Treating the Whole Body…. Not JUST Treating Symptoms

“The doctor of the future will give no medicine, but will instruct his patient in the care of the human frame, in diet, and in the cause and prevention of disease.” – Thomas A. Edison

Let’s start with an excerpt from the services page on my website**:

• OMM is a treatment commonly used for patients who have strained their back either playing sports or at work, or have been involved in a “whiplash” injury from an accident. Also, many people who have sedentary jobs, or sit for a long time at a desk develop “knots” in the shoulder blade region. By performing OMM, a procedure designed to mobilize the restricted motion of the joint, a DO helps relieve symptoms which then aid in tapping into your body’s self-healing capabilities.

Manual medicine is one component of total health care and is most effective in the long term when combined with diet, exercise, and lifestyle modification. As well, OMM can work alongside conventional approaches to help patients with a wide variety of conditions. Consider a concept forwarded by Edward Stiles, DO (http://omtsos.com/index.php?page=philosophy) that further describes the goal of manual medicine practitioners with the following equation:

 HOST + DISEASE = ILLNESS

Using the equation above, consider a patient with asthma: the patient is the Host component and asthma represents the Disease component of this equation. To treat the host, manual medicine is directed at the patient’s mechanical restriction which commonly occurs in the thoracic spine and rib cage region (http://www.spine-health.com/conditions/spine-anatomy/thoracic-spine-anatomy-and-upper-back-pain).  The primary goal is to restore motion to the ribcage, diaphragm, and thorax, and in doing so, restore normal ventilation of the lungs.

Furthermore, to treat the disease (asthma has two components: inflammation or mucus build-up in the airways and broncho-constriction or narrowing of the airways), inhaled steroids to decrease inflammation in the lungs and other medicines called broncho-dilators to expand the lungs are used to treat the patient successfully. From a 2010 article in OMPC, Osteopathic Medicine and Primary Care (http://www.om-pc.com/content/4/1/2 Noll et al.), hospital patients with pneumonia were treated in a similar fashion described above (using OMM and conventional therapy –  ie; antibiotics – versus just conventional therapy). Patients treated with the combined approach of OMM and conventional treatment were discharged from the hospital sooner than those just treated with the conventional treatment of medications without OMM.

So, what are the implications of this model for healthcare? Approaching the patient with this integrative method takes us away from just treating symptoms, and when taking into consideration that the HOST is connected to the ILLNESS equation (and not just the DISEASE – ie; symptoms), this optimizes the patient’s own healing capabilities.

** http://www.pursuitsports.us/services/

For more information, please visit: www.pursuitsports.us

AAOM Annual Meeting 2013: “Future Directions in Regenerative Medicine”

“Anatomy is to physiology as geography is to history; it describes the theatre of events.”
– Jean Francois Fernel, De Naturali Parte Medicinae Libri Septem, 1592

 

At the 2013 Annual Meeting of the AAOM, there were some compelling lectures on what may possibly become treatments of choice for difficult conditions such as discogenic back pain (back pain originating from a “pinched nerve” or “slipped disk” in the lower back region), and knee arthritis.

Back pain with associated leg pain is a condition that, first of all, can be very difficult to diagnose because there may be overlapping pain patterns, or pain going down the leg from different sources such as muscle, tendon, ligament, facet joint, or what many people are familiar with as a “slipped disk”. This is otherwise known as the intervertebral disk which acts like a shock absorber between the vertebra of the spine. It is located close to the nerve roots as they come out of the spinal cord which can become “impinged” or inflamed by the disk or its material as it degenerates over time, or from injury.

Common treatments for this condition include epidural steroid injections aimed at decreasing the inflammation on the nerve root, or even more aggressively, surgery is performed to decompress the nerve. Both of these treatments have mixed results, therefore, more recent research has focused on restoring a more normal size and functioning of the disk.

Furthermore, in a study on intradiscal injections to essentially prop up or restore the disk back to its normal functioning anatomy (kind of like re-inflating a tire), Yin and Pauza (Pain Med 2009; 10(5):955.abstract) show a greater than 50% reduction in both back and leg pain at 12 weeks in preliminary studies of this type of treatment.  A multi-center, randomized controlled phase III trial is currently underway in the United States, which supports these preliminary findings.

Another speaker, Chris Centeno, MD of Regenexx, presented some “registry data” (a registry is a group of patients followed in time to monitor the effects of a treatment) on stem cell treatment for knee arthritis. While this type of scientific data is limited in its strength in terms of scientific design, patients in the registry reported an almost 60% relief in their knee pain symptoms (www.regenexx.com). An update of this information from the registry is forthcoming this summer according to Dr Centeno. We have better science for platelet rich plasma (PRP) injections for knee arthritis in terms of “controlled trials” as published in:  http://www.arthroscopyjournal.org/article/S0749-8063(11)00523-8/abstract
http://link.springer.com/article/10.1007/s00167-010-1238-6#page-1

So, what does this mean for patients? Regenerative Medicine as a field is coming up with ways to restore more normal structure and function of the anatomy, as opposed to a surgical option such as “cutting it out or fusing it”. If stem cells go the way of PRP in terms of their scientific study, we will be seeing a paradigm shift in our treatment of degenerative conditions.

For more information, please visit: http://www.pursuitsports.us

Physical Therapy vs Surgery for Meniscal Tears

 “I don’t deserve this award, but I have arthritis and I don’t deserve that either.” 
-Jack Benny

Before I dive into the findings of a recent New England Journal of Medicine study and how this connects to what is called “conservative treatment” (ie; non-surgical), here is a brief description of the medical terminology needed to understand the results and how this fits into your own treatment choices.

The two medical terms involved with this study are menisci and arthritis.

• Menisci are C-shaped cartilage structures within the knee joint which act like shock absorbers or cushions between the thigh bone (femur) and the shin bone (tibia). The menisci also provide stability with various motions of the knee including pivoting, twisting and squatting. Surgery for meniscal tears is the most commonly performed orthopedic surgery.
• Meniscectomy is surgically removing the torn part of the meniscus which takes out the “pain generator” and prevents torn pieces from breaking off and causing further injury
• Arthritis is a narrowing of the joint space associated with degeneration of the cartilage and bony structures of a joint.

Now to the findings of the study published in the New England Journal of Medicine, (NEJM, March 19, 2013 – http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 ). This study indicated that physical therapy vs surgery is no different in efficacy for the treatment of meniscal tears among patients with mild to moderate arthritis. In this well designed study, patients with an average age of 56 were randomly assigned to either the conservative treatment group consisting of physical therapy or the surgical group which was treated with a partial meniscectomy. Further results showed that 30% of the patients in the conservative treatment group receiving physical therapy “crossed over” to get surgical treatment within 6 months. At 6 months and 12 months, the conservative treatment group compared to the surgery group indicated no difference on the WOMAC pain and function scales (http://en.wikipedia.org/wiki/WOMAC ).

Furthermore, as cited in my December 2012 blog article: (https://pursuitsports.wordpress.com/2012/12/14/huh-an-introduction-to-making-sense-of-what-your-doctor-is-trying-and-failing-to-tell-you/ ), shoulder MRI’s in the general population of asymptomatic patients show a high proportion of rotator cuff tears. Similarly,  35% of patients older than 50 will have meniscal tears seen on an MRI, and 67% of them will be asymptomatic (this means that patients do not report any painful symptoms). So, it is worth mentioning again the importance of the physical examination to determine if the meniscus truly is the origin of the pain and then correlating these findings with the MRI before considering aggressive or surgical procedures.

So, what does this mean for patients? General recommendations can emphasize non-surgical treatments for meniscal tears first, as long as they do not have mechanical symptoms (ie; locking, catching or giving way). If the patient shows no improvement after non-surgical treatments or has mechanical symptoms, then considering surgical management would be the next step.

Finally, what about regenerative injections to optimize conservative treatments? There is mounting medical evidence that regenerative injections can be helpful in patients with knee arthritis, so why not engage in this non-surgical treatment for meniscal tears? At present, there are no studies in this specific population of patients who have meniscal tears without arthritis, however, I generally tell patients who want to avoid surgery that we can try non-surgical treatments as long as mechanical symptoms (knee joint locking or catching) are not present. In this New England Journal of Medicine article, the study participants will be followed into the future in order to answer the question as to weather surgery on the meniscus leads to a higher risk of arthritis. If this turns out to be so, then it would be another argument to treat these injuries conservatively with physical therapy and regenerative injections.

For more information, please visit: www.pursuitsports.us
 

 

MUSCULOSKELETAL MEDICINE 101: Prolotherapy, Lifestyle & the Body’s Healing Process

“There has never been a great athlete who died not knowing what pain is.” – Bill Bradley

With all integrative medicine techniques, there will be pros and cons backed up by statistics and studies; some that are based on solid scientific methodology, some based on decades of experiential knowledge, and some based on both. Furthermore in all medical disciplines, there are conflicting arguments for or against any given technique, and one can find evidence to support almost every point of view. In addition, consider that there are not-so-hidden agendas for all concerned – insurance companies, lobbyists, health care professionals, hospitals, pharmaceutical companies, and politicians all have something at stake with new medical information. Fair enough. And now with the onset of ask.com, medicine.com, doctors.com, wikipedia.com, and the blogsophere, patients are becoming both highly educated and deeply disillusioned. Is it any wonder that when one doctor recommends a treatment method, a patient’s knee-jerk reaction is to ask for a second opinion?

I naturally have a scientific mind, have been mentored by some of the best doctors around, and have been working in the osteopathic/sports medicine arena since I started medical school in 1998. My commitment is to relay valuable information I have learned to my patients. I want every patient to leave my office with the feeling that they know what their issue is, what the treatment will be, how it works, and what to expect. If a patient wants to know the “why” of a treatment method, I am excited to share a more in-depth conversation. I believe that knowledge is power, and the more patients understand their individual situations, the more successful their treatment results are likely to be.

Let’s start with an overview of prolotherapy – what is it and how does it work for healing pain?

Prolotherapy is a treatment that stimulates the natural production of new connective tissue such as ligaments and tendons by inducing a mild inflammatory reaction in the weakened ligaments and tendons by producing collagen. Proliferation injection therapy, or prolotherapy, uses dextrose and an anesthetic to create a ‘controlled injury’ at the tender part of the body. The idea of this treatment is to stimulate the healing response of the body which is triggered by the injections. Recent discoveries of prolotherapy have shown that this technique is not only able to restore damaged ligaments and tendons, but is able to repair damaged cartilage as well.

Prolotherapy works by exactly the same process that the human body naturally uses to stimulate the body’s healing system, by a process called inflammation. This injection technique causes an inflammatory response which “turns on” the healing process, and the growth of new ligament and tendon tissue is then stimulated. The ligaments and tendons produced after prolotherapy look almost the same as normal tissues except that they are thicker, stronger, and contain fibers of varying thickness. The ligament and tendon tissue, which forms as a result of prolotherapy, is up to 40% thicker and stronger than normal tissue in some cases.

It is important to add here a brief overview of a more traditional treatment approach to musculoskeletal pain – cortisone shots. A cortisone shot contains an anti-inflammatory medicine called corticosteroid medicine. This method has been used to treat injuries such as tennis elbow, overused and weakened tendons and ligaments, and other strains that are not truly inflammatory problems by nature. Although cortisone shots give patients some temporary pain relief, they don’t fundamentally help long-term because the core issue is weakness, not inflammation. For pain induced by non-inflammatory issues, prolotherapy injection techniques help promote healing via strengthening a weak and injured area.

As I have mentioned in previous articles, a DO provides comprehensive health care services; we use traditional medical practices such as drugs and surgery as well as integrative, musculoskeletal medicine methods.

These musculoskeletal methods include:

Musculoskeletal Ultrasound (MSKUS): This type of ultrasound is used for evaluating muscles, tendons, and ligaments associated with various joints. The advantages of using ultrasound include a comparable, if not more accurate diagnosis of soft tissue injury than an MRI, decreased costs, and the ability to perform what we call “dynamic tests” in real-time, at the point-of-service. MSKUS is also used for guiding injection therapies.

Regenerative Injection Techniques (RIT): There are two types of RIT – platelet rich plasma (PRP) and prolotherapy. PRP involves taking the patient’s blood, spinning it down in a centrifuge to separate platelet cells from the rest of the blood, and then injecting the platelet cells that contain growth factors into the injured area to promote healing. Prolotherapy has been described above in detail. Also, keep in mind that working in tandem with one or both of these types of injection therapies, patients often continue to work with their physical therapists to get the most out of their treatments.

Osteopathic Manipulative Medicine (OMM): This is a treatment commonly used for patients who have strained their back either playing sports or at work, or have been involved in a “whiplash” injury from a motor vehicle accident. Also, many people who have sedentary jobs or sit for a long time at a desk develop “knots” in the shoulder blade region. By performing OMM, a procedure designed to mobilize the restricted motion of the joint, a DO helps relieve symptoms which then aid in tapping into the body’s self-healing capabilities. Osteopathic doctors believe the expanded use of OMM reduces reliance on drugs for many patients who suffer from chronic pain.

Lifestyle Changes: A doctor of osteopathy will also encourage patients to examine their lifestyles, diet, exercise regimens, and mental attitudes. They will look at the whole body, not just where it aches. DOs will also make sure that their treatment regimen fits into a patient’s daily life with their personal commitment to recovery. As I have mentioned before, recovery is a two-way street.

So, where do these integrative, state-of-the-art methods come from?

The father of osteopathy is Andrew Taylor Still, who first used the term in 1874. He was trained as a medical doctor and while most doctors of his time focused on treating sick people, Dr Still became fascinated with what supported health in the first place. He was concerned that many common medical treatments did more to harm patients than to help cure their ailments. Dr Still believed there was a way to help the body heal itself and was particularly interested in the role of the musculoskeletal system (the muscles, bones and nerves that make up 60% of our body mass) in promoting health. In fact, the word “osteopathy” comes from the Greek word for “bone.”

Integrative medical approaches such as prolotherapy are making the medical profession at large stand up and take notice. Asking a patient “where does it hurt?” is just one of many ways a doctor contributes to the healing process. Also key are factors such as: how and how much people sleep, what a patient’s sex life is like, what people eat everyday, how much exercise they get, and what kind of jobs they have… all are indicators for doctors to help support a patient’s recovery. In osteopathic medicine, taking into consideration the whole person works to cure ailments and pain. Of course, further medical research will no doubt add to the positive results that my patients are experiencing now. This is cutting edge medicine at its best.

For more information, please visit: http://www.pursuitsports.us

Medical Studies 101: How Test Results Can Shift Philosophies and Support Your Recovery

“Declare the past, diagnose the present, foretell the future.” – Hippocrates

Medical studies on various medical issues are used by doctors of all disciplines as guidelines for present and future knowledge. There are things like the WOMAC scale, percentages of “success”, and the scientific research base-lines which help determine results. These results can then be a tool for doctors which of course lend to helping increase patient recovery rates.

In this article, I would like to explain this behind the scenes world of medical research and how this relates to your recovery.

1.    Keep in mind that medical studies get funding for ailments that are the most common and most costly to society. Is it any wonder that celebrities spend so much time promoting medical causes that are important to them? Funding is unfortunately not readily available for less common ailments and diseases.

2.    In musculoskeletal medicine, many studies focus on knee arthritis, arthritis of other joints, and lower back pain because of the overall burden of these conditions to healthcare systems and the workplace. Some causes of these issues are genetic, while others are lifestyle-related.

3.    Even within each specialty (in my case, sports medicine), doctors do not always agree on approaches to treatment and how to decipher and implement the data obtained from the latest studies. Of course, more accurate data can mean better treatment, and a better recovery for patients.

4.    Fundamental differences in philosophy can hinder recovery. In osteopathic medicine, the body is seen as a “functional unit”. In other medical approaches, the body is seen as parts to be examined individually. For example, if a patient is experiencing pain in the lower back region, the cause might be from an area that is out of alignment at the neck, or muscles in the low back region that get “turned off” because of an injury such as an ankle sprain. Some medical philosophies would treat the lower back area only, while a DO would look at areas that may also be the reason for pain and discomfort. Again, these DOs approach the body as a “functional unit”.

Let’s talk about knee arthritis studies performed by several different hospitals, foundations, and research labs across the country. First, the WOMAC scale is a widely respected scale to determine pain – it stands for The Western Ontario and McMaster Universities Arthritis Index (http://en.wikipedia.org/wiki/WOMAC). This scale is used as a  measure of function and pain associated with knee arthritis and a standard base-line comparison to help understand what patients are experiencing and how to translate this valuable information into usable data. There will usually be 3 or 4 groups studied over an extended period of time, for example:

• Group 1: Patients who receive an experimental treatment or drug.
• Group 2: Patients who receive prolotherapy injections separated one month apart, followed up for evaluation for a full year from the beginning of a one year study period.
• Group 3: Patients who receive saline injections (a “placebo” group) during the same intervals as Group 2.
• Group 4: Patients who do regular physical exercises at home.

Now, let’s talk about results. For example, cancer research study results are analyzed as follows: if a new drug or treatment method shows a 30% positive result, it is solid enough for future study and therefore for future funding. Over 30% improvement is called a “meaningful clinical outcome”. Results less than 30% are considered to have a “minimal clinical significance”. Of course, patients want a 100% positive result, right? But now you get the bigger picture of what might get more funding, more research time… or not.

Now, let’s talk about knee arthritis studies and the osteopathic approach. Thankfully, the WOMAC scale is very useful for understanding what a patient is actually feeling and offers an excellent standard for communication between doctors and patients. Furthermore just to reiterate: the osteopathic philosophy is to treat “the body as a functional unit”. In the case of knee arthritis, the thought is that it’s not just the knee-joint surface that is causing pain; it is also the surrounding soft-tissue support structures. Some of these support structures become worn out and develop laxity (looseness or weakness) with associated pain symptoms.

Traditionally, injections around the knee are poorly studied in past medical literature since many doctors will focus in on the knee-joint surface only. In contrast, prolotherapists over the decades have come to develop the practice of injecting these “extra-articular” structures (ligaments and tendons surrounding the knee-joint) because on physical examination, knee arthritis patients often have pain in these areas as well. Also, although ultrasound is an excellent tool for detecting visual defects, there are other “bio-mechanical” reasons for pain: lifestyle, mental attitude, posture, and overuse (every daily PC or Mac user knows what carpal tunnel syndrome is, right?). Osteopathic medicine “considers the entire body, not just where it aches.” This is key in a sound examination, an accurate diagnosis, an effective treatment, and a speedy recovery. It is also key when funding useful medical studies and correctly interpreting test results for the benefit of better patient recovery rates.

Why is any of this interesting to patients?

It comes down to a million-dollar question: Surgery or no surgery for knee pain? Surgical decisions such as joint replacement for severe knee arthritis are still common. Insurance pays for it, surgeons are good at it, people feel relief, and everyone is happy. But think about this for a moment: approximately 90% of sports and lifestyle related injuries do not need surgery. If test results show the effectiveness of prolotherapy injections for knee and knee arthritis pain without going to the hospital, would that not be preferable? Of course, sometimes surgery is recommended for some situations. AND, the non-surgical prolotherapy injection treatment is one method that works, medical studies consistently show this to be true, and patients can only benefit from this knowledge. Shifting from automatically going into surgery… to deciding on a non-surgical, alternative treatment method just makes sense. Medical Studies 101 says: think about this before making your treatment choices. Food for thought.

For more information, please visit: http://www.pursuitsports.us

Commitment to Recovery is a Two-Way Street

“I heard a definition once: Happiness is health and a short memory! I wish I’d invented it, because it is very true.”   – Katherine Hepburn

When I was working as an intern, I was at an underserved community health clinic on the Southside of Chicago where there is a high prevalence of obesity, high blood pressure and diabetes. I was taught to treat the symptoms of these conditions via drugs with only cursory attention given to advising patients on lifestyle modifications.  After watching this approach only slow down or “manage” the conditions as patients were oftentimes only passively involved in their care, I found myself wanting some structure to get to the “root cause” as a doctor in training.

Finally, I began to have patients journal their dietary intake and what they ate everyday for two weeks, as well as document their activities such as walking or other forms of exercise. Then I would invite them back for an office visit and ask them to take an honest assessment of what they ate and what they could do without. Patients were amazed when they reviewed their diets and often commented on certain habits and “automatic eating” types of behaviors relating to stress or “self-medicating”. For some of the patients, the awareness gained from creating a journal propelled them into “I can do without that second snickers bar” or “I can take the stairs instead of the elevator”. They embarked on successful weight loss programs with this simple strategy by decreasing dietary intake and increasing physical activity. Several patients succeeded with this approach, and one in particular that I recall (Mary G.) lost over 60 pounds and kept it off the remainder of my residency training!

So, why does this matter?

We know that when patients are more engaged in their care, it leads to better outcomes. That’s a fact. On average, patients with high blood pressure and diabetes when stable, go to their doctor 4 times a year for a 15 minute appointment – so that is 1 hour of time with their doctor per year. Really, it’s what patients can do on a daily basis with their own health that can make a positive impact on their health… and of course, working in collaboration with health care providers.

In musculoskeletal medicine and for conditions such as chronic neck and back pain, we see that this engagement of the patient via therapeutic exercise along with spinal manipulation works. As reported in a review on spinal pain in The Spine Journal, 2008, a patient’s commitment to recovery decreases pain and increases function. I never get tired of repeating certain pieces of advice or “truths” in my experience: get informed, get involved with the entire program to recovery, make sure a sincere commitment has been made to move forward. Make sure your friends and family understand what your condition is and what recovery looks like. Get support. Do the exercises.

Eat ice cream (unless you are lactose intolerant – then have some dark chocolate!). That last suggestion is for unplugging and lightening up, too. Obesity is often a disease of the mind as well, so focus on reversing inertia tendencies in your lives and ask yourselves what you could do without? Get a journal and write it all down – two weeks worth of food and drink. Write down some goals you have, too. You might be surprised at what the results will tell you. Time to get going. Let you and your doctor work together for a full recovery. It’s a two-way street, right? You can do this!

For more information, please visit: www.pursuitsports.us

HUH? An Introduction to Making Sense of What Your Doctor is Trying (and Failing) to Tell You

“They certainly give very strange names to diseases.” – Plato

When a doctor orders an x-ray, ultrasound, MRI (or any other test for that matter), it is done to help make a diagnosis of the patient’s problem after a thorough history and physical exam are performed. This in turn guides the treatment, and patients don’t need to have a medical certificate to recognize that “the treatment is only as good as the diagnosis”. When test results come back, patients want to learn what the findings mean and how this information can support their recovery – getting clarity is the first thing on their list. Unfortunately, patients are often introduced to a barrage of medical terminology which does not create more lucidity – in fact, they leave the doctor’s office feeling even worse with a bowl of murky information soup swimming inside their heads, not quite knowing what to do next. And finally, in addition to the daunting task of having to interpret medical terminology, patients are sometimes informed that there are other “unrelated” issues found on the x-ray or MRI… in areas where they aren’t even experiencing any pain!

So, what do doctors do with this information and how are patients supposed to process it?

Radiologists are trained doctors who interpret all of the imaging studies (X-rays, MRI’s, CAT scans etc.). In the radiology report handed over to an MD/DO, sometimes the words clinical correlation required will be included. Basically, this means that there may be some identifiable problems or what doctors call “pathology”, but they may not be clinically active or significant. Here is one of many examples, as cited in a general population study (J Bone Joint Surg Am 1995;77:10–5.): MRI studies were performed on “asymptomatic” patients – those who are not experiencing pain – and the results showed that 35 out of 100 patients  had at least partial tears of the rotator cuff. Similar findings were also seen in the lumbar spine – the lower back region – when general population MRI studies were again performed on asymptomatic patients.

The important part of the diagnostic process in musculoskeletal medicine is to not only correlate the physical exam findings with the x-ray or MRI, but to also look for any possible “bio-mechanical precursors” to the problem such as abnormal motion patterns of the shoulder blade (scapula) thus predisposing the patient to shoulder pain, or tight hip flexors leading to inhibition or inactivation of muscles that stabilize the lower back region.  In the orthopeadic paradigm, we diagnose a patient’s problem by reproducing their typical symptoms during the physical exam and then order the appropriate study – such as an MRI –  if the patient doesn’t get better with conservative measures such as manual or physical therapy… or if the patient is potentially a candidate for surgery. By linking the physical exam, patients’ complaints and the radiological findings, doctors can offer a more accurate, meaningful, applicable, and successful treatment to patients.

When this happens, clarity becomes the first thing patients experience… not the last.

For more information, please visit: http://www.PursuitSports.us

Uncovering the Difference: Tendinitis vs Tendinosis

“Diagnosis is not the end, but the beginning of practice.”   ~Martin H. Fischer

Medical terminology can be confusing for patients and even for doctors in training. In medical school we are taught that an elbow or shoulder sprain is a “tendinitis”. Unless physicians go onto a specialty concentrating on the musculoskeletal system, it is very likely they will continue to diagnose a shoulder “bursitis” or “tendinitis”. Some of these diagnoses are sound, however they happen only in a small minority of cases. Most of the time, problems such as “tennis elbow” and “shoulder bursitis” are overuse problems, and we use the terminology “itis” to actually imply that the condition is acute, or new.

The more accurate terminology describing the underlying problems associated with tennis elbow or shoulder bursitis is tendinosis, which describes a state of micro-tears, disrepair, weakening and what physicians call the “disorganized architecture” of the tendon or ligament. In the early 1980’s, an Orthopedist at Georgetown University, Robert P. Nirschl MD, first described the concept of tendinosis by taking tissue samples from patients who had surgery for tennis elbow. The study results of these injured soft tissues of the lateral elbow revealed a state of disrepair of the tendon, and contrary to conventional thinking of the time, showed an absence of inflammatory cells.

Thus, a new idea was introduced to the medical profession: tennis elbow and other conditions like it are not truly inflammatory problems and subsequently, the use of anti-inflammatory injection therapies for such ailments has no lasting positive effect. Of course, they provide temporary relief but do not offer a long-term solution, and medical studies have proven this over and over again. A case in point is a medical review in the November, 2010 issue of the British medical journal Lancet, that looked into the safety and efficacy of corticosteroid injections for various musculoskeletal conditions such as tennis elbow. Little evidence was found that supported such treatment beyond some temporary pain relief.

So, what does this all mean for patients? I often explain to patients that tendons and ligaments are like ropes. When the rope is strong, it is compact and tight. When the rope is weakened, over-used and causes pain, it has become thickened and frayed. Physicians can also see this concept on ultrasound of the various tendons and ligaments, and with this tool are able to provide a more accurate diagnosis. In the majority of these tendinosis cases, an anti-inflammatory injection therapy might be offered to help someone only to help them get back to work, for example, in a very short time. However, pain will undoubtedly begin to resurface, and patients are back to square one. Therefore, a long-term solution would include other therapies such as the combination of prolotherapy, OMM, and regular physical therapy.

My professional advice? Make sure your physician knows the distinction between tendonitis and tendinosis. A more acurate diagnosis of your condition will certainly help you get the best therapy methods available, ones that will support a long-lasting recovery.

For more information, please visit: www.PursuitSports.us

New Ideas on the ‘Cell’ and Implications for Musculoskeletal Medicine

“Once you learn to quit, it becomes a habit.“   – Vince Lombardi

From the American Association of Orthopaedic Medicine Conference, April 19th, 2012

Donald Inger (MD, PhD, Harvard Pathologist, Researcher), gave a compelling lecture entitled, “Tensegrity, Mechanotransduction and Regenerative Medicine”. He talked about how the cell is constructed more like a “tent” with continuous tension holding it up which is contrary to conventional ideas we learned in medical school on how the cell is constructed “like a balloon” of chemicals. Inger shows through his experiments that mechanical forces are as important as chemical/genetic factors in determining the fate of a cell. Without the appropriate amount of tension and compression of the cells’ micro-structure – also known as “tensional integrity” – there is programmed cell death. Therefore, development and cellular growth is an interaction between the mechanical forces, mechano-transduction and chemical/genetic elements.

Now, that’s a mouthful…

So, what are the implications of this paradigm shift in our thinking on the construction of the cell which is seen in virtually all of the sub-specialties in medicine? In the area of orthopaedic medicine, this concept is echoed in the reports of researcher David Rabago, MD at the University of Wisconsin, Madison, who says prolotherapy together with exercise approaches for musculoskeletal pain (for example, chronic mechanical low back pain, or recalcitrant tennis elbow) are thought of as a “whole protocol”, supporting the notion and importance of mechano-transduction or the mechanical input to be performed in conjunction with prolotherapy treatments to have a successful outcome for the patient.

What does this mean to patients ?  The slogan for the American College of Sports Medicine (ACSM) pretty much sums it all up: “Exercise is Medicine”. Yes, movement, the mechanical operation of joints, tendons, ligaments, and muscles… all make a vast difference in sustained, cellular health. In other words, along with prolotherapy or OMM, your physical therapist and your daily physical workout commitments are key in supporting our treatment for your full recovery.

For more information, please visit: www.PursuitSports.us

A Brief Introduction to Regenerative Injection Therapy

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”   ~Plato

Most patients understand that corticosteroid injections, or the commonly known term “steroid shots”, don’t work in general. At best, they may temporarily help ease the pain for many of the conditions they are used for, however, they are not getting to the core of the issue.

I have common interactions with patients who have various conditions such as tennis or golfers elbow, jumpers knee, or shoulder bursitis (rotator cuff syndrome). They tell me that they have actually declined offers for a steroid shot, saying that they have heard this treatment does not get to the “root cause of the problem and only masks the symptoms.” For many of these conditions, these patients are echoing mounting medical evidence.

A well written article from the Journal of Physical Medicine and Rehabilitation by Harvard Medical School clinicians cites various studies where regenerative injections are useful, especially in augmenting non-surgical options in the treatment of these ailments. Despite this evidence, insurance carriers will not cover this procedure and patients have to pay for it themselves.

So I ask: why hasn’t the medical establishment or the insurance industry gotten on board? My take on it is that surgeons “rule the roost” and tend to have much more input and influence on these kinds of policies. With all due respect, this is not a fair and balanced way to set policy. For example, expensive and experimental surgeries are being performed using robotics that are covered by most insurance carriers. Yet, the effectiveness of this new technology has not been fully examined in the scientific method, but they are considered sound enough to be a covered procedure.

There seems to be a bias towards surgical procedures over other effective, medically sound alternatives. Food for thought.

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