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March 27, 2014

Making Sense of Guidelines for Care

Not too long ago, the Eighth Joint National Committee (originally commissioned by the National Heart, Lung, and Blood Institute) released a new set of evidence-based guidelines for evaluation and treatment of hypertension (high blood pressure). The guidelines committee, comprised of 17 academics, spent five years reviewing evidence as preparation for developing the new recommendations.

The committee’s report represents nothing less than a sea change in the treatment of patients with higher-than-normal blood pressure readings. The primary shift is from a long-held standard of implementing treatment when a person’s blood pressure is higher than 140/90 mmHg. The new guidelines recommend beginning treatment only when blood pressure readings are higher than 150/90 mmHg. The new standard is a huge modification of decades-old practice methods, and has generated substantial controversy.1.2 Of course, a good portion of the pushback is from those who have a vested interest in maintaining the status quo, such as physicians who dispense medications from their office and earn substantial income from selling antihypertensive drugs at multiples of their wholesale costs. In addition to physicians who act as pharmacies, drug companies who manufacture antihypertensive medications also stand to lose significant revenue. But aside from considerations related to the practice of medicine as a business, the real issues should be focused on the benefits and harms to patients. In this context, it may be reasonably stated that fewer medications are, by and large, a good thing.

The new blood pressure guidelines have two primary impacts. First, for people over age 60, treatment for presumed hypertension should be initiated when blood pressure readings are higher than 150/90 mm/Hg. More than 7.4 million Americans over age 60 will be in the new safe range. Many of these millions of people have been taking antihypertensive medication for years, possibly needlessly as implied by the new guidelines. Next, for all those under age 60, there is insufficient medical evidence that a systolic blood pressure (the first number in the reading) threshold exists that would dictate treatment. In other words, for many years the systolic threshold had been 140 (as in 140/90 mmHg). Higher systolic readings virtually mandated antihypertensive treatment. Although the committee expressed its opinion that the systolic threshold of 140 mmHg ought to be maintained for those younger than age 60, even though evidence for such a threshold is weak. Thus, it may be that many millions more people have been taking antihypertensive medication without such recommendations being backed by sound scientific research.

The point here is not that people should stop taking their blood pressure medication.3 All such types of decisions should be made in consultation with the prescribing physician. The main consideration is having the ability to make informed choices. Some medication regimens may be appropriate. Some may not. Some may need to be reevaluated. As always, regular chiropractic care is of value by providing you with the best opportunity to achieve maximum good health.

1 Mitka M:Groups spar over new hypertension guidelines. JAMA 311(7):663-664, 2014
2 Kieldsen SE, et al: Hypertension management by practice guidelines. Blood Press 23(1):1-2, 2014
3 Sheppard JP, et al: Missed opportunities in prevention of cardiovascular disease in primary care: a cross-sectional study. Br J Pract 2014, Jan;64(618):e38-46. doi: 10.3399/bjgp14X676447

Chiropractic Care and Chronic Health Problems

Chronic health problems such as high blood pressure and diabetes often require treatment plans from several different specialists. Effective treatment of high blood pressure may involve a person’s family physician, internist, and cardiologist. A person with diabetes may be receiving treatment from her internist and endocrinologist, and possibly from an ophthalmologist and even a neurologist. An additional key specialist involved in any of these scenarios is a chiropractor.

Of course, chiropractic care is not directed toward treatment of any disease. Rather, chiropractic care focuses on the health and well being of the whole person. By concentrating on biomechanics and the nerve system, that is, the integrity and functioning of the spinal column and spinal nerves, chiropractic care helps ensure that the body as a whole is working effectively. This means that whatever a person’s clinical circumstances may be, regular chiropractic care is essential to his or her long-term health. Your chiropractor is a key member of your health care team in any situation.


March 13, 2014

The Best Treatment for Trigger Points

Trigger points are painful nodules in muscular tissue, commonly found in the upper back, low back, and gluteal muscles. Trigger points are frequently chronic, persisting from day to day without much relief. When someone says, “My muscles are all in knots”, those knots are most likely trigger points.

The formal definition of a trigger point describes a localized region of tenderness, located in a tight band of muscle, which is associated with a palpable twitch in response to deep pressure over the tight band.1 Such deep pressure usually results in pain radiating from the trigger point to the surrounding soft tissues. Formally, if the twitch response is not present, the localized muscle tightness cannot accurately be termed a trigger point. It may also be argued that characterizing a local muscle “knot” as a trigger point requires the presence of the above mentioned radiating pain. These definitions are of importance when making decisions about appropriate care for painful muscle knots.

As with any care management decision-making process, some procedures make sense and others do not. Many so-called pain management physicians will recommend injecting painful trigger points with an anesthetic or even botulinum toxin.2,3 Such an invasive procedure is rarely required. Pain management practitioners and even specialists in internal medicine will recommend muscle relaxers such as Robaxin, Flexeril, or even Soma in attempts to diminish muscular pain in the shoulders or low back that may or may not be associated with the presence of trigger points. The problem with such medications is they do not address the underlying cause of the painful muscle knots. Further, their efficacy with respect to muscular pain is questionable.

The mistake, as is frequently the case, is in thinking of trigger points as a real entity. But trigger points do not exist in a vacuum. These painful muscle knots arise as a consequence of mechanical disturbances and stress in the rest of the body. Attempting to treat the trigger points themselves with injections or medications misses the real problem. Trigger points have arisen in a person’s shoulders or low back owing to chronic issues elsewhere, typically involving the spinal column itself and the small muscles that enable those vertebras to move in three-dimensional space.

Trigger points are best managed by directing care to the underlying issues, primarily involving loss of full mobility of spinal vertebras and resultant inflammation in spinal muscles. As with many other biomechanical problems, chiropractic care is often the best solution. By utilizing a specific, highly targeted, noninvasive approach, chiropractic care helps alleviate the factors that have led to the painful muscle spasms known as trigger points. As the underlying biomechanics improve, the trigger points themselves begin to resolve, all without the need for injections or medications.

1 Fernández-de-las-Peñas C, Dommerholt J: Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep 16(1):395, 2014
2 Kim SA, et al: Ischemic compression after trigger point injection affect the treatment of myofascial trigger points. Ann Rehabil Med 37(4):541-546, 2013
3 Zhou JY, Wang D: An update on botulinum toxin a injections of trigger points for myofascial pain. Curr Pain Headache Rep 18(1):386, 2014

Chiropractic Care, Your Nerve System, and Pain

The experience of pain causes all sorts of unpleasant physical reactions. Tight muscles are one such response, and muscular tightness may progress to localized knots, known as trigger points, and even muscle spasm. These responses are never a good thing, and usually result in more widespread and more intense pain.

The solution to most types of musculoskeletal pain involves getting at the underlying cause of the problem. Often, the underlying cause is biomechanical. Neck pain or low back pain, for example, frequently results from a lack of full mobility of spinal vertebras and the resulting irritation and inflammation of spinal muscles and spinal ligaments. Bigger problems may ensue when this irritation and inflammation begins to affect spinal nerves. Nerve inflammation may then involve other tissues and organs, with subsequent development of various symptoms and disorders.

By addressing the underlying cause of biomechanical pain, regular chiropractic care helps restore maximum function to both your spinal column and your spinal nerves. The long-term result is enhanced health and well being for you and your family.


March 2, 2014

Choosing the Right Diet for Me

It seems as if every few months there’s a new diet whose rules and requirements we must follow if we’re going to reach the goal of good health. The “paleo” diet provides a great example of this phenomenon. We’re exhorted by paleo proponents to eat lots of fats and animal protein. Carbohydrate consumption should befairly light.Grass-fed beef is prized by paleo-dieters. You may consume unlimited amounts of butter, and must eliminate all cereals, legumes, and dairy products (except butter of course) from your diet. Now unless you’re a paleo convert, these prescriptions may seem to fly in the face of everything you’ve ever known about healthy eating. Paleo supporters will respond with the claim that human biology developed over the course of hundreds of thousands of years and that agriculture is brand new, having arrived about 10,000 years ago. That’s worth thinking about, but we may remember that other diets backed by correspondingly compelling logic and dollops of science have come and gone over the course of many decades.

For instance, the Atkins diet is still going strong for more than 50 years. The main requirement of the Atkins diet is low carbohydrate consumption, and in this way the Atkins program resembles the paleo diet. High-protein consumption is the other pillar of the Atkins approach. The rationale was that such an eating plan would force your body to burn fat, rather than glucose, for energy. But the diet hasn’t withstood rigorous scientific scrutiny.1,2

Vegan and vegetarian diets have also been popular for many decades.3 The vegetarian lifestyle has wide appeal and vegetarian recipes are famed for their simplicity and palate-pleasing qualities. However, vegetarian contrarians do exist. Some studies even suggest that vegetarian or vegan diets may be associated with anxiety, depression, and neurologic dysfunction.3

The bottom line is that good sense should prevail. Starting a diet because the program was touted in a magazine article or a talk-show interview may not be in every person’s best interest. Simply put, any diet may be harmful to a particular person. It’s important to remember that what works for one person may not work for another. Paleo, Atkins, and vegetarian diets may create great benefits for certain persons, but may cause real medical problems for other people. The best overall approach for most us is to eat regularly from a wide variety of food groups, make sure to eat five servings of fresh fruits and vegetables every day, and pay close attention to portion control and calorie intake. Those desiring more detailed information and recommendations will find their chiropractors and family physicians excellent sources of expert guidance.

Regular Chiropractic Care and Your Diet

fruitsRegular chiropractic care is helpful for musculoskeletal conditions such as back pain, neck pain, and headache. Regular chiropractic care is also important for maintaining the functioning of other key components of your health and well-being such as digestion and metabolism. As the normal physiological activities of all your body systems depend on the nerve system for instructions, proper timing, and signaling, the nerve system itself needs to be kept in working order. This is the role of chiropractic care.

Effective, healthy functioning of your digestive system and a well-orchestrated metabolic system will help you get the most benefit from the good food you’re eating. Regular chiropractic care helps make this possible.

1 Noto H, et al: Low-carbohydrate diets and all-cause mortality: a systematic review and meta-analysis of observational studies. PLoS One 2013;8(1):e55030. doi: 10.1371/journal.pone.0055030. Epub 2013 Jan 25
2 Lagiou P, et al: Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study. Br Med J 2012 Jun 26;344:e4026. doi: 10.1136/bmj.e4026
3 Plotnikoff GA: Nutritional assessment in vegetarians and vegans: questions clinicians should ask. Minn Med 95(12):36-36, 2012


February 27, 2014

Effective Diagnosis and Treatment of Low Back Pain

Here’s an all-too-common situation. You develop low back pain that lasts for more than a few days and you’re uncomfortable enough to go see your primary care physician. He or she tells you it’s not clear what’s going on and sends you for a magnetic resonance imaging (MRI) study of your lumbar spine. The study comes back showing one or two herniated intervertebral discs. [Intervertebral discs are cartilaginous shock absorbers interspaced between pairs of spinal vertebras.] Your doctor informs you that you have “herniated discs in your back” and prescribes medications and a course of physical therapy. Your doctor may even refer you to an orthopedic surgeon to evaluate the need for surgery on your back.

Now, all of these recommendations may be necessary. Or none of them may be necessary and all that’s needed is some rest and an exercise rehabilitation program that you could do on your own if you were given the proper instructions. The culprit here is how the presence of the herniated disc or discs is interpreted. It’s important to remember that not all herniated discs are a problem requiring a solution. In fact, a sizable proportion of such disc herniations (30% or more)1 represent the progression of natural processes and are not a problem at all.2,3 But many family doctors and even specialists are not appropriately trained in accurate differentiation among the various possibilities. When faced with MRI evidence of a herniated disc, such doctors see it as a disorder or disease that needs to be treated and fixed. Such an approach results in significant stress and leads to unnecessary procedures and financial hardship for many patients.

Given the frequency of occurrence of such instances of “over-diagnosis”, how can a person with back pain expect to receive appropriate care? Of course, people as patients are usually not in a position to be able to overrule their doctor’s recommendations. The answer lies in obtaining relevant information. Let your doctor know you’re aware that up to one-third of normal persons have herniated discs, and ask whether it’s possible that your disc herniation is in fact unrelated to your back pain and merely an incidental finding. Further, if your back pain is not accompanied by leg pain radiating below your knee, it may be that the disc herniation is not affecting spinal nerve roots and may be treated by very conservative measures such as rest followed-up with exercise.

Thus, not all disc herniations have the same impact on a person’s health. Some represent normal findings, even if they are present in a person who has back pain. Let your doctor explain to you exactly why your particular problem requires more than watchful waiting. Your local chiropractor will be able to provide you with the very best expert advice and recommendations for any necessary treatment.

1 Takatalo J, et al: Does lumbar disc degeneration on magnetic resonance imaging associate with low back symptom severity in young Finnish adults? Spine (Phila PA 1976) 36(25):2180-2189, 2011
2 Spontaneous regression of herniated lumbar discs. Kim ES, et al: J Clin Neurosci 2013 Oct 24. pii: S0967-5868(13)00552-3. doi: 10.1016/j.jocn.2013.10.008. [Epub ahead of print]
3 Endean A, et al: Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. Spine (Phila PA 1976) 36(2):160-169, 2011

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