What are Modic type 1 and 2 changes on spine MRI?

Recently I've been looking at a lot of MRIs with patients, trying to go through each line of the report and make sense of the medical jargon. One term that seems to be completely foreign to most patients is the mention of Modic type I and Modic type II changes.

Modic changes refer to some abnormal signal on the bone marrow of the vertebrae adjacent to a spinal disc. They look like abnormal coloring on the top and bottom of the vertebrae. They represent some changes in the normal bone and bone marrow with some infiltration of inflammatory cells, edema. Modic changes are the reflection of the severity and active nature of degenerative changes of the vertebral segment, where the disc degeneration starts to progress to the point of involving the adjacent bone. Modic type I changes are acute, fresh, active, and almost always correlated with active bone pain, whereas Modic type II changes are more of the chronic, potentially non-symptomatic scar tissue of a previous acute episode. The importance of noting those on an MRI is that they tend to be much more correlated with active pain than certain disc changes, especially disc bulges, which can be found at a high prevalence level in the general population but can be completely asymptomatic.

You have to remember that MRI images are extraordinary at giving you a lot of information, including pretty much everything that's ever happened to you but doesn't help you differentiate what's relevant to your particular current complaint. The presence of Modic changes, especially type I Modic changes, can help you differentiate between background degenerative findings versus an active problem. How you treat Modic one changes is more complicated than the intent of this short blog, but does need to get to the root of the mechanical stress to the affected segment and sometimes involve oral supplemental anti-inflammatory control, whether pharmacological or botanical.

Cat and Cow 2.0: expanded version of a classic

This is an expanded version of the traditional cat and cow active range of motion stretch that incorporates a full child's pose and an upward dog for better lumbosacral decompression as well as anterior hip flexor lengthening. I would not recommend this for a beginner or someone with an acute injury at the onset of their recovery and rehabilitation, however it becomes a very useful tool to maximize your stretch once you are a little further along.

https://www.youtube.com/watch?v=MdrcTyjU0vM

FATS: the good, the bad and the ugly

https://www.rupahealth.com/the-root-cause-medicine-podcast/the-truth-about-seed-oils-and-how-to-avoid-them

I have wanted to post information about good versus bad fats for a while, but struggling to write a clear blog or connecting with the right, scientifically based and patient friendly resources. So I was really excited to come across this blog in the root cause medicine podcast. The DrCate website was just what you need: clear information, validated, and very practical in directing patients to know what to use in the pantry and what ingredients to look for on labels.

The topic of good and bad fats is incredibly relevant not just for metabolic syndrome and lipid profile. It's extremely important in managing chronic inflammation, and its even more important in understanding oxidative stress in the body. The majority of oils and fats in food preparation are highly unstable and oxidize quickly. It's often a source of oxidative stress that's overlooked and no amount of "super antioxidant foods" is going to make up for their continuous toxicity to our health.

https://drcate.com/list-of-good-fats-and-oils-versus-bad/

Rethinking the toebox

I always have great intentions to put myself a calendar reminder when it's time to replace my work shoes, and inevitably the reminder flashes and goes in the midst of a busy storm and is forgotten. Until my footsies starts barking up about new shoes, a reminder that is harder to ignore.

This most recent swapping of the footwear was an opportunity to think a little more intentionally about optimal footwear that is truly designed for the human foot. It's the subject of millions of blogs and discussion posts, and quite a bit of research too. But in the end, there is still not a great consensus and still several opposing camps when it comes to supportive versus minimalist shoes for example. The purpose of this discussion is not to weigh in on this debate, which I think needs to be nuanced and little more individualized based on the terrain you walk on,existing foot stability and injuries However one area that is pretty universally agreed upon is the fact that the shape of the toebox needs to be matching the shape of the forefoot, which in most people is going to be quite a bit wider than the heel.

During 1 of my recent tango dancing trip out of state, I was surprised to see how many female dancers had switched from the traditionally extremely aesthetically pleasing high heel ritzy shoes to very plain looking flats with an anatomically correct wide toebox. It was a little odd to see the combination of the elegant silk dresses with the type of shoe you more traditionally associate with a long dog walk on a trail, but in the end, that new trend is here to stay and none of the dancers I talked to are ever going back. Nor should they. From a biomechanical and functional standpoint, the ability of the front of your foot to have adequate space for every joint of your metatarsals and toes to properly articulate during the gait cycle is a total no-brainer. It allows normal kinetic chain muscular activation in the lower extremity all the way to the trunk, something that should be remembered in cases of chronic lower back and hip discomfort during walking. There is even evidence based on pediatric studies that wide toebox shoes result in better concentration and cognitive processing in children. Probably the reason why many children with no divergence tend to instinctively go barefoot the majority of the time.

The photo attached shows on one side more traditional shoe and a wide toebox with my barefoot in between (. I should have remembered to get a pedicure before the photo..). My foot is not much different than the average foot and you can clearly say how much wider my toes are than the shape of the shoe on the right side, almost identically matching the shape of the shoe on the left. Going forward, I am slowly replacing all of the shoes in which I spend any meaningful amount of time with something that looks more anatomic correct at the front, and I invite you to do the same. The number of shoe vendors who are starting to redesign the shoes accordingly is increasing, with a greater variety of styles available. It is taking all of us a little bit to get used to the new look of our shoes, but about 100 years ago, the world suddenly got used to seeing women with normal size waists after most of them exited their corsets, and the world has been a better place for all of us as a result. So let your toes shed their "corset" and enjoy some much deserved freedom.

FINALLY ! REVAMPED SENSIBLE NUTRITIONAL GUIDELINES

After many years of often biased and poorly data driven debate on the animal versus non animal product composition of the optimal human diet I welcome this latest piece of research consensus out of the Brussels University. The data they used to come to their recommendation is really quite solid.

The take away message is that after many years of being vilified, animal products are now recognized for their value in the human diet because of the nutrient density of certain hard to get nutrients. This would include things like certain essential amino acids, certain minerals like iron zinc, certain essential fatty acids and many more. While some non animal products may contain many of these nutrients, they are often not bioavailable to humans because our digestive tract is different from animals who can easily extract them (Think of a cow’s ability to extract essential fatty acids from grass that goes right through a human digestive tract).

The recommendation is for approximately one third of human calories to come from animal sources in order to ensure adequate essential nutrient intake. It does not discount the fact that plants and non-animal products still have a very important role in the human diet obviously, but they need to be eaten in combination with animal products for optimal results. Interesting piece of information buried within the long consensus paper was that the risk of obesity with strict vegan diet may increase, since the body will continue to upregulate the eating reflex until the minimum intake of certain key nutrients, especially essential amino acids, has been met. This would mean that someone’s hunger reflex would continue to drive food seeking behaviors until they have eaten 3000 calories on a vegan diet to obtain the same amount of amino acids that would be obtained after 1800 calories of a mixed animal vegan diet.

As always, the quality of the animal product needs to be emphasized in the context of an omnivore diet. Thankfully we live in an area where properly raised animal products are relatively easy to come by.

https://sustainablefoodtrust.org/news-views/a-new-perspective-on-healthy-eating/?utm_source=klaviyo&utm_medium=email&utm_campaign=%28Email%20-%20Chris%20Kresser%20General%20News%29%20Chris%27s%20Friday%20Favorites%20%28LINKS%20FIXED%29&utm_term=new%20dietary%20framework&utm_content=new%20dietary%20framework&_kx=ZpXBDTeEF9QJhwDqQXXrImrT_HpFsBz1ZlYMbsx_Vq0.my75y6

Cervical core strength

When discussing core strength and stability training, we often focus exclusively on the trunk and lumbar spine, while forgetting the cervical spine. This does not do us justice since cervical core strength is equally important, possibly more so since our modern sedentary lifestyle tend to deactivate a lot of our stabilizing postural muscles from the shoulder girdle up to the head. It should be noted that cervical strength and stability also depends a lot on the overall strength and stability of the trunk and upper extremity especially, so any attempt to stabilize the cervical spine from chronic reinjury does need to involve some shoulder strength training for sure. However this relatively simple exercise done in the supine position can be very powerful in engaging the deep cervical core muscle group, which is the equivalent of the deep abdominal group in the lumbar spine. Most patients are surprised to find out how really weak this muscle group is when we test them in the office. It will often require patients to start with relatively short interval of times in order to practice the exercise and stable form. It's also important for patients to have a slight chin tucked, imagining holding a tennis ball or an orange between their chin and the chest, in order to gauge the deep cervical muscles and other superficial muscles like the SCM.

https://www.youtube.com/shorts/VR8uic1-0N4

Chiropractic, posture and risk of falling

https://www.researchgate.net/publication/378090792_Risk_of_Fall_Cognition_and_Static_Posture_in_Aging

I came across this very interesting article while listening to one of my chiropractic research podcasts. It reminded me of a conversation I had with a patient and her adult daughter who drove her to her appointment last year. The mother, in her early 80s, had moved closer to her daughter’s family and was trying to reestablish chiropractic care on a more consistent basis. She was a lifelong chiropractic patient, for episodic neck injuries and later on decided to stay on a preventive checkup schedule because she felt overall better and more balanced when she did so. During the history, her daughter chimed in on her mother’s comment that “ she has a tendency to be more clumsy and trip “ when she has not had a chiropractic check and adjustment in a while. The daughter was unfamiliar with chiropractic and simply curious about the correlation between the two. At the time, I share my 30 years of clinical experience in observing that correlation and the biological mechanisms connecting the chiropractic treatment on the neurological adjustment of proprioception and reflex time. I wish I had had that piece of research to add to the conversation.

The research led by a lesser known Brazilian colleague showed a correlation between two key measures of sagittal posture and the risk of fall: the degree of anterior neck shifting in relationship to the trunk, and the anterior angle of the ankle. Both indicating that the body is off its center of gravity and thus has less time to respond to stay upright before hitting the ground. Both posture indicators are exam findings that we observe and report, and both are factors that we aim to improve/correct with manual therapy and guidance on home activities and corrective exercises. One little golden nugget for me to take away from this research is that I can use it in conversation with patients when they question why I work on their lower extremities, especially their ankles and feet, when their primary problem seems to lie elsewhere. I almost often look at the lower extremity alignment when doing my initial evaluation and I will adjust them if needed, something that makes some folks a little testy when I ask them to take off their shoes and poke at one more body area. Now I can remind them that when I take on that additional endeavor at 5 pm, when their footsies are a little more “ aromatic”, it is indeed solely for their own benefit and backed by solid scientific research

(photo courtesy Freepik)

LEG LIFT EXERCISES WITHOUT LOW BACK INJURY

https://www.youtube.com/watch?v=Q2m3qCbinzA

After 30 years of practice there are some injuries that you know like the back of your hand. One such common injury is the lumbosacral hyperextension strain from leg lifts. It mostly happens to patients who have not been doing any form of core workout for while and decide to take on this rather challenging workout practice without the appropriate gradual ramp-up, but I've seen it happen even in seasoned gym rats. The problem is the amount of hyperextension loading when someone tries to do bilateral leg lift starting in a supine position with flat legs on the table. It's an extremely high leverage for the lumbosacral spine if the abdominals are not optimally efficient at immediate initiation and stabilization of the low back. Leg lifts can be a great addition to a core workout and can be safely done with 2 small modifications: starting with the legs in the up position, only lowering them in a range that allows the lowback to stay in contact with the exercise mat; during the exercise one leg at a time to build up strength and endurance and stability rather than both legs at the time, which may be achieved over time.