Revisiting the best Vit D supplementation for the winter months

It feels a little paradoxical to be adding this blog while the temperature is scheduled to hit the mid 80s today, however the weather forecast is calling for a temperature cliff at the end of the week, and my Windows automatic photo update posted a beautiful snowy landscape upon firing my machine this morning. I take that as a sign from the universe that it's time to talk about a topic that will very soon affect us all.

The topic of vitamin D levels in health and disease has waned a little bit in popularity since its peak of research around 2010, although it did enjoy a resurgence during the Covid pandemic. The research has really been all over the map for laypeople, and even at times confusing for healthcare professionals, until you dig a little bit deeper into the details of the study such as the type of biomarker measured, the target population, etc.

I recently polished up on the latest research and recommendation from a couple of pretty good trusted nutritional sources to see what a commonsense consensus would be. Here are my highlighted suggestions:

1st of all, vitamin D metabolism is extremely variable among different people so generic recommendations about intake are only going to go so far. Ideally you should get your vitamin D level tested. It's typically lowest in the spring, and highest at the end of the summer. This is assuming that humans follow an ancestral pattern of having outdoors skin exposure for vitamin D manufacturing for the summer, which is not always true of our modern lifestyle and individual lives. I recommend getting it tested at both of these peaks. Testing can be done through a variety of manners, including traditional testing through primary care, through Labcorp/Quest direct, or through home kits using blood spot finger prick method. (It's beyond this blog to talk about resources, but patients can contact the office and schedule a consult for that separately).

Vitamin D absorption is impacted by digestive issues especially along the biliary tree since vitamin D is a fat-soluble vitamin, as well as medications that impact lipid absorption and metabolism (especially certain cholesterol medications). Vitamin D need is also increased by certain illnesses. So you really need to look at your own individual factors when trying to eyeball your needs.

As far as ideal blood levels, you'll see different schools of thoughts. Some outfits recommending very high levels of vitamin D3 above 50 and sometimes close to 80, and some people making much lower recommendations. Looking at the more recent research I think the average population does best between 30 and 50. This would be in line with what we have historically known of traditional human population with levels never exceeding 46 with whole foods diet and outdoor sun exposure. However there are subpopulation of peoples with special health needs, especially autoimmune, that may do better with a therapeutic goal above 50. However those people should always be working with a healthcare professional to ensure that those high levels of vitamin D are not causing secondary problems.

Vitamin D is part of a group of fat-soluble vitamins that are finally regulated as a whole, and depend on each other for the proper management of calcium deposition in bone and soft tissues. Probably the strongest recommendation update I am pushing forward now would be to not routinely supplement vitamin D alone, but rather look at a minimum combination of vitamin D3/K2/A in the right ratios. This will prevent some unwanted effects of over dominant vitamin D3 among fat-soluble vitamin, which could negatively impact the deposition of calcium into soft tissues rather than bone. This is especially true in patients with cardiovascular disease and osteoporosis, and with patients who have to limits the intake of dairy products (which tends to provide the vitamin K2). Professional brands of nutritional supplements have started reformulating their fat-soluble vitamins along those lines with several good options both in gel caps and liquid forms.

THE MONSTER LURKING IN THE BACKPACK

Although it seems impossible it's already that time of year... I'm seeing mountains of pens, highlighters, folders, and backpacks lining up the entrance shelves of my local general store. The munchkins are already on week 2 of the great school year !

Parents may be tempted to skip over this blog entry because we've become numb to the fact that backpacks can be a problem. We really shouldn't be. There's so much at stake for long-term spinal health and stability that will be irreversible if we don't pay attention to it at this stage. The research article below from 2018 took some interesting measurements that actually quantify the mechanical stress load on the developing spine. The results are not encouraging. However picking a backpack with the right features and occasionally dropping it on the scale before letting you munchkin out of the door can help you mitigate the worst of the problem.

Here is a bit of basic math that illustrates the extent of the problem. According to the authors of the article, the multiplication factor of the weight of the backpack on the actual spinal structure such as a developing disc is anywhere between seven and 11. In plain English, if you have a backpack of 10 pounds, the actual load on the spine is anywhere between 70 and 110 pounds, and a backpack of 20 pounds anywhere from 120 to 220lbs. This is really quite astounding but explains why so many kids will come home saying they're sore everywhere in their back and shoulders. This is even more of a problem if your child has to walk any distances with their backpacks, either from classroom to classroom, walking to and from school, and to and from the school bus.

You only have two real decent strategies to mitigate the issues: first select a backpack that has good padding, wide padded shoulder straps, a waist strap, and all adjustable straps in the waist band, shoulder straps, and possible chest strap. Arguably you will probably get some pushback from you kid about the look they want versus the functionality you want as a parent. Second, grab your kids backpack every so often when they come home from school and put it on your home scale. Wait until a couple months into the school year to do that because the amount of things they have to carry will change, and you'll have a more authentic idea of how much they're hauling around by the time activities and sports roll around. When you start seeing numbers that amount to the same weight as your child, it is time to ruthlessly review which contents get to stay and which ones get to go. Also remember to reach out to the teachers and share your conundrum. Some will be willing to be practical and adjust their homework to tasks that do not involve the dragging of larger textbooks home

https://pubmed.ncbi.nlm.nih.gov/30204924/

Chiropractic care in patients with Parkinson's and Alzheimer's disease

https://www.researchgate.net/publication/380154147_The_Effects_of_Chiropractic_Spinal_Adjustment_on_EEG_in_Adults_with_Alzheimer's_and_Parkinson's_Disease_A_Pilot_Randomised_Cross-over_Trial

This research article caught my attention recently, as I have been dealing with loved ones in various stages of neurodegenerative progressive diseases (Alzheimer's disease especially). It's a small pilot study testing the effect on brain waves from a single chiropractic adjustment on a sample population of patients with diagnosed Alzheimer's and Parkinson's disease. Both of those diseases share common neurodegenerative pathological mechanisms. It also brought some bittersweet memories of a loved one who passed away a decade ago from Huntington's disease, another albeit genetically transmitted form of neurodegeneration. I was attending neurology appointment for this patient with a well-known Huntington specialist who was also a medical neurogenetic researcher. When she found out I was a chiropractor, she was really excited. She was noticing that a lot of her patients who were receiving chiropractic care seem to have slower progression of diseases, and she was very interested in seeing some formal research in that area. That type of research is notoriously difficult to conduct much less fund, so I was quite elated to find out that our colleague Dr. Heidi Haavik from down under in New Zealand had managed to line up a pilot study, hopefully opening the door to a larger scale research.

This particular pilot study showed some rather surprising effect on brain waves of patients with neurodegenerative diseases following a single chiropractic adjustment, showing some improvement in the normal electrical excitability and conductivity in some key areas of the brain. Anyone who's ever dealt with patients with those terrible diseases know that maintaining quality of life and cognitive function as long as possible is usually important, and that any available tools in the toolbox should be available to those patients and their families. I look forward to see what the next 5 years of research in that area brings about and how it may impact our ability to more routinely treat, and hopefully help, these lovely folks.

Can I have a pinched blood vessel ?

Patients will often precede a question with the disclaimer “ this may be a dumb question, but I am wondering if….”. This disclaimer almost always guarantees that they are usually pretty astute in their observation and closing in on some matter of importance.

The latest “dumb question” that came up this week was interesting: could my symptoms be caused by a pinched blood vessel ?  The patient had some pins and needles sensations in the front of the shoulder, they had noticed that the skin on the front of the arm was a little darker and a little colder than on the other side. Good logic led them to wonder if there was decreased blood flow in the affected area.

The surprising answer to that question is not only: yes !, but the fact that most instances of pinched nerves probably have some degree of pinched vascular structures that go along with the pinched nerve. And there is a very simple reason for that: if you go back to basic anatomy, nerves, arteries and veins very often travel as a trio before splitting off prior to their final destination. Anyone who has done college level anatomy will recall the acronym NAV, standing for  nerve, artery and vein, describing the bundles of the three structures lumped together. And anyone who has done anatomy cadaver dissection recalls how difficult it was to separate the three structures from each other and tell them apart.

From a practical and clinical standpoint, there is a lot of overlap in the symptoms of nerve and vascular compression. Both can cause pain, and both can cause abnormal sensation like numbness and tingling, making it difficult to differentiate them based on symptoms alone. Physical examination can be helpful, but also somewhat limited. Mild vascular compression can cause subtle swelling, changes in color and temperature, but those can be difficult to differentiate from inflammation related edema, and most body areas have collateral circulation that can take over when there is mild vascular compression from one source. 

In day to day chiropractic practice, we tend not to aim our treatment to relieve mild vascular compression independent from relieving nerve compression, which is probably why we talk about this topic infrequently. Relieving nerve compression is the main goal, and vascular structures will basically benefit from that approach. Nerve tissue and vascular tissues have distinct features that makes nerves more vulnerable in NAV bundles: they lack collateral back up, and they are not as adaptable to move out of the way of compressive forces. But that is not to say that some patients will show up with unusually strong vascular compression symptoms that need to be taken into account when setting up a treatment plan, for example limiting the use cold pack therapy and compression

Shoulder strength and stability: hug the ball

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

When working with patients with shoulder girdle weakness and instability, whether from an acute injury or more of a chronic postural strain, there are a couple of foundational exercises that we will use as a starting point for strength and stability recovery. Those exercises can be done safely as a starting point with little to no risk of injury when performed correctly, and can be used as a progression tool to more aggressive strength building.

The "hug the ball" (or hug the pillows) exercise allows patients to recruit the scapula stabilizing muscles and prevent some of the chronic rounded shoulder and shoulder blade winging. The ball or the pillows allow for a counter resistance that can be light or intense, and allows for a slow eccentric release. The main technique to pay attention to is making sure to engage the deep interior blade muscles to squeeze the ball and not the biceps.

Shoulder strength and stability exercise: crocodile pushup

https://www.youtube.com/watch?v=frjhTszm3Cc&t=21s

On the same topic of shoulder strength and stability foundational exercises, this form of modified push-up is a great tool to be used as a stepping block when patients are extremely weak following a shoulder injury and not quite ready to do more traditional plank type exercises. Like the hug the ball exercise, it can be gradually made more challenging as the patient progresses in their recovery.

The "crocodile push-up" ensures that the elbows are facing the knees, keeping the elbows from flailing out, and the glenohumeral joint firmly centered in the socket. The patient will start doing the exercise from the knees up, and can bend as little as needed in order for the isometric hold to be tolerated for about 5 seconds before a slow release. The patient can eventually progressed to lower push up, longer hold time, and full plank starting position.

CHIROPRACTIC FOR PELVIC OUTLET CONSTIPATION: WHEN YOUR GUT AND YOUR BUTT DON’T LINE UP

CHIROPRACTIC FOR PELVIC FLOOR OUTLET CONSTIPATION: WHEN YOUR GUT AND YOUR BUTT DON’T LINE UP

After 30 years of practice I am glad to report that I learn new things almost every day and for certain every week. And recently I had 2 cases, one pediatric and one adult, that made me realize that certain subtypes of constipation are closely linked to distortion patterns in the spine, pelvis, and pelvic floor.

On my wish list is the ability to take the full pelvic floor clinical management review, which may happen in the next year when I'm able to make time and travel to the teaching outfiit I have selected. In the meantime, I have been hitting the books and doing short online webinars to try to get a better understanding of the pelvic floor anatomy, which in our profession and historical training has been a little bit of "no man's zone" of management, although I've come to appreciate over the last few years that it could often be the missing link between the trunk and the lower extremity.

The tongue-in-cheek title of this blog actually comes from a patient trying to describe her problem, as she had developed some unusual constipation, which really was the inability to release stools from the very lowest part of her rectum, following a pretty severe lumbar and gluteal injury. She felt foolish describing to me the sensation that her lower rectum did not align with her anus, with the sensation that it was almost sitting too far back onto the sacrum. But in reality she was describing exactly what was happening to her. It is a known clinical presentation that has been assigned an ICD 10 code (the official medical nomenclature of every medical condition for the sake of insurance coding and research): pelvic outlet constipation,K95.02.

Constipation is a term that covers a variety of symptoms that have an equal variety of causes. Pelvic outlet constipation is a very specific form of constipation that does not involve other traditional causes (low intestinal wall muscular activity, low fiber/bulk, internal stool dehydration). It is the inability of the lower rectum to empty out the stool content through the anal sphincter. Upwards digestion and motility and bulk are okay, but things are literally mechanically stuck trying to get out at the very end. Patients will describe a different sensation from other forms of constipation, sensing that the stool is very low, causing a lot of pressure in the rectum, and an urgent need to evacuate, but no matter how much they push they feel that things are stuck and not able to get out. This can cause the patient to spend an inordinate amount of time trying to push very hard, to the point of causing local injury in the form of hemorrhoids and occasional prolapse.

To make sense of this phenomenon you need to understand the basic anatomy of the lower colon in relationship to the pelvic floor and the pelvis itself.

The distal colon descends from the left lower abdomen into the front of the sacrum, where it's posterior to the anal opening. The muscular sphincter is surrounded by a complex set of pelvic floor muscles, which can move the sphincter further forward under voluntary control, thus holding stool in the rectum rather than letting them evacuate.

In order to let stool pass through, the pelvic floor muscles need to relax so that the sphincter can move a little further backwards and align itself with the rectum. In addition, the sphincter must be central in the pelvic floor, not shifted or pulled to one side, in order to have the easiest and smoothest stool evacuation.

If you look at the anatomical drawings of the pelvic floor muscle and the lower colon, you will notice that the pelvic floor muscles attach to the entirety of the bony pelvis, from the posterior part ( ilium and ischium, sacrotuberous ligament, tailbone) to the anterior part behind the pubic bone. In addition, all the pelvic floor muscles are innervated by by the lower lumbar segment and sacral segments.

The intimate neurological and structural connection of the pelvic floor to the lumbar spine and pelvis means that distortion patterns, trauma, repetitive strain of the lumbar spine and pelvis can result in some significant distortion of the muscular activity and tone of the pelvic floor, with the risk of chronically altering the central positioning of the sphincter in relationship to the lower rectum. This means that at the time of voluntary evacuation, it would take more effort and straining to bypass this suboptimal relationship between the lower large intestine and the outlet.

It occurred to me at the time I started writing this blog that I've probably been incidentally treating a lot of mild pelvic outlet constipation cases for a while, as a byproduct of my chiropractic treatments to the lumbar spine and pelvis. However it's only more recently that I've started paying attention more closely and in more detail to the structures of the posterior pelvic floor, which abuts structures we routinely palpate in the lower sacrum, inferior external rotators of the hip and sacral ligaments. I've also started asking the patients a few more pointed question about symptoms, which they may not volunteer, partially because these body parts are pretty private and partially because people don't make the connection between their G.I. symptoms and their lumbar pelvic symptoms.

To be effective, a chiropractic treatment in patients suffering from pelvic outlet constipation needs to incorporate several elements: addressing the structural alignment issues in the lumbar spine and especially in the pelvis; addressing the muscular imbalance of the external rotators of the hip, especially the most inferior group; addressing abnormal tone texture and scar tissue in the posterior pelvic ligaments (sacrotuberous and sacral spinous); and being able to give the patient basic information about how to do a proper pelvic floor stretch and strengthen based on which side is involved.

I'm also very fortunate to have access to several excellent pelvic floor specialty providers (physical therapist and occupational therapist) in my area of practice, who can take care of more direct pelvic floor manual therapy in patients who need it

K59.02

Outlet dysfunction constipationK59. 02 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM K59.

https://www.icd10data.com/ICD10CM/Codes/K00-K95/K55-K64/K59-/K59.02#:~:text=Outlet%20dysfunction%20constipation,-2016%202017%202018&text=Billable%2FSpecific%20Code-,K59.,ICD%2D10%2DCM%20K59.

Femoral neuritis: the "other sciatica"

Femoral Neuritis

Sciatica enjoys quite a bit of popularity, and rightfully so. It is not technically a medical diagnosis but the description of symptoms encompassing pain in the leg, generally assumed to stem from the low back. The sciatic nerve originates at 5 levels spanning the last two lumbar vertebrae/discs, and the upper three sacral segments. It travels through several soft tissue structures in the buttock, down the posterior thigh, before splitting into two different branches at the knee, covering the lateral and posterior calf and foot. As such, sciatica describes referred pain affecting this distribution pattern.

Patients often use the term “sciatica” pretty liberally, to describe any sort of pain in the leg, including pain in the front of the thigh, which is not a sciatic nerve distribution. Enter its lesser known cousin, the femoral nerve.

Femoral neuritis is actually surprisingly common but getting little recognition ( it is still less common than sciatic neuritis). The femoral nerve originates in the mid lumbar spine and is made up from nerve roots from lumbar segments L2 through L4.  It travels in the front of the lumbar spine, deep in the abdomen, through the intersection of the two branches of the iliopsoas hip flexor muscles, through the groin and into the anterior and medial aspect of the thigh. It does not extend very far below the knee, unlike the sciatic nerve, which extends all the way into the foot.

The femoral nerve can be compressed in the lumbar spine, by a mid lumbar disc herniation, and just as commonly by myofascial injuries in the hip flexors. The patient will often present with unexplained groin, hip, thigh and medial knee pain and tingling. Unlike sciatic neuritis, many patients will not initially recognize  femoral neuritis as referred pain from the lumbar spine since it manifests in the front of the trunk and leg.

Femoral neuritis will be treated in the same manner as sciatic neuritis, based on the source / cause of the problem: chiropractic adjustments, myofascial release, corrective exercise, supportive therapies etc.