Importance of chiropractic research

Hello all,

I recently became a contributing member to the Canadian Chiropractic Research Foundation. This organization is led by Dr. Allan Gotlib, a passionate chiropractic researcher that understands the future of chiropractic relies on good quality research to help us treat our patients better. Recently, the CCRF with the help of the British Columbia Chiropractic Association (BCCA) and the University of British Columbia put together the following videos promoting the importance of this type of research that some of the professions best and brightest are involved with.

Here they are for your review:

Research is the Foundation - Dr. Greg Kawchuk
Spinal Disc Degeneration Research - Dr. Mark Erwin
Spine Research at UBC - Dr. Jean-Sébastien Blouin

Amazing stuff! Keep up the good work!

Here's to your Saúde!

Henry

www.saudeclinic.ca

Update on consussion in sport

Hello again!

Long time I know. I've been hoping to be more consistent with posting and updating my blog but unfortunately have been unable to keep up my half of the bargain. I'm currently working on revamping the purpose of this blog and am learning of ways to spread the good word about it. Anyways, work in progress...

I wanted to share a link to a very interesting and informative lecture that was recently put on by UofT's Sport Medicine group and given by Dr. Doug Richards. Dr. Richards is a very well respected sports medicine physician in Toronto and has worked with many professional sports teams in the Toronto area. I was first introduced to Dr. Richards back in my PHE days while at UofT and since then, he has been one of my favorite lecturers to listen to.

Click here for the link to the presentation.

This lecture was given at University of Toronto on Tuesday June 21, 2011 and is approximately 45 minutes in length. Unfortunately, the first 15 minutes of the lecture was on mute (and removed by the administrators), and the last little bit on the UofT management model of concussion was cut short. However, prior to being cut off, (SPOILER ALERT!! STOP READING NOW IF YOU INTEND TO WATCH THE ENTIRETY OF THE WEBCAST!!) I was very interested to learn that from a rehab perspective, their first order of conduct (after the patient has been medically screened and formally diagnosed with a concussion) is to provide an exercise program that emphasizes neck stabilization. Interesting since all physical activity is out right banned in the acute setting. Unfortunately the presentation ended here... a question that I would've had for Dr. Richards is why the contradiction? I suppose one could argue that it is very symptom dependent and that the athlete is closely monitored but the argument can be made that this may be a contradictory recommendation based on his previous statement of "thou shalt not participate in any physical activity... including sex... with self or otherwise!" Nonetheless, based on his earlier arguments surrounding the potential involvement of the upper cervical ligamentous structures in long standing symptomatic concussions, that stabilization would appear appropriate.

With the increasing focus on concussion in sport, I'm hopeful that these and other pathophysiological questions will become clearer in time.

Please let me know what your thoughts are. Better yet, if you can help answer my questions above (or if you were at the presentation) please enlighten me!

Thanks and here's to your Saúde!

Henry

www.saudeclinic.ca

Chiropractic integration: Where we are today

Hello all,

I trust that this post finds you all well. It has been quite the hiatus since my last post. Time has not been on my side. Things have been busy but I'm hoping to dedicate more time to posting thoughts and clinical experiences here. In that spirit, a good friend and colleague of mine, Dr. Ryan Shum, sent me this interesting article. Take a look when you have a chance.

http://www.ecupresident.org/2010/09/what-will-it-take-to-gain-acceptance.html

Here's to your Saúde!

Joint health and supplementation

Hello all,

It has again been a while since my previous post but I thought that I would add something that I came across recently.

I have patients who come to me to help treat their joint related aches and pains, and have never really been a big proponent of supplementation but recently was invited to try out a product on myself... I'm getting older and my body doesn't bounce back as quickly as it used to after physical activity.

After doing some "consumer research", I came across this site that ranks a number of different products on the market. It likely wasn't done based on rigorous scientific method, but by the sounds of it, they did their best with the information available to them. Check it out and feel free to contact me should you have any questions.

http://www.consumerhealthportal.com/NaturalJointSupport/

Here's to your Saúde!

Back Pain and Pregnancy: How Can We Address the Problem

It has been a while since my previous post and I am hopeful that with practice settling a little, I'll be able to contribute regularly. On with the show...

I have been inspired to share this with you because of the increasing number of friends who have decided to start a family. 'Tis the season I suppose! :) For those of you who are pregnant, know someone who is pregnant, know someone who is planning on having a baby sometime in the near future, or is just interested in how to decrease the chance of back pain during or after pregnancy, this will be of interest to you!

Back Pain and Pregnancy: How Can We Address the Problem

Pregnancy is one of the most gratifying experiences in life. However, back pain is often a common symptom of many pregnant and post-partum women, and in severe cases, can be debilitating. A recent study by Mens and colleagues looked at the prevalence of low back pain during and after pregnancy and found that 67% of women experienced low back pain leading up to and at the time of delivery, while 37% reported that they experienced low back pain within 18 months after delivery. A possible explanation for this may be a combination of factors including hormonal changes, increased weight due to the presence of a fetus, and a forward shift in the centre of gravity. However, women have also reported low back pain very early in their pregnancy when the weight of the fetus is insignificant. As a result, researchers now believe that the major contributing factor is the increase in the hormone relaxin which promotes loosening of ligaments of the pelvis to allow for ease of passage through the birth canal. The everyday wear and tear that your joints experience is therefore amplified during pregnancy as a result of a decreased supportive and dampening role that is usually provided by ligaments in your pelvis and low back. As a result of this, your ligaments have an increased range of motion which may place extra stress on the associated ligaments causing pain.

What to Avoid

What can we do, or NOT DO, to prevent the severity of the back pain during pregnancy? Some of the things that have been shown to be associated with low back pain during pregnancy include the following:

• Standing for more than 30 minutes (90%)
• Carrying a full shopping bag (86%)
• Favoring weight on one leg/leaning on one leg (81%)
• Walking for more than 30 minutes (81%)

The percentages represent the number of pregnant women that experience low back pain as a result of the stated activity. As you can see from the above activities, these are things that are done on a daily basis and should therefore be avoided to prevent low back pain. This is not to say that one should lie in bed and do nothing, but it does serve as some leverage next time your partner requests that you do help carry the groceries in the house!

How Can We Prevent It?

In terms of intervention and rehabilitation, van Wingerde and colleagues propose that an emphasis must be placed on muscles of the low back region. They investigated whether or not muscles of this area contributed to stabilization of the joints of the pelvis and low back. They found that the hamstrings, gluts, lats and your deep low back muscles all contribute to stabilizing the joints that are often the culprits in low back pain during pregnancy. But it is important to realize that strengthening these muscles using machines or free weights will often times, NOT do the trick. What needs to be implemented is a specific exercise program to improve the endurance and strength of these muscles and those of the pelvic floor.

A knowledgeable health professional such as a chiropractor, physiotherapist, athletic therapist, or massage therapist will be able to demonstrate exercises such as the bird-dog, planking, side-planking, kegel and pelvic bridge. All these exercises involve nothing but your own body weight and a floor mat, and should be included in any pregnancy exercise program as long as it is tolerated by the patient. It is difficult to describe these exercises in writing and they are only really appreciated when they are demonstrated and performed under supervision. As such, if you currently have a chiropractor or physical therapist, please follow up with them regarding these exercises.

So, if you are planning on having a child, are currently pregnant, have had a child in the past, or have recently given birth to a baby, first of all, congratulations, and secondly, ensure that these exercises are included in any exercise program in which you may be participating. If you have any further questions, feel free to contact me at info@saudeclinic.ca or visit www.saudeclinic.ca for more information on where you can find a qualified health professional to help with back pain in pregnancy or any other musculoskeletal issue that you may have.

Henry Candelaria, BPHE, Dip. Acu., DC © 2010


References

McGill, S. (2004). Ultimate Back Fitness and Performance. Waterloo: Wabuno Publishers.

Mens, J. M. A., Vleeming, A., Stoeckart, R, Stam, H. J., and Snijders, C. J. (1996). Understanding Peripartum Pelvic Pain: Implications of a Patient Survey. Spine, 21(11): 1363-1369.

van Wingerden, J. P., Vleeming, A., Buyruk, H. M., and Raissadat, K. (2004). Stabilization of the sacroiliac joint in vivo: verification of muscular contribution to force closure of the pelvis. Eur Spine J, 13:199–205.

Stretching Part 3: Take-Home Points and Conclusion

The controversy over what stretching technique to use, how long one should use the technique, and how frequent should the technique be used is very evident given the information that I have provided in this three part series. The lack of clear cut answers can generally be attributed to lack of quality research available to answer some of the above questions. However, the following major points can be made as a review of the material alluded to in this three part series:

1. the increase in ROM experienced with any stretching protocol is likely due to an increase in tolerance to the discomfort associated with the stretch rather than an actual increase in extensibility of the muscle tissue itself;

2. regular stretching will result in an increase in performance markers such as isometric force production and velocity of contraction but will have no effect on the efficiency/ease of movement

3. acute/pre-exercise stretching does not have a positive effect on performance markers but is associated with an improved running economy/efficiency. Therefore, acute stretching prior to leisure running may be of benefit but is not recommended in advance of performance dependent sporting activities;

4. it appears that a single 30-second stretching bout once a day may be the most effective practice and that periods greater than 30 seconds are no more effective; this however is dependent on the individual who is performing the stretching and serves as a general recommendation. Therefore, adjust the duration of stretching accordingly.

5. in terms of modalities such as ice or heat applied prior to stretch, it does not matter as both appear to improve the outcome of a stretch not by affecting tissue temperature but by adding to the analgesic effect of the stretch;

6. if the main objective of stretching is to prevent injury, then the recommendation would be to eliminate the stretching and increase the warm-up; therefore, it would be a better idea to spend time performing a thorough warm-up, and not so much time stretching prior to activity. However, as mentioned above, it is dependent on the activity that is being performed and the goals of that activity.

7. Finally, due to poor quality research, a recommendation on the optimal stretching technique that would allow for the most efficient increase in ROM is difficult to develop. The focus should be on duration, frequency, and individuality of the stretching protocol rather than a blanket recommendation.

In closing, it is hoped that this three part series has provided some enlightenment on a topic that many trainers/therapists recommend often based on traditional strength and conditioning practices rather than evidenced-based practice. With an increase in research dedicated to the seemingly simple topic of stretching, we will soon have clear cut answers to some of the remaining questions that I have outlined above. For now, if someone asks you about stretching in terms of incorporating it into a general exercise regiment, the one thing you can say with certain is that “it depends.”

If you have any questions or comments on this topic or any other topic related to neuromusculoskeletal health, please feel free to contact me at info@saudeclinic.ca or visit my website at www.saudeclinic.ca

Here's to your saude!

Dr. Henry

Stretching Part 2: Can it decrease risk of injury and/or improve performance?

In the May edition of my post, we talked about stretching and its effects on the muscle tissue itself. This edition will focus on the question: does stretching improve performance and thereby reduce the risk of injury?

Let’s begin by clarifying the role that stretching could play in reducing the risk of injury. The argument behind this proposed benefit is that it allows for increased muscle extensibility and decreased muscle stiffness via changes in the visco-elastic properties of muscle tissue. For purposes of a review, visco-elasticity of biological tissue implies that upon holding tissue under tension for a prolonged period of time, the force required to hold that tissue at that length is reduced over time. This implies that a tissue can therefore withstand more tensile force at a specific length without experiencing damage. This has obvious implications for athletic events in terms of reduction in injury and improvement in performance. If an athlete can achieve increased ROM without injury and by using less energy to achieve that range, then theoretically, that athlete’s performance will improve and her/his risk of injury will be reduced. However, as mentioned in May’s post, increases in ROM are achieved via increased stretch tolerance on the part of the subject in the long-term, rather than a change in the mechanical or visco-elastic properties of the muscle (Hollie et al, 2006, Magnusson et al., 1996). Also, in regards to improved performance, it is almost impossible to objectively measure performance during an actual athletic event due to the confounding variables inherently present. However, specific performance related outcome measures have been used in the literature to determine the effect of stretching on performance. Shrier in 2004 performed a review of the literature and found that of the 23 articles that looked at the effect of pre-exercise stretching on isometric force, isokinetic torque, or jumping height, 22 of them showed no benefit of stretching on the specific performance tests analyzed. So, what this means is that stretching technically has little to no effect on performance. But does it have an effect on other aspects of athletics, such as running ability?
Shrier (2004) also reviewed 5 studies on the effect of stretching on running performance. One study specifically looked at running economy and found that stretching had a positive effect improving the efficiency of running. However, the study only included runners with short and/or stiff hip flexors or extensor muscles. Therefore, whether or not stretching is beneficial for those who are fairly flexible in the above mentioned muscle groups remain unanswered. With respect to running speed, four studies were of acceptable quality to qualify for the review, and of those four, two had equivocal results, while the remaining two reported contradictory findings. One study reported beneficial results with dynamic stretching, while the other reported detrimental outcomes to running speed with static stretching. This may imply therefore, that dynamic pre-exercise stretching is beneficial when attempting to improve running speed and that static stretching may limit the ability to achieve optimal running speed.

Results from Shrier (2004) were the exact opposite when the literature on regular stretching was reviewed. What qualifies as “regular” varied between the seven studies that found benefit to stretching. Generally, regular stretching can be considered stretching that is performed at regular frequencies throughout a week period and for a predetermined length of time. This is in contrast to the stretching described above as “acute/pre-exercise” stretching where stretching is only performed before an athletic event or a specific bout of exercise. The evidence suggests that with regular stretching, force production and velocity of contraction both increase, while it had no effect on the economy of motion. As mentioned above, this is in stark contrast to the effects of acute/pre-exercise stretching on performance in which no effect was reported on isometric force production and velocity of contraction, but a positive effect was seen with running economy.

So, what does this all mean? Well, the benefit that you experience from stretching will depend on your specific goals. If your goal is to improve the efficiency of your runs, then acute/pre-exercise stretching performed dynamically may be of more benefit. But if your goal is to improve the amount of force and speed that your muscles can produce at a given length as in most athletic events, then regular bouts of stretching may be of benefit, and you should avoid acute/pre-exercise stretching all together. Now, in terms of injury prevention, the theory remains that with improvement in specific measures of performance, one would ultimately reduce the risk of injury. However, it is important to emphasize that you have to know when to use stretching and what type of stretching to use at that specific instance. This will be topic of Part 3 of this three part series that can be found in the next edition of my blog posts.

Here's to your Saúde!

Dr. Henry

References

Hollie, F., Simon, D., Harvey, L. A., and Gwinn, T. (2006). Can apparent increases in muscle extensibility with regular stretch be explained by changes in tolerance to stretch? Australian Journal of Physiotherapy 52: 45-50.

Magnusson, S. P., Simonsen, E. B., Aagaard, P., Sorensen, H., and Michael Kjaer, M. (1996). A mechanism for altered flexibility in human skeletal muscle. Journal of Physiology 497(1): 291-298.

Shrier, I. (2004). Does Stretching Improve Performance? A Systematic and Critical Review of the Literature. Clinical Journal of Sports Medicine 14: 267–273.