Inflammation: The Root Cause of Pain

picture of hands with inflammation

How to Treat Inflammation Naturally

What are Signs of Inflammation?

When you sustain an injury you may notice that the area is swollen, painful, red and feels hot to the touch. These are all common signs of inflammation that you may experience on a superficial level. Chronic inflammation can also occur in our bodies and can present itself in other ways. When inflammation triggers sensory nerve endings, it can result in pain. Symptoms such as fatigue, rashes, digestion problems, allergies, asthma, and chest, abdominal and joint pain can also be signs of inflammation.

What is Inflammation?

Inflammation is a natural immune system function. It’s a reaction to infection or injury that triggers a slew of chemical messages to your immune system to prompt healing and repair. It’s a word most of us associate with pain, discomfort and poor health — yet its ultimate purpose is actually to help us get better. Without inflammation, injuries wouldn’t heal and infections could become deadly.

When the body is injured, the swelling and pain of inflammation is a signal to your immune system to send white blood cells so the healing process may begin. Unfortunately, when inflammation becomes chronic, it can trigger numerous other health problems in your body including cancers, depression, asthma and heart disease. In fact, some say inflammation is the “new cholesterol” due to its direct link to heart disease.

In some cases, inflammation occurs when the immune system revolts against us and attacks our own bodies as in autoimmune diseases. Autoimmune diseases include rheumatoid arthritis, type 1 diabetes, IBD, and Hashimoto’s thyroiditis among dozens of others. There are over 80 different autoimmune diseases.

Top Tips to Reduce Inflammation

Which Foods Cause Inflammation?

First, let’s take a quick look at inflammatory foods that you want to limit or avoid. You probably already know all the usual suspects.

  1. Sugar and artificial sweeteners – A 2018 study in children found that a 46% decrease in sugar intake, significantly reduced proinflammatory markers and increased the levels of anti-inflammatory markers.
  2. Fried foods – A 2016 study on deep-fried oil consumption, revealed that intake of deep-fried canola oil could impair metabolism of triglycerides, destroy the gut wall structure and unbalance healthy gut bacteria. All of which could contribute to inflammation.
  3. Grains – Wheat and other cereal grains contain anti-nutrients like gluten that may contribute to inflammation by increasing intestinal permeability and initiating a pro-inflammatory immune response.
  4. Dairy – Proteins in milk and dairy products can trigger an immune reaction that contributes to inflammation. Research on milk containing a protein known as A1 beta-casein significantly increases gastrointestinal transit time, production of dipeptidyl peptidase-4 and the inflammatory marker myeloperoxidase compared with milk containing A2 beta-casein. Cows here in Canada tend to produce more of the A1 beta-casein protein, therefore dairy products here tend to be more pro-inflammatory.
  5. Alcohol – A 2015 study showed that alcohol-induced changes to the gastrointestinal tract microbiome and metabolic function may contribute to the well-established link between alcohol-induced oxidative stress, intestinal hyperpermeability (leaky gut), and the subsequent development of alcoholic liver disease (ALD), as well as other diseases.

What are Anti-inflammatory Foods?

Wondering what those anti-inflammatory foods are? The good news is they are delicious and come with multiple health benefits.

Raw, Organic Fruits & Veggies

Organic foods are a great place to start when looking to adhere to a more anti-inflammatory diet. Grown in mineral-dense soil, organic foods tend have a higher vitamin and mineral content.

In order to keep those vitamin and mineral levels high, it’s also helpful to eat raw or lightly cooked fruits and veggies. Cooking can deplete minerals, which is why it’s important to take every opportunity you can to get eat fresh and raw so you get to enjoy the full nutritional benefits. For example, Vitamin K is found in dark leafy greens like kale and spinach and is excellent for reducing inflammation.

Add in lots of Alkaline Foods

In addition to fruits and vegetables, nuts and legumes are also alkaline foods that can help balance your pH and reduce acidity. While being mindful of your body’s pH, you might be wonder about the impact of acidic foods, like tomatoes or citrus, and how they affect inflammation. Surprisingly these foods don’t create acidity in the body. Although they are acidic in nature, that acidity is quickly neutralized by buffers in the small intestine when they exit the stomach. Therefore, they may actually help to restore your pH balance. Even apple cider vinegar is alkaline-forming (however, other vinegars are not).

Fish & Plant Proteins

Believe it or not, most high protein animal foods, like meat, can actually be acid forming. In this case, plant proteins, such as nuts and beans, are great alternatives to reduce acidity and inflammation.

Need your meat? Then eat more fish. Fish oils, as well as other foods rich in healthy fats like omega 3, are proven to have a variety of health benefits, including significant anti-inflammatory effects.

Fish is also a great source of Vitamin D. Vitamin D deficiency has been associated with a wide range of inflammatory conditions.

Antioxidant-Rich Foods: Natural Anti-inflammatories

Those susceptible to chronic inflammation may also benefit from supplementing their diets with food sources that contain bioactive molecules. For example, curcumin is a compound found in turmeric root. It is a powerful antioxidant. Curcumin’s ability to reduce brain inflammation has been shown to be beneficial in both Alzheimer’s disease and major depression. Curcumin has been shown to not only prevent memory problems from worsening, but also to improve them.

Complement your curry with a little watercress salad on the side, including pears, dill weed, onion and chives – all sources of the antioxidant known as isorhamnetin.

Add a little red wine and some berries for dessert, which are rich in resveratrol, and you’ve got yourself an anti-inflammatory party. Resveratrol is an antioxidant produced by certain plants in response to injury or when under attack by bacteria or fungi. This is what makes dark-coloured grapes and berries such excellent health boosters for your body.

And of course, you can’t forget the dark chocolate! The flavonoids found in cacao are extremely potent antioxidants and anti-inflammatory agents, which are great for your brain and your heart. New research also shows that consuming dark chocolate with a high concentration of cacao (minimum 70% with 30% organic cane sugar) has a positive effect on stress levels and inflammation, while also improving your memory, immunity and mood. You read that right – chocolate really is good for you (but make sure its good quality and that you are not over doing it).

How to Reduce Inflammation: Going Beyond Diet

While diet definitely plays a role, stress is also a major contributor to inflammation in the body. Stress can be triggered by lack of sleep, lifestyle changes, or any other number of factors. Getting a good night’s rest and making time to meditate or practice other stress-reducing activities, like yoga or Tai chi, are also very effective ways to promote good health and reduce inflammation. Psychotherapy can help you formulate a plan to reduce stress, improve your lifestyle and your relationships.

All it takes is a few conscious decisions about your diet and lifestyle and you are on your way to a healthier you.

Herbs for Inflammation

  1. Curcumin – Research has shown curcumin to be a molecule that is capable of interacting with numerous targets that are involved in inflammation. Clinical trials indicate that curcumin may have potential as a therapeutic agent in diseases such as inflammatory bowel disease, pancreatitis, arthritis, and chronic anterior uveitis, as well as certain types of cancer.
  2. Boswellia -Boswellia is also known as Frankinsence. It is an important traditional medicine plant that possesses several pharmacological properties. It has anti-inflammatory, antimicrobial, and antitumour effects.
  3. Pedalium murex – This Ayurvedic herb, native to South India, Mexico and parts of Africa, is used as an anti-inflammatory, and helps treat many diseases including asthma, gastric ulcer, heart disease and urinary tract disorders.

Chiropractic and Inflammation

In a 2010 study on the effects of chiropractic on markers of inflammation in sufferers of chronic low back pain, 9 chiropractic lower back manipulations caused the mediators of inflammation to present a normalization response in individuals suffering from chronic low back pain.

Massage Therapy and Inflammation

In a 2018 review article, the most powerful techniques for reducing inflammation after exertion were massage and cold exposure. Massage therapy also proved to be the most effective method for reducing delayed onset muscle soreness after exercise and perceived fatigue.

Acupuncture and Inflammation

A 2018 study on rats showed that acupuncture reduced inflammation by down-regulating the levels of the inflammatory markers IL-1 β, IL-6 and IL-8, and in regulating cerebral SIRT1/NF-κB signaling. Numerous studies have demonstrated the benefits of acupuncture for reducing pain in inflammatory conditions like arthritis and back pain.

Osteopathic Manipulative Therapy and Inflammation

Fibroblasts are the main fascial cells that respond to different types of strain by secreting anti-inflammatory chemicals and growth factors, thus improving wound healing and muscle repair processes. Osteopathic manual practitioners, use myofascial release therapy and other osteopathic manipulative therapies to stimulate fibroblasts to reduce inflammation and improve wound healing, muscle repair and regeneration.

Are you dealing with chronic health issues triggered by inflammation? Do you still have more questions about how you can make greater changes towards a pain-free life? Do you want a customized approach to managing inflammation and preventing disease? Please feel free to contact us and we can find your best solutions together. Call or email us at 416-481-0222 or Maria@ForcesofNature.ca

To your best health!

The Team at Forces of Nature Wellness Clinic – Chiropractor, Naturopathic Doctors, Acupuncturist/TCM, Psychotherapist, Registered Dietitian, Massage Therapist/RMT, Craniosacral Therapist, Osteopath

References:

https://www.sciencedaily.com/releases/2012/02/120223103920.htm

https://www.sciencedaily.com/releases/2006/04/060404085719.htm

https://www.sciencedaily.com/releases/2018/04/180424133628.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836295/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715939/

https://www.ncbi.nlm.nih.gov/pubmed/12148098

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036413/

https://www.sciencedirect.com/science/article/pii/S1064748117305110?via%3Dihub#bib0015

Sawani A, Farhangi M, N CA, Maul TM, Parthasarathy S, Smallwood J, Wei JL. Limiting Dietary Sugar Improves Pediatric Sinonasal Symptoms and Reduces Inflammation. J Med Food. 2018 May 31. doi: 10.1089/jmf.2017.0126. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/29851540

Zhou Z, Wang Y, Jiang Y, Diao Y, Strappe P, Prenzler P, Ayton J, Blanchard C. Deep-fried oil consumption in rats impairs glycerolipid metabolism, gut histology and microbiota structure. Lipids Health Dis. 2016 Apr 28;15:86. doi: 10.1186/s12944-016-0252-1. https://www.ncbi.nlm.nih.gov/pubmed/27121709

de Punder K, Pruimboom L. The dietary intake of wheat and other cereal grains and their role in inflammation. Nutrients. 2013 Mar 12;5(3):771-87. doi: 10.3390/nu5030771. https://www.ncbi.nlm.nih.gov/pubmed/23482055

Pal S, Woodford K, Kukuljan S, Ho S. Milk Intolerance, Beta-Casein and Lactose. Nutrients. 2015 Aug 31;7(9):7285-97. doi: 10.3390/nu7095339. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476926/

Engen PA, Green SJ, Voigt RM, Forsyth CB, Keshavarzian A. The Gastrointestinal Microbiome: Alcohol Effects on the Composition of Intestinal Microbiota. Alcohol Res. 2015;37(2):223-36. https://www.ncbi.nlm.nih.gov/pubmed/26695747

Schwalfenberg GK. The alkaline diet: is there evidence that an alkaline pH diet benefits health? J Environ Public Health. 2012;2012:727630. doi: 10.1155/2012/727630. Epub 2011 Oct 12. https://www.ncbi.nlm.nih.gov/pubmed/22013455

Devanesan AA, Zipora T, G Smilin BA, Deviram G, Thilagar S. Phytochemical and pharmacological status of indigenous medicinal plant Pedalium murex L.-A review. Biomed Pharmacother. 2018 Jul;103:1456-1463. doi: 10.1016/j.biopha.2018.04.177. Epub 2018 May 7. https://www.ncbi.nlm.nih.gov/pubmed/29864930

Jurenka JS. Anti-inflammatory properties of curcumin, a major constituent of Curcuma longa: a review of preclinical and clinical research. Altern Med Rev. 2009 Jun;14(2):141-53. https://www.ncbi.nlm.nih.gov/pubmed/19594223

Beghelli D, Isani G, Roncada P, Andreani G, Bistoni O, Bertocchi M, Lupidi G, Alunno A. Antioxidant and Ex Vivo Immune System Regulatory Properties of Boswellia serrata Extracts. Oxid Med Cell Longev. 2017;2017:7468064. doi: 10.1155/2017/7468064. Epub 2017 Mar 13. https://www.ncbi.nlm.nih.gov/pubmed/28386311

Roy RA, Boucher JP, Comtois AS. Inflammatory response following a short-term course of chiropractic treatment in subjects with and without chronic low back pain. J Chiropr Med. 2010 Sep;9(3):107-14. doi: 10.1016/j.jcm.2010.06.002. https://www.ncbi.nlm.nih.gov/pubmed/22027032

Dupuy O, Douzi W, Theurot D, Bosquet L, Dugué B. An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis. Front Physiol. 2018 Apr 26;9:403. doi: 10.3389/fphys.2018.00403. ECollection 2018. https://www.ncbi.nlm.nih.gov/pubmed/29755363

Rosenkranz MA, Davidson RJ, Maccoon DG, Sheridan JF, Kalin NH, Lutz A. A comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic inflammation. Brain Behav Immun. 2013 Jan;27(1):174-84. doi: 10.1016/j.bbi.2012.10.013. Epub 2012 Oct 22. https://www.ncbi.nlm.nih.gov/pubmed/23092711

Should you get your thyroid tested?

woman checking her thyroid

How Healthy is Your Thyroid and Why Does it Matter?

Did you know that a tiny, butterfly-shaped gland nestled in your neck is responsible for producing some of the most important hormones in your body? This small but mighty gland is called the thyroid.  While it’s relatively small in size, it plays a huge role in our endocrine (hormone) system.

This gland produces hormones that interact with many other hormones (like insulin, cortisol, estrogen, progesterone, and testosterone).  Looking at how intimately all hormones communicate with each other, it’s no wonder so many symptoms are connected to a poorly performing thyroid!

How does this gland work?

Most of what the thyroid produces is an inactive hormone called thyroxine, or T4. Most of the active thyroid hormone, triiodothyronine (or T3), comes from the conversion of T4 to T3 in different areas of your body, including your liver, gut, brain and muscles.

This “active” T3 is then able to regulate many functions in your body including energy production and regulation of your metabolism. Think of the thyroid as the “gas pedal” for your body.  Constantly regulating the speed that everything else runs.  When all of the systems in your body are working well, the right amounts of T4 and T3 are produced. But if something is negatively affecting the thyroid or other organ systems in the body, this hormone balance gets disrupted and we start to experience various symptoms.

Some of the factors that impact a healthy functioning thyroid are nutritional imbalances, toxins, allergens, infections, and stress. All of these can all be problematic, leading to dysfunction of the gland, and potentially to wider spread systemic disease.

What happens when the thyroid can’t function normally?

When the thyroid is compromised, the body is unable to produce or convert the right amounts of thyroid hormone. Consequently, we experience disorders such as hypothyroidism, hyperthyroidism, and thyroid cancer. In fact, these diseases are highly prevalent in North America.  An estimated 20 million Americans and 1 in every 10 Canadians have some form of thyroid disease.  Over 12% of all Americans will develop such a condition during their lifetime. Because thyroid conditions are tied to so many varying symptoms, up to 60% of people with disease are unaware of their condition.   Women are 5-8x more likely to be affected than men. It is estimated that one in eight women will suffer from such a disorder during her lifetime.

Thyroid disease is tied to many less obvious disorders including acne, autoimmune diseases, eczema, fibromyalgia, gum disease, constipation or irritable bowel syndrome, migraines and infertility. Because the thyroid is like your gas pedal for all of your cells, it can be linked to almost every bodily function.  Symptoms of an underlying thyroid problem are wide and varied which can make diagnosis difficult.  As a result, many people are misdiagnosed and treated for other conditions before looking at their thyroid.

Hypothyroidism

Symptoms of an underactive thyroid

  • Lethargy or fatigue
  • Foggy thinking
  • Depression
  • Weight gain even if you’ve been exercising and eating well consistently
  • Persistently rough/scaly skin
  • Dry/tangled hair
  • Hair loss (particularly in women)
  • Sensitivity to cold
  • An inability to warm up in a sauna or to sweat during exercise
  • Consistently low basal (resting, first morning) body temperature

Hyperthyroidism

Symptoms of an overactive thyroid

  • Feeling restless, nervous, or emotional
  • Poor sleep quality or insomnia
  • Fatigue
  • Muscle weakness
  • Difficulty concentrating
  • Frequent bowel movements
  • The disappearance of or irregular menstruation
  • Weight loss
  • Rapid, forceful, or irregular heartbeat
  • Eye problems (associated with Graves’ disease)
  • Swelling in your neck or having a goitre

Hashimoto’s Thyroiditis

Hashimoto’s is an autoimmune condition where your immune system is creating antibodies that are attacking your thyroid.  Over time, this autoimmune attack can damage the gland and cause it to cease working properly.  Autoimmune disorders are complicated, but they can be improved through natural medicine.  Factors like food sensitivities, latent infections, and adrenal fatigue all need to be considered to reverse Hashimoto’s.

Euthyroid Sick Syndrome

This is a condition where blood tests for the thyroid may show normal levels of TSH or thyroid stimulating hormone.  Yet, levels of T3 are low.  When T3 drops, your pituitary ought to respond by producing more TSH to stimulate more production of T4 and then conversion to T3.  Euthyroid refers to the fact that thyroid itself appears to be in working order as TSH is normal.  Treatment of Euthyroid Sick Syndrome often entails looking at the person as a whole and supporting the entire endocrine system as well as resolving stressors.

Thyroid Tests

Simple blood tests can identify a potential problem.  We prefer to do comprehensive thyroid blood work that includes TSH, free T3, free T4, anti-TPO (or anti-thyroperoxidase) and anti-thyroglobulin.  It’s a common misconception that if TSH is normal, then all of the remaining tests will also be normal.  This is not true.  I have reviewed hundreds, if not thousands, of thyroid test results and found that patients can have a normal level of TSH, and even normal levels of free T3 and free T4, but thyroid antibody levels are not normal.  If you suspect a problem, I would highly recommend having complete testing done.

Whether you have an obvious problem or not, it’s important to understand how the thyroid works so that you can keep your body functioning optimally.

Tips to Improve Thyroid Function

When it comes to managing the optimal function of your glands, the building blocks are almost always found in nutrition first and foremost.

6 Tips to maintain a healthy thyroid through diet

  1. Go gluten and dairy free: Most people go gluten and dairy free only when there is an obvious sensitivity like a gut problem to either type of food. Sensitivity to gluten and dairy can be much more subtle when it comes to the thyroid. These foods trigger inflammation, disordered immune system function and are associated with autoimmune thyroid issues.
  2. Focus on your iodine level: Iodine is present in almost every organ and tissue and has a direct effect on the thyroid. Iodine is just one of the most important nutrients for this gland.  Chemical agents in commercial food ingredients have the side effect of decreasing your iodine level. Daily exposure to chemicals found in water such as bromine, fluorine, and chlorine all negatively impact iodine levels by competing with iodine for absorption. You do not need to take iodine supplements, however, and too much iodine can also damage your thyroid.  Using a little bit of good iodized sea salt each day will meet your iodine needs.
  3. Look for “no bromine” or “bromine-free” labels on organic whole-grain bread and flours if you eat grains
  4. Increase your dietary intake of wild-caught seafood and ocean fish
  5. Seek out foods containing zinc and selenium: Zinc and selenium are two micronutrients that play critical roles in thyroid health. Because they can be toxic in very high doses, it’s best to achieve healthy levels through diet. Zinc-rich foods include oysters, beef, pork, egg yolks, shellfish and chicken while selenium-rich foods include Brazil nuts, fish, and liver.
  6. Manage stress: Stress and overall health are inextricably linked. Make sure you’re taking time to meditate, relieve stress, and get your mindset on track so that you can enjoy the benefits of overall health.

You can gain control over your health by learning how to manage and maintain your thyroid through nutrition, lifestyle, and naturopathic medicine support. If you’re dealing with, or suspect you have this or other health issues, please take time to book an appointment to visit us at our clinic. We want to help you take control of your health! Comprehensive testing and hormone assessments are available.

Call or email us at 416-481-0222 or Info@ForcesofNature.ca

To your best health!

The team at Forces of Nature Wellness Clinic

References:
https://articles.mercola.com/thyroid.aspx
https://www.thyroid.org/media-main/about-hypothyroidism/
J Clin Endocrinol Metab. 2015 Aug 25:jc20152222. Epub 2015 Aug 25. PMID: 26305620

Autoimmune disease

woman with autoimmune disease arthritis

What is an auto-immune disease?

It’s a disease where the immune system, which is programmed to ignore “self”, has gone haywire and started attacking the person’s own tissues.

Which conditions are considered to be autoimmune?

The list of what is now thought to be autoimmune is expanding. There are now more than 80 different conditions listed as autoimmune diseases. Some of the more common ones are Lupus, Rheumatoid arthritis, Sjogren’s, Scleroderma, type I diabetes, MS, Guillain Barre, psoriasis, Grave’s disease (hyperthyroid), Hashimoto’s (hypothyroid) and vasculitis. For a full list of autoimmune disorders, click here: www.aarda.org

What causes autoimmune diseases?

Good question with a complex answer, since it doesn’t appear to be just one thing, but the factors that may contribute to autoimmune disorders are:

  1. Gut health – since 70-80% of your immune system is there, an unhealthy or leaky gut can cause unhealthy immune system activity.
  2. Food sensitivities – foods that aggravate the immune system will cause production of antibodies and inflammation.
  3. Latent infections – low level viral (herpes, Epstein Barr), fungal (yeast) or bacterial infections (strep) can cause excessive or disordered immune system activity.
  4. Poorly functioning adrenal glands – the adrenal glands produce powerful anti-inflammatories called corticosteroids. This is what will often be prescribed as a medication for auto-immune problems.

How can we fix auto-immune disorders?

Our naturopathic doctors can assess your symptoms related to each of the above situations and address them naturally.

  1. Gut health – a healthy gut requires nutrients like l-glutamine, vitamin A, and fiber. Fiber feeds the good bacteria in the gut, which then break it down into short chain fatty acids that nourish the cells that line the colon. Good bacteria help to moderate the immune system and prevent overgrowth of harmful bacteria or yeast.
  2. Food sensitivity detective work – we can determine your food sensitivities (almost everyone has some) either by process of elimination (also called an elimination challenge diet) or through science based testing for IgG and/or IgA antibodies in your blood stream to particular foods (up to 184 foods!).
  3. If you are prone to genital herpes, cold sores, had mono or recurring sore throats or strep, recurring yeast infections or BV these viruses, yeast or bacteria can be lurking in your system and firing up the immune system.  Natural anti-microbials like oregano oil, garlic, caprylic acid, black walnut, uva ursi and grapefruit seed extract can help rid your body of some of these (the herpes viruses stay in your system).
  4. Your adrenal glands are your stress glands.  They are also your body’s source of corticosteroids.  Corticosteroids are powerful immune suppressors that keep the immune system in check and on track. Prednisone is a drug that is often used to get autoimmune diseases in check.  Your body makes its own internal Prednisone via your adrenal glands. They require lots of vitamin B5, B6, vitamin C, zinc and magnesium to function at their best.  Adaptogens are also herbs that can help them work well and help you deal with stress more easily.

Autoimmune disease and natural medicine research

Zamani B, Golkar HR, Farshbaf S, Emadi-Baygi M, Tajabadi-Ebrahimi M, Jafari P, Akhavan R, Taghizadeh M, Memarzadeh MR, Asemi Z. Clinical and metabolic response to probiotic supplementation in patients with rheumatoid arthritis: a randomized, double-blind, placebo-controlled trial. Int J Rheum Dis. 2016 May 2. doi: 10.1111/1756-185X.12888.
Li J, Yan H, Chen H, Ji Q, Huang S, Yang P, Liu Z, Yang B. The Pathogenesis of Rheumatoid Arthritis is Associated with Milk or Egg Allergy. N Am J Med Sci. 2016 Jan;8(1):40-6. doi: 10.4103/1947-2714.175206.
Draborg A, Izarzugaza JM, Houen G. How compelling are the data for Epstein-Barr virus being a trigger for systemic lupus and other autoimmune diseases? Curr Opin Rheumatol. 2016 Jul;28(4):398-404. doi: 10.1097/BOR.0000000000000289.
Mravcova M, Chovanova L, Paulikova L, Vlcek M, Rovensky J, Killinger Z, Wendl J, Imrich R. Genetics of neuroendocrine factors in rheumatoid arthritis. Horm Metab Res. 2015 Jun;47(6):411-7. doi: 10.1055/s-0034-1395667. Epub 2014 Dec 12.