Lyrica for Back and Leg Pain: What Does the Research Say ?

https://www.nejm.org/doi/full/10.1056/NEJMoa1614292

I was reminded of this research article from a few years ago after a patient encounter earlier this week. There is (thankfully) a strong push to move patients with various sources of chronic pain away from using opioid management. However the flip side of the equation is that the alternatives often prescribed can be problematic.

One medication that is increasingly used for chronic pain resulting from a compressed spinal nerve (chronic disc problem or stenosis) is Gabapentin or Lyrica. While slightly different, they both fall in a class of medications called anticonvulsants (originally used as first generation anti-seizure meds), working as gaba analogs, later used for chronic idiopathic or diabetic neuropathic pain. In the past three years I have seen more and more patients showing up with both in their medication list for pain resulting from chronic nerve root compression causing sciatic type symptoms.

As was the case with the patient encounter I had this week, patients are often questioning the gaba analog meds because the sides effects are really quite intense for a lot of them. The other consideration is whether or not the medication is truly effective in their particular situation, since gaba analog medications were initially released for nerve pain caused by non- neuromusculoskeletal conditions.

The research paper in question sought to get some answers and the results from that trial at least were not suggesting that gaba analogs were effective compared to placebo, but that the side effect in the medication groups were high. I have shared that paper with many patients, often confirming their gut feeling and as a starting point to revisit the medication usage with the prescribing doctor. It is also a good conversation for me to have with our patients that reverting some forms of chronic pain will require patience, good detective work to assess the true origin of the pain, and the willingness to do what is necessary to recover because the “magic pill” is not as magic as touted.

Soft Tissue Care- Part II

What does cupping and IASTM actually do? Well in order to explain this, we need to discuss what fascia is. Fascia is an intertwining web of connective tissue that connects literally everything. We use cupping and/ or IASTM to lift or compress the top tissue layers as well as incorporating movement to create heat or “controlled inflammation” in order to allow for the hyaluronic acid binding points to separate and collagen fibers to realign to parallel pieces that slide with each other in the appropriate movements rather than perpendicular pieces that fight and create further binding or disrupted smooth movement patterns. 

Here is a blog that discusses fascia as a living matrix, it’s pretty cool:

https://sports-seminars.com/fascia-as-a-living-matrix/

Yoga and Chiropractic Part 3: Standing Alignment, Mountain Pose

Pretty much any yoga routine is going to have a standing sequence. This will usually be at the beginning with sun salutations, and will emphasize proper alignment of the body in the frontal plane (when looking at the body from the front) and sagittal plane (looking at the body from the side).

I want to spend more time today talking about the importance of the sagittal alignment, because I see so few people in group classes that perform the salutation with good side alignment.

Modern life is all happening in front of us and often below our ribcage, creating a pattern of posture distortion pulling us forward in relationship to our center of gravity. There is a brain element to this pattern, as our postural righting centers become “numb” to the fact that we are offset too far forward. This creates a constant mechanical overload of both the joint structures of the neck, upper back, down to the heels, as well as the posterior muscle groups. Practicing normal side alignment allows our brains to recognize when we have shifted away into forward stress and move back into a gravity neutral alignment.

The traditional yoga mountain pose is an ideal place to practice this. The photo demonstrates how the hips stack over the heels, the shoulder stack over the hips, and the head stack over the shoulders. In the brief video, we will go over the sequence in which you realign your body one joint at the time, starting at the feet / ankles and ending at the head

Here is the link to the YouTube video going over this alignment: https://youtu.be/vWDng2vm4dA

Microbiome In The COVID Era

As much as I wish it were differently, the outlook regarding the quick resolution of the viral pandemic in 2020 is looking highly unlikely to put it mildly. I had a two hour conference last week with some professional groups who have been providing valuable information to small health care businesses like ours on infection mitigation protocols. The most optimistic estimate is that we will continue with the current sanitization for at least 8 months.

While necessary in the short and medium term, some of the sanitation practices are also clearly suboptimal for some aspects of our long term immune function, and I think it may be overdue to talk about good strategies to mitigate some of those side effects. The rapid acting COVID disinfectants recognized by the EPA for health care use are not the friendly natural cleaners I have historically used at my house. The office is currently using a quaternary ammonium cleaner with a 2 min kill time on COVID. It is effective, but it is also harsh. The addition of the three medical grade HEPA machine in the office have helped decreasing the gassing off. However, I know that some residues are still getting into our bodies, and that the staff and I are exposed to some quac residues no matter how careful we try to be.

This may also be true for many of you who work outside the home in environments that do a good job at keeping surfaces free of viral contamination. If so, I wanted to share some thoughts on what you can do to limit the adverse effects of the cleaners, and more specifically, on your gut flora (later referred to as your microbiome, or the totality of your GI bacterial ecology).

The health of your gut bacteria depends upon factors that either improve or damage those bacteria. Right now, you are exposed to cleaners that are antibacterial in nature regardless if it is a good bacteria like a Lactobacillus, or a bad bacteria like Salmonella. So you are dealing with a new and heightened damaging factor.

Your strategy to support your gut bacteria in times of increased challenges can be two fold:

• Limit other factors that damage the gut bacterial ecology-

  • Drink non-chlorinated water by using a simple filtering system like a good quality water filtering pitcher.

  • Focus on unprocessed foods. Processed foods and even some appearing fresh food that has a long shelf life, contain high levels of preservatives that are anti-bacterial in nature. The more you eat, the more you kill off your good bugs.

  • Avoid all artificial sweeteners. The worst offenders for the gut bacteria is the sucralose (Splenda)family and all of the sugar alcohols. Even one serving a day can drop your gut bacteria number by as much as 50% in a week. They are prevalent in drinks, “sugar-free” and “low calorie” sweets.

  • Limit straight sugar and refined flour products to a minimum. They tend to selectively favor the growth of microbe strains that compete with the good bugs.

• Enhance the practices that tend to improve the health and variety of your existing gut bacteria-

  • Increase food based fiber, both in quantity, but mostly in diversity. Supplemental fiber such as psyllium does very little for your gut ecology. The best way is to incorporate at least 8 different fruit, veggies, root starches, legumes, nuts in your diet every day. Variety is the key.

  • Get some exercise, especially aerobic activity. This is a huge boost to your gut health.

  • Avoid grazing throughout the day. Your gut microbe colonies expand when you have a 12 hour fast at night and about 5 hours between meals.

  • Probiotic foods and supplements is the second tier approach, but definitely a good strategy when it may be difficult to control some of the exposure to other things like antibacterial cleaners, chlorinated water, or some medications (antibiotics, steroids, immunomodulators, NSAIDs). Emphasize foods over supplements when possible since their delivery method to the lower GI is better.

Yoga and Chiropractic Part 2: Child's Pose and Lumbar Flexion Decompression

Today I want to start exploring several key poses of yoga that are frequently incorporated into a home care recommendation routine for chiropractic patients. Let’ start with child’s pose.

The positions of child’s pose allows for the combination of two powerful axis onto the lumbosacral spine: flexion and decompression. Considering that lumbosacral extension and facet imbrication, along with weightbearing compression are two common drivers of mechanical misalignment and pain, you can start to understand why child’s pose is so popular.

There are two version of the pose: traditional and extended. The traditional version has the knees together and the arms along the legs. The extended version (more popular in US vinyasa yoga) has the legs in a V shape and the arms extended above the head. The traditional pose tends to isolate the central portion of the lumbosacral spine, while the extended version starts adding stretch to the upper sacroiliac and iliolumbar ligaments. One is not better than the other, they isolate different structures. If I am unsure which one will benefit a patient most, I usually have the patient perform each one in the office while I palpate how much traction is generated by each while in the position. The extended pose requires more flexion of the hip socket, which is not always accessible to patients with advanced degeneration or with traditional hip replacements.

Child’s pose may require a few modifications for ankles and knees that you can see demonstrated on the photos:

• If full flexion of the ankle is uncomfortable, you can perform the pose on the edge of a bed with your ankles at 90’, or with a rolled towel under the ankle.

• For patients with limited knee flexion, you may be able to do the pose with a towel behind your knees, or assume the alternate “puppy pose” position which keeps your buttock away from fully contacting the heels but still creates maximum lengthening of the lumbosacral spine.

Soft Tissue Care- Part I

Recently I have been asked more and more about the soft tissue care I do here in the office. Here is a little introduction into that. The different instruments I use include a few different stainless steel options that I use for Instrument Assisted Soft Tissue Mobilization as well as either some silicone or plastic cups for cupping. Thanks to Micheal Phelps and the 2008 Olympics most people have seen what static cupping can look like, however most of my cupping is done with some motion, either by the cup or by the soft tissue underneath. I personally am a FAKTR (Functional and Kinetic Treatment with Rehab)- certified provider, meaning I use their methods. Feel free to visit FAKTR to read yourself or take a peak of a few pieces I have included:

“What conditions can FAKTR treat?

FAKTR can treat a wide variety of musculoskeletal conditions including tendinopathy, sprains, strains, entrapment syndromes, fascial restrictions such as plantar fasciitis, ITB syndrome, myofascial pain syndromes, adhesive capsulitis, shin splints and post-surgical recovery.  This list of conditions that can be treated with FAKTR protocols are too numerous to list here!”

Vitamin D, How Much?

Vitamin D is on people’s minds a lot lately. There is always a renewed interest in the subject with the migration toward fall and winter, but this year, with the added concern over supporting the immune system through the COVID pandemic, and especially with uncertainty surrounding the return to school, it’s raising a lot of questions at the office. So here is a brief collective response.

How much to take for prevention? There is no one size fits all since people have various intake, sun exposure, and fat soluble vitamin metabolism. The more important question is : What is my target blood level ? There is some variation in the research but optimum is somewhere between 35-50 for healthy individuals. Some folks in health care push for higher levels for the average population, but in another blog I will share research that shows why that is not optimal for most people. It can take anywhere from 2000 IUs to 8000 IUs to achieve that level. My recommendation is to start between 2000 to 4000 IUs per day and test your blood levels after 6 weeks and adjust the dose accordingly. Be aware that there is an annual fluctuation with levels lowest around March for those of us in the Northern climate. Patients with active auto-immune illnesses or chronic inflammation do better is the blood level is somewhere in the 50-60 range.

How much to take during acute illness or when there has been a suspected infectious exposure? My recommendation is to take 10,000 IUs for the duration of the illness or for 7 days if asymptomatic.

What kind should I take? The active form of the vitamin, vitamin D3 is preferred over D2, but it needs to be taken daily for most people. Vitamin D3 is readily available everywhere and quite inexpensive, however you want to look for a brand that has as little added ingredients like fillers as possible. Vitamin D3 is a fat soluble vitamin and is best taken with a meal that has some healthy fats for optimal absorption. The liquid forms are easy to take for a lot of people, especially kids, and are pretty tasteless. When using vitamin D3 for immune support, especially mucosal immune support, taking it along straight vitamin A (not beta-carotene), and some essential fatty acids, is ideal. Since fat soluble vitamins control several metabolic processes as a group, I also recommend vitamin K2 along with vitamin D3 for patients who have reduced dietary intake (patients on strict dairy free diets who cannot have any aged cheese, or patients who do not eat fermented food on a regular basis). At the office I tend to use the liquid Apex vitamin D3 (2000 IUs per drop), and the Ultra D complex for the added vitamin A and DHA, and over the counter cod liver oil from a good brand (Carlson’s Nordic Natural) is a good option.

Chiropractic and Yoga, Part 1

September is Yoga Awareness month, a good reminder to chat about a topic that has been on my to-do list for a while.

To be exact, what most of us refer to as yoga is the physical practice of yoga, also referred to as asana, distinct from the spiritual practice. Going forward I will use the word yoga to mean the asana physical practice, as the method of interest for our chiropractic care application.

Yoga is enjoying a robust and well deserved popularity in the West, as a complete form of physical activity. For myself I first started discovering the benefits of yoga about 15 years ago, and have come to realize that along with my other recreation, dancing, it is going to be a continued learning curve.

I saw the benefits of using yoga in my chiropractic practice quite early on, but did not feel comfortable incorporating any elements of it until I had more experience several years later. Yoga practice, among many great options for rehabilitation, offers several distinct benefits:

• Yoga focuses on the strength and stability of a whole body area and a particular function / movement rather than an isolated muscle group. This mimmicks more closely what we do in real life.

• Yoga incorporates balance and lengthening with strength building

• Yoga builds all movement and transitions with the unit of breath

• Yoga practice can target autonomic nervous function

• Yoga require little to no prop beyond a mat, and optional strap and blocks

One caveat of yoga practice that is often overlooked is that it is a complex skill that, in my clinical opinion, should not be acquired without early supervised training before you start practicing on your own. While I am by no means an expert, I still cringe at a lot of what I see in popular group classes. Not only is the technique (or lack thereof), displayed by my fellow yogis not beneficial, it can be outright harmful and a source of injury. I strongly encourage all prospective yogis to work in a small group class with a dedicated instructor for a couple of months before joining a larger class or practicing remote.