Tag Archives: inflammation

“Inflammation… It’s Not a Bad Thing”

Clinicians are supposed to be evidence-based, but we’re not. We are sheep that follow the herd. Or, as a friend of mine from the University of Illinois often says “follow the Sacred Cows”. I am just as guilty. We go through the same mundane and antiquated treatment protocols that we always have. We don’t want to change our ways because that is what we are comfortable doing and that is what our patient expects. It takes a global paradigm shift in order for us change how we practice. Can a paradigm shift finally be underway in how we treat inflammation?

As followers, I knew our mindset toward ice and anti-inflammatory medication would only change if mainstream media started sharing the data. Now, this is just one story, but it is in the New York Times. Perhaps more articles like this will reach the public. Better yet, perhaps stories like this can appear on TV, like Dr. Oz or GMA. For now, I am just happy it’s finally being shared with the public and I look forward to more. A change will be coming folks. Below is a link to the NY Times article, with the best line saying: “There’s a reason for the inflammation” in the body after exercise, she says. “It’s part of the regenerative process and not a bad thing.”
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RICE: The End of an Ice Age

Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.” – Gabe Mirkin, MD, March 2014


ice-for-injuriesIn 1978, Gabe Mirkin, MD coined the term RICE. Health care practitioners to laypersons are quick to recognize RICE as the ‘gold standard’ treatment option following injury. Followers of my blog know my stance against ice and now there is support from the physician who coined the term. Yes, the very same physician, Dr. Gabe Mirkin, who coined RICE, is now taking a step back. I reached out to Dr. Mirkin and asked for permission to share his story. As you will read below in Dr. Mirkin’s full post, the lack of evidence for cryotherapy is something we must listen to.

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Ice: The Overused Modality?

Many years ago I got tired of watching my athletes roll in to the ice-for-injuriesathletic training room and slap on ice. These athletes are in a drug-like induced state of ice addiction. Their athletic trainers keep feeding the disease, by recommending cold treatment and doing the easy – here’s ice, shut-up, leave. I felt I was doing a disservice to my athletes and asked myself, “Why are we icing this injury?” I never had an answer that was supported by evidence. So I began my own case study.

I took 9 Division I athletes (6 patellar tendinopathy, 2 bicipital tendinopathy and 1 subacromial impingement) and  had the athletes cease all cryotherapy and electrical stimulation.

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Is the US Government Responsible for the American Obesity and Chronic Disease Epidemic?

Chronic medical conditions is the leading cause of death in the United States. Nearly half of all adults have at least one chronic medical condition. Over the past 20 years there has been a significant rise in chronic disease. Over the past 15 years childhood obesity and diabetes is growing at an astronomical rate. Who is to blame? Nobody can really state exactly who, but  is it possible that the US government, specifically the United States Department of Agriculture (USDA) is responsible?

1992 Food Guide Pyramid

In 1992, the USDA released the first Food Guide Pyramid. The USDA obviously had good intentions, through heavy research the pyramid was developed to prevent, chronic disease, obesity, and dental carries. Over the years the Food Guide Pyramid evolved to in to more user-friendly versions, MyPyramid (2005) and MyPlate (2011). Despite making the guides more user-friendly, the USDA did little to evaluate data and change the science supporting the pyramid.  Unfortunately, the USDA got it completely wrong. Since the ’92 Food Guide Pyramid was released there has been a dramatic increase in chronic disease and obesity. Has the Food Guides failed the American people?

Let us evaluate the guides. The ’92 version has grains, fruits, and vegetables filling the bottom two rows of the pyramid, accounting for 20 of 26 possible servings. The 2005 version is much of the same, with a large portion dedicated to carbohydrates, but like the ’92 version, the largest portion is dedicated to grains. The 2011, MyPlate is simplified for the consumer, but again indicates most of your plate be comprised of carbohydrates. In fact, when you breakdown the percentages the guides recommend the consumer eat approximately 75% of calories from carbohydrate sources. What is wrong with this you ask? Well, below I have outlined 5 reasons why the USDA might be responsible for the rise in chronic disease and obesity.

Five Reasons Why the USDA Might Be Responsible for the American Obesity and Chronic Disease Epidemic

Reason #1: Misleading information

The guides suggest grains (bread, pasta, rice) account for the largest portion of carbohydrate consumption. The guides do not state 100% whole-grain. To the average consumer, this gives the impression that refined breads and pasta is a fantastic option.  So, the lay person, goes to a restaurant orders a plate of spaghetti and a side of garlic bread, and thinks -‘this is a healthy low-fat meal’. After all, according to the guides this meal is well within the guidelines set forth by the USDA.

Additionally, the original guide said 6-11 servings of breads, grains, and pasta / day. Servings is key, because most individuals, myself included, grossly overestimate what constitutes a serving. Another note on servings: it gives a range of servings; 6-11 servings. This tells the consumer that you must have a minimum of 6 servings of grains. This misleading information has led to over-eating and over-eating of the wrong foods.

Reason #2: Satiety

Countless studies have correlated carbohydrate intake to increased hunger, specifically foods with high glycemic index (1, 2, 3). Primarily because of the insulin and blood glucose spike caused following the ingestion of carbohydrates. Newer research indicates that a higher than normal protein diet may actually be the reason for their partial success in inducing weight loss (4). Weigle, et al, found that the subjects felt more satiated with high-protein diet (5). In addition, Weigle’s team found total caloric intake decreased with when consuming more protein (5). There are two theories behind protein’s ability to increase satiety: 1 – High protein foods take longer to digest and leave the gut. 2 – Protein may impact our the hunger and satiety hormones of ghrelin and leptin. So the USDA is telling us to eat foods, that physiologically trigger us to eat more.

Reason #3: Insulin

When we eat carbohydrates insulin is released by the pancreas to begin glucose uptake from the blood. Insulin’s job is to take blood glucose and facilitate storage of glycogen  – our primary energy source. Insulin is also an indirect gate-keeper to fat metabolism, by inhibiting the release of glucagon. Glucagon is a hormone that has the opposite role of insulin. Glucagon is designed to take glycogen and convert it to glucose. Glucagon also creates glucose through lipolysis (the breakdown of fat). If we eat carbohydrates, the insulin response inhibits glucagon – thus prevents us from burning fat.

Reason #4: Elevated Inflammatory Markers

Chronic inflammation is a primary cause of most chronic diseases (6). Excessive consumption of refined carbohydrates, low dietary fiber intake, and a high omega-6 to omega-3 ratios are strongly associated with the production of proinflammatory molecules (7). One large study compared a Western diet and high protein diet. In this study, the western diet group had greater levels of inflammatory markers, including CRP and E-selectin, whereas those on the high protein diet had a significant decrease of inflammatory markers (8).

Reason #5: Importance Fat

In the original food guide pyramid it is stated that fats should be used sparingly. In both the 2005 version and 2011 version, the USDA’s guide says nothing about fat. This gives the impression that fat should be avoided. This is a huge mistake. Fat, specifically, Omega-3 fats – found in nuts, fish, and seeds – is very important. Clinical studies in adults with high cholesterol have shown that nuts lower LDL-cholesterol and improve the overall blood lipid profile (9). Additionally, frequent nut and seed consumption is associated with lower levels of inflammatory markers such as C-reactive protein (CRP), IL-6 and fibrinogen(10).

Does this indicate the USDA got it wrong and led the American people down the wrong path? I believe the aforementioned reasons have led to an increase in obesity and chronic disease in America. Is it really a coincidence that following the release of the guides there has been a dramatic rise in obesity and chronic disease? That being said, I believe in personal responsibility – I think it is up to the individual to make wise decisions. The USDA is not telling people to stop exercising. So, although I believe the USDA may have been a contributor – some blame should be put on the people.

What do you think? Can we blame the USDA’s Food Guides for steering the American people in the wrong direction?

References:

  1. Wien M A, et al. Almonds vs complex carbohydrates in a weight reduction program. Int J Obes 2003. 27:1365-1372
  2. Roberts SB. High-glycemic index foods, hunger, and obesity: is there a connection? Nutrition Review 2000. 58:163-169
  3. Arumugam V, et al. A high-glycemic meal pattern elicited increased subjective appetite sensations in overweight and obese women. Appetite. July, 2007.
  4. Astrup A, Meinert Larsen T, Harper A. Atkins and other low-carbohydrate diets: hoax or an effective tool for weight loss? Lancet 2004;364:897
  5. Weigle DS, Breen PA, Matthys CC, et al. A high-protein diet induces sustained reductions in appetite, ad libitum caloric intake, and body weight despite compensatory changes in diurnal plasma leptin andghrelin concentrations. Am J Clin Nutr 2005;82:41–8.
  6. Stehouwer CDA, Gall M-A. Twisk JWR, Knudsen E. Emeis JJ. Parving H-H. Increased urinary albumin excretion, endothelial dysfunction and chronic low-grade inflammation in type 2 diabetes: progressive, interrelated, and independently associated with risk of death. Diabetes.2002;51(4): 1157-1165.
  7. Neustadt J. Western Diet and Inflammation. IMCJ. Vol. 10: 2  Apr/May 2011.
  8. Lopez-Garcia E, Schulze MB, Fung TT, et al. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am JClin Nutr.2004;80(4):1029-1035.
  9. Mukuddem-Petersen J, Oosthuizen W & Jerling J. A systematic review of the effects of nuts on blood lipid profiles in humans. J Nutr. 135: 2005. 2082–2089.
  10. Rajaram, S, Connell, KM, and Sabate´ J. Effect of almond-enriched high-monounsaturated fat diet on selected markers of inflammation: a randomised, controlled, crossover study. BR J of Nut.  2010: 103, 907–912.

Arthritis: Causation, Symptomalogy, and Management

According to the CDC approximately 1 in 5 adults and 50% of older adults (> 65 yrs of age) have been diagnosed with some form of arthritis (1). The physical pain associated with arthritis is well documented, however, there is a large social impact on arthritis suffers. From an outsiders perspective, arthritis goes undetected. Outsiders do not see the pain or suffering that arthritic patients must suffer through. They are often labeled as weak, malingerer’s, or even lazy. Point is, many people with arthritis are having difficulty performing simple activities of daily living.

The purpose of this blog is to provide a high-level overview of the disease and share basic exercise and dietary guidelines that can provide a holistic approach to reducing symptoms, improve quality of life, and functional outcomes.

Disease Overview: 

There are more than 100 rheumatic diseases and conditions that affect joints, the tissues which surround the joint and other connective tissue (1). It is the most common chronic musculoskeletal condition in older adults. The two most common forms of arthritis include osteoarthritis (caused by damage or wear and tear) and rheumatoid arthritis (autoimmune causes).

Osteoarthritis:

Osteoarthritis (OA) is characterized by the gradual deterioration of cartilage within a joint (2). It is commonly developed in load-bearing or highly mobile joints, such as the knee, hips, fingers, lower back, and feet. Often, those who suffered a significant injury to a joint are at an increased risk of developing OA. For example, knee OA is very common following ACL tears and surgery. The internal joint damage caused by the injury compounded by incomplete rehabilitation (prolonged inflammation and muscle weakness) are the perfect ingredients for OA development.

The synovium of a joint produces the lubricating substance, synovial fluid. Healthy cartilage functions much like a sponge, it is receives nourishment by absorbing synovial fluid during joint movement. As we age, the synovium decreases its production of synovial fluid, we move less, and inflammation the articular cartilage increases resulting in dehydrated / malnourished cartilage). This creates a vicous inflammatory cycle.

Inflammation causes pain, loss of function, which eventually leads to muscle wasting and cartilage deterioration. Overtime, the poor cartilage condition can result in the formation of exotosis (bone spurs) that further damage the joint structures, increases pain, and creates a loss of function.

The most common symptoms of OA are pain, inflammation, reduced range of motion, and grinding sensations upon movement. As cartilage continues to detoriorate, pieces of cartilage my break free and float withing the joint (osteochondritis dissecans). The floating bodies will sometimes lock or catch the joint during movement. This locking or catching is very uncomfortable and sometimes painful.

There is no cure for osteoarthritis. Since pain is alleviated with rest, many of those afflicted tend to avoid regular exercise for fear of pain or flare-ups. Despite this, a recent study demonstrated that older adults who regularly participate in aerobic and resistance exercise are effectively able to relieve arthritic pain and improve joint function (4, 5). This creates a paradox for optimal treatment (movement vs. rest).

Rheumatoid arthritis:

Rheumatoid arthritis affects approximately 1% of Americans. It is an autoimmune disease where by the body’s own immune system attacks joint structures, including cartilage, synovial membrane, and ligaments. Rheumatoid arthritis is a systemic condition characterized by periods of activity and remission where affected joints are painful and swollen in addition to whole body symptoms of fever and malaise. Currently, there is no cure of rheumatoid arthritis, but there are medications designed to relieve symptoms.

Rheumatoid arthritis of the hands

 

Holistic Approach to Arthritis Treatment and Prevention:

Although I have great respect for western medicine and the research that pharmaceutical companies do to help cure chronic diseases, I have always been a believer in the holistic approach. The body is a self-healer – its own internal mechanic.

As I mentioned previously, cartilage gets nourishment through dynamic pressure gradients caused by movement and joint loading. Most people with arthritis can safely participate in physical activity programs to help the disease. Many studies have shown physical activity to have a positive effect on the reduction of arthritic pain. A 2010 agenda released by CDC lists physical activity as a priority intervention to improve arthritis symptoms and prevent arthritis-related limitations in activity (6). Unfortunately, there is a fine line; arthritis causes pain and subsequently, sufferers will not move due to pain. The perpetuates the disease and worsens symptoms. So movement is prudent, however we must be careful and be cognizant of exacerbating the issue. Below are some exercise guidelines.

Exercise Guidelines:

Things to avoid:

  • Rheumatoid arthritis results in early morning stiffness, so avoid early morning exercise.
  • Avoid end ranges of motion exercise as extreme cases may allow you to move in a small mid-range of motion only.
  • Be certain to distinguish between exertional pain in the muscles and pain in the joints.
  • If any movement causes moderate pain in a joint, stop immediately and modify or regress the exercise.
  • Always move joints through a slow and controlled range of motion.
  • Avoid fast or jerky movements.
  • Progress and increase exercise intensity very slowly.

Exercise tips and suggestions:

  • Exercise sessions should be relatively short and of low to moderate intensity.
    • Use circuit training (to give body parts a rest between exercises)
  • Aerobic exercise should be comprised of multiple sessions of using various cardio equipment (treadmill, to bike, to rower, etc)
  • Flexibility:
    • Self myofascial release (foam rolling) might be painful, but try it.
    • Static stretching as tolerated but avoid end range of motion for the joint
  • Resistance:
    • Low intensity
    • 1–3 sets of 10–12 repetitions 2–3 days per week
    • Work on core musculature
    • Use a circuit or peripheral heart action training system.
    • Avoid high reps or high loads.
  • Use thera-bands or cuffs when possible to avoid gripping if hand and grip strength is a problem.
  • In severe cases training sessions maybe have to be limited to short bouts (8-10 minutes at a time).
  • Emphasize the development of functional flexibility and eccentric control through simple reactive training exercises.
    • forward lunge with emphasis on lowering.
    • Eccentric training will improve soft tissue to absorb ground reaction forces and reduce the force transmission to damaged joint structures.
  • Water aerobics or swimming may be the best environment for clients with severe arthritis.

Dietary Considerations:

Arthritis is a chronic inflammation cycle, where inflammatory mediators remained elevated and a continued process of degradation ensues. Individuals with chronically elevated inflammatory markers are at high risk of chronic disease and now research shows that poor diet can also contribute to increased inflammatory markers. I wrote about this in a previous blog entry titled “Is Your Diet Making You Sick?”.

Excessive consumption of refined carbohydrates and low dietary fiber intake is strongly associated with the production of proinflammatory molecules (7). One large study compared a western diet, which contained more red meat, refined carbohydrates and saturated fat to a paleolithic diet (8). The Western diet group had greater levels of inflammatory markers, including C- reactive protein (CRP) and E-selectin when compated to those following a paleo-like diet (8).

Clinical studies in found frequent nut and seed consumption is associated with lower levels of CRP, Insulin-like growth factor (IL-6) and fibrinogen(9). Consuming an almond-enriched diet for four weeks significantly decreased serum E-selectin compared with the control diet in healthy men and women (9).

The rise of these inflammatory diseases over the past few decades may be linked to the Western diet of saturated fats, low antioxidants, and refined carbohydrates. A diet rich in omega-3 fatty acids such as fish and nuts as well as whole grains and high fiber have been shown to reduce chronic inflammation markers in the blood.

Summary:

Arthritis is a serious chronic inflammatory disease which has both physiological and psychological effects on overall health. Pharmaceutical companies continue to search for a magical cure for arthritic conditions, but to date nothing has been found. Thankfully, we can do something to help relieve the pain and symptoms of arthritis. Creating a safe and systematic physical activity program can help prevent cartilage deterioration and improve overall function. In addition, a dietary change can also help. By limiting intake of refined carbohydrates, excessive sugar, and foods high  in saturated fat we can lower chronically elevated inflammatory markers that are responsible for chronic diseases such as arthritis. I hope these tips help you or someone you know improve quality of life.

 References:

  1. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. retrieved August, 23, 2012
  2. Ferrini AF, Ferrini RL. Health in the Later Years. 4th ed. New York, NY: McGraw-Hill; 2008.
  3. Hills, B. A., Ethell, M. T., and Hodgson, D. R. Release of Lubricating Synovial Surfactant By Intra-Articular Steroid.  Br J of Rheum. 1998;37:649–652.
  4. Petrella RJ. Is exercise an effective treatment of osteoarthritis of the knee? West J Emerg Med.2001; 174(3): 191-196.
  5. Ettinger WH, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997: 277(1): 25-31
  6. Centers for Disease Control and Arthritis Foundation. A National Public Health Agenda for Osteoarthritis. 2010
  7. Neustadt J. Western Diet and Inflammation. IMCJ. Vol. 10: 2  Apr/May 2011.
  8. Lopez-Garcia E, Schulze MB, Fung TT, et al. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am JClin Nutr.2004;80(4):1029-1035.
  9. Rajaram, S, Connell, KM, and Sabate´ J. Effect of almond-enriched high-monounsaturated fat diet on selected markers of inflammation: a randomised, controlled, crossover study. BR J of Nut.  2010: 103, 907–912.

Stop Destroying your Body!!

Have you ever wondered why the ankle swells after a sprain or why we get a fever or why you get allergies around pollen? This does not happen because our body is weak; it happens because our body is strong and functioning as it should. Swelling after a sprain is needed to heal damaged tissue. Fever from flu is because our immune system is attacking a virus. Runny nose, watery eyes from allergies is a histamine response from your body to protect. Our body is designed to protect itself – we are robots that have specific programs in place to counteract disease or illness. Unfortunately, we are preventing our body from doing its job.

In the cells of your body is a class of proteins called Sirtuins. These have specific jobs that are designed to help the body function, live, and heal. SIRT1 is a specific type of Sirtuin that is specifically designed to facilitate metabolism. Yes this little guy helps breakdown and utilize the food you eat. Previously, Leonard Guarente of MIT found that this protein has many benefits including protection against Alzheimer’s, and Parkinson’s diseases. Most recently, they found that when mice were fed high-fat diets a myriad of metabolic disorders developed when the protein was absent.  These proteins are helping to keep cells alive and healthy.

We are killing these proteins and preventing them from doing their job. Research has proven that diets high in fat produce inflammation (see my blog). During the inflammation process an enzyme called Capase-1 is released. The specific job of Capase-1 is to go out and cleave (destroy) proteins and ultimately alter the primary objective of the protein. Are you following me?

When we eat a high-fat diet SIRT1 wants to begin metabolism, however the Capase-1 enzyme destroys SIRT1 before it can do its job. What happens next? Well, fatty deposit storage increases, followed by multiple metabolic and cardiovascular disorders such as diabetes, obesity, and hypertension (to name a few). By limiting high-fat intake and foods that initiate inflammation, we can allow our body’s natural protective mechanisms to go to work.

Stop Destroying your Body.
Reference:
Massachusetts Institute of Technology. “Protein that boosts longevity may protect against diabetes: Sirtuins help fight off disorders linked to obesity.” ScienceDaily, 8 Aug. 2012. Web. 11 Aug. 2012.