COVID and vitamin D

https://www.sciencedirect.com/science/article/pii/S0188440922000455?via%3Dihub

Even in a post-pandemic endemic COVID world, the rate of ongoing Covid infections is surprisingly high. We have certainly reached the point where it's become unmanageable illness, however still one that can be extremely disrupting to work and life routine. We're heading into indoor activities for several months, with the potential for higher rates of transmission. This article courtesy of the Kreser Institute weekly digest is a bit of good news in this forecast. Especially if you feel you need short-term protection to prevent an infection, it appears that a burst of vitamin D supplementation even in patients who are not vitamin D deficient may be helpful in warding off a symptomatic routine infection. The dose studied in this particular research article was 4000 IUs, which is going to be safe for almost everyone. However if you do choose to supplement, look at the total amount of vitamin D you're getting from a variety of sources. Many supplements that you may use for other purposes will have often some vitamin D added, so you want to know what your total is.

WHEN IS IT TIME FOR A JOINT REPLACEMENT ?

Patients considering a joint replacement, like pregnant patients, seem to come in cycles at the office and right now we have a lot of folks considering getting new hardware for hips and knees before the end of the year. I have seen lots of patients go through joint replacement in the last 29 years in practice, and I have also seen a lot of improvement in the surgical techniques for joint replacements in particular for hips and shoulders. One of the biggest questions is the ideal timing for the procedure. And while there is certainly a more nuanced discussion about it than there was 25 years ago, it seems to still boil down to one defining factor, namely how much pain the patient is dealing with.

Looking at pain alone comes with a lot of downfalls in making the right decision, and I would like to propose a more diverse set of factors by which to make that important decision.

– Is the amount of pain caused by the joint in question requiring the patient to take daily pain medication? If yes, this definitely would push the decision towards a joint replacement since none of the pain medications whether over-the-counter or prescription a devoid of side effects when used long-term.

– Is the problem joint causing some limitation of physical activity that leads to deconditioning and thus worsening general health? Some patients managed to keep the pain under control as long as they basically don't do anything physical. This is not a viable long-term strategy, leading to poor recovery when there is an eventual joint replacement, and deterioration of the person's general health.

– Is the joint in question causing pain that interferes with sleep? If so, this is a big red flag for going ahead with the joint replacement. Sleep quality deterioration leads to all sorts of adverse health outcomes.

– Is the joint involved becoming unstable, even though it may not be particularly painful, leading to an increased risk of fall? This is also a big red flag, since instability can lead to much worse injuries than the original joint problem and can also complicate the recovery from a joint replacement especially if it happens as an emergency in response to trauma.

– Is there harm in waiting for a joint replacement in the sense that delaying the replacement will lead to more difficult surgery with worse outcomes? This is ultimately a question that only an orthopedic surgeon can answer. From a chiropractic standpoint, I also think that patients often wait too long for joint replacement, leading to significant soft tissue contractures, muscle atrophy, both factors making the patient experience a less than optimal recovering from the joint replacement even with an optimal surgery.

– Is delaying a joint replacement running the risk of making the patient ineligible at a later date because of predictable progressive other health problems? This is especially a concern in some of our aging population that may develop progressive cardiovascular diseases that would conflict with the anesthesia required for the procedure.

In the end, you need to look at more than simply immediate pain in making the decision, and I hope that answering each of the above six questions can give you a more nuanced way to make an important decision.

Exonerating the iliotibial band

Pain along the iliotibial band, like all other conditions it seems, seem to arrive in clusters at the office. I've had my quota this past month to qualify as the next blog topic.

The iliotibial band is a long tendinous ligamentous band that runs from a small lateral superficial hip muscle called the tensor fascia lata, all the way down to the lateral knee at the level of the upper fibular head. The tensor fascia lata, later referred to as TFL, is a superficial muscle that guides some precision work of the hip and knee, but is not meant to be the primary stabilizing muscle during ambulating and other weight-bearing stability activities of the lower extremity.
As a result, the tensor fascia lata will become symptomatic and injured during failure of deeper stabilization mechanisms as it has to take over some additional stability and weight bearing loads that it's not engineered to handle. The typical presentation is a deep pain along the lateral lower hip, leg, and into the lateral knee. It can mimic lateral knee pain from internal knee derangement such as a meniscus.
While iliotibial band syndrome is common, and quite painful, it really should not be treated as a standalone problem. Suddenly at times it's become a self-perpetuating problem that requires soft tissue treatment, but trying to treat it alone is really unsuccessful in the long run since there is usually an underlying problem driving its overload. In my clinical experience some of the more common sources include chronic sacroiliac functional problems, chronic weakness of the hip extension, anatomical or functional short leg related to ankle pronation.

Next time you find yourself stuck in a persistent IT band painful cycle, stop blaming and come in to find the real culprit

NECK RETRACTION EXERCISES

NECK RETRACTION EXERCISES

I teach patients this exercise so much that I decided to make a short tutorial video to send ahead of time and for patients to have at home for review. The retraction routine has a lot of benefits:

- improve sagittal alignment away from forward head posture

- decompresses chronic lower cervical facet pain

- sends proprioceptive information to the cerebellum to help in patients with chronic vertigo

- maintains and improves cervical ranges of motion

https://www.youtube.com/watch?v=FZOAafeEtVA

The Strange Paradox of Sugar and Diabetes

https://chrismasterjohnphd.substack.com/p/003-sometimes-sugar-is-better-than

I'm working my way through 120 hours worth of detailed nutrition and biochemistry podcasts during my commute and our last module was on glycemic management. I know it's an area of incredible confusion to the general public and a lot of frustration for people dealing with prediabetic management: patients are not always able to correlate carbohydrate intake with glycemic spikes, and in particular for some people going on very restricted carbohydrate diets, the improvement in blood sugar and body composition is not always visible and sometimes seems to paradoxically regress.

Glycemic management is overall very complicated and I could not do justice to it in a blog obviously. However this particular podcast episode was talking about a phenomenon that was yet unknown to me. Humans are equipped with salivary enzymes that quickly break down starch into glucose for oral absorption into the bloodstream, and the general understanding of this phenomenon is that the body is looking for early signaling of a carbohydrate load in order to be ready to respond with the appropriate insulin release.

It also appears that part of the population has genetic mutation in the amylase gene that makes them less responsive to oral exposure to starch, which means that their body is not as efficient at managing carbohydrate intake with the appropriate insulin response as people without that gene mutation. In those cases, those people may not utilize carbohydrate properly for energy, and could be dealing with post meal excessive elevation of blood glucose (leading to post meal fatigue and fat storage). For those people, paradoxically, having something very slightly sweet at the beginning of a meal or an appetizer drink may benefit them as it will give a stronger signal of appropriate insulin response and carbohydrate utilization from that meal. It may not apply to the majority of you reading this but it will apply to a small subset of people who have found themselves dealing with worsening post meal sugar spikes when they lowered the carbohydrate percentage of their meal.

PROCESSED FOOD CONSUMPTION AND DEMENTIA RISK

Gut to Brain Dysbiosis: Mechanisms Linking Western Diet Consumption, the Microbiome, and Cognitive Impairment.

Dementia has been particularly on the mind of our family recently as we are dealing with a loved one in accelerated decline. This has been very puzzling to us since there is no known history anywhere else in the family. This article reminds me that there are a lot of modifiable risk factors for dementia, and diet is a big one. In particular, processed foods diets which are known to be low in some key nutrients for brain longevity have been pretty clearly documented as a risk factor. Current stats showed that the average American is consuming 60% of their diet from highly processed foods. This is alarming in many ways.
Remember that when it comes to dementia risk, inherited genetic factors appear to be making up only 15% of the total risk pool for the average person. The rest is in your camp.

NECK AND SHOULDER PAIN AFTER BREAST SURGERY

I have meant to blog about this for a while, but it always takes a couple of really whopper cases of something to move me in that direction, and last week was no exception. I saw probably one of the worst case of post breast surgery pain that I have seen in a decade.

When I graduated from school 29 years ago. It never occurred to me I would be working on feet and breasts as much as I do. When you consider that 20% of the American adult population suffers from daily impairing foot pain, the foot work should not come to you as a surprise, but the work on the chest wall and breasts associated soft tissues probably will. The reality I encounter in practice is that a lot of women will have breast surgeries for variety of reasons: mostly mastectomies or lumpectomies for breast cancer, breast reconstruction surgeries, and some elective surgeries.

Thankfully, when you consider the sheer number of women having breast surgeries every year, a lot of them will come through the experience with full recoveries and no further issues. However, even with the small percentage of women having complications, that is still an enormous amount of women walking around with daily discomfort in the area of the breast itself, the armpit, the anterior neck and shoulder, and sometimes down the arm.

The most common issues I tend to run into and hopefully address in women post breast surgeries are the following:

– Pain along the anterior neck, upper back, and shoulder blade. This is often the result of generalized shortening of the anterior tissues in the chest wall, post surgery scar tissue, and immobilization, causing some anterior jutting and internal rotation of the shoulder, pulling on the shoulder blade.

– Pain along the breast tissue itself, most commonly along the lateral breast, chest wall, and axilla. This is most commonly associated with scar tissue formation on the lateral aspect of the breast. This is often associated with a phenomenon referred to as "chording", which refers to a form of scar tissue formation that looks like the strings of a musical instrument.

– Pain or tingling, numbing down the arm. This is often mistaken for secondary cardiac complication and leading to multiple cardiac testing and chest CAT scans. The scar tissue from the breast surgery and the immobilization can lead to some strangulation of the neurovascular bundle in the axilla. Patients will often have a shooting tingling pain down the triceps, as well as a sensation of hot and cold in the arm that remains unexplained.

– Continued uncomfortable swelling in the armpit to the upper arm, from lymphedema associated with scar tissue obliterating normal lymph return.

The treatment for these issues boils down to several concurrent interventions including:

– Chiropractic adjustments to the neck, thoracic spine, shoulder blade, and shoulder.

– Rehabilitative exercises to restore normal alignment of the shoulder girdle.

– Intense soft tissue scar manual therapy, to improve normal lengthening and flexibility of the affected tissues. This would include specific nerve to soft tissue manual adhesion release therapy, which often produces lasting relief of chronic breast and arm pain.

– When necessary lymph drainage therapy.

– Home self-care including knowing how to stretch, sometimes self treatment of soft tissue adhesions.

– Sometimes supportive home measures such as sports taping of the breast to improve normal realignment of the breast tissue towards midline and avoiding crowding of the armpit where the neurovascular bundle to the arm is located.

– Picking out the right bra going forward to properly support and shift the breast implant material post mastectomy scar.

Free Online Exercise Resources for Seniors through the Silver Sneakers Program

https://tools.silversneakers.com/

I'm running into senior patients more frequently who have not fully returned to a robust exercise program, primarily because they have opted out of returning to a physical gym facility or group classes. Some of it is driven by various factors, including some very legitimate ones that have to do with difficulty driving and not being able to get away from caregiving duties.

Many seniors are not aware of Silver Sneakers resources at all, and the majority of them are definitely not aware of the online classes that are offered by Silver Sneakers for free. These classes are both live stream classes, as well as on-demand classes from a pretty robust collection of videos that are catering to the needs of some of our seniors, including some balance limitations, arthritis, and people recovering from major illnesses with a lot of deconditioning requiring very gradual ramp-up.

Increasingly I find myself setting up patients to use these online videos and selecting the videos that I feel will be most appropriate for them based on their clinical needs at the time of the chiropractic encounters. Signing up for your free online Silver Sneakers account is ridiculously easy. All you need is your name, your date of birth, the zip code in which you live, and where your Medicare supplement policy is registered. You then have to pick a password and your account is all set up and ready to go.

If you would like set up a Silver sneakers account and need a little bit of help, let the staff know before scheduling your next appointment so they can give us a few extra minutes, and bring in whatever device you'll be using to life stream the videos.