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.

The future of chiropractic!

Hi everyone!

I apologize for the absence but my computer has been on the mend. Don't worry... I backed it up!! The continuation of the stretching piece is coming but in the interim, here's a story about a project and a fellow chiropractor who is truly inspirational... Dr. Deborah Kopansky-Giles. I first met Dr. Kopansky-Giles at an Ontario Chiropractic Association sponsored event where she reported on the preliminary results of her work at St. Mike's Hospital. It was truly inspirational and an eye opener for me as to the possibilities for the profession. I have attempted to follow in her foot steps on two separate occasions but haven't had much luck. I haven't given up however and am continuing to foster those relationships in hopes that they will develop into similar positions for chiropractic within hospital settings.

Check out the link for the full story! http://www.thestar.com/article/642057

Here's to your Saúde!!

Dr. Henry

Stretching Part 1: Are you really lengthening muscle?

For years, stretching has been promoted as an integral part of any exercise program because of a reported decrease in risk of injury by improving range of motion (ROM), reduction in pain, reducing stiffness, and increasing overall athletic performance. Many different stretching techniques exist and therefore many different recommendations also exist, some based on scientific literature and others based on traditional strength and conditioning practices. However, new research has challenged these long-held concepts about common stretching programs and it is the hope of these series of articles to clarify some of those concepts and clear up the misconceptions through highlighting some of the new recommendations.

In this first installment, we will reveal what is actually happening during a stretch and how stretching appears to be increasing extensibility of muscle. In the second installment, we will talk about the role that stretching has to play, if any, in reducing the risk of injury and improving athletic performance. In the final installment of this three part series, we will summarize the current literature on the best stretching techniques to use, when to use them, and how frequent stretching is to be performed.

Let’s begin by talking about what happens during a stretch. There is a vast amount of evidence to support that stretching will improve ROM of a joint by allowing the muscles that cross that joint to be more extensible. If you think of a thick elastic band that undergoes repetitive stretching or a prolonged stretch, the elastic band will become less resistant to stretch over time due to the heating effect that occurs to the band with repetitive motion. The theory behind stretching is similar, except instead of elastic bands, we are dealing with living muscle tissue. There is a special property of living tissue that is referred to as viscoelasticity. What this means is that upon holding living 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 undergoing damaging changes to the structure of that tissue. So, what this means is that a muscle tissue that is stretched is theoretically able to produce more force at a specific length without causing injury. This has obvious implications for performance. If an athlete is able to produce more force at a greater ROM without undergoing injury, then theoretically they are likely to have greater success than their counterpart who is limited in force production at extremes of ROM. This will be discussed further in the follow-up installments in this three part series.

However, this is not the whole picture. Recent evidence has suggested a neural based reason for the apparent increase in ROM that is seen with stretching. How does the nervous system influence ROM and what is the difference between objective and apparent increases in ROM? Well, all of us have experienced that uncomfortable sensation that is associated with stretching which feels like a numbing pull on muscles. It is not really painful but it is not comfortable either. That sensation is the key to improving apparent ROM. Before we continue, let me define what I mean by apparent and objective ROM. Apparent ROM implies that the joint appears to be traveling through a greater ROM because of nervous system factors, when in fact there is no change in length of the muscle if measured histologically. Objective ROM is when there are histological increases in ROM meaning that the muscle tissue itself has actually become longer. The majority of ROM increase that is experienced during stretching is achieved through apparent increases in ROM. That is that the increase in ROM that is seen with stretching is a function of an analgesic effect that occurs during the stretch. In other words, it hurts less to stretch!! We actually become numb, in a sense, to that uncomfortable sensation associated with stretching, and therefore over time and with repetition, we can take our joints to extremes of ROM.

It is important to note that this effect is subtle and does not mean that if held and pulled to an extreme ROM, a muscle will increase extensibility without causing damage to that muscle or an associated joint! Taking a joint to extreme ranges is always dangerous and should be done under the supervision of a qualified professional, if done at all! Stretching as normal however, has many other proposed benefits that will be discussed in my next two blog post, so please look out for these along with my other monthly installments on neuromusculoskeletal health.

If you have any questions related to this article, or any neuromusculoskeletal related questions, feel free to contact me at info@saudecentre.ca. Also, if you or anyone you know has an injury or musculoskeletal complaint, please feel free to let them know about my services or direct them to my website www.saudeclinic.ca.

Here’s to your Saúde!

Dr. Henry

Swine Flu

Hello again,

With the WHO declaring a Phase 4 Pandemic alert (http://www.who.int/csr/disease/avian_influenza/phase/en/index.html), people should get prepared for the possibility of a full blown pandemic. There are simple and effective ways of combating and reducing the risk of contributing to the spreading of the virus and help to contain the disease. Below you can find information on effective means of preventing spread of human swine influenza.

1. Sneeze and cough into your sleeve!!! If you do sneeze/cough into a handkerchief, tissue paper, or your hands, remember to wash your hands thoroughly afterwards. Influenza and the common cold are spread through contact with bodily fluids, most commonly nasal and oral droplets. Check out this link, you'll get the picture... http://www.coughsafe.com/media.html.
2. Frequent hand washing is a must... most effective with soap and water. Disinfectant alcohol based hand sanitizers are also good.
3. If you are feeling ill or if you feel like you're coming down with something, be sure to avoid contact with others, do not go into work, and see your doctor. This way, you'll ensure that you're not infecting other people. Also, if you are feeling fluish, it is wise to wear a mask to avoid human air born transmission of the disease.

For more information and answers to many questions, check out this link... http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/faq_rg_swine-eng.php#tphp.

Here's to your Saúde!!

Dr. Henry