The 'Wear and Tear' Myth

There have be recent advances in osteoarthritis (OA) and cartilage research that have changed what we know to be true about OA. In light of new evidence, clinicians should alter their interactions and protocols with regard to patients affected by OA. It has been widely believed for many year that people suffering with arthritis will need a joint replacement eventually and that that is the only option. It is also widely believed that cartilage will not regrow or become healthy again.

Patients are often told that reducing weight is the most effective way to decrease OA associated joint pain because it decreases the impact on the joint and the stress on the cartilage. However, recent research has shown that it is not so much the weight, but the percentage of body fat (1). A higher percentage of body fat has been shown to increase cartilage loss over time, while a higher percentage of lean muscle mass is associated with maintaining cartilage over time. Obesity has been shown to predict the progression of hand OA, which is not a weight bearing joint, so how does increased weight contribute to that? Further research found that obesity contributes to inflammatory responses in the joint which affects the cartilage and its ability to repair and thus can add to the progression of OA.

A commonly held belief is that once there is no cartilage left on a joint surface it will only get worse with more activity. Activities like bike riding, which don’t involve impact or loading of the joint, are preferred because they don’t wear the cartilage down more. As it turns out, cartilage loves loading. It has been found that astronauts after having spent substantial time in space have thinner cartilage upon returning to earth which is less healthy. In contrast, marathon runners have been shown to have thicker, more healthy cartilage than “normal” individuals (2). Cartilage doesn’t get its nutrients like other tissues of the body because cartilage doesn’t have a blood supply. Cartilage gets it nutrients through compression and load, by physically pushing the nutrients into the cartilage tissue. Furthermore, compression and load stimulates chondrocytes (the cells of cartilage) to make collagen and aggregan (parts of your cartilage) and loading also creates daughter cells that help repair cartilage. Instead of the “wear and tear” that we always think of, cartilage can “wear and repair”

Lastly, another part of this myth is the psychologic message that “wear and tear” sends. It casts the shadow that joint replacement is inevitable and there are no alternatives. It assumes that he joint will continue to wear out so you’d better get used to it. These ideas are, however, not evidence based. The body, even the cartilage, is “bioplastic”. That means that the body has the ability to change and adapt, even the bones and cartilage. Exercise and activity has been shown to improve cartilage health in people with OA and to decrease the system wide inflammation associated with OA (5, 6).

This isn’t to say that all joint replacements are unnecessary and ill-advised. Certainly many people need this procedure and have favorable outcomes. There are 10-34% who do have unfavorable long term outcomes, such as moderate to severe pain, two to five years after a total knee replacement (7).

1. van der Kraan PM. Osteoarthritis year 2012 in review: biology. Osteoarthritis Cartilage. 2012 Dec;20(12):1447-50. doi: 10.1016/j.joca.2012.07.010. Epub 2012 Aug 13. PMID: 22897882.

2. Smith, David & Gardiner, Bruce & Zhang, Lihai & Grodzinsky, Alan. (2019). Articular Cartilage Dynamics. 10.1007/978-981-13-1474-2.

3. Berthelot JM, Sellam J, Maugars Y, Berenbaum F. Cartilage-gut-microbiome axis: a new paradigm for novel therapeutic opportunities in osteoarthritis. RMD Open. 2019;5(2):e001037. Published 2019 Sep 20. doi:10.1136/rmdopen-2019-001037

4. Gwilym SE, Keltner JR, Warnaby CE, Carr AJ, Chizh B, Chessell I, Tracey I. Psychophysical and functional imaging evidence supporting the presence of central sensitization in a cohort of osteoarthritis patients. Arthritis Rheum. 2009 Sep 15;61(9):1226-34. doi: 10.1002/art.24837. PMID: 19714588.

5. Naugle KM, Ohlman T, Naugle KE, Riley ZA, Keith NR. Physical activity behavior predicts endogenous pain modulation in older adults. Pain. 2017 Mar;158(3):383-390. doi: 10.1097/j.pain.0000000000000769. PMID: 28187102.

6. Wallis JA, Taylor NF. Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis. Osteoarthritis Cartilage. 2011 Dec;19(12):1381-95. doi: 10.1016/j.joca.2011.09.001. Epub 2011 Sep 10. PMID: 21959097.

7. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012 Feb 22;2(1):e000435. doi: 10.1136/bmjopen-2011-000435. PMID: 22357571; PMCID: PMC3289991.

Hurt Doesn't Always Equal Harm

Hurt doesn’t always mean harm. “Hurt” is a protective mechanism produced by the brain to warn us when we are in danger. “Harm” we will define as disease or bodily tissue damage. We typically assume if we experience pain we have injured our bodies and, vice versa, if we see an injury we expect to feel some pain. However, this is often not the case. For instance, the lifetime prevalence of lower back pain (LBP) is reported to be as high as 84% (1). That means that as much as 84% of the population will experience lower back pain at one point in their life. Imaging findings are weakly related to LBP symptoms. In one cross-sectional study of asymptomatic persons aged 60 years or older, 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc (2) .

Pain is normal and is what your brain judges to be threatening. Even in the presence of tissue damage, if your brain doesn’t determine it to be threatening you will not experience pain. In the exact same way, in the absence of any tissue damage, the brain may protect you (with pain) from what it judges to be dangerous. Non-specific lower back pain (NSLBP), back pain that has no identifiable pain generator, is a common example of this. Recurrent pain (say, months after an injury) doesn’t demand that there has been a reinjury of the tissue. It is often your brain recognizing familiar cues and signals from your body that it then judges to be threatening.

There are four “essential pain facts”. 1.) Pain protects us and promotes healing. It provides a “safety buffer” from going beyond tissue tolerance (i.e., burning yourself, getting a cut, tearing a ligaments or tendon) As soon as you have an injury, the “safety buffer” becomes much larger and so you experience pain with, perhaps, any movement. 2.) Persistent pain overprotects us and prevents recovery. Your brain and spinal cord “learn” to be more protective or hypersensitive so that the “safety buffer” remains very large. This must be treated very differently from an acute injury. The aim of treatment and therapy is to return the safety buffer towards normal 3.) Many factors influence pain. Pain can be influenced by psychological factors, such as stress, depression, and/or anxiety (3). Life circumstances (living situation, socio-economic status, etc) can affect your ability to deal with and treat pain upstream of an injury 4.) There are many ways to reduce pain and promote recovery. One effective way to reduce pain is to understand your pain and can help you identify how you can influence your own system.

If you suffer from pain, acute or chronic, and need help, please find a therapist who can help guide you through recovery. Also, enjoy the video below about pain and injury. Take care and be well.

1. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6. PMID: 21982256.

2. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8. PMID: 2312537.

3. Besen E, Young AE, Shaw WS. Returning to work following low back pain: towards a model of individual psychosocial factors. J Occup Rehabil. 2015 Mar;25(1):25-37. doi: 10.1007/s10926-014-9522-9. PMID: 24846078; PMCID: PMC4333236.

Menopause and Weight Lifting

Menopause is characterized by the cessation of the female menstrual cycle for a calendar year. Perimenopause is the time period around this year that can last for about 7 to 12 years. This period involves a slow decline in female hormones, most importantly, estrogen. The decrease in these hormones causes a number of different symptoms such as hot flashes, muscle loss, fatigue, mood changes, difficulty sleeping, and joint pains.

The decrease in estrogen during perimenopause and menopause also results in bone loss. Estrogen concentrations in the blood can even be used as a predictor for bone fractures. It has been well documented in research that weight-bearing exercises are a great way to improve bone density. An 8-month course of high-intensity resistance training and weight-bearing exercise improved bone density scores at all sites of the body and improved physical performance scores in menopausal women with osteopenia when compared to women who performed low-intensity home exercises.

As women get older they have more difficulty building and maintaining muscle mass. This is in part due to changes in the proportion of muscle fiber types within the muscles. Specifically, type I muscle fibers (slow contraction, more endurance-oriented fibers) are maintained while type II fibers (fast contraction, strength-oriented fibers) decrease in numbers. This change in proportions is due to reduced amounts of estrogen in the blood stream. A great way to counteract this change is by strength training. Several studies have shown that strength training can increase muscle strength in menopausal women. Improving strength and muscle mass also has the added benefit of increasing one’s metabolism since lean muscle takes more energy to maintain.

This brings me to the last benefit of weight training during perimenopause and menopause that I will touch on. The mechanism behind resistance exercise and fat loss is two-fold. Besides the obvious reason of burning calories from actually doing the exercise, resistance exercise works to increase the calories burnt at while resting – our basal metabolism. This occurs over time as you slowly increase the amount of lean muscle tissue in the body because, like other living organs in the body, muscles have their own energy demand in order to be sustained.

The effect of strength training on body composition and weight control in menopausal women has been studied by numerous groups and different methods. Longer-term approaches (>6 months) had more consistent effects but positive results were found in interventions lasting only 8-12 weeks. Higher intensity exercise was shown to have greater effectiveness at facilitating fat loss than lower intensity exercise. In many of the long-term studies, the control groups (who didn’t strength train) lost muscle tissue and gained fat mass so simply maintaining baseline level composition is also considered progress.

Perimenopausal and menopausal women often gravitate towards cardio machines for weight control and fat loss without considering the possible benefits of weight and resistance training. For maintaining lean muscle mass and bone density and increasing basal metabolic rate, high intensity resistance training should be incorporated into their weekly routine.

Here’s a great podcast called Hit Play Not Pause for more information from an exercise physiologist, Dr. Stay Sims, who also recommends including high intensity, Tabata type training followed by protein to maintain muscle, energy and performance during their menopausal years.

Covid-19 Update

It has been a while since my last post so I wanted to take some time to let you know all the things going on with me and Pro-Motion Chiropractic. To begin, I contracted covid-19 back in mid-January. My symptoms were mild but present and I did not require any further medical attention. After my symptoms subsided and my quarantine ended I kept the office closed for another week because one of my sons had tested positive as well (he had no symptoms to speak of). After five weeks of “togetherness” in quarantine with my family I received an email from public health about getting vaccinated, so less than one month after testing positive, I was eligible for vaccination which I did. I’m happy to report that as of Monday, March 8th, I am fully vaccinated!

The next big “happening” with Pro-Motion, is that it has moved locations. I am still in the same building as the Teton Sports Club, but now am on the north side of the building instead of the south side. The new space is great for the practice. I no longer share a space but continue to have an entrance to the outside of the building as well as to the gym, so you may enter from either direction. I also no longer get to enjoy the loud noises of people working out from upstairs, so that’s nice. I currently don’t have any signs up, but that will soon change.

Lastly, I am maintaining the same safety protocols as I have from the start of the pandemic and have incorporated some new ones. Those are, patients (and I) must wear a mask during the appointments, patient visits will be spaced throughout the day to allow for the transfer of air and all surfaces will be disinfected between patient visits. Lastly, a patient was generous enough to lend me an “air scrubber” to use in the office. An air scrubber uses several filters to clean the air of contaminants. When used properly, air cleaners and HVAC filters can help reduce airborne contaminants including viruses in a building or small space. I’m just doing my best to reduce the risk of any transmission of covid-19.

Thank you for your support through all of this, I wish you all health and happiness, take care!

If I Go Once, Do I have to Keep Going?

False—mostly. Like many things in life, this isn’t a black and white issue. Chiropractic can be used as a short-term acute treatment or as part of a long-term preventative and health maintenance protocol.
Sometimes a person may get injured, which can result in pain or limited performance. This can happen due to a car accident, lifting heavy objects in an awkward manner, or perhaps taking a hard hit while playing sports. This can result in debilitating pain that prevents the ability to continue with the same lifestyle that existed prior to injury—whether that means having to modify one’s occupation, an exercise routine, hobbies, or a specific daily routine. Chiropractic treatments are an excellent means to correct acute issues related to the spine. It is possible that a very short-term stint of care will properly address the pain or performance issue and result in healing for the patient that requires no follow-up.

I often have patients come in bent over in excruciating pain who are able to walk out of the office with little to no pain. Neither surgery nor medicine was required to make this patient well. These examples powerfully depicts how chiropractic is able to immediately resolve functional issues, eliminate pain, and get the patient back to the life they love to live.
While there are instances where chiropractic can be used as an isolated treatment option there is also a tremendous benefit to consistently using adjustments to maintain excellent health, manage and eliminate pain, and enjoy top physical performance. Many professional athletes such as Olympic hopefuls and NFL players include chiropractic as part of their training regimens. They know that their bodies perform optimally when their spine, joints, and nervous system are carefully maintained with chiropractic adjustments.
Think about it, you probably visit the dentist annually or semi-annually to ensure your pearly whites are in tip-top shape with a checkup and cleaning. Keeping a close watch on your spinal health and getting regular “check-up” adjustments or treatments is an excellent proactive step towards ensuring optimal spinal health. Some studies have shown that regular chiropractic treatments promote increased lung capacity, visual acuity, reaction time, balance, and cardiovascular health. The spine has an impact on all other bodily systems and therefore should be a priority for routine maintenance and wellness.
Discuss your health goals and concerns with your chiropractor to determine if they will best be met by consistent care over time or if perhaps reaching your goals will require a shorter duration of care.

Chiropractic Foot Therapy

Chiropractic During Pregnancy

Why Do We Hurt?

Chronic pain is any pain that lasts for more than three months. At that point in time, any tissue that might have been damaged at the onset of injury will have healed and therefore, should no longer be painful. So why do we hurt?

Pain is an output of the brain. The possibility of pain starts when nerve fibers that transmit pain signals (nociception) send information to the brain. Then the brain decides if it is important or not, and what to do about it. To make this decision the brain incorporates all the information you have about pain and all the context around you (your environment). That context could include your beliefs and thoughts about your back (you think it’s weak, unstable, degenerative, etc), your history of injuries, memories of others who have had back injuries, the smell in the room, or the amount of lighting. Any credible evidence of danger to your body will modulate pain (a dark room will upregulate a pain response). If the brain determines there are more “danger cues” than there are “safe cues”, then the brain will say “yeah, we’re gonna make that hurt”.

After pain has been present for an extended time a couple things happen: 1. There is increased sensitivity to that area. In effect, your brain becomes better at creating pain, and 2.) There is decreased precision in deciphering the location of the pain whereby the pain starts to spread, move around, or changes in how it feels (achy, stabbing, etc.). These changes represent real and significant changes in the circuitry of your brain. It may be difficult for people with chronic pain to believe because their pain is 100% real but it no longer accurately signals damage to the tissues.

There is significant evidence that when people in pain are taught about the pain mechanisms of the body and brain, their pain will decrease. There is significant evidence that the brain can regain precision in the areas of chronic pain. The brain is plastic and does change and even the circuitry of pain can be retrained. “Movement is king” with retraining the brain to reduce pain. I often use a “stop light” analogy to guide patients. If there is no pain when doing an activity you have the “green light”. If you have some awareness or pain while doing an activity but there is no residual pain after doing the activity, you have the “yellow light” and can proceed with caution. If you have pain while doing an activity and residual pain after the activity, that is a “red light” and you should avoid that activity until a later time.

If you have questions or want to learn more feel free to contact Pro-Motion Chiropractic. Or, here are some links you may find helpful.

https://www.tamethebeast.org/

TedX talk with Lorimer Moseley

Central Sensitisation

I often have people come into my office who have been dealing with pain for a long time. These people suffering from chronic pain are often frustrated, depressed and anxious. Anything they do may set off their pain, they’ve tried “everything” and sometimes they feel there is no hope and that they just have to “live with it”. In the article “Where pain lives” the author discusses how science is learning that chronic pain isn’t just “acute pain that goes on and on”.

There are several possible mechanisms of how chronic pain starts, propagates and persists, but they all take into account that pain doesn’t equal tissue damage. Meaning that patients with chronic pain no longer have injured or damaged tissue (muscles, ligaments, discs, nerves) that might’ve have long ago been a mechanism for pain, but suffer from the brain creating “circuits” that constant re-live the pain or becoming hypersensitive to any form of stimuli, known as “central sensitisation”.

It is important for people living with chronic pain to understand what they are going through and the specific brain changes that have allowed their pain to continue and then take steps to rehab and strengthen their body knowing that “hurt does not typically mean harm”. There are no pharmaceutical means to treat this type of pain yet but there has been a lot of success using “Cognitive Behavioral Therapy” and graded “non-pain contingent” exercises. I have always said that my “ideal” practice includes a pain psychologist for this reason.

This article contains a lot more detailed information and deserves a read. I hope you will take the time and learn something from it and if you have more questions please feel free to contact me at Pro-Motion Chiropractic.

https://aeon.co/essays/to-treat-back-pain-look-to-the-brain-not-the-spine

Whiplash

Now that the snow is starting to fall, soon the roads will become a bit more dangerous. There’s nothing like the helpless feeling of sliding towards the car in front of you as your anti-lock brakes shutter and try to gain a grip on the ice beneath you. Whiplash is the most common injury following a car accident and can occur even at very low speeds. Here are some interesting statistics about whiplash that may surprise you.

Whiplash Statistics

• Most injuries occur when traveling less than 12 mph
• A read-end collision generally causes more damage to the cervical spine than side or frontal collisions do
• Whiplash injuries are more severe in women and children because their necks are smaller
• Whiplash injuries occur 5 times more often in women than men
• Symptoms of whiplash can often appear weeks or months after an accident
• In 75% of patients, symptoms of whiplash can last 6 months or longer
• Victims of whiplash lose approximately 8 weeks of work
• Whiplash injuries occur more often in people 30 to 50 years of age
• A whiplash injury can increase your chances of chronic shoulder and neck pain
• People suffering from chronic pain due to whiplash injuries often have abnormal psychological profiles
• More than 60% of people who have whiplash injuries require long-term medical follow-up
• More than 50% of those who have whiplash injuries will still have chronic pain 20 years after the injury
• Pre-existing health conditions such as arthritis will lead to greater severity of injury and greater pain

Signs of a Whiplash Injury

After an accident, you are likely to feel some pain and limited ranges of motion. Even if the pain is minimal, it could worsen hours after the crash. Some signs of whiplash can include:

• Pain when moving your head side to side
• Tenderness
• Headaches at the base of the skull
• Fatigue
• Dizziness
• Difficulty sleeping
• Memory problems
• Tingling or numbness in the arms

Signs and symptoms of whiplash usually develop within 24 hours of the accident, which is why it is crucial to seek medical treatment immediately. If you’ve had an accident please let a professional make sure you are ok. You don’t want to be one of the 50% who has chronic pain 20 years after the injury.

Breathing and Low Back Pain

So often I have patients come in with neck pain, headaches, or lower back pain who exhibit something I call “paradoxical breathing”. Paradoxical breathing is characterized by inward motion of the abdomen with expansion of the chest and rib cage. This type of breathing utilizes “accessory muscles of respiration”, including intercostal muscles (those in between the ribs) and muscle of the neck, while excluding the diaphragm. There is a significant correlation between low back pain and dysfunctional breathing patterns.

The reasoning for this is that the diaphragm plays an important role in trunk stability and postural control. When someone exhibits paradoxical breathing, the diaphragm doesn’t descend (contract) like it should and instead rib expansion and lifting is used for inspiration. By constantly using accessory muscles for inspiration, those muscles start to have increased resting tone which can be perceived as neck pain and tension. In contrast, the diaphragm becomes weak and inactive.

There is a significant “co-contraction” between the diaphragm, the transversus abdominus, the lumbar multifidi, and the muscles of the pelvic floor which stabilizes the spine during movement (1). It has also been found that this co-contraction significantly reduces stresses on the spine by as much as 50% (50% in the upper lumbar spine and 30% in the lower lumbar spine) and reduces the loads experienced by the muscles of the low back by as much as 50% (2). When one of these muscles is injured or weak the co-contraction fails to reduce stress to the lumbar spine and musculature and can lead to injury and pain.

The good news is that the diaphragm can be trained and by practice and training the function can be restored and trunk stability increased. Breathing mechanics should always be assessed when treating patients with lower back pain and included with a specific core stability treatment plan when appropriate.

1. Nele Beeckmans et al., “The presence of respiratory disorders in individuals with low back pain: A systematic review”, Manual Therapy, 2016, Vol 26, page 77–86.

2. The Effects of Deep Abdominal Muscle Strengthening Exercises on Respiratory Function and Lumbar Stability. Eunyoung Kim, PhD, PT1 and Hanyong Lee, PhD2

The "Big 3", with Stuart McGill

 I just read a great q & a about the "Big 3" core stability exercises according to Stuart McGill. I have studied his books and followed his research for years and am excited to hear more and more about him in the media. It's a good read and you'll learn about some causes of lower back pain and how the "Big 3" help to alleviate it. Have a good one!

https://www.lifetimedaily.com/leading-back-pain-expert-reveals-fix-back-pain/

The Brain and Pain

I found a couple studies that I wanted to share with you. I often discuss the brains role in pain processing and changes that occur in the brain as a result of pain. The psychological effect pain has on us is immense and is just starting to be recognized and understood. Here are the studies that, I think, help shed some light on how we, as health care providers and manual therapists, can help our patients.

• Bunzli, S., Smith, A., Schutze, R., Lind, I., & O’Sullivan, P. (2017). Making sense of low back pain and pain related fear. Journal of Orthopaedic & Sports Physical Therapy.

This narrative (not a study per se) is especially interesting to me because I deal with it all the time. The authors conclude that the Common Sense Model (CSM) can be used to cope with “fear-avoidance behaviors”. In the “Fear Avoidance Model”, patients foresee extremely negative outcomes of their pain and so they avoid any and all activity that might exacerbate the pain, which leads to disuse atrophy, depression and chronic pain. By using the CSM patients can 1.) identify the pain, 2.) know what causes the pain, 3.) understand the consequences of the pain, 4.) learn how to control it, and 5.) know how long it will last. With this knowledge the patient is able to better cope with and treat their pain.

• Kregel, J., Coppieters, I., De Pauw, R., Malfliet, A., Danneels, L., Nijs, J. & Meeus, M. (2017) Does Conservative Treatment Change the Brain in Patients with Chronic Musculoskeletal Pain? ASystematic Review. Pain Physician, 20(3), 139-154

This study reviewed 9 different studies which used MRI to determine if functional and/or structural changes occurred in the brain of patients suffering with chronic musculoskeletal pain after a course of conservative care. They found that conservative care seemed to produce both functional and structural changes in the brain and also that these changes were associated with positive clinical outcomes (decreased pain, increased function).