Should physical therapists augment their therapeutic practice with the strategic use of CBD-rich hemp oil extract?

The endocannabinoid system (ECS) is a master endogenous regulatory, adaptogenic set of lipid-based compounds (endocannabinoids), specialized cannabinoid receptors they bind to and enzymes responsible for synthesizing and metabolizing those very same endocannabinoids. One of the interesting distinctions with endocannabinoid lipid mediators (e.g., Anandamide, 2-AG, PEA, and OEA) is that they are synthesized and released ‘on demand,’ as opposed to other neurotransmitters (e.g., glutamate, GABA, 5-HTP, etc.) that are stored in vesicles and released ‘upon stimulation.’ This implies that the endocannabinoid system is more sensitive to real-time environmental and mechanical stimuli, such as an orthopedic or connective/ musculoskeletal tissue injury. Moreover, there is clear evidence of endocannabinoid compounds and hemp-derived phytocannabinoids (plant-Cannabis derived) promoting restoration and remodeling of healthy bone, tendon, ligament, muscular and connective tissue integrity via a healthy inflammatory and resolution response.

Rehabilitation and physical therapy professionals concerned with the treatment or improvement of the musculoskeletal, orthopedic, nervous system and connective tissue would benefit from optimizing the endocannabinoid system (e.g., from Physical Therapist to Physiatrist, Orthopedic Surgeon, Pain Physician, Neurologist, to Athletic Trainer or Strength/Conditioning Professional). Supplementing with a phytocannabinoid-rich CBD hemp extract product may complement lifestyle factors for optimizing the ECS: routine exercise, adequate sleep, stress management techniques and a diet focused on high-quality fats (weighted toward Omega-3), complete protein while limiting hyper-palatable foods and caloric excess.

The occurrence of chronic stress, depression, and anxiety can increase nociception or peripherally perceived pain in humans and may facilitate the transition from acute, localized to widespread chronic pain. Chronic pain and psychophysiological factors that interact with the pain-modulating system can lead to fear-avoidant behavior that may severely limit the rehabilitation potential of patients undergoing physical therapy. As such, it is no surprise that Lomazzo et al. demonstrated that enhancing endocannabinoid signaling is a potential treatment strategy using an animal model for chronic pain associated with chronic stress and negative psychological overly. The connection between the ECS and orthopedic conditions that physical therapists are often tasked with managing doesn’t end with stress/anxiety conditions that amplify pain states, as cannabinoid receptors have been characterized on chondrocytes, fibroblasts, tenocytes, bone, synovial and muscle, suggesting a role of cannabinoids in musculoskeletal remodeling, rehabilitation and recovery.

Finally, it has been well-established that inflammation and pro-inflammatory cytokines play a significant role in the pathology, treatment, and rehabilitation of active orthopedic, joint and post-surgical conditions where physical therapy is paramount. Animal and human studies have demonstrated that activation of cannabinoid receptors attenuate inflammation and nociceptive processing in models of musculoskeletal and joint inflammation. Interestingly, several NSAID COX (cyclooxygenase) inhibitors have also been shown to inhibit FAAH (fatty acid amide hydrolase), which suggests that the endocannabinoid system may be a secondary target in addition to prostaglandins and leukotrienes.

Full-spectrum agricultural hemp extracts, rich in CBD, provide a wide range of phytocannabinoids, terpenes, flavonoids and supportive bioactive constituents that result in a more linear dose-dependent therapeutic response than 99% CBD isolates. CBD oil products on the market may not explicitly disclose that this phenomenon has been described in animal models comparing the anti-inflammatory and nociceptive properties of whole-plant extracts with the synergies of a matrix of bioactives from agricultural hemp vs. CBD isolates (Gallily R et al. 2015). Moreover, human clinical trials examining effects of cannabinoids on public-speaking induced anxiety and chronic neuropathic pain have also demonstrated the dose-response differences, in addition to increased efficacy and “entourage” effect from smaller doses of a combination of phytocannabinoids vs. either CBD or THC in isolation (Zuardi AW et al. 2017 and Johnson JR et al., 2010). This class of hemp-derived, CBD-rich bioactive nutraceuticals may have an unusually broad (or wide) therapeutic index relative to other botanical extracts. In essence, it is a great idea to start with small doses and titrate up over a 1-2 week period until the patient or consumer feels an acceptable level of benefit (efficacy) while avoiding any adverse responses such as somnolence (sleepiness) or any other undesirable effect. However, due to the broad therapeutic index, many integrative and functional medicine practitioners are often surprised by how two patients, each with similar goals and presentations end up requiring doses sometimes as varied as 3x-6x fold difference, yet without “adverse responses.”

Look for brands of CBD Oil that pay particular attention to professional and consumer education, quality control/ assurance, independent safety toxicology studies on the actual product sold into commerce, and supply chain measures from seed to shelf that not only meets but far exceeds federal regulatory compliance requirements. This will bring rehabilitation and physical therapy professionals, practitioners, patients and consumers alike, a unique level of reassurance.

Hence, it follows that physical therapists may augment or integrate their therapeutic practice with the strategic use of CBD-rich hemp oil extract for optimizing the ECS and thereby improve the efficacy and potential outcomes of patients.

REFERENCES:

Lomazzo E, Bindila L, Remmers F, et al. Therapeutic potential of inhibitors of endocannabinoid degradation for the treatment of stress-related hyperalgesia in an animal model of chronic pain. Neuropsychopharmacology. 2015 Jan;40(2):488-501.

Valastro C, Campanile D, Marinaro M, et al. Characterization of endocannabinoids and related

acylethanolamides in the synovial fluid of dogs with osteoarthritis: a pilot study. BMC Vet Res. 2017 Nov 6;13(1):309.

Richardson D, Pearson RG, Kurian N, et al. Characterisation of the cannabinoid receptor system in synovial tissue and fluid in patients with osteoarthritis and rheumatoid arthritis. Arthritis Res Ther. 2008;10(2): R43.

Ruth Gallily R, Yekhtin Z, Hanuš LO. Overcoming the Bell-Shaped Dose-Response of CBD by Using Cannabis Extract Enriched in CBD. Pharmacology & Pharmacy, Vol.6 No.2, 2015.

Zuardi AW, Rodrigues NP, Silva AL, et al. Inverted U-Shaped Dose-Response Curve of the Anxiolytic Effect of Cannabidiol during Public Speaking in Real Life. Front Pharmacol. 2017 May

11;8:259.

Johnson JR, Burnell-Nugent M, Lossignol D, et al. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC: CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage. 2010 Feb;39(2):167-79.