Spinal Manipulation versus Diclofenac for Low Back Pain

Prevalence of low back pain is between 31% - 47 % in the general population.  80 % of patients with acute low back pain who receive treatment return to work within one month, but that 7 % can develop chronic low back pain.  On the other hand, more than 60% of people with acute low back pain who do not receive treatment develop chronic low back pain or have reoccurrence.  Therefore, proper and early treatment appears to avoid the transition into chronic low back pain. 

A 2013 clinical trial published in Spine compared Spinal Manipulation Therapy (SMT) to the nonsteroidal anti-inflammatory Diclofenac  (NSAID) for acute, non specific low back pain.  A total of 101 patients with acute low back pain (LBP) for less than 48 hours were recruited.  The subjects were randomized into three groups:

Group 1: Spinal manipulation, placebo diclofenac

Group 2: Sham manipulation, diclofenac

Group 3: Sham manipulation and placebo diclofenac

Outcomes were measured by a blinded investigator that included self rated physical disability, function, time off work, and rescue medication during the 12 week study.  The double placebo group 3 had a high number of dropouts due to unsustainable pain, so that group was closed before the end of the trial.  Comparing the two active interventions, the manipulation group was significantly superior then the diclofenac group, with no adverse effects recorded.  Subjects reported a better quality of life after spinal manipulation compared to diclofenac and patients in the NSAID group took almost three times as much rescue medication compared to the spinal manipulation group. 

Citation:  Spinal High Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain:  A Double Blinded Randomized Controlled Trial in Comparision with Diclofenac and Placebo.

Von Heymann, et al.  Spine 38(7)540-548, April, 2013

Musculoskeletal Effects of Cigarette Smoking

It is well known that cigarette smoking is implicated in lung cancer, respiratory conditions, cardiovascular disease and impaired immunity.  Heavier smokers (over a pack a day) also create a hypoxic state (lack of oxygen) in the body, which can be attributed to other health issues.  Researchers reviewed the current literature to specifically look at the effects of cigarette smoking on the musculoskeletal system and here are some of their findings: 

Bone Metabolism and Fracture Risk: Smoking appears to affect both osteoblasts and osteoclasts, both of which are important for balanced bone health, and can lead to a decrease in bone mineral density (osteoporosis).  This leads to an increased risk of fracture of the hip, spine, and radius. 

Fracture Healing:  Smoking leads to reduced blood supply and local tissue hypoxia, which increases fracture healing time, and increases the risk of poor healing, infection, and non union of fractures. 

Soft Tissue Healing:  Smokers tend to have delayed wound and soft tissue healing of tendons and ligaments, a higher risk of tendon injuries, increased wound infections and complications compared to non smokers.  Smokers have been shown to have a higher incidence of rotator cuff tears.

Back Pain:  The increased levels of pro inflammatory mediators by smokers can amplify pain as well smoking appears to be associated with an increase risk of degenerative disc disease and low back pain.  However, it is difficult to say how smoking is associated with low back pain, as smokers often have worse health, both mentally and physically, than non smokers. 

Arthritis:  There is an unclear relationship with smoking and osteoarthritis as some studies have shown increased knee cartilage loss in smokers, but it is an accepted risk factor for rheumatoid arthritis.  Smokers have also been shown to have a greater chance of developing lupus, an inflammatory autoimmune disorder.

Perioperative Management:  The negative effects of smoking on wound healing appear to improve after 4 weeks of smoking cessation.  Former smokers tend to do better than current smokers in terms of improved recovery from surgical wounds and have less post operative complications.  It would therefore be highly recommended that smokers cease smoking at least 4 weeks prior to any surgery. 

There are many health reasons to quit smoking, now we can add musculoskeletal conditions to the list!

Citation: Lee et al, The Musculoskeletal Effects of Cigarette Smoking; Journal of Bone and Joint Surgery (Am) 2013; 95: 850-859.

Exercise for Metabolic Syndrome

Metabolic syndrome is made up of five conditions: hypertension, diabetes, hypercholesterolemia, hyperlipidemia and obesity.  There are commonalities among these conditions, so treatment can have an effect on more than one condition in the syndrome.  One such treatment is EXERCISE aimed at weight loss.  Most health care providers understand the benefits of exercise, and often suggest to patients to exercise and lose weight, but they provide minimal instruction on how to do this. 

Aerobic training is the easiest type of exercise to begin with, and once started other components can be added such as flexibility and strength training.  Due to the often poor health status of the person with metabolic syndrome, it would be recommended that a physical exam be conducted before an aerobic conditioning program is started.  Blood pressure, pulse rate, body weight and circumferential measurements of the waist, hip and thighs should be recorded to establish a baseline. 

Aerobic exercise is anything that can elevate your heart rate.   Walking indoors or outdoors, walk/run intervals, running, stair climbing, water aerobics, swimming, rowing, jumping rope, cycling on a stationary bike or outdoors, and dancing are activities that are aerobic.

Exercise can be recommended as a number of sessions a week for a certain length of time, and should be referred to as a prescription, as patients are more inclined to see it therapeutically to treat their metabolic syndrome.  Monitoring is important, for motivation and compliance as well to determine if there are any concerns to address.  Depending on the patient’s pre-existing conditions, assessments should be done monthly if they are just beginning or returning from an injury, but patients who are in better shape or have been exercising longer may have a longer period between assessments.   

The rule for determining minimal intensity is that the patient must be sweating within the first 10 minutes of exercise, and maximum intensity is that the patient must be able to carry on a conversation while exercising.  Another method to determine intensity is to monitor heart rate.  To determine a patient’s target heart rate, subtract the patient’s age from 220 than subtract the resting heart rate from this number.  To burn fat, the number is multiplied by 60-70 percent, for endurance the number is multiplied by 80. 

The final step in aerobic exercise is to keep track of activity by recording duration and dates of exercise sessions.  This helps with compliance and to determine progress.  Of course, exercise is always more fun when you do it with someone else, so get family and friends to join you! 

Unique Characteristics of the High Arch

When it comes to abnormal foot mechanics, a pronated or flat foot is the most common condition, but there is a smaller minority or people that have a high arch or supinated foot which can equally cause problems in the lower extremity.  An elevated arch tends to transmit rather than absorb shock as it is very rigid and inflexible, this results in increased forces up the kinetic chain to the knee and hip, making it susceptible to stress fractures of the foot and leg.  A study reported in Clinical Biomechanics found that high arched subjects had increased leg stiffness and vertical loading rates compared to low arched runners. 

While athletes with excessive pronation or supination of the feet are susceptible to more knee injuries, they differ in the type of injury patterns.  High arched runners report more lateral knee injuries, as they tend to be more bow legged, as opposed to low arched runners who show more medial knee injuries as they are knocked kneed.  Stress fractures in the calcaneus and seasmoids bones of the feet are more common in high arches, whereas soft tissue injuries are more common in low arches.  High arched runners experience more lateral ankle sprains and iliotibial band problems, while low arched runners have more medial meniscus and patellar tendonitis problems. 

A high arched foot generally requires improved flexibility (mobilization/stretching) of the foot and stabilizing orthotics to help decrease the shock at the heel strike, absorbing some of the forces and minimizing transmission up the leg.  These components would help to reduce the injury potential of the rigid foot with associated knee injuries, particularly in the case of runners, as running multiplies the forces three times more on heel strike.   

The unique nature of a rigid, high arch was recently reinforced to me when I had a patient who had one high rigid foot, and requested fitting for orthotics.  Her history included being a runner in the past and suffering a calcaneal stress fracture and a long history of iliotibial band issues on the rigid foot side, both conditions associated with a high arch.  

Plantar fasciitis and heel spurs can occur with both a pronated or supinated foot, due to the abnormal structure and pulling on the fascia.  Treatment is similar with both of these conditions, which can include ice, cold laser, mobilization, stretching, and orthotics.  Just as with a low arch, a person with a high arch will have to take extra care of the feet and have good foot wear for life. 

Restricted Carbohydrate Diet

In order to obtain and maintain your ideal body weight there is no magic bullet.  Obviously getting rid of processed food in your diet and increasing your veggie and fruit intake are  essential, as well as weight training to preserve lean muscle mass and cardio to burn fat stores.  The controversy seems to be in the low or no carbohydrate diets that are the current fad.

Weight loss without carbohydrate restriction is very difficult for most people.  When you eat a carbohydrate compared to a protein or fat, it is broken down rather quickly into glucose.  Once your bloodstream is flooded with glucose from your meal, insulin has to be released to make the energy accessible to the cells, but if there is excess glucose floating around, it gets stored as fat.  There is a strong correlation with type two diabetes and high carbohydrate diets, as when there is a constant stimulation of the pancreas to release insulin to process the excessive glucose, it eventual “wears out”.

So what does carbohydrate restriction mean?  One gram of carbohydrates equals four calories.  Many low carbohydrate diets reduce carbohydrate consumption to 20% or less of your diet, but a restricted carbohydrate is a more realistic 30% of your total calories from carbohydrates.  So if an average woman eats 1200 calories a day, than no more than 360 calories should be from carbohydrates, or roughly 90 grams of carbohydrates.  The change to a diet with reduced carbohydrates would put the body into ketosis, and shift the focus of energy from the immediate glucose available in the bloodstream to ketones, thus accessing fat stores to lose weight. 

There has been much research in the field of restricted carbohydrate diets. The New England Journal of Medicine published a clinical trial in 2008 comparing a low carbohydrate diet versus a low fat diet in obese patients and found that the low carbohydrate diet produced increased weight loss, decreased triglycerides and increased insulin sensitivity as opposed to the low fat diet. 

So the bottom line is start cutting back on your processed grains, such as bread, pasta, rice, cookies, pastries; and critically look at the nutritional information on all processed foods for the carbohydrate count.  Make sure any of the carbohydrates that you do consume are of high quality, preferably whole foods such as fruit and veggies and whole grains. 

Balance Exercises to Reduce Falls in the Elderly

As our society grays, it will become more important to avoid a health care crisis if a focus can be kept on keeping the elderly living in their own homes as independently as possible for as long as possible.  One of the largest sources of injury and hospitalization is from falls in seniors.  If the result is a hip fracture, there is a 50 % chance of permanent mobility issues that may result in the senior being unable to return to their home. 

Exercise is touted as one of the best preventative measures to not only reduce cardiovascular disease, type two diabetes and certain cancers, but to also stave off the progression of unhealthy aging, such as loss of muscle and bone mass; less flexible joints and reduced elasticity of tendons and ligaments.  One of the biggest barriers to exercise in the senior population is the fear of a fall, hence often the best strategy to get seniors moving is to start with restoring their balance to reduce this fear.  Balance is a function of input to the brain from information gathered in the vestibular (inner ear) system, visual system and somatosensory system (muscle, joint and skin receptors). 

There are a lot of exercises that can be used to enhance the balance of seniors, but they should all be done supervised and graduated within limits of the senior’s abilities.  There should always be a support available to the senior, such as a chair, wall, or counter to give the senior stability and confidence to perform the exercises.  Most balance exercises can be performed at home with little to no equipment needed, making it very cost effective.

One of the simpliest balance exercises to start with is by standing on one foot, while hanging on to a support.  Progression can be made to letting go of the support, but keeping it in reach if needed.  Once this has been mastered, the next step is closing the eyes, thereby removing the visual input, and having the mechanoreceptors in the muscles and joints to work harder.  

Another simple balance exercise is to go to the corner of the room, and with the two walls as support, place one foot in front of the other, keeping the weight is on the back foot.  This is challenging as it narrows the base of support for the body, as many seniors start to develop a wide stance to compensate for their lack of balance.   Again, the further challenge would be to not touch the walls, but keep the hands out for support if needed, and then to progress to closing the eyes. 

The internet is filled with websites on balance exercises, and another source would be the health district and senior centres, which may offer supervised classes.  So to keep the seniors in your life independent longer, think about doing some simple balance exercises and encourage them get more active. 

Cold Laser Post Knee Replacement

With an aging baby boomer population that have been more active than past generations, advanced osteoarthritis of the knee is a common condition in modern society.  Seniors who typically have a knee replaced are in poor physical shape due to inactivity; have poor muscle tone or bone mass; and are often overweight, which leads to long recovery and rehabilitation.  Boomers generally are in better physical shape and are having knee replacements at a younger age in order to return to their activities.

Cold laser therapy is a modality that is used to help reduce pain and inflammation; speed tissue healing by increasing vasodilation to bring in oxygen and nutrients and most importantly increasing ATP production, the cell’s energy source, to promote collagen formation.  Cold laser is safe to use on orthopedic appliances such as pins, plates and replaced joints as it does not heat. Ultrasound is contraindicated as it produces heat and electrotherapy is contraindicated as it conducts. 

Cold laser can be applied almost immediately after surgery as long as the wound is not open and there is no infection.  With surgery, the soft issues have been traumatized and your body is rapidly repairing the damage.  This is a time when there is a high need for cellular energy and nutrients.  The Theralase cold laser can penetrate 2 inches directly and 4 inches indirectly into the soft tissue;  speeding  the healing process by up to 50%, with much stronger collagen and less scar tissue.  This can allow the patient to participate in rehabilitation to strengthen up the muscles and allow an earlier return to activities.

Predicting Childhood Obesity

A simple formula, more accurately than complex genetic tests, can predict whether a baby is likely to become obese in childhood.  The formula is available as an online calculator http://files-good.ibl.fr/childhood-obesity which esitmates the child's obesity risk based on a few factors:
            
              - birth weight
              - body mass index of parents
              - number of people in household
              - the mother's professional status
              - the mother's smoking status during pregnancy

The researchers behind the study, published in the online journal PLOS ONE, hope that their calculator can be used to spot infants at high risk and help their families to prevent their children from putting on too much weight, as once a child becomes obese, it is difficult to lose.

The study, lead by Professor Philipe Froguel, from the School of Public Health at Imperial College in London, looked at 4,000 children born in Finland.  They were looking for genetic profiles as markers for childhood obesity, but failed to make accurate predictions.  Instead they looked at information readily available at the time of birth, and found those factors were more accurate.  The formula has worked not only in Finnish kids, but has been replicated in Italy and the US. 

Professor Froguel states that the beauty of the formula is its simplicity, it takes very little time to gather the information and costs nothing.  While not all children who have the risk factors are destined to become obese, as one in ten cases are caused by a rare genetic mutation that affects appetite, the majority of children can be targeted early to prevent a life time of struggles with their weight. 

Relaxation with Deep Breathing

Effective relaxation techniques provide a powerful antidote to stress; it can revitalize the body, steady the emotions, and create greater mental clarity.  It is a matter of letting go, instead of holding on to, of not doing, rather than doing.  As you relax, muscle tension is reduced and there is a decrease in the activity of the sympathetic nervous system. 

Deep breathing can be learned in minutes and have immediate benefits, but long lasting effects will be appreciated after several weeks of practice.  It can quickly reduce anxiety and pain on the spot, allowing emotional control.  Longer term it can alleviate irritability, muscle tension, fatigue, panic attacks and depression.  Steps for effective deep breathing include:

• Allow for 10 minutes of undisturbed time
• Find a quiet place to sit or lie down
• Close your eyes, scan your body for tension and begin to relax those muscles
• Place your hand on your stomach and breathe through your nose
• Focus breathing through your stomach by visualizing a balloon expanding and contracting
• Count down 10 seconds for each inhale/exhale

Meditation can be added on to deep breathing, by consciously focusing the mind on an object, word, phrase or activity and allowing background noise, thoughts or concerns to fade away.  Follow the steps for deep breathing, but allow your relaxation to deepen by meditating to the natural rhythm of your breathing.  As your mind wanders, choose to bring it back to your focus point.  With practice, you will begin to lose awareness of thoughts and experience a profound stillness of the mind. 

Dental Applications with Cold Laser

The dental profession has been on the leading edge of research using cold laser, with over 100 clinical trials in the last year alone.  The cold laser is effective in reducing pain and inflammation, as well as accelerate soft tissue repair by increasing collagen formation.  The five following dental conditions are common and have shown excellent results by applying cold laser:

TMJ Dysfunction is dentally addressed with TMJ splints to realign a bite issue, but it is often treated in conjunction with manual therapy, as there is increased soft tissue pain and headaches when the splint is adjusted.  Studies have shown that there is a clinically significant reduction in jaw pain and increased mandibular movement with cold laser, as effective as splinting.  Even greater results are shown when using both splints and cold laser together. 

Gingivitis improved dramatically with the inclusion of cold laser with traditional periodontal treatment than with traditional treatment alone.  There was a reduction in bleeding, gum inflammation, and plaque, all important to prevent advancement of dental cavities.

Dental extraction pain can be substantially reduced with using cold laser following the extraction. Studies showed substantial reduction of pain and inflammation and improved healing compared to the control groups.

Orthodontic forces involving braces were split mouth studies, where laser was applied on one side of the mouth only, so the patient is their own control.  There was significant reduction of pain on the laser side after brace readjustments and interestingly increased tooth movement, which could decrease treatment time.  Cold laser was also used in a clinical trial involving maxilla expansion, and there was not only a reduction of pain, but increased opening of the midpalate suture and accelerated bone regeneration compared to the control group. 

Oral ulcers and cold sores are seen secondarily in the dental profession, and using cold laser has shown to not only reduce pain, but speed healing of these conditions and in the instance of cold sores, even help prevent reoccurrence. 

 The amount of time involved for dental applications of laser is minimal, as the area is often small, so only minutes would be required, allowing an easy integration into the dental practice.  But best of all would be improved patient outcomes, and less pain, making it less fearful to go to the dentist!

Negative Self Talk

Self-talk can have a powerful impact on your emotional well-being and motivation.  Unfortunately negative self-talk has a way of becoming a self-fulfilling prophecy, which can occur when there is a stressful life event, when you are anxious or when you are feeling down on yourself.  At these times, you are least able to be truly rational and objective. The key is to recognize flawed self-talk and replace the errors with more appropriate thinking, a strategy often used in cognitive behavioral therapy. 

Some examples of flawed thinking:

·         All or nothing thinking: if anything is less than perfect, you see it as total failure

·         Filtering out the positive: you think positive outcomes were just dumb luck

·         Jumping to conclusions: either mind reading, when you conclude someone is reacting negatively to you or fortune telling, where you predict things will turn out bad

·         Magnification: you exaggerate the importance of your problems or short comings

·         Should statements: you tell yourself that things should be the way you expected them to be, often not reality

·         Labeling: instead of saying I made a mistake you attach a negative label, I am a loser

·         Self blame: you hold yourself personally responsible for events not in your control

Positive self talk can give you the confidence to use your talents to the fullest.  Remember your positive traits and skills when your thoughts turn negative. Review your previous successes in your mind and correct your flawed self talk.  The ultimate purpose of examining your self-talk is to change actions that are self defeating.  The real power of self talk lies in how it changes your behavior.

How Does Cold Laser Work?

Cold laser, or low level laser, was added as a new service at the White House in May 2011.  Since using this new technology, we have been having great results with a variety of muscle, tendon, ligament, joint, and nerve conditions. 

Cold laser works by activating three biological pathways:

·         Adenosine Triphosphate (ATP) Pathway:  The mitochondria (the cell engine) absorbs the light energy and chemically converts it into ATP, which is the cell’s fuel.  This process accelerates tissue regeneration by increasing synthesis of collagen, the building block of all soft tissue.  Secondary reactions include increased protein synthesis and stimulating cell division.

·         Nitric Oxide Pathway:  Nitric Oxide relaxes the lymphatic system, which allows reabsorption to occur, reducing inflammation and pain.  There is also an increase in vasodilation, to get more blood and oxygen to injured tissues.

·         Lipid Absorption Pathway:  Increased porosity of the cell membrane allows a rebalancing of the sodium-potassium pump, thereby decreasing the pain signal.  Low level laser also reduces pain by stimulating endorphin synthesis, the body’s natural pain reliever.

The end result of cold laser treatment is to not only reduce pain and speed up healing time, but by naturally increasing collagen synthesis, you have true tissue repair at a cellular level! 

Why Europeans are Skinnier than North Americans

I am late publishing a monthly blog as my family spent three weeks in Europe visiting four countries (Netherlands, France, Austria and Croatia).  While it has been 10 years since returning to Europe, I was even more "hit in the face" at how much slimmer Europeans are compared to North Americans. 

The food was very similar to what we would eat (McDonald's is everywhere), and they seem to eat more bread, cheeses and processed meats, but I found it difficult to see any native Europeans that were obese.  An observation was also made of not only the higher amount of alcohol consumed (beer is cheaper than coke), but also the large number of smokers, particularly in Paris. 

So why are the Europeans slimmer?  My only conclusion can be that they walk more, as many do not own cars in the city, due to lack of parking and high cost, and also excellent transportation systems.  In Amsterdam, they have also developed an impressive bike system, with bike lanes paralleling roads and bike parking lots.  I had never seen women in short skirts and high heels bike before, but it can be done! 

On spending time in rural Austria, however, I did find much more "weighty" people, as they were more reliant on vehicles.  So a conclusion can be made,  that we have to encourage more people to get out of their cars and on to their feet or bikes.  This will only be possible if we have more compact cities, and also improved public transit.  A three times expected load of the light rail transit system in one year happened in Vancouver after the Canada Line was constucted for the Olympics.  So the old saying goes "build it and they will come"! 

Neck Pain: No Drugs Required

A January 2012 study published in the Annals of Internal Medicine has found that conservative care consisting of either spinal manipulation or home exercise to be more effective than over the counter and prescription medication for relieving both acute and subacute neck pain.  The study involved 272 adults with nonspecific (muscle-ligament-joint) neck pain of 2-12 weeks duration, excluding more serious pathologies such as discs, fractures, and instabilities. 

Subjects were randomized into three groups for 12 weeks: spinal manipulation (SMT), home exercise and medication. Self report outcomes (pain, function) were measured at 2, 4, 8 and 12 weeks during the trial period,  and at 6 and 12 months follow up.  Results were as follows:

12 week comparisions of pain reduction

Improvement                   >50%                     75%                        100%

SMT Group                       82 %                       57 %                       32 %

Exercise Group                 77 %                       48 %                       30 %

Medication Group           69 %                       33 %                       13 %

At long term follow up, 75 % at 6 months, and 81 % at 12 months of SMT group reported at least a 50 % reduction of pain.  71 % at 6 months and 69 % of 12 months of exercise groups reported at least a 50 % reduction of pain.  59 % of 6 month and 69 % at 12 month of the medication group had a pain reduction of at least 50 %. 

What can be concluded is that both the SMT and exercise groups had similar short and long term outcomes, more favorable than the medication group.  This further reinforces past research which has shown active therapies for neck and back pain (exercise and manipulation) to be the most effective treatment for these common and reoccurring conditions.

Four Pillars to Manage Osteoarthritis

Osteoarthritis (OA), common in 80% of the population after age 50, is considered an inevitable part of aging, but research is showing that there are steps you can take to minimize OA or stabilize further joint erosion once you have it.   A contributing cause of OA is now thought to be due to age related decline in the body’s synthesis of glucosamine after the age of 40.  Glucosamine is important in making proteogylcans, the ground substance to form joint cartilage; as well as hyaluronic acid, which is used to increase viscosity of synovial fluid to reduce wear and tear on the joints and allow nutrition to the cartilage.

Inflammation occurs with the degeneration of cartilage and causes the pain associated with OA.  Inflammation occurs when the body makes a hormone like substance called prostaglandin-2 (PG2), whereas the synthesis of PG1 and PG3 exert and anti-inflammatory effect and can control the symptoms of OA.  PG2 is produced by the polyunsaturated fats that we consume, mainly from high fat meat and dairy products.  Omega-3 fats from fish and flaxseed provides the building blocks for PG3 and borage oil, evening primrose oil and black current oils for PG1.  There is also a natural anti-inflammatory that is often used in OA, MSM, which research shows not only helps inflammation but the sulfur in MSM is used to make enzymes that are needed for connective tissue, such as cartilage.

The first two pillars of managing osteoarthritis involve dietary changes and supplements to improve the structural integrity of the joint itself.  The other two pillars involve improving the function of the joint.  As cartilage has no blood supply, it relies on its nutrition from the synovial fluid, but if there is no movement in the joint, this increases the likelihood of OA changes to develop.  Movement of the joint involves exercise, which is important even in advanced OA to decrease joint stiffness and slow progression of the disease.   If the joint becomes fixated, periodic treatment from a manual therapist such as a chiropractor to mobilize and manipulate joints is also recommended to maintain joint function. 

Four Pillars of Osteoarthritis Prevention and Treatment

1. Eat a diet low in saturated fats: reduce red meat, dairy products above 1% MF, fried foods, high fat pastries
2. Supplement with Omega -3 (1200 mg/day) and Gluscosamine Sulfate (1500 mg/day) with additional MSM (400 mg/day)
3. 30 minutes at least 3 times a week of endurance exercise (walking,biking,swimming), adding strengthening  and flexibility exercises is also beneficial
4. Periodic mobilization or manipulation of fixated joints (monthly maintenance)

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is a common cause of knee pain in athletes, particularly young women and those who are involved in running.  The pain is felt around or behind the kneecap, and is often of gradual onset unless trauma is involved.  There is increased pain with prolonged sitting (knee flexion), stair climbing, squatting, running, kneeling and jumping.  Generally there is no swelling around the knee cap, nor is there any pain in the patella tendon or surrounding ligaments.

PFPS is usually a functional problem rather than a structural one.  It has to be differentiated from another patella condition, chondromalacia, which is the wearing down of the cartilage under the knee cap, and may accompany PFPS.  The causes are multifactorial and can be broken down into three categories:

Biomechanical, or patellar tracking problems, are caused by lower extremity malalignment, which pulls the patella out of its groove.  Factors such as flat feet which cause the knee to internally rotate (knock knees) and wider Q angles of the hip, which are more common in women, contribute to PFPS.  A “J” sign can be seen with lateral patellar tracking, as the knee is extended from 90 degrees of flexion to full extension. 

Muscular imbalance is another factor, with weak quad muscles (particularly the medial quad) and a tight iliotibial band and hamstring, as well as weak hip extensors/abductors and tight hip flexors. Overuse or overload of the patella caused by repeated weight bearing impact, such as with running, is also a contributing factor in PFPS. 

 Conservative treatment is multipronged, based on the underlying reasons for the PFPS.  Relative rest from aggravating activity (running) to another non impact activity (swimming, elliptical); icing after activity; cold laser therapy to reduce pain/inflammation and heal the tissue; taping or a knee brace with a U shaped insert to keep the patella in alignment; orthotics to help support the arch; and specific exercises to strengthen weak muscles (quads and gluts) and stretch tight muscles (TFL ,hams and psoas).  Rarely surgery is indicated, but true chondromalacia may be amenable to arthroscopic surgery to smooth out the cartilage under the knee cap, and lateral retinaculum release if the problem is caused by excessive lateral pulling.

Peripheral Neuropathy

Peripheral neuropathy is nerve damage which is caused by long standing diabetes.  The injury to the blood vessels by elevated blood sugars causes a lack of oxygen and nutrients to the nerves, most commonly in the toes, feet and lower legs, but also in the fingers and hands.

Symptoms include progressive numbness or insensitivity to pain or temperature; tingling, burning, prickling sensation; sharp pain or cramps; or extreme sensitivity to touch.  If symptoms are in the lower limbs, loss of balance or coordination can occur because of the weakened muscles leading to falls.  Blisters or sores may develop in numb areas, resulting in infections which may lead to amputation, making it important to have regular foot exams.

The risk of developing neuropathy increases with age and with those who have uncontrolled blood sugars, elevated blood fat, and high blood pressure.    Other causes include autoimmune factors which lead to inflammation of the nerves and smoking which decreased oxygen to tissues.

Besides keeping the blood sugars in a normal range, treatment for pain includes antidepressants, anticonvulsants or opiods; and topical lidocaine or capsaicin cream.  Some supplements that have shown promise include alpha lipoic acid (50mg/day) and omega 3 oils for inflammation.  Acupuncture may also help with pain control.  A newer therapy, cold laser, has shown in clinical trials to increase blood flow and help regenerate damaged nerves as well as accelerate wound healing for diabetic ulcers.

Sources:

 http://diabetes.niddk.nih.gov/dm/pubs/neuropathies

Diabetic distal symmetric polyneuropathy: effect of low intensity laser therapy; Lasers Med Sci, 2011

A randomized clinical trial on the effect of low level laser therapy on chronic diabetic foot wound healing; Photmed Laser Surg; 2011

Cold Laser in the treatment of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is caused by the entrapment of the median nerve as it travels through the carpal tunnel in the wrist.  Signs are pain, numbness and paresthesia in the thumb, index, middle and inside ring finger; increased pain and numbness at night due to prolonged wrist flexion; and if long standing, weakness in pinching and grip strength and atrophy of the hand muscles. 

Causes of CTS include inflammatory conditions such as pregnancy, rheumatoid arthritis, hypothyroidism, diabetes, and obesity.  Cumulative trauma from repetitive activities such as typing and guitar playing which puts the wrist into forced flexed positions are also implicated.  History and clinical tests to stress the nerve give a diagnosis, with a nerve conduction study being conclusive. 

Non surgical treatments have included night splints, NSAIDs, cortisone injections, ultrasound and modifying or changing certain activities.  Cold laser, a new treatment now being offered at our clinic, has shown promise in treating CTS to reduce pain and inflammation, as well accelerate healing. Surgical release of the carpal ligament may be indicated if conservative treatment has failed, if so cold laser can also be used post surgically to assist in healing. 

Several recent clinical trials have compared cold laser with sham laser, splinting and ultrasound. Results have shown cold laser to be effective in pain alleviation; reducing the numbness and paresthesia; improving hand grip strength and even improved EMG findings with no side effects, and to be superior to both splinting and ultrasound.   

Sources: The effectiveness of conservative treatment of carpal tunnel syndrome: splinting, ultrasound, and low level laser therapies; Photomed Laser Surg, Feb 2009 and The effects of low level laser in clinical outcome and neurophysiological results of carpal tunnel syndrome; Electromyogr Clin Neurophysiol; June 2008                                              

Sports Supplements that are Clinically Proven to Work

Athletes may ask about the value of certain supplements to enhance performance or gain muscle strength, but many supplements have more hype than science to support their use. While whey protein in shakes to replace protein loss during workouts is common, creatine, L-glutamine, ornithine and arginine also top the list of legitimate sports supplements. 

Creatine leads to an increase in muscle mass which is thought to occur from increased protein synthesis, this allows athletes to train harder as there is increased energy available for muscle contraction, promoting strength gain.  Creatine can also preserve strength as athletes age, keeping them functional longer. A loading dose of creatine monohydrate crystals is 20-25 grams per day for the first week, and than 10 grams per day for maintenance. 

 L-glutamine has been shown to decrease muscle breakdown during workouts and also reduce the incidence of upper respiratory infections by providing fuel for immune cells.  Optimal dosage of L-glutamine is 1,000 – 2,000 mg per day.

Ornithine and arginine are amino acids that have been shown to increase the release of growth hormone.  As we age, growth hormone declines, facilitating breakdown of lean muscle and bone mass.  Supplementing with arginine and ornithine may not only enhance muscle mass and strength gains, but as it elevates metabolism, it can help reduce body fat too.  Recommended dosage is 500 mg twice a day for five days a week.

So to maximize your athletic performance, consider using creatine monohydrate, L-glutamine, ornithine and arginine at these clinically proven dosages stirred into a glass of juice on an empty stomach.  Happy training!

Author:  James Meschino, DC, MS, ND; Dynamic Chiropractic

Laser Therapy for Shoulder Impingement

A 2011 study published in Clinical Rheumatology compared the traditional treatment of exercise for impingement syndrome of the shoulder to exercise with the addition of low level laser therapy.  Research has shown low level laser therapy to be beneficial in accelerating tissue repair by increasing fibroblast formation and circulation, while also decreasing inflammation and pain.

80 patients were divided into two groups; with neither the participant nor therapist knowing which patients were receiving laser therapy or sham laser.  Treatment consisted of 10 sessions over two weeks.  The intervention group showed significant improvement in both pain and increased range of motion than the exercise group alone.  The results were further strengthened as the same therapist performed all the treatment, eliminating practitioner bias. 

One weakness of the study was that the study did not differentiate only impingement syndrome, but rather lumped it with biceps tendonitis and other rotator cuff pathologies as they commonly occur together.   Strengths of the study were not only the large research group and “gold standard” of being double blinded and randomized, but that the low level laser improved the pain and range of motion, regardless of the underlying musculoskeletal condition.