VITAMIN D STACKING OVERLOAD

For most of the last 20 years we have been talking to patients about maintaining healthy levels of vitamin D and avoiding deficiencies because of the widespread health ramifications. However more recently we've had a bit of a turnaround in that I have run into several cases of elevated vitamin D levels on blood samples that were in a concerning range. And based on the review of the most recent literature I'm not the only one raising a bit of an alarm.

First it's important to briefly remember your metrics: vitamin D levels below 30 are generally considered insufficient, and vitamin D levels above 80 considered unhealthy high. There is some debate in the medical and integrative space about the upper range, with some groups advocating healthy levels closer to 8 fo certain at-risk populations (autoimmune, active oncology), and the purpose of this blog is not to enter that debate (although my careful review of the issue seems to indicate that something more physiological that humans have experienced over the last 10,000 years based on sun exposure and skin manufacturing of vitamin D would be closer to 60 – 70 as an upper healthy range). But I would like to point out that there is a real risk of overdosing on vitamin D3 if you're taking several supplements at the same time, and not factoring the total vitamin D that may be found in all of them.

Many nutritional supplements sold both professionally and over-the-counter do contain some background level of vitamin D as a synergist, somewhere around 400 IUs on average. The original idea behind the supplementation was that the average person was not getting enough vitamin D and they would roll in a minimum level within a supplement to ensure results. This well-intentioned idea resulted in an unexpected problem over time, as more patients started self administering a variety of supplements for general health and stacking these 400 IU doses of vitamin D. For some of our patients, who are taking a regimen of prescribed supplements for specific goals, such as G.I. restoration, inflammation control etc., That amount could easily get above 10,000. More recently we had a patient whose routine blood level was above 200 (I didn't even think it was possible and had the patient get a second test to rule out or lab error). Looking at the supplementation that I was recommending the total amount she was taking was 6000 IUs, a dose that would never get her anywhere higher than 70 on her vitamin D serum levels. It was really her head scratching mystery for a while, until the patient started looking in her kitchen cabinet at some of the supplements she was taking most days, only to realize that a winter immune support and a hair and skin support she was taking on the side were both stacking over 10,000 IUs combined between those two alone.

The moral of the story: vitamin D supplementation is beneficial for most patients especially in our northern climates, but you have to remember to calculate your total intake. And it's also a great idea to get it measured once a year as part of your annual physical to make sure you're in the ballpark.

Car seat, neck and head pain, irritability

It's one of those overdue blogs about a somewhat seasonal topic, which slips my mind before I have a chance to dictate my thoughts.

Many families are about to hit the road for longer car trips with young children, including some of babes in car seats. Car seats were designed with safety in mind first and foremost, and in the quest to prevent any sort of airway obstruction, were meant to be remarkably safe and remarkably uncomfortable for many children at the same time. As a result, car trips can turn into screaming matches of unhappy little humans balking at the pressure on the back of the head and neck from a rigid cart seats with no support. If you look at it from an adult perspective, none of us would want to be resting her head in that manner for very long either. The problem is compounded by the fact that many children with post birth related upper cervical extension misalignment will really be digging the back of the occiput into the rather inflexible material of the car seat, or aggravating any sort of upper cervical rotational misalignment when they fall asleep.

A relatively happy middle-of-the-road solution that doesn't compromise airway and provides much-needed comfort is one of these cervical support pillows that are designed for car seats. The earlier model were called the butterfly pillows, and only addressed cervical support, but some of the newer versions have a posterior occipital credible as well. I find is more beneficial especially for the children that are still trying to recover from occipital plates protrusion, a common birth related cranium miss shaping.

101 SELF CUPPING BASISC

I find a lot of my patients decide to be proactive to try to treat some of the soft tissue problems between treatments, often acquiring popular tools, but with little knowledge on how to operate them effectively much less safely. At some point we really should be offering a one hour class small group format to take people through the proper use and self customization of the home therapy, but in the meantime, I decided to at least have a quick reference video of the very basics of application and safety.

https://www.youtube.com/shorts/vCveLlXyj9Q

Some light on the dark subject of eating disorders

https://www.rupahealth.com/the-root-cause-medicine-podcast/eating-disorder-treatment-a-functional-medicine-approach

This is a topic that is little bit or a lot outside of my wheelhouse so to speak, but I worked with enough families dealing with this issues which often feels like there is little hope on the horizon, to feel compelled to at least post this as a resource. This podcast came up on my series of integrative health podcasts that I listen to on a daily basis. While I do a fair amount of work with people working out some of their nutritional plan and customize supplementation, the other whole dimension of how people relate to food sometimes in a very pathologically disordered way, is not something that I have really felt comfortable tackling, instead referring to other healthcare professionals. I was aware of Dr. Greenblatt's work in other areas of nutritional psychiatry (especially his work on ADHD and weaning off psychiatric medications), but his no-nonsense practical approach to eating disorders using the concept of nutritional replenishing was brand-new to me. Feel free to use that for resource for yourself and your loved ones, as well as passing it along to people in your life.

INFANT CERVICAL COSTAL SYNDROME ( NECK-RIB-ARM)

I have had more recently the pleasure of working in close collaboration with craniosacral therapists that specialize in pediatric and infant care. It's a highly symbiotic clinical relationship, that allows to get the best outcome if both parties can properly assess and address the problems in our little humans. More recently, I've had a few referrals for evaluation of infants with persistent delayed milestones, general positional discomfort and irritability on very young children, where the therapist indicated to me that the shoulder was the source of continued relapses.

Neuromusculoskeletal pediatric providers normally do a pretty good job at assessing cervical related birth insults, such as torticollis, however there is a particular type of birth related injury that often goes unrecognized, much less untreated, even in our profession and beyond. There is not a classic clinical textbook term to describe the finding below, but in my own notetaking system, I have dubbed it "cervical costal clavicular injury".

The anatomy of the anterior neck and shoulder girdle in infant is ultimately not all that different from adults, with the exception that the bony structures are not fully ossified, and that the clavicle in particular is very malleable, allowing for distortion and occasional green stick fractures so that a child can survive birth if they have large shoulders. The purpose of this blog is not to review the rather complicated anatomical path that an infant has to traversed during birthing, through the maternal pelvis, but rather to pinpoint this particular problem, its presentation and its corrective intervention.

Once the infant's head has cleared the maternal pelvic floor, the shoulders are next, and the shoulders are typically going to be broader. So there could be a delay of multiple pushes between the head and shoulder delivery. This is a particularly vulnerable time for torsional extension and traction injuries in the area of the junction of the neck and the shoulder girdle. Depending upon the position of the head in relationship to the torso, the cervical spine could already be in pretty significant lateral flexion and rotation. The point of failure so to speak, could be in the cervical spine, but in many cases it's going to be in the shoulder girdle, and especially in the anterior part of the shoulder girdle, where the anterior neck meets the sterno-clavicular joint (the joint between the clavicle and the breastbone), as well as the area of the first rib, just posterior to the clavicle, and connected to the neck through anterior cervical muscles called the scalenes. The cervical costal clavicular insults can happen even when there's no overt history of shoulder dystocia during delivery, it can happen simply with a couple really hard pushes between the head and shoulder delivery, and may not be recalled by the parents or birth attendant at the time when I take a history on the infant.

The result can be a pretty significant misalignment and impingement between the first rib, the clavicle, and sometimes the brachial plexus (the nerve bundle exiting the front of the cervical spine to go into the arm). As a result, the infant will often exhibit the following:

– being very uncomfortable while held against a chest and only being able to face a parent with their head in one direction. The parent may also notice that one arm feels very stiff and pushing back against the chest when they're holding the child facing them

– generally being fussy, uncomfortable especially being held facing the parent, or in the prone position, since it causes pressure on the affected shoulder girdle.

– Having some difficulty comfortably turning their head in both directions equally, not being able to nurse well on both sides (although that's a finding that overlaps significantly with cervical problems)

– being very uncomfortable and crying if their head is moved away from the affected side, usually because it increased the amount of pinching and impingement between the first rib and the clavicle, or increases pressure and traction on the brachial plexus.

– Having some difficulty propping themselves up on their arms in the prone position, crying when put on the stomach, and some delay in normally propping themselves up in the stomach lying position. This may be especially noticed on one side more than the other

– delay in rolling over, especially on one side, since you need to have adequate integrity of the anterior shoulder girdle in order to do so.

– Sometimes difficulty with suckling, with the sensation of a really tight jaw on one side. (Moms will often notice that the jaw tends to go sideways with a harsh latch, since the anterior neck muscles connect to the root of the tongue)

– significant difference between position and use of one arm versus the other. Very often the presentation is that of the "T Rex arm", where the infant will hold their affected arm closer to their breastbone and less likely to extend it or relax it normally

The chiropractic intervention for this problem requires a careful examination of the child’s cervical spine, as well as the entire shoulder girdle, sternoclavicular, first rib, anterior cervical, and mid cervical spine. The corrective adjustments are really quite different than the cervical adjustments, and do require very specifically correcting the relationship between the first rib the clavicle and sometimes the mid cervical spine, in order to achieve normal mobility of the sternoclavicular joint, normal brachial plexus integrity and movement at the outlet from the cervical spine. The good news about the treatment is that it's usually remarkably quick, with changes in arm and neck movement and position, within one or two treatments. There may need to to be a few more treatments to stabilize the situation away from rebound, especially if the problem has been there for more than four weeks, but it's not unusual for a child to suddenly start rolling over for the first time within two days of the first treatment.

SHOULDER PAIN AND SIDE SLEEPING

https://www.youtube.com/watch?v=7Qrcm2jk6CM

A very overdue simple hack blog about shoulder pain in the side sleeping position. I think a lot of people understand the problem with sleeping on the painful shoulder, but not as many people understand that the top shoulder can also be a problem due to side sleeping position.

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