Archives for November 2016

Nov
26
2016

Chronic Shoulder Pain Treatment

This overview is about chronic shoulder pain treatment. A 71- year old health conscious patient was exercising in a gym. When he used the shoulder machine, he suddenly experienced a stinging pain in his left shoulder. The pain seemed to be localized in the upper (superior) portion of the trapezius muscle. With this he also felt pain in his left neck.

This was fitness gone wrong! It can happen, that exercise is overdone or lack of judgment leads to injury. Trainers caution us, when we embark on exercise programs, and yet, it happens! Often the road to recovery is a bumpy stretch, and if the problem is not corrected, it can lead to chronic pain. With this knowledge the patient sought help. The first approach was visiting a

Chiropractor

He sought the help of a chiropractor and had 6 manipulations in the neck and thoracic spine. The spine had good range of motion, but the left shoulder pain in the trapezius muscle stayed.

He found that heat application to the trapezius muscle helped, so he bought an electric heating pad that he applied once or twice a day for pain relief. He also sought the input of his G.P. He was offered

Pain pills

This was the predictable regimen, but the patient was concerned about the side effects of pain pills, and he declined. He had heard of a supplement, called Trilipotropic (from Trophic), which contains 300 mg of choline bitartrate, 300mg of inositol and 300 mg of methionine in one tablet. He learnt at a medical conference that two of these tablets were as effective in relieving the pain as one tablet of Motrin, an anti-inflammatory drug. He took two of these pain relievers from the health food store a couple of times per day alternating with the heating pad to control his pain.

Since the condition improved only marginally, he looked at the option of

Prolotherapy

When the chiropractor mentioned after 5 treatments that he could not treat the pain successfully, the patient decided to try prolotherapy, because he had heard that this would be good for chronic musculoskeletal pain. The naturopath whom he saw examined thoroughly and determined that the patient would be a good candidate for 2 to 4 prolotherapy treatments. After one treatment on the left side along the cervical spine and the left trapezius area the pain was reduced by 30% of what it was before. The second prolotherapy treatment was given again to the left side and also to the right side to keep it symmetrical. The naturopathic physician told the patient that he would see him for follow-up in 4 weeks. The treatment of the right asymptomatic side did not cause any pain, but the left side started flaring up after the second treatment, causing pain that was almost as bad as the original pain. When the patient returned to the naturopath and told him about the flare-up of pain in his left shoulder, he was told that this is what sometimes happens when treatments are not spaced far enough apart. He felt that this should be observed now and reassessed in 6 months in case there was

No progress. It was time to look at other options:

IMS treatments

When the chiropractor had admitted that he could not help removing the pain, he suggested that maybe a physiotherapist trained in intramuscular stimulation treatment (IMS), also known as dry needling could be of help. The patient was waiting for the appointment with the naturopath for prolotherapy when he saw the physiotherapist for IMS treatments. He examined the patient and noticed a persistent trigger point in the upper trapezius muscle, which he thought was causing the chronic pain.

Two IMS treatments relieved the pain by about 50%. But about two or three days later the pain came back to about 75% of the original pain after the gym injury. The appointment for the prolotherapy by the naturopath had taken two months to wait for, so he had already had 3 IMS treatments just before the prolotherapy to get some pain relief. The IMS trained physiotherapist thought that perhaps a few more treatments, up to five or six might be able to take the pain away. So the patient continued treatments on a weekly basis.

Unfortunately the hope for pain relief did not materialize. The pain improved to about 30 to 40% of the original pain, but it always came back just 2 or 3 days later. Fortunately for him he could apply the heating pad and the pain would stay away for 3 to 5 hours. It also responded to taking two tablets of the choline bitartrate/inositol/methionine combination that took the residual pain away for several hours. Self-massaging the trigger point also gave some relief. But occasionally the pain came back with a vengeance and felt like a charley horse that suddenly could occur in his left shoulder making it difficult to move his left arm, particularly when he needed an outstretched arm for ballroom dancing, lifting of heavy objects or for working out in the gym. Even just holding on to the rails of the treadmill when doing a fast walk on the treadmill for half an hour could lead to a flare up of the left shoulder pain. It is frustrating, when there is only temporary relief, but no real cure, but giving up is no option. Often we find more information on the Internet. What came up was

Low-dose laser therapy

The patient remembered having heard of low-dose laser therapy that might be useful in treating chronic pain. This method, called interstitial low-laser therapy was used to treat his trigger point in his left shoulder. A physician who is the president of ISLA –the international society for laser applications- specializing in laser treatment treated him by inserting a cannula into his left trapezius muscle close to the trigger point. He injected a small amount of procaine (local anesthetic), then 5 ml of normal saline. This was followed by three low-laser beam treatments for 10 minutes each, first blue, then green and finally yellow color, all given interstitially after which the cannula was removed.

He was surprised to feel relief almost instantly. There was still a bit of pain from the interstitial needle for about two days, but he noticed that the trigger point in the trapezius muscle had completely vanished. Finally after 6 months of intermittent pain there was relief of about 50% of the original pain. This time the pain in that particular trigger point stayed away, which was encouraging.

But there were two other trigger points that were bothering him. After one month he got a second interstitial low dose laser treatment by the naturopath who had previously given him the prolotherapy into another trigger point, and finally 2 weeks after this, the third laser treatment was given for yet another trigger point. This continued on for another few months. The pain disappeared, then it crept in slowly again, but at a lower level. It became a quest to eradicate the trigger points! Each time the latest trigger point that was still palpable was treated with the same low-dose laser treatment method. It took a total of 9 interstitial treatments to finally reach the point where all of the pain was gone.

It felt strange: the chronic left shoulder pain had disappeared!

Chronic Shoulder Pain Treatment

Chronic Shoulder Pain Treatment

Conclusion

When pain lasts for more than 3 months, it is referred to as “chronic pain” and is often termed neuropathic pain that is difficult to treat. You may have guessed by now that I was the patient in this blog, and so I had a vested interest in getting rid of this pain. I had previously described a similar pain in my lower back that was relieved with just one interstitial low-dose laser treatment at that time and my back has remained pain free since. Shortly after that successful treatment I developed the left shoulder pain from a soft tissue injury in the gym as mentioned. I was fortunate that Dr. Weber could treat me again, this time at his clinic in Lauenförde, Germany on occasion of a Germany trip that I had booked for holiday purposes.

I was lucky that this treatment responded similar to the one in my lower back. The difference was that my left shoulder required a total of nine low-dose laser treatments to be resolved and my pain had lasted a total of 14 months!

It occurred to me that a successful outcome of treating pain requires collaboration between patient and therapist. Call it trial and error. In my case it was only the fourth treatment modality, the low-dose laser therapy that worked permanently.

I feel that the chiropractor did his best to ensure there was no nerve root irritation and told me when he had reached his limits.

The IMS trained physiotherapist treated me before and after the prolotherapy and also told me after a total of 12 visits that he likely could not help me any more than he did.

The naturopath who did the prolotherapy said that he had strengthened the ligaments along the spine on the left side, but that the trigger point from the gym injury likely was not responding to prolotherapy.

The final answer came from the treatment by Dr. Weber in Germany and the naturopath in Kelowna using the same Weber system machine with low-dose lasers. I think that this is an under-recognized treatment modality of musculoskeletal injuries, including sports injuries. You can find treatment providers for low-dose laser therapy throughout the US, Canada and Europe where many physicians and naturopathic physicians use it as part of their pain management methods. The equipment has been FDA approved; Health Canada approved and is approved by the Medical Devices Directive in Europe. Please note that this type of laser (low-dose laser) has nothing to do with laser treatment for cosmetic purposes.

It has to be stressed that chronic pain treatment requires attention to detail, feedback from the patient to the healthcare provider and persistence on behalf of the patient to follow through until the chronic pain is resolved. It also shows that giving up is not an option!

Nov
19
2016

New Breast Cancer Cure?

According to the popular press there is a new breast cancer cure. But we have to be careful with general statements like this. First of all, only 20% of breast cancers are HER2 positive. When the surgeon biopsies breast cancer, the sample is sent to the pathologist. Out of 100 samples, 20 come back with the finding that it is HER2 positive breast cancer.

Herceptin ® (trastuzumab), the first step of breast cancer cure

Trastuzumab is a monoclonal antibody that interferes with the HER2 receptor. Its main use is to treat HER2 positive breast cancers. But trastuzumab (brand name Herceptin ®) has serious side effects. In early HER2 positive breast cancer it can cause heart failure in 5.7–35.4% of patients, while it can cure breast cancer with a 35% cure rate of Her2-positive patients. It is significant to note that many of the studies used trastuzumab in combination with the chemotherapeutic agent anthracycline concomitantly. Anthracycline by itself has some cardio-toxic effect. Most of the studies that investigated heart toxicity of trastuzumab used this monoclonal antibody for 52 weeks. Newer studies show that as little as 9 weeks can be as effective in tumor cures, which reduces the risk of toxic effects on the heart to 2.2–2.3%.

Here is a link that shows visually what the effect of Herceptin ® may be on the HER2 surface marker in a woman with this type of breast cancer.

Lapatinib (Tykerb ® or Tyverb ®), the second step of breast cancer cure

Absorption of aging cancer cells, called apoptosis, is inhibited by overexpression of oncogenic receptor tyrosine kinases. These are proteins that normally function to remove dying cells at the end of their life span. In HER2 breast cancer these kinases are particularly common and are responsible for the cancer cell survival. Lapatinib is a dual tyrosine kinase inhibitor, which interrupts the HER2 and epidermal growth factor receptor (EGFR) pathways. Expressed in simpler terms, it removes dying cancer cells, so they cannot get reactivated or continue to survive.

A phase 3 clinical trial was done with Lapatinib and a chemotherapeutic agent, capecitabine (brand name Xeloda ®).  When the two drugs were combined there was a 51% reduction in the risk of the disease progression.

Herceptin ® and Lapatinib combined as new breast cancer cure

At the 10th European Breast Cancer Conference in Amsterdam professor Nigel Bundred reported about a trial involving 257 women with newly diagnosed, operable, HER2 positive disease. They were recruited between November 2010 and September 2015. Their biopsies were taken and the surgery was scheduled for 2 weeks later.

The trial was in two parts: The first 130 women were treated with trastuzumab (Herceptin ®) only, or lapatinib (Tyverb ®) only, for 11 days after diagnosis and before surgery. From other trials evidence became known that the combination of trastuzumab and lapatinib had better survival rates. The investigators decided to include a second part into their trial starting August 2013 with 127 women. Part of this trial was a combination treatment of trastuzumab and lapatinib.

Samples of tissue were taken from the original breast biopsies and then again two weeks later from the material of the breast surgery.

The pathologist examined the breast cells for a drop in the Ki67 protein, an indicator of cell proliferation. They also looked for an increase of apoptosis of 30% or more from the first date of the first biopsy. A “pathological complete response” was the term they used for a cure. When there was a partial cure, this was termed “minimal residual disease“. This meant that the tumor was less than 5 mm in diameter at the time of surgery. Women who had received the combination treatment had 11% pathological complete response (11% cure rate). 17% of the combination therapy group had minimal residual disease. There was no cure for those randomized to only trastuzumab and only 3% of that group had minimal residual disease.

New Breast Cancer Cure?

New Breast Cancer Cure?

Conclusion

Essentially this new research shows that two inhibitor drugs together are better than one or one in combination with conventional chemotherapy.

But we have to keep in mind that HER2 breast cancer includes only 20% of all types of breast cancer. When you hear that 11% of HER2 breast cancer was cured with the combination therapy in 11 days, it translates into only 2.2% of all types of breast cancer cured and only 3.4% of all breast cancer cases had minimal residual disease (tumor size less than 5 mm in diameter). This could be easily removed by surgery.

What everybody is excited about are the cures of 2.2% of all types of breast cancer (or 11% of HER2 breast cancer). This is a good start. But much more research needs to be done to increase this number of cures. While we are seeing some progress for one group of breast cancer patients, it is not nearly sufficient to advertise this treatment as a “cure”.

For all breast cancers a more promising option is available. A study from Wayne State University, Detroit, Michigan has shown that cryoablation therapy for breast cancer without excision can give a much higher cure rate of 100% over a period of 1 ½ years. In this procedure the tumor is left in place, but killed by cryotherapy (extreme local cold temperatures). It gives a cosmetically superior result. This is an accepted alternative, but is not yet widely practiced.

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Nov
12
2016

Stress Drives Our Lives

Every year the American Psychological Association (APA) monitors the American public how stress drives our lives. This yearly report has been compiled since 2007. About 75% of the people questioned reported that they have experienced moderate to high stress over the past month.

Symptoms when stress drives our lives

What kind of symptoms can stress cause? It can cause sleep deprivation, anxiety, headaches and depression. But there can be more symptoms from any disease that stress may cause. The “Stress in America” report from February 2016 shows on page 5 that unhealthy life habits are used by low-income Americans to cope with stress. A bar graph shows that watching television or movies for more than 2 hours per day is common. Another way of coping is to surf the Internet more often, take more naps or sleep longer. Eating more, drinking alcoholic beverages and smoking more are other unhealthy ways to cope with stress.

As the stressed person gains extra weight and eventually becomes obese, there is a higher rate of diabetes that can develop with all of its complications.

Causes of stress in our lives

The “Stress in America” survey was based on 3,068 adults in the US who completed the survey during August 2015. 72% were stressed out about financial issues. 22% of these said that they were extremely stressed in the past month as a result of money concerns. Other common concerns were work, the economy, family responsibilities and concerns about personal health. Average stress levels among Americans decreased when compared to 2007. On a 10-point stress score respondents rated their stress at 4.9 in 2016 compared to 6.2 in 2007. But according to the American Psychological Association this is much higher than a stress rating of 3.7 considered to be a healthy level.

Stress affects people from all walks of life, workers, women, young adults, students and those with lower incomes.

“Stress is caused by the loss or threat of loss of the personal, social and material resources that are primary to us” Stevan Hobfoll, PhD, a clinical psychologist from Rush University Medical Center said. “So, threat to self, threat to self-esteem, threat to income, threat to employment and threat to our family or our health…” is what causes stress.

Stress drives our lives causing disease

When stress is too much for our system, we are starting to see pathology develop. “Stress is seldom the root cause of disease, but rather interacts with our genetics and our state of our bodies in ways that accelerate disease” professor Hobfoll says. The following are common diseases that can result from chronic stress.

Heart attacks and strokes

In a 2015 Lancet study 603,838 men and women who worked long hours were followed for a mean of about 8 years with respect to heart disease or strokes. All of the subjects were free of heart attacks and strokes when they entered into the study. There were a total of 13% more heart attacks in those who worked extra hours compared to those who worked 40 hours per week or less. With respect to strokes there were 33% more strokes in those who worked long hours. A dose-response association was calculated for strokes in groups with various workloads. Compared to standard working hours there were 10% additional strokes for 41-48 working hours, 27% for 49-54 working hours and 33% for 55 or more working hours per week.

Stress drives our lives and causes substance abuse

In order to cope with stress many of us treat daily stress with alcohol. It makes you feel good subjectively, but it can raise your blood pressure causing heart attacks and strokes down the road. A low dose of alcohol may be healthy, but medium and high doses are detrimental to your health.

Next many people still smoke, which has been proven long time ago to be bad for your health. It can cause heart attacks, various cancers and circulatory problems leading to leg amputations.

Overeating is another common problem. As comfort food relieves stress, extra pounds are put on. As you know it is easier to put weight on than get it off. Being overweight or being obese has its own problems: arthritis in the hips and knees makes walking more difficult. The metabolic syndrome sets in, which is a characteristic metabolic change causing diabetes, high blood pressure, heart attacks, strokes and certain cancers. The more weight you carry, the less likely you are to exercise. This deteriorates your health outlook.

Diabetes

Stress causes too much cortisol secretion from the adrenal glands. This raises blood sugar, and when chronic can cause diabetes. In addition unhealthy eating habits associated with stress can cause weight gain and high blood sugars leading to diabetes.

In a 2012 California study 148 adult Korean immigrants were examined. They all had elevated blood sugars confirming the diagnosis of type 2 diabetes. Their waist/hip ratio was elevated.

A high percentage of the study subjects had risk factors for type 2 diabetes. This included being overweight or obese and having high blood glucose readings. 66% of them said that they were feeling stressed, 51% reported feeling anxious, 38% said they were feeling restless, 30% felt nervous and 3% said they were feeling hopeless.

An Australian long-term follow-up study computed risk factors for developing type 2 diabetes. Stress was a major contributor to diabetes.

Diabetes was significantly associated with a 30-day episode of any anxiety disorder with a 1.53-fold risk. A depressive disorder had a 1.37-fold risk to cause diabetes and posttraumatic stress disorder had a risk of 1.42-fold to cause diabetes.

Infertility

Stress changes hormones in women causing ovulation problems and infertility. 1 in 8 couples in America have problems getting pregnant. Stress has been identified as being at least a contributing factor. But in men stress can also reduce sperm count and semen quality as this study describes.

Alzheimer’s disease

A 2010 study from Gothenburg University, Sweden examined 1462 woman aged 38-60 and followed them for 35 years.

Psychological stress was rated in 1968,1974 and 1980. 161 females developed dementia (105 Alzheimer’s disease, 40 vascular dementia and 16 other dementias). The risk of dementia was reported higher in those women who had frequent/constant stress in the past and was more severe the more stress they were exposed to in the past. Women who were exposed to stress on one, two or three examinations were observed to have higher dementia rates later in life, when compared to women who were not exposed to any significant stress. Specifically, dementia rates were 10% higher when exposed to one stressful episode, 73% higher after two stressful episodes and 151% higher when exposed to three stressful episodes.

Remedies for stress

Before you can attempt to remedy stress, you must first detect that you are under stress. You can recognize this when you have problems sleeping, you suffer from fatigue, when overeating or undereating is a problem, and if you feel depressed. Others may feel angry or are irritable. Some bad lifestyle habits may also make you aware that you are under stress. You may smoke or drink more in an attempt to manage stress. Some people abuse drugs.

Here are some suggestions how to remedy stress:

  1. Seek support from family, friends or religious organizations. If you engage in drugs or alcohol overuse or you feel suicidal, it is best to seek the advice from a psychiatrist or psychologist.
  2. Engage in regular exercise. This produces endorphins, the natural “feel-good” brain hormone. This reduces symptoms of depression and improves sleep quality.
  3. Do something that increases pleasure, such as having a meal with friends, starting a hobby or watching a good movie.
  4. Positive self-talk: avoid negative thoughts like “I can’t do this”. Instead say to yourself “I will do the best I can”. Psychologists have developed a technique where they teach patients how to turn negatives into positives. It is called “cognitive therapy”. You may want to seek the advice of a psychologist to have a few cognitive therapy sessions.
  5. Daily relaxation: you may want to use self-hypnosis, tai-chi exercises or meditation to reduce your stress levels.
Stress Drives Our Lives

Stress Drives Our Lives

Conclusion

Stress is very common. Diverse diseases like heart attacks, strokes, diabetes and Alzheimer’s disease can all be caused by stress. It is important to minimize the impact of stress by seeking family support and support from friends. Engaging in regular exercise will release endorphins and make you feel better. Relaxation exercises and seeking counselling can all help you to manage stress. It is not a force in your life that can be ignored or simply tolerated. Stress is indeed there, but we can make a difference by managing it to avoid that stress manages us.

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Nov
05
2016

Health Risks Of Night Shifts

One of the news stories in 2016 was about health risks of night shifts. The Bureau of Labor Statistics reported in 2000 that 15 million workers (16.8 % of the working population) were doing alternative shifts (night shift work mixed with daytime shifts). In 2016 they reported 14.8% were working alternate shifts. Among blacks, Asians and Latino Americans the percentage of working alternative shifts was higher, namely 20.8%, 15.7% and 16%, respectively.

Shift work is more common in certain industries, such as protective services like the police force, food services, health services and transportation.

Evidence of health risks of night shifts

There are several publications that showed evidence of health risks of night shift workers. Here is a random selection to illustrate the health risks of night shifts.

  1. A study from 2015 examined the sleep patterns of 315 shift nurses and health care workers in Iranian teaching hospitals. They found that 83.2% suffered from poor sleep and half of them had moderate to excessive sleepiness when they were awake.
  2. This South Korean study examined 244 male workers, aged 20 to 39 in a manufacturing plant. Blood tests from daytime workers were compared to night shift workers. Inflammatory markers like the C-reactive protein and leukocyte counts were obtained. Night shift workers had significantly higher values. The investigators concluded that shift workers have increased inflammatory markers. This is a sign of a higher risk of developing cardiovascular disease in the future.
  3. A Swedish study found that white-collar shift workers had a 2.6-fold higher mortality over a control group of daytime white-collar workers.
  4. Another study compared night workers in the age group of 45 to 54 with daytime workers and found a 1.47-fold higher mortality rate in the night shift workers.
  5. In a study from China 25,377 participants were included in a study that investigated cancer risk in males with more than 20 years of night shift work. They had a 2.03-fold increased risk to develop cancer compared to males working day shifts. Women with night shift work were unaffected with regard to cancer.
  6. A Polish study examined hormones and the body mass index (BMI) among 263 women who worked night shifts and 269 women who worked day shifts. When night shift workers had worked more than 15 years at nights, their estrogen levels, particularly in postmenopausal women were elevated compared to the daytime workers who served as controls. The BMI was also increased in the nighttime workers.
  7. Chronic lymphocytic leukemia (CLL): a study in Spain showed that working for more than 20 years in rotating night shifts was associated with a 1.77-fold higher risk of developing CLL. The authors noted that melatonin levels in that group were much lower than in controls that worked only day shifts. Working in straight night shifts did not show higher risks of CLL compared to daytime workers.
  8. In a Korean study from Seoul 100 female medical technologist who worked nighttime had their melatonin levels tested, which were compared to daytime workers.  They measured 1.84 pg/mL of melatonin for the nighttime workers compared to 4.04 pg/mL of melatonin in the daytime workers. The authors felt that this is proof that the diurnal hormone system has been disrupted. When the melatonin level is altered, the circadian hormone rhythm is also changed.
  9. A group of 168 female hospital employees doing rotating nightshift work in Southern Ontario hospitals were compared to 160 day workers. Cortisol production was assessed. Cortisol production in day workers and in shift workers on their day shift was similar. However, shift workers on their night shift had flatter cortisol curves and produced less cortisol. The authors felt that this disruption of cortisol production would explain why rotating night shift workers have a higher risk of cardiovascular diseases.
  10. A Danish study with female nurses followed 28,731 nurses between 1993 and 2015. Daytime nurses were compared to rotating nighttime nurses and the incidence of diabetes was measured. Night shift workers had a risk between 1.58-fold to 1.99-fold when compared to daytime workers to develop diabetes. The risk for evening shift workers was less (between 1.29-fold and 1.59-fold).

Diurnal hormone rhythm behind health risks of night shifts

Your body has its own rules. It rewards you, if you sleep 7 to 8 hours during the night, but it will penalize you severely, if you turn it upside down. The reason is our built-in diurnal hormone rhythm. A peak of melatonin regulates sleep during the night. Melatonin is released by the pineal gland (on the base of the skull) when it gets dark outside. Daytime wakefulness is regulated by the stress hormone cortisol from the adrenal glands. These two hormones inhibit each other, cortisol inhibits melatonin and melatonin inhibits cortisol. All the other hormones are also regulated according to the diurnal rhythm: testosterone is highest in the morning, human growth hormone is highest between midnight and 3 AM etc.

When you work daytime shifts, your diurnal hormone rhythm is unchanged. But if you work night time shifts, your hormones have to adapt. This is very similar to traveling east or west where you cross several time zones. Your internal diurnal hormone system has to adjust to these changes. Typically it takes 1 day to adjust to a 1-hour time zone difference.

In people who work permanent night shifts, the hormone changes stay adjusted and there is no further switching. But most employers want to be “fair” to everybody, so they introduced the rotating night shifts, which as all the publications cited above show is the worst thing you can do. It messes with your diurnal hormone rhythm, and some people never switch completely to the new hours worked. They don’t get enough daytime sleep because the kids are loud during the day etc. The rotating shift workers are running the highest risk of getting cancer, diabetes, cardiovascular diseases, obesity, cancer, leukemia, and they have low levels of melatonin.

Health Risks Of Night Shifts

Health Risks Of Night Shifts

Conclusion

When shift workers work constant night shifts, this is less stressful to our system than the more common rotating shift work. This is where you work night shifts for a period of time, then the schedule switches to day shift, and you keep on rotating. The least health risks are associated with regular daytime work. People exposed to rotating night shifts suffer from poor sleep. They have a higher risk of gaining weight, getting obese and acquiring diabetes in time. They are at a higher risk for heart attacks, strokes and cancer. All-cause mortality is about twofold higher than for workers who work day shifts.

The underlying problem seems to be a disturbance of the diurnal hormone rhythm. Normally this regulates our waking/sleeping rhythm and keeps us healthy. But with nighttime work melatonin production weakens, cortisol production is reduced and hormone rejuvenation during rest periods suffers greatly. This weakens the immune system, allows cancer to develop and leads to chronic inflammation causing cardiovascular disease and diabetes. The remedy to prevent this from happening is to catch little naps whenever you can during the day and, if at all possible, work daytime shifts permanently.

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