Dental anaesthetics

Preventing complications in polio survivors undergoing dental procedures

Richard L. Bruno, Ph.D.

Lincolnshire Post-Polio Library copy by arrangement with the Harvest Center Library. As the original source is no longer live

  • Director: Post-Polio Rehabilitation and Research Service, Kessler Institute for Rehabilitation – Saddle Brook
  • Associate Professor: Clinical Physical Medicine and Rehabilitation, New Jersey Medical School/UMDNJ
  • Chairperson, International Post-Polio Task Force

Unfortunately, only a handful of specialists treat Post-Polio Sequelae (PPS) – the unexpected and often disabling fatigue, muscle weakness, joint pain, cold intolerance, and swallowing, sleep and breathing problems – occurring in America’s 1.63 million polio survivors 40 years after their acute polio. [1,2] However, all medical professionals need to be familiar with the neurological damage done by the original poliovirus infection that today causes unnecessary discomfort, excessive physical pain and occasionally serious complications with surgery. This is a brief overview to inform patients and professionals about the cause and prevention of complications in polio survivors undergoing dental surgery.

PRE-OPERATIVE PREPARATION

The pre-operative period is the most important, since it is when polio survivors must establish communication with their dentist or oral surgeon. Patients need to ask the dentist to read this article and the references cited. Then, patients must meet with the dentist (and anesthesiologist, if one will be involved) to discuss in detail patients’ complete polio and general medical histories and the problems that may arise before, during and after the procedure.

The Psychology of Polio Survivors. Polio survivors often have difficulty with any medical procedure, even dental surgery. They may have insomnia, anxiety, and even have panic attacks. These symptoms are easy to understand when it is remembered that as young children, polio survivors were ripped away from their families and underwent multiple surgeries and painful physical therapy, procedures administered often without explanation and certainly without their consent. [2,3,4] Questions or complaints about painful and frightening procedures were not infrequently met by staff anger or even physical arose.

It is not surprising that polio survivors can be terrified of again becoming powerless patients at the mercy of medical professionals. The dental staff’s appreciation of the childhood trauma polio survivors experienced, and taking a moment to actually listen and respond to the real needs of the adult post-polio patient, will go far toward making the patient feel safer and more comfortable.

Breathing and Swallowing. We recommend that all polio survivors have pulmonary function studies before surgery, especially if a gaseous anesthetic will be used. [5] This is vital for those who had bulbar polio, which affected the respiratory centers in the brain stem, whether or not patients used a respirator or an iron lung following the acute polio. Even patients who have (or had) neck, arm or chest muscle weakness or have swallowing problems should have their lung function tested, since even these individuals may have difficulty breathing or clearing secretions (swallowing saliva) during or after the procedure. Polio survivors with a lung capacity below 70% may need respiratory therapy or even a respirator after surgery if a gaseous anesthetic was used. [1] Of course, polio survivors who use a respirator during the day or at night must discuss their respirator use in detail with their dentist, anesthesiologist, and their own pulmonologist before any surgery. [5]

It should also be noted that breathing and swallowing can be compromised in those who had bulbar polio or chest wall paralysis, not only by anesthetics, but also merely by reclining in the dental chair. Polio survivors often have difficulty breathing or swallowing saliva when reclining. A comfortable reclined position must be identified before the procedure begins. And the procedure may need to be interrupted frequently to allow the patient to breath fully and to swallow. Also, a number of polio survivors have experienced severe neck or back pain following lengthy procedures, since their muscles spasm easily when placed in unusual or awkward positions, including hyperextension (extreme bending backward) of the neck.

Physical Assistance. Transferring to and from the dental chair are important considerations for polio survivors who have long-standing paralysis, newly weakened muscles or joint instability and pain due to PPS. Some patients may not be able to stand or pull themselves into the dental chair. Thus, polio survivors must ask for help in transferring, especially after the procedure when they are still partially anesthetized.

Polio survivors, who typically never ask anyone for help under any circumstances, need to find a phrase with which they are comfortable that will communicate their needs. Long explanations about having had polio or PPS or the specifics of which muscles are weak or paralyzed are not necessary. For example, a simple “My legs (arms) are paralyzed and I can’t get into/out of that chair. I will need help” should suffice. This phrase may have to be repeated before the polio survivor will be assisted.

If the professional replies, “Oh, I bet you can do it by yourself if you try!” or “Don’t expect me to lift you,” an appropriate response is “I cannot get into the chair. Please ask someone else to help me or let me speak to the doctor.” A pleasant but steadfast refusal to do difficult or dangerous transfers is the polio survivor’s best defense against injury before or after the procedure.

General Anesthetics. Polio survivors are exquisitely sensitive to anesthetic. It has been known for 50 years that the poliovirus damaged the area of the brain stem – called the reticular activating system (RAS) – responsible for keeping the brain awake. [6,7] Because the RAS was damaged in those who had paralytic and non-paralytic polio, a little anesthetic goes a long way and lasts for a long time.

For example, the pre-operative medication used to ‘calm’ patients – often a combination of Valium® and Demerol® – may by itself put polio survivors to sleep for 8 hours. Such excessive and prolonged sedation can also occur when I.V. Valium® is used alone. Add to a pre-operative ‘calming cocktail’ an intravenous anesthetic (like sodium pentothol) or a gaseous anesthetic, and polio survivors have been known to sleep for several days. In addition, polio survivors with respiratory problems may have trouble clearing gaseous anesthetics. A number of our patients have awakened from anesthesia on a respirator in I.C.U. to the frightened faces of their family, surgeon and anesthesiologist several days after surgery.

Here is the first of rule of thumb – we call them ‘Rules of 2’ – for polio survivors’ having surgery:

GENERAL ANESTHETIC RULE OF 2:

Polio survivors need the typical dose of general anesthetic divided by 2.

This first ‘Rule of 2’ is certainly not intended to dictate the dose of anesthetic, but merely to remind oral surgeons that polio survivors need much less anesthetic than do other patients. This does not mean that a given polio survivor might require less than 1/2 the typical anesthetic dose, or that another won’t need more anesthetic. As always, the dose of anesthetic must be individually adjusted (for body weight, lipid space, etc.) and be adequate to keep patients under during surgery but not cause them to sleep for a week.

Nerve Blocks. Unfortunately, polio survivors also have problems with local anesthetics. While polio survivors are more sensitive to general anesthesia, they seem to require more local anesthetic. Two research studies have shown that polio survivors are twice as sensitive to pain as those who did not have polio, apparently as a result of poliovirus-damage to endogenous opiate-secreting cells in the brain (paraventricular hypothalamus and periaquiductal gray) and spinal cord (Lamina II of the dorsal cord). [6,7,8]

LOCAL ANESTHETIC RULE OF 2:

Polio survivors need 2 times the typical dose of local anesthetic.

However, the injection of a local anesthetic can result in both pain-conducting and motor nerves being anesthetized. Polio survivors are very sensitive to anything that further impairs their poliovirus-damaged motor neurons, and a local anesthetic may cause facial, tongue and pharyngial (throat) muscles to be paralyzed for many hours, impairing swallowing and breathing, especially in those who use accessory (shoulder and upper chest) muscles to assist their diaphragm in breathing.

Also, polio survivors sometimes have adverse reactions – e.g., tachycardia, panic attacks – to the epinephrine that is typically included with the local anesthetic to cause vasoconstriction (narrowing of blood vessels) to prevent the spread of the anesthetic. If additional doses of local anesthetic are required, a preparation without epinephrine may be advisable.

Regardless of whether a local or general anesthetic is used, the following applies:

POST-ANESTHETIC RULE OF 2:

Polio survivors need 2 times as long to recover from the effects of any anesthetic.

Even applying the ‘Anesthetic Rules of 2’ polio survivors may be very sedated, if not asleep, or have their breathing and swallowing impaired for many hours after the surgery. This is one of the reasons why in-office surgery for complicated dental procedures is not advisable for polio survivors. Sleeping, excessively sedated or facially paralyzed polio survivors cannot be expected to return home and take care of themselves after surgery, since sedation-impaired coordination makes falling likely and complications may go unnoticed. In spite of HMO pressure or usual practice, NO POLIO SURVIVOR SHOULD HAVE IN-OFFICE OR SAME-DAY SURGERY except for the most simple procedures that require only a small dose of local anesthetic that does not compromise breathing or swallowing.

Blood and Guts. There are yet additional concerns. Polio survivors with muscle atrophy, especially in the thigh muscles, will have a smaller blood volume than would be expected for their height or weight. Therefore, excessive bleeding during surgery may be more of a problem. Prolonged gum bleeding is also more likely since many polio survivors are taking the maximum dose of non-steroidal anti-inflamatory drugs. The dentist should be informed before the procedure of all medications the patient is taking, including over-the-counter preparations.

Also, polio survivors can be sensitive to atropine-like drugs used to dry secretions during surgery. [9] Atropine-like drugs also slow the gut, and polio survivors may be excessively constipated after surgery or, rarely, actually have their intestines stop moving (paralytic ileus) for a period of time. These problems can be treated symptomatially as they would in someone who did not have polio.

POST-OPERATIVE CARE

Pain. The single most troublesome problem after surgery is pain control. A number of studies have shown that many surgical patients are under medicated for pain. Under medication is a serious problem for post-polio patients since they are twice as sensitive to pain as those who did not have polio. [8]

RULE OF 2 for PAIN:

Polio survivors need 2 times the dose of pain medication for 2 times as long.

Since polio survivors are known to be extremely stoic, they are not likely to abuse or become dependent upon narcotics.

Vomiting. Another post-op problem related to brain stem damage is vomiting. As in anyone who receives a general anesthetic, polio survivors can develop nausea and vomit. However, polio survivors are more apt to faint (have vasovagal syncope and even brief asystoles) when they attempt to vomit. [9] It is very important that post-operative emetic (anti-vomiting) control be discussed and administered before the procedure and that additional medication is provided as needed post-operatively.

Choking. As has been described, polio survivors may not be able to clear secretions, may choke (or feel like they are choking) and even aspirate if they are lying on their backs, still half asleep, as the anesthetic is clearing. Polio survivors’ secretions need to be monitored after the procedure and they should be positioned on their side so that secretions can drain. [10]

RECOVERY

When polio survivors do awaken from a general anesthetic they may still be twice as sedated as are other patients. Since polio survivors need a very clear head to be able to control their weakened, polio-affected muscles to stand and walk, a fuzzy-headed polio survivor is at serious risk for falling. Polio survivors may also have low blood pressure after surgery that could itself cause lightheadedness, fainting and falls.

RULE OF 2 for RECOVERY:

Polio survivors need 2 times longer to recover than do other patients.

Under any circumstances, polio survivors should get up slowly after the procedure, first sitting up, then getting into a chair with assistance, then standing with assistance and finally walking with assistance and appropriate assistive devices. Polio survivors have learned to be very aware of what their bodies can and cannot do. They are the best judges of when they can move, stand and walk safely.

Post-Op PPS? The 1985 National Survey of Polio Survivors has shown that emotional stress is the second most frequent cause of PPS (physical overexertion being the first). [4] Certainly, there are few emotional or physical stressor more potent then surgery. So, polio survivors should expect some increase in fatigue and muscle weakness resulting from the combination of the physical and emotional effects of the surgery, anesthesia and other medications. However, patients should be reassured that only a small handful of post-polio patients permanently lose function after surgery. Strength or endurance lost after surgery are typically recovered . Polio survivors need to remember:

RULE OF 2 for FEELING BETTER:

Polio survivors need 2 times longer to feel ‘back to normal’ again.

CONCLUSION

All of the ‘Rules of 2’ are suggestions for polio survivors, the dentist and oral surgeon; they are not intended as substitutes for specific information about the individual patient, communication between doctor and patient, and clinical judgment. All polio survivors must be evaluated and managed according to their individual needs. Please take the time to read the following references (especially those in bold type) so that you will be fully knowledgeable about and be able to help meet polio survivors’ special needs before, during and after dental procedures.

REFERENCES

  1. Bruno RL. Ultimate burnout: Post-polio sequelae basics. New Mobility, 1996; 7: 50-59 [Lincolnshire Library Full Text]
  2. Frick NM, Bruno RL. Post-Polio Sequelae: Physiological and psychological overview. Rehabilitation Literature, 1986; 47: 106 – 111. [Lincolnshire Library Full Text]
  3. Bruno RL, Frick NM. The psychology of polio as prelude to Post-Polio Sequelae: Behavior modification and psychotherapy. Orthopedics, 1991; 14: 1185 – 1193. [Lincolnshire Library Full Text]
  4. Bruno RL, Frick NM. Stress and “Type A” behavior as precipitants of Post-Polio Sequelae. In LS Halstead and DO Wiechers (Eds.): Research and Clinical Aspects of the Late Effects of Poliomyelitis. White Plains: March of Dimes Research Foundation, 1987. [Lincolnshire Library Full Text]
  5. Bach JR, Alba AS. Pulmonary dysfunction and sleep disorder breathing as post-polio sequelae: Evaluation and management. Orthopedics, 1991; 14 : 1329-1337. [Lincolnshire Library Full Text]
  6. Bodian D. Histopathological basis of clinical findings in poliomyelitis. Am J Med. 1949; 6: 563-578. 
  7. Bruno RL, Frick NM, Cohen J. Polioencephalitis, stress and the etiology of Post-Polio Sequelae. Orthopedics, 1991; 14: 1269 – 1276. [Lincolnshire Library Full Text]
  8. Bruno RL, Johnson JC, Berman WS. Motor and sensory functioning with changing ambient temperature in post-polio subjects. In LS Halstead and DO Wiechers (Eds.): Late Effects of Poliomyelitis. Miami: Symposia Foundation, 1985. 
  9. Bruno RL, Frick NM. Parasympathetic abnormalities as post-polio sequelae. Archives of Physical Medicine and Rehabilitation, 1995; 76: 594. 
  10. Bucholtz DW, Jones B. Post-Polio dysphagia: Alarm or caution. Orthopedics, 1991; 14: 1303-1305. [PubMed Abstract]

Bruno RL. Preventing complications in polio survivors undergoing dental procedures. 

PPS Monograph Series. Volume 6(1):1-8. Hackensack: Harvest Press, 1996. 

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Caution with drugs and exercise

Polio and Post-Polio Sequelae: The Lived Experience

Dorothy Woods Smith, PhD, RN, AHN-BC, QTTT, Associate Professor Emerita
University of Southern Maine, Portland, ME, 04103

Published in the Journal of Orthopaedic Nursing, Vol.8/No.5, 1989, pp. 24-28
Excerpts from this Journal edition

Treatment for PPS

My concerns are shared by other polio survivors, and are not unfounded. There is general agreement that the vigorous exercise programs, which once helped polio survivors regain function, are contraindicated when weakness and fatigue recur. Both marked aggravation of weakness and permanent loss of function have been reported by people put on vigorous exercise regimens (Halstead and Rossi, 1985). Swimming in warm water is the most widely recommended exercise to promote comfort and flexibility, since cardiorespiratory function can be maintained while mechanical stresses to the musculoskeletal system are minimized. Gentle stretching exercises may also promote comfort. Fatigue and chilling should be avoided and no exercise should be continued past pain, or resumed while pain is present.

Before attempting to treat pain, it is important to determine its origin.

Pain may be associated with years of functional misuse, for example soft tissue problems from weight bearing by the shoulders, and carpal tunnel syndrome from using canes or crutches (Maynard, 1988). This type of pain may be diminished by the use of orthotics and adaptive aids. Inflammatory musculoskeletal pain syndrome will frequently respond well to rest, modified activity, moist or dry heat, or anti-inflammatory drugs. Postwood (1987) reports success treating post-polio musculo-skeletal pain and neuralgias using acupuncture or tricyclic antidepressants to increase the body’s serotonin levels. Other pain relief modalities reported to be meeting with some success include TENS units, ultrasound and neuroprobe treatments, acupuncture and acupressure, therapeutic touch and biofeedback.

Drugs should be used by polio survivors with caution. My own experience with Valium, prescribed in the early seventies for muscle spasm, led to a month’s hospitalization for unremitting muscle spasm. The drug, increased gradually from 10 to 40 mgm. per day when the spasms continued, acted paradoxically, and created not only increased fatigue and pain but also a concomitant depression. I had somehow blamed myself for allowing this to happen until 1987, when I attended the international polio conference in St. Louis, where I first heard that Valium has been associated with increased weakness and increased spasm in some patients. Narcotics and other drugs which can lead to addiction are contraindicated because of the long-term nature of the needs.

There have also been numerous anecdotal reports of respiratory problems associated with the use of curare-type drugs and general anesthesia, and of polio survivors being unable to regain previous levels of muscle strength following surgery.

Information for clinicians

J. M. Walker, PhD, PT, C. McGowan & G. Vardy
School of Physiotherapy, Dalhousie University

Leaflet published by Nova Scotia Polio Survivors Support Group, 1996
Lincolnshire Post-Polio Library version by kind permission of J. M. Walker

Concerns of Polio Survivors that may require attention

As a result of the polio epidemics in the 1940’s to 1961 affected individuals underwent a variable period of rehabilitation and got on with their lives to the best of their abilities. While some exhibited obvious weakness as a result of the damage and loss of anterior horn cells, possibly wearing braces, or using ambulatory aids, many appeared to have a full recovery. The latter however was deceptive. Individuals with Grade 5 muscle strength (normal) may only have 60% of the normal complement of anterior horn cells. These individuals have been functioning for several decades at almost 100% of capacity; many are now wearing out and showing new health problems related to their prior poliomyelitis infection.

Late effects of poliomyelitis may include:

  • extreme fatigue
  • new muscle weakness which may involve muscle groups thought to be originally unaffected 
  • muscle and joint pain: due to overuse and possibly abnormal biomechanics, limb alignment 
  • cold intolerance
  • respiratory difficulties
  • coughing & swallowing problems
  • decreased balance

Response to Medications: special attention is needed

Polio survivors and particularly those showing post polio sequelae, possibly diagnosed with post polio syndrome (PPS) may be more susceptible to adverse drug reactions. As polio survivors are often operating at or near their maximum level of function when performing even the simplest of daily routines, certain medications can seriously impair their functioning. Common medications may have this effect.

Emergency / Surgery medications which should be used with greater caution are:

  • analgesics (narcotics): depress an already weakened cough reflex; increase muscle weakness & decrease ability to breathe, cough, perform basic activities (walking, eating, sitting, toileting). 
  • analgesics (non-narcotic): dizziness, allow over strain of unstable joints. 
  • muscle relaxants: may further impair voluntary breathing, coughing, ADLs. 
  • sedatives, hypnotics: decrease respiratory drive. 

Medications administered in the emergency setting to be taken for long term use should be only given to the patient in partial allotment. The patient should be advised to consult their family physician (? Neurologist) to determine if that medication will pose any potential risk, considering their polio history. Lower than usual doses may be adequate.

Special Considerations for the patient who is a polio survivor & especially those with PPS

Pulmonary function:

  • may be challenged due to respiratory muscle paresis. 
  • sleep apnoea may be experienced 
  • may require ventilatory support.
  • breathing & coughing exercises may cause fatigue and aggravate breathing problems. 

Use of anaesthetic should be carefully monitored because its effects are heightened & prolonged in the patient with PPS or respiratory paresis.

Swallowing & coughing difficulties: Pharyngeal & laryngeal muscle weakness (patient may not be aware of) may cause a decreased cough reflex & increased risk of aspiration.

When intubating these patients, take the diminished cough reflex into consideration.

Weakness & fatigue:

  • often associated with stress 
  • may be due to chronic strain & overuse 
  • may be accompanied by decreased arousal, attention and memory 

If casting is required, patients will benefit from the use of fiberglass casts

A wheelchair or other ambulatory aids may be needed

The patient who just managed to be independent may not be able to with a cast

May require an extended stay

Cold Intolerance:

  • limbs with paresis or paralysis have poor circulation, be normally cool or cold. 
  • greater heat loss is experienced which decreases dexterity & strength, heightens fatigue 
  • Use of vasodilators increases the risk of postural hypotension and further heat loss

Extra blankets may be required to ensure adequate insulation.

Pain:

  • may result from muscle weakness, degenerative joint changes or nerve compression 
  • analgesics may enhance weakness greater than pain relief benefit

Interaction between pain relief and person’s fatigue levels and muscle weakness must be considered

Energy conservation is important. May need to use wheelchair rather than walk, sit not stand, lie down not sit, need regular rest periods & not be woken during rest periods.

Important questions to ask of patients in the Emergency Care setting

  • Have you ever had poliomyelitis? (specially if over 40 years of age) 
  • Are you currently on any medication(s)? 
  • Are you adversely affected by any medications, eg. analgesics, sleep drugs? 
  • Do you experience unusual fatigue (excessive after activity)? Do you have to intersperse periods of activity with periods of rest? 
  • Were your breathing or swallowing muscles affected? Do you now have any breathing or swallowing difficulties? 
  • Do you have problems sleeping? Do you wake up frequently during the night? 
  • Do you experience chronic pain? Is it increased with activity, exercise? 
  • Are you frequently cold? 

Polio survivors may carry an Injury Control Checklist which provides a list of contacts for additional information in the case of an emergency.

For further information contact:
Nova Scotia Polio Survivors Support Group
c/o Abilities Foundation of Nova Scotia
3670 Kempt Rd., Halifax, N.S. B3K 4X8

J.M.Walker Ph.D., PT, C. McGowan & G. Vardy
School of Physiotherapy
4th Floor, Forrest Building,
Dalhousie University,
5869 University Ave.,
Halifax, NS Canada B3H 3J5

Medications after Polio

Susan Perlman MD

This article is reprinted from “Polio Network News”, Winter 1999, Vol. 15, No. 1, with permission of Gazette International Networking Institute (GINI), 4207 Lindell Blvd., #110, Saint Louis, Missouri 63108-2915, USA. Permission to reproduce the article must be sought from GINI. I have tried to find the source so that it could be linked (more appropriately) from this website, but it seems to be too old? However, there are many excellent publications to be found at the website that GINI has evolved to.

Susan Perlman MD is Associate Clinical Professor of Neurology and Director of the Post-polio Clinic at the University of California Los Angeles (UCLA). Since 1988, the clinic has evaluated and treated 600 polio survivors, with an approach combining neurological assessment, neuro-rehabilitation techniques, medication intervention, and consultation with associates in orthopedics, medicine, sleep disorders, psychology, and alternative (complementary) medicine. The clinic coordinates with the dedicated support groups in southern California and offers educational outreach to the health care community.

Post-polio syndrome is a constellation of new symptoms (fatigue, weakness, pain, cold intolerance, muscle atrophy, or new problems with activities of daily living), occurring in survivors of definitively (by history, exam, or electrical studies) proven acute poliomyelitis, after a period of at least 15 years of stable recovery and performance, and in the absence of any other medical or neurological condition. It is felt to result from the weakening and loss of previously recovered lower motor neuron connections to muscle, possibly due to aging, greater fragility of the recovered nerves, or immune system dysregulation. Onset can be insidious, progression is usually slow, and treatment is most successful with rehabilitation strategies.
Until we better understand the causes of post-polio syndrome, we will have no curative medication. At best, we can use medication to treat the symptoms and to improve the quality of life, and we can avoid using medication that could make the symptoms worse. Certain other diseases (elevated blood cholesterol levels, high blood pressure, heart disease, and cancers) require use of medications with side effects that can exacerbate symptoms of post-polio syndrome. These should be used, but with careful monitoring of the polio survivor’s functioning.

Symptomatic Medication

The three primary symptoms that we can treat with medication are weakness of muscle, fatigue (individual muscle and generalized), and pain, that is, post-polio pain, overuse pain, bio-mechanical pain, and bone pain (Gawne, AC, 1995).

Drugs to reverse muscular atrophy or to improve muscle strength by stimulating motor nerve endings to reconnect with muscle fibers (nerve growth factors) are all still experimental. They are currently being tested for use with other motor nerve diseases. Only insulin-like growth factor type 1 (IGF-1), also known as myotrophin or somatomedin-C, has been tested in people with post-polio syndrome (Miller, RG, 1997) (see chart on page 6). It brought no change in strength or fatiguability, but did improve recovery from fatigue after exercise. Human growth hormone has been given to increase a person’s natural level of IGF-1, but showed little or no improvement in strength (Gupta, KI, 1994).

Another approach has been to develop and test drugs that would protect the nerve-muscle connection from new damage in the first place (neuro-protective agents). Again, several have been studied in other diseases, but only selegiline has been tested in post-polio syndrome, bringing some improvement in symptoms but no clear stabilization of the disease (Bamford, CR, 1993). Although many people use over-the-counter anti-oxidant preparations of various types, these have never been formally tested to prove any ability to slow down the changes of post-polio syndrome.

Anabolic steroids, often used by body builders to improve muscle bulk and power, have been tried by polio survivors and other persons with neuromuscular diseases, but The Medical Letter on Drugs and Therapeutics reports the side effects (risk of prostate cancer in men, masculinization in women) greatly outweigh the potential benefits. Metabolic stimulants(L-carnitine*, L-acylcarnitine, coenzyme Q), used to improve the ability of muscle to make energy and possibly reduce fatigue and improve strength, have also been tried by polio survivors, but have been associated with rare allergic reactions and insomnia (Lehmann, T, 1994; Nibbett, JI, 1996).

Specific anti-fatigue drugs can act either in the brain itself (on pathways controlled by dopamine and noradrenaline) or by improving communication at the nerve-muscle connection. These are, respectively, central and peripheral agents. Centrally-acting anti-fatigue medications include amantadine, bromocriptine, selegiline, pemoline, ephedrine, and certain antidepressants (selective seretonin re-uptake inhibitors, which may also have nonadrenaline activity). All have been tested in other fatiguing neurologic illnesses, but only the first three have been studied in post-polio syndrome. Amantadine provided no reduction in fatigue (Stein, DP, 1995), but bromocriptine (Bruno, RL, 1996) and selegiline (Bamford, CR, 1993) did. Several studies have been done using pyridostigmine, a peripherally-acting drug, (Trojan, DA, 1993, 1995; Seizert, BP, 1994; Trojan, DA, 1997) that reflected variable effects on fatigue, possible mild improvement in strength in very weak muscles, and notable side effects (primarily gastrointestinal) .

When contemplating the use of anti-fatigue drugs, we first treat any concomitant problems (other medical or neurological illnesses, sleep disorders, depression) that could be adding to fatigue.
When rehabilitation techniques have not given adequate pain relief and medications must be used, we determine where the pain is coming from before choosing the most specific treatment agents. In our experience, for true post-polio muscle pain, centrally acting, non-narcotic drugs work best (serotonin-stimulating medications, for example tricyclic antidepressants, clonazepam tramadol; central nerve relaxants, for example baclofen, tizanidine; nerve stabilizers, for example anticonvulsant drugs like carbamazepine or gabapentin).

Fortunately, we have no drug for overuse pain. If we did, using it would be like taking the batteries out of a smoke detector because it is noisy at night. This pain makes polio survivors aware that they are overdoing and need to cut back.

Biomechanical pain resistant to non-drug strategies may respond to short-term use of non-steroidal anti-inflammatory drugs (NSAIDs). Some survivors may experience the side effect of gastrointestinal problems.

Joint-related pain may require cautious long-term anti-inflammatory therapy. When a true analgesic is required, whether it is as simple as acetaminophen or as strong as a narcotic, it should be taken in moderate amounts and on a schedule, not just when the pain is so severe that a higher dose is necessary. If taken together, mild anti-histamines or anti-anxiety medication may make pain-killers work better and at a lower dose, but do have their own side effects.

Acupuncture, electro-acupuncture, acupressure massage, and possibly magnetic therapy may work on painful muscle areas along the same pathways as narcotics, and all have been tried in post-polio syndrome. Pain caused by fibromyalgia may respond to low, bedtime doses of amitriptyline (Trojan, DA, 1994).

Cautions about Medications

Many drugs may have drowsiness as a side effect or may increase fatigue within the general population. (Always check the label or ask the pharmacist or physician.) These include central nervous system (brain) depressants, for example narcotics, sedatives, tranquilizers, sleeping pills, and alcohol; antihistamines; antidepressants; and anti-anxiety agents. Polio survivors who take these medications may experience an increase in polio-related weakness and fatigue.

Diuretics (water pills) and laxatives may deplete the body of essential minerals required by nerves and muscles for normal functioning. Many other drugs (antibiotics, chemotherapy agents, even mega doses of some vitamins, for example B6) can contribute to nerve damage. Muscle relaxants and drugs similar to them in chemical structure (quinine, quinidine, procainamide), as well as other medications used for heart or blood pressure problems (beta-blockers, calcium channel blockers), may add to polio-related weakness and fatigue.

Anecdotal evidence suggests that cholesterol-lowering medications of the “statin” family may also increase polio-related weakness and fatigue. Polio survivors, particularly those with a lesser muscle mass, have reported fewer and less dramatic side effects from some medications when taking a lower dose.

Polio survivors and their physicians should scrutinize all medications – current and newly added – used to treat various medical problems to be assured that related conditions, such as fibromyalgia, elevated cholesterol, high blood pressure, etc., are appropriately treated, but with minimal effect on polio-related symptoms. ·

  1. Stein DP et al. A double-blind, placebo-controlled trial of amantadine for the treatment of fatigue in patients with the post-polio syndrome. Ann NY Acad Sci 1995;753:296-302.
  2. Dinsmore S et al. A double-blind, placebo-controlled trial of high-dose prednisone for the treatment of post-poliomyelitis syndrome. Ann NY Acad Sci 1995;753:303-313.
  3. Gupta KL et al. Human growth hormone effect on serum IGF-1 and muscle function in poliomyelitis survivors.Arch Phys Med Rehabil 1994;75:889-894.
  4. Bruno RL et al. Bromocriptine in the treatment of post-polio fatigue. Am J Phy Med Rehabil 1996;75:340-347.
  5. Bamford CR et al. Postpolio syndrome response to deprenyl (selegiline). Int J Neurosci 1993;71:183-188.
  6. Trojan DA et al. Anticholinesterase-responsive neuromuscular junction transmission defects in post-poliomyelitis fatigue. J Neurol Sci 1993;114:170-177.
  7. Trojan DA, Cashman NR. An open trial of pyridostigmine in post-poliomyelitis syndrome. Can J Neurol Sci 1995;22:223-227.
  8. Seizert BP et al. Pyridostigmine effect on strength, endurance, and fatigue in post-polio patients (Abstract). Arch Phys Med Rehabil 1994;75:1049.
  9. Miller RG et al. The effect of recombinant insulin-like growth factor 1 upon exercise-induced fatigue and recovery in patients with post polio syndrome (Abstract). Neurology 1997 (in press).


© Copyright 1997. BioScience Communications, a division of Edelman Healthcare Worldwide. All rights reserved.

Cholesterol

Dr. Richard Bruno is Chairperson of the International Post-Polio Task Force and director of The Post-Polio Institute and International Centre for Post-Polio Education and Research at Englewood (NJ) Hospital and Medical Center. His book, How to STOP Being Vampire Bait: Your Personal Stress Annihilation Program, published in 2004. E-mail him at ppsforum@newmobility.com.

Note: This column is for information purposes only and is not intended as a substitute for professional medical advice.

Q: I have been taking a statin drug to lower my cholesterol for several years. I recently started to have muscle pain in both arms and went to my doctor. He did blood tests and said the statin wasn’t causing the pain. But, he discontinued the drug and, after a few days, the pain went away. Was the statin causing the pain or was it a coincidence? 

Problems with cholesterol lowering drugs in polio survivors redux … again!

I’ve written two columns about cholesterol-lowering drugs potentially causing unique problems in polio survivors. The first column was published five years ago. The buzz in the post-polio community then was that rhabdomyolysis — a very serious condition where kidney and muscle tissues breakdown — occurred more frequently in polio survivors who take statins, the then newish cholesterol-lowering drugs. There have been no specific studies of cholesterol-lowering drugs in polio survivors, but there seemed to be no reason polio survivors should be more prone to rhabdomyolysis. Only about one-half of 1 percent of anyone who takes a statin, such as Lipitor, develops rhabdomyolysis, which can indeed cause muscle pain (usually in the calves), muscle weakness and possibly even kidney failure. With rhabdomyolysis, the enzyme creatine phosphokinase (CK, also called CPK) is released as muscle breaks down, CK sometimes increasing more than ten times the normal limit. 

You should be aware that polio survivors can have an elevated CK without taking a statin. Two studies have found that 40 percent of polio survivors had abnormally elevated CK, with men having significantly higher CK than did women. In one study, CK increased with the number of steps polio survivors walked in a day. In 50 polio survivors seen at the Post-Polio Institute who were not taking statins, 21 percent had an abnormally elevated CK of about 225, which is one-third higher than normal, but not 10 times higher. Still, an elevated CK may mean that polio survivors are making their muscles work too hard and causing the fibers to break down, but isn’t evidence of rhabdomyolysis. Regardless, your CK was normal and you had arm muscle pain — not calf pain — that went away when you stopped the statin. Drug companies are now reporting that statins can cause muscle pain anywhere in the body, not just in the calves, without causing muscle breakdown or elevating CK. An exception is Zocor, which, although it can cause rhabdomyolysis, is reported by its manufacturer to cause muscle pain no more frequently than in those taking placebo.

Newer cholesterol-lowering drugs, the fibrates (Tricor and Lopid), also can cause rhabdomyolysis, elevated CK and “diffuse muscle pain, tenderness and weakness.” Even one of the oldest cholesterol-lowering drugs, the bile-acid sequestrant Welcol, is reported to cause muscle pain in 2 percent of people taking it versus none of those on placebo. What’s more, the cholesterol lowering B vitamin, Niacin, has also been reported to cause “pain,” although no more frequently than in those taking a placebo. The good news is that the newest cholesterol-lowering drug, Zetia, is said to produce “no excess” rhabdomyolysis or increase in CK, and produced only slightly more (.04 percent) muscle pain than did placebo. 

Whatever drug you chose with your doctor, remember that rhabdomyolysis and muscle pain are more likely if you’re taking a combination of cholesterol-lowering drugs, calcium channel blockers, immune system inhibitors, certain antibiotics or antifungal drugs, have kidney disease, diabetes, a slow thyroid or drink more than a quart of grapefruit juice a day. If you’re taking a cholesterol-lowering drug and feel muscle pain, even if you’ve been on the medication for a while, stop the drug immediately and call your doctor.

Also, remember that there is more to managing cholesterol than taking a pill. Reducing saturated fat and eating foods high in soluble fiber — such as cereal grains, beans, peas, legumes, and fruits and vegetables — can help lower triglycerides and the “bad” low-density cholesterol (LDL) while raising the “good” high-density (HDL) cholesterol. It is also recommended that you lose weight, decrease stress, treat high blood pressure, stop smoking and have a five-ounce glass of wine with dinner.

By following these suggestions and The Post-Polio Institute diet that recommends eating more protein, especially at breakfast and reducing carbs and portion size, you can lose weight, fuel your neurons to feel less fatigue and muscle weakness, while keeping your plumbing clear of cholesterol. 

Despite all the hype around about the need for statins to lower cholesterol and the push by drug companies and the media for everyone to take statins to prevent heart disease, is there really another side to all this.

Iodine the antiseptic

Iodine is by far the best antibiotic, antiviral and antiseptic of all time. 
                                                   Dr. David Derry

    The antiseptic properties of iodine are used to sterilize every surface and material in hospitals. Iodine is an excellent microbicide with a broad range of action that includes almost all of the important health-related microorganisms, such as enteric bacteria, enteric viruses, bacterial viruses, fungi and protozoan cysts.[v] The minimum number of iodine molecules required to destroy one bacterium varies with the species. For H. influenzae it was calculated to be 15000 molecules of iodine per cell. When bacteria are treated with iodine, the inorganic phosphate up-take and oxygen consumption by the cells immediately ceases. [vi]

  Though iodine kills all single celled organisms such as these it is not exploited for internal use by modern day physicians to combat internal infections, which of course is a great mistake. Dr. Derry says iodine is effective “for standard pathogens such as Staphylococcus, but also iodine has the broadest range of action, fewest side effects and no development of bacterial resistance.” Some doctors have reported that it is excellent for the treatment of mononucleosis.   

Iodine is able to penetrate quickly
 through the cell walls of microorganisms.

     Iodine is a deadly enemy of single cell microorganisms thus it can be our best friend. Iodine was not available to these life forms at the beginning of evolution and it was not until seaweed concentrated it did it become involved in higher life forms. It is for this reason that the simplest level of life cannot tolerate iodine. Iodine kills single celled organisms by combining with the amino acids tyrosine or histidine when they are exposed to the extra-cellular environment. All single cells showing tyrosine on their outer cell membranes are killed instantly by a simple chemical reaction with iodine that denatures proteins. Nature and evolution have given us an important mechanism to control pathogenic life forms and we should use it and trust it to protect us in ways that antibiotics can’t. As we shall see directly below, so powerful is iodine in a protective sense that it also helps us rid the body, not only of harmful chemicals and heavy metals, but also rids the body of abnormal cells meaning it qualifies as an anticancer agent.

      Elemental iodine is a potent germicide with a wide spectrum of activity and low toxicity to tissues. A solution containing 50 ppm iodine kills bacteria in 1 min and spores in 15 min. It is poorly soluble in water but readily dissolves in ethanol, which enhances its antibacterial activity. Iodine tincture contains 2% iodine and 2.4% sodium iodide (NaI) dissolved in 50% ethanol; it is used as a skin disinfectant. Strong iodine tincture contains 7% iodine and 5% potassium iodide (KI) dissolved in 95% ethanol; it is more potent but also more irritating than tincture of iodine. Iodine solution contains 2% iodine and 2.4% NaI dissolved in aqueous solution; it is used as a nonirritant antiseptic on wounds and abrasions. Strong iodine solution (Lugol’s solution) contains 5% iodine and 10% KI in aqueous solution. Iodophores (eg, povidone-iodine) are water-soluble combinations of iodine with detergents, wetting agents that are solubilizers, and other carriers. They slowly release iodine as an antimicrobial agent and are widely used as skin disinfectants, particularly before surgery.  

Medical iodophobia has reached pandemic proportions. 
It is highly contagious and has wreaked havoc on the
practice of medicine and on the U.S. population. 
                                                                                    Dr. Guy Abraham

    According to current W.H.O. statistics more than 3 billion people in the world live in iodine deficient countries and it is known that deficiencies of selenium, vitamin A and iron may exacerbate the effects of iodine deficiency. In the analysis of ‘National Health and Nutrition Examination Surveys’ data of moderate to severe iodine deficiency is present now in a significant proportion of the U.S. population, with a clear increasing trend over the past 20 years, caused by reduced iodized table salt usage [Vii]. Along with magnesium and selenium, iodine is one of the most deficient minerals in our bodies. Iodine is essential for the synthesis of thyroid hormone, but selenium-dependent enzymes (iodothyronine deiodinases) are also required for the conversion of thyroxine (T4) to the biologically active thyroid hormone, triiodothyronine (T3). Selenium is the primary mineral responsible for T4 to T3 (thyroid hormones) conversion in the liver. (Selenium is absolutely essential in the age of mercury toxicity for it is the perfect antidote for mercury exposure. It is literally raining mercury all over the world but especially in the northern hemisphere. And of course with the dentists poisoning a world of patients with mercury dental amalgam and the doctors with their mercury laden vaccines, selenium is more important than most of us can imagine. One must remember that mercury strips the body of selenium for the selenium stores get used up quickly because of its great affinity for mercury)

Iodine is the agent which arouses (kindles) and keeps going the 
flame of life. With the aid of our thyroid, in which the iodine is
 manifesting, it can either damp this flame or kindle it to a dissolute fire.
                                                                                                          Scholz 1990.

     Symptoms of iodine deficiency include muscle cramps, cold hands and feet, proneness to weight gain, poor memory, constipation, depression and headaches, edema, myalgia, weakness, dry skin, and brittle nails. Sources include most sea foods, (ocean fish, but not fresh fish, shellfish, especially oysters), unrefined sea salt, kelp and other sea weeds, fish broth, butter, pineapple, artichokes, asparagus, dark green vegetables and eggs. Certain vegetables, such as cabbage and spinach, can block iodine absorption when eaten raw or unfermented and are called goitrogens. But eating fish won’t give you iodine in mg amounts.  To get 13.8 mg iodine, you would have to eat 10-20 pounds of fish per day. [viii]

Iodine is needed in microgram amounts for the thyroid,
 mg amounts for breast and other tissues, and can
 be used therapeutically in gram amounts  [ix]   
                                                                            Dr. David Miller  

Dr Jeffrey Dach and Dr Derry write about the impact of iodine deficiency on breast and prostate cancers.

Perth’s own Dr Igor Tabrizian reports on many other clinical uses for iodine, including

  • Anti-viral eg Betadine gargle for sore throat
  • Anti-bacterial eg leg ulcers, wound infections, boils
  • Anti-fungal eg cold sores, thrush, rashes, tinea
  • Anti-parasitic eg tape worms and other worms
  • Anti-toxin (esp mercury, arsenic, aluminium)
  • Part of thyroid hormone production
  • Hormone regulator including adrenal, liver, pancreas, sex hormones
  • Prevents auto-immunity incl thyroid
  • Reduces cholesterol
  • Improves energy
  • Attracts ionising radiation and excretes it
  • Alkalises body as is an alkaline mineral

Narrow Angle Glaucoma

Open-angle glaucoma is more common than narrow- (or closed-) angle glaucoma. In open-angle glaucoma, the drainage canals in the eyes gradually become clogged with tiny, microscopic deposits over months or years. However, narrow angle glaucoma is a medical emergency.

Southland Eye Clinic has plenty of background information, which you can access using these links:

What is Narrow or Closed Angle Glaucoma (NAG)? 
Why do attacks happen? 
What are the symptoms of NAG? 
How dangerous is an acute attack of NAG? 
What medicines should patients with Narrow Angle Glaucoma avoid? 
Steroids and Narrow Angle Glaucoma. 
How is an acute attack of NAG treated? 
How can you prevent glaucoma attacks? 
Can laser-made openings close?

Merck manuals has a nifty video to explain the complex anatomy.

Normal Fluid Drainage

Fluid is produced in the ciliary body behind the iris (in the posterior chamber), passes into the front of the eye (anterior chamber), and then exits through the drainage canals.

What is Narrow or Closed Angle Glaucoma (NAG)? 
This is the second most common form of glaucoma. Patients often have acute attacks of eye pain due to sudden increases in eye pressure. Between attacks the eye pressure is normal.

Why do attacks happen? 
A watery fluid is generated inside the normal eye. It circulates through the eye and drains out of the eye in the “angle” between the cornea (the clear window of the eye) and the iris (the coloured part of the eye). Some people are born with narrow, slit-like draining angles. In such people, anything that further narrows the angle prevents adequate drainage and causes the pressure to build up. The patient then experiences an acute attack of Narrow or Closed Angle Glaucoma.

What are the symptoms of NAG?
Between attacks the eye pressure is normal and there are no symptoms. During the attack there are often eye pain, nausea and sometimes vomiting. The eye may be red, vision may be blurry and patients may see halos around the lights.

How dangerous is an acute attack of NAG? 
An attack of this type of glaucoma is an emergency. Untreated, it may cause blindness in a day or two.

What medicines should patients with Narrow Angle Glaucoma avoid?
Patients with Narrow Angle Glaucoma should avoid cold remedies which contain Pseudoephedrine, Phenylephrine or Neo-Synephrine; anti-histaminics Chlorpheniramine, Diphenhydramine or Benadryl and overactive bladder remedies such as Detrol. These remedies often carry a warning telling you not to use them if you have glaucoma. If your Narrow Angle Glaucoma has been treated with laser, these medicines become safe for you to use. The above medicines generally do not cause problems to patients who have POAG type glaucoma.

Steroids and Narrow Angle Glaucoma. 
Steroids (cortisone, hydrocortisone, prednisolone, etc.) increase eye pressure. They are potential problem for patients with the POAG type glaucoma, not for patients with Narrow Angle type glaucoma.

How is an acute attack of NAG treated? 
Narrow Angle Glaucoma is treated with a laser. In this office procedure a small drain hole is created in the iris, the colored part of the eye. The hole is of microscopic size. The operation is painless. In addition to laser treatment, eyedrops are administered to lower the pressure.

How can you prevent glaucoma attacks? 
An easy and painless way to prevent attacks is to create a microscopic drain hole with the laser. This preventive treatment can be done at any time. We recommended this approach to people prone to acute attacks (people born with narrow angles). When such people are traveling they may not have access to prompt treatment. If they have an attack, serious damage may occur in a matter of hours, long before they reach a treatment center. Also, people may delay treatment until it is too late because they do not recognize that they are having a glaucoma attack. They often think that they are just having a headache, or a migraine. Because they do not suspect glaucoma they fail to seek treatment and damage to the nerve takes place. Once the nerve fibers are dead, the damage cannot be reversed.

Can laser-made openings close? 
Yes, rarely. Then new attacks may occur. If the pain comes back while you are taking medicines known to cause glaucoma attacks, do not take any more and call us immediately. Explain to the receptionist your situation. Tell her that you might be having an acute glaucoma attack. Ask her to have your pressure checked now. If the office is closed, call or page me or go to KEI to be checked (see “Emergencies”). 

Dizziness

Some quick remedies from Healthline

Certain foods and nutrients may help relieve symptoms of dizziness.

Water

Dehydration is a common cause of dizziness. If you feel tired and thirsty and urinate less often when you’re dizzy, try drinking water and staying hydrated.

Ginger

Ginger may help relieve symptoms of motion sickness and dizziness. It may also help treat nausea in pregnant women.

You can take ginger in many forms. Add fresh or ground ginger to your diet, drink ginger tea, or take ginger supplements.

However, you should always consult your doctor before taking any kind of supplement, even if it’s natural. Supplements can interfere with other medical conditions you have or medications you take.

Shop for ginger tea

Vitamin C

According to the Meniere’s Society, consuming vitamin C can reduce vertigo in if you have Meniere’s disease. Foods rich in vitamin C include:

  • oranges
  • grapefruits
  • strawberries
  • bell peppers

Vitamin E

Vitamin E can help maintain the elasticity of your blood vessels. This can help prevent circulation problems. Vitamin E can be found in:

  • wheat germ
  • seeds
  • nuts
  • kiwis
  • spinach

Vitamin D

Vitamin D has been shown to help you improve after BPPV attacks.

Iron

If your doctor thinks you have anemia, they may encourage you to get more iron. Iron can be found in foods such as:

  • red meat
  • poultry
  • beans
  • dark leafy greens

Vitamin B12

Chilblains Help Sheet

Chilblains are triggered by poor circulation and are characterised by red inflamed areas that affect the extremities. Chilblains can cause intense itching, swollen toes and sensitivity to heat and cold. Some unfortunate individuals suffer in both hands and feet. It is more common in cold weather, because the small blood vessels in the skin naturally constrict when it is cold. If you tend to suffer with chilblains every winter then you need to improve your circulation. In the long-term to prevent chilblains you need to make sure your circulation is as efficient as possible.

Vitamin B3 can be used for the following conditions:  

  • To treat high cholesterol (hyperlipidaemia)
  • To treat Vitamin B3 deficiency e.g. Pellagra – a vitamin B3 deficiency 
  • To decrease the severity and frequency of attacks of vertigo (dizziness) 
  • To decrease severity of chilblains

Chilblains happen when small blood vessels constrict in cold weather, causing impaired circulation, which leads to cold, itchy and inflamed fingers and toes.  Keep hands and feet warm and dry – but don’t wear tight-fitting shoes – and exercise daily to stimulate circulation.  

Important nutrients are: 

Vitamin E and B3, to enhance circulation 

Vitamin C (with bioflavonoids), to strengthen the blood vessel walls and reduce inflammation

Fish and fish oils. 

Eat plenty of fresh fruit (particularly berries and kiwi), colourful vegetables, avocados, nuts, seeds and their oils, and warming foods such as ginger, garlic, onion, pepper and spices. 

Recipes

Last century, we ate home-grown fruit and veg in season – and knew when it was time to pick it. Mums were home to cook the meals – and cakes and biscuits, pumpkin scones, apple pies, fruit cakes, gingerbread, coconut slice, cinnamon teacakes, lemon meringue, carrot cake. The puddings – jelly, custard, stewed fruit, plum pudding, macaroni, vermicelli, lemon sago, creamy rice, bread & butter pudding, mulberry pie. All good wholesome food that kept us healthy! Where have we gone wrong? Our cravings tell us what is missing nutrition-wise in our diet, that our body needs to function properly and in good health.

Take EXTRA SLOW K or potassium water or broth if

  • the heat drains you of energy
  • you have hot flushes
  • you have a urinary infection
  • you have oedema

When we think of jellies we tend to think of kid’s parties. Jelly used to be a popular sweet. Gelatine was very much part of our diet in by-gone years but today has largely disappeared from our tables. Shop-bought cooking gelatine is an inexpensive means of obtaining Gelatin Hydrolysates with equal potency to significantly more expensive pharmaceutical forms.

Here is some information on the benefits of butter, as well as how to make stock and a quick vegetable soup.

Resistant starches reduce blood sugar. Small amounts of resistant starch (about 5% of the total) are produced when some starchy cooked foods, such as toast, potatoes, pasta and rice, are allowed to cool before eating. Freezing before re-heating is even better! Check this PDF out for more information.

Eat more dairy? Or less? We want to protect our bones from osteoporosis, but can we over-do dairy? Too much calcium, as well as causing cramps and muscle aches, can cause fatigue, exhaustion, depression, anxiety, panic attacks, headaches, paranoia, loss of memory, poor concentration, crying spells and insomnia.

Do you get food cravings? What do they mean?

Lemons can be helpful to keep your blood sugar levels stable, reduce reflux and can help with asthma and nausea. Protein is also good for stabilising you blood sugar level, and a good source is eggs.

Pumpkin seeds can reduce antioxidants, reduce cholesterol, reduce osteoporosis, improve sleep, reduce inflammation, boost energy, improve urinary function. They can be eaten raw or roasted.