What is a contrecoup sprain?

Growing up speaking French as a 1st language I enjoy lording it over people with little French inspired vocabulary from time to time. However the term"contrecoup" is not just a futile exercise of language, but something very relevant at this season.

The original term "contrecoup injury" is meant to describe a type of concussion whereby the brain is injured on the opposite side of the impact, and the result of the soft brain hitting the hard skull bone during an acceleration deceleration impact. However I have been using the term " contrecoup" a little more broadly to define a scenario whereby the injury can be on the opposite end of the point of impact.

The most common scenario I run into is when a patient falls on their buttocks, and finds themselves with a cervical injury. This happens quite a bit when we slip on the ice at this season. The patient is originally very concerned about bruising and soreness at the point of impact, but are really baffled when they wake up a few days later with massive cervical pain and headaches although they did not hit their head or neck on the ice. The force transmitted from the pelvis to the neck and head during the deceleration phase of your hind end hitting the ground is in the 3 digit, and it's virtually a mini whiplash. The moral of the story is that because you did not hit your head doesn't mean you did not injure your neck.

Abdominal Massage For Chronic Constipation

Chronic constipation is one of those health scourges nobody likes to discuss with friends over coffee. It significantly impacts your quality of life, it's a very unglamorous problem, and conventional healthcare does not offer a lot of solutions (and to be fair even good integrative healthcare sometimes struggles to achieve that as well.)

Once medical reasons for chronic constipation have been ruled out, and they are quite few of them actually, patients are instructed to follow some basic self-care practices to improve transit time. By the time people reach us, they have already improved their hydration, increased their fiber intake, and their aerobic activity to no avail. They walk in the door with a diagnosis of "functional constipation" which basically means they are chronically constipated and we have no idea why.

This blog entry is not meant to be a comprehensive review of the algorithm to workup chronic constipation, since that would take 20 pages, but to review one particular aspect of managing functional constipation that most patients have never been exposed to: the effectiveness of self directed abdominal massage to improve normal bowel muscular activity. The technique is quite simple, can be taught in about 20 minutes, is painless, and only takes a few minutes a day. What is even more remarkable is that a recent double-blind controlled clinical trial showed it to be remarkably more effective than placebo and other conventional methods.

In the video Anne demonstrates the basic technique you can use on yourself. I highly recommend however that you make an appointment with a massage therapist for 30 minutes to practice the method on yourself so you feel confident that you will get the benefit of doing it at home.

https://www.youtube.com/watch?v=BykR20PmdQs

https://pubmed.ncbi.nlm.nih.gov/35554601/

"Grandparent Syndrome"

I want to bring to peoples’ attention a pattern that has been crossing my radar increasingly over the last few months. I am nicknaming it “Grandparent Syndrome”. It simply consists of a patient coming into the clinic and saying something to the affect of: “I babysat my grandchild/children over the weekend, and boy, I hurt.” I am not saying this is a new thing by any means, but my guess is that many grandparents took a hiatus from babysitting over the Covid years. Now many grandparents are jumping back into the swing of things and they are doing things that are certainly out of their normal activities of daily living.

I want to highlight a few of the likely stressors that the average grandparent is going to face when babysitting. One is simply that when you take care of children, your attention is mainly focused on them; this can make it more difficult to notice when you are getting tired, or are holding a muscular strain beyond the comfort point. If you can regularly take a moment to direct your attention toward your body, you may be able to spot muscular tension before it gets to a high pitch.

The second thing is to be aware of positioning. For example, you are holding a 5 month old child. You unconsciously prefer holding on the right side of you body. You then might spend 2 hours with your right shoulder medially rotated and your head tilted right and downward as you look at the infant. A better solution is to hold the baby on both sides. This will still be a strain, but it will be divided between the two sides, and you will avoid a one sided holding pattern. This may seem like a silly addendum, but if you like to lay down with an infant, take a little time to have a comfortable pillow. Remember, you might be in that position for a while!

The last thing is for grandparents with grandchildren in 2-4 year age range. Grandparents are expected to be a soft touch as far as doing what the grandchildren want. (I remember this very well from my young days). What you should keep in mind is whether or not you can pick up and hold an older grandchild comfortably. Maybe for some grandparents, they can comfortably hold an older child for a little while. Others may not be able to pick up a child without aggravating a shoulder, hip, arm, etc. My recommendation for those who cannot hold a child with comfort is to harden their hearts, and modify their response to the child’s wish. Maybe you can sit with them on a couch or come down to their level. Or hold them only for the amount of time it is comfortable.

The overall takeaway is to bring some awareness to your babysitting, so that you can enjoy your grandchildren without causing undo Grandparent Syndrome.

Vagal Autonomic Breathing Exercise

https://www.youtube.com/watch?v=aXiXCK0U08c

This is probably one of the most important videos I have recorded, and a long time coming. We often tell people they need to breathe more and better but we don't give them specifics about what constitutes beneficial breathing. This particular exercise is very specifically geared to improve parasympathetic autonomic function, also known as vagal breathing, to try to counteract the chronic fight and flight response that most of us are stuck in. It is especially helpful for people trying to have easily accessible tools to break anxiety.

Shining some light on Seasonal Affective Disorder

For some people the winter season is more than a little crabbiness about cold weather, shoveling, and post holiday bulging waist. It can be a time of low moods, at times nearly debilitating, that last several months and leads to a sense of dread at the end of the fall. It's a complex disorder and this blog is not meant to be a comprehensive review of all that is available but to give you pointers on some key interventions that when taken together can make the next one month more manageable and possibly enjoyable.

Seasonal affective disorder, later referred to as SAD, is triggered by a combination of seasonal external factors (change in outdoor temperature and light cycles), compounded by our response to those external factors, both internally in our own biology as well as in our habits and self-care. I'm going to address interventions in each category.

Change in light pattern: Outdoor light is a powerful regulator of our sleep-wake cycle and moods, and is at its lowest level between October and March, at the same time as our lower temperatures in the northern hemisphere. Outdoor light has a spectrum of colors that changes from morning to noon, with a spectrum that increases wakefulness prior to noon, and gradually decreases wakefulness in the evening with warmer hues. For a lot of people with day jobs, this means that your brain may never be exposed to the natural cycle light for several months out of the year, with significant disruption to normal wake sleep mood regulation. To make it worse, light emitted from indoor traditional light sources, and especially from technology screens, tends to be blue dominant, which is stimulatory and blocks the release of melatonin (a hormone triggered at the time of initiation of sleep) consequently setting off a cascade of dysregulated wakefulness and leading to low mood. If getting out to be exposed to natural light prior to noon is not routinely available to you during the winter months, consider using a light therapy box for 20 minutes earlier in the morning most days of the week (nowadays those lights can easily fit on your desk or on your kitchen counter wherever you may be for an hour in the morning), and get yourself a pair of blue filtering glasses (nonprescription, can be available from any online retailer) to use starting midafternoon on, to protect your vision from the suppressive effect of your computer screen on melatonin. Maintaining a normal melatonin cycle is essential to maintaining normal moods during the winter.

Change in temperature pattern: Exposure to seasonal cold can have a ripple effect on blood circulation and our own physical activity level. In particular, our brain has a powerful ancestral mechanism to protect core organs from hypothermia, which are still somewhat active even for modern creatures living with indoor heat. This can lead to slightly decreased general blood perfusion in our extremities (including our head, which is the hardest organ to reach for circulation going uphill against gravity). In addition, for a lot of people there is a general decrease in physical activity and cardiovascular endurance during the winter month, as our level of the day to day movement is less when cooped up inside. This is especially a problem when compounded by the fact that many people do not have a robust exercise routine to transition to in the winter. This leads to decreased blood circulation to the brain, which is a big driver for decreased general metabolic activity of normal neurotransmitter and hormonal balance. I always encourage people to be accountable to themselves by using a fitness tracker in the winter to see if they meet physical activity standards (10,000 steps or equivalent). There are lots of options for exercise that can be done from the comfort of your home, refer to other blog entries on that subject.

Change in vitamin D metabolism: Unless you have a consistent vitamin D3 supplementation during the winter months, you're very unlikely to have enough outdoor skin exposure to produce your own. Everyone metabolizes vitamin D a little differently so there is not a hard and fast rule about how much to take but the range is anywhere from 2000 IUs – 5000 IUs, with the goal of maintaining serum levels between 30 – 50. Remember that multiple supplements used for other purposes than straight vitamin D3 supplementation will have some low level of vitamin D3 added so make sure you look at the total amount of vitamin D3 you may be ingesting. Vitamin D3 serum levels has been repeatedly associated with chronic mood disturbances.

Change in eating patterns: The holiday season in particular can be a real minefield for people to maintain a diet containing necessary nutrients for adequate mood modulation (adequate protein, antioxidants, clean essential fatty acids, fiber), opening the door for high sugar food and a lot of glycemic spikes. This can be another major contributing factors to poor mood control. Knowing that you moods can be so negatively impacted by your food choices in the winter should hopefully be an encouragement for people to try to stay on the proverbial wagon, and if splurging, keep it to a few days.

For people who feel that they have implemented all the self-care methods available to them to control seasonal affective disorder but not achieving satisfactory results, it may be beneficial to test for your individual hormonal and neurotransmitter imbalances, in particular the role of melatonin, cortisol, dopamine, serotonin, and glutamine. This can give you much needed insight and specifically and individually managing your own imbalances. https://www.zrtlab.com/test-specialties/neurotransmitters/

Armaid: home self care for chronic soft tissue pain of the arm and wrist

https://www.youtube.com/watch?v=0SfmM1BRdi8

I have always known to be judicious to the point of slightly skeptical when it comes to a lot of self-care tools that patients want to use at home for relief of a variety of neuromusculoskeletal conditions. Many of them have come and gone after a brief surge in popularity driven by intense social media marketing. I am a frequent thrift store shopper and invariably there are miscellaneous home goods that look like a graveyard of various such tools that were once the hottest item on the market.

There are of course notorious exceptions to that, and the Armaid and several offbrand similar devices fit in that category. It's a relatively simple tool designed originally by rock climbers to perform some specific deep self massage and soft tissue release of the elbow and down primarily. Many of our patients have to engage in activities, whether professionally or recreationally, that place high repetitive demands on wrist and finger flexor muscle groups, with high likelihood of setting off a chronic repetitive injury cycle. As a supplement to in office treatment, I will often recommend the ongoing use of the Armaid for patients to control and stay ahead of escalating soft tissue injuries. We have a loaner unit at the office that I will send home with patients after training them specifically on how to use it for their particular condition. If patient find it successful, we will direct them to purchase their own unit. The cost is still below $100, paying for itself many times over in saved in office visits.

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.