The need for artful incorporation of Hippocrates’ wisdom is great in today’s healthcare landscape. As conversation of nutrition broadens into multidisciplinary fields, his wisdom resonates: first, “we must make a habit of two things; to help; or at least to do no harm”. Second, we must modernize the ancient adage: “let food be thy medicine and let medicine be thy food”. And finally, health care providers will do well to be guided by his insight that “all disease starts in the gut”. Hippocrates’ keen observations during his era, modern science is confirming, hold keys to the plight of our times as we seek to find better ways to manage complex conditions commonly encountered in pelvic rehab practice settings and beyond.
Considered some of the oldest writings on medicine, the “Hippocratic Corpus” is a collection of more than 60 medical books attributed directly and indirectly to Hippocrates himself who lived from approximately 460 to 377 BCE.2 According to the Corpus, Hippocratic approach recommends physical exercise and a “healthy diet” as a remedy for most ailments - with plants being prized for their healing properties. If -during illness states - employment of nourishment and movement strategies fail, then medicinal considerations could be made. This logos - the ancient Greek word for logic - is the art of reason whose relevance today is perhaps more poignant than in ancient times.
In this logos, by making a habit of helping, or at the very least, not harming, it becomes particularly important to identify the unique nutritional landscape that surrounds us. The Hippocratic Oath emanates reason. It is logical that we would seek to practice (healthcare) to the best of our ability, share knowledge with other providers, employ sympathy, compassion and understanding, and help in disease prevention whenever possible.2 One of the most helpful and powerful aspects of rehabilitation is the gift of time we have for meaningful and instructional conversation with our clients. Our interactions with clients can and should address the realm of nutrition as it relates to the health of the mind and body. Because, after all - to help - is why many become health care providers in the first place.
Detailing a “healthy diet” in Hippocratic times was certainly simpler, as the uncontrolled variable of processed foods- as we know them- did not exist. Therefore, we reflect upon the quote: “let food be thy medicine and let medicine be thy food” and acknowledge that this modern food landscape is vastly different 1 than in ancient times. Compounding the issue, our standard logic for helping has gotten somewhat out of order. And both medicine and food carry meanings today reflective of modern times. The issues of poly-pharmacy and the tragedy of medically prescribed unintentional overdoses (or intolerances) remind us of our ‘medicine first’ mentality and the unfortunate reality that medicine is not the cure-all we so wish it could be. Further, not all ‘food’ today is food. Real food sustains and nourishes us. Real food can also heal. We need to celebrate real food for being real food, and champion it’s miraculous ability to support, heal, and transform the human condition.
Finally, health care providers will do well to be guided by Hippocratic insight that “all disease starts in the gut” and to logically extrapolate the opposite: much healing can begin in the gut. It is through this ancient concept that we can organize our modern science and begin to concretely and intentionally help heal ourselves and others from the inside out. Once we understand the key role of digestion and our gut on our health and well-being, the rest is pure logic. We simply need a map for navigation of these universal concepts to go along with our renewed appreciation for the art of reason.
Let Nutrition Perspectives for the Pelvic Rehab Therapist help provide this map. Evolve your nutritional logos into a beautiful and nourishing framework by joining the hundreds of pelvic rehab therapists and other health care providers who have attended Nutrition Perspectives in Pelvic Rehab. Be inspired and empowered on your integrative journey. Live courses will be offered at three sites in 2019: March 1-3 in Arlington, VA, June 7-9 in Houston, TX, and October 11-13 in Tampa, FL!
Fardet, A., Rock, E., Bassama, J., Bohuon, P., Prabhasankar, P., Monteiro, C., . . . Achir, N. (2015). Current food classifications in epidemiological studies do not enable solid nutritional recommendations for preventing diet-related chronic diseases: the impact of food processing. Adv Nutr, 6(6), 629-638. doi:10.3945/an.115.008789
Biography.com https://www.biography.com/people/hippocrates-082216. Accessed January 11, 2019.
There are moments when I pause and realize how far we’ve come in a short period of time, and then others when I’m acutely reminded how far we have yet to go. Our destination is an integrative health care system which addresses nourishment first and early versus last, not at all, or only when all else fails. My mission is to support the concept of nourishment first and early though sharing of “Nutrition Perspectives for the Pelvic Rehab Therapist” through the Herman & Wallace Pelvic Rehab Institute.
After each weekend I teach Nutrition Perspectives for the Pelvic Rehab Therapist, I feel affirmed that this class, this information is vital and at times life-changing for practicing clinicians. And every time I teach, participants share that they take away much more than they expected. It’s a course that makes accessible complex concepts to entry level participants while offering timely and cutting edge integrative instruction to the advanced clinician eager to incorporate this knowledge into their practice. Supportive literature is woven throughout the tapestry of the course.
After the most recent live course event, a participant shared with me a letter she received from a patient in 2016 who mentions the lack of nutritional attention during her cancer treatment. I want to share with you the essence of this letter:
“In October 2015, I was diagnosed with cancer. The following December I started treatments of radiation and chemotherapy. I really appreciate all the fine employees who helped me through care and treatments. Every clinician I came across, whether a doctor, nurse, phlebotomist, radiation and chemo teams, and my PT, were all exceptional in showing care, concern and knowledge.
However, one area I felt was lacking in was nutrition. I was frequently offered a standard hospital-issue protein drink. When offered, I explained that I would not take it due to it containing high fructose corn syrup (HFCS). I asked if they knew that HFCS was like putting and accelerant on a fire? I received a smile and a nod of head as to say they understood.
I was also offered soda pop to wash down bad tasting medicines/ liquids I was to take. I opted to just down the medication without chasing it as I didn’t want to exacerbate my condition. While taking chemotherapy, I was offered snacks containing HFCS and other non-nutritive so-called foods.
I was also offered limited entree choices, but there were plenty of pies, cakes, jellies, and other non-nutritive foods to choose from. All Items I would not consider for a cancer diet or even a healthy diet. I finally took a picture of the menu selection sheet as I thought no one would believe such a thing could happen.
I received excellent care throughout your system with the exception of nutrition . I would ask that you take a look at making menus with truly healthy options as well as giving patients options that do not contain ingredients that feed the cancer.”
While this letter addresses an inpatient issue at one regional health system, it correspondingly brings into focus the irony present in the vast majority of health care settings across the nation from inpatient to outpatient settings: there is a profound lack of clarity about what it means to be nourished, especially when we are at our most vulnerable.
I cannot claim “Nutrition Perspectives” will solve our nation-wide problem, however, I am certainly encouraging a movement towards a collective understanding of the imperative fact that food is medicine - powerful medicine - and we must as front-line practitioners harness what this understanding can offer. Pelvic rehab practitioners are uniquely positioned to process this information and begin immediately sharing it in clinical practice.
Like many providers, this same participant shared with me that upon receipt of this letter two years ago, she struggled to make progress with what and how to offer nutritional information - mainly because of the overwhelming nature of the subject, and also because of the conflicting and oftentimes confusing information traditionally shared with the public. After attending Nutrition Perspectives, she said “I cannot even begin to describe how much your course has met ALL my hopes for helping clients!….I had struggled to put something together and here it all is - so unbelievably grateful.”
And that’s what this course is all about - empowering you as you broaden your scope of knowledge in a way that teaches you not facts, but deep understanding. Once that foundational understanding is laid, this grass-roots effort will progress like putting an accelerant on the integrative movement. Soon we’ll see the inclusion of nourishment information as first-line practice, and the lives impacted in a positive way will continue to grow.
Please join me at the next opportunity to share in this live experience with other like-minded clinicians. Nutrition Perspectives for the Pelvic Rehab Therapist will be coming to Denver, CO September 15 & 16, 2018!
Gratitude filled my heart after being able to take part in the pre-conference course sponsored by the APTA Orthopedic Section’s Pain Management Special Interest Group this past February. For two days, participants heard from leaders in the field of progressive pain management with integrative topics including neuroscience, cognitive behavioral therapy, motivational interviewing, sleep, yoga, and mindfulness to name a few. It’s exciting to witness and participate in the evolution of integrative thinking in physical therapy. When it was my turn to deliver the presentation, I had prepared about nutrition and pain, I could hardly contain my passion. While so much of our pain-related focus is placed on the brain, I realized acutely the stone yet unturned is the involvement of the enteric nervous system (aka the gut) on pain and….well…everything.
Much appreciation is due to those on the forefront of pain sciences for their research, their insight, their tireless work to fill our tool boxes with pain education concepts. Neuroscience has made tremendous leaps and bounds as has corresponding digital media to help explain pain to our patients. One such brilliant 5-minute tool can be found on the Live Active YouTube channel.
What I love about this video is how intelligently (and artistically!) it puts into accessible language some incredibly complex processes. It even mentions lifestyle and nutrition as playing a role in what is commonly referred to as a maladaptive central nervous system.
Ok. I’ll admit, I struggle with the implications of this term. However, what doesn’t sit right with me is the concept of chronic or persistent pain being entirely in the brain as though the brain is a static entity. We know the brain to be plastic but often do not identify just how this is so.
What about the role of our second brain…. the one with 200-600 million neurons that live in that middle part of our body (right next to / inside our pelvis)? Termed the enteric nervous system, this second brain both stores and produces neurotransmittersTurna, et.al., 2016, serves as the scaffolding of interplay between the ENS, SNS, and CNS. This ENS is home to the interface of “bugs, gut, and glial” which are “not only in anatomical proximity, but also influence and regulate each other…interconnected for mutual homeostasis.”Lerner, et.al., 2017 In fact, part of this process then directly impacts the brain. “Healthy brain function and modulation are dependent upon the microbiota’s [gut bugs] activity of the vagus nerve.”Turna, et.al., 2016. Further, “by direct routes or indirectly, through the gut mucosal system and its local immune system, microbial factors, cytokines, and gut hormones find their ways to the brain, thus impacting cognition, emotion, mood, stress resilience, recovery, appetite, metabolic balance, interoception and PAIN.”Lerner, et.al., 2017
So, by process of logic, it requires little convincing to conclude that the food we eat or fail to eat directly impacts the health or dysfunction of this magnificently orchestrated system. One that directly and profoundly impacts our brain, our body, our being. And it’s a concept that our patients, our clients, ourselves, know in our gut to be true.
And it’s thanks to all the hard work of those who have come before us that we can share in the advancing understanding for the benefit of thousands who need your help, expertise and guidance. Please join me for Nutrition Perspectives for the Pelvic Rehab Therapist. The next course will be in Springfield, MO on June 23-24, 2018. Vital and clarifying information awaits you!
Live Active. (2013, Jan) Understanding Pain in less than 5 minutes, and what to do about it! https://www.youtube.com/watch?v=C_3phB93rvI Retrieved March 28, 2018.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Turna, J., Grosman Kaplan, K., Anglin, R., & Van Ameringen, M. (2016). "What's Bugging the Gut in Ocd?" a Review of the Gut Microbiome in Obsessive-Compulsive Disorder. Depress Anxiety, 33(3), 171-178. doi:10.1002/da.22454
“Keep Calm and Treat Pain” is perhaps an affirmation for therapists when encountering patients suffering from pain, whether acute or chronic. The reality is this: treating pain is complicated. Treating pain has brought many a health care provider to his or her proverbial knees. It has also led us as a nation into the depths of the opioid epidemic which claimed over 165,000 lives between the years of 1999 and 2014 (Dowell & Haegerich, 2016). That number has swollen to over 200,000 in up-to-date calculations and according to the CDC, 42,000 human beings, not statistics, were killed by opioids in 2016 - a record.
So why has treating pain eluded us as a nation? The answers are as complicated as treating pain itself. Which is why we as health care providers must seek out not simply alternatives, but the truth in the matter. Why are so many suffering? Why has chronic pain become the enormous beast that it has become? What might we do differently, collectively, and how might we examine this issue through a holistic mindset?
In just a few weeks, I have the privilege of teaching amongst 10 physical therapy professionals and one physician from around the nation who with coordinated efforts created a landmark pre-conference course at CSM in New Orleans through the Orthopaedic Section of the APTA. Included in the 11 are myself and another Herman & Wallace instructor Carolyn McManus, PT, MS, MA who teaches “Mindfulness Based Pain Treatment” through the Institute.
The CSM pre-conference course title is “Keep Calm and Treat Pain” representing a necessary effort to provide the clinician with ideas and inspiration for helping the profession as a whole treat pain with an integrative approach.
“Pain and Nutrition: Building Resilience Through Nourishment” is the section I look forward to sharing. It will introduce concepts we can leverage to allow us confidence in seeking alternate ways of taming this beast which is chronic pain - ways which can enhance health and well-being of our clients in pelvic rehabilitation. We must not be passive observers of the opioid epidemic. We must come to terms with the fact that our nations go-to tool for treating pain unfortunately causes side-effects which can and does include loss of life. We can do better. And we will.
While the CSM pre-conference course will give you a taste of the nutrition concepts available to you, it is a mere tip of the nourishment iceberg. I continue my passion and mission with the two-day course titled “Nutrition Perspectives for the Pelvic Rehab Therapist”, an experience that can elevate your conversations with clients. It will pave a path of understanding for the provider, allowing us to share options, understanding, and hope. “Nutrition Perspectives for the Pelvic Rehab Therapist is coming next to Maywood, IL March 3 & 4, 2018. I welcome you to join me.
APTA CSM: https://apta.expoplanner.com/index.cfm?do=expomap.sess&event_id=27&session_id=13763. Accessed January 8, 2018.
CDC: https://www.cdc.gov/drugoverdose/index.html. Accessed January 8, 2018.
Dowell, D., & Haegerich, T. M. (2016). Using the CDC Guideline and Tools for Opioid Prescribing in Patients with Chronic Pain. Am Fam Physician, 93(12), 970-972.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Murthy, V. H. (2016). Ending the Opioid Epidemic - A Call to Action. N Engl J Med, 375(25), 2413-2415. doi:10.1056/NEJMp1612578
Anxiety and depression are frequently encountered co-morbidities in the clients we serve in pelvic rehabilitation. This observation several years ago in clinical practice is one of many that prompted me down the path of exploring the connection between the gut, the brain, and overall health. In answering the question about these connections, I discovered many nutritionally related truths that are being rapidly elucidated in the literature.
A recent study by Sandhu, et.al. (2017) examines the role of the gut microbiota on the health of the brain and it’s influence on anxiety and depression. The title of the study, “Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry” gives us pause to consider the impact of our diets on this axis and in turn, on the health of our nervous system. The authors state:
It is diet composition and nutritional status that has been repeatedly been shown to be one of the most critical modifiable factors regulating the gut microbiota at different time points across the lifespan and under various health conditions.
With diet and nutritional status being the most critical modifiable factors in the health of this system, it becomes our responsibility to seek to understand this system and its influencing factors. We need to learn how to nourish the microbiota-gut-brain axis.
While anxiety and depression are common co-morbidities we encounter, we also commonly detect imbalance between the sympathetic and parasympathetic nervous system in our patients leading to, for example, pelvic floor muscle tension. In light of this study we must first and foremost ask: what is the microbiota? How can it influence our nervous system? How does this correlate to anxiety and depression? The answers to these questions provide clinical insight with far-reaching impact. We also consider: which circumstances disrupt the health of this system and which improve it? Finally, could understanding of this axis, among other nutritional correlates, provide a novel approach to bowel dysfunction, bladder dysfunction, chronic pelvic pain?
Be a part of the paradigm shift to integrative understanding as we explore these and many other burning questions. Please join us for insightful discussion in White Plains, NY March 31-April 1, 2017 for our next offering of Nutrition Perspectives for the Pelvic Rehab Therapist.
Sandhu, K. V., Sherwin, E., Schellekens, H., Stanton, C., Dinan, T. G., & Cryan, J. F. (2017). Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry. Transl Res, 179, 223-244. doi:10.1016/j.trsl.2016.10.002
When it comes to discussing nutrition with our clients in pelvic rehab, it is normal to initially feel both uncertain and perhaps a bit overwhelmed at the prospect of delving into this topic. Yet we know that there must be links, some association between nutrition and the many chronic conditions we encounter. Gradually, over the last several years, a cornerstone of my practice with patients in pelvic rehabilitation has become providing nutritional guidance.
I was both humbled and immensely grateful when many of my colleagues and peers attended Nutrition Perspectives for the Pelvic Rehab Therapist (NPPR) in Kansas City last March. In the following months, our clinics underwent a significant change in the types of discussions occurring with our patients. By embracing concepts presented in NPPR, a continuous stream of patient stories developed about lives having been touched by this shift. For many, “one small change” made a very big difference or served as the catalyst to many more positive lifestyle changes. Simply placing a high priority on re-thinking health situations through the lens of nourishment has been a very important shift, one that can occur across the spectrum of pelvic rehab practitioners if we choose to answer the call to “do what’s necessary”.
Learning the essence of a topic outside our comfort zone is not easy, yet in present time is necessary for providers trying to grapple with how to wrap our professional minds around what we know in our hearts to be true: the effect of nourishment on health is profound. This brings to mind the resonating wisdom of Francis of Assisi:
“Start by doing what’s necessary, then do what’s possible;
and suddenly you are doing the impossible.”
At this crossroads in our health care system we know that nutrition matters. We must start by doing what’s necessary: acknowledging our role in helping patients along their path to a better life through less pain, ease of movement, normalization of function, and healing. With commitment to our patient’s well-being, we too must commit to investigating the realm of nutrition and rehabilitation. Next, we can strive to do what’s possible. NPPR can serve as a springboard for professionals ready to develop programs incorporating sound nourishment principles in relation to both specific conditions in pelvic rehab and general health and well-being. Finally, we may - in a few short years - realize that suddenly we are doing the impossible; integrating these vital principles as standard care in rehabilitation.
Please join us in White Plains, NY March 31-April 1, 2017 for Nutrition Perspectives for the Pelvic Rehab Therapist. Whether you are just beginning to integrate nutrition and its correlates to pelvic rehab or are already well on your way along this path, you will come away with both a strong understanding of how food affects function along with tools you can immediately begin sharing with the clients you serve.
Megan Pribyl, MSPT is the author and instructor for Nutrition Perspectives for the Pelvic Rehab Therapist. Megan is passionate about nutritional science and manual therapy. Megan holds a dual-degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) from Kansas State University, and has actively sought to fill in missing links between orthopedics and nutrition.
APTA Landmark Motion Passes
RC 12-15: The Role of the Physical Therapist in Diet and Nutrition
Is nutrition within our scope of practice? As the instructor for “Nutrition Perspectives for the Pelvic Rehab Therapist” offered through Herman & Wallace, I hear this question frequently! To me, the answer has always been a clear “yes*!”; now the APTA is endorsing this view. It’s an exciting time to be a rehab professional, especially for those looking to broaden clinical perspectives and scope of services to include basic nutrition and lifestyle information.
At the APTA House of Delegates in early June 2015, a landmark motion passed - RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. As our profession advances towards a more integrative model, this motion symbolizes an acknowledgement of the rehab professional’s broader role as a health care provider. We, as physical therapists, are uniquely positioned to offer patients more comprehensive lifestyle-related education including discussion of nutrition. Both the World Health Organization (WHO, 2008) and the Physical Therapy Summit on Global Health (Dean, et.al, 2014) have called upon all health care providers to stand in unity to help the public with epidemics of lifestyle-related diseases; the APTA has given it’s nod of approval as well.
The motion states: “as diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patient, clients, and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist*.” Further, “this motion clearly incorporates the intent of the new Vision Statement for the Physical Therapy Profession by transforming society and improving the human experience.” (APTA, 2015)
This powerful development provides us with both challenge and opportunity. How can we, as pelvic rehab professionals, be armed with the most cutting edge nutritional information available? What nutrition information lies within our scope of practice? How can we apply this information to our pelvic rehab patient population? For the answer to these pressing questions and much more, plan now to attend Nutrition Perspectives for the Pelvic Rehab Therapist” March 5 & 6, 2016 in Kansas City, MO. It is my passion to share this information and I welcome you to join me for this timely CEU opportunity. It is designed to help you obtain the skills needed to confidently identify nutritional correlates in pelvic rehabilitation.
ATPA (2015) http://www.apta.org/uploadedFiles/2015PacketI.pdf
Dean, E., de Andrade, A. D., O'Donoghue, G., Skinner, M., Umereh, G., Beenen, P., . . . Wong, W. P. (2014). The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract, 30(4), 261-275. (http://www.ncbi.nlm.nih.gov/pubmed/24252072)
World Health Organization. (2008). 2008-2013 Action plan for the global strategy for the prevention and control of non communicable diseases. Geneva, Switzerland: WHO. (http://www.who.int/mediacentre/news/releases/2015/noncommunicable-diseases/en/)
This post was written by Megan Pribyl MSPT, who teaches the course Nutrition Perspectives for the Pelvic Rehab Therapist. You can catch Megan teaching this course in June in Seattle.
Convalescence and mitohormesis…really big words that in a scientific way suggest “BALANCE”. In our modern world, there are many factors that influence the pervasive trend of being “on” or in perpetual “go mode”. We see the effects of this in clinical practice every day. The sympathetic system is in overdrive and the parasympathetic system is in a state of neglect and disrepair. And so we reflect on that word “balance” through the concepts of convalescence and mitohormesis.
“In the past, it was taken for granted that any illness would require a decent period of recovery after it had passed, a period of recuperation, of convalescence, without which recurrence was possible or likely.
Convalescence fell out of favor as powerful modern drugs emerged. It appeared that [antibiotics] and the steroid anti-inflammatories produced so dramatic a resolution of the old killer diseases… that all the time spent convalescing was no longer necessary.” (Bone, 2013)
How many of us take the time to convalesce after even a minor cold or flu? “Convalescence needs time, one of the hardest commodities now to find.” (Bone, 2013) We live in a culture where getting well FAST typically takes priority over getting well WELL.
On the flip-side of convalescence lies mitohormesis, or stress-response hormesis. Simply put, hormesis describes the beneficial effects of a treatment (or stressor) that at a higher intensity is harmful. Without mitohormesis, the driving, adaptive forces of life might lie dormant or find dysfuction. In a recent article (Ristow, 2014) mitohormesis is discussed: “Increasing evidence indicates that reactive oxygen species (ROS) do not only cause oxidative stress, but rather may function as signaling molecules that promote health by preventing or delaying a number of chronic diseases, and ultimately extend lifespan. While high levels of ROS are generally accepted to cause cellular damage and to promote aging, low levels of these may rather improve systemic defense mechanisms by inducing an adaptive response.”
Relevant to nutritional trends, Tapia (2006) suggests this perspective: “it may be necessary…to engender a more sanguine perspective on organelle level physiology, as… such entities have an evolutionarily orchestrated capacity to self-regulate that may be pathologically disturbed by overzealous use of antioxidants, particularly in the healthy.” Think of mitohormesis as the cellular-level forces that spur change. Motivation….drive….exhilaration. These life-sprurring stressors include physical activity and glucose restriction among other interventions.
The natural world is full of contrasts; day and night, winter and summer, land and sea, sun and rain. These contrasts are not only essential in creating rhythm to our existence, but necessary as driving forces of life. But what happens when there is not a balance of activity and rest? What happens when our energy systems go haywire? What nutritional factors play a role in whether a client of yours will have a healing and helpful course of therapy or may struggle with the healing process? How might we frame our understanding of the importance of balance through the lens of nourishment?
March is “National Nutrition Month”! It’s a perfect time to register for our brand new continuing education course Nutrition Perspectives for the Pelvic Rehab Therapist to learn more about how nutrition impacts our clinical practice. To register for the course taking place in June in Seattle, click here.
Bone, K. Mills, S. (2013) Principles and Practice of Phytotherapy; Modern Herbal Medicine. Second Edition. Churchill Livingstone Elsevier.
Gems, D., & Partridge, L. (2008). Stress-response hormesis and aging: "that which does not kill us makes us stronger". Cell Metab, 7(3), 200-203. doi: 10.1016/j.cmet.2008.01.001
Ristow, M., & Schmeisser, K. (2014). Mitohormesis: Promoting Health and Lifespan by Increased Levels of Reactive Oxygen Species (ROS). Dose Response, 12(2), 288-341. doi: 10.2203/dose-response.13-035.Ristow
Tapia, P. C. (2006). Sublethal mitochondrial stress with an attendant stoichiometric augmentation of reactive oxygen species may precipitate many of the beneficial alterations in cellular physiology produced by caloric restriction, intermittent fasting, exercise and dietary phytonutrients: "Mitohormesis" for health and vitality. Med Hypotheses, 66(4), 832-843. doi: 10.1016/j.mehy.2005.09.009