Kimberly Burnham, IMTC, PhD Candidate

Essays and articles written by Kimberly Burnham, whose interests include Integrative Manual Therapy (IMT), CenterIMT, Neurodegenerative Disorders, Parkinson's Disease, Vision, VisionIMT, Eye Disorders, Travel, Languages, PhD Candidate, Westbrook University, Connecticut School of Integrative Manual Therapy.

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Location: Bloomfield, Connecticut, United States

Wednesday, December 29, 2004

Essay - Clinical Use of Circadian Rhythms

Physiologic and psychological processes exhibit rhythmic fluctuations, known as circadian rhythms, which are adaptable to changes in the environment, particularly light, temperature and stressors. The word circadian comes from: "circa" or about and "dian" or a day, a 24 hours period. The field of chronobiology examines circadian rhythms and the how human responses are affected by these rhythmic fluctuations. Many practitioners in both traditional medicine and complementary medicine use these circadian rhythms diagnostically and clinically. Chronobiology is a term derived from chronos (time), bios (life), and logos (science). Chronotherapy is defined as the use of treatment timed according to the stages in the sensitivity-resistance cycles.

Parkinson’s is one of the many disease processes that exhibits fluctuations over a 24 hour period. Integrative Manual Therapy (IMT), which positively affects the symptoms of Parkinson’s disease, has many techniques focuses on balancing circadian rhythms and other rhythmical activity in the body. An aspect of IMT treatment focuses on biologic rhythms, which are a regularly recurring component in a series of measurements of a biologic variable obtained as a function of time.

In the literature about human circadian rhythms, there are several factors that contribute to the body’s rhythmic nature. The anatomy of the human timing system includes the suprachiasmatic nuclei (SCN) considered the pacemaker of human rhythmical activity, the retina and the pineal gland (Andre, 1998). The SCN is situated above the optic chiasm (hence the name suprachiasmatic) and receives information from the retina.

In 1993, Binkley described how melatonin from the retina and the pineal gland functions in the neuroendocrine system, which includes photoreceptors and oscillators. Photoreceptors (eyes and extraretinal structures) detect light. Oscillators (the pineal and suprachiasmatic nuclei) act as pacemakers. Light controls the fluctuations in melatonin production. Melatonin levels influence circadian rhythms that control for example the muscle activity in walking, body temperature and reproductive cycles. (Binkley, 1993). Instability of circadian rhythms leads to internal temporal (timing related) disorders and may be a precursor of disease states. (Armstrong, 1991).

How well light enters the retina and influences melatonin levels is, in part, dependent on the function of the eye and the pupil, which selects how much light enters. Integrative Manual Therapists treat the structure in and around the eye, working with people with a variety of visual dysfunctions as well as circadian rhythm related problems, including Parkinson’s and Seasonal Affective Disorder (SAD). Typically in the United States, as people age, their night vision decreases and sensitivity to bright sunlight increases, affecting their ability to take in light. This is the same population in which sleep disorders and other disturbances of the circadian rhythm system are common. The incidence of neurodegenerative disorders also rises in this older American population.

In the Parkinson’s process an imbalance in the dopamine and melatonin systems influences retinal degeneration. This is significant because the retina has three catecholamine neurotransmitters: dopamine (DA); norepinephrine (NE); and epinephrine (EPI), thus influences the neuroendocrine system. (Hadjiconstantinou, 1984).

There is further evidence of melatonin’s anti-aging and immuno-hematopoietic role. It also has a regulatory function in adjusting the tone of cerebral arteries. "Melatonin is one of the most powerful scavengers of free radicals. Because it easily penetrates the blood-brain barrier, this antioxidant may, in the future, be used for the treatment of Alzheimer's and Parkinson's diseases, stroke, nitric oxide, neurotoxicity and hyperbaric oxygen exposure." (Bubenik, 1998). "Extensive evidence points out that the antioxidant melatonin, which is also rich in cherries, is significant in improving the body’’s circadian rhythms. Since melatonin is found in small quantities in the body, a slight increase can produce great results." (Mercola, 2004).

Essential for our daily well-being, the SCN, prepares us for the upcoming period of activity by an anticipatory rise in heart rate, glucose and cortisol. At the same time melatonin, the 'hormone of the darkness' decreases. "Thus, the time-of-day message penetrates into all tissues, interestingly not only by means of hormones but also by a direct neuronal influence of the SCN on the organs of the body. This relationship between the SCN and the paraventricular nucleus of the hypothalamus (PVN) synchronizes the neuroendocrine and autonomic nervous system with the time of day and prepares the body for shifts in hormone levels. (Buijs, 2003).

In humans and other mammals, circadian oscillators reside not only in the SCN, but also in most peripheral tissues. In a 2000 study, Balsalobre showed that the glucocorticoid hormone analog dexamethasone induces circadian gene expression in the liver, kidney, and heart. (Balsalobre, 2000). Glucocorticoid hormone is secreted in the adrenal fasciculata cells and is under the control of ACTH. (Doghman, 2004). There are a number of rhythmical fluctuations reported in the immune system, (ie) lymphocytes, and circadian variation in primary and secondary immune responsiveness. The observation that many of these rhythms are inversely correlated to the glucocorticoid rhythm has led to the suggestion that fluctuations in the immune system may be a result of the glucocorticoid circadian rhythm. (McGillis, 1983).

In the nervous system the circadian rhythm affects sleep, depression, pain, Alzheimer’s, Parkinson’s, cognition, epilepsy and strokes. Circadian rhythms also affect the immune system and the predisposition to cancer.

Sleep: Disturbances in human biological clock function may occur in several diseases, such as Alzheimer's disease and seasonal depression. (Dai, 1998).

Depression: The suprachiasmatic nucleus is significant in both sleep disorders, depression and in hypertension. (Buijs, 2003). The inhibitory transmitter gamma-aminobutyric acid (GABA), present in the small interneurones of the suprachiasmatic nucleus, plays an important role in circadian timekeeping. This has enabled the formulation of strategies for treatment of patients with manic depressive illness and certain sleep disorders." (Borsook, 1986).

Pain Sensitivity: Our sensitivity to pain varies considerably at different times of day and night. (Circadian Acupuncture Website, 2004).

Alzheimer’s: levels of agitation and dementia are related to a breakdown of SCN and a deterioration of circadian activity (Ancoli-Israel, 2003).

Parkinson’s: Between 9 p.m. and midnight, the disabling symptoms of the disease frequently disappear altogether. (Circadian Acupuncture Website, 2004).

Cognitive performance is often impaired in situations where circadian rhythms are disrupted. This includes a general decline in cognitive ability and fragmentation of behavioral rhythms in the aging population. (Antoniadis, 2000).

Strokes: People with subcortical strokes affecting the hypothalamus blood supply have more sleep related problems than people with either Alzheimer’s disease or Parkinsons alone. (Bliwise, 2002).

Cancer: One of the cellular processes regulated by circadian rhythm is cell proliferation, which often shows asynchrony between normal and malignant tissues. This asynchrony highlights the importance of the circadian clock in tumor suppression in vivo. (Fu, 2003).

There are a variety of ways to use knowledge about circadian rhythms and the ability to palpate these rhythms in treatment. Balancing the rhythms and the processes that they represent enables the client to feel and function more ideally. Current treatments which pay attention to circadian rhythms includes, the timing of the administration of certain medications, herbs and supplements, light therapy, acupuncture, osteopathy and Integrative Manual Therapy.

The most common form of sensory related therapy used for circadian rhythm disturbances is light therapy. There are a wide range of website selling light therapy equipment and research supporting the benefits of light therapy, particularly during the winter in places with very short day time light phases.

There is also a particular form of acupuncture, call Circadian Acupuncture, which considers the time of day and season in choosing which acupuncture points will be most effective for certain conditions. The following passage appears in The Inner Classics, from the second century BC: "Those who have a disease of the liver are animated and quick-witted in the early morning. Their spirits are heightened in the evening and at midnight they are calm and quiet. Those who suffer from a sick heart are animated and quick-witted at noon, around midnight their spirits are heightened, and in the early morning they are peaceful and quiet. Those who suffer from a disease of the spleen are animated and quick-witted around sunset, their spirits are heightened around sunrise and towards evening they become quiet and calm. Those who suffer from a disease of the lungs are animated and quick-witted during evening, their spirits are heightened at noon and they are calm and peaceful at midnight Those who suffer from a disease of the kidneys are quick-witted and active at midnight, and their spirits are heightened during the entire days of the last months of Spring, Summer, Autumn, and Winter, and they become calm and quiet toward sunset." (Circadian Acupuncture website, 2004).

IMT therapists find that the palpation of circadian rhythms is a skill that can be developed through attention to palpable perceptions and training of the sensory system. "Humans can distinguish around 10,000 different smells via 400 receptor proteins lining the nasal cavity." (Hollingham, 2004). Color is detected by millions of cone cells in the retina and in a normal person there are three types, responding to red, green, and blue light. "This makes humans trichromatic and in theory allows us to distinguish between more than 2 million different colors." (Hollingham, 2004). An MRI brain scan study "found a clear correlation between the amount of pain people reported and the amount of brain activity that accompanies it in the cerebral cortex. Those most susceptible showed much more activity. The perception of pain varies by a strikingly large amount and these experiments show that those differences are real and objective." (Hollingham, 2004).

Integrative Manual Therapists palpate and treat circadian rhythm dysfunctions in a variety of ways. These rhythms or motilities in the body can be used diagnostically. Simply put, if the rhythm of a particular structure or physiology is evenly rhythmical, strong and balanced, it indicates that the structure or process is functioning normally. If, on the other hand, the rhythms are weak or arrhythmical or absent in a place where they should be palpable, this indicates that the structure or process is not functioning normally. Treatment with Integrative Manual Therapy of circadian rhythms is called "Resistance Therapy". This therapy consists of using the hands to provide micro-second resistance to the rhythm. The goal is to bring the body’s attention to the structure or process and activate normal healing mechanisms, which in turn balance or strengthen the rhythm and improve function. The expectation is that with Resistance Therapy the function of a particular structure or process will improve and the client will feel and function better.

In Integrative Manual Therapy, we have also found what are called aberrant motilities which are considered to be a reflection of dysfunctional physiology. Theses rhythms should not be palpable in a healthy individual. Treatment is also with Resistance Therapy. The goal is to have healing occur so the rhythm is no longer present, indicating the dysfunctional physiology has improved. The therapist’s expectation is that with treatment the aberrant rhythm or the Physical Functional Medicine (PFM) motility will disappear and the client will feel better and functionally improve.

The most commonly palpated circadian rhythm among manual therapists is the Cranial Rhythmic Impulse (CRI). This is treated by Osteopaths, Cranial-Sacral Therapists and Integrative Manual Therapists. This rhythm is a reflection of the fluctuations in production and flow of cerebrospinal fluid.

The ability to palpate circadian rhythms is not without controversy. "Osteopaths who practice in the "Cranial Field" utilize small motions that are palpated around a patient's head to diagnose and treat a wide range of dysfunctional or disease states. The controversy surrounding palpable phenomena will exist while it cannot be objectively verified. Those who cannot palpate the phenomena will be skeptical, and the ability to test hypothetical models presented to explain aspects associated with the phenomena will be limited." (Myers, 1998).

Myers continues by saying, "The existing literature is contradictory regarding the rate of the motion and inconclusive or unreliable regarding the amplitude. This study used non invasive photogrammetric techniques to take measurements of healthy volunteers. The change in shape of the orbit of the eye was measured to indicate the presence of any motion, as the diagonal of the orbit is reported to increase and decrease with the cranial rhythmic impulse (CRI). The Fourier analysis of the 30 measurements taken on 29 healthy subjects revealed a complex wave form with up to 8 frequencies significant at 95% confidence levels. At the precision obtained in this study frequencies at 2.0, 3.5, 5.5, 7.5, 9.5 and 13.0 cycles per minute were seen to be independent of respiration. The amplitudes of these rhythms ranged from 0.02 mm to 0.12 mm calculated from the Fourier analysis, which are within the reported limits of human palpation. This study suggests that the explanation for poor inter-examiner reliability may be that the CRI is in fact a group of frequencies and the ability of the operator to focus on a rhythm may depend upon their physiological state and their training (Myers, 1998).

Norton remarks that "A tissue pressure model was developed to provide a possible physiologic basis for the manifestation of the cranial rhythmic impulse (CRI). The model assumes that the sensation described as the CRI is related to activation of slowly adapting cutaneous mechanoreceptors by tissue pressures of both the examiner and the subject, and that the sources of change in these tissue pressures are the combined respiratory and cardiovascular rhythms of both examiner and subject. The model generates rhythmic impulses with patterns similar to those reported for the CRI. Also, a significant correlation was found between frequencies calculated from the model and published values for CRI obtained by palpation. These comparisons suggest that the CRI may arise in soft tissues and represents a complex interaction of at least four different physiologic rhythms (Norton, 1991).

Viola Frymann, DO explained, "The hypothesis of inherent motility of the cranium has been supported by palpation of the living head. The hypothesis that a rhythm syncronous with the arterial pulse and another associated with thoracic respiration might be detected is in accord with known physiologic phenomena. The report of a third palpable rhythm, slower than either pulse or respiration, required more study." She records a series of experiments conducted with instrumentation suitable for studying minute expansile-contractile motions of the live cranium. "The recordings show that there is a cranial motility slower than and distinguishable from the motility of the vascular pulse and thoracic respiration, and that such motion can be recorded instrumentally. Studies of rhythmic cellular function and movement of cerebrospinal fluid have been reported elsewhere. More investigation is needed to establish the relations among the various physiologic phenomena described. Additionally, the clinical significance of the rhythmic motion of the cranium needs documentation. (Frymann, 1971).

Another biologic rhythm described by Sharon Weiselfish-Giammatteo, PT, IMTS, PhD. in her book Integrative manual therapy for the autonomic nervous system and related disorders : utilizing advanced strain and counterstrain technique, is the muscle rhythm. "When the muscle is palpated at the origin and musculotendinous insertion, there is a cycle which consists of: a shortening phase and an elongation phase. This is possibly the cyclic motility of actin and myosin protein locking and unlocking which is required for muscle fiber contraction. This rhythm, the piston-like shortening and elongation of the muscle, is not a reflection of a voluntary muscle contracting on demand, and relaxing upon demand. This motility, this cyclic motion, is a reflection of the normal status of tone in the muscle at all times. This rhythm will be present throughout a 24 hour day. This rhythm does not change during rest, sleep, or movement." (Weiselfish-Giammatteo 1997).

"Treatment with Muscle Rhythm Therapy is simple, but requires good palpation skills. The muscle is contacted with both of the therapist’s hands. The piston-like motion of the muscle is palpated. There is supposed to be a shortening phase of the muscle, followed by an elongation phase of the muscle. Each phase of the cycle is approximately 5-7 seconds, so that the duration of the cycle of muscle rhythm is 10-14 seconds. There are approximately 6 cycles a minute." (Weiselfish-Giammatteo, 1997).

Clinical results indicate that the muscle rhythm can be used diagnostically in people with spinal cord injuries because de-innervated muscles do not have a muscle rhythm. The muscle rhythm is most easily palpated at the muscle belly and if present, indicates that the muscle has nerve innervation and the potential for function.

Another common motility treated by Integrative Manual Therapists is the Immune Deficiency Motility. This is an aberrant motility reflective of less than ideal immune function in an area. The motility has a circular feel to it and because it is aberrant the rhythm fluctuates significantly between individuals and between areas of the body.

Thymus Physical Functional Medicine (PFM) motility is an another aberrant motility also reflective of immune dysfunction. This motility can be palpated at the thymus and with Resistance Therapy can disappear, indicating that the thymus is functioning better and clients often have an improved sense of well-being and have stronger immune function after treatment with Resistance Therapy to the PFM.

Biologic rhythms are generated by oscillations and fluctuations in nervous system tissue, hormonal levels and are a response to the environment in which we find ourselves. The knowledge gained about circadian rhythms in the past 50 years is making a significant difference to many people with sleep disturbances, movement disorders, digestive and endocrine dysfunctions as well as neurodegenerative disorders. Many practitioners both within the traditional medical system and those who are part of the complementary care system are using this knowledge to the benefit of their clients.

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