Cold Water Immersion

Cold water plunging, or cold water immersion (CWI), has gained attention for its potential health benefits, including aiding recovery, reducing inflammation, and boosting mental well-being. Let’s explore how this practice works, the benefits it offers, and how to do it safely.

How Cold Water Plunging Works

When the body is exposed to cold water (typically between 50°F to 59°F or 10°C to 15°C), the temperature shock causes physiological changes. These include vasoconstriction, where blood vessels narrow to preserve core body temperature, and the release of endorphins, which are feel-good chemicals. The cold also triggers the production of norepinephrine, a hormone and neurotransmitter that helps regulate inflammation and pain.

Benefits of Cold Water Plunging

• Reduces Inflammation and Speeds Recover: Cold water immersion can help reduce muscle soreness and inflammation, particularly after intense physical exercise. The cold reduces tissue temperature, slows down metabolic processes, and helps minimize swelling and tissue breakdown. A 2016 study in The Journal of Physiology suggested that CWI can be effective for reducing delayed onset muscle soreness (DOMS) after exercise . By reducing blood flow to the affected muscles during the plunge and increasing it post-immersion, CWI aids in the removal of metabolic waste that accumulates after intense activity.

• Mental Health Benefits: Cold exposure triggers the release of norepinephrine, which has been linked to improved mood, attention, and focus. It may also reduce symptoms of anxiety and depression. A small study published in Medical Hypotheses in 2008 proposed that cold showers and immersion could be helpful as a treatment for depression, though more extensive research is needed to solidify this claim .

• Boosts Immune Function: There is evidence that cold exposure might stimulate the immune system. One study found that individuals who regularly engaged in cold water swimming had higher counts of white blood cells and a stronger antioxidant defense system . This suggests that cold exposure might help improve immune function, making the body more resilient to infections.

• Improved Circulation: When you immerse yourself in cold water, your heart rate increases, and blood flow is redirected to the core to maintain warmth. Over time, regular cold exposure can improve circulation by encouraging blood flow back into your extremities when you warm up afterward.

• Enhanced Mood and Stress Resilience: The cold activates the body’s “fight-or-flight” response, releasing stress hormones like adrenaline and cortisol, which may, paradoxically, help reduce chronic stress over time by making the body more resilient. Additionally, the release of endorphins and dopamine can help improve mood and promote a sense of well-being.

Cold Water Immersion and Inflammation

Cold water immersion is particularly effective at controlling inflammation by triggering vasoconstriction. When blood vessels constrict, less blood is delivered to the affected area, reducing swelling. After leaving the cold environment, vasodilation (the reopening of blood vessels) occurs, which helps flush out toxins and promote healing. Norepinephrine, released during cold exposure, also plays a key role in reducing inflammatory markers such as TNF-alpha.

Other Potential Benefits

• Improved Sleep: Some people report better sleep quality after cold plunging, possibly due to the calming effect on the nervous system.

• Fat Loss: Exposure to cold may activate brown fat, a type of fat tissue that burns calories to generate heat, leading to potential weight loss.

• Pain Management: CWI may provide temporary pain relief, especially for conditions involving chronic pain or injury.

How and When to Cold Plunge

• Duration: For beginners, it’s recommended to start with short sessions of 1-2 minutes. As you get more comfortable, you can gradually increase to 5-10 minutes. Most benefits are said to occur within that timeframe.

• Time of Day: There’s no hard rule, but many people find cold plunges beneficial in the morning as a wake-up tool or after workouts to aid recovery. Immersing in cold water after exercise can reduce soreness and speed up recovery time.

• Water Temperature: Optimal temperatures for cold plunging range from 50°F to 59°F (10°C to 15°C). You don’t want the water to be too cold initially, especially if you’re new to the practice, as it can be a shock to the system.

Risks of Cold Water Immersion

While cold water plunging can be beneficial, there are risks, especially for certain individuals. People with heart conditions, hypertension, or cold intolerance should avoid or be cautious with cold plunging, as the rapid changes in blood pressure can be harmful. Sudden immersion in cold water can also trigger a cold shock response, which may lead to hyperventilation or even drowning if not carefully managed. Prolonged immersion in extremely cold water can lead to hypothermia. Always ensure that you plunge safely, preferably with supervision or in a controlled environment.

Conclusion

Cold water plunging offers numerous potential benefits, from reducing inflammation and aiding recovery to boosting mental health and stress resilience. By understanding how it works and incorporating it safely into your routine, you may experience these advantages. However, it’s important to be mindful of the risks, especially if you have underlying health conditions. Always start with shorter plunges at milder temperatures, and listen to your body as you develop a tolerance for the cold.

References

Peake, J. M., Roberts, L. A., Figueiredo, V. C., Egner, I. M., Bastiani, M., Aas, S. N., … & Coffey, V. G. (2016). The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise. The Journal of Physiology, 594(18), 5375-5388.

Shevchuk, N. A. (2008). Adapted cold shower as a potential treatment for depression. Medical Hypotheses, 70(5), 995-1001.

Kourtidou-Papadeli, C., Nikolaidis, M. G., & Mougios, V. (2003). Seasonal variation of stress responses and antioxidant defense in swimmers and cold water swimmers. Cell Stress & Chaperones, 8(4), 359-363.

Red Light Therapy

Red Light Therapy (RLT), also known as low-level laser therapy (LLLT), is a non-invasive treatment that uses low wavelength red light to promote healing, reduce inflammation, and improve cellular function. Research on RLT is still developing, but several studies suggest it may offer a wide range of therapeutic benefits. However, limitations exist due to variability in methodology and lack of long-term data. Below is an overview of the potential benefits, who might benefit, and risks, along with guidance on proper dosing.

Benefits of Red Light Therapy

• Wound Healing and Tissue Repair: RLT has been shown to accelerate wound healing and tissue repair. It stimulates fibroblast production and enhances collagen synthesis, both of which are critical for skin repair. A review of clinical studies indicated that RLT improves healing times in acute wounds and even chronic conditions such as diabetic ulcers.

• Pain Reduction and Inflammation: One of the well-established uses of RLT is in managing pain and inflammation. Studies show it can help reduce pain associated with conditions like arthritis, muscle soreness, and joint pain. Research suggests it reduces oxidative stress, promoting anti-inflammatory responses in damaged tissues.

• Skin Health: RLT is frequently used in dermatology for improving skin tone, reducing fine lines and wrinkles, and treating conditions like acne, psoriasis, and eczema. It promotes collagen production, which may reduce signs of aging and improve skin elasticity.

• Muscle Recovery and Athletic Performance: Athletes might benefit from RLT due to its ability to improve muscle recovery and reduce fatigue. Several studies suggest that it enhances mitochondrial function, leading to better energy production (ATP), which accelerates muscle recovery post-exercise.

• Hair Growth: RLT has shown promise in stimulating hair growth in people with androgenetic alopecia (male or female pattern baldness). It may increase blood circulation to the scalp and encourage the hair follicles’ activity.

• Mood and Sleep: Some research points to the ability of red light to improve sleep quality and mood by affecting circadian rhythms and boosting melatonin production.

Limitations in Research

While the preliminary research is promising, several limitations exist:

• Variability in Dosage and Equipment: Different studies use varying light intensities, wavelengths (ranging from 600 to 1000 nm), and application times, making it challenging to standardize protocols.

• Short-Term Studies: Many clinical trials are short-term, with few long-term data on the sustained effects of RLT. More comprehensive, large-scale studies are necessary to validate long-term efficacy and safety.

Who Might Benefit?

• Individuals with Chronic Pain Conditions: People suffering from arthritis, tendonitis, or back pain may experience reduced pain and inflammation.

• Patients with Skin Conditions: Those with acne, psoriasis, or aging-related skin concerns could see improvements in skin appearance and health.

• Athletes and Active Individuals: RLT may benefit those seeking faster muscle recovery and improved performance post-exercise.

• Individuals Experiencing Hair Loss: Those with early-stage alopecia or thinning hair may benefit from hair regrowth.

• Those Seeking Improved Sleep or Mood: People struggling with sleep disorders or seasonal affective disorder may benefit from the mood-regulating effects of red light therapy.

Contraindications and Risks

While RLT is considered safe, there are some risks and contraindications to consider:

• Eye Safety: Direct exposure of the eyes to RLT should be avoided. Protective eyewear is recommended to prevent potential damage to the retina.

• Cancer Patients: Some experts caution against using RLT on cancerous lesions or tumors, as it may stimulate cell growth. Individuals with a history of cancer should consult a physician before using RLT.

• Photosensitivity: People with conditions that cause photosensitivity or those taking medications like isotretinoin (Accutane) may experience adverse reactions to light exposure.

• Pregnancy: There is limited research on RLT’s effects during pregnancy, so it’s best to consult with a healthcare provider before use.

Proper Dosing for Red Light Therapy

The proper dosing of RLT depends on factors like the condition being treated, the wavelength used, and the duration and frequency of exposure. Here are general guidelines:

• Wavelength: The most effective wavelengths for red light therapy are typically in the 600 to 700 nm range for surface-level treatments like skin rejuvenation. For deeper tissue repair (e.g., muscle recovery or joint pain), wavelengths in the 800 to 1000 nm range are recommended.

• Duration and Frequency: Treatment times typically range from 10 to 20 minutes per session. Frequency varies depending on the condition, with many protocols suggesting 3 to 5 sessions per week. For acute pain or inflammation, daily treatments may be necessary initially, while maintenance may require fewer sessions.

• Energy Dosage: The recommended dosage is often expressed in joules (J/cm²). For most skin conditions, 3 to 6 J/cm² is sufficient. For muscle recovery or deeper tissues, 8 to 12 J/cm² may be more appropriate.

Conclusion

Red light therapy offers numerous potential benefits, from pain relief and wound healing to improved skin health and muscle recovery. However, the variability in research methodologies and lack of long-term data make it important for individuals to approach RLT with reasonable expectations and consult healthcare professionals, especially if they have underlying conditions.

References

Hamblin, M. R. (2016). “Mechanisms and applications of the anti-inflammatory effects of photobiomodulation.” APL Photonics, 1(6), 061603. This review highlights how RLT stimulates cytochrome c oxidase in the mitochondria, leading to increased ATP production and enhanced cellular function.

Pastore, D., Greco, M., Passarella, S. (2000). “Specific helium-neon laser sensitivity of the purified cytochrome c oxidase.” International Journal of Radiation Biology, 76(6), 863-870. This study explores how red light directly influences mitochondrial enzymes, particularly cytochrome c oxidase, to boost ATP production.

Silveira, P. C. L., Silva, L. A., Pinho, R. A. (2011). “Effects of low-level laser therapy on oxidative stress and fibrosis in rat lungs.” Journal of Photochemistry and Photobiology B: Biology, 105(1), 58-64. This paper discusses how RLT reduces oxidative stress markers and promotes antioxidant defenses in cells.

Avci, P., Gupta, A., Sadasivam, M., Vecchio, D., Pam, Z., Pam, N., Hamblin, M. R. (2013). “Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring.” Seminars in Cutaneous Medicine and Surgery, 32(1), 41-52. This review emphasizes RLT’s effect on fibroblasts, leading to increased collagen production and improved skin health.

Schindl, A., Schindl, M., Schindl, L., Jurecka, W., Honigsmann, H., Breier, F. (1999). “Increased dermal angiogenesis after low-intensity laser therapy for a chronic radiation ulcer determined by a video measuring system.” Journal of the American Academy of Dermatology, 40(3), 481-484. The study shows how RLT enhances angiogenesis and improves tissue regeneration in skin.

Almeida-Lopes, L., Rigau, J., Zangaro, R. A., Guidugli-Neto, J., Jaeger, M. M. (2001). “Comparison of the low-level laser therapy effects on cultured human gingival fibroblasts proliferation using different irradiance and same fluence.” Lasers in Surgery and Medicine, 29(2), 179-184. This paper presents findings on how red light modulates inflammation by affecting cellular signaling pathways.

Chow, R. T., Johnson, M. I., Lopes-Martins, R. A., Bjordal, J. M. (2009). “Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials.” The Lancet, 374(9705), 1897-1908. This meta-analysis confirms the anti-inflammatory and analgesic effects of RLT, particularly for pain management in neck conditions.

Mitchell, U. H., Mack, G. L. (2013). “Low-level laser treatment with near-infrared light increases venous nitric oxide levels acutely: a single-blind, randomized clinical trial of efficacy.” American Journal of Physical Medicine & Rehabilitation, 92(2), 151-156. This study examines how RLT increases nitric oxide production, leading to vasodilation and improved circulation.

Tuby, H., Maltz, L., Oron, U. (2006). “Modulations of VEGF and iNOS in the rat heart by low-level laser therapy are associated with cardioprotection and enhanced angiogenesis.” Lasers in Surgery and Medicine, 38(7), 682-688. This paper highlights how RLT induces the release of nitric oxide and promotes angiogenesis, aiding in tissue repair and healing.

Fiber: What Is It and Why Do We Need It?

Fiber is an essential component of a healthy diet, yet many people struggle to get enough of it from their food. Fiber is a type of carbohydrate that the body cannot digest and absorb, so it passes through the digestive system without being broken down. This makes it beneficial for a variety of reasons, including improved digestion, weight management, and overall health. Supplementing with fiber can help people get the dietary fiber they need for optimal health. The benefits of fiber supplementation are numerous.

First and foremost, fiber helps to promote regular bowel movements. It adds bulk to the digestive system, which helps to move food more quickly and efficiently through the body. This can reduce constipation and help prevent conditions like hemorrhoids, diverticulitis, and irritable bowel syndrome. Fiber can also help to lower “bad” cholesterol levels and reduce the risk of heart disease.

Fiber can also help with weight management because it helps to keep you feeling fuller longer. This can help to reduce snacking and cravings throughout the day, which can help you to maintain a healthy weight. Additionally, research suggests that fiber can help to boost metabolism, which can also contribute to weight loss.

Fiber has also been linked to improved blood sugar control. Eating fiber-rich foods has been shown to slow the absorption of sugar in the bloodstream, which can help to regulate blood sugar levels. This is especially beneficial for people with diabetes or pre-diabetes. Additionally, fiber can help to reduce inflammation throughout the body, which can help to reduce the risk of chronic diseases like cancer and heart disease.

Of course, fiber supplementation isn’t without its drawbacks. For one, it can cause bloating, gas, and abdominal discomfort in some people. Additionally, too much fiber can interfere with the absorption of other important nutrients, such as minerals and vitamins. It’s important to always speak to a doctor or nutritionist before supplementing with fiber to make sure it’s the right choice for you.

Overall, fiber supplementation can be a great way to get the dietary fiber you need for optimal health. It can help to improve digestion, reduce constipation, and control blood sugar levels. It can also help to reduce inflammation, lower cholesterol, and promote weight loss. Just make sure to speak to a doctor or nutritionist first to make sure it’s the right choice for you.

The Importance of Sleep

Sleep is incredibly important to our physical and mental health. It helps to restore our energy levels, allowing us to be productive and efficient throughout the day. It also helps to maintain our immune system, allowing us to fight off sickness. Sleep also plays a key role in our mental health, helping to reduce stress and anxiety levels and improve our overall mood. It also helps to improve our memory and cognitive performance, allowing us to think more clearly and make better decisions. Getting enough quality sleep is essential for us to be able to feel our best and live our best lives.

Sleep plays an important role in recovery from physical activity. During sleep, our body is able to repair itself, replenish energy levels, and restore balance. Adequate amounts of sleep help to reduce muscle soreness and fatigue, allowing us to recover quicker and be more prepared for our next workout. Sleep also helps to reduce inflammation, which can help to speed up recovery time. Getting enough sleep is essential for athletes to be able to perform at their best and recover quickly from physical activity.

Insufficient sleep has been linked to an increase in systemic inflammation, which can lead to a variety of health problems and diseases. A lack of sleep can also lead to an increase in stress and anxiety, which can further contribute to inflammation. Adequate amounts of quality sleep can help to reduce systemic inflammation and keep our bodies healthy.

Sleep also helps to regulate the hormones that control digestion and appetite, allowing us to better absorb nutrients. It also helps to reduce stress and anxiety, which can have a negative impact on gut health. Getting enough quality sleep can help to keep our digestive system healthy and functioning properly.

During sleep, our brain is able to process and store information that we have learned during the day. Adequate amounts of sleep can help us to better recall information and improve our ability to remember things. Getting enough quality sleep can also help to improve our concentration and focus, which can make it easier to learn and remember new information.

Things you can do to help improve your quality of sleep:

1. Go to bed around the same time every night

2. No screen time within the 90 minutes before bedtime and after waking up the next morning.

3. Watch the sunrise and sunset, this helps with your body’s natural circadian rhythm.

4. No caffeine intake after lunch.

5. Do not eat after 8pm.

6. Taking a bath or meditating after dinner can help calm the central nervous system and prepare the body for restful sleep.

Tell us in the comments below what you like to do as part of your bedtime routine!

What are the benefits of Apple Cider Vinegar?

• Helps with Weight Loss: Apple cider vinegar can help with weight loss due to its acetic acid content which may help reduce fat storage and boost metabolism.

• Lowers Blood Sugar Levels: Studies have shown that apple cider vinegar can help lower blood sugar levels in people with type 2 diabetes.

• Improves Gut Health: Apple cider vinegar can help improve digestion, reduce gut inflammation and increase the growth of beneficial gut bacteria.

• Fights Bacteria and Fungus: Apple cider vinegar can be used as a natural disinfectant to fight bacteria and fungus.

• Enhances Skin Health: Apple cider vinegar can help reduce acne, skin discoloration and wrinkles.

• Reduces Cholesterol Levels: Studies have shown that apple cider vinegar can help reduce cholesterol levels.

• Aids Detoxification: Apple cider vinegar can help detoxify the body by removing toxins from the liver and digestive system.

Do Adjustments/Manipulations cause Strokes?

This is another common topic of conversation I have with patients, particularly new patients, who have never had their neck adjusted/manipulated either based on fear or otherwise. First, the terms adjustment and manipulation can be used interchangeably in relation to the technique, but each describe a different rationale for the treatment.

Adjustments are typically used by chiropractors to ‘re-align’ the spine, referring to the ‘Vertebral subluxation theory’. In short, a vertebrae is ‘out of ‘alignment’ causing issues which needs to be ‘adjusted back into alignment’.

Manipulations are used more commonly by DPTs and DO’s to manipulate joints or segments of the spine in order to improve mobility, range of motion, and reduce muscle tension. Some of the techniques are very similar, if not the same, but the difference is the reason behind performing them.

The most common fear that I hear is the risk of having a stroke following the treatment. After having studied and performing these techniques for years, I know this is possible, but unlikely. And here’s why…

First, there is between a 1 in 400,000 and 1 in 1 million chance of manipulation or an adjustment resulting in a severe complication (Dvorak & Orelli 1985).

OR 1 in 1.3 million (Klougart 1996).

Second, active, voluntary range of motion of the neck (i.e. turning the neck, looking up, etc.) has between 1.2%-12.5% strain placed on the vertebral artery compared to at rest. Compare this to manipulation, which puts only 6.2% strain on the same artery compared to at rest. Meaning, turning your head to check your blind spot before merging puts your vertebral artery at more risk of tearing the artery and possibly resulting in a stroke than a proper manipulation (Symons et al. 2002).

Third, there is an overlap of symptoms, specifically headache and neck pain, between stroke and other diagnoses, for which patients initially seek the help of a healthcare provider. In this article cited below, the authors concluded that the instances in which stroke resulted from a cervical adjustment, those patients were exhibiting signs of a stroke prior to the treatment. Meaning, it is the practitioners responsibility to thoroughly evaluate and determine if the patient is experiencing those symptoms due to a stroke or other cause before performing any sort of treatment (Murphy et al. 2010).

Also, in a case-control and case-crossover study, 818 hospitalized stroke cases were analyzed and found that there was a stronger correlation to primary care physician visits and subsequent stroke compared to that of chiropractic care. This suggests that properly trained physical therapists and chiropractors are better equipped to assess and diagnose the cause of neck pain and headaches and recognize the symptoms of a stroke better than general primary care physicians (Cassidy et al. 2009).

Summary…

• 1 in 1 million chance (Dvorak & Orelli 1985)

• Active movements of the head puts twice the amount of strain on the vertebral artery than properly performed manipulation (Symons et al. 2002)

• Most of these documented cases demonstrate signs of stroke prior to receiving any treatment, meaning the stroke was already underway (Murphy et al. 2010)

• Stronger correlation to primary care physician visits and subsequent stroke due to reports of head and neck pain compared to that of chiropractic visits and subsequent stroke (Cassidy et al. 2009)

Make sure your practitioner is well trained and well-versed in the realm of cervical adjustments/manipulations and differential diagnosis!!

Inflammation is a Good thing?

On this edition, I am going to briefly discuss inflammation and it’s role in pain and adaptations. The majority of the general population believes that inflammation is bad. In part, this is true. However, there is also healthy inflammation which is necessary for the body to heal and adapt.

Perhaps this common misconception is rooted from pharmaceutical companies pushing the sales of their NSAIDs (non-steroidal anti-inflammatory drugs) as safe and effective. We have all taken Advil, Ibuprofen, or Motrin at some point for a variety of reasons. However, these medications also have detrimental effects to recovery, performance, and adaptability which is often overlooked.

Inflammation is one of the means by which the body triggers adaptations and healing to occur. For instance, when we lift weights, certain protein pathways are triggered which stimulates muscle growth. This process includes the influx of cellular metabolites and fluids in order to repair and create new tissue (a.k.a. Inflammation). Without this inflammation, no adaptations would occur. When we train while taking NSAIDS, these inflammatory pathways are blocked, thus, limiting the amount of healing, repair, and recovery that would normally occur.

We run into two problems when dealing with inflammation; when there is none, and when there is too much. When there is none, the body is unaware there is a need for adaption and/or healing.  When there is too much, the inflammation simply gets in the way of any amount of adaptation to occur.

An easy example of when there is too much inflammation is immediately post-op following a total knee replacement. The knee swells to the size of a watermelon because of the amount of trauma during surgery. In these cases, our primary goal is to establish movement and minimize pain and swelling. If the swelling persists too long, it can create chronic pain, limitations in range of motion, capsular adhesions, etc. Once the swelling is minimal, we can begin challenging the knee to get stronger to improve function. If this process is started too early, the significant inflammation in and around the knee would prevent these adaptations to occur.

However, examples of none or too little inflammation is harder to describe. We can conceptualize that an old injury becomes chronic due to it’s lack of healing. The inflammation has come and gone, though the injury never fully healed. In these scenarios, stimulation of new inflammation through exercise or manual interventions can help to re-trigger this healing response.

These responses do not happen overnight and are not quick to heal. It is unlike medication which will have an immediate effect and possibly wear-off. It is permanent change in the tissue structure, quality, and integrity. Often times, medications are ‘band-aids’, failing to address the root of the problem. They are effective at treating the symptoms, but can leave some in chronic pain if the original injury is not addressed.

To address these causes, we have to look at many different factors. One primary factor is nutrition. Foods that contain sugar, dairy, trans fats, red and processed meats, and gluten are some of the most common inflammatory foods. Now, none of these foods in moderation are going to cause harm. It’s when they are a part of every meal, every day, when they begin to cause chronic inflammation and get in the way of our body healing and adapting on it’s own.

One of the most potent naturally-occurring anti-inflammatory foods is Curcumin (turmeric). Other anti-inflammatory foods include mega-3’s (fish oil), fruits, vegetables, and green tea. Incorporating these foods into your daily routine can help fight chronic inflammation and allow for proper healing and adaptions to occur.

IT IS IMPORTANT TO NOTE that turmeric alone is not enough. By itself, the GI system is slow to absorb Curcumin and most of what is ingested is excreted. Though, black pepper is known to be an effective agent or shuttle to facilitate absorption of curcumin into the bloodstream. Thus, be sure that in whatever dish you decide to add curcumin (or turmeric), black pepper is added as well.

Quick tip- it is very easy to add powdered turmeric, salt, and pepper to your eggs first thing in the morning. It hardly tastes any different and a great way to start your day!

Costamagna D, Costelli P, Sampaolesi M, Penna F. Role of Inflammation in Muscle Homeostasis and Myogenesis. Mediators Inflamm. 2015;2015:805172. doi: 10.1155/2015/805172. Epub 2015 Oct 5. PMID: 26508819; PMCID: PMC4609834.

Lilja M, Mandić M, Apró W, Melin M, Olsson K, Rosenborg S, Gustafsson T, Lundberg TR. High doses of anti-inflammatory drugs compromise muscle strength and hypertrophic adaptations to resistance training in young adults. Acta Physiol (Oxf). 2018 Feb;222(2). doi: 10.1111/apha.12948. Epub 2017 Sep 16. PMID: 28834248.

Maroon JC, Bost JW, Maroon A. Natural anti-inflammatory agents for pain relief. Surg Neurol Int. 2010 Dec 13;1:80. doi: 10.4103/2152-7806.73804. PMID: 21206541; PMCID: PMC3011108.

Hewlings SJ, Kalman DS. Curcumin: A Review of Its Effects on Human Health. Foods. 2017 Oct 22;6(10):92. doi: 10.3390/foods6100092. PMID: 29065496; PMCID: PMC5664031.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial

Click here to view this peer-reviewed article written by Dr. Smith and his colleagues regarding the most evidence-based method to treat temporomandibular disorders, or TMD.

Chronic Pain: How PNE can help

In this edition, we are going to discuss Pain Neuroscience Education, or PNE, for short. What is PNE? It references a method of treatment that involves the discussion and education of what pain is, why we have it, and why it can persist long after the onset of injury. This type of treatment is extremely important in those with chronic pain because it helps explain why they continue to suffer despite tests, imaging, physicians telling them there is no obvious answer as to what is wrong. 

For this, I am going to use an example of a whiplash injury from a car accident. 

When you experience a traumatic event or are exposed to a dangerous situation, such as a car accident, the body is very quick to jump into a ‘Fight or Flight’ response. This sympathetic response triggers the release of adrenaline, causes your muscles to spasm/guard against further injury, and dials up your nervous system. This process doesn’t happen immediately. In fact, it can take a few hours which is why many people do not feel pain until hours later, even not until the next morning. In some cases, pain hours later is the result of tissue damage and subsequent swelling and inflammation, but not always.

This initial bout of pain is normal and appropriate. However, as time goes on and injuries that may have occurred heal, pain can persist. Why is this? This is where PNE comes into play. In many cases, the nervous system has adapted unfavorably so that painless stimuli is perceived as being painful. This is due to the combination of muscle guarding/spasms and dialing up of the nervous system to detect injury. 

Why does this occur? To help explain this part, I am going to use the analogy of an Amazon warehouse…

With heightened sensitivity from the nervous system in combination with muscle guarding and spasms, your body begins sending more information to the brain than before the accident. In our example, the Amazon warehouse starts to receive more orders than it can handle. What does it do? It hires more personnel and buys more delivery trucks. These acquisitions aid the warehouse in processing and delivering more orders. Your brain and spinal cord act in the same manner. The spinal cord recruits and creates more receptors so that more information can be received, processed, and sent along to the brain. One receptor that we know acts this way are NMDA receptors, which are responsible for receiving and processing pain. 

At this point, it is much easier for the spinal cord to receive and process painful stimuli than before. Even painless stimulus, such as light touch, can sometimes trigger a painful response due to this heightened ability to process painful stimuli. 

The brain also undergoes unfavorable adaptations by recruiting neurons responsible for receiving pain and other information from other areas of the body. The brain ‘hacks’ these neurons and converts them to assist in receiving the incoming pain stimuli. 

While the body believes it is acting in your best interest by adding these new receptors to handle more incoming signals, this is more harmful than beneficial. This adaptation makes it easier to feel pain, and makes that pain more intense, despite no obvious tissue damage or injury. 

Not only does this adaption in the nervous system make it more difficult to recover, the stress and anxiety that follows makes the muscle guarding and spasms worse. I will be covering this topic in another post later on, but I wanted to mention it here to paint a full picture. 

In addition to chemical and cellular changes from chronic pain, we see behavioral as well. Activities that once were considered pain-free and safe to perform, begin triggering pain, such as taking out the trash, stairs, or driving. Subconsisously, we then begin to associate these activities with pain. This association not only deters you from these activities, it can also trigger pain before the signal reaches the brain. Have you ever heard of Pavlov’s theory of Classic Conditioning? The dogs began to salivate with the ringing of the metronome, despite the lack of food present because they had begun to associate the bell with food.

How does this help us in treatment? Studies show that by simply having this educational conversation, the healing process has already begun. By reinforcing that there is no obvious tissue damage, injury, or apparent reason for feeling chronic pain and explaining how this process occurs, we have begun reversing these unfavorable adaptions. This is the premise of PNE. 

This diagram below can help explain how these adaptations effect you and how they interact with one another, exacerbating the effects of each and create a vicious cycle of pain. 

Imaging: Significant finding or normal ‘Wear & Tear’?

On this edition, I’m excited to discuss another topic of conversation I frequently discuss. Radiographs (X-rays) and Magnetic Resonance Imaging (MRI’s) are very commonly used to get a better understanding as to what may be causing pain and/or dysfunction. When combined with a clinical or functional diagnosis, the use of imaging can be very reliable and paint a very accurate picture to help explain the problem in question. 

However, a clinical diagnosis is <usually> missing when determining best course of treatment. Unfortunately, our current healthcare system dictates that our Physicians see roughly 50-60 patients each day. This means they only have roughly 5-7 minutes to perform a complete examination, interpret the results of imaging, determine the best course of treatment, and discuss this with the patient for their consent. At no fault of their own, this system does not allow them to fully evaluate the patient at a functional level. They must rely primarily on the findings of imaging to determine the next steps. Often times, this can lead to unnecessary interventions, such as surgery and injections, that don’t work or leave a matter of the problem left unresolved. 

‘But if a doctor sees arthritis on my X-ray, isn’t that obviously the reason for my knee pain?’

The short answer: possibly! But not guaranteed. Why is this? What we often forget to consider is what’s considered ‘normal wear and tear’, and what is pathological. In a 2014 study published by Brinjikji et al., they looked at Lumbar MRI’s of 3,110 asymptomatic patients across 33 different studies, meaning these patients had no history of low back pain. What they found is that 37% of 20-year-old individuals displayed signs of degenerative discs (aka ‘Arthritis’ of the spine), increasing to 96% of 80-year-old individuals. 

What about something more serious like bulging or herniated discs? That can’t possibly be ‘normal’… 

In fact, it is. They found 30% of 20-year-olds showed disc bulging increasing to 84% of 80-year-olds and protruding discs in 29% of 20-year-olds and 43% of those in their 80’s. 

The only possible way to accurately conclude that these findings are the sole contributor of pain and dysfunction is to perform an MRI immediately before the onset of pain and then again immediately after the onset of pain and compare the difference. Though, this is obviously not feasible. Even still, there could be minor changes that are not detected on the image that explain the onset of pain. 

But imaging doesn’t lie, does it?

It does, sometimes. In another study by Herzog et al. In 2017, they asked a 63-year-old female to receive an MRI at ten different MRI centers over a 3 week span. This lady did have a history of low back pain and shooting pains down the leg. Across the 49 distinct findings amongst all 10 of the MRI’s, there were NO findings that were reported in all ten reports. One finding was reported in 9/10 MRI’s and 32.7% of the findings were only reported once. Let that sink in… 

How can an image lie? 

Because images are interpreted by a radiologist to produce a summary of what they see and don’t see. Some radiologists consider certain findings ‘normal’ and some don’t, some may miss something others see, and sometimes the image is blurry and difficult to accurately assess. While this process is meant to be as objective as possible, there is still room for interpreter bias. 

However, imaging is absolutely necessary sometimes and I do not mean to take away from it’s importance in diagnosis and treatment. It certainly helps us paint a complete picture, especially when there is such intense pain that a full functional exam is not appropriate. 

This edition simply aims to help educate the general population about the use of imaging and to always take the findings of an image with a grain of salt, or two, and using the results of an image combined with a functional exam can help you decide the best course of treatment. 

If you have any questions, don’t hesitate to ask! Grant@advancedmanualtherapies.com

Thanks for reading!

-Dr. Grant

Heat vs Ice

This feature is going to be the first of many to discuss topics of conversation I frequently have with my patients. In this edition, I want to talk about the use of heat or ice following injury. In addition, when to use each and when to avoid. 

The mnemonic RICE was created in 1978 by Gabe Mirkin, a Sports Medicine Physician, that describes the use of Rest, Ice, Compression, and Elevation to treat sport-specific injuries. Today, this mnemonic has become standard practice immediately following any injury. However, after many years of experience and practice, Dr. Mirkin began to notice that the site of injury reaches a point where it no longer requires the anti-inflammatory effects of ice. In fact, if used past the acute stage of injury, it can impede and interfere with the body’s natural healing response. Because of this, Dr. Mirkin recanted his mnemonic in 2014. 

Before we talk about heat or ice, let’s discuss the stages of healing. 

First, we have the Acute stage, a.k.a. the Inflammatory phase. This stage most commonly lasts between 24-72 hours following the injury. During this stage, the body is focusing white blood cells and inflammatory markers to the site of injury in order to protect it from further injury/infection and begin the healing process. This is what causes swelling. 

Next, we have the Sub-Acute stage, a.k.a. the Proliferative phase. This stage can occur anywhere from 2 days to 6 weeks where the body transitions from the Acute to Chronic Stages. We typically see a reduction in swelling, though pain and loss of function persist. The body has sent the proper chemicals to the area signaling a need for repair and the healing process has begun by lying down new tissue. However, this new tissue is not mature enough to replace the original, damaged tissue.

Finally, the Chronic stage, a.k.a. the Remodeling phase. During this stage, the new tissue is being remodeled and strengthened in order to perform the function of the original, damaged tissue. This stage can last from weeks to months, even years, depending on the severity of the injury. Typically we see scar tissue first. But over time, can be replaced with viable, functioning tissue more similar to that of the original, damaged tissue.

What are the effects of Heat and Ice?

Ice reduces blood flow via vasoconstriction, or narrowing of the blood vessels. Ice also increases fluid viscosity (makes it thicker), makes the area numb to pain, and reduces the flexibility/mobility of the underlying tissue by reducing it’s elasticity. 

On the other hand, Heat increases blood flow, decreases fluid viscosity (makes it thinner), and increases the flexibility/mobility of underlying tissue by increasing it’s elasticity. 

So how does this relate to tissue injury?

Injuries with a specific Mechanism Of Injury (MOI), such as a traumatic event, sets off the 3 stages of healing. Ice can be useful during the acute stage in order to prevent excessive inflammation and swelling. Inflammation is necessary and helpful during this stage, but too much can be harmful. This is where the ice is important during the first 24-72 hours. 

If ice is used after this stage of healing, it can inhibit the body’s natural healing response by reducing blood flow, reducing mobility/flexibility, and increasing the viscosity of the interstitial fluid or remaining swelling. These effects make it more difficult for the body to remove and flush the area of the swelling and slow down the laying of new, healthy tissue. 

During the sub-acute and chronic stages, heat is more appropriate in order to continue bringing healthy blood, oxygen, and nutrients to the area and remove swelling and metabolic byproducts. Continued use of heat can facilitate this process. In addition, the heat will further improve the tissue’s flexibility and mobility as it matures and strengthens as to avoid a loss in any range of motion or elasticity during this time. 

I see many people that come in and are still using ice weeks and months following the onset of injury or pain. At this point, the ice is simply slowing down the body’s natural healing response and likely contributing to a bigger problem! 

What about Chronic pain without a specific MOI? 

In this scenario, we need to conceptualize a different model of healing. Chronic pain can be due to many factors, from neurological, centrally-mediated pain sensitivity, muscle guarding/spasms, etc. Because of this, heat or ice recommendations should be on a case-by-case basis. However, what’s most important is achieving some form of relief. For this reason, I usually ask my patients to try both and go with whichever one feels better! 

While this is a very generalized explanation of tissue healing and the effects of heat or ice, I hope this edition provides some clarity to the Heat vs Ice debate and helps you make a decision as to which is most appropriate for you. 

If you’d like to discuss further, please feel free to reach out to grant@advancedmanualtherapies.com. 

Thanks for reading! 

-Dr. Grant