Archive for the ‘Musculo-skeletal’ Category

The good news about arthritis – it’s not as simple as you’ve been told…

Saturday, October 31st, 2015

“…they found that it is very common for people to be walking around without any pain who have terrible joints!”

 Knee pain pic

Western medicine is updating it’s understanding of why arthritis hurts – the answer is that they are not completely sure anymore.

For most of the 20th century, the arthritis story was very simple.  The patient was told “See these changes on the X-ray/ MRI? That’s what is causing the pain.”   Patients then feel educated while they wait for for the surgeon – back fusion, knee replacement etc. etc.  The expectation is, if no change to the bone and cartilage of the joint – no pain relief.

But in the 21st century, new information has made that picture become less clear.

Researchers began to ask questions:

For example, if the bone pathology causes the pain, why does it not hurt all the time?

Why do some people have flare ups of pain after overeating?

Why is it when people actually have corrective surgery, the pain does not always go away?

Finally they began to take X-rays and MRI’s of people who are totally without any pain or stiffness.  To their amazement, they found that it is very common for people to be walking around without any pain who have terrible joints!  Even when finding the dreaded “bone on bone” situation.

In fact, if radiologists have never met the patients and only look at the X-rays, they cannot predict which patient has no pain, which patient has pain and if so what kind of pain they have in terms of location, intensity and frequency.  Some predictability is possible for very severe cases, but even then, not always.

This is really good news – the patient can now explore all the other factors for why the joint may have pain and stiffness, with reasonable expectation of preventing or delaying surgery.

So what does cause the pain?

The research suggests that arthritic changes to joints happen against the background of many other changes to nerve physiology, tendons, ligaments, muscle and immune system physiology.  There can also be a significant stress/ psychological component.

Using the word”physiology” here very specifically refers to changes in gene expression, enzyme function, immune function lymph and blood flow changes, as well as biomechanical changes.  Many of which have been shown to be reduced or eliminated by electroacupuncture, bodywork, herbs, nutrition and lifestyle factors.  (I will have a more detailed post about the science of pain in a few weeks.  Try Googling “genetic control of central sensitization” if you are curious before then.)

This explains situations I see in the clinic.  I often have patients who have been told that they need surgery but wanted to try acupuncture first.  Well of course, those of you familiar to my practice know it’s not just acupuncture that they may need. These patients receive a thorough review of their current and past global metabolic situations before various procedures and options may be utilized.

What can be done about the pain and stiffness then?

old-couple-jogging-healthy-ageing

Consider the following situations for patients with osteoarthritic pathology seen on an X-ray or MRI. When I find trigger points in the thigh muscle, the arthritic knee pain can go away completely in 1 or 2 sessions.  When a patient regularly overeats on foods that cause inflammation, 3 or 4 weeks of digestive repair and lifestyle changes can also restore function.  Some folk are over exercising or doing the ‘wrong’ types of exercise, some are too sedentary and do not know how even just a little more activity will create a big change.  Some people do not even need office procedures at all but need to simply move the joint regularly throughout the day in the range without pain.  This will allow the lymphatic and blood circulation to improve.  Also common is pain in a joint on a limb that had previously experienced poorly healed strain and injury – e.g. clearing the effects of an old neck injury can help wrist or hand pain.

We you come to see me, I take the label from your surgeon’s diagnosis off the the table for a moment and look at the whole picture.  A good diagnosis means a good treatment, and understanding the whole person is the best route to the best diagnosis. Detailing what the body needs allows us to design treatments using many options to surround the problem and get stable progress.

Happy healing!

Still limber

 

 

Try all your pain relief options before reaching for ibuprofen

Friday, July 31st, 2015

FDA recall

I try to avoid fear mongering on my posts but I have been feeling a growing moral pressure to tell the new ibuprofen story for some time.  After reading how long term higher dose ibuprofen use can have the same heart attack or stroke risk as Vioxx, the time felt right to update you all on the issue.  Vioxx was banned by the FDA as unsafe. (The Lancet 2013 382:9894;746-8)

Ibuprofen (aka Advil©, Motrin© etc.) seems harmless enough.  Maybe you’ve worked out too hard, maybe you have arthritis, maybe bad period pains.  For many mild pain patients, this pill can be quite a satisfactory pain management tool. I have taken it myself occasionally.  It certainly is more forgiving than acetaminophen (Tylenol© and other brand names), where even one or 2 pills past the regular dose can land you in hospital with liver damage.

However what I see in my clinic is that people keep taking it.  They come to rely on it.  Some athletes and military personnel even call their daily dose of ibuprofen “Vitamin I”.  And like many chronic self-medicating patients, over time the dosage and the risks go up as the benefits diminish.  I see multi-year users describing how the pain goes down just a couple points, say from a 6/10 to a 4/10 yet when they started the drug totally eliminated the pain. So now they have all this risk just for a minor nudge of pain levels.  Not worth it.

They masked the pain and prevented themselves from learning about the cause and effect their choices had on their body.  If you can learn where cause and effect impact your life, your quality of life will blossom in many profound ways.

Basic common sense suggests that it is better to understand and change the root cause of the pain rather than trying to suppress it once injury occurs.  Working with a professional such as myself will allow you to identify why you have that inflammation so often – and no its probably not aging!  I discuss everything with patients from shoe choices to making sure you vary your workout routine based on your body type.  The treatments I offer can eliminate the need for the drugs completely and can even help with issues like weight loss.

Take the example of arthritis.  I will post more about arthritis later, but a sneak preview here is the fact that the bone changes themselves do not cause the pain directly.  Arthritis pain is now understood to be very complex, and involves changes to the immune and nervous systems.  Note that many people with the bone changes do not have any pain at all!  You cannot predict pain levels just from looking at an x-ray.  Obesity is ofetn the difference between pain or no pain.  Seeing me to kick the ibuprofen habit for osteo-arthritis allows you attack the reasons for the pain in a safe, controlled manner.

So what are the risks with ibuprofen?

Well for example, a dose of hard exercise normally causes minor intestinal tears in healthy people.  These tears usually heal up just fine.  But the ibuprofen makes them worse and can can even slow the repair, so over weeks and months you are causing quite a bit of damage.  Beyond the digestive damage directly, weakening the lining of the gut causes all kinds of other inflammation such as in joints or the heart, or blood vessels – especially those in the brain. (from “Medicine & Science in Sports and Exercise” December 2012 44:12; 2257-62).

The Physician’s Desk Reference 2015 lists several other issues.  Cardiovascular risk including stroke and heart attack.  Renal papillary necrosis (the tissue has died) and other renal injury leading to possible kidney failure, liver failure, blood pathologies.  All noted that risk increases with duration of use.

All of this risk is really quite unnecessary.  Call me, call your PT DC DO LMT etc. etc. and start living pain free without damaging your health.

I found this chart on Pinterest.  It is not complete, e.g. does not have the cautions about using if you are diabetic or asthmatic,  but I hope you find it informative.  (You have to click on it to see the detail…)

NSAID risk

 

 

 

 

Real acupuncture is often ignored in clinical research

Saturday, January 31st, 2015

 

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When providers dive into the clinical research about acupuncture and pain, they find many papers that conclude acupuncture is simply a placebo. Yet what the papers are calling”real”, “true” or “verum” acupuncture is often not.  This post is a brief discussion about this issue, written for the lay person.

Research often A./ oversimplifies the diagnosis and care that patients receive in real clinical situations and B./ misses many important phenomena that require investigation.

A./ Oversimplified diagnoses and treatments

The actual care L.Ac.’s provide to their patients could be compared to an equation,

Treatment = [the exact nature of the problem] + [many individual details of the patient]

Due to time and money constraints, the second term is usually ignored and the first term is over simplified.   So for a study looking at back pain, the patients are all grouped together without clarification of their stress levels, psychological history, exactly what tissue/ muscle group is causing the pain, how genes involved in central sensitization are being expressed or not expressed, levels of blood markers for inflammation, other metabolic differences, etc. etc. The study looks at this group of patients with this wide variety of physiological states and gives them all one label, eg. mechanical back pain.  The study then puts severe restrictions on what points the practitioner can use and how to use them, due to the limitation of the statistics they want to use at the end.  The practitioners then cannot change anything to match the individual needs of the patient when it appears early in the care that that point prescription will not work for them.   In other words, the forced clinical behavior in the study would not survive the first week internship in any acupuncture school.

Imagine 2 patients aged 60 with a slipped disc at L5 causing back pain.  One is a robust ex pro football payer with years of fibrosis and fat marbling in the muscles around the injured nerve. The other is anemic, hypothyroid and who lived a very sedentary life and is also being treated for anxiety due to an abusive marriage.  The ball player may receive thick needles with strong stimulation with 100 Hz electro-acupuncture and deep tissue massage. Most L.Ac.’s could predict that were I to provide the same treatment in the anxious patient, I would likely make them worse.  The patient with an anxious, weaker metabolism needs a much lighter touch so as to not trigger the flight or fight reflex nor increase fatigue or cause other damage.

This is common sense, but is in fact quite difficult to add this common sense into a clinical study using current research techniques.  Unfortunately, the poorer quality studies are not removed from the statistics of the meta-reviews so we have quite a bit of “garbage in, garbage out” when maths is applied to the body of the research.

B./ Phenomena missing in the research that could disprove placebo predominance

I find the really interesting thing about acupuncture is that when I change something in the treatment that the patient is not aware of, their symptoms can change suddenly.   As I fine tune the treatment, I can see symptoms get strongly better or even strongly worse.   Thus I can navigate the patient to improvement in a very clear manner.  A placebo would not be able to have this power.

Even testing points before needling shows wide variety of results, allowing me to choose the best points.  Migraines are a great example.  I ask the patient “When I press on a point, please tell me if this makes the pain worse, better or has no effect on the pain.”

If acupuncture was only placebo, why do some points make the patient feel worse and some make the patient feel better?  With light pressure on one point, immediate exacerbation. With light pressure on another point, an 8/10 headache can completely clear.

Again, due to limited funding and the limits of current technology, many of these sorts of daily phenomena are not brought into the peer reviewed clinical research but do show up in the basic investigational research. They are crucial to elucidating the physiological mechanism of “real” acupuncture.

The moral of the story is that when you receive treatment by an L.Ac., they will pay attention to you and your symptoms in order to always try to optimize the best outcome during care.

 

 

 

Do you think its age causing the trouble?

Monday, July 21st, 2014

In many cases I see, it’s not really age.
Our bodies need three things to be thrive –
…Good Sleep
……..Good Nutrition
…………..and Good Movement!

Many of my over 80 patients (and even younger) experience poor mood coming from how their body just isn’t what it used to be. I regularly hear “My mind is so much better than my body but I don’t know why.”

My response is that the answer is obvious – the mind has received all the attention! They do crosswords, listen to music, watch TV, read, socialize. But over the course of the day they are largely immobile. Use it or lose it, if you spend time with the “equipment” it lasts longer.
The amount of movement you need to feel a lot better is not a lot of movement. This is the surprising thing.

Of course if you do Tai chi and take a regular class you will feel improvement.  But in my clinical experience many people can increase mood and reduce pain by developing the habit of moving something every 15 minutes. Just like a dog or a cat – every few minutes, move something for a few seconds.  Reach up in the air, jab a few shadow boxing moves, lift one leg, then the other.  Even people with severe disease who are in bed can usually find some part of their body that can move freely. Even just straightening up and breathing deeply once or twice can help.

The classical chinese medical view is that the blood flows to where function is happening, the function happens in places where the mind engages that function.

For the average person, who is well enough to walk into my office when they come for a session,
Here’s the plan to start:

Every 15 minutes over the course of your day, stand up.
Every 15 minutes move your arms or your legs for 7 to 10 seconds, try a variety of directions including up and behind the back.
Move within a range of motion that causes no pain what so ever, no matter how small a movement this may be.
Give it a week and see how you feel!

What does getting better look like when using Chinese medicine and acupuncture?

Thursday, November 21st, 2013

Progress and clinical success at my clinic can be experienced quite differently compared to using drugs or surgery.

• For people who had complete relief or otherwise fully achieved their clinical goals, we can look back in their chart and see that some treatment days or weeks were better than others.

• Sometimes people notice improvement right away, sometimes over the next day or two. We know the results of an office procedure within 1-2 days of the session.

• Sometimes the treatment can occasionally irritate the problem initially and then feel better later. When symptoms return, they are less intense than pre-treatment.

• It is normal for symptoms to fluctuate anyways, especially those influenced by activity and stress levels. We keep track of it all, looking for the trend and adapting care as events warrant.

• Before treatment starts, it is not common for people to follow their symptoms with a high level of detail especially objective detail. After we start working on the issue, we tend to pay more attention which of itself can change the experience of the problem.

• In general there are 2 phases of healing. First we deal with the legacy of the situation, i.e. the accumulation of stress on the system from the past. There is then a phase where healing the past is over and we then aim to increase performance out of the affected system, so that damage from ongoing circumstance (perhaps beyond our control like a job situation) do not cause trouble.

It can be difficult remembering how bad a situation was before care started. If you are not certain how you are doing, lets talk about it and look through your chart. I once had a patient with knee pain who was sad that she could not hike 5 miles like she used to, even after 3 weeks of care. 3 days before her next session she had tried the long hike and failed due to pain. I was able to reassure her with her chart notes.

At her first appointment, she could not walk from the car park to the office and had to have her husband drop her off due to the pain. She had been this bad for 6 months before acupuncture, while in hesitation about whether to do surgery or not. On the day we addressed her progress concerns, she had come in unaided from the car park and in fact had several 1-2 mile hikes in her chart (from second week of care), where she only had 1/3 to 1/2 the pre-treatment pain level.

This was an otherwise normal, emotionally healthy person who simply lost track of this fine level of detail due to being very busy in her life, and also feeling the sting of recent failure.

Looking at the trend was all the reminder she needed to to continue care through to successfully getting back to her long hikes pain free. She did not need surgery within one year follow up, the medical cause of the pain was really one of trigger points and neuropathic pain more than being due to the findings on the MRI.

Returning to exercise safely & injury free (or “You’ll get there in the end”)

Monday, October 21st, 2013

Returning to physical activity is like making a camp fire. Making a camp fire means understanding fire’s nature, and acting appropriately.

How to make a nice roaring camp fire:

Start with a tiny spark from a flint or a wood drill.
If you add the spark to a log, it’s extinguished right away. If you blow too hard on the spark, that will overwhelm the spark as well.

The spark must be carefully cultivated with an understanding of its nature.

The successful spark goes on dry moss, maybe sawdust. Then more sparks form, then you can add more moss. Now, maybe a small wood shaving, then another. More moss, then a small twig. Never large pieces at this stage. Some gentle air from the breath is good now.

Then add several twigs, maybe some more moss. Then a bigger piece of wood, then large sticks. Now blow hard as possible, stoking the heart of the fire.

Now its ready for logs that will achieve the desired function of keeping warm.

This whole process totally fails if you push the envelope too soon. Yes, fire needs wood and yes it needs air, but these can smother the sparks if used at the wrong moment.

If you judge the small spark as being useless, you will never get the benefit from it. A large, warm fire has very humble beginnings but the beginnings exist and have power to develop.

Translate this analogy to exercise –

The goal of the first week or more is to simply get used to moving without triggering pain. Let the body be gently reintroduced to gravity and perhaps the kind of activity you intend to carry on with.

The goal is not to go for endorphins, stress relief, weight loss or other athletic performance. Get this goal correct and you are on the quickest path to victory. Anything else is risky.

Many people are hurting themselves by judging their own small spark of capacity to be useless and either overdoing it or deciding to do nothing.

I once had a patient only able to do 5 seconds of a shoulder qigong exercise I prescribed. This was case where workers comp covered work on the ankle but not the preexisting shoulder issue so she asked for a self-care protocol. But at 6 seconds, severe pain kicked in. This small functionality made her upset. She felt useless, thinking that 5 seconds was a fail. I recommended that she just do the 5 seconds. She was convinced that 5 seconds was completely pointless and we spent some time talking about this. She agreed to try the 5 seconds every day. After all, at 5 seconds at least there was no pain. In a few days she could do 10 seconds. In 2 weeks she was doing 10 minutes twice a day, and this finally took her into the range where the exercise made the shoulder feel pain free.

A more commonly used example I use for very overweight people over 75, who are in recovery from surgery or prolonged illness. I start these patients with 5 minutes per day on a playground swing. Sounds almost silly, but it moves a lot of lymph around and gets the body warmed up. From this innocuous beginning, within 6 months many can walk several miles a week or return to a keep fit class.

The moral is this –

It is totally irrelevant how small your abilities are when you start. Start where you are at, learn to enjoy the fact you have that much function at all. Development of your performance will then come without injury and with a deeper understanding of your own body’s needs.

Exercising outside during cold weather

Wednesday, October 9th, 2013

If you want to cultivate all the benefit that your body derived from summer training, be mindful how Cold and Damp can not only damage your system in the short term, but in the long term as well.
Stay warm.
In Chinese Medicine, the advice to stay warm is very specific – keep the joints used in your exercise warm, dry and wind protected. This regularly means that the athlete must stay covered up to the extent that they feel slightly “too” warm for the large percentage of workouts aimed at maintaining fitness. Workouts that try to push the envelope can be handled a little differently.
Folk that wear shorts and T-shirts to train outside in cold weather will rapidly chill the entire body once they finish the workout. This uncontrolled chilling runs the risk of lowering your resistance to disease. Digestion, joints, the immune system and even aspects of the menstrual cycle can become more subject to imbalance and disease with chronic exposure to the elements. These preventable imbalances can build up over time. And remember, in Chinese medicine prevention is always preferred to treatment.
Warmth increases blood flow and keeps flexible, shock absorbing tissue pliant. Warmth allows enzymes involved in muscle, tendon and ligament repair to work better.
Ice is fine after a workout, when the affected area is not trying to perform. Icing within 24 hours of a workout can speed up recovery time and is great for managing some types of injury. But this kind of icing is applied to specific, limited areas when the rest of the body is warm
If you want to maximize health as you age, keep warm, dry and wind protected during any outside physical activity for most of your workouts.