Tuesday, December 10, 2013

Food For Health

Most people are aware of the worldwide epidemics of diabetes and obesity. The World Health Organization definition of overweight is a body mass index (BMI) equal to or greater than 25. Obesity is defined as a BMI equal to or greater than 30.1 Worldwide obesity has doubled since 1980. In 2008, 35% of adults aged 20 and older throughout the world were overweight and an additional 11% were obese. Further, more than 347 million people worldwide have diabetes.2 In other worlds, one out of every 20 persons has diabetes.

What's going on? Why be concerned? These conditions do not exist by themselves. Both contribute to additional severe health issues. Obesity is the leading cause of pediatric high blood pressure and increases the risk of coronary heart disease. Uncontrolled diabetes, over time, can lead to kidney disease, heart disease, disorders of the nerve system, and blindness.

In the face of these life-threatening epidemics it's important to look for any good news. The good news is that both obesity and diabetes can be addressed with lifestyle-related changes. A suboptimal diet and lack of exercise are causes of both conditions. This is well-known. It is also well-known that maintaining a healthy diet and getting regular exercise prevents obesity and prevents or delays the most common type diabetes (type 2 diabetes).

A healthy diet consists of regularly consuming food from all major food groups and consistently eating only that amount of food necessary for your daily energy requirements. If you're interested in losing weight and then maintaining the best weight for your body, a daily calorie intake between 1800 and 2100 calories is good for most men, and a daily calorie intake between 1700 and 1800 calories is good for most women.3 There is a third component of healthy eating that regulates how your body uses the food you eat. This additional component is known as food combining.

Food combining involves combining protein and complex carbohydrates at each meal. This important step is the key to a healthy, optimally functioning metabolism. When your metabolic processes are working efficiently, you’re burning carbohydrates for energy. Your blood insulin levels are steady throughout the day. In contrast, without food combining, your digestive processes send unregulated amounts of glucose into the blood stream every time you eat a meal. The result is frequent swings in insulin levels and storage of these glucose molecules (broken-down carbohydrates) as fat. Long-term, over months and years, such eating patterns can lead to being overweight, obesity, and diabetes.

Putting the dietary principle of food combining into practice is easy. All that's required is paying attention to meal planning. The result of this simple series of steps is better health for you and your family, now and in the future.

1WHO Fact Sheet No. 311 (March 2013): http://www.who.int/mediacentre/factsheets/fs311/en/

2Danaei G, et al: National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980. Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 378(9785):31–40. 2011

3Campbell KL, et al: J Clin Oncol Reduced-Calorie Dietary Weight Loss, Exercise, and Sex Hormones in Postmenopausal Women: Randomized Controlled Trial. J Clin Oncol 30(19):2314-2326, 2012

Dr. Joshua Brooks
Chiropractor Falls Church VA 22046

Friday, September 27, 2013

Get Fit at Fifty and Beyond

What if you used to be really fit and now you're not? What if, as the years have gone by, you've added a couple of pounds here and there, and you suddenly notice you're 30 pounds heavier than you were at your 10th high school reunion? Or, what if you've never enjoyed the idea of exercising, exercise was never part of your world-view, but you're not feeling as good as you'd like to feel and think that exercise might help improve your overall health and sense of well-being?

Many people want to get fit or want to regain a former level of fitness for a variety of considerations, including the above scenarios.1,2 But most of us need guidance in the process of getting fit. We need information and even instruction on what to do and how to do it. For example, it would be a serious mistake for someone older than 50, and even older than 40, to simply go out and try to run 4 miles if he had never run before. Muscle strains, shin splints, or even a stress fracture of one of the bones in the foot would be a likely and unwanted result. Similarly, going to the gym and trying to "work heavy" would assuredly create various problems for an out-of-shape person who wanted to "get fit" as quickly as possible. The injured tendons and sprained ligaments resulting from trying to rush would set back your hoped-for progress by at least four to six weeks, further delaying achievement of improved health.

The best way to get fit or return to fitness after a long period of inactivity is to start slowly, progress in small increments, and gain an authentic, long-lasting level of fitness over months and years. Being a smart exerciser means not doing too much too soon, in other words, respecting your body's capabilities. Also, smart exercise involves engaging in a blend of activities, usually on alternating days. Persons who only bike or run and persons who only lift weights will never be as healthy and fit as those who do both aerobic activity and strength training.3 Developing a two-week schedule will provide a thorough, balanced fitness program. In week A you do aerobic exercise (walking, running, biking, swimming laps) on Monday, Wednesday, and Friday. You do strength training on Tuesday and Thursday. In week B you reverse activities, doing strength training Monday, Wednesday, and Friday and aerobic exercise on Tuesday and Thursday. This alternating pattern ensures you are getting the full benefit of your valuable time spent exercising.

It is important to remember that what works for you, works for you. Each of us needs to find his or her best way forward. Some methods of exercise will be experienced as intuitive and enjoyable. Others will be experienced as the opposite. You probably won't want to continue any of the latter. For example, the exercise program suggested by your friend may not be effective for your physical makeup and may even be harmful. Your chiropractor is an expert in healthy exercise and will be able to recommend fitness activities that will be right for you.

1Johanssen NM, et al: Categorical analysis of the impact of aerobic and resistance exercise training, alone and in combination, on cardiorespiratory fitness levels in patients with type 2 diabetes mellitus: results from the HART-D study. Diabetes Care 2013 July 22 [Epub ahead of print]

2Stanton R, el al: Is cardiovascular or resistance exercise better to treat patients with depression? A narrative review. Issues Ment Health Nurs 34(7):531-538, 2013

3Lorenz D, Reiman M: The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and acl reconstruction. Int J Sports Phys Ther 6(1):27-44, 2011

Dr. Joshua Brooks
Chiropractor Falls Church VA 22046

Thursday, August 1, 2013

Short Term and Long Term Health

Chiropractic care is the one form of health care that keeps on giving. Chiropractic care certainly helps people to recover from short-term health problems, but this powerful method of healing also helps people stay well and assists in preventing new problems from developing.

Your chiropractor treats a wide variety of musculoskeletal problems. Neck pain, back pain, pain that travels from the neck to the arm and hand, pain that travels from the back to the leg and foot, headaches, and muscle spasms are conditions commonly treated by chiropractic care. Your chiropractor also treats many types of exercise- and sports-related injuries, such as rotator cuff injuries, tennis elbow, wrist sprains, knee injuries, ankle sprains, and shin splints. Repetitive stress injuries such as carpal tunnel syndrome are also treated by chiropractic care. Also, chiropractic care may be a valuable addition to treatment for sleep disorders, digestive problems, menstrual cramps, asthma, and various allergies. Chiropractic care may also be of great assistance during pregnancy, in helping to relieve neck pain and back pain and to ease the process of delivery.

Chiropractic care can be beneficial for so many health problems owing to the fact that chiropractic care directly affects the functioning of your nerve system. Your nerve system, consisting of your brain, spinal cord, and nerves that branch out to the rest of your body, is your master physiologic system. Your nerve system, by sending signals to every cell, tissue, and organ in your body, controls all the other systems. Your heart relies on the nerve system so that it can pump blood at the right time and in the right amount.1 Your small intestine relies on the nerve system so that it can complete the digestion of food and transmit usable nutrients to the bloodstream.2 Your white blood cells and other immune system agents rely on the nerve system so that they can quickly identify and destroy foreign invaders such as bacteria and viruses.3

But your nerve system can break down, in a sense, if spinal nerve interference is present. Such nerve interference, caused by irritation and inflammation of spinal nerves, is caused by loss of full mobility of spinal vertebras. Limited spinal motion irritates the muscles that move the spinal bones and the ligaments that hold those bones together. Inflamed spinal muscles and spinal ligaments cause spinal nerve inflammation. The immediate result is distortion in the quality and flow of information sent from the brain to the rest of the body. Too much or too little information is sent to the cells, tissues, and organs. The messages they receive are the wrong messages, or the messages arrive at the wrong time. The outcome is decreased functioning and/or inappropriate functioning of many other physiologic systems. Thus, spinal nerve interference is one of the primary causes of the many problems that may bring a person to his or her chiropractor's office.

Chiropractic care helps reduce and remove nerve interference by restoring increased functioning of your spinal column. The direct result is improved overall functioning of the rest of your body. By directly focusing on your spine and nerve system, your chiropractor can help restore quality of life and overall health and well-being.

Dr. Joshua Brooks
Chiropractor Falls Church VA 22046

1Muller MD, et al: Mental stress elicits sustained and reproducible increases in skin sympathetic nerve activity. Physiol Rep  2013 Mar 1(1). pii: e00002.
2Zhou G, et al: White-matter microstructural changes in functional dyspepsia: a diffusion tensor imaging study. Am J Gastroenterol 108(2):260-269, 2013
3Straub RH, et al: Role of neuroendocrine and neuroimmune mechanisms in chronic inflammatory rheumatic diseases-The 10-year update. Semin Arthritis Rheum 2013 May 31 doi: 10.1016/j.semarthrit.2013.04.008 [Epub ahead of print]

Sunday, July 21, 2013

Taking Care of Older Joints (and Younger Joints Too!)

Many people experience increasing musculoskeletal joint stiffness as they get older. Shoulders, knees, and ankles don't seem to be as flexible as they once were. It seems more difficult to bend over and pick up a dropped object. It may be uncomfortable to turn your head around to see the car in the next lane that's right in the center of your driver's blind spot. The bad news is that, left unattended, your joints do get stiffer as you get older. Left on their own, your joints will likely lose full mobility. The good news is there's plenty you can do about it. You can regain and retain much of your youthful flexibility if you are willing to be proactive.
First, some basic physiology. Joints such as the shoulder, knee, and ankle are lubricated by synovial fluid. Synovial fluid keeps joints moist, provides oxygen and nutrition, and washes away toxic end-products of normal metabolic processes. The joints in your spine are also lubricated and maintained in this way. But aging reduces the amount of available synovial fluid. Also, normal aging processes increase the viscosity of the remaining synovial fluid. You have less available lubricant and the lubricant that you do have is thicker. The result is stiffer joints, pretty much from top to bottom.
The specific countermeasure to such physiologic aging is to keep active. This is a pretty challenging prescription in a world in which most of our time is spent seated. Our bodies were designed for hard, physical work. But as we've transformed from an agrarian to an industrial society, and more recently from an industrial to a service-based society, the nature of our work has changed dramatically. The vast majority of our work is now done seated at a desk. When we're not typing on a computer keyboard or reading a spreadsheet, we're at home watching TV, playing games on our computing devices, or very rarely, reading. None of these activities involves active motion. If we want to take care of our bodies, we're going to have to be proactive about creating the time to do so.
We're going to be creating time for exercise. Almost any type of exercise causes synovial fluid to be more available, pumping synovial fluid into joint spaces and helping to lubricate joints.1,2 Exercise increases your internal core temperature, which in turn decreases the viscosity of synovial fluid. The overall result is increased joint flexibility. This benefit is often experienced immediately. The benefit will be long-lasting provided that you continue to exercise regularly.
Thirty minutes of exercise per day, 5 days per week, will assist most of us in maintaining as much joint flexibility as possible. Alternating a cardiovascular exercise day with a strength training day is an optimal program.3 Yoga provides a total body workout which incorporates cardiovascular exercise, strength training, and flexibility. Ultimately, the types of exercise you do are less important than the long-term consistency. Regular, vigorous exercise, done over months and years, will provide great benefit, not only in terms of improved joint flexibility, but also in terms of overall health and well-being.
1Seco J, et al: A long-term physical activity training program increases strength and flexibility, and improves balance in older adults. Rehabil Nurs 38(1):37-47, 2013
2Garber CE, et al: American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 43(7):1334-1359, 2011
3Micheo W, et al: Basic principles regarding strength, flexibility, and stability exercises. PM R 4(11):805-811, 2012
Dr. Joshua Brooks
Chiropractor Falls Church, VA 22046

Monday, May 20, 2013

Kobes Achilles Rehab Process

A good read from Espn regarding Kobe Bryants Rehab protocol...

Even before an MRI Saturday confirmed a complete (Grade III) rupture of Kobe Bryant's left Achilles tendon, everyone, especially Bryant, already knew the extent of the injury. After all, Bryant had experienced the telltale symptom of a torn Achilles, saying after Friday night's game that he felt like he "had been kicked." If not literally, Bryant was at least figuratively struck by an injury that will force a premature end to his season and raise the question in everyone's minds as to what happens next.
As it turns out, Bryant didn't waste much time deliberating the future. On Saturday he underwent surgery to repair his Achilles with orthopedic surgeons Dr. Neal ElAttrache and Lakers team physician Stephen Lombardo, and in that moment began his road to recovery. All indications are that Bryant intends to play again, and while the rehabilitation process is lengthy and intense, there is reason to believe he will indeed see the court in the 2013-14 season.
Here are some of the key points to consider in recovering from an Achilles tendon repair:
1. Controlling swelling: The first few days following surgery are targeted at controlling swelling as much as possible and promoting healing of the wound (where the surgical incision was made). Guarding against infection is essential in moving the recovery forward. There is always a risk of infection with any surgical procedure, so close monitoring of the wound and controlling inflammation are imperative.
2. Protect the repair: The most important element in the early stages of recovery is protecting the Achilles repair. Specifically, it is critical not to overstretch the tendon, which would result in over-lengthening, which would then be impossible to reverse. Consider that the functionality of the tendon is dependent on energy and explosiveness that comes when pushing off the foot. If the tendon loses elasticity -- which would happen if it were to lengthen excessively -- the athlete would lose the ability to push off the foot effectively, a requisite skill for any sport,  especially basketball.
To guard against this, the tendon is protected in a shortened position in the early phase post-surgery. Bryant's ankle will be maintained in a slightly plantar-flexed position (toes pointing downward) with the assistance of a splint and he will not be allowed to bear weight initially. Even his early range-of-motion exercises will be limited to focusing on pointing the ankle down; there will be no stretching of the calf.
3. Progress to normal walking: Bryant will be transitioned from an immobilizing splint to a boot with extra heel support inside (again, to avoid overstretching the tendon) but will still be on crutches and bear only partial weight. Gradually he will progress off crutches while still in the boot, then eventually he will move to a normal (athletic) shoe with a heel support inside. The final step is moving the heel support out of the shoe and getting the foot to its normal resting (neutral) position. Throughout this time, Bryant will be working on range of motion, light strengthening and cardiovascular exercise (such as stationary bike).
4. Restore movement patterns: By approximately three months, Bryant should be approaching full range of motion. He will likely have incorporated walking on an Alter-G treadmill, which reduces total body weight so that there is less load on the healing tissue but still permits the athlete to restore normal movement patterns. It's important for the body's nervous system to relearn normal motion after that motion has been forcibly interrupted for a period of time. The sooner that process begins, the less likelihood of developing compensations which can lead to additional problems down the line.
5. Rebuild sports-specific skills, training: Once the repair has had the opportunity to heal and normal walking has been restored, then it's a matter of pushing the athlete's cardiovascular training, strength, balance and coordination. Agility and sports-specific drills are added later with an eventual return to basketball activity. Controlled time and exposure to contact progresses to increasing minutes and unrestricted contact.
For the first few months, the athlete has to be restrained from progressing too quickly in order to protect the repair. Once the repair has healed to the point where it is safe to resume more aggressive activity, the athlete then has to push himself hard to regain what he's lost during the protective period.
[+] Enlarge
Kobe Bryant
Andrew D. Bernstein/NBAE/Getty ImagesBryant has a long six to nine months ahead of him.
If all goes well, the hope is that Bryant will be able to return to play within six to nine months, the timetable offered by the Lakers. It's worth noting that there isn't a large pool of comparables in the NBA when it comes to return to play following an Achilles tendon repair. Some have returned to play successfully (Dominique Wilkins) and others have retired in the wake of the injury (Isaiah Thomas). Chauncey Billups of the Los Angeles Clippers is perhaps the most recent example of an NBA player to return from a torn Achilles. After tearing his Achilles in February 2012, Billups returned to play in late November of the same year. However, he has been challenged by several other ailments (foot, back, groin) throughout the season.
The obvious and most routine demands on the Achilles of running up and down the court and jumping and landing repeatedly can be more easily overcome by the athlete. Perhaps the most challenging element of a basketball player's game to regain following this type of surgery, however, is sudden acceleration, the quickness off the foot necessary to make a sharp move around an opponent.
Athletes will often say that it is this explosiveness, this quickness that takes nearly a year to regain, perhaps long after returning to competition. Internally, the tendon continues to be shaped and modeled by the stress the athlete places on it as he returns to increasingly demanding activity. That internal adaptation is essential for the athlete to ultimately regain the feel of a "normal" leg, one that no longer feels different than the other. Simply put, it takes time.
Of course, Bryant is anything but normal even within the sphere of elite athletes. He has proved that he has the mental toughness and physical fortitude to push himself beyond what others around him might be doing. He will need to call on both, particularly in the later stages of his recovery from this Achilles repair, in order to return to the court this fall.
By then, Bryant might have everyone thinking back to the sight of him limping off the court in April and wondering whether there was ever really any doubt about what would happen next.

Dr. Joshua Brooks
Chiropractor Falls Church, VA 22046

Sunday, April 7, 2013

Cervical Adjacent Level Degeneration, a Case Study


A 51-year-old man, who is a former professional lacrosse player status post C3-C7 laminectomy without fusion (10 years prior) and C5-C6 ACDF (5 years prior) for myelopathy, presents with right arm pain (mild to moderate) and severe right triceps weakness (2 out of 5 strength).


No evidence of myelopathy. Triceps strength 2/5, decreased triceps reflex 0.  Sensory deficit in C7 distribution.  Absent deep tendon reflex right triceps.

Prior Treatment

Prior surgery C3-C7 laminectomy without fusion (10 years prior).  C5-C6 ACDF 5 years prior.
Extensive PT (no improvement).  One C7 selective nerve root block (temporary relief).


Right C7 herniated disc and C7 palsy

Case Discussion

This case highlights many of the issues that we face with adjacent level degeneration after cervical surgery.  This patient underwent a C3-C7 laminectomy in the past with subsequent C5-C6 ACDF.  The patient exhibits significant and recalcitrant C7 radiculopathy that is affecting his quality of life.  The MRI displays anterior compression cephalad at C4-C5 with some posterior scar or residual ligamentum flavum hypertrophy as well as a significant C6-C7 disc herniation that is commensurate with the C7 radiculopathy that the patient endorses in subjective questioning and objective examination.  Since the patient underwent a prior multilevel laminectomy and decompression, a revision posterior operation (even to perform a C6-C7 foraminotomy) can be fraught with potential complications, including dural tear, nerve root injury and likelihood of residual scar formation post-operatively.  The concept of a fusionless operation at C6-C7 is intriguing; however, with the patient being 50 years of age, the likelihood of his displaying facet arthrosis is significant and a relative contraindication for a disc replacement. (Comparison of magnetic resonance imaging and computed tomography in predicting facet arthrosis in the cervical spine. Lehman RA Jr, Helgeson MD, Keeler KA, Bunmaprasert T, Riew KD. Spine (Phila Pa 1976). 2009 Jan 1;34(1):65-8)
After obtaining pre-operative consultation with ENT to perform a direct laryngoscopy to assess the vocal cords after the previous anterior approach, a good option is to address this pathology from an anterior operation since that is the site of the compression.  Performing a discectomy from a posterior approach in the setting of previous laminectomy may lead to a higher complication rate.  Removal of the plate at C5-C6 and performance of a generous discectomy and foraminotmy with take down of the posterior longitudinal ligament (PLL) allows for adequate excision of the disc fragment and decompression of the posterior osteophytes. The other consideration is to properly evaluate the C4-C5 level to determine if there is a decreased threshold for symptoms at the C6-C7 level because of the compression at C4-C5.  This level could be contributing to the post-operative pain experienced by the patient and should be followed longitudinally for development of symptoms. I agree with the treatment of addressing the C6-C7 level from an anterior approach.  Continued follow up with particular attention to the C4-C5 level is warranted.
Dr. Joshua Brooks

Friday, March 22, 2013

Updated Concussion Guidelines, New Article


Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article.
Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations.
Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Report of the Guideline Development Subcommittee of the American Academy of Neurology

  1. Ross Zafonte, DO
Dr. Joshua Brooks