In this sense, natural medicine practitioners who are able to update their understanding of Nutritional Medicine to include the production of custom nutritional medicines (through Nutritional Compounding) as a fundamental practice, follow in much the same heritage as the Herbal Medicine practitioners of yesteryear who contributed to the currently ubiquitous understanding and practice of personalised herbal medicines.
Who Can Compound In Australia? The dispensing of pharmaceutical (S3 and S4) ingredients are restricted to medical doctors and pharmacists (e.g. Compounding Pharmacies) in Australia, for obvious reasons related to their specialist qualifications and areas of training and expertise.
The dispensing of natural medicine ingredients (such as amino acids, vitamins, minerals, botanicals, nutraceuticals, etc.) are restricted to healthcare practitioners that are sufficiently trained and qualified in an ingestive modality (such as Clinical Nutritionists, Herbalists and Naturopaths), as accredited by a professional association (such as those recognised by Australia’s Therapeutic Goods Administration (TGA), including ANTA).
This means that the practice of compounding is restricted to qualified healthcare professionals only, and the ingredients allowed to be used are limited by qualifications, scope of practice, and various other regulatory controls.
However, this also means that numerous (non-TGA) ingredients which are not currently available to be used in mass-produced commercial supplement products in Australia, can in fact be used by Australian natural medicine practitioners when making their own custom medicines. Which may, therefore, present an opportunity to access powerful therapeutic ingredients that would otherwise be unobtainable to a given patient who could benefit from them. Regulatory Requirements: Some of the regulatory requirements of this exclusive practitioner privilege include that a compounded medicine must be: • Made for an individual person (not mass-produced) • After private consultation with the patient (at the time it will be dispensed) • Made on the premises (they will be dispensed from) • By a suitably qualified professional (using their own knowledge and judgement) • Appropriately sourced, assembled, documented, and labelled.
Ingredient Sourcing: The appropriate ‘sourcing’ of ingredients to use within compounding requires that: • For products/ingredients that are not registered with the TGA: Only use pure single ingredients (no premixes, no excipients – otherwise they would need to be listed with the TGA) • When using ‘pre-mixed’ commercial formulas: Only use TGA registered products (otherwise they would breach the on-premises provisions) • Only use ingredients permitted by all national regulations (e.g. TGA, agricultural, etc.) • Within scope of practice (according to training and qualifications) • Accurately identified (knowing precisely what is being sourced).
Assembling Compounded Medicines: The process usually begins with the initial clinical evaluation of a patient’s needs, e.g. via a thorough case history and investigations. Which may sometimes include laboratory testing to gain insights into unique metabolic processes (such as hormone levels, nutrient levels, toxin levels, etc.).
After considering which substances and nutrients may be most beneficial to the patient in their current circumstances, some specific ingredient forms and their quantities need to be decided.
Once these desirable ingredients and their quantities have been decided, the process of assembling the medicine can begin (usually immediately after the consultation).
Note: The responsibility for any decisions related to doses and quantities remains exclusively with the prescribing practitioner (this key responsibility should not be delegated to staff or external resources without confirmation by the responsible practitioner). The ‘appropriate assembly’ of a compounded medicine includes a number of requirements that should be kept in mind, practiced, and planned for, whenever carrying out compounding in clinical practice.
The following sequence outlines the key steps involved:
Note: All key stages of the assembly of a compounded medicine should be carried out by the suitably qualified/trained practitioner/s in a clinic. Any unqualified staff (such as reception staff) need to be supervised by a practitioner in order for them to participate in assembly steps.
Step 1: Calculate the amounts of ingredient needed to deliver the desired daily dose, divided by the number of doses per day, for the number of days the prescription should be taken (which will help determine the total amount of ingredient required).
Step 2: Each intended ingredient should be correctly identified and gathered (e.g. via clear bulk container labelling) and checks for expiry dates (to the end of the intended prescription).
Step 3: The intended total quantity of each ingredient required to achieve the overall formula should be accurately measured (using well-calibrated highprecision scales). measured ingredient quantities need to be blended (through the thorough rotation/shaking of a sufficiently spacious container to create an even mixture).
Step 5: The ingredient/mixture then needs to be poured into a suitable container and sealed, to be dispensed to the patient (along with a suitably sized scoop and some instructions to assist accurate dosing).
Documentation Requirements: Maintaining ‘appropriate documentation’ i.e. for giving to the patient as well as for keeping on file within practitioner clinical records, is particularly important when dispensing medicines and should include at least the following: • Full patient details (especially Name, Date of Birth, contact details) • Full formula details (all substances and input quantities used) • Full dosing instructions (when, how much, how often, for how long) • Other advice and rationale (why, what for).
Labelling Requirements: Ensuring that ‘appropriate labelling’ is provided with all medicines being dispensed is one of the most important requirements of all, and given the overlap with many of the same items of information described in the above documentation requirements, it may be most efficient for practitioners to simply provide their patient prescription information on the label at the same time.
Practitioners should ensure their medicine labels include: • Secure attachment to the dispensed container • Patient Identifiers (at least Name and Date of Birth) • Prescriber/Dispenser Identifiers (Name, Contact details, Modality/Qualifications) • The names and quantities of all active ingredients (e.g. mg per dose) • The Dosing Unit (e.g. scoop size) • How many of the dosing units to take (to achieve a Single Dose) • The Dosing Frequency (e.g. how many doses per day) • Instructions for Use (e.g. with/without food, at certain times of day, etc.) • Expiry/Duration of Supply (how long to take before renewal is required)
• The Total Quantity of medicine being supplied.
The Benefits of Compounding: Personalisation It is one of the most fundamental tenets of natural and holistic medicine to ‘treat the individual rather than the disease’. Compounding therefore provides one of the most profoundly individualistic ways to approach clinical treatment.
Better Results Getting access to certain powerful active ingredients that would be highly beneficial but otherwise unavailable to use in a prescription for a given patient, as well as ensuring that a medicine delivers all that it should and nothing it shouldn’t (e.g. avoiding unnecessary ingredients and even potentially obstructive excipients), often yields better compliance and better clinical outcomes.
Increased Value The value of a medicine can be gauged in a number of ways, not least of which its potential to yield potent improvements to the clinical outcomes described above. However compounded medicines are often able to achieve this whilst also being more cost effective (through reduced overall cost and/or higher delivery of key ingredients).
Furthermore, the value to practitioners can include creating some exclusivity for their patient, which can in turn build their rapport and engagement with their treatment. This, along with compliance, are often critical to achieving long term clinical success, and long-term success is particularly important within natural medicine practice, given how many natural medicine goals seek to address long term chronic health risks and processes. It could therefore be said that compounding may be key to the success of certain modalities, and overcome some of the over commercialisation of industry prescribing practices.
Putting It Into Practice: The next steps for any practitioner who has not yet tried making custom formulas, is simply to begin. Thankfully there are now numerous ranges of compounding ingredients in Australia that are specifically provided for natural medicine practitioners to use in their practice, along with some of the further equipment and guidance required.
For an example formula sheet, practitioners may wish to view a manual compounding template online here: wmed.link/manualsheet
Once the basics have been mastered (for example the dispensing of a single ingredient, and establishing accurate in-clinic compounding processes), practitioners may then wish to seek out further tools and resources to make the process easier and more efficient (e.g. through automation), as well as potentially more advanced and complex (e.g. for those particularly difficult cases that require a practitioner with the care and attention to detail to go the extra mile).
For more tools and resources intended to help practitioners to implement compounding and personalised medicines into their practice go to warrenmaginn.com.
Happy Compounding.
For references log into your ANTA Member Centre > The Natural Therapist > Journal Articles
ANTA Member BHSc (Naturopathy)
Homeopathy Materia Medica: Small Stinging Nettle (Urtica Urens)
Taxonomic Rank: • Domain: Eukaryota • Kingdom: Plantae • Phylum: Spermatophyta • Subphylum: Angiospermae • Class: Dicotyledonae • Order: Urticales • Family: Urticaceae • Genus: Urtica • Species: Urtica urens1.
Major Constituents: Contains: • Hydroxycinnamic acid derivatives • Flavonoids and flavones • Antioxidants • Flavonol type glycosides • Silica.
The major constituents of Urtica urens consists of its active components, such as: • Acetylcholine • Histamine • Formic acid • Serotonin2.
The major constituents of formic acid, acetylcholine, histamine3 and serotonin leads to the inflammatory response and perceived pain. These constituents also act as irritants on the integumentary system2 . These constituents may also have possible synergistic effects, prolonging the inflammatory response4 .
Parts Used: Fresh plant in flower. Method for Homeopathic Preparation: Urtica urens is prepared as a mother tincture5, which eliminates formic acid from the plant. This allows for safe internal consumption2. The whole plant is chopped into fine pieces and soaked in alcohol, which is then strained and diluted to a low potency5 .
Pathogenic Trials: There are no modern human pathogenetic trails on Urtica urens. Therefore, there is no significant current data to inform clinical reasoning in homeopathic treatment.
Toxicology/Poisonings: No known poisonings or toxicology reports. However, when the skin comes into contact with this plant it exhibits a red, itchy and burning rash that might swell1. These symptoms may last for up to 36 hours in sensitive individuals6. This is supported by the European Medicines Agency (2010)7 .
Major Clinical Contributors: James Compton Burnett utilised Urtica urens for spleen affections, gout, headaches, rush of blood to the head, a painful abdomen, dysentery, burning and itching of the anus, oedema, urticaria, rheumatic complaints and fevers8. Burnett gave this remedy to a middle-aged women, who passed large amounts of gravel, and aided in decreasing abdominal pain over a few days. The urine was noticeably more plentiful, dark and loaded with uric acid8. This affinity for the urinary system is supported by Boericke (1999)5, as he utilised this remedy for gout and uric acid diathesis, as the plant favours elimination9 . Additionally, the symptoms tend to return every year at the same time9 . Tissue/Organ Affinity: This remedy has an affinity for the skin, kidneys and bladder, joints and cartilage. It also has an affinity for the breasts, in particular with suppressed breast milk10. Symptoms usually occur on the right side of the body8 .
Characteristic Symptoms: Urticaria-like eruptions, rheumatism, spleen affections, neuritis, agalactia and lithiasis9 .
Mental Generals: Vertigo, headache with spleen pains9, sensation of a fullness in the head all day with giddiness, sensation of blood rushing to the head and headaches over the eyes8. Anger, aversion to company, confusion, wandering thoughts and a fear of survival11 .
Physical Generals: Allergic reactions after eating shellfish, complaints come yearly/periodically, ailments from supressed nettle rash, suppressed breast milk, urticaria alternating with rheumatism and symptoms are aggravated for cold bathing or cool damp air10. Also, aggravated for touch9 .
Physical Particulars: • Chest: Disturbances in lactation, excessive swelling of breasts with burning and stinging pains10 . • Extremities: Acute gout, rheumatism associated with urticaria-like eruptions, pain in right deltoid, which is aggravated by rotating the arm inwards10 , and pain in ankles and wrists9 . • Skin: Urticaria-like eruptions, urticaria, burning and stinging, red blotches, sensitive to touch, aggravated by over-heating, burns and scalds of first and second degree, insect bites and stings and chicken pox10. Also indicated in itching swellings over fingers and hands resembling ‘bold hives’, lumps and red spots on hands, and fever blisters on lips. Feeling of heat in the skin of the face, arms, shoulders and chest with formication, numbness and itching. Intense burning on skin after sleep8 .
Usage in Other Medicinal Systems: Urtica urens is utilised as a valid treatment for various allergies, arthritis, bladder infections, skin complaints, neurological disorders, cancer treatment, respiratory diseases, and gum inflammation12. This is due to the plant’s high antioxidant and antiinflammatory activity12, as well as its antimicrobial actions2. Furthermore, it also contains various
phytochemicals that enables a hostile environment for gram positive and negative bacteria2 .
Urtica urens is considered safe for internal consumption, as it was found that in a bioactive extract it didn’t create a cytotoxic environment to macrophages and hepatocytes13. This is supported by the European Food Safety Authority, concluding that Urtica urens is a safe plant to consume with no immediate or delayed harmful effects2. This allows the plant to be utilised as medicinal food.
Major Homeopathic Medicinal Relationships: Clarke (2000)8 states that Urtica urens is similar to Natrium Muriaticum and Urinum for skin conditions, such as urticaria. Clarke (2000)8 also compares the similarities of Urtica urens with Apis for genitourinary organs, as well as Pulsatilla for female reproductive issues associated with pain8. Furthermore, it is similar to Medusa, Lac Caninum, Ricinus for diminished mammary secretions and Lycopodium Clavatum and Hedeoma for uric acid conditions5 .
Compare and Contrast Action of Urtica urens and Urtica diocia: Compared to other nettles, Urtica urens has a higher affinity for inflammation, thus is indicative in inflammatory conditions13. This is due to higher amounts of acetylcholine and histamine giving it a greater therapeutic affect3 compared to Urtica diocia. It also demonstrates chemoprotective, anxiolytic and anti-bacterial properties, alongside its antioxidant, antimicrobial and anti-arthritis actions, which is also seen in Urtica dioica14. Furthermore, Urtica urens is a specific remedy chosen for its actions on uric acid and the suppression of breast milk9 .
Medicine Posology: Urtica urens is utilised at low doses of 1x potency. For acute conditions, take one pilule or five drops of the remedy every 15 minutes (for intense symptoms) to 4 hours (for mild symptoms). Once an improvement is noticed, cease remedy and repeat if symptoms return. If there is no improvement within three doses, consider another remedy15 .
Published Research: • Its antioxidant property protects against imidacloprid intoxication, which aids in bone health16. Also, the antioxidant action prevents against ovarian injury accompanied with disturbances of oxidant status induced by imidacloprid17 . • The leaves contain saponin glycosides which has the capability to inhibit pancreatic lipase enzyme.
This remedy may be suitable in the treatment of obesity18 . • Urtica urens reduces CYP1A1 and CYP1A2 expression levels and associated activities by modulating CYP1A enzymes, thus having a chemoprotective action. It also prevents CCI4induced hepatotoxicity by boosting the antioxidant defence system in animal studies19 .
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