Occipital neuralgia is a debilitating condition characterized by sharp, throbbing, or electric shock-like pain in the upper neck, back of the head, and behind the ears, often radiating to the scalp. This pain originates from the irritation or compression of the greater and lesser occipital nerves. In this educational post, I, Dr. Alex Jimenez, will take you on a journey to understand the physiological underpinnings of occipital neuralgia, exploring its causes, symptoms, and the latest in diagnostic and treatment strategies. We will delve into how our integrative practice combines evidence-based medicine with a holistic philosophy. A key component of our approach is the collaboration between me, with a background in chiropractic and functional medicine, and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD, a Board-Certified Internist with over four decades of experience. Together, we provide a multidisciplinary framework that integrates chiropractic care, medical oversight, functional medicine, and rehabilitative therapies to offer comprehensive, personalized solutions for patients with this painful condition. We will also examine a specific interventional technique—the occipital nerve block—and discuss how it fits within our broader, patient-centered treatment paradigm.
Hello, I’m Dr. Alex Jimenez. With my extensive training as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Family Nurse Practitioner (FNP-BC), and certifications in functional medicine (CFMP, IFMCP), I have dedicated my career to understanding and treating complex neuromusculoskeletal conditions. At Injury Medical Clinic PA, our mission is to provide a beacon of hope for those navigating the often-frustrating world of chronic pain.
A condition I frequently encounter in my clinical practice is occipital neuralgia. This isn’t just a simple headache; it’s a distinct neurological disorder that can severely impact one’s quality of life. The pain is often described as sharp, jolting, and unrelenting, stemming from the occipital nerves that run from the top of the spinal cord up through the scalp.
Our clinic uses a unique, powerful model of integrative care. I work closely with Dr. Maria Guadalupe Cardenas, MD. As a Board-Certified Internist with over 40 years of dedicated patient care (NPI #1164426749, Texas MD License #J2933), Dr. Cardenas serves as our Medical Director and Collaborative Physician. This partnership allows us to seamlessly blend the diagnostic precision and medical oversight of internal medicine with the holistic, biomechanical focus of chiropractic and functional medicine. This multidisciplinary approach ensures our patients receive a comprehensive, well-rounded treatment plan tailored to their individual needs, whether they are dealing with a personal injury, a chronic condition like occipital neuralgia, or are on a journey toward optimal wellness.
The Anatomy of Pain: What Are the Occipital Nerves?
To truly understand occipital neuralgia, we must first explore the anatomy involved. The primary culprits are the greater and lesser occipital nerves. These nerves are not part of the brain but are peripheral nerves that emerge from the upper cervical spine, specifically from the C2 and C3 nerve roots.
Greater Occipital Nerve: This is the larger of the two and originates from the C2 nerve root. It travels up through the deep muscles at the back of the neck, pierces the trapezius muscle, and then branches to provide sensation to most of the scalp on the back and top of the head.
Lesser Occipital Nerve: This nerve originates from the C2 and C3 nerve roots. It runs along the side of the neck, behind the ear, providing sensation to the skin in that area and the scalp just behind it.
When these nerves become inflamed, compressed, or injured anywhere along their path, they send distress signals that the brain interprets as intense pain. This is the essence of neuralgia—nerve pain.
Identifying the Root Cause of Occipital Neuralgia
Effective treatment depends on identifying the underlying cause of the nerve irritation. Occipital neuralgia is often secondary to another issue. Based on my clinical observations and leading research, common causes include:
Muscle Tension and Spasm: Chronic tension in the suboccipital muscles (the small muscles connecting the skull to the top of the spine) is a primary driver. Poor posture, such as “tech neck” from looking down at devices, can lead to hypertonicity in these muscles, effectively entrapping the occipital nerves as they pass through.
Trauma or Injury: Whiplash from a car accident, a direct blow to the back of the head, or even repetitive micro-trauma can injure the nerves or surrounding tissues, leading to inflammation and compression.
Cervical Spine Misalignments (Subluxations): From a chiropractic perspective, misalignments in the upper cervical vertebrae (atlas and axis) can directly irritate the C2 and C3 nerve roots from which the occipital nerves originate. This biomechanical dysfunction is a critical factor we address with chiropractic adjustments.
Degenerative Conditions: Osteoarthritis or degenerative disc disease in the upper cervical spine can lead to bone spurs or narrowing of the spaces where nerves exit the spinal column (foraminal stenosis), causing nerve compression.
Systemic Conditions: Less commonly, conditions like gout, diabetes, or infections can cause inflammation that affects the occipital nerves.
The Role of Integrative Chiropractic Care
This is where our integrative model truly shines. As a chiropractor, I focus on the biomechanical integrity of the spine and nervous system. When a patient presents with symptoms of occipital neuralgia, my assessment begins with a thorough examination of the cervical spine.
Chiropractic Adjustments: Using precise, gentle adjustments, I work to restore proper motion and alignment to the C1 (atlas) and C2 (axis) vertebrae. By correcting these vertebral subluxations, we can alleviate direct pressure on the nerve roots. This is not merely “cracking the neck”; it is a specific intervention designed to improve nerve function at its source (Taylor & Murphy, 2020).
Soft Tissue Mobilization: The nerves don’t exist in a vacuum. Muscles, fascia, and other soft tissues surround them. I utilize techniques like myofascial release, trigger point therapy, and instrument-assisted soft tissue mobilization (IASTM) to release tension in the suboccipital and trapezius muscles. This creates space for the nerve, reducing entrapment and inflammation.
Functional Rehabilitation: Treatment doesn’t end in the clinic. We empower patients with specific postural correction exercises, neck-muscle stretches, and strengthening exercises for the deep cervical flexors. This proactive approach helps prevent the recurrence of muscle tension and postural strain that often trigger occipital neuralgia.
This chiropractic foundation sets the stage for resolving the condition’s biomechanical triggers. However, for some patients, the inflammation and pain are so acute that they create a barrier to effective manual therapy. This is where medical intervention, under Dr. Cardenas’s guidance, becomes crucial.
Medical Intervention: The Occipital Nerve Block
For patients experiencing severe, intractable pain, an occipital nerve block can be a game-changer. This minimally invasive procedure serves both diagnostic and therapeutic purposes. It involves injecting a small amount of local anesthetic and a corticosteroid directly around the inflamed occipital nerves.
Let’s walk through the procedure, as performed in our clinic under my scope as a Family Nurse Practitioner, to understand the “why” behind each step.
Step 1: Precise Identification of Tender Points
The first and most critical step is locating the exact points of maximum tenderness. The patient’s feedback is paramount. I use my fingers to palpate the area where the occipital nerves emerge, just below the base of the skull (the occiput). I’ll ask, “Is that the spot?” When the patient confirms, “Yes, that’s it,” I know I’ve found a primary trigger point. Because we’re working in the hairline, I make a small indentation with a capped pen and a tiny ink mark just below it for reference. This ensures absolute precision.
Step 2: Aseptic Preparation
Patient safety is non-negotiable. I thoroughly cleanse the marked areas with alcohol swabs. In a hairy area like the scalp, this is a practical, effective way to prepare the skin and minimize infection risk.
Step 3: The Therapeutic Combination
The syringe contains a carefully measured mixture of two key components:
Lidocaine: This is a local anesthetic. It provides immediate pain relief by blocking sodium channels in nerve fibers. This stops pain signals from reaching the brain. The rapid relief it provides also serves a diagnostic function—if the pain disappears almost instantly, it confirms that the occipital nerve was indeed the source of the pain.
Cortisone: This is a powerful anti-inflammatory steroid. While lidocaine provides short-term relief, cortisone targets the underlying inflammation. It suppresses the local inflammatory response, reduces swelling around the nerve, and provides longer-lasting pain relief that can last for weeks or even months (Govindappagari & V, 2022). The goal is to break the pain-inflammation cycle.
Step 4: The Injection Process
Using a fine-gauge needle (a 25-gauge in this case) to minimize discomfort, I perform the injection. I always alert the patient, saying, “You’re going to feel a little stick.” I advance the needle until it is near the occiput, in the vicinity of the nerve.
Before injecting, I perform an aspiration. This means I gently pull back on the plunger to ensure the needle tip is not inside a blood vessel. If blood were to enter the syringe, it would indicate an intravascular position, and injecting the steroid there could lead to systemic side effects. Seeing no blood on aspiration confirms we are in the correct tissue plane. I then slowly inject the solution, bathing the nerve in the anesthetic and anti-inflammatory medication. I repeat this for each identified trigger point.
Step 5: Immediate Post-Procedure Assessment
Immediately after the injection, I gently massage the area to help disperse the medication. Then comes the moment of truth. I apply pressure to the same spots that were excruciatingly painful just moments before. I ask, “Does that hurt right there?” The typical response is one of relief: “It feels better.” or “I just feel pressure now.”
This immediate feedback is invaluable. The patient’s significantly reduced pain confirms the block’s success. This relief, even if temporary from the anesthetic, breaks the cycle of pain and muscle guarding. It opens a crucial “window of opportunity” to apply our other therapies more effectively. With pain diminished, the patient can better tolerate chiropractic adjustments and engage in the necessary rehabilitative exercises.
A True Integrative Framework: Tying It All Together
The occipital nerve block is not a standalone cure; it is a strategic tool within our comprehensive care plan. Here is how the pieces fit together:
Initial Crisis Management: The occipital nerve block, overseen medically by Dr. Cardenas and performed by me as an FNP, provides rapid, significant pain relief. This calms the hypersensitive nervous system.
Restoring Biomechanical Function: During the pain-free window created by the block, I implement integrative chiropractic care. This includes targeted upper cervical spinal adjustments and soft tissue work to release muscular entrapment of the occipital nerves.
Addressing Systemic Drivers: As a functional medicine practitioner, I also look deeper. Is there a systemic inflammatory issue at play? We may use advanced lab testing to investigate nutritional deficiencies, food sensitivities, or metabolic imbalances that could be contributing to chronic inflammation. A pro-inflammatory diet can certainly worsen conditions like neuralgia.
Rehabilitation and Empowerment: Our physical therapy and rehabilitation team guides the patient through exercises to correct posture, strengthen supporting muscles, and improve overall spinal health, empowering them to maintain their results and prevent future flare-ups.
This cyclical, mutually reinforcing process is the heart of our practice. Medical intervention makes chiropractic care more effective, and chiropractic care addresses the root biomechanical issues to provide a long-term solution. Dr. Cardenas’s internal medicine expertise ensures we identify and manage any underlying systemic health issues, providing a complete safety net for the patient’s overall health.
By weaving together the latest evidence-based research and techniques from multiple disciplines, we create a patient journey that is not just about managing symptoms, but about restoring function, health, and quality of life. If you are struggling with head and neck pain, know that there are comprehensive, integrative solutions available that go beyond a simple prescription.
Taylor, R. S., & Murphy, F. (2020). Cervical spine manipulation for the treatment of headache: A case series. Chiropractic & Manual Therapies, 28(1), 25. https://doi.org/10.1186/s12998-020-00311-5
Testosterone is often associated with men, but women naturally produce this hormone throughout life. In women, testosterone contributes to sexual function and interacts with muscle, bone, metabolism, and other body systems. When testosterone therapy is clinically appropriate, treatment should be individualized and monitored so hormone levels remain within the normal female physiologic range. Subcutaneous testosterone injections place a small amount of medication into fatty tissue just beneath the skin, where it is gradually absorbed. However, the strongest clinical evidence for testosterone therapy in women remains with transdermal treatment, especially for postmenopausal women with hypoactive sexual desire disorder, or HSDD.
At ChiroMed – Integrated Medicine in El Paso, Texas, this topic fits within a broader model of coordinated healthcare. Chiropractic care, nurse practitioner services, rehabilitation, nutrition, functional health strategies, and medical oversight can work together to address a patient’s musculoskeletal function and overall health rather than focusing on hormone levels alone. ChiroMed describes its approach as bringing multiple healthcare disciplines together to create individualized, patient-centered treatment plans.
Understanding Testosterone in Women
Testosterone is a natural part of female physiology. The ovaries and adrenal glands contribute to androgen production, and testosterone levels normally change with age. Levels can also fall more quickly after ovary removal.
Testosterone interacts with many tissues throughout the body, including the brain, muscles, bones, reproductive tissues, and blood-forming system. However, recognizing these biological roles does not mean testosterone therapy has been proven to treat every symptom that may occur during menopause.
The strongest evidence currently supports systemic testosterone therapy for appropriately evaluated postmenopausal women with HSDD. HSDD involves persistent loss of sexual desire that causes personal distress. Major international organizations have concluded that this is the clearest evidence-supported indication for testosterone therapy in women (Davis et al., 2019).
A large systematic review and meta-analysis also found that testosterone can improve several areas of sexual function in postmenopausal women, including sexual desire, arousal, pleasure, orgasm, responsiveness, and sexual self-image (Islam et al., 2019).
A subcutaneous, or SubQ, injection places medication into fatty tissue beneath the skin rather than deeply into a muscle.
Testosterone cypionate may be prepared in concentrations that allow very small doses to be administered. Once placed into subcutaneous tissue, the medication forms a depot from which testosterone is gradually absorbed.
For women, the treatment goal is very different from testosterone treatment designed to produce male hormone concentrations. When testosterone is used for female HSDD, expert guidance recommends keeping concentrations within the physiologic range normally seen in premenopausal women rather than pushing testosterone above that range (Parish et al., 2021).
The attached clinical white paper makes an important distinction about SubQ injections. Randomized efficacy evidence in women is strongest for transdermal patches, creams, and gels. It describes subcutaneous injection as a titratable route with physiologic reasoning behind it, but notes that there is no dedicated randomized efficacy trial establishing SubQ testosterone injections for women.
That means SubQ testosterone should not be described as better proven than transdermal therapy. It is an alternative route that requires careful medical prescribing, laboratory monitoring, informed consent, and follow-up.
A “Low Testosterone” Number Is Not the Diagnosis
Laboratory testing is useful, but testosterone therapy in women should not begin solely because one test result falls near the lower end of a reference range.
The ISSWSH clinical guideline recommends a biopsychosocial assessment before treatment. A clinician may need to consider menopause status, medications, relationship factors, depression or anxiety, sleep, vaginal discomfort, pain during intercourse, medical illnesses, and other issues that can affect sexual desire. Total testosterone is useful mainly as a baseline and monitoring measurement rather than as a diagnostic test for HSDD (Parish et al., 2021).
The clinical white paper emphasizes the same principle. Testosterone measurements become especially important after therapy begins, because they help the healthcare team determine whether treatment remains within a physiologic female range and whether the patient is receiving too much hormone.
Testosterone, Muscle, and Musculoskeletal Health
Testosterone interacts with skeletal muscle biology, which is one reason the hormone receives attention in discussions about aging, physical function, and strength.
A randomized study examined different testosterone doses in postmenopausal women who had undergone hysterectomy. Higher testosterone concentrations were associated with changes in lean body mass and some measurements of muscle power. Importantly, the clearer muscle effects occurred with the highest dose and testosterone concentrations above typical female physiologic levels. The authors also stated that longer-term trials were needed to balance potential benefits against long-term risks (Huang et al., 2014).
This research should not be interpreted to mean that testosterone is a proven muscle-building treatment for women. The clinical white paper specifically notes that body-composition benefits have not been established as an approved indication for female testosterone therapy.
This is where physical rehabilitation becomes important. Hormones may influence the environment in which muscle tissue functions, but stronger muscles still require appropriate loading, movement, nutrition, recovery, and neuromuscular training.
Connecting Testosterone Therapy With Chiropractic Care
Chiropractic treatment and testosterone therapy perform very different jobs.
Testosterone therapy is a medical treatment that requires appropriate prescribing and monitoring. Chiropractic care focuses on the musculoskeletal system, including joint movement, spinal mechanics, posture, physical function, and rehabilitation.
For a woman who is also trying to maintain strength and mobility as she ages, an integrated plan may include:
medically supervised hormone assessment when clinically indicated;
chiropractic evaluation of the spine, pelvis, and extremities;
resistance and strength rehabilitation;
balance, mobility, and stability exercises;
adequate dietary protein and overall nutrition;
evaluation of sleep and recovery;
management of previous injuries or chronic musculoskeletal limitations;
progressive exercise based on the patient’s current ability;
laboratory monitoring when hormone therapy is prescribed;
ongoing reassessment of both symptoms and physical function.
The important idea is that testosterone does not replace exercise or rehabilitation. Likewise, an adjustment cannot correct a hormone disorder. When appropriate, the two approaches can address different parts of the patient’s health.
How This Fits the ChiroMed Integrated Medicine Model
ChiroMed – Integrated Medicine in El Paso brings several healthcare services into a multidisciplinary setting. The clinic currently describes chiropractic care, nurse practitioner services, rehabilitation, nutrition, acupuncture, and related integrative services as parts of its overall healthcare model.
That structure can be useful when women’s hormone concerns overlap with other health issues.
For example, a woman discussing hormonal symptoms may also have chronic back pain, reduced physical activity, previous injury, poor sleep, loss of conditioning, weight concerns, or difficulty maintaining muscle strength. Treating only a laboratory number would not address all of those factors.
ChiroMed’s integrated injury model similarly describes combining medical evaluation, chiropractic care, rehabilitation, soft-tissue treatment, and functional medicine strategies within a coordinated recovery plan.
Dr. Alexander Jimenez, DC, APRN, FNP-BC, works within this multidisciplinary environment by integrating chiropractic and musculoskeletal assessment with his advanced-practice nursing and functional medicine background. His clinical approach emphasizes movement, nutrition, metabolic health, rehabilitation, and other factors that affect how a patient feels and functions.
Medical oversight is also part of the ChiroMed structure. ChiroMed identifies Maria Guadalupe Cardenas, MD, a board-certified internal medicine physician, as Medical Director, Clinical Director, and Collaborative Physician. The ChiroMed website lists her Texas medical license as J2933 and NPI as 1164426748.
In a multidisciplinary model, the goal is not to make chiropractic treatment a substitute for medical hormone management. Instead, medical and musculoskeletal professionals can contribute within their respective scopes of practice.
Monitoring Testosterone Therapy in Women
If testosterone treatment is selected, follow-up is an essential part of care.
The clinical guideline recommends monitoring testosterone concentrations to prevent exposure above the physiologic premenopausal range. Patients should also be evaluated for clinical signs of androgen excess (Parish et al., 2021).
Possible concerns can include acne, increased facial or body hair, scalp hair changes, and other androgenic effects. Voice changes are less common but deserve prompt attention. The attached white paper explains that these effects tend to be dose-related and that scheduled reassessment helps identify excessive exposure early.
A clinician may also consider the patient’s overall medical history, cardiovascular health, breast health, medications, and other hormone therapy.
Importantly, testosterone should not simply be increased because symptoms have not changed quickly. Expert guidance suggests evaluating response over several months and stopping treatment when there is no meaningful benefit rather than pushing testosterone beyond the normal female physiologic range.
What We Still Do Not Know
Testosterone therapy in women is an area where evidence and clinical practice do not always move at the same speed.
Transdermal testosterone has the strongest randomized evidence. The evidence supporting subcutaneous injections in women remains much more limited. The attached white paper specifically identifies subcutaneous injection evidence as pharmacokinetic rather than supported by dedicated female efficacy trials.
Long-term cardiovascular and breast safety also remain incompletely defined. Available shorter-term findings at physiologic doses are reassuring, but researchers still lack adequately powered studies that answer every safety question over many years.
This is why individualized treatment and shared decision-making matter.
Integrating Hormone Health With Movement and Strength
Women’s health is rarely about one hormone, one joint, or one treatment.
For selected women with HSDD, properly monitored testosterone therapy may be one part of care. If a SubQ route is considered, the treatment should remain medically supervised and should recognize that evidence for female subcutaneous injections is still developing.
At the same time, maintaining musculoskeletal health requires movement.
Progressive resistance exercise, adequate nutrition, good sleep, rehabilitation, healthy body composition, joint mobility, and injury management all contribute to maintaining strength and physical independence.
That concept fits naturally with the ChiroMed – Integrated Medicine approach in El Paso: combining conventional medical oversight with chiropractic care, rehabilitation, nutrition, functional strategies, and individualized patient education. ChiroMed describes its purpose as bringing different disciplines together so treatment plans can address both symptoms and underlying contributors to health and function.
Testosterone therapy and chiropractic care should therefore not be viewed as competing treatments. When clinically appropriate, each addresses different parts of the larger goal—helping women maintain healthy physiology, functional muscles and joints, mobility, and quality of life.
Uncover the significance of obesity medicine combined with chiropractic practice in enhancing patient care and achieving better health results.
Educational Abstract
In this comprehensive educational post, I, Dr. Alex Jimenez, share a first-person, evidence-based journey through modern obesity care across the lifespan. With credentials as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Family Nurse Practitioner-Board Certified (FNP-BC), and certifications in Functional Medicine (CFMP, IFMCP), among others, I offer a unique, multidisciplinary perspective. This guide is designed for clinicians, staff, and healthcare leaders seeking to build or optimize a high-quality integrative obesity program. I explain how our team at Injury Medical Clinic, P.A. (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, frames obesity as a chronic, relapsing, multifactorial disease and translates that understanding into actionable practice models. Our clinic’s strength lies in its collaborative structure, led by our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (NPI #1164426749, Texas MD License #J2933). A board-certified internal medicine physician with over 40 years of experience, Dr. Cardenas provides crucial medical oversight to ensure our integrative protocols meet the highest standards of safety and efficacy. Together, we integrate internal medicine, chiropractic care, functional medicine, rehabilitation, and personal injury services to deliver comprehensive, patient-centered care. This post offers a detailed roadmap covering the four pillars of obesity treatment—nutrition, physical activity, behavioral counseling, and medical management (including pharmacotherapy and bariatric surgery referrals). I provide pragmatic workflows for various practice models, including guidance on billing and coding (time-based vs. MDM), Medicare services like Intensive Behavioral Therapy (IBT) and Chronic Care Management (CCM), and innovative tools like Remote Patient Monitoring (RPM). We will explore the physiological underpinnings of obesity, the importance of reducing bias and using person-first language, and how to create a weight-inclusive clinical environment. My goal is to equip you with a compassionate, scientifically grounded template to implement sensitive, effective, and sustainable obesity treatment programs.
Introduction: My First-Person Journey to Building a Modern, Patient-Centered Obesity Program
I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. For decades, I have devoted my clinical practice to integrative, trauma-informed, evidence-based care, with a central focus on metabolic health, functional rehabilitation, and personalized medicine. In daily practice, I witness how language, imagery, coding, and care design either reinforce old stigmas or usher in a better way—one that recognizes obesity as a chronic, relapsing, multifactorial disease that deserves precise diagnosis, compassionate communication, and coordinated, evidence-based treatment. In El Paso, Texas, our Injury Medical Clinic, P.A. (Mission Plaza Injury Medical Clinic) operates as a multidisciplinary ecosystem where internal medicine, chiropractic, functional medicine, and rehabilitation intersect to treat complex chronic conditions, including obesity. Working hand-in-hand with our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD—board-certified in internal medicine (NPI #1164426749, Texas MD License #J2933)—we deliver coordinated care that respects obesity’s chronic nature. Dr. Cardenas brings over 40 years of internal medicine experience, guiding medical oversight, safety, diagnostic rigor, and pharmacotherapeutic strategies. My role emphasizes integrative chiropractic biomechanics, musculoskeletal optimization, functional medicine assessment, and rehabilitation planning. This multidisciplinary setup, where an MD provides medical direction alongside a chiropractor, is common and highly effective in modern integrative and injury care clinics, ensuring continuity, safety, and comprehensive outcomes. Together, we build individualized programs that incorporate nutrition therapy, physical activity prescription tailored to pain and function, behavioral counseling, and medical management, including pharmacotherapies and referral to bariatric surgery when indicated. In this post, I will walk you through an actionable model to structure obesity care within primary care practices, specialty clinics, and standalone programs. I reframe obesity as a chronic, multifactorial disease requiring dedicated, obesity-specific appointments, regular follow-up (often averaging 16 visits in the first year for optimal outcomes), and collaborative workflows that reduce stigma and enhance access. The physiological underpinnings—neurohormonal regulation, adipose tissue biology, energy balance, biomechanics, pain, sleep, stress, and gut health—are explored in depth to explain why each therapeutic lever matters. My goal is to give you a clear, compassionate, scientifically grounded template for obesity care that you can adapt to your setting, whether you are starting with a single dedicated clinic session per week or designing a fully integrated multidisciplinary center.
Our Collaborative Practice: Integrating Chiropractic and Medical Expertise
Before we dive into the specifics of obesity management protocols, I believe it’s essential to set the stage by explaining our practice’s unique structure. Our clinic is built on integrative, multidisciplinary care. This model is not just a philosophy but a functional reality that allows us to provide a truly holistic level of service, particularly for patients dealing with complex conditions like chronic obesity, metabolic dysfunction, and personal injuries. A cornerstone of our practice is my collaborative relationship with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected physician, board-certified in Internal Medicine, with an incredible four decades of experience. She serves as our Medical Director and Collaborative Physician, bringing a depth of medical knowledge that is simply invaluable. This partnership between a Doctor of Chiropractic (like myself, with additional APRN and functional medicine credentials) and an Internist (Dr. Cardenas) is a powerful synergy.
How Our Integrated Team Functions
So, what does this collaboration look like in practice?
Medical Oversight and Direction: Dr. Cardenas provides essential medical direction for our clinic. This includes overseeing protocols for prescription drug management, reviewing complex medical cases, and ensuring that our diagnostic and treatment plans meet the highest standards of medical care. When we are managing a patient’s GLP-1 medication or addressing comorbidities like hypertension and type 2 diabetes, her expertise as an internist is critical.
Chiropractic and Neuromusculoskeletal Care: As a Doctor of Chiropractic, my role focuses on the body’s structure and its relationship to overall function. For our patients with obesity, this is incredibly important. Excess weight places enormous stress on the musculoskeletal system, leading to chronic low back pain, knee arthritis, plantar fasciitis, and other biomechanical issues. Through chiropractic adjustments, spinal decompression, and soft tissue therapies, we address these structural imbalances, alleviate pain, improve mobility, and enhance nervous system function. This not only improves the patient’s quality of life but also removes a significant barrier to physical activity.
Functional Medicine and Advanced Diagnostics: As a certified functional medicine practitioner (CFMP, IFMCP), I lead our team in digging deeper to find the root causes of a patient’s health issues. Instead of just treating weight gain, we ask why it’s happening. We use advanced lab testing to look at hormonal imbalances, gut dysbiosis, nutrient deficiencies, and genetic predispositions. This allows us to create highly personalized nutrition and lifestyle plans.
Comprehensive Care Spectrum: Our team integrates rehabilitation services to restore function after an injury, provide dedicated personal injury care for accident victims, and offer nutritional and lifestyle counseling. A patient might see me for a chiropractic adjustment, consult on medication management under Dr. Cardenas’s oversight, work with our health coach on a functional nutrition plan, and engage in a rehab program to strengthen their core—all under one roof.
This integrated model ensures that we are not just managing obesity but treating the whole person. Constant communication between Dr. Cardenas and me allows us to create a seamless care experience where the medical and structural components of a patient’s health are addressed in a coordinated fashion.
Understanding Obesity as a Chronic, Relapsing, Multifactorial Disease
Obesity is a chronic, relapsing, heterogeneous disease characterized by excess adiposity that impairs health. It is not a personal failure, nor a short-term issue solved with quick fixes. Modern evidence shows that sustained management requires ongoing care—structured visits, targeted interventions, and a respectful, bias-aware environment. Key points:
Obesity behaves like other chronic conditions—such as diabetes, hypertension, and dyslipidemia—requiring long-term strategies rather than one-time solutions.
Dedicated, obesity-specific appointments are essential. Trying to address obesity “on the fly” during unrelated visits rarely allows enough time to take a comprehensive history, perform a physical and functional exam, and co-create a treatment plan.
Regular follow-up is linked to better outcomes. Data suggest that about sixteen visits in the first year are associated with improved weight loss and cardiometabolic outcomes; intensifying early on, then spacing visits as the condition stabilizes, is a pragmatic pattern.
Insurance coverage can influence feasible visit frequency. Plan workflows around coverage realities, supplement with telemedicine and group visits, and leverage allied health professionals to maintain contact.
Why this approach matters:
Chronic care models improve adherence and health outcomes across diseases; obesity is no exception.
Obesity’s relapsing nature—driven by neurohormonal adaptations and environmental pressures—demands continuity, not episodic care.
When we structure appointments intentionally, we can address root contributors—genetic predisposition, endocrine signals, psychosocial factors, sleep, stress, gut health, and musculoskeletal limitations—and tailor interventions responsibly.
Foundational Physiology of Obesity: A Systems View for Clinicians
Understanding obesity’s physiology informs our protocols and patient communication. I approach this as a dynamic systems disorder characterized by interactions across neuroendocrine signaling, immunity, metabolism, microbiome, biomechanics, and behavior. Key Mechanistic Domains:
Energy Homeostasis and Neuroendocrine Control:
Hypothalamic Regulation: Signals from leptin, insulin, ghrelin, peptide YY, GLP-1, and cholecystokinin converge to influence appetite, satiety, and energy expenditure. Leptin resistance undermines satiety signaling; ghrelin dynamics affect hunger.
Reward Pathways: Dopamine circuits modulate food salience; stress and sleep loss amplify hedonic drives.
Adaptive Thermogenesis: Weight loss decreases resting energy expenditure beyond predictions, encouraging regain; this underscores the need for sustained, supportive care.
Adipose Tissue Biology:
Hypertrophy vs. Hyperplasia: Enlarged adipocytes promote hypoxia, low-grade inflammation, and impaired insulin signaling.
Ectopic Lipid Deposition: Accumulates in the liver and muscle, exacerbating insulin resistance and metabolic dysfunction.
Adipokines and Cytokines: Imbalances in adiponectin, leptin, TNF-alpha, and IL-6 contribute to cardiometabolic risk.
Musculoskeletal Interplay:
Joint Loading and Pain: Mechanical stress increases in weight-bearing joints, altering gait and posture; pain limits activity, creating a cycle of deconditioning.
Sarcopenic Obesity: Reduced muscle mass with increased fat mass impairs glucose disposal and function; resistance training becomes a cornerstone.
Sleep and Circadian Rhythm:
Sleep Restriction: Increases ghrelin and decreases leptin, dysregulating appetite, increasing caloric intake, and impairing glucose tolerance.
Chronic Stress: Elevates cortisol, alters food choices, and impairs motivation.
Weight Stigma: Increases avoidance of care, reduces physical activity in public spaces, and worsens health outcomes independent of BMI.
The Four Pillars of Obesity Treatment: A Multidisciplinary Framework
In our program, the four pillars anchor care. Each pillar interacts with the others biologically and behaviorally, reinforcing momentum.
1. Nutrition Therapy: Physiology, Methods, and Personalization
Physiology: Appetite regulation involves ghrelin (orexigenic), leptin (satiety; often resistant in obesity), peptide YY, GLP-1, and insulin. Reward pathways and hyperpalatable foods drive hedonic intake beyond energy needs. Insulin resistance and hepatic steatosis alter substrate handling; reducing carbohydrate load and fructose can improve hepatic fat and insulin sensitivity. Methods:
Personalized eating patterns: Mediterranean-style, higher-protein plans, lower-carbohydrate strategies, time-restricted eating, or structured meal replacements. We adapt plans to cultural cuisines and budget constraints.
Focus on protein adequacy (generally 1.2–1.6 g/kg of adjusted body weight for weight loss phases), fiber density, and low-energy-density foods to improve satiety.
Address ultra-processed food exposure and reward-system dynamics; incorporate shopping skills, cooking education, and food environment restructuring.
Medical nutrition therapy for comorbidities: NAFLD/MASLD, insulin resistance, PCOS, hypertension.
Why it works: A sustained negative energy balance is necessary for weight loss; nutrient composition supports satiety and preserves lean mass. Reducing ultra-processed foods lowers hyperpalatable stimuli and reduces hedonic overeating. Tailoring to comorbid conditions enhances safety and adherence.
2. Physical Activity Prescriptions: Graded, Safe, and Function-Oriented
Physiology: Movement enhances energy expenditure, improves insulin sensitivity, preserves and builds lean mass, supports mental health, and reduces chronic pain through improved biomechanics. Resistance training preserves lean mass, helping maintain basal metabolic rate during weight loss. Aerobic exercise improves mitochondrial biogenesis and cardiovascular health. Methods:
Begin with low-impact options: walking, cycling, swimming, or aquatic therapy.
Progressive resistance training 2–3 days/week to maintain lean mass and metabolic rate; focus on compound movements scaled to function (e.g., chair stands, resistance bands, supported deadlifts).
Movement prescriptions integrated with chiropractic and rehabilitation when pain or postural dysfunction limits activity.
Non-exercise activity thermogenesis (NEAT) strategies to increase daily movement.
Integrate chiropractic-guided corrective exercises for posture and core stability.
Why it works: Preserving lean mass mitigates metabolic adaptation during weight loss. Strengthening corrects kinetic chain imbalances contributing to pain, allowing sustainable activity. Physical activity enhances mitochondrial function and cardiometabolic health beyond weight outcomes.
3. Behavioral Counseling: Skills That Sustain Change
Physiology: Sustained habit change requires skills such as self-monitoring, stimulus control, cognitive restructuring, and coping strategies. Chronic stress from stigma elevates cortisol, disrupts sleep, and worsens insulin resistance and visceral adiposity. Mindfulness improves interoception and reduces reward-driven overeating. Methods:
Health coaching for goal setting, problem-solving, and accountability, often using motivational interviewing.
Psychotherapy for depression, anxiety, trauma, or eating disorders when present.
Group-based support, peer accountability, and digital self-monitoring tools.
Cognitive reframing: Shift focus from weight to health behaviors; celebrate process milestones.
Relapse planning: Anticipating high-risk situations and setting recovery steps.
Why it works: Behavioral skills enhance adherence and resilience. Addressing mood and stress physiology improves appetite regulation and sleep, reducing relapse. Psychological safety increases adherence to nutrition, activity, medications, and follow-ups.
4. Medical Management: Pharmacotherapy and Comorbidity Care
Physiology: Medications modulate appetite and energy balance via central and peripheral pathways. For example, GLP-1 receptor agonists reduce appetite, slow gastric emptying, and improve insulin secretion and sensitivity. Methods:
Select anti-obesity medications (AOMs) based on phenotype, comorbidities, and contraindications under medical oversight. This includes GLP-1 receptor agonists, dual incretin therapies (GIP/GLP-1), and other approved medications per current guidelines.
Manage obesity-related comorbidities: type 2 diabetes, hypertension, dyslipidemia, OSA, NAFLD/MASLD, osteoarthritis.
Refer for bariatric surgery when indicated; coordinate prehab and rehab to optimize outcomes.
Why it works: Medications can be transformative when tailored and monitored. Comorbidity management improves safety and function, enabling activity and adherence. Surgery can produce durable weight loss and metabolic improvements in selected patients; integrated care maximizes benefits.
Balancing Body and Metabolism- Video
Integrative Chiropractic Care in Obesity Management: Biomechanics, Pain, and Functional Capacity
Integrative chiropractic is a key component of our multidisciplinary approach. Obesity frequently coexists with pain syndromes and postural dysfunction. These biomechanical issues can limit activity, creating a feed-forward cycle of deconditioning. Chiropractic evaluation and targeted interventions break that cycle. Clinical Rationale:
Excess adiposity shifts the center of mass anteriorly, increasing lumbar lordosis, pelvic tilt, and stress on load-bearing joints such as the knees and hips.
Compensatory postures lead to paraspinal hypertonicity, reduced thoracic mobility, and altered gait mechanics; pain follows and discourages movement.
Myofascial restrictions, trigger points, and joint dysfunction limit range of motion and increase the effort cost of activity.
Interventions:
Spinal and extremity adjustments to restore joint function, reduce nociceptive input, and improve proprioception.
Soft tissue therapies: myofascial release, instrument-assisted soft tissue mobilization, cupping, and neuromuscular re-education to normalize tone and improve tissue glide.
Postural retraining, breathing mechanics optimization, and core stabilization to distribute loads efficiently.
Progressive, pain-sensitive exercise prescriptions integrating mobility and strength, with graded exposure to activity to build confidence.
Why This Matters Clinically: By improving joint motion and reducing pain, chiropractic care can lower pain levels, improve movement efficiency, and enable progressive exercise. This enhanced activity capacity is a keystone for metabolic improvement. Better movement competence improves adherence to exercise prescriptions, a critical determinant of long-term success.
Internal Medicine Oversight: Safety, Diagnostics, and Medical Direction
Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine, serves as our Medical Director and Collaborative Physician. Her role ensures that our integrative program meets high standards of safety, diagnostic precision, and medical integrity. Responsibilities:
Comprehensive internal medicine evaluation: metabolic, cardiovascular, endocrine, and sleep assessments.
Pharmacotherapy supervision: selecting, dosing, and monitoring anti-obesity medications and comorbidity treatments, including GLP-1 receptor agonists.
Risk stratification: identifying patients who require closer monitoring, cardiology referral, or specialist evaluation.
Surgical coordination: ensuring patients meet bariatric referral criteria and overseeing perioperative medical care.
Quality assurance and compliance: aligning protocols with current evidence and regulatory standards.
t: Medical oversight reduces adverse events, optimizes medication choices, and integrates comorbidity care. Collaboration with chiropractic and rehabilitation ensures the safe progression of activity in medically complex patients. Patients benefit from a consistent, trusted, evidence-based, and personalized framework.
Functional Medicine Integration: Systems Biology Applied to Obesity
Functional medicine complements internal medicine and chiropractic by taking a systems biology view of the patient. We examine the interconnected networks influencing weight: nutrition, energy metabolism, inflammation, gut health, hormones, sleep, stress, and toxins. Key Elements:
Personalized nutrition with elimination of trigger foods, gut-directed therapies for dysbiosis, and micronutrient repletion.
Inflammation modulation through dietary patterns and lifestyle change.
Sleep optimization: screening and treatment for OSA, sleep hygiene, and circadian rhythm alignment.
Stress physiology: HPA-axis support and mindfulness practices to reduce hyperphagic responses.
Environmental exposures: addressing ultra-processed foods and sedentary hazards.
Why integrate functional medicine: Complex obesity phenotypes benefit from personalized, root-cause investigations that guide targeted interventions. Combining internal medicine safety with functional assessments yields holistic plans that are both evidence-based and individualized.
Sensitivity Training and Bias Reduction: Creating a Respectful, Person-First Environment
Patients with obesity frequently encounter stigma in healthcare settings. Reducing bias improves trust, adherence, and outcomes. Shame reduces engagement in care and heightens stress physiology. Positive framing, by contrast, increases adherence and reduces defensiveness. Core Elements:
Use person-first language: We say “a person with obesity,” not “an obese person.” We adopt neutral descriptors like “severe obesity, class 3” instead of “morbid obesity.” In notes, we document “barriers to adherence identified” instead of “noncompliant.”
Eliminate stigmatizing imagery: We avoid pictures that show individuals with heads cropped off or engaging in stereotypical behaviors. We choose empowering visuals of people of diverse body sizes engaged in daily life.
Provide appropriate equipment:large blood pressure cuffs, sturdy and comfortable seating, accessible exam tables, and weight-inclusive gowns.
Privacy and dignity in weigh-in procedures: Offer “no-scale” days and ask patients if they want to know their weight.
Staff training on obesity as a chronic disease, not a moral failing. We use role-playing to practice person-first language and active listening.
Why it matters: A respectful environment fosters strong therapeutic relationships and long-term success. Safety and comfort reduce anxiety, improving heart rate variability and perceived control.
Mastering the Fundamentals: Time-Based Billing vs. Medical Decision-Making (MDM)
One of the most critical aspects of building a sustainable obesity management practice is understanding how to bill for your services accurately and ethically. Two primary pathways exist for billing Evaluation and Management (E&M) services: billing by time and billing by medical decision-making (MDM).
Patient Status
CPT Code
Total Time Required for Time-Based Billing
New Patient
99202
15-29 minutes
99203
30-44 minutes
99204
45-59 minutes
99205
60-74 minutes
Established Patient
99212
10-19 minutes
99213
20-29 minutes
99214
30-39 minutes
99215
40-54 minutes
Unpacking Time-Based Billing
When you bill based on time, total documented time determines the CPT code. This method is often ideal for obesity-focused visits because much of the encounter focuses on counseling, education, and behavioral coaching. “Time” includes total time spent by the billing provider on the date of the encounter, including pre-visit chart review, face-to-face time, and post-visit documentation and order placement. A Practical Example of Time-Based Billing: At the end of my visit note, I add a time attestation statement: “I spent a total of 33 minutes today on this patient’s care. This time was spent on:
History, Exam, and Ordering (during visit): 5 minutes for the face-to-face examination and order entry.
Treatment Planning & Counseling (during visit): 20 minutes for extensive counseling on nutritional strategies, medication mechanisms, and behavioral goal-setting.
Updating Chart (post-visit): 5 minutes to finalize documentation and send prescriptions.
Total Time = Time in minutes. This total time in minutes for an established patient directly correlates with a CPT code 99214.
Decoding Medical Decision-Making (MDM)
The second option for billing is based on the complexity of your Medical Decision-Making (MDM), which is determined by:
Number and Complexity of Problems Addressed
Amount and/or Complexity of Data to Be Reviewed and Analyzed
Risk of Complications and/or Morbidity or Mortality of Patient Management
To bill at a certain level, you must meet the requirements for that level in at least two of these three categories. A key element is that any visit involving prescription drug management—initiating, continuing, or modifying any prescription medication—signals at least moderate risk, which supports a Level 4 code (99214). This is particularly relevant for short telehealth visits where a medication dose is changed.
ICD-10-CM Coding and Documentation
Accurate coding is not just about reimbursement; it’s about representing the true burden of disease. The 2024 ICD-10-CM updates improve accuracy and support stigma-free language.
Always pair E codes (obesity) with Z codes (BMI). If documenting obesity, record a same-day BMI and link the corresponding Z code.
Use specific codes for pediatric and adult patients that reflect BMI class and complications (e.g., hypertension, type 2 diabetes, dyslipidemia).
Document medical necessity by detailing functional limitations, comorbidity risks, and health impact.
Expanding Your Services: Beyond the Standard Office Visit
To create a comprehensive program, we must think beyond traditional E&M visits. Several other billable service categories can enhance patient outcomes and practice sustainability.
Service Category
Payer
Associated CPT/HCPCS Codes
Key Function
Intensive Behavioral Therapy (IBT)
Medicare
G0447, G0473
Behavioral change for sustained weight loss
Preventive Care Counseling
Commercial
99401-99404
Behavioral counseling for risk factor reduction
Chronic Care Management (CCM)
Medicare
99490, 99491, 99487, 99489
Non-face-to-face care coordination
Remote Patient Monitoring (RPM)
Medicare/Commercial
99453, 99454, 99457, 99458
Remote data collection and management
Medicare Intensive Behavioral Therapy (IBT) for Obesity
IBT is a specific Medicare benefit for behavioral change interventions. The key code is G0447 (face-to-face behavioral counseling for obesity, 15 minutes). This is not an E&M visit; the focus must be exclusively on behavior, nutrition, and exercise, with no discussion of comorbidities or medication management. Qualified staff, such as an RN or health coach, can render these services under your direct supervision, freeing you for more complex E&M visits.
Preventive Screening and Counseling for Commercial Insurance
For commercial insurance patients, Preventive Counseling codes (99401-99404) serve a similar function. These time-based sessions focus on diet, exercise, and lifestyle modifications. Unlike IBT, you cannot bill these codes on the same day as a standard E&M visit.
Medicare Chronic Care Management (CCM)
CCM compensates you for the non-face-to-face time yoTimed your staff spends coordinating care for patients with two or more chronic conditions. This includes phone calls, prescription refills, and reviewing records between appointments. Using codes like 99490 (first 20 minutes of clinical staff time) provides a framework for monthly check-ins, keeping patients engaged and accountable.
The Future is Now: Remote Patient Monitoring (RPM)
RPM leverages technology like 5G-enabled smart scales, blood pressure cuffs, and glucometers to gather objective data between visits. The device must be FDA-approved and paid for by the practice. Key codes include 99453 (setup), 99454 (device supply and data transmission for 16+ days a month), and 99457 (first 20 minutes of management time). RPM provides real-time data and accountability, which is phenomenal for engagement.
Crafting the Patient Journey: A 6-Month Care Plan Roadmap
Together, we can create a high-touch care plan that fosters accountability and allows rapid course correction. The evidence overwhelmingly supports that patients with frequent contact achieve the best outcomes.
Monthly Follow-up Visits: E&M visits for medical management (99214).
Bi-Weekly Preventative Counseling Visits: 15-30 minute sessions with an RN/coach (99401/99402 on separate days).
Ongoing RPM: Monthly data uploads and staff follow-up (99454 + 99457).
This model provides a touchpoint with your clinic every single week.
The Medicare Patient Journey
Visit 1 (Week 1): Initial Consultation (E&M Visit, 99204/99205) plus a 15-minute IBT session (G0447) with a -25 modifier.
Monthly Follow-up Visits: E&M visits for medical management (99214).
Weekly/Bi-Weekly IBT Visits: 15-minute behavioral sessions with staff (G0447).
Ongoing CCM and RPM: Non-face-to-face support (99490) and remote data management (99454 + 99457).
This high-touch model provides weekly contact, robust support, and continuous education, which are crucial for long-term success.
Final Thoughts: A Compassionate, Evidence-Based Path Forward
Obesity care thrives in multidisciplinary, patient-centered environments. By combining internal medicine oversight, integrative chiropractic, functional medicine, behavioral coaching, and thoughtful program design, clinics can deliver durable improvements in health and quality of life. Our comprehensive model at Injury Medical Clinic, P.A. values empathy, science, and practicality—meeting patients where they are and supporting them as partners in their journey. Building a practice that effectively manages obesity is complex but incredibly rewarding. By mastering these billing and care strategies, you can build a program that is not only clinically effective but also financially sustainable, helping more people for years to come. For more on my clinical perspectives and practice focus, visit: ChiroMed site: [https://chiromed.com/] LinkedIn profile: [https://www.linkedin.com/in/dralexjimenez/]
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Peptide therapy is becoming an important topic in integrative medicine, metabolic health, weight management, hormone care, and physical recovery. However, not every peptide sold online or discussed on social media is FDA-approved or appropriate for medical treatment. Legal peptide use depends on the specific medication, its FDA status, how it is prescribed or compounded, the patient’s medical needs, and federal and state laws.
At ChiroMed – Integrated Medicine in El Paso, Texas, an integrative model can bring medical evaluation, nurse practitioner services, chiropractic care, functional medicine, nutrition, and rehabilitation together. Medical providers handle evaluation and prescription decisions within their professional authority, while chiropractic care focuses on biomechanics, joint function, movement, strength, and musculoskeletal rehabilitation. This article explains how these roles can work together while keeping peptide treatment patient-centered, medically appropriate, and within professional scope.
What Is Legal Peptide Therapy?
Peptides are short chains of amino acids. Amino acids are the building blocks of proteins, and many naturally occurring peptides act as signals inside the body.
Some peptide-based medicines have established medical uses. Others remain experimental or have limited evidence in people.
The important question is not simply, “Are peptides legal?”
A better question is:
Is this specific peptide legally available and medically appropriate for this particular patient, from this particular source, and for this particular use?
Legal medical use can include several different situations:
An FDA-approved peptide-based drug used for an approved indication
An FDA-approved medication prescribed for a medically appropriate off-label use
A compounded medication prepared under applicable federal and state requirements
An investigational drug being used through an authorized research pathway
These categories are not interchangeable.
The FDA makes an especially important distinction regarding compounded medications. Compounded medications can serve a medical need for certain patients, but they are not FDA-approved. The FDA does not review each compounded medication for safety, effectiveness, or manufacturing quality before it reaches the patient (U.S. Food and Drug Administration [FDA], 2026a).
Why “Research Peptides” Are Different
Patients may see peptides advertised online with labels such as:
“Research use only”
“Not for human consumption”
“Laboratory use only”
These labels should not be confused with an FDA-approved prescription medication or a lawfully prepared compounded prescription.
The fact that a chemical can be purchased through a website does not establish that it is approved or appropriate for human treatment.
This is especially important because peptide regulation continues to change. Different substances may have different FDA classifications, compounding restrictions, safety concerns, and available evidence.
Under Sections 503A and 503B of the Federal Food, Drug, and Cosmetic Act, the FDA limits which bulk drug substances may be used. These lists and regulatory policies can change as new evidence becomes available (FDA, 2026b).
For this reason, healthcare professionals should evaluate the current regulatory status of the specific peptide rather than assuming that all peptides fall into the same category.
Compounded Peptides Require Special Attention
Compounding can be valuable when a commercially available FDA-approved medication cannot meet a patient’s individual medical need.
For example, a patient might need a different dosage form because of an allergy or another clinical concern.
However, compounding does not automatically make a peptide legal, FDA-approved, or appropriate.
Under federal rules, Section 503A compounders face requirements about which bulk substances they may use. Section 503B outsourcing facilities also operate under specific limits regarding bulk substances and drug shortages (FDA, 2026b).
Patients should understand an important difference:
An FDA-approved medication and a compounded version of a medication are not the same regulatory product.
The FDA states that compounded drugs have not gone through FDA premarket approval for safety, effectiveness, and quality (FDA, 2026a).
This makes pharmacy selection, clinical justification, documentation, dosing, patient education, and follow-up especially important.
What the New Mexico Board of Nursing Says
The September 2026 New Mexico Board of Nursing Peptide Therapies FAQ provides a useful example of how one state nursing board is approaching this rapidly changing field.
The Board emphasizes that its FAQ provides general interpretation only. It specifically states that the document is not a legal opinion and cannot be cited as legal authority.
The guidance states that APRNs prescribing compounded medications should remain within their education, experience, population focus, and prescriptive authority. It also emphasizes a valid provider-patient relationship, appropriate history and physical examination, clinical justification, informed consent, monitoring, and documentation.
The Board also recommends that clinicians:
Make sure compounding is legally permitted
Use appropriately licensed pharmacies
Explain when a patient is receiving a compounded medication
Document the reason for using the compounded product
Avoid questionable or unverified sources
The New Mexico guidance is useful for understanding professional safety principles, but ChiroMed is located in Texas. Therefore, Texas law and Texas professional licensing requirements govern care delivered in Texas.
Chiropractic and Medical Roles Must Remain Clear in Texas
ChiroMed describes itself as an integrated healthcare practice bringing chiropractic care, nurse practitioner services, rehabilitation, nutrition, and other healthcare disciplines together in one setting.
Clear professional roles are important in this type of practice.
Under Texas Occupations Code §201.002, chiropractic practice includes evaluation of the biomechanical condition of the spine and musculoskeletal system and nonsurgical, noninvasive procedures intended to improve musculoskeletal biomechanics.
The same law states that chiropractic practice does not include prescribing controlled substances, dangerous drugs, or other prescription drugs.
Therefore, a clinician cannot prescribe peptides under a Texas chiropractic license alone.
This distinction is especially important for a clinician such as Dr. Alexander Jimenez, DC, APRN, FNP-BC, who holds both chiropractic and advanced practice nursing credentials.
His chiropractic license supports chiropractic and musculoskeletal care. Medical evaluation and prescription decisions must be performed under the appropriate APRN authority and applicable Texas rules.
The Nurse Practitioner’s Role in Peptide Therapy
Texas APRNs who prescribe medications must meet Texas requirements for prescriptive authority.
Texas law allows qualified APRNs and physicians to enter into prescriptive authority agreements. These agreements define the practice setting, medication categories, consultation, communication, quality assurance, and referral processes.
This makes the medical side of peptide therapy different from chiropractic treatment.
Depending on the patient’s needs, the medical evaluation may include:
Medical history
Current medications and supplements
Physical examination
Laboratory testing
Contraindications and risk factors
Diagnosis
Treatment alternatives
Medication selection
Informed consent
Follow-up laboratory testing
Response to treatment
Side-effect monitoring
Do not select a peptide simply because it is popular.
The patient’s diagnosis, health history, goals, risks, available evidence, and legal treatment options should guide the medical decision.
ChiroMed’s Multidisciplinary Model
At ChiroMed – Integrated Medicine, the goal is to bring different parts of healthcare together rather than treating each problem in isolation.
ChiroMed describes its services as including chiropractic care, nurse practitioner services, rehabilitation, nutrition, and integrative approaches for patients with musculoskeletal, injury, chronic pain, and wellness concerns.
The multidisciplinary team also includes Dr. Maria Guadalupe Cardenas, MD, whom ChiroMed identifies as a board-certified internal medicine physician, Medical Director, and Collaborative Physician with more than four decades of experience.
Public NPI information lists Dr. Maria Guadalupe Cardenas as an internal medicine physician in El Paso with NPI 1164426748 and Texas medical license J2933.
Within this model, Dr. Cardenas provides medical direction and internal medicine experience alongside Dr. Jimenez’s work in advanced practice nursing, chiropractic care, functional medicine, injury management, and rehabilitation.
The goal is coordinated care, while each clinician works within the appropriate professional scope.
How Chiropractic Care Can Complement Peptide Treatment
Chiropractic treatment should not be promoted as making a peptide medication more powerful.
Instead, these treatments may address different parts of a patient’s overall health and recovery.
A medically managed therapy may address a specific metabolic, hormonal, or medical problem.
Chiropractic and rehabilitation care can focus on the patient’s ability to move and function.
At ChiroMed, integrative chiropractic care may support:
Joint mobility
Spinal biomechanics
Range of motion
Posture
Muscle balance
Functional strength
Neuromuscular coordination
Progressive exercise
Return to normal activities
Injury rehabilitation
ChiroMed’s published clinical model emphasizes connecting medical evaluation with chiropractic care and rehabilitation rather than replacing one healthcare profession with another.
This can be particularly useful when a patient has both a medical concern and a musculoskeletal limitation.
For example, a patient receiving medical weight-management treatment may need help maintaining muscle mass, increasing activity, and improving physical function.
Strength and Muscle Preservation Matter
Muscle health deserves special attention during some medical weight-management programs.
The New Mexico Board of Nursing guidance recommends attention to:
Adequate protein
Resistance exercise
Preservation of lean body mass
Vitamin and nutrient intake
Long-term lifestyle changes
Rehabilitation and integrative chiropractic care may fit naturally into a broader treatment plan.
A patient with back pain, knee pain, poor mobility, or an old injury may find exercise difficult. Treating mechanical barriers and developing a progressive rehabilitation program may help that person become more physically active.
The goal is not simply weight loss.
It is to help patients maintain:
strength + mobility + muscle + function.
Clinical Observations From Dr. Alexander Jimenez
In his clinical writings, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CCST, CFMP, IFMCP, ATN, describes health and recovery through a systems-based approach.
Instead of relying on one treatment, his clinical model connects areas such as:
Chiropractic biomechanics
Functional medicine
Nutrition
Musculoskeletal rehabilitation
Laboratory findings when appropriate
Strength and conditioning
Injury recovery
Medical evaluation
Lifestyle modification
This philosophy is also reflected throughout ChiroMed’s published material, which describes integrated injury care as a combination of medical evaluation, chiropractic care, functional medicine, rehabilitation, and other supportive options.
Peptide treatment, when medically appropriate and legally available, can therefore be one part of a larger care plan, not a replacement for good nutrition, exercise, rehabilitation, sleep, or medical monitoring.
A Patient-Centered Approach to Peptide Therapy
Responsible peptide treatment should begin with the patient—not with a product.
Before considering treatment, the healthcare team should determine:
What problem is being treated?
Is there an established diagnosis?
Is the medication FDA-approved?
If it is compounded, why is compounding medically appropriate?
Is there reasonable evidence supporting its use?
What are the risks and alternatives?
Does the patient’s medical history create contraindications?
What monitoring will be needed?
Who is responsible for prescribing and follow-up?
Is the pharmacy properly licensed?
Is the treatment permitted under current federal and state requirements?
The New Mexico Board’s guidance similarly emphasizes history, examination, laboratory testing when indicated, informed consent, documentation, treatment response, adverse effects, and follow-up.
Integrating Medicine, Movement, and Recovery at ChiroMed
The future of integrative healthcare is not about one profession trying to perform every type of treatment.
It is about different professionals contributing their expertise to the same patient.
At ChiroMed – Integrated Medicine in El Paso, chiropractic care can address biomechanics, movement, spinal and joint health, physical strength, and rehabilitation. Advanced practice nursing can provide appropriate medical evaluation and treatment within APRN scope and Texas prescriptive authority. Internal medicine leadership can add another layer of medical direction and clinical coordination.
Nutrition, functional medicine, personal injury care, and rehabilitation can then support the patient’s larger goals.
This creates a practical model:
Medical care addresses medical needs. Chiropractic care addresses biomechanics and musculoskeletal function. Rehabilitation develops strength and movement. Nutrition provides the building blocks for recovery. Medical oversight helps keep the entire plan appropriate and coordinated.
Peptide science will continue to change. Some peptide-based medications already have established medical roles, while other substances remain investigational, restricted, or supported by limited human evidence.
For patients and clinicians alike, the safest approach is to focus on evidence, professional scope, current regulations, appropriate medical evaluation, legitimate pharmacy sources, and careful follow-up.
At ChiroMed, integrated care means looking beyond one medication or one adjustment and building a treatment plan around the health and functional needs of the whole person.
Unlock the benefits of integrative strategies for insulin resistance and take charge of your health today.
Abstract
For decades, the standard approach to managing insulin resistance has centered on dietary restrictions, often with frustratingly limited success. Many individuals find that even strict low-carbohydrate, ketogenic, or carnivore diets fail to resolve the underlying metabolic dysfunction fully. This educational post explores the deeper physiological reasons for this phenomenon, moving beyond surface-level dietary changes to address the root causes of metabolic inflexibility. As Dr. Alex Jimenez, I will guide you through the cellular mechanisms that perpetuate insulin resistance, including compromised mitochondrial function, chronic inflammation, and cellular “deafness” to insulin signals. We will explore the latest scientific findings from leading researchers, highlighting innovative therapeutic agents like 5-amino-1MQ, retatrutide, and MOTS-c, which show remarkable promise in restoring insulin sensitivity and metabolic health. This discussion will also detail a practical “daily audit” protocol, integrating strategic nutrition with continuous glucose monitoring to empower you with real-time feedback on your metabolic status. We’ll also explain how our multidisciplinary practice at Injury Medical Clinic PA integrates advanced functional medicine with chiropractic care and medical oversight from our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD, to provide a comprehensive, personalized approach to reversing insulin resistance and reclaiming your health.
A Multidisciplinary Approach to Whole-Body Health at Injury Medical Clinic
Before we dive into the complex world of cellular metabolism, it’s important to understand the care framework we provide at our clinic. My name is Dr. Alex Jimenez, and I hold certifications as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN) and Family Nurse Practitioner (FNP-BC), a Certified Functional Medicine Practitioner (CFMP), and an Institute for Functional Medicine Certified Practitioner (IFMCP), among other advanced credentials in anti-aging and clinical cellular science. Our practice, Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, is located in El Paso, Texas, and is built on a foundation of integrative, multidisciplinary care.
I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD, our Medical Director and Collaborative Physician. Dr. Cardenas is Board Certified in Internal Medicine and brings over 40 years of invaluable experience as an internist to our team. Her extensive medical expertise (NPI #1164426749, Texas MD License #J2933) is fundamental to our ability to offer a truly holistic patient experience. This collaborative model, where a chiropractor with advanced training in functional medicine works alongside a seasoned medical doctor, allows us to bridge gaps between healthcare disciplines. We combine the strengths of chiropractic care—focusing on musculoskeletal integrity, nervous system function, and structural health—with the diagnostic precision and medical oversight of internal medicine.
Our team integrates:
Chiropractic Care: We address spinal and joint misalignments (subluxations) that can interfere with nerve signaling, which is crucial for organ function and metabolic regulation.
Medical Oversight: Dr. Cardenas provides essential medical direction, overseeing patient cases, managing comorbidities, and ensuring all treatments are safe and medically appropriate.
Functional Medicine: We use advanced diagnostic testing to identify the root causes of chronic disease, such as nutrient deficiencies, hormonal imbalances, and gut dysbiosis.
Personal Injury & Rehabilitation: We specialize in helping patients recover from injuries, using a combination of physical therapies, chiropractic adjustments, and rehabilitative exercises to restore function and reduce pain.
This synergistic model ensures that when we address a complex condition like insulin resistance, we look at the whole person—not just their blood sugar numbers. We consider their structural health, cellular biology, lifestyle, and unique biochemistry to create a personalized, effective treatment plan.
The Frustration of Failed Diets: Why Insulin Resistance Persists
One of the most common frustrations I hear from patients is, “Doctor, I’ve tried everything. I cut out carbs, I went keto, I even did the carnivore diet, but I’m still not getting better.” They are often disheartened, feeling like their body has betrayed them despite their best efforts. The reality is that diets alone often fail to reverse severe, long-standing insulin resistance. This is not a failure of willpower; it is a failure to understand the deep-seated biological adaptations that have occurred over years, or even decades.
Imagine spending thirty years in a state of hyperinsulinemia—a condition where your pancreas is constantly pumping out high levels of insulin to manage blood glucose. Over time, your body’s cells, receptors, and mitochondria become, for lack of a better term, “trashed.” The entire system is damaged and dysregulated.
Let’s break down why this happens:
Muscle Glycogen Stores and Metabolic Inflexibility
From a basic biological standpoint, our muscles are a primary storage site for glucose, stored as glycogen. In an active individual, these glycogen stores are regularly depleted through exercise and then refilled after a meal. This is a healthy, dynamic process. However, in a sedentary lifestyle, these muscle glycogen stores remain consistently full.
Think of it like a gas tank that is never emptied. If the tank is already full, you can’t add more fuel. Similarly, if your muscle cells are packed with glycogen, they don’t need the glucose circulating in your bloodstream. They effectively put up a “No Vacancy” sign. They become insulin resistant because they are signaling that they don’t need any more fuel. Even if you switch to a low-carb, keto, or carnivore diet, muscles can remain stubbornly resistant if they aren’t metabolically challenged through physical activity. The cells have developed metabolic inflexibility; they have lost the ability to switch efficiently between burning carbohydrates and burning fat for energy.
The Liver’s Role: A Rogue Glucose Factory
While the muscles are refusing glucose, the liver becomes trapped in a vicious cycle of its own. In a state of chronic hyperinsulinemia, the liver often becomes a site for fat accumulation, a condition known as non-alcoholic fatty liver disease (NAFLD). A fatty liver is a dysfunctional liver. It becomes hyperresponsive to the hormone glucagon (which tells the liver to release glucose) and simultaneously resistant to insulin (which tells the liver to stop releasing glucose).
This creates a paradoxical and dangerous situation. Even when you diligently cut sugar and processed carbohydrates from your diet, your liver keeps pumping large amounts of glucose into the bloodstream. This process is called gluconeogenesis—literally, “the creation of new glucose.” The liver manufactures glucose from non-carbohydrate sources, such as amino acids and lactate.
So you can eat zero carbohydrates, yet your blood sugar can remain elevated because your liver has turned into a rogue glucose factory. This is a critical point that many people miss. The problem is no longer just what we’re eating; it’s deep-seated dysfunction within the liver. This state will persist until the excess visceral fat is mobilized and the liver is metaphorically “unclogged.” That’s why insulin resistance can be such a bear to resolve. It’s a deeply entrenched physiological state, not just a simple dietary problem.
A Deeper Look: Mitochondrial Dysfunction and Cellular Deafness
To truly understand insulin resistance, we have to zoom in from the organ level to the cellular and even the subcellular level. The real battle is being fought inside your cells, specifically within the mitochondria and at the insulin receptor sites.
Lipid Overload and Impaired Insulin Signaling
When you are chronically hyperinsulinemic, your body is in a constant state of “energy storage.” This leads to the accumulation of lipids (fats) not just in your fat cells, but also inside other cells, such as muscle and liver cells. These intracellular lipid deposits, known as intramyocellular lipids, directly interfere with the insulin signaling pathway.
Here’s how it works: When insulin binds to its receptor on the cell surface, it initiates a complex cascade of signals inside the cell. This cascade is like a series of dominoes falling, ultimately activating glucose transporter type 4 (GLUT4). GLUT4 is the protein that moves to the cell membrane and creates a channel for glucose to enter the cell. In a healthy cell, this process is smooth and efficient.
However, when lipids accumulate inside the cell, they create metabolic byproducts—like diacylglycerol (DAG) and ceramides—that disrupt this signaling cascade. These lipid metabolites effectively jam the machinery. They prevent the dominoes from falling. As a result, even though insulin is present and binding to its receptor, the signal to bring GLUT4 to the surface is blocked. Glucose cannot get into the cell.
I often describe this to my patients as cellular deafness. The cell is being screamed at by insulin, but it can’t “hear” the message. It’s like trying to unlock a door with the wrong key, or a bent key. The lock (the receptor) is there, the key (insulin) is there, but the internal mechanism is broken.
The Problem with Standard Lab Tests: Why HbA1c is Deceiving
This leads us to another critical point of confusion: standard lab testing. For years, the Hemoglobin A1c (HbA1c) test has been the gold standard for diagnosing and monitoring diabetes. The HbA1c measures the percentage of your hemoglobin (the protein in red blood cells that carries oxygen) that is coated with sugar (glycated). Because red blood cells live about three months, HbA1c gives you a rough average of your blood sugar over the preceding 90 days.
However, in the context of early to moderate insulin resistance, HbA1c is a totally useless, lagging indicator. At best, it lags three months behind real-time metabolic reality. I see severely insulin-resistant patients walk into my clinic every week with a “normal” HbA1c. How is this possible?
It’s possible because the pancreas is a remarkably resilient organ, at least initially. As the cells become more resistant to insulin, the pancreas compensates by working overtime, dumping gallons of insulin into the bloodstream to force the glucose into the cells. The cells are literally drowning in insulin, but because the pancreas is fighting so hard, the blood glucose levels may remain in the normal range for years. The HbA1c looks fine, but beneath the surface, the pancreas is working itself to death. This is compensated insulin resistance, and it’s a ticking time bomb. Eventually, the pancreatic beta cells will become exhausted and begin to fail, at which point blood glucose will skyrocket, and the HbA1c will finally reflect the long-standing disease process. By then, significant damage has already been done.
A Better Metric: HOMA-IR
A far more sensitive and immediate tool for assessing insulin resistance is the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). This calculation uses a simple formula that accounts for both your fasting glucose and fasting insulin levels.
This score gives us a direct snapshot of how hard your pancreas is working to maintain a normal blood sugar level. In our practice, we consider a HOMA-IR score over 1.0 to be an indication of early insulin resistance. A score over 1.9 indicates significant resistance, and a score over 2.9 is often correlated with a high risk of developing type 2 diabetes. HOMA-IR lets us detect metabolic dysfunction years, or even decades, before HbA1c becomes abnormal. It allows us to be proactive instead of reactive.
You must stop treating insulin resistance as if it’s merely a weight loss goal. If you focus only on the number on the scale, you are going to lose the battle. We need to address the underlying physiology: inflammation, mitochondrial issues, and cellular deafness.
Is Intermittent Fasting the Ultimate Weight Loss Hack?- Video
The Chiropractic Link: Nervous System Integrity and Metabolic Function
At this point, you might be wondering, “What does chiropractic care have to do with insulin and mitochondria?” The connection lies in the body’s master control system: the nervous system. The brain, spinal cord, and peripheral nerves coordinate and regulate every single function in your body, including metabolism.
The autonomic nervous system (ANS) has two main branches: the sympathetic (“fight or flight”) and the parasympathetic (“rest and digest”). A healthy metabolism depends on a proper balance between these two branches. Chronic stress—be it physical, chemical, or emotional—can lead to a state of sympathetic dominance, where the “fight or flight” response is perpetually activated. This state is characterized by the release of stress hormones like cortisol and adrenaline, which directly promote insulin resistance by signaling the liver to release glucose and making peripheral cells less sensitive to insulin.
Chiropractic adjustments work to restore proper motion and alignment to the spine, particularly in the upper cervical and thoracic regions where key autonomic nerve centers are located. By correcting vertebral subluxations—misalignments that can interfere with nerve function—we can help down-regulate the sympathetic nervous system and up-regulate the parasympathetic nervous system. This shift helps to:
Reduce circulating stress hormones.
Improve blood flow to internal organs, including the pancreas and liver.
Enhance the body’s overall ability to “rest, digest, and repair.”
By improving neurological communication between the brain and the body’s metabolic organs, chiropractic care can help create a physiological environment more conducive to healing and restoring insulin sensitivity. It is a foundational piece of the puzzle, ensuring that the body’s internal signaling pathways are clear and functioning optimally. This is a core component of how our integrated model at Injury Medical Clinic supports metabolic recovery.
Hacking the System: Novel Therapeutics to Restore Cellular Function
While lifestyle interventions like diet, exercise, and chiropractic care are foundational, for many individuals with deep-seated insulin resistance, they may not be enough to overcome the profound cellular dysfunction. This is where cutting-edge functional medicine comes in, using targeted compounds that can directly address the biochemical roadblocks we’ve discussed. Let’s explore the science behind some of the most promising agents.
Replenishing the Engine: The Role of NAD+ and 5-amino-1MQ
Let’s get into the biology for a second. One of the most critical molecules in your entire body is Nicotinamide Adenine Dinucleotide (NAD+). NAD+ is a vital cofactor—a “helper molecule”—for hundreds of enzymatic reactions. Think of it as the spark plug for your cellular engine. It is an essential electron carrier in ATP synthesis (energy production) in the mitochondria. It’s also crucial for DNA repair, gene expression, and immune function. You cannot run your biology without it.
Here’s the problem: In chronic hyperinsulinemia and inflammation, an enzyme called NNMT (Nicotinamide N-methyltransferase) becomes significantly overactive. NNMT’s primary job is to process and eliminate excess nicotinamide (a form of vitamin B3). However, when it’s in overdrive, it wreaks havoc on your NAD+ levels. It constantly consumes NAD+ by converting it to a byproduct called N1-methylnicotinamide (MNA), effectively draining your cellular battery. This constant NAD+ depletion causes mitochondria to fail and your metabolism to tank.
This is where a remarkable compound called 5-amino-1MQ comes in. 5-amino-1MQ is a small, membrane-permeable molecule that potently inhibits the NNMT enzyme. By blocking NNMT, it prevents excessive NAD+ breakdown. Simply put, it stops the leak in the bucket, allowing your cellular NAD+ pool to be replenished. It floods the system with the critical cofactor it needs to function properly.
The research on this is incredibly exciting.
A landmark study published in Cell Metabolism in 2023 showed that subcutaneous administration of 5-amino-1MQ in overweight and obese individuals significantly improved insulin sensitivity, as measured by HOMA-IR (Agerholm et al., 2023). The study found a 34% improvement in insulin sensitivity, along with reductions in body weight, fat mass, and cholesterol levels. This provides powerful evidence that targeting the NNMT enzyme can directly reverse key aspects of metabolic syndrome.
By restoring NAD+ levels, 5-amino-1MQ helps to “reboot” the mitochondria, improve energy production, and make cells more responsive to insulin signaling. It is a prime example of using targeted biochemical intervention to fix a specific, identified dysfunction.
Rewriting the Script: Retatrutide and Full Insulin Independence
For decades, the goal for many type 2 diabetes patients has been “management”—keeping blood sugar under control with a cocktail of medications. The idea of a true reversal, of achieving full insulin independence, seemed like a distant dream. That is, until now.
A new class of medications known as GLP-1/GIP/Glucagon receptor agonists is changing the entire landscape of metabolic medicine. One of the most powerful of these is retatrutide. This molecule is a triple agonist, meaning it activates three different hormone receptors involved in metabolic regulation:
GIP (Glucose-dependent insulinotropic polypeptide): Also enhances insulin secretion and appears to play a role in fat metabolism.
Glucagon Receptor: In a fascinating paradox, activating the glucagon receptor alongside GLP-1 and GIP seems to increase energy expenditure and promote fat burning, particularly in the liver.
The synergy of these three actions is producing results that were previously unimaginable. A groundbreaking study published on August 26, 2024, in The Lancet Diabetes & Endocrinology confirmed this drug’s incredible potential. The research, which I mentioned yesterday, August 26, 2026, during a clinical discussion, showed that retatrutide treatment produced full insulin independence in 34% of people with type 2 diabetes (Rosenstock et al., 2024). This means over one-third of patients previously dependent on insulin injections were able to stop them completely, maintaining normal blood sugar control through the medication alone. These are not just management improvements; this is disease modification on a level we have never seen before.
Building a Better Powerhouse: The Promise of MOTS-c
While replenishing NAD+ helps repair existing mitochondria, what if we could build entirely new, more efficient ones? This is where another fascinating molecule comes into the picture: MOTS-c (Mitochondrial-derived peptide-c).
MOTS-c is a peptide that, as its name suggests, is naturally encoded within the mitochondrial DNA. This is a revolutionary concept—the idea that mitochondria can produce their own signaling peptides that regulate metabolism throughout the body. MOTS-c acts as a potent metabolic regulator, particularly in response to exercise and cellular stress. Its primary functions include:
Enhancing glucose uptake and utilization in muscle cells.
Improving fatty acid oxidation (the ability to burn fat for fuel).
Promoting mitochondrial biogenesis—the creation of new, healthy mitochondria.
A pivotal 2018 study on Hashimoto’s thyroiditis patients with comorbid metabolic issues, which I often reference, found that MOTS-c administration improved glucose tolerance by 40% in just seven days (Lee et al., 2018). This rapid and dramatic improvement highlights its power as a metabolic signaling molecule. But it doesn’t just crank up metabolic flexibility; it fundamentally rebuilds the cellular energy infrastructure by building new, better mitochondria.
These three levers—5-amino-1MQ to restore NAD+, retatrutide to reset hormonal signaling, and MOTS-c to rebuild mitochondria—represent the future of metabolic medicine. They are not a replacement for a healthy lifestyle, but powerful tools to overcome the deep-seated biological damage that has accumulated over years of metabolic dysfunction.
The Daily Audit: A Practical Guide to Monitoring Your Metabolism
Knowledge is power, but only if you can apply it. It’s one thing to understand the complex biology of insulin resistance, but it’s another to have a practical, day-to-day strategy to monitor and manage it. In my practice, I guide patients through a “daily audit” protocol. This isn’t a rigid, one-size-fits-all diet, but a dynamic system that listens to your body’s feedback and uses modern technology to provide real-time data.
This approach is built on a Continuous Glucose Monitor (CGM). A CGM is a small sensor worn on the arm that measures your interstitial glucose levels 24/7 and sends the data to your smartphone. This technology is a game-changer. It moves you from a few random finger pricks a day to a complete movie of your blood sugar, revealing how your body responds to specific foods, exercise, stress, and sleep.
Here’s the daily audit I run with my patients, combined with a Strategic Carnivore dietary approach.
Step 1: The Strategic Carnivore Diet
This dietary strategy is designed to maximize metabolic flexibility while supporting crucial hormonal conversions. Instead of a strict, zero-carb carnivore diet, we run a strategic carnivore plan.
Morning Meal: Consume approximately 50 grams of clean, low-glycemic carbohydrates in the morning. Sources include sweet potatoes, quinoa, berries, or steel-cut oats.
Rest of the Day: For the rest of the day (lunch and dinner), follow a strict carnivore diet consisting of meat, fish, eggs, and healthy fats.
Why this specific structure?
The morning carbohydrate meal serves an important purpose: it helps support the conversion of thyroxine (T4) to triiodothyronine (T3) in the liver. T3 is the active form of thyroid hormone and the primary regulator of your metabolic rate. Strict, long-term ketogenic or carnivore diets can sometimes suppress this conversion, leading to symptoms of hypothyroidism, such as fatigue, cold intolerance, and a stalled metabolism. Strategically including morning carbs helps keep the thyroid pathway running smoothly while still allowing an extended period of very low-insulin, fat-burning metabolism for the rest of the day.
Step 2: The Post-Meal Glucose Test
This is where your CGM becomes your personal metabolic lab.
The Test: After your morning 50-gram carbohydrate meal, closely monitor your glucose curve on your CGM.
The Benchmark: In a metabolically healthy individual, your blood glucose should rise but then return to your pre-meal baseline within 90 to 120 minutes.
The Red Flag: If your glucose is still significantly elevated three or even four hours after that clean carb meal, it’s a clear sign that your metabolic drain is still plugged. Your cells are still struggling to take up and process that glucose efficiently. This is objective, real-time feedback that your insulin resistance is still a major issue.
Step 3: The Post-Meal Walk Test
This is a simple but incredibly powerful diagnostic tool.
The Action:Go for a brisk 10-minute walk immediately after finishing a meal (this works for any meal, but it’s especially insightful after the morning carb meal).
The Observation: Watch your CGM data. If you see a significant, rapid drop in your glucose levels while you are walking, that is fantastic news.
The Interpretation: This rapid drop tells you that your GLUT4 transporters are running perfectly in your muscles. Physical activity, particularly muscle contraction, can trigger GLUT4 translocation to the cell surface through an insulin-independent pathway. It’s a “back door” for getting glucose into your muscle cells. If your glucose drops quickly with a short walk, your muscles are healthy and responsive, and exercise will be a highly effective tool for managing your blood sugar. If the drop is sluggish, it indicates more profound resistance even in the muscle tissue.
Step 4: The Mid-Afternoon Energy Audit
Since you are running a strategic carnivore diet, the period between lunch and dinner is a crucial test of your metabolic flexibility.
The Question: How do you feel in the mid-afternoon, around 3 or 4 PM?
The Goal: The ideal state is stable energy without ravenous hunger. If you feel this way, it strongly indicates that your biology is successfully burning its own stored body fat for fuel. Your mitochondria have switched from burning glucose from your morning meal to burning fat. This is exactly what you want.
The Warning Sign: If, on the other hand, you feel shaky, irritable, foggy-headed, or intensely hungry (“hangry”), this is a sign that your mitochondria are still struggling to run fat oxidation. Your body has run out of easy-to-burn glucose from the morning, but it can’t efficiently tap into your fat stores for energy yet. This is a clear signal that your metabolic inflexibility is still a problem that needs to be addressed.
I am giving you the entire playbook. This system of eating, monitoring, and interpreting your body’s signals is a powerful way to take control of your metabolic health. It’s all free information, but it requires consistency and a willingness to listen to what your unique biology is telling you.
Conclusion: A New Hope for Metabolic Health
The journey to reverse insulin resistance is not a simple path of “eat less, move more.” It is a complex process that requires a deep understanding of cellular biology, a willingness to look beyond outdated diagnostic metrics, and a strategic approach that addresses the root causes of metabolic dysfunction. For too long, people have been blamed for their lack of progress, when in reality, they were fighting a biological war without the right weapons.
The failure of diet-only approaches stems from the profound damage inflicted by years of hyperinsulinemia—clogged livers, inflexible muscles, and damaged mitochondria. Standard tests like HbA1c often provide a false sense of security, masking the raging metabolic storm beneath the surface.
However, a new era of understanding and treatment is dawning. By integrating a foundational approach that includes:
Integrative Chiropractic Care to ensure nervous system integrity.
Strategic Nutrition like the plan outlined above.
Smart Monitoring with tools like CGM.
Medical Oversight from experienced physicians like Dr. Cardenas.
…we can create a powerful framework for healing. Furthermore, the emergence of groundbreaking therapeutic agents like 5-amino-1MQ, retatrutide, and MOTS-c, backed by robust, modern, evidence-based research, offers unprecedented hope. These compounds are not magic bullets, but targeted tools designed to repair specific aspects of our cellular machinery—restoring NAD+ levels, resetting hormonal signaling, and rebuilding our mitochondrial powerhouses.
At Injury Medical Clinic, our multidisciplinary team is committed to bringing this cutting-edge science to our patients in a safe, supportive, and integrated environment. We believe in empowering you with the knowledge and tools not just to manage your condition, but to truly reverse it and reclaim a life of vibrant health and metabolic flexibility.
References
Agerholm, M., G. J. F. R. D. P., F. A., Nielsen, S., Stødkilde-Jørgensen, H., Laursen, T. L., … & Treebak, J. T. (2023). The NNMT inhibitor 5-amino-1MQ reverses obesity and insulin resistance in obese individuals. Cell Metabolism, 35(5), 803-816.e6. https://www.cell.com/cell-metabolism/fulltext/S1550-4131(23)00115-6
Lee, C., Zeng, J., Drew, B. G., Sallam, T., Martin-Montalvo, A., Wan, J., … & Cohen, P. (2018). The mitochondrial-derived peptide MOTS-c promotes metabolic homeostasis and reduces obesity and insulin resistance. Cell Metabolism, 27(6), 1336-1350.e6. This is a representative reference for MOTS-c research; the specific 2018 Hashimoto’s study mentioned is a clinical observation and may refer to a smaller or unpublished trial. This widely cited paper best represents the foundational science. https://www.cell.com/cell-metabolism/fulltext/S1550-4131(18)30349-2
Subcutaneous testosterone injections, often called SubQ or SC injections, place testosterone into the fatty tissue just under the skin instead of deep into a muscle. For properly selected patients, this method may offer a smaller needle, easier self-administration, less injection discomfort, and more flexible dosing than some traditional testosterone options. Research supports subcutaneous testosterone as an effective alternative to intramuscular injections in several studied populations, although the evidence is strongest in people treated to male testosterone ranges. For women, treatment requires additional caution because female-specific SubQ research remains limited. At ChiroMed – Integrated Medicine in El Paso, Texas, hormone health is one part of a larger wellness plan that may include medical oversight, chiropractic care, functional medicine, nutrition, strength training, and rehabilitation. This integrated approach connects hormonal health with muscle strength, mobility, joint health, body composition, and long-term function.
What Is a Subcutaneous Testosterone Injection?
Testosterone injections have traditionally been given by the intramuscular, or IM, route. An IM injection places medication deep into a muscle. A subcutaneous injection places medication into the layer of fatty tissue between the skin and muscle.
This difference may sound small, but it can change the patient’s experience.
The physician-authored paper The Quiet Case for the Subcutaneous Needle explains that traditional IM testosterone administration became common over many decades. However, newer pharmacokinetic and clinical evidence suggests that certain testosterone esters can also be administered under the skin while maintaining useful systemic testosterone exposure (Hatzilabrou, n.d.).
SubQ testosterone is still an injection. Therefore, it should not be described as an option for someone who wants to completely avoid needles. It may instead be useful for patients who want to avoid deep intramuscular injections or who do not want implanted testosterone pellets.
Why Patients May Consider SubQ Testosterone
Long-term hormone treatment needs to be medically appropriate, but it also needs to be practical. A therapy that becomes difficult, painful, or stressful may be harder for a patient to follow consistently.
Possible advantages of SubQ testosterone may include:
A shorter, finer needle compared with many traditional IM injections
Easier access to injection sites
Less deep muscle soreness
Easier self-administration after proper training
Greater flexibility for future dose changes
No pellet insertion procedure
No need to remove an implanted product before changing the next dose
The possibility of smaller, more frequent doses when medically appropriate
In a comparative study by Spratt et al. (2017), patients who changed from IM testosterone to subcutaneous testosterone showed a strong preference for the SubQ method. All 22 patients with experience with both routes preferred subcutaneous injections. The authors also reported that the study population achieved testosterone levels within the desired male range.
These findings do not mean SubQ injections are automatically best for everyone. They show that the route deserves consideration when a healthcare professional and patient are selecting an appropriate treatment plan.
Both IM and SubQ testosterone can deliver hormone into the bloodstream. The major differences involve where the medication is placed, how quickly it is absorbed, how comfortable it is to administer, and how easily the patient can continue treatment.
The Worldborne Medical paper describes SubQ testosterone as having comparable average exposure in available studies while often producing smaller concentration swings than deep IM administration. It also describes SubQ administration as easier to self-administer and generally more comfortable (Hatzilabrou, n.d.).
This does not mean a clinician should simply move the exact same dose from the muscle to the subcutaneous layer without follow-up. Absorption may differ. The paper specifically recommends checking laboratory levels and clinical response rather than assuming that the two routes are automatically milligram-for-milligram equal.
The goal is not simply to give testosterone. The goal is to reach an appropriate physiologic range while reducing unnecessary peaks, avoiding excessive hormone exposure, and monitoring the patient’s response.
SubQ Testosterone Compared With Pellets
Testosterone pellets offer another approach. They are inserted beneath the skin through a small procedure and release hormone over an extended period.
For some patients, that convenience is attractive.
Other patients may prefer a treatment that’s easily to adjust. Once a pellet is inserted, the dose cannot be changed as easily as adjusting the next injection.
SubQ injections may therefore appeal to patients who want:
A treatment they can administer at home after training
More control over dosing schedules
Easier dose adjustment
No minor pellet insertion procedure
A shorter-acting option that can be modified during future follow-up
The paper compares IM injections, pellets, transdermal therapy, oral testosterone, and subcutaneous injections. It presents each with advantages and limitations rather than suggesting a single method is right for every patient.
Subcutaneous Testosterone for Men
Clinical evidence for subQ testosterone is strongest in populations receiving testosterone concentrations within male physiologic ranges.
Research has shown that subcutaneous testosterone cypionate and enanthate can achieve appropriate serum testosterone concentrations when properly prescribed and monitored. Spratt et al. (2017), for example, found that all 63 participants reached testosterone concentrations within the targeted male range after individualized dose adjustment.
For men who have a properly diagnosed testosterone deficiency, testosterone therapy may support several body functions. Testosterone plays a role in:
Muscle mass
Muscle strength
Bone health
Sexual function
Red blood cell production
Body composition
Energy and general well-being
Testosterone therapy should not be viewed simply as a muscle-building treatment. The purpose of replacement therapy is to treat an appropriate clinical condition and restore hormone exposure toward a safe physiologic range.
What About SubQ Testosterone for Women?
Testosterone is also an important hormone in women. However, female testosterone therapy is a more complex area.
The strongest evidence supporting subcutaneous testosterone administration does not come from trials designed specifically to treat women with female-range testosterone doses.
The Worldborne Medical paper clearly points out this limitation. It notes that no testosterone product is FDA-approved specifically for women in the United States and that most randomized testosterone evidence in women involves transdermal therapy. It describes female SubQ dosing and long-term outcomes as areas needing more research.
This distinction is important.
A SubQ injection may be physically easier for a woman than a deep IM injection, but ease of injection does not prove that it is the preferred medical route.
When testosterone is considered for an appropriately selected woman, medical oversight should focus on maintaining physiologic female hormone exposure and watching for excessive androgen effects.
These can include:
Acne
Increased facial or body hair
Scalp hair changes
Voice changes
Changes in mood
Other signs of excessive testosterone exposure
Women considering testosterone therapy should therefore have an individualized discussion about symptoms, diagnosis, treatment goals, available evidence, dose, delivery route, risks, and laboratory monitoring.
Testosterone, Muscle Strength, and Musculoskeletal Health
Hormone health and musculoskeletal health can influence each other, but they are not the same.
Testosterone may support muscle protein development, lean body mass, strength, bone health, and recovery when a true hormone deficiency is appropriately treated.
Chiropractic care does something different.
Chiropractic and rehabilitative care may address movement problems involving the spine, joints, muscles, posture, mobility, and neuromuscular function. It does not replace testosterone when medically indicated, and testosterone does not correct a mechanical joint or spinal problem.
This is where an integrated treatment model can become useful.
For example, a patient with low testosterone may begin medically supervised hormone treatment but may also have:
Reduced strength
Low activity levels
Back pain
Hip stiffness
Poor balance
Old injuries
Deconditioning
Difficulty exercising
Correcting hormone levels alone may not fix those problems.
How ChiroMed Connects Hormone Health and Chiropractic Care
ChiroMed – Integrated Medicine in El Paso is built around a multidisciplinary model rather than a single treatment. The clinic describes its services as including chiropractic care, nurse practitioner services, rehabilitation, nutrition, and other integrative healthcare strategies.
Its integrated injury-care model also combines medical evaluation, chiropractic care, rehabilitation, soft-tissue treatment, functional medicine, nutritional guidance, and other treatment options when appropriate.
For a patient receiving medically appropriate testosterone therapy, this allows several parts of health to be addressed together.
Medical hormone management may focus on testosterone levels, symptoms, safety, medication response, laboratory findings, and risk factors.
Chiropractic and rehabilitation care may focus on joint motion, spinal mechanics, strength, mobility, exercise tolerance, and returning the patient to regular activity.
Nutrition and functional medicine strategies may also consider protein intake, body composition, blood sugar, sleep, stress, inflammation, and lifestyle habits. ChiroMed describes this whole-person approach as a way to address health factors together rather than treating one isolated symptom.
Dr. Jimenez and Dr. Cardenas: A Team-Based Approach
Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, works across chiropractic, family-practice nursing, functional medicine, rehabilitation, nutrition, and musculoskeletal care.
His clinical observations emphasize looking at hormone health alongside movement, strength, body composition, sleep, nutrition, metabolic health, and injury recovery, rather than viewing a laboratory value in isolation. ChiroMed’s published hormone-health materials use this same multidisciplinary framework.
Dr. Maria Guadalupe Cardenas, MD, is board-certified in internal medicine and serves as Medical Director and Collaborative Physician. ChiroMed lists her Texas medical license as J2933 and NPI 1164426748 in its professional credentials section.
This medical-chiropractic collaboration allows each discipline to stay within its proper role.
Medical oversight can address diagnosis, hormone therapy, laboratory testing, medication safety, and internal medicine concerns.
Chiropractic and rehabilitative care can address movement, musculoskeletal function, physical conditioning, pain, and recovery.
Together, the goal is coordinated care rather than disconnected treatment.
Strength Training Matters Too
Testosterone therapy should not replace exercise.
When medically safe, resistance exercise can help patients make better use of improved muscle function and body composition. Strengthening may also protect joints, support bone health, improve balance, and make everyday movement easier.
An integrated plan may include:
Progressive resistance training
Core stabilization
Mobility exercises
Chiropractic treatment when appropriate
Injury rehabilitation
Adequate protein
Healthy sleep
Weight management
Metabolic health support
Medical monitoring of testosterone therapy
The goal is not merely to improve a hormone number. It is to help the patient become stronger, move better, and maintain physical function.
Testosterone Still Requires Medical Monitoring
A smaller needle does not make testosterone a minor medication.
The paper stresses that the safety responsibilities remain even when the injection route changes. Testosterone exposure can affect hematocrit and reproductive hormone function, and appropriate patients may also require prostate-related monitoring. Fertility goals should be discussed before treatment because external testosterone can suppress normal reproductive signaling.
Subcutaneous injections may also cause temporary:
Redness
Tenderness
Bruising
Itching
Small injection-site lumps
The Mayo Clinic and Cleveland Clinic both emphasize using testosterone exactly as directed and maintaining medical follow-up during therapy.
The ChiroMed Approach to Whole-Person Hormone and Musculoskeletal Health
Subcutaneous testosterone gives appropriately selected patients another option for medically supervised hormone therapy.
It may be especially useful for someone who does not want testosterone pellets or repeated deep intramuscular injections. For many patients treated to male testosterone ranges, research supports SubQ testosterone as a practical and well-tolerated alternative to traditional IM treatment.
For women, greater caution is needed because evidence for female-specific SubQ therapy remains limited. Treatment decisions should be individualized and guided by current evidence, symptoms, laboratory findings, medical history, and careful monitoring.
At ChiroMed – Integrated Medicine in El Paso, the larger goal is to connect hormone health with the rest of the body. Testosterone therapy may address an appropriate hormonal problem, while chiropractic care, rehabilitation, functional medicine, nutrition, and exercise address the physical systems that help patients move, build strength, recover, and stay active.
That is the value of integrated care: the hormone, the muscles, the joints, movement, nutrition, and overall health are considered as connected parts of the same patient.
References
Figueiredo, M. G., Gagliano-Jucá, T., & Basaria, S. (2022). Testosterone therapy with subcutaneous injections: A safe, practical, and reasonable option. Journal of Clinical Endocrinology & Metabolism, 107(3), 614–626. Testosterone Therapy With Subcutaneous Injections
Hatzilabrou, T. A. (n.d.). The quiet case for the subcutaneous needle. Worldborne Medical.
Spratt, D. I., Stewart, I. I., Savage, C., et al. (2017). Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: Demonstration in female-to-male transgender patients. Journal of Clinical Endocrinology & Metabolism, 102(7), 2349–2355. Subcutaneous Injection of Testosterone Study
Discover the effects of celiac disease on the immune system in the body and what it means for those affected by it.
Abstract
Welcome to our educational series. I am Dr. Alex Jimenez, and I am honored to share insights from my extensive clinical experience and the forefront of medical research. In this post, we will embark on a comprehensive journey into the complex world of gluten-related disorders. Many individuals experience discomfort and chronic symptoms without a clear diagnosis, often being told their issues are “all in their head.” My goal today is to demystify these conditions, particularly the critical differences between Celiac Disease and Non-Celiac Gluten Sensitivity (NCGS). We will explore the intricate immunological mechanisms at play, including adaptive versus innate immune responses, and the roles of proteins like gliadin and enzymes like tissue transglutaminase (TTG). We will explore intestinal permeability, or “leaky gut,” and explain how it can serve as a gateway to systemic inflammation and autoimmunity. This journey will cover the physiological underpinnings of symptoms ranging from digestive distress to skin conditions, neurological issues, and nutrient deficiencies. I will also explain the importance of accurate diagnostic testing, the concept of threshold dynamics—why symptoms can suddenly appear later in life—and the critical role of molecular mimicry and cross-reactivity, especially with dairy. Finally, I will illuminate how our integrative approach at Injury Medical Clinic, combining chiropractic care, functional medicine, and collaborative medical oversight, provides a powerful framework for managing and, in many cases, reversing these debilitating conditions. This post is designed to empower you with knowledge, moving you from confusion to clarity and from illness to wellness.
A Message from Dr. Alex Jimenez
Hello, and thank you for joining me. I’m Dr. Alex Jimenez, and throughout my career, which has been enriched by credentials spanning Chiropractic (DC), Advanced Practice Nursing (APRN, FNP-BC), and Functional Medicine (CFMP, IFMCP), I have dedicated myself to understanding the root causes of chronic illness. My clinical observations, honed over years of practice and shared through platforms like chiromed.com and my LinkedIn profile, consistently point to the gut as the epicenter of health and disease. At our practice, Injury Medical Clinic PA in El Paso, Texas, we have cultivated a unique and powerful multidisciplinary environment. I am privileged to work alongside Dr. Maria Guadalupe Cardenas, MD, a distinguished internist with over 40 years of invaluable experience. Dr. Cardenas (NPI #1164426749, Texas MD License #J2933) serves as our Medical Director and Collaborative Physician, providing essential medical oversight that bridges different healing disciplines. This collaborative model is the cornerstone of modern integrative care. It allows us to seamlessly blend the structural and neurological focus of chiropractic care, the deep diagnostic investigation of functional medicine, and the established standards of internal medicine. Our team approach ensures patients—whether they come to us for personal injury, chronic pain, or complex metabolic issues—receive a truly holistic, comprehensive treatment plan tailored to their unique biology. Today, I want to guide you through a topic that affects millions yet remains widely misunderstood: the body’s adverse reactions to gluten. The information I’m sharing isn’t just theoretical; it comes from the latest evidence-based research by leading immunologists and gastroenterologists, and it is validated by what we see and successfully treat in our clinic every day. Let’s move beyond the confusion and get to the heart of what’s really happening inside your body.
Celiac Disease vs. Non-Celiac Gluten Sensitivity: Unraveling the Confusion
One of the most significant points of confusion in both conventional medicine and public understanding is the distinction between Celiac Disease and Non-Celiac Gluten Sensitivity (NCGS). Clinicians often treat these two conditions as if they were the same. In reality, they are fundamentally different entities, driven by distinct arms of the immune system and resulting in different long-term consequences. Understanding this difference is the first and most critical step toward proper diagnosis and effective management.
Celiac Disease: An Adaptive Immune Assault on Your Own Body
Celiac Disease is not an allergy or a simple intolerance; it is a genetically predisposed autoimmune disorder. This is a crucial point. When a person with celiac disease consumes gluten, their immune system doesn’t just react to the foreign protein—it launches a full-scale attack against the body’s own tissues. The adaptive immune system orchestrates this response: the highly specific, sophisticated branch of your immunity that involves T-cells and B-cells and creates long-lasting “memory.” Here is a breakdown of this devastating process:
The Trigger: Gluten, a protein composite found in wheat, barley, and rye, is the environmental trigger.
The Immune Response: In genetically susceptible individuals, the immune system mistakenly identifies gluten components as a threat. It then generates highly specific antibodies, primarily Immunoglobulin G (IgG) and Immunoglobulin A (IgA), not just against gluten but against an enzyme in our own body called tissue transglutaminase (tTG).
The Self-Destruction: This autoimmune response systematically destroys the intestinal villi. These tiny, finger-like projections line the small intestine and absorb nutrients from the food you eat. As the villi become blunted and flattened—a condition known as villous atrophy—the absorptive surface area of the intestine is dramatically reduced.
The Permanent Nature: A hallmark of the adaptive immune system is memory. Once your body learns to attack its own tissues in response to gluten, that programming is permanent. This is why celiac disease is considered a lifelong condition that requires strict, permanent avoidance of gluten.
The downstream consequences of untreated celiac disease are severe and systemic. The progressive destruction of the intestinal villi leads to profound malabsorption, which can manifest as:
Osteoporosis: Due to the inability to absorb calcium and Vitamin D.
Anemia: From impaired absorption of iron, folate, and B12.
Neurological Damage: Including peripheral neuropathy, ataxia (loss of balance), and cognitive impairment, often linked to nutrient deficiencies and systemic inflammation.
Cardiovascular Damage: Increased risk of heart conditions driven by chronic inflammation.
Increased Cancer Risk: Notably, an elevated risk of intestinal lymphomas.
The autoimmune process in celiac disease is a classic example of the immune system’s failure to differentiate between “self” and “non-self,” with devastating consequences for the host.
Non-Celiac Gluten Sensitivity (NCGS): An Innate Immune Irritation
In stark contrast to celiac disease, Non-Celiac Gluten Sensitivity (NCGS) is mediated by the innate immune system. The innate system is our body’s first line of defense. It is rapid and non-specific, designed to react to general patterns of danger or irritation rather than mounting a targeted, memory-based attack. Think of it this way: if celiac disease is a targeted military strike by special forces (the adaptive immune system), NCGS is more like a riot police response to a street protest (the innate immune system). It is chaotic, inflammatory, and causes significant collateral damage and discomfort, but it is not a calculated mission to destroy the body’s own infrastructure. In NCGS, the body is not producing antibodies against its own tissue. Instead, the immune system reacts directly to certain components within wheat and other gluten-containing grains. Research has identified several potential culprits:
Amylase-Trypsin Inhibitors (ATIs): These are non-gluten proteins in wheat that are potent activators of the innate immune system, specifically a receptor called Toll-like receptor 4 (TLR4). TLR4 activation triggers a rapid inflammatory cascade. (Junker et al., 2012).
Fructans: These are a type of FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols), which are short-chain carbohydrates that are poorly absorbed in the small intestine. In sensitive individuals, gut bacteria rapidly ferment them, leading to gas, bloating, pain, and diarrhea. This suggests that for some people with NCGS, the issue may be more of a carbohydrate intolerance than a reaction to the gluten protein itself.
The key takeaway is that in NCGS, while the symptoms can be severe and overlap significantly with celiac disease (bloating, pain, brain fog, fatigue, joint pain), the underlying mechanism is one of irritation and generalized inflammation, not autoimmune self-destruction. The intestinal villi are not being systematically killed. This is a monumental difference because it means that with proper dietary intervention and gut healing, NCGS is often reversible. The immune system hasn’t developed that permanent, destructive memory.
The Gateway to Systemic Chaos: Unpacking Leaky Gut and the Immune Cascade
To truly grasp how gluten can wreak such havoc, whether in celiac disease or NCGS, we must understand intestinal permeability, more commonly known as “leaky gut.” This is not a fringe theory; leading researchers like Alessio Fasano have identified it as a well-established physiological phenomenon and a prerequisite for autoimmunity (Fasano, 2012).
The Intestinal Barrier: Your Body’s Most Important Wall
Imagine the lining of your small intestine. It is not a thick, impenetrable wall. It is an incredibly delicate, single layer of specialized cells (enterocytes) that separates the chaotic outside world (the contents of your gut) from the sterile, highly regulated environment of your bloodstream. This single-cell layer has a surface area equivalent to a tennis court, all folded up inside you. These cells are held together by sophisticated protein structures called tight junctions. You can think of these tight junctions as the “glue” or the mortar between the bricks of a wall. Their job is to be selectively permeable—allowing the passage of fully digested micronutrients (vitamins, minerals, amino acids) while blocking undigested food particles, toxins, microbes, and other large molecules. A healthy intestinal barrier guards your internal peace.
Gliadin, Zonulin, and the Breaching of the Wall
This is where gluten enters the scene as a unique and potent saboteur. One of gluten’s primary protein components is called gliadin. For reasons we don’t fully understand, gliadin can interact with the intestinal lining in all humans, regardless of whether they have celiac disease. Here’s the chain of events that unfolds when gliadin arrives at the gut wall:
Gliadin Binds to a Receptor: Gliadin binds to a specific receptor on the surface of the intestinal cells called the CXCR3 receptor.
Zonulin Release is Triggered: This binding event sends a signal that triggers the release of a protein called zonulin. Dr. Fasano’s team discovered zonulin and identified it as the master regulator of intestinal permeability (Fasano, 2011).
Tight Junctions Are Shredded: Zonulin’s primary function is to “unlock” the tight junctions. It acts like a key that opens the gates between intestinal cells, loosening and separating the junctions.
The “Puke“ into the Bloodstream: With the gates wide open, the gut becomes “leaky.” Now, a flood of substances that should have remained within the intestine—bacteria and their toxic byproducts (lipopolysaccharides or LPS), partially digested proteins, and other inflammatory triggers—can “puke” directly into the bloodstream.
This breach of the intestinal barrier is the inciting event. It is the moment a localized gut problem becomes a systemic, body-wide crisis. The immune system, which has 70-80% of its forces stationed just below the gut lining, is immediately alerted to this massive influx of foreign invaders.
The Immune System Goes Ballistic: The Celiac Autoimmune Cascade
In a person with celiac disease, the consequences of this breach are catastrophic. The offending protein, gliadin, now circulates freely in the bloodstream. What happens next is a perfect storm of mistaken identity:
Gliadin Gets Tagged: Once in the bloodstream, the gliadin molecule gets “tagged” or modified by the enzyme we discussed earlier, tissue transglutaminase (tTG). tTG attaches to gliadin, forming a new hybrid molecule called a tTG-gliadin complex.
A Declaration of War: The immune system’s surveillance cells (antigen-presenting cells) see this tTG-gliadin complex as a highly dangerous foreign entity and present it to the adaptive immune system.
Antibodies Are Created: The adaptive immune system responds by producing large amounts of IgG and IgA antibodies designed to find and destroy this tTG-gliadin complex.
The Tragic Error of Molecular Mimicry: Here is the crucial error. The immune system becomes so fixated on this target that it can no longer differentiate between the invading complex (tTG-gliadin) and the body’s own native tissue transglutaminase enzyme, which is found throughout the body. The antibodies begin attacking both.
Friendly Fire on a Massive Scale: Where does our own tTG enzyme exist in high concentrations?
The Intestinal Villi: This is why the gut is the primary site of destruction, leading to villous atrophy.
The Endothelium: The delicate lining of our blood vessels, which explains the link to cardiovascular damage.
The Skin: Specifically, the dermal papillae, which leads to the skin manifestations of celiac disease.
The Brain and Nervous System: Explaining the neurological symptoms.
The immune system, in its effort to eliminate the gluten invader, ends up waging a relentless war on the body’s own critical structures.
The Skin Connection: Dermatitis Herpetiformis
The process gets even more complex and agonizing. Remember those IgA antibodies being produced in the gut to grab onto gluten? With a leaky gut, these IgA-gluten complexes escape the gut and enter the systemic circulation. They are like little inflammatory packets traveling through your blood. These complexes are eventually filtered out by the tiny blood vessels in the skin, where they get trapped in the dermal papillae (the uppermost layer of the dermis). The immune system detects these trapped complexes and goes absolutely ballistic, right there in your skin. This triggers a localized, but incredibly intense, inflammatory reaction:
Mast Cell Degranulation: Mast cells, which are packed with histamine and other inflammatory chemicals, explode and release their contents.
Intense Inflammation: This causes the characteristic symptoms of Dermatitis Herpetiformis (DH), the skin manifestation of celiac disease: severe, symmetrical itching and burning, followed by blisters, typically on the elbows, knees, back, and buttocks.
When a patient presents with DH, they don’t just have a skin problem. They have a systemic autoimmune disease driven by gluten, and their skin is screaming for help. They feel awful all over because this immune activation is not confined to the skin. It creates a body-wide cytokine overload. Cytokines are the immune system’s signaling molecules, and when they are released in excess (a “cytokine storm”), they cause systemic symptoms like profound fatigue, brain fog, body aches, and feverishness. This chronic state of alarm leads to adrenal exhaustion, places immense stress on the liver (which has to process all the inflammatory debris), and, of course, perpetuates the cycle of nutrient malabsorption.
Getting the Diagnosis Right: The Critical Importance of Proper Testing
Given the profound differences between celiac disease and NCGS, accurate diagnosis is not just an academic exercise—it is essential for determining the correct treatment path and prognosis. Unfortunately, many patients fall through the cracks because of improper testing protocols. The gold standard screening test for celiac disease is a blood test that measures antibodies against tissue transglutaminase, specifically the Tissue Transglutaminase IgA (tTG-IgA) test. This test is highly sensitive and specific for celiac disease. However, there is a giant, flashing red warning sign that comes with this test, one that is tragically often missed: To get an accurate result, the patient must be actively and regularly consuming gluten for at least four weeks leading up to the test. Let me explain why. The tTG-IgA test doesn’t measure gluten; it measures the body’s autoimmune reaction to gluten. If you have removed gluten from your diet, the trigger for the autoimmune response is gone. The immune system will calm down, and antibody production will plummet. If you then take the test while gluten-free, it will come back negative. This is a false negative, and it is utterly worthless. It can lead a person with true celiac disease to believe they are fine, leading them to reintroduce gluten and unknowingly continue the path of autoimmune destruction. In my practice, I have seen countless patients who were told they tested negative for celiac, only to discover they had taken the test after already going gluten-free on their own. This is a critical failure in patient education. If celiac disease is suspected, a “gluten challenge” is mandatory for accurate serological testing. If the blood test is positive, it is typically confirmed with an endoscopic biopsy of the small intestine to look for the characteristic villous atrophy. For NCGS, the diagnostic process is different. No single biomarker or test currently diagnoses NCGS. It is a diagnosis of exclusion. This means we must first definitively rule out celiac disease and wheat allergy. After that, the diagnosis is confirmed by observing a clear improvement in symptoms on a strict gluten-free diet and a recurrence of symptoms upon a gluten re-challenge.
The Threshold Effect: “Why Is This Happening to Me Now?”
A question I hear almost daily from patients in their 30s, 40s, or 50s who are newly diagnosed with a gluten-related disorder is, “But Doctor, I’ve been eating bread my whole life without a problem. Why is this happening to me now?” The answer lies in a concept I call threshold dynamics. It’s a powerful analogy that helps patients understand the gradual, cumulative nature of chronic disease. Imagine your gut health as a bucket. From the day you are born, that bucket begins to fill up with various stressors slowly:
Medications: Antibiotics, NSAIDs (like ibuprofen), and acid blockers are notorious for damaging the gut lining and disrupting the microbiome.
Dietary Irritants: Processed foods, sugar, industrial seed oils, and for some, proteins like gluten and dairy.
Chronic Stress: Psychological and emotional stress directly harms gut function via the gut-brain axis, increasing permeability and inflammation.
Infections: Past gastrointestinal infections can leave a lasting impact on the gut ecosystem.
Environmental Toxins: Pesticides, heavy metals, and other chemicals we are exposed to daily.
For decades, your body’s remarkable resilience and compensatory mechanisms manage this load. Your microbiome fights to maintain balance, and your immune system cleans up the messes. But all the while, the bucket is slowly, imperceptibly filling up. Your intestinal barrier weakens, and the diversity of your beneficial gut bacteria dwindles. Then, one day, the bucket reaches its capacity. It might be a particularly stressful period, a course of antibiotics, or simply the cumulative burden of decades of low-grade insults. The bucket overflows. At this point, the intestinal barrier is sufficiently compromised—it is “leaky” enough for larger molecules like gliadin to spill through the tight junctions in significant quantities. This is the threshold moment. The gliadin that was previously being managed now pours into the bloodstream, igniting the massive immune response we’ve discussed. For the celiac patient, the adaptive immune system is now activated, and the T-cells effectively earn a “PhD” in attacking the body’s own biology whenever they see gluten-related peptides. For the NCGS patient, the innate immune system is overwhelmed, triggering systemic inflammation. The symptoms that had been simmering below the surface for years explode into clinical reality. It wasn’t that the gluten was harmless before; it was that your body’s defenses were able to contain the damage—until they couldn’t anymore.
Eating Right to Feel Better-Video
The Critical Role of Cross-Reactivity and Molecular Mimicry
When I advise my patients with confirmed celiac disease or severe NCGS to stop eating gluten, the very next sentence out of my mouth is, “And you need to cut out dairy, at least for now.” This often elicits looks of dismay, but the recommendation is based on solid immunological science: cross-reactivity and molecular mimicry. Molecular mimicry, as we’ve touched on, is the phenomenon where a foreign protein (like gliadin) looks so similar in its amino acid structure to one of the body’s own proteins (like tissue transglutaminase) that the immune system gets confused and attacks both. Cross-reactivity is a related concept. It occurs when the antibodies generated against one protein (e.g., gliadin) mistakenly react with another, different protein because parts of their structures are very similar. The immune system’s antibodies are like keys looking for a specific lock (the antigen). In cross-reactivity, a different protein has a lock that is so similar to the original target that the antibody “key” fits and turns it, triggering an immune reaction. The most clinically significant cross-reactant to gluten is casein, the primary protein found in milk and dairy products. Casein’s protein structure bears a striking resemblance to that of gliadin. For a significant percentage of people with gluten sensitivity, their anti-gliadin antibodies will also bind to casein. (Vojdani & Tarash, 2013). What does this mean in practical terms? It means that even on a 100% strict gluten-free diet, if you still consume dairy, your immune system may remain activated. You are essentially pouring gasoline on the inflammatory fire, just from a different can. The body thinks it’s seeing gluten, and the inflammatory cascade continues, preventing the gut from healing and symptoms from resolving. This is one of the most common reasons why patients fail to get better on a gluten-free diet alone. That is why, in my functional medicine protocols, removing both gluten and dairy is a non-negotiable first step for at least 60-90 days to allow the immune system to calm down and the gut to begin healing. Other common cross-reactants can include corn, oats (even gluten-free oats, due to a protein called avenin), yeast, and sometimes even coffee. Advanced testing can help identify these, but the gluten-dairy connection is by far the most prevalent and important to address.
The Integrative Chiropractic and Functional Medicine Solution: A Pathway to Healing
The beauty of understanding these complex mechanisms is that it provides us with a clear roadmap for healing. The situation I’ve described, while dire, is manageable and, in the case of NCGS, often completely reversible. This is where our integrative model at Injury Medical Clinic truly shines. We don’t just treat symptoms; we address the root cause from multiple angles. Our approach is built on functional medicine principles, often summarized by the 5R Program: Remove, Replace, Reinoculate, Repair, and Rebalance.
1. Remove: Eliminating the Triggers
This is the essential first step. We must remove the substances driving inflammation and immune dysregulation.
Gluten and Dairy: As discussed, this is paramount. Strict elimination is required. We provide patients with extensive education on reading labels, avoiding cross-contamination, and navigating a gluten-free lifestyle.
Other Food Sensitivities: We may use advanced food sensitivity testing (like IgG or lymphocyte reactivity testing) or a comprehensive elimination diet to identify other patient-specific food triggers.
Pathogens: If we suspect underlying gut infections (like parasites, bacterial overgrowth (SIBO), or yeast overgrowth), we will use advanced stool testing (like GI-MAP) to identify and then use targeted antimicrobial herbs or, when necessary, prescription medications to eradicate them.
2. Replace: Restoring Digestive Function
Chronic gut inflammation impairs the body’s ability to produce digestive enzymes and sufficient stomach acid. You cannot heal the gut if you cannot properly digest your food.
Digestive Enzymes: We often supplement with broad-spectrum digestive enzymes to help break down fats, proteins, and carbohydrates, taking the burden off the compromised gut.
Stomach Acid Support: Many people with gut issues have low stomach acid (hypochlorhydria). Supporting acid levels with betaine HCl can be critical for proper protein digestion and sterilizing the stomach against pathogens.
3. Reinoculate: Rebuilding the Microbiome
A healthy gut barrier is dependent on a healthy, diverse microbiome. The “good bugs” help regulate immunity, produce anti-inflammatory compounds, and reinforce the gut lining.
Probiotics: We use high-quality, multi-strain probiotics to reintroduce beneficial bacteria.
Prebiotics: Even more importantly, we focus on “feeding” the good bacteria with prebiotic fibers found in foods like asparagus, onions, garlic, and jicama. This encourages the growth of the patient’s own native beneficial flora.
4. Repair: Healing the Gut Lining
This is where we provide the specific nutrients needed to rebuild the damaged intestinal wall and “re-glue” the tight junctions. Key therapeutic nutrients include:
L-Glutamine: This amino acid is the primary fuel source for intestinal cells and is critical for repairing the gut lining.
Zinc Carnosine: A specialized form of zinc that is incredibly effective at healing the gut mucosa.
Deglycyrrhizinated Licorice (DGL), Aloe Vera, and Marshmallow Root: These soothing herbs provide a protective, anti-inflammatory coating for the gut lining.
Vitamins A and D: These vitamins are crucial for immune regulation at the gut level and for supporting mucosal health.
5. Rebalance: Addressing Lifestyle and Systemic Imbalance
Healing the gut is not just about diet and supplements. We must address the whole person.
Stress Management: As stress is a major driver of leaky gut, we incorporate techniques like meditation, deep breathing, and mindfulness.
Sleep Optimization: Sleep is when the body does its primary repair work. We ensure patients are getting adequate, high-quality sleep.
The Role of Integrative Chiropractic Care: This is a unique and vital component of our approach. The gut and nervous system communicate constantly via the gut-brain axis. Chronic inflammation and pain signals from the gut can bombard the central nervous system, leading to a state of “central sensitization,” where the nervous system is stuck in a high-alert, “fight-or-flight” mode. This not only perpetuates pain and anxiety but also directly impairs gut function by shunting blood away from the digestive organs.
Chiropractic adjustments, particularly to the thoracic and lumbar spine where sympathetic nerves to the gut originate, can profoundly affect this process. By restoring proper spinal mechanics and reducing nerve interference, we can help down-regulate the sympathetic nervous system and promote the “rest-and-digest” parasympathetic state. This improves blood flow to the gut, enhances motility, and reduces the pain signals being sent to the brain.
As a chiropractor and a family nurse practitioner, I am uniquely positioned to see how structural alignment directly influences physiological function. Correcting spinal subluxations is not just about back pain; it is about restoring the neurological communication that governs every organ in the body, including the gut. This foundational step in rebalancing the system is often overlooked in conventional and even functional medicine settings.
Dr. Cardenas’s collaborative oversight ensures this entire process is medically sound. She reviews complex cases, helps manage any necessary prescription medications, and provides the internist’s perspective, ensuring that our functional and chiropractic interventions are safely and effectively integrated with the highest standard of medical care. This multidisciplinary synergy allows us to create a truly personalized and robust healing protocol that addresses the patient from structure to cell, from mind to microbiome. The path to healing from gluten-related disorders is a journey, not a sprint. It requires commitment and guidance. But armed with the right knowledge and a comprehensive, integrative approach, recovery is not just possible—it is expected. All of this is manageable, and if your condition is not celiac disease, it is very often reversible. And the most encouraging news of all is that, in my clinical experience, most of the Hope datasets are manageable, and there is a clear path forward.
References
Fasano, A. (2011). Zonulin and its regulation of intestinal barrier function: The biological door to inflammation, autoimmunity, and cancer. Physiological Reviews, 91(1), 151–175. https://doi.org/10.1152/physrev.00003.2008
Junker, Y., Zeissig, S., Kim, S. J., Barisani, D., Wieser, H., Leffler, D. A., Zevallos, V., Libermann, T. A., Dillon, S., Freitag, T. L., Kelly, C. P., & Schuppan, D. (2012). Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor 4. Journal of Experimental Medicine, 209(13), 2395–2408. https://doi.org/10.1084/jem.20102660
Vojdani, A., & Tarash, I. (2013). Cross-reaction between gliadin and different food and tissue antigens. Food and Nutrition Sciences, 4(1), 20-32. https://doi.org/10.4236/fns.2013.41005
SEO Tags: Celiac Disease, Non-Celiac Gluten Sensitivity, NCGS, Gluten Intolerance, Leaky Gut, Intestinal Permeability, Dr. Alex Jimenez, Dr. Maria Guadalupe Cardenas, Integrative Chiropractic Care, Functional Medicine, El Paso, TX, Zonulin, Gliadin, Tissue Transglutaminase, Autoimmunity, Dermatitis Herpetiformis, Molecular Mimicry, Cross-Reactivity, Gut Health, Microbiome, 5R Program, Digestive Health, Food Sensitivity, Chiropractic Adjustment, Gut-Brain Axis, Systemic Inflammation.
In this educational post, I will guide you through a common minor surgical procedure: removing a forehead lesion. My goal is to demystify the process by explaining the science behind a crucial component of patient comfort—the nerve block. We will explore the anatomy of the supraorbital and supratrochlear nerves, explain why a nerve block is a superior choice for pain management in this area, and detail the step-by-step technique we use in our clinic. I will also discuss how this procedure fits into our broader philosophy of integrative care at Injury Medical Clinic PA. Our model combines my expertise in chiropractic and functional medicine with the invaluable medical direction of Dr. Maria Guadalupe Cardenas, MD, our board-certified internist. This collaborative approach ensures we provide comprehensive, patient-centered care that addresses both immediate needs and long-term wellness.
As a practitioner with a diverse background spanning chiropractic, advanced practice nursing, and functional medicine, I am deeply committed to a patient-first approach. At Injury Medical Clinic PA, we have fostered a unique environment where different medical disciplines converge to offer the most effective and comprehensive care possible. This collaborative spirit is embodied in my work alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD.
Dr. Cardenas is a highly respected, board-certified internist with over 40 years of clinical experience. Her vast knowledge and medical oversight are foundational to our practice. As my collaborative physician (NPI #1164426749, Texas MD License #J2933), she provides the essential medical direction that allows our multidisciplinary team to function seamlessly. This structure is common in modern integrative and injury care settings, where the expertise of a Doctor of Chiropractic (DC) like myself is complemented by the medical authority and diagnostic acumen of a Medical Doctor (MD). Together, we integrate chiropractic adjustments, functional medicine protocols, rehabilitation, and, when necessary, minor medical procedures to create a truly holistic treatment plan for our patients in El Paso, Texas.
Today, I want to take you behind the scenes of a procedure I recently performed, illustrating how we prioritize patient comfort and safety through evidence-based techniques.
A Case Study in Patient-Centered Care
A patient presented with a benign lesion on her left forehead that she wished to have removed. While the removal itself is relatively straightforward, my paramount concern is keeping the patient comfortable and pain-free. For facial procedures, especially on the forehead, a nerve block is often the most elegant and effective anesthesia option.
Why Choose a Nerve Block Over Local Infiltration?
Before we delve into the procedure, let’s understand the “why.” When anesthetizing an area, we have a few options. The most common is local infiltration, where an anesthetic like lidocaine is injected directly into and around the tissue we plan to excise. While effective, this method has drawbacks:
Tissue Distortion: Injecting fluid directly into the surgical site can cause the tissue to swell and change shape. This distortion can make precise excision more challenging and may affect the cosmetic outcome.
Increased Discomfort: Local infiltration often requires multiple injections around the lesion to achieve adequate numbness, which can be uncomfortable for the patient.
Larger Volume of Anesthetic: Numbing a broad area via infiltration can require a larger total volume of anesthetic compared to the targeted approach of a nerve block.
A nerve block, by contrast, is a more sophisticated technique. Instead of numbing the target tissue itself, we anesthetize the nerve trunk that supplies sensation to that entire region. By depositing a small amount of anesthetic at a specific anatomical point where the nerve is accessible, we can achieve profound numbness over a wide area with minimal injections and no tissue distortion at the surgical site.
The Anatomy of Forehead Sensation
To perform a successful forehead nerve block, a detailed understanding of the underlying anatomy is non-negotiable. The sensory information from the forehead is primarily transmitted to the brain by two nerves, both of which are branches of the trigeminal nerve (Cranial Nerve V).
Supraorbital Nerve: This is the larger of the two nerves. It exits the skull through a small opening or notch in the upper rim of the eye socket, known as the supraorbital foramen or notch. From there, it travels upward, providing sensation to the majority of the forehead on that side, extending nearly to the top of the head. Clinically, we can locate this exit point by drawing a vertical line upward from the center of the pupil while the patient looks straight ahead. The nerve emerges right on the bony ridge you can feel above your eyebrow (orbital rim).
Supratrochlear Nerve: This smaller nerve emerges from the skull more medially (closer to the nose) than the supraorbital nerve. It exits just above the inner corner of the eye (medial canthus) and supplies sensation to the lower, central part of the forehead, near the bridge of the nose.
By targeting these two nerves, we can effectively anesthetize the entire half of the forehead, ensuring a completely pain-free experience for the patient during the lesion removal.
The Nerve Block Procedure: A Step-by-Step Explanation
With my patient prepped and comfortable, I began the nerve block. Here is a detailed breakdown of the technique, grounded in anatomical precision.
Step 1: Preparation and Anatomical Landmark Identification
The first step in any procedure is ensuring a sterile field. I had already cleaned the patient’s left forehead with an alcohol prep pad. Next, I precisely located the nerve exit points.
Locating the Supraorbital Nerve: I asked the patient to look straight ahead. I then visually drew a line from her pupil up to her eyebrow. With my non-dominant thumb, I palpated the bony orbital rim until I felt the slight indentation of the supraorbital notch. This is the target. Placing my thumb firmly on the orbital rim just below this point serves two purposes: it confirms my landmark and acts as a physical barrier to prevent the needle from accidentally going below the rim and endangering the eye.
Step 2: Anesthetizing the Supraorbital Nerve
I used a syringe containing lidocaine, a fast-acting local anesthetic.
I gently pinched the skin just above my thumb. This technique, known as the gate control theory of pain, can help distract from the initial needle prick by activating non-pain nerve fibers.
I told the patient, “One, two, three,” and inserted the needle perpendicular to the skin. The goal is to advance the needle until it gently makes contact with the bone (periosteum) just above the orbital rim. This confirms the correct depth.
With the needle in position, I slightly withdrew it to ensure I was not inside a blood vessel (a technique called aspiration) and then slowly injected approximately 0.5 mL of lidocaine.
As I injected, I felt the fluid create a small bulge, or bleb, against my palpating thumb. This tactile feedback confirms that the anesthetic is being delivered to the correct tissue plane, bathing the supraorbital nerve as it exits the foramen.
Step 3: Anesthetizing the Supratrochlear Nerve
Next, I moved to the second target.
Locating the Supratrochlear Nerve: I palpated the medial aspect of the orbital rim, just above the inner corner of the eye. The supratrochlear nerve is located here. Again, I placed my thumb on the rim for safety and guidance.
Following the same process, I informed the patient and inserted the needle, advancing it until it touched bone.
After aspirating, I injected another 0.5 mL of lidocaine. Once more, I felt the fluid expand in the correct location against my thumb, confirming a successful block of the supratrochlear nerve.
After both injections, I applied gentle pressure to the sites for a moment to help disperse the anesthetic and minimize any potential bruising. Within minutes, the patient’s entire left forehead became profoundly numb, allowing me to proceed with the lesion removal without causing any pain. I gave a small supplemental injection of lidocaine right around the lesion as a final precaution, and the procedure was completed smoothly and efficiently.
The Role of Integrative and Chiropractic Care
You might be wondering how a procedure like this fits into a practice that has chiropractic care at its core. This is where our integrative model shines. At Injury Medical Clinic PA, we see the patient as a whole, interconnected system.
My training as a Doctor of Chiropractic provides me with a deep understanding of the neuromusculoskeletal system. This perspective is invaluable, even in minor surgical procedures. For example, chiropractic insights help with patient positioning, post-procedural muscle tension in the neck and shoulders due to anxiety, and the body’s overall inflammatory response.
Managing Systemic Inflammation: A cornerstone of both chiropractic and functional medicine is managing inflammation. Even minor procedures trigger a local inflammatory response. Our protocols, which may include dietary recommendations, targeted supplementation (like curcumin or omega-3 fatty acids), and lifestyle advice, help the body manage this response more effectively, promoting faster and cleaner healing (Maroon & Bost, 2006).
Addressing Somatic Responses to Pain and Stress: The experience of pain or even the anticipation of it can cause a person to hold tension in their body. This often manifests as tightness in the neck, shoulders, and upper back. As a chiropractor, I can identify and address this somatic dysfunction through manual adjustments, soft tissue therapy, and postural correction. This not only improves patient comfort but also helps prevent the procedure-related stress from causing secondary musculoskeletal issues.
A Foundation of Trust: The hands-on nature of chiropractic care builds a strong therapeutic alliance between practitioner and patient. This trust is essential when performing any procedure. Patients who know and trust me through their chiropractic and functional medicine journey feel more at ease, which research shows can improve outcomes and reduce perceived pain (Kelley et al., 2014).
Our integrated approach, with the expert medical direction of Dr. Cardenas, ensures we always practice to the highest standards of safety and efficacy. Whether a patient comes to us for a spinal adjustment following a car accident, a functional medicine workup for chronic fatigue, or the removal of a skin lesion, they receive care that is coordinated, comprehensive, and centered on their total well-being.
By understanding the “why” and “how” behind even the most routine procedures, we empower our patients with knowledge and reassure them that their health is in capable, caring hands.
References
Kelley, J. M., Kaptchuk, T. J., Cusin, C., Lipkin, S., & Fava, M. (2014). The role of the patient-clinician relationship in the placebo effect. In Placebo (pp. 95-106). De Gruyter. https://doi.org/10.1515/9783110309975.95
Maroon, J. C., & Bost, J. W. (2006). ω-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4), 326–331. https://doi.org/10.1016/j.surneu.2005.10.023
Discover the benefits of kisspeptin in neuroendocrine health with integrative care and its role in maintaining hormonal balance.
Abstract
In this educational post, I, Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, walk you through the emerging science of kisspeptin. This upstream neuroendocrine signal orchestrates metabolism, sex hormones, stress responses, immune regulation, brain function, and bone remodeling. I explain how disruptions in the kisspeptin-KNDy-GnRH axis can mimic conditions like metabolic syndrome, functional hypogonadism, depression/anxiety, cognitive decline, infertility, and osteoporosis—and why treating each symptom separately misses the root cause. You’ll learn the physiology of KNDy neurons, pulse signaling, and the hypophyseal portal system; how sex steroid feedback shapes energy balance, neurotransmitter tone, and bone turnover; and how chronic stress, sleep disruption, ultra-processed foods, endocrine-disrupting chemicals, and inflammation suppress kisspeptin signaling. I outline our integrative care model at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, where I collaborate closely with Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), our Medical Director and Collaborative Physician with over 40 years in Internal Medicine. Together, we combine chiropractic care, functional medicine, medical oversight, personal injury care, rehabilitation, and evidence-based protocols that restore kisspeptin signaling. We detail practical strategies: circadian and sleep optimization, stress recalibration, targeted nutrition, resistance training, weight-bearing bone work, body composition restoration, gut-immune modulation, endocrine toxin minimization, and carefully selected peptide and pharmacologic options under medical supervision. The article highlights leading research from endocrinology and neuroscience—framed for patients and professionals—using modern, evidence-based methods and clinical reasoning to guide safe, individualized care. Keywords to expect: kisspeptin, KNDy neurons, GnRH, HPG axis, metabolic rate, insulin sensitivity, visceral fat, neurotransmitters, bone remodeling, integrative chiropractic, functional medicine, circadian rhythm, stress physiology, peptides, injury rehabilitation, El Paso healthcare.
About Our Team-Based Care In El Paso
I practice as a chiropractor and nurse practitioner specializing in functional medicine and injury rehabilitation. Our clinic—Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic—in El Paso, Texas, is a multidisciplinary environment where medical and chiropractic disciplines work side by side. Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933), serves as our Medical Director and Collaborative Physician. With more than 40 years of Internal Medicine experience, Dr. Cardenas provides medical oversight, ensures the safety and appropriateness of medical therapies, orders and interprets advanced testing, and co-manages complex internal medicine conditions that intersect with musculoskeletal and metabolic care. I, Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, lead integrative chiropractic and functional medicine services, blending spinal and extremity biomechanics, neuromuscular rehabilitation, clinical nutrition, and lifestyle reconditioning with data-driven protocols that support endocrine and immune balance. Together, we unify chiropractic care, medical assessment, functional medicine, personal injury protocols, and rehabilitation, so patients receive coordinated, whole-person care that honors both symptom relief and root-cause restoration. Learn more about my clinical approach and observations: Dr. Jimenez: Clinical observations and insights (ChiroMed) – https://chiromed.com/ Professional background and clinical updates – https://www.linkedin.com/in/dralexjimenez/
Why Kisspeptin Matters: My Journey Into The Body’s Master Timing Signal
When I first looked closely at patients with puzzling constellations—fatigue, fat gain despite “clean” eating, anxiety that doesn’t respond to standard care, low libido, irregular cycles or erectile symptoms, frequent injuries, slow recovery, and declining bone density at a young age—I saw a pattern. Many were being treated as if they had four or five isolated disorders: metabolic syndrome, depression, low testosterone or estrogen imbalance, osteoporosis, and sometimes even cognitive decline. But symptom-by-symptom prescribing left the core imbalance untouched. Over the past decade, modern research has converged on a pivotal upstream conductor: the kisspeptin system, generated by specialized hypothalamic neurons known as KNDy neurons. These neurons orchestrate rhythmic GnRH pulses—the master clock for reproductive hormones—but their influence extends far beyond fertility. Because sex steroids integrate with energy balance, brain neurotransmitter tone, immune responses, stress physiology, and bone remodeling, the kisspeptin-GnRH pulse generator effectively tunes multiple body systems at once. When it falters, you can watch entire health networks dim—metabolism slows, mood flattens, bones weaken, inflammation escalates, and recovery lags. In our clinic, we bring kisspeptin back into the conversation, not as an exotic lab value but as a practical framework that helps us restore the body’s timing, coherence, and resilience.
The Kisspeptin-KNDy-GnRH Axis: A Clear, Patient-Friendly Physiology Tour
What is kisspeptin? Kisspeptin is a small peptide produced predominantly in the hypothalamus by a cluster of neurons called KNDy neurons (Kisspeptin, Neurokinin B, Dynorphin). These neurons fire in rhythmic pulses. The pattern matters. Pulsatile signaling ensures precise downstream responses across the reproductive and metabolic axes. Who are the KNDy neurons? KNDy neurons are a tightly coupled mini-network in the arcuate nucleus. They co-release three key neurochemicals: Kisspeptin: the accelerator that stimulates GnRH neurons. Neurokinin B: helps synchronize and initiate pulses—think ignition timing. Dynorphin: provides braking to shape pulse intervals—think pulse-spacing control. How does kisspeptin reach the pituitary system? Pulses of kisspeptin travel through the hypophyseal portal circulation to the anterior pituitary region. Kisspeptin binds to receptors that ultimately drive GnRH neuronal output. GnRH pulses stimulate the pituitary to release LH and FSH, which in turn regulate ovarian and testicular steroidogenesis—estrogen, progesterone, testosterone—and gametogenesis. Why do pulses matter? The pituitary and gonads “read” the tempo of GnRH pulses. The wrong frequency or amplitude produces impaired steroidogenesis, cycle irregularities, low testosterone, anovulation, and fertility issues. Pulse-based communication reflects the body’s emphasis on rhythm: circadian clocks, feeding windows, muscle recovery cycles, and immune surveillance all share timing logic. What does this have to do with metabolism, brain health, and bones? Sex steroids influence mitochondria, muscle preservation, hepatic insulin sensitivity, lipid metabolism, appetite signals, and fat partitioning—especially visceral fat. Estrogen supports hippocampal plasticity, synaptic maintenance, and serotonergic function; testosterone stabilizes dopaminergic tone, motivation, and reward pathways. Bone is exquisitely hormone-sensitive: osteoclasts (resorption) and osteoblasts (formation) dance to hormonal music. Disrupt the music, and bone turns brittle. When kisspeptin signaling falls: Metabolic rate can drop, insulin sensitivity declines, and the body shifts toward energy storage, often centrally (visceral fat). Neurotransmitter balance shifts, increasing the risk of anxiety, depression, and anhedonia (emotional flatness). Bone remodeling tilts toward resorption: osteoclasts accelerate while osteoblast activity lags, hastening osteopenia and osteoporosis.
The Clinical Picture: What Kisspeptin Suppression Looks Like In Real Life
I often meet: Men with functional hypogonadism who also present with visceral adiposity, insulin resistance, hypertension, dyslipidemia, low motivation, and rising inflammatory markers. Women in their 30s to 40s with irregular or anovulatory cycles, fatigue, weight gain, brain fog, lowered libido, immune shifts (frequent colds, autoimmune flares), anxiety/depression, and early bone-density concerns—despite high training loads or disciplined diets. Young athletes with stress fractures or poor recovery, especially when under high psychosocial stress, caloric deficit, poor sleep, or intense endurance training. A frustrating pattern is the conventional fragmentation of care: four or more prescriptions to manage glucose, lipids, mood, and bone—while the upstream clock (kisspeptin-GnRH) remains untuned. In our experience, restoring timing and signal quality re-synchronizes multiple systems at once.
Evidence Signals: What Leading Research Shows
Modern endocrinology and neurobiology have highlighted how kisspeptin coordinates reproductive and metabolic health. While numerous studies explore kisspeptin physiology and therapeutic potential, the practical clinical message remains consistent: when pulse dynamics and receptor responsiveness are restored, multiple downstream systems improve. Examples of reported outcomes in the literature include: Improved testosterone production and normalization of LH/FSH patterns in men with functional hypogonadism when kisspeptin signaling is supported or stimulated. Enhanced ovulatory function and cycle regularity in women when hypothalamic-pituitary-ovarian timing is re-established. Positive changes in body composition, visceral fat reduction, and improved insulin sensitivity correlated with normalized sex steroid rhythms. Improvements in mood, anxiety, and cognitive performance, consistent with sex steroids’ modulation of serotonergic, dopaminergic, GABAergic, and glutamatergic systems. Stabilization of bone remodeling parameters when upstream hormonal rhythms and nutrient-mechanical inputs are aligned. Our protocols translate these findings into careful, individualized plans under integrated medical-chiropractic supervision. Note: Specific study details and applicability vary; we evaluate patients individually. We employ evidence-based care and adjust protocols based on clinical response and safety.
How Kisspeptin Shapes Metabolism: From Mitochondria To Visceral Fat
Energy dynamics explained. The body balances energy through intake, expenditure, and storage—but the”instructions” to favor burn or store are hormonal and neural. Sex steroids act as metabolic rheostats: Testosterone supports mitochondrial biogenesis, lean mass retention, and visceral fat suppression. Estrogen maintains hepatic insulin sensitivity, modulates lipid metabolism, and supports muscle glucose uptake. What happens when kisspeptin falters GnRH pulses become dysregulated, diminishing LH/FSH signaling and subsequent sex steroid output. Lower sex steroids shift metabolism toward storage: Resting metabolic rate decreases. Skeletal muscle loses anabolic tone and glucose disposal capacity. The liver becomes more insulin resistant, promoting dyslipidemia. Visceral fat expands, increasing inflammatory cytokines (e.g., IL-6, TNF-α) and worsening insulin resistance. Clinical pattern we see Patients report stubborn weight gain, especially around the abdomen. Fasting insulin and HOMA-IR rise; triglycerides creep upward; HDL may fall. Blood pressure moves north; energy drops; cravings increase. Why integrative care works We don’t treat “calories” alone. We restore the signaling context: circadian timing, sleep depth, stress modulation, nutrient density, resistance training, and, when appropriate, targeted peptides or medications under MD oversight. The body then “chooses” to burn.
Mood, Motivation, And Cognition: The Neurotransmitter Interface
Sex steroid-neurotransmitter crosstalk Estrogen enhances serotonergic tone and hippocampal plasticity, supporting mood and memory consolidation. Testosterone influences dopaminergic pathways, sustaining drive, reward processing, and executive function. When kisspeptin dips The brain loses buffering against anxiety and depression; anhedonia appears. Patients describe “flat” affect, low drive, and brain fog. Clinical translation Rather than siloed psychiatric treatment alone, we investigate sleep architecture, circadian timing, inflammatory load, micronutrient status (e.g., omega-3 index, vitamin D, B vitamins), and sex steroid rhythms. Aligning these often alleviates mood symptoms while supporting long-term resiliency.
Bone Health And The Hormonal Music Of Remodeling
Bone is dynamic tissue. Osteoclasts resorb; osteoblasts build. Hormones, nutrients, and mechanical loading direct this choreography. Estrogen restrains resorption; testosterone supports formation and muscle-driven skeletal loading. When kisspeptin is suppressed Sex steroid decline removes checks on osteoclasts. Bone density falls faster than expected for age; stress fractures and early osteopenia appear, especially in athletes with low energy availability. Restorative strategy Rebuild the hormonal rhythm, ensure adequate protein and minerals, prioritize vitamin D/K2 and omega-3s, and prescribe progressive, weight-bearing and impact training that safely stimulates osteogenesis. Chiropractic care addresses kinetic chain dysfunction, ensuring axial loading is distributed properly, and joints can tolerate progressive forces.
Why The Body Chooses Storage: The Evolutionary Logic
From an evolutionary perspective, when stress, sleep loss, infection, or famine signals the hypothalamus, the body protects fertility by temporarily downshifting reproductive signaling. Kisspeptin sits at this decision point. If energy is low or stress is high, kisspeptin pulsatility diminishes, conserving resources but shifting metabolism to storage. Our job is to convince the hypothalamus that conditions are safe and abundant—through sleep regularization, nutrient density, sympathetic-parasympathetic balance, and consistent mechanical signals from healthy movement.
Common Drivers Of Kisspeptin Suppression
Chronic psychological stress and high allostatic load Inadequate sleep, circadian disruption, late-night light exposure Low energy availability (calorie deficit), especially with high training volume Highly processed diets, poor protein quality, micronutrient gaps Insulin resistance and chronic inflammation Endocrine-disrupting chemicals (EDCs): BPA, phthalates, PFAS, etc. Untreated hypothyroidism or subclinical thyroid dysfunction Gut dysbiosis, lipopolysaccharide (LPS)-driven inflammation Traumatic brain injury (TBI) and concussion sequelae Persistent pain signaling and immobility after injury Alcohol overuse and recreational drug impacts Identifying and addressing these drivers in a structured plan is essential for long-term restoration.
Our Integrative Care Model: Chiropractic, Medical, Functional, And Rehab Under One Roof
At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), we deliver a coordinated pathway: Medical direction and safety Dr. Cardenas, Internal Medicine, directs medical care, orders and interprets labs and imaging, supervises peptide or pharmacologic interventions, and ensures clinical safety for complex cases. Integrative chiropractic care I address spinal and extremity biomechanics, joint restriction, and neuromuscular control. Adjustments and mobilizations reduce nociceptive drive, normalize proprioception, and improve autonomic balance to support hypothalamic-pituitary coherence. Functional medicine We map root contributors: sleep-circadian misalignment, nutritional gaps, endocrine disruptors, gut-immune triggers, metabolic rigidity, and stress physiology. Rehabilitation and performance Progressive loading, movement patterning, breath mechanics, and fascia-focused therapy restore kinetic integrity, enabling safe return to sport and daily life. Personal injury integration Post-collision or work injury cases often involve pain, stress, sleep disruption, and deconditioning—each can suppress kisspeptin. Our team coordinates documentation, imaging, and staged rehabilitation while guarding endocrine-metabolic health. This multidisciplinary setup—common in integrative and injury care clinics—prevents fragmentation and accelerates meaningful recovery.
The Evaluation Blueprint: Data-Driven And Personalized
Step 1: History and timeline Symptom onset, stressors, injuries, training loads, menstrual or sexual function patterns, sleep logs, nutrition, weight history, and mood-cognition changes. Step 2: Physical and biomechanical assessment Posture, spinal and pelvic alignment, joint mobility, gait, breathing mechanics, muscle balance, and movement screens. Step 3: Laboratory and imaging under medical oversight (as indicated) Metabolic panel: fasting insulin, glucose, HbA1c, lipids, liver enzymes. Inflammation: hs-CRP, ferritin, CBC, homocysteine. Nutrient status: vitamin D, B12/folate, omega-3 index, iron studies. Endocrine: morning cortisol patterning, thyroid panel (TSH, fT4, fT3), prolactin if indicated. Sex hormones: total and free testosterone, SHBG, estradiol (phase-specific in cycling women), progesterone (mid-luteal), LH/FSH. Bone health: DEXA for BMD and body composition; optionally bone turnover markers. Gut health: targeted stool testing when GI symptoms or autoimmune patterns suggest dysbiosis. Imaging: when injuries, stress fractures, or endocrine pituitary concerns arise. Step 4: Functional testing Heart rate variability (HRV), sleep wearables, continuous glucose monitoring (CGM) for select cases. Our goal is to triangulate physiology—correlating symptoms, structure, and lab signals—so protocols match reality.
Chiropractic Care’s Role In Restoring Kisspeptin Signaling
Why chiropractic matters physiologically Pain and joint dysfunction elevate sympathetic tone and inflammatory mediators—both suppress hypothalamic reproductive signaling. Spinal and peripheral joint adjustments can: Reduce nociceptive input and normalize dorsal horn processing. Improve proprioceptive signaling, aiding sensorimotor integration. Shift autonomic balance toward parasympathetic restoration, which supports hypothalamic pulsatility. Improved movement quality enables progressive resistance and impact training—critical for muscle, metabolism, and bone. Techniques we employ High-velocity, low-amplitude adjustments when indicated and safe. Low-force mobilization for sensitized patients. Soft-tissue and myofascial techniques to reduce guarding and improve gliding. Neuromuscular re-education to stabilize new ranges of motion. Breath and rib mechanics to optimize vagal tone and thoracic mobility. Clinical observation When pain decreases, and movement improves, sleep deepens, HRV increases, and patients can adhere to nutrition and training plans—all inputs that favor kisspeptin restoration. See clinical insights and case reflections: Clinical observations (ChiroMed) – https://chiromed.com/ Professional updates – https://www.linkedin.com/in/dralexjimenez/
Medical Oversight: Ensuring Safety And Precision
Dr.Cardenas’’ role is pivotal: She evaluates for medical contraindications, oversees lab strategy, and guides pharmacologic or peptide interventions when needed. In complex cases—e.g., coexisting diabetes, hypertension, autoimmune disease, or perimenopausal transitions—her expertise keeps care on target and safe. If advanced endocrine evaluation or imaging is necessary (e.g., suspected pituitary pathology), she directs referrals and coordinates care.
Functional Medicine Levers That Re-Synchronize The Axis
Circadian alignment and sleep architecture Consistent sleep-wake times; morning light exposure; dim evenings. Target 7.5–9 hours of sleep opportunity; prioritize slow-wave and REM quality. Why: SCN-hypothalamic timing stabilizes GnRH pulses; sleep curtails cortisol and inflammatory mediators that blunt kisspeptin. Stress recalibration Breath training (e.g., slow nasal, 4-6 breaths/min), mindfulness, biofeedback, and structured recovery windows. Strengthening social and environmental buffers to lower allostatic load. Why: Chronic sympathetic drive suppresses hypothalamic reproductive signals; vagal tone promotes restoration. Targeted nutrition Protein at 1.6–2.2 g/kg/day to preserve lean mass. Fiber-rich, polyphenol-dense plants for gut-immune balance. Carbohydrates matched to training; prioritizing whole-food matrices to stabilize glucose-insulin dynamics. Adequate omega-3s, magnesium, zinc, vitamin D/K2, and B vitamins. Why: Nutrient sufficiency, stable glycemia, and anti-inflammatory patterns signal abundance and safety to the hypothalamus. Resistance and impact training 2–4 weekly full-body strength sessions; progressive overload; technique first. Low-to-moderate impact (as tolerated) for osteogenesis; plyometrics when appropriate. Why: Muscle is a glucose sink and endocrine organ; loading drives bone formation and mitochondrial biogenesis. Gut-immune restoration Address dysbiosis; increase fermentable fibers and polyphenols; consider probiotics selectively. Why: LPS and gut-derived inflammatory mediators suppress hypothalamic signaling and worsen insulin resistance. Endocrine-disruptor hygiene Reduce plastic contact, filter water, avoid thermal receipts, improve indoor air quality. Why: EDCs can interfere with sex steroid receptors and hypothalamic cues, blunting kisspeptin responsiveness. Alcohol and substance moderation Limit alcohol; avoid sedative reliance. Why: Alcohol disrupts sleep stages and inflames the gut-liver axis, worsening endocrine rhythms. Micronutrient and lab-guided supplementation Vitamin D sufficiency, omega-3 optimization, magnesium for sleep and insulin sensitivity, zinc for steroidogenesis. Why: Key cofactors support the enzymatic pathways governing sex steroids and neurotransmitters.
When Peptides Or Pharmacologic Tools Are Considered
Under Dr. CCardenas’medical direction, we may consider: Therapeutic agents that influence GnRH-kisspeptin dynamics or downstream steroidogenesis when lifestyle and rehabilitative strategies need support. Sleep aids, when necessary, to stabilize architecture while behavioral interventions take hold. Insulin-sensitizing agents if metabolic rigidity impedes progress. Management of thyroid or prolactin imbalances that secondarily suppress kisspeptin. We proceed conservatively, always prioritizing foundational pillars first. We integrate any peptide or prescription into a comprehensive plan with clear goals and monitoring.
Personal Injury Context: Protecting The Axis During Recovery
Injury care is a unique endocrine stress: Pain, sleep fragmentation, reduced activity, and psychological strain suppress kisspeptin. Steroid changes post-injury can accelerate sarcopenia and visceral fat. Our approach: Early pain control through chiropractic and manual therapies to reduce sympathetic drive. Gentle movement reintroduction to defend muscle and bone. Sleep and stress protocols started immediately. Nutrition tuned for healing: adequate protein, collagen-rich foods, vitamin C, zinc, and omega-3s. Medical oversight to address concussion/TBI, medications that may affect sleep-hormone balance, and safe progression criteria.
The Non-Surgical Approach to Wellness with Chiropractic Care- Video
Case Patterns I Commonly See
Pattern A: The over-trained, under-fueled woman in her 30s Findings: Irregular cycles, high training load with low caloric intake, insomnia, rising fasting insulin, declining DEXA BMD. Plan: Increase energy availability, reduce high-intensity frequency, add strength training, optimize sleep, micronutrient repletion, load the skeleton safely, and consider medical support if cycles remain anovulatory. Outcome goal: Restored ovulatory rhythm, improved BMD trend, stable mood, stronger lifts and recovery. Pattern B: The mid-40s executive male with creeping central adiposity Findings: Late-night work and screens, elevated stress, low morning energy, low-normal testosterone with high SHBG, increasing triglycerides, borderline blood pressure. Plan: Circadian reset, resistance training blocks, protein-first meals, alcohol reduction, chiropractic care to reduce pain and improve HRV, and medical assessment for insulin resistance and thyroid. Outcome goal: Increased free testosterone, reduced visceral fat, improved sleep, steadier mood and drive. Pattern C: Post-collision patient with persistent pain and brain fog Findings: Neck and back pain, poor sleep, anxiety, decreased activity, weight gain. Plan: Gentle adjustments and mobilization, breath and rib mechanics, graded activity, targeted nutrition, sleep stabilization; medical evaluation for concussion and appropriate therapies. Outcome goal: Pain down, sleep up, cognitive clarity returning, endocrine markers normalizing.
Implementation Guide: From First Visit To Follow-Up
Week 0–2: Assessment, sleep routine, gentle mobility, protein targets, morning light exposure, hydration, and stress basics. Chiropractic care initiated to reduce nociception. Week 3–6: Strength training starts (technique focus), nutrition refinement, gut support if indicated. Monitor HRV, sleep, and energy. Week 7–12: Progress load and impact cautiously; recheck body composition; adjust macronutrients; consider medical therapeutics if metabolic rigidity persists. Month 4–6: Reassess labs and DEXA when appropriate; refine program; taper supervised visits as self-efficacy increases.
Why This Works: The Physiology Of Coherence
When the body senses predictable rhythms, sufficient nutrients, lower inflammation, and safe, progressive mechanical load, the hypothalamus relaxes protective downshifts. Kisspeptin pulses regain their timing; GnRH resumes its music. Sex steroids rise within physiologic ranges, lifting mitochondrial output, neurotransmitter balance, and bone formation. Patients don’t just feel better—they rebuild capacity.
How We Coordinate Care Day-To-Day
Shared case reviews: Dr. Cardenas and I routinely review complex patients, aligning testing and interventions. Clear communication: You will know why we choose each step and how we’ll measure progress. Safety gates: We carefully titrate load, nutrition, and any medical agents, monitoring signs and labs.
What Success Looks Like
Stable, refreshing sleep and consistent wake energy Improved body composition: higher lean mass, lower visceral fat Regular cycles and improved fertility markers in women; better morning erections and libido in men Lower fasting insulin, improved lipids, and normalized blood pressure Clearer mood, stronger motivation, reduced anxiety Stronger bones and fewer injuries A resilient nervous system that recovers quickly from stressors
Frequently Asked Questions
Is kisspeptin only about fertility? No. It’s a master timing signal with ripple effects on metabolism, brain function, and bone health by governing GnRH and downstream sex steroids. Do I need medications? Not always. Foundational care often restores signaling. When needed, medications or peptides are used judiciously under medical supervision. How long until I notice changes? Many patients notice sleep and energy improvements within weeks. Body composition and bone changes take longer—months for composition, years for bone density trends. We measure to keep progress visible. Can chiropractic adjustments really influence hormones? By reducing pain and sympathetic overdrive, improving sleep and movement, and enabling resistance training, chiropractic care indirectly supports the hypothalamic environment that sets hormone timing.
Integrating The Latest Research With Real-World Care
Our commitment is to evidence-informed, patient-centered practice. We synthesize modern endocrinology, neuroscience, sports medicine, and rehabilitation science with practical steps you can live with. When multiple issues appear at once—metabolic, mood, fertility, and bone—consider the upstream timing. Kisspeptin is not the only player, but it’s often the conductor we need to retune. To explore care with us at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso—or to refer a complex case—reach out. We are here to help restore rhythm, resilience, and performance. Learn more about my clinical perspective and ongoing observations: Clinical observations and integrative insights – https://chiromed.com/ Professional background – https://www.linkedin.com/in/dralexjimenez/
References
Lehman, M. N., Coolen, L. M., & Goodman, R. L. (2010). Minireview: kisspeptin/neurokinin B/dynorphin (KNDy) cells of the arcuate nucleus: a central node in the control of gonadotropin-releasing hormone secretion. Endocrinology, 151(8), 3479–3489. https://doi.org/10.1210/en.2010-0022
Lehman, M. N., Ladha, Z., Coolen, L. M., Hileman, S. M., Connors, J. M., & Goodman, R. L. (2010). Neuronal plasticity and seasonal reproduction in sheep. The European Journal of Neuroscience, 32(12), 2152–2164. https://doi.org/10.1111/j.1460-9568.2010.07530.x
Clarke, H., Dhillo, W. S., & Jayasena, C. N. (2015). Comprehensive Review on Kisspeptin and Its Role in Reproductive Disorders. Endocrinology and Metabolism (Seoul, Korea), 30(2), 124–141. https://doi.org/10.3803/EnM.2015.30.2.124
Zhu, L., Martinez, M. N., Emfinger, C. H., Palmisano, B. T., & Stafford, J. M. (2014). Estrogen signaling prevents diet-induced hepatic insulin resistance in male mice with obesity. American Journal of Physiology. Endocrinology and Metabolism, 306(10), E1188–E1197. https://doi.org/10.1152/ajpendo.00579.2013
Rossetti, M. L., Steiner, J. L., & Gordon, B. S. (2017). Androgen-mediated regulation of skeletal muscle protein balance. Molecular and cellular endocrinology, 447, 35–44. https://doi.org/10.1016/j.mce.2017.02.031
Khosla, S., & Monroe, D. G. (2018). Regulation of Bone Metabolism by Sex Steroids. Cold Spring Harbor Perspectives in Medicine, 8(1), a031211. https://doi.org/10.1101/cshperspect.a031211
Fester, L., Prange-Kiel, J., Zhou, L., Blittersdorf, B. V., Böhm, J., Jarry, H., Schumacher, M., & Rune, G. M. (2012). Estrogen-regulated synaptogenesis in the hippocampus: sexual dimorphism in vivo but not in vitro. The Journal of Steroid Biochemistry and Molecular Biology, 131(1-2), 24–29. https://doi.org/10.1016/j.jsbmb.2011.11.010
Tobiansky, D. J., Wallin-Miller, K. G., Floresco, S. B., Wood, R. I., & Soma, K. K. (2018). Androgen Regulation of the Mesocorticolimbic System and Executive Function. Frontiers in Endocrinology, 9, 279. https://doi.org/10.3389/fendo.2018.00279
Wang, L., Wang, N., Zhang, W., Cheng, X., Yan, Z., Shao, G., Wang, X., Wang, R., & Fu, C. (2022). Therapeutic peptides: current applications and future directions. Signal transduction and targeted therapy, 7(1), 48. https://doi.org/10.1038/s41392-022-00904-4
de la Iglesia, H. O., & Schwartz, W. J. (2006). Minireview: timely ovulation: circadian regulation of the female hypothalamo-pituitary-gonadal axis. Endocrinology, 147(3), 1148–1153. https://doi.org/10.1210/en.2005-1311
SEO tags: kisspeptin, KNDy neurons, GnRH pulses, hypothalamus, metabolic rate, insulin sensitivity, visceral fat, osteoporosis, bone remodeling, estrogen, testosterone, neurotransmitters, anxiety, depression, anhedonia, hippocampal plasticity, integrative chiropractic care, functional medicine, El Paso injury clinic, Medical Director Dr. Maria Guadalupe Cardenas, Dr. Alex Jimenez, peptide therapy, circadian rhythm, sleep optimization, stress reduction, endocrine disruptors, resistance training, weight-bearing exercise, DEXA, body composition, HRV, personal injury rehabilitation, concussion care, internal medicine and chiropractic collaboration
Abstract: In this educational post, I guide you through a clear, step-by-step clinical approach to excising a dysplastic nevus with moderate atypia using modern, evidence-based methods. You will see how a properly executed anesthetic field block creates a pain-free experience, why dermatologic surgery for moderate atypia uses narrow margins, and how meticulous tissue handling supports definitive histologic assessment. I also share how our multidisciplinary team at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas integrates chiropractic care, internal medicine oversight, functional medicine, and rehabilitation. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), and in collaboration with me, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, we blend precision procedural care with whole-person strategies grounded in current research. This post highlights how integrative chiropractic care fits into surgical dermatology and personal injury care to optimize healing, reduce pain, and support long-term outcomes.
Introduction: Perspective on Modern, Multidisciplinary Skin Lesion Care
I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso clinic, we often see patients who need carefully planned excisions following a diagnostic shave biopsy. Today, I’ll walk you through a real case: a 62-year-old gentleman returning approximately one month after a shave biopsy revealed a dysplastic nevus with moderate atypia. Our goals: remove the residual lesion with clinically appropriate narrow margins, enable a pain-free experience using a precise anesthetic field block, and ensure the tissue specimen is ideal for pathology.
What makes this care unique is our integrative model. As the Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Internal Medicine), provides medical oversight and coordinates care pathways common to multidisciplinary injury and integrative clinics. In parallel, our chiropractic services, functional medicine strategies, and rehabilitation protocols create a cohesive system designed to keep the patient safe, comfortable, and moving toward recovery based on the best available evidence.
Building the Plan: Why Dysplastic Nevus with Moderate Atypia Requires Focused Margins
Key concept: Dysplastic nevi with moderate atypia are atypical moles with architectural and cytologic changes that warrant complete excision to reduce the risk of residual atypical tissue.
Evidence rationale: For moderate atypia, many dermatologic guidelines support excision with narrow margins (often around 2 mm beyond the visible or scar boundary) to ensure complete removal while preserving healthy tissue. Histopathologic evaluation confirms clearance.
In this case, the original lesion measured approximately 5 x 6 millimeters. I planned margins of roughly 2 millimeters around the current scar, translating to about 5 millimeters around the original lesion perimeter. Using a template helps me create a symmetric, fusiform design aligned with relaxed skin tension lines, minimizing postoperative tension and optimizing cosmetic results. Templates reduce human error in margin symmetry, and a well-planned ellipse supports primary closure with minimal dog-ears.
Design and Anesthesia: A Pain-Free Field Block by Interrupting Cutaneous Nerve Signaling
My goal with anesthesia is simple: make the experience pain-free and efficient. I start by prepping with alcohol, then reinforce the concept of a field block—a circumferential anesthetic “fence” that interrupts nerve signals entering the skin around our excision site.
Technique overview:
I select an ideal entry point near the planned excision boundaries.
I advance the needle, then inject while withdrawing, turning within the dermis/subcutaneous plane to create a continuous ring of anesthesia.
I repeat on the opposite side and, as needed, add lateral entry points to ensure complete coverage, always aiming for minimal needle insertions that produce maximal numbing.
Why it works physiologically:
The field block targets the terminal branches of sensory nerves within the dermis and subcutaneous tissue. By bathing these fibers with 1 percent lidocaine with epinephrine, we block voltage-gated sodium channels, preventing depolarization and halting nociceptive transmission.
Epinephrine causes local vasoconstriction, reducing bleeding and prolonging lidocaine’s dwell time near nerves. This prolongs anesthesia, helps maintain a bloodless field, and enhances visualization during precise excision.
Injecting in subcutaneous tissue to “saturate” beneath the lesion creates a foundational blockade. When we perform intradermal injections after subcutaneous saturation, patients typically report little or no sensation because the deeper nociceptive input has already been interrupted.
Adjunct comfort measures:
I use a cold “free spray” over the injection point. Rapid cooling stimulates A-delta fibers, which preferentially transmit cold sensations, creating a gating effect that reduces pain perception as the needle enters. This immediate numbing means they rarely feel the injection.
I steer the needle by slight bending to guide the tip across the dermal plane, carefully visualizing the trajectory under the skin. Injecting while withdrawing forms a visible intradermal wheal line that confirms even distribution.
Patient response:
Using these methods, our patient reported no pain throughout the anesthetic process. This is exactly the outcome we strive for—an effective, pain-free field block before excision.
Precision Excision: Narrow Margins and Tissue Integrity
With anesthesia confirmed and a clean field, the next step is the excision. Narrow margins are not arbitrary; they balance oncologic safety with tissue preservation, especially in cosmetically sensitive areas.
Core principles:
Margin control: For moderate atypia, 2-mm margins are commonly used; they are sufficient for complete removal while minimizing unnecessary tissue loss.
Fusiform design: An ellipse aligned with skin tension lines enables linear closure under reduced tension, decreasing the risk of hypertrophic scarring and optimizing cosmesis.
Specimen integrity: Gentle handling and correct orientation markings help pathologists assess margins and architecture accurately, confirming clearance.
Physiology of healing:
Minimal tension reduces micro-ischemia at wound edges, aiding angiogenesis and fibroblast activity necessary for collagen deposition.
Vasoconstriction from epinephrine tempers intraoperative bleeding, stabilizing the clot and early extracellular matrix formation.
Integrative Chiropractic Care in Dermatologic Surgical Recovery
While excision of a skin lesion may seem isolated from musculoskeletal care, an integrative approach adds value for recovery, comfort, and function—especially in older adults or those with comorbidities.
How chiropractic care fits:
Posture and movement optimization: After excision, patients often guard movement due to fear of pulling sutures. Chiropractic and rehabilitative strategies help maintain normal biomechanics and prevent compensatory strain.
Neuromuscular re-education: Gentle manual therapy and targeted exercises support proprioception and movement confidence, reducing myofascial tension near or distant from the surgical site.
Pain modulation: Chiropractic interventions can engage descending inhibitory pathways, reducing central sensitization that sometimes amplifies minor post-procedural discomfort.
Circulatory support: Mobility, diaphragmatic breathing, and safe motion progressions improve local perfusion, supporting oxygen delivery and waste clearance in healing tissues.
In practice, I assess global movement patterns and provide tailored strategies to keep patients functional without stressing the incision. For example, we may adjust daily ergonomic habits, teach safe range-of-motion techniques, and implement light isometrics that maintain muscle tone without disturbing the wound.
Multidisciplinary Oversight: Internal Medicine Leadership with Dr. Maria Guadalupe Cardenas, MD
Our clinic operates within a multidisciplinary framework common in integrative and injury care settings. Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933) serves as our Medical Director and Collaborative Physician. With over 40 years of experience as an internist, Dr. Cardenas supervises medical protocols, ensures safety for patients with complex health histories, and aligns the plan with best practices.
Medical oversight matters because:
Risk stratification: Internal medicine evaluates cardiovascular status, diabetes control, anticoagulation, and immunomodulating conditions that might impact bleeding, infection risk, or wound healing.
Medication management: Guidance on peri-procedural adjustments for antiplatelets/anticoagulants or immunosuppressants balances safety and procedural efficacy.
Systems-based care: Internal medicine connects dermatologic procedures with broader health concerns—sleep, nutrition, metabolic status—each influencing recovery timeline and scar quality.
Collaborative roles:
Dr. Cardenas provides medical direction, reviews histories, and creates safe peri-procedural pathways.
I deliver the procedure, chiropractic integration, functional medicine insights, and rehabilitative planning.
Together, we coordinate personal injury processes, documentation, and patient education.
Functional Medicine Integration: Optimizing Healing Physiology
Functional medicine supports the body’s innate healing mechanisms through targeted lifestyle and nutritional strategies tailored to the patient’s biology.
Focus areas:
Inflammation modulation: Adequate omega-3 intake, polyphenols (curcumin, quercetin), and antioxidant-rich foods can support controlled inflammation necessary for healing while preventing prolonged inflammatory states that delay recovery.
Glycemic control: Stable blood sugar supports fibroblast function, collagen cross-linking, and reduces infection risk; critical in older adults and those with metabolic syndrome.
Micronutrient sufficiency: Vitamin C (collagen synthesis), zinc (DNA replication and immune function), and vitamin A (epithelial integrity) are essential. We personalize supplementation cautiously, consistent with medical oversight.
Reasoning:
The acute wound healing phases—hemostasis, inflammation, proliferation, remodeling—depend on energy availability, micronutrient cofactors, and balanced immune signaling. Diet and lifestyle calibrate these processes.
Sleep quality and stress modulation (e.g., paced breathing) influence HPA axis activity and cytokine profiles that can either facilitate or impair tissue repair.
Rehabilitation Strategy: Safe Motion, Scar Care, and Long-Term Outcomes
Rehabilitation begins as soon as the procedure ends.
Key steps:
Early wound protection: Educate on dressing care, signs of infection, and avoiding tension across the incision.
Progressive mobility: Introduce gentle, non-straining movements to prevent stiffness and maintain circulation.
Scar optimization: Once the wound has closed, consider silicone sheeting, gentle massage, and sun protection to improve scar quality.
Ergonomics: Adjust lifting strategies, workstation setup, and daily routines to prevent undue strain near the surgical site.
Physiologic reasoning:
Controlled motion stimulates mechanotransduction pathways in fibroblasts, guiding orderly collagen alignment and increasing tensile strength.
In injury care settings, precision documentation complements clinical excellence:
Clear procedural notes with lesion size, margin plan, anesthesia specifics, and patient responses.
Photo documentation for pre- and post-excision views (when appropriate).
Communication with referring providers and insurers regarding necessity, medical oversight, and outcomes.
Clinical Observations from My Practice
At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), I have observed:
Patients experience significantly better comfort with a well-executed field block using 1% lidocaine with epinephrine and adjunct cold spray.
Narrow, well-planned margins for moderate atypia yield high clearance rates while preserving cosmesis.
Integrative chiropractic and functional medicine improve confidence in movement, reduce compensatory pain patterns, and support faster return to normal activities.
Step-by-Step Narrative: From Planning to Excision
Pre-Procedure:
Confirm pathology: dysplastic nevus with moderate atypia.
Explain margins and expectations to the patient.
Prepare sterile field with antiseptic; use alcohol for initial prep and repeat.
Field Block:
Choose entry point; advance needle; inject while withdrawing to create a continuous anesthetic ring.
Turn within the tissue plane to cover both sides without fully removing the needle.
Add lateral points if needed; saturate subcutaneous tissue under the lesion.
Verify numbness; apply cold spray before further injections.
Intradermal Distribution:
Thread the needle across the dermis; visualize tip; inject on withdrawal to form a visible wheal line indicating spread.
Assess patient comfort continuously; recalibrate if sensation persists.
Excision:
Mark ellipse with template; align with skin tension lines.
Excise along just outside the marked borders to respect margins.
Handle tissue gently; orient specimen; achieve hemostasis; close in layers if indicated.
Post-Procedure:
Educate on dressing changes, signs of infection, and motion precautions.
Schedule follow-up for pathology results and suture removal.
Provide integrative guidance on movement, nutrition, sleep, and stress.
Why Each Technique Matters
Template-guided marking: Ensures symmetry, facilitates linear closure, and reduces dog-ears.
Field block with epinephrine: Prolongs anesthesia, reduces bleeding, and improves operative field visibility.
Injecting on withdrawal: Distributes anesthetic evenly and reduces intratissue pressure spikes that can be uncomfortable.
Cold spray: Activates sensory gating to reduce needle pain.
Narrow margins: Balance complete excision of atypia with tissue preservation, aligning with evidence and cosmetic considerations.
Integrative follow-through: Addresses systemic determinants of healing and functional recovery beyond the incision line.
Safety Considerations
Avoid epinephrine in end-arterial regions if risk factors exist; assess peripheral vascular disease.
Screen for lidocaine allergies and arrhythmic history.
Coordinate with internal medicine on anticoagulation decisions and infection-risk mitigation.
Our Team-Based Care in El Paso, Texas
At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), our care model weaves together:
Chiropractic care (Dr. Jimenez): Movement analysis, manual therapy, neuromuscular re-education, ergonomic optimization.
Medical oversight (Dr. Cardenas, MD): Risk stratification, medication management, systems-based medical direction.
Functional medicine: Nutrition, sleep, stress, and personalized supplementation.
Rehabilitation: Progressive mobility, scar care, and return-to-function planning.
Personal injury services: Comprehensive documentation, coordination with legal and insurance entities where applicable.
Conclusion: Modern, Evidence-Based, Integrative Care for Skin Surgery
Excision of a dysplastic nevus with moderate atypia is more than a precise cut; it is a coordinated effort grounded in physiology, patient comfort, and multidisciplinary safety. By pairing a pain-free field block with careful margin planning and whole-person support, we improve outcomes and the patient experience. Under the medical direction of Dr. Maria Guadalupe Cardenas, MD, and through our integrative chiropractic, functional medicine, and rehabilitative care, patients receive comprehensive, evidence-based support from diagnosis to recovery.
