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Carpal Tunnel Syndrome and Vitamin B6.

19 Feb

Carpal Tunnel Syndrome (CTS) is a common condition usually associated with repetitive strain from jobs that require a fast, constant movement of the arms and hands (such as working on an assembly line). Up to 9% of adult women develop CTS and the incidence increases after age 50. A common medical treatment approach has been a combination of drugs (including corticosteroids), diuretics, splinting at night, and modifying activities, often including a “light duty” status until the symptoms calm down. Prior to accepting surgery as, “…the only option left,” an “alternative treatment” approach of vitamin B6 (and of course, chiropractic manual therapies) is chosen by many. Many treatment approaches have been previously discussed; however, today, we’ll take a closer look at the vitamin B6 /CTS connection.

Research regarding the use of vitamin B6 or, pyridoxine, can be traced way back into the ‘70s and ‘80s when it was reported that B6 is involved in several metabolic pathways, including neural function (“neurotransmission”). This is how it helps CTS patients since CTS occurs as the consequence of a pinched (median) nerve at the wrist. Findings from the initial studies, though quite small in terms of the number of subjects, suggested B6 improved the symptoms of CTS (such as, numbness and tingling into the 2nd to 4th palm-side fingers) by raising the pain threshold (that is, the point when symptoms occurred). Another study reported improvements in pain scores and mild improvements in electromyography and nerve conduction velocity (EMG-NCV) studies. Another study reported that at least 7 patients in their study were B6 deficient when blood tested. Regarding the dose, one study reported that taking only 2mg of B6 was enough to improve the patient’s CTS symptoms, but 100mg was needed for the avoidance of surgery. In a large “retrospective literature review” of 994 CTS patient files, it was reported that when 494 patients were treated with 100mg twice a day, the rate of symptom alleviation was 68%, much higher than group that did not receive B6 (only 14.3%). Yet, controversy is still reported about the effectiveness of B6 and firm conclusions are lacking. Despite this uncertainty, 200 mg of vitamin B6 is frequently included as part of the non-surgical “package” (along with NSAIDs like ibuprofen, nighttime splints, and an ergonomic workstation evaluation).

So, how much B6 is “enough?” The recommended daily intake is only 2 mg or less for all ages, genders and lifestyles with an upper limit set at 100 mg/day. The main toxicity issue is sensory neuropathy, which (oddly) is very similar to the symptoms caused by CTS! The good news is that CTS symptoms rapidly disappear at doses < 1000 mg/day and most studies indicate no toxic neuropathy by taking doses between 40 and 500 mg/day. Hence, it is recommended to never exceed 500mg/day and most recommendations are in the 100-200 mg/day range. If symptoms improve, a gradual reduction in the dose after about 3 months is advised. Closer monitoring of symptoms in those taking >200mg/day is recommended, especially since the symptoms of toxicity and CTS are so similar. Other B6 toxicity symptoms include depression, fatigue, impaired memory, irritability, headaches, altered walking, and bloating. So, keep your eyes open if doses >200mg/day are taken. Other micronutrients to consider that are anti-inflammatory in nature include omega 3 fatty acids, vitamin D, magnesium (often in combination with calcium), Co-Q10, proteolytic enzymes, and herbs such as ginger, tumeric, boswellia, white willow bark and more.

We realize you have a choice in who you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs.  If you, a friend or family member require care for CTS, we would be honored to render our services.

 

Fibromyalgia – The Latest on Exercise!

19 Feb

Exercise therapies have been identified as one of the most effective forms of treatment for Fibromyalgia (FM). Unfortunately, in a study of 121 newly diagnosed FM patient files, less than half included an exercise recommendation. This statistic is alarming! This month’s article will focus on recent FM studies supporting the benefits of exercise.

The first study looked at the immediate effects of a 6-mo. combined exercise program and its impact on quality-of-life, physical function, depression, and aerobic capacity in 41 FM females. Also, it studied the impact of starting and stopping the program. A group of 21 women were placed into the exercise group and 20 into the control group. Questionnaires and a physical fitness screen were used to measure the outcome or benefits of the program vs. no intervention at baseline (initial), and after 6 months of exercise training followed by 6 months of no exercise training over a 30 month timeframe. Results highly favored the exercise training group over the control group in all parameters both during the exercise training (immediate effects) and during the no exercise 6 month time frames (long-term benefits).

A Chicago-based pilot (small-scaled) study evaluated the use of aerobic conditioning (VO2 max.) on 26 FM subjects at baseline and after a 12-week home-based aerobic exercise program. The exercises included a 30 minute program at 80% of the maximum heart rate, and also measured pain, disability, depression and stress. Results showed those who successfully completed the 12-week program demonstrated an increase in aerobic conditioning, and a trend towards less pain, disability and stress reduction. Those who were unable or unwilling to participate had significantly higher pain, disability and a trend toward more depression at baseline vs. those that completed the program. The conclusions suggest aerobic exercises benefits the FM patient’s quality of life and, VO2 max is a useful marker for measuring exercise benefits. Also, those scoring initially high in the pain, disability, depression/stress measures were more likely to fail and may benefit from a more comprehensive guided program.

Another study looked at the effects of a 3x/week, 16-week exercise program in a chest-high pool of warm water measuring global symptoms and exercise adherence (compliance) levels. A group of 60 middle-aged FM women were compared to 20 healthy, similarly age matched females before and after a 16 week aquatic exercise program that included strength training, aerobic training and relaxation exercises. Tender point count, health status, sleep quality, physical endurance, psychologic and cognitive function were measured and, compliance at 12-months was studied. Again, the results revealed statistical improvement in most of the parameters tested in the FM exercise group and, 23 of the 60 were still exercising at 12 months. Again, the conclusions favor the need for exercises in the management of FM.

As noted in the initial paragraph, in spite of all the positive research support for including exercise training in FM patients, less than half of newly diagnosed FM suffers are given exercises as part of their treatment plan. The need for exercises to be part of the FM treatment plan is clear, and training needs to be initially structured to enhance compliance.

If you, a friend or family member requires care for FM, we sincerely appreciate the trust and confidence shown by choosing our services!

 

Neck Pain and the Deep Neck Flexors.

19 Feb

It’s safe to say that if you haven’t had neck and/or shoulder pain, you probably will. Like low back pain, there is a statistical increase in probability that once you’ve had neck pain, the chances of having another episode are significantly increased. A recent study reported that over a 12-month period, 16-18% of the population studied complained of neck and shoulder pain and each year, medical care was obtained by 21-38% of that same group. Moreover, 13-21% lost work time because of their neck and/or shoulder pain. The study reported there was a “…strong episodic nature…” as this condition was found to frequently come and go. Neck pain can arise from a number of structures including muscles, ligaments, bone, joint capsules, and more. Typically, a patient presenting with neck pain is treated for a few weeks and is then quite satisfied with their result… until the next time. Unfortunately, there is usually, “…a next time.” So, the question is, what can we do to prevent neck pain or its reoccurrence?

When considering the many causes of neck pain and the high rate of recurrence, one common finding in those with this popular “come and go” neck/shoulder pain pattern is weakness of the deep flexors muscles located in the front of the neck. One reason for this common finding is that it is very difficult to strengthen the deep, intrinsic muscles of the neck as they are “involuntary.” That means, we cannot consciously “flex” or purposely contract our deep neck flexor muscles. Also, the larger extrinsic muscles tend to be too tight and by reflex, “turn off” or, inhibit the deep neck flexor muscles, compounding the problem.

Therefore, in order to exercise them, we must “trick” the deep muscles into contracting without contracting the larger, extrinsic muscles. This can be accomplished by doing a very specific, controlled exercise with our neck by laying on the back with a partially inflated blood pressure cuff (or, by using a special device purposely made for this test and exercise) placed behind the neck. The inflatable bag is pumped up partially to about 20mmHg and then in a VERY controlled manner, we tuck in our chin and flatten our neck pressing into the bag raising the pressure by 2mmHg and holding that steady for 3-5 seconds. This is repeated in increments by pushing down a little harder until the gauge reads 24mmHg and again, holding that for 3-5 seconds. This pattern is repeated 5x or, until you reach 30mmHg and the process is then reversed releasing the pressure in 2mmHg increments at 3-5 second holds until you reach 20mmHg again. Sound easy? Not quite!!! This exercise requires “fine motor control” to accomplish the task and most of us haven’t specifically addressed these fine moving muscles and end up only exercising the larger extrinsic muscles by doing traditional neck strengthening exercises, which further inhibits the deep neck flexors.

The first time you try this, you’ll be amazed at how challenging and tiring it is. But, after a few days of performing the exercise, you may find you feel much better!  Of course, this depends on the degree of injury one has, but often, once cervical spine stability is improved by strengthening these deep neck flexors, symptoms usually improve. So, the question is, can we achieve good deep neck flexor strength by doing a more practical, upright position exercise rather than requiring a costly apparatus that requires a laying down position?  In a recent study, a standing exercise where a similar movement called, a “neck-lengthening maneuver” was performed producing similar results as the laying down exercise (relaxation of the strong, extrinsic – outside – muscles and strengthening of the deep neck flexors). Simply tuck in the chin and stand tall, “lengthening” your neck!

We realize that you have a choice in where you choose your healthcare services.  If you, a friend or family member requires care for neck pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

 

Whiplash and Muscle Weakness.

19 Feb

Whiplash, as previously discussed, occurs quicker than the speed at which we can voluntarily contract our muscles in attempt to guard ourselves against injury. Hence, it is nearly impossible to properly brace in anticipation of an impending collision. When muscles, ligament, and joint capsules become injured, there is pain, and as a result, reflex muscle spasm occurs as the body attempts to “splint” the area to protect it. This sometimes sets up a vicious cycle which can make the pain last longer, hurt more intensely and / or hurt more frequently. Because of pain, as well as direct muscle injury that sometimes occurs in whiplash associated disorders (WAD), the natural tendency is to stop doing many activities and guard against motion both because of pain and the fear of it hurting worse. In both cases, the result is the same: muscle atrophy or shrinkage and muscle weakness due to not using the muscle.

There are other reasons that muscles become weak. When an injury occurs, a herniated or “ruptured” disk can injure the spinal nerves exiting the spine. The disk is like a jelly donut where the center is liquid-like surrounded by a thick ring of fibrocartilage and functions as a “shock-absorber” as it sits between 2 vertebral bodies

Think of the spinal nerves like electrical wires that connect a fuse box to a house. The fuse box is the spinal cord and each wire represents the spinal nerves going to different parts of the house (body). In the cervical spine or neck, each wire goes to different parts like the head, shoulder, arm, and hand and innervates specific areas. Patients who have a pinched nerve from a whiplash injury describe their symptoms as numbness, tingling, pain and/or muscle weakness in a specific distribution or area.

There are 8 pairs of nerves in the neck that travel to different parts of the head (C1-3), the shoulders (C4, 5), and the arm (C6-T2). Let’s say a patient has numbness and tingling down the arm to the 4th & 5th fingers and the pinky side of the hand. That immediately tells us as chiropractors that the C8 nerve is injured (pinched) because that’s the pain pattern of the C8 nerve.  Certain muscles are controlled by C8 that we can test in our office to determine if they are weak (abnormal) or strong (normal).

We grade the weakness between 0-5 (5=normal). The chiropractic treatment is aimed at un-pinching the nerve which results in a return of normal nerve function or no numbness/tingling and a strong C8 muscle (finger flexion strength). To accomplish this, we may use a combination of treatments such as spinal adjustments, mobilization, traction, exercises, and/or modalities (electric stim, light therapy, ultrasound or others).

We realize you have a choice in where you choose your healthcare services.  If you, a friend or family member requires care for whiplash, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

 

Carpal Tunnel Syndrome – More Facts!

10 Feb

Carpal Tunnel Syndrome (CTS) is a condition where a nerve in the wrist gets pinched resulting in numbness, tingling and sometimes grip strength loss. One of the first symptoms of CTS involves waking up at night due to the numb, tingly sensations. This initially occurs once in a while but  eventually  becomes more frequent, leading to very un-restful, sleepless nights. Most people do not initially attribute this sleep interruption to CTS but rather report, “…it’s coming from sleeping on my arm or lying in a funny position.” Because restful sleep is a very important health issue, this early CTS symptom should prompt the person to investigate the problem, but usually they wait, sometimes for months or even years, making treatment more challenging.

Other symptoms may include waking up in the morning with wrist and/or hand pain, difficulty buttoning a shirt or threading a needle, radiating arm symptoms into the forearm, shoulder and/or neck, dropping silverware, pens, coffee cups, and, a specific pattern of numbness such as the index, middle, and part of the ring finger. The degree of functional loss varies from none to total disability, not being able to work or carry out many home activities. Some people notice the symptoms during the day while performing fast, repetitive movements such as playing piano, typing, using a computer mouse, crocheting/knitting, writing, assembly work, and more. Some of the most frustrating complaints from CTS patients are lost work time (due to both CTS symptoms and fatigue from not sleeping at night), a loss in earnings, lack of dexterity (buttons, tying shoes, turning a key in a door or car, fixing hair, applying make-up), daytime grogginess, and irritability that can impact their quality of life, including their relationships.

A question that often arises is, what is carpal tunnel syndrome? A simple answer is “tendonitis” or, inflammation of the tendons that connect the muscles on the palm side of the forearm (flexor muscles) to their respective tendons that attach in the hand and fingers. Digging a little deeper, there are nine of these tendons that travel through the tunnel, rubbing together as we move our fingers and all is usually well unless there is too much friction resulting in swelling in this confined space. In fact, CTS remains silent until the swelling starts pushing or compressing the median nerve at which point the numbness, tingling, pain, etc., are noticed.

So, the next question is, what can be done to stop the inflammation from compressing the nerve? A very common treatment approach is the use of a cock-up splint at night, which stops us from bending the wrist in our sleep. In a normal, non-CTS wrist, the pressure in the carpal tunnel increases 2-fold when we bend our wrist; however, if inflammation already exists inside the carpal tunnel, the pressure increases by many multiples. This is why sleep interruption is so common in CTS as we just can’t control our wrist position at night. Another common anti-inflammatory approach is cortisone shots into the carpal tunnel and/or taking an anti-inflammatory drug like ibuprofen. The chiropractic answer to anti-inflammation is ice (preferably ice massage over the palm side wrist) and anti-inflammatory nutrients such as ginger, tumeric, boswellia, and others. What gives chiropractic the “edge” over non-surgical medical care is the addition of joint and soft tissue manipulation of the hand, wrist, forearm, elbow and when needed, the shoulder and neck. The latter improves circulation, reduces fixation or adhesion between tissues and allows the tendons to slide with less friction resulting in better function as noted by longer ability to play piano, type, write, etc.

Another “key” item to CTS treatment is identifying and finding a solution to a poorly designed workstation so the wrist/hand does not have to work in an awkward manner. Here, the position of a computer screen, how a tool is held, and how long repetitive work is allowed are modified.

We realize you have a choice in who you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs.  If you, a friend or family member require care for CTS, we would be honored to render our services.

 

You’re Not Dead Yet!!

10 Feb

The Most Important Principles For Staying Young: 

You’re Not Dead Yet!!

Dr. Michael F. Roizen

Co-Author of 4 #1 NY Times Bestsellers including: YOU Staying Young.

The Owner’s Manual For Extending Your Warranty (Free Press)

Our basic premise is that your body is amazing:  You get a do over: it doesn’t take that long, and isn’t that hard if you know what to do.  In these notes, we give you a short course in what to do so it becomes easy for you and then to teach others. We want you to know how much control you have over your quality and length of life.

This month, one of our readers, John (not his real name, he asked that not be printed) wrote in with: “I recently had a heart attack while having sex… [I] want to know when I can start enjoying sex again… and how will I know if I am in trouble short of serious chest pain…that was the first sign last time. My doctor doesn’t seem to want to address those questions with me.”

I’ll start my answer by referencing a favorite PBS show, Monty Python’s Holy Grail (look it up on YOUTube).  In one memorable (for me at least) scene, John Cleese carries out John Young (a dead body), when John Young utters the immortal words, “I’m not dead.”

I want to be very clear about this, John: If you’ve had a heart attack and you’re reading this, you’re not either! That means you can live life passionately.

Yes, check in with your doctor, but if it’s been 10 days since you were released from the hospital and you’re healthy enough to walk at a nice pace for a mile or so, and climb two flights of stairs (a la Jack Nicholson in “As Good As It Gets”), then you’re likely to be cleared for sex.

Your doc is unfortunately typical. Most docs don’t talk about post-heart-attack sex with their patients. Only half of male and a third of female patients are ever told when to restart their love machine. Without that info, many patients are too timid to test the waters. So, I am glad you asked the question. Two long flights easily we say, and then get cleared by the doc.  I’ve been very disappointed that 87% or so of patients after heart attacks (both nationwide and in Cleveland and surroundings) do not avail themselves of either the usual cardiac rehab or any of the three Intensive Cardiac Rehab programs we offer [the ICR of Dean Ornish –paid for by Medicare, The Granddaddy of all programs–the Esselstyn Program (developed in Cleveland)—or the Lifestyle180 program].

You should take one of these programs (many are offered in other parts of the country) if you are at high risk of a heart attack, so you don’t have another one.

By the way, beta blocking drugs like metoprolol were commonly prescribed after heart attacks until two months ago for rhythm control if you had abnormal heart beats after your attack.  But, they caused patients to eat more, have insulin resistance and even have problems achieving an orgasm. New data supports rhythm control with rhythm specific drugs, which means you won’t need those beta blockers and can probably perform better (better orgasms for both males and females). If you are at high risk (50% of men over 65 are), and don’t go for Intensive Cardiac Rehab, and do have a heart attack, you’ll probably feel like a dolt – and you should. You can prevent all that pain, and suffering for you and your loved ones, and not have that heart attack in the first place. (The Essy program is only one day!)

Worse, worrying about sex after a heart attack can be harder on the heart than having sex. Sex reduces stress, and reducing stress and having a great partner with whom you enjoy life helps reduce heart-stopping belly fat. That’s one reason why sex twice a week cuts your risk of heart attack in half.

By the way, why would Medicare pay for it? Probably because it just might save your life, allow you much more fun (I’m not sure Medicare cares about your fun), and reduces your lifetime Medicare costs (Intensive Cardiac Rehab does in randomized controlled trials). So, don’t be an 87 percenter and remember, if you are reading this, you aren’t dead yet.   So John, and all you John wannabees, after that two flights of stairs test and after Intensive Cardiac Rehab has started, snuggle up with your honey and remember: you’re doing this for your health!

Thanks for reading.

Young Dr Mike

You can follow Dr Roizen  (and get updates on the latest and most important medical stories  of the week) on twitter @YoungDrMike. 

 

Feel free to continue to send questions to youdocs@gmail.com. You can follow Dr Roizen on twitter @YoungDrMike (and get updates on the latest and most important medical stories of the week).  The YOU docs have a new web site: YOUBeauty.com  and its companion BeautySage.com the only site we know of where you can find skin products proven to meet the claims (opened for business on June 1st, 2012), and a new book: YOU: The Owner’s Manual for Teens.  It makes a great (even late) graduation gift.  Thanks for reading.

 

Michael F. Roizen, M.D., is chief wellness officer and chair of the Wellness Institute at the Cleveland Clinic. His radio show streams live on http://www.healthradio.net  Saturdays from 5-7 p.m . E-mail him questions at YouDocs@gmail.com.   He is the co-author of 4 #1 NY Times Best Sellers including : YOU Staying Young and YOU: The Owner’s Manual. He is Chief Medical Consultant to the two year running Emmy award winning Dr Oz show– The Dr Oz show is #2 nationally in daytime TV.  See what all the fun is about, and what he, The Enforcer, is up to. Check local listings or log onto DoctorOz.com for channel and time. And for more health info, log onto youbeauty.com anytime.

NOTE: You should NOT take this as medical advice. This article is of the opinion of its author.  

Before you do anything, please consult with your doctor.

 

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