This weeks blog or “vlog” is actually in video format!
Check it out!
Gentle Exercise for Knee Cap Pain
While there are many different varietals of knee strengthening and stability exercises, persistent pain crepitus and catching around the kneecap can remain very difficult to resolve in spite of compliance with an exercise program. Backwards pedaling in the air is an exercise that I learned from my mentors 25 years ago, and I have found it to be a surprisingly simple and effective way to improve patella symptoms in addition to the more traditional adjustment and strengthening programs.
MODALITIES: PART I- ULTRASOUND
What is Ultrasound therapy or therapeutic ultrasound?
Therapeutic ultrasound is a modality we may use in the office to assist with deep soft tissue recovery. Most are familiar with the ultrasound women receive during pregnancy. Even though that ultrasound is super awesome (blog for another day), that is a diagnostic ultrasound and not what we are using in the office.
When is it used?
We are going to use ultrasound when we are trying to target a subacute or chronic injury with a deeper heat. Injuries with a deep edema or reducing spasms in the muscle or even to increase blood flow via vasodilation with the goal of increasing some function or range of motion within the injured area.
When is it NOT used?
We are usually not going to use ultrasound when someone is experiencing acute inflammation or poor circulation. We also avoid use for those individuals with poor sensation as many units produce heat and when someone is unable to determine what may be too warm, it isn’t in their best interest to place a sensation they cannot determine may be too much.
FIBROMYALGIA, CHIROPRACTIC AND THE UPPER CERVICAL SPINE
https://pubmed.ncbi.nlm.nih.gov/25782585/
The topic of fibromyalgia can be daunting because it's broad and complicated. Fibromyalgia remains a diagnosis of exclusion, although over time we’re starting to identify it as a constellation of symptoms that tend to occur together and usually in targeted populations (women in particular.)
Chiropractors routinely see patients with a fibromyalgia diagnosis as part of their practice. That is because fibromyalgia patients can have very discrete neuromusculoskeletal lesions amenable to chiropractic care that if left unattended, can greatly amplified the chronic background pain.
This article explores another aspect in which chiropractic care can fit in the overall treatment plan of patients with fibromyalgia, and this time from a very different angle. Research in fibromyalgia of the last 10 years has unearthed multiple mechanisms of causation, including some degree of autonomic nervous system dysfunction. The upper cervical spine is extremely rich in sensory afferents to the brainstem, where most of our autonomic control is located. Spinal functional lesions in the upper cervical spine does have a greater impact on autonomic dysregulation, and potentially a great therapeutic impact with chiropractic correction in fibromyalgia patients.
One item of note: fibromyalgia are very slowly changing conditions over time so treatment plans need to adapt to that reality and involve slightly more spread out treatment over a longer period of time to be effective.,
Pregnancy Support & Tape
While looking for a less bulky and more consistent support during pregnancy we decided to give taping support a try. I have been familiar with taping different injuries for tissue offload, support or proprioceptive changes, but I haven't had a lot of chances to work on taping during pregnancy. In the images you can see a tan tape wrapped around the low abdomen pulling up and back to assist in the pulling forward mechanism that a growing baby imposes on the low backs of many pregnant women. What you may not be able to tell is this, but this particular tape application also is having more tension on the right and we were able to place the tape in a particular stretch position in order to help offload and decrease that tension on the right side and distribute towards the left.
Some pregnant women may be familiar with the braces, bands or scarf techniques to help offload, but if you've used many of them you’ll notice they tend to be bulky & uncomfortable. Sometime you may even need to redo or adjust throughout the day. Having a tape placed directly to the skin that tends to last a number of days may be a better option. You can even shower with the tape on!
OSTEOPOROSIS PART 6
On the final segment of the osteoporosis series, I wanted to answer a question that often comes up in relationship to osteoporosis and briefly talk about nonpharmacological approaches.
Patients often ask if osteoporosis by itself can be pain producing. I think that in most cases the answer is no and that is the general traditional medical understanding. Obviously complications of osteoporosis like stress fractures can be extremely pain producing, but as to the question of how symptomatic a low bone mass can be, the general understanding has been that it is silent. However I would say that in the last five years I have started shifting my thinking on the subject after encountering several patients with fairly advanced osteoporosis with T-scores well below -3.5, who reported some generalized vague bone pain, not related to position or movement, and I have started to wonder if in some extreme cases, osteoporosis can give you some non- localized symptoms. In most cases however, when a patient presents with back pain and osteoporosis, the source of the pain is going to be mechanical, postural, myofascial, degenerative or inflammatory in nature.
As far as treatment options, the recommendations are obviously going to be based on the results of the workup that we have described in the first five segments.
We would first address some of the basic bony needs such as adequate dietary intake of bone matrix nutrients (protein, calcium, minerals,) as well as adequate weight-bearing resistance training to stimulate the body's deposition of bone.
Second, we would try to address and correct some of the abnormalities found on lab testing: treat digestive inefficiencies such as hypochlorhydria, significant menopausal hormone deficit, elevated chronic stress hormones, etc. The limitation is sometimes the medications that the patient have to continue taking long terms. In which case it may not be fully possible to correct the underlying problem, and more aggressive supportive supplementation is needed.
Third, nutritional supplementation and intervention has to be catered to a particular patient's need. There is not a one-size-fits-all supplementation for all patient with osteoporosis/osteopenia. But in most cases, the patients will need to make sure they have adequate intake of vitamin D3 and vitamin K2. The exact dosage varies but usually ranges somewhere between 2000 and 5000 IUs daily to achieve a healthy blood level around 30/40. Vitamin K 2 can be used in physiological doses, similar to what would be a normal dietary intake and absorption around 800 µg, but can be used in more aggressive therapeutic doses of a few grams a day, especially in patients who are exhibiting significant elevation of D-pyrilink on urinary excretion testing.
Cofactors and minerals are extremely important for the body's ability to properly incorporate calcium into the bone matrix, so most commercial supplementation will often contain additional things such as magnesium, boron, strontium. It is also important to note that not all forms of calcium are created equal for the sake of absorption, and that higher-quality supplementation will typically contain bioavailable forms of calcium rather than calcium carbonate. And since calcium is notoriously hard to digest, especially with age, due to decreased stomach acid production, taking the calcium with mildly acidic food can be very beneficial to improve gastrointestinal uptake.
Taking a look into the tool box for soft tissue care
In past blogs we have discussed different techniques and uses for soft tissue care and why it is important. I was thinking having an idea of what each of these instruments actually look like may be helpful as well.
Tennis ball- mostly used for at home soft tissue care.
Tape- there is one whole blog on this, but to recap. In this office kinesiology tape & biomechanical tape is most frequently used.
Resistance bands- used for at home care and activities for continued development.
IASTM & Cupping- there is also a blog published on this awhile ago. This is used mostly in the office and the different instruments I use include a few different stainless steel options that I use for Instrument Assisted Soft Tissue Mobilization (IASTM) as well as either some silicone or plastic cups for cupping. The IASTM provides more of a compression as where the cupping creates more of a pulling or suction to the targeted underlying soft tissue.
What are some of your favorites?
OSTEOPOROSIS PART 5: IT IS COMPLICATED, HOW YOU GET IT, WHAT YOU DO ABOUT IT
Today I would like to expand on the last discussion and discuss a more comprehensive testing strategy beyond DEXA scan to look for root causes of osteoporosis.
The first additional testing that I would consider when someone comes in with questions about recent DEXA score would be a D-pyrilink urinary test. The D-pyrilink is a protein that is part of the bone matrix. During the process of bone break down and recapture for new bone formation, the D-pyrilink protein is briefly circulating in free-form and can be excreted through the urine, and the amount can be measured. If the bone is reabsorbing and being rebuilt at a normal rate without excessive loss, the amount of D-pyrilink in the urine will be relatively modest. If the body is breaking down bone faster than recapturing and rebuilding, the amount will be elevated. So measuring urinary D-pyrilink excretion can be a useful addition to a DEXA scan to see if the active state of bone loss.
Additional tests that can be helpful in circling in on the causes of a person's osteoporosis and bone loss includes:
– A hormone panel to assess the adequacy of estrogen, progesterone, testosterone, cortisol, and DHEA (basic anabolic adrenal marker). Incidentally most of the commercially available D-Pyrilink tests are lumped together with the above hormones in a single bone health panel.
– A vitamin D metabolite panel. This would include not only the commonly tested D3, but a metabolite called calcitriol, which is directly converted from vitamin D3 in response to the body's needs to improve calcium absorption in the gastrointestinal tract. This can be a useful indicator of the body’s perceived lack of available calcium, either from inadequate dietary intake or difficult absorption for a variety of reasons. In which case the ratio of calcitriol to vitamin D3 will be elevated. In addition, we will often get a basic parathyroid hormone level. The parathyroid hormone is the master control of calcium blood level regulation. Under normal circumstances with adequate vitamin D/calcium economy, the parathyroid levels will be in the lower end of the range. Even slight elevations of parathyroid hormone still considered normal but suboptimal can indicate the body's perception of inadequate calcium/vitamin D economy.
– A gastrointestinal functional markers profile. This can be very useful when we suspect that the patient has adequate dietary intake of nutrients necessary for bone formation such as protein and calcium, however the body is unable to properly absorb those nutrients for variety of reasons (prior abdominal surgeries, chronic infections, hypochlorhydria, mild digestion, inflammatory bowel disease etc.) the panel can measure stool residues of various digestive enzymes and nutrients, telling us if absorption is the problem causing osteoporosis.
– Last but not least, and probably first and foremost in most cases, a good diet history to see if the patient has a reasonable amount of nutrients available for normal bone formation.